Barbara J. Howard

The recently coined term “helicopter parents” refers to parents who hover close to their children with the impression that this will keep them safe or ensure their success. We more formally call these parents “overprotective,” “overintrusive,” or “facilitators” for their kids. The new term may make this behavior seem more normal or even more amusing than it really is.

When you see helicopter parents in your practice, it's hard to know exactly what your role should be. How intrusive should you be to try to change their ways? Is helicopter parenting just a trendy societal or cultural phenomenon? Or do you really have enough information that it is a problem to justify your offering advice?

Even though answers to those questions may still be “up in the air,” overall such overprotection can have significant side effects and should be “on our radar”!

There are some pretty obvious reasons for the increase in helicopter parenting. One is cell phones. Everybody has cell phones, even some 6-year-old children. All the calling and texting back and forth makes it too easy to know every move the child makes. These days, if the children are not out of the house with their cell phones, they likely are at home playing video games or in a sport to which they were driven by the parent.

And these activity choices are part of a vicious cycle being selected – if not to promote entry to Harvard then to keep kids busy. Once one family puts their kids in planned activities, there are fewer peers available to play with after school, so other parents do the same. Smaller family sizes also can encourage helicopter parenting. If parents have five children, there is no time for hovering! Families with fewer children also may have more psychologically invested in each child.

I think that it is no accident that helicopter parenting has emerged at the same time most women are in the workplace full time. When home, working mothers, full of guilt, “up their efforts” to make sure they are being good parents.

Other reasons for a heightened level of hovering is parents' perception that they need to keep their kids safe in what feels like a threatening world. Families also are responding to increased competitiveness for college entry and jobs by doing all they can to position their children to achieve these goals. Of course, parents also want to show their love and concern. In some cases, high levels of protectiveness are appropriate: The child may attend a school where kids are carrying knives, or Dad is coming home drunk and the child needs to be protected. Such circumstances are the exception, though. More common pathology is that a parent is overanxious in general or even has an anxiety disorder.

While overprotectiveness may be understandable, it has significant developmental consequences. When parents dictate most of the children's activities, this can preclude the children from discovering, pursuing, and “owning” their interests. Overall, it can lessen the children's self-esteem because they have fewer opportunities to achieve things they consider to be all their own. Also, when a parent participates in the child's activities, they, as adults, will likely be more competent than the child. That can make a child feel less competent, whereas a kid doing things with peers has a decent chance of being the best. Helicopter parents also typically are aiming to avoid all kinds of risk for their precious child. The protected child may be physically safe, but can become risk aversive and miss the chance to learn how to appropriately assess real dangers. If parents “helicopter” because they are always afraid something bad is going to happen – like a pedophile is going to jump out of the bushes or the child is going to be abducted – they also transmit these fears to the child.

Children who are too restricted may even have health effects from sitting at home, eating too much, and not getting enough exercise.

But what can you do when you think problems may be developing from a helicopter parent? Parents may not perceive any problem at all. In this case, motivational interviewing can help. This technique can be used to move many different types of behavior and can fit into a primary care visit.

A motivational interview is a dialogue between the clinician and patient with specific steps. First, find out if the parent or child perceives any problem at all. You might say, “Wow, you certainly have your kid in all kinds of activities and are working hard to provide all these opportunities. Is your level of involvement a problem for you or your child in any way?” Watching the child's face when you ask this can be very revealing, and can also be used as a point of reflection for the interview.

You might also say: “Have you considered whether you really need to or want to do all of these things?” or “Have you considered backing off?” If the response is, “No, I've never thought about this before,” the parent may ask you in return: “Do you think it's a problem?” Then you have the opportunity to go over the potential pros and cons I've already outlined.

You might ask: “What are the good things about being this involved with your child?” And when you ask this, push them to include not only the effects (he's learned to play the violin or is now state ranked in tennis) but the way they feel about it as well. Parents might say things that reveal their reasons such as: “It makes me feel that I'm a good parent because I've done all these things for her” or “I feel more comfortable when I'm at work because I know he is safe at his karate class.”

Then you might ask them: “Is there any downside to being so involved in all of your child's activities?” You might get this response: “I'm beginning to resent it. I signed him up for all these activities, and now I don't have any free time any more.”

The next step in motivational interviewing is to ask about their readiness for change in a gentle way. “Do you think you might consider backing off?” If they say yes, you can ask, “What would be one of the things you could back off on now?” Make sure it is specific and also includes a time frame: “When would you be able to make this change?” In one family I was helping, the child had been talking to his parents on the phone 20 times a day. For him, a goal-setting question was, “What would it take to cut that down to 15 times?” Don't set an unrealistic goal such as stopping altogether.

Some parents initially will not be amenable to changing their behavior. For example, if they say, “I don't know. I never thought about this before,” you may need to be more circumspect. You might say, “Is there something else about this way of relating to your child that is making you want to continue?” Or use other parents as an example: “Some parents find when they back off the child becomes more relaxed, gets right on his homework by himself, and is happier.”

Garnering support for a change in behavior is an important component. You might ask: “Who could help you back off?” Finding other parents to have as friends who are not so intense, who don't feel the need to have a perfect child, or who are willing to let their kids be more autonomous may be key. Some websites and social networks developing to help parents back off from helicoptering promote “slow parenting,” “free-range parenting,” or “simplicity parenting.”

One important goal of the motivational interview is to come away with a time-based action plan. For a parent who says: “I don't want to change anything” or “This is the most important thing I'm doing for my kid,” you can keep change on the agenda by saying something like: “OK, perhaps we can talk about it when you bring her back for her vaccine in 2 months” and then make a note in the chart so you remember.

Inability to follow an agreed-upon plan can reveal where the parents or child is getting stuck, so this can be subsequently addressed. On a follow-up contact ask how it went and praise them, especially if they exceeded the goal. Or the parent may say, “When I tried to do that, he had a panic attack” or “I got depressed. I felt worthless, like I was not protecting my child.” That will help you understand the barriers for these parents and help you arrange appropriate treatment.

Even though helicopter parenting sounds like something new, addressing it employs your same old clinical skills.

---Barbara J. Howard, M.D.

The recently coined term “helicopter parents” refers to parents who hover close to their children with the impression that this will keep them safe or ensure their success. We more formally call these parents “overprotective,” “overintrusive,” or “facilitators” for their kids. The new term may make this behavior seem more normal or even more amusing than it really is.

When you see helicopter parents in your practice, it's hard to know exactly what your role should be. How intrusive should you be to try to change their ways? Is helicopter parenting just a trendy societal or cultural phenomenon? Or do you really have enough information that it is a problem to justify your offering advice?

Even though answers to those questions may still be “up in the air,” overall such overprotection can have significant side effects and should be “on our radar”!

There are some pretty obvious reasons for the increase in helicopter parenting. One is cell phones. Everybody has cell phones, even some 6-year-old children. All the calling and texting back and forth makes it too easy to know every move the child makes. These days, if the children are not out of the house with their cell phones, they likely are at home playing video games or in a sport to which they were driven by the parent.

And these activity choices are part of a vicious cycle being selected – if not to promote entry to Harvard then to keep kids busy. Once one family puts their kids in planned activities, there are fewer peers available to play with after school, so other parents do the same. Smaller family sizes also can encourage helicopter parenting. If parents have five children, there is no time for hovering! Families with fewer children also may have more psychologically invested in each child.

I think that it is no accident that helicopter parenting has emerged at the same time most women are in the workplace full time. When home, working mothers, full of guilt, “up their efforts” to make sure they are being good parents.

Other reasons for a heightened level of hovering is parents' perception that they need to keep their kids safe in what feels like a threatening world. Families also are responding to increased competitiveness for college entry and jobs by doing all they can to position their children to achieve these goals. Of course, parents also want to show their love and concern. In some cases, high levels of protectiveness are appropriate: The child may attend a school where kids are carrying knives, or Dad is coming home drunk and the child needs to be protected. Such circumstances are the exception, though. More common pathology is that a parent is overanxious in general or even has an anxiety disorder.

While overprotectiveness may be understandable, it has significant developmental consequences. When parents dictate most of the children's activities, this can preclude the children from discovering, pursuing, and “owning” their interests. Overall, it can lessen the children's self-esteem because they have fewer opportunities to achieve things they consider to be all their own. Also, when a parent participates in the child's activities, they, as adults, will likely be more competent than the child. That can make a child feel less competent, whereas a kid doing things with peers has a decent chance of being the best. Helicopter parents also typically are aiming to avoid all kinds of risk for their precious child. The protected child may be physically safe, but can become risk aversive and miss the chance to learn how to appropriately assess real dangers. If parents “helicopter” because they are always afraid something bad is going to happen – like a pedophile is going to jump out of the bushes or the child is going to be abducted – they also transmit these fears to the child.

Children who are too restricted may even have health effects from sitting at home, eating too much, and not getting enough exercise.

But what can you do when you think problems may be developing from a helicopter parent? Parents may not perceive any problem at all. In this case, motivational interviewing can help. This technique can be used to move many different types of behavior and can fit into a primary care visit.

A motivational interview is a dialogue between the clinician and patient with specific steps. First, find out if the parent or child perceives any problem at all. You might say, “Wow, you certainly have your kid in all kinds of activities and are working hard to provide all these opportunities. Is your level of involvement a problem for you or your child in any way?” Watching the child's face when you ask this can be very revealing, and can also be used as a point of reflection for the interview.

