How Do You Know When Your Teen’s Warning Signs are Really Red Flags?

By Jan Hamilton, Founder, Doorways Teen Counseling and Psychiatric Services Phoenix ArizonaJan Hamilton, MS, PMHNP-BC


For parents with children who are suffering from a mental illness, it can be very difficult to know when their child’s problems are typical and manageable, and when those problems begin to endanger other people.

There are warning signs you can watch for if you are concerned that there may be something going on with your child that might endanger themselves or others.  Here are four tips parents can use in these difficult situations.

1.     When Something Feels Off, Pay Attention

As parents, we know our children better than anyone and the most important thing you can do is to trust your instincts.  If something feels off, check it out.  If your child’s behavior seems to change overnight or they suddenly stop participating in things they used to enjoy, talk to them and don’t stop talking and listening until you find out what is going on.

2.     Challenges with Peers

Often times, the peers of teens who act out in dangerous ways or harmed their families also sensed something was off or strange about them.  If your child is having difficulty interacting with their peers, getting bullied, or having trouble fitting in with others in their age group, seek a second opinion.  Often, as parents, we are too close to form an objective opinion about whether our child is struggling to fit in because they have some social anxiety, a few extra pounds, or braces and when their peers avoid them because they sense they are anti-social, odd, or dangerous.  Someone outside the situation can provide valuable insight into what is normal and what needs immediate attention.

3.     Keep Lines of Communication Open

One of the biggest challenges every parent faces is keeping communication going when times get tough.  Often, the times when our children need us the most are also the times they are least likely to seek our counsel or ask for our help.  Create safe spaces for your child to open up about things you don’t approve of so that they don’t let small problems become life-altering situations simply because they didn’t want to get in trouble.  Remember that communicating is a two way street and that you need to listen at least as much as you talk.

4.      No Such Thing as Perfect Parents

Remind yourself that there is no such thing as perfect parents or perfect children.  Be the best parent you can and provide your children with a solid foundation, room to learn to make mistakes, and opportunities to make decisions, even bad ones.  Be there for them in whatever ways you can when they falter but remember that they have free will and they are going to make their own choices.  Even amazing parents can have children who make very bad choices.   But, the opposite is also true, even when parents seem to do everything wrong, most adolescents turn out to be amazing, wonderful adults!


Jan Hamilton, MS, PMHNP-BC

Jan is a nationally Board Certified Psychiatric Nurse Practitioner who specializes in adolescent treatment.  She earned her Master’s of Science and Psychiatric Nurse Practitioner certification through the University of Arizona. She then worked for over eight years at Remuda Ranch providing inpatient services for adolescents and adults suffering from eating disorders. Jan has been a registered nurse for 31 years and worked in a wide variety of medical settings, including 30 years of serving young people through her work with Young Life, an interdenominational outreach program. Her desire to provide quality psychological and psychiatric care for adolescents and young adults in an outpatient, faith based setting has led to the opening of Doorways in 2008.

What Is “Normal Teenage Behavior” Anyway?

Normal Teenager Behavior

If you’ve ever wondered if the things your teen does is normal, read more to find out. (photo credit:

One of the things we strive to help the parents in our community to understand is the signs and symptoms that their teenager is struggling so that they know when it is time to get help.  But one of the challenges every parent faces is to know when their teenager’s behavior is “normal” and when it is a red flag.  To help, let’s look at what constitutes normal behavior in teens.

1.     Normal = Typical

At a general level, the first step to determining if the behavior of your teenager is normal is to look at their friends and at other teenagers their age.  Is their behavior comparable?  Does your teen act moodier or more defiant?  Ask the other parents you know with similarly aged children about their experiences to help you form a baseline of how typical teenagers today act.

