Question: Hello, My daughter is a 16 year old who has been struggling with depression and mood disorder issues; she is currently on Wellbutrin and Lamictal, in counseling as well, and yet, meds are seeming less effective, even though dosage raised. Thoughts about the GeneSight testing? Other thoughts? Thanks, Lisa

Jim LaPierre Says...:

Hi there and thank you for your question. There's a lot of missing info here so I'm guessing a bit

First, does her counselor and med manager agree that they are treating the same conditions?

Does she find meeting with the counselor helpful? (sometimes therapists are like shoes - you have to try a few to get a good fit)

Lamictal is a mood stabilizer - and I note the mood disorder diagnosis

Mood disorders come in a variety of forms and my guess is her med manager is considering or has diagnosed bi-polar disorder

(which is actually quite rare in young women)

My best advice: talk with her. What are her unmet needs? What is missing in her life and what does she think would help?

Always look at situations factors and environmental factors before considering treating with medications.

Please ask if she is being bullied, is struggling with stress, is sexually active, and please have her see her PCP for consideration of potential medical issues that are related to depression (thyroid most notably)

If I can help further, please email me: counseling@roadrunner.com

Best,

Jim

Question: Our 17 year old may have tried marijuana once. But he seems to be very interested in it. He's for instance googling on what campuses have a "good weed scene". He's chatting with others and expresses admiration for older kids who are able to party with marijuana. We have talked to him about the dangers of marijuana on the teenage brain, discussed the recent book (from UPenn Neuro chair) on it. But nothing seems to have diminished his interest. What should we do? He won't listen to us parents.

David Johnson Says...:

I feel for you. You are left with few choices. Soon he will be 18 and he will be able to make his choices without your
interference. And marijuana is now legal for recreational use in a
growing number of states.

I would encourage you to let your son know your opinion, and be sure he has access to reliable information about the drug. Other than that your options are limited. I would advise against lecturing or making a big deal out of his choices. That may push him further down the path to regular use.

Tell him you disagree, express your concern, love and support. Then let him learn on his own.

Question: I need any advice on how to create a connection with my 16 year old son. I left him and his mother when he was just a baby. I was an alcoholic and actually she kicked me out, not that I made any effort to stay or to stay involved in his life. I sent birthday gifts but I missed some years. I have more than 2 years of non stop sobriety behind me now. Long story short my exwife wants my son to get to know me. She is really a wonderful and forgiving person and she wants us to have a relationship. I want it also. We went out to the park with her and it was OK and we even all laughing and joking but then I took him out for dinner alone the next weekend and it was so awkward and uncomfortable for both of us. He would not say anything but yes or no and I don’t know what to do. He obviously does not want to do this so should I force things?

Rev. Christopher Smith Says...:

While there could be more going on in your particular situation where it would be helpful to have someone sit down and help you talk, the situation you describe sounds quite normal and may not really have the conclusions that you have reached. Interacting with teenagers is different. It is tempting to think of them as children, yet they are pushing for more autonomy and self-definition. It is tempting to look at them as adults, but they have not quite developed to that point either.

One of the questions to ask is what type of a relationship are you wanting to establish with your son and what might he be looking for, even if he is not saying it. Just from what you have said, it does not sounds like you are looking to be in a strong parenting role and neither of the other two are looking for that either. I would also suspect that you are not looking to try and foster a "best friend" role. Once you work out what type of a relationship everyone is hoping for (perhaps more akin to a mentor) then you may find it easier to move towards that goal.

When you met with your son and ex-wife, the conversation was moderated by the fact that your ex-wife was a connection between the two of you. When you were on your own, the training wheels were off. Connecting with teens is not an easy task. Every year, high school teachers have to try and bridge that gap and gain the trust of their new students. People of your son's age are more focused on peers than forming relationships with adults. Developmentally, they are more involved in breaking away from parents than forging new relationships with adults. However, teenagers do look for people that have something to offer, especially if they have the choice to take it or not. This is to say that I would not be so certain that he doesn't want to have some type of a relationship with you but that it will take time.

You can't regain the time that has passed. You will not have a strong role as a child's father but you may develop a positive relationship over time and even be able to take on the role of an adult parent. Working at it, allowing things to be awkward at times, you can journey to a place where there will be peace and wholeness.

Question: My son is a regular user of marijuana. He is a junior in high school and duel enrolled into our community college and doing very well. He has a part time job, is active in our churches youth group, and in boy scouts. He doesn't see anything wrong with smoking marijuana and has even said he does well to prove all "stereotypes wrong". He will not see a expert. I don't know what to do. DO you have any advice?