You might also say: “Have you considered whether you really need to or want to do all of these things?” or “Have you considered backing off?” If the response is, “No, I've never thought about this before,” the parent may ask you in return: “Do you think it's a problem?” Then you have the opportunity to go over the potential pros and cons I've already outlined.

You might ask: “What are the good things about being this involved with your child?” And when you ask this, push them to include not only the effects (he's learned to play the violin or is now state ranked in tennis) but the way they feel about it as well. Parents might say things that reveal their reasons such as: “It makes me feel that I'm a good parent because I've done all these things for her” or “I feel more comfortable when I'm at work because I know he is safe at his karate class.”

Then you might ask them: “Is there any downside to being so involved in all of your child's activities?” You might get this response: “I'm beginning to resent it. I signed him up for all these activities, and now I don't have any free time any more.”

The next step in motivational interviewing is to ask about their readiness for change in a gentle way. “Do you think you might consider backing off?” If they say yes, you can ask, “What would be one of the things you could back off on now?” Make sure it is specific and also includes a time frame: “When would you be able to make this change?” In one family I was helping, the child had been talking to his parents on the phone 20 times a day. For him, a goal-setting question was, “What would it take to cut that down to 15 times?” Don't set an unrealistic goal such as stopping altogether.

Some parents initially will not be amenable to changing their behavior. For example, if they say, “I don't know. I never thought about this before,” you may need to be more circumspect. You might say, “Is there something else about this way of relating to your child that is making you want to continue?” Or use other parents as an example: “Some parents find when they back off the child becomes more relaxed, gets right on his homework by himself, and is happier.”

Garnering support for a change in behavior is an important component. You might ask: “Who could help you back off?” Finding other parents to have as friends who are not so intense, who don't feel the need to have a perfect child, or who are willing to let their kids be more autonomous may be key. Some websites and social networks developing to help parents back off from helicoptering promote “slow parenting,” “free-range parenting,” or “simplicity parenting.”

One important goal of the motivational interview is to come away with a time-based action plan. For a parent who says: “I don't want to change anything” or “This is the most important thing I'm doing for my kid,” you can keep change on the agenda by saying something like: “OK, perhaps we can talk about it when you bring her back for her vaccine in 2 months” and then make a note in the chart so you remember.

Inability to follow an agreed-upon plan can reveal where the parents or child is getting stuck, so this can be subsequently addressed. On a follow-up contact ask how it went and praise them, especially if they exceeded the goal. Or the parent may say, “When I tried to do that, he had a panic attack” or “I got depressed. I felt worthless, like I was not protecting my child.” That will help you understand the barriers for these parents and help you arrange appropriate treatment.

Even though helicopter parenting sounds like something new, addressing it employs your same old clinical skills.

---Barbara J. Howard, M.D.

The recently coined term “helicopter parents” refers to parents who hover close to their children with the impression that this will keep them safe or ensure their success. We more formally call these parents “overprotective,” “overintrusive,” or “facilitators” for their kids. The new term may make this behavior seem more normal or even more amusing than it really is.

When you see helicopter parents in your practice, it's hard to know exactly what your role should be. How intrusive should you be to try to change their ways? Is helicopter parenting just a trendy societal or cultural phenomenon? Or do you really have enough information that it is a problem to justify your offering advice?

Even though answers to those questions may still be “up in the air,” overall such overprotection can have significant side effects and should be “on our radar”!

There are some pretty obvious reasons for the increase in helicopter parenting. One is cell phones. Everybody has cell phones, even some 6-year-old children. All the calling and texting back and forth makes it too easy to know every move the child makes. These days, if the children are not out of the house with their cell phones, they likely are at home playing video games or in a sport to which they were driven by the parent.

And these activity choices are part of a vicious cycle being selected – if not to promote entry to Harvard then to keep kids busy. Once one family puts their kids in planned activities, there are fewer peers available to play with after school, so other parents do the same. Smaller family sizes also can encourage helicopter parenting. If parents have five children, there is no time for hovering! Families with fewer children also may have more psychologically invested in each child.

I think that it is no accident that helicopter parenting has emerged at the same time most women are in the workplace full time. When home, working mothers, full of guilt, “up their efforts” to make sure they are being good parents.

Other reasons for a heightened level of hovering is parents' perception that they need to keep their kids safe in what feels like a threatening world. Families also are responding to increased competitiveness for college entry and jobs by doing all they can to position their children to achieve these goals. Of course, parents also want to show their love and concern. In some cases, high levels of protectiveness are appropriate: The child may attend a school where kids are carrying knives, or Dad is coming home drunk and the child needs to be protected. Such circumstances are the exception, though. More common pathology is that a parent is overanxious in general or even has an anxiety disorder.

While overprotectiveness may be understandable, it has significant developmental consequences. When parents dictate most of the children's activities, this can preclude the children from discovering, pursuing, and “owning” their interests. Overall, it can lessen the children's self-esteem because they have fewer opportunities to achieve things they consider to be all their own. Also, when a parent participates in the child's activities, they, as adults, will likely be more competent than the child. That can make a child feel less competent, whereas a kid doing things with peers has a decent chance of being the best. Helicopter parents also typically are aiming to avoid all kinds of risk for their precious child. The protected child may be physically safe, but can become risk aversive and miss the chance to learn how to appropriately assess real dangers. If parents “helicopter” because they are always afraid something bad is going to happen – like a pedophile is going to jump out of the bushes or the child is going to be abducted – they also transmit these fears to the child.

Children who are too restricted may even have health effects from sitting at home, eating too much, and not getting enough exercise.

But what can you do when you think problems may be developing from a helicopter parent? Parents may not perceive any problem at all. In this case, motivational interviewing can help. This technique can be used to move many different types of behavior and can fit into a primary care visit.

A motivational interview is a dialogue between the clinician and patient with specific steps. First, find out if the parent or child perceives any problem at all. You might say, “Wow, you certainly have your kid in all kinds of activities and are working hard to provide all these opportunities. Is your level of involvement a problem for you or your child in any way?” Watching the child's face when you ask this can be very revealing, and can also be used as a point of reflection for the interview.

You might also say: “Have you considered whether you really need to or want to do all of these things?” or “Have you considered backing off?” If the response is, “No, I've never thought about this before,” the parent may ask you in return: “Do you think it's a problem?” Then you have the opportunity to go over the potential pros and cons I've already outlined.

You might ask: “What are the good things about being this involved with your child?” And when you ask this, push them to include not only the effects (he's learned to play the violin or is now state ranked in tennis) but the way they feel about it as well. Parents might say things that reveal their reasons such as: “It makes me feel that I'm a good parent because I've done all these things for her” or “I feel more comfortable when I'm at work because I know he is safe at his karate class.”

Then you might ask them: “Is there any downside to being so involved in all of your child's activities?” You might get this response: “I'm beginning to resent it. I signed him up for all these activities, and now I don't have any free time any more.”

The next step in motivational interviewing is to ask about their readiness for change in a gentle way. “Do you think you might consider backing off?” If they say yes, you can ask, “What would be one of the things you could back off on now?” Make sure it is specific and also includes a time frame: “When would you be able to make this change?” In one family I was helping, the child had been talking to his parents on the phone 20 times a day. For him, a goal-setting question was, “What would it take to cut that down to 15 times?” Don't set an unrealistic goal such as stopping altogether.

Some parents initially will not be amenable to changing their behavior. For example, if they say, “I don't know. I never thought about this before,” you may need to be more circumspect. You might say, “Is there something else about this way of relating to your child that is making you want to continue?” Or use other parents as an example: “Some parents find when they back off the child becomes more relaxed, gets right on his homework by himself, and is happier.”

Garnering support for a change in behavior is an important component. You might ask: “Who could help you back off?” Finding other parents to have as friends who are not so intense, who don't feel the need to have a perfect child, or who are willing to let their kids be more autonomous may be key. Some websites and social networks developing to help parents back off from helicoptering promote “slow parenting,” “free-range parenting,” or “simplicity parenting.”

One important goal of the motivational interview is to come away with a time-based action plan. For a parent who says: “I don't want to change anything” or “This is the most important thing I'm doing for my kid,” you can keep change on the agenda by saying something like: “OK, perhaps we can talk about it when you bring her back for her vaccine in 2 months” and then make a note in the chart so you remember.

Inability to follow an agreed-upon plan can reveal where the parents or child is getting stuck, so this can be subsequently addressed. On a follow-up contact ask how it went and praise them, especially if they exceeded the goal. Or the parent may say, “When I tried to do that, he had a panic attack” or “I got depressed. I felt worthless, like I was not protecting my child.” That will help you understand the barriers for these parents and help you arrange appropriate treatment.

Even though helicopter parenting sounds like something new, addressing it employs your same old clinical skills.

---Barbara J. Howard, M.D.

www.CHADIS.com[email protected]

“The preschool just called for the second time about Jason's behavior! What can I do?” This plea to you the pediatrician makes your stomach turn upside down. “What am I supposed to do about that?” you ask yourself. You're not there to see what is happening, and the parent isn't either.

This scenario is made even more difficult because the parents can be desperate for advice and quick solutions. It is incredibly inconvenient when a child is thrown out of child care or preschool for bad behavior, especially for parents who both work. Parents may even get hysterical because they immediately envision their darling failing to get into Harvard based on an inability to interact properly in preschool.

The differential diagnosis of this complaint takes some good sleuthing, but can make a big difference in the life of a young child.

Young children deal with social interaction issues that also confront grown-ups, but without the skills to navigate and manage them.