2.     My Normal May Not Be Your Normal

With a better idea of how other teenagers are behaving, you can now take an objective look at your own teen.  At this point, you need to factor in things like their individual personality.  For example, if your child has always been more on the shy and quiet side it wouldn’t be abnormal for them to be quieter and more shy than others in their peer group or social circle.  If your child has always been a bit of a risk taker, it isn’t necessarily a red flag that he is participating in risky activities like skateboarding.  You can use your knowledge of your child at the different stages of their life to get a feel for what normal would be for them.

3.     Normal Exists to a Certain Degree

Another challenge parents face in determining if their child’s behavior or attitude is normal is that normal to not normal exists on a sliding scale.  Being moody or defiant one day a week might be normal whereas being moody and defiant all the time is usually a red flag.  Understand that even a small amount of acting out generally falls within the range of normal, especially for teenagers.

4.     Being Bad Isn’t Normal

One of the things you can always consider when trying to determine if your teen’s behavior is normal or not is the degree to which what they are doing is interfering with their lives.  Skipping a single day of school isn’t good but it isn’t going to jeopardize their education.  Skipping school all the time interferes with their ability to learn and will lead to serious consequences.  Getting pulled over for going a few miles above the speed limit isn’t good but it isn’t inherently dangerous or destructive like driving 100 miles an hour or racing against other cars.  Every teenager tests rules and steps over lines, but if this is the norm rather than the exception, you are outside the range of normal.

The key to making sure your child has whatever support they need to succeed is to seek out the opinion of a professional if you are concerned.  A mental health practitioner, tutor, pediatrician, or coach can offer their advice on what your child needs to excel and how you can help them.

Doorways Now Accepting New Patients in Intensive Outpatient Programs

A Note from Jan, Founder of Doorways:


I am excited to let you know that we are now accepting new patients for our Intensive Outpatient Programs at Doorways!

These programs are highly successful as they offer an intensive, therapeutic approach to meet the individual’s needs.

We are also contracted with Blue Cross Blue Shield and United Behavioral Healthcare for our IOP’s. 

If you know anyone who may benefit from one of our specialty IOP programs listed below or would like to register, please give us a call at (602) 997-2880. We would love to help!


Doorways Celebrates National Nurse Practitioners Week, November 10-16, 2013

logoUnder proclamation by Governor Jan Brewer, Arizona officially recognizes National Nurse Practitioners Week on November 10-16, 2013. There are more than 150,000 licensed Nurse Practitioners in the United States, with over 5,000 Registered Nurse Practitioners in the state of Arizona!

Nurse Practitioners see over six million patients annually in the United States, providing patient-centered, high-quality healthcare. Doorways, LLC is proud to have three Psychiatric Nurse Practitioners on staff, specializing in the care and treatment of adolescents and young adults. These core members of the team truly have a passion for improving the lives of young people and helping them on the road to healing. Without their heart for service and commitment to providing the best patient care, Doorways would not be what it is today.

Jan Hamilton is the Founder and Owner of Doorways. She is a Nationally Board Certified Psychiatric Nurse Practitioner who specializes in adolescent treatment. Jan worked as a registered nurse for 20 years prior to receiving her Master’s degree in Nursing from the University of Arizona and her Psychiatric Nurse Practitioner certification in 1999. Her desire to provide quality psychological and psychiatric care for adolescents and young adults in an outpatient, faith-based setting led to the opening of Doorways in 2008. She’s thrilled about the opportunity for teens, young adults and families to receive the best care possible on their journey of healing!

Laura Ross, MSN, FPMHNP-BC,  a Family Psychiatric Nurse Practitioner, graduated from Case Western Reserve University with a Master’s in Nursing and is a nationally Board Certified Family Psychiatric Mental Health Nurse Practitioner. Laura practices from a holistic perspective incorporating non-pharmacological treatments and family involvement in her care.

Wayne, MacKenzie Sr. RN, BSN, MSN, PMHNP-BC is the newest addition to the team at Doorways.  Also a graduate a Case Western Reserve University, Wayne is a certified Family Mental Health Nurse Practitioner. He enjoys working with young people and being on staff at Doorways.


