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Climate Change, Climate Anxiety, Climate Hope
Clinical Case: Sol is a 10 year-old cisgender White girl who appears sad at her annual well visit. On further inquiry she describes that her father is angry that there is no snow, her mother keeps talking about the forests disappearing, and local flooding closed down her favorite family restaurant for good. She is worried “the planet is in trouble and there’s nothing we can do” so much that she gets stomachaches when she thinks about it.
Climate Anxiety
Climate change is a complex phenomenon that has been subject to decades of political disagreement. Lobbying by groups like the fossil fuel industry, state legislation to implement recycling, oil spills and pollution disasters, and outspoken icons like former US Vice President Al Gore and Swedish activist Greta Thunberg have kept the climate crisis a hot topic. What was once a slow burn has begun to boil as climate-related disasters occur — wildfires, droughts, floods, and increasingly powerful and frequent severe weather events — alongside increasing temperatures globally. With heroic efforts, the UN-convened Paris Agreement was adopted by 196 nations in 2015 with ambitious goals to reduce global greenhouse emissions and limit Earth’s rising temperature.1 Yet doomsday headlines on this topic remain a regular occurrence.
Between sensationalized news coverage, political controversy, and international disasters, it is no wonder some youth are overwhelmed. .2 Direct effects could include a family losing their home to flooding or wildfires, resulting in post-traumatic stress symptoms or an anxiety disorder. Indirect effects might include a drought that results in loss of agricultural income leading to a forced migration, family stress and/or separation, and disordered substance use.
Add to these direct and indirect effects the cultural and media pressures, such as frequent debate about the consequences of failure to reduce greenhouse gas emissions by 2030,3 and youth can encounter a sense of existential dread that intersects squarely with their developmental trajectory. “Climate anxiety,” also called eco-anxiety or solastalgia, refers to “distress about climate change and its impacts on the landscape and human existence.”4 Eco-anxiety is not a formal psychiatric diagnosis and is not found in the DSM-5-TR.
In practice, existential climate-centered fears range from worrying about what to do to help with the climate crisis all the way to being overwhelmed about humanity’s future to the point of dysfunction. Some argue that this is not pathological, but rather a practical response to real-world phenomena.5 An international survey of youth found 59% were “very or extremely” worried about climate change with a mix of associated emotions, and almost half described eco-anxiety as something that affects their daily functioning.6 The climate crisis often amplifies the inequities already experienced by youth from historically marginalized groups.
Managing Climate Anxiety
Climate anxiety presents with many of the typical features of other anxieties. These include worries that cycle repetitively and intrusively through the mind, somatic distress such as headaches or stomachaches, and avoidance of things that remind one of the uncertainty and distress associated with climate change. Because the climate crisis is so global and complex, hopelessness and fatigue are not uncommon.
However, climate anxiety can often be ameliorated with the typical approaches to treating anxiety. Borrowing from cognitive-behavioral and mindfulness-based interventions, many recommendations have been offered to help with eco-anxiety. External validation of youth’s concerns and fears is a starting point that might build a teen’s capacity to tolerate distressing emotions about global warming.
Once reactions to climate change are acknowledged and accepted, space is created for reflection. This might include a balance of hope and pragmatic action. For example, renewable energy sources have made up an increasing share of the market over time with the world adding 50% more renewable capacity in 2023.7 Seventy-two percent of Americans acknowledge global warming, 75% feel schools should teach about consequences and solutions for global warming, and 79% support investment in renewable energy.8
Climate activism itself has been shown to buffer climate anxiety, particularly when implemented collectively rather than individually.4 Nature connectedness, or cognitive and emotional connections with nature, not only has many direct mental health benefits, but is also associated with climate activism.9 Many other integrative interventions can improve well-being while reducing ecological harm. Nutrition, physical activity, mindfulness, and sleep are youth mental health interventions with a strong evidence base that also reduce the carbon footprint and pollution attributable to psychiatric pharmaceuticals. Moreover, these climate-friendly interventions can improve family-connectedness, thus boosting resilience.
Without needing to become eco-warriors, healthcare providers can model sustainable practices while caring for patients. This might include having more plants in the office, recycling and composting at work, adding solar panels to the rooftop, or joining local parks prescription programs (see mygreendoctor.org, a nonprofit owned by the Florida Medical Association).
Next Steps
Sol is relieved to hear that many kids her age share her family’s concerns. A conversation about how to manage distressing emotions and physical feelings leads to a referral for brief cognitive behavioral interventions. Her parents join your visit to hear her concerns. They want to begin a family plan for climate action. You recommend the books How to Change Everything: The Young Human’s Guide to Protecting the Planet and Each Other by Naomi Klein and The Parents’ Guide to Climate Revolution: 100 Ways to Build a Fossil-Free Future, Raise Empowered Kids, and Still Get a Good Night’s Sleep by Mary DeMocker.
Dr. Rosenfeld is associate professor of psychiatry and pediatrics at the University of Vermont, Burlington.
References
1. Maizland L. Global Climate Agreements: Successes and Failures. Council on Foreign Relations. https://www.cfr.org/backgrounder/paris-global-climate-change-agreements.
2. van Nieuwenhuizen A et al. The effects of climate change on child and adolescent mental health: Clinical considerations. Curr Psychiatry Rep. 2021 Dec 7;23(12):88. doi: 10.1007/s11920-021-01296-y.
3. Window to Reach Climate Goals ‘Rapidly Closing’, UN Report Warns. United Nations. https://news.un.org/en/story/2023/09/1140527.
4. Schwartz SEO et al. Climate change anxiety and mental health: Environmental activism as buffer. Curr Psychol. 2022 Feb 28:1-14. doi: 10.1007/s12144-022-02735-6.
5. Pihkala P. Anxiety and the ecological crisis: an analysis of eco-anxiety and climate anxiety. Sustainability. 2020;12:7836. doi: 10.3390/su12197836.
6. Hickman C et al. Climate Anxiety in Children and Young People and Their Beliefs About Government Responses to Climate Change: A Global Survey. Lancet Planet Health. 2021 Dec;5(12):e863-e873. doi: 10.1016/S2542-5196(21)00278-3.
7. IEA (2021), Global Energy Review 2021, IEA, Paris. https://www.iea.org/reports/global-energy-review-2021/renewables.
8. Marlon J et al. Yale Climate Opinion Maps 2023. https://climatecommunication.yale.edu/visualizations-data/ycom-us/.
9. Thomson EE, Roach SP. The Relationships Among Nature Connectedness, Climate Anxiety, Climate Action, Climate Knowledge, and Mental Health. Front Psychol. 2023 Nov 15:14:1241400. doi: 10.3389/fpsyg.2023.1241400.
Clinical Case: Sol is a 10 year-old cisgender White girl who appears sad at her annual well visit. On further inquiry she describes that her father is angry that there is no snow, her mother keeps talking about the forests disappearing, and local flooding closed down her favorite family restaurant for good. She is worried “the planet is in trouble and there’s nothing we can do” so much that she gets stomachaches when she thinks about it.
Climate Anxiety
Climate change is a complex phenomenon that has been subject to decades of political disagreement. Lobbying by groups like the fossil fuel industry, state legislation to implement recycling, oil spills and pollution disasters, and outspoken icons like former US Vice President Al Gore and Swedish activist Greta Thunberg have kept the climate crisis a hot topic. What was once a slow burn has begun to boil as climate-related disasters occur — wildfires, droughts, floods, and increasingly powerful and frequent severe weather events — alongside increasing temperatures globally. With heroic efforts, the UN-convened Paris Agreement was adopted by 196 nations in 2015 with ambitious goals to reduce global greenhouse emissions and limit Earth’s rising temperature.1 Yet doomsday headlines on this topic remain a regular occurrence.
Between sensationalized news coverage, political controversy, and international disasters, it is no wonder some youth are overwhelmed. .2 Direct effects could include a family losing their home to flooding or wildfires, resulting in post-traumatic stress symptoms or an anxiety disorder. Indirect effects might include a drought that results in loss of agricultural income leading to a forced migration, family stress and/or separation, and disordered substance use.
Add to these direct and indirect effects the cultural and media pressures, such as frequent debate about the consequences of failure to reduce greenhouse gas emissions by 2030,3 and youth can encounter a sense of existential dread that intersects squarely with their developmental trajectory. “Climate anxiety,” also called eco-anxiety or solastalgia, refers to “distress about climate change and its impacts on the landscape and human existence.”4 Eco-anxiety is not a formal psychiatric diagnosis and is not found in the DSM-5-TR.
In practice, existential climate-centered fears range from worrying about what to do to help with the climate crisis all the way to being overwhelmed about humanity’s future to the point of dysfunction. Some argue that this is not pathological, but rather a practical response to real-world phenomena.5 An international survey of youth found 59% were “very or extremely” worried about climate change with a mix of associated emotions, and almost half described eco-anxiety as something that affects their daily functioning.6 The climate crisis often amplifies the inequities already experienced by youth from historically marginalized groups.
Managing Climate Anxiety
Climate anxiety presents with many of the typical features of other anxieties. These include worries that cycle repetitively and intrusively through the mind, somatic distress such as headaches or stomachaches, and avoidance of things that remind one of the uncertainty and distress associated with climate change. Because the climate crisis is so global and complex, hopelessness and fatigue are not uncommon.
However, climate anxiety can often be ameliorated with the typical approaches to treating anxiety. Borrowing from cognitive-behavioral and mindfulness-based interventions, many recommendations have been offered to help with eco-anxiety. External validation of youth’s concerns and fears is a starting point that might build a teen’s capacity to tolerate distressing emotions about global warming.
Once reactions to climate change are acknowledged and accepted, space is created for reflection. This might include a balance of hope and pragmatic action. For example, renewable energy sources have made up an increasing share of the market over time with the world adding 50% more renewable capacity in 2023.7 Seventy-two percent of Americans acknowledge global warming, 75% feel schools should teach about consequences and solutions for global warming, and 79% support investment in renewable energy.8
Climate activism itself has been shown to buffer climate anxiety, particularly when implemented collectively rather than individually.4 Nature connectedness, or cognitive and emotional connections with nature, not only has many direct mental health benefits, but is also associated with climate activism.9 Many other integrative interventions can improve well-being while reducing ecological harm. Nutrition, physical activity, mindfulness, and sleep are youth mental health interventions with a strong evidence base that also reduce the carbon footprint and pollution attributable to psychiatric pharmaceuticals. Moreover, these climate-friendly interventions can improve family-connectedness, thus boosting resilience.
Without needing to become eco-warriors, healthcare providers can model sustainable practices while caring for patients. This might include having more plants in the office, recycling and composting at work, adding solar panels to the rooftop, or joining local parks prescription programs (see mygreendoctor.org, a nonprofit owned by the Florida Medical Association).
Next Steps
Sol is relieved to hear that many kids her age share her family’s concerns. A conversation about how to manage distressing emotions and physical feelings leads to a referral for brief cognitive behavioral interventions. Her parents join your visit to hear her concerns. They want to begin a family plan for climate action. You recommend the books How to Change Everything: The Young Human’s Guide to Protecting the Planet and Each Other by Naomi Klein and The Parents’ Guide to Climate Revolution: 100 Ways to Build a Fossil-Free Future, Raise Empowered Kids, and Still Get a Good Night’s Sleep by Mary DeMocker.
Dr. Rosenfeld is associate professor of psychiatry and pediatrics at the University of Vermont, Burlington.
References
1. Maizland L. Global Climate Agreements: Successes and Failures. Council on Foreign Relations. https://www.cfr.org/backgrounder/paris-global-climate-change-agreements.
2. van Nieuwenhuizen A et al. The effects of climate change on child and adolescent mental health: Clinical considerations. Curr Psychiatry Rep. 2021 Dec 7;23(12):88. doi: 10.1007/s11920-021-01296-y.
3. Window to Reach Climate Goals ‘Rapidly Closing’, UN Report Warns. United Nations. https://news.un.org/en/story/2023/09/1140527.
4. Schwartz SEO et al. Climate change anxiety and mental health: Environmental activism as buffer. Curr Psychol. 2022 Feb 28:1-14. doi: 10.1007/s12144-022-02735-6.
5. Pihkala P. Anxiety and the ecological crisis: an analysis of eco-anxiety and climate anxiety. Sustainability. 2020;12:7836. doi: 10.3390/su12197836.
6. Hickman C et al. Climate Anxiety in Children and Young People and Their Beliefs About Government Responses to Climate Change: A Global Survey. Lancet Planet Health. 2021 Dec;5(12):e863-e873. doi: 10.1016/S2542-5196(21)00278-3.
7. IEA (2021), Global Energy Review 2021, IEA, Paris. https://www.iea.org/reports/global-energy-review-2021/renewables.
8. Marlon J et al. Yale Climate Opinion Maps 2023. https://climatecommunication.yale.edu/visualizations-data/ycom-us/.
9. Thomson EE, Roach SP. The Relationships Among Nature Connectedness, Climate Anxiety, Climate Action, Climate Knowledge, and Mental Health. Front Psychol. 2023 Nov 15:14:1241400. doi: 10.3389/fpsyg.2023.1241400.
Clinical Case: Sol is a 10 year-old cisgender White girl who appears sad at her annual well visit. On further inquiry she describes that her father is angry that there is no snow, her mother keeps talking about the forests disappearing, and local flooding closed down her favorite family restaurant for good. She is worried “the planet is in trouble and there’s nothing we can do” so much that she gets stomachaches when she thinks about it.
Climate Anxiety
Climate change is a complex phenomenon that has been subject to decades of political disagreement. Lobbying by groups like the fossil fuel industry, state legislation to implement recycling, oil spills and pollution disasters, and outspoken icons like former US Vice President Al Gore and Swedish activist Greta Thunberg have kept the climate crisis a hot topic. What was once a slow burn has begun to boil as climate-related disasters occur — wildfires, droughts, floods, and increasingly powerful and frequent severe weather events — alongside increasing temperatures globally. With heroic efforts, the UN-convened Paris Agreement was adopted by 196 nations in 2015 with ambitious goals to reduce global greenhouse emissions and limit Earth’s rising temperature.1 Yet doomsday headlines on this topic remain a regular occurrence.
Between sensationalized news coverage, political controversy, and international disasters, it is no wonder some youth are overwhelmed. .2 Direct effects could include a family losing their home to flooding or wildfires, resulting in post-traumatic stress symptoms or an anxiety disorder. Indirect effects might include a drought that results in loss of agricultural income leading to a forced migration, family stress and/or separation, and disordered substance use.
Add to these direct and indirect effects the cultural and media pressures, such as frequent debate about the consequences of failure to reduce greenhouse gas emissions by 2030,3 and youth can encounter a sense of existential dread that intersects squarely with their developmental trajectory. “Climate anxiety,” also called eco-anxiety or solastalgia, refers to “distress about climate change and its impacts on the landscape and human existence.”4 Eco-anxiety is not a formal psychiatric diagnosis and is not found in the DSM-5-TR.