Learning social skills is a major benefit of preschool and kindergarten, particularly for children with few siblings or siblings of much different ages. The poem “All I Need to Know I Learned in Kindergarten” describes many of these social benefits, including learning to share, take turns, act kindly, and use manners. The poem does not mention some of the other less poetic skills developed at this age, however: learning how to tease successfully, pull your punches, stand tall when there is a bully, bounce back when people insult you or after you wet your pants, tell if someone is a real friend, and deal with a critical teacher who is screaming all the time.

Young children normally practice a social interaction known as “inclusion/exclusion,” where one day they say, “Oh, you're my best friend. Let's go have our secret club.” But the next day they say, “You're not my friend anymore. I've got a new best friend. You can't play with me.” In general, the best short- and long-term outcomes occur when children work out minor interaction problems on their own, with a little teacher support, but serious problems are handled privately by the adults.

Ask for specific information about one of the incidents from both the child and the parent. If a child comes home from school and says, “This kid called me names,” parents can ask, “What kind of names?” to distinguish normal teasing from a toxic environment that needs to be changed. Abnormal teasing is more vicious and adultlike, for example, a peer calling the child a “whore” or using a racial epithet.

Don't forget to suggest ways to pump up resilience such as getting sufficient sleep and proper nutrition.

Next, assess the child with problematic peer behavior for skill deficits. A child with a gap may act up to distract others from noticing, out of frustration or as result of discrimination the child experiences. Often children this age who are aggressive have shortcomings in language. They may speak a different language at home or still communicate only in two- or three-word phrases, and therefore are unable to keep up with others and feel – or actually are – left out. They don't have the repartee to negotiate social situations and can become the victim of taunting and teasing, a specialty of girls.

Children with gross motor skill deficits, particularly boys, also may experience difficulty keeping up with their peers. In some cases, they are rejected by the group for being unable to kick a soccer ball or to climb a jungle gym as well as others can, and they are angry as a result.

Check fine motor skills as well. A child with poor coordination may be slow to finish work and/or be ashamed of what they do produce. Children can be very self-critical at this age and even tear up their papers. If the teacher asks everyone to draw a truck, and another student pointedly says, 'That doesn't look like a truck,” the child might punch in return. The child is acting up in frustration.

While children at this age are just on the edge of acquiring “perspective taking” (considering another's point of view), in the most severe form, difficulty in doing this can be a sign of autism spectrum disorder. Peers quickly pick up on this and may tease them, call them names, and/or reject their awkward attempts to engage. Try telling them a joke or asking them to tell one, and you may see why.

You can help by addressing any detected skill deficits with language therapy or physical therapy. Importantly, suggest ways to build their skills while allowing them to bypass social humiliation. Let children who are not athletic skip recess, assigning them the task of getting out the snacks to avoid further humiliation. Then work on their motor skills through after-school karate instead.

Anxiety can spark aggression, too. If you are afraid, it seems better to strike first. If anxiety seems key, the parents and school will need to soften their handling of the child and help him or her put feelings into words to assist the child in not acting out.

Since some children will misbehave to get a teacher's attention, recommend that the parents drop in unannounced. Often the way a classroom appears (or is staffed) at 8 a.m. drop-off time is not the same way it operates at 10:30 a.m. Suggest a parent watch the part of the day their child complains about the most, which is frequently recess.

Even though there are bad situations and bad schools, most schools have great teachers and other professionals from whom parents can gain valuable information and advice.

Generally teachers can explain the timing of a child's troubles, for example, during circle time he cannot sit still or during craft time because his fine motor skills are not well developed. Having parents seek out these examples is the most efficient way to identify deficits in need of help.

Suggest parents speak to their child empathically instead of giving instructions. In this culture, boys especially are told to “keep a stiff upper lip” or “be a big soldier.” A better approach is to say, “Yes, it's tough when kids talk to you like that” or “I understand this really makes you sad and you feel like crying.”

It also helps when parents share a similar experience from their own childhood. For example, parents can say, “You know, when I was your age, I had an experience like this – I had a kid who was always on my case.”

Parents can promote social development as well. For example, role playing can clearly help a child develop appropriate socioemotional skills. Parents can use this strategy either before an incident – for example, to rehearse how a child might react to a bully in class – or afterward, to help the child determine what he or she might have said or done differently and prepare for the next time. Use of social stories can foster these skills (see www.socialstories.com

Parents who experienced a bad peer interaction as a preschooler or kindergartener may project their concerns on their child who may be doing just fine. The parents might be supersensitive to teasing, for example, and bring an otherwise minor incident to your attention and/or become overintrusive at school. Asking, “How was it for you when you were little? Did you ever run into anything like this?” may bring out past experiences as an important factor predisposing to overreaction. If they wet their pants in kindergarten and never got over it, realizing this connection makes it possible for them to back off and let the school and child handle the current problem.

Watch for red flags or warning signs that problematic behaviors are not within the range of normal stress. The child initially doing well at school who suddenly does not want to return is one example.

Sadly, you need to always consider whether there is abuse going on at school, including sexual abuse. Sudden adjustment problems at home, such as trouble sleeping, nightmares, or bed-wetting, also should raise your level of concern.

Also ask parents if their preschooler suddenly became more difficult to manage at home. Some children who experience negative peer interactions will cling to parents, but oppositional or defiant behavior is more common. Of course, 4-year-old children are notoriously brassy, so you cannot consider back talk a warning sign unless it is part of a sudden change in the normal flow of the child's behavior.

A child this stressed over school may need to be cared for at home or moved to a family day care situation

Unfortunately, the modern practice of grouping of kids of the same age together in a classroom increases the likelihood of interactions going badly. Ten 2-year-old children are not necessarily capable of peacefully spending hours together at a time. When a serious behavioral problem arises in this kind of setting, I frequently recommend family-based day care instead of center-based day care because children will be with others of different ages and different skill levels, and hopefully some of them will be more mature.

Support parents in deciding to pull the child out of a school if the situation is bad. If, for example, the school administration is unresponsive to or dismissive of a parent, removal of the child may be the best option. A new parent recently came to the parent group at our clinic. She reported that a teacher responded to her child's behavior problem by putting him in a closet, which would have been egregious enough, but the teacher also said that there were spiders and bugs in the closet that were going to get him before closing the door. I was flabbergasted. The school tried to defend the teacher for doing this, and my final advice was to “pull the kid.” Any school that ignorant of normal child development cannot be fixed.

www.CHADIS.com[email protected]

“The preschool just called for the second time about Jason's behavior! What can I do?” This plea to you the pediatrician makes your stomach turn upside down. “What am I supposed to do about that?” you ask yourself. You're not there to see what is happening, and the parent isn't either.

This scenario is made even more difficult because the parents can be desperate for advice and quick solutions. It is incredibly inconvenient when a child is thrown out of child care or preschool for bad behavior, especially for parents who both work. Parents may even get hysterical because they immediately envision their darling failing to get into Harvard based on an inability to interact properly in preschool.

The differential diagnosis of this complaint takes some good sleuthing, but can make a big difference in the life of a young child.

Young children deal with social interaction issues that also confront grown-ups, but without the skills to navigate and manage them.

Learning social skills is a major benefit of preschool and kindergarten, particularly for children with few siblings or siblings of much different ages. The poem “All I Need to Know I Learned in Kindergarten” describes many of these social benefits, including learning to share, take turns, act kindly, and use manners. The poem does not mention some of the other less poetic skills developed at this age, however: learning how to tease successfully, pull your punches, stand tall when there is a bully, bounce back when people insult you or after you wet your pants, tell if someone is a real friend, and deal with a critical teacher who is screaming all the time.

Young children normally practice a social interaction known as “inclusion/exclusion,” where one day they say, “Oh, you're my best friend. Let's go have our secret club.” But the next day they say, “You're not my friend anymore. I've got a new best friend. You can't play with me.” In general, the best short- and long-term outcomes occur when children work out minor interaction problems on their own, with a little teacher support, but serious problems are handled privately by the adults.

Ask for specific information about one of the incidents from both the child and the parent. If a child comes home from school and says, “This kid called me names,” parents can ask, “What kind of names?” to distinguish normal teasing from a toxic environment that needs to be changed. Abnormal teasing is more vicious and adultlike, for example, a peer calling the child a “whore” or using a racial epithet.

Don't forget to suggest ways to pump up resilience such as getting sufficient sleep and proper nutrition.

Next, assess the child with problematic peer behavior for skill deficits. A child with a gap may act up to distract others from noticing, out of frustration or as result of discrimination the child experiences. Often children this age who are aggressive have shortcomings in language. They may speak a different language at home or still communicate only in two- or three-word phrases, and therefore are unable to keep up with others and feel – or actually are – left out. They don't have the repartee to negotiate social situations and can become the victim of taunting and teasing, a specialty of girls.

Children with gross motor skill deficits, particularly boys, also may experience difficulty keeping up with their peers. In some cases, they are rejected by the group for being unable to kick a soccer ball or to climb a jungle gym as well as others can, and they are angry as a result.

Check fine motor skills as well. A child with poor coordination may be slow to finish work and/or be ashamed of what they do produce. Children can be very self-critical at this age and even tear up their papers. If the teacher asks everyone to draw a truck, and another student pointedly says, 'That doesn't look like a truck,” the child might punch in return. The child is acting up in frustration.

While children at this age are just on the edge of acquiring “perspective taking” (considering another's point of view), in the most severe form, difficulty in doing this can be a sign of autism spectrum disorder. Peers quickly pick up on this and may tease them, call them names, and/or reject their awkward attempts to engage. Try telling them a joke or asking them to tell one, and you may see why.

