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In praise of parents and children
The COVID-19 pandemic has changed the lives of children, teenagers, and parents worldwide. While some families are experiencing the unburdening of overly packed schedules and may be having a romantic or nostalgic “Little House on the Prairie” experience, for most it is at a minimum uncomfortable and inconvenient. For others it’s unbearable as they experience loss and feel relationship strain intensified by social distancing, seclusion, or quarantine. Some children have found respite from bullying at school, while other children have lost their only respite from being mistreated at home. Now may be as critical a time as ever for health care providers to listen carefully, empathize, validate, and proactively reach out to provide encouraging guidance and counsel, as well as express concern for families and children.
Many parents across the country are taking on an enormous, unanticipated task. Many parents have lost employment and income, while many mandatory professionals now struggle to keep up with increased work hours and work stress. Parents are trying to become multitaskers who assume the role of the music teacher, the soccer coach, the drama instructor, the friend, and of course their original role as a parent.
This seems an appropriate time to consider the work of Donald W. Winnicott, FRCP, the English pediatrician known for the concept of the “good enough parent.”1 This notion of parental competence was in part born out of a desire to defend parents against possible erosion of their confidence in following loving instincts by encroachment from professional expertise. The concept of the “good enough” parent is also related to the idea that young children who believe their parent is perfect will eventually know better. Now is a fitting time for pediatricians to buoy up imperfect but striving parents who are plenty “good enough” as they follow loving instincts to support their children during unforeseen changes associated with the pandemic.
Social distancing has led to family condensing. Many parents and children remain within the same four walls all day, every day. For many parents, the outlet of water cooler banter or yoga classes is gone. Even the commute home, with all its frustration, may have allowed decompression in the form of an audiobook, favorite music, or verbal transference of frustration onto the stranger who just cut you off. That commute might be gone too. Now, for many the good, bad, and the ugly is all happening at home. The 3-year-old may still adorably see a parent who can do no wrong, but in the end, the truth will prevail. A timely word of encouragement to parents: It’s okay to not be omnipotent. In fact, it will help children have a richer view of the world and more realistic expectations of themselves.
For children, they’ll need praise too, and the upheaval caused by the pandemic may be a fitting opportunity to make that praise more meaningful. But sports are off, the school musical is canceled, and the spelling bee is gone. The dojo is closed, the art fair is postponed, and the dance recital isn’t happening. Report cards in many schools may now transition from letter grades to pass/fail. Parents may be asking, “How on earth are we going to celebrate and praise the children?”
Research has shown us that praising the process is more valuable than praising the person.2 If Lucy participates in a soccer game and Javier gets his math results back, there are many possible approaches to praise. “You scored a goal!” or “You got an A on your math test!” is outcome- or product-focused praise. “You’re a good soccer player” or “You’re smart at math!” is person-focused praise. Instead, the most effective praise is process-focused praise: “You worked hard and ran hard even when it looked tiring” or “I noticed that you kept trying different strategies on those math problems until you figured them out.”
This may be a time when children face less comparison, less ranking, and receive less direct reward. With help, they can focus more on the process of learning and less on the outcomes of learning. They may more readily enjoy the efforts in their hobbies, not just the outcomes of their hobbies. When children receive praise for their work, effort, and actions rather than outcomes, externally validating things may be pleasantly replaced by internally validating traits. With process praise, children are more likely to feel self-confident, to set higher learning goals, and to accurately believe that intelligence is related to effort rather than a fixed trait that has been divided up among haves and have nots.3
Families currently face immense change, uncertainty, and discouragement largely unprecedented in their lifetimes. As care providers, we can look to lasting principles as we encourage parents in their provision of love. We can effectively provide praise and celebrate effort using evidence-based strategies uniquely fitted to our current circumstances. As we do this, we can provide healing of some of the less visible ailments associated with the COVID-19 pandemic.
Dr. Jackson is in the department of psychiatry at the University of Vermont, Burlington. He said he had no relevant financial disclosures. Email Dr. Jackson at [email protected].
References
1. “The Child, the Family, and the Outside World.” London: Penguin; 1973. p. 173.
