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Anxiety in teens
It seems that every week there is a new headline about the rising rates of anxiety in today’s adolescents. Schools often are asked to address high levels of stress and anxiety in their students, and the pediatrician’s office is often the first place worried parents will call. We will try to help you differentiate between what is normal – even healthy – adolescent stress, and what might represent treatable psychiatric problems. And we will review how to approach stress management with your patients and their parents. For all adolescents, even those with psychiatric diagnoses, learning to manage stress and anxiety is critical to their healthiest development into capable, confident, resilient adults.
Stress is the mental or emotional strain resulting from demanding or adverse circumstances. Anxiety is a feeling of unease about an imminent event with an uncertain outcome. An anxiety disorder is a psychiatric illness characterized by a state of excessive unease leading to functional impairment. These distinctions are critical, as both stress and anxiety are normal-but-uncomfortable parts of the adolescent experience. When all of a teenager’s stress and anxiety is medicalized, it promotes avoidance, which in turn may worsen your patient’s functional impairment rather than improving it.
This is not to suggest that there are not real (and common) psychiatric illnesses that can affect the levels of anxiety in your patients. Anxiety disorders start the earliest, with separation anxiety disorder, specific phobia, and social phobia all having a mean onset before puberty. Anxiety disorders are the most prevalent psychiatric disorders in youth (30% of youth psychiatric illness), and anxiety also may be related to substance use disorders (25%), disruptive behavior disorders (20%), and mood disorders (17%). Despite the excited news coverage, there is no evidence of a statistically significant increase in the incidence of anxiety or mood disorders in young people over the past decade.
It is not difficult to imagine that the challenges facing adolescents are considerable. Of course, adolescence is a time of major change starting with puberty, in which young people actively develop independence, identity, and a rich array of deep relationships beyond their families. Typically, this is a 5- to 10-year process of risk-taking, new experiences, setbacks, delight, heartbreak, and triumphs all alongside growing autonomy.
These forces may make their parents even more stressed than the adolescents themselves, but there is one dramatically different feature of adolescent life today: the constant presence of smartphones. While these devices can improve connectedness to school, family, and friends, use of smartphones also means that today’s teenagers often have little downtime cognitively or socially. Use of smartphones can facilitate both supportive affirmation from friends and relentless social pressures, and the feeling of being excluded or bullied. Smartphone use can interfere with restful sleep, and some virtual activities may compete with the genuine experimentation and exploration where teenagers discover their interests and abilities and develop meaningful confidence and independence.
Several factors might impair an adolescent’s ability to cope with challenge and stress. Those teenagers who have not had the opportunity to face and manage modest setbacks, difficulties, and discomforts during their elementary and middle school years may be overwhelmed by starting with the higher-stakes strains of adolescence. This can happen when young children have not explored many new activities, have been shielded from the consequences of failures, or have tried only activities that came easily to them. Certainly, teenagers who are managing a depressive or anxiety disorder as well as those with learning disabilities may have limited ability to cope with routine stress, although those who have a well-treated disorder often have robust coping skills.
Perhaps obvious, but still very important, chronic sleep deprivation can leave adolescents irritable, impatient, and distractible, all of which make coping with a challenge very difficult. Likewise, substance use can directly impair coping skills, and can create the habit of trying to escape stress rather than manage it.
So what does this mean for you? If your patient has an anxiety, depressive, or substance use disorder, refer for appropriate therapy. For both those who screen in and those who do not, your next task is to help them improve their coping skills. What specifically has them so stressed? 
Are there family stressors or unrealistic expectations that can be addressed? Can they see their situation as a challenge and focus on what is within their control to do in response? Remind your patients that challenges are uncomfortable. Mastery comes with practice and, inevitably, some setbacks and failures. Have they identified personal goals or a transcendent purpose? This can improve motivation and keep a challenge in perspective. They might focus on learning about their coping style: Do they do better with a slow, steady, methodical approach or intense bursts of effort? Talk with them about self-care. Adequate sleep, regular exercise, putting effort into relaxation as well as work, and spending time with their actual (not just virtual) friends all are essential to keeping their batteries charged while doing the intense work of normal adolescence.
For those patients who do not meet criteria for depression or anxiety disorders, there are circumstances in which a referral for therapy can be helpful. If they are noticeably disconnected from their parents or their parents seem to be more reactive to the stress and pressures than they are, an outside therapist can be a meaningful support as they build skills. Those patients who are socially isolated and stressed, are using substances regularly, are withdrawing from other interests to manage their source of stress, or are having difficulty telling facts from feelings are at risk for failing to adequately manage their stress and for the development of psychiatric problems. Starting early, helping them to build autonomy as preadolescents, experiencing successes and failures, begins the cultivation of resilience and meaningful confidence they will need during adolescence. Your attention and guidance can help all of your adolescent patients improve their coping and lower both their stress and their anxiety.
It seems that every week there is a new headline about the rising rates of anxiety in today’s adolescents. Schools often are asked to address high levels of stress and anxiety in their students, and the pediatrician’s office is often the first place worried parents will call. We will try to help you differentiate between what is normal – even healthy – adolescent stress, and what might represent treatable psychiatric problems. And we will review how to approach stress management with your patients and their parents. For all adolescents, even those with psychiatric diagnoses, learning to manage stress and anxiety is critical to their healthiest development into capable, confident, resilient adults.
Stress is the mental or emotional strain resulting from demanding or adverse circumstances. Anxiety is a feeling of unease about an imminent event with an uncertain outcome. An anxiety disorder is a psychiatric illness characterized by a state of excessive unease leading to functional impairment. These distinctions are critical, as both stress and anxiety are normal-but-uncomfortable parts of the adolescent experience. When all of a teenager’s stress and anxiety is medicalized, it promotes avoidance, which in turn may worsen your patient’s functional impairment rather than improving it.
This is not to suggest that there are not real (and common) psychiatric illnesses that can affect the levels of anxiety in your patients. Anxiety disorders start the earliest, with separation anxiety disorder, specific phobia, and social phobia all having a mean onset before puberty. Anxiety disorders are the most prevalent psychiatric disorders in youth (30% of youth psychiatric illness), and anxiety also may be related to substance use disorders (25%), disruptive behavior disorders (20%), and mood disorders (17%). Despite the excited news coverage, there is no evidence of a statistically significant increase in the incidence of anxiety or mood disorders in young people over the past decade.
It is not difficult to imagine that the challenges facing adolescents are considerable. Of course, adolescence is a time of major change starting with puberty, in which young people actively develop independence, identity, and a rich array of deep relationships beyond their families. Typically, this is a 5- to 10-year process of risk-taking, new experiences, setbacks, delight, heartbreak, and triumphs all alongside growing autonomy.
These forces may make their parents even more stressed than the adolescents themselves, but there is one dramatically different feature of adolescent life today: the constant presence of smartphones. While these devices can improve connectedness to school, family, and friends, use of smartphones also means that today’s teenagers often have little downtime cognitively or socially. Use of smartphones can facilitate both supportive affirmation from friends and relentless social pressures, and the feeling of being excluded or bullied. Smartphone use can interfere with restful sleep, and some virtual activities may compete with the genuine experimentation and exploration where teenagers discover their interests and abilities and develop meaningful confidence and independence.
Several factors might impair an adolescent’s ability to cope with challenge and stress. Those teenagers who have not had the opportunity to face and manage modest setbacks, difficulties, and discomforts during their elementary and middle school years may be overwhelmed by starting with the higher-stakes strains of adolescence. This can happen when young children have not explored many new activities, have been shielded from the consequences of failures, or have tried only activities that came easily to them. Certainly, teenagers who are managing a depressive or anxiety disorder as well as those with learning disabilities may have limited ability to cope with routine stress, although those who have a well-treated disorder often have robust coping skills.
Perhaps obvious, but still very important, chronic sleep deprivation can leave adolescents irritable, impatient, and distractible, all of which make coping with a challenge very difficult. Likewise, substance use can directly impair coping skills, and can create the habit of trying to escape stress rather than manage it.
So what does this mean for you? If your patient has an anxiety, depressive, or substance use disorder, refer for appropriate therapy. For both those who screen in and those who do not, your next task is to help them improve their coping skills. What specifically has them so stressed?
Are there family stressors or unrealistic expectations that can be addressed? Can they see their situation as a challenge and focus on what is within their control to do in response? Remind your patients that challenges are uncomfortable. Mastery comes with practice and, inevitably, some setbacks and failures. Have they identified personal goals or a transcendent purpose? This can improve motivation and keep a challenge in perspective. They might focus on learning about their coping style: Do they do better with a slow, steady, methodical approach or intense bursts of effort? Talk with them about self-care. Adequate sleep, regular exercise, putting effort into relaxation as well as work, and spending time with their actual (not just virtual) friends all are essential to keeping their batteries charged while doing the intense work of normal adolescence.
For those patients who do not meet criteria for depression or anxiety disorders, there are circumstances in which a referral for therapy can be helpful. If they are noticeably disconnected from their parents or their parents seem to be more reactive to the stress and pressures than they are, an outside therapist can be a meaningful support as they build skills. Those patients who are socially isolated and stressed, are using substances regularly, are withdrawing from other interests to manage their source of stress, or are having difficulty telling facts from feelings are at risk for failing to adequately manage their stress and for the development of psychiatric problems. Starting early, helping them to build autonomy as preadolescents, experiencing successes and failures, begins the cultivation of resilience and meaningful confidence they will need during adolescence. Your attention and guidance can help all of your adolescent patients improve their coping and lower both their stress and their anxiety.
It seems that every week there is a new headline about the rising rates of anxiety in today’s adolescents. Schools often are asked to address high levels of stress and anxiety in their students, and the pediatrician’s office is often the first place worried parents will call. We will try to help you differentiate between what is normal – even healthy – adolescent stress, and what might represent treatable psychiatric problems. And we will review how to approach stress management with your patients and their parents. For all adolescents, even those with psychiatric diagnoses, learning to manage stress and anxiety is critical to their healthiest development into capable, confident, resilient adults.
Stress is the mental or emotional strain resulting from demanding or adverse circumstances. Anxiety is a feeling of unease about an imminent event with an uncertain outcome. An anxiety disorder is a psychiatric illness characterized by a state of excessive unease leading to functional impairment. These distinctions are critical, as both stress and anxiety are normal-but-uncomfortable parts of the adolescent experience. When all of a teenager’s stress and anxiety is medicalized, it promotes avoidance, which in turn may worsen your patient’s functional impairment rather than improving it.
This is not to suggest that there are not real (and common) psychiatric illnesses that can affect the levels of anxiety in your patients. Anxiety disorders start the earliest, with separation anxiety disorder, specific phobia, and social phobia all having a mean onset before puberty. Anxiety disorders are the most prevalent psychiatric disorders in youth (30% of youth psychiatric illness), and anxiety also may be related to substance use disorders (25%), disruptive behavior disorders (20%), and mood disorders (17%). Despite the excited news coverage, there is no evidence of a statistically significant increase in the incidence of anxiety or mood disorders in young people over the past decade.
It is not difficult to imagine that the challenges facing adolescents are considerable. Of course, adolescence is a time of major change starting with puberty, in which young people actively develop independence, identity, and a rich array of deep relationships beyond their families. Typically, this is a 5- to 10-year process of risk-taking, new experiences, setbacks, delight, heartbreak, and triumphs all alongside growing autonomy.
These forces may make their parents even more stressed than the adolescents themselves, but there is one dramatically different feature of adolescent life today: the constant presence of smartphones. While these devices can improve connectedness to school, family, and friends, use of smartphones also means that today’s teenagers often have little downtime cognitively or socially. Use of smartphones can facilitate both supportive affirmation from friends and relentless social pressures, and the feeling of being excluded or bullied. Smartphone use can interfere with restful sleep, and some virtual activities may compete with the genuine experimentation and exploration where teenagers discover their interests and abilities and develop meaningful confidence and independence.
Several factors might impair an adolescent’s ability to cope with challenge and stress. Those teenagers who have not had the opportunity to face and manage modest setbacks, difficulties, and discomforts during their elementary and middle school years may be overwhelmed by starting with the higher-stakes strains of adolescence. This can happen when young children have not explored many new activities, have been shielded from the consequences of failures, or have tried only activities that came easily to them. Certainly, teenagers who are managing a depressive or anxiety disorder as well as those with learning disabilities may have limited ability to cope with routine stress, although those who have a well-treated disorder often have robust coping skills.
Perhaps obvious, but still very important, chronic sleep deprivation can leave adolescents irritable, impatient, and distractible, all of which make coping with a challenge very difficult. Likewise, substance use can directly impair coping skills, and can create the habit of trying to escape stress rather than manage it.
So what does this mean for you? If your patient has an anxiety, depressive, or substance use disorder, refer for appropriate therapy. For both those who screen in and those who do not, your next task is to help them improve their coping skills. What specifically has them so stressed?
Are there family stressors or unrealistic expectations that can be addressed? Can they see their situation as a challenge and focus on what is within their control to do in response? Remind your patients that challenges are uncomfortable. Mastery comes with practice and, inevitably, some setbacks and failures. Have they identified personal goals or a transcendent purpose? This can improve motivation and keep a challenge in perspective. They might focus on learning about their coping style: Do they do better with a slow, steady, methodical approach or intense bursts of effort? Talk with them about self-care. Adequate sleep, regular exercise, putting effort into relaxation as well as work, and spending time with their actual (not just virtual) friends all are essential to keeping their batteries charged while doing the intense work of normal adolescence.
For those patients who do not meet criteria for depression or anxiety disorders, there are circumstances in which a referral for therapy can be helpful. If they are noticeably disconnected from their parents or their parents seem to be more reactive to the stress and pressures than they are, an outside therapist can be a meaningful support as they build skills. Those patients who are socially isolated and stressed, are using substances regularly, are withdrawing from other interests to manage their source of stress, or are having difficulty telling facts from feelings are at risk for failing to adequately manage their stress and for the development of psychiatric problems. Starting early, helping them to build autonomy as preadolescents, experiencing successes and failures, begins the cultivation of resilience and meaningful confidence they will need during adolescence. Your attention and guidance can help all of your adolescent patients improve their coping and lower both their stress and their anxiety.
Preventing substance use
Substance use disorders are affecting every pediatric practice as they are major contributors to morbidity and mortality in young people. With the ongoing risks of binge drinking, the current epidemic of opioid addiction and overdose deaths in the United States, and the shifting legal status and public perception of the risk of marijuana, how to deal with substance use disorders seems to be the focus of public conversation these days. , such as parent education and early recognition in pediatric practice.
Substance abuse risk
We cannot yet predict who can safely “experiment” with substances or who will develop dependency. However, there is information that we can use to identify those at greater risk. Youth who have a first-degree relative with a substance use disorder are at greater risk for developing such a disorder themselves, and this is especially so if there is a family history of alcoholism. Youth who suffer from a psychiatric illness, particularly from anxiety and mood disorders, have a special vulnerability to abusing substances, particularly when their underlying illness is untreated or incompletely treated. Youth with ADHD are at substantially elevated risk of developing substance use disorders, although there is a complex relationship between these two problems. The evidence currently suggests that for youth who began effective treatment prior to puberty, there is no elevation in risk, but for those who did not, there is a substantially elevated risk of substance use disorders. Finally, there has been research that indicates that children with a combination of sensation-seeking, high impulsivity, anxiety-sensitivity, and hopelessness are at the highest risk for substance use disorders.2
Prevention efforts you can make: To your patients
The first step in your prevention efforts is an open conversation about drugs and alcohol. Ask your middle schoolers about whether they have tried alcohol or any drugs. Have their friends? What are kids saying about alcohol? About marijuana? Vaping? Are there other substances that kids are talking about or trying? Be genuinely curious, warm, and nonjudgmental. Find out what they think the risks of these substances may be. If appropriate, offer them some education about known risks of substances to the developing brain, to school or athletic performance, and so on. You can teach them about other trusted resources, such as the National Institute on Drug Abuse (NIDA), which has a resource specifically for teens (teens.drugabuse.gov).
For your high school students and those heading off to college, provide a safe place to talk about what they have tried and whether they (or you) have any worries about substance use. You have a unique combination of clinical authority and expertise in them as individuals, and can help them meaningfully plan how to handle their choices. You might talk about the specific risks of binge drinking, from sexual assault to alcohol poisoning and permanent cognitive effects on their developing brains. They also can benefit from hearing about the actual risks of frequent marijuana use, including impaired cognitive performance (and permanent IQ decline), and ongoing risks to their still-developing brains. Don’t be surprised if your older adolescent patients want to educate you about risks. Be curious and humble, and don’t be afraid to go together to a third party for information. You should encourage their efforts to think critically, and be empathic to their dilemma as they try to balance risks against their drive to have new experiences, to be independent, and to be strongly connected to their peers.
Adolescents should hear about your concern about their specific risks with drugs and alcohol, such as a history of traumatic brain injury (concussion), a family history of drug or alcohol dependence, or their own diagnosis of anxiety, depression, or ADHD. You might point out that because they have not tried any drugs or alcohol in high school, they may be prone to having too much to drink when they first try it. Or you might observe that because they have an anxiety disorder, they are vulnerable to becoming dependent on alcohol. Hearing about their specific level of risk equips them to make wiser choices in the context of their growing autonomy.
Prevention efforts you can make: To the parents
Your other prevention strategies should include parents. Studies have shown that when parents have clear rules and expectations about drug and alcohol use, and are consistent about enforcing consequences in their home, their children are significantly less likely than their peers to have experimented with drugs or alcohol by their senior year in high school. Parents of children headed to middle school should hear about this fact, alongside accurate information about the risks associated with alcohol and specific drugs for the developing brain.
Finally, parents need to hear that they can be effective disciplinarians, while also making clear to their children that safety comes first, and that their rules should have clear exceptions for safety. If the parents have a rule against any use of alcohol or drugs, there should be an exception if their child is out and feels unsafe. If they are drunk, or their driver has been drinking, they can call for a ride and will not be in (much) trouble. Rules don’t have to be draconian to be effective; they should always support honesty and safety first. This is a lot of territory to cover, and you do not have to be the only resource for parents. Reliable online resources, such as NIDA’s and SAMHSA’s websites, are full of useful information, and others, such as teen-safe.org, have detailed resources for parents in particular.