You can help by addressing any detected skill deficits with language therapy or physical therapy. Importantly, suggest ways to build their skills while allowing them to bypass social humiliation. Let children who are not athletic skip recess, assigning them the task of getting out the snacks to avoid further humiliation. Then work on their motor skills through after-school karate instead.

Anxiety can spark aggression, too. If you are afraid, it seems better to strike first. If anxiety seems key, the parents and school will need to soften their handling of the child and help him or her put feelings into words to assist the child in not acting out.

Since some children will misbehave to get a teacher's attention, recommend that the parents drop in unannounced. Often the way a classroom appears (or is staffed) at 8 a.m. drop-off time is not the same way it operates at 10:30 a.m. Suggest a parent watch the part of the day their child complains about the most, which is frequently recess.

Even though there are bad situations and bad schools, most schools have great teachers and other professionals from whom parents can gain valuable information and advice.

Generally teachers can explain the timing of a child's troubles, for example, during circle time he cannot sit still or during craft time because his fine motor skills are not well developed. Having parents seek out these examples is the most efficient way to identify deficits in need of help.

Suggest parents speak to their child empathically instead of giving instructions. In this culture, boys especially are told to “keep a stiff upper lip” or “be a big soldier.” A better approach is to say, “Yes, it's tough when kids talk to you like that” or “I understand this really makes you sad and you feel like crying.”

It also helps when parents share a similar experience from their own childhood. For example, parents can say, “You know, when I was your age, I had an experience like this – I had a kid who was always on my case.”

Parents can promote social development as well. For example, role playing can clearly help a child develop appropriate socioemotional skills. Parents can use this strategy either before an incident – for example, to rehearse how a child might react to a bully in class – or afterward, to help the child determine what he or she might have said or done differently and prepare for the next time. Use of social stories can foster these skills (see www.socialstories.com

Parents who experienced a bad peer interaction as a preschooler or kindergartener may project their concerns on their child who may be doing just fine. The parents might be supersensitive to teasing, for example, and bring an otherwise minor incident to your attention and/or become overintrusive at school. Asking, “How was it for you when you were little? Did you ever run into anything like this?” may bring out past experiences as an important factor predisposing to overreaction. If they wet their pants in kindergarten and never got over it, realizing this connection makes it possible for them to back off and let the school and child handle the current problem.

Watch for red flags or warning signs that problematic behaviors are not within the range of normal stress. The child initially doing well at school who suddenly does not want to return is one example.

Sadly, you need to always consider whether there is abuse going on at school, including sexual abuse. Sudden adjustment problems at home, such as trouble sleeping, nightmares, or bed-wetting, also should raise your level of concern.

Also ask parents if their preschooler suddenly became more difficult to manage at home. Some children who experience negative peer interactions will cling to parents, but oppositional or defiant behavior is more common. Of course, 4-year-old children are notoriously brassy, so you cannot consider back talk a warning sign unless it is part of a sudden change in the normal flow of the child's behavior.

A child this stressed over school may need to be cared for at home or moved to a family day care situation

Unfortunately, the modern practice of grouping of kids of the same age together in a classroom increases the likelihood of interactions going badly. Ten 2-year-old children are not necessarily capable of peacefully spending hours together at a time. When a serious behavioral problem arises in this kind of setting, I frequently recommend family-based day care instead of center-based day care because children will be with others of different ages and different skill levels, and hopefully some of them will be more mature.

Support parents in deciding to pull the child out of a school if the situation is bad. If, for example, the school administration is unresponsive to or dismissive of a parent, removal of the child may be the best option. A new parent recently came to the parent group at our clinic. She reported that a teacher responded to her child's behavior problem by putting him in a closet, which would have been egregious enough, but the teacher also said that there were spiders and bugs in the closet that were going to get him before closing the door. I was flabbergasted. The school tried to defend the teacher for doing this, and my final advice was to “pull the kid.” Any school that ignorant of normal child development cannot be fixed.

www.CHADIS.com[email protected]

“The preschool just called for the second time about Jason's behavior! What can I do?” This plea to you the pediatrician makes your stomach turn upside down. “What am I supposed to do about that?” you ask yourself. You're not there to see what is happening, and the parent isn't either.

This scenario is made even more difficult because the parents can be desperate for advice and quick solutions. It is incredibly inconvenient when a child is thrown out of child care or preschool for bad behavior, especially for parents who both work. Parents may even get hysterical because they immediately envision their darling failing to get into Harvard based on an inability to interact properly in preschool.

The differential diagnosis of this complaint takes some good sleuthing, but can make a big difference in the life of a young child.

Young children deal with social interaction issues that also confront grown-ups, but without the skills to navigate and manage them.

Learning social skills is a major benefit of preschool and kindergarten, particularly for children with few siblings or siblings of much different ages. The poem “All I Need to Know I Learned in Kindergarten” describes many of these social benefits, including learning to share, take turns, act kindly, and use manners. The poem does not mention some of the other less poetic skills developed at this age, however: learning how to tease successfully, pull your punches, stand tall when there is a bully, bounce back when people insult you or after you wet your pants, tell if someone is a real friend, and deal with a critical teacher who is screaming all the time.

Young children normally practice a social interaction known as “inclusion/exclusion,” where one day they say, “Oh, you're my best friend. Let's go have our secret club.” But the next day they say, “You're not my friend anymore. I've got a new best friend. You can't play with me.” In general, the best short- and long-term outcomes occur when children work out minor interaction problems on their own, with a little teacher support, but serious problems are handled privately by the adults.

Ask for specific information about one of the incidents from both the child and the parent. If a child comes home from school and says, “This kid called me names,” parents can ask, “What kind of names?” to distinguish normal teasing from a toxic environment that needs to be changed. Abnormal teasing is more vicious and adultlike, for example, a peer calling the child a “whore” or using a racial epithet.

Don't forget to suggest ways to pump up resilience such as getting sufficient sleep and proper nutrition.

Next, assess the child with problematic peer behavior for skill deficits. A child with a gap may act up to distract others from noticing, out of frustration or as result of discrimination the child experiences. Often children this age who are aggressive have shortcomings in language. They may speak a different language at home or still communicate only in two- or three-word phrases, and therefore are unable to keep up with others and feel – or actually are – left out. They don't have the repartee to negotiate social situations and can become the victim of taunting and teasing, a specialty of girls.

Children with gross motor skill deficits, particularly boys, also may experience difficulty keeping up with their peers. In some cases, they are rejected by the group for being unable to kick a soccer ball or to climb a jungle gym as well as others can, and they are angry as a result.

Check fine motor skills as well. A child with poor coordination may be slow to finish work and/or be ashamed of what they do produce. Children can be very self-critical at this age and even tear up their papers. If the teacher asks everyone to draw a truck, and another student pointedly says, 'That doesn't look like a truck,” the child might punch in return. The child is acting up in frustration.

While children at this age are just on the edge of acquiring “perspective taking” (considering another's point of view), in the most severe form, difficulty in doing this can be a sign of autism spectrum disorder. Peers quickly pick up on this and may tease them, call them names, and/or reject their awkward attempts to engage. Try telling them a joke or asking them to tell one, and you may see why.

You can help by addressing any detected skill deficits with language therapy or physical therapy. Importantly, suggest ways to build their skills while allowing them to bypass social humiliation. Let children who are not athletic skip recess, assigning them the task of getting out the snacks to avoid further humiliation. Then work on their motor skills through after-school karate instead.

Anxiety can spark aggression, too. If you are afraid, it seems better to strike first. If anxiety seems key, the parents and school will need to soften their handling of the child and help him or her put feelings into words to assist the child in not acting out.

Since some children will misbehave to get a teacher's attention, recommend that the parents drop in unannounced. Often the way a classroom appears (or is staffed) at 8 a.m. drop-off time is not the same way it operates at 10:30 a.m. Suggest a parent watch the part of the day their child complains about the most, which is frequently recess.

Even though there are bad situations and bad schools, most schools have great teachers and other professionals from whom parents can gain valuable information and advice.

Generally teachers can explain the timing of a child's troubles, for example, during circle time he cannot sit still or during craft time because his fine motor skills are not well developed. Having parents seek out these examples is the most efficient way to identify deficits in need of help.

Suggest parents speak to their child empathically instead of giving instructions. In this culture, boys especially are told to “keep a stiff upper lip” or “be a big soldier.” A better approach is to say, “Yes, it's tough when kids talk to you like that” or “I understand this really makes you sad and you feel like crying.”

It also helps when parents share a similar experience from their own childhood. For example, parents can say, “You know, when I was your age, I had an experience like this – I had a kid who was always on my case.”

Parents can promote social development as well. For example, role playing can clearly help a child develop appropriate socioemotional skills. Parents can use this strategy either before an incident – for example, to rehearse how a child might react to a bully in class – or afterward, to help the child determine what he or she might have said or done differently and prepare for the next time. Use of social stories can foster these skills (see www.socialstories.com

Parents who experienced a bad peer interaction as a preschooler or kindergartener may project their concerns on their child who may be doing just fine. The parents might be supersensitive to teasing, for example, and bring an otherwise minor incident to your attention and/or become overintrusive at school. Asking, “How was it for you when you were little? Did you ever run into anything like this?” may bring out past experiences as an important factor predisposing to overreaction. If they wet their pants in kindergarten and never got over it, realizing this connection makes it possible for them to back off and let the school and child handle the current problem.

Watch for red flags or warning signs that problematic behaviors are not within the range of normal stress. The child initially doing well at school who suddenly does not want to return is one example.

