Cutting & Self-Harm – PediaCast 350

Show Notes

Description

  • Dr Raymond Troy visits Dr Mike in the PediaCast Studio to talk about cutting and other forms of self-harm. We discuss reasons teenagers injure themselves, along with risk factors and associated mental health conditions. Where can families turn for help? And what treatment strategies are most effective? It’s an important topic… we hope you can join us!

Topics

  • Cutting
  • Self-Injury
  • Self-Harm
  • Cognitive Behavioral Therapy
  • Dialectical Behavior Therapy

Guest

Links

Transcription

Announcer 1: This is PediaCast.

[Music]

Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello everyone, and welcome once again to PediaCast. It's a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. 

It is Episode 350 for August 24th, 2016. We're calling this one "Cutting and Self-Injury". I want to welcome everyone to the program.  

It's the kick-off to our second decade of pediatric podcast for moms and dads. We celebrated our ten-year anniversary with our last program, episode number 349. And during that show, we answered more of your questions including one on the best parenting books on the market today, which was a fantastic question because even though I love digital media and make a living producing podcasts for parents, there's still something about holding a book. You know, flipping the pages, exploring the content. 

So, of course, in our usual fashion, we went the extra mile for you guys. And rather than just recommending two or three parenting books, we assembled a library of over 40 books. Now, I know you may be thinking, is that really helpful? I mean 40 books, how's that  helps us pick which one to read. Actually this, because in one way or another this library of books covers every age range, every learning style and just about every common problem that parents face. 

So there's something for everyone in the Dr. Mike recommended library of parenting books. You can learn more about it on our ten-year anniversary show, PediaCast Episode 349, which like all of our episodes, you can find at PediaCast.org. Also on iTunes and iHeart Radio and on most podcasting apps for IOS and Android. 

There's also a link to a library itself on the Show Notes page for Episode 349 over PediaCast.org. We try to make it as easy as possible for you. We have them all assembled, just click on that link and you'll find all of them.

0:02:37

Another recent show I want to call your attention to, food allergies with our superstar guest, Dr. Wesley Burks. We cover everything food allergy related, including oral immunotherapy, which there's a lot of promising research on this and will probably become standard treatment for food allergies at some point in the future. Still experimental right now, but you want to hear about that. We also go into great detail on peanut allergies, even peanut patches to treat peanut allergies. Skin patches, again experimental but really not one of those things that's farfetched that a decade from now people might be doing. This is something that is probably going to be coming soon. 

So, if your family is dealing with food allergies or you know someone who is, make sure you check out our food allergy episode.  Now, you'll find that one on our podcast for pediatric providers. But I mentioned it here because that particular episode will also be a great interest to many parents and families out there. You'll find it on PediaCastCME. CME stands for Continuing Medical Education. Again, aimed at providers, but I really tried to do a good job on that episode of really explaining things. I mean, we go into considerable detail but in terms that just about anybody can understand. So, you can track along with that. 

That podcast series is available at PediaCastCME, again Continuing Medical Education, PediaCastCME.org. Or, search in iTunes for PediaCastCME. Also in most podcasting apps, also on the PediaCast iHeart Radio feeds. So lots of places you can find it. Actually, if you do a Google search for PediaCast food allergies and maybe put CME, those three letters together in there, I'm sure it'll come up right on the front page there for you.

0:04:31

So, be sure to check out that episode if food allergies are an interest. Really informative show with one of the top food allergy investigators in the world, Dr. Wesley Burks from The University of North Carolina at Chapel Hill. 

All right, what are we talking about today as we kick-off our next decade of podcast for parents? It's an important topic that affects lots of teenagers and their families, "Cutting and Self-Injury". And I love the way that this idea as a show topic came about. It came from you in the form of a couple of listener questions, like all the questions that our audience sends in. They're great ones. There's no silly questions on PediaCast. We're happy to answer all of them.

But this particular topic, it's a serious issue. I mean, lot of topics are, but this one can really cause a lot of distress within the family and also for the teenagers who it affects. And rather than tackle a cutting behavior on my own, I really wanted to pull in some expert help from the world of the child and adolescent psychiatry. So Dr. Raymond Troy will join us today. He's a child and adolescent psychiatrist from Nationwide Children's in the Ohio State University-College of Medicine. 

He'll be here in a couple of moments, and I'll share a couple of listener questions that sort of sparked this topic. And then, we'll cover cutting behavior, self-injury, self-harm and also address our particular listener questions as we go about exploring this topic. 

0:06:06

And now, you may have a great question, too. And, in fact, I'm sure that you do about your child's health. It's really easy to get in touch with me, just head over to PediaCast.org and click on the Contact link. You can also call the voice line, 347-404-KIDS, 347-404-5437 and leave your message that way.

Also, I want to remind you, the information presented in every episode of our program is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So, if you have a concern about your child's health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement which you can find at PediaCast.org. 