Rob Danzman Says...:

Dear Anonymous,

In the mental health/substance abuse world, we typically use a response approach rather than preventative approach (similar to the medical model). One of the 'tests' we use is asking the question 'Does this thought/feeling/behavior get in the way of a major life domain such as social, academic, career or intrapersonal'? 

In this situation, your son sounds like a good kid that has clearly been brought up with a strong work ethic and healthy boundaries. That doesn't mean he is immune from screwing up and making bad choices. But you came very close to articulating the real problem - If (...and then how) to intervene if he's doing well across the board but engaging in an activity which is illegal (but increasingly accepted and legal in many states)? 

First off - I definitely do not condone the use of illegal drugs, or any other illegal behavior. With that said, let's remove the idea/label of pot for a second and replace it with 'undesirable activity.' Why do this? To give us a bit of perspective since pot has loaded legal/ethical/etc. considerations that may distract us from the bigger questions. Let's be real, he's going to use pot whether you allow it or not. Instead of focusing on the pot use (not to say it's a good habit) I would recommend focusing on your relationship with him and the relationship he has with the family. I would also seek to understand why he is using. Again, just to be super real about this, people smoke pot for only a few reasons, most of which has to do with feeling chilled-out. If your son is a super achiever, he may be using as a form of anti-anxiety. It may be his way of counterbalancing his performance-obsessed lifestyle. 

Take home message

1. Ignore the pot 

2. Focus on relationship 

3. Support him in avoiding/coping with achievement pressures 

So when is it effective to draw a line? When it's a safety issue. Period. When it puts him at immediate risk like when he drives to a party, etc. I'd make it clear that you will not get into a power struggle with him but that he's not allowed to drive impaired, if he's going to be impaired or get into a vehicle with anyone else who is high. This is where consequences need to be swift, consistent and intense (ie. Loss of car privileges for 2 months). When safety is an issue it's time to not worry about how he feels. 

Bottom line here is that you've raised a responsible young man who will continue to do well. Pot will make him feel good in the short term but likely become a speed bump as he gets older. Find that sweet spot between setting clear limits while also supporting him. I doubt he needs therapy. I doubt there are deep seeded issues. But it wouldn't be a bad idea to consult a professional if nothing else just to act as parent consultant and a fresh perspective. If you find the right therapist/counselor who can play it cool, he'll see them and likely reduce his use. We see it at our agency all the time. 

Hope this helps. 

Rob Danzman, MS, NCC, LPC

www.fonthillcounseling.com 

Question: My children are 10 and 12 and neither has ever gotten into any trouble. I am a geologist and I am considering a career relocation that would put us into an area which has a major drug situation with meth and with oxycontin and other prescription drugs. This is a rural area so there is only one high school to attend and there is no way to minimize their exposure to this. I know that there have been numerous cases of high school students overdosing and getting in trouble with the law. This is what I have been able to find out just by searching the local newspaper so I bet it is worse on the ground. I am dragging my feet on accepting this offer because I am worried that we would be putting our kids in harms way. I remember being a teenage and going along with the crowd. If everybody else is doing drugs won’t my kids get sucked into that too?

Rob Danzman Says...:

Interesting dilemma. On the one hand, you have a career opportunity that provides either more income, job satisfaction, or a bit of both - basically, a move that would make you happy or more fulfilled. But, the environment for your children is substantially compromised and could expose them to behaviors incongruent with your values. Rather than a simple response, this requires a bit a breaking-down of all the variables.

First, I’d want to know more about why this career move is important. Money, fresh-start, job satisfaction, etc.? All of them are reasonable reasons to take the job. If your family is deep in a financial hole and this is the best way out, environmental conditions could seem a bit less important. If, on the other hand, this is one of many options and mostly about career satisfaction, it’s harder to make the argument it’s a necessary move. Definitely a topic for more conversation with a good counselor/therapist. Understanding your own motives may help put each of the variables in a priority order and may make decision making easier.

Secondly - Let’s talk kids. Kids are resilient. Kids from educated, caring and loving parents are even more resilient. You clearly are thoughtful and likely have actively supported them their whole life - this accomplishes many things related to developing a healthy, appropriate kid. There are plenty of children raised in sketchy parts of our country that do great things. There are also plenty of examples of kids raised in upper-middle class areas that get into heaps of trouble (those are typically our clients). Parenting matters. Parents that have a good balance between focusing on their career and focusing on family model equilibrium that promotes good decision making and respect for boundaries. This new place could be an opportunity to talk with your kids about what sort of teen and young adult they would like to be. Discussion about moving could also be an opportunity for them to hear about the information you have and talk about their concerns, fears and excitements.

