Welcome to the first of many Q & A episodes where I answer your questions!
Our first question is from Gina,
“My 13-year-old daughter is struggling with anxiety and mood issues. It seems to be worse the past year and a half. She seems to be anxious about school work, her relationship with her friend, and bad things happening to us (her parents). She’s spending a lot of time in her room, has decided not to eat meat, and seems tired and out of touch. She saw a counselor before COVID and seemed to find that helpful. What should I do?“
In the episode, I break down some observations and helpful tips into these categories normal teen behavior, anxiety symptoms and triggers, sleep, nutrition, and counseling. These kinds of questions are very common in my practice and so I think this episode will resonate well with parents of tweens and teens. Tune in each week for more Q & A episodes!
You can submit a question by emailing us at email@example.com with the subject line “Podcast Question.”
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13 Yr old Daughter struggling with anxiety and mood issues
- Prone to anxiety from a young age
- Particularly anxious the past year and a half
- Something bad happening to her parents
- Worries that friends are mad at her
- On her phone a lot
- Yawns a lot during the day
- Complains of being tired
- Wants to try vegetarian and vegan like her friends
- Counseling off and on over the years sometimes it seems to work
- This is an age where there are mood fluctuations and peer issues
- Recognize that the pandemic has been really hard on teens
- They need their friends and a social life
- Try not to discount the normal developmental process
- It means they are growing up
What to do about the anxiety symptoms
- Keep lines of communication open and try to stay casual
- Let her know you are making observations and you are there to support her
- “Seems like you’re tired, I wonder what’s going on?”
- Try to have some positive interactions with her
- Watch a movie, go to the store to check out something she’s interested in
- Phone use is a big issue for teens
- They run into issues with social comparison when spending time scrolling and observing other people’s lives
- This can cause a lot of self-doubt and self-confidence issues
- One thing to observe is phone use and screen time in general and how that aligns with her mood or level of anxiety
- Ask her what she notices about mood and anxiety after time spent on her phone
- Limits and boundaries are necessary so that they can use phones and screen time in a healthy way
What to do about issues related to sleep
- Teens are in a rapid physical and brain growth phase during this time
- Staying up late and waking up early for school takes a major toll on their mood, anxiety, focus
- A helpful rule that will ensure teens get enough sleep at night is – no devices in the room at night
- Ask if there are things that are keeping her from falling or staying asleep
- Monitor caffeine intake after lunchtime
What to do about nutrition
- Many of the issues described signal possible insufficient or suboptimal Iron levels
- Eating less meat can cause iron to be low along with other minerals
- If labs come back showing low iron, there are ways to correct that through diet and supplementation
- Diet is key here. Many teens who try a vegetarian or vegan diet often don’t know how to incorporate nutrient-dense foods into that diet to balance it out and support their brain function and mental health
- Stabilizing blood sugar is another important part of the diet that can have a big impact on energy levels and mental health
- Consider a high-quality multivitamin
- Vitamin D, magnesium, amino acids are all good considerations as well
What to do about counseling
- Counseling can be very beneficial for teens
- A third party person that they can trust and open up to, helps them talk about their feelings and work through the hard parts of being a teen
Connect with Dr. Nicole Beurkens on…
Episode Intro … 00:00:30
Question about anxiety … 00:01:00
Considerations … 00:04:30
What to do about anxiety … 00:08:30
What to do about sleep issues … 00:11:30
What to do about nutrition … 00:14:30
What to do about counseling … 00:21:25
Episode Wrap up … 00: 23:00
Dr. Nicole Beurkens:
Hi everyone, welcome to the show, I am Dr. Nicole, and today, I’m starting a new type of episode where I answer a listener question. I get so many questions each week, and I thought this would be a great way to provide answers that many of you might find helpful. These are going to be shorter episodes around a specific question. If you have a question you’d like me to consider answering on a future episode, email it to firstname.lastname@example.org, and you just might hear it on an upcoming show.