Let's take a quick break. We'll get Dr. Raymond Troy settled into the studio and talk about cutting and self-injury. That's coming up, right after this.

[Music]

Dr. Mike Patrick: Dr. Raymond Troy is a child and adolescents psychiatrist at Nationwide Children's Hospital and an assistant professor of Pediatrics and Psychiatry at the Ohio State University-College of Medicine. He treats and counsels teenagers and their families on a wide range of mental health concerns including cutting and other self-injuries behavior. That's what he's here to talk about today, cutting  and self-injuries. So let's give a warm PediaCast welcome to Dr. Raymond Troy.

Thanks for joining us today.

Dr. Raymond Troy: Thank you very much for having me. 

Dr. Mike Patrick: Really appreciate it. As I mentioned in the intro, the topic was really sparked by a couple of listener questions. I just wanted to share those with the audience really quick, then we'll talk through cutting and self-injury. 

0:08:13

Dr. Mike Patrick: First up was Beth in Florida, and Beth says, "Have you done any podcast episodes on teen self-cutting? If not, could you? I've just downloaded your PediaCast Episode 315 on teen suicide and 187 on teen self-embedding. But from the Show Notes, it looks like those episodes just address cutting in passing. One of my many questions is what is the scientific basis for DBT or Dialectical Behavioral Therapy? Which is a therapy I had never heard of until I needed to research teen cutting because one of my own children has started doing this. There's lot of information online and you always do a good job sorting through it all."  

Thank you. 

She adds, "It probably goes without saying about my husband and I are definitely getting local in-person help for our daughter. I'm writing to you because I'd like to know more about cutting and cutting treatments in general."

So, very good, Beth. Of course, we always want you to find someone local and to see your child. It very important. But we can certainly talk about cutting in general.

And then question number two comes from Jackie in Pennsylvania. Jackie says, "Hi, Dr. Mike. I've been listening to your podcast for the last few weeks. And I'm so grateful for your insights. I'm not yet a parent but hopefully will be soon. I'm 28 years old, happy, healthy and married to my wonderful husband who is just as excited to start family as I am.

I'm a planner and a big fan of evidence-based decision-making. Through the dozens of relevant parenting books and articles I've dived into, I'm still uncertain how will I address one concern. During my adolescence, I had depression which involves self-injury. I have noticeable scars and my question is this, what is the best way to explain this to a child? Should I be honest from the start? What explanation is appropriate for a 5-year-old? What about a 12-year-old? Also, shall I consult with other parents about what they want me to tell their children if they ever asked? 

This has been on my mind for years and I would love to hear any ideas you might have. Thanks in advance — Jackie.

0:10:12

So, couple of great questions, and I think these are going to really stimulate some great conversations. That's the goal anyway. I think a good place to start is just what counts as cutting and other self-injurious behavior? What would qualify there?

Dr. Raymond Troy: Generally, when we talk about cutting or we talk about non-suicidal self-injury, it generally refers to people who are engaging in a form of self-harm — usually, cutting using an object or a razor and cutting on their body. It usually has multiple functions for them. 

That's different than suicide. It's uniquely different, and it's important that you recognize that non-suicidal self-injury is very different than suicidal behavior. 

So, as for why it happens, there's a lot of reasons why people do it? It's both as a kind way to regulate themselves. And as pediatricians, we know that there's lots of things that children do, whether it be rocking or sucking their thumb or sometimes banging their head or screaming that are attempts to kind of self-regulate. And for these individuals, it's another type of self-regulation. 

It also speaks to the idea of recruitment. And that's what children tend to do. When they're frustrated, when they're having problems, they're attempting to recruit help. And it's a help-seeking behavior, to signal to others that they're overwhelmed and they're exceeding their developmental capacity to be able to handle this stress they're under at the time. 

Dr. Mike Patrick: You've mentioned it's not always just cutting. It could be scratching, piercing, carving, hitting, punching, burning, rubbing, pulling your hair out. I mean, there's really lots of different ways that one could… And it's basically still kind of lumped in to this same type of behavior, still self-regulation and attention-seeking, wanting help.

0:12:08

Dr. Raymond Troy: Of course, it's that sometimes others want to perceive cutting as something distinct. But we know that lots of people engage in behaviors that are not necessarily healthy for them. For the person who's on a diet, who engages in eating snacks or things they shouldn't do, it is helpful for them for the moment and it releases the tension. But in the end, it increases their own stress. 

As I said for the person who's on a diet, who tends to sneak or the person who tends to procrastinate. There's all types of self-harm. But in this, it's a direct self-harm to their body and that they're not able to utilize other resources or other people for a myriad of reasons. 

Dr. Mike Patrick: Now, in terms of suicide, obviously, the goal there is either to end their life, or they might not really want to die. That could also be… And we've done an episode on teen suicide not too long ago, we'll have links to that in the Show Notes. But does self-injury behavior increase? So if a child is doing that or a teenager, is there then an increased risk of suicide attempt down the road, should that be a concern for parents?