Lastly, if things get bad, if your kids start getting messed up with the wrong group, you can always leave or get them enrolled in online classes (not ideal but better than idiots at school). It will not be easy when they are teens but it’s also not easy to make this decision right now. Just that fact that you are slowing things down and reaching out and researching this move tells me you all will be just fine. And even when things don’t go as planned, you will rally together and overcome whatever obstacles present themselves. This opportunity will likely make your family stronger.

Best of luck!

Question: My 13 year old daughter wants to go on the birth control pill. She talked to my ex wife about this. WTF am I supposed to do about this? Should she get some kind of therapy?

Rev. Christopher Smith Says...:

There is a lot not represented in this question that could easily change how someone might answer it, so you will have to consider your own situation to make decisions about it. Let me address some of those aspects first.

The first factor is that women (young and older alike) may begin taking birth control pills for a variety of reasons. The most obvious of which is to prevent conception when they are sexually active. Depending on your faith tradition background and your own spirituality, you may find that this is not an option that is acceptable regardless of the age of the woman. There also are cases where young women (and yes, your thirteen year old daughter qualifies, at least physically) desire to begin use of oral contraceptives even when they are not sexually active. This could be because they believe the occasion could come up where they would become sexually intimate with someone and want to be prepared in case this would happen. In some communities, it could be the result of fear of being sexually attacked. Depending on lots of things around this and whether you feel your daughter is being impulsive or has really thought things through, there might be a need to have someone for her to talk these things through with.

However, it is also possible that your daughter's desires have nothing to do with sexual behavior. There are different types of pills that can be used and they have a range of other benefits. These benefits can include things such as reducing menstrual cramps and make the woman's periods lighter as well as preventing certain types of diseases. There are also women who go on the combination pill to help with a variety of other conditions including acne, iron deficiency and some PMS symptoms. Some birth control methods will to limit the number of periods in the month or to eliminate them all together. These motivations are quite different than those in the last paragraph. These, too, could require counseling before she should start using the birth control pill. However, rather than a therapist, her physician should be able to provide this counsel. If it is really affecting her then entering therapy might be appropriate.

Another dimension to the situation that the questioner originally raises is that his daughter spoke about this with his ex-wife. This is an area of life where it is natural for a daughter to speak to her mother rather than her father. Some sensitive topics are difficult for people to talk about with certain parents. However, if you are your ex-wife are not on the same page around parenting issues, then this will add difficulty for your children as they get different messages at different points. If this is drastic, but not volatile, the two of you as parents may benefit from therapy or at least mediation to help you be able to provide more consistency and to have appropriate communication between you. It also raises the question of how involved you are in your daughter's life. This will also affect what role you might have in this situation. Interestingly, research that has come out in the last five years (for example Mendle et al in Child Dev., 2009 Sep-Oct 80(5)) has found that absent or partially absent fathers can affect the mean age at which young women have their first sexual intercourse by lowering the mean by as much as a year. There are lots of factors that go into this.

Looking across all teenagers, not paying attention to factors that tend to earlier or later sexual activity, studies state that half of all teenagers have had first intercourse before the age of seventeen. There is certainly variability in this age based upon the other factors (for example half of black male teenagers in these same studies have had sexual intercourse before fifteen). With these being median figures, there are people who will have had sexual intercourse before these ages, even years before. Some people have said that we should expect this as there is some evidence that puberty is occurring earlier. The average age for puberty among girls/women is generally seen to be eight to fourteen. This raises the question of how this affects the child/young adult to physically have matured and be physically ready for sexual activity but yet to have not matured emotionally and not be ready to have children. This is an issue that can cause tension for someone in that situation, as well as for their parents. In an ideal world, there might be some form of group therapy for these children/young adults and space for their parents to process, but this is not commonly offered. If you were trying to find a way to give your daughter space to talk through these issues in a group, it might be in a normal therapeutic setting but it might also happen in another setting, such as a church or community group.

Your daughter is growing up. This will provide challenges for her as well as for you. If this becomes too much at any stage, then seeking out therapy is appropriate. Talking with each other can also help. If you have instilled good values in her, then she will come through these challenging times. There is hope for a future where she will experience wholeness and peace, as ill you.