2. Dev Psychol. 1999;35(3):835-47.
3. J Exp Child Psychol. 2018;173:116-35.
The COVID-19 pandemic has changed the lives of children, teenagers, and parents worldwide. While some families are experiencing the unburdening of overly packed schedules and may be having a romantic or nostalgic “Little House on the Prairie” experience, for most it is at a minimum uncomfortable and inconvenient. For others it’s unbearable as they experience loss and feel relationship strain intensified by social distancing, seclusion, or quarantine. Some children have found respite from bullying at school, while other children have lost their only respite from being mistreated at home. Now may be as critical a time as ever for health care providers to listen carefully, empathize, validate, and proactively reach out to provide encouraging guidance and counsel, as well as express concern for families and children.
Many parents across the country are taking on an enormous, unanticipated task. Many parents have lost employment and income, while many mandatory professionals now struggle to keep up with increased work hours and work stress. Parents are trying to become multitaskers who assume the role of the music teacher, the soccer coach, the drama instructor, the friend, and of course their original role as a parent.
This seems an appropriate time to consider the work of Donald W. Winnicott, FRCP, the English pediatrician known for the concept of the “good enough parent.”1 This notion of parental competence was in part born out of a desire to defend parents against possible erosion of their confidence in following loving instincts by encroachment from professional expertise. The concept of the “good enough” parent is also related to the idea that young children who believe their parent is perfect will eventually know better. Now is a fitting time for pediatricians to buoy up imperfect but striving parents who are plenty “good enough” as they follow loving instincts to support their children during unforeseen changes associated with the pandemic.
Social distancing has led to family condensing. Many parents and children remain within the same four walls all day, every day. For many parents, the outlet of water cooler banter or yoga classes is gone. Even the commute home, with all its frustration, may have allowed decompression in the form of an audiobook, favorite music, or verbal transference of frustration onto the stranger who just cut you off. That commute might be gone too. Now, for many the good, bad, and the ugly is all happening at home. The 3-year-old may still adorably see a parent who can do no wrong, but in the end, the truth will prevail. A timely word of encouragement to parents: It’s okay to not be omnipotent. In fact, it will help children have a richer view of the world and more realistic expectations of themselves.
For children, they’ll need praise too, and the upheaval caused by the pandemic may be a fitting opportunity to make that praise more meaningful. But sports are off, the school musical is canceled, and the spelling bee is gone. The dojo is closed, the art fair is postponed, and the dance recital isn’t happening. Report cards in many schools may now transition from letter grades to pass/fail. Parents may be asking, “How on earth are we going to celebrate and praise the children?”
Research has shown us that praising the process is more valuable than praising the person.2 If Lucy participates in a soccer game and Javier gets his math results back, there are many possible approaches to praise. “You scored a goal!” or “You got an A on your math test!” is outcome- or product-focused praise. “You’re a good soccer player” or “You’re smart at math!” is person-focused praise. Instead, the most effective praise is process-focused praise: “You worked hard and ran hard even when it looked tiring” or “I noticed that you kept trying different strategies on those math problems until you figured them out.”
This may be a time when children face less comparison, less ranking, and receive less direct reward. With help, they can focus more on the process of learning and less on the outcomes of learning. They may more readily enjoy the efforts in their hobbies, not just the outcomes of their hobbies. When children receive praise for their work, effort, and actions rather than outcomes, externally validating things may be pleasantly replaced by internally validating traits. With process praise, children are more likely to feel self-confident, to set higher learning goals, and to accurately believe that intelligence is related to effort rather than a fixed trait that has been divided up among haves and have nots.3
Families currently face immense change, uncertainty, and discouragement largely unprecedented in their lifetimes. As care providers, we can look to lasting principles as we encourage parents in their provision of love. We can effectively provide praise and celebrate effort using evidence-based strategies uniquely fitted to our current circumstances. As we do this, we can provide healing of some of the less visible ailments associated with the COVID-19 pandemic.
Dr. Jackson is in the department of psychiatry at the University of Vermont, Burlington. He said he had no relevant financial disclosures. Email Dr. Jackson at [email protected].
References
1. “The Child, the Family, and the Outside World.” London: Penguin; 1973. p. 173.
2. Dev Psychol. 1999;35(3):835-47.
3. J Exp Child Psychol. 2018;173:116-35.
The COVID-19 pandemic has changed the lives of children, teenagers, and parents worldwide. While some families are experiencing the unburdening of overly packed schedules and may be having a romantic or nostalgic “Little House on the Prairie” experience, for most it is at a minimum uncomfortable and inconvenient. For others it’s unbearable as they experience loss and feel relationship strain intensified by social distancing, seclusion, or quarantine. Some children have found respite from bullying at school, while other children have lost their only respite from being mistreated at home. Now may be as critical a time as ever for health care providers to listen carefully, empathize, validate, and proactively reach out to provide encouraging guidance and counsel, as well as express concern for families and children.