Dr. Raymond Troy: It's a great question and not inherently. Non-suicidal self-injury is distinct. We make the distinction between that kind of behavior and actual suicide risk. But what we do know however is that individuals who tend to engage in longer periods of self-injury and tend to use other forms and had broader areas where they're not able to effectively communicate their needs or regulate, tend to be at a greater risk for suicide as a result. But they are distinct and separate.

Dr. Mike Patrick: So cutting behavior wouldn't necessarily then evolve into a suicide attempt. But if you have underlying depression, anxiety, there's other mental health issues at play and those underlying issues could have suicidal as a possible outcome.

0:14:12

Dr. Raymond Troy: Absolutely. So I think it's important that when we look at self-injury, perceive it as one of the issues we talk about as we get into DBT. And we talk about the listener's question of what is DBT. It's important to characterize the non-suicidal self-injury as a behavior, but we know that we're much more complex than the behaviors we show. It's about a failure of emotional regulation. It's about a failure of how do I communicate my needs? It's sometimes a failure of being self-aware of how we're feeling at the moment and being able to do something before it becomes out of our control, and being mindful of what we're experiencing. 

And it's important to recognize that there's — we call it a biopsychosocial model — and to say that sometimes there are biological reasons such as a major depression, other mood disorder or anxiety disorders that can underlie and predisposes. There are psychological reasons. For example, there may be real reasons why we can't communicate some of our feelings to other people, that even though we say we should be able to talk to our friends or talk to our parents, it's not always that simple. We recognize there are factors in our families, in our lives, that make that difficult.

Dr. Mike Patrick: Yeah, there may be barriers that aren't even in that particular patient's control.

Dr. Raymond Troy: Correct, and that brings also the social factors that for many people, they have very few options as outlet, when we talk about the availability of outlet to be able to work out, to take out distress some place else. For many people and children, they have few resources. And so, we look at self-injury not simply as a behavior, but also what are the other factors that we can work and improve on to give them other options or other outlets for expressing their frustration, improving their communication and understanding what they're experiencing so that they can gain better self-control.

0:16:18

Dr. Mike Patrick: How common is cutting and self-injury?

Dr. Raymond Troy: So, there'd been a number of studies both in the United States and around the world. And the prevalence tends to be fairly consistent. And it is the same across genders and socio-economic status, and ethnicities. It tends to run around anywhere from around 18 to 23%, depending upon the age.

In adolescents, looking at that particular so, in a prospective study — that meaning they went to a population of students who had no history of self-injury and follow them over the course of time — in about 18% of  11- to 14-year-olds had engaged in cutting over about a two-year period. Also, we know in younger kids, about 7.5% of sixth to eighth graders can engage in self-harm. 

Dr. Mike Patrick: So that's fairly common and I think that when parents come across this in their own kids, there's a lot distress, like, "This is happening to my child." But there are a lot of other folks out there who share a similar experience. Folks don't always like to talk about these things. And we do have a good body of evidence in terms of how to help these kids and families.

Dr. Raymond Troy: Absolutely. 

Dr. Mike Patrick: And experience.

Dr. Raymond Troy: Right. And again contextualizing rather than being reactive to self-harm, recognizing that there's a number of forms of self-injury or self-harm. As we say, procrastination or they don't eat proper foods, that reflect with the same process but are just expressed differently.

Dr. Mike Patrick: Yeah, that makes sense. 

Dr. Raymond Troy: But this one is very alarming to a lot of parents and other teens.

Dr. Mike Patrick: Are there particular social risk factors that make cutting and self-harm more likely?

0:18:17

Dr. Raymond Troy: There's a variety of issues and we don't understand all the complexity. Certainly, again when we look at from a biological perspective, when we look at people who have non-suicidal self-injury, about 88% of those individuals qualify for a major mood disorder. And, so that's certainly a biologic factor we have to consider. 

We also know that these children tend to have deficits, whether it be something about their person or their temperament or about how they learn to socially communicate. But they have some deficits in interpersonal communication, being able to effectively communicate what they feel, and be aware of what they're experiencing in a time frame in order to be able to communicate that effectively to other people, also to people that will actually help them process it. 

And then, again, there are these social factors of what are some other outlets that they may have access to or may not have access to for emotional regulation, for displacement of the tensions that they're experiencing. Because that's what we're really talking about. We're talking about emotional regulation, distress tolerance, interpersonal effectiveness and self-awareness. When we look at those risk factors, people who don't have options for those are at greater risk. 

Dr. Mike Patrick: Substance abuse, do you see that coinciding with these kind of behaviors?

Dr. Raymond Troy: When we follow individuals with non-suicidal self-injury, those individuals are increased risk for substance abuse, about 68%.

Dr. Mike Patrick: And what about friends and social contacts who also engage in these behaviors, would that be a risk factor?

