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Encourage participation in team sports
Participation in sports, competitive team sports in particular, is very good for the physical well-being and emotional development of children and adolescents. Specifically, there is growing evidence that sports promote healthy development socially and emotionally, protecting against drug use, poor body image, and against psychiatric illness in youth.
Sustaining academic productivity and team sports is demanding. By the middle of autumn, the amount of homework can begin to wear on teenagers, and the burden of getting them to practices and games can wear on parents. It can be very tempting for youth and their parents to drop team sports in high school, and turn their time and effort more completely to the serious work of school. But advocating for your patients and their parents to protect the time for team sports participation will pay dividends in the health and well-being of your patients and may even support rather than detract from academic performance.
The benefits of regular exercise for physical health are well established. Most teenagers do not get the recommended 60 minutes daily of moderate to vigorous physical activity. Participating in a team sport enforces this level of activity, in ways that parents typically don’t have to enforce. This level of physical activity typically promotes healthy eating and a healthy weight. Daily exercise promotes adequate, restful sleep, one of the most critical (and usually compromised) components of adolescent health. These exercise habits are easier to maintain into adulthood – when they protect against cardiovascular and inflammatory diseases – if they have been established early.
Beyond physical health, participation in team sports has been shown to promote good mental health and protect against psychiatric illnesses. They generally are less likely to use drugs and more likely to have a healthy body image than are their nonathlete peers. It is worth noting that the mental health benefits of team sports are even more robust than the benefits of solitary exercise in teenagers,1 possibly because of the social connections to peers and adults that grow out of them.
In the Monitoring the Future surveys (biannual national surveys of high school student health and behaviors funded by the National Institutes of Health) from 2010 to 2015, teenagers who participated in team sports were more likely to describe higher self-esteem and lower levels of loneliness. It is important to note that it has been difficult to establish the causal direction of the association between team sports and mental health in youth. We need more prospective randomized controlled trials to assert that the benefit is not simply an artifact of healthier youth choosing to participate in sports, but actually an active consequence of that choice. For now, though, we can say with confidence that physical activity promotes good mental health in youth and may protect against mental illness.
While student athletes benefit from the opportunity to develop deep social connections – ones forged in the intense setting of competition, collaboration, and sustained teamwork – they also benefit from strong mentorship connections with adults, including coaches, trainers, and even the parents of teammates who participate in all of the efforts that go into team sports in youth. While it might seem that all of the mental and physical benefits must be offset by lower academic performance, it turns out that is not the case. It is well established that regular exercise promotes healthy cognitive function, including processing speed, working memory, and even creativity. According to data from the Monitoring the Future survey, adolescents who participated in team sports were more likely to have As and to plan on attending a 4-year college than were their nonathlete peers.
Beyond the physiologic and social benefits of exercise, team sports provide adolescents with a powerful opportunity to get comfortable with failure. Even the best athletes cannot win all the time, and sports are unique in building failure into the work. Practice is almost entirely about failure, gradually getting better at something that is difficult. While everyone aims to win, they also prepare to struggle and lose. Athletes must learn how to persevere through a match that they are losing, and then pick themselves up and prepare again for the next match. When young people get comfortable with facing and managing challenges, managing setbacks and failure, they are ready to face the larger challenges, setbacks, and failures of adult life.
Team sports enable young people to learn what they are actually capable of managing – they build resilience. This promotion of resilience is illustrated in recent research that demonstrated that team sports may be especially protective for young people who have experienced trauma (adverse childhood experiences, or “ACEs”). Researchers at the University of California, Los Angeles, followed teenagers with and without high ACE scores into their mid 20s. They found that those with high ACE scores who participated in team sports as adolescents were 24% less likely to have depression and 30% less likely to have anxiety diagnoses as adults, compared with their peers who did not participate in team sports.2
Of course, the details matter in team sports. If your patients are participating and they or their parents are worried about spending so much time on something other than homework, talk to them about all of these exceptional benefits of team sports. But the culture of the team matters also. Some teams may be focused on winning at all costs, or have a practice culture that is humiliating or bullying. Some teams may have a culture of partying after games, with binge drinking and drug use. Ask your patients about whether they feel they are respected members of the team, and if effort and sportsmanship are valued as well as performance. Do they trust their coaches? Do they believe their coaches know and care about them? If your patients are not participating in a team sport, encourage them to find one (or more) that engage their interests. The benefits of track and field, crew, and tennis can be just as robust as the benefits of football or soccer. Speak with your patients and their parents about the payoff for their physical, mental, and developmental health the time and effort they are putting into a team sport can provide.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Int J Nutr Phys Act. 2013 Aug 15. doi: 10.1186/1479-5868-10-98.
2. JAMA Pediatr. 2019 Jul 1;173(7):681-8.
Participation in sports, competitive team sports in particular, is very good for the physical well-being and emotional development of children and adolescents. Specifically, there is growing evidence that sports promote healthy development socially and emotionally, protecting against drug use, poor body image, and against psychiatric illness in youth.
Sustaining academic productivity and team sports is demanding. By the middle of autumn, the amount of homework can begin to wear on teenagers, and the burden of getting them to practices and games can wear on parents. It can be very tempting for youth and their parents to drop team sports in high school, and turn their time and effort more completely to the serious work of school. But advocating for your patients and their parents to protect the time for team sports participation will pay dividends in the health and well-being of your patients and may even support rather than detract from academic performance.
The benefits of regular exercise for physical health are well established. Most teenagers do not get the recommended 60 minutes daily of moderate to vigorous physical activity. Participating in a team sport enforces this level of activity, in ways that parents typically don’t have to enforce. This level of physical activity typically promotes healthy eating and a healthy weight. Daily exercise promotes adequate, restful sleep, one of the most critical (and usually compromised) components of adolescent health. These exercise habits are easier to maintain into adulthood – when they protect against cardiovascular and inflammatory diseases – if they have been established early.
Beyond physical health, participation in team sports has been shown to promote good mental health and protect against psychiatric illnesses. They generally are less likely to use drugs and more likely to have a healthy body image than are their nonathlete peers. It is worth noting that the mental health benefits of team sports are even more robust than the benefits of solitary exercise in teenagers,1 possibly because of the social connections to peers and adults that grow out of them.
In the Monitoring the Future surveys (biannual national surveys of high school student health and behaviors funded by the National Institutes of Health) from 2010 to 2015, teenagers who participated in team sports were more likely to describe higher self-esteem and lower levels of loneliness. It is important to note that it has been difficult to establish the causal direction of the association between team sports and mental health in youth. We need more prospective randomized controlled trials to assert that the benefit is not simply an artifact of healthier youth choosing to participate in sports, but actually an active consequence of that choice. For now, though, we can say with confidence that physical activity promotes good mental health in youth and may protect against mental illness.
While student athletes benefit from the opportunity to develop deep social connections – ones forged in the intense setting of competition, collaboration, and sustained teamwork – they also benefit from strong mentorship connections with adults, including coaches, trainers, and even the parents of teammates who participate in all of the efforts that go into team sports in youth. While it might seem that all of the mental and physical benefits must be offset by lower academic performance, it turns out that is not the case. It is well established that regular exercise promotes healthy cognitive function, including processing speed, working memory, and even creativity. According to data from the Monitoring the Future survey, adolescents who participated in team sports were more likely to have As and to plan on attending a 4-year college than were their nonathlete peers.
Beyond the physiologic and social benefits of exercise, team sports provide adolescents with a powerful opportunity to get comfortable with failure. Even the best athletes cannot win all the time, and sports are unique in building failure into the work. Practice is almost entirely about failure, gradually getting better at something that is difficult. While everyone aims to win, they also prepare to struggle and lose. Athletes must learn how to persevere through a match that they are losing, and then pick themselves up and prepare again for the next match. When young people get comfortable with facing and managing challenges, managing setbacks and failure, they are ready to face the larger challenges, setbacks, and failures of adult life.
Team sports enable young people to learn what they are actually capable of managing – they build resilience. This promotion of resilience is illustrated in recent research that demonstrated that team sports may be especially protective for young people who have experienced trauma (adverse childhood experiences, or “ACEs”). Researchers at the University of California, Los Angeles, followed teenagers with and without high ACE scores into their mid 20s. They found that those with high ACE scores who participated in team sports as adolescents were 24% less likely to have depression and 30% less likely to have anxiety diagnoses as adults, compared with their peers who did not participate in team sports.2
Of course, the details matter in team sports. If your patients are participating and they or their parents are worried about spending so much time on something other than homework, talk to them about all of these exceptional benefits of team sports. But the culture of the team matters also. Some teams may be focused on winning at all costs, or have a practice culture that is humiliating or bullying. Some teams may have a culture of partying after games, with binge drinking and drug use. Ask your patients about whether they feel they are respected members of the team, and if effort and sportsmanship are valued as well as performance. Do they trust their coaches? Do they believe their coaches know and care about them? If your patients are not participating in a team sport, encourage them to find one (or more) that engage their interests. The benefits of track and field, crew, and tennis can be just as robust as the benefits of football or soccer. Speak with your patients and their parents about the payoff for their physical, mental, and developmental health the time and effort they are putting into a team sport can provide.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Int J Nutr Phys Act. 2013 Aug 15. doi: 10.1186/1479-5868-10-98.
2. JAMA Pediatr. 2019 Jul 1;173(7):681-8.
Participation in sports, competitive team sports in particular, is very good for the physical well-being and emotional development of children and adolescents. Specifically, there is growing evidence that sports promote healthy development socially and emotionally, protecting against drug use, poor body image, and against psychiatric illness in youth.
Sustaining academic productivity and team sports is demanding. By the middle of autumn, the amount of homework can begin to wear on teenagers, and the burden of getting them to practices and games can wear on parents. It can be very tempting for youth and their parents to drop team sports in high school, and turn their time and effort more completely to the serious work of school. But advocating for your patients and their parents to protect the time for team sports participation will pay dividends in the health and well-being of your patients and may even support rather than detract from academic performance.
The benefits of regular exercise for physical health are well established. Most teenagers do not get the recommended 60 minutes daily of moderate to vigorous physical activity. Participating in a team sport enforces this level of activity, in ways that parents typically don’t have to enforce. This level of physical activity typically promotes healthy eating and a healthy weight. Daily exercise promotes adequate, restful sleep, one of the most critical (and usually compromised) components of adolescent health. These exercise habits are easier to maintain into adulthood – when they protect against cardiovascular and inflammatory diseases – if they have been established early.
Beyond physical health, participation in team sports has been shown to promote good mental health and protect against psychiatric illnesses. They generally are less likely to use drugs and more likely to have a healthy body image than are their nonathlete peers. It is worth noting that the mental health benefits of team sports are even more robust than the benefits of solitary exercise in teenagers,1 possibly because of the social connections to peers and adults that grow out of them.
In the Monitoring the Future surveys (biannual national surveys of high school student health and behaviors funded by the National Institutes of Health) from 2010 to 2015, teenagers who participated in team sports were more likely to describe higher self-esteem and lower levels of loneliness. It is important to note that it has been difficult to establish the causal direction of the association between team sports and mental health in youth. We need more prospective randomized controlled trials to assert that the benefit is not simply an artifact of healthier youth choosing to participate in sports, but actually an active consequence of that choice. For now, though, we can say with confidence that physical activity promotes good mental health in youth and may protect against mental illness.
While student athletes benefit from the opportunity to develop deep social connections – ones forged in the intense setting of competition, collaboration, and sustained teamwork – they also benefit from strong mentorship connections with adults, including coaches, trainers, and even the parents of teammates who participate in all of the efforts that go into team sports in youth. While it might seem that all of the mental and physical benefits must be offset by lower academic performance, it turns out that is not the case. It is well established that regular exercise promotes healthy cognitive function, including processing speed, working memory, and even creativity. According to data from the Monitoring the Future survey, adolescents who participated in team sports were more likely to have As and to plan on attending a 4-year college than were their nonathlete peers.
Beyond the physiologic and social benefits of exercise, team sports provide adolescents with a powerful opportunity to get comfortable with failure. Even the best athletes cannot win all the time, and sports are unique in building failure into the work. Practice is almost entirely about failure, gradually getting better at something that is difficult. While everyone aims to win, they also prepare to struggle and lose. Athletes must learn how to persevere through a match that they are losing, and then pick themselves up and prepare again for the next match. When young people get comfortable with facing and managing challenges, managing setbacks and failure, they are ready to face the larger challenges, setbacks, and failures of adult life.
Team sports enable young people to learn what they are actually capable of managing – they build resilience. This promotion of resilience is illustrated in recent research that demonstrated that team sports may be especially protective for young people who have experienced trauma (adverse childhood experiences, or “ACEs”). Researchers at the University of California, Los Angeles, followed teenagers with and without high ACE scores into their mid 20s. They found that those with high ACE scores who participated in team sports as adolescents were 24% less likely to have depression and 30% less likely to have anxiety diagnoses as adults, compared with their peers who did not participate in team sports.2
Of course, the details matter in team sports. If your patients are participating and they or their parents are worried about spending so much time on something other than homework, talk to them about all of these exceptional benefits of team sports. But the culture of the team matters also. Some teams may be focused on winning at all costs, or have a practice culture that is humiliating or bullying. Some teams may have a culture of partying after games, with binge drinking and drug use. Ask your patients about whether they feel they are respected members of the team, and if effort and sportsmanship are valued as well as performance. Do they trust their coaches? Do they believe their coaches know and care about them? If your patients are not participating in a team sport, encourage them to find one (or more) that engage their interests. The benefits of track and field, crew, and tennis can be just as robust as the benefits of football or soccer. Speak with your patients and their parents about the payoff for their physical, mental, and developmental health the time and effort they are putting into a team sport can provide.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Int J Nutr Phys Act. 2013 Aug 15. doi: 10.1186/1479-5868-10-98.
2. JAMA Pediatr. 2019 Jul 1;173(7):681-8.
Family dinners are good medicine
Intuitively, we have come to believe that adding more to each family members’ schedule – a lesson, an activity, more homework time – is more enriching or meaningful than is a family dinner, which appears to have less direct impact. However, there is a growing body of evidence that, when an entire family eats dinner together 5 or more nights weekly, the emotional health and well-being of all family members is improved. Not only is their health improved, as there is a greater likelihood of eating nutritious food, but so are a child’s school performance and emotional well-being.
But less than 60% of children eat five or more meals with their parents each week (National Center on Addiction and Substance Abuse [CASA], 2012). Few people would suggest that encouraging families to eat dinner together is a bad idea, but time is the ultimate scarce resource. Preparing food and eating together takes time, and parents and children have many demands on that time that feel nonnegotiable, such as homework, exercise, team practice, or work obligations. When you meet with your patients and explain the tremendous health benefits of eating dinner together, you help your patients and their parents make informed decisions about how to rebalance time to prioritize family dinners that have real but fewer obvious impacts then do a piano lesson or dance class.
Of course, children who eat regular family dinners eat more fruits and vegetables and fewer fried foods and soft drinks than do their peers who eat dinner with their families less often. They are less likely to become obese in youth and more likely to eat healthily and maintain a healthy weight once they live on their own as adults.
Scientific evidence of the mental health benefits to children of eating meals with their families first emerged in the 1990s when the National Center on Addiction and Substance Abuse at Columbia University, New York, began surveying various family behaviors and correlating them with the risk of adolescent substance use and misuse. They found strong evidence that when families ate dinner together five or more times weekly (we’ll call this “frequent family dinners”), their adolescents were far less likely to initiate alcohol and cigarette use and less likely to regularly abuse alcohol and drugs. Subsequent studies have demonstrated that the protective effect may be greater for girls than boys and may be greater for alcohol, cigarettes, and marijuana than for other drugs. But earlier age of first use of substances substantially raises the risk of later addiction, so the health benefits of any delay in first use are significant.
Since CASA’s first studies in the 1990s, researchers began paying closer attention to family meals and a variety of psychiatric problems in youth. They demonstrated that frequent family dinners lowered the risk of other externalizing behaviors in youth, including risky sexual behaviors, threats of physical harm, aggression, fights leading to injury, and carrying or using a weapon.1,2 Frequent family dinners are associated with lower rates of disordered eating behaviors and disordered body image in adolescent girls.3,4 Multiple studies have found a powerful association between frequent family dinners and lower rates of depressive symptoms and suicide attempts in both male and female adolescents.1 Frequent family dinners even have been shown to mitigate against the risks of multiple poor health and academic outcomes in children with high adverse childhood experience (ACE) scores.5
Beyond protecting against problems, frequent family meals are associated with improved well-being and performance. Studies have demonstrated positive associations between frequent family meals and higher levels of self-esteem, self-efficacy, and well-being in adolescents, both male and female. They have consistently found significant associations between frequent family meals and higher grade point averages, commitment to learning, and rich vocabularies in children and adolescents, even after adjustment for demographic and other familial factors.6 And children are not the only ones who benefit. Frequent family meals even have been shown to be associated with higher self-reported levels of well-being and self-esteem, and lower levels of stress among parents.7,8 While investing the time in preparing meals and eating them together may sound stressful, it’s clear the benefits outweigh the risks for parents as well as for their children.
It is important to set the framework for what really matters in a family dinner so that your patients can enjoy all of these benefits. Parents may assume that the meal must be prepared from scratch with only fresh, local, or organic ingredients. But what matters most is that the food is delicious and nutritious, and that the time spent eating (and preparing it) is fun, and promotes conversation and connection. Homemade food usually is more nutritious and will bring more of the physical health benefits, but many store-bought ingredients or even take-out options can be healthy and can promote time for the family to sit together and connect. If parents enjoy preparing food, then it’s worthwhile! And they should not worry about having every member of the family together at every meal. Even if only one parent and child are present for a dinner, they each will enjoy the benefits.
Parents can use this time to help promote good habits in their children. Talking about why manners matter while practicing them at the table is powerful for young children. Let them know manners are how we show people that we care about them, whether by taking turns talking or chewing with our mouths closed! Older children and adolescents can learn about how effort is an essential ingredient in every important area in life, from school to meals. Tell them that sometimes the work or effort will be uncomfortable, and pitching in to share the effort lightens everyone’s load. When parents ask for help, they show their children how to do the same and that they have confidence in their child’s ability to be helpful.
Parents should share the joy of the effort, too! They can invite their young children to help with the meal preparation in age-appropriate ways: pulling herbs off of their stems, rinsing vegetables, sprinkling spices, or emptying a box of spaghetti into a pot of water. Older children feel honored to be given bigger responsibilities, such as carrying plates to the table or cutting vegetables (with supervision, when appropriate). And adolescents, exploring their interests and enjoying their independence, may enjoy building their own menus for the family, doing the shopping or leading the preparation of a dish or full meal themselves.