In practice, existential climate-centered fears range from worrying about what to do to help with the climate crisis all the way to being overwhelmed about humanity’s future to the point of dysfunction. Some argue that this is not pathological, but rather a practical response to real-world phenomena.5 An international survey of youth found 59% were “very or extremely” worried about climate change with a mix of associated emotions, and almost half described eco-anxiety as something that affects their daily functioning.6 The climate crisis often amplifies the inequities already experienced by youth from historically marginalized groups.
Managing Climate Anxiety
Climate anxiety presents with many of the typical features of other anxieties. These include worries that cycle repetitively and intrusively through the mind, somatic distress such as headaches or stomachaches, and avoidance of things that remind one of the uncertainty and distress associated with climate change. Because the climate crisis is so global and complex, hopelessness and fatigue are not uncommon.
However, climate anxiety can often be ameliorated with the typical approaches to treating anxiety. Borrowing from cognitive-behavioral and mindfulness-based interventions, many recommendations have been offered to help with eco-anxiety. External validation of youth’s concerns and fears is a starting point that might build a teen’s capacity to tolerate distressing emotions about global warming.
Once reactions to climate change are acknowledged and accepted, space is created for reflection. This might include a balance of hope and pragmatic action. For example, renewable energy sources have made up an increasing share of the market over time with the world adding 50% more renewable capacity in 2023.7 Seventy-two percent of Americans acknowledge global warming, 75% feel schools should teach about consequences and solutions for global warming, and 79% support investment in renewable energy.8
Climate activism itself has been shown to buffer climate anxiety, particularly when implemented collectively rather than individually.4 Nature connectedness, or cognitive and emotional connections with nature, not only has many direct mental health benefits, but is also associated with climate activism.9 Many other integrative interventions can improve well-being while reducing ecological harm. Nutrition, physical activity, mindfulness, and sleep are youth mental health interventions with a strong evidence base that also reduce the carbon footprint and pollution attributable to psychiatric pharmaceuticals. Moreover, these climate-friendly interventions can improve family-connectedness, thus boosting resilience.
Without needing to become eco-warriors, healthcare providers can model sustainable practices while caring for patients. This might include having more plants in the office, recycling and composting at work, adding solar panels to the rooftop, or joining local parks prescription programs (see mygreendoctor.org, a nonprofit owned by the Florida Medical Association).
Next Steps
Sol is relieved to hear that many kids her age share her family’s concerns. A conversation about how to manage distressing emotions and physical feelings leads to a referral for brief cognitive behavioral interventions. Her parents join your visit to hear her concerns. They want to begin a family plan for climate action. You recommend the books How to Change Everything: The Young Human’s Guide to Protecting the Planet and Each Other by Naomi Klein and The Parents’ Guide to Climate Revolution: 100 Ways to Build a Fossil-Free Future, Raise Empowered Kids, and Still Get a Good Night’s Sleep by Mary DeMocker.
Dr. Rosenfeld is associate professor of psychiatry and pediatrics at the University of Vermont, Burlington.
References
1. Maizland L. Global Climate Agreements: Successes and Failures. Council on Foreign Relations. https://www.cfr.org/backgrounder/paris-global-climate-change-agreements.
2. van Nieuwenhuizen A et al. The effects of climate change on child and adolescent mental health: Clinical considerations. Curr Psychiatry Rep. 2021 Dec 7;23(12):88. doi: 10.1007/s11920-021-01296-y.
3. Window to Reach Climate Goals ‘Rapidly Closing’, UN Report Warns. United Nations. https://news.un.org/en/story/2023/09/1140527.
4. Schwartz SEO et al. Climate change anxiety and mental health: Environmental activism as buffer. Curr Psychol. 2022 Feb 28:1-14. doi: 10.1007/s12144-022-02735-6.
5. Pihkala P. Anxiety and the ecological crisis: an analysis of eco-anxiety and climate anxiety. Sustainability. 2020;12:7836. doi: 10.3390/su12197836.
6. Hickman C et al. Climate Anxiety in Children and Young People and Their Beliefs About Government Responses to Climate Change: A Global Survey. Lancet Planet Health. 2021 Dec;5(12):e863-e873. doi: 10.1016/S2542-5196(21)00278-3.
7. IEA (2021), Global Energy Review 2021, IEA, Paris. https://www.iea.org/reports/global-energy-review-2021/renewables.
8. Marlon J et al. Yale Climate Opinion Maps 2023. https://climatecommunication.yale.edu/visualizations-data/ycom-us/.
9. Thomson EE, Roach SP. The Relationships Among Nature Connectedness, Climate Anxiety, Climate Action, Climate Knowledge, and Mental Health. Front Psychol. 2023 Nov 15:14:1241400. doi: 10.3389/fpsyg.2023.1241400.
Nutritional psychiatry: Does it exist?
Matt was diagnosed with ADHD combined type when he was 6 years old. Given his age, the family was reluctant to try medications, but after a couple years of parenting classes and reward charts, the parents requested a stimulant. He had significant improvement in focus and impulsivity but also reduced appetite. Now at age 13, irritability and depressive symptoms have been increasing for 9 months. Skeptical of adding another medication, his parents ask whether nutrition might be an alternative tool to treat his symptoms?
What a healthy diet even consists of seems to be a moving target over decades and years. Trendy research, supplements, and dietary approaches proliferate alongside appealing theories of action. In the end, weighing which intervention is effective for which disorder and at what cost becomes murky.
Yet several fundamental principles seem clear and consistent over time and across studies.
Starting early
There is reliable evidence that in the perinatal environment, nutrition sets the stage for many aspects of healthy development. These effects are likely mediated variously through the hypothalamic-pituitary-adrenal axis, the trillions of gut bacteria that make up the microbiome, gene-environment interactions, and more. Maternal malnutrition and stress prenatally puts infants at risk for not only poor birth outcomes but also psychiatric challenges throughout childhood, such as ADHD, anxiety, depression, and autism.1
Intervening in the perinatal period has long-term benefits. A first step includes assessing food security, beginning with consistent access to nutritious food. It is important to inquire about the role of food and nutrition in the family’s history and culture, as well as identifying resources to support access to affordable nutrition. This can be paired with parenting interventions, such as family meals without screens. This may require scaffolding positive conversations in high-conflict family settings (see The Family Dinner Project).
Healthy diets promote mental health
If food security is achieved, what is next? Clinicians can inquire about the who, what, where, when, and why of nutrition to learn about a family’s eating habits.2 While randomized controlled data is very limited, both cross-sectional and longitudinal studies show that healthy diets in youth correlate with mental health – more healthy foods reducing internalizing and externalizing disorders, and more typical Western diets increasing the risk. On average, dietary interventions include higher levels of fruits and vegetables, fish, and nuts, and lower levels of processed foods.2 There is not evidence that restrictive diets or fasting is appropriate or safe for youth. Additionally, involving children in getting, growing, or preparing food with gradually increasing autonomy fosters self-confidence and skill development.
In those struggling with restrictive eating disorders, food is medicine – helping those with restrictive diets to develop more balanced and adequate intake for metabolic needs. Outside of diagnosable eating disorders, weight or body mass index is less of a goal or marker when it comes to mental health. Instead, look for participation in enjoyable activities, opportunities to move and rest, and a body image that supports self-care and self-confidence (see the National Institutes of Health’s We Can! Program). Creating dissonance with cultural ideals of appearance centered on thinness can prevent future eating disorders.3
Nutraceutical options
Outside of eating disorders, specific foods and plants with health or medicinal properties – variously called nutraceuticals, phytoceuticals, or micronutrients – have emerging evidence in mental health. A 2022 expert academic consensus panel reviewed the literature to create clinical guidelines in this area.4 For major depression, adding omega-3 fatty acids to standard antidepressant treatment or standalone St. John’s wort have adequate evidence to recommend, while adjunctive probiotics, zinc, saffron, and curcumin have sufficient though less robust evidence. S-adenosyl methionine, vitamin D, and methyfolate showed only weak evidence for depression, while vitamin C, magnesium, creatine, N-acetylcysteine, folate, and monotherapy omega-3s do not have sufficient evidence to be recommended. For ADHD there was weak support for vitamin D, but no clear evidence for omega-3s, zinc, gingko, or acetyl L-carnitine. For anxiety, there is moderate evidence for ashwagandha and lavender in adults. A child psychiatry review suggests also trying chamomile for generalized anxiety based on the evidence in young adults, and underscores some data for N-acetylcysteine for OCD in particular.5
Many of these nutraceuticals exhibit small or moderate effects in a limited number of trials, with generally much less data for youth, compared with adults. While the same could be said for many on- and off-label uses of psychiatric medications for kids, clinicians would be wise to consider these highly specific nutritional interventions as items on the menu of treatment options rather than stand-alone treatments.
Revisitng the case study
Reflecting on Matt’s care, his pediatrician first assessed his dietary patterns, noting late-night eating and caffeine use with minimal hydration or fiber across the day. Recommendations for keeping fruit and vegetable snacks easily accessible as well as carrying a water flask are well received. They also discuss adding omega-3 fatty acids and probiotics with his morning stimulant while he awaits a referral for cognitive-behavioral therapy in order to address his depressive symptoms and minimize medication needs.
Beyond addressing food security and balanced family meals, specific interventions may be appropriate as initial treatment adjuncts for mild and some moderate mental illness. For more intense moderate to severe illness, nutritional psychiatry may be considered in combination with treatments with stronger evidence. At a community level, clinicians can help advocate for universal school meal programs to address food security, and so-called salad bar interventions to increase fruit/vegetable uptake among school-age children.
Dr. Rosenfeld is associate professor of psychiatry and pediatrics at University of Vermont and the Vermont Center for Children, Youth, and Families, both in Burlington. He has no disclosures.
References
1 Vohr BR et al. Pediatrics. 2017;139:S38-49.
2. Hosker DK et al. Child Adol Psychiatr Clin N Am. 2019;28(2):171-93.
3. Stice E et al. Int J Eat Disord. 2013;46(5):478-85.
4. Sarris J et al. World J Biol Psychiatry. 2022;23(6):424-55.
5. Simkin DR et al. Child Adolesc Psychiatric Clin N Am. 2023;32:193-216.
Matt was diagnosed with ADHD combined type when he was 6 years old. Given his age, the family was reluctant to try medications, but after a couple years of parenting classes and reward charts, the parents requested a stimulant. He had significant improvement in focus and impulsivity but also reduced appetite. Now at age 13, irritability and depressive symptoms have been increasing for 9 months. Skeptical of adding another medication, his parents ask whether nutrition might be an alternative tool to treat his symptoms?
What a healthy diet even consists of seems to be a moving target over decades and years. Trendy research, supplements, and dietary approaches proliferate alongside appealing theories of action. In the end, weighing which intervention is effective for which disorder and at what cost becomes murky.
Yet several fundamental principles seem clear and consistent over time and across studies.
Starting early
There is reliable evidence that in the perinatal environment, nutrition sets the stage for many aspects of healthy development. These effects are likely mediated variously through the hypothalamic-pituitary-adrenal axis, the trillions of gut bacteria that make up the microbiome, gene-environment interactions, and more. Maternal malnutrition and stress prenatally puts infants at risk for not only poor birth outcomes but also psychiatric challenges throughout childhood, such as ADHD, anxiety, depression, and autism.1
Intervening in the perinatal period has long-term benefits. A first step includes assessing food security, beginning with consistent access to nutritious food. It is important to inquire about the role of food and nutrition in the family’s history and culture, as well as identifying resources to support access to affordable nutrition. This can be paired with parenting interventions, such as family meals without screens. This may require scaffolding positive conversations in high-conflict family settings (see The Family Dinner Project).
Healthy diets promote mental health
If food security is achieved, what is next? Clinicians can inquire about the who, what, where, when, and why of nutrition to learn about a family’s eating habits.2 While randomized controlled data is very limited, both cross-sectional and longitudinal studies show that healthy diets in youth correlate with mental health – more healthy foods reducing internalizing and externalizing disorders, and more typical Western diets increasing the risk. On average, dietary interventions include higher levels of fruits and vegetables, fish, and nuts, and lower levels of processed foods.2 There is not evidence that restrictive diets or fasting is appropriate or safe for youth. Additionally, involving children in getting, growing, or preparing food with gradually increasing autonomy fosters self-confidence and skill development.
In those struggling with restrictive eating disorders, food is medicine – helping those with restrictive diets to develop more balanced and adequate intake for metabolic needs. Outside of diagnosable eating disorders, weight or body mass index is less of a goal or marker when it comes to mental health. Instead, look for participation in enjoyable activities, opportunities to move and rest, and a body image that supports self-care and self-confidence (see the National Institutes of Health’s We Can! Program). Creating dissonance with cultural ideals of appearance centered on thinness can prevent future eating disorders.3
Nutraceutical options
Outside of eating disorders, specific foods and plants with health or medicinal properties – variously called nutraceuticals, phytoceuticals, or micronutrients – have emerging evidence in mental health. A 2022 expert academic consensus panel reviewed the literature to create clinical guidelines in this area.4 For major depression, adding omega-3 fatty acids to standard antidepressant treatment or standalone St. John’s wort have adequate evidence to recommend, while adjunctive probiotics, zinc, saffron, and curcumin have sufficient though less robust evidence. S-adenosyl methionine, vitamin D, and methyfolate showed only weak evidence for depression, while vitamin C, magnesium, creatine, N-acetylcysteine, folate, and monotherapy omega-3s do not have sufficient evidence to be recommended. For ADHD there was weak support for vitamin D, but no clear evidence for omega-3s, zinc, gingko, or acetyl L-carnitine. For anxiety, there is moderate evidence for ashwagandha and lavender in adults. A child psychiatry review suggests also trying chamomile for generalized anxiety based on the evidence in young adults, and underscores some data for N-acetylcysteine for OCD in particular.5
Many of these nutraceuticals exhibit small or moderate effects in a limited number of trials, with generally much less data for youth, compared with adults. While the same could be said for many on- and off-label uses of psychiatric medications for kids, clinicians would be wise to consider these highly specific nutritional interventions as items on the menu of treatment options rather than stand-alone treatments.
Revisitng the case study
Reflecting on Matt’s care, his pediatrician first assessed his dietary patterns, noting late-night eating and caffeine use with minimal hydration or fiber across the day. Recommendations for keeping fruit and vegetable snacks easily accessible as well as carrying a water flask are well received. They also discuss adding omega-3 fatty acids and probiotics with his morning stimulant while he awaits a referral for cognitive-behavioral therapy in order to address his depressive symptoms and minimize medication needs.
Beyond addressing food security and balanced family meals, specific interventions may be appropriate as initial treatment adjuncts for mild and some moderate mental illness. For more intense moderate to severe illness, nutritional psychiatry may be considered in combination with treatments with stronger evidence. At a community level, clinicians can help advocate for universal school meal programs to address food security, and so-called salad bar interventions to increase fruit/vegetable uptake among school-age children.
Dr. Rosenfeld is associate professor of psychiatry and pediatrics at University of Vermont and the Vermont Center for Children, Youth, and Families, both in Burlington. He has no disclosures.