Now, onto today’s question from Gina. Gina writes: “Hi Dr. Nicole. My daughter is 13 years old and really struggling with anxiety and mood issues. She has always been prone to anxiety since she was in preschool, but it’s really ramped up over the last year and a half in particular. I’m sure the pandemic has something to do with it, but honestly, she really isn’t anxious about COVID or getting sick or those kinds of things. It’s more that she always seems to be keyed up about something and is anxious about things like making mistakes on schoolwork, getting bad grades, something bad happening to me or her dad when we’re away, and she gets really distressed wondering if one of her friends is mad at her. She started spending a lot more time in her room alone with her phone and resists coming out to do things with the rest of the family. She yawns a lot during the day and complains of being tired, even though I feel like she’s getting enough sleep.
A few months ago, a couple of her friends began talking about vegetarian and vegan diets and so she has kind of been on a kick of not wanting to eat meat as a result. Seems like one more thing to fight about for her to eat anything healthy at meals. I also wonder about hormone changes, as she got her period about a year ago, and I know there can be some mental health issues with that. We’ve had her in some counseling off and on over the years and that seems to help a bit, although I don’t really know what goes on in the sessions. She said in the past it’s good to have someone to talk with about things. We’re on the waiting list to get her back in, but it’s been slow because of the pandemic. I’m looking for any advice you might have on how we can help her feel better in general. Are there things we should be doing with nutrition or something else? Thanks for any suggestions you can provide.”
Well, Gina, these are great questions and you provided a lot of helpful information here to have some background, so I think there are lots of things that we can dive into that may be helpful. First of all, I want to just start by talking about the fact that at these preteen and teen ages, there certainly can be developmentally normal mood fluctuations, peer issues, all of those things that can happen. So we don’t want to discount the normal developmental process in adolescents and even kids in those preteen years. Those are sort of par for the course, and it means that they’re growing up and we know that there can be hormone changes, there certainly can be shifts in anxiety and mood and those kinds of things. And any of us who remember what it was like to be a preteen or teen or certainly those of us parenting them know that that’s a real thing. But what you’re talking about, it sounds like, is that you’ve noticed that things with your daughter go beyond just those normal mood and anxiety and behavior fluctuations with kids at that age, so it is important to delve into that a bit more. I just want to make sure that we’re all thinking about the fact that a certain amount of this is typical for this age group, and we also do need to recognize that with the pandemic, over the last year, there are especially issues with those kinds of things.
And we know studies and surveys are showing that our teens have been hit the hardest in many ways by what has gone on with the pandemic, because they’re in this developmental phase where their relationships are so important to them outside of the home, with friends, their school activities, being able to do social things. So a lot of their normal healthy coping outlets have been taken away. So it’s been a tough time for teens in general. So we certainly want to take all of that into account. That being said, let me give some suggestions of things that could be helpful to consider for you, as well as for all of the rest of you who are parenting kids in this age range and with these kinds of struggles.
First, it’s important to keep lines of communication open. This can be a real challenge, especially with a teen who is not wanting to leave their room, and a lot of teens aren’t really wanting to talk to us as parents too much when they get to this age range. So it’s certainly understandable that it’s a challenge, but we want to do our part to keep lines of communication open and to let our kids know that we are making observations about them, that we want to be helpful with and that we’re there to support them.
So it’s important to not force conversation, to not approach it in a way that makes kids feel like we’re backing them into a corner or making them talk with us about what’s going on. We want to keep it kind of casual and nonchalant, but we do want to make some statements about what we’re observing, like, “Wow, seems like you’re tired all the time. I wonder what’s going on with that?” Or “Boy, you seemed really distressed after you talked to your friend on the phone, let me know if there is anything I can do to help.” Just some comments and statements like that let our kids know that we’re aware of what’s going on with them, that we care, and that we want to be available to them as a resource, but we’re not forcing it on them. So that’s really important. And I should say that certainly, there are times when we do need to sit our kids down and force a conversation. Certainly, there can be times for that, but in general, we want to approach it a little more openly, a little more lightly, just to let them know that we care and that we’re there.