While there is a role for supporting good manners and helpful habits, help parents avoid getting into power struggles with their children over what they will eat or how they conduct themselves at the table. There should be reasonable rules and expectations around mealtime, and predictable, reasonable consequences. If children try a food and don’t like it, they can have a bowl of (nutritious) cereal and stay at the table with the family. Phones should not be allowed at the table, and televisions should be off during the meal (although music may enhance the sense of pleasure or celebration). Mealtime should be time for relaxing, listening, and connecting.
Offer some ideas about how to facilitate conversations. Asking about how a child’s day went may spark conversations sometimes, but usually people benefit from specific questions. What made you really laugh today? What did you have for lunch? Whom did you sit next to on the bus? If a parent starts by telling a story about his or her day, even better! This is especially potent if a parent talks about something embarrassing or challenging, or mentions a failure. Young children will have plenty of these stories, and adolescents build resilience by internalizing the idea that setbacks and difficulties are a normal, healthy part of every day. This is a great time to talk about current events, whether in the news, entertainment, or sports. And telling stories about when children were younger, when the parents were children, or even about grandparents or more distant ancestors is a wonderful way to engage children in the greater story of their family narrative, and is always engaging and memorable.
At a deeper level, the family dinner is a time that recognizes each person’s contribution to a discussion, and facilitates a calm discussion of the families’ history and values. There is connection, communication, and building of trust. Families that cannot schedule a minimum number of dinners or that have dinners filled with tension and conflict, are very likely to have children at risk. For those conflicted and often unhappy families, a pediatrician’s early recognition and intervention could make a meaningful difference.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. J Adolesc Health. 2006;39(3):337-45.
2. J Adolesc. 2010;33(1):187-96.
3. J Adolesc Health. 2009;44(5):431-6.
4. Health Psychol. 2008;27(Suppl 2):s109-17.
5. J Adolesc Health. 2009;45(4):389-95.
6. Pediatrics. 2019 Jul 8. doi: 10.1542/peds.2018-945.
7. Arch Pediatr Adolesc Med. 2004;158(8):792-6.
8. Prev Med. 2018;113:7-12.
Intuitively, we have come to believe that adding more to each family members’ schedule – a lesson, an activity, more homework time – is more enriching or meaningful than is a family dinner, which appears to have less direct impact. However, there is a growing body of evidence that, when an entire family eats dinner together 5 or more nights weekly, the emotional health and well-being of all family members is improved. Not only is their health improved, as there is a greater likelihood of eating nutritious food, but so are a child’s school performance and emotional well-being.
But less than 60% of children eat five or more meals with their parents each week (National Center on Addiction and Substance Abuse [CASA], 2012). Few people would suggest that encouraging families to eat dinner together is a bad idea, but time is the ultimate scarce resource. Preparing food and eating together takes time, and parents and children have many demands on that time that feel nonnegotiable, such as homework, exercise, team practice, or work obligations. When you meet with your patients and explain the tremendous health benefits of eating dinner together, you help your patients and their parents make informed decisions about how to rebalance time to prioritize family dinners that have real but fewer obvious impacts then do a piano lesson or dance class.
Of course, children who eat regular family dinners eat more fruits and vegetables and fewer fried foods and soft drinks than do their peers who eat dinner with their families less often. They are less likely to become obese in youth and more likely to eat healthily and maintain a healthy weight once they live on their own as adults.
Scientific evidence of the mental health benefits to children of eating meals with their families first emerged in the 1990s when the National Center on Addiction and Substance Abuse at Columbia University, New York, began surveying various family behaviors and correlating them with the risk of adolescent substance use and misuse. They found strong evidence that when families ate dinner together five or more times weekly (we’ll call this “frequent family dinners”), their adolescents were far less likely to initiate alcohol and cigarette use and less likely to regularly abuse alcohol and drugs. Subsequent studies have demonstrated that the protective effect may be greater for girls than boys and may be greater for alcohol, cigarettes, and marijuana than for other drugs. But earlier age of first use of substances substantially raises the risk of later addiction, so the health benefits of any delay in first use are significant.
Since CASA’s first studies in the 1990s, researchers began paying closer attention to family meals and a variety of psychiatric problems in youth. They demonstrated that frequent family dinners lowered the risk of other externalizing behaviors in youth, including risky sexual behaviors, threats of physical harm, aggression, fights leading to injury, and carrying or using a weapon.1,2 Frequent family dinners are associated with lower rates of disordered eating behaviors and disordered body image in adolescent girls.3,4 Multiple studies have found a powerful association between frequent family dinners and lower rates of depressive symptoms and suicide attempts in both male and female adolescents.1 Frequent family dinners even have been shown to mitigate against the risks of multiple poor health and academic outcomes in children with high adverse childhood experience (ACE) scores.5
Beyond protecting against problems, frequent family meals are associated with improved well-being and performance. Studies have demonstrated positive associations between frequent family meals and higher levels of self-esteem, self-efficacy, and well-being in adolescents, both male and female. They have consistently found significant associations between frequent family meals and higher grade point averages, commitment to learning, and rich vocabularies in children and adolescents, even after adjustment for demographic and other familial factors.6 And children are not the only ones who benefit. Frequent family meals even have been shown to be associated with higher self-reported levels of well-being and self-esteem, and lower levels of stress among parents.7,8 While investing the time in preparing meals and eating them together may sound stressful, it’s clear the benefits outweigh the risks for parents as well as for their children.
It is important to set the framework for what really matters in a family dinner so that your patients can enjoy all of these benefits. Parents may assume that the meal must be prepared from scratch with only fresh, local, or organic ingredients. But what matters most is that the food is delicious and nutritious, and that the time spent eating (and preparing it) is fun, and promotes conversation and connection. Homemade food usually is more nutritious and will bring more of the physical health benefits, but many store-bought ingredients or even take-out options can be healthy and can promote time for the family to sit together and connect. If parents enjoy preparing food, then it’s worthwhile! And they should not worry about having every member of the family together at every meal. Even if only one parent and child are present for a dinner, they each will enjoy the benefits.
Parents can use this time to help promote good habits in their children. Talking about why manners matter while practicing them at the table is powerful for young children. Let them know manners are how we show people that we care about them, whether by taking turns talking or chewing with our mouths closed! Older children and adolescents can learn about how effort is an essential ingredient in every important area in life, from school to meals. Tell them that sometimes the work or effort will be uncomfortable, and pitching in to share the effort lightens everyone’s load. When parents ask for help, they show their children how to do the same and that they have confidence in their child’s ability to be helpful.
Parents should share the joy of the effort, too! They can invite their young children to help with the meal preparation in age-appropriate ways: pulling herbs off of their stems, rinsing vegetables, sprinkling spices, or emptying a box of spaghetti into a pot of water. Older children feel honored to be given bigger responsibilities, such as carrying plates to the table or cutting vegetables (with supervision, when appropriate). And adolescents, exploring their interests and enjoying their independence, may enjoy building their own menus for the family, doing the shopping or leading the preparation of a dish or full meal themselves.
While there is a role for supporting good manners and helpful habits, help parents avoid getting into power struggles with their children over what they will eat or how they conduct themselves at the table. There should be reasonable rules and expectations around mealtime, and predictable, reasonable consequences. If children try a food and don’t like it, they can have a bowl of (nutritious) cereal and stay at the table with the family. Phones should not be allowed at the table, and televisions should be off during the meal (although music may enhance the sense of pleasure or celebration). Mealtime should be time for relaxing, listening, and connecting.
Offer some ideas about how to facilitate conversations. Asking about how a child’s day went may spark conversations sometimes, but usually people benefit from specific questions. What made you really laugh today? What did you have for lunch? Whom did you sit next to on the bus? If a parent starts by telling a story about his or her day, even better! This is especially potent if a parent talks about something embarrassing or challenging, or mentions a failure. Young children will have plenty of these stories, and adolescents build resilience by internalizing the idea that setbacks and difficulties are a normal, healthy part of every day. This is a great time to talk about current events, whether in the news, entertainment, or sports. And telling stories about when children were younger, when the parents were children, or even about grandparents or more distant ancestors is a wonderful way to engage children in the greater story of their family narrative, and is always engaging and memorable.
At a deeper level, the family dinner is a time that recognizes each person’s contribution to a discussion, and facilitates a calm discussion of the families’ history and values. There is connection, communication, and building of trust. Families that cannot schedule a minimum number of dinners or that have dinners filled with tension and conflict, are very likely to have children at risk. For those conflicted and often unhappy families, a pediatrician’s early recognition and intervention could make a meaningful difference.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. J Adolesc Health. 2006;39(3):337-45.
2. J Adolesc. 2010;33(1):187-96.
3. J Adolesc Health. 2009;44(5):431-6.
4. Health Psychol. 2008;27(Suppl 2):s109-17.
5. J Adolesc Health. 2009;45(4):389-95.
6. Pediatrics. 2019 Jul 8. doi: 10.1542/peds.2018-945.
7. Arch Pediatr Adolesc Med. 2004;158(8):792-6.
8. Prev Med. 2018;113:7-12.
Intuitively, we have come to believe that adding more to each family members’ schedule – a lesson, an activity, more homework time – is more enriching or meaningful than is a family dinner, which appears to have less direct impact. However, there is a growing body of evidence that, when an entire family eats dinner together 5 or more nights weekly, the emotional health and well-being of all family members is improved. Not only is their health improved, as there is a greater likelihood of eating nutritious food, but so are a child’s school performance and emotional well-being.
But less than 60% of children eat five or more meals with their parents each week (National Center on Addiction and Substance Abuse [CASA], 2012). Few people would suggest that encouraging families to eat dinner together is a bad idea, but time is the ultimate scarce resource. Preparing food and eating together takes time, and parents and children have many demands on that time that feel nonnegotiable, such as homework, exercise, team practice, or work obligations. When you meet with your patients and explain the tremendous health benefits of eating dinner together, you help your patients and their parents make informed decisions about how to rebalance time to prioritize family dinners that have real but fewer obvious impacts then do a piano lesson or dance class.
Of course, children who eat regular family dinners eat more fruits and vegetables and fewer fried foods and soft drinks than do their peers who eat dinner with their families less often. They are less likely to become obese in youth and more likely to eat healthily and maintain a healthy weight once they live on their own as adults.
Scientific evidence of the mental health benefits to children of eating meals with their families first emerged in the 1990s when the National Center on Addiction and Substance Abuse at Columbia University, New York, began surveying various family behaviors and correlating them with the risk of adolescent substance use and misuse. They found strong evidence that when families ate dinner together five or more times weekly (we’ll call this “frequent family dinners”), their adolescents were far less likely to initiate alcohol and cigarette use and less likely to regularly abuse alcohol and drugs. Subsequent studies have demonstrated that the protective effect may be greater for girls than boys and may be greater for alcohol, cigarettes, and marijuana than for other drugs. But earlier age of first use of substances substantially raises the risk of later addiction, so the health benefits of any delay in first use are significant.
Since CASA’s first studies in the 1990s, researchers began paying closer attention to family meals and a variety of psychiatric problems in youth. They demonstrated that frequent family dinners lowered the risk of other externalizing behaviors in youth, including risky sexual behaviors, threats of physical harm, aggression, fights leading to injury, and carrying or using a weapon.1,2 Frequent family dinners are associated with lower rates of disordered eating behaviors and disordered body image in adolescent girls.3,4 Multiple studies have found a powerful association between frequent family dinners and lower rates of depressive symptoms and suicide attempts in both male and female adolescents.1 Frequent family dinners even have been shown to mitigate against the risks of multiple poor health and academic outcomes in children with high adverse childhood experience (ACE) scores.5
Beyond protecting against problems, frequent family meals are associated with improved well-being and performance. Studies have demonstrated positive associations between frequent family meals and higher levels of self-esteem, self-efficacy, and well-being in adolescents, both male and female. They have consistently found significant associations between frequent family meals and higher grade point averages, commitment to learning, and rich vocabularies in children and adolescents, even after adjustment for demographic and other familial factors.6 And children are not the only ones who benefit. Frequent family meals even have been shown to be associated with higher self-reported levels of well-being and self-esteem, and lower levels of stress among parents.7,8 While investing the time in preparing meals and eating them together may sound stressful, it’s clear the benefits outweigh the risks for parents as well as for their children.
It is important to set the framework for what really matters in a family dinner so that your patients can enjoy all of these benefits. Parents may assume that the meal must be prepared from scratch with only fresh, local, or organic ingredients. But what matters most is that the food is delicious and nutritious, and that the time spent eating (and preparing it) is fun, and promotes conversation and connection. Homemade food usually is more nutritious and will bring more of the physical health benefits, but many store-bought ingredients or even take-out options can be healthy and can promote time for the family to sit together and connect. If parents enjoy preparing food, then it’s worthwhile! And they should not worry about having every member of the family together at every meal. Even if only one parent and child are present for a dinner, they each will enjoy the benefits.
Parents can use this time to help promote good habits in their children. Talking about why manners matter while practicing them at the table is powerful for young children. Let them know manners are how we show people that we care about them, whether by taking turns talking or chewing with our mouths closed! Older children and adolescents can learn about how effort is an essential ingredient in every important area in life, from school to meals. Tell them that sometimes the work or effort will be uncomfortable, and pitching in to share the effort lightens everyone’s load. When parents ask for help, they show their children how to do the same and that they have confidence in their child’s ability to be helpful.
Parents should share the joy of the effort, too! They can invite their young children to help with the meal preparation in age-appropriate ways: pulling herbs off of their stems, rinsing vegetables, sprinkling spices, or emptying a box of spaghetti into a pot of water. Older children feel honored to be given bigger responsibilities, such as carrying plates to the table or cutting vegetables (with supervision, when appropriate). And adolescents, exploring their interests and enjoying their independence, may enjoy building their own menus for the family, doing the shopping or leading the preparation of a dish or full meal themselves.
While there is a role for supporting good manners and helpful habits, help parents avoid getting into power struggles with their children over what they will eat or how they conduct themselves at the table. There should be reasonable rules and expectations around mealtime, and predictable, reasonable consequences. If children try a food and don’t like it, they can have a bowl of (nutritious) cereal and stay at the table with the family. Phones should not be allowed at the table, and televisions should be off during the meal (although music may enhance the sense of pleasure or celebration). Mealtime should be time for relaxing, listening, and connecting.
Offer some ideas about how to facilitate conversations. Asking about how a child’s day went may spark conversations sometimes, but usually people benefit from specific questions. What made you really laugh today? What did you have for lunch? Whom did you sit next to on the bus? If a parent starts by telling a story about his or her day, even better! This is especially potent if a parent talks about something embarrassing or challenging, or mentions a failure. Young children will have plenty of these stories, and adolescents build resilience by internalizing the idea that setbacks and difficulties are a normal, healthy part of every day. This is a great time to talk about current events, whether in the news, entertainment, or sports. And telling stories about when children were younger, when the parents were children, or even about grandparents or more distant ancestors is a wonderful way to engage children in the greater story of their family narrative, and is always engaging and memorable.
At a deeper level, the family dinner is a time that recognizes each person’s contribution to a discussion, and facilitates a calm discussion of the families’ history and values. There is connection, communication, and building of trust. Families that cannot schedule a minimum number of dinners or that have dinners filled with tension and conflict, are very likely to have children at risk. For those conflicted and often unhappy families, a pediatrician’s early recognition and intervention could make a meaningful difference.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. J Adolesc Health. 2006;39(3):337-45.
2. J Adolesc. 2010;33(1):187-96.
3. J Adolesc Health. 2009;44(5):431-6.
4. Health Psychol. 2008;27(Suppl 2):s109-17.
5. J Adolesc Health. 2009;45(4):389-95.
6. Pediatrics. 2019 Jul 8. doi: 10.1542/peds.2018-945.
7. Arch Pediatr Adolesc Med. 2004;158(8):792-6.
8. Prev Med. 2018;113:7-12.
Is there an epidemic of anxiety and depression among today’s adolescents?
It seems that every week there are fresh headlines about a mental health crisis in children and adolescents, reporting exploding rates of severe anxiety and depression in youth. These reports raise the question of whether or not there has been a significant change in their incidence: Are more children developing depressive and anxiety disorders? Are they having greater difficulty accessing care? Are the disorders more severe than they were in the past? Or are young people failing to develop appropriate skills to manage anxiety, sadness, and other forms of distress that are a normal (if unpleasant) part of life? These are important questions, as they will help us to advocate for the proper services to address the public health challenge that underlies this “epidemic.”
What do the data show?
It is important to start by noting that epidemiologic data on child psychiatry in the United States are not as robust as we might like. It was only in 1999 that the Surgeon General’s Report on Mental Health articulated that there was a need for a more systematic approach to collecting epidemiologic data on psychiatric illness in children and adolescents. At that time, the consensus was that approximately one in five children would develop a psychiatric illness by the age of 18 and that approximately 5% of all children would experience a severe or persistent mental illness.1 In the 2 decades since then there have been expanded efforts to collect data, including the addition of an adolescent supplement to the National Comorbidity Survey sponsored by the National Institute of Mental Health, although our current estimates still are based on representative surveys of thousands of U.S. children and teenagers, often with questionnaires filled out by their parents. Thus, we may have overestimates of some behavioral disorders that are obvious and of concern to parents or underestimates of certain internalizing disorders such as depression that can remain unstated and contained in the mind of the adolescent. And even with accurate current estimates, our ability to make statements about trends or changes in rates of disease is limited by the very short period of time in which we have been studying these disease rates in U.S. youth, some changes in definitions, and the unknown impact of increasing recognition rather than true change in incidence.
What is unequivocally clear is that psychiatric illnesses usually present in youth and that these illnesses are among the most common illnesses of youth. Current estimates are that nearly one in four young people will have a psychiatric illness (by The Diagnostic and Statistical Manual of Mental Disorders [DSM], Fifth Edition criteria) by the time they turn 18,2 although only 10% of youth will experience an illness that meets the Substance Abuse and Mental Health Services Administration criteria for a serious emotional disturbance, or one that has a substantial impact on a child’s ability to function socially, emotionally, and academically.3
While it once was believed that children did not experience psychiatric illness, we now know that the majority of psychiatric illnesses present during childhood, adolescence, and young adulthood. The Centers for Disease Control and Prevention estimates that 50% of lifetime psychiatric illness has presented by the age of 15 years and 75% by the age of 24. Only one-quarter of all lifetime psychiatric illnesses emerge in full adulthood, or after the age of 24. Early diagnosis and treatment can make a significant difference in the overall impact of serious illnesses such as schizophrenia and bipolar disorder. We also can state with confidence that anxiety disorders are the most common psychiatric illnesses of youth, making up over 30% of all diagnoses, followed by disorders of behavior (19%), mood (14%), and then substance use (11%).4 Even compared with asthma (with a prevalence of approximately 11%), widely considered to be among the most common disease of childhood, psychiatric illnesses are the most common in youth.