References
1 Vohr BR et al. Pediatrics. 2017;139:S38-49.
2. Hosker DK et al. Child Adol Psychiatr Clin N Am. 2019;28(2):171-93.
3. Stice E et al. Int J Eat Disord. 2013;46(5):478-85.
4. Sarris J et al. World J Biol Psychiatry. 2022;23(6):424-55.
5. Simkin DR et al. Child Adolesc Psychiatric Clin N Am. 2023;32:193-216.
Matt was diagnosed with ADHD combined type when he was 6 years old. Given his age, the family was reluctant to try medications, but after a couple years of parenting classes and reward charts, the parents requested a stimulant. He had significant improvement in focus and impulsivity but also reduced appetite. Now at age 13, irritability and depressive symptoms have been increasing for 9 months. Skeptical of adding another medication, his parents ask whether nutrition might be an alternative tool to treat his symptoms?
What a healthy diet even consists of seems to be a moving target over decades and years. Trendy research, supplements, and dietary approaches proliferate alongside appealing theories of action. In the end, weighing which intervention is effective for which disorder and at what cost becomes murky.
Yet several fundamental principles seem clear and consistent over time and across studies.
Starting early
There is reliable evidence that in the perinatal environment, nutrition sets the stage for many aspects of healthy development. These effects are likely mediated variously through the hypothalamic-pituitary-adrenal axis, the trillions of gut bacteria that make up the microbiome, gene-environment interactions, and more. Maternal malnutrition and stress prenatally puts infants at risk for not only poor birth outcomes but also psychiatric challenges throughout childhood, such as ADHD, anxiety, depression, and autism.1
Intervening in the perinatal period has long-term benefits. A first step includes assessing food security, beginning with consistent access to nutritious food. It is important to inquire about the role of food and nutrition in the family’s history and culture, as well as identifying resources to support access to affordable nutrition. This can be paired with parenting interventions, such as family meals without screens. This may require scaffolding positive conversations in high-conflict family settings (see The Family Dinner Project).
Healthy diets promote mental health
If food security is achieved, what is next? Clinicians can inquire about the who, what, where, when, and why of nutrition to learn about a family’s eating habits.2 While randomized controlled data is very limited, both cross-sectional and longitudinal studies show that healthy diets in youth correlate with mental health – more healthy foods reducing internalizing and externalizing disorders, and more typical Western diets increasing the risk. On average, dietary interventions include higher levels of fruits and vegetables, fish, and nuts, and lower levels of processed foods.2 There is not evidence that restrictive diets or fasting is appropriate or safe for youth. Additionally, involving children in getting, growing, or preparing food with gradually increasing autonomy fosters self-confidence and skill development.
In those struggling with restrictive eating disorders, food is medicine – helping those with restrictive diets to develop more balanced and adequate intake for metabolic needs. Outside of diagnosable eating disorders, weight or body mass index is less of a goal or marker when it comes to mental health. Instead, look for participation in enjoyable activities, opportunities to move and rest, and a body image that supports self-care and self-confidence (see the National Institutes of Health’s We Can! Program). Creating dissonance with cultural ideals of appearance centered on thinness can prevent future eating disorders.3
Nutraceutical options
Outside of eating disorders, specific foods and plants with health or medicinal properties – variously called nutraceuticals, phytoceuticals, or micronutrients – have emerging evidence in mental health. A 2022 expert academic consensus panel reviewed the literature to create clinical guidelines in this area.4 For major depression, adding omega-3 fatty acids to standard antidepressant treatment or standalone St. John’s wort have adequate evidence to recommend, while adjunctive probiotics, zinc, saffron, and curcumin have sufficient though less robust evidence. S-adenosyl methionine, vitamin D, and methyfolate showed only weak evidence for depression, while vitamin C, magnesium, creatine, N-acetylcysteine, folate, and monotherapy omega-3s do not have sufficient evidence to be recommended. For ADHD there was weak support for vitamin D, but no clear evidence for omega-3s, zinc, gingko, or acetyl L-carnitine. For anxiety, there is moderate evidence for ashwagandha and lavender in adults. A child psychiatry review suggests also trying chamomile for generalized anxiety based on the evidence in young adults, and underscores some data for N-acetylcysteine for OCD in particular.5
Many of these nutraceuticals exhibit small or moderate effects in a limited number of trials, with generally much less data for youth, compared with adults. While the same could be said for many on- and off-label uses of psychiatric medications for kids, clinicians would be wise to consider these highly specific nutritional interventions as items on the menu of treatment options rather than stand-alone treatments.
Revisitng the case study
Reflecting on Matt’s care, his pediatrician first assessed his dietary patterns, noting late-night eating and caffeine use with minimal hydration or fiber across the day. Recommendations for keeping fruit and vegetable snacks easily accessible as well as carrying a water flask are well received. They also discuss adding omega-3 fatty acids and probiotics with his morning stimulant while he awaits a referral for cognitive-behavioral therapy in order to address his depressive symptoms and minimize medication needs.
Beyond addressing food security and balanced family meals, specific interventions may be appropriate as initial treatment adjuncts for mild and some moderate mental illness. For more intense moderate to severe illness, nutritional psychiatry may be considered in combination with treatments with stronger evidence. At a community level, clinicians can help advocate for universal school meal programs to address food security, and so-called salad bar interventions to increase fruit/vegetable uptake among school-age children.
Dr. Rosenfeld is associate professor of psychiatry and pediatrics at University of Vermont and the Vermont Center for Children, Youth, and Families, both in Burlington. He has no disclosures.
References
1 Vohr BR et al. Pediatrics. 2017;139:S38-49.
2. Hosker DK et al. Child Adol Psychiatr Clin N Am. 2019;28(2):171-93.
3. Stice E et al. Int J Eat Disord. 2013;46(5):478-85.
4. Sarris J et al. World J Biol Psychiatry. 2022;23(6):424-55.
5. Simkin DR et al. Child Adolesc Psychiatric Clin N Am. 2023;32:193-216.
Screaming for screens: Digital well-being in the 2020s
Charlie is a 15-year-old male whose medical history includes overweight and autism spectrum disorder. While his autism symptoms are stable and he is doing fairly well in school, your sense is that he is underperforming and unhappy. His screening for anxiety and depression is not outstanding and you wonder whether to leave well enough alone.
Historically, pediatrician queries about media use happen in a minority of visits,1 overcrowded by the multitude of screening and acute care needs, let alone the pressures of electronic health record prompts, billing, and documentation. Yet the COVID-19 pandemic has emphasized what was already getting louder: screen life is becoming a ubiquitous, increasing, and normative function of child development. Digital well-being exhibits bidirectional interactions with most of the core indicators of child health: sleep, nutrition, safety, mood, relationships, and many other aspects of physical and mental health.1
The pandemic unveiled the blessings and curses of digital life by shifting many into remote work and school situations where screen time became both necessary and uncontrollable. Reeling with changes in employment, health, finances, and more, families struggled to forge a new screen-life balance that could bridge academic, professional, and recreational use.
Research has wavered in producing a verdict on the effects of screen time, in part because of limitations in methodology and follow-up time,2 and exacerbated by the quickly changing nature of screen use. Screen time may put youth at risk for obesity and behavior problems,3 but the latter may be mediated in part by loss of sleep because of late-night digital activity.4 While survey data at the population level show little link between screen time and well-being impairments,5 zooming in on individuals may tell a different story. Twenge and Campbell show light use of digital media (compared with nonuse) is associated with greater well-being while heavy use is associated with lower well-being and a higher risk for depression and suicidal behavior – especially in girls.6,7 Largely cross-sectional data show a small detriment to psychological well-being associated with digital technology, though this may be bidirectional and does not clearly differentiate types of technology.2
Recent neuroscience suggests that, compared with active play, sedentary screen time after school reduced impulse control and increased brain activity in regions associated with craving.8 This may explain some of the link between screen time and obesity. Brain imaging of preschoolers showed that greater screen time correlated with lower reading readiness as well as less integrity of white-matter tracts involved in language and executive function,9 whereas nurturing home reading practices were protective for language development and white matter integrity.10
Returning to the care of Charlie, providers may benefit from taking time to reflect on their own digital environment. What does the patient-side view of your office look like? Many offices use telephone reminders and patient portals, fill prescriptions electronically, and have waiting rooms with WiFi or devices for children’s use. Office visits share space with providers’ desktops, laptops, and smartphones, with EMRs guiding the visit. EMRs may come home for evening documentation. How does this affect provider digital well-being? How do you start the conversation with families about digital well-being?
The American Academy of Pediatrics recommends media screening be incorporated into routine pediatric care, with several tools available to support this. Adapting the HEADSSS model for psychosocial check-ins, Clark and colleagues propose an additional “S” to capture screen time.11 Their model queries which apps and social media are used, quantity of use, effects on self-confidence, and whether cyberbullying or sexting are occurring. Smartphones themselves provide an eye-opening and accessible dataset, with built-in features (for example, Screen Time for iOS) tracking not just daily duration of use, but also how frequently the phone is picked up and which apps get more use. Screening may be followed by motivational coaching, emphasizing nonjudgment, curiosity, empathy, and flexibility — for patient and provider.12
In Charlie’s case, screening reveals heavy use of social Internet games that connect him with like-minded peers. While he describes an inclusiveness and level of socialization that he has not found outside the home, the quantity of use is interfering with sleep, schoolwork, and physical activity.
Significant problematic Internet use may lead to intervention or referral – addictive behaviors and mental health symptoms may warrant connection with mental health providers. Cyberbullying or unsafe behaviors may additionally benefit from parental and school-based support. There is early and limited evidence that psychological and educational interventions may be of benefit for problematic Internet use.13
When digital life is not so dramatically affecting well-being, providers may begin by working with families on a media use plan. The AAP offers its own website to support this. Other well-researched and well-designed sites include Digital Wellness Lab For Parents, with developmentally staged information and plentiful research, and Common Sense Media, which reviews apps, movies, and more; plus they have a knowledge/advice section under “Parents Need to Know.” Keep in mind that digital media can also support youth in managing psychiatric problems, e.g., a digital intervention promoting positive psychology practices looked very helpful for young people with psychosis.14
For Charlie, a health coaching approach is adopted. Using Gabrielli’s TECH parenting rubric,15 Charlie’s parents are coached to make space to talk about and coview media and apps, as well as creating a Family Media Use Plan for everyone – parents included. Alongside setting limits on screen time; health promotion activities like exercise, reading, and schoolwork are also rewarded with extra screen time. When Charlie returns 3 months later, the family reports that, in recognition of their collective digital overload, they preserved dinnertime and after 10 p.m. as screen-free downtime. While they still have concerns about Charlie’s gaming and social life, his sleep is somewhat improved and family tension is lower.
Attention to digital well-being stands to benefit provider and patient alike, and over time may gain from the scaffolding of handouts, standardized assessments, and health coaching providers that may be in place to support other important domains like sleep hygiene, food security, and parenting.
Dr. Rosenfeld is assistant professor, University of Vermont, Vermont Center for Children, Youth, and Families, Burlington. He has no relevant disclosures.
References
1. Chassiakos YR et al. Pediatrics. 2016;138(5)e20162593.
2. Orben A. Soc Psychiatry Psych Epi. 2020;55(4):407.
3. Fang K et al. Child Care Health Dev. 2019;45(5):744-53.
4. Janssen X et al. Sleep Med Rev. 2020;49:101226.
5. George MJ et al. J Ped. 2020;219:180.
6. Twenge JM and Campbell WK. Psychiatry Q. 2019;90(2):311-31.
7. Twenge JM and Martin GN. J Adolesc. 2020;79:91.
8. Efraim M et al. Brain Imaging Behav. 2021;15(1):177-89.
9. Hutton JS et al. JAMA Pediatr. 2020;174(1):e193869.
10. Hutton JS et al. Acta Paediatr. 2020;109(7):1376-86.
11. Clark DL et al. Pediatrics. 2018;141(6).
12. Jericho M and Elliot A. Clin Child Psychol Psychiatry. 2020;25(3):662.
13. Malinauskas R and Malinauskine V. J Behav Addict. 2019;8(4):613.
14. Lim MH et al. Soc Psychiatry Psychiatr Epi. 2020;55(7):877-89.
15. Gabrielli J et al. Pediatrics. 2018;142(1)e20173718.
Charlie is a 15-year-old male whose medical history includes overweight and autism spectrum disorder. While his autism symptoms are stable and he is doing fairly well in school, your sense is that he is underperforming and unhappy. His screening for anxiety and depression is not outstanding and you wonder whether to leave well enough alone.
Historically, pediatrician queries about media use happen in a minority of visits,1 overcrowded by the multitude of screening and acute care needs, let alone the pressures of electronic health record prompts, billing, and documentation. Yet the COVID-19 pandemic has emphasized what was already getting louder: screen life is becoming a ubiquitous, increasing, and normative function of child development. Digital well-being exhibits bidirectional interactions with most of the core indicators of child health: sleep, nutrition, safety, mood, relationships, and many other aspects of physical and mental health.1
The pandemic unveiled the blessings and curses of digital life by shifting many into remote work and school situations where screen time became both necessary and uncontrollable. Reeling with changes in employment, health, finances, and more, families struggled to forge a new screen-life balance that could bridge academic, professional, and recreational use.
Research has wavered in producing a verdict on the effects of screen time, in part because of limitations in methodology and follow-up time,2 and exacerbated by the quickly changing nature of screen use. Screen time may put youth at risk for obesity and behavior problems,3 but the latter may be mediated in part by loss of sleep because of late-night digital activity.4 While survey data at the population level show little link between screen time and well-being impairments,5 zooming in on individuals may tell a different story. Twenge and Campbell show light use of digital media (compared with nonuse) is associated with greater well-being while heavy use is associated with lower well-being and a higher risk for depression and suicidal behavior – especially in girls.6,7 Largely cross-sectional data show a small detriment to psychological well-being associated with digital technology, though this may be bidirectional and does not clearly differentiate types of technology.2
Recent neuroscience suggests that, compared with active play, sedentary screen time after school reduced impulse control and increased brain activity in regions associated with craving.8 This may explain some of the link between screen time and obesity. Brain imaging of preschoolers showed that greater screen time correlated with lower reading readiness as well as less integrity of white-matter tracts involved in language and executive function,9 whereas nurturing home reading practices were protective for language development and white matter integrity.10
Returning to the care of Charlie, providers may benefit from taking time to reflect on their own digital environment. What does the patient-side view of your office look like? Many offices use telephone reminders and patient portals, fill prescriptions electronically, and have waiting rooms with WiFi or devices for children’s use. Office visits share space with providers’ desktops, laptops, and smartphones, with EMRs guiding the visit. EMRs may come home for evening documentation. How does this affect provider digital well-being? How do you start the conversation with families about digital well-being?
The American Academy of Pediatrics recommends media screening be incorporated into routine pediatric care, with several tools available to support this. Adapting the HEADSSS model for psychosocial check-ins, Clark and colleagues propose an additional “S” to capture screen time.11 Their model queries which apps and social media are used, quantity of use, effects on self-confidence, and whether cyberbullying or sexting are occurring. Smartphones themselves provide an eye-opening and accessible dataset, with built-in features (for example, Screen Time for iOS) tracking not just daily duration of use, but also how frequently the phone is picked up and which apps get more use. Screening may be followed by motivational coaching, emphasizing nonjudgment, curiosity, empathy, and flexibility — for patient and provider.12
In Charlie’s case, screening reveals heavy use of social Internet games that connect him with like-minded peers. While he describes an inclusiveness and level of socialization that he has not found outside the home, the quantity of use is interfering with sleep, schoolwork, and physical activity.