Question: My 15 year old son has way too much money and I can’t figure out where he is getting it from. He always has a story about how his ‘friends bought him this or that or how his friend gave him an old ipad mini or how he bought a scratch off and won $100. He won’t admit that he is doing something wrong and I am worried he is doing something illegal to get this money. I feel powerless because I worry he is going to get in a lot of trouble but I don’t know how to stop him what should I do?

Rob Danzman Says...:

Dear Powerless Parent,

Though I do not know your son, I know teenagers in general and showing up with cash in that amount that frequently sounds suspicious. But as a therapist, I am less interested in discovering the truth or facts and more interested in developing rapport with him and providing a judgmental place for him to share what's going on. This takes time. 

Prognosis: Depends on where you all live and past behaviors. I can tell you for sure this definitely is the right time to bring in a professional, even if only for a consultation. If left to his own brain and his friends' influence, he will likely get into academic trouble and possibly legal trouble. This is the time to intervene to help him avoid that mess. 

Parent's Role: As a parent, your role is different in that the facts do and should matter. If he is selling drugs or stealing stuff and selling it on craigslist, you and he are liable. This is where some creative boundary setting would come in. Not your basic discussions about giving him 'tv time' if he gets an 'A' on a report card, but a deep understanding of what motivates him (both rewards and consequences). If he's around shady characters (like I guess he is) getting into trouble might be a badge of honor for him. 

Professional's Role: It's hard to give specifics from afar but this type of family/individual therapy really should start with the parents to help them regain control. If after learning higher-level parenting skills your entrepreneurial son continues to engage in less than reputable behavior, we would start talking about increased levels of care (ie. therapeutic wilderness program, residential treatment, therapeutic boarding school, day treatment). There could also be a very early substance use issue here. There could be bullying going on. Until someone sits down with the individuals and family as a whole, the recommendations really are to find some good professional support. 

How We Would Do It: We work with families like yours all the time and help the parents navigate through the therapeutic process. Sometimes, basic boundary setting and outpatient therapy are all that's needed. Other times, we uncover a super hidden world of substance use and move quickly with treatment. Until then, I recommend you focus on setting some basic boundaries (ie. curfews, grades, homework time) and, instead of asking him where he got his magical wealth (he probably hates lying to you as much as you hate it) simply let him know that you understand he is hiding part of his life from you but if he ever needs to talk with you, you will do the best you can to listen, not judge and help if asked. Making a statement like that and walking away is way more congruent with the adolescent brain and how they process parental dialogue. 

I hope this helps point you in the right direction and normalizes your experience. Lots of parents struggle with their kids doing stupid stuff but with the correct support, his choices do not have to have a permanent affect on his life. 

Question: My son is 10 and he is very fearful and anxiety prone. He is popular and well liked at school so he hides his fears there but at home he still doesn’t want to go to his room upstairs unless someone will go with him and about 1 night a week he can’t sleep because he lays awake with worries that he has trouble articulating. They just seem to be this vague sense of unease. He is doing well in school and he is generally a happy child, other than this anxiety and fear he deals with. I have been reluctant to take him to a psychologist because I think that once I do he will no-doubt come away with a label and then he will be labeled as having some type of mental illness. Do you think that it is urgent, given his age and the fact that he is generally happy, that we tackle this now. Can you recommend a book or give some advice on how I can help overcome his worrying? He is very intelligent and he is looking for me to tell him how to not worry and I feel like I am failing him that I can’t.

Rev. Christopher Smith Says...:

It is difiuclt to be able to advise in your specific case, particularly as there are certain questions that are left open in what you describe. As such, I can only answer aout similar types of cases and encourage you to explore your particulars with someone in your are.

At the beginning of your account, you give some details about your son's behavior at school. The connection between being popular and well liked at his age and not having fears is not necessarily so clear. It is also not clear from what you described what fears your son would be hiding when at school. Even at home, it appears that his fears are very specific and do not overwhelm his whole expereince of life.

It would be interesting to know about things that happened before or around the time that he started having these problems. It is not clear whether he is experiencing general worries that are most prominent when he tries to go to sleep, whether he is afraid of his bedroom or something in it or whether his fears are more connected with sleeping. Of course, there are ways of working this out, but the question as posed is pretty hard to determine which would in fact be the case. Each of these could have very different root causes and would then want to be looked at differently. For example, if it is general anxiety being aplified at nighttime, which could be normal for a pre-adolescent who may be facing changes in his environment as he ages, then there are techniques that could be used to ease these anxieties. Also, if it is general anxiety and other techniques don't work, there are other alternatives that a mental health team could utilize, although they would not be the first line of attack for someone his age. On the other hand, if it is his room that is the source and for example this came from a movie that he watched, there are ways to talk through the differences between the movie an reality and to help him beyond fears of things that are not likely. As a final example, if it is about sleeping there are a number of things that could be behind this and one of them might be a fear of dying, especially if euphanisms about sleeping were used to describe someone he knew that died.