The question then is whether these numbers are changing. The National Comorbidity Survey conducted in 2014 found that the incidence of major depressive episodes in adolescents had increased significantly between 2005 and 2014, from 9% to 11%.5 This is a survey of nearly 200,000 youth across the United States, interviewed by phone with a structured questionnaire assessing their (self-reported) DSM criteria for a major depressive episode, along with other illnesses. During this time frame, access to specialty mental health providers increased among adolescents, alongside their rate of use of psychiatric medications and inpatient hospitalization.
In Europe, where they have more robust epidemiological data, there also has been a public perception of an increase in depression in adolescents. Studies there have suggested that prevalence rates have not changed significantly, and that the problem actually may be a function of a growing population, greater public awareness, and higher rates of psychological distress.6
In the United States, it is difficult to place the prevalence rates in a meaningful context, given the shorter time frame during which we have been following these rates in young people. It is worth highlighting that although the rates at which young people are gaining access to mental health clinicians, being prescribed medications, and being admitted to psychiatric hospitals all have increased, there has not been an associated decrease in the rate of illness or in the severity of symptoms. It certainly is possible that the increase in use of services by youth is being driven by the increased prevalence of this diagnosis, or it may be that other factors, such as those detailed in international studies, are driving this increase in the incidence of depression.
What about the suicide rate?
Another statistic that addressed the question of whether there may be an epidemic of anxiety and depression in adolescents is the recent increase in the suicide rate. While the rate of completed suicide in 15- to 24-year-olds has been trending upward over the last decade, it is worth noting that this phenomenon appears to be occurring across age groups and is not isolated to adolescents. While adolescents may have a unique underlying set of issues driving the increase, it also may be that factors affecting the entire population (access to firearms, the epidemic of opioid addiction) may be at the core of this worrisome trend.
What about the role of stress?
It is worth noting that there is evidence of an increased rate of psychological distress in adolescents and young adults separate from any increase in the rate of psychiatric illness. Surveys of adolescents in high school and entering college demonstrate higher self-reported rates of severe stress and anxiety. One survey from the American Psychological Association from August 2018 found teenagers reporting higher levels of stress and related sadness and anxiety than the levels among the adults who were surveyed. So more young people are struggling with feelings of anxiety and sadness, without necessarily meeting criteria for a psychiatric illness. This suggests that levels of external stressors may have increased, or that the establishment of healthy coping skills has somehow been compromised in young people, or both.
What can you do as a clinician?
While the broader question of whether actual incidence rates of depression are on the rise will not be settled any time soon, when a patient of yours complains of high levels of stress, anxiety, or feelings of depression, it is very possible that the individual has a psychiatric diagnosis. A quick screening evaluation, using a questionnaire such as the Pediatric Symptom Checklist and/or a brief interview, can indicate if the patient may benefit from a referral.
In addition, all children, including those who have a psychiatric diagnosis, will benefit from a calm, patient, supportive adult who is interested in their distress. It would be very helpful if you are ready to talk about healthy coping skills, and how they are developed over time and only in the setting of actually struggling with some adversity. Help them frame their source of stress as a challenge rather than a threat. Help them identify their meaningful supports, particularly adults who know them well, and offer concrete and practical advice and motivation. And remind them about how self-care is essential to managing the normal stress of adolescence. Have handouts (or virtual ones) ready on good sleep hygiene, the value of exercise, and fact-based nutritional guidance. Offer strategies to manage screen time so that it is a recharging break and not a time sink. Support their identification of other strategies to decompress and manage stress: Are they recharged by time with friends? Exercise? Playing music? Listening to music? Playing video games? They should be building their personalized list, and it should include more active as well as passive strategies. Educate them about the risks of using drugs and alcohol “to relax,” or only having one way of unwinding. Educate your patients and parents about the special value of a mindfulness practice, whether meditation, yoga, or any activity in which they practice a nonjudgmental observation and acceptance of strong emotions.
Accurate prevalence rates can help us consider the statistical probability of a psychiatric diagnosis. By talking with your patients about stressful feelings, you can consider the individual need for a fuller psychiatric evaluation while also helping them reframe their approach to stress to one that is more empowering, adaptive, and healthy.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Mental Health: A Report of the Surgeon General, National Institutes of Mental Health (1999).
2. Prevalence of psychiatric disorders in childhood and adolescence, in “Mental Health Services: A Public Health Perspective,” 2nd ed. (Oxford, UK: Oxford University Press; 2004, pp. 111-28).
3. Public Health Rep. 2006 May-Jun;121(3):303-10.
4. J Am Acad Child Adolesc Psychiatry. 2010 Oct;49(10):980-9.
5. Pediatrics. 2016 Dec;138(6):e20161878.
6. Depress Anxiety. 2014 Jun;31(6):506-16.
It seems that every week there are fresh headlines about a mental health crisis in children and adolescents, reporting exploding rates of severe anxiety and depression in youth. These reports raise the question of whether or not there has been a significant change in their incidence: Are more children developing depressive and anxiety disorders? Are they having greater difficulty accessing care? Are the disorders more severe than they were in the past? Or are young people failing to develop appropriate skills to manage anxiety, sadness, and other forms of distress that are a normal (if unpleasant) part of life? These are important questions, as they will help us to advocate for the proper services to address the public health challenge that underlies this “epidemic.”
What do the data show?
It is important to start by noting that epidemiologic data on child psychiatry in the United States are not as robust as we might like. It was only in 1999 that the Surgeon General’s Report on Mental Health articulated that there was a need for a more systematic approach to collecting epidemiologic data on psychiatric illness in children and adolescents. At that time, the consensus was that approximately one in five children would develop a psychiatric illness by the age of 18 and that approximately 5% of all children would experience a severe or persistent mental illness.1 In the 2 decades since then there have been expanded efforts to collect data, including the addition of an adolescent supplement to the National Comorbidity Survey sponsored by the National Institute of Mental Health, although our current estimates still are based on representative surveys of thousands of U.S. children and teenagers, often with questionnaires filled out by their parents. Thus, we may have overestimates of some behavioral disorders that are obvious and of concern to parents or underestimates of certain internalizing disorders such as depression that can remain unstated and contained in the mind of the adolescent. And even with accurate current estimates, our ability to make statements about trends or changes in rates of disease is limited by the very short period of time in which we have been studying these disease rates in U.S. youth, some changes in definitions, and the unknown impact of increasing recognition rather than true change in incidence.
What is unequivocally clear is that psychiatric illnesses usually present in youth and that these illnesses are among the most common illnesses of youth. Current estimates are that nearly one in four young people will have a psychiatric illness (by The Diagnostic and Statistical Manual of Mental Disorders [DSM], Fifth Edition criteria) by the time they turn 18,2 although only 10% of youth will experience an illness that meets the Substance Abuse and Mental Health Services Administration criteria for a serious emotional disturbance, or one that has a substantial impact on a child’s ability to function socially, emotionally, and academically.3
While it once was believed that children did not experience psychiatric illness, we now know that the majority of psychiatric illnesses present during childhood, adolescence, and young adulthood. The Centers for Disease Control and Prevention estimates that 50% of lifetime psychiatric illness has presented by the age of 15 years and 75% by the age of 24. Only one-quarter of all lifetime psychiatric illnesses emerge in full adulthood, or after the age of 24. Early diagnosis and treatment can make a significant difference in the overall impact of serious illnesses such as schizophrenia and bipolar disorder. We also can state with confidence that anxiety disorders are the most common psychiatric illnesses of youth, making up over 30% of all diagnoses, followed by disorders of behavior (19%), mood (14%), and then substance use (11%).4 Even compared with asthma (with a prevalence of approximately 11%), widely considered to be among the most common disease of childhood, psychiatric illnesses are the most common in youth.
The question then is whether these numbers are changing. The National Comorbidity Survey conducted in 2014 found that the incidence of major depressive episodes in adolescents had increased significantly between 2005 and 2014, from 9% to 11%.5 This is a survey of nearly 200,000 youth across the United States, interviewed by phone with a structured questionnaire assessing their (self-reported) DSM criteria for a major depressive episode, along with other illnesses. During this time frame, access to specialty mental health providers increased among adolescents, alongside their rate of use of psychiatric medications and inpatient hospitalization.
In Europe, where they have more robust epidemiological data, there also has been a public perception of an increase in depression in adolescents. Studies there have suggested that prevalence rates have not changed significantly, and that the problem actually may be a function of a growing population, greater public awareness, and higher rates of psychological distress.6
In the United States, it is difficult to place the prevalence rates in a meaningful context, given the shorter time frame during which we have been following these rates in young people. It is worth highlighting that although the rates at which young people are gaining access to mental health clinicians, being prescribed medications, and being admitted to psychiatric hospitals all have increased, there has not been an associated decrease in the rate of illness or in the severity of symptoms. It certainly is possible that the increase in use of services by youth is being driven by the increased prevalence of this diagnosis, or it may be that other factors, such as those detailed in international studies, are driving this increase in the incidence of depression.
What about the suicide rate?
Another statistic that addressed the question of whether there may be an epidemic of anxiety and depression in adolescents is the recent increase in the suicide rate. While the rate of completed suicide in 15- to 24-year-olds has been trending upward over the last decade, it is worth noting that this phenomenon appears to be occurring across age groups and is not isolated to adolescents. While adolescents may have a unique underlying set of issues driving the increase, it also may be that factors affecting the entire population (access to firearms, the epidemic of opioid addiction) may be at the core of this worrisome trend.
What about the role of stress?
It is worth noting that there is evidence of an increased rate of psychological distress in adolescents and young adults separate from any increase in the rate of psychiatric illness. Surveys of adolescents in high school and entering college demonstrate higher self-reported rates of severe stress and anxiety. One survey from the American Psychological Association from August 2018 found teenagers reporting higher levels of stress and related sadness and anxiety than the levels among the adults who were surveyed. So more young people are struggling with feelings of anxiety and sadness, without necessarily meeting criteria for a psychiatric illness. This suggests that levels of external stressors may have increased, or that the establishment of healthy coping skills has somehow been compromised in young people, or both.
What can you do as a clinician?
While the broader question of whether actual incidence rates of depression are on the rise will not be settled any time soon, when a patient of yours complains of high levels of stress, anxiety, or feelings of depression, it is very possible that the individual has a psychiatric diagnosis. A quick screening evaluation, using a questionnaire such as the Pediatric Symptom Checklist and/or a brief interview, can indicate if the patient may benefit from a referral.
In addition, all children, including those who have a psychiatric diagnosis, will benefit from a calm, patient, supportive adult who is interested in their distress. It would be very helpful if you are ready to talk about healthy coping skills, and how they are developed over time and only in the setting of actually struggling with some adversity. Help them frame their source of stress as a challenge rather than a threat. Help them identify their meaningful supports, particularly adults who know them well, and offer concrete and practical advice and motivation. And remind them about how self-care is essential to managing the normal stress of adolescence. Have handouts (or virtual ones) ready on good sleep hygiene, the value of exercise, and fact-based nutritional guidance. Offer strategies to manage screen time so that it is a recharging break and not a time sink. Support their identification of other strategies to decompress and manage stress: Are they recharged by time with friends? Exercise? Playing music? Listening to music? Playing video games? They should be building their personalized list, and it should include more active as well as passive strategies. Educate them about the risks of using drugs and alcohol “to relax,” or only having one way of unwinding. Educate your patients and parents about the special value of a mindfulness practice, whether meditation, yoga, or any activity in which they practice a nonjudgmental observation and acceptance of strong emotions.
Accurate prevalence rates can help us consider the statistical probability of a psychiatric diagnosis. By talking with your patients about stressful feelings, you can consider the individual need for a fuller psychiatric evaluation while also helping them reframe their approach to stress to one that is more empowering, adaptive, and healthy.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Mental Health: A Report of the Surgeon General, National Institutes of Mental Health (1999).
2. Prevalence of psychiatric disorders in childhood and adolescence, in “Mental Health Services: A Public Health Perspective,” 2nd ed. (Oxford, UK: Oxford University Press; 2004, pp. 111-28).
3. Public Health Rep. 2006 May-Jun;121(3):303-10.
4. J Am Acad Child Adolesc Psychiatry. 2010 Oct;49(10):980-9.
5. Pediatrics. 2016 Dec;138(6):e20161878.
6. Depress Anxiety. 2014 Jun;31(6):506-16.
It seems that every week there are fresh headlines about a mental health crisis in children and adolescents, reporting exploding rates of severe anxiety and depression in youth. These reports raise the question of whether or not there has been a significant change in their incidence: Are more children developing depressive and anxiety disorders? Are they having greater difficulty accessing care? Are the disorders more severe than they were in the past? Or are young people failing to develop appropriate skills to manage anxiety, sadness, and other forms of distress that are a normal (if unpleasant) part of life? These are important questions, as they will help us to advocate for the proper services to address the public health challenge that underlies this “epidemic.”
What do the data show?
It is important to start by noting that epidemiologic data on child psychiatry in the United States are not as robust as we might like. It was only in 1999 that the Surgeon General’s Report on Mental Health articulated that there was a need for a more systematic approach to collecting epidemiologic data on psychiatric illness in children and adolescents. At that time, the consensus was that approximately one in five children would develop a psychiatric illness by the age of 18 and that approximately 5% of all children would experience a severe or persistent mental illness.1 In the 2 decades since then there have been expanded efforts to collect data, including the addition of an adolescent supplement to the National Comorbidity Survey sponsored by the National Institute of Mental Health, although our current estimates still are based on representative surveys of thousands of U.S. children and teenagers, often with questionnaires filled out by their parents. Thus, we may have overestimates of some behavioral disorders that are obvious and of concern to parents or underestimates of certain internalizing disorders such as depression that can remain unstated and contained in the mind of the adolescent. And even with accurate current estimates, our ability to make statements about trends or changes in rates of disease is limited by the very short period of time in which we have been studying these disease rates in U.S. youth, some changes in definitions, and the unknown impact of increasing recognition rather than true change in incidence.
What is unequivocally clear is that psychiatric illnesses usually present in youth and that these illnesses are among the most common illnesses of youth. Current estimates are that nearly one in four young people will have a psychiatric illness (by The Diagnostic and Statistical Manual of Mental Disorders [DSM], Fifth Edition criteria) by the time they turn 18,2 although only 10% of youth will experience an illness that meets the Substance Abuse and Mental Health Services Administration criteria for a serious emotional disturbance, or one that has a substantial impact on a child’s ability to function socially, emotionally, and academically.3
While it once was believed that children did not experience psychiatric illness, we now know that the majority of psychiatric illnesses present during childhood, adolescence, and young adulthood. The Centers for Disease Control and Prevention estimates that 50% of lifetime psychiatric illness has presented by the age of 15 years and 75% by the age of 24. Only one-quarter of all lifetime psychiatric illnesses emerge in full adulthood, or after the age of 24. Early diagnosis and treatment can make a significant difference in the overall impact of serious illnesses such as schizophrenia and bipolar disorder. We also can state with confidence that anxiety disorders are the most common psychiatric illnesses of youth, making up over 30% of all diagnoses, followed by disorders of behavior (19%), mood (14%), and then substance use (11%).4 Even compared with asthma (with a prevalence of approximately 11%), widely considered to be among the most common disease of childhood, psychiatric illnesses are the most common in youth.
The question then is whether these numbers are changing. The National Comorbidity Survey conducted in 2014 found that the incidence of major depressive episodes in adolescents had increased significantly between 2005 and 2014, from 9% to 11%.5 This is a survey of nearly 200,000 youth across the United States, interviewed by phone with a structured questionnaire assessing their (self-reported) DSM criteria for a major depressive episode, along with other illnesses. During this time frame, access to specialty mental health providers increased among adolescents, alongside their rate of use of psychiatric medications and inpatient hospitalization.
In Europe, where they have more robust epidemiological data, there also has been a public perception of an increase in depression in adolescents. Studies there have suggested that prevalence rates have not changed significantly, and that the problem actually may be a function of a growing population, greater public awareness, and higher rates of psychological distress.6
In the United States, it is difficult to place the prevalence rates in a meaningful context, given the shorter time frame during which we have been following these rates in young people. It is worth highlighting that although the rates at which young people are gaining access to mental health clinicians, being prescribed medications, and being admitted to psychiatric hospitals all have increased, there has not been an associated decrease in the rate of illness or in the severity of symptoms. It certainly is possible that the increase in use of services by youth is being driven by the increased prevalence of this diagnosis, or it may be that other factors, such as those detailed in international studies, are driving this increase in the incidence of depression.
What about the suicide rate?
Another statistic that addressed the question of whether there may be an epidemic of anxiety and depression in adolescents is the recent increase in the suicide rate. While the rate of completed suicide in 15- to 24-year-olds has been trending upward over the last decade, it is worth noting that this phenomenon appears to be occurring across age groups and is not isolated to adolescents. While adolescents may have a unique underlying set of issues driving the increase, it also may be that factors affecting the entire population (access to firearms, the epidemic of opioid addiction) may be at the core of this worrisome trend.
What about the role of stress?
It is worth noting that there is evidence of an increased rate of psychological distress in adolescents and young adults separate from any increase in the rate of psychiatric illness. Surveys of adolescents in high school and entering college demonstrate higher self-reported rates of severe stress and anxiety. One survey from the American Psychological Association from August 2018 found teenagers reporting higher levels of stress and related sadness and anxiety than the levels among the adults who were surveyed. So more young people are struggling with feelings of anxiety and sadness, without necessarily meeting criteria for a psychiatric illness. This suggests that levels of external stressors may have increased, or that the establishment of healthy coping skills has somehow been compromised in young people, or both.
What can you do as a clinician?
While the broader question of whether actual incidence rates of depression are on the rise will not be settled any time soon, when a patient of yours complains of high levels of stress, anxiety, or feelings of depression, it is very possible that the individual has a psychiatric diagnosis. A quick screening evaluation, using a questionnaire such as the Pediatric Symptom Checklist and/or a brief interview, can indicate if the patient may benefit from a referral.