Significant problematic Internet use may lead to intervention or referral – addictive behaviors and mental health symptoms may warrant connection with mental health providers. Cyberbullying or unsafe behaviors may additionally benefit from parental and school-based support. There is early and limited evidence that psychological and educational interventions may be of benefit for problematic Internet use.13
When digital life is not so dramatically affecting well-being, providers may begin by working with families on a media use plan. The AAP offers its own website to support this. Other well-researched and well-designed sites include Digital Wellness Lab For Parents, with developmentally staged information and plentiful research, and Common Sense Media, which reviews apps, movies, and more; plus they have a knowledge/advice section under “Parents Need to Know.” Keep in mind that digital media can also support youth in managing psychiatric problems, e.g., a digital intervention promoting positive psychology practices looked very helpful for young people with psychosis.14
For Charlie, a health coaching approach is adopted. Using Gabrielli’s TECH parenting rubric,15 Charlie’s parents are coached to make space to talk about and coview media and apps, as well as creating a Family Media Use Plan for everyone – parents included. Alongside setting limits on screen time; health promotion activities like exercise, reading, and schoolwork are also rewarded with extra screen time. When Charlie returns 3 months later, the family reports that, in recognition of their collective digital overload, they preserved dinnertime and after 10 p.m. as screen-free downtime. While they still have concerns about Charlie’s gaming and social life, his sleep is somewhat improved and family tension is lower.
Attention to digital well-being stands to benefit provider and patient alike, and over time may gain from the scaffolding of handouts, standardized assessments, and health coaching providers that may be in place to support other important domains like sleep hygiene, food security, and parenting.
Dr. Rosenfeld is assistant professor, University of Vermont, Vermont Center for Children, Youth, and Families, Burlington. He has no relevant disclosures.
References
1. Chassiakos YR et al. Pediatrics. 2016;138(5)e20162593.
2. Orben A. Soc Psychiatry Psych Epi. 2020;55(4):407.
3. Fang K et al. Child Care Health Dev. 2019;45(5):744-53.
4. Janssen X et al. Sleep Med Rev. 2020;49:101226.
5. George MJ et al. J Ped. 2020;219:180.
6. Twenge JM and Campbell WK. Psychiatry Q. 2019;90(2):311-31.
7. Twenge JM and Martin GN. J Adolesc. 2020;79:91.
8. Efraim M et al. Brain Imaging Behav. 2021;15(1):177-89.
9. Hutton JS et al. JAMA Pediatr. 2020;174(1):e193869.
10. Hutton JS et al. Acta Paediatr. 2020;109(7):1376-86.
11. Clark DL et al. Pediatrics. 2018;141(6).
12. Jericho M and Elliot A. Clin Child Psychol Psychiatry. 2020;25(3):662.
13. Malinauskas R and Malinauskine V. J Behav Addict. 2019;8(4):613.
14. Lim MH et al. Soc Psychiatry Psychiatr Epi. 2020;55(7):877-89.
15. Gabrielli J et al. Pediatrics. 2018;142(1)e20173718.
Charlie is a 15-year-old male whose medical history includes overweight and autism spectrum disorder. While his autism symptoms are stable and he is doing fairly well in school, your sense is that he is underperforming and unhappy. His screening for anxiety and depression is not outstanding and you wonder whether to leave well enough alone.
Historically, pediatrician queries about media use happen in a minority of visits,1 overcrowded by the multitude of screening and acute care needs, let alone the pressures of electronic health record prompts, billing, and documentation. Yet the COVID-19 pandemic has emphasized what was already getting louder: screen life is becoming a ubiquitous, increasing, and normative function of child development. Digital well-being exhibits bidirectional interactions with most of the core indicators of child health: sleep, nutrition, safety, mood, relationships, and many other aspects of physical and mental health.1
The pandemic unveiled the blessings and curses of digital life by shifting many into remote work and school situations where screen time became both necessary and uncontrollable. Reeling with changes in employment, health, finances, and more, families struggled to forge a new screen-life balance that could bridge academic, professional, and recreational use.
Research has wavered in producing a verdict on the effects of screen time, in part because of limitations in methodology and follow-up time,2 and exacerbated by the quickly changing nature of screen use. Screen time may put youth at risk for obesity and behavior problems,3 but the latter may be mediated in part by loss of sleep because of late-night digital activity.4 While survey data at the population level show little link between screen time and well-being impairments,5 zooming in on individuals may tell a different story. Twenge and Campbell show light use of digital media (compared with nonuse) is associated with greater well-being while heavy use is associated with lower well-being and a higher risk for depression and suicidal behavior – especially in girls.6,7 Largely cross-sectional data show a small detriment to psychological well-being associated with digital technology, though this may be bidirectional and does not clearly differentiate types of technology.2
Recent neuroscience suggests that, compared with active play, sedentary screen time after school reduced impulse control and increased brain activity in regions associated with craving.8 This may explain some of the link between screen time and obesity. Brain imaging of preschoolers showed that greater screen time correlated with lower reading readiness as well as less integrity of white-matter tracts involved in language and executive function,9 whereas nurturing home reading practices were protective for language development and white matter integrity.10
Returning to the care of Charlie, providers may benefit from taking time to reflect on their own digital environment. What does the patient-side view of your office look like? Many offices use telephone reminders and patient portals, fill prescriptions electronically, and have waiting rooms with WiFi or devices for children’s use. Office visits share space with providers’ desktops, laptops, and smartphones, with EMRs guiding the visit. EMRs may come home for evening documentation. How does this affect provider digital well-being? How do you start the conversation with families about digital well-being?
The American Academy of Pediatrics recommends media screening be incorporated into routine pediatric care, with several tools available to support this. Adapting the HEADSSS model for psychosocial check-ins, Clark and colleagues propose an additional “S” to capture screen time.11 Their model queries which apps and social media are used, quantity of use, effects on self-confidence, and whether cyberbullying or sexting are occurring. Smartphones themselves provide an eye-opening and accessible dataset, with built-in features (for example, Screen Time for iOS) tracking not just daily duration of use, but also how frequently the phone is picked up and which apps get more use. Screening may be followed by motivational coaching, emphasizing nonjudgment, curiosity, empathy, and flexibility — for patient and provider.12
In Charlie’s case, screening reveals heavy use of social Internet games that connect him with like-minded peers. While he describes an inclusiveness and level of socialization that he has not found outside the home, the quantity of use is interfering with sleep, schoolwork, and physical activity.
Significant problematic Internet use may lead to intervention or referral – addictive behaviors and mental health symptoms may warrant connection with mental health providers. Cyberbullying or unsafe behaviors may additionally benefit from parental and school-based support. There is early and limited evidence that psychological and educational interventions may be of benefit for problematic Internet use.13
When digital life is not so dramatically affecting well-being, providers may begin by working with families on a media use plan. The AAP offers its own website to support this. Other well-researched and well-designed sites include Digital Wellness Lab For Parents, with developmentally staged information and plentiful research, and Common Sense Media, which reviews apps, movies, and more; plus they have a knowledge/advice section under “Parents Need to Know.” Keep in mind that digital media can also support youth in managing psychiatric problems, e.g., a digital intervention promoting positive psychology practices looked very helpful for young people with psychosis.14
For Charlie, a health coaching approach is adopted. Using Gabrielli’s TECH parenting rubric,15 Charlie’s parents are coached to make space to talk about and coview media and apps, as well as creating a Family Media Use Plan for everyone – parents included. Alongside setting limits on screen time; health promotion activities like exercise, reading, and schoolwork are also rewarded with extra screen time. When Charlie returns 3 months later, the family reports that, in recognition of their collective digital overload, they preserved dinnertime and after 10 p.m. as screen-free downtime. While they still have concerns about Charlie’s gaming and social life, his sleep is somewhat improved and family tension is lower.
Attention to digital well-being stands to benefit provider and patient alike, and over time may gain from the scaffolding of handouts, standardized assessments, and health coaching providers that may be in place to support other important domains like sleep hygiene, food security, and parenting.
Dr. Rosenfeld is assistant professor, University of Vermont, Vermont Center for Children, Youth, and Families, Burlington. He has no relevant disclosures.
References
1. Chassiakos YR et al. Pediatrics. 2016;138(5)e20162593.
2. Orben A. Soc Psychiatry Psych Epi. 2020;55(4):407.
3. Fang K et al. Child Care Health Dev. 2019;45(5):744-53.
4. Janssen X et al. Sleep Med Rev. 2020;49:101226.
5. George MJ et al. J Ped. 2020;219:180.
6. Twenge JM and Campbell WK. Psychiatry Q. 2019;90(2):311-31.
7. Twenge JM and Martin GN. J Adolesc. 2020;79:91.
8. Efraim M et al. Brain Imaging Behav. 2021;15(1):177-89.
9. Hutton JS et al. JAMA Pediatr. 2020;174(1):e193869.
10. Hutton JS et al. Acta Paediatr. 2020;109(7):1376-86.
11. Clark DL et al. Pediatrics. 2018;141(6).
12. Jericho M and Elliot A. Clin Child Psychol Psychiatry. 2020;25(3):662.
13. Malinauskas R and Malinauskine V. J Behav Addict. 2019;8(4):613.
14. Lim MH et al. Soc Psychiatry Psychiatr Epi. 2020;55(7):877-89.
15. Gabrielli J et al. Pediatrics. 2018;142(1)e20173718.
Getting unstuck: Helping patients with behavior change
Kyle is a 14-year-old cisgender male who just moved to your town. At his first well-check, his single father brings him in reluctantly, stating, “We’ve never liked doctors.” Kyle has a history of asthma and obesity that have been relatively unchanged over time. He is an average student, an avid gamer, and seems somewhat shy. Privately he admits to occasional cannabis use. His father has no concerns, lamenting, “He’s always been pretty healthy for a fat kid.” Next patient?
Of course there is a lot to work with here. You might be concerned with Kyle’s asthma; his weight, sedentary nature, and body image; the criticism from his father and concerns about self-esteem; the possibility of anxiety in relation to his shyness; and the health effects of his cannabis use. In the end, recommendations for behavior change seem likely. These might take the form of tips on exercise, nutrition, substance use, study habits, parenting, social activities, or mental health support; the literature on behavior change would suggest that any success will be predicated on trust. How can we learn from someone we do not trust?1
To build trust is no easy task, and yet is perhaps the foundation on which the entire clinical relationship rests. Guidance from decades of evidence supporting the use of motivational interviewing2 suggests that the process of building rapport can be neatly summed up in an acronym as PACE. This represents Partnership, Acceptance, Compassion, and Evocation. Almost too clichéd to repeat, the most powerful change agent is the person making the change. In the setting of pediatric health care, we sometimes lean on caregivers to initiate or promote change because they are an intimate part of the patient’s microsystem, and thus moving one gear (the parents) inevitably shifts something in connected gears (the children).
So Partnership is centered on the patient, but inclusive of any important person in the patient’s sphere. In a family-based approach, this might show up as leveraging Kyle’s father’s motivation for behavior change by having the father start an exercise routine. This role models behavior change, shifts the home environment around the behavior, and builds empathy in the parent for the inherent challenges of change processes.
Acceptance can be distilled into knowing that the patient and family are doing the best they can. This does not preclude the possibility of change, but it seats this possibility in an attitude of assumed adequacy. There is nothing wrong with the patient, nothing to be fixed, just the possibility for change.
Similarly, Compassion takes a nonjudgmental viewpoint. With the stance of “this could happen to anybody,” the patient can feel responsible without feeling blamed. Noting the patient’s suffering without blame allows the clinician to be motivated not just to empathize, but to help.
And from this basis of compassionate partnership, the work of Evocation begins. What is happening in the patient’s life and relationships? What are their own goals and values? Where are the discrepancies between what the patient wants and what the patient does? For teenagers, this often brings into conflict developmentally appropriate wishes for autonomy – wanting to drive or get a car or stay out later or have more privacy – with developmentally typical challenges regarding responsibility.3 For example:
Clinician: “You want to use the car, and your parents want you to pay for the gas, but you’re out of money from buying weed. I see how you’re stuck.”
Teen: “Yeah, they really need to give me more allowance. It’s not like we’re living in the 1990s anymore!”
Clinician: “So you could ask for more allowance to get more money for gas. Any other ideas?”
Teen: “I could give up smoking pot and just be miserable all the time.”
Clinician: “Yeah, that sounds too difficult right now; if anything it sounds like you’d like to smoke more pot if you had more money.”
Teen: “Nah, I’m not that hooked on it. ... I could probably smoke a bit less each week and save some gas money.”
The PACE acronym also serves as a reminder of the patience required to grow connection where none has previously existed – pace yourself. Here are some skills-based tips to foster the spirit of motivational interviewing to help balance patience with the time frame of a pediatric check-in. The OARS skills represent the fundamental building blocks of motivational interviewing in practice. Taking the case of Kyle as an example, an Open-Ended Question makes space for the child or parent to express their views with less interviewer bias. Reflections expand this space by underscoring and, in the case of complex Reflections, adding some nuance to what the patient has to say.
Clinician: “How do you feel about your body?”
Teen: “Well, I’m fat. Nobody really wants to be fat. It sucks. But what can I do?”
Clinician: “You feel fat and kind of hopeless.”
Teen: “Yeah, I know you’re going to tell me to go on a diet and start exercising. Doesn’t work. My dad says I was born fat; I guess I’m going to stay that way.”
Clinician: “Sounds like you and your dad can get down on you for your weight. That must feel terrible.”
Teen: “Ah, it’s not that bad. I’m kind of used to it. Fat kid at home, fat kid at school.”
Affirmations are statements focusing on positive actions or attributes of the patient. They tend to build rapport by demonstrating that the clinician sees the strengths of the patient, not just the problems.
Clinician: “I’m pretty impressed that you’re able to show up here and talk about this. It can’t be easy when it sounds like your family and friends have put you down so much that you’re even putting yourself down about your body.”
Teen: “I didn’t really want to come, but then I thought, maybe this new doctor will have some new ideas. I actually want to do something about it, I just don’t know if anything will help. Plus my dad said if I showed up, we could go to McDonald’s afterward.”
Summaries are multipurpose. They demonstrate that you have been listening closely, which builds rapport. They provide a chance to put information together so that both clinician and patient can reflect on the sum of the data and notice what may be missing. And they provide a pause to consider where to go next.
Clinician: “So if I’m getting it right, you’ve been worried about your weight for a long time now. Your dad and your friends give you a hard time about it, which makes you feel down and hopeless, but somehow you stay brave and keep trying to figure it out. You feel ready to do something, you just don’t know what, and you were hoping maybe coming here could give you a place to work on your health. Does that sound about right?”
Teen: “I think that’s pretty much it. Plus the McDonald’s.”
Clinician: “Right, that’s important too – we have to consider your motivation! I wonder if we could talk about this more at our next visit – would that be alright?”