0:20:13

Dr. Raymond Troy: Whether it would be a risk factor can't be said, but certainly, it would be something that might normalize the experience, as with any other outlet of behavior. Whether we talk about teen smoking, teen alcohol use, the idea of normalizing that as an outlet. So again, it seems that non-suicidal self-injury is an outlet for other pressures that are common, but looking to peers to say, "Is this something that's socially acceptable?"

Dr. Mike Patrick: Do you that cutting and other forms of self-harm are on the rise? Are we seeing more of this or is there just more awareness about it?

Dr. Raymond Troy: We certainly have greater awareness, and that's a wonderful thing. Greater awareness leads to early intervention and touchpoints for us to be able to intervene. When we look at adults such as from the data on suicidality, 19% of adults say that they have had suicidal ideation. And only about 8% have said they have engaged in an actual suicide attempt. 

When we look at adolescents presently, that is slightly up for both of those numbers. We can't say is it really better awareness, are we doing better tracking to this? Certainly, we are we doing better screening? Versus is this something that has been present for a long time? As I said when we look across cultures, this tends to be present, prevalent, whether it is male or female, regardless of ethnicity, regardless of socio-economic status. 

So again, we know that people undergo pressures and have difficulties in communication, and this is simply an outlet for that.

Dr. Mike Patrick: As a pediatrician, we think in terms of benefits and risks or something. 

Dr. Raymond Troy: Absolutely.

Dr. Mike Patrick: And so, the person who's engaging in this behavior, as you have mentioned, what are they getting out of it? So sort of from their perspective, what is the benefit of doing this? And obviously, from the long-term perspective, they end up being more stress because of it, because others are asking about it. Or they're seeing a physician because of it, and their parents are upset. But in the short term, there is something they're getting out of it. 

You mentioned auto-regulation. Explain to us exactly what that is or what that means. Why is that something they would seek? 

0:22:33

Dr. Raymond Troy: I think that's a fantastic question. As a pediatrician, I think we experience this all the time, whether it be the toddler who's seeking out emotional regulation, who we're consoling and trying to help them process what they are experiencing. It's something we do with children from the moment of born. However, when they obtain language, we somehow think they're somewhat suppose to act like us as adults, when the reality is they still need help processing what they are feeling, what they are experiencing. 
Whether you're an infant or you're an adult, when we are emotional, we say that it's hard. We'd like to be able to think that we're thinking through things but actually we're feeling. And no matter how old you are or no matter how many degrees you have, when we're emotional, we're not really thinking through clearly. 

And our job as parents is to help our children understand not just what they're experiencing and give language to, give a context to it, but also help them understand how this arises. 

When we talk to the woman like about children, just because they share our language doesn't mean they understand everything the way we do and that can very be frustrating, whether it be a ten-year-old who at one point thinks parents know everything to the adolescent who thinks parents know nothing. But we understand that they don't see the world the way that we do. 

And also, more importantly, they don't see themselves the way. So when they want to talk about their emotions and what trigger their emotions, what their thoughts are and interpretations about these emotions, knowing what they're experiencing and understanding what they're experiencing while they're experiencing it. How are they expressing? Are they aware of what they're expressing and what the impact is to other people? And what are the after-effects?

0:24:27

So, children need our guidance in understanding what we call change of behavior and be able to see how the trigger lead to consequence. 

Dr. Mike Patrick: So, again, my brain tries to over-simplify these things to a degree. But is it, so if you're experiencing a lot of emotion and you want to get back to your baseline, is this a behavior that sort of then takes your extreme emotion and brings it back to your normal where you usually are?

Dr. Raymond Troy: Right. It is an attempt to regulating yourself, just like any of the other things that children tend to do. However, as we know, children are often put into a situations that they're not emotionally prepared for. And as a result, they may engage in behavior that are that they're out of proportion. 

We also get concerned that some emotional experiences are very overwhelming. And some children even disassociate to an extent. They feel overwhelmed as somebody in a panic attack does. And the behavior they engage in, although they don't seem logical to us at the time, they're what we do in order to bring ourselves out of that anxiety and misery. 

Dr. Mike Patrick: And to some degree, they have ultimate control over their body. Does that come into play as well? Like the objects and things, like a parent can say, "You can't do this," "You can't do that," but it's a little harder to keep someone from doing something to their body. Is there a control issue there?

Dr. Raymond Troy: I need you to kind of clarify the question, because it gets to be complicated.

0:26:09

Dr. Mike Patrick: I think if there's something that they can actually control in their lives. So a lot of decisions were made for them. You know, "You have to stay here now. You can't go out with your friends." There's certain restrictions. So you feel out of control but this is one area where, "It's my body. I have control over it."

Dr. Raymond Troy: That's one way of seeing it. It's one perspective, but it's certainly not the only perspective.

Dr. Mike Patrick: Because that's a little different than the auto-regulation concept.

Dr. Raymond Troy: It's somewhat the same in terms of interpersonal. But for all of us, we only have so much control over how we react, that our emotions in the way we respond and that we would like to think we're always in control. Particularly when we become emotional, it is out of our control. We're no longer thinking. We are now feeling. And for some, the distance between thinking and feeling is short. And the distance between feeling and acting is also short. 