Many parents across the country are taking on an enormous, unanticipated task. Many parents have lost employment and income, while many mandatory professionals now struggle to keep up with increased work hours and work stress. Parents are trying to become multitaskers who assume the role of the music teacher, the soccer coach, the drama instructor, the friend, and of course their original role as a parent.
This seems an appropriate time to consider the work of Donald W. Winnicott, FRCP, the English pediatrician known for the concept of the “good enough parent.”1 This notion of parental competence was in part born out of a desire to defend parents against possible erosion of their confidence in following loving instincts by encroachment from professional expertise. The concept of the “good enough” parent is also related to the idea that young children who believe their parent is perfect will eventually know better. Now is a fitting time for pediatricians to buoy up imperfect but striving parents who are plenty “good enough” as they follow loving instincts to support their children during unforeseen changes associated with the pandemic.
Social distancing has led to family condensing. Many parents and children remain within the same four walls all day, every day. For many parents, the outlet of water cooler banter or yoga classes is gone. Even the commute home, with all its frustration, may have allowed decompression in the form of an audiobook, favorite music, or verbal transference of frustration onto the stranger who just cut you off. That commute might be gone too. Now, for many the good, bad, and the ugly is all happening at home. The 3-year-old may still adorably see a parent who can do no wrong, but in the end, the truth will prevail. A timely word of encouragement to parents: It’s okay to not be omnipotent. In fact, it will help children have a richer view of the world and more realistic expectations of themselves.
For children, they’ll need praise too, and the upheaval caused by the pandemic may be a fitting opportunity to make that praise more meaningful. But sports are off, the school musical is canceled, and the spelling bee is gone. The dojo is closed, the art fair is postponed, and the dance recital isn’t happening. Report cards in many schools may now transition from letter grades to pass/fail. Parents may be asking, “How on earth are we going to celebrate and praise the children?”
Research has shown us that praising the process is more valuable than praising the person.2 If Lucy participates in a soccer game and Javier gets his math results back, there are many possible approaches to praise. “You scored a goal!” or “You got an A on your math test!” is outcome- or product-focused praise. “You’re a good soccer player” or “You’re smart at math!” is person-focused praise. Instead, the most effective praise is process-focused praise: “You worked hard and ran hard even when it looked tiring” or “I noticed that you kept trying different strategies on those math problems until you figured them out.”
This may be a time when children face less comparison, less ranking, and receive less direct reward. With help, they can focus more on the process of learning and less on the outcomes of learning. They may more readily enjoy the efforts in their hobbies, not just the outcomes of their hobbies. When children receive praise for their work, effort, and actions rather than outcomes, externally validating things may be pleasantly replaced by internally validating traits. With process praise, children are more likely to feel self-confident, to set higher learning goals, and to accurately believe that intelligence is related to effort rather than a fixed trait that has been divided up among haves and have nots.3
Families currently face immense change, uncertainty, and discouragement largely unprecedented in their lifetimes. As care providers, we can look to lasting principles as we encourage parents in their provision of love. We can effectively provide praise and celebrate effort using evidence-based strategies uniquely fitted to our current circumstances. As we do this, we can provide healing of some of the less visible ailments associated with the COVID-19 pandemic.
Dr. Jackson is in the department of psychiatry at the University of Vermont, Burlington. He said he had no relevant financial disclosures. Email Dr. Jackson at [email protected].
References
1. “The Child, the Family, and the Outside World.” London: Penguin; 1973. p. 173.