Offices with additional resources might be able to offer some of those as well, if timing seems appropriate; for example, referral to a wellness coach or social worker or nutritionist could be helpful int his case. With the spirit of PACE and the skills of OARS, you can be well on your way to fostering behavior changes that could last a lifetime! Check out the resources from the American Academy of Pediatrics with video and narrative demonstrations of motivational interviewing in pediatrics.
Dr. Rosenfeld is assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center and the university’s Robert Larner College of Medicine, Burlington. He reported no relevant disclosures. Email him at [email protected].
References
1. Miller WR, Rollnick S. “Engagement and disengagement,” in “Motivational interviewing: Helping people change,” 3rd ed. (New York: Guilford, 2013).
2. Miller WR, Rollnick S. “The spirit of motivational interviewing,” in “Motivational interviewing: Helping people change,” 3rd ed. (New York: Guilford, 2013).
3. Naar S, Suarez M. “Adolescence and emerging adulthood: A brief review of development,” in “Motivational interviewing with adolescents and young adults” (New York: Guilford, 2011).
Kyle is a 14-year-old cisgender male who just moved to your town. At his first well-check, his single father brings him in reluctantly, stating, “We’ve never liked doctors.” Kyle has a history of asthma and obesity that have been relatively unchanged over time. He is an average student, an avid gamer, and seems somewhat shy. Privately he admits to occasional cannabis use. His father has no concerns, lamenting, “He’s always been pretty healthy for a fat kid.” Next patient?
Of course there is a lot to work with here. You might be concerned with Kyle’s asthma; his weight, sedentary nature, and body image; the criticism from his father and concerns about self-esteem; the possibility of anxiety in relation to his shyness; and the health effects of his cannabis use. In the end, recommendations for behavior change seem likely. These might take the form of tips on exercise, nutrition, substance use, study habits, parenting, social activities, or mental health support; the literature on behavior change would suggest that any success will be predicated on trust. How can we learn from someone we do not trust?1
To build trust is no easy task, and yet is perhaps the foundation on which the entire clinical relationship rests. Guidance from decades of evidence supporting the use of motivational interviewing2 suggests that the process of building rapport can be neatly summed up in an acronym as PACE. This represents Partnership, Acceptance, Compassion, and Evocation. Almost too clichéd to repeat, the most powerful change agent is the person making the change. In the setting of pediatric health care, we sometimes lean on caregivers to initiate or promote change because they are an intimate part of the patient’s microsystem, and thus moving one gear (the parents) inevitably shifts something in connected gears (the children).
So Partnership is centered on the patient, but inclusive of any important person in the patient’s sphere. In a family-based approach, this might show up as leveraging Kyle’s father’s motivation for behavior change by having the father start an exercise routine. This role models behavior change, shifts the home environment around the behavior, and builds empathy in the parent for the inherent challenges of change processes.
Acceptance can be distilled into knowing that the patient and family are doing the best they can. This does not preclude the possibility of change, but it seats this possibility in an attitude of assumed adequacy. There is nothing wrong with the patient, nothing to be fixed, just the possibility for change.
Similarly, Compassion takes a nonjudgmental viewpoint. With the stance of “this could happen to anybody,” the patient can feel responsible without feeling blamed. Noting the patient’s suffering without blame allows the clinician to be motivated not just to empathize, but to help.
And from this basis of compassionate partnership, the work of Evocation begins. What is happening in the patient’s life and relationships? What are their own goals and values? Where are the discrepancies between what the patient wants and what the patient does? For teenagers, this often brings into conflict developmentally appropriate wishes for autonomy – wanting to drive or get a car or stay out later or have more privacy – with developmentally typical challenges regarding responsibility.3 For example:
Clinician: “You want to use the car, and your parents want you to pay for the gas, but you’re out of money from buying weed. I see how you’re stuck.”
Teen: “Yeah, they really need to give me more allowance. It’s not like we’re living in the 1990s anymore!”
Clinician: “So you could ask for more allowance to get more money for gas. Any other ideas?”
Teen: “I could give up smoking pot and just be miserable all the time.”
Clinician: “Yeah, that sounds too difficult right now; if anything it sounds like you’d like to smoke more pot if you had more money.”
Teen: “Nah, I’m not that hooked on it. ... I could probably smoke a bit less each week and save some gas money.”
The PACE acronym also serves as a reminder of the patience required to grow connection where none has previously existed – pace yourself. Here are some skills-based tips to foster the spirit of motivational interviewing to help balance patience with the time frame of a pediatric check-in. The OARS skills represent the fundamental building blocks of motivational interviewing in practice. Taking the case of Kyle as an example, an Open-Ended Question makes space for the child or parent to express their views with less interviewer bias. Reflections expand this space by underscoring and, in the case of complex Reflections, adding some nuance to what the patient has to say.
Clinician: “How do you feel about your body?”
Teen: “Well, I’m fat. Nobody really wants to be fat. It sucks. But what can I do?”
Clinician: “You feel fat and kind of hopeless.”
Teen: “Yeah, I know you’re going to tell me to go on a diet and start exercising. Doesn’t work. My dad says I was born fat; I guess I’m going to stay that way.”
Clinician: “Sounds like you and your dad can get down on you for your weight. That must feel terrible.”
Teen: “Ah, it’s not that bad. I’m kind of used to it. Fat kid at home, fat kid at school.”
Affirmations are statements focusing on positive actions or attributes of the patient. They tend to build rapport by demonstrating that the clinician sees the strengths of the patient, not just the problems.
Clinician: “I’m pretty impressed that you’re able to show up here and talk about this. It can’t be easy when it sounds like your family and friends have put you down so much that you’re even putting yourself down about your body.”
Teen: “I didn’t really want to come, but then I thought, maybe this new doctor will have some new ideas. I actually want to do something about it, I just don’t know if anything will help. Plus my dad said if I showed up, we could go to McDonald’s afterward.”
Summaries are multipurpose. They demonstrate that you have been listening closely, which builds rapport. They provide a chance to put information together so that both clinician and patient can reflect on the sum of the data and notice what may be missing. And they provide a pause to consider where to go next.
Clinician: “So if I’m getting it right, you’ve been worried about your weight for a long time now. Your dad and your friends give you a hard time about it, which makes you feel down and hopeless, but somehow you stay brave and keep trying to figure it out. You feel ready to do something, you just don’t know what, and you were hoping maybe coming here could give you a place to work on your health. Does that sound about right?”
Teen: “I think that’s pretty much it. Plus the McDonald’s.”
Clinician: “Right, that’s important too – we have to consider your motivation! I wonder if we could talk about this more at our next visit – would that be alright?”
Offices with additional resources might be able to offer some of those as well, if timing seems appropriate; for example, referral to a wellness coach or social worker or nutritionist could be helpful int his case. With the spirit of PACE and the skills of OARS, you can be well on your way to fostering behavior changes that could last a lifetime! Check out the resources from the American Academy of Pediatrics with video and narrative demonstrations of motivational interviewing in pediatrics.
Dr. Rosenfeld is assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center and the university’s Robert Larner College of Medicine, Burlington. He reported no relevant disclosures. Email him at [email protected].
References
1. Miller WR, Rollnick S. “Engagement and disengagement,” in “Motivational interviewing: Helping people change,” 3rd ed. (New York: Guilford, 2013).
2. Miller WR, Rollnick S. “The spirit of motivational interviewing,” in “Motivational interviewing: Helping people change,” 3rd ed. (New York: Guilford, 2013).
3. Naar S, Suarez M. “Adolescence and emerging adulthood: A brief review of development,” in “Motivational interviewing with adolescents and young adults” (New York: Guilford, 2011).
Kyle is a 14-year-old cisgender male who just moved to your town. At his first well-check, his single father brings him in reluctantly, stating, “We’ve never liked doctors.” Kyle has a history of asthma and obesity that have been relatively unchanged over time. He is an average student, an avid gamer, and seems somewhat shy. Privately he admits to occasional cannabis use. His father has no concerns, lamenting, “He’s always been pretty healthy for a fat kid.” Next patient?
Of course there is a lot to work with here. You might be concerned with Kyle’s asthma; his weight, sedentary nature, and body image; the criticism from his father and concerns about self-esteem; the possibility of anxiety in relation to his shyness; and the health effects of his cannabis use. In the end, recommendations for behavior change seem likely. These might take the form of tips on exercise, nutrition, substance use, study habits, parenting, social activities, or mental health support; the literature on behavior change would suggest that any success will be predicated on trust. How can we learn from someone we do not trust?1
To build trust is no easy task, and yet is perhaps the foundation on which the entire clinical relationship rests. Guidance from decades of evidence supporting the use of motivational interviewing2 suggests that the process of building rapport can be neatly summed up in an acronym as PACE. This represents Partnership, Acceptance, Compassion, and Evocation. Almost too clichéd to repeat, the most powerful change agent is the person making the change. In the setting of pediatric health care, we sometimes lean on caregivers to initiate or promote change because they are an intimate part of the patient’s microsystem, and thus moving one gear (the parents) inevitably shifts something in connected gears (the children).
So Partnership is centered on the patient, but inclusive of any important person in the patient’s sphere. In a family-based approach, this might show up as leveraging Kyle’s father’s motivation for behavior change by having the father start an exercise routine. This role models behavior change, shifts the home environment around the behavior, and builds empathy in the parent for the inherent challenges of change processes.
Acceptance can be distilled into knowing that the patient and family are doing the best they can. This does not preclude the possibility of change, but it seats this possibility in an attitude of assumed adequacy. There is nothing wrong with the patient, nothing to be fixed, just the possibility for change.
Similarly, Compassion takes a nonjudgmental viewpoint. With the stance of “this could happen to anybody,” the patient can feel responsible without feeling blamed. Noting the patient’s suffering without blame allows the clinician to be motivated not just to empathize, but to help.
And from this basis of compassionate partnership, the work of Evocation begins. What is happening in the patient’s life and relationships? What are their own goals and values? Where are the discrepancies between what the patient wants and what the patient does? For teenagers, this often brings into conflict developmentally appropriate wishes for autonomy – wanting to drive or get a car or stay out later or have more privacy – with developmentally typical challenges regarding responsibility.3 For example:
Clinician: “You want to use the car, and your parents want you to pay for the gas, but you’re out of money from buying weed. I see how you’re stuck.”
Teen: “Yeah, they really need to give me more allowance. It’s not like we’re living in the 1990s anymore!”
Clinician: “So you could ask for more allowance to get more money for gas. Any other ideas?”
Teen: “I could give up smoking pot and just be miserable all the time.”
Clinician: “Yeah, that sounds too difficult right now; if anything it sounds like you’d like to smoke more pot if you had more money.”
Teen: “Nah, I’m not that hooked on it. ... I could probably smoke a bit less each week and save some gas money.”
The PACE acronym also serves as a reminder of the patience required to grow connection where none has previously existed – pace yourself. Here are some skills-based tips to foster the spirit of motivational interviewing to help balance patience with the time frame of a pediatric check-in. The OARS skills represent the fundamental building blocks of motivational interviewing in practice. Taking the case of Kyle as an example, an Open-Ended Question makes space for the child or parent to express their views with less interviewer bias. Reflections expand this space by underscoring and, in the case of complex Reflections, adding some nuance to what the patient has to say.
Clinician: “How do you feel about your body?”
Teen: “Well, I’m fat. Nobody really wants to be fat. It sucks. But what can I do?”
Clinician: “You feel fat and kind of hopeless.”
Teen: “Yeah, I know you’re going to tell me to go on a diet and start exercising. Doesn’t work. My dad says I was born fat; I guess I’m going to stay that way.”
Clinician: “Sounds like you and your dad can get down on you for your weight. That must feel terrible.”
Teen: “Ah, it’s not that bad. I’m kind of used to it. Fat kid at home, fat kid at school.”
Affirmations are statements focusing on positive actions or attributes of the patient. They tend to build rapport by demonstrating that the clinician sees the strengths of the patient, not just the problems.
Clinician: “I’m pretty impressed that you’re able to show up here and talk about this. It can’t be easy when it sounds like your family and friends have put you down so much that you’re even putting yourself down about your body.”
Teen: “I didn’t really want to come, but then I thought, maybe this new doctor will have some new ideas. I actually want to do something about it, I just don’t know if anything will help. Plus my dad said if I showed up, we could go to McDonald’s afterward.”
Summaries are multipurpose. They demonstrate that you have been listening closely, which builds rapport. They provide a chance to put information together so that both clinician and patient can reflect on the sum of the data and notice what may be missing. And they provide a pause to consider where to go next.
Clinician: “So if I’m getting it right, you’ve been worried about your weight for a long time now. Your dad and your friends give you a hard time about it, which makes you feel down and hopeless, but somehow you stay brave and keep trying to figure it out. You feel ready to do something, you just don’t know what, and you were hoping maybe coming here could give you a place to work on your health. Does that sound about right?”
Teen: “I think that’s pretty much it. Plus the McDonald’s.”
Clinician: “Right, that’s important too – we have to consider your motivation! I wonder if we could talk about this more at our next visit – would that be alright?”
Offices with additional resources might be able to offer some of those as well, if timing seems appropriate; for example, referral to a wellness coach or social worker or nutritionist could be helpful int his case. With the spirit of PACE and the skills of OARS, you can be well on your way to fostering behavior changes that could last a lifetime! Check out the resources from the American Academy of Pediatrics with video and narrative demonstrations of motivational interviewing in pediatrics.
Dr. Rosenfeld is assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center and the university’s Robert Larner College of Medicine, Burlington. He reported no relevant disclosures. Email him at [email protected].
References
1. Miller WR, Rollnick S. “Engagement and disengagement,” in “Motivational interviewing: Helping people change,” 3rd ed. (New York: Guilford, 2013).
2. Miller WR, Rollnick S. “The spirit of motivational interviewing,” in “Motivational interviewing: Helping people change,” 3rd ed. (New York: Guilford, 2013).
3. Naar S, Suarez M. “Adolescence and emerging adulthood: A brief review of development,” in “Motivational interviewing with adolescents and young adults” (New York: Guilford, 2011).
Beyond symptom improvement: Practicing happiness
Kailah is a 13-year-old cisgender female with two working parents, two younger siblings, and a history of mild asthma and overweight who recently presented for a problem-focused visit related to increasing anxiety. An interview of Kailah and her parents led to a diagnosis of generalized anxiety disorder, and she was referred for cognitive-behavioral therapy (CBT) and started on a low-dose SSRI. She now presents 3 months later with decreased anxiety and is compliant with the SSRI and CBT. What next?
Positive psychology and psychiatry have emerged as scientific disciplines since Seligman et al.1 charged the field of psychology with reclaiming its stake in helping everyday people to thrive, as well as cultivating strengths and talents at each level of society – individual, family, institutional, and beyond. This call to action revealed the shift over time from mental health care toward a focus only on mental illness. And study after study confirmed that being “not depressed,” “not anxious” and so on was not the same as flourishing.2
Returning to Kailah, from a mental-health-as-usual approach, your job may be done. Her symptoms have responded to first-line treatments. Perhaps you even tracked her symptoms with a freely available standardized assessment tool like the Screen for Child Anxiety Related Disorders (SCARED)3 and noted a significant drop in her generalized anxiety score.
