Therapy Space with Dr. Sara

I am noticing abrupt emotional and behavioral shifts in my daughter since she started middle school. I don’t know if this is just expected behaviors for her age or if they are warning signs. What are some warning signs of mental illness I should be looking for? How can I help her?

It is important that you are taking note of these changes and not just ascribing this to a “middle school phase.” One in five children in the US shows signs of a mental disorder. In addition to these symptoms, I would recommend first familiarizing yourself with developmental changes for her age group. There are important developmental shifts occurring, and in fact, this recognition is what initiated the creation of middle schools in the first place. 

Middle school students seek independence from their parents. They are gaining autonomy, seeing themselves as individuals, which can foster insecurity in the search for acceptance and contact with their sense of vulnerability. These kids have limited control over physical changes as hormones shift and puberty begins. When am I going to get my period? Wear a bra? Get pimples? We think, “Well, everyone has to go through it,” but when you stop to think about it, their bodies are preparing for what is seen as the most important evolutionary task. In addition, hormones are having a direct impact on the brain, stimulating the limbic system and portions responsible for emotions. However, the prefrontal cortex, responsible for impulse control, planning, and regulating these emotions is underdeveloped. Students at this age are more likely to test rules if they appear arbitrary or do not appear to impact anyone directly, and so “their behavior often falls in a moral gap between the fidelity to the rules they showed as young kids and the more complex moral reasoning they develop in their later teens” ( Studies have shown that ultimately middle schoolers are likely to make decisions that align with their morals over decisions that align with societal conventions or the rules. In-person discussions that raise awareness of the invisible impact decisions may have on others offer students insight into why seemingly arbitrary societal conventions were established.

Next, the signs of mental illness: (Mayo Clinic)

  • Mood changes. Look for feelings of sadness or withdrawal that last at least two weeks or severe mood swings that cause problems in relationships at home or school.

  • Intense feelings. Be aware of feelings of overwhelming fear for no reason — sometimes with a racing heart or fast breathing — or worries or fears intense enough to interfere with daily activities.

  • Behavior changes. These include drastic changes in behavior or personality, as well as dangerous or out-of-control behavior. Fighting frequently, using weapons and expressing a desire to badly hurt others also are warning signs.

  • Difficulty concentrating. Look for signs of trouble focusing or sitting still, both of which might lead to poor performance in school.

  • Unexplained weight loss. A sudden loss of appetite, frequent vomiting or use of laxatives might indicate an eating disorder.

  • Physical symptoms. Compared with adults, children with a mental health condition might develop headaches and stomachaches rather than sadness or anxiety.

  • Physical harm. Sometimes a mental health condition leads to self-injury, also called self-harm. This is the act of deliberately harming your own body, such as cutting or burning yourself. Children with a mental health condition also might develop suicidal thoughts or attempt suicide.

  • Substance abuse. Some kids use drugs or alcohol to try to cope with their feelings.

Take note of what you are observing with your daughter - the frequency and types of changes, the identifiable triggers. For example, if she is irritable, is it before school or after school? Does she avoid some friends, but not all? Your daughter spends a lot of time at school. It will be helpful for you to get a sense of the overall school environment, socially and academically. Is your child being stimulated by the social and academic demand or feeling overwhelmed? This is a time in life when their brains are programmed to seek social input, think and debate, act on desires, express ideas and feelings on a larger scale (note the increase in marches and walk-outs,) resolve conflict, use artistic expression, understand their bodies, feel passion, and seek out topics that are emotionally stimulating. Feeling emotion leads to metacognition – the awareness and understanding of one’s own thought process. Remember that this can be an exciting time in your daughter’s life where she can find her voice and use it for good. The hope is that her school environment provides these opportunities. You can check with teachers to find out about strategies used at school to give students healthy expressive outlets. A beneficial opportunity would be student involvement in establishing the classroom expectations. As described earlier, students are more invested when they understand the reasoning behind rules and it aligns with their own moral beliefs.  

Set aside some time to talk with your daughter to share some of your observations. This may feel anxiety-provoking, therefore strategize ways to manage your stress, as she may sense your anxiety and try to pacify you or assume something is wrong with her. Be conscious of timing, finding space when she is not agitated or overwhelmed. Set intentions. What are your hopes and expectations for this conversation? The goal is not to seek confirmation that she is “fine” in order to move on. Rather, you want to set the stage for future conversations, confirming that you care and can tolerate uncomfortable emotions or topics. She may not have the language to openly describe her feelings or experiences. When you offer suggestions, check-in with her and ask, “Does that seem right?” Normalize her experiences and the developmental, physical, and cognitive shifts occurring. It may be helpful at some point to share some of your own emotional experiences when you started middle school. Be gentle and direct. You can share some of your observations and concerns. Follow her lead. She may need reassurance from you about her strengths and the qualities that you love about her. Middle school can be tough, we all know that, and she will need to connect with people who know her best and love her and see all of her beautiful qualities without her having to prove herself.

You didn’t mention the behaviors that you have observed, so I can’t speak to the red flags. However, if they align with the list or if during your discussion with her there are immediate concerns regarding self-harm and suicidal thoughts, it will be important to get help as soon as possible. The National Alliance on Mental Health has a Marin County branch that responds to emergency mental health crises. If you feel there are non-crisis concerns, there are many helpful resources. If it feels appropriate, utilize a team approach. The school, her pediatrician, a therapist can all provide different types of input and support, while working together to ensure continuity of care. Early treatment is most effective. If you decide to have your child see a therapist, include her in the process of choosing someone. She can read professional bios online (one option is Reiterate that she can follow her intuition and find someone who feels like a good fit. Also, remember to prioritize your own self-care and mental health. I am a huge proponent of all parents having a resource that feels non-judgmental and supportive.

Best of luck!

The Misunderstood Middle Schooler

Mental illness in children: Know the signs

Middle Schools: Social, Emotional, and Metacognitive Growth

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Dr. Sara Edrington is a clinical psychologist practicing in San Rafael. She is passionate about her work with adults, adolescents, and couples, using an interactive approach that explores neurobiology, shame, trauma, relationships, parenting and managing stress during life-transitions. She facilitates a group for Toddlers and Parents, encouraging socialization, narrative play, and educational support for the parents. 

She received her Doctorate in Psychology in 2005 at the Los Angeles campus of CSPP. She holds a certification in early childhood education, has presented at several high schools, and works to bring learning outside the classroom through community service, which has enhanced her own personal and professional growth. She is the proud mother of a spirited daughter and son who keep her on her toes, even when everyone should be sleeping.

She accepts PPO insurances. For information about individual services or the Toddler/Parent group, she can be reached at: 415-690-8208 or