Sadly, you need to always consider whether there is abuse going on at school, including sexual abuse. Sudden adjustment problems at home, such as trouble sleeping, nightmares, or bed-wetting, also should raise your level of concern.

Also ask parents if their preschooler suddenly became more difficult to manage at home. Some children who experience negative peer interactions will cling to parents, but oppositional or defiant behavior is more common. Of course, 4-year-old children are notoriously brassy, so you cannot consider back talk a warning sign unless it is part of a sudden change in the normal flow of the child's behavior.

A child this stressed over school may need to be cared for at home or moved to a family day care situation

Unfortunately, the modern practice of grouping of kids of the same age together in a classroom increases the likelihood of interactions going badly. Ten 2-year-old children are not necessarily capable of peacefully spending hours together at a time. When a serious behavioral problem arises in this kind of setting, I frequently recommend family-based day care instead of center-based day care because children will be with others of different ages and different skill levels, and hopefully some of them will be more mature.

Support parents in deciding to pull the child out of a school if the situation is bad. If, for example, the school administration is unresponsive to or dismissive of a parent, removal of the child may be the best option. A new parent recently came to the parent group at our clinic. She reported that a teacher responded to her child's behavior problem by putting him in a closet, which would have been egregious enough, but the teacher also said that there were spiders and bugs in the closet that were going to get him before closing the door. I was flabbergasted. The school tried to defend the teacher for doing this, and my final advice was to “pull the kid.” Any school that ignorant of normal child development cannot be fixed.

www.CHADIS.com[email protected]

Adolescents are often the most intimidating of our patients. Let's face it: Most of us chose pediatrics because we like little kids. If a 15-minute office visit with a sullen teenager can be so difficult, imagine living with one 24/7. Actually, many of us won't have to imagine—we ourselves are the parents of adolescents, and we know just how challenging that can be.

Despite our own feelings of inadequacy, we can help parents make the transition from raising the innocent younger child to guiding the testy teen into adulthood. A failure to make that transition in parenting style can contribute greatly to a suboptimal outcome.

But your guidance needs to start early. When a parent comes into the office demanding that you administer a drug test or a pregnancy test, you have probably missed the window for effective action. The horse is well out of the barn.

The time to start is earlier—much earlier. All of parenting involves the balancing act between supporting dependency and promoting independence. When people first become parents, they are consumed with accepting the huge dependency of their baby. As the child gets older, parents must allow the child more independence for things to go smoothly.

But adolescence is a time when that balancing act requires truly skilled acrobatics. Teens and their parents need to negotiate the “Four I's” of adolescent development: Initiative, Individuation, Independence, and Intimacy.

Adolescents clearly need to take the initiative in their activities, including when they do their chores and how they manage homework. If parents get in the way and try to structure all of that, they're going to get a lot of pushback.

In terms of individuation—discovering who they are—teenagers are highly sensitive to the standards of peers. They're more interested in what their peers think they should do than what their parents think they should do. On one level, this includes how many ear piercings they have and how they dress. But on a broader level, they need to think their parents are wrong about most things in order to feel “like their own person.” Offering an opinion can be beneficial in giving the adolescent something to counter, but ideally save consequences for more substantial failings. In terms of independence, teenagers are better educated by learning from the consequences of their own actions when those actions are not harmful to their futures.

And in terms of intimacy, teens want and need privacy for their budding relationships. Parents need to learn how to be available to talk about relationships, but not ask too many questions.

Different teens move through these changes at different times. And on top of that, the transition may not always go in one direction. A teen may want to be very independent in choosing her clothes. But the same teen may want a lot of parental help on getting her homework done and on handling peer situations. That's part of what makes parenting adolescents so difficult.

Parents need to gradually release control and let their teens exert more independence. But the key word in that sentence is “gradually,” and parents need to be alert for signs that the child is not ready or has not yet earned that freedom.

Let's say the parents have allowed their 13-year-old to have a cell phone. Let's say that a few weeks later, the child hurls the phone against the wall in anger, shattering it beyond repair. Some parents might be tempted to say: “That's it. I'm not buying you another cell phone until you're in college,” but that is unlikely to be the most educational solution. The time frame should be measured in days or weeks, not in months or years. If consequences are too severe, kids tend to write their parents off completely and feel they have been written off.

Instead, the parents should give the teen a clear path to re-earning the privilege, negotiating the terms. Maybe he has to contribute 80% of his allowance and do some extra chores until the phone is paid for. Showing that they're reasonable and willing to negotiate is a model of adult behavior, and it's also their key to success.

The older the child, the more important it is to negotiate what the rules are to be, and also what exceptions there might be. It's fine if there's a general rule that they can't stay out after 11 o'clock. But if a special event comes along that starts at 10 o'clock and won't end until 2 a.m., it's best to be flexible about the curfew this one time. When teens and parents negotiate one-time exceptions as needed, there is structure but rebellion or sneaking is not brought out.

Negotiation is important. A 30-year longitudinal study from the University of California, Berkeley, demonstrated that parents who managed to negotiate the rules with their children had more harmonious relationships with them later (New Dir. Child Adolesc. Dev. 2005;108:61–9). Often a dynamic arises in families where the parents are so generally annoyed with their teen that they reflexively answer, “No!” to any request. That can be really counterproductive when it comes to parenting adolescents. The first response should be: “Yes, if at all possible. Let's talk about it.”

I recommend that parents explicitly discuss the request using the following six points in deciding with the adolescent on their request. Posting these on the refrigerator and making discussing them a routine lets the teen know they are being taken seriously, slows the reflex to say “no,” and may help install them as a mantra in the teen's brain for future decision making:

Six Guides for Decision Making

1. Is it safe?

2. Is it legal?

3. Does it conflict with responsibilities?

4. Does it meet a developmental need?

5. Does it interfere with others?

6. Could it harm his/her development?

Anyone who's read “The Catcher in the Rye” (New York: Little, Brown and Co., 1951) by J.D. Salinger knows that teenagers are especially sensitive to hypocrisy. Parents often talk about the importance of being a moral person, but the teen is aware that they're cheating on their income taxes. They will reject their parents' moral code if they see them being hypocritical.

Clearly, the best way for the parent to encourage their offspring to uphold good moral standards is to actually live those standards 24/7. But almost everyone fails to live up to those standards from time to time, and if they're parents of an adolescent, the teen is sure to be right there when they do. Adolescents appreciate and learn from honesty when that happens. The parent could admit, “Yes, I know I said that you should never curse another driver, but I was so angry that I forgot my own rule.”

In these days of one- and two-child families, where parents often depend on their own children for friendship and companionship, it can be especially devastating to hear a teen say: “I hate you. You're the worst parents ever.” When that happens—and it's almost certain to happen, since it's the rare child who never utters such a sentiment—the parent's best response is not to rise to the bait of an angry teenager. They don't really mean it. And if the parent shows too much visible distress, or starts to punish them for saying those things, there won't be as much opportunity to recover. A simple “I am sorry you feel that way right now. I can see that you are really angry about [my decision, your curfew, what I said].”

And when the teen notices that the parent has not reacted to such provocation, that in itself is a valuable life lesson. The next time a street tough tosses off an insult, he'll be more likely to simply shrug his shoulders and walk away. For additional information on dealing with adolescents, the American Academy of Pediatrics maintains a particularly good collection of resources for parents at www.healthychildren.org

www.CHADIS.com[email protected]

Adolescents are often the most intimidating of our patients. Let's face it: Most of us chose pediatrics because we like little kids. If a 15-minute office visit with a sullen teenager can be so difficult, imagine living with one 24/7. Actually, many of us won't have to imagine—we ourselves are the parents of adolescents, and we know just how challenging that can be.

Despite our own feelings of inadequacy, we can help parents make the transition from raising the innocent younger child to guiding the testy teen into adulthood. A failure to make that transition in parenting style can contribute greatly to a suboptimal outcome.

But your guidance needs to start early. When a parent comes into the office demanding that you administer a drug test or a pregnancy test, you have probably missed the window for effective action. The horse is well out of the barn.

The time to start is earlier—much earlier. All of parenting involves the balancing act between supporting dependency and promoting independence. When people first become parents, they are consumed with accepting the huge dependency of their baby. As the child gets older, parents must allow the child more independence for things to go smoothly.

But adolescence is a time when that balancing act requires truly skilled acrobatics. Teens and their parents need to negotiate the “Four I's” of adolescent development: Initiative, Individuation, Independence, and Intimacy.

Adolescents clearly need to take the initiative in their activities, including when they do their chores and how they manage homework. If parents get in the way and try to structure all of that, they're going to get a lot of pushback.

In terms of individuation—discovering who they are—teenagers are highly sensitive to the standards of peers. They're more interested in what their peers think they should do than what their parents think they should do. On one level, this includes how many ear piercings they have and how they dress. But on a broader level, they need to think their parents are wrong about most things in order to feel “like their own person.” Offering an opinion can be beneficial in giving the adolescent something to counter, but ideally save consequences for more substantial failings. In terms of independence, teenagers are better educated by learning from the consequences of their own actions when those actions are not harmful to their futures.

And in terms of intimacy, teens want and need privacy for their budding relationships. Parents need to learn how to be available to talk about relationships, but not ask too many questions.

Different teens move through these changes at different times. And on top of that, the transition may not always go in one direction. A teen may want to be very independent in choosing her clothes. But the same teen may want a lot of parental help on getting her homework done and on handling peer situations. That's part of what makes parenting adolescents so difficult.