After a couple decades of research, the science of well-being has led to some consistent findings that can be translated into office practice with children and families. As with any new science, the first steps to building well-being are defining and measuring what we are talking about. I recommend the Flourishing Scale4 for its brevity, availability, and ease of use. It covers the domains included in Seligman’s formula for thriving: PERMA. This acronym represents a consolidation of the first decades of research on well-being, and stands for Positive Emotions, Engagement, (Positive) Relationships, Meaning, and Accomplishments. For a readable but deeper look at the science behind this, check out Seligman’s “Flourish.”5
With the Flourishing Scale total score as a starting point, the acronym PERMA itself can be a good rubric to guide assessment and treatment planning in the office. You can query each of the elements to understand a youth’s current status and areas for building strengths. What brings positive emotions? What activities bring a sense of harmonious engagement without self-consciousness or awareness of time (such as a flow state)? What supportive relationships exist? Where does the youth find meaning or purpose – connection to something larger than themselves (family, work, community, teams, religion, and so on)? And where does the youth derive a sense of competence or self-esteem – something they are good at (accomplishment)?
Your clinical recommendations can flow from this assessment discussion, melding the patient’s and family’s strengths and priorities with evidence-based interventions. “The Resilience Drive,” by Alexia Michiels,6 is a good source for the latter – each chapter has segments relating research to straightforward happiness practices. The Growing Happy card deck (available online) also has brief and usable recommendations suitable for many young people. You can use these during office visits, loan out cards, gift them to families, or recommend families purchase a deck.
To build relationships, I recommend the StoryCorps and 36 Questions To Fall In Love apps. They are free and can be used with parents, peers, or others to build relationship supports and positive intimacy. Try them out yourself first; they essentially provide a platform to generate vulnerable conversations.
Mindfulness is a great antidote to lack of engagement, and it can be practiced in a variety of forms. Card decks make good office props or giveaways, including Growing Mindful (mindfulness practices for all ages) and the YogaKids Toolbox. Plus, there’s an app for that – in fact, many. Two that are free and include materials accessible for younger age groups are Smiling Mind (a nonprofit) and Insight Timer (searchable). This can build engagement and counter negative emotions.
For increasing engagement and flow, I recommend patients and family members assess their character strengths at Strengths-Based Resilience by the University of Toronto SSQ72. Research shows that using your strengths in novel ways lowers depression risk, increases happiness,7 and may be a key to increasing engagement in everyday activities.
When Kailah came in for her next visit, a discussion of PERMA led to identifying time with her family and time with her dog as significant relationship supports that bring positive emotions. However, she struggled to identify a realm where she felt some sense of mastery or competence. Taking the strengths survey (SSQ72) brought out her strengths of love of learning and curiosity. This led to her volunteering at her local library – assisting with programs and eventually creating and leading a teens’ book group. Her CBT therapist supported her through these challenges, and she was able to taper the frequency of therapy sessions so that Kailah only returns for a booster session now every 6 months or so. While she still identifies as an anxious person, Kailah has broadened her self-image to include her resilience and love of learning as core strengths.
Dr. Andrew J. Rosenfeld is an assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center, Burlington. He said he has no relevant disclosures. Email him at [email protected].
References
1. Am Psychol. 2000;55(1):5-14.
2. Am Psychol. 2007 Feb-Mar;62(2):95-108.
3. J Am Acad Child Adolesc Psychiatry. 1999 Oct;38(10):1230-6.
4. Soc Indic Res. 2009; 39:247-66.
5. “Flourish: A visionary new understanding of happiness and well-being” (New York: Free Press, 2011).
6. “The Resilience Drive” (Switzerland: Favre, 2017).
7. Am Psychol. 2005 Jul-Aug;60(5):410-21.
Kailah is a 13-year-old cisgender female with two working parents, two younger siblings, and a history of mild asthma and overweight who recently presented for a problem-focused visit related to increasing anxiety. An interview of Kailah and her parents led to a diagnosis of generalized anxiety disorder, and she was referred for cognitive-behavioral therapy (CBT) and started on a low-dose SSRI. She now presents 3 months later with decreased anxiety and is compliant with the SSRI and CBT. What next?
Positive psychology and psychiatry have emerged as scientific disciplines since Seligman et al.1 charged the field of psychology with reclaiming its stake in helping everyday people to thrive, as well as cultivating strengths and talents at each level of society – individual, family, institutional, and beyond. This call to action revealed the shift over time from mental health care toward a focus only on mental illness. And study after study confirmed that being “not depressed,” “not anxious” and so on was not the same as flourishing.2
Returning to Kailah, from a mental-health-as-usual approach, your job may be done. Her symptoms have responded to first-line treatments. Perhaps you even tracked her symptoms with a freely available standardized assessment tool like the Screen for Child Anxiety Related Disorders (SCARED)3 and noted a significant drop in her generalized anxiety score.
After a couple decades of research, the science of well-being has led to some consistent findings that can be translated into office practice with children and families. As with any new science, the first steps to building well-being are defining and measuring what we are talking about. I recommend the Flourishing Scale4 for its brevity, availability, and ease of use. It covers the domains included in Seligman’s formula for thriving: PERMA. This acronym represents a consolidation of the first decades of research on well-being, and stands for Positive Emotions, Engagement, (Positive) Relationships, Meaning, and Accomplishments. For a readable but deeper look at the science behind this, check out Seligman’s “Flourish.”5
With the Flourishing Scale total score as a starting point, the acronym PERMA itself can be a good rubric to guide assessment and treatment planning in the office. You can query each of the elements to understand a youth’s current status and areas for building strengths. What brings positive emotions? What activities bring a sense of harmonious engagement without self-consciousness or awareness of time (such as a flow state)? What supportive relationships exist? Where does the youth find meaning or purpose – connection to something larger than themselves (family, work, community, teams, religion, and so on)? And where does the youth derive a sense of competence or self-esteem – something they are good at (accomplishment)?
Your clinical recommendations can flow from this assessment discussion, melding the patient’s and family’s strengths and priorities with evidence-based interventions. “The Resilience Drive,” by Alexia Michiels,6 is a good source for the latter – each chapter has segments relating research to straightforward happiness practices. The Growing Happy card deck (available online) also has brief and usable recommendations suitable for many young people. You can use these during office visits, loan out cards, gift them to families, or recommend families purchase a deck.
To build relationships, I recommend the StoryCorps and 36 Questions To Fall In Love apps. They are free and can be used with parents, peers, or others to build relationship supports and positive intimacy. Try them out yourself first; they essentially provide a platform to generate vulnerable conversations.
Mindfulness is a great antidote to lack of engagement, and it can be practiced in a variety of forms. Card decks make good office props or giveaways, including Growing Mindful (mindfulness practices for all ages) and the YogaKids Toolbox. Plus, there’s an app for that – in fact, many. Two that are free and include materials accessible for younger age groups are Smiling Mind (a nonprofit) and Insight Timer (searchable). This can build engagement and counter negative emotions.
For increasing engagement and flow, I recommend patients and family members assess their character strengths at Strengths-Based Resilience by the University of Toronto SSQ72. Research shows that using your strengths in novel ways lowers depression risk, increases happiness,7 and may be a key to increasing engagement in everyday activities.
When Kailah came in for her next visit, a discussion of PERMA led to identifying time with her family and time with her dog as significant relationship supports that bring positive emotions. However, she struggled to identify a realm where she felt some sense of mastery or competence. Taking the strengths survey (SSQ72) brought out her strengths of love of learning and curiosity. This led to her volunteering at her local library – assisting with programs and eventually creating and leading a teens’ book group. Her CBT therapist supported her through these challenges, and she was able to taper the frequency of therapy sessions so that Kailah only returns for a booster session now every 6 months or so. While she still identifies as an anxious person, Kailah has broadened her self-image to include her resilience and love of learning as core strengths.
Dr. Andrew J. Rosenfeld is an assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center, Burlington. He said he has no relevant disclosures. Email him at [email protected].
References
1. Am Psychol. 2000;55(1):5-14.
2. Am Psychol. 2007 Feb-Mar;62(2):95-108.
3. J Am Acad Child Adolesc Psychiatry. 1999 Oct;38(10):1230-6.
4. Soc Indic Res. 2009; 39:247-66.
5. “Flourish: A visionary new understanding of happiness and well-being” (New York: Free Press, 2011).
6. “The Resilience Drive” (Switzerland: Favre, 2017).
7. Am Psychol. 2005 Jul-Aug;60(5):410-21.
Kailah is a 13-year-old cisgender female with two working parents, two younger siblings, and a history of mild asthma and overweight who recently presented for a problem-focused visit related to increasing anxiety. An interview of Kailah and her parents led to a diagnosis of generalized anxiety disorder, and she was referred for cognitive-behavioral therapy (CBT) and started on a low-dose SSRI. She now presents 3 months later with decreased anxiety and is compliant with the SSRI and CBT. What next?
Positive psychology and psychiatry have emerged as scientific disciplines since Seligman et al.1 charged the field of psychology with reclaiming its stake in helping everyday people to thrive, as well as cultivating strengths and talents at each level of society – individual, family, institutional, and beyond. This call to action revealed the shift over time from mental health care toward a focus only on mental illness. And study after study confirmed that being “not depressed,” “not anxious” and so on was not the same as flourishing.2
Returning to Kailah, from a mental-health-as-usual approach, your job may be done. Her symptoms have responded to first-line treatments. Perhaps you even tracked her symptoms with a freely available standardized assessment tool like the Screen for Child Anxiety Related Disorders (SCARED)3 and noted a significant drop in her generalized anxiety score.
After a couple decades of research, the science of well-being has led to some consistent findings that can be translated into office practice with children and families. As with any new science, the first steps to building well-being are defining and measuring what we are talking about. I recommend the Flourishing Scale4 for its brevity, availability, and ease of use. It covers the domains included in Seligman’s formula for thriving: PERMA. This acronym represents a consolidation of the first decades of research on well-being, and stands for Positive Emotions, Engagement, (Positive) Relationships, Meaning, and Accomplishments. For a readable but deeper look at the science behind this, check out Seligman’s “Flourish.”5
With the Flourishing Scale total score as a starting point, the acronym PERMA itself can be a good rubric to guide assessment and treatment planning in the office. You can query each of the elements to understand a youth’s current status and areas for building strengths. What brings positive emotions? What activities bring a sense of harmonious engagement without self-consciousness or awareness of time (such as a flow state)? What supportive relationships exist? Where does the youth find meaning or purpose – connection to something larger than themselves (family, work, community, teams, religion, and so on)? And where does the youth derive a sense of competence or self-esteem – something they are good at (accomplishment)?
Your clinical recommendations can flow from this assessment discussion, melding the patient’s and family’s strengths and priorities with evidence-based interventions. “The Resilience Drive,” by Alexia Michiels,6 is a good source for the latter – each chapter has segments relating research to straightforward happiness practices. The Growing Happy card deck (available online) also has brief and usable recommendations suitable for many young people. You can use these during office visits, loan out cards, gift them to families, or recommend families purchase a deck.
To build relationships, I recommend the StoryCorps and 36 Questions To Fall In Love apps. They are free and can be used with parents, peers, or others to build relationship supports and positive intimacy. Try them out yourself first; they essentially provide a platform to generate vulnerable conversations.
Mindfulness is a great antidote to lack of engagement, and it can be practiced in a variety of forms. Card decks make good office props or giveaways, including Growing Mindful (mindfulness practices for all ages) and the YogaKids Toolbox. Plus, there’s an app for that – in fact, many. Two that are free and include materials accessible for younger age groups are Smiling Mind (a nonprofit) and Insight Timer (searchable). This can build engagement and counter negative emotions.
For increasing engagement and flow, I recommend patients and family members assess their character strengths at Strengths-Based Resilience by the University of Toronto SSQ72. Research shows that using your strengths in novel ways lowers depression risk, increases happiness,7 and may be a key to increasing engagement in everyday activities.
When Kailah came in for her next visit, a discussion of PERMA led to identifying time with her family and time with her dog as significant relationship supports that bring positive emotions. However, she struggled to identify a realm where she felt some sense of mastery or competence. Taking the strengths survey (SSQ72) brought out her strengths of love of learning and curiosity. This led to her volunteering at her local library – assisting with programs and eventually creating and leading a teens’ book group. Her CBT therapist supported her through these challenges, and she was able to taper the frequency of therapy sessions so that Kailah only returns for a booster session now every 6 months or so. While she still identifies as an anxious person, Kailah has broadened her self-image to include her resilience and love of learning as core strengths.
Dr. Andrew J. Rosenfeld is an assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center, Burlington. He said he has no relevant disclosures. Email him at [email protected].
References
1. Am Psychol. 2000;55(1):5-14.
2. Am Psychol. 2007 Feb-Mar;62(2):95-108.
3. J Am Acad Child Adolesc Psychiatry. 1999 Oct;38(10):1230-6.
4. Soc Indic Res. 2009; 39:247-66.
5. “Flourish: A visionary new understanding of happiness and well-being” (New York: Free Press, 2011).
6. “The Resilience Drive” (Switzerland: Favre, 2017).
7. Am Psychol. 2005 Jul-Aug;60(5):410-21.
Mindful kids, part 1: Origins and evidence
Open a magazine or turn on the radio and you are likely to hear someone extolling the benefits of mindfulness for any number of purposes, conditions, or age groups. Businesses, schools, and health care organizations are incorporating mindfulness techniques to boost employee, student, and patient well-being and engagement, as well as to help employers, teachers, and providers to thrive. In this two-part series, part 1 will attempt to distill some of the fundamentals with regard to the following questions: 1. What is mindfulness? 2. What is the evidence for mindfulness, particularly in youth? and 3. How would you apply mindfulness techniques in your office setting?
Mindfulness was largely brought into the mainstream health care world by Jon Kabat-Zinn, PhD, of the University of Massachusetts Medical Center, Worcester. Drawing on Buddhist traditions, he created a secularized version of meditative and movement techniques used for thousands of years to promote healthy living. A growing evidence base showed that these practices, combined in a formal curriculum dubbed mindfulness-based stress reduction (MBSR), could alleviate symptoms and distress in conditions as diverse as chronic pain, psoriasis, and anxiety. This has spawned numerous research programs and spin-offs, and remains a foundational approach to utilizing mindfulness in medical care. Dr. Kabat-Zinn’s definition of the term is thus worth noting – mindfulness is “the awareness that arises by paying attention on purpose, in the present moment, and nonjudgmentally.”1 Put simply, mindfulness means having your mind and your body in the same place at the same time. If your mind is wandering to what happened yesterday or planning for what might happen later today, then your mind and body are not in the same time. If your mind is thinking about what is going on at home while you are at work, or what your friends are doing, your mind and body are not in the same place.