And so, for a three-year-old, the distance between thinking and acting out is very short. And our goal is to teach our children to, hopefully as adults, as adults have more time in thinking, spend less time in acting out, and be able to understand our feelings, we don't  act out on those behaviors and impulses. 

Dr. Mike Patrick: It's very complex, complex thing. I guess our brain tries to simplify things and that just it doesn't always work out that way.

Dr. Raymond Troy: Parenting is hard.

Dr. Mike Patrick: So, the opposite then of what are they getting out of it, are there then risks or complications that arise out of this behavior that we need to pay special attention to?

Dr. Raymond Troy: When we look at what are the underlying risk factors, what we focus on is how well are they regulating their emotions and what predisposes them to be at risk? The more that we spend time being emotional and not thinking, the greater chance that we're going to engage in behaviors that move us farther away from thinking logically, that put us into situations that make our life even more disruptive.

0:28:27

Interpersonal communication can break down. And when some of these behaviors or any behavior for an adolescent who argues with an adult as a way towards from being independent, there are moments where we want our child to be assertive. But we  don't want them to argue. And so, it can lead to a breakdown in the communication in the family system. And that puts children at incredible risk because it takes them away from the primary support that they need, and can move them towards other things such as drugs, such as alcohol, such us other peers that may not have their best interest. And that puts them at greater risk, as with anything else.

Dr. Mike Patrick: So this is really something that parents should really pay attention to because it would be easy from their own psychology, the parent psychology, to sort of turn your back on this, or say, "I'm not going to feed in to this behavior," and then do that in such a way that the lines of communication between you and your child are cut off. I suppose that's where family counseling also is very important in terms of the inter-communications of the family to really get this under control.

Dr. Raymond Troy: Absolutely. So when we talk about dialectical behavioral therapy, when we work with children — and we always say there no such thing as a child — to quote Leonard Sax, that children exist within systems. And we teach both that there's individual psychotherapies as part of DBT. There is skill learning which is part of a group, which involves parents. There's is coaching. And 24/7, they have a coach that they can go to reinforce those skills as a support. As are therapists, we also work in treatment groups. Because they need support. 

0:30:28

So it is a family process. We don't treat the child in isolation. We treat them together as a team. 

Dr. Mike Patrick: There's also medical and physical complications that can arise from self-harm, obviously. They may not be meaning to hurt themselves in a way that puts their life at risk, but if you hit an artery. You can have bleeding or there can be unintentional consequences of this, and of course, infection and scars, disfigurement, that sort of thing to think about. 

What about just sort of worsening already underlying feelings? It may be self-auto regulation, but then you realized "What I've just done ?" and then that increases shame, guilt, those kind of things. You kind of get into a feedback loop, so to speak.

Dr. Raymond Troy: Absolutely. And that's why we call it behavior chain. It does become a cycle. And what's important to recognize about that is you don't have to. You don't have to change everything. You just have to change a piece in the link for the chain of behaviors, and then the chain or circle stops. 

So it does happen, where some people can have shame or concerns with scarring because it is more permanent. So we teach radical acceptance. That's the idea. We may not feel to control everything. We may not agree with everything, but we have to kind of accept both where we are at, and we have to accept the need for change. 

Dr. Mike Patrick: Yeah, it absolutely makes sense. From a parent standpoint and teachers and caregivers, are there some warning signs that a child may be doing this? Because I would imagine that there's also a lot of teenagers out there who may self harm and then tried to hide it?

0:32:10

Dr. Raymond Troy: Well, many of those factors again, I may sound a little bit like a broken record, but it's when we see patterns of emotional disregulation and our children aren't able to function successfully under the level of stress or the current system in which they're in, whether at school, socially. We find that there's increased emotional disregulation there they're not able to manage. There's more emotional episodes. So we talk about high emotional expressivity not just within the child but also in the family that everyone becomes off balance. 

That's certainly when we see a breakdown in interpersonal communication. As with any of all children, there's a breakdown of not knowing their friends, or there's increased conflict in the friends. And those friends are the people who we are asking to support our children for the eight hours of the day when they are not with us. They are very important people. 

When we see less tolerance for minor distress, certainly adolescence is a very tumultuous time, and it is very difficult. Even though we look back on it as adults as sometimes an easier time, it's a very difficult period most personally for adolescents whose bodies are changing, whose relationships are changing on a constant basis. 

But we want to have a kind of a marker of how well they are handling the stress. Is this becoming a pattern? Is it just occasional? Or, do I see this is as my child's coping strategies are not working effectively, that I need to bolster? Either the supports, identify triggers, reduce chronic stress, or help them reframe how they see thing in their environment, that maybe the way they're perceiving thing can become a never-ending cycle.

0:34:08

Dr. Mike Patrick: What should parents do if they find out, that they do discover that  their child is harming themselves?