In addition, all children, including those who have a psychiatric diagnosis, will benefit from a calm, patient, supportive adult who is interested in their distress. It would be very helpful if you are ready to talk about healthy coping skills, and how they are developed over time and only in the setting of actually struggling with some adversity. Help them frame their source of stress as a challenge rather than a threat. Help them identify their meaningful supports, particularly adults who know them well, and offer concrete and practical advice and motivation. And remind them about how self-care is essential to managing the normal stress of adolescence. Have handouts (or virtual ones) ready on good sleep hygiene, the value of exercise, and fact-based nutritional guidance. Offer strategies to manage screen time so that it is a recharging break and not a time sink. Support their identification of other strategies to decompress and manage stress: Are they recharged by time with friends? Exercise? Playing music? Listening to music? Playing video games? They should be building their personalized list, and it should include more active as well as passive strategies. Educate them about the risks of using drugs and alcohol “to relax,” or only having one way of unwinding. Educate your patients and parents about the special value of a mindfulness practice, whether meditation, yoga, or any activity in which they practice a nonjudgmental observation and acceptance of strong emotions.
Accurate prevalence rates can help us consider the statistical probability of a psychiatric diagnosis. By talking with your patients about stressful feelings, you can consider the individual need for a fuller psychiatric evaluation while also helping them reframe their approach to stress to one that is more empowering, adaptive, and healthy.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Mental Health: A Report of the Surgeon General, National Institutes of Mental Health (1999).
2. Prevalence of psychiatric disorders in childhood and adolescence, in “Mental Health Services: A Public Health Perspective,” 2nd ed. (Oxford, UK: Oxford University Press; 2004, pp. 111-28).
3. Public Health Rep. 2006 May-Jun;121(3):303-10.
4. J Am Acad Child Adolesc Psychiatry. 2010 Oct;49(10):980-9.
5. Pediatrics. 2016 Dec;138(6):e20161878.
6. Depress Anxiety. 2014 Jun;31(6):506-16.
Failure to launch can happen to college students
March often is the time of year when college freshmen truly begin to feel comfortable in their new settings. Many students report feeling excited to get back to campus after the long winter break, and once into their second semester, they feel more comfortable with the independence from family and high school supports. It also is a time for some college freshmen to return home after failing to manage this major transition.
Of the latter group, many will have had difficult months of depression, anxiety, or substance use, and most will be suffering from a deep sense of shame after failing to navigate this long-anticipated transition. Asking detailed questions about their academic challenges, social lives, self-care, and sleep while they were on campus will help you make thoughtful recommendations to your patients and their parents about how they might best get back on track.
Some students will report a great social experience, but academic struggles. They will report some normal ups and downs emotionally, but most of their distress will have been focused on their academic performance. Many 18-year-olds have not had to organize their time and effort around homework without the attention and support of parents and teachers. College often has much bigger classes, with less personal attention. There is a lot of assigned reading, but no regular incremental homework, only a major midterm and final exam, or a substantial paper. For a student who gets anxious about performance, or one with organizational challenges, this can lead to procrastination and poor performance.
Find out details about how they did academically. Did they fail one class or many classes? Did they receive some incompletes in their first semester and then struggle to catch up with them while keeping up with their second semester work? Did they have tutoring or support? Were they unrealistic about their course load? Or did they have their first serious relationship and not spend enough time on homework? Did they spend too much time partying with their new friends and not enough time sleeping and getting their homework done?
It is important to dig deeper if patients report regular or binge drug and alcohol use that interfered with their academic performance, as they may need more substantial substance use disorder treatment. Most students, though, will not have a substance use disorder. Instead, their academic failure could represent something as simple as the need for more academic support and time management support. Many schools have such programs to help students learn how to better manage their time and effort as they take fuller responsibility than they had for it in high school.
For other students, you will learn that their emotional distress preceded their academic troubles. The stress of the transition to college may be enough to trigger an episode of depression or to exacerbate a mood or anxiety disorder that was subclinical or in remission before school started. These students usually will report that sadness, intense anxiety, or loss of interest came early in their semester; perhaps they were even doing well academically when these problems started.
Ask about how their sleep was. Often they had difficulty falling asleep or woke up often at night, unlike most college students, whose sleep is compromised because they stay up late with new friends or because they are hard at work, but could easily sleep at any time.
Find out about their eating habits. Did they lose their appetite? Lose weight? Did they become preoccupied with weight or body image issues and begin restricting their intake? Eating disorders can begin in college when vulnerable students are stressed and have more control over their diet. While weight gain is more common in freshman year, it often is connected to poor stress management skills, and is more often a marker of a student who was struggling academically and then managing stress by overeating.
In the case where the distress came first, it is critical that your patients have a thorough psychiatric evaluation and treatment. It may be possible for them to return to school quickly, but it is most important that they are engaged in effective treatment and in at last partial remission before adding to their stress by attempting to return to school. Often, ambitious students and their parents need to hear this message very clearly from a pediatrician. A rushed return to school may be a set-up for a more protracted and difficult course of illness. For these students, it may be better to have a fresh start in a new semester. Help them (and their parents) to understand that they should use their time off to focus on treatment and good self-care so they might benefit from the many opportunities of college.
For a small minority of college students who do not succeed at college, their social withdrawal, academic deterioration, anxiety, and loss of interest in previous passions may occur alongside more serious psychiatric symptoms such as auditory hallucinations, paranoia, or grandiosity. Any time there is a suggestion of psychotic symptoms in a previously healthy person in the late teens or early 20s, a prompt comprehensive psychiatric evaluation is critical. These years are when most chronic psychotic disorders, such as schizophrenia, are likely to emerge. These patients require a thorough evaluation to distinguish these disorders from other illnesses, especially when they occur with substance use. And these patients require specialized care.
If your patient appears to have any psychotic symptoms, it is critical that you help the family find an excellent psychiatrist, or even a clinic that specializes in thought disorders so that he or she may get the best possible care early.
There is another class of students who withdraw from college who will need more comprehensive remediation, but not connected to any psychiatric diagnosis. Some young people may not be developmentally ready for college. These are your patients who often were excellent performers in high school, perhaps academically and athletically, but whose performance was more connected to pleasing important adults than to genuine motivating passions or sense of purpose. These young adults may have been drawn into the intense, results-oriented forces that are powerful in many of our high schools. If they did not have enough time or space to explore a host of interests, and to then manage the routine failures, setbacks, and disappointments that are essential to healthy adolescent development, they are going to run out of fuel in college. Such students often are quite dependent on their parents, and struggle with the independence college offers.
If your patients report that they could not muster the same intense work ethic they previously had, without any evidence of a psychiatric illness interfering with motivation, they may need time to finish the developmental work of cultivating a deep and rich sense of their own identity. Some students can do this at college, provided they, their parents and their school offer them adequate time before they have to declare a major. Other students will need to get a job and explore interests with a few courses at a community college, cultivating independence while learning about their own strengths and weaknesses and their genuine interests. This way, when they return to school, they will be motivated by a genuine sense of purpose and self-knowledge.
“Failure to launch” is a critical symptom at a key transitional moment. Pediatric providers can be essential to their patients and families by clarifying the nature of the difficulty and coordinating a reasonable plan to get these young adults back on track to healthy adulthood.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
March often is the time of year when college freshmen truly begin to feel comfortable in their new settings. Many students report feeling excited to get back to campus after the long winter break, and once into their second semester, they feel more comfortable with the independence from family and high school supports. It also is a time for some college freshmen to return home after failing to manage this major transition.
Of the latter group, many will have had difficult months of depression, anxiety, or substance use, and most will be suffering from a deep sense of shame after failing to navigate this long-anticipated transition. Asking detailed questions about their academic challenges, social lives, self-care, and sleep while they were on campus will help you make thoughtful recommendations to your patients and their parents about how they might best get back on track.
Some students will report a great social experience, but academic struggles. They will report some normal ups and downs emotionally, but most of their distress will have been focused on their academic performance. Many 18-year-olds have not had to organize their time and effort around homework without the attention and support of parents and teachers. College often has much bigger classes, with less personal attention. There is a lot of assigned reading, but no regular incremental homework, only a major midterm and final exam, or a substantial paper. For a student who gets anxious about performance, or one with organizational challenges, this can lead to procrastination and poor performance.
Find out details about how they did academically. Did they fail one class or many classes? Did they receive some incompletes in their first semester and then struggle to catch up with them while keeping up with their second semester work? Did they have tutoring or support? Were they unrealistic about their course load? Or did they have their first serious relationship and not spend enough time on homework? Did they spend too much time partying with their new friends and not enough time sleeping and getting their homework done?
It is important to dig deeper if patients report regular or binge drug and alcohol use that interfered with their academic performance, as they may need more substantial substance use disorder treatment. Most students, though, will not have a substance use disorder. Instead, their academic failure could represent something as simple as the need for more academic support and time management support. Many schools have such programs to help students learn how to better manage their time and effort as they take fuller responsibility than they had for it in high school.
For other students, you will learn that their emotional distress preceded their academic troubles. The stress of the transition to college may be enough to trigger an episode of depression or to exacerbate a mood or anxiety disorder that was subclinical or in remission before school started. These students usually will report that sadness, intense anxiety, or loss of interest came early in their semester; perhaps they were even doing well academically when these problems started.
Ask about how their sleep was. Often they had difficulty falling asleep or woke up often at night, unlike most college students, whose sleep is compromised because they stay up late with new friends or because they are hard at work, but could easily sleep at any time.
Find out about their eating habits. Did they lose their appetite? Lose weight? Did they become preoccupied with weight or body image issues and begin restricting their intake? Eating disorders can begin in college when vulnerable students are stressed and have more control over their diet. While weight gain is more common in freshman year, it often is connected to poor stress management skills, and is more often a marker of a student who was struggling academically and then managing stress by overeating.
In the case where the distress came first, it is critical that your patients have a thorough psychiatric evaluation and treatment. It may be possible for them to return to school quickly, but it is most important that they are engaged in effective treatment and in at last partial remission before adding to their stress by attempting to return to school. Often, ambitious students and their parents need to hear this message very clearly from a pediatrician. A rushed return to school may be a set-up for a more protracted and difficult course of illness. For these students, it may be better to have a fresh start in a new semester. Help them (and their parents) to understand that they should use their time off to focus on treatment and good self-care so they might benefit from the many opportunities of college.
For a small minority of college students who do not succeed at college, their social withdrawal, academic deterioration, anxiety, and loss of interest in previous passions may occur alongside more serious psychiatric symptoms such as auditory hallucinations, paranoia, or grandiosity. Any time there is a suggestion of psychotic symptoms in a previously healthy person in the late teens or early 20s, a prompt comprehensive psychiatric evaluation is critical. These years are when most chronic psychotic disorders, such as schizophrenia, are likely to emerge. These patients require a thorough evaluation to distinguish these disorders from other illnesses, especially when they occur with substance use. And these patients require specialized care.
If your patient appears to have any psychotic symptoms, it is critical that you help the family find an excellent psychiatrist, or even a clinic that specializes in thought disorders so that he or she may get the best possible care early.
There is another class of students who withdraw from college who will need more comprehensive remediation, but not connected to any psychiatric diagnosis. Some young people may not be developmentally ready for college. These are your patients who often were excellent performers in high school, perhaps academically and athletically, but whose performance was more connected to pleasing important adults than to genuine motivating passions or sense of purpose. These young adults may have been drawn into the intense, results-oriented forces that are powerful in many of our high schools. If they did not have enough time or space to explore a host of interests, and to then manage the routine failures, setbacks, and disappointments that are essential to healthy adolescent development, they are going to run out of fuel in college. Such students often are quite dependent on their parents, and struggle with the independence college offers.
If your patients report that they could not muster the same intense work ethic they previously had, without any evidence of a psychiatric illness interfering with motivation, they may need time to finish the developmental work of cultivating a deep and rich sense of their own identity. Some students can do this at college, provided they, their parents and their school offer them adequate time before they have to declare a major. Other students will need to get a job and explore interests with a few courses at a community college, cultivating independence while learning about their own strengths and weaknesses and their genuine interests. This way, when they return to school, they will be motivated by a genuine sense of purpose and self-knowledge.
“Failure to launch” is a critical symptom at a key transitional moment. Pediatric providers can be essential to their patients and families by clarifying the nature of the difficulty and coordinating a reasonable plan to get these young adults back on track to healthy adulthood.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
March often is the time of year when college freshmen truly begin to feel comfortable in their new settings. Many students report feeling excited to get back to campus after the long winter break, and once into their second semester, they feel more comfortable with the independence from family and high school supports. It also is a time for some college freshmen to return home after failing to manage this major transition.
Of the latter group, many will have had difficult months of depression, anxiety, or substance use, and most will be suffering from a deep sense of shame after failing to navigate this long-anticipated transition. Asking detailed questions about their academic challenges, social lives, self-care, and sleep while they were on campus will help you make thoughtful recommendations to your patients and their parents about how they might best get back on track.
Some students will report a great social experience, but academic struggles. They will report some normal ups and downs emotionally, but most of their distress will have been focused on their academic performance. Many 18-year-olds have not had to organize their time and effort around homework without the attention and support of parents and teachers. College often has much bigger classes, with less personal attention. There is a lot of assigned reading, but no regular incremental homework, only a major midterm and final exam, or a substantial paper. For a student who gets anxious about performance, or one with organizational challenges, this can lead to procrastination and poor performance.
Find out details about how they did academically. Did they fail one class or many classes? Did they receive some incompletes in their first semester and then struggle to catch up with them while keeping up with their second semester work? Did they have tutoring or support? Were they unrealistic about their course load? Or did they have their first serious relationship and not spend enough time on homework? Did they spend too much time partying with their new friends and not enough time sleeping and getting their homework done?
It is important to dig deeper if patients report regular or binge drug and alcohol use that interfered with their academic performance, as they may need more substantial substance use disorder treatment. Most students, though, will not have a substance use disorder. Instead, their academic failure could represent something as simple as the need for more academic support and time management support. Many schools have such programs to help students learn how to better manage their time and effort as they take fuller responsibility than they had for it in high school.
For other students, you will learn that their emotional distress preceded their academic troubles. The stress of the transition to college may be enough to trigger an episode of depression or to exacerbate a mood or anxiety disorder that was subclinical or in remission before school started. These students usually will report that sadness, intense anxiety, or loss of interest came early in their semester; perhaps they were even doing well academically when these problems started.
Ask about how their sleep was. Often they had difficulty falling asleep or woke up often at night, unlike most college students, whose sleep is compromised because they stay up late with new friends or because they are hard at work, but could easily sleep at any time.
Find out about their eating habits. Did they lose their appetite? Lose weight? Did they become preoccupied with weight or body image issues and begin restricting their intake? Eating disorders can begin in college when vulnerable students are stressed and have more control over their diet. While weight gain is more common in freshman year, it often is connected to poor stress management skills, and is more often a marker of a student who was struggling academically and then managing stress by overeating.
In the case where the distress came first, it is critical that your patients have a thorough psychiatric evaluation and treatment. It may be possible for them to return to school quickly, but it is most important that they are engaged in effective treatment and in at last partial remission before adding to their stress by attempting to return to school. Often, ambitious students and their parents need to hear this message very clearly from a pediatrician. A rushed return to school may be a set-up for a more protracted and difficult course of illness. For these students, it may be better to have a fresh start in a new semester. Help them (and their parents) to understand that they should use their time off to focus on treatment and good self-care so they might benefit from the many opportunities of college.
For a small minority of college students who do not succeed at college, their social withdrawal, academic deterioration, anxiety, and loss of interest in previous passions may occur alongside more serious psychiatric symptoms such as auditory hallucinations, paranoia, or grandiosity. Any time there is a suggestion of psychotic symptoms in a previously healthy person in the late teens or early 20s, a prompt comprehensive psychiatric evaluation is critical. These years are when most chronic psychotic disorders, such as schizophrenia, are likely to emerge. These patients require a thorough evaluation to distinguish these disorders from other illnesses, especially when they occur with substance use. And these patients require specialized care.
If your patient appears to have any psychotic symptoms, it is critical that you help the family find an excellent psychiatrist, or even a clinic that specializes in thought disorders so that he or she may get the best possible care early.
There is another class of students who withdraw from college who will need more comprehensive remediation, but not connected to any psychiatric diagnosis. Some young people may not be developmentally ready for college. These are your patients who often were excellent performers in high school, perhaps academically and athletically, but whose performance was more connected to pleasing important adults than to genuine motivating passions or sense of purpose. These young adults may have been drawn into the intense, results-oriented forces that are powerful in many of our high schools. If they did not have enough time or space to explore a host of interests, and to then manage the routine failures, setbacks, and disappointments that are essential to healthy adolescent development, they are going to run out of fuel in college. Such students often are quite dependent on their parents, and struggle with the independence college offers.
If your patients report that they could not muster the same intense work ethic they previously had, without any evidence of a psychiatric illness interfering with motivation, they may need time to finish the developmental work of cultivating a deep and rich sense of their own identity. Some students can do this at college, provided they, their parents and their school offer them adequate time before they have to declare a major. Other students will need to get a job and explore interests with a few courses at a community college, cultivating independence while learning about their own strengths and weaknesses and their genuine interests. This way, when they return to school, they will be motivated by a genuine sense of purpose and self-knowledge.
“Failure to launch” is a critical symptom at a key transitional moment. Pediatric providers can be essential to their patients and families by clarifying the nature of the difficulty and coordinating a reasonable plan to get these young adults back on track to healthy adulthood.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
Help parents manage screen time thoughtfully
It has been 2 years since we last wrote about the potential risks to children and adolescents of spending too much time on screens. While there have been studies in the interval that offer us more information about the effects of heavy screen use and the developing brain, there is little certainty about what is optimal for children and adolescents, and less still on how parents might effectively equip their children to make good use of screens without suffering ill effects.
You might recall that back in October of 2016, the American Academy of Pediatrics published screen time guidelines: recommending no screen time for infants and children up to 18 months old, limiting all screen time to 1 hour per day for children up to 5 years old, and 2 hours daily for older children (up to 11 years old), so that it would not interfere with homework, social time, exercise, and sleep. At the time, data suggested that children from 2 to 11 years old were spending an average of 4.5 hours per day on screens (TV, computer, tablets, or smartphones, not counting homework).
The Adolescent Brain Cognitive Development Study began in September 2016 to evaluate the effects of Canadian recommendations for 8- to 11-year-olds (9-11 hours sleep nightly, 1 hour of exercise daily, and 2 hours or less of screen time daily; the study subjects are in the United States). This fall they published their initial results, demonstrating that only 51% get the recommended amount of sleep, only 37% kept their daily screen time to under 2 hours, and only 18% were getting the recommended amount of exercise. Only 5% of children consistently met all three recommendations while 29% of children didn’t meet any of the recommendations.