References
1. Hum Genet. 2012 Jun;131(6):779-89.
2. Alcohol Clin Exp Res. 2013 Jan;37(Suppl 1):E281-90.
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.
Substance use disorders are affecting every pediatric practice as they are major contributors to morbidity and mortality in young people. With the ongoing risks of binge drinking, the current epidemic of opioid addiction and overdose deaths in the United States, and the shifting legal status and public perception of the risk of marijuana, how to deal with substance use disorders seems to be the focus of public conversation these days. , such as parent education and early recognition in pediatric practice.
Substance abuse risk
We cannot yet predict who can safely “experiment” with substances or who will develop dependency. However, there is information that we can use to identify those at greater risk. Youth who have a first-degree relative with a substance use disorder are at greater risk for developing such a disorder themselves, and this is especially so if there is a family history of alcoholism. Youth who suffer from a psychiatric illness, particularly from anxiety and mood disorders, have a special vulnerability to abusing substances, particularly when their underlying illness is untreated or incompletely treated. Youth with ADHD are at substantially elevated risk of developing substance use disorders, although there is a complex relationship between these two problems. The evidence currently suggests that for youth who began effective treatment prior to puberty, there is no elevation in risk, but for those who did not, there is a substantially elevated risk of substance use disorders. Finally, there has been research that indicates that children with a combination of sensation-seeking, high impulsivity, anxiety-sensitivity, and hopelessness are at the highest risk for substance use disorders.2
Prevention efforts you can make: To your patients
The first step in your prevention efforts is an open conversation about drugs and alcohol. Ask your middle schoolers about whether they have tried alcohol or any drugs. Have their friends? What are kids saying about alcohol? About marijuana? Vaping? Are there other substances that kids are talking about or trying? Be genuinely curious, warm, and nonjudgmental. Find out what they think the risks of these substances may be. If appropriate, offer them some education about known risks of substances to the developing brain, to school or athletic performance, and so on. You can teach them about other trusted resources, such as the National Institute on Drug Abuse (NIDA), which has a resource specifically for teens (teens.drugabuse.gov).
For your high school students and those heading off to college, provide a safe place to talk about what they have tried and whether they (or you) have any worries about substance use. You have a unique combination of clinical authority and expertise in them as individuals, and can help them meaningfully plan how to handle their choices. You might talk about the specific risks of binge drinking, from sexual assault to alcohol poisoning and permanent cognitive effects on their developing brains. They also can benefit from hearing about the actual risks of frequent marijuana use, including impaired cognitive performance (and permanent IQ decline), and ongoing risks to their still-developing brains. Don’t be surprised if your older adolescent patients want to educate you about risks. Be curious and humble, and don’t be afraid to go together to a third party for information. You should encourage their efforts to think critically, and be empathic to their dilemma as they try to balance risks against their drive to have new experiences, to be independent, and to be strongly connected to their peers.
Adolescents should hear about your concern about their specific risks with drugs and alcohol, such as a history of traumatic brain injury (concussion), a family history of drug or alcohol dependence, or their own diagnosis of anxiety, depression, or ADHD. You might point out that because they have not tried any drugs or alcohol in high school, they may be prone to having too much to drink when they first try it. Or you might observe that because they have an anxiety disorder, they are vulnerable to becoming dependent on alcohol. Hearing about their specific level of risk equips them to make wiser choices in the context of their growing autonomy.
Prevention efforts you can make: To the parents
Your other prevention strategies should include parents. Studies have shown that when parents have clear rules and expectations about drug and alcohol use, and are consistent about enforcing consequences in their home, their children are significantly less likely than their peers to have experimented with drugs or alcohol by their senior year in high school. Parents of children headed to middle school should hear about this fact, alongside accurate information about the risks associated with alcohol and specific drugs for the developing brain.
Finally, parents need to hear that they can be effective disciplinarians, while also making clear to their children that safety comes first, and that their rules should have clear exceptions for safety. If the parents have a rule against any use of alcohol or drugs, there should be an exception if their child is out and feels unsafe. If they are drunk, or their driver has been drinking, they can call for a ride and will not be in (much) trouble. Rules don’t have to be draconian to be effective; they should always support honesty and safety first. This is a lot of territory to cover, and you do not have to be the only resource for parents. Reliable online resources, such as NIDA’s and SAMHSA’s websites, are full of useful information, and others, such as teen-safe.org, have detailed resources for parents in particular.
References
1. Hum Genet. 2012 Jun;131(6):779-89.
2. Alcohol Clin Exp Res. 2013 Jan;37(Suppl 1):E281-90.
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.
Substance use disorders are affecting every pediatric practice as they are major contributors to morbidity and mortality in young people. With the ongoing risks of binge drinking, the current epidemic of opioid addiction and overdose deaths in the United States, and the shifting legal status and public perception of the risk of marijuana, how to deal with substance use disorders seems to be the focus of public conversation these days. , such as parent education and early recognition in pediatric practice.
Substance abuse risk
We cannot yet predict who can safely “experiment” with substances or who will develop dependency. However, there is information that we can use to identify those at greater risk. Youth who have a first-degree relative with a substance use disorder are at greater risk for developing such a disorder themselves, and this is especially so if there is a family history of alcoholism. Youth who suffer from a psychiatric illness, particularly from anxiety and mood disorders, have a special vulnerability to abusing substances, particularly when their underlying illness is untreated or incompletely treated. Youth with ADHD are at substantially elevated risk of developing substance use disorders, although there is a complex relationship between these two problems. The evidence currently suggests that for youth who began effective treatment prior to puberty, there is no elevation in risk, but for those who did not, there is a substantially elevated risk of substance use disorders. Finally, there has been research that indicates that children with a combination of sensation-seeking, high impulsivity, anxiety-sensitivity, and hopelessness are at the highest risk for substance use disorders.2
Prevention efforts you can make: To your patients
The first step in your prevention efforts is an open conversation about drugs and alcohol. Ask your middle schoolers about whether they have tried alcohol or any drugs. Have their friends? What are kids saying about alcohol? About marijuana? Vaping? Are there other substances that kids are talking about or trying? Be genuinely curious, warm, and nonjudgmental. Find out what they think the risks of these substances may be. If appropriate, offer them some education about known risks of substances to the developing brain, to school or athletic performance, and so on. You can teach them about other trusted resources, such as the National Institute on Drug Abuse (NIDA), which has a resource specifically for teens (teens.drugabuse.gov).
For your high school students and those heading off to college, provide a safe place to talk about what they have tried and whether they (or you) have any worries about substance use. You have a unique combination of clinical authority and expertise in them as individuals, and can help them meaningfully plan how to handle their choices. You might talk about the specific risks of binge drinking, from sexual assault to alcohol poisoning and permanent cognitive effects on their developing brains. They also can benefit from hearing about the actual risks of frequent marijuana use, including impaired cognitive performance (and permanent IQ decline), and ongoing risks to their still-developing brains. Don’t be surprised if your older adolescent patients want to educate you about risks. Be curious and humble, and don’t be afraid to go together to a third party for information. You should encourage their efforts to think critically, and be empathic to their dilemma as they try to balance risks against their drive to have new experiences, to be independent, and to be strongly connected to their peers.
Adolescents should hear about your concern about their specific risks with drugs and alcohol, such as a history of traumatic brain injury (concussion), a family history of drug or alcohol dependence, or their own diagnosis of anxiety, depression, or ADHD. You might point out that because they have not tried any drugs or alcohol in high school, they may be prone to having too much to drink when they first try it. Or you might observe that because they have an anxiety disorder, they are vulnerable to becoming dependent on alcohol. Hearing about their specific level of risk equips them to make wiser choices in the context of their growing autonomy.
Prevention efforts you can make: To the parents
Your other prevention strategies should include parents. Studies have shown that when parents have clear rules and expectations about drug and alcohol use, and are consistent about enforcing consequences in their home, their children are significantly less likely than their peers to have experimented with drugs or alcohol by their senior year in high school. Parents of children headed to middle school should hear about this fact, alongside accurate information about the risks associated with alcohol and specific drugs for the developing brain.
Finally, parents need to hear that they can be effective disciplinarians, while also making clear to their children that safety comes first, and that their rules should have clear exceptions for safety. If the parents have a rule against any use of alcohol or drugs, there should be an exception if their child is out and feels unsafe. If they are drunk, or their driver has been drinking, they can call for a ride and will not be in (much) trouble. Rules don’t have to be draconian to be effective; they should always support honesty and safety first. This is a lot of territory to cover, and you do not have to be the only resource for parents. Reliable online resources, such as NIDA’s and SAMHSA’s websites, are full of useful information, and others, such as teen-safe.org, have detailed resources for parents in particular.
References
1. Hum Genet. 2012 Jun;131(6):779-89.
2. Alcohol Clin Exp Res. 2013 Jan;37(Suppl 1):E281-90.
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.
Alternative therapies
Alternative therapies, from vitamins and supplements to meditation and acupuncture, have become increasingly popular treatments in the United States for many medical problems in the past few decades. In 2008, the National Institutes of Health reported that nearly 40% of adults and 12% of children had used “complementary or alternative medicine” (CAM) in the preceding year. Other surveys have suggested that closer to 30% of general pediatric patients and as many as 75% of adolescent patients have used CAM at least once. These treatments are especially popular for chronic conditions that are managed but not usually cured with current evidence-based treatments. Psychiatric conditions in childhood sometimes have a long course, and have effective but controversial treatments, as with stimulants for ADHD. Parents sometimes feel guilty about their child’s problem and want to use “natural” methods or deny the accepted understanding of their child’s illness. So it is not surprising that families may investigate alternative treatments, and such treatments have multiplied.
While there is evidence that parents and patients rarely discuss these treatments with their physicians, it is critical that you know what therapies your patients are using. You should focus on tolerance in the context of protecting the child from harm and improving the child’s functioning. If you have ever recommended chicken soup for a cold, then you have prescribed complementary medicine, so it is not a stretch for you to offer some input about the other alternative therapies your patients may be considering.
It is important to note that rigorous, case-controlled studies of efficacy of most alternative therapies are few in number and usually small in size (so any evidence of efficacy is weaker), and that the products themselves are not regulated by the Food and Drug Administration or other public body. This means that the family (and you) will have to do some homework to ensure that the therapy they purchase comes from a reputable source and is what it purports to be.
Many of the alternative therapies patients are investigating will be herbs or supplements. Omega-3 fatty acids are critical to multiple essential body functions, and are taken in primarily via certain foods, primarily fish and certain seeds and nuts. A deficiency in certain omega-3 fatty acids can cause problems in infant neurological development and put one at risk for heart disease, rheumatologic illness, and depression. Supplementation with Omega-3 fatty acids (eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA], specifically) has a solid evidence base as an effective adjunctive treatment for depression and bipolar disorder in adults. In addition, randomized, placebo-controlled, double-blind studies have demonstrated efficacy in treatment of children with mild to moderate ADHD at doses of 1,200 mg/day. There are some studies that have demonstrated improvement in hyperactivity in children with autism with supplementation at similar doses. These supplements have very low risk of side effects. They are a reasonable recommendation to your patients whose children have mild to moderate ADHD, and they want to manage it without stimulants.
Families also may be considering physical or mechanical treatments. Acupuncture has demonstrated efficacy in the treatment of fatigue and pain, migraines, and addiction, although there are very few studies in children and adolescents. There is some evidence for its efficacy in treatment of mild to moderate depression and anxiety in adults, but again no research has been done in youth. Hypnotherapy has shown modest efficacy in treatment of anticipatory anxiety symptoms, headache, chronic pain, nausea and vomiting, migraines, hair-pulling and skin picking as well as compulsive eating and smoking cessation in adults. There is some clinical evidence for its efficacy in children and adolescents, and its safety is well established. Massage therapy has shown value in improving mood and behavior in children with ADHD, but not efficacy as a first-line treatment for ADHD symptoms. Chiropractic care, which is among the most commonly used alternative therapies, claims to be effective for the treatment of anxiety, depression, ADHD, behavioral problems of autism and even schizophrenia and bipolar disorder, but there is no significant scientific evidence to support these claims. And neurofeedback, which is a variant of biofeedback in which patients practice calming themselves or improving focus while watching an EEG has shown modest efficacy in the treatment of ADHD in children in early studies. It is worth noting that all of these therapies may be costly and not covered by insurance.
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@frontlinemedcom.com.
Additional readings
1. Child Adolesc Psychiatr Clin N Am. 2013 Jul;22(3):375-80.
2. J Am Acad Child Adolesc Psychiatry. 2008;47(4):364-8.
3. J Am Acad Child Adolesc Psychiatry. 2011;50(10):991-1000.
4. J Am Acad Child Adolesc Psychiatry. 2014 Jun; 53(6):658-66.
5. J Am Acad Child Adolesc Psychiatry. 2016 Oct;55(10):S168-9.
Alternative therapies, from vitamins and supplements to meditation and acupuncture, have become increasingly popular treatments in the United States for many medical problems in the past few decades. In 2008, the National Institutes of Health reported that nearly 40% of adults and 12% of children had used “complementary or alternative medicine” (CAM) in the preceding year. Other surveys have suggested that closer to 30% of general pediatric patients and as many as 75% of adolescent patients have used CAM at least once. These treatments are especially popular for chronic conditions that are managed but not usually cured with current evidence-based treatments. Psychiatric conditions in childhood sometimes have a long course, and have effective but controversial treatments, as with stimulants for ADHD. Parents sometimes feel guilty about their child’s problem and want to use “natural” methods or deny the accepted understanding of their child’s illness. So it is not surprising that families may investigate alternative treatments, and such treatments have multiplied.
While there is evidence that parents and patients rarely discuss these treatments with their physicians, it is critical that you know what therapies your patients are using. You should focus on tolerance in the context of protecting the child from harm and improving the child’s functioning. If you have ever recommended chicken soup for a cold, then you have prescribed complementary medicine, so it is not a stretch for you to offer some input about the other alternative therapies your patients may be considering.
It is important to note that rigorous, case-controlled studies of efficacy of most alternative therapies are few in number and usually small in size (so any evidence of efficacy is weaker), and that the products themselves are not regulated by the Food and Drug Administration or other public body. This means that the family (and you) will have to do some homework to ensure that the therapy they purchase comes from a reputable source and is what it purports to be.
Many of the alternative therapies patients are investigating will be herbs or supplements. Omega-3 fatty acids are critical to multiple essential body functions, and are taken in primarily via certain foods, primarily fish and certain seeds and nuts. A deficiency in certain omega-3 fatty acids can cause problems in infant neurological development and put one at risk for heart disease, rheumatologic illness, and depression. Supplementation with Omega-3 fatty acids (eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA], specifically) has a solid evidence base as an effective adjunctive treatment for depression and bipolar disorder in adults. In addition, randomized, placebo-controlled, double-blind studies have demonstrated efficacy in treatment of children with mild to moderate ADHD at doses of 1,200 mg/day. There are some studies that have demonstrated improvement in hyperactivity in children with autism with supplementation at similar doses. These supplements have very low risk of side effects. They are a reasonable recommendation to your patients whose children have mild to moderate ADHD, and they want to manage it without stimulants.
Families also may be considering physical or mechanical treatments. Acupuncture has demonstrated efficacy in the treatment of fatigue and pain, migraines, and addiction, although there are very few studies in children and adolescents. There is some evidence for its efficacy in treatment of mild to moderate depression and anxiety in adults, but again no research has been done in youth. Hypnotherapy has shown modest efficacy in treatment of anticipatory anxiety symptoms, headache, chronic pain, nausea and vomiting, migraines, hair-pulling and skin picking as well as compulsive eating and smoking cessation in adults. There is some clinical evidence for its efficacy in children and adolescents, and its safety is well established. Massage therapy has shown value in improving mood and behavior in children with ADHD, but not efficacy as a first-line treatment for ADHD symptoms. Chiropractic care, which is among the most commonly used alternative therapies, claims to be effective for the treatment of anxiety, depression, ADHD, behavioral problems of autism and even schizophrenia and bipolar disorder, but there is no significant scientific evidence to support these claims. And neurofeedback, which is a variant of biofeedback in which patients practice calming themselves or improving focus while watching an EEG has shown modest efficacy in the treatment of ADHD in children in early studies. It is worth noting that all of these therapies may be costly and not covered by insurance.
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@frontlinemedcom.com.
Additional readings
1. Child Adolesc Psychiatr Clin N Am. 2013 Jul;22(3):375-80.
2. J Am Acad Child Adolesc Psychiatry. 2008;47(4):364-8.
3. J Am Acad Child Adolesc Psychiatry. 2011;50(10):991-1000.
4. J Am Acad Child Adolesc Psychiatry. 2014 Jun; 53(6):658-66.
5. J Am Acad Child Adolesc Psychiatry. 2016 Oct;55(10):S168-9.
Alternative therapies, from vitamins and supplements to meditation and acupuncture, have become increasingly popular treatments in the United States for many medical problems in the past few decades. In 2008, the National Institutes of Health reported that nearly 40% of adults and 12% of children had used “complementary or alternative medicine” (CAM) in the preceding year. Other surveys have suggested that closer to 30% of general pediatric patients and as many as 75% of adolescent patients have used CAM at least once. These treatments are especially popular for chronic conditions that are managed but not usually cured with current evidence-based treatments. Psychiatric conditions in childhood sometimes have a long course, and have effective but controversial treatments, as with stimulants for ADHD. Parents sometimes feel guilty about their child’s problem and want to use “natural” methods or deny the accepted understanding of their child’s illness. So it is not surprising that families may investigate alternative treatments, and such treatments have multiplied.