The other piece in the big picture with kids at this age, is even when they seem like they don’t want to spend any time with us, and they roll their eyes and they don’t want to do things with the family, or they seem to want to do everything that they can to stay away from us — really, they do still need us, and they know that. That’s part of this push and pull at this adolescent phase of development, especially for, this is a 13-year-old girl, she’s becoming aware that she wants to be independent, she wants to not need mom and dad, she wants to sort of do her own thing and be in charge and be able to manage things, and at the same time, she knows that in many ways, she really can’t yet, and she does still need mom and dad, and she does still need support and security and guidance and all of that. So this is sort of that push-pull that we can experience with kids at that age range and as a parent, it can feel a bit like whiplash, right? Like one minute they’re pushing us away, they want nothing to do with us, the next minute, they’re curling up next to us on the couch, wanting us to be there with them. So that’s normal in this phase of development. It can be challenging for us to manage as parents, it’s really important for us to manage our own emotions and try to stay steady and even-keeled for them during these times.
So I think that it is important to make some observations, put some things out there, let your daughter know that you’re there to support, and try to have some positive interactions regularly. That may mean sitting down to watch a TV show or a movie together that she chooses. It might mean just out of the blue, sometimes saying things like, “Hey, let’s go grab some ice-cream” or “I have to run some errands, why don’t you come to Target with me, and let’s check out that book that you wanted to look at.” Just something that is positive that lets your daughter know that you want to spend time with her, that you enjoy her, and that will allow for a positive interaction.
So those are some overarching general things. Now some things that stand out in the information that you gave and are worth considering when it comes to the mood and anxiety issues that you’re noticing. The first thing that I want to comment on is phone use. This is a big issue with teens, especially, around how much time they’re spending on their [phone and the quality of activities that they’re doing on their phone, because it’s not just about time, it’s also about what they’re doing and how they’re using it. And we know from the research that girls, especially, at this age — boys too, but girls especially, who are spending a lot of time on social media, whether it’s things like Instagram, Snapchat, it can be TikTok, it’s less likely to be Facebook for kids of this age, at this point, but any of those kinds of platforms- we can run into a lot of issues with social comparison, with endlessly scrolling and looking at everybody else’s life and developing a negative self-image, a negative vision of themselves appearance-wise, the activities that they’re involved in, who they are as a person, and we know that that can especially have a detrimental effect on preteen and teen girls.
So I bring up this issue because you mentioned that your daughter is spending a lot more time on her phone and a lot more time alone in her room on her phone. So one thing to look at is phone use and just screen time in general as it might be related to her mood and anxiety level, and looking at how much she is using the phone. Is that crowding out other activities and things that would be healthier and helpful for her? What is she spending her time on? Is it maybe some things that are creating worse mood or anxiety issues? So I would really look at that and I would talk with her about that. What she notices with that, and just make some observations to her.
If she’s spending a lot more time isolated in her room on social media or doing things online that are detrimental, you’re going to want to put some limits and boundaries around that, that’s really important. We want to give kids, certainly an opportunity to use technology and to engage in social interaction with it, but they also still need guidance and boundaries from us to do that in a healthy way. Because the research so clearly shows that screen time can be connected to these issues in kids, I would encourage you to look at that. And if you don’t already have limits in place for screen time use, if you aren’t using some kind of parent monitoring software of a program or an app or even the screen time tools that come on your daughter’s device, I would highly recommend that, sitting down and talking about what you feel is going to be healthy, and then implementing some of those limits. She’s not going to be happy about that, but ultimately, what we’re doing there is helping kids learn how to use devices in a healthier, more adaptive way , developing healthy habits for that, and also, there can be safety issues too. So that’s the first thing to think about.
The second thing is you brought up some issues related to sleep, and I’m glad that you did because sleep, for children and teens is very connected to mood, to anxiety, to focus and attention, to all of those aspects of mental health. Teens are in a phase of rapid physical and brain growth and development, and they need even more sleep. Children in general need more sleep than adults, but teens go through this phase of really needing more sleep, wanting to sleep in, and that’s because of this rapid phase of growth and development that they’re in. So when they’re not getting enough sleep as can happen when they maybe are staying up really late and then they have to get up early for school, they can easily become sleep-deprived, which takes a major toll on their mood, on their anxiety, on their focus, school performance, all of that.