The researchers assessed the children’s cognitive development and found that after 1 year, those children who met the screen time recommendations, both screen time and sleep, or all three recommendations demonstrated “superior global cognition.” Children were spending an average of 3.7 hours daily on screens, and those children who were spending 2 hours or less on screens performed 4% better on tests of cognitive function than did children spending the average amount of time. Sleep and exercise differences alone did not contribute to significant differences in cognitive function. This study will continue for another 10 years.1
In a much smaller study out of Cincinnati Children’s Hospital, researchers asked parents to describe the amount of time a child spent on reading and in screen-based media activities, then completed MRI scans of the children’s brains.2 They found a strong association between reading time and higher functional connectivity between the parts of the brain responsible for visual word formation and those responsible for language and cognitive control, with a negative correlation between functional connectivity and time spent in screen-based media activities.
While these studies are important pieces of data as we build a deeper understanding about the effects of screen-based media use on children’s cognitive and behavioral development, they do not offer certainty about causality. These studies do not yet clarify whether certain children are especially vulnerable to the untoward effects of heavy screen-based media use. Perhaps the research will someday offer guidelines with certainty, but families need guidance now. Without doubt, digital devices are here to stay, are important to homework, and can facilitate independence, long-distance connections, important technical work-skills, and even senseless fun and relaxation. So we will focus on offering some principles to help you guide young people (or their parents) in approaching screen time thoughtfully.
While recommending no more than 2 hours of daily screen time seems reasonable, it may be more useful to focus on what young people are doing with the rest of their time. Are they getting adequate, restful sleep? Are they able to exercise most days? Do they have enough time for homework? Do they have time for friends (time actually together, not just texting)? What about time for hobbies? When parents focus on the precious resource of time and all of the activities their children both need and want to do, it sets the frame for them to say that their children are allowed to have time to relax with screen-based media as long as it does not take away from these other priorities. Ensuring that the child has at least 8 hours of sleep, after homework and sports, also will set natural limits on screen time.
Parents also can use the frame of development to guide their rules about screen time. If use of an electronic device serves a developmental task, then it is reasonable. If it interferes with a developmental task, then it should be limited. Adolescents (ages 12-20) should be exploring their own identities, establishing independence, deepening social relationships, and learning to manage their impulses. Some interests can be most easily explored with the aid of a computer (such as with programming, art history, or astronomy). Use of cellphones can facilitate teenagers’ being more independent with plans or transportation. Social connections can be supported by texting or FaceTime. Some close friends may be in a different sport or live far away, and it is possible to stay connected only virtually. However, when use of electronic devices keeps the child from engaging with new friends and new interests or from getting into the world to establish real independence (i.e., a job), then there should be limits. In all of these cases, it is critical that adults explain to teenagers what is guiding their thinking about limits on screen time. Open discussions about the great utility and fun that screens can provide, as well as the challenge of keeping those activities in balance with other important activities, helps adolescents set the frame for that rapidly approaching time when they will be making those choices without adult supervision.
Younger children (ages 8-11) should be sampling a wide array of activities and interests and experiencing challenges and eventual mastery across domains. Video games can be very compelling for this age group because they appeal to exactly this drive to master a challenge. Parents want to ensure that their children can have senseless fun, and still have enough time to explore actual activities: social, athletic, creative, and academic. They can be ready to explain the why of rules, but consistent rules, enforced for everyone at home, are most helpful for this age group.
You also can help parents to consider the child’s temperament when thinking about which rules will be appropriate. Anxious children and teenagers may be especially prone to immersive virtual activities that allow them to avoid the stress of real undertakings or interactions. But anxious children may be able to prepare for something anxiety provoking by exploring it virtually first. Youth with ADHD are going to struggle with shifting away from video games or other electronic activities they enjoy that don’t have a natural ending, and will need strict rules and patient support around balanced screen time use. Screen time may play to a child’s strengths, enabling creative children to take in a wide range of art or music and even create their own when other resources are limited.
Finally, all parents should consider what their own screen use is teaching their children. Adolescents are unlikely to listen to their parents’ recommendations if the parents spend hours online after work. Younger children need their parents’ engaged attention: being coaches and cheerleaders for all of their efforts at mastery. You can help parents to imagine rules that the whole family can follow. They can consider how screen time helps them connect with their children, such as watching a favorite program or sport together. They can explore shared interests online together. They can even relax with ridiculous cat videos together! Screen time together is valuable if it supports parents’ connections with their children, while their rules ensure adequate time for sleep, physical activity, and developmental priorities.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Lancet Child Adolesc Health. 2018 Nov 1;2(11):783-91.
2. Acta Paediatra. 2018 Apr;107(4):685-93
It has been 2 years since we last wrote about the potential risks to children and adolescents of spending too much time on screens. While there have been studies in the interval that offer us more information about the effects of heavy screen use and the developing brain, there is little certainty about what is optimal for children and adolescents, and less still on how parents might effectively equip their children to make good use of screens without suffering ill effects.
You might recall that back in October of 2016, the American Academy of Pediatrics published screen time guidelines: recommending no screen time for infants and children up to 18 months old, limiting all screen time to 1 hour per day for children up to 5 years old, and 2 hours daily for older children (up to 11 years old), so that it would not interfere with homework, social time, exercise, and sleep. At the time, data suggested that children from 2 to 11 years old were spending an average of 4.5 hours per day on screens (TV, computer, tablets, or smartphones, not counting homework).
The Adolescent Brain Cognitive Development Study began in September 2016 to evaluate the effects of Canadian recommendations for 8- to 11-year-olds (9-11 hours sleep nightly, 1 hour of exercise daily, and 2 hours or less of screen time daily; the study subjects are in the United States). This fall they published their initial results, demonstrating that only 51% get the recommended amount of sleep, only 37% kept their daily screen time to under 2 hours, and only 18% were getting the recommended amount of exercise. Only 5% of children consistently met all three recommendations while 29% of children didn’t meet any of the recommendations.
The researchers assessed the children’s cognitive development and found that after 1 year, those children who met the screen time recommendations, both screen time and sleep, or all three recommendations demonstrated “superior global cognition.” Children were spending an average of 3.7 hours daily on screens, and those children who were spending 2 hours or less on screens performed 4% better on tests of cognitive function than did children spending the average amount of time. Sleep and exercise differences alone did not contribute to significant differences in cognitive function. This study will continue for another 10 years.1
In a much smaller study out of Cincinnati Children’s Hospital, researchers asked parents to describe the amount of time a child spent on reading and in screen-based media activities, then completed MRI scans of the children’s brains.2 They found a strong association between reading time and higher functional connectivity between the parts of the brain responsible for visual word formation and those responsible for language and cognitive control, with a negative correlation between functional connectivity and time spent in screen-based media activities.
While these studies are important pieces of data as we build a deeper understanding about the effects of screen-based media use on children’s cognitive and behavioral development, they do not offer certainty about causality. These studies do not yet clarify whether certain children are especially vulnerable to the untoward effects of heavy screen-based media use. Perhaps the research will someday offer guidelines with certainty, but families need guidance now. Without doubt, digital devices are here to stay, are important to homework, and can facilitate independence, long-distance connections, important technical work-skills, and even senseless fun and relaxation. So we will focus on offering some principles to help you guide young people (or their parents) in approaching screen time thoughtfully.
While recommending no more than 2 hours of daily screen time seems reasonable, it may be more useful to focus on what young people are doing with the rest of their time. Are they getting adequate, restful sleep? Are they able to exercise most days? Do they have enough time for homework? Do they have time for friends (time actually together, not just texting)? What about time for hobbies? When parents focus on the precious resource of time and all of the activities their children both need and want to do, it sets the frame for them to say that their children are allowed to have time to relax with screen-based media as long as it does not take away from these other priorities. Ensuring that the child has at least 8 hours of sleep, after homework and sports, also will set natural limits on screen time.
Parents also can use the frame of development to guide their rules about screen time. If use of an electronic device serves a developmental task, then it is reasonable. If it interferes with a developmental task, then it should be limited. Adolescents (ages 12-20) should be exploring their own identities, establishing independence, deepening social relationships, and learning to manage their impulses. Some interests can be most easily explored with the aid of a computer (such as with programming, art history, or astronomy). Use of cellphones can facilitate teenagers’ being more independent with plans or transportation. Social connections can be supported by texting or FaceTime. Some close friends may be in a different sport or live far away, and it is possible to stay connected only virtually. However, when use of electronic devices keeps the child from engaging with new friends and new interests or from getting into the world to establish real independence (i.e., a job), then there should be limits. In all of these cases, it is critical that adults explain to teenagers what is guiding their thinking about limits on screen time. Open discussions about the great utility and fun that screens can provide, as well as the challenge of keeping those activities in balance with other important activities, helps adolescents set the frame for that rapidly approaching time when they will be making those choices without adult supervision.
Younger children (ages 8-11) should be sampling a wide array of activities and interests and experiencing challenges and eventual mastery across domains. Video games can be very compelling for this age group because they appeal to exactly this drive to master a challenge. Parents want to ensure that their children can have senseless fun, and still have enough time to explore actual activities: social, athletic, creative, and academic. They can be ready to explain the why of rules, but consistent rules, enforced for everyone at home, are most helpful for this age group.
You also can help parents to consider the child’s temperament when thinking about which rules will be appropriate. Anxious children and teenagers may be especially prone to immersive virtual activities that allow them to avoid the stress of real undertakings or interactions. But anxious children may be able to prepare for something anxiety provoking by exploring it virtually first. Youth with ADHD are going to struggle with shifting away from video games or other electronic activities they enjoy that don’t have a natural ending, and will need strict rules and patient support around balanced screen time use. Screen time may play to a child’s strengths, enabling creative children to take in a wide range of art or music and even create their own when other resources are limited.
Finally, all parents should consider what their own screen use is teaching their children. Adolescents are unlikely to listen to their parents’ recommendations if the parents spend hours online after work. Younger children need their parents’ engaged attention: being coaches and cheerleaders for all of their efforts at mastery. You can help parents to imagine rules that the whole family can follow. They can consider how screen time helps them connect with their children, such as watching a favorite program or sport together. They can explore shared interests online together. They can even relax with ridiculous cat videos together! Screen time together is valuable if it supports parents’ connections with their children, while their rules ensure adequate time for sleep, physical activity, and developmental priorities.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Lancet Child Adolesc Health. 2018 Nov 1;2(11):783-91.
2. Acta Paediatra. 2018 Apr;107(4):685-93
It has been 2 years since we last wrote about the potential risks to children and adolescents of spending too much time on screens. While there have been studies in the interval that offer us more information about the effects of heavy screen use and the developing brain, there is little certainty about what is optimal for children and adolescents, and less still on how parents might effectively equip their children to make good use of screens without suffering ill effects.
You might recall that back in October of 2016, the American Academy of Pediatrics published screen time guidelines: recommending no screen time for infants and children up to 18 months old, limiting all screen time to 1 hour per day for children up to 5 years old, and 2 hours daily for older children (up to 11 years old), so that it would not interfere with homework, social time, exercise, and sleep. At the time, data suggested that children from 2 to 11 years old were spending an average of 4.5 hours per day on screens (TV, computer, tablets, or smartphones, not counting homework).
The Adolescent Brain Cognitive Development Study began in September 2016 to evaluate the effects of Canadian recommendations for 8- to 11-year-olds (9-11 hours sleep nightly, 1 hour of exercise daily, and 2 hours or less of screen time daily; the study subjects are in the United States). This fall they published their initial results, demonstrating that only 51% get the recommended amount of sleep, only 37% kept their daily screen time to under 2 hours, and only 18% were getting the recommended amount of exercise. Only 5% of children consistently met all three recommendations while 29% of children didn’t meet any of the recommendations.
The researchers assessed the children’s cognitive development and found that after 1 year, those children who met the screen time recommendations, both screen time and sleep, or all three recommendations demonstrated “superior global cognition.” Children were spending an average of 3.7 hours daily on screens, and those children who were spending 2 hours or less on screens performed 4% better on tests of cognitive function than did children spending the average amount of time. Sleep and exercise differences alone did not contribute to significant differences in cognitive function. This study will continue for another 10 years.1
In a much smaller study out of Cincinnati Children’s Hospital, researchers asked parents to describe the amount of time a child spent on reading and in screen-based media activities, then completed MRI scans of the children’s brains.2 They found a strong association between reading time and higher functional connectivity between the parts of the brain responsible for visual word formation and those responsible for language and cognitive control, with a negative correlation between functional connectivity and time spent in screen-based media activities.
While these studies are important pieces of data as we build a deeper understanding about the effects of screen-based media use on children’s cognitive and behavioral development, they do not offer certainty about causality. These studies do not yet clarify whether certain children are especially vulnerable to the untoward effects of heavy screen-based media use. Perhaps the research will someday offer guidelines with certainty, but families need guidance now. Without doubt, digital devices are here to stay, are important to homework, and can facilitate independence, long-distance connections, important technical work-skills, and even senseless fun and relaxation. So we will focus on offering some principles to help you guide young people (or their parents) in approaching screen time thoughtfully.
While recommending no more than 2 hours of daily screen time seems reasonable, it may be more useful to focus on what young people are doing with the rest of their time. Are they getting adequate, restful sleep? Are they able to exercise most days? Do they have enough time for homework? Do they have time for friends (time actually together, not just texting)? What about time for hobbies? When parents focus on the precious resource of time and all of the activities their children both need and want to do, it sets the frame for them to say that their children are allowed to have time to relax with screen-based media as long as it does not take away from these other priorities. Ensuring that the child has at least 8 hours of sleep, after homework and sports, also will set natural limits on screen time.
Parents also can use the frame of development to guide their rules about screen time. If use of an electronic device serves a developmental task, then it is reasonable. If it interferes with a developmental task, then it should be limited. Adolescents (ages 12-20) should be exploring their own identities, establishing independence, deepening social relationships, and learning to manage their impulses. Some interests can be most easily explored with the aid of a computer (such as with programming, art history, or astronomy). Use of cellphones can facilitate teenagers’ being more independent with plans or transportation. Social connections can be supported by texting or FaceTime. Some close friends may be in a different sport or live far away, and it is possible to stay connected only virtually. However, when use of electronic devices keeps the child from engaging with new friends and new interests or from getting into the world to establish real independence (i.e., a job), then there should be limits. In all of these cases, it is critical that adults explain to teenagers what is guiding their thinking about limits on screen time. Open discussions about the great utility and fun that screens can provide, as well as the challenge of keeping those activities in balance with other important activities, helps adolescents set the frame for that rapidly approaching time when they will be making those choices without adult supervision.
Younger children (ages 8-11) should be sampling a wide array of activities and interests and experiencing challenges and eventual mastery across domains. Video games can be very compelling for this age group because they appeal to exactly this drive to master a challenge. Parents want to ensure that their children can have senseless fun, and still have enough time to explore actual activities: social, athletic, creative, and academic. They can be ready to explain the why of rules, but consistent rules, enforced for everyone at home, are most helpful for this age group.
You also can help parents to consider the child’s temperament when thinking about which rules will be appropriate. Anxious children and teenagers may be especially prone to immersive virtual activities that allow them to avoid the stress of real undertakings or interactions. But anxious children may be able to prepare for something anxiety provoking by exploring it virtually first. Youth with ADHD are going to struggle with shifting away from video games or other electronic activities they enjoy that don’t have a natural ending, and will need strict rules and patient support around balanced screen time use. Screen time may play to a child’s strengths, enabling creative children to take in a wide range of art or music and even create their own when other resources are limited.
Finally, all parents should consider what their own screen use is teaching their children. Adolescents are unlikely to listen to their parents’ recommendations if the parents spend hours online after work. Younger children need their parents’ engaged attention: being coaches and cheerleaders for all of their efforts at mastery. You can help parents to imagine rules that the whole family can follow. They can consider how screen time helps them connect with their children, such as watching a favorite program or sport together. They can explore shared interests online together. They can even relax with ridiculous cat videos together! Screen time together is valuable if it supports parents’ connections with their children, while their rules ensure adequate time for sleep, physical activity, and developmental priorities.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Lancet Child Adolesc Health. 2018 Nov 1;2(11):783-91.
2. Acta Paediatra. 2018 Apr;107(4):685-93
How to manage school failure
The start of the school year brings excitement and some expected anxiety, around seeing friends and undertaking new challenges. While setbacks, small failures, and disappointments are an essential part of a child’s mastery of new challenges, academic and otherwise, occasionally a child will experience school failure in many areas. When this happens, the school usually will engage parents to help understand and address what might be interfering with the child’s performance at school. Parents may turn to their trusted pediatricians for guidance in sorting out school failure, as the list of possible causes is very long. By asking the right questions and knowing your patient, you can efficiently investigate this problem so that your patient may quickly get back on track, both academically and in overall development.
Are their academic problems a striking change from prior years? If your patients previously had managed coursework with ease, then there is a new problem interfering with their performance, unless they are young enough that earlier years were not as challenging. Possibly a previous school was not as demanding or new academic expectations such as writing an essay or a dramatic increase in reading expectations have exposed a learning disability or attentional issue that is interfering with performance. This can be sorted out by asking more specific questions about their function. Do they struggle more with reading, essay writing, or math? Do they struggle with sustained attention on assignments or handing in completed work? Your patients can help answer these questions, as can as parents and teachers. Neuropsychological testing can elucidate specific learning disabilities or indicate marked problems with attention, working memory, or processing speed that may be improved with cognitive coaching, in-class strategies, and even medications. With older patients, a new problem is less likely to be the first presentation of an underlying learning or attentional issue and will need further investigation.
Do your patients still enjoy school or are they resisting attending? Students who are avoiding school may be struggling with anxiety. This may be a consequence of their academic struggles, as they try to avoid the shame, embarrassment, or discomfort of their failure to understand material, keep up, or perform. Alternately, the anxiety may have come first, leading to an inability to manage the challenges of school and then failure academically. Similarly, a mood disorder such as depression can create problems with attention, energy, interest, and motivation that make it difficult to attend and participate in school.
Ask about any family history of school problems and psychiatric disorders as these issues often run in families. Ask if there is anxiety around academic or social performance or more generalized anxiety. Are they experiencing trouble with sleep, energy, appetite? Have they withdrawn from other interests? Are they more tearful or irritable in all settings? When these symptoms are universal (i.e., occurring across settings and affecting school), there is likely an underlying psychiatric disorder driving them, and they require a full psychiatric assessment. It is worth noting that often children or adolescents with mood or anxiety disorders will experience somatic symptoms such as stomach aches or headaches alongside the loss of energy and motivation. They may come to the pediatrician first, and it is important to investigate the likely psychiatric illnesses (anxiety in prepubertal children and anxiety or depression in adolescents) as well as the more esoteric medical problems that could be causing such universal impairment in a child or teenager. Stigma still exists around psychiatric illness and it is powerful when a pediatrician can tell a family that these illnesses are common in young people (affecting nearly 20% of children by the age of 18) and very treatable.