Dr. Raymond Troy: Certainly, parents are best persons to address the issue with their child. Not every episode requires a psychiatric evaluation. You openly communicate about what are the triggers? How are they feeling? Helping them understand what they're experiencing. Is this an isolated incident? And as we say, this kind of radical acceptance, instead of judging a behavior, accepting that it and it has occurred, but recognizing the need to change. 

They can certainly use resources if they're feeling overwhelmed and they're feeling it's beyond their resources. Certainly going to therapist is certainly the first and foremost to be able to get it additional help. Because as parents, everyone needs help with the very complex part of parenting. They can certainly contact Nationwide Children's and the Mood and Anxiety Program. They can go to NationwideChildrens.org and Mood and Anxiety Program and look some of the resources that we have available in terms of the treatment programs available for parents and their children.

Dr. Mike Patrick: Yeah, and we'll put some links in the Show Notes for that.  Let's say that it's someone that's not necessarily in our service area. Where's a good sort of order for parents to seek out help? 

Dr. Raymond Troy: First and foremost, especially in the rural areas, your pediatrician is someone who can help understand the nature of this process. As pediatricians, we often help parents understand developmental processes and question, "Is this an acute process or is this something chronic?" 

Certainly, again, thinking rural areas, going towards the school, gathering information, making links, because communication — interpersonal communication — is important. Knowing your school counselor, knowing your teacher, knowing your child's friends and family is probably first and foremost in terms of making links for safety and knowledge. 

0:36:23

Certainly, there may be counselors in their community as an extended resource, but being aware about the communication with your child is first and foremost. And then, eventually, if you believe that the child has an underlying disorder that may predisposed them to emotional disregulation, a psychiatric evaluation can be beneficial if that's a significant concern. 

Dr. Mike Patrick: And that may start with your pediatrician or family doctor that's going to know the resources that are really geared toward teenagers. 

Dr. Raymond Troy: Absolutely. 

Dr. Mike Patrick: Kind of plug you in with what's available for you. I also want to mention here that if you have a concern that your child may be suicidal, that's a whole different ballgame then. And that is something that you want to get help fairly quickly, correct? 

Dr. Raymond Troy: Absolutely. We want to understand the reasons for that. We want to understand if there's something we can help them process. How can we help the family system to deal with this in a non-judgmental fashion. Yes, we strongly encourage that be evaluated and get assistance to build the process as quickly. 

When you talked earlier about what are some of the risk factors for non-suicidal self-injury leading to suicide — chronicity. The longer any process goes on untreated, the potential for worst outcome is higher. And early intervention cannot be underestimated. 

Dr. Mike Patrick: And if you don't have anywhere else to go, your closest emergency room will get you plug in to the system. 

Dr. Raymond Troy: Absolutely. 

0:38:05

Dr. Mike Patrick: So you talked a little bit about and our listener question was on DBT or Dialectical Behavioral Therapy. So, let's say a family with a teenager who is exhibiting cutting behavior does make it to a therapist, what kind of strategies are employed then to treat this? 

Dr. Raymond Troy: Dialectical Behavior Therapy was one of the first evidence-based treatments and has extensive since Marsha Linehan had developed it and published it in 1991. She created a model that emphasize working on emotional regulation, understanding emotions, understanding what you're experiencing in your body and developing point of intervention, also understanding how you express and what the after-effects are of that expression. We work on interpersonal communication. 

Again, cutting and self-injury and sometimes acting out is a way of recruiting help. It may not always appear that way but our children are attempting to recruit our assistance for when they're feeling overwhelmed. So we focus on how do we communicate effectively, what it is that we want to do in assertive way, not a passive or dominant way, but how can we effectively communicate better within the family and reduce the overall emotional tone in the system. 

How do we work on distress? So, teaching distress skills so that we can develop points of intervention early on in early year. So that we can avoid that cycle as you said of engaging in self-harm, feeling defeat, feeling failure from whether it be self-harm or not adhering to diet or not adhering to other behavior change. But to be able to kind of intervene early and to develop other coping skills that are a skill set. And that's really what we're trying to work with kids is, we say that we accept the emotional disregulation that you have, but recognize that you have not learned or you've been unable to acquire for whatever reason a certain set of skills that others may possess. 

0:40:31

So our focus is to say, we don't judge that. We are focused on teaching that set of skills that you may lack, and understanding that once you acquire them and understand how to use them in an effective manner and an early effective manner that non-suicidal self-injury will go away. 

Dr. Mike Patrick: And I would imagine that this can be very difficult when you have a family where the barrier really is the parents.  That to try to find support systems outside of the home can be complex and difficult. 

Dr. Raymond Troy: As we said, when we look at these behaviors, it's usually more complex than cell. It is a combination of an underlying mood disorder. There are psychological resources, interpersonal effectiveness skills, distress skills that the person may have acquired or may have never had the opportunity to acquire. And there are social circumstances that they may not have access to therapy resources or psychiatric resources or people that understand this type of behavior. And all of those put you at increased risk. 