While there is evidence that parents and patients rarely discuss these treatments with their physicians, it is critical that you know what therapies your patients are using. You should focus on tolerance in the context of protecting the child from harm and improving the child’s functioning. If you have ever recommended chicken soup for a cold, then you have prescribed complementary medicine, so it is not a stretch for you to offer some input about the other alternative therapies your patients may be considering.
It is important to note that rigorous, case-controlled studies of efficacy of most alternative therapies are few in number and usually small in size (so any evidence of efficacy is weaker), and that the products themselves are not regulated by the Food and Drug Administration or other public body. This means that the family (and you) will have to do some homework to ensure that the therapy they purchase comes from a reputable source and is what it purports to be.
Many of the alternative therapies patients are investigating will be herbs or supplements. Omega-3 fatty acids are critical to multiple essential body functions, and are taken in primarily via certain foods, primarily fish and certain seeds and nuts. A deficiency in certain omega-3 fatty acids can cause problems in infant neurological development and put one at risk for heart disease, rheumatologic illness, and depression. Supplementation with Omega-3 fatty acids (eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA], specifically) has a solid evidence base as an effective adjunctive treatment for depression and bipolar disorder in adults. In addition, randomized, placebo-controlled, double-blind studies have demonstrated efficacy in treatment of children with mild to moderate ADHD at doses of 1,200 mg/day. There are some studies that have demonstrated improvement in hyperactivity in children with autism with supplementation at similar doses. These supplements have very low risk of side effects. They are a reasonable recommendation to your patients whose children have mild to moderate ADHD, and they want to manage it without stimulants.
Families also may be considering physical or mechanical treatments. Acupuncture has demonstrated efficacy in the treatment of fatigue and pain, migraines, and addiction, although there are very few studies in children and adolescents. There is some evidence for its efficacy in treatment of mild to moderate depression and anxiety in adults, but again no research has been done in youth. Hypnotherapy has shown modest efficacy in treatment of anticipatory anxiety symptoms, headache, chronic pain, nausea and vomiting, migraines, hair-pulling and skin picking as well as compulsive eating and smoking cessation in adults. There is some clinical evidence for its efficacy in children and adolescents, and its safety is well established. Massage therapy has shown value in improving mood and behavior in children with ADHD, but not efficacy as a first-line treatment for ADHD symptoms. Chiropractic care, which is among the most commonly used alternative therapies, claims to be effective for the treatment of anxiety, depression, ADHD, behavioral problems of autism and even schizophrenia and bipolar disorder, but there is no significant scientific evidence to support these claims. And neurofeedback, which is a variant of biofeedback in which patients practice calming themselves or improving focus while watching an EEG has shown modest efficacy in the treatment of ADHD in children in early studies. It is worth noting that all of these therapies may be costly and not covered by insurance.
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@frontlinemedcom.com.
Additional readings
1. Child Adolesc Psychiatr Clin N Am. 2013 Jul;22(3):375-80.
2. J Am Acad Child Adolesc Psychiatry. 2008;47(4):364-8.
3. J Am Acad Child Adolesc Psychiatry. 2011;50(10):991-1000.
4. J Am Acad Child Adolesc Psychiatry. 2014 Jun; 53(6):658-66.
5. J Am Acad Child Adolesc Psychiatry. 2016 Oct;55(10):S168-9.
Depression in adolescence
As many as 20% of children and adolescents experience a psychiatric disorder, with 50% of all lifetime psychiatric illnesses occurring by the age of 14 years. ADHD and depression are among the most common. The National Institutes of Health estimate that, in 2015, 3 million 12- to 17-year-old American children experienced a major depressive episode. Any illness that affects over 10% of adolescents will present regularly in the primary care provider’s office. It is important to know whom to screen and how to start treatment when your patient appears to be suffering from this serious but treatable condition.
While there are many screening instruments, it is important to be ready to ask patients diagnostic questions when your clinical suspicion of depression is high. In addition to asking about mood, sleep, appetite, energy, and the other DSM5 criteria of a major depressive episode, it is important to remember that teens with depression might present with irritability as much as sadness. While they lose interest in school, sports, or hobbies, they still may be distracted or cheered up by friends. And 
Explain to your patient (and their parents) that depression is very treatable, but most effective treatments take time. Psychotherapy usually works over several months, and even effective medications can take 6 weeks or more. But, without treatment, their symptoms may persist for over a year and can disrupt their healthy development.
This is also a good time to ask your patient about suicidal thoughts. Have they been imagining how their death would affect others? Wishing they could just sleep? Do they have a plan? Do they have access to a means of killing themselves? Do they feel attached or connected to family, friends, religion, or a goal? Explain to your patient that these thoughts are common symptoms of depression, and work with their parents to ensure that they are connected and safe when starting treatment.
Psychotherapy is considered the first line treatment for mild to moderate episodes of depression and should be used alongside medications in severe episodes. While structured therapies such as cognitive behavioral therapy or interpersonal therapy have a strong evidence base to support their use, the best predictor of an effective therapy appears to be a strong alliance between therapist and patient. So, help your patient to find a therapist, and explain the importance of finding someone with whom they feel comfortable. Suggest to your patients that they have three visits with a new therapist to see if it feels like a “good match,” before considering trying another.
Finally, antidepressant medications are first-line treatment for more severe episodes of depression and episodes in which significant suicidal ideation or functional impairment are present. If the symptoms are more severe, or if therapy alone has not been effective after 4-6 weeks, you might consider starting antidepressant treatment. Psychiatrists usually start with an selective serotonin reuptake inhibitor, typically of a medium half-life, at a low dose to minimize the chances of side effects. While real efficacy takes up to 6 weeks, there should be some improvement in energy within the first 2 weeks on an effective medication. If there is no change, the dose can be raised gradually as tolerated. It is important to tell patients and their families about common side effects (mild GI upset) and the more rare but dangerous ones (such as hypomania or an increase in the frequency or intensity of suicidal thoughts).
Even when you do not refer your patient to someone else for treatment of depression, it is important that you not be alone in their management. Work closely with their therapist or consider having a psychiatric social worker join your team to offer therapy in close connection with your management. You might also periodically consult with a child psychiatrist to address treatment and medication questions and identify needed resources. Staying in touch with parents or connected adults at school (with the appropriate permission) can be very useful with those patients you are more concerned about. The educated and attuned primary care provider can provide thoughtful first-line treatment of depression in young people and can be an important part of managing this public health challenge. It is always rewarding to help an adolescent overcome depression.
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@frontlinemedcom.com.
As many as 20% of children and adolescents experience a psychiatric disorder, with 50% of all lifetime psychiatric illnesses occurring by the age of 14 years. ADHD and depression are among the most common. The National Institutes of Health estimate that, in 2015, 3 million 12- to 17-year-old American children experienced a major depressive episode. Any illness that affects over 10% of adolescents will present regularly in the primary care provider’s office. It is important to know whom to screen and how to start treatment when your patient appears to be suffering from this serious but treatable condition.
While there are many screening instruments, it is important to be ready to ask patients diagnostic questions when your clinical suspicion of depression is high. In addition to asking about mood, sleep, appetite, energy, and the other DSM5 criteria of a major depressive episode, it is important to remember that teens with depression might present with irritability as much as sadness. While they lose interest in school, sports, or hobbies, they still may be distracted or cheered up by friends. And
Explain to your patient (and their parents) that depression is very treatable, but most effective treatments take time. Psychotherapy usually works over several months, and even effective medications can take 6 weeks or more. But, without treatment, their symptoms may persist for over a year and can disrupt their healthy development.
This is also a good time to ask your patient about suicidal thoughts. Have they been imagining how their death would affect others? Wishing they could just sleep? Do they have a plan? Do they have access to a means of killing themselves? Do they feel attached or connected to family, friends, religion, or a goal? Explain to your patient that these thoughts are common symptoms of depression, and work with their parents to ensure that they are connected and safe when starting treatment.
Psychotherapy is considered the first line treatment for mild to moderate episodes of depression and should be used alongside medications in severe episodes. While structured therapies such as cognitive behavioral therapy or interpersonal therapy have a strong evidence base to support their use, the best predictor of an effective therapy appears to be a strong alliance between therapist and patient. So, help your patient to find a therapist, and explain the importance of finding someone with whom they feel comfortable. Suggest to your patients that they have three visits with a new therapist to see if it feels like a “good match,” before considering trying another.
Finally, antidepressant medications are first-line treatment for more severe episodes of depression and episodes in which significant suicidal ideation or functional impairment are present. If the symptoms are more severe, or if therapy alone has not been effective after 4-6 weeks, you might consider starting antidepressant treatment. Psychiatrists usually start with an selective serotonin reuptake inhibitor, typically of a medium half-life, at a low dose to minimize the chances of side effects. While real efficacy takes up to 6 weeks, there should be some improvement in energy within the first 2 weeks on an effective medication. If there is no change, the dose can be raised gradually as tolerated. It is important to tell patients and their families about common side effects (mild GI upset) and the more rare but dangerous ones (such as hypomania or an increase in the frequency or intensity of suicidal thoughts).
Even when you do not refer your patient to someone else for treatment of depression, it is important that you not be alone in their management. Work closely with their therapist or consider having a psychiatric social worker join your team to offer therapy in close connection with your management. You might also periodically consult with a child psychiatrist to address treatment and medication questions and identify needed resources. Staying in touch with parents or connected adults at school (with the appropriate permission) can be very useful with those patients you are more concerned about. The educated and attuned primary care provider can provide thoughtful first-line treatment of depression in young people and can be an important part of managing this public health challenge. It is always rewarding to help an adolescent overcome depression.
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@frontlinemedcom.com.
As many as 20% of children and adolescents experience a psychiatric disorder, with 50% of all lifetime psychiatric illnesses occurring by the age of 14 years. ADHD and depression are among the most common. The National Institutes of Health estimate that, in 2015, 3 million 12- to 17-year-old American children experienced a major depressive episode. Any illness that affects over 10% of adolescents will present regularly in the primary care provider’s office. It is important to know whom to screen and how to start treatment when your patient appears to be suffering from this serious but treatable condition.
While there are many screening instruments, it is important to be ready to ask patients diagnostic questions when your clinical suspicion of depression is high. In addition to asking about mood, sleep, appetite, energy, and the other DSM5 criteria of a major depressive episode, it is important to remember that teens with depression might present with irritability as much as sadness. While they lose interest in school, sports, or hobbies, they still may be distracted or cheered up by friends. And
Explain to your patient (and their parents) that depression is very treatable, but most effective treatments take time. Psychotherapy usually works over several months, and even effective medications can take 6 weeks or more. But, without treatment, their symptoms may persist for over a year and can disrupt their healthy development.
This is also a good time to ask your patient about suicidal thoughts. Have they been imagining how their death would affect others? Wishing they could just sleep? Do they have a plan? Do they have access to a means of killing themselves? Do they feel attached or connected to family, friends, religion, or a goal? Explain to your patient that these thoughts are common symptoms of depression, and work with their parents to ensure that they are connected and safe when starting treatment.
Psychotherapy is considered the first line treatment for mild to moderate episodes of depression and should be used alongside medications in severe episodes. While structured therapies such as cognitive behavioral therapy or interpersonal therapy have a strong evidence base to support their use, the best predictor of an effective therapy appears to be a strong alliance between therapist and patient. So, help your patient to find a therapist, and explain the importance of finding someone with whom they feel comfortable. Suggest to your patients that they have three visits with a new therapist to see if it feels like a “good match,” before considering trying another.
Finally, antidepressant medications are first-line treatment for more severe episodes of depression and episodes in which significant suicidal ideation or functional impairment are present. If the symptoms are more severe, or if therapy alone has not been effective after 4-6 weeks, you might consider starting antidepressant treatment. Psychiatrists usually start with an selective serotonin reuptake inhibitor, typically of a medium half-life, at a low dose to minimize the chances of side effects. While real efficacy takes up to 6 weeks, there should be some improvement in energy within the first 2 weeks on an effective medication. If there is no change, the dose can be raised gradually as tolerated. It is important to tell patients and their families about common side effects (mild GI upset) and the more rare but dangerous ones (such as hypomania or an increase in the frequency or intensity of suicidal thoughts).
Even when you do not refer your patient to someone else for treatment of depression, it is important that you not be alone in their management. Work closely with their therapist or consider having a psychiatric social worker join your team to offer therapy in close connection with your management. You might also periodically consult with a child psychiatrist to address treatment and medication questions and identify needed resources. Staying in touch with parents or connected adults at school (with the appropriate permission) can be very useful with those patients you are more concerned about. The educated and attuned primary care provider can provide thoughtful first-line treatment of depression in young people and can be an important part of managing this public health challenge. It is always rewarding to help an adolescent overcome depression.
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@frontlinemedcom.com.
Adolescents and sleep, or the lack thereof
Every parent will attest that bright-eyed children grow into sleepy adolescents, and the science confirms their observations. There are multiple factors that prevent adolescents from getting the sleep they need, and inadequate sleep has serious consequences – from impaired learning to depressive symptoms, obesity to deadly accidents – all of which are potentially preventable with some practical strategies to promote adequate sleep.
Adolescence is a period of intense growth and development, so it is no surprise that adolescents require a lot of sleep, over 9 hours nightly. But surveys have shown that only 3% of American adolescents get 9 hours of sleep nightly, and the average amount of weeknight sleep is only 6 hours.1 Sleep deprivation is not a problem in childhood, so why can’t adolescents get enough sleep?
Over the last 15 years, a new factor – screen time – has worsened the adolescent sleep situation. Most teens have an electronic device in their bedroom and use it for homework, entertainment, and socializing well into the night. Multiple studies have confirmed that electronic exposure in the evening is associated with less sleep at night and more day time sleepiness,by competing with sleep and suppression of nocturnal melatonin release, which can delay the onset of sleep.2
It is ironic that many teens are staying up late for homework, when their lack of sleep can interfere with consolidation of learning. It also has powerful effects on working memory and reaction time, making both academic and athletic performance suffer. Chronically sleep-deprived teenagers often complain of difficulty with initiating and sustaining attention, which may lead to a mistaken diagnosis of ADHD, and stimulant treatment may further complicate sleep.
Good mental health is not the only casualty of inadequate sleep. A growing body of evidence links short sleep duration with an increased risk of obesity. This appears to be mediated by alterations in neurohormones associated with sleep, leading to higher carbohydrate and fat intake, more snacking and insulin resistance.
Anything that compromises attention and reaction time, including sleep deprivation, adds risk to driving, particularly for inexperienced and impulsive adolescent drivers. The National Highway Transportation Safety Administration estimates that drivers 25 and younger cause more than half of all “fall asleep” crashes.
Teenagers generally know that they are exhausted, but the strategies they might use to manage their fatigue can actually make things worse. Sleepy teenagers often consume large amounts of caffeine to get through their days and their homework at night. Caffeine, in turn, interferes with both the onset and quality of sleep, perpetuating the cycle. Even “catch-up” sleep on weekends is a strategy that can contribute to the problem, as it can lead to more disrupted sleep by pushing the onset of school night sleepiness even later.
While growing autonomy is part of why teenagers are sleep deprived, they will consider the caring and informed guidance of their pediatricians about their health. Ask your teenage patients how much sleep they usually get on a school night. It can be validating to show them how sleep deprived they are, and point out how strategies like caffeine and oversleeping might be making it worse. Explain that people (adults, too!) need to make time for sleep just as they might for exercise or friends. Tell them about “good sleep hygiene,” the practice of having consistent sleep times and routines that are conducive to restful sleep. This can include a hot shower before bed, reading for the last 30 minutes before lights out, and no screen time for at least 1 hour before bed. Indeed, it can be powerful to urge that everyone in the family takes screens out of their bedrooms.
Additionally, while they might sleep in on weekends, it shouldn’t be much more than an hour longer than on weekdays. And no naps after school! It is common for teens to feel overwhelmed by their commitments and that sleep must be the first thing to go. Use their growing sense of autonomy to remind them that they get to choose how to use their time, and balance will pay off much more than sacrificing sleep. A practical conversation about sleep can help them to make informed choices and thoughtfully take care of themselves before they head off to college.
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@frontlinemedcom.com.
Resources
1. “Adolescent Sleep Needs and Patterns: Research Report and Resource Guide.” (Arlington, Va.: National Sleep Foundation, 2000.)
2. Pediatrics. 2014 Sep;134(3):e921-32.
3. Sleep. 2004 Nov 1;27(7):1351-8.
Every parent will attest that bright-eyed children grow into sleepy adolescents, and the science confirms their observations. There are multiple factors that prevent adolescents from getting the sleep they need, and inadequate sleep has serious consequences – from impaired learning to depressive symptoms, obesity to deadly accidents – all of which are potentially preventable with some practical strategies to promote adequate sleep.
Adolescence is a period of intense growth and development, so it is no surprise that adolescents require a lot of sleep, over 9 hours nightly. But surveys have shown that only 3% of American adolescents get 9 hours of sleep nightly, and the average amount of weeknight sleep is only 6 hours.1 Sleep deprivation is not a problem in childhood, so why can’t adolescents get enough sleep?
Over the last 15 years, a new factor – screen time – has worsened the adolescent sleep situation. Most teens have an electronic device in their bedroom and use it for homework, entertainment, and socializing well into the night. Multiple studies have confirmed that electronic exposure in the evening is associated with less sleep at night and more day time sleepiness,by competing with sleep and suppression of nocturnal melatonin release, which can delay the onset of sleep.2
It is ironic that many teens are staying up late for homework, when their lack of sleep can interfere with consolidation of learning. It also has powerful effects on working memory and reaction time, making both academic and athletic performance suffer. Chronically sleep-deprived teenagers often complain of difficulty with initiating and sustaining attention, which may lead to a mistaken diagnosis of ADHD, and stimulant treatment may further complicate sleep.
Good mental health is not the only casualty of inadequate sleep. A growing body of evidence links short sleep duration with an increased risk of obesity. This appears to be mediated by alterations in neurohormones associated with sleep, leading to higher carbohydrate and fat intake, more snacking and insulin resistance.