A study of a modified version of Dr. Kabat-Zinn’s MBSR in middle schoolers in an inner city environment compared 12 weeks of mindfulness training versus a typical health curriculum discussing adolescence, stress, and puberty. In this inner city environment, students randomized to mindfulness training reported less depression, less hostility, fewer ruminations, and fewer PTSD symptoms as well as fewer physical complaints.10 Regarding clinical populations, mindfulness training in adolescents has shown promise for ADHD, with improvement in both core symptoms and functionality.11 This especially seems pronounced when caregivers are supported in learning mindful parenting techniques alongside their teens’ mindfulness training.12
In a general psychiatry clinic, an 8-week adolescent MBSR program was added to supplement treatment as usual – psychotherapy and medication management. Those randomized to mindfulness showed improvements in sleep and self-esteem, as well as a decline in depressive and anxiety symptoms, perceived stress, and interpersonal problems.13 Perhaps most impressively, half of the MBSR group dropped at least one diagnosis after the 8-week program, whereas none of those in the wait list group, receiving psychiatric specialty care as usual, decreased their diagnosis count.
While the sum of such research in adults and children builds a strong case for the value of mindfulness at both the universal (well-child check) and problem-focused levels, there are limitations to our knowledge base. The number of studies and total number of children and adolescents enrolled in mindfulness research is far fewer than in studies with adults. A variety of mindfulness practices have been incorporated into study interventions such that results are not always comparable and distinguishing the mechanism of action is difficult. Additionally, double-blind and placebo-controlled studies are harder to accomplish with such active interventions, although headway is being made.14
Despite what remains to be discovered, bringing mindfulness into the lives of children and adolescents seems increasingly sensible, given the growing body of scientific support for the benefits of mindfulness practices at the behavioral and functional neuroanatomic levels. As is the case with recommending healthy diets, exercise, and other universal health-promoting behaviors, the knowledge that mindfulness practices are beneficial may not be enough to get patients and their families engaged in these methods. The second article in this series will address some nuts and bolts of prescribing mindfulness in a pediatric health care setting.
Dr. Rosenfeld is an assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center, Robert Larner College of Medicine, Burlington. He said he has no relevant disclosures.
References
1. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness (New York: Bantam Books, Penguin Random House, 2013).
2. J Pers Soc Psychol. 2003 Apr;84(4):822-48.
3. Gen Hosp Psychiatry. 1982 Apr;4(1):33-47.
4. Am J Psychiatry. 1992 Jul;149(7):936-43.
5. Clin Psychol Rev. 2011 Aug;31(6):1041-56.
6. Neuroreport. 2005 Nov 28;16(17):1893-7.
7. Soc Cogn Affect Neurosci. 2010 Mar;5(1):11-7.
8. Neuroimage. 2009 Apr 15;45(3):672-8.
9. Psychiatry Res. 2011 Jan 30;191(1):36-43.
10. Pediatrics. 2016 Jan;137(1):e20152532.
11. J Atten Disord. 2008 May;11(6):737-46.
12. J Child Fam Stud. 2012 Oct;21(5):775-87.
13. J Consult Clin Psychol. 2009 Oct;77(5):855-66.
14. Biol Psychiatry. 2016 Jul 1;80(1):53-61.
Open a magazine or turn on the radio and you are likely to hear someone extolling the benefits of mindfulness for any number of purposes, conditions, or age groups. Businesses, schools, and health care organizations are incorporating mindfulness techniques to boost employee, student, and patient well-being and engagement, as well as to help employers, teachers, and providers to thrive. In this two-part series, part 1 will attempt to distill some of the fundamentals with regard to the following questions: 1. What is mindfulness? 2. What is the evidence for mindfulness, particularly in youth? and 3. How would you apply mindfulness techniques in your office setting?
Mindfulness was largely brought into the mainstream health care world by Jon Kabat-Zinn, PhD, of the University of Massachusetts Medical Center, Worcester. Drawing on Buddhist traditions, he created a secularized version of meditative and movement techniques used for thousands of years to promote healthy living. A growing evidence base showed that these practices, combined in a formal curriculum dubbed mindfulness-based stress reduction (MBSR), could alleviate symptoms and distress in conditions as diverse as chronic pain, psoriasis, and anxiety. This has spawned numerous research programs and spin-offs, and remains a foundational approach to utilizing mindfulness in medical care. Dr. Kabat-Zinn’s definition of the term is thus worth noting – mindfulness is “the awareness that arises by paying attention on purpose, in the present moment, and nonjudgmentally.”1 Put simply, mindfulness means having your mind and your body in the same place at the same time. If your mind is wandering to what happened yesterday or planning for what might happen later today, then your mind and body are not in the same time. If your mind is thinking about what is going on at home while you are at work, or what your friends are doing, your mind and body are not in the same place.
A study of a modified version of Dr. Kabat-Zinn’s MBSR in middle schoolers in an inner city environment compared 12 weeks of mindfulness training versus a typical health curriculum discussing adolescence, stress, and puberty. In this inner city environment, students randomized to mindfulness training reported less depression, less hostility, fewer ruminations, and fewer PTSD symptoms as well as fewer physical complaints.10 Regarding clinical populations, mindfulness training in adolescents has shown promise for ADHD, with improvement in both core symptoms and functionality.11 This especially seems pronounced when caregivers are supported in learning mindful parenting techniques alongside their teens’ mindfulness training.12
In a general psychiatry clinic, an 8-week adolescent MBSR program was added to supplement treatment as usual – psychotherapy and medication management. Those randomized to mindfulness showed improvements in sleep and self-esteem, as well as a decline in depressive and anxiety symptoms, perceived stress, and interpersonal problems.13 Perhaps most impressively, half of the MBSR group dropped at least one diagnosis after the 8-week program, whereas none of those in the wait list group, receiving psychiatric specialty care as usual, decreased their diagnosis count.
While the sum of such research in adults and children builds a strong case for the value of mindfulness at both the universal (well-child check) and problem-focused levels, there are limitations to our knowledge base. The number of studies and total number of children and adolescents enrolled in mindfulness research is far fewer than in studies with adults. A variety of mindfulness practices have been incorporated into study interventions such that results are not always comparable and distinguishing the mechanism of action is difficult. Additionally, double-blind and placebo-controlled studies are harder to accomplish with such active interventions, although headway is being made.14
Despite what remains to be discovered, bringing mindfulness into the lives of children and adolescents seems increasingly sensible, given the growing body of scientific support for the benefits of mindfulness practices at the behavioral and functional neuroanatomic levels. As is the case with recommending healthy diets, exercise, and other universal health-promoting behaviors, the knowledge that mindfulness practices are beneficial may not be enough to get patients and their families engaged in these methods. The second article in this series will address some nuts and bolts of prescribing mindfulness in a pediatric health care setting.
Dr. Rosenfeld is an assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center, Robert Larner College of Medicine, Burlington. He said he has no relevant disclosures.
References
1. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness (New York: Bantam Books, Penguin Random House, 2013).
2. J Pers Soc Psychol. 2003 Apr;84(4):822-48.
3. Gen Hosp Psychiatry. 1982 Apr;4(1):33-47.
4. Am J Psychiatry. 1992 Jul;149(7):936-43.
5. Clin Psychol Rev. 2011 Aug;31(6):1041-56.
6. Neuroreport. 2005 Nov 28;16(17):1893-7.
7. Soc Cogn Affect Neurosci. 2010 Mar;5(1):11-7.
8. Neuroimage. 2009 Apr 15;45(3):672-8.
9. Psychiatry Res. 2011 Jan 30;191(1):36-43.
10. Pediatrics. 2016 Jan;137(1):e20152532.
11. J Atten Disord. 2008 May;11(6):737-46.
12. J Child Fam Stud. 2012 Oct;21(5):775-87.
13. J Consult Clin Psychol. 2009 Oct;77(5):855-66.
14. Biol Psychiatry. 2016 Jul 1;80(1):53-61.
Open a magazine or turn on the radio and you are likely to hear someone extolling the benefits of mindfulness for any number of purposes, conditions, or age groups. Businesses, schools, and health care organizations are incorporating mindfulness techniques to boost employee, student, and patient well-being and engagement, as well as to help employers, teachers, and providers to thrive. In this two-part series, part 1 will attempt to distill some of the fundamentals with regard to the following questions: 1. What is mindfulness? 2. What is the evidence for mindfulness, particularly in youth? and 3. How would you apply mindfulness techniques in your office setting?
Mindfulness was largely brought into the mainstream health care world by Jon Kabat-Zinn, PhD, of the University of Massachusetts Medical Center, Worcester. Drawing on Buddhist traditions, he created a secularized version of meditative and movement techniques used for thousands of years to promote healthy living. A growing evidence base showed that these practices, combined in a formal curriculum dubbed mindfulness-based stress reduction (MBSR), could alleviate symptoms and distress in conditions as diverse as chronic pain, psoriasis, and anxiety. This has spawned numerous research programs and spin-offs, and remains a foundational approach to utilizing mindfulness in medical care. Dr. Kabat-Zinn’s definition of the term is thus worth noting – mindfulness is “the awareness that arises by paying attention on purpose, in the present moment, and nonjudgmentally.”1 Put simply, mindfulness means having your mind and your body in the same place at the same time. If your mind is wandering to what happened yesterday or planning for what might happen later today, then your mind and body are not in the same time. If your mind is thinking about what is going on at home while you are at work, or what your friends are doing, your mind and body are not in the same place.
A study of a modified version of Dr. Kabat-Zinn’s MBSR in middle schoolers in an inner city environment compared 12 weeks of mindfulness training versus a typical health curriculum discussing adolescence, stress, and puberty. In this inner city environment, students randomized to mindfulness training reported less depression, less hostility, fewer ruminations, and fewer PTSD symptoms as well as fewer physical complaints.10 Regarding clinical populations, mindfulness training in adolescents has shown promise for ADHD, with improvement in both core symptoms and functionality.11 This especially seems pronounced when caregivers are supported in learning mindful parenting techniques alongside their teens’ mindfulness training.12
In a general psychiatry clinic, an 8-week adolescent MBSR program was added to supplement treatment as usual – psychotherapy and medication management. Those randomized to mindfulness showed improvements in sleep and self-esteem, as well as a decline in depressive and anxiety symptoms, perceived stress, and interpersonal problems.13 Perhaps most impressively, half of the MBSR group dropped at least one diagnosis after the 8-week program, whereas none of those in the wait list group, receiving psychiatric specialty care as usual, decreased their diagnosis count.
While the sum of such research in adults and children builds a strong case for the value of mindfulness at both the universal (well-child check) and problem-focused levels, there are limitations to our knowledge base. The number of studies and total number of children and adolescents enrolled in mindfulness research is far fewer than in studies with adults. A variety of mindfulness practices have been incorporated into study interventions such that results are not always comparable and distinguishing the mechanism of action is difficult. Additionally, double-blind and placebo-controlled studies are harder to accomplish with such active interventions, although headway is being made.14
Despite what remains to be discovered, bringing mindfulness into the lives of children and adolescents seems increasingly sensible, given the growing body of scientific support for the benefits of mindfulness practices at the behavioral and functional neuroanatomic levels. As is the case with recommending healthy diets, exercise, and other universal health-promoting behaviors, the knowledge that mindfulness practices are beneficial may not be enough to get patients and their families engaged in these methods. The second article in this series will address some nuts and bolts of prescribing mindfulness in a pediatric health care setting.
Dr. Rosenfeld is an assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center, Robert Larner College of Medicine, Burlington. He said he has no relevant disclosures.
References
1. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness (New York: Bantam Books, Penguin Random House, 2013).
2. J Pers Soc Psychol. 2003 Apr;84(4):822-48.
3. Gen Hosp Psychiatry. 1982 Apr;4(1):33-47.
4. Am J Psychiatry. 1992 Jul;149(7):936-43.
5. Clin Psychol Rev. 2011 Aug;31(6):1041-56.
6. Neuroreport. 2005 Nov 28;16(17):1893-7.
7. Soc Cogn Affect Neurosci. 2010 Mar;5(1):11-7.
8. Neuroimage. 2009 Apr 15;45(3):672-8.
9. Psychiatry Res. 2011 Jan 30;191(1):36-43.
10. Pediatrics. 2016 Jan;137(1):e20152532.
11. J Atten Disord. 2008 May;11(6):737-46.
12. J Child Fam Stud. 2012 Oct;21(5):775-87.
13. J Consult Clin Psychol. 2009 Oct;77(5):855-66.
14. Biol Psychiatry. 2016 Jul 1;80(1):53-61.
Mindful kids, part 2: Integration into practice
In this follow-up to last month’s column on mindfulness, in which the evidence base makes a compelling argument for incorporating mindfulness into our list of healthy practices for youth brain development, the challenge of implementing mindfulness “prescriptions” in practice is considered in more depth. As a reminder, a working definition of mindfulness was offered as, “the awareness that arises by paying attention on purpose, in the present moment, and nonjudgmentally.”1
An important piece of prescribing, either pharmaceuticals or health-promoting practices, is sharing the risks, benefits, and alternatives to the recommended treatment. Last month’s article considered the potential benefits of cultivating a mindfulness practice. Few risks have been well-documented, particularly in the pediatric population. While some case reports describe adults having profoundly disturbing emotional reactions,these are in the context of intensive meditation experiences (think 10-day silent retreat).2 While there is not evidence of harm in youth, the lesson to be learned from adult experiences may be to consult with an advanced teacher if a patient chooses to become intensely involved in any meditative practice.
Bringing mindfulness practices to your office practice could occur anywhere along the spectrum from integrating some mindfulness moments into your standard physical exam to collaborating with an experienced mindfulness or yoga instructor to offer individual and group support to patients and families. My focus here is on simple practices and tools to begin introducing mindfulness to families.
A key component is clinician and caregiver buy-in. Developing your own practice, even if it’s simply three mindful breaths before entering each patient exam room, goes miles in terms of your being able to speak genuinely about the benefits and challenges of mindfulness in a relatable way. Similarly, the more kids see their families practicing and supporting mindfulness, the more likely they are to develop their own routines.
Legitimizing mindfulness practices with a “prescription” also can add to success rates. Considering diaphragmatic breathing as a foundational technique, the following prescription can be printed on cards and reviewed briefly in a visit:
- Show me how you breathe. Now let’s practice belly (abdominal/diaphragmatic) breathing.
- Move both hands to your belly. Imagine you are breathing behind your belly button. Feel your belly rise like a balloon.
- As you breathe out, feel your belly drop as you let air out.
- Bonus: Now breathe through your nose only as you continue belly breathing. Next, notice your belly rising and falling without placing your hands on it.
In a physical exam, the following might work: When you place your stethoscope on the chest and back to auscultate the lungs, instruct the child to “place a hand on your belly and take a deep breath into your belly button so that your hand moves out. Keep taking slow, deep belly breaths while I listen.”
This breathing technique activates the parasympathetic nervous system, quelling the fight-or-flight response that may contribute to anxiety, aggressive reactivity, and interfere with sleep. Prescribing five of these belly breaths before bedtime is a good beginning, increasing frequency and duration over time as the practice becomes routine, then adding the “bonus” techniques. Introducing abdominal breathing also makes a good opportunity to ask the child about sources of stress in their lives.