2. Dev Psychol. 1999;35(3):835-47.
3. J Exp Child Psychol. 2018;173:116-35.
Teen e-cigarette use: A public health crisis
After 2 decades of steady decline in adolescent and young adult use of tobacco products, e-cigarettes have dramatically altered the landscape of substance use in youth. E-cigarette use among teens has been on the rise for years but the recent exponential increase is unprecedented. From 2017 to 2018, adolescent e-cigarette use had the largest year-to-year increase (78%, from 12% to 21%) of any individual substance or class of substances at any time during the past 2 decades of nationwide monitoring.1 This has appropriately caught the nation’s attention. In 2016, Surgeon General Vivek H. Murthy, MD, commissioned an extensive report about electronic cigarettes, and in 2018 Surgeon General Jerome Adams, MD, MPH, issued an advisory declaring e-cigarettes a public health crisis for adolescents.2
E-cigarettes have received attention as a possible boon to adult cigarette smokers seeking a less hazardous product. We can consider the use of tobacco products along a continuum from smoked tobacco, dual use (both smoked tobacco and electronic nicotine delivery), electronic nicotine delivery only, and finally, nonuse. For some adults, transitioning from smoked tobacco products to electronic delivery systems has been a step toward less overall harm from substance use, with a small minority of that population going on to achieve abstinence from all nicotine products.3 For youth and teens, the story has been the opposite. With the rapid rise of e-cigarettes, adolescents overwhelmingly have been moving in the wrong direction at each potential step along this continuum.4 Less than 8% of teens who use e-cigarettes indicated that smoking cessation is a factor in their use.5 An estimated 1.3 million U.S. teens now are dependent or at high risk for dependence upon nicotine because of e-cigarette use. Furthermore, these teens are at a fourfold higher risk of progression to cigarette use, compared with their peers.6
One product in particular gives us information as to why this trend has accelerated so rapidly. Juul, now the sales leader among electronic nicotine delivery systems, rose from approximately 25% to a dominant 75% of market share in just over 1 fiscal year after a social media campaign targeted toward youth and young adults. The device is shaped like an elongated flash drive, is marketed as “sleek,” “looking cool,” and being “super easy” to use. This product touts its use of nicotine salts that can deliver higher concentrations of nicotine more rapidly to mimic the experience of smoking a cigarette as closely as possible. The fruity flavors in Juul “pods” and many other devices also appeal to teens. Many youth are left misinformed, thinking they are using a relatively harmless alternative to cigarettes.
E-cigarette use in youth carries many risks. Among the physical risks is exposure to harmful chemicals (even if less numerous than smoked tobacco products) such as diacetyl (a known cause of bronchiolitis obliterans, or “popcorn lung”), formaldehyde, acrolein, benzene, and metals such as nickel, tin and lead.7 “Safer than cigarettes” is a low bar indeed. Cognitive and emotional risks of early nicotine exposure include poor focus and attention, permanent lowering of impulse control, and a higher risk of mood and anxiety disorders.
Furthermore, nicotine is a gateway drug, with a clearly understood molecular basis for how it can potentiate the effects of later used substances, especially stimulants such as cocaine.8 The gateway and priming effect is compounded for youth because of ongoing brain development and plasticity during teen years. E-cigarette use also is associated with other risk behaviors including a manyfold higher likelihood of binge drinking, having multiple sexual partners in a short period of time, and using other substances such as cannabis, cocaine, methamphetamine, and heroin or nonprescribed opioids.9 An electronic system for vaporization also presents a risk for use of other substances. In just 1 year from 2017 to 2018, marijuana “vaping” increased by more than 50% among all ages surveyed.10
Pediatric health care providers are essential educators for both teens and parents regarding the risks of e-cigarette use. Many youth don’t know what they’re using; 66% of youth reported that the vapors they were inhaling contained only flavoring. Only 13% reported they were inhaling nicotine.10 In stark contrast to these self-reports, all Juul “pods” contain nicotine. As has been a pattern with nationwide surveys of substance use for decades, adolescent use is inversely correlated with perception of risk; 70% of 8th-12th graders do not foresee great harm in regular e-cigarette use. In addition, adolescents use substances less often when they know their parents disapprove. Parents also must be taught about the risks of e-cigarette use and can be provided with resources and taught effective strategies if they have difficulty communicating their disapproval to their children.
Age-appropriate screening in primary care settings must include specific language regarding the use of electronic cigarettes, with questions about “vaping” and “juuling.” Discussions with teens may be more effective with emphasis on issues that resonate with youth such as the financial cost, loss of freedom when dependence develops, and the fact that their generation is once again being targeted by the tobacco industry. Referral for further treatment, including individual and group therapy as well as family-focused interventions, should be considered for teens who use daily, use other substances regularly, or could benefit from treatment for co-occurring mental health disorders.