Anything that compromises attention and reaction time, including sleep deprivation, adds risk to driving, particularly for inexperienced and impulsive adolescent drivers. The National Highway Transportation Safety Administration estimates that drivers 25 and younger cause more than half of all “fall asleep” crashes.
Teenagers generally know that they are exhausted, but the strategies they might use to manage their fatigue can actually make things worse. Sleepy teenagers often consume large amounts of caffeine to get through their days and their homework at night. Caffeine, in turn, interferes with both the onset and quality of sleep, perpetuating the cycle. Even “catch-up” sleep on weekends is a strategy that can contribute to the problem, as it can lead to more disrupted sleep by pushing the onset of school night sleepiness even later.
While growing autonomy is part of why teenagers are sleep deprived, they will consider the caring and informed guidance of their pediatricians about their health. Ask your teenage patients how much sleep they usually get on a school night. It can be validating to show them how sleep deprived they are, and point out how strategies like caffeine and oversleeping might be making it worse. Explain that people (adults, too!) need to make time for sleep just as they might for exercise or friends. Tell them about “good sleep hygiene,” the practice of having consistent sleep times and routines that are conducive to restful sleep. This can include a hot shower before bed, reading for the last 30 minutes before lights out, and no screen time for at least 1 hour before bed. Indeed, it can be powerful to urge that everyone in the family takes screens out of their bedrooms.
Additionally, while they might sleep in on weekends, it shouldn’t be much more than an hour longer than on weekdays. And no naps after school! It is common for teens to feel overwhelmed by their commitments and that sleep must be the first thing to go. Use their growing sense of autonomy to remind them that they get to choose how to use their time, and balance will pay off much more than sacrificing sleep. A practical conversation about sleep can help them to make informed choices and thoughtfully take care of themselves before they head off to college.
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@frontlinemedcom.com.
Resources
1. “Adolescent Sleep Needs and Patterns: Research Report and Resource Guide.” (Arlington, Va.: National Sleep Foundation, 2000.)
2. Pediatrics. 2014 Sep;134(3):e921-32.
3. Sleep. 2004 Nov 1;27(7):1351-8.
Every parent will attest that bright-eyed children grow into sleepy adolescents, and the science confirms their observations. There are multiple factors that prevent adolescents from getting the sleep they need, and inadequate sleep has serious consequences – from impaired learning to depressive symptoms, obesity to deadly accidents – all of which are potentially preventable with some practical strategies to promote adequate sleep.
Adolescence is a period of intense growth and development, so it is no surprise that adolescents require a lot of sleep, over 9 hours nightly. But surveys have shown that only 3% of American adolescents get 9 hours of sleep nightly, and the average amount of weeknight sleep is only 6 hours.1 Sleep deprivation is not a problem in childhood, so why can’t adolescents get enough sleep?
Over the last 15 years, a new factor – screen time – has worsened the adolescent sleep situation. Most teens have an electronic device in their bedroom and use it for homework, entertainment, and socializing well into the night. Multiple studies have confirmed that electronic exposure in the evening is associated with less sleep at night and more day time sleepiness,by competing with sleep and suppression of nocturnal melatonin release, which can delay the onset of sleep.2
It is ironic that many teens are staying up late for homework, when their lack of sleep can interfere with consolidation of learning. It also has powerful effects on working memory and reaction time, making both academic and athletic performance suffer. Chronically sleep-deprived teenagers often complain of difficulty with initiating and sustaining attention, which may lead to a mistaken diagnosis of ADHD, and stimulant treatment may further complicate sleep.
Good mental health is not the only casualty of inadequate sleep. A growing body of evidence links short sleep duration with an increased risk of obesity. This appears to be mediated by alterations in neurohormones associated with sleep, leading to higher carbohydrate and fat intake, more snacking and insulin resistance.
Anything that compromises attention and reaction time, including sleep deprivation, adds risk to driving, particularly for inexperienced and impulsive adolescent drivers. The National Highway Transportation Safety Administration estimates that drivers 25 and younger cause more than half of all “fall asleep” crashes.
Teenagers generally know that they are exhausted, but the strategies they might use to manage their fatigue can actually make things worse. Sleepy teenagers often consume large amounts of caffeine to get through their days and their homework at night. Caffeine, in turn, interferes with both the onset and quality of sleep, perpetuating the cycle. Even “catch-up” sleep on weekends is a strategy that can contribute to the problem, as it can lead to more disrupted sleep by pushing the onset of school night sleepiness even later.
While growing autonomy is part of why teenagers are sleep deprived, they will consider the caring and informed guidance of their pediatricians about their health. Ask your teenage patients how much sleep they usually get on a school night. It can be validating to show them how sleep deprived they are, and point out how strategies like caffeine and oversleeping might be making it worse. Explain that people (adults, too!) need to make time for sleep just as they might for exercise or friends. Tell them about “good sleep hygiene,” the practice of having consistent sleep times and routines that are conducive to restful sleep. This can include a hot shower before bed, reading for the last 30 minutes before lights out, and no screen time for at least 1 hour before bed. Indeed, it can be powerful to urge that everyone in the family takes screens out of their bedrooms.
Additionally, while they might sleep in on weekends, it shouldn’t be much more than an hour longer than on weekdays. And no naps after school! It is common for teens to feel overwhelmed by their commitments and that sleep must be the first thing to go. Use their growing sense of autonomy to remind them that they get to choose how to use their time, and balance will pay off much more than sacrificing sleep. A practical conversation about sleep can help them to make informed choices and thoughtfully take care of themselves before they head off to college.
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@frontlinemedcom.com.
Resources
1. “Adolescent Sleep Needs and Patterns: Research Report and Resource Guide.” (Arlington, Va.: National Sleep Foundation, 2000.)
2. Pediatrics. 2014 Sep;134(3):e921-32.
3. Sleep. 2004 Nov 1;27(7):1351-8.
Self-injury
Whether you have heard about “cutting” from breathless gossip reports about young starlets or anxious parents of adolescent girls, it seems to be a phenomenon that is on the rise.
As a pediatrician, you may be the first (or only) adult in a young person’s life who notices evidence of self-injury or who asks about it. Self-injurious behaviors may signal significant underlying psychiatric issues or something more benign and brief. Being alert to self-injury is not an easy task. The thought of teenagers cutting themselves on a regular basis and acknowledging their inner distress in your office requires a pediatrician’s self-awareness and emotional preparation.
Self-injury, or nonsuicidal self-injury (NSSI) as it is known in the psychiatric literature, is indeed a relatively common phenomenon. In the United States, it affects approximately 10% of adolescents in a community sample, and as many as 35% of adolescents in treatment for any psychiatric illness. It begins most commonly between the ages of 13 and 15 years, and grows in prevalence through adolescence, dropping off in early adulthood. While adolescent girls are likely to start this behavior earlier than adolescent boys, the gender difference attenuates with age. Some studies have shown adolescent boys are more likely to engage in this behavior than girls by late adolescence.
NSSI typically takes the form of cutting oneself with a sharp object, but it also could involve scratching at the skin until it bleeds, hitting or burning oneself, or interfering with the healing of wounds. It classically was thought of as a symptom of borderline personality disorder, but is a behavior that also may occur with eating disorders, substance use disorders, and anxiety and depressive disorders in adolescents. Clinicians have conceptualized it as a maladaptive way to relieve intense emotional distress, signal distress to others, or inflict self-punishment. It usually starts as an impulsive behavior, and the combination of the intense emotions and high impulsivity of adolescence is why it is so common among this age group. For some adolescents, the impulse will be primarily one of curiosity, perhaps in the setting of some stress, and is more likely to occur if the behavior is common among a teenager’s peers. For those in intense emotional distress, it typically brings a fleeting sense of calm or numbing and an easing of tension. But this relief is usually followed by guilt and shame, and a return, sometimes compounded, of those uncomfortable emotions. Thus what starts as an impulse can become a repetitive, almost compulsive behavior.
If the self-injury happens regularly, it is very important that you show both concern and compassion. You might offer that whatever emotional pain they are experiencing, they deserve more support than a sharp object offers. You could ask about those illnesses that are frequently comorbid with self-injury: substance use, eating disorders, and anxiety and depressive disorders.
But it is essential that you ask about suicidal ideation and suicide attempts. If they are acutely suicidal or describe a history of previously hidden attempts, you will need to help them access care quickly, possibly recommending a visit to the emergency department unless they already have an outpatient treatment team. In these cases, you will need to share your concerns with their parents and help them find their way into the complex mental health system to get a comprehensive psychiatric evaluation and treatment.
Identifying and referring adolescents with NSSI is emotionally demanding work. Learn more from your patients, talk to those who evaluate them, and discuss the issues with colleagues – both to gain skills and to have support as you worry about these patients and help guide them through a complex system of care.
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.
Whether you have heard about “cutting” from breathless gossip reports about young starlets or anxious parents of adolescent girls, it seems to be a phenomenon that is on the rise.
As a pediatrician, you may be the first (or only) adult in a young person’s life who notices evidence of self-injury or who asks about it. Self-injurious behaviors may signal significant underlying psychiatric issues or something more benign and brief. Being alert to self-injury is not an easy task. The thought of teenagers cutting themselves on a regular basis and acknowledging their inner distress in your office requires a pediatrician’s self-awareness and emotional preparation.
Self-injury, or nonsuicidal self-injury (NSSI) as it is known in the psychiatric literature, is indeed a relatively common phenomenon. In the United States, it affects approximately 10% of adolescents in a community sample, and as many as 35% of adolescents in treatment for any psychiatric illness. It begins most commonly between the ages of 13 and 15 years, and grows in prevalence through adolescence, dropping off in early adulthood. While adolescent girls are likely to start this behavior earlier than adolescent boys, the gender difference attenuates with age. Some studies have shown adolescent boys are more likely to engage in this behavior than girls by late adolescence.
NSSI typically takes the form of cutting oneself with a sharp object, but it also could involve scratching at the skin until it bleeds, hitting or burning oneself, or interfering with the healing of wounds. It classically was thought of as a symptom of borderline personality disorder, but is a behavior that also may occur with eating disorders, substance use disorders, and anxiety and depressive disorders in adolescents. Clinicians have conceptualized it as a maladaptive way to relieve intense emotional distress, signal distress to others, or inflict self-punishment. It usually starts as an impulsive behavior, and the combination of the intense emotions and high impulsivity of adolescence is why it is so common among this age group. For some adolescents, the impulse will be primarily one of curiosity, perhaps in the setting of some stress, and is more likely to occur if the behavior is common among a teenager’s peers. For those in intense emotional distress, it typically brings a fleeting sense of calm or numbing and an easing of tension. But this relief is usually followed by guilt and shame, and a return, sometimes compounded, of those uncomfortable emotions. Thus what starts as an impulse can become a repetitive, almost compulsive behavior.
If the self-injury happens regularly, it is very important that you show both concern and compassion. You might offer that whatever emotional pain they are experiencing, they deserve more support than a sharp object offers. You could ask about those illnesses that are frequently comorbid with self-injury: substance use, eating disorders, and anxiety and depressive disorders.
But it is essential that you ask about suicidal ideation and suicide attempts. If they are acutely suicidal or describe a history of previously hidden attempts, you will need to help them access care quickly, possibly recommending a visit to the emergency department unless they already have an outpatient treatment team. In these cases, you will need to share your concerns with their parents and help them find their way into the complex mental health system to get a comprehensive psychiatric evaluation and treatment.
Identifying and referring adolescents with NSSI is emotionally demanding work. Learn more from your patients, talk to those who evaluate them, and discuss the issues with colleagues – both to gain skills and to have support as you worry about these patients and help guide them through a complex system of care.
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.
Whether you have heard about “cutting” from breathless gossip reports about young starlets or anxious parents of adolescent girls, it seems to be a phenomenon that is on the rise.
As a pediatrician, you may be the first (or only) adult in a young person’s life who notices evidence of self-injury or who asks about it. Self-injurious behaviors may signal significant underlying psychiatric issues or something more benign and brief. Being alert to self-injury is not an easy task. The thought of teenagers cutting themselves on a regular basis and acknowledging their inner distress in your office requires a pediatrician’s self-awareness and emotional preparation.
Self-injury, or nonsuicidal self-injury (NSSI) as it is known in the psychiatric literature, is indeed a relatively common phenomenon. In the United States, it affects approximately 10% of adolescents in a community sample, and as many as 35% of adolescents in treatment for any psychiatric illness. It begins most commonly between the ages of 13 and 15 years, and grows in prevalence through adolescence, dropping off in early adulthood. While adolescent girls are likely to start this behavior earlier than adolescent boys, the gender difference attenuates with age. Some studies have shown adolescent boys are more likely to engage in this behavior than girls by late adolescence.
NSSI typically takes the form of cutting oneself with a sharp object, but it also could involve scratching at the skin until it bleeds, hitting or burning oneself, or interfering with the healing of wounds. It classically was thought of as a symptom of borderline personality disorder, but is a behavior that also may occur with eating disorders, substance use disorders, and anxiety and depressive disorders in adolescents. Clinicians have conceptualized it as a maladaptive way to relieve intense emotional distress, signal distress to others, or inflict self-punishment. It usually starts as an impulsive behavior, and the combination of the intense emotions and high impulsivity of adolescence is why it is so common among this age group. For some adolescents, the impulse will be primarily one of curiosity, perhaps in the setting of some stress, and is more likely to occur if the behavior is common among a teenager’s peers. For those in intense emotional distress, it typically brings a fleeting sense of calm or numbing and an easing of tension. But this relief is usually followed by guilt and shame, and a return, sometimes compounded, of those uncomfortable emotions. Thus what starts as an impulse can become a repetitive, almost compulsive behavior.
If the self-injury happens regularly, it is very important that you show both concern and compassion. You might offer that whatever emotional pain they are experiencing, they deserve more support than a sharp object offers. You could ask about those illnesses that are frequently comorbid with self-injury: substance use, eating disorders, and anxiety and depressive disorders.
But it is essential that you ask about suicidal ideation and suicide attempts. If they are acutely suicidal or describe a history of previously hidden attempts, you will need to help them access care quickly, possibly recommending a visit to the emergency department unless they already have an outpatient treatment team. In these cases, you will need to share your concerns with their parents and help them find their way into the complex mental health system to get a comprehensive psychiatric evaluation and treatment.
Identifying and referring adolescents with NSSI is emotionally demanding work. Learn more from your patients, talk to those who evaluate them, and discuss the issues with colleagues – both to gain skills and to have support as you worry about these patients and help guide them through a complex system of care.
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.
50 years of child psychiatry, developmental-behavioral pediatrics
The 50th anniversary of Pediatric News prompts us to look back on the past 50 years in child psychiatry and developmental-behavioral pediatrics, and reflect on the evolution of the field. This includes the approach to diagnosis, the thinking about development and family, and the approach and access to treatment during this dynamic period.
While some historians identify the establishment of the first juvenile court in Chicago in 1899 and the work to help judges evaluate juvenile delinquency as the origin of child psychiatry in the United States, it was not until after World War II that the field really began to take root here, largely based on psychiatrists fleeing Europe and the seminal work of Anna Freud. Some of the earliest connections between pediatrics and child psychiatry were based on the work in England of Donald W. Winnicott, a practicing pediatrician and child psychiatrist, Albert J. Solnit, MD, at the Yale Child Study Center, and psychologically informed work of pediatrician Benjamin M. Spock, MD.
The first Diagnostic and Statistical Manual (DSM) was published in 1952, based on a codification of mental disorders established by the Navy during WWII. The American Academy of Child & Adolescent Psychiatry was established in 1953, the same year that the first “tranquilizer,” chlorpromazine (Thorazine) was introduced (in France), marking the start of a revolution in psychiatric care. In 1959, the first candidates sat for a licensing examination in child psychiatry. The Section on Developmental and Behavioral Pediatrics was established as part of the American Academy of Pediatrics in 1960 to support training in this area. The AACAP established a journal in 1961. Child guidance clinics started affiliating with hospitals and universities in the 1960’s, after the Community Mental Health Act of 1963. Then, in 1965, Julius B. Richmond, MD, (a pediatrician) and Uri Bronfenbrenner, PhD, (a developmental psychologist), recognizing the importance of ecological systems to child development, were involved in the creation of Head Start, and the first Joint Commission on Mental Health for Children was established by federal legislation in 1965. The field was truly coalescing into a distinct discipline of medicine, one that bridged pediatrics, psychiatry, and neurology with nonmedical disciplines such as justice and education.
The decade between 1967 and 1977 was a period of transition from the focus on psychoanalytic concepts typical of the first half of the century to a more systematic approach to diagnosis. Children in psychiatric treatment had commonly been seen for extended individual treatments, and those with more disruptive disorders often were hospitalized for long periods. Psychoanalysis focused on the unconscious (theoretical drives and conflicts) to guide treatment. Treatment often focused on the role (causal) of parents, and family treatment was common, even on inpatient units. The second edition of the DSM (DSM-II) was published in 1968, with its first distinct section for disorders of childhood and adolescence, and an overarching focus on psychodynamics. In 1974, the decision was made to publish a new edition of the DSM that would establish a multiaxial assessment system (separating “biological” mental health problems from personality disorders, medical illnesses, and psychosocial stressors) and research-oriented diagnostic criteria that would attempt to facilitate reliable diagnoses based on common clusters of symptoms. Field trials sponsored by the National Institute of Mental Health began in 1977 to establish the reliability of the new diagnoses.
The year 1977 saw the first Apple computer, the New York City blackout, the release of the first “Star Wars” movie, and also the start of a momentous decade in general and child psychiatry. The third edition of the DSM (DSM-III) was published in 1980, the beginning of a revolution in psychiatric diagnosis and treatments. It created reliable, reproducible diagnostic constructs to serve as the basis for studies on epidemiology and treatment. Implications of causality were replaced by description; for example, hyperkinetic reaction of childhood was redefined and labeled attention-deficit disorder. Recognizing the importance of research and training in this rapidly changing field, W.T. Grant Foundation funded 11 fellowship programs in 1977, and the Society for Developmental and Behavioral Pediatrics was founded in 1982 by the leaders of those programs.