So look at what’s happening with the sleep. You notice that you’re seeing her yawn a lot more, she’s complaining of being tired. I would definitely prioritize improving the sleep situation. That might include no devices in the room at night, if that’s not already a rule. It is a hard and fast rule for me in my home as well as professionally with families I work with: No devices in the room at night. And that is for safety as well as — you know when kids have devices, like she’s got her smartphone in there, notifications could be waking her up, she might be staying up later than you think, maybe she’s got a friend texting her or Snapchatting her in the night and it’s waking up her up, and then she’s engaging in drama with friends and that’s impacting sleep. I hear all of these kinds of things from the kids that I work with. So don’t assume that if she has her device in there, she’s not using it. And for safety and health reasons, no devices in the room at night.
Talk with her about her sleep: How’s that going? Is she noticing that she’s having trouble falling asleep, or is she waking up more or having nightmares? Is there something uncomfortable environmentally in the room? Talk about that and see what can be done there. Monitor caffeine, that’s another thing for teens. Sometimes they get into drinking coffee or more soda or even teas with caffeine in them, so you want to make sure that if she is struggling to fall asleep that she knows about the connection between caffeine and sleep and is limiting that, especially after lunchtime, not having that, the recommendation is not later than 2 PM. If she’s struggling to fall asleep or her mind is racing, there are helpful sleep story apps, there are mindfulness and meditation apps, lots of those kinds of things that she can do on her phone or another device, and then the device can either be shut off by you, using screen time or parental controls, or the device can be placed in another room. So definitely looking at what’s going on with the sleep. Now, connected to that, in terms of noticing she’s more tired, she’s complaining of fatigue, it’s important to look at her iron levels. A few things in what you wrote that stand out to me that make iron something that I’d want to look at here. First of all, when girls and women are getting their period, they tend to be more prone to iron deficiency or even anemia because of the blood loss through having her period.
Now, I don’t know how heavy her periods are or what’s happening there, but it is a frequent issue for girls, and if you’re noticing that she’s more fatigued, it could be related to getting her period, so that’s one thing that stands out that says to me that we should look at an iron level. The other thing is just the complaints of fatigue, feeling more tired, also the mood and anxiety issues, those can also signal suboptimal or deficient iron levels. You also mentioned that she’s been eating less meat. She’s been kind of experimenting with this idea of vegetarianism or what her friends are talking about with being a vegan, and that she’s been more resistive to meat. That can also cause a person to become low, not only in iron, but other essential vitamins and minerals, so that can be an issue there.
So iron is a simple thing to look at. You want to talk with her primary care provider about getting an iron panel blood draw. Blood draw is not anybody’s favorite thing to have done, but in my experience, we can get them done with kids and teens one way or another. We get them done, and that’s really important because of the symptoms that you’re noticing here. If the iron comes back showing that she either has a suboptimal level of iron, or is actually clinically deficient or anemic, then there are specific strategies to look at there in terms of diet, but also supplementation to get those levels up, and that will make a big difference. So that’s something I would definitely look at. Then sort of staying in the realm of nutrition, thinking about the diet pieces. This can be really tough with teens, because we always, with any kid, want to strike a balance between talking about diet and food intake in a way that is supportive and healthy and that doesn’t drive them into any kind of disordered eating patterns or anxiety around food.
It can also be tough, because you know, as I mentioned earlier, teens are wanting to exert their independence and have more control and make their choices, so it can be a challenge, but I put it out there because it is something to consider, and to be talking with her about and providing some education. It sounds like she’s not eating a lot of nutrient-dense foods and she is avoiding meat. Those can all be a big factor in mental health changes, especially in those teen years when kids are not eating enough nutrient-dense foods, when they’re tending to more of the processed kinds of foods that aren’t very nutrient dense and she’s not eating much meat or any meat in her diet, we can get big changes because they’re not getting the amino acids that they need to produce neurotransmitters. Amino acids are in proteins, particularly in animal meats. They’re not getting the B vitamins that are needed to run lots of processes in the brain and the body, including those neurotransmitters for things like serotonin and dopamine and those types of things, not getting enough iron, not getting enough magnesium, all of those kinds of things.