Electronic cigarette use should not be recommended as a smoking cessation strategy for teens.11 Pediatric health care providers must advocate for regulation of these products, including increasing the legal age of purchase and banning flavoring in e-cigarettes products, Internet sales, and advertisements targeted to youth.
The rapid rise in e-cigarette use among teens is of great concern. As with all classes of substances, early initiation of nicotine drastically increases the risk of developing a substance use disorder and portends a prolonged course and greater accumulation of adverse consequences. There is an urgent need for education, prevention, and early identification of e-cigarette use to protect the current and future well-being of children and adolescents.
Dr. Jackson is assistant professor of psychiatry at the University of Vermont, Burlington. He said he had no relevant financial disclosures. Email Dr. Jackson at [email protected].
References
1. MMWR Morb Mortal Wkly Rep. 2018;67:1276-7.
2. e-cigarettes.surgeongeneral.gov
3. N Engl J Med 2019;380:629-37.
4. Pediatrics. 2018 Dec; 142(6):e20180486.
5. MMWR Morb Mortal Wkly Rep 2018;67:196-200.
6. JAMA Pediatr. 2017 Aug 1;171(8):788-97.
7. “Public health consequences of e-cigarettes” (Washington, DC: National Academies Press, January 2018).
8. N Engl J Med 2014;371:932-43.
9. N Engl J Med 2019;380:689-90.
10. MMWR Morb Mortal Wkly Rep. 2016 Jan 8;64(52):1403-8.
11. Pediatrics. 2019 Feb;143(2). pii: e20183652.
After 2 decades of steady decline in adolescent and young adult use of tobacco products, e-cigarettes have dramatically altered the landscape of substance use in youth. E-cigarette use among teens has been on the rise for years but the recent exponential increase is unprecedented. From 2017 to 2018, adolescent e-cigarette use had the largest year-to-year increase (78%, from 12% to 21%) of any individual substance or class of substances at any time during the past 2 decades of nationwide monitoring.1 This has appropriately caught the nation’s attention. In 2016, Surgeon General Vivek H. Murthy, MD, commissioned an extensive report about electronic cigarettes, and in 2018 Surgeon General Jerome Adams, MD, MPH, issued an advisory declaring e-cigarettes a public health crisis for adolescents.2
E-cigarettes have received attention as a possible boon to adult cigarette smokers seeking a less hazardous product. We can consider the use of tobacco products along a continuum from smoked tobacco, dual use (both smoked tobacco and electronic nicotine delivery), electronic nicotine delivery only, and finally, nonuse. For some adults, transitioning from smoked tobacco products to electronic delivery systems has been a step toward less overall harm from substance use, with a small minority of that population going on to achieve abstinence from all nicotine products.3 For youth and teens, the story has been the opposite. With the rapid rise of e-cigarettes, adolescents overwhelmingly have been moving in the wrong direction at each potential step along this continuum.4 Less than 8% of teens who use e-cigarettes indicated that smoking cessation is a factor in their use.5 An estimated 1.3 million U.S. teens now are dependent or at high risk for dependence upon nicotine because of e-cigarette use. Furthermore, these teens are at a fourfold higher risk of progression to cigarette use, compared with their peers.6
One product in particular gives us information as to why this trend has accelerated so rapidly. Juul, now the sales leader among electronic nicotine delivery systems, rose from approximately 25% to a dominant 75% of market share in just over 1 fiscal year after a social media campaign targeted toward youth and young adults. The device is shaped like an elongated flash drive, is marketed as “sleek,” “looking cool,” and being “super easy” to use. This product touts its use of nicotine salts that can deliver higher concentrations of nicotine more rapidly to mimic the experience of smoking a cigarette as closely as possible. The fruity flavors in Juul “pods” and many other devices also appeal to teens. Many youth are left misinformed, thinking they are using a relatively harmless alternative to cigarettes.
E-cigarette use in youth carries many risks. Among the physical risks is exposure to harmful chemicals (even if less numerous than smoked tobacco products) such as diacetyl (a known cause of bronchiolitis obliterans, or “popcorn lung”), formaldehyde, acrolein, benzene, and metals such as nickel, tin and lead.7 “Safer than cigarettes” is a low bar indeed. Cognitive and emotional risks of early nicotine exposure include poor focus and attention, permanent lowering of impulse control, and a higher risk of mood and anxiety disorders.