In 1983, The AACAP published “Child Psychiatry: A Plan for the Coming Decades.” It was the result of 5 years’ work by 100 child psychiatrists, general psychiatrists, pediatricians, epidemiologists, nurses, leaders of the NIMH, and various child advocates. This report laid out a challenge for child psychiatry to develop research strategies that would allow evidence-based understanding and treatment of the mental illnesses of children. The established focus on individual experience and anecdotal data, particularly about social and psychodynamic influences, would shift towards a more scientific approach to diagnosis and treatment. This decade started an explosion in epidemiologic research, medication trials, and controlled studies of nonbiological treatments in child psychiatry. At the same time, the political landscape changed, and an ascendant conservatism began the process of closing publicly funded residential treatment centers that had offered care to the more chronically mentally ill and children with profound developmental disorders. This would accelerate the shift towards outpatient psychiatric care of children. Ironically, as research would accelerate in child psychiatry, access to effective treatments would become more difficult.
The decade from 1987 to 1997 was a period of dramatic growth in medication use in child psychiatry. Prozac was approved by the Food and Drug Administration for use in the United States in 1988 and soon followed by other selective serotonin reuptake inhibitors (Zoloft in 1991 and Paxil in 1992). The journal of the AACAP began to publish more randomized controlled trials of medication treatments in children with DSM-codified diagnoses, and clinicians became more comfortable using stimulants, antidepressants, and even antipsychotic medications in the outpatient setting. This trend was enhanced by the emergence of managed care and the denial of coverage for alleged “nonbiological” diagnoses and for many psychiatric treatments. Loss of reimbursement led to a significant decline in resources, particularly inpatient child psychiatry beds and specialized clinics. This, in turn, contributed to the growing emphasis on medication treatments for children’s mental health problems. For-profit managed care companies underbid each other to provide mental health coverage and incentivized medication visits. Of note, the medical budgets, not the mental health carve outs, were billed for the medication prescribed.
The Americans with Disabilities Act was passed in 1990, increasing the funding for school-based mental health resources for children, and in 1996, Congress passed the Mental Health Parity Act, the first of several legislative attempts to ensure parity between insurance coverage for medical and psychiatric illnesses – legislation that to this day has not achieved parity of access to care. As pediatricians took on more of mental health care, a multidisciplinary team created a primary care version of DSM IV, the DSM-IV-PC, in 1995, to assist with defining levels of symptoms less than disorder to facilitate earlier intervention. A formal subspecialty of developmental-behavioral pediatrics was established in 1999 to educate leaders. Pediatric residents have had required training in developmental-behavioral pediatrics since 2008.
The year 1997 saw the first nationwide survey of parents about attention-deficit/hyperactivity disorder, kicking off what could be called the decade of ADHD, in which prevalence rates steadily climbed, from 5.7% in 1997 to 9.5% in 2007. The prevalence of stimulant treatment in children skyrocketed in this period. According to the NIMH, stimulants were prescribed to 4.2% of 6- to 12-year-olds in 1996, and that number grew to 5.1% in 2008. For 13- to 18-year-olds, the rate more than doubled during this time, from 2.3% in 1996 to 4.9% in 2008. The prevalence of autism also grew dramatically during this time, from 1.9 per 1,000 in 1997-1999 to 7.4 per 1,000 in 2006-2008, probably based on an evolving understanding of the disorder and this diagnosis providing special access to resources in schools.
Research during this decade became increasingly focused on imaging studies of children (and adults), as leaders in the field were trying to move from symptom clusters to anatomic and physiologic correlates of psychiatric illness. The great increase in medication use in children hit a speed bump in October 2004, when the Food and Drug Administration issued a controversial public warning about an increased risk of suicidal thoughts or behaviors in youth being treated with SSRI antidepressants. As access to child psychiatric treatment had become more difficult over the preceding decades, pediatricians had assumed much of the medication treatment of common psychiatric problems. The FDA’s black box warning complicated pediatricians’ efforts to fill this void.
The last decade has been the decade of genetics and efforts to improve access to care. It started in 2007 with the FDA expanding its SSRI warning to acknowledge that depression itself increased the risk for suicide, in an effort to not discourage needed depression treatment in young people. But studies demonstrated that the rates of diagnosing and treating depression dropped dramatically in the years following the warning: Diagnoses of depression declined by as much as 42% in children, and the rate of antidepressant treatment in adolescents dropped by as much as 32% in the 2 years following the warning (N Engl J Med. 2014 Oct 30;371(18):1666-8). There was no compensatory increase in utilization of other kinds of treatments. While suicide rates in young people had been stubbornly steady from the mid-1970’s to the mid-1990’s, they began to decline in 1996, according to the Centers for Disease Control and Prevention. But that trend was broken in 2004, with a jump in attempted and completed suicides in young people. The rate stabilized later in the decade, but has never returned to the lows that were being achieved prior to the warning.
This decade was marked by the passage of the Affordable Care Act, including – again – an unfulfilled mandate for mental health parity for any insurance plans in the marketplace. Although diagnosis is still symptom based, the effort to define psychiatric disorders based on brain anatomy, neurotransmitters, and genomics continues to intensify. There is growing evidence that psychiatric disorders are not nature or nurture, but nature and nurture. Epigenetic findings show that environment impacts gene expression and brain functioning. These findings promise to deepen our understanding of the critical role of early experiences (consider Adverse Childhood Experiences [ACE] scores) and the promise of protective relationships, in schools and parenting.
And what will come next? We believe that silos – medical, psychiatric, parenting, school, environment – will be bridged to understand the many factors that impact behavior and treatment, but the need to advocate for policies that support funding for the education and mental health care of children and the training of professionals to provide that care is never ending. As our knowledge of the genome marches forward, we may discover effective strategies for preventing the emergence of mental illness in children or create individualized treatments. We may learn more about the role of nutrition and the microbiome in health and disease, about autoimmunity and mental illness. Our focus may return to parents, not as culprits, but as the mediators of health from the prenatal period on. Technology may enable us to improve access to effective treatments, with teens monitoring their sleep and mood, and accessing therapy on their smart phones. And our understanding of development and vulnerability may help us stem the rise in autism or collaborate with educators so that education could better put every child on their healthiest possible path. We look forward to experiencing it – and writing about it – with you!
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. They said they had no relevant financial disclosures. Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email them at pdnews@frontlinemedcom.com.
The 50th anniversary of Pediatric News prompts us to look back on the past 50 years in child psychiatry and developmental-behavioral pediatrics, and reflect on the evolution of the field. This includes the approach to diagnosis, the thinking about development and family, and the approach and access to treatment during this dynamic period.
While some historians identify the establishment of the first juvenile court in Chicago in 1899 and the work to help judges evaluate juvenile delinquency as the origin of child psychiatry in the United States, it was not until after World War II that the field really began to take root here, largely based on psychiatrists fleeing Europe and the seminal work of Anna Freud. Some of the earliest connections between pediatrics and child psychiatry were based on the work in England of Donald W. Winnicott, a practicing pediatrician and child psychiatrist, Albert J. Solnit, MD, at the Yale Child Study Center, and psychologically informed work of pediatrician Benjamin M. Spock, MD.
The first Diagnostic and Statistical Manual (DSM) was published in 1952, based on a codification of mental disorders established by the Navy during WWII. The American Academy of Child & Adolescent Psychiatry was established in 1953, the same year that the first “tranquilizer,” chlorpromazine (Thorazine) was introduced (in France), marking the start of a revolution in psychiatric care. In 1959, the first candidates sat for a licensing examination in child psychiatry. The Section on Developmental and Behavioral Pediatrics was established as part of the American Academy of Pediatrics in 1960 to support training in this area. The AACAP established a journal in 1961. Child guidance clinics started affiliating with hospitals and universities in the 1960’s, after the Community Mental Health Act of 1963. Then, in 1965, Julius B. Richmond, MD, (a pediatrician) and Uri Bronfenbrenner, PhD, (a developmental psychologist), recognizing the importance of ecological systems to child development, were involved in the creation of Head Start, and the first Joint Commission on Mental Health for Children was established by federal legislation in 1965. The field was truly coalescing into a distinct discipline of medicine, one that bridged pediatrics, psychiatry, and neurology with nonmedical disciplines such as justice and education.
The decade between 1967 and 1977 was a period of transition from the focus on psychoanalytic concepts typical of the first half of the century to a more systematic approach to diagnosis. Children in psychiatric treatment had commonly been seen for extended individual treatments, and those with more disruptive disorders often were hospitalized for long periods. Psychoanalysis focused on the unconscious (theoretical drives and conflicts) to guide treatment. Treatment often focused on the role (causal) of parents, and family treatment was common, even on inpatient units. The second edition of the DSM (DSM-II) was published in 1968, with its first distinct section for disorders of childhood and adolescence, and an overarching focus on psychodynamics. In 1974, the decision was made to publish a new edition of the DSM that would establish a multiaxial assessment system (separating “biological” mental health problems from personality disorders, medical illnesses, and psychosocial stressors) and research-oriented diagnostic criteria that would attempt to facilitate reliable diagnoses based on common clusters of symptoms. Field trials sponsored by the National Institute of Mental Health began in 1977 to establish the reliability of the new diagnoses.
The year 1977 saw the first Apple computer, the New York City blackout, the release of the first “Star Wars” movie, and also the start of a momentous decade in general and child psychiatry. The third edition of the DSM (DSM-III) was published in 1980, the beginning of a revolution in psychiatric diagnosis and treatments. It created reliable, reproducible diagnostic constructs to serve as the basis for studies on epidemiology and treatment. Implications of causality were replaced by description; for example, hyperkinetic reaction of childhood was redefined and labeled attention-deficit disorder. Recognizing the importance of research and training in this rapidly changing field, W.T. Grant Foundation funded 11 fellowship programs in 1977, and the Society for Developmental and Behavioral Pediatrics was founded in 1982 by the leaders of those programs.
In 1983, The AACAP published “Child Psychiatry: A Plan for the Coming Decades.” It was the result of 5 years’ work by 100 child psychiatrists, general psychiatrists, pediatricians, epidemiologists, nurses, leaders of the NIMH, and various child advocates. This report laid out a challenge for child psychiatry to develop research strategies that would allow evidence-based understanding and treatment of the mental illnesses of children. The established focus on individual experience and anecdotal data, particularly about social and psychodynamic influences, would shift towards a more scientific approach to diagnosis and treatment. This decade started an explosion in epidemiologic research, medication trials, and controlled studies of nonbiological treatments in child psychiatry. At the same time, the political landscape changed, and an ascendant conservatism began the process of closing publicly funded residential treatment centers that had offered care to the more chronically mentally ill and children with profound developmental disorders. This would accelerate the shift towards outpatient psychiatric care of children. Ironically, as research would accelerate in child psychiatry, access to effective treatments would become more difficult.
The decade from 1987 to 1997 was a period of dramatic growth in medication use in child psychiatry. Prozac was approved by the Food and Drug Administration for use in the United States in 1988 and soon followed by other selective serotonin reuptake inhibitors (Zoloft in 1991 and Paxil in 1992). The journal of the AACAP began to publish more randomized controlled trials of medication treatments in children with DSM-codified diagnoses, and clinicians became more comfortable using stimulants, antidepressants, and even antipsychotic medications in the outpatient setting. This trend was enhanced by the emergence of managed care and the denial of coverage for alleged “nonbiological” diagnoses and for many psychiatric treatments. Loss of reimbursement led to a significant decline in resources, particularly inpatient child psychiatry beds and specialized clinics. This, in turn, contributed to the growing emphasis on medication treatments for children’s mental health problems. For-profit managed care companies underbid each other to provide mental health coverage and incentivized medication visits. Of note, the medical budgets, not the mental health carve outs, were billed for the medication prescribed.
The Americans with Disabilities Act was passed in 1990, increasing the funding for school-based mental health resources for children, and in 1996, Congress passed the Mental Health Parity Act, the first of several legislative attempts to ensure parity between insurance coverage for medical and psychiatric illnesses – legislation that to this day has not achieved parity of access to care. As pediatricians took on more of mental health care, a multidisciplinary team created a primary care version of DSM IV, the DSM-IV-PC, in 1995, to assist with defining levels of symptoms less than disorder to facilitate earlier intervention. A formal subspecialty of developmental-behavioral pediatrics was established in 1999 to educate leaders. Pediatric residents have had required training in developmental-behavioral pediatrics since 2008.
The year 1997 saw the first nationwide survey of parents about attention-deficit/hyperactivity disorder, kicking off what could be called the decade of ADHD, in which prevalence rates steadily climbed, from 5.7% in 1997 to 9.5% in 2007. The prevalence of stimulant treatment in children skyrocketed in this period. According to the NIMH, stimulants were prescribed to 4.2% of 6- to 12-year-olds in 1996, and that number grew to 5.1% in 2008. For 13- to 18-year-olds, the rate more than doubled during this time, from 2.3% in 1996 to 4.9% in 2008. The prevalence of autism also grew dramatically during this time, from 1.9 per 1,000 in 1997-1999 to 7.4 per 1,000 in 2006-2008, probably based on an evolving understanding of the disorder and this diagnosis providing special access to resources in schools.
Research during this decade became increasingly focused on imaging studies of children (and adults), as leaders in the field were trying to move from symptom clusters to anatomic and physiologic correlates of psychiatric illness. The great increase in medication use in children hit a speed bump in October 2004, when the Food and Drug Administration issued a controversial public warning about an increased risk of suicidal thoughts or behaviors in youth being treated with SSRI antidepressants. As access to child psychiatric treatment had become more difficult over the preceding decades, pediatricians had assumed much of the medication treatment of common psychiatric problems. The FDA’s black box warning complicated pediatricians’ efforts to fill this void.
The last decade has been the decade of genetics and efforts to improve access to care. It started in 2007 with the FDA expanding its SSRI warning to acknowledge that depression itself increased the risk for suicide, in an effort to not discourage needed depression treatment in young people. But studies demonstrated that the rates of diagnosing and treating depression dropped dramatically in the years following the warning: Diagnoses of depression declined by as much as 42% in children, and the rate of antidepressant treatment in adolescents dropped by as much as 32% in the 2 years following the warning (N Engl J Med. 2014 Oct 30;371(18):1666-8). There was no compensatory increase in utilization of other kinds of treatments. While suicide rates in young people had been stubbornly steady from the mid-1970’s to the mid-1990’s, they began to decline in 1996, according to the Centers for Disease Control and Prevention. But that trend was broken in 2004, with a jump in attempted and completed suicides in young people. The rate stabilized later in the decade, but has never returned to the lows that were being achieved prior to the warning.
This decade was marked by the passage of the Affordable Care Act, including – again – an unfulfilled mandate for mental health parity for any insurance plans in the marketplace. Although diagnosis is still symptom based, the effort to define psychiatric disorders based on brain anatomy, neurotransmitters, and genomics continues to intensify. There is growing evidence that psychiatric disorders are not nature or nurture, but nature and nurture. Epigenetic findings show that environment impacts gene expression and brain functioning. These findings promise to deepen our understanding of the critical role of early experiences (consider Adverse Childhood Experiences [ACE] scores) and the promise of protective relationships, in schools and parenting.
And what will come next? We believe that silos – medical, psychiatric, parenting, school, environment – will be bridged to understand the many factors that impact behavior and treatment, but the need to advocate for policies that support funding for the education and mental health care of children and the training of professionals to provide that care is never ending. As our knowledge of the genome marches forward, we may discover effective strategies for preventing the emergence of mental illness in children or create individualized treatments. We may learn more about the role of nutrition and the microbiome in health and disease, about autoimmunity and mental illness. Our focus may return to parents, not as culprits, but as the mediators of health from the prenatal period on. Technology may enable us to improve access to effective treatments, with teens monitoring their sleep and mood, and accessing therapy on their smart phones. And our understanding of development and vulnerability may help us stem the rise in autism or collaborate with educators so that education could better put every child on their healthiest possible path. We look forward to experiencing it – and writing about it – with you!
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. They said they had no relevant financial disclosures. Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email them at pdnews@frontlinemedcom.com.
The 50th anniversary of Pediatric News prompts us to look back on the past 50 years in child psychiatry and developmental-behavioral pediatrics, and reflect on the evolution of the field. This includes the approach to diagnosis, the thinking about development and family, and the approach and access to treatment during this dynamic period.
While some historians identify the establishment of the first juvenile court in Chicago in 1899 and the work to help judges evaluate juvenile delinquency as the origin of child psychiatry in the United States, it was not until after World War II that the field really began to take root here, largely based on psychiatrists fleeing Europe and the seminal work of Anna Freud. Some of the earliest connections between pediatrics and child psychiatry were based on the work in England of Donald W. Winnicott, a practicing pediatrician and child psychiatrist, Albert J. Solnit, MD, at the Yale Child Study Center, and psychologically informed work of pediatrician Benjamin M. Spock, MD.
The first Diagnostic and Statistical Manual (DSM) was published in 1952, based on a codification of mental disorders established by the Navy during WWII. The American Academy of Child & Adolescent Psychiatry was established in 1953, the same year that the first “tranquilizer,” chlorpromazine (Thorazine) was introduced (in France), marking the start of a revolution in psychiatric care. In 1959, the first candidates sat for a licensing examination in child psychiatry. The Section on Developmental and Behavioral Pediatrics was established as part of the American Academy of Pediatrics in 1960 to support training in this area. The AACAP established a journal in 1961. Child guidance clinics started affiliating with hospitals and universities in the 1960’s, after the Community Mental Health Act of 1963. Then, in 1965, Julius B. Richmond, MD, (a pediatrician) and Uri Bronfenbrenner, PhD, (a developmental psychologist), recognizing the importance of ecological systems to child development, were involved in the creation of Head Start, and the first Joint Commission on Mental Health for Children was established by federal legislation in 1965. The field was truly coalescing into a distinct discipline of medicine, one that bridged pediatrics, psychiatry, and neurology with nonmedical disciplines such as justice and education.