Drug and alcohol abuse may be associated with another psychiatric illness or can be independent problems that interfere with the healthy development and school performance of young people, including middle school students. Find out if your patients are drinking alcohol, using marijuana, vaping, utilizing prescription medications that are not their own, or using other illegal drugs. Substance use that has led to problems at school is by definition a problem (in addition to being illegal) and will not improve without treatment. These young people need a full psychiatric evaluation, and they and their parents require specialized treatment and support to address the substance abuse problem.
Of course, school failure may represent other sources of stress. It is critical to find out from your patients if they feel safe at school. Are they being bullied or threatened? Do they have a safe way to get to and from school? Has something else occurred at the school that has left them feeling vigilant and unable to concentrate on classwork? While bullying or living in a neighborhood plagued by violence may not be easy problems to fix, it is critical to find out about them so the adults – parents, teachers, and others – can provide the students with support while directly addressing the safety issue. Do not fail to find out if the fear is at home. Children who are managing physical or sexual abuse may be too stressed to complete homework or even attend school. A caring, curious pediatrician will be a lifeline to a safer future for these children.
Similarly, it is important to find out if your patient is managing less dramatic stresses at home. Perhaps a parent has been seriously ill, working two jobs, or managing a problem with drugs or alcohol, and your patient is caring for that person, or for siblings, instead of keeping up with schoolwork. Perhaps there has been a stressful loss or transition, such as the death of a grandparent or pet, the loss of a job, or a big move, or family discord/violence that has made it difficult for your patient to focus on homework or interfered with parental supervision or homework help. Perhaps your patient has gotten a job to help the family financially and has no time for homework. Bringing such a challenge out into the open and rallying support for your patient and the family in these circumstances is often enough to foster adaptation to these stresses and a return to healthy function in school.
Finally, it is possible that school failure is a function of milder imbalances in a young person’s life. Some children may respond to the expanded independence of adolescence by making poor choices. When do they go to bed at night? Are they staying up late playing video games or surfing the web? Not all insomnia represents illness. Find out how much independence your patients have and how they are managing their time and responsibilities. Help them to think about how to protect time for both responsibilities and relaxation. You also may help the parents of these young people think about how to set expectations and basic rules while stepping back appropriately to allow for expanding independence in ways that will help their children to flourish.
Once defined, Setting reasonable expectations, curriculum adjustments, any needed psychiatric treatment, building on a child’s strengths, and paying attention to self-esteem are the hallmarks of effective interventions.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
The start of the school year brings excitement and some expected anxiety, around seeing friends and undertaking new challenges. While setbacks, small failures, and disappointments are an essential part of a child’s mastery of new challenges, academic and otherwise, occasionally a child will experience school failure in many areas. When this happens, the school usually will engage parents to help understand and address what might be interfering with the child’s performance at school. Parents may turn to their trusted pediatricians for guidance in sorting out school failure, as the list of possible causes is very long. By asking the right questions and knowing your patient, you can efficiently investigate this problem so that your patient may quickly get back on track, both academically and in overall development.
Are their academic problems a striking change from prior years? If your patients previously had managed coursework with ease, then there is a new problem interfering with their performance, unless they are young enough that earlier years were not as challenging. Possibly a previous school was not as demanding or new academic expectations such as writing an essay or a dramatic increase in reading expectations have exposed a learning disability or attentional issue that is interfering with performance. This can be sorted out by asking more specific questions about their function. Do they struggle more with reading, essay writing, or math? Do they struggle with sustained attention on assignments or handing in completed work? Your patients can help answer these questions, as can as parents and teachers. Neuropsychological testing can elucidate specific learning disabilities or indicate marked problems with attention, working memory, or processing speed that may be improved with cognitive coaching, in-class strategies, and even medications. With older patients, a new problem is less likely to be the first presentation of an underlying learning or attentional issue and will need further investigation.
Do your patients still enjoy school or are they resisting attending? Students who are avoiding school may be struggling with anxiety. This may be a consequence of their academic struggles, as they try to avoid the shame, embarrassment, or discomfort of their failure to understand material, keep up, or perform. Alternately, the anxiety may have come first, leading to an inability to manage the challenges of school and then failure academically. Similarly, a mood disorder such as depression can create problems with attention, energy, interest, and motivation that make it difficult to attend and participate in school.
Ask about any family history of school problems and psychiatric disorders as these issues often run in families. Ask if there is anxiety around academic or social performance or more generalized anxiety. Are they experiencing trouble with sleep, energy, appetite? Have they withdrawn from other interests? Are they more tearful or irritable in all settings? When these symptoms are universal (i.e., occurring across settings and affecting school), there is likely an underlying psychiatric disorder driving them, and they require a full psychiatric assessment. It is worth noting that often children or adolescents with mood or anxiety disorders will experience somatic symptoms such as stomach aches or headaches alongside the loss of energy and motivation. They may come to the pediatrician first, and it is important to investigate the likely psychiatric illnesses (anxiety in prepubertal children and anxiety or depression in adolescents) as well as the more esoteric medical problems that could be causing such universal impairment in a child or teenager. Stigma still exists around psychiatric illness and it is powerful when a pediatrician can tell a family that these illnesses are common in young people (affecting nearly 20% of children by the age of 18) and very treatable.
Drug and alcohol abuse may be associated with another psychiatric illness or can be independent problems that interfere with the healthy development and school performance of young people, including middle school students. Find out if your patients are drinking alcohol, using marijuana, vaping, utilizing prescription medications that are not their own, or using other illegal drugs. Substance use that has led to problems at school is by definition a problem (in addition to being illegal) and will not improve without treatment. These young people need a full psychiatric evaluation, and they and their parents require specialized treatment and support to address the substance abuse problem.
Of course, school failure may represent other sources of stress. It is critical to find out from your patients if they feel safe at school. Are they being bullied or threatened? Do they have a safe way to get to and from school? Has something else occurred at the school that has left them feeling vigilant and unable to concentrate on classwork? While bullying or living in a neighborhood plagued by violence may not be easy problems to fix, it is critical to find out about them so the adults – parents, teachers, and others – can provide the students with support while directly addressing the safety issue. Do not fail to find out if the fear is at home. Children who are managing physical or sexual abuse may be too stressed to complete homework or even attend school. A caring, curious pediatrician will be a lifeline to a safer future for these children.
Similarly, it is important to find out if your patient is managing less dramatic stresses at home. Perhaps a parent has been seriously ill, working two jobs, or managing a problem with drugs or alcohol, and your patient is caring for that person, or for siblings, instead of keeping up with schoolwork. Perhaps there has been a stressful loss or transition, such as the death of a grandparent or pet, the loss of a job, or a big move, or family discord/violence that has made it difficult for your patient to focus on homework or interfered with parental supervision or homework help. Perhaps your patient has gotten a job to help the family financially and has no time for homework. Bringing such a challenge out into the open and rallying support for your patient and the family in these circumstances is often enough to foster adaptation to these stresses and a return to healthy function in school.
Finally, it is possible that school failure is a function of milder imbalances in a young person’s life. Some children may respond to the expanded independence of adolescence by making poor choices. When do they go to bed at night? Are they staying up late playing video games or surfing the web? Not all insomnia represents illness. Find out how much independence your patients have and how they are managing their time and responsibilities. Help them to think about how to protect time for both responsibilities and relaxation. You also may help the parents of these young people think about how to set expectations and basic rules while stepping back appropriately to allow for expanding independence in ways that will help their children to flourish.
Once defined, Setting reasonable expectations, curriculum adjustments, any needed psychiatric treatment, building on a child’s strengths, and paying attention to self-esteem are the hallmarks of effective interventions.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
The start of the school year brings excitement and some expected anxiety, around seeing friends and undertaking new challenges. While setbacks, small failures, and disappointments are an essential part of a child’s mastery of new challenges, academic and otherwise, occasionally a child will experience school failure in many areas. When this happens, the school usually will engage parents to help understand and address what might be interfering with the child’s performance at school. Parents may turn to their trusted pediatricians for guidance in sorting out school failure, as the list of possible causes is very long. By asking the right questions and knowing your patient, you can efficiently investigate this problem so that your patient may quickly get back on track, both academically and in overall development.
Are their academic problems a striking change from prior years? If your patients previously had managed coursework with ease, then there is a new problem interfering with their performance, unless they are young enough that earlier years were not as challenging. Possibly a previous school was not as demanding or new academic expectations such as writing an essay or a dramatic increase in reading expectations have exposed a learning disability or attentional issue that is interfering with performance. This can be sorted out by asking more specific questions about their function. Do they struggle more with reading, essay writing, or math? Do they struggle with sustained attention on assignments or handing in completed work? Your patients can help answer these questions, as can as parents and teachers. Neuropsychological testing can elucidate specific learning disabilities or indicate marked problems with attention, working memory, or processing speed that may be improved with cognitive coaching, in-class strategies, and even medications. With older patients, a new problem is less likely to be the first presentation of an underlying learning or attentional issue and will need further investigation.
Do your patients still enjoy school or are they resisting attending? Students who are avoiding school may be struggling with anxiety. This may be a consequence of their academic struggles, as they try to avoid the shame, embarrassment, or discomfort of their failure to understand material, keep up, or perform. Alternately, the anxiety may have come first, leading to an inability to manage the challenges of school and then failure academically. Similarly, a mood disorder such as depression can create problems with attention, energy, interest, and motivation that make it difficult to attend and participate in school.
Ask about any family history of school problems and psychiatric disorders as these issues often run in families. Ask if there is anxiety around academic or social performance or more generalized anxiety. Are they experiencing trouble with sleep, energy, appetite? Have they withdrawn from other interests? Are they more tearful or irritable in all settings? When these symptoms are universal (i.e., occurring across settings and affecting school), there is likely an underlying psychiatric disorder driving them, and they require a full psychiatric assessment. It is worth noting that often children or adolescents with mood or anxiety disorders will experience somatic symptoms such as stomach aches or headaches alongside the loss of energy and motivation. They may come to the pediatrician first, and it is important to investigate the likely psychiatric illnesses (anxiety in prepubertal children and anxiety or depression in adolescents) as well as the more esoteric medical problems that could be causing such universal impairment in a child or teenager. Stigma still exists around psychiatric illness and it is powerful when a pediatrician can tell a family that these illnesses are common in young people (affecting nearly 20% of children by the age of 18) and very treatable.
Drug and alcohol abuse may be associated with another psychiatric illness or can be independent problems that interfere with the healthy development and school performance of young people, including middle school students. Find out if your patients are drinking alcohol, using marijuana, vaping, utilizing prescription medications that are not their own, or using other illegal drugs. Substance use that has led to problems at school is by definition a problem (in addition to being illegal) and will not improve without treatment. These young people need a full psychiatric evaluation, and they and their parents require specialized treatment and support to address the substance abuse problem.
Of course, school failure may represent other sources of stress. It is critical to find out from your patients if they feel safe at school. Are they being bullied or threatened? Do they have a safe way to get to and from school? Has something else occurred at the school that has left them feeling vigilant and unable to concentrate on classwork? While bullying or living in a neighborhood plagued by violence may not be easy problems to fix, it is critical to find out about them so the adults – parents, teachers, and others – can provide the students with support while directly addressing the safety issue. Do not fail to find out if the fear is at home. Children who are managing physical or sexual abuse may be too stressed to complete homework or even attend school. A caring, curious pediatrician will be a lifeline to a safer future for these children.
Similarly, it is important to find out if your patient is managing less dramatic stresses at home. Perhaps a parent has been seriously ill, working two jobs, or managing a problem with drugs or alcohol, and your patient is caring for that person, or for siblings, instead of keeping up with schoolwork. Perhaps there has been a stressful loss or transition, such as the death of a grandparent or pet, the loss of a job, or a big move, or family discord/violence that has made it difficult for your patient to focus on homework or interfered with parental supervision or homework help. Perhaps your patient has gotten a job to help the family financially and has no time for homework. Bringing such a challenge out into the open and rallying support for your patient and the family in these circumstances is often enough to foster adaptation to these stresses and a return to healthy function in school.
Finally, it is possible that school failure is a function of milder imbalances in a young person’s life. Some children may respond to the expanded independence of adolescence by making poor choices. When do they go to bed at night? Are they staying up late playing video games or surfing the web? Not all insomnia represents illness. Find out how much independence your patients have and how they are managing their time and responsibilities. Help them to think about how to protect time for both responsibilities and relaxation. You also may help the parents of these young people think about how to set expectations and basic rules while stepping back appropriately to allow for expanding independence in ways that will help their children to flourish.
Once defined, Setting reasonable expectations, curriculum adjustments, any needed psychiatric treatment, building on a child’s strengths, and paying attention to self-esteem are the hallmarks of effective interventions.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
How to bring behavioral care into your office
There is consensus within both the medical and public health communities that an integrated model of health care, in which behavioral health is integrated into primary care settings, is the optimal way to improve the health of a population (not just treat disease) while managing costs and improving the patient’s experience of care. Such a model is especially compelling for pediatric care.
There are 74 million children under 18 years in the United States and the prevalence of psychiatric disorders in youth is 20%, or 15 million; after vaccinations and following development, managing psychiatric symptoms is the most common issue in pediatric primary care.
While some psychiatric illnesses can be well managed by primary care clinicians alone, some illnesses require specialized therapy or more complex pharmacologic treatment. Untreated or inadequately treated childhood mental illness can lead to a longer and worse course of illness, academic difficulties, emergence of associated illnesses (such as substance use disorders), and legal problems. For those children with chronic medical conditions, emotional disorders cause distress, and affect adherence and family functioning. We will discuss some practical strategies to begin to bring behavioral health care into the pediatric primary care setting.
Start by implementing behavioral health screening into annual and sick visits. Broad instruments, such as the Pediatric Symptom Checklist (PSC, 35 items) or the Child Behavior Check List (CBCL, 113 items) can be filled out by caregivers in the waiting room or online before a visit, and can suggest specific disorders or simply the need for a full psychiatric assessment. Electronic medical records may have publicly available questionnaires such as PSC built into their software, facilitating use of a tablet or home computer, and may ease scoring and downloading of results. Depending on the structure of your practice, you could have one clinician in charge of managing screening. You may become comfortable diagnosing certain disorders, such as ADHD, a major depressive episode, or an anxiety disorder, and you may begin medication treatment when appropriate. You can use instruments developed for specific disease entities (such as ADHD, obsessive compulsive disorder [OCD], anxiety, or depression) to monitor your patient’s treatment response, and they may be done virtually to minimize unnecessary visits.
Treatment algorithms for most psychiatric illnesses are available through the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry, and can guide you through the early stages of treatment. Psychotherapy is the first-line treatment for mild to moderate anxiety and mood disorders, and it is critical to the treatment of more severe disorders. Difficulty in finding a therapist who is skilled in a specific treatment, is a good fit, and accepts insurance can be a significant barrier to care. Establishing a coordinated relationship with a team of therapists can facilitate referrals. Some states have programs in which primary care physicians can have telephone consultations with mental health clinicians or to access referral services for therapy, such as the Massachusetts Child Psychiatry Access Project.
If you have a busy enough practice, consider bringing a social worker or psychologist to work with you. Such a clinician could perform diagnostic assessments, ongoing therapy, parent guidance, family work, or care coordination. Consider how to make it cost-effective for this clinician and your group, whether by inviting that person to sublet one of your offices, or having that person directly employed by you and benefiting from your office staff and patient flow. Many states now reimburse for screening and these funds could contribute to the expense of a social worker. This approach would bring you from coordination to true colocation, which greatly improves the likelihood of compliance with therapy, enhances coordination of a patient’s care, creates opportunities for ongoing education between disciplines, and diminishes stigma of acknowledging a mental illness. Anxiety disorders are the most common illnesses of youth, with mood disorders emerging in adolescence, and substance use disorders in later adolescence. Consider this in seeking a clinician with a specific interest or skill set (such as cognitive behavioral therapy for anxiety or mood problems, dialectical behavior therapy for chronic suicidality, or motivational interviewing for substance abuse).
Beyond diagnosing and treating psychiatric illness in your patients, a primary care pediatric setting with integrated behavioral health would improve the health of our young patients by investing in prevention and parental support. Universal prevention efforts are a hallmark of good pediatric care, from vaccines to educating parents and children about injury prevention (bike helmets, smoke detectors, and car seats) and risky behaviors (smoking). Educate your patients and their parents about best practices to promote good mental health, from good sleep hygiene to regular exercise and healthy stress management techniques. You could use posters and pamphlets, videos and smartphone apps, or screening instruments and discussion.
If you invest in a colocated mental health clinician, you can expand your prevention efforts beyond the universal. Screen for a family history of anxiety, mood, and substance use disorders, and screen for adverse childhood experiences scores. Chronic stress and a family history of specific psychiatric illnesses significantly increase the risk of specific illnesses in your patients. There are evidence-based interventions that can be used to prevent the emergence of many disorders in young people at specific risk. For example, parents who have struggled with anxiety can learn specific strategies for managing their children’s anxiety, significantly lowering the risk of anxiety disorders in their children. These skills can be taught individually or in groups, depending on the prevalence in your practice. Those insurers who reimburse for therapy have a reimbursement schedule for work with parents as well.
There may be funds available to support your investment in integrated care. Under the Affordable Care Act, Medicaid enhanced funding for Health Homes for enrolled children. There have been federal grants for primary care offices to engage in different levels of integration and measure outcomes (Project LAUNCH – Linking Actions for Unmet Needs in Children’s Health). There may be funding at the state level or from private foundations dedicated to public health research and initiatives. Even if you do not invest in procuring outside funding, you should consider how to measure patient outcomes once you are making any efforts at integrating behavioral health care into your practice. Outcome measures include questionnaire scores, treatment adherence, number of school absences, number of office or ED visits, or global measurements, such as the Child Global Assessment Scale (CGAS). Such data can inform you about how to adjust your approach, and could contribute to the larger effort to understand what strategies are most effective and feasible. Addressing the behavioral health needs of your patients could meaningfully contribute to the efforts to make the vision of integrated care – that which truly promotes health in our young people – a reality.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics at Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
There is consensus within both the medical and public health communities that an integrated model of health care, in which behavioral health is integrated into primary care settings, is the optimal way to improve the health of a population (not just treat disease) while managing costs and improving the patient’s experience of care. Such a model is especially compelling for pediatric care.
There are 74 million children under 18 years in the United States and the prevalence of psychiatric disorders in youth is 20%, or 15 million; after vaccinations and following development, managing psychiatric symptoms is the most common issue in pediatric primary care.