National Nurse Practitioner Week celebrated Nov 10-16

Nurse practitioners provide more than 155,000 solutions to the health care crisis

National Nurse Practitioner Week celebrated Nov 10-16


As the health care provider shortage continues to top the national agenda, it is important that the public be aware that there are more than 155,000 nurse practitioners (NPs) in the United States who provide high-quality, cost-effective, comprehensive, patient-centered care to patients across the country.


NPs are licensed, expert clinicians with advanced education (most have master’s and many have doctorate degrees) and extensive clinical training who provide primary, acute and specialty health care services. In addition to providing a full range of services, NPs work as partners with their patients, guiding them to make educated health care decisions and healthy lifestyle choices. The confidence that patients have in NP-delivered health care is evidenced by the more than 600 million visits made to NPs every year.


NPs are informed regarding the unique concerns of diverse patient populations and in touch with the needs of each individual. Through a partnership with the American Academy of Nurse Practitioners (AANP) and Joining Forces (a White House initiative to raise awareness of the health care needs of veterans, active service members and their families), NPs are increasingly well-prepared to care for this important patient group.


National Nurse Practitioner Week, November 11 – 17, 2012 is a time to celebrate these exceptional health care providers and to remind lawmakers of the importance of removing outdated barriers to practice so that NPs will be allowed to practice to the full extent of their experience and education. Nurse practitioners are informed, in touch and involved, making them the health care providers of choice for millions and a solution to the primary care crisis in America.


Jan Hamilton, MS, PMHNP-BC is the Founder and owner of Doorways, LLC in Arizona. She is a Nationally Board Certified Psychiatric Nurse Practitioner who specializes in adolescent treatment. Her desire is to provide quality psychological, nutritional and psychiatric care for adolescents and young adults in an outpatient, faith-based setting. Doorways has been open for 4 ½ years and has seen significant growth as they address the needs in this difficult developmental time period of adolescence and young adulthood.


The American Academy of Nurse Practitioners (AANP) is the oldest and largest national professional organization for nurse practitioners (NPs) of all specialties. AANP represents the interests of approximately 155,000 nurse practitioners in the country and advocates for the active role of NPs as providers of high-quality, cost-effective, comprehensive, patient-centered and personalized health.

What is IOP?

Teen Advisory Committee-13

Doorways Arizona currently offers two ongoing IOP groups. (Photo credit: Vancouver Public Library)

To most people, there are two kinds of mental health treatment. First, there is inpatient treatment where you live at a facility for weeks to months and which includes treatment for chronic issues or addictions and secondly, Outpatient treatment, which is meeting with a group or an individual provider, typically once a week. Here at Doorways, we understand that there are times where adolescents and young adults need more than a weekly one on one with a therapist or other provider, but who don’t need to be in an inpatient program.  In an effort to fill this need, we developed an adolescent and young adult-specific Intensive Outpatient Program (IOP) that target specific disorders.

IOPs meet several times over the course of a week and participants are part of several different kinds of therapy each day.  These programs enable us to provide more comprehensive treatment options in the specific areas where a more intensive experience is warranted.

Doorways currently offers two ongoing IOP groups, the Young Adult Trauma IOP and the Adolescent Eating Disorder IOP.  These specialty groups each meet three days a week and have rolling, open enrollment.

The Young Adult Trauma IOP is for those ages 17-25.  The program requires 10 hours a week spread over a three day period.  Each week, attendees participate in the following different types of therapy and group sessions.

  • Art Group – These groups are designed to enhance and reinforce positive emotion.  Participation helps promote peace and calm.
  • Process Group – These groups help participants practice identifying and expressing emotions, learning to let go of shame, and how to build relationships with interpersonal skills.  By sharing their experiences, participants grow and learn to trust others.
  • Yoga and Mindfulness – This group uses yoga and mindfulness practice to increase participants’ awareness of thoughts, feelings, urges, and actions in an observational and non-judgmental way.
  • DBT Skills Group – These groups use the concepts and theories from Dialectical Behavior Therapy to help participants develop effective life coping skills.
  • Skills Card Process Group – This group expands on the skills learned in the DBT Skills Groups and helps participants learn to process thoughts, emotions, feelings, self destructive behaviors, and urges.  The emphasis is to put the skills, learned in the DBT Skills Groups, into practice.
  • Voice, Power, & Trust Group – This group provides participants with a place to tell their story in a safe space and is designed to help trauma victims recover their voice and learn to trust again.
  • Trauma Theory – This session combines psychoeducation and processing in an effort to explore a model of trauma and how it is manifested in adulthood.

The Adolescent Eating Disorders IOP is for those ages 13-18.  The program requires 13 hours a week spread over a three day period.  Each week, attendees participate in a variety of therapy and group sessions.  In addition to the Process Group, Yoga/Mindfulness Group, and DBT Skills Group outlined above, this IOP also includes the following:

  • Group Meals – Each meal or snack is an Exposure with Response Prevention (ERP) session supervised by a dietician or therapist.  ERP is a premiere method of learning to tolerate the kind of anxiety often experienced with eating disorders.
  • Nutrition Group – This group’s focus is promoting a healthy, balanced approach to eating that is supported by the latest research and is taught by a registered dietician with years of experience treating children and adolescents with eating disorders.
  • Body Image Group – This group provides participants with a place to tell their story in a safe space and is designed to help those with eating disorders recover their voice.
  • CRT Group – Cognitive Remediation Therapy (CRT) is on the cutting edge of eating disorder treatment.
  • Parent Group – The goal of this group is to give parents and guardians the necessary information to assist in their loved one’s recovery process.  This group is for parents and guardians only.
  • Parent Update – The focus of this group will be to discuss client progress, barriers, obstacles, concerns, and expectations for the weekend while establishing the type of structure that is conducive to the recovery process.

Dating Violence and Teens

Teenagers of various backgrounds in Oslo, Norw...

Though technology affords teens the ability to interact without being together, teen violence and abuse still readily exists.. (Photo credit: Wikipedia)

Times have changed since today’s parents were teenagers and the rules about almost everything seem to be different.  Parents who used to spend hours hanging out with their friends at the arcade or the mall now wonder if their child is well-adjusted and socially engaged because they don’t seem to hang out with their friends much at all.  What many parents don’t realize is that the way teenagers interact and engage with each other is completely different from their own experience.   Teens used to need to be separate from their parents physically in order to interact with other teens without parental awareness or involvement.  But now, all they need is an internet connection and a smart phone and they can get that separation without ever having to leave the living room.

These differences cross all the different types of relationships teenagers engage in, including dating.  Where parents “went out” with each other, figuratively and literally, today’s teens may never go “out” on what their parents would recognize as a date.  So much has changed in the span of a generation that it can be difficult for parents to understand their teen’s relationships or even recognize when they are involved in one.  Even though technology affords teenagers the ability to interact with one another without leaving their own family’s living room, they may still meet up with each other outside of their home and possibly get involved in behavior that could be dangerous, even though it wouldn’t be recognized as a typical dating scenario. Unfortunately, there is one thing about teen relationships that hasn’t really changed in the face of technology, the possibility that a teenager’s relationship will become abusive.

According to the Centers for Disease Control, 9% of teenagers report that they have experienced some form of physical abuse in the past 12 months.   If you factor in other forms of partner abuse including emotional, sexual, and psychological, 1 in 4 teens report some form of dating violence each year.  The long term consequences of dating violence amongst teens are significant.  Teenagers who experience or witness dating violence can find it difficult to excel academically and may be more likely to skip school or drop out.  Victims of this kind of abuse are more likely to smoke, use illicit or illegal drugs, struggle with eating disorders, and consider suicide.  The pregnancy rate amongst teen girls who have been victims of dating violence is 3 times higher than their peers.

What Parents Can Do

One of the most important things parents can do is to talk to their teenagers about dating violence.  Teaching teens what is and is not a healthy relationship helps them see when a boyfriend or girlfriend’s behavior crosses the line.  Teach teens these warning signs that their relationship is becoming or has become abusive:

  • Being called names
  • Being embarrassed, put down, or degraded in front of others
  • Possessiveness including non-stop texting and calling, demanding to know whereabouts and who they are with
  • Threats
  • Controlling behavior
  • Any physical violence
  • Pressure to have sex or forced sex

Additionally, parents need to know which warning signs to watch for so that they will know if their teen is in trouble but unable or unwilling to report it.  Parents need to be alert for:

  • Rapid drops in grades
  • Changes in mood or personality
  • Struggling to make decisions
  • Hesitant to offer their opinion, even when asked
  • Signs of physical abuse
  • Negative attitude and talk towards themselves

If your child is being abused, contact the police department immediately.

Self-Harm Study Finds Kids as Young as 7 Cut, Burn, Hit Themselves

The study, just published in the journal Pediatrics, found nearly 8 percent of third-graders admitted to intentionally hurting themselves. About two-thirds told researchers they had done it more than once.

Researchers discovered that children, even those as young as 7, found that causing physical pain helps them cope with emotional stress. The study found 4 percent of sixth-graders and nearly 13 percent of ninth-graders reported harming themselves.

By ninth-grade, girls were three times more likely to self-injure than boys with cutting and carving of skin the most common method for girls. The findings are based on interviews with 665 kids in the Denver area and central New Jersey.

Depression, anger and anxiety can lead to self-injury,” explains Psychiatric Nurse Practitioner Jan Hamilton. “Parents need to pay attention and ask their children about cuts and bruises.”

How Do You Know Your Teenager is on Drugs?

As a counselor who works with teens and parents, this is one of the most common questions I am asked. Parents often struggle with this issue because the natural mood swings and personality changes that are a part of the teen years can make it difficult to determine if their child is acting normal or needs help. They are also hesitant to ask difficult questions because they don’t want to damage their relationship with their teen by accusing them of taking drugs.  Maintaining a relationship built on trust can be an important part of successfully navigating the teenage years and it only takes one misstep to demolish the foundation of that trust. Parents may be hesitant to approach their teens when they are concerned because they don’t want to alienate them or push them further away.

In order to know when to be concerned, when to ask questions, and when to intervene, you need to know the facts. Here are the common signs of teenage drug use.

1. Changes in Social Circles
One sign that parents should be watching for is a significant change in their child’s friends or social circles. If your teenager has been friends with the same kids since elementary school and suddenly shifts to an entirely different set of friends, this may be cause for concern. First, look for other factors like joining a new club, or playing on a sports team that may explain an influx of new friends. Changes in social circles or standing by themselves are not always indicative of drug use, but parents should pay attention to these types of changes as they can point toward several teenage problems.

2. Changes in School Participation
Another thing to watch for is the development of a negative attitude about school in general. This includes spending less time and effort on school work and home work, skipping classes, and grades that are going down.

3. Changes in Personality
When teenagers begin using drugs, they often become more secretive and are touchier about privacy and having their own space. Signs of these behavior changes include getting angry if you are in their room, unwillingness to let you borrow their cell phone, refusing to leave their backpacks or school bags where others could access them, or offering vague answers about where they are going and who they are spending their time with.

4. Changes in Aromatic Usage
If your teen suddenly develops the need to burn incense or use room deodorizer on a regular basis, but doesn’t seem more concerned with cleaning their room, they may be trying to hide the smell of smoke or other odors. Intensified use of body spray or perfume is also a sign that something may be amiss.

5. Changes in Financial Needs
One indication that your teen may be using drugs is an increased need for money. This may be evident because of an increase in their requests to borrow money, offers to work around the house for cash, or money disappearing from purses and wallets. Teens that become suddenly invested in selling or pawning things like video games and other electronics may also have a problem that needs parental attention.

Parents and their involvement in their teenager’s lives are still the best deterrent to drug use. Providing a supportive environment with clear expectations helps set the stage for drug-free teen years. But it is equally important to know the signs that your teen is in trouble and how to help them through whatever problems they are facing.


by Jan Hamilton, MS, PMHNP-BC
Psychiatric Nurse Practitioner


“Help! I Can’t Talk to My Teenager, He Says I Don’t Understand!”

By: Jan Hamilton, MS, PMHNP-BC

Every parent who has ever had a teenager understands this feeling.  It is a topic I get asked about a lot and a frequent topic in family therapy.  As teenagers grow, one of the fundamental changes they are making is the formulation of their own identity, separate and distinct from that of their parents.  In former centuries, this change more closely coincided with actual changes in circumstances as well, like getting married, striking out on their own, or taking on more adult responsibilities.  Even so, there were probably quite a few shouting matches and just as much misunderstanding between parents and their teenagers as there is today.

Communication is the key to helping our teenagers navigate the often rocky path between childhood and adulthood.  Unfortunately, the very nature of that change creates significant challenges and barriers to communication.  In order to keep the communication channels open, parents need to take charge of keeping them clear.  Here are 6 things that will help you communicate better with your teen.

1.      Communication is more than Words

Remember that there is more to communicating than just the words that come out of your mouth.  Your teenager is attuned to the subtle and silent messages you send with your body language and the tone of your voice.  If these messages don’t match, your child will interpret what they think you really mean and respond accordingly.

2.     Watch What You Say

Most teenagers have heard what you are about to say a hundred times.  They can tell by the circumstances, your body language, and the tone of your voice what is coming and if it is old news or an unwelcome message, they may tune it out.  Pay attention to all the messages you are sending and look for ways to impart the same message without wandering into a well-known battlefield.

3.     Listen

Communication is not just about talking or educating the other person or convincing them that your point of view is right.  Communication is about a two-way exchange.  You need to learn to listen, to truly listen, to what your teen is saying before you can learn to communicate with them.  Too often, parents tune out their kids as well, only hearing the things they want to hear or using the time their child is talking to think about what they are going to say next.  Listening to your teenager is the most empowering thing you can do.

4.     Trust Your Parenting

Trust in the foundation you provided them and give them room to make choices, fail, and then learn from their mistakes.  Believe in the guidance and education you instilled in them.  Don’t lecture. Focus on listening and allow them to make decisions for themselves.  Bolster their belief in themselves by showing them you believe in their ability to make good decisions.

5.     Be a Curious Observer

One of the reasons teenagers feel so misunderstood is that their lives, bodies, hormones, and relationships are in a constant state of flux.  You can help them through these challenges by providing validation that they are OK, that they are good people, and that what they are going through is normal.  To do this, you must be curious about their lives, ask open-ended questions, and then listen to what they have to say.  But you must only be an observer; you cannot force openness and you shouldn’t use curiosity to spy or pry into their lives.

6.     Watch Out for Transference

Remember that your child is not you.   If you have issues to work through, take the initiative and work through them yourself, don’t assume your child is going down the same path you did or that they will make the same mistakes you made.  You don’t want to  limit their freedom to find their own path, make their own mistakes, and learn to live with the consequences that result because of your own fears or guilt about your past.  The healthier you are, the better you are able to let go when you need to.


About Jan Hamilton, MS, PMHNP-BC

Jan is a nationally Board Certified Psychiatric Nurse Practitioner who specializes in adolescent treatment.  She earned her Master’s of Science and Psychiatric Nurse Practitioner certification through the University of Arizona. She then worked for over eight years at Remuda Ranch providing inpatient services for adolescents and adults suffering from eating disorders. Jan has been a registered nurse for 31 years and worked in a wide variety of medical settings, including 30 years of serving young people through her work with Young Life, an interdenominational outreach program. Her desire to provide quality psychological and psychiatric care for adolescents and young adults in an outpatient, faith based setting has led to the opening of Doorways in 2008.