The decade between 1967 and 1977 was a period of transition from the focus on psychoanalytic concepts typical of the first half of the century to a more systematic approach to diagnosis. Children in psychiatric treatment had commonly been seen for extended individual treatments, and those with more disruptive disorders often were hospitalized for long periods. Psychoanalysis focused on the unconscious (theoretical drives and conflicts) to guide treatment. Treatment often focused on the role (causal) of parents, and family treatment was common, even on inpatient units. The second edition of the DSM (DSM-II) was published in 1968, with its first distinct section for disorders of childhood and adolescence, and an overarching focus on psychodynamics. In 1974, the decision was made to publish a new edition of the DSM that would establish a multiaxial assessment system (separating “biological” mental health problems from personality disorders, medical illnesses, and psychosocial stressors) and research-oriented diagnostic criteria that would attempt to facilitate reliable diagnoses based on common clusters of symptoms. Field trials sponsored by the National Institute of Mental Health began in 1977 to establish the reliability of the new diagnoses.
The year 1977 saw the first Apple computer, the New York City blackout, the release of the first “Star Wars” movie, and also the start of a momentous decade in general and child psychiatry. The third edition of the DSM (DSM-III) was published in 1980, the beginning of a revolution in psychiatric diagnosis and treatments. It created reliable, reproducible diagnostic constructs to serve as the basis for studies on epidemiology and treatment. Implications of causality were replaced by description; for example, hyperkinetic reaction of childhood was redefined and labeled attention-deficit disorder. Recognizing the importance of research and training in this rapidly changing field, W.T. Grant Foundation funded 11 fellowship programs in 1977, and the Society for Developmental and Behavioral Pediatrics was founded in 1982 by the leaders of those programs.
In 1983, The AACAP published “Child Psychiatry: A Plan for the Coming Decades.” It was the result of 5 years’ work by 100 child psychiatrists, general psychiatrists, pediatricians, epidemiologists, nurses, leaders of the NIMH, and various child advocates. This report laid out a challenge for child psychiatry to develop research strategies that would allow evidence-based understanding and treatment of the mental illnesses of children. The established focus on individual experience and anecdotal data, particularly about social and psychodynamic influences, would shift towards a more scientific approach to diagnosis and treatment. This decade started an explosion in epidemiologic research, medication trials, and controlled studies of nonbiological treatments in child psychiatry. At the same time, the political landscape changed, and an ascendant conservatism began the process of closing publicly funded residential treatment centers that had offered care to the more chronically mentally ill and children with profound developmental disorders. This would accelerate the shift towards outpatient psychiatric care of children. Ironically, as research would accelerate in child psychiatry, access to effective treatments would become more difficult.
The decade from 1987 to 1997 was a period of dramatic growth in medication use in child psychiatry. Prozac was approved by the Food and Drug Administration for use in the United States in 1988 and soon followed by other selective serotonin reuptake inhibitors (Zoloft in 1991 and Paxil in 1992). The journal of the AACAP began to publish more randomized controlled trials of medication treatments in children with DSM-codified diagnoses, and clinicians became more comfortable using stimulants, antidepressants, and even antipsychotic medications in the outpatient setting. This trend was enhanced by the emergence of managed care and the denial of coverage for alleged “nonbiological” diagnoses and for many psychiatric treatments. Loss of reimbursement led to a significant decline in resources, particularly inpatient child psychiatry beds and specialized clinics. This, in turn, contributed to the growing emphasis on medication treatments for children’s mental health problems. For-profit managed care companies underbid each other to provide mental health coverage and incentivized medication visits. Of note, the medical budgets, not the mental health carve outs, were billed for the medication prescribed.
The Americans with Disabilities Act was passed in 1990, increasing the funding for school-based mental health resources for children, and in 1996, Congress passed the Mental Health Parity Act, the first of several legislative attempts to ensure parity between insurance coverage for medical and psychiatric illnesses – legislation that to this day has not achieved parity of access to care. As pediatricians took on more of mental health care, a multidisciplinary team created a primary care version of DSM IV, the DSM-IV-PC, in 1995, to assist with defining levels of symptoms less than disorder to facilitate earlier intervention. A formal subspecialty of developmental-behavioral pediatrics was established in 1999 to educate leaders. Pediatric residents have had required training in developmental-behavioral pediatrics since 2008.
The year 1997 saw the first nationwide survey of parents about attention-deficit/hyperactivity disorder, kicking off what could be called the decade of ADHD, in which prevalence rates steadily climbed, from 5.7% in 1997 to 9.5% in 2007. The prevalence of stimulant treatment in children skyrocketed in this period. According to the NIMH, stimulants were prescribed to 4.2% of 6- to 12-year-olds in 1996, and that number grew to 5.1% in 2008. For 13- to 18-year-olds, the rate more than doubled during this time, from 2.3% in 1996 to 4.9% in 2008. The prevalence of autism also grew dramatically during this time, from 1.9 per 1,000 in 1997-1999 to 7.4 per 1,000 in 2006-2008, probably based on an evolving understanding of the disorder and this diagnosis providing special access to resources in schools.
Research during this decade became increasingly focused on imaging studies of children (and adults), as leaders in the field were trying to move from symptom clusters to anatomic and physiologic correlates of psychiatric illness. The great increase in medication use in children hit a speed bump in October 2004, when the Food and Drug Administration issued a controversial public warning about an increased risk of suicidal thoughts or behaviors in youth being treated with SSRI antidepressants. As access to child psychiatric treatment had become more difficult over the preceding decades, pediatricians had assumed much of the medication treatment of common psychiatric problems. The FDA’s black box warning complicated pediatricians’ efforts to fill this void.
The last decade has been the decade of genetics and efforts to improve access to care. It started in 2007 with the FDA expanding its SSRI warning to acknowledge that depression itself increased the risk for suicide, in an effort to not discourage needed depression treatment in young people. But studies demonstrated that the rates of diagnosing and treating depression dropped dramatically in the years following the warning: Diagnoses of depression declined by as much as 42% in children, and the rate of antidepressant treatment in adolescents dropped by as much as 32% in the 2 years following the warning (N Engl J Med. 2014 Oct 30;371(18):1666-8). There was no compensatory increase in utilization of other kinds of treatments. While suicide rates in young people had been stubbornly steady from the mid-1970’s to the mid-1990’s, they began to decline in 1996, according to the Centers for Disease Control and Prevention. But that trend was broken in 2004, with a jump in attempted and completed suicides in young people. The rate stabilized later in the decade, but has never returned to the lows that were being achieved prior to the warning.
This decade was marked by the passage of the Affordable Care Act, including – again – an unfulfilled mandate for mental health parity for any insurance plans in the marketplace. Although diagnosis is still symptom based, the effort to define psychiatric disorders based on brain anatomy, neurotransmitters, and genomics continues to intensify. There is growing evidence that psychiatric disorders are not nature or nurture, but nature and nurture. Epigenetic findings show that environment impacts gene expression and brain functioning. These findings promise to deepen our understanding of the critical role of early experiences (consider Adverse Childhood Experiences [ACE] scores) and the promise of protective relationships, in schools and parenting.
And what will come next? We believe that silos – medical, psychiatric, parenting, school, environment – will be bridged to understand the many factors that impact behavior and treatment, but the need to advocate for policies that support funding for the education and mental health care of children and the training of professionals to provide that care is never ending. As our knowledge of the genome marches forward, we may discover effective strategies for preventing the emergence of mental illness in children or create individualized treatments. We may learn more about the role of nutrition and the microbiome in health and disease, about autoimmunity and mental illness. Our focus may return to parents, not as culprits, but as the mediators of health from the prenatal period on. Technology may enable us to improve access to effective treatments, with teens monitoring their sleep and mood, and accessing therapy on their smart phones. And our understanding of development and vulnerability may help us stem the rise in autism or collaborate with educators so that education could better put every child on their healthiest possible path. We look forward to experiencing it – and writing about it – with you!
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. They said they had no relevant financial disclosures. Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email them at pdnews@frontlinemedcom.com.
Stress management for ambitious students
Most parents hope that their children will be motivated and hard-working at school, but ambitious students usually face very high levels of stress. Ambitious young people typically push themselves very hard and may not spend enough time in play, relaxation, or exploring potential interests. Their time with peers might be more competitive than social or fun. They may become rigidly focused on a goal, paving the way for devastation if they fall short of their own expectations. They may internalize stress and not ask for help if it starts to take a toll on their mental health. But ambition is not incompatible with healthy development and well-being. Pediatricians usually know who the ambitious students in their practice are, and will hear about the stress they may be experiencing. You have the opportunity to offer them (or their parents) some strategies to manage their high stress levels, and build resilience.
Support ambition, but not perfectionism
It can be helpful to acknowledge to young people that they are ambitious, enabling them to acknowledge this fact about themselves. This kind of drive can be an admirable strength when it is part of an emerging identity, a wish to be successful as defined by the patient.
It is more likely to be problematic if it is a product of a parent’s need to have a child perform as they deem best. Second, it is critical to differentiate ambition from perfectionism. While ambition can keep someone focused and motivated in the face of difficulty, perfectionism is a bully that leaves a person feeling perpetually inadequate. Ambition without a specific interest or focus can lead to general perfectionism in a young person, and parents might unwittingly support this by applauding successes or becoming overinvested in this success reflecting onto them. When the pediatrician points out to a patient (and parents) that perfection is neither possible nor desirable, they may respond, “why wouldn’t I want to be perfect?” Remind them that perfectionism is actually the enemy of long-term accomplishment, discouraging risk-taking, reflection, and growth.
Celebrate failure!
The critical difference between an ambitious person who is persistent and determined (and thus equipped to succeed) and the brittle perfectionist is the ability to tolerate failure and setbacks. Point out to your patients that ambition means there will be a lot of setbacks, disappointments, and failures, as they attempt things that are challenging. Indeed, they should embrace each little failure, as that is how real learning and growth happen, especially if they are constantly stretching their goals.
As children or teenagers learn that failure is evidence that they are on track, working hard, and improving, they will develop tenacity and flexibility. Carol S. Dweck, PhD, a psychologist who has studied school performance in young people, has demonstrated that when young people are praised for their results they tend to give up when they fail, whereas if they are praised for their hard work and persistence, they redouble their effort when they fail. Parents, teachers, and pediatricians have the power to shift an ambitious child’s mindset (Dweck’s term) by helping the child change his or her thinking about what failure really means.
Cultivate self-awareness and perspective
It is one of the central tasks of growing up to learn what one’s interests, talents, and values are, and this self-knowledge is especially critical in ambitious young people. Without genuine interests or passions, ambition may feel like a hollow quest for approval. It is more likely to become general perfectionism. So children and teenagers need adults who are curious about their underlying interests, who patiently help them to cultivate these interests and dedicate their ambition to the pursuit of these passions. Younger children need adult time and support to explore a variety of interests, dabbling so they might figure out where their interests and talents converge. This can provide plenty of opportunity to celebrate effort over achievement. By adolescence, they should have a clearer sense of their personal interests and abilities, and will be deepening their efforts in fewer areas. Adolescence is also when they start to build a narrative of who they are and what values are truly their own. Parents can serve as models and facilitators for their teenagers’ emerging sets of values. Values such as honesty, compassion, or generosity (for example) organize one’s efforts, giving them deeper meaning and keeping difficulties in perspective. Values also will help ambitious young people set their own goals and create an individualized and meaningful definition of success, and keep bigger failures, losses, or disappointments in perspective.
Teach self-care
It seems obvious to state that learning how to care for one’s self is essential to well-being, but for ambitious young people (and adults), self-care is often the first thing to go (or the last thing they consider) in their busy days. Explain to your patients (and parents) that without adequate, consistent, restful sleep, all of their hard work will be inefficient or likely squandered. Explain that daily cardiovascular exercise is not frivolous, but rather essential to balance their cognitive efforts, and offers potent protection for their physical and mental health. There is even robust evidence that sleep and exercise are directly helpful to memory, learning, and creativity. When a parent models this kind of self-care, it is far more powerful than simply talking about it!
Relaxation is self-care!
While most teenagers do not need to be taught how to relax, those very ambitious ones are likely to need permission and even help in learning how to effectively and efficiently blow off steam. Help them to approach relaxation as they would approach a new subject, open-minded and trying different things to determine what works for them. Some may find exercise relaxing, while some may need a cognitive distraction (sometimes called “senseless fun,” an activity not dedicated to achievement) such as reading, family games, or television. Social time often is very effective relaxation for teenagers, and they should know that it is as important as sleep and studying for their performance. Some may find that a calming activity such as yoga or meditation recharges their batteries, whereas others may need noisy video games to feel renewed. Suggest that they should protect (just a little) time for relaxation even on their busiest days to help them develop good habits of self-care. Without consistent, reliable relaxation, ambitious young people are at risk for burnout or for impulsive and extreme behaviors such as binge-drinking.
Be on the lookout for red flags
In the same way that high performing athletes are at risk for stress fractures or other injuries of repetitive, intense physical activity, ambitious students are vulnerable to some of the problems that can follow sustained, intense cognitive effort. These risks go up if they are sleep deprived, stop exercising, or are socially isolated. Parents can be on the lookout for signs of depression or anxiety disorders, such as loss of energy, withdrawal from friends or beloved activities, persistent unhappiness or irritability (sustained over days to weeks), and of course morbid preoccupations.
Intense perfectionism is common among young people at risk for eating disorders, depression and self-injury, and anxiety disorders. Beyond recognizing signs, it is even more important for parents and pediatricians to equip ambitious young people to stay connected and ask for help if they experience a change in their emotional equilibrium. Suggest to your patients that they should never worry alone. They should ask for help if they are struggling to sleep, to sustain their motivation or effort, or notice feeling panicked, unusually tearful, or hopeless. Depression and anxiety are common and treatable problems in adolescents, but ambitious adolescents might be inclined to try to soldier through them. Caring adults should demystify and destigmatize mood and anxiety problems. You might point out that they would ask for help for a toothache or a painful knee joint, and that their mental health should be no different.
Many ambitious children have ambitious parents who might look back on their own adolescence and wonder if they were sufficiently balanced in their approach or whether they overreacted to failure. Sometimes honest sharing of successes, failures, and enduring dilemmas can build an empathic bridge from one generation to the next.
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@frontlinemedcom.com.
Most parents hope that their children will be motivated and hard-working at school, but ambitious students usually face very high levels of stress. Ambitious young people typically push themselves very hard and may not spend enough time in play, relaxation, or exploring potential interests. Their time with peers might be more competitive than social or fun. They may become rigidly focused on a goal, paving the way for devastation if they fall short of their own expectations. They may internalize stress and not ask for help if it starts to take a toll on their mental health. But ambition is not incompatible with healthy development and well-being. Pediatricians usually know who the ambitious students in their practice are, and will hear about the stress they may be experiencing. You have the opportunity to offer them (or their parents) some strategies to manage their high stress levels, and build resilience.
Support ambition, but not perfectionism
It can be helpful to acknowledge to young people that they are ambitious, enabling them to acknowledge this fact about themselves. This kind of drive can be an admirable strength when it is part of an emerging identity, a wish to be successful as defined by the patient.
It is more likely to be problematic if it is a product of a parent’s need to have a child perform as they deem best. Second, it is critical to differentiate ambition from perfectionism. While ambition can keep someone focused and motivated in the face of difficulty, perfectionism is a bully that leaves a person feeling perpetually inadequate. Ambition without a specific interest or focus can lead to general perfectionism in a young person, and parents might unwittingly support this by applauding successes or becoming overinvested in this success reflecting onto them. When the pediatrician points out to a patient (and parents) that perfection is neither possible nor desirable, they may respond, “why wouldn’t I want to be perfect?” Remind them that perfectionism is actually the enemy of long-term accomplishment, discouraging risk-taking, reflection, and growth.
Celebrate failure!
The critical difference between an ambitious person who is persistent and determined (and thus equipped to succeed) and the brittle perfectionist is the ability to tolerate failure and setbacks. Point out to your patients that ambition means there will be a lot of setbacks, disappointments, and failures, as they attempt things that are challenging. Indeed, they should embrace each little failure, as that is how real learning and growth happen, especially if they are constantly stretching their goals.
As children or teenagers learn that failure is evidence that they are on track, working hard, and improving, they will develop tenacity and flexibility. Carol S. Dweck, PhD, a psychologist who has studied school performance in young people, has demonstrated that when young people are praised for their results they tend to give up when they fail, whereas if they are praised for their hard work and persistence, they redouble their effort when they fail. Parents, teachers, and pediatricians have the power to shift an ambitious child’s mindset (Dweck’s term) by helping the child change his or her thinking about what failure really means.
Cultivate self-awareness and perspective
It is one of the central tasks of growing up to learn what one’s interests, talents, and values are, and this self-knowledge is especially critical in ambitious young people. Without genuine interests or passions, ambition may feel like a hollow quest for approval. It is more likely to become general perfectionism. So children and teenagers need adults who are curious about their underlying interests, who patiently help them to cultivate these interests and dedicate their ambition to the pursuit of these passions. Younger children need adult time and support to explore a variety of interests, dabbling so they might figure out where their interests and talents converge. This can provide plenty of opportunity to celebrate effort over achievement. By adolescence, they should have a clearer sense of their personal interests and abilities, and will be deepening their efforts in fewer areas. Adolescence is also when they start to build a narrative of who they are and what values are truly their own. Parents can serve as models and facilitators for their teenagers’ emerging sets of values. Values such as honesty, compassion, or generosity (for example) organize one’s efforts, giving them deeper meaning and keeping difficulties in perspective. Values also will help ambitious young people set their own goals and create an individualized and meaningful definition of success, and keep bigger failures, losses, or disappointments in perspective.
Teach self-care
It seems obvious to state that learning how to care for one’s self is essential to well-being, but for ambitious young people (and adults), self-care is often the first thing to go (or the last thing they consider) in their busy days. Explain to your patients (and parents) that without adequate, consistent, restful sleep, all of their hard work will be inefficient or likely squandered. Explain that daily cardiovascular exercise is not frivolous, but rather essential to balance their cognitive efforts, and offers potent protection for their physical and mental health. There is even robust evidence that sleep and exercise are directly helpful to memory, learning, and creativity. When a parent models this kind of self-care, it is far more powerful than simply talking about it!
Relaxation is self-care!
While most teenagers do not need to be taught how to relax, those very ambitious ones are likely to need permission and even help in learning how to effectively and efficiently blow off steam. Help them to approach relaxation as they would approach a new subject, open-minded and trying different things to determine what works for them. Some may find exercise relaxing, while some may need a cognitive distraction (sometimes called “senseless fun,” an activity not dedicated to achievement) such as reading, family games, or television. Social time often is very effective relaxation for teenagers, and they should know that it is as important as sleep and studying for their performance. Some may find that a calming activity such as yoga or meditation recharges their batteries, whereas others may need noisy video games to feel renewed. Suggest that they should protect (just a little) time for relaxation even on their busiest days to help them develop good habits of self-care. Without consistent, reliable relaxation, ambitious young people are at risk for burnout or for impulsive and extreme behaviors such as binge-drinking.
Be on the lookout for red flags
In the same way that high performing athletes are at risk for stress fractures or other injuries of repetitive, intense physical activity, ambitious students are vulnerable to some of the problems that can follow sustained, intense cognitive effort. These risks go up if they are sleep deprived, stop exercising, or are socially isolated. Parents can be on the lookout for signs of depression or anxiety disorders, such as loss of energy, withdrawal from friends or beloved activities, persistent unhappiness or irritability (sustained over days to weeks), and of course morbid preoccupations.
Intense perfectionism is common among young people at risk for eating disorders, depression and self-injury, and anxiety disorders. Beyond recognizing signs, it is even more important for parents and pediatricians to equip ambitious young people to stay connected and ask for help if they experience a change in their emotional equilibrium. Suggest to your patients that they should never worry alone. They should ask for help if they are struggling to sleep, to sustain their motivation or effort, or notice feeling panicked, unusually tearful, or hopeless. Depression and anxiety are common and treatable problems in adolescents, but ambitious adolescents might be inclined to try to soldier through them. Caring adults should demystify and destigmatize mood and anxiety problems. You might point out that they would ask for help for a toothache or a painful knee joint, and that their mental health should be no different.
Many ambitious children have ambitious parents who might look back on their own adolescence and wonder if they were sufficiently balanced in their approach or whether they overreacted to failure. Sometimes honest sharing of successes, failures, and enduring dilemmas can build an empathic bridge from one generation to the next.
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@frontlinemedcom.com.
Most parents hope that their children will be motivated and hard-working at school, but ambitious students usually face very high levels of stress. Ambitious young people typically push themselves very hard and may not spend enough time in play, relaxation, or exploring potential interests. Their time with peers might be more competitive than social or fun. They may become rigidly focused on a goal, paving the way for devastation if they fall short of their own expectations. They may internalize stress and not ask for help if it starts to take a toll on their mental health. But ambition is not incompatible with healthy development and well-being. Pediatricians usually know who the ambitious students in their practice are, and will hear about the stress they may be experiencing. You have the opportunity to offer them (or their parents) some strategies to manage their high stress levels, and build resilience.
Support ambition, but not perfectionism
It can be helpful to acknowledge to young people that they are ambitious, enabling them to acknowledge this fact about themselves. This kind of drive can be an admirable strength when it is part of an emerging identity, a wish to be successful as defined by the patient.
It is more likely to be problematic if it is a product of a parent’s need to have a child perform as they deem best. Second, it is critical to differentiate ambition from perfectionism. While ambition can keep someone focused and motivated in the face of difficulty, perfectionism is a bully that leaves a person feeling perpetually inadequate. Ambition without a specific interest or focus can lead to general perfectionism in a young person, and parents might unwittingly support this by applauding successes or becoming overinvested in this success reflecting onto them. When the pediatrician points out to a patient (and parents) that perfection is neither possible nor desirable, they may respond, “why wouldn’t I want to be perfect?” Remind them that perfectionism is actually the enemy of long-term accomplishment, discouraging risk-taking, reflection, and growth.
Celebrate failure!
The critical difference between an ambitious person who is persistent and determined (and thus equipped to succeed) and the brittle perfectionist is the ability to tolerate failure and setbacks. Point out to your patients that ambition means there will be a lot of setbacks, disappointments, and failures, as they attempt things that are challenging. Indeed, they should embrace each little failure, as that is how real learning and growth happen, especially if they are constantly stretching their goals.
As children or teenagers learn that failure is evidence that they are on track, working hard, and improving, they will develop tenacity and flexibility. Carol S. Dweck, PhD, a psychologist who has studied school performance in young people, has demonstrated that when young people are praised for their results they tend to give up when they fail, whereas if they are praised for their hard work and persistence, they redouble their effort when they fail. Parents, teachers, and pediatricians have the power to shift an ambitious child’s mindset (Dweck’s term) by helping the child change his or her thinking about what failure really means.
Cultivate self-awareness and perspective
It is one of the central tasks of growing up to learn what one’s interests, talents, and values are, and this self-knowledge is especially critical in ambitious young people. Without genuine interests or passions, ambition may feel like a hollow quest for approval. It is more likely to become general perfectionism. So children and teenagers need adults who are curious about their underlying interests, who patiently help them to cultivate these interests and dedicate their ambition to the pursuit of these passions. Younger children need adult time and support to explore a variety of interests, dabbling so they might figure out where their interests and talents converge. This can provide plenty of opportunity to celebrate effort over achievement. By adolescence, they should have a clearer sense of their personal interests and abilities, and will be deepening their efforts in fewer areas. Adolescence is also when they start to build a narrative of who they are and what values are truly their own. Parents can serve as models and facilitators for their teenagers’ emerging sets of values. Values such as honesty, compassion, or generosity (for example) organize one’s efforts, giving them deeper meaning and keeping difficulties in perspective. Values also will help ambitious young people set their own goals and create an individualized and meaningful definition of success, and keep bigger failures, losses, or disappointments in perspective.
Teach self-care
It seems obvious to state that learning how to care for one’s self is essential to well-being, but for ambitious young people (and adults), self-care is often the first thing to go (or the last thing they consider) in their busy days. Explain to your patients (and parents) that without adequate, consistent, restful sleep, all of their hard work will be inefficient or likely squandered. Explain that daily cardiovascular exercise is not frivolous, but rather essential to balance their cognitive efforts, and offers potent protection for their physical and mental health. There is even robust evidence that sleep and exercise are directly helpful to memory, learning, and creativity. When a parent models this kind of self-care, it is far more powerful than simply talking about it!
Relaxation is self-care!
While most teenagers do not need to be taught how to relax, those very ambitious ones are likely to need permission and even help in learning how to effectively and efficiently blow off steam. Help them to approach relaxation as they would approach a new subject, open-minded and trying different things to determine what works for them. Some may find exercise relaxing, while some may need a cognitive distraction (sometimes called “senseless fun,” an activity not dedicated to achievement) such as reading, family games, or television. Social time often is very effective relaxation for teenagers, and they should know that it is as important as sleep and studying for their performance. Some may find that a calming activity such as yoga or meditation recharges their batteries, whereas others may need noisy video games to feel renewed. Suggest that they should protect (just a little) time for relaxation even on their busiest days to help them develop good habits of self-care. Without consistent, reliable relaxation, ambitious young people are at risk for burnout or for impulsive and extreme behaviors such as binge-drinking.
Be on the lookout for red flags
In the same way that high performing athletes are at risk for stress fractures or other injuries of repetitive, intense physical activity, ambitious students are vulnerable to some of the problems that can follow sustained, intense cognitive effort. These risks go up if they are sleep deprived, stop exercising, or are socially isolated. Parents can be on the lookout for signs of depression or anxiety disorders, such as loss of energy, withdrawal from friends or beloved activities, persistent unhappiness or irritability (sustained over days to weeks), and of course morbid preoccupations.
Intense perfectionism is common among young people at risk for eating disorders, depression and self-injury, and anxiety disorders. Beyond recognizing signs, it is even more important for parents and pediatricians to equip ambitious young people to stay connected and ask for help if they experience a change in their emotional equilibrium. Suggest to your patients that they should never worry alone. They should ask for help if they are struggling to sleep, to sustain their motivation or effort, or notice feeling panicked, unusually tearful, or hopeless. Depression and anxiety are common and treatable problems in adolescents, but ambitious adolescents might be inclined to try to soldier through them. Caring adults should demystify and destigmatize mood and anxiety problems. You might point out that they would ask for help for a toothache or a painful knee joint, and that their mental health should be no different.
Many ambitious children have ambitious parents who might look back on their own adolescence and wonder if they were sufficiently balanced in their approach or whether they overreacted to failure. Sometimes honest sharing of successes, failures, and enduring dilemmas can build an empathic bridge from one generation to the next.
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@frontlinemedcom.com.
Discussing screen time with parents
The American Academy of Pediatrics released a new set of recommendations for the appropriate amount of screen time for children and adolescents in October 2016.
Among other changes, the AAP now recommends no screen time (except for video chatting) for infants and children up to 18 months old. For 18- to 24-month-olds, the AAP discourages screen time, recommending that parents introduce only selected “high-quality” programming and cowatch with their children. Likewise, for children up to 5 years old, the AAP urges parents to limit all screen time to 1 hour/day, half of its previous recommendation, and again recommends that parents cowatch with their children and use only reliable providers of quality content, such as the Public Broadcasting Service (PBS). For older children, the AAP does not set specific time limits, but recommends that parents collaborate with the children on a media plan that limits screen time so that it does not interfere with other important activities, including homework, social time, exercise, and sleep.
There also is evidence that teenagers who spend substantial time engaged passively in social media (seeing what others are doing or saying via Facebook or Instagram) report higher levels of depression and anxiety, whereas those who use social media as a platform to stay connected (via two-way communication) report lower levels of these symptoms. While many young people use social sites as a forum to find peer support, share concerns, or develop their own “voice,” some young people might be vulnerable to exploitation, cyberbullying, or even online solicitation. The key here may be for parents, who have a sense of their child’s strengths and vulnerabilities, to be aware of where their children are spending their virtual time and to check in about the kinds of connections they have there. Of course, screen time can be equally seductive for parents. And when a parent is spending time reading texts or checking for Facebook updates, they are missing opportunities to be engaged with their children, helping them with homework or simply noticing that they seem stressed, or catching an opportunity to talk with them.
The pediatrician has the opportunity to educate parents about the potential risks that unchecked screen time can pose to their children’s healthy development. But it is critical that you approach these conversations with specificity and compassion. Customize the conversation to the age and personality of the child and family. A computer in the bedroom may make sense for an academically oriented 9th grader in a demanding school who is generally well-balanced in activities and friendships. A bedroom computer may be a poor choice for an isolated 9th grader almost addicted to video games with few friends or activities.
Simply reciting recommendations may heighten a parent’s feelings of isolation and shame, and not lead to meaningful change. Instead, start by asking about the details: Where are the screens in the home? Bedrooms? Who has a computer, tablet, or smartphone? How are these screens used in the context of the child’s overall psychosocial functioning? Depending on the circumstance, a smaller change, such as “no phones while doing homework,” can make a big difference. Simple, clear rules can be easier to explain and enforce, and protect parents from the perils of daily negotiations of screen terms with their children or teenagers. Perhaps they can have a “phone zone” where phones get parked and charged once kids get home from school. Perhaps there are limits on TV or video games on school nights (for the student performing below potential, rather than the driven student who would benefit from down time). Perhaps for preteens, computer-based homework can be done only on the desktop computer that is kept in a family study, rather than a laptop in a bedroom where kids are more likely to become distracted and surf the net. Pediatricians can help families think through the right approach to screen time that may range from restriction to shared use exploring shared interests to jointly watching a favorite TV show or sporting event.
You can help parents consider how they will talk about all this, acknowledging what is fun and rewarding about TV shows, social media, and the Internet alongside the problems of excessive use. Ask parents if it is hard for them to put down their own phones or tablets. They can acknowledge this explicitly with their children when establishing new media use rules. It is powerful for children, especially teenagers, to hear their parents acknowledge that “phones, tablets, and computers are powerful tools, but we all need to improve our skills at being in control of our use of them.” You might suggest that parents try this exercise: list all of the activities they wish they had time for in every day, and how much time they would spend in them. Then they should guess how much time they spend in screen-based entertainment. If they wish to protect time for screen-based entertainment, they can actively choose to do so. If you are able to help parents better understand the risks of excessive screen time and facilitate desired and appropriate use of media, you will have added to the quality of the family’s life.
The AAP has resources to help pediatricians partner with parents to create a Family Media Use Plan (www.healthychildren.org/MediaUsePlan).
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@frontlinemedcom.com.
The American Academy of Pediatrics released a new set of recommendations for the appropriate amount of screen time for children and adolescents in October 2016.
Among other changes, the AAP now recommends no screen time (except for video chatting) for infants and children up to 18 months old. For 18- to 24-month-olds, the AAP discourages screen time, recommending that parents introduce only selected “high-quality” programming and cowatch with their children. Likewise, for children up to 5 years old, the AAP urges parents to limit all screen time to 1 hour/day, half of its previous recommendation, and again recommends that parents cowatch with their children and use only reliable providers of quality content, such as the Public Broadcasting Service (PBS). For older children, the AAP does not set specific time limits, but recommends that parents collaborate with the children on a media plan that limits screen time so that it does not interfere with other important activities, including homework, social time, exercise, and sleep.
There also is evidence that teenagers who spend substantial time engaged passively in social media (seeing what others are doing or saying via Facebook or Instagram) report higher levels of depression and anxiety, whereas those who use social media as a platform to stay connected (via two-way communication) report lower levels of these symptoms. While many young people use social sites as a forum to find peer support, share concerns, or develop their own “voice,” some young people might be vulnerable to exploitation, cyberbullying, or even online solicitation. The key here may be for parents, who have a sense of their child’s strengths and vulnerabilities, to be aware of where their children are spending their virtual time and to check in about the kinds of connections they have there. Of course, screen time can be equally seductive for parents. And when a parent is spending time reading texts or checking for Facebook updates, they are missing opportunities to be engaged with their children, helping them with homework or simply noticing that they seem stressed, or catching an opportunity to talk with them.
The pediatrician has the opportunity to educate parents about the potential risks that unchecked screen time can pose to their children’s healthy development. But it is critical that you approach these conversations with specificity and compassion. Customize the conversation to the age and personality of the child and family. A computer in the bedroom may make sense for an academically oriented 9th grader in a demanding school who is generally well-balanced in activities and friendships. A bedroom computer may be a poor choice for an isolated 9th grader almost addicted to video games with few friends or activities.
Simply reciting recommendations may heighten a parent’s feelings of isolation and shame, and not lead to meaningful change. Instead, start by asking about the details: Where are the screens in the home? Bedrooms? Who has a computer, tablet, or smartphone? How are these screens used in the context of the child’s overall psychosocial functioning? Depending on the circumstance, a smaller change, such as “no phones while doing homework,” can make a big difference. Simple, clear rules can be easier to explain and enforce, and protect parents from the perils of daily negotiations of screen terms with their children or teenagers. Perhaps they can have a “phone zone” where phones get parked and charged once kids get home from school. Perhaps there are limits on TV or video games on school nights (for the student performing below potential, rather than the driven student who would benefit from down time). Perhaps for preteens, computer-based homework can be done only on the desktop computer that is kept in a family study, rather than a laptop in a bedroom where kids are more likely to become distracted and surf the net. Pediatricians can help families think through the right approach to screen time that may range from restriction to shared use exploring shared interests to jointly watching a favorite TV show or sporting event.
You can help parents consider how they will talk about all this, acknowledging what is fun and rewarding about TV shows, social media, and the Internet alongside the problems of excessive use. Ask parents if it is hard for them to put down their own phones or tablets. They can acknowledge this explicitly with their children when establishing new media use rules. It is powerful for children, especially teenagers, to hear their parents acknowledge that “phones, tablets, and computers are powerful tools, but we all need to improve our skills at being in control of our use of them.” You might suggest that parents try this exercise: list all of the activities they wish they had time for in every day, and how much time they would spend in them. Then they should guess how much time they spend in screen-based entertainment. If they wish to protect time for screen-based entertainment, they can actively choose to do so. If you are able to help parents better understand the risks of excessive screen time and facilitate desired and appropriate use of media, you will have added to the quality of the family’s life.
The AAP has resources to help pediatricians partner with parents to create a Family Media Use Plan (www.healthychildren.org/MediaUsePlan).
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@frontlinemedcom.com.
The American Academy of Pediatrics released a new set of recommendations for the appropriate amount of screen time for children and adolescents in October 2016.
Among other changes, the AAP now recommends no screen time (except for video chatting) for infants and children up to 18 months old. For 18- to 24-month-olds, the AAP discourages screen time, recommending that parents introduce only selected “high-quality” programming and cowatch with their children. Likewise, for children up to 5 years old, the AAP urges parents to limit all screen time to 1 hour/day, half of its previous recommendation, and again recommends that parents cowatch with their children and use only reliable providers of quality content, such as the Public Broadcasting Service (PBS). For older children, the AAP does not set specific time limits, but recommends that parents collaborate with the children on a media plan that limits screen time so that it does not interfere with other important activities, including homework, social time, exercise, and sleep.
There also is evidence that teenagers who spend substantial time engaged passively in social media (seeing what others are doing or saying via Facebook or Instagram) report higher levels of depression and anxiety, whereas those who use social media as a platform to stay connected (via two-way communication) report lower levels of these symptoms. While many young people use social sites as a forum to find peer support, share concerns, or develop their own “voice,” some young people might be vulnerable to exploitation, cyberbullying, or even online solicitation. The key here may be for parents, who have a sense of their child’s strengths and vulnerabilities, to be aware of where their children are spending their virtual time and to check in about the kinds of connections they have there. Of course, screen time can be equally seductive for parents. And when a parent is spending time reading texts or checking for Facebook updates, they are missing opportunities to be engaged with their children, helping them with homework or simply noticing that they seem stressed, or catching an opportunity to talk with them.
The pediatrician has the opportunity to educate parents about the potential risks that unchecked screen time can pose to their children’s healthy development. But it is critical that you approach these conversations with specificity and compassion. Customize the conversation to the age and personality of the child and family. A computer in the bedroom may make sense for an academically oriented 9th grader in a demanding school who is generally well-balanced in activities and friendships. A bedroom computer may be a poor choice for an isolated 9th grader almost addicted to video games with few friends or activities.
Simply reciting recommendations may heighten a parent’s feelings of isolation and shame, and not lead to meaningful change. Instead, start by asking about the details: Where are the screens in the home? Bedrooms? Who has a computer, tablet, or smartphone? How are these screens used in the context of the child’s overall psychosocial functioning? Depending on the circumstance, a smaller change, such as “no phones while doing homework,” can make a big difference. Simple, clear rules can be easier to explain and enforce, and protect parents from the perils of daily negotiations of screen terms with their children or teenagers. Perhaps they can have a “phone zone” where phones get parked and charged once kids get home from school. Perhaps there are limits on TV or video games on school nights (for the student performing below potential, rather than the driven student who would benefit from down time). Perhaps for preteens, computer-based homework can be done only on the desktop computer that is kept in a family study, rather than a laptop in a bedroom where kids are more likely to become distracted and surf the net. Pediatricians can help families think through the right approach to screen time that may range from restriction to shared use exploring shared interests to jointly watching a favorite TV show or sporting event.
You can help parents consider how they will talk about all this, acknowledging what is fun and rewarding about TV shows, social media, and the Internet alongside the problems of excessive use. Ask parents if it is hard for them to put down their own phones or tablets. They can acknowledge this explicitly with their children when establishing new media use rules. It is powerful for children, especially teenagers, to hear their parents acknowledge that “phones, tablets, and computers are powerful tools, but we all need to improve our skills at being in control of our use of them.” You might suggest that parents try this exercise: list all of the activities they wish they had time for in every day, and how much time they would spend in them. Then they should guess how much time they spend in screen-based entertainment. If they wish to protect time for screen-based entertainment, they can actively choose to do so. If you are able to help parents better understand the risks of excessive screen time and facilitate desired and appropriate use of media, you will have added to the quality of the family’s life.
The AAP has resources to help pediatricians partner with parents to create a Family Media Use Plan (www.healthychildren.org/MediaUsePlan).
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@frontlinemedcom.com.
School refusal
As summer winds down, it is routine for children and adolescents to feel a little melancholy or even worried about the approaching start of school. But for some students, anxiety about school is more than routine; it is insurmountable. School refusal is a serious behavioral problem: without assertive management, it can become a pattern which is very difficult to alter. Whether a child is complaining of vague somatic concerns or is explicitly refusing to go to school, the pediatrician’s office is often the first place a parent will turn to for help. If you can recognize the true nature of the problem, help to determine its cause, and facilitate the needed management, you will have effectively treated what can become a disabling problem for vulnerable young people.
School refusal is happening when a child has major difficulty attending school, associated with intense emotional distress. It can be a refusal to attend school or difficulty remaining in school for an entire day. It is distinct (but not mutually exclusive) from truancy, which is a failure to attend school associated with antisocial behavior or other conduct problems. In the pediatrician’s office, school refusal sounds like, “He was moaning about a stomachache yesterday, I kept him home, but he had no fever and ate okay. Then it all repeated again this morning.” Or you might hear, “She was whining about a headache, but when I said she had to go to school, she started crying and couldn’t stop. She was hysterical!” In teenagers, there may be somatic complaints or just a sleepy, sulky refusal to get out of bed. Children with truancy might fake illness (as compared with feeling sick), or simply leave school. Truant children often want to be out of school doing other things, and may keep their whereabouts a secret from their parents. While it might seem like just one tough morning that can be shrugged off, true school refusal will continue or escalate unless it is properly managed.
School refusal affects approximately 5% of all children annually, affecting girls and boys in equal numbers and with peaks in incidence at the ages of 5 to 6 years and again at 10 to 11 years. Approximately half of children and teenagers with school refusal have a treatable psychiatric illness. In the Great Smoky Mountain Study of 2003, where more than 1,400 children were observed, they categorized children as being anxious school refusers, truant, or “mixed school refusers,” with features of both truancy and anxiety. In children with truancy or anxious school refusal, 25% had a psychiatric illness. In the mixed school refusers, they found 88% had at least one psychiatric diagnosis and 42% had somatic complaints. While pure truancy will require different management strategies from school and parents, those young people who display features of both anxiety and truancy around school attendance are most likely to be suffering from a psychiatric illness. Those illnesses most commonly associated with difficulty attending school include anxiety disorders (separation anxiety, social phobia, generalized anxiety disorder) and depression.
While psychiatric illness is a common factor, there is also always a behavioral component to school refusal. This simply means that children are either avoiding unpleasant feelings associated with school, such as anxiety, or escaping uncomfortable situations, such as bullying or the stress of performance. On the positive side, children may be refusing school because they are pursuing the attention of important people (parents, peers) or pursuing pleasurable activities (playing video games, surfing the web or hanging out in town). Beyond an internal anxiety disorder, some children may be facing bullying or threats at school or may have to walk through a dangerous neighborhood to get to school. Some children may be missing school because of significant stress or transitions at home, such as financial difficulties or divorce. Other children may be staying home to take care of younger siblings because of a parent’s medical illness or substance abuse problem. Children who are being abused may be kept home to prevent suspicion about bruises. Lastly, some children feel they have to stay home to be with a lonely or depressed parent. Gently asking about these very real concerns will help determine the necessary course of action.
Pediatricians can play a central role in the management of school refusal. Often, the most important step is helping parents to understand that there is not an insidious medical problem driving the morning stomachaches and headaches. It is critical to clarify that (usually) their child is not feigning illness, but that there is significant distress around school that has led to this behavioral problem. Even children who have a genuine medical problem also can have school refusal. Once parents understand that without proper management, this behavior will continue or worsen, they usually are ready to collaborate on effective management. Their child may need a thorough psychiatric evaluation to rule out a treatable underlying psychiatric diagnosis, particularly if they have both anxious and truant behaviors. Most of the psychiatric problems associated with school refusal will require therapy and some may require medications for effective treatment.
Successfully getting children back to school will require a behavior plan that is agreed upon by the parents and the school, and then used consistently. This plan will simply detail strategies to “demagnetize” the home and “remagnetize” the school. Such strategies might include ensuring that children are not allowed “screen time” when home from school, and that their homework expectations continue. It should support healthy routines, including a regular sleep schedule and exercise. It should facilitate their being able to gradually manage any anxiety associated with school (shorter days initially, the option to have time-outs in a favorite part of the school or with a favorite teacher). A behavior plan should detail strategies for the child to manage stress (relaxation strategies, connecting with supportive individuals, even singing a favorite song). This plan can detail reasonable accommodations for a medical or psychiatric condition and appropriate rewards for regular attendance, such as being able to go on a class trip.
Through all of this, the pediatrician is in a uniquely authoritative position to provide support and reassurance to parents of a school refusing child. The pediatrician has a unique ability to clarify for parents the seriousness of the behavioral problem, even if there is no medical problem. Compassionately acknowledging how much a child is suffering (and the parents, as well) is powerful. Remind parents that accommodating anxiety only shows a child you don’t think they can master it, and often keeps them from trying. Express confidence that this is a relatively common and treatable phenomenon. If a pediatrician’s and parents’ efforts do not work quickly, in a matter of a few days, urgent referral to a mental health consultant is indicated, as falling behind in school and any acceptance of staying home makes return to school more difficult every day.
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.
As summer winds down, it is routine for children and adolescents to feel a little melancholy or even worried about the approaching start of school. But for some students, anxiety about school is more than routine; it is insurmountable. School refusal is a serious behavioral problem: without assertive management, it can become a pattern which is very difficult to alter. Whether a child is complaining of vague somatic concerns or is explicitly refusing to go to school, the pediatrician’s office is often the first place a parent will turn to for help. If you can recognize the true nature of the problem, help to determine its cause, and facilitate the needed management, you will have effectively treated what can become a disabling problem for vulnerable young people.
School refusal is happening when a child has major difficulty attending school, associated with intense emotional distress. It can be a refusal to attend school or difficulty remaining in school for an entire day. It is distinct (but not mutually exclusive) from truancy, which is a failure to attend school associated with antisocial behavior or other conduct problems. In the pediatrician’s office, school refusal sounds like, “He was moaning about a stomachache yesterday, I kept him home, but he had no fever and ate okay. Then it all repeated again this morning.” Or you might hear, “She was whining about a headache, but when I said she had to go to school, she started crying and couldn’t stop. She was hysterical!” In teenagers, there may be somatic complaints or just a sleepy, sulky refusal to get out of bed. Children with truancy might fake illness (as compared with feeling sick), or simply leave school. Truant children often want to be out of school doing other things, and may keep their whereabouts a secret from their parents. While it might seem like just one tough morning that can be shrugged off, true school refusal will continue or escalate unless it is properly managed.
School refusal affects approximately 5% of all children annually, affecting girls and boys in equal numbers and with peaks in incidence at the ages of 5 to 6 years and again at 10 to 11 years. Approximately half of children and teenagers with school refusal have a treatable psychiatric illness. In the Great Smoky Mountain Study of 2003, where more than 1,400 children were observed, they categorized children as being anxious school refusers, truant, or “mixed school refusers,” with features of both truancy and anxiety. In children with truancy or anxious school refusal, 25% had a psychiatric illness. In the mixed school refusers, they found 88% had at least one psychiatric diagnosis and 42% had somatic complaints. While pure truancy will require different management strategies from school and parents, those young people who display features of both anxiety and truancy around school attendance are most likely to be suffering from a psychiatric illness. Those illnesses most commonly associated with difficulty attending school include anxiety disorders (separation anxiety, social phobia, generalized anxiety disorder) and depression.
While psychiatric illness is a common factor, there is also always a behavioral component to school refusal. This simply means that children are either avoiding unpleasant feelings associated with school, such as anxiety, or escaping uncomfortable situations, such as bullying or the stress of performance. On the positive side, children may be refusing school because they are pursuing the attention of important people (parents, peers) or pursuing pleasurable activities (playing video games, surfing the web or hanging out in town). Beyond an internal anxiety disorder, some children may be facing bullying or threats at school or may have to walk through a dangerous neighborhood to get to school. Some children may be missing school because of significant stress or transitions at home, such as financial difficulties or divorce. Other children may be staying home to take care of younger siblings because of a parent’s medical illness or substance abuse problem. Children who are being abused may be kept home to prevent suspicion about bruises. Lastly, some children feel they have to stay home to be with a lonely or depressed parent. Gently asking about these very real concerns will help determine the necessary course of action.
Pediatricians can play a central role in the management of school refusal. Often, the most important step is helping parents to understand that there is not an insidious medical problem driving the morning stomachaches and headaches. It is critical to clarify that (usually) their child is not feigning illness, but that there is significant distress around school that has led to this behavioral problem. Even children who have a genuine medical problem also can have school refusal. Once parents understand that without proper management, this behavior will continue or worsen, they usually are ready to collaborate on effective management. Their child may need a thorough psychiatric evaluation to rule out a treatable underlying psychiatric diagnosis, particularly if they have both anxious and truant behaviors. Most of the psychiatric problems associated with school refusal will require therapy and some may require medications for effective treatment.
Successfully getting children back to school will require a behavior plan that is agreed upon by the parents and the school, and then used consistently. This plan will simply detail strategies to “demagnetize” the home and “remagnetize” the school. Such strategies might include ensuring that children are not allowed “screen time” when home from school, and that their homework expectations continue. It should support healthy routines, including a regular sleep schedule and exercise. It should facilitate their being able to gradually manage any anxiety associated with school (shorter days initially, the option to have time-outs in a favorite part of the school or with a favorite teacher). A behavior plan should detail strategies for the child to manage stress (relaxation strategies, connecting with supportive individuals, even singing a favorite song). This plan can detail reasonable accommodations for a medical or psychiatric condition and appropriate rewards for regular attendance, such as being able to go on a class trip.
Through all of this, the pediatrician is in a uniquely authoritative position to provide support and reassurance to parents of a school refusing child. The pediatrician has a unique ability to clarify for parents the seriousness of the behavioral problem, even if there is no medical problem. Compassionately acknowledging how much a child is suffering (and the parents, as well) is powerful. Remind parents that accommodating anxiety only shows a child you don’t think they can master it, and often keeps them from trying. Express confidence that this is a relatively common and treatable phenomenon. If a pediatrician’s and parents’ efforts do not work quickly, in a matter of a few days, urgent referral to a mental health consultant is indicated, as falling behind in school and any acceptance of staying home makes return to school more difficult every day.
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.
As summer winds down, it is routine for children and adolescents to feel a little melancholy or even worried about the approaching start of school. But for some students, anxiety about school is more than routine; it is insurmountable. School refusal is a serious behavioral problem: without assertive management, it can become a pattern which is very difficult to alter. Whether a child is complaining of vague somatic concerns or is explicitly refusing to go to school, the pediatrician’s office is often the first place a parent will turn to for help. If you can recognize the true nature of the problem, help to determine its cause, and facilitate the needed management, you will have effectively treated what can become a disabling problem for vulnerable young people.
School refusal is happening when a child has major difficulty attending school, associated with intense emotional distress. It can be a refusal to attend school or difficulty remaining in school for an entire day. It is distinct (but not mutually exclusive) from truancy, which is a failure to attend school associated with antisocial behavior or other conduct problems. In the pediatrician’s office, school refusal sounds like, “He was moaning about a stomachache yesterday, I kept him home, but he had no fever and ate okay. Then it all repeated again this morning.” Or you might hear, “She was whining about a headache, but when I said she had to go to school, she started crying and couldn’t stop. She was hysterical!” In teenagers, there may be somatic complaints or just a sleepy, sulky refusal to get out of bed. Children with truancy might fake illness (as compared with feeling sick), or simply leave school. Truant children often want to be out of school doing other things, and may keep their whereabouts a secret from their parents. While it might seem like just one tough morning that can be shrugged off, true school refusal will continue or escalate unless it is properly managed.
School refusal affects approximately 5% of all children annually, affecting girls and boys in equal numbers and with peaks in incidence at the ages of 5 to 6 years and again at 10 to 11 years. Approximately half of children and teenagers with school refusal have a treatable psychiatric illness. In the Great Smoky Mountain Study of 2003, where more than 1,400 children were observed, they categorized children as being anxious school refusers, truant, or “mixed school refusers,” with features of both truancy and anxiety. In children with truancy or anxious school refusal, 25% had a psychiatric illness. In the mixed school refusers, they found 88% had at least one psychiatric diagnosis and 42% had somatic complaints. While pure truancy will require different management strategies from school and parents, those young people who display features of both anxiety and truancy around school attendance are most likely to be suffering from a psychiatric illness. Those illnesses most commonly associated with difficulty attending school include anxiety disorders (separation anxiety, social phobia, generalized anxiety disorder) and depression.
While psychiatric illness is a common factor, there is also always a behavioral component to school refusal. This simply means that children are either avoiding unpleasant feelings associated with school, such as anxiety, or escaping uncomfortable situations, such as bullying or the stress of performance. On the positive side, children may be refusing school because they are pursuing the attention of important people (parents, peers) or pursuing pleasurable activities (playing video games, surfing the web or hanging out in town). Beyond an internal anxiety disorder, some children may be facing bullying or threats at school or may have to walk through a dangerous neighborhood to get to school. Some children may be missing school because of significant stress or transitions at home, such as financial difficulties or divorce. Other children may be staying home to take care of younger siblings because of a parent’s medical illness or substance abuse problem. Children who are being abused may be kept home to prevent suspicion about bruises. Lastly, some children feel they have to stay home to be with a lonely or depressed parent. Gently asking about these very real concerns will help determine the necessary course of action.
Pediatricians can play a central role in the management of school refusal. Often, the most important step is helping parents to understand that there is not an insidious medical problem driving the morning stomachaches and headaches. It is critical to clarify that (usually) their child is not feigning illness, but that there is significant distress around school that has led to this behavioral problem. Even children who have a genuine medical problem also can have school refusal. Once parents understand that without proper management, this behavior will continue or worsen, they usually are ready to collaborate on effective management. Their child may need a thorough psychiatric evaluation to rule out a treatable underlying psychiatric diagnosis, particularly if they have both anxious and truant behaviors. Most of the psychiatric problems associated with school refusal will require therapy and some may require medications for effective treatment.
Successfully getting children back to school will require a behavior plan that is agreed upon by the parents and the school, and then used consistently. This plan will simply detail strategies to “demagnetize” the home and “remagnetize” the school. Such strategies might include ensuring that children are not allowed “screen time” when home from school, and that their homework expectations continue. It should support healthy routines, including a regular sleep schedule and exercise. It should facilitate their being able to gradually manage any anxiety associated with school (shorter days initially, the option to have time-outs in a favorite part of the school or with a favorite teacher). A behavior plan should detail strategies for the child to manage stress (relaxation strategies, connecting with supportive individuals, even singing a favorite song). This plan can detail reasonable accommodations for a medical or psychiatric condition and appropriate rewards for regular attendance, such as being able to go on a class trip.
Through all of this, the pediatrician is in a uniquely authoritative position to provide support and reassurance to parents of a school refusing child. The pediatrician has a unique ability to clarify for parents the seriousness of the behavioral problem, even if there is no medical problem. Compassionately acknowledging how much a child is suffering (and the parents, as well) is powerful. Remind parents that accommodating anxiety only shows a child you don’t think they can master it, and often keeps them from trying. Express confidence that this is a relatively common and treatable phenomenon. If a pediatrician’s and parents’ efforts do not work quickly, in a matter of a few days, urgent referral to a mental health consultant is indicated, as falling behind in school and any acceptance of staying home makes return to school more difficult every day.
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.