While some psychiatric illnesses can be well managed by primary care clinicians alone, some illnesses require specialized therapy or more complex pharmacologic treatment. Untreated or inadequately treated childhood mental illness can lead to a longer and worse course of illness, academic difficulties, emergence of associated illnesses (such as substance use disorders), and legal problems. For those children with chronic medical conditions, emotional disorders cause distress, and affect adherence and family functioning. We will discuss some practical strategies to begin to bring behavioral health care into the pediatric primary care setting.
Start by implementing behavioral health screening into annual and sick visits. Broad instruments, such as the Pediatric Symptom Checklist (PSC, 35 items) or the Child Behavior Check List (CBCL, 113 items) can be filled out by caregivers in the waiting room or online before a visit, and can suggest specific disorders or simply the need for a full psychiatric assessment. Electronic medical records may have publicly available questionnaires such as PSC built into their software, facilitating use of a tablet or home computer, and may ease scoring and downloading of results. Depending on the structure of your practice, you could have one clinician in charge of managing screening. You may become comfortable diagnosing certain disorders, such as ADHD, a major depressive episode, or an anxiety disorder, and you may begin medication treatment when appropriate. You can use instruments developed for specific disease entities (such as ADHD, obsessive compulsive disorder [OCD], anxiety, or depression) to monitor your patient’s treatment response, and they may be done virtually to minimize unnecessary visits.
Treatment algorithms for most psychiatric illnesses are available through the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry, and can guide you through the early stages of treatment. Psychotherapy is the first-line treatment for mild to moderate anxiety and mood disorders, and it is critical to the treatment of more severe disorders. Difficulty in finding a therapist who is skilled in a specific treatment, is a good fit, and accepts insurance can be a significant barrier to care. Establishing a coordinated relationship with a team of therapists can facilitate referrals. Some states have programs in which primary care physicians can have telephone consultations with mental health clinicians or to access referral services for therapy, such as the Massachusetts Child Psychiatry Access Project.
If you have a busy enough practice, consider bringing a social worker or psychologist to work with you. Such a clinician could perform diagnostic assessments, ongoing therapy, parent guidance, family work, or care coordination. Consider how to make it cost-effective for this clinician and your group, whether by inviting that person to sublet one of your offices, or having that person directly employed by you and benefiting from your office staff and patient flow. Many states now reimburse for screening and these funds could contribute to the expense of a social worker. This approach would bring you from coordination to true colocation, which greatly improves the likelihood of compliance with therapy, enhances coordination of a patient’s care, creates opportunities for ongoing education between disciplines, and diminishes stigma of acknowledging a mental illness. Anxiety disorders are the most common illnesses of youth, with mood disorders emerging in adolescence, and substance use disorders in later adolescence. Consider this in seeking a clinician with a specific interest or skill set (such as cognitive behavioral therapy for anxiety or mood problems, dialectical behavior therapy for chronic suicidality, or motivational interviewing for substance abuse).
Beyond diagnosing and treating psychiatric illness in your patients, a primary care pediatric setting with integrated behavioral health would improve the health of our young patients by investing in prevention and parental support. Universal prevention efforts are a hallmark of good pediatric care, from vaccines to educating parents and children about injury prevention (bike helmets, smoke detectors, and car seats) and risky behaviors (smoking). Educate your patients and their parents about best practices to promote good mental health, from good sleep hygiene to regular exercise and healthy stress management techniques. You could use posters and pamphlets, videos and smartphone apps, or screening instruments and discussion.
If you invest in a colocated mental health clinician, you can expand your prevention efforts beyond the universal. Screen for a family history of anxiety, mood, and substance use disorders, and screen for adverse childhood experiences scores. Chronic stress and a family history of specific psychiatric illnesses significantly increase the risk of specific illnesses in your patients. There are evidence-based interventions that can be used to prevent the emergence of many disorders in young people at specific risk. For example, parents who have struggled with anxiety can learn specific strategies for managing their children’s anxiety, significantly lowering the risk of anxiety disorders in their children. These skills can be taught individually or in groups, depending on the prevalence in your practice. Those insurers who reimburse for therapy have a reimbursement schedule for work with parents as well.
There may be funds available to support your investment in integrated care. Under the Affordable Care Act, Medicaid enhanced funding for Health Homes for enrolled children. There have been federal grants for primary care offices to engage in different levels of integration and measure outcomes (Project LAUNCH – Linking Actions for Unmet Needs in Children’s Health). There may be funding at the state level or from private foundations dedicated to public health research and initiatives. Even if you do not invest in procuring outside funding, you should consider how to measure patient outcomes once you are making any efforts at integrating behavioral health care into your practice. Outcome measures include questionnaire scores, treatment adherence, number of school absences, number of office or ED visits, or global measurements, such as the Child Global Assessment Scale (CGAS). Such data can inform you about how to adjust your approach, and could contribute to the larger effort to understand what strategies are most effective and feasible. Addressing the behavioral health needs of your patients could meaningfully contribute to the efforts to make the vision of integrated care – that which truly promotes health in our young people – a reality.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics at Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
There is consensus within both the medical and public health communities that an integrated model of health care, in which behavioral health is integrated into primary care settings, is the optimal way to improve the health of a population (not just treat disease) while managing costs and improving the patient’s experience of care. Such a model is especially compelling for pediatric care.
There are 74 million children under 18 years in the United States and the prevalence of psychiatric disorders in youth is 20%, or 15 million; after vaccinations and following development, managing psychiatric symptoms is the most common issue in pediatric primary care.
While some psychiatric illnesses can be well managed by primary care clinicians alone, some illnesses require specialized therapy or more complex pharmacologic treatment. Untreated or inadequately treated childhood mental illness can lead to a longer and worse course of illness, academic difficulties, emergence of associated illnesses (such as substance use disorders), and legal problems. For those children with chronic medical conditions, emotional disorders cause distress, and affect adherence and family functioning. We will discuss some practical strategies to begin to bring behavioral health care into the pediatric primary care setting.
Start by implementing behavioral health screening into annual and sick visits. Broad instruments, such as the Pediatric Symptom Checklist (PSC, 35 items) or the Child Behavior Check List (CBCL, 113 items) can be filled out by caregivers in the waiting room or online before a visit, and can suggest specific disorders or simply the need for a full psychiatric assessment. Electronic medical records may have publicly available questionnaires such as PSC built into their software, facilitating use of a tablet or home computer, and may ease scoring and downloading of results. Depending on the structure of your practice, you could have one clinician in charge of managing screening. You may become comfortable diagnosing certain disorders, such as ADHD, a major depressive episode, or an anxiety disorder, and you may begin medication treatment when appropriate. You can use instruments developed for specific disease entities (such as ADHD, obsessive compulsive disorder [OCD], anxiety, or depression) to monitor your patient’s treatment response, and they may be done virtually to minimize unnecessary visits.
Treatment algorithms for most psychiatric illnesses are available through the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry, and can guide you through the early stages of treatment. Psychotherapy is the first-line treatment for mild to moderate anxiety and mood disorders, and it is critical to the treatment of more severe disorders. Difficulty in finding a therapist who is skilled in a specific treatment, is a good fit, and accepts insurance can be a significant barrier to care. Establishing a coordinated relationship with a team of therapists can facilitate referrals. Some states have programs in which primary care physicians can have telephone consultations with mental health clinicians or to access referral services for therapy, such as the Massachusetts Child Psychiatry Access Project.
If you have a busy enough practice, consider bringing a social worker or psychologist to work with you. Such a clinician could perform diagnostic assessments, ongoing therapy, parent guidance, family work, or care coordination. Consider how to make it cost-effective for this clinician and your group, whether by inviting that person to sublet one of your offices, or having that person directly employed by you and benefiting from your office staff and patient flow. Many states now reimburse for screening and these funds could contribute to the expense of a social worker. This approach would bring you from coordination to true colocation, which greatly improves the likelihood of compliance with therapy, enhances coordination of a patient’s care, creates opportunities for ongoing education between disciplines, and diminishes stigma of acknowledging a mental illness. Anxiety disorders are the most common illnesses of youth, with mood disorders emerging in adolescence, and substance use disorders in later adolescence. Consider this in seeking a clinician with a specific interest or skill set (such as cognitive behavioral therapy for anxiety or mood problems, dialectical behavior therapy for chronic suicidality, or motivational interviewing for substance abuse).
Beyond diagnosing and treating psychiatric illness in your patients, a primary care pediatric setting with integrated behavioral health would improve the health of our young patients by investing in prevention and parental support. Universal prevention efforts are a hallmark of good pediatric care, from vaccines to educating parents and children about injury prevention (bike helmets, smoke detectors, and car seats) and risky behaviors (smoking). Educate your patients and their parents about best practices to promote good mental health, from good sleep hygiene to regular exercise and healthy stress management techniques. You could use posters and pamphlets, videos and smartphone apps, or screening instruments and discussion.
If you invest in a colocated mental health clinician, you can expand your prevention efforts beyond the universal. Screen for a family history of anxiety, mood, and substance use disorders, and screen for adverse childhood experiences scores. Chronic stress and a family history of specific psychiatric illnesses significantly increase the risk of specific illnesses in your patients. There are evidence-based interventions that can be used to prevent the emergence of many disorders in young people at specific risk. For example, parents who have struggled with anxiety can learn specific strategies for managing their children’s anxiety, significantly lowering the risk of anxiety disorders in their children. These skills can be taught individually or in groups, depending on the prevalence in your practice. Those insurers who reimburse for therapy have a reimbursement schedule for work with parents as well.
There may be funds available to support your investment in integrated care. Under the Affordable Care Act, Medicaid enhanced funding for Health Homes for enrolled children. There have been federal grants for primary care offices to engage in different levels of integration and measure outcomes (Project LAUNCH – Linking Actions for Unmet Needs in Children’s Health). There may be funding at the state level or from private foundations dedicated to public health research and initiatives. Even if you do not invest in procuring outside funding, you should consider how to measure patient outcomes once you are making any efforts at integrating behavioral health care into your practice. Outcome measures include questionnaire scores, treatment adherence, number of school absences, number of office or ED visits, or global measurements, such as the Child Global Assessment Scale (CGAS). Such data can inform you about how to adjust your approach, and could contribute to the larger effort to understand what strategies are most effective and feasible. Addressing the behavioral health needs of your patients could meaningfully contribute to the efforts to make the vision of integrated care – that which truly promotes health in our young people – a reality.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics at Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
U.S. immigration policy: What harms will persist?
The Trump policy of separating children and teenagers from their parents after crossing the U.S. border has been called un-American, immoral, cruel, and inhumane. The policy thankfully has been reversed or at least subject to delay. However, as I write today, 2,300 children and their parents are separated, not in contact, lost to each other, and with no clear plan on reunification. The ultimate outcome of immigration legislation and policy is unknown and mired in partisan politics. The policy hopefully has changed permanently, but what are the harms that will persist?
1. Many if not all of the 2,300 children taken from their parents to institutional settings will have suffered acute anxiety and despair. Following data gathered by René Spitz and John Bowlby 80 years ago, children forced to separate from their parents for long hospitalizations with limited visitation went through phases of protest, despair, and if repeated or lengthy separations, “detachment” that impaired their ability to form relationships.1
2. Many of these children have suffered traumas in their country of origin and through the journey to the U.S. border. Some of this traumatic experience was mitigated by being in the presence of their parent(s). Very likely some children have psychiatric and physical disorders that will add to the level of risk. The current trauma, forcible separation by armed guards into restrictive facilities, will compound or intensify the previous traumas without the benefit of parental support.
3. Will the harms persist? Likely this level of trauma has such a strong neurologic and psychological impact that many of the children will suffer from nightmares, depression, and persistent anxiety about trusting the safety of their setting. 2
4. The parents who are jailed, have had their children removed, and do not know where they are and aren’t able to talk to them have suffered a massive trauma. We all have lost sight of a child for a minute or two in a store or on the beach. Our anxiety is immediate, and if the separation is longer, we may remember those frightening minutes for the rest of our lives. How many immigrant parents will develop depression and posttraumatic stress disorder?
5. Guards were ordered to be the front-line implementers of the policy and must have been torn between their sworn duty and their inner knowledge that what they are doing is wrong. Hearing the children crying and calling for their parents must have elicited painful feelings of what it would have been like to have their own children taken away with no way to reach them or knowing where they were taken. Implementing this policy dehumanized them, and I believe made them feel guilty or unworthy.
6. Millions of immigrants – whether lawful, dreamers, or undocumented – must have felt fearful, powerless, and angry about this policy. Millions of their children must have been worried and lost a little bit of faith in their parents and in the United States.
7. Did U.S. citizens, many from immigrant roots, wonder if this could happen to them? How many children felt a little less secure? Was the anxiety higher for descendants of the U.S. citizens remembering the trauma of the World War II Japanese internment camps? Other descendants (like me) will remember quite vividly their mother’s story of being on the St. Louis steam ship and being turned away from the United States to face a high likelihood of death in Nazi Germany. A bit of fear will replace trust in and loyalty to the United States.
Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email him at pdnews@mdedge.com.
References:
1. Dev Psychol. 1992;28:759-75.
2. www.cdc.gov/violenceprevention/acestudy/index.html
The Trump policy of separating children and teenagers from their parents after crossing the U.S. border has been called un-American, immoral, cruel, and inhumane. The policy thankfully has been reversed or at least subject to delay. However, as I write today, 2,300 children and their parents are separated, not in contact, lost to each other, and with no clear plan on reunification. The ultimate outcome of immigration legislation and policy is unknown and mired in partisan politics. The policy hopefully has changed permanently, but what are the harms that will persist?
1. Many if not all of the 2,300 children taken from their parents to institutional settings will have suffered acute anxiety and despair. Following data gathered by René Spitz and John Bowlby 80 years ago, children forced to separate from their parents for long hospitalizations with limited visitation went through phases of protest, despair, and if repeated or lengthy separations, “detachment” that impaired their ability to form relationships.1
2. Many of these children have suffered traumas in their country of origin and through the journey to the U.S. border. Some of this traumatic experience was mitigated by being in the presence of their parent(s). Very likely some children have psychiatric and physical disorders that will add to the level of risk. The current trauma, forcible separation by armed guards into restrictive facilities, will compound or intensify the previous traumas without the benefit of parental support.
3. Will the harms persist? Likely this level of trauma has such a strong neurologic and psychological impact that many of the children will suffer from nightmares, depression, and persistent anxiety about trusting the safety of their setting. 2
4. The parents who are jailed, have had their children removed, and do not know where they are and aren’t able to talk to them have suffered a massive trauma. We all have lost sight of a child for a minute or two in a store or on the beach. Our anxiety is immediate, and if the separation is longer, we may remember those frightening minutes for the rest of our lives. How many immigrant parents will develop depression and posttraumatic stress disorder?
5. Guards were ordered to be the front-line implementers of the policy and must have been torn between their sworn duty and their inner knowledge that what they are doing is wrong. Hearing the children crying and calling for their parents must have elicited painful feelings of what it would have been like to have their own children taken away with no way to reach them or knowing where they were taken. Implementing this policy dehumanized them, and I believe made them feel guilty or unworthy.
6. Millions of immigrants – whether lawful, dreamers, or undocumented – must have felt fearful, powerless, and angry about this policy. Millions of their children must have been worried and lost a little bit of faith in their parents and in the United States.
7. Did U.S. citizens, many from immigrant roots, wonder if this could happen to them? How many children felt a little less secure? Was the anxiety higher for descendants of the U.S. citizens remembering the trauma of the World War II Japanese internment camps? Other descendants (like me) will remember quite vividly their mother’s story of being on the St. Louis steam ship and being turned away from the United States to face a high likelihood of death in Nazi Germany. A bit of fear will replace trust in and loyalty to the United States.
Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email him at pdnews@mdedge.com.
References:
1. Dev Psychol. 1992;28:759-75.
2. www.cdc.gov/violenceprevention/acestudy/index.html
The Trump policy of separating children and teenagers from their parents after crossing the U.S. border has been called un-American, immoral, cruel, and inhumane. The policy thankfully has been reversed or at least subject to delay. However, as I write today, 2,300 children and their parents are separated, not in contact, lost to each other, and with no clear plan on reunification. The ultimate outcome of immigration legislation and policy is unknown and mired in partisan politics. The policy hopefully has changed permanently, but what are the harms that will persist?
1. Many if not all of the 2,300 children taken from their parents to institutional settings will have suffered acute anxiety and despair. Following data gathered by René Spitz and John Bowlby 80 years ago, children forced to separate from their parents for long hospitalizations with limited visitation went through phases of protest, despair, and if repeated or lengthy separations, “detachment” that impaired their ability to form relationships.1
2. Many of these children have suffered traumas in their country of origin and through the journey to the U.S. border. Some of this traumatic experience was mitigated by being in the presence of their parent(s). Very likely some children have psychiatric and physical disorders that will add to the level of risk. The current trauma, forcible separation by armed guards into restrictive facilities, will compound or intensify the previous traumas without the benefit of parental support.
3. Will the harms persist? Likely this level of trauma has such a strong neurologic and psychological impact that many of the children will suffer from nightmares, depression, and persistent anxiety about trusting the safety of their setting. 2
4. The parents who are jailed, have had their children removed, and do not know where they are and aren’t able to talk to them have suffered a massive trauma. We all have lost sight of a child for a minute or two in a store or on the beach. Our anxiety is immediate, and if the separation is longer, we may remember those frightening minutes for the rest of our lives. How many immigrant parents will develop depression and posttraumatic stress disorder?
5. Guards were ordered to be the front-line implementers of the policy and must have been torn between their sworn duty and their inner knowledge that what they are doing is wrong. Hearing the children crying and calling for their parents must have elicited painful feelings of what it would have been like to have their own children taken away with no way to reach them or knowing where they were taken. Implementing this policy dehumanized them, and I believe made them feel guilty or unworthy.
6. Millions of immigrants – whether lawful, dreamers, or undocumented – must have felt fearful, powerless, and angry about this policy. Millions of their children must have been worried and lost a little bit of faith in their parents and in the United States.
7. Did U.S. citizens, many from immigrant roots, wonder if this could happen to them? How many children felt a little less secure? Was the anxiety higher for descendants of the U.S. citizens remembering the trauma of the World War II Japanese internment camps? Other descendants (like me) will remember quite vividly their mother’s story of being on the St. Louis steam ship and being turned away from the United States to face a high likelihood of death in Nazi Germany. A bit of fear will replace trust in and loyalty to the United States.
Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email him at pdnews@mdedge.com.