So even for the families, isolation is a risk factor. So getting help, getting them to resources is key to change. 

Dr. Mike Patrick: You talked about a lot of these kids having an associated major mood disorder. So I would imagine it's important to identify and treat that at the same time as well. 

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Dr. Raymond Troy: Absolutely. Absolutely. I would say about 63% of the people have externalizing disorders, meaning acting out. About 57% act in anxiety. And l would say about 67% have substance abuse. So getting treatment for that, and we emphasize that looking at just one piece is not sufficient. It is one piece that's part of a larger whole. But absolutely, we must treat those into two pieces but medication alone is certainly not enough. 

Dr. Mike Patrick: What is the long-term outlook for these kids? So when you think about treating any associated co-morbidities that may be there from a mental health standpoint and you're doing the psychotherapy, in your experience, is this something that you really do get control over and it's gone for good? Or, is this kind of waxing and waning issue that can be long-term? 

Dr. Raymond Troy: So going back to a developmental model, that is the goal of teaching our kids, is how to self-regulate. So yes, as we see with most of our kids, the outcomes are good. 

What are the risk factors? The risk factors are when it tends to spread longer, and spread beyond the initial issue of emotional regulation, or how do I communicate effectively? When we get in to the secondary issues of sexual activity, substance abuse, not adhering with other rules and school truancy and other factors, the combination of those is what ends up creating a great deal of problems. But the outcomes can be good the earlier in the intervention, the better.  

Dr. Mike Patrick: And I would imagine that the more investment that you have from the family and from the parents and kind of everybody working together at communications and the interpersonal relationship stuff, that's an important thing in terms of long term. 

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Dr. Raymond Troy: Absolutely, because as we say, there's no such thing as a child, child exist within a family. Children don't learn to regulate their emotions on their own. They need our help. They need our guidance. They need our experience to help frame things for them. Family is essential for treatment. 

Dr. Mike Patrick: Is there increased risk of depression, anxiety, in adulthood for these teenagers? 

Dr. Raymond Troy: So when we look at the studies, of course, again as I said, about 80% have a major mood disorder at the time of self-injury. So certainly, having any mood disorder puts one at increased risk for mood disorders in the future. 

But we also know that adolescence is a time of change. It's a very volatile time change. There's a great deal of stress. You and I go to work every day. This is our job. It's what we do every day. But for the adolescents, the assignment from yesterday is not good enough. It is a new assignment tomorrow. It is constant changing stress. Getting to adulthood, getting to that stabilization is the goal. The majority of people, once they acquired these skills of adulthood, of self-regulation, do very well. 

Dr. Mike Patrick: Good. That's good to know. 

One of our listeners asked how do you explain scars to your children when she had been engaging in cutting behavior, self-injury? How do you go about talking to your kids about that?

Dr. Raymond Troy: A very good question. I put it into a context of how do we talk to our children about a lot of things. And we do have to take a developmental approach to it. If a child is five, and they're asking about a scar that we have, they're not really asking about us personally. So you will say, "Yes, when I was younger, I got hurt." And that's a true statement, but we're trying to put it in words that they can understand and not overwhelm them with things they may not be prepared for. 

0:46:29

So, as a child gets older into latency age, they can start to reflect on other people's experiences more, and we can choose to share those other aspects. I think that's a very personal decision. 

Dr. Mike Patrick: Yeah, there's not a one-size-fits-all answer. 

Dr. Raymond Troy: It's a very personal decision. And as with anything in our lives, I think it's very hard as parents that we maintain how much do we share with our children and how much do we keep at the parental level, whether it be the finances or work or even their awareness of the complications of how the house works — why are we going to the soccer team? Why do we do those things? 

And we have to pair it to what's their developmental level and what's their real understanding, and what's their real question. Are they're really just expressing concern about you as a parent which is appropriate? Or, they're asking something deeper? Or are they asking about themselves? It's very hard to put up a global answer to that. 

Dr. Mike Patrick: And she had mentioned also, do I talk to other families in case their children asked about it? But I think just leaving it as "Yeah, I got hurt at some point in the past," is easy enough. Because when you're talking about other families that may not really have a need to know, then it's easy just to sort of deflect it with that sort of an answer. 

0:48:01

Dr. Raymond Troy: Correct. And so, I think one of the skills that we emphasize in DBT for the parents as well as the kids is how I effectively communicate what I want to say but maintain appropriate boundaries for myself and not feel burdened to convey more or comply? It is an art that all of us have to do every day in terms of being assertive but maintaining our personal boundaries. 

Again, I think it is individual in each case and every circumstance because the needs are different. 

Dr. Mike Patrick: Absolutely. We really appreciate you stopping by and talking to us about cutting and self-harm. Tell us a little bit more about the Behavioral Health Program here at Nationwide Children's Hospital. 