For the distracted or stressed-out youth, focus is key. Those children who seem to be always multitasking or never sit still may benefit from cultivating a focus practice. It also may help still the mind before bedtime. A mindfulness prescription for focus is as follows:
- The rays of the sun are much more powerful when they are brought into focus. Just like building a muscle, focus can be built up to be stronger. Let’s practice focusing.
- As you breathe in, count slowly to 5, raising one finger for each count. As you breathe out, count down to 0, lowering each finger.
- Notice when you get distracted during the counting. Exercise your focus by coming back to counting your breath.
- Let your hands rest in your lap. Then, move to counting silently in your head.
Alternative options for focus objects include watching the secondhand on a clock, balancing a peacock feather on a fingertip, listening to a bell or chime until it can no longer be heard, watching a sand timer until every grain falls.
In a physical exam, the following might work: During the neurologic exam for cranial nerves (eye movements), direct the child to focus on your finger. Hold it still for 10 seconds, gently reminding them to keep their focus on your finger if needed. Then, as you move to each quadrant, move slowly and stay in each quadrant for 5 seconds. Encourage them to “keep your focus on my finger.”
After practicing a focus exercise, inquire about the patient’s focus during school, homework, and activities. Suggest making the focused breathing, or an alternative focus activity, part of the daily routine. Parents are encouraged to participate alongside their children.
Depending on the amount of time you have in the visit, your mindfulness intervention may simply be how you conduct the physical exam. With more time or a child or family who seems to have an indication for prescribing mindfulness (stress, anxiety, inattention, insomnia, etc.), a more didactic approach toward mindfulness techniques accompanied by a specific prescription may be in order. Developmentally, clinicians in our practice have found that hands-on activities and games can help involve younger children, while teens can get into one of the apps developed to facilitate mindful practices. (See Online resources.) Diagnostically, more hyperactive or distractible children may mesh better with movement-based practices. Depressed or anxious children may enjoy quieter activities or benefit from small incentives to increase motivation. Children with traumatic histories may benefit from a slow pace, keeping their eyes open and looking at the floor rather than eyes closed and avoiding physical contact initially.
Methods of meditation and mindfulness exist in most every philosophical and religious tradition, but the neuroscientific value of these practices is a more recent take on these wisdom traditions. As we follow the growing research literature on mindfulness, consider incorporating this “new” prescription into your toolbox of healthy practices for the developing brain.
Dr. Rosenfeld is assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center and the university’s Robert Larner College of Medicine, Burlington. He reported no relevant disclosures. Email him at [email protected].
Online resources:
- A Sesame Street video on belly breathing (for younger children): “Belly Breathe” with Elmo at www.youtube.com/watch?v=_mZbzDOpylA.
- Card decks: Growing Mindful: Mindfulness Practices for All Ages; Be Mindful Card Deck for Teens; Yoga 4 Classrooms Activity Card Deck.
- Apps: Smiling Mind (differentiated by age); Calm; Breathe; Breathe2Relax; Insight Timer; Grow (mindfulness for teens).
- Props: peacock feathers; sand timers; clock with secondhand; Tibetan singing bell or other; Hoberman spheres (“breathing balls”) to visualize belly breathing.
References
1. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. (New York: Bantam Books, Penguin Random House, 2013).
2. Rocha, Tomas. “The Dark Knight of the Soul.” The Atlantic. June 25, 2014.
In this follow-up to last month’s column on mindfulness, in which the evidence base makes a compelling argument for incorporating mindfulness into our list of healthy practices for youth brain development, the challenge of implementing mindfulness “prescriptions” in practice is considered in more depth. As a reminder, a working definition of mindfulness was offered as, “the awareness that arises by paying attention on purpose, in the present moment, and nonjudgmentally.”1
An important piece of prescribing, either pharmaceuticals or health-promoting practices, is sharing the risks, benefits, and alternatives to the recommended treatment. Last month’s article considered the potential benefits of cultivating a mindfulness practice. Few risks have been well-documented, particularly in the pediatric population. While some case reports describe adults having profoundly disturbing emotional reactions,these are in the context of intensive meditation experiences (think 10-day silent retreat).2 While there is not evidence of harm in youth, the lesson to be learned from adult experiences may be to consult with an advanced teacher if a patient chooses to become intensely involved in any meditative practice.
Bringing mindfulness practices to your office practice could occur anywhere along the spectrum from integrating some mindfulness moments into your standard physical exam to collaborating with an experienced mindfulness or yoga instructor to offer individual and group support to patients and families. My focus here is on simple practices and tools to begin introducing mindfulness to families.
A key component is clinician and caregiver buy-in. Developing your own practice, even if it’s simply three mindful breaths before entering each patient exam room, goes miles in terms of your being able to speak genuinely about the benefits and challenges of mindfulness in a relatable way. Similarly, the more kids see their families practicing and supporting mindfulness, the more likely they are to develop their own routines.
Legitimizing mindfulness practices with a “prescription” also can add to success rates. Considering diaphragmatic breathing as a foundational technique, the following prescription can be printed on cards and reviewed briefly in a visit:
- Show me how you breathe. Now let’s practice belly (abdominal/diaphragmatic) breathing.
- Move both hands to your belly. Imagine you are breathing behind your belly button. Feel your belly rise like a balloon.
- As you breathe out, feel your belly drop as you let air out.
- Bonus: Now breathe through your nose only as you continue belly breathing. Next, notice your belly rising and falling without placing your hands on it.
In a physical exam, the following might work: When you place your stethoscope on the chest and back to auscultate the lungs, instruct the child to “place a hand on your belly and take a deep breath into your belly button so that your hand moves out. Keep taking slow, deep belly breaths while I listen.”
This breathing technique activates the parasympathetic nervous system, quelling the fight-or-flight response that may contribute to anxiety, aggressive reactivity, and interfere with sleep. Prescribing five of these belly breaths before bedtime is a good beginning, increasing frequency and duration over time as the practice becomes routine, then adding the “bonus” techniques. Introducing abdominal breathing also makes a good opportunity to ask the child about sources of stress in their lives.
For the distracted or stressed-out youth, focus is key. Those children who seem to be always multitasking or never sit still may benefit from cultivating a focus practice. It also may help still the mind before bedtime. A mindfulness prescription for focus is as follows:
- The rays of the sun are much more powerful when they are brought into focus. Just like building a muscle, focus can be built up to be stronger. Let’s practice focusing.
- As you breathe in, count slowly to 5, raising one finger for each count. As you breathe out, count down to 0, lowering each finger.
- Notice when you get distracted during the counting. Exercise your focus by coming back to counting your breath.
- Let your hands rest in your lap. Then, move to counting silently in your head.
Alternative options for focus objects include watching the secondhand on a clock, balancing a peacock feather on a fingertip, listening to a bell or chime until it can no longer be heard, watching a sand timer until every grain falls.
In a physical exam, the following might work: During the neurologic exam for cranial nerves (eye movements), direct the child to focus on your finger. Hold it still for 10 seconds, gently reminding them to keep their focus on your finger if needed. Then, as you move to each quadrant, move slowly and stay in each quadrant for 5 seconds. Encourage them to “keep your focus on my finger.”
After practicing a focus exercise, inquire about the patient’s focus during school, homework, and activities. Suggest making the focused breathing, or an alternative focus activity, part of the daily routine. Parents are encouraged to participate alongside their children.
Depending on the amount of time you have in the visit, your mindfulness intervention may simply be how you conduct the physical exam. With more time or a child or family who seems to have an indication for prescribing mindfulness (stress, anxiety, inattention, insomnia, etc.), a more didactic approach toward mindfulness techniques accompanied by a specific prescription may be in order. Developmentally, clinicians in our practice have found that hands-on activities and games can help involve younger children, while teens can get into one of the apps developed to facilitate mindful practices. (See Online resources.) Diagnostically, more hyperactive or distractible children may mesh better with movement-based practices. Depressed or anxious children may enjoy quieter activities or benefit from small incentives to increase motivation. Children with traumatic histories may benefit from a slow pace, keeping their eyes open and looking at the floor rather than eyes closed and avoiding physical contact initially.
Methods of meditation and mindfulness exist in most every philosophical and religious tradition, but the neuroscientific value of these practices is a more recent take on these wisdom traditions. As we follow the growing research literature on mindfulness, consider incorporating this “new” prescription into your toolbox of healthy practices for the developing brain.
Dr. Rosenfeld is assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center and the university’s Robert Larner College of Medicine, Burlington. He reported no relevant disclosures. Email him at [email protected].
Online resources:
- A Sesame Street video on belly breathing (for younger children): “Belly Breathe” with Elmo at www.youtube.com/watch?v=_mZbzDOpylA.
- Card decks: Growing Mindful: Mindfulness Practices for All Ages; Be Mindful Card Deck for Teens; Yoga 4 Classrooms Activity Card Deck.
- Apps: Smiling Mind (differentiated by age); Calm; Breathe; Breathe2Relax; Insight Timer; Grow (mindfulness for teens).
- Props: peacock feathers; sand timers; clock with secondhand; Tibetan singing bell or other; Hoberman spheres (“breathing balls”) to visualize belly breathing.
References
1. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. (New York: Bantam Books, Penguin Random House, 2013).
2. Rocha, Tomas. “The Dark Knight of the Soul.” The Atlantic. June 25, 2014.
In this follow-up to last month’s column on mindfulness, in which the evidence base makes a compelling argument for incorporating mindfulness into our list of healthy practices for youth brain development, the challenge of implementing mindfulness “prescriptions” in practice is considered in more depth. As a reminder, a working definition of mindfulness was offered as, “the awareness that arises by paying attention on purpose, in the present moment, and nonjudgmentally.”1
An important piece of prescribing, either pharmaceuticals or health-promoting practices, is sharing the risks, benefits, and alternatives to the recommended treatment. Last month’s article considered the potential benefits of cultivating a mindfulness practice. Few risks have been well-documented, particularly in the pediatric population. While some case reports describe adults having profoundly disturbing emotional reactions,these are in the context of intensive meditation experiences (think 10-day silent retreat).2 While there is not evidence of harm in youth, the lesson to be learned from adult experiences may be to consult with an advanced teacher if a patient chooses to become intensely involved in any meditative practice.
Bringing mindfulness practices to your office practice could occur anywhere along the spectrum from integrating some mindfulness moments into your standard physical exam to collaborating with an experienced mindfulness or yoga instructor to offer individual and group support to patients and families. My focus here is on simple practices and tools to begin introducing mindfulness to families.
A key component is clinician and caregiver buy-in. Developing your own practice, even if it’s simply three mindful breaths before entering each patient exam room, goes miles in terms of your being able to speak genuinely about the benefits and challenges of mindfulness in a relatable way. Similarly, the more kids see their families practicing and supporting mindfulness, the more likely they are to develop their own routines.
Legitimizing mindfulness practices with a “prescription” also can add to success rates. Considering diaphragmatic breathing as a foundational technique, the following prescription can be printed on cards and reviewed briefly in a visit:
- Show me how you breathe. Now let’s practice belly (abdominal/diaphragmatic) breathing.
- Move both hands to your belly. Imagine you are breathing behind your belly button. Feel your belly rise like a balloon.
- As you breathe out, feel your belly drop as you let air out.
- Bonus: Now breathe through your nose only as you continue belly breathing. Next, notice your belly rising and falling without placing your hands on it.
In a physical exam, the following might work: When you place your stethoscope on the chest and back to auscultate the lungs, instruct the child to “place a hand on your belly and take a deep breath into your belly button so that your hand moves out. Keep taking slow, deep belly breaths while I listen.”
This breathing technique activates the parasympathetic nervous system, quelling the fight-or-flight response that may contribute to anxiety, aggressive reactivity, and interfere with sleep. Prescribing five of these belly breaths before bedtime is a good beginning, increasing frequency and duration over time as the practice becomes routine, then adding the “bonus” techniques. Introducing abdominal breathing also makes a good opportunity to ask the child about sources of stress in their lives.
For the distracted or stressed-out youth, focus is key. Those children who seem to be always multitasking or never sit still may benefit from cultivating a focus practice. It also may help still the mind before bedtime. A mindfulness prescription for focus is as follows:
- The rays of the sun are much more powerful when they are brought into focus. Just like building a muscle, focus can be built up to be stronger. Let’s practice focusing.
- As you breathe in, count slowly to 5, raising one finger for each count. As you breathe out, count down to 0, lowering each finger.
- Notice when you get distracted during the counting. Exercise your focus by coming back to counting your breath.
- Let your hands rest in your lap. Then, move to counting silently in your head.
Alternative options for focus objects include watching the secondhand on a clock, balancing a peacock feather on a fingertip, listening to a bell or chime until it can no longer be heard, watching a sand timer until every grain falls.
In a physical exam, the following might work: During the neurologic exam for cranial nerves (eye movements), direct the child to focus on your finger. Hold it still for 10 seconds, gently reminding them to keep their focus on your finger if needed. Then, as you move to each quadrant, move slowly and stay in each quadrant for 5 seconds. Encourage them to “keep your focus on my finger.”
After practicing a focus exercise, inquire about the patient’s focus during school, homework, and activities. Suggest making the focused breathing, or an alternative focus activity, part of the daily routine. Parents are encouraged to participate alongside their children.
Depending on the amount of time you have in the visit, your mindfulness intervention may simply be how you conduct the physical exam. With more time or a child or family who seems to have an indication for prescribing mindfulness (stress, anxiety, inattention, insomnia, etc.), a more didactic approach toward mindfulness techniques accompanied by a specific prescription may be in order. Developmentally, clinicians in our practice have found that hands-on activities and games can help involve younger children, while teens can get into one of the apps developed to facilitate mindful practices. (See Online resources.) Diagnostically, more hyperactive or distractible children may mesh better with movement-based practices. Depressed or anxious children may enjoy quieter activities or benefit from small incentives to increase motivation. Children with traumatic histories may benefit from a slow pace, keeping their eyes open and looking at the floor rather than eyes closed and avoiding physical contact initially.
Methods of meditation and mindfulness exist in most every philosophical and religious tradition, but the neuroscientific value of these practices is a more recent take on these wisdom traditions. As we follow the growing research literature on mindfulness, consider incorporating this “new” prescription into your toolbox of healthy practices for the developing brain.
Dr. Rosenfeld is assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center and the university’s Robert Larner College of Medicine, Burlington. He reported no relevant disclosures. Email him at [email protected].
Online resources:
- A Sesame Street video on belly breathing (for younger children): “Belly Breathe” with Elmo at www.youtube.com/watch?v=_mZbzDOpylA.
- Card decks: Growing Mindful: Mindfulness Practices for All Ages; Be Mindful Card Deck for Teens; Yoga 4 Classrooms Activity Card Deck.
- Apps: Smiling Mind (differentiated by age); Calm; Breathe; Breathe2Relax; Insight Timer; Grow (mindfulness for teens).
- Props: peacock feathers; sand timers; clock with secondhand; Tibetan singing bell or other; Hoberman spheres (“breathing balls”) to visualize belly breathing.
References
1. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. (New York: Bantam Books, Penguin Random House, 2013).
2. Rocha, Tomas. “The Dark Knight of the Soul.” The Atlantic. June 25, 2014.