References:
1. Dev Psychol. 1992;28:759-75.
2. www.cdc.gov/violenceprevention/acestudy/index.html
Detached parents: How to help
While most of the parents you will see in your office will be thoughtful, engaged, and even anxious, occasionally you will encounter parents who seem detached from their children. Spending just a few extra minutes to understand this detachment could mean an enormous difference in the psychological health and developmental well-being of your patient.
It is striking when you see it: Flat affect, little eye contact, no questions or comments. If the parents seem unconnected to their children, it is worth being curious about it. Whether they are constantly on their phones or just disengaged, you should start by directing a question straight to them. Perhaps a question about the child’s sleep, appetite, or school performance is a good place to start. You would like to assess their knowledge of the child’s development, performance at school, friendships, and interests, to ensure that they are up to date and paying attention.
Once alone, you might start by offering your impression of how the child is doing, then observe that you noticed that they (the parents) seem quiet or distant. The following questions should help you better understand the nature of their detachment.
Depression
Ask about how they are sleeping. If the child is very young or the parents have a difficult work schedule, they might simply be sleep deprived, which you might help them address. Difficulty sleeping also can be a symptom of depression. Have they noticed any changes in their appetite or energy? Is it harder to concentrate? Have they felt more tearful, sad, or irritable? Have they noticed that they don’t get as much pleasure from things that usually bring them joy? Do they worry about being a burden to others? Major depressive disorder is relatively common, affecting as many as one in five women in the postpartum period and one in ten women generally.
Men experience depression at about half that rate, according the Centers for Disease Control and Prevention. It is a condition that can cause feelings of guilt and shame, so many suffer silently, missing the chance for treatment and raising the risk for suicide. Infants of depressed mothers often appear listless and may be fussier about sleeping and eating, which can exacerbate poor attachment with their parents, and lead to problems in later years, including anxiety, mood, or behavioral problems. A parent’s depression, particularly in the postpartum period, represents a serious threat to the child’s healthy development and well-being.
Tell the parents that what they have described to you sounds like it could be a depressive episode and that depression has a serious impact on the whole family. Offer that their primary care physicians can evaluate and treat depression, or learn about other resources in your community that you can refer them to for accessible care.
Overwhelming stress
Is the newborn or special needs child feeling like more responsibility than the parents can handle? Where do the parents find support? Has there been a recent job loss or has there been a financial setback for the family? Is a spouse ill, or are they also caring for an aging parent? Has there been a separation from the spouse? Many adults face multiple significant stresses at the same time. It is not uncommon for working parents to be in “soldiering on” mode, just surviving. But this takes a toll on being present and engaged with the children, and puts them at risk for depression and substance abuse.
Traumatic stress
Have they recently experienced a crime or accident, the unexpected loss of a loved one, or threats or abuse at home? They may be grieving, or may be experiencing symptoms of posttraumatic stress disorder that lead them to appear distant and detached. Grief will improve with time, but they may benefit from extra support or from assistance with their responsibilities (a leave from work or more child care). If they have experienced a traumatic stress, they will need a clinical evaluation for potential treatment options. If they are being threatened or abused at home, you need to find out if their children have witnessed the abuse or may be victims as well. You can offer these parents resources for survivors of domestic abuse and speak with them about your obligation to file with your state’s agency responsible for children’s welfare. It is critical that you listen to any concerns they may have about this filing, from losing their children to enraging their abusers.
A detached parent may make a child feel worried, worthless, or guilty. There is no substitute for a loving, engaged parent, and your brief interventions to help a parent reconnect with the child will be invaluable.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com
While most of the parents you will see in your office will be thoughtful, engaged, and even anxious, occasionally you will encounter parents who seem detached from their children. Spending just a few extra minutes to understand this detachment could mean an enormous difference in the psychological health and developmental well-being of your patient.
It is striking when you see it: Flat affect, little eye contact, no questions or comments. If the parents seem unconnected to their children, it is worth being curious about it. Whether they are constantly on their phones or just disengaged, you should start by directing a question straight to them. Perhaps a question about the child’s sleep, appetite, or school performance is a good place to start. You would like to assess their knowledge of the child’s development, performance at school, friendships, and interests, to ensure that they are up to date and paying attention.
Once alone, you might start by offering your impression of how the child is doing, then observe that you noticed that they (the parents) seem quiet or distant. The following questions should help you better understand the nature of their detachment.
Depression
Ask about how they are sleeping. If the child is very young or the parents have a difficult work schedule, they might simply be sleep deprived, which you might help them address. Difficulty sleeping also can be a symptom of depression. Have they noticed any changes in their appetite or energy? Is it harder to concentrate? Have they felt more tearful, sad, or irritable? Have they noticed that they don’t get as much pleasure from things that usually bring them joy? Do they worry about being a burden to others? Major depressive disorder is relatively common, affecting as many as one in five women in the postpartum period and one in ten women generally.
Men experience depression at about half that rate, according the Centers for Disease Control and Prevention. It is a condition that can cause feelings of guilt and shame, so many suffer silently, missing the chance for treatment and raising the risk for suicide. Infants of depressed mothers often appear listless and may be fussier about sleeping and eating, which can exacerbate poor attachment with their parents, and lead to problems in later years, including anxiety, mood, or behavioral problems. A parent’s depression, particularly in the postpartum period, represents a serious threat to the child’s healthy development and well-being.
Tell the parents that what they have described to you sounds like it could be a depressive episode and that depression has a serious impact on the whole family. Offer that their primary care physicians can evaluate and treat depression, or learn about other resources in your community that you can refer them to for accessible care.
Overwhelming stress
Is the newborn or special needs child feeling like more responsibility than the parents can handle? Where do the parents find support? Has there been a recent job loss or has there been a financial setback for the family? Is a spouse ill, or are they also caring for an aging parent? Has there been a separation from the spouse? Many adults face multiple significant stresses at the same time. It is not uncommon for working parents to be in “soldiering on” mode, just surviving. But this takes a toll on being present and engaged with the children, and puts them at risk for depression and substance abuse.
Traumatic stress
Have they recently experienced a crime or accident, the unexpected loss of a loved one, or threats or abuse at home? They may be grieving, or may be experiencing symptoms of posttraumatic stress disorder that lead them to appear distant and detached. Grief will improve with time, but they may benefit from extra support or from assistance with their responsibilities (a leave from work or more child care). If they have experienced a traumatic stress, they will need a clinical evaluation for potential treatment options. If they are being threatened or abused at home, you need to find out if their children have witnessed the abuse or may be victims as well. You can offer these parents resources for survivors of domestic abuse and speak with them about your obligation to file with your state’s agency responsible for children’s welfare. It is critical that you listen to any concerns they may have about this filing, from losing their children to enraging their abusers.
A detached parent may make a child feel worried, worthless, or guilty. There is no substitute for a loving, engaged parent, and your brief interventions to help a parent reconnect with the child will be invaluable.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com
While most of the parents you will see in your office will be thoughtful, engaged, and even anxious, occasionally you will encounter parents who seem detached from their children. Spending just a few extra minutes to understand this detachment could mean an enormous difference in the psychological health and developmental well-being of your patient.
It is striking when you see it: Flat affect, little eye contact, no questions or comments. If the parents seem unconnected to their children, it is worth being curious about it. Whether they are constantly on their phones or just disengaged, you should start by directing a question straight to them. Perhaps a question about the child’s sleep, appetite, or school performance is a good place to start. You would like to assess their knowledge of the child’s development, performance at school, friendships, and interests, to ensure that they are up to date and paying attention.
Once alone, you might start by offering your impression of how the child is doing, then observe that you noticed that they (the parents) seem quiet or distant. The following questions should help you better understand the nature of their detachment.
Depression
Ask about how they are sleeping. If the child is very young or the parents have a difficult work schedule, they might simply be sleep deprived, which you might help them address. Difficulty sleeping also can be a symptom of depression. Have they noticed any changes in their appetite or energy? Is it harder to concentrate? Have they felt more tearful, sad, or irritable? Have they noticed that they don’t get as much pleasure from things that usually bring them joy? Do they worry about being a burden to others? Major depressive disorder is relatively common, affecting as many as one in five women in the postpartum period and one in ten women generally.
Men experience depression at about half that rate, according the Centers for Disease Control and Prevention. It is a condition that can cause feelings of guilt and shame, so many suffer silently, missing the chance for treatment and raising the risk for suicide. Infants of depressed mothers often appear listless and may be fussier about sleeping and eating, which can exacerbate poor attachment with their parents, and lead to problems in later years, including anxiety, mood, or behavioral problems. A parent’s depression, particularly in the postpartum period, represents a serious threat to the child’s healthy development and well-being.
Tell the parents that what they have described to you sounds like it could be a depressive episode and that depression has a serious impact on the whole family. Offer that their primary care physicians can evaluate and treat depression, or learn about other resources in your community that you can refer them to for accessible care.
Overwhelming stress
Is the newborn or special needs child feeling like more responsibility than the parents can handle? Where do the parents find support? Has there been a recent job loss or has there been a financial setback for the family? Is a spouse ill, or are they also caring for an aging parent? Has there been a separation from the spouse? Many adults face multiple significant stresses at the same time. It is not uncommon for working parents to be in “soldiering on” mode, just surviving. But this takes a toll on being present and engaged with the children, and puts them at risk for depression and substance abuse.
Traumatic stress
Have they recently experienced a crime or accident, the unexpected loss of a loved one, or threats or abuse at home? They may be grieving, or may be experiencing symptoms of posttraumatic stress disorder that lead them to appear distant and detached. Grief will improve with time, but they may benefit from extra support or from assistance with their responsibilities (a leave from work or more child care). If they have experienced a traumatic stress, they will need a clinical evaluation for potential treatment options. If they are being threatened or abused at home, you need to find out if their children have witnessed the abuse or may be victims as well. You can offer these parents resources for survivors of domestic abuse and speak with them about your obligation to file with your state’s agency responsible for children’s welfare. It is critical that you listen to any concerns they may have about this filing, from losing their children to enraging their abusers.
A detached parent may make a child feel worried, worthless, or guilty. There is no substitute for a loving, engaged parent, and your brief interventions to help a parent reconnect with the child will be invaluable.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com
Engaging skeptical parents
While every day seems to bring extraordinary new advances in science – robotic surgery, individually targeted medications, and even gene therapy – there are many people who currently approach the science of medicine with skepticism.
While it is the right of legally competent adults in a free society to chose how best to care for their own health, to explore holistic or alternative therapies, or avoid medicine altogether, it is more complex when they are skeptical of accepted medical practice in managing the health of their children. For those parents who trust you enough to bring their children to you for care but remain skeptical of vaccines or other treatments, you have an opportunity to work with that trust and engage in a discussion so that they might reconsider their position on valuable and even life-saving treatments for their children.
In each of these cases, launching into an enthusiastic explanation of the advanced statistics that underpin your recommendation is unlikely to bridge the gap. Instead, you want to start with these parents by being curious. Resist the urge to tell, and listen instead. What is their understanding of the problem you are treating or preventing? What have they heard or read about the treatment or test in question? What do they most fear is going to happen to their child if they do or do not accept your recommendation? Are there specific events (with their child or with the health care system) that have informed this fear?
Respectfully listening to their experiences, thoughts, and feelings goes a long way toward building a trusting alliance. It can help overcome feelings of distrust or defensiveness around authority figures. And it models the thoughtful, respectful give and take that are essential to a healthy collaboration between pediatrician and parents.
Once you have information about what they think and some about how they think and make decisions, you then can offer your perspective. “You are the expert on your child, what I bring to this equation is experience with (this problem) and with assessing the scientific evidence that guides treatments in medicine. It is true that treatments often change as we learn more, but here is what the evidence currently supports.”
After learning something about how they think, you might offer more data or more warm acknowledgment of how difficult it can be to make medical decisions for your children with imperfect information. Be humble while also being accurate about your level of confidence in a recommendation. Humility is important because it is easy for parents to feel insecure and condescended to. You understand their greatest fear, now let them know what your greatest worry is for their child should they forgo a recommended treatment. Explaining all of this with humility and warmth makes it more likely that the parents will take in the facts you are trying to share with them and not be derailed by suspicion, defensiveness, or insecurity.
Make building an alliance with the parents your top priority. This does not mean that you do not offer your best recommendation for their child. Rather, it means that, if they still decline recommended treatment, you treat them with respect and invest your time in explaining what they should be watching or monitoring their child for without recommended treatment. Building trust is a long game. If you patiently stick with parents even when it’s not easy, they may be ready to trust you with a subsequent decision when the stakes are even higher.
Of course, all this thoughtful communication takes a lot of time! You may learn to block off more time for certain families. It also can be helpful to have these conversations as a team. If you and your nurse or social worker can meet with parents together, then some of the listening and learning can be done by the nurse or social worker alone, so that everyone’s time might be managed more efficiently. And managing skeptical parents as a team also can help to prevent frustration or burnout. It will not always succeed, but in some cases, your investment will pay off in a trusting alliance, mutual respect, and healthy patients.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics at Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
While every day seems to bring extraordinary new advances in science – robotic surgery, individually targeted medications, and even gene therapy – there are many people who currently approach the science of medicine with skepticism.
While it is the right of legally competent adults in a free society to chose how best to care for their own health, to explore holistic or alternative therapies, or avoid medicine altogether, it is more complex when they are skeptical of accepted medical practice in managing the health of their children. For those parents who trust you enough to bring their children to you for care but remain skeptical of vaccines or other treatments, you have an opportunity to work with that trust and engage in a discussion so that they might reconsider their position on valuable and even life-saving treatments for their children.
In each of these cases, launching into an enthusiastic explanation of the advanced statistics that underpin your recommendation is unlikely to bridge the gap. Instead, you want to start with these parents by being curious. Resist the urge to tell, and listen instead. What is their understanding of the problem you are treating or preventing? What have they heard or read about the treatment or test in question? What do they most fear is going to happen to their child if they do or do not accept your recommendation? Are there specific events (with their child or with the health care system) that have informed this fear?
Respectfully listening to their experiences, thoughts, and feelings goes a long way toward building a trusting alliance. It can help overcome feelings of distrust or defensiveness around authority figures. And it models the thoughtful, respectful give and take that are essential to a healthy collaboration between pediatrician and parents.
Once you have information about what they think and some about how they think and make decisions, you then can offer your perspective. “You are the expert on your child, what I bring to this equation is experience with (this problem) and with assessing the scientific evidence that guides treatments in medicine. It is true that treatments often change as we learn more, but here is what the evidence currently supports.”
After learning something about how they think, you might offer more data or more warm acknowledgment of how difficult it can be to make medical decisions for your children with imperfect information. Be humble while also being accurate about your level of confidence in a recommendation. Humility is important because it is easy for parents to feel insecure and condescended to. You understand their greatest fear, now let them know what your greatest worry is for their child should they forgo a recommended treatment. Explaining all of this with humility and warmth makes it more likely that the parents will take in the facts you are trying to share with them and not be derailed by suspicion, defensiveness, or insecurity.
Make building an alliance with the parents your top priority. This does not mean that you do not offer your best recommendation for their child. Rather, it means that, if they still decline recommended treatment, you treat them with respect and invest your time in explaining what they should be watching or monitoring their child for without recommended treatment. Building trust is a long game. If you patiently stick with parents even when it’s not easy, they may be ready to trust you with a subsequent decision when the stakes are even higher.
Of course, all this thoughtful communication takes a lot of time! You may learn to block off more time for certain families. It also can be helpful to have these conversations as a team. If you and your nurse or social worker can meet with parents together, then some of the listening and learning can be done by the nurse or social worker alone, so that everyone’s time might be managed more efficiently. And managing skeptical parents as a team also can help to prevent frustration or burnout. It will not always succeed, but in some cases, your investment will pay off in a trusting alliance, mutual respect, and healthy patients.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics at Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
While every day seems to bring extraordinary new advances in science – robotic surgery, individually targeted medications, and even gene therapy – there are many people who currently approach the science of medicine with skepticism.
While it is the right of legally competent adults in a free society to chose how best to care for their own health, to explore holistic or alternative therapies, or avoid medicine altogether, it is more complex when they are skeptical of accepted medical practice in managing the health of their children. For those parents who trust you enough to bring their children to you for care but remain skeptical of vaccines or other treatments, you have an opportunity to work with that trust and engage in a discussion so that they might reconsider their position on valuable and even life-saving treatments for their children.
In each of these cases, launching into an enthusiastic explanation of the advanced statistics that underpin your recommendation is unlikely to bridge the gap. Instead, you want to start with these parents by being curious. Resist the urge to tell, and listen instead. What is their understanding of the problem you are treating or preventing? What have they heard or read about the treatment or test in question? What do they most fear is going to happen to their child if they do or do not accept your recommendation? Are there specific events (with their child or with the health care system) that have informed this fear?
Respectfully listening to their experiences, thoughts, and feelings goes a long way toward building a trusting alliance. It can help overcome feelings of distrust or defensiveness around authority figures. And it models the thoughtful, respectful give and take that are essential to a healthy collaboration between pediatrician and parents.
Once you have information about what they think and some about how they think and make decisions, you then can offer your perspective. “You are the expert on your child, what I bring to this equation is experience with (this problem) and with assessing the scientific evidence that guides treatments in medicine. It is true that treatments often change as we learn more, but here is what the evidence currently supports.”
After learning something about how they think, you might offer more data or more warm acknowledgment of how difficult it can be to make medical decisions for your children with imperfect information. Be humble while also being accurate about your level of confidence in a recommendation. Humility is important because it is easy for parents to feel insecure and condescended to. You understand their greatest fear, now let them know what your greatest worry is for their child should they forgo a recommended treatment. Explaining all of this with humility and warmth makes it more likely that the parents will take in the facts you are trying to share with them and not be derailed by suspicion, defensiveness, or insecurity.
Make building an alliance with the parents your top priority. This does not mean that you do not offer your best recommendation for their child. Rather, it means that, if they still decline recommended treatment, you treat them with respect and invest your time in explaining what they should be watching or monitoring their child for without recommended treatment. Building trust is a long game. If you patiently stick with parents even when it’s not easy, they may be ready to trust you with a subsequent decision when the stakes are even higher.
Of course, all this thoughtful communication takes a lot of time! You may learn to block off more time for certain families. It also can be helpful to have these conversations as a team. If you and your nurse or social worker can meet with parents together, then some of the listening and learning can be done by the nurse or social worker alone, so that everyone’s time might be managed more efficiently. And managing skeptical parents as a team also can help to prevent frustration or burnout. It will not always succeed, but in some cases, your investment will pay off in a trusting alliance, mutual respect, and healthy patients.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics at Harvard Medical School, Boston. Email them at pdnews@mdedge.com.