I notice a big issue when I have teens and young adults who come in and they have suddenly decided to try a vegetarian or vegan diet and they’re not doing it in what we would calla nutrient-dense healthy way, because certainly there are ways to do those diets where you are getting enough protein and enough of the nutrients that you need, but even then, people with a very healthy, nutrient-dense vegan diet often need to supplement with certain B vitamins, may need to supplement with some iron, but often, kids aren’t doing this in a healthy way, so they just cut all of these essential protein sources out of their diet, they’re not eating enough nutrient dense vegetables, they’re not getting enough whole grains, and that really creates issues, and I see that frequently in my practice, of kids who come in and now suddenly, they’ve developed pretty acute depression, anxiety, even some more significant kinds of mental health things, so we really want to look at the diet piece there and do some education around that in trying to move towards getting enough protein or if they’re absolutely not going to eat meat or incorporate more nutrient-dense foods in their diet, then we need to look at supplements.
From a food standpoint as well, trying to stabilize blood sugar, that’s a big one, again, educating about the connection between the kinds of foods that we eat and our mood and anxiety levels, talking about how we’re feeling when we’re eating a bunch of sugary foods versus things like fruits and vegetables, talking about healthier, more blood sugar stabilizing snack options, having those things available in the house, I always tell parents especially with the teen age, you want to control what you can within the house, so making lots of healthy, nutrient-dense options available and not purchasing things that you don’t want them eating, but you don’t try to micromanage and control what they’re doing outside of the house, because that just creates power struggles and that’s going to end up making things worse. But you can control what you have in the house and what you’re making available and incorporate her feedback in terms of what she’d like to have available and what she might like to try, maybe she can even go grocery shopping with you.
From a supplement standpoint, again, if she’s not open to incorporating more nutrient-dense foods or that’s going to be a challenge, or even if she is open to it, it could be very beneficial to consider a high quality multivitamin to get those basic nutrient levels covered could also be beneficial to test for vitamin D status if you’re going to go to the pediatrician or primary care physician and get an iron panel done, ask for vitamin D as well. Vitamin D status is very related to mood and anxiety and just general wellness for kids and adults, so if that is low, you will definitely want to give a vitamin D supplement to help boost those levels. Magnesium as a supplement can be very helpful for supporting a healthier stress level, reducing anxiety, and even helping with the sleep. So looking at magnesium can be helpful there. Then we might also consider some amino acid types of supplements, sometimes tryptophan or 5HTP or something like Gaba Calm can be helpful. Those are some of the types of nutrients that I’d be looking at or supplements that I’d be looking at to use that can be supportive of balancing mood, reducing anxiety and those kinds of things. So that gives some areas to look at there, based on what you shared about your daughter.
And then, lastly, I would mention about the counseling, I think it’s a great idea to restart that. It can be very beneficial for helping kids to have a third party, not a parent or someone involved in their day to day life to get feedback from, to vent to, to get support from in processing all of the big feelings and things that come along with being a teenager. Kids at that age are more likely to open up to someone that they trust that isn’t directly involved in their lives, so I think that’s a great idea. And the focus in those counseling appointments aside from processing those feelings and things that are going on, should really be about teaching and developing healthy coping skills, whether that is teaching some mindfulness strategies, working on cognitive behavior therapy kinds of techniques, relaxation training and breathing, counseling should always be strategy-driven in terms of tools and things that your child is learning that they can then take and practice outside of sessions. If your daughter is just going to counseling and it’s basically 45-50 minutes of sitting and chatting, while that may help her to feel better at the moment, she’s not learning tools. So it should be working with a counselor who is able to build rapport and a trusting relationship and have that feedback and that good processing and discussion, while also teaching skills and giving things for your daughter to be practicing. And you should be involved in that too. Not necessarily sitting in on the sessions, but there should be communication between you and your daughter’s therapist about what they’re working on and the tools that she’s learning and how you can be helpful with utilizing or encouraging the practice of those. So I think that that’s a great idea. There are also lots of apps available that can be helpful for kids at this age for developing mindfulness kinds of skills, working on their breathing and all of those kinds of things. So those may be helpful to look into as well. So those are the main things that stood out to me, Gina, from your questions and I hope that it’s helpful for you as you think about ways to support your daughter. I hope that this information and insight is helpful to all of you who are looking at supporting a child with anxiety and mood symptoms. Remember, if you have a question that you would like to hear answered on a future show, go ahead and email it to us at email@example.com. Thanks as always to all of you for listening, and I’ll catch you back here next time.