Furthermore, nicotine is a gateway drug, with a clearly understood molecular basis for how it can potentiate the effects of later used substances, especially stimulants such as cocaine.8 The gateway and priming effect is compounded for youth because of ongoing brain development and plasticity during teen years. E-cigarette use also is associated with other risk behaviors including a manyfold higher likelihood of binge drinking, having multiple sexual partners in a short period of time, and using other substances such as cannabis, cocaine, methamphetamine, and heroin or nonprescribed opioids.9 An electronic system for vaporization also presents a risk for use of other substances. In just 1 year from 2017 to 2018, marijuana “vaping” increased by more than 50% among all ages surveyed.10
Pediatric health care providers are essential educators for both teens and parents regarding the risks of e-cigarette use. Many youth don’t know what they’re using; 66% of youth reported that the vapors they were inhaling contained only flavoring. Only 13% reported they were inhaling nicotine.10 In stark contrast to these self-reports, all Juul “pods” contain nicotine. As has been a pattern with nationwide surveys of substance use for decades, adolescent use is inversely correlated with perception of risk; 70% of 8th-12th graders do not foresee great harm in regular e-cigarette use. In addition, adolescents use substances less often when they know their parents disapprove. Parents also must be taught about the risks of e-cigarette use and can be provided with resources and taught effective strategies if they have difficulty communicating their disapproval to their children.
Age-appropriate screening in primary care settings must include specific language regarding the use of electronic cigarettes, with questions about “vaping” and “juuling.” Discussions with teens may be more effective with emphasis on issues that resonate with youth such as the financial cost, loss of freedom when dependence develops, and the fact that their generation is once again being targeted by the tobacco industry. Referral for further treatment, including individual and group therapy as well as family-focused interventions, should be considered for teens who use daily, use other substances regularly, or could benefit from treatment for co-occurring mental health disorders.
Electronic cigarette use should not be recommended as a smoking cessation strategy for teens.11 Pediatric health care providers must advocate for regulation of these products, including increasing the legal age of purchase and banning flavoring in e-cigarettes products, Internet sales, and advertisements targeted to youth.
The rapid rise in e-cigarette use among teens is of great concern. As with all classes of substances, early initiation of nicotine drastically increases the risk of developing a substance use disorder and portends a prolonged course and greater accumulation of adverse consequences. There is an urgent need for education, prevention, and early identification of e-cigarette use to protect the current and future well-being of children and adolescents.
Dr. Jackson is assistant professor of psychiatry at the University of Vermont, Burlington. He said he had no relevant financial disclosures. Email Dr. Jackson at [email protected].
References
1. MMWR Morb Mortal Wkly Rep. 2018;67:1276-7.
2. e-cigarettes.surgeongeneral.gov
3. N Engl J Med 2019;380:629-37.
4. Pediatrics. 2018 Dec; 142(6):e20180486.
5. MMWR Morb Mortal Wkly Rep 2018;67:196-200.
6. JAMA Pediatr. 2017 Aug 1;171(8):788-97.
7. “Public health consequences of e-cigarettes” (Washington, DC: National Academies Press, January 2018).
8. N Engl J Med 2014;371:932-43.
9. N Engl J Med 2019;380:689-90.
10. MMWR Morb Mortal Wkly Rep. 2016 Jan 8;64(52):1403-8.
11. Pediatrics. 2019 Feb;143(2). pii: e20183652.
After 2 decades of steady decline in adolescent and young adult use of tobacco products, e-cigarettes have dramatically altered the landscape of substance use in youth. E-cigarette use among teens has been on the rise for years but the recent exponential increase is unprecedented. From 2017 to 2018, adolescent e-cigarette use had the largest year-to-year increase (78%, from 12% to 21%) of any individual substance or class of substances at any time during the past 2 decades of nationwide monitoring.1 This has appropriately caught the nation’s attention. In 2016, Surgeon General Vivek H. Murthy, MD, commissioned an extensive report about electronic cigarettes, and in 2018 Surgeon General Jerome Adams, MD, MPH, issued an advisory declaring e-cigarettes a public health crisis for adolescents.2
E-cigarettes have received attention as a possible boon to adult cigarette smokers seeking a less hazardous product. We can consider the use of tobacco products along a continuum from smoked tobacco, dual use (both smoked tobacco and electronic nicotine delivery), electronic nicotine delivery only, and finally, nonuse. For some adults, transitioning from smoked tobacco products to electronic delivery systems has been a step toward less overall harm from substance use, with a small minority of that population going on to achieve abstinence from all nicotine products.3 For youth and teens, the story has been the opposite. With the rapid rise of e-cigarettes, adolescents overwhelmingly have been moving in the wrong direction at each potential step along this continuum.4 Less than 8% of teens who use e-cigarettes indicated that smoking cessation is a factor in their use.5 An estimated 1.3 million U.S. teens now are dependent or at high risk for dependence upon nicotine because of e-cigarette use. Furthermore, these teens are at a fourfold higher risk of progression to cigarette use, compared with their peers.6
One product in particular gives us information as to why this trend has accelerated so rapidly. Juul, now the sales leader among electronic nicotine delivery systems, rose from approximately 25% to a dominant 75% of market share in just over 1 fiscal year after a social media campaign targeted toward youth and young adults. The device is shaped like an elongated flash drive, is marketed as “sleek,” “looking cool,” and being “super easy” to use. This product touts its use of nicotine salts that can deliver higher concentrations of nicotine more rapidly to mimic the experience of smoking a cigarette as closely as possible. The fruity flavors in Juul “pods” and many other devices also appeal to teens. Many youth are left misinformed, thinking they are using a relatively harmless alternative to cigarettes.
E-cigarette use in youth carries many risks. Among the physical risks is exposure to harmful chemicals (even if less numerous than smoked tobacco products) such as diacetyl (a known cause of bronchiolitis obliterans, or “popcorn lung”), formaldehyde, acrolein, benzene, and metals such as nickel, tin and lead.7 “Safer than cigarettes” is a low bar indeed. Cognitive and emotional risks of early nicotine exposure include poor focus and attention, permanent lowering of impulse control, and a higher risk of mood and anxiety disorders.
Furthermore, nicotine is a gateway drug, with a clearly understood molecular basis for how it can potentiate the effects of later used substances, especially stimulants such as cocaine.8 The gateway and priming effect is compounded for youth because of ongoing brain development and plasticity during teen years. E-cigarette use also is associated with other risk behaviors including a manyfold higher likelihood of binge drinking, having multiple sexual partners in a short period of time, and using other substances such as cannabis, cocaine, methamphetamine, and heroin or nonprescribed opioids.9 An electronic system for vaporization also presents a risk for use of other substances. In just 1 year from 2017 to 2018, marijuana “vaping” increased by more than 50% among all ages surveyed.10
Pediatric health care providers are essential educators for both teens and parents regarding the risks of e-cigarette use. Many youth don’t know what they’re using; 66% of youth reported that the vapors they were inhaling contained only flavoring. Only 13% reported they were inhaling nicotine.10 In stark contrast to these self-reports, all Juul “pods” contain nicotine. As has been a pattern with nationwide surveys of substance use for decades, adolescent use is inversely correlated with perception of risk; 70% of 8th-12th graders do not foresee great harm in regular e-cigarette use. In addition, adolescents use substances less often when they know their parents disapprove. Parents also must be taught about the risks of e-cigarette use and can be provided with resources and taught effective strategies if they have difficulty communicating their disapproval to their children.
Age-appropriate screening in primary care settings must include specific language regarding the use of electronic cigarettes, with questions about “vaping” and “juuling.” Discussions with teens may be more effective with emphasis on issues that resonate with youth such as the financial cost, loss of freedom when dependence develops, and the fact that their generation is once again being targeted by the tobacco industry. Referral for further treatment, including individual and group therapy as well as family-focused interventions, should be considered for teens who use daily, use other substances regularly, or could benefit from treatment for co-occurring mental health disorders.
Electronic cigarette use should not be recommended as a smoking cessation strategy for teens.11 Pediatric health care providers must advocate for regulation of these products, including increasing the legal age of purchase and banning flavoring in e-cigarettes products, Internet sales, and advertisements targeted to youth.
The rapid rise in e-cigarette use among teens is of great concern. As with all classes of substances, early initiation of nicotine drastically increases the risk of developing a substance use disorder and portends a prolonged course and greater accumulation of adverse consequences. There is an urgent need for education, prevention, and early identification of e-cigarette use to protect the current and future well-being of children and adolescents.
Dr. Jackson is assistant professor of psychiatry at the University of Vermont, Burlington