Dr. Raymond Troy: Of course, I'd be glad to tell you about that, specifically the Mood and Anxiety Program for which I'm the director and my colleague, Wendy Cleveland is the clinical director over the therapists. So, we work on a broad array of mood and anxiety issues and provide number of different levels of service, whether it be outpatient for people who just may require therapy. Also, providing psychiatric management for those people that may require psychiatric management in addition to therapy services to help facilitate therapy process. 

We also provide intensive outpatient, which is a program that involves three-day-a-week treatment for three hours a day over a period of a month. So providing out 40 hours of therapy in a very condensed fashion to try and help those individuals who are struggling on an outpatient level but do not need a higher level of care such as in-patient in order to stabilize. That gives us an opportunity to teach those various skills that we're talking about in a condensed fashion and hopefully help them restabilize themselves. That goes in our outpatient. 

0:50:08

We also have a high-level program, and that's the DBT Program which usually involves a 16-week program that is both individual psychotherapy, group-based skill treatment, 24 hours/7 day a week coaching by phone, as well as a therapeutic group for the therapists to collaborate and discuss cases that is very intense wrap-around service for those individuals who are at greatest risk for non-suicidal self-injury and suicidal ideation. 

So we try to provide a comprehensive, multi-level system of care to be able to contain and provide assistance for those individuals who have mood or anxiety problems and provide continuity from the start of them entering treatment to when they're able to be independent. 

Dr. Mike Patrick: That's great. Great work. We have lots of links for folks that we'll have in the Show Notes over at PediaCast.org for this episode. It's Episode 350. We'll have links to the Mood and Anxiety Program, Behavioral Health here at Nationwide Children's, the podcast that we did on teen suicide. That was Episode 315. Also, the one we did on teenage self-embedding, that was Episode 187. It's been a little while but still good information. 

And then, one of the programs that we did on Continuing Medical Education for providers dealt with treating depression and anxiety. But I think that parents who want to learn more about that especially if your kids are being treated for depression or anxiety, you may find that interesting. I'll put the link in the Show Notes there — also, the Kristin Brooks Hope Center, the Jason Foundation, some things that we talked about when we did the teen suicide podcast. And, of course, the National Suicide Prevention Lifeline and National Hopeline Network and phone numbers for you in case you don't have any local resources immediately at your disposal and you're facing a family emergency with regard to that. 

0:52:10

So thanks again to our listeners who wrote in their questions, Beth in Florida and Jackie in Pennsylvania. And, of course, Dr. Raymond Troy, child and adolescent psychiatrist here at Nationwide Children's Hospital. Really appreciate you taking time with us today.

Dr. Raymond Troy: It was a pleasure, thank you for having me. 

[Music]

Dr. Mike Patrick: All right, we are back with just enough time to say thanks to all of you for taking time out of your day to make PediaCast a part of it. Really do appreciate that.

Also, thanks to our guest, Dr. Raymond Troy, child and adolescent psychiatrist here at Nationwide Children's Hospital. And, of course, thanks to our listeners who wrote in and sparked the conversation on this particular topic today — Beth from Florida and Jackie from Pennsylvania. We really do appreciate both of you taking time to write in. I'm sure there are a lot of listeners out there who were able to get a lot out of this episode. And I'm not sure that this episode would have existed without the two of you writing in with your questions. So thanks so much for doing that. 

If you have a question for me, and I'm sure you probably do, it's easy to get in touch. Just head over to PediaCast.org, click on the Contact link and ask away. I read each and every comment that comes in that, by that particular mechanism. We also have a Skype line. You can call 347-404-KIDS, 347-404-5437 and you can leave a message that way as well. 

That's all the time we have today. PediaCast is a production of Nationwide Children's Hospital.

0:54:06

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And then, there's the landing site, PediaCast.org. You'll find hundreds of past episodes, all the way back to number one. We have all of our Show Notes, our transcripts, our terms of use and a handy contact page, as I've mentioned previously, to ask questions and suggest show topics.

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Of course, we always appreciate you talking us up with your family, friends, neighbors and co-workers, really, anyone with kids or those who take care of children, including your child's healthcare provider. In fact, next time you're in for a sick office visit, maybe it's well check-up or a sports physical, medicine recheck, really whatever the occasion, let them know you found an evidence-based pediatric podcast for moms and dads. Evidence-based, make sure you point that part out. 

We've been around for nearly a decade, so tons of content, deep enough to be helpful but in language parents can hopefully understand. That our goal.  

And while you have your providers ear, let them know we have a podcast for them as well — PediaCast CME, which stands for Continuing Medical Information. It's similar to this program. We turn up the science a couple of notches and provide free Category 1 CME Credit for listening. Shows and details are available at PediaCastCME.org. 

0:56:30

We also have posters, if you like to share the show the old-fashioned way. That works, too. Those are available under the Resources tab at PediaCast.org. 

Thanks again for stopping by, and until next time, this is Dr. Mike, saying stay safe, stay healthy, and stay involved with your kids. So long, everybody. 

[Music] 

Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.

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