You may need to use a mental health professional to help you get to the bottom of this if he is not able to express his fears and anxieties to you. The mental health professional does not have to be a psychologist but could also be a masters level clincian (social worker, mental health counselor, marriage and family therapist, etc) or even a school counselor. Unless being done through school, you would likely be using your insurance or your employee assistance program to help pay for the sessions. If you do this, the mental health professional will have to provide a diagnosis. However, insurance companies and the whole system do not require this diagnosis to be something that is a life-long serious mental illness. There are diagnoses (such as adjustment disorder with anxiety or bereavement) which are by their nature not necessarily expected to be life-long. In any case, stigma around mental illness is decreasing in our society and many family and consumer groups would state that it is better to be labelled and getting help for what is going on than to not be labelled and to continue to suffer. In the case of anxiety disorders, a 2005 study (Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE (June 2005). "Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication". Arch. Gen. Psychiatry 62 (6): 593–602. ) found that 29% of people in the UNited States suffer from an anxiety disorder at some point in their life , with 11-18% adults having a current anxiety disorder in a given year. If your son was diagnosed, he would be fitting along with about a third fo the population and there is hope that he could erturn to a place of peace and wholeness in his life.

As you seek to discern what to do in this situation, I wish you well. As you take time to think, I would encourage you to decide on a course of action sooner rather than later. Losing a night of sleep each week will have a toll on your son's physical and mental health and could end up having an impact on other parts of his life including school and social circles that are currently working well. It is also possible that an untreated anxiety disorder (if that is what he has) could draw out other related disorders. At the minimum, I would try to involve his school counselor in what is going on. If you are particularly concerned about possible labels still, you could seek help through your work's employee assistance program (as these programs are short term and thus more likely to utilize situational diagnoses unless a referral for further treatment was needed) or a professional in private practice that you can afford to go to on a cash basis and thus not generate any diagnosis trail. This is not soemthing that I would be really concerned about but you have to judge your own comfort level.

Question: My 14 year old son is not interested in extracurricular or community activities. He is shy and he would rather be at home playing on his computer. I know he does not enjoy these things but I think they are important so I try to force him to participate, which causes endless battling at home. Should I give up on this battle or is it worth persevering with?

Rev. Christopher Smith Says...:

Parents (such as probably the one who intially raised this question) who were very socially involved often have difficulty understanding their children who are introverted, especially if they are also not highly involved with other people. There can be a difference between shyness and truly drawing your strength from yourself (as is the case for an introvert). If the roles were reversed, the extroverted parent would be frustrated and angry if they were being made to stay at home and away from the social settings that act to recharge them.

Before deciding what to do, the first thing to look at is why the child is engaging in the activities that they are. Does the child truly enjoy and feel drawn to the current activities? Is the child using the current activities to avoid alternate activities? If that is so, is it because there is no real interest or aptitude for those activities or is it operating out of fear or other negative emotional reasons that may not truly play out? Understanding this will help you as a parent to decide whether or not this is something that you should consider trying to influence, encourage or support your child to do differently.

Even if the earlier questions make you want to work with your child, there is still another important thing to think about. How important is participating in the alternate activities? In answering this question it is important to look at it from the present time frame and from the perspective of your child's life. It is very important to not simply move forward because you think that these activities are important based on your experience and personality. This will help to understand whether engaging the alternative activities is significant enough to make a fight or battle worthwhile.

Using these basic areas of thinking, you should be able to work out whether you want to continue the battles around this area or whether you should back off and not strongly engage in this issue. It should also make it less of a battle if this is something that you are wanting to continue as you will have a better understanding of how it i important from your child's perspective. Whichever way your own situation ends up deciding, there is the possibility of finding wholeness and peace as you move forward.