Parents need to gradually release control and let their teens exert more independence. But the key word in that sentence is “gradually,” and parents need to be alert for signs that the child is not ready or has not yet earned that freedom.

Let's say the parents have allowed their 13-year-old to have a cell phone. Let's say that a few weeks later, the child hurls the phone against the wall in anger, shattering it beyond repair. Some parents might be tempted to say: “That's it. I'm not buying you another cell phone until you're in college,” but that is unlikely to be the most educational solution. The time frame should be measured in days or weeks, not in months or years. If consequences are too severe, kids tend to write their parents off completely and feel they have been written off.

Instead, the parents should give the teen a clear path to re-earning the privilege, negotiating the terms. Maybe he has to contribute 80% of his allowance and do some extra chores until the phone is paid for. Showing that they're reasonable and willing to negotiate is a model of adult behavior, and it's also their key to success.

The older the child, the more important it is to negotiate what the rules are to be, and also what exceptions there might be. It's fine if there's a general rule that they can't stay out after 11 o'clock. But if a special event comes along that starts at 10 o'clock and won't end until 2 a.m., it's best to be flexible about the curfew this one time. When teens and parents negotiate one-time exceptions as needed, there is structure but rebellion or sneaking is not brought out.

Negotiation is important. A 30-year longitudinal study from the University of California, Berkeley, demonstrated that parents who managed to negotiate the rules with their children had more harmonious relationships with them later (New Dir. Child Adolesc. Dev. 2005;108:61–9). Often a dynamic arises in families where the parents are so generally annoyed with their teen that they reflexively answer, “No!” to any request. That can be really counterproductive when it comes to parenting adolescents. The first response should be: “Yes, if at all possible. Let's talk about it.”

I recommend that parents explicitly discuss the request using the following six points in deciding with the adolescent on their request. Posting these on the refrigerator and making discussing them a routine lets the teen know they are being taken seriously, slows the reflex to say “no,” and may help install them as a mantra in the teen's brain for future decision making:

Six Guides for Decision Making

1. Is it safe?

2. Is it legal?

3. Does it conflict with responsibilities?

4. Does it meet a developmental need?

5. Does it interfere with others?

6. Could it harm his/her development?

Anyone who's read “The Catcher in the Rye” (New York: Little, Brown and Co., 1951) by J.D. Salinger knows that teenagers are especially sensitive to hypocrisy. Parents often talk about the importance of being a moral person, but the teen is aware that they're cheating on their income taxes. They will reject their parents' moral code if they see them being hypocritical.

Clearly, the best way for the parent to encourage their offspring to uphold good moral standards is to actually live those standards 24/7. But almost everyone fails to live up to those standards from time to time, and if they're parents of an adolescent, the teen is sure to be right there when they do. Adolescents appreciate and learn from honesty when that happens. The parent could admit, “Yes, I know I said that you should never curse another driver, but I was so angry that I forgot my own rule.”

In these days of one- and two-child families, where parents often depend on their own children for friendship and companionship, it can be especially devastating to hear a teen say: “I hate you. You're the worst parents ever.” When that happens—and it's almost certain to happen, since it's the rare child who never utters such a sentiment—the parent's best response is not to rise to the bait of an angry teenager. They don't really mean it. And if the parent shows too much visible distress, or starts to punish them for saying those things, there won't be as much opportunity to recover. A simple “I am sorry you feel that way right now. I can see that you are really angry about [my decision, your curfew, what I said].”

And when the teen notices that the parent has not reacted to such provocation, that in itself is a valuable life lesson. The next time a street tough tosses off an insult, he'll be more likely to simply shrug his shoulders and walk away. For additional information on dealing with adolescents, the American Academy of Pediatrics maintains a particularly good collection of resources for parents at www.healthychildren.org

www.CHADIS.com[email protected]

Adolescents are often the most intimidating of our patients. Let's face it: Most of us chose pediatrics because we like little kids. If a 15-minute office visit with a sullen teenager can be so difficult, imagine living with one 24/7. Actually, many of us won't have to imagine—we ourselves are the parents of adolescents, and we know just how challenging that can be.

Despite our own feelings of inadequacy, we can help parents make the transition from raising the innocent younger child to guiding the testy teen into adulthood. A failure to make that transition in parenting style can contribute greatly to a suboptimal outcome.

But your guidance needs to start early. When a parent comes into the office demanding that you administer a drug test or a pregnancy test, you have probably missed the window for effective action. The horse is well out of the barn.

The time to start is earlier—much earlier. All of parenting involves the balancing act between supporting dependency and promoting independence. When people first become parents, they are consumed with accepting the huge dependency of their baby. As the child gets older, parents must allow the child more independence for things to go smoothly.

But adolescence is a time when that balancing act requires truly skilled acrobatics. Teens and their parents need to negotiate the “Four I's” of adolescent development: Initiative, Individuation, Independence, and Intimacy.

Adolescents clearly need to take the initiative in their activities, including when they do their chores and how they manage homework. If parents get in the way and try to structure all of that, they're going to get a lot of pushback.

In terms of individuation—discovering who they are—teenagers are highly sensitive to the standards of peers. They're more interested in what their peers think they should do than what their parents think they should do. On one level, this includes how many ear piercings they have and how they dress. But on a broader level, they need to think their parents are wrong about most things in order to feel “like their own person.” Offering an opinion can be beneficial in giving the adolescent something to counter, but ideally save consequences for more substantial failings. In terms of independence, teenagers are better educated by learning from the consequences of their own actions when those actions are not harmful to their futures.

And in terms of intimacy, teens want and need privacy for their budding relationships. Parents need to learn how to be available to talk about relationships, but not ask too many questions.

Different teens move through these changes at different times. And on top of that, the transition may not always go in one direction. A teen may want to be very independent in choosing her clothes. But the same teen may want a lot of parental help on getting her homework done and on handling peer situations. That's part of what makes parenting adolescents so difficult.

Parents need to gradually release control and let their teens exert more independence. But the key word in that sentence is “gradually,” and parents need to be alert for signs that the child is not ready or has not yet earned that freedom.

Let's say the parents have allowed their 13-year-old to have a cell phone. Let's say that a few weeks later, the child hurls the phone against the wall in anger, shattering it beyond repair. Some parents might be tempted to say: “That's it. I'm not buying you another cell phone until you're in college,” but that is unlikely to be the most educational solution. The time frame should be measured in days or weeks, not in months or years. If consequences are too severe, kids tend to write their parents off completely and feel they have been written off.

Instead, the parents should give the teen a clear path to re-earning the privilege, negotiating the terms. Maybe he has to contribute 80% of his allowance and do some extra chores until the phone is paid for. Showing that they're reasonable and willing to negotiate is a model of adult behavior, and it's also their key to success.

The older the child, the more important it is to negotiate what the rules are to be, and also what exceptions there might be. It's fine if there's a general rule that they can't stay out after 11 o'clock. But if a special event comes along that starts at 10 o'clock and won't end until 2 a.m., it's best to be flexible about the curfew this one time. When teens and parents negotiate one-time exceptions as needed, there is structure but rebellion or sneaking is not brought out.

Negotiation is important. A 30-year longitudinal study from the University of California, Berkeley, demonstrated that parents who managed to negotiate the rules with their children had more harmonious relationships with them later (New Dir. Child Adolesc. Dev. 2005;108:61–9). Often a dynamic arises in families where the parents are so generally annoyed with their teen that they reflexively answer, “No!” to any request. That can be really counterproductive when it comes to parenting adolescents. The first response should be: “Yes, if at all possible. Let's talk about it.”

I recommend that parents explicitly discuss the request using the following six points in deciding with the adolescent on their request. Posting these on the refrigerator and making discussing them a routine lets the teen know they are being taken seriously, slows the reflex to say “no,” and may help install them as a mantra in the teen's brain for future decision making:

Six Guides for Decision Making

1. Is it safe?

2. Is it legal?

3. Does it conflict with responsibilities?

4. Does it meet a developmental need?

5. Does it interfere with others?

6. Could it harm his/her development?

Anyone who's read “The Catcher in the Rye” (New York: Little, Brown and Co., 1951) by J.D. Salinger knows that teenagers are especially sensitive to hypocrisy. Parents often talk about the importance of being a moral person, but the teen is aware that they're cheating on their income taxes. They will reject their parents' moral code if they see them being hypocritical.

Clearly, the best way for the parent to encourage their offspring to uphold good moral standards is to actually live those standards 24/7. But almost everyone fails to live up to those standards from time to time, and if they're parents of an adolescent, the teen is sure to be right there when they do. Adolescents appreciate and learn from honesty when that happens. The parent could admit, “Yes, I know I said that you should never curse another driver, but I was so angry that I forgot my own rule.”

In these days of one- and two-child families, where parents often depend on their own children for friendship and companionship, it can be especially devastating to hear a teen say: “I hate you. You're the worst parents ever.” When that happens—and it's almost certain to happen, since it's the rare child who never utters such a sentiment—the parent's best response is not to rise to the bait of an angry teenager. They don't really mean it. And if the parent shows too much visible distress, or starts to punish them for saying those things, there won't be as much opportunity to recover. A simple “I am sorry you feel that way right now. I can see that you are really angry about [my decision, your curfew, what I said].”

And when the teen notices that the parent has not reacted to such provocation, that in itself is a valuable life lesson. The next time a street tough tosses off an insult, he'll be more likely to simply shrug his shoulders and walk away. For additional information on dealing with adolescents, the American Academy of Pediatrics maintains a particularly good collection of resources for parents at www.healthychildren.org

www.CHADIS.com[email protected]

From Cane and Abel to Linus and Lucy, Wally and the Beaver to Bart and Lisa Simpson, sibling rivalry is the stuff of legend and comedy. But when it presents as a source of serious concern for parents during pediatric office visits, it's usually no laughing matter for them.

Research suggests that 64% of school-age siblings fight “sometimes or often”—a figure likely matched in magnitude if not muscle by younger siblings as well.

Sibling rivalry is so common, in fact, that we may tend to think back to our own sibling spats, or those of our kids, roll our eyes and offer the “they'll grow out of it” platitude.

But in truth, sibling wars can have consequences. While injuries are rare in most sibling disputes, in 25% of child abuse cases a sibling has been involved in victimization (usually in concert with adults).

Serious sibling conflict tremendously compromises quality of life for children, and for their parents as well. We know that marriages suffer in households with high levels of sibling discord, with the issue a common flashpoint for disagreements between parents about how to respond. Children exposed to serious sibling conflict in middle childhood appear to suffer higher levels of anxiety, depression, and delinquent behavior in early adolescence. Down the road, people carry the grudges of sibling difficulties for decades, undermining bonds that might otherwise be a significant source of support in our increasingly fragmented society.

So sibling struggles are worthy of our time and thoughtfulness, and addressing them productively will build trust in your relationship with parents and perhaps bring some semblance of peace to their households.

The first response to a parent's frustration over sibling quarrels should be to listen with respect. Their pain is often significant as they describe the battles unfolding among children they hold precious. Patiently listening to the details of sibling encounters also can help you sort out whether the issues they're describing fall into the normal range or may signify more serious individual or relational issues that deserve attention.

Assuming it's the former, I think it helps to remind parents of how common sibling rivalry is, and more importantly, why it occurs. Annoying as they may be, fracases actually serve a number of important biological functions. Watch any nature documentary featuring lions lounging under a tree on the savannah, and what are the cubs doing? Attacking, defending, tumbling, and biting, growling all the while.

In kids, like cubs, important social skills arise from the sibling relationship, even when the dust flies. Siblings teach each other to giggle and laugh, bait and switch, sneak and chase, parry and defend. From each other, they learn which jokes fly and which land with a thud, how to toss out an insult and absorb one tossed their way.

Siblings also learn how to pull their punches, practicing evolutionarily useful conflict skills while stopping short of inflicting serious harm.

The question remains, how does a family foster productive resilience-building sibling interactions while preserving affectionate connections and at least a modicum of household calm?

Like so many things in life, household chaos is associated with unhealthy levels of sibling conflict, according to research by psychologist Judy Dunn, the author of “Sisters and Brothers” (Cambridge: Harvard University Press, 1985), “Separate Lives: Why Siblings Are So Different” (New York: Basic Books, 1992), and “From One Child to Two” (New York: Ballantine Books, 1995).

Corporal punishment in the family makes rivalry worse as well.

Individual temperaments, the presence of a child with special needs, and family structure (children of opposite sexes) also have been found to play roles in sibling relationships, but spacing of children makes less of a difference than most people think. In general, children spaced more than 4 years apart have less conflict, but they also spend less time together and have less of an integrated relationship than closely spaced siblings do.

When looking at underlying dynamics, research points to the perception of favoritism by the parents as the main contributing factor. Importantly, the children's impressions of favoritism are not always accurate, but they are such an important driver of sibling conflict that they deserve consideration.

I suggest to parents that they make a special effort to provide roughly equal “alone” time with each child. When one child's needs really do require inordinate attention—as in the case of homework time for a child with learning disabilities—they need to be up front about that reality, and say, “If you need something special, I will be there for you, too.” Remind the child who feels slighted about exceptional times when all the focus was on them: during assembly of the science fair project, or when they learned to ride a bike, for example.

Acknowledge jealousy as a real and understandable emotion, but one that must be handled within limits and household rules.

Parents will do well to practice prevention with siblings, reinforcing cooperation in general and any specific examples of good deeds performed on behalf of each other with acknowledgment or even rewards if the rivalry is serious.

Advise parents to be sensitive to situations, like boredom, that lend themselves to sibling disputes, and to intervene with distractions. Promote cooperative projects and noncompetitive games: building a fort or puzzle, playing in the sprinkler, or making breakfast as a family, instead of games with winners and losers.

When board games are necessarily competitive, make it a practice to turn the board around every fourth move to minimize age-related inequities. Even out the teams in driveway basketball as well.

Once children are old enough to participate, family meetings are an excellent forum in which to air grievances. Again, ground rules apply; everyone gets to be heard. No interrupting. Solutions can be brainstormed and tried out, to be reviewed at the next regularly scheduled session.

A stepwise approach to dealing with actual sibling disputes also helps bring order to the chaos that feeds sibling wars. Parents may want to read the popular if optimistically titled book by Adele Faber and Irene Mazlish, “Siblings Without Rivalry” (New York: HarperCollins Publishing, 2004).

Essentially, their basic plan is to teach parents to ignore whatever can be ignored, thus avoiding a self-feeding loop of inadvertent reinforcement of the conflicts.

Situations that are a bit too much to ignore should be handled dispassionately. The parent may want to ask, “Is this a real fight or a play fight?” If it's a play fight but noisy, they might want to suggest a new venue—in the basement or outdoors.

If it's a real fight, encourage parents to simply describe the situation they see. “It looks like you both want to play with the truck, and it's hard to decide how to work it out.” Follow this with an affirming statement like, “I'm sure you can figure out a solution.”

If things are even more volatile—maybe someone has hit or pinched—parents should intervene, but in an unbiased manner and with the least amount of punishment that makes sense. They need to emphasize that hitting is never acceptable, but not take sides. A useful mantra for parents: “Don't try to judge who started it. You can never tell.”

Depending on the situation, both children may need to be sent to a room away from the toy to make a plan for resolution. The toy may need to be put in time out. Both kids may need to be put in time out for the same amount of time, with duration based on the younger child's age. Each child may need to take on an individual chore card, or even chores requiring the effort of both kids.

Whatever the solution, it should be brief.

Counsel parents that rivalry is part of sibling interaction: a challenge best met through prevention, structured responses, and reliance on family rules.

Remind them of the fleeting nature of sibling spats—don't they hear the kids giggling 15 minutes later?—and the permanence of warm, mutually respectful, sibling bonds through a lifetime.

www.CHADIS.com[email protected]

From Cane and Abel to Linus and Lucy, Wally and the Beaver to Bart and Lisa Simpson, sibling rivalry is the stuff of legend and comedy. But when it presents as a source of serious concern for parents during pediatric office visits, it's usually no laughing matter for them.

Research suggests that 64% of school-age siblings fight “sometimes or often”—a figure likely matched in magnitude if not muscle by younger siblings as well.

Sibling rivalry is so common, in fact, that we may tend to think back to our own sibling spats, or those of our kids, roll our eyes and offer the “they'll grow out of it” platitude.

But in truth, sibling wars can have consequences. While injuries are rare in most sibling disputes, in 25% of child abuse cases a sibling has been involved in victimization (usually in concert with adults).

Serious sibling conflict tremendously compromises quality of life for children, and for their parents as well. We know that marriages suffer in households with high levels of sibling discord, with the issue a common flashpoint for disagreements between parents about how to respond. Children exposed to serious sibling conflict in middle childhood appear to suffer higher levels of anxiety, depression, and delinquent behavior in early adolescence. Down the road, people carry the grudges of sibling difficulties for decades, undermining bonds that might otherwise be a significant source of support in our increasingly fragmented society.

So sibling struggles are worthy of our time and thoughtfulness, and addressing them productively will build trust in your relationship with parents and perhaps bring some semblance of peace to their households.

The first response to a parent's frustration over sibling quarrels should be to listen with respect. Their pain is often significant as they describe the battles unfolding among children they hold precious. Patiently listening to the details of sibling encounters also can help you sort out whether the issues they're describing fall into the normal range or may signify more serious individual or relational issues that deserve attention.

Assuming it's the former, I think it helps to remind parents of how common sibling rivalry is, and more importantly, why it occurs. Annoying as they may be, fracases actually serve a number of important biological functions. Watch any nature documentary featuring lions lounging under a tree on the savannah, and what are the cubs doing? Attacking, defending, tumbling, and biting, growling all the while.

In kids, like cubs, important social skills arise from the sibling relationship, even when the dust flies. Siblings teach each other to giggle and laugh, bait and switch, sneak and chase, parry and defend. From each other, they learn which jokes fly and which land with a thud, how to toss out an insult and absorb one tossed their way.

Siblings also learn how to pull their punches, practicing evolutionarily useful conflict skills while stopping short of inflicting serious harm.

The question remains, how does a family foster productive resilience-building sibling interactions while preserving affectionate connections and at least a modicum of household calm?

Like so many things in life, household chaos is associated with unhealthy levels of sibling conflict, according to research by psychologist Judy Dunn, the author of “Sisters and Brothers” (Cambridge: Harvard University Press, 1985), “Separate Lives: Why Siblings Are So Different” (New York: Basic Books, 1992), and “From One Child to Two” (New York: Ballantine Books, 1995).

Corporal punishment in the family makes rivalry worse as well.

Individual temperaments, the presence of a child with special needs, and family structure (children of opposite sexes) also have been found to play roles in sibling relationships, but spacing of children makes less of a difference than most people think. In general, children spaced more than 4 years apart have less conflict, but they also spend less time together and have less of an integrated relationship than closely spaced siblings do.

When looking at underlying dynamics, research points to the perception of favoritism by the parents as the main contributing factor. Importantly, the children's impressions of favoritism are not always accurate, but they are such an important driver of sibling conflict that they deserve consideration.

I suggest to parents that they make a special effort to provide roughly equal “alone” time with each child. When one child's needs really do require inordinate attention—as in the case of homework time for a child with learning disabilities—they need to be up front about that reality, and say, “If you need something special, I will be there for you, too.” Remind the child who feels slighted about exceptional times when all the focus was on them: during assembly of the science fair project, or when they learned to ride a bike, for example.

Acknowledge jealousy as a real and understandable emotion, but one that must be handled within limits and household rules.

Parents will do well to practice prevention with siblings, reinforcing cooperation in general and any specific examples of good deeds performed on behalf of each other with acknowledgment or even rewards if the rivalry is serious.

Advise parents to be sensitive to situations, like boredom, that lend themselves to sibling disputes, and to intervene with distractions. Promote cooperative projects and noncompetitive games: building a fort or puzzle, playing in the sprinkler, or making breakfast as a family, instead of games with winners and losers.

When board games are necessarily competitive, make it a practice to turn the board around every fourth move to minimize age-related inequities. Even out the teams in driveway basketball as well.

Once children are old enough to participate, family meetings are an excellent forum in which to air grievances. Again, ground rules apply; everyone gets to be heard. No interrupting. Solutions can be brainstormed and tried out, to be reviewed at the next regularly scheduled session.

A stepwise approach to dealing with actual sibling disputes also helps bring order to the chaos that feeds sibling wars. Parents may want to read the popular if optimistically titled book by Adele Faber and Irene Mazlish, “Siblings Without Rivalry” (New York: HarperCollins Publishing, 2004).

Essentially, their basic plan is to teach parents to ignore whatever can be ignored, thus avoiding a self-feeding loop of inadvertent reinforcement of the conflicts.

Situations that are a bit too much to ignore should be handled dispassionately. The parent may want to ask, “Is this a real fight or a play fight?” If it's a play fight but noisy, they might want to suggest a new venue—in the basement or outdoors.

If it's a real fight, encourage parents to simply describe the situation they see. “It looks like you both want to play with the truck, and it's hard to decide how to work it out.” Follow this with an affirming statement like, “I'm sure you can figure out a solution.”

If things are even more volatile—maybe someone has hit or pinched—parents should intervene, but in an unbiased manner and with the least amount of punishment that makes sense. They need to emphasize that hitting is never acceptable, but not take sides. A useful mantra for parents: “Don't try to judge who started it. You can never tell.”

Depending on the situation, both children may need to be sent to a room away from the toy to make a plan for resolution. The toy may need to be put in time out. Both kids may need to be put in time out for the same amount of time, with duration based on the younger child's age. Each child may need to take on an individual chore card, or even chores requiring the effort of both kids.

Whatever the solution, it should be brief.

Counsel parents that rivalry is part of sibling interaction: a challenge best met through prevention, structured responses, and reliance on family rules.

Remind them of the fleeting nature of sibling spats—don't they hear the kids giggling 15 minutes later?—and the permanence of warm, mutually respectful, sibling bonds through a lifetime.

www.CHADIS.com[email protected]

From Cane and Abel to Linus and Lucy, Wally and the Beaver to Bart and Lisa Simpson, sibling rivalry is the stuff of legend and comedy. But when it presents as a source of serious concern for parents during pediatric office visits, it's usually no laughing matter for them.

Research suggests that 64% of school-age siblings fight “sometimes or often”—a figure likely matched in magnitude if not muscle by younger siblings as well.

Sibling rivalry is so common, in fact, that we may tend to think back to our own sibling spats, or those of our kids, roll our eyes and offer the “they'll grow out of it” platitude.

But in truth, sibling wars can have consequences. While injuries are rare in most sibling disputes, in 25% of child abuse cases a sibling has been involved in victimization (usually in concert with adults).

Serious sibling conflict tremendously compromises quality of life for children, and for their parents as well. We know that marriages suffer in households with high levels of sibling discord, with the issue a common flashpoint for disagreements between parents about how to respond. Children exposed to serious sibling conflict in middle childhood appear to suffer higher levels of anxiety, depression, and delinquent behavior in early adolescence. Down the road, people carry the grudges of sibling difficulties for decades, undermining bonds that might otherwise be a significant source of support in our increasingly fragmented society.

So sibling struggles are worthy of our time and thoughtfulness, and addressing them productively will build trust in your relationship with parents and perhaps bring some semblance of peace to their households.

The first response to a parent's frustration over sibling quarrels should be to listen with respect. Their pain is often significant as they describe the battles unfolding among children they hold precious. Patiently listening to the details of sibling encounters also can help you sort out whether the issues they're describing fall into the normal range or may signify more serious individual or relational issues that deserve attention.

Assuming it's the former, I think it helps to remind parents of how common sibling rivalry is, and more importantly, why it occurs. Annoying as they may be, fracases actually serve a number of important biological functions. Watch any nature documentary featuring lions lounging under a tree on the savannah, and what are the cubs doing? Attacking, defending, tumbling, and biting, growling all the while.

In kids, like cubs, important social skills arise from the sibling relationship, even when the dust flies. Siblings teach each other to giggle and laugh, bait and switch, sneak and chase, parry and defend. From each other, they learn which jokes fly and which land with a thud, how to toss out an insult and absorb one tossed their way.

Siblings also learn how to pull their punches, practicing evolutionarily useful conflict skills while stopping short of inflicting serious harm.

The question remains, how does a family foster productive resilience-building sibling interactions while preserving affectionate connections and at least a modicum of household calm?

Like so many things in life, household chaos is associated with unhealthy levels of sibling conflict, according to research by psychologist Judy Dunn, the author of “Sisters and Brothers” (Cambridge: Harvard University Press, 1985), “Separate Lives: Why Siblings Are So Different” (New York: Basic Books, 1992), and “From One Child to Two” (New York: Ballantine Books, 1995).

Corporal punishment in the family makes rivalry worse as well.

Individual temperaments, the presence of a child with special needs, and family structure (children of opposite sexes) also have been found to play roles in sibling relationships, but spacing of children makes less of a difference than most people think. In general, children spaced more than 4 years apart have less conflict, but they also spend less time together and have less of an integrated relationship than closely spaced siblings do.

When looking at underlying dynamics, research points to the perception of favoritism by the parents as the main contributing factor. Importantly, the children's impressions of favoritism are not always accurate, but they are such an important driver of sibling conflict that they deserve consideration.

I suggest to parents that they make a special effort to provide roughly equal “alone” time with each child. When one child's needs really do require inordinate attention—as in the case of homework time for a child with learning disabilities—they need to be up front about that reality, and say, “If you need something special, I will be there for you, too.” Remind the child who feels slighted about exceptional times when all the focus was on them: during assembly of the science fair project, or when they learned to ride a bike, for example.

Acknowledge jealousy as a real and understandable emotion, but one that must be handled within limits and household rules.

Parents will do well to practice prevention with siblings, reinforcing cooperation in general and any specific examples of good deeds performed on behalf of each other with acknowledgment or even rewards if the rivalry is serious.

Advise parents to be sensitive to situations, like boredom, that lend themselves to sibling disputes, and to intervene with distractions. Promote cooperative projects and noncompetitive games: building a fort or puzzle, playing in the sprinkler, or making breakfast as a family, instead of games with winners and losers.

When board games are necessarily competitive, make it a practice to turn the board around every fourth move to minimize age-related inequities. Even out the teams in driveway basketball as well.

Once children are old enough to participate, family meetings are an excellent forum in which to air grievances. Again, ground rules apply; everyone gets to be heard. No interrupting. Solutions can be brainstormed and tried out, to be reviewed at the next regularly scheduled session.

A stepwise approach to dealing with actual sibling disputes also helps bring order to the chaos that feeds sibling wars. Parents may want to read the popular if optimistically titled book by Adele Faber and Irene Mazlish, “Siblings Without Rivalry” (New York: HarperCollins Publishing, 2004).

Essentially, their basic plan is to teach parents to ignore whatever can be ignored, thus avoiding a self-feeding loop of inadvertent reinforcement of the conflicts.

Situations that are a bit too much to ignore should be handled dispassionately. The parent may want to ask, “Is this a real fight or a play fight?” If it's a play fight but noisy, they might want to suggest a new venue—in the basement or outdoors.

If it's a real fight, encourage parents to simply describe the situation they see. “It looks like you both want to play with the truck, and it's hard to decide how to work it out.” Follow this with an affirming statement like, “I'm sure you can figure out a solution.”

If things are even more volatile—maybe someone has hit or pinched—parents should intervene, but in an unbiased manner and with the least amount of punishment that makes sense. They need to emphasize that hitting is never acceptable, but not take sides. A useful mantra for parents: “Don't try to judge who started it. You can never tell.”

Depending on the situation, both children may need to be sent to a room away from the toy to make a plan for resolution. The toy may need to be put in time out. Both kids may need to be put in time out for the same amount of time, with duration based on the younger child's age. Each child may need to take on an individual chore card, or even chores requiring the effort of both kids.

Whatever the solution, it should be brief.

Counsel parents that rivalry is part of sibling interaction: a challenge best met through prevention, structured responses, and reliance on family rules.

Remind them of the fleeting nature of sibling spats—don't they hear the kids giggling 15 minutes later?—and the permanence of warm, mutually respectful, sibling bonds through a lifetime.