Question: What do I do with a girl who is 17 and in her last year of high school who is taking diet pills and who won’t stop. I can make her promise to stop but I cannot make her actually do it. I am starting to feel like the police man in the house. Whenever she pours a big glass of water I am wondering if she is drinking to avoid eating and I bite my tongue to ask her but I often can’t resist and that does not help when I am badgering her about what she is doing especially when I cannot prove one way or the other what is going on in her head. I am so frustrated with her. She has taken diet pills in the past and I caught her and we had a big talk and she promised she would not do it again. She knows the risks. Then she lost a ton of weight this last month and I got suspicious again and I started asking her if she was taking anything. Of course she denied everything but then my youngest daughter found the pills in her bag and she still denies that she is taking them she says she is just selling them at school (she says they are not ilegal). What am I supposed to do? I can’t make her do anything and being thin seems more important to her than her future health.

Rob Danzman Says...:

Dear Anonymous,

Unfortunately, your situation is not unique and is a very difficult one to deal with. Our agency spends a significant amount of time supporting families like yours since easting disorders are almost never just an individual issue. Hopefully, my responses to each of your questions below will help you all get through this difficult time.

A: What do I do with a girl who is 17 and in her last year of high school who is taking diet pills and who won’t stop. I can make her promise to stop but I cannot make her actually do it. 

RD: You are totally correct, you can not make her do anything. Having her promise to stop only deepens feelings of failure, lack of control and sadness often associated with eating disorders. That does not mean there is nothing you can do, though. First of all, if it's a REAL safety issue (she is not eating anything, her period has stopped or you can see she is physically weak and tired) medical intervention is more important than a psychological intervention. It's time to have her admitted to the hospital immediately. 

If it's not a safety issue, I would not focus on changing her behavior (not right away at least) but get a better understanding of why she is using this coping skill. I'd like to know what pressures she is experiencing, why restrictive eating seems like the best way to get her needs/wants met. It sounds like she does not feel comfortable coming to you or any other family member and asking for help. I'd like to understand why. 

Now, let's talk leverage and responsibility. I'd like to know if she (and you) are planning on her leaving for college next Fall. Are you visiting colleges now? I'd also be interested to understand what sort of privileges she has right now (ie. iPhone, car, etc). Basically, going away to college is a privilege and is only an option for mental and physically healthy kids (this is what I would tell her). Next, if she is not taking care of herself, she needs to start working with a therapist. Having a phone, car, etc. are privileges she can use when she takes care of herself. Be specific with what you need to see (behavior - not attitude or motivation) and tie it to privileges. This can be tricky since you do not want to increase her stress but, you want to set specific and firm expectations. 

A: I am starting to feel like the police man in the house. Whenever she pours a big glass of water I am wondering if she is drinking to avoid eating and I bite my tongue to ask her but I often can’t resist and that does not help when I am badgering her about what she is doing especially when I cannot prove one way or the other what is going on in her head. I am so frustrated with her. 

RD: Don't bother spending time trying to prove anything or getting into power struggles. If she is in your house, your rules and expectations apply. It's not a bad thing to tell her how how behavior makes you feel ("When you don't eat, I feel scared and angry that you are unhealthy."). This may not change her mind or behavior, but you will at least accurately communicate your thoughts and feelings. 

A: She has taken diet pills in the past and I caught her and we had a big talk and she promised she would not do it again. She knows the risks. Then she lost a ton of weight this last month and I got suspicious again and I started asking her if she was taking anything. Of course she denied everything but then my youngest daughter found the pills in her bag and she still denies that she is taking them she says she is just selling them at school (she says they are not illegal). 

RD: Whether she is taking diet pills, restricting her eating, or purging after meals, she's not taking care of herself. It's not a bad idea to set a line with her and let her know what you will do when she crosses it ("If I see that you are physically too weak, unhealthy or look too thin, I will admit you to the hospital to get help. I would rather you be alive and angry at me rather than dead."). Even if she claims to 'know the risks' teenagers are neurologically designed to think the risks do not apply to them. Also - I'd set an expectation that your younger daughter NOT get in the middle of this. Tell her how she can support and care about her older sister without feeling the need to rat her out to you. Puts her in a bad spot. 

A: What am I supposed to do? I can’t make her do anything and being thin seems more important to her than her future health.

RD: The ultimate goal may not be to be thin, it more than likely to be attractive, be in control, or punish herself for not being good enough at something. It's vital that you find a therapist in your area that specializes in eating disorders. If individual therapy does not seem like it will be enough, agencies like ours (Fonthill Counseling) help families find residential treatment programs. We've worked with great programs around the country that provide great service to the client and fantastic support to the family. This issue is likely much bigger than any parent can handle on their own since your daughter does not likely have the internal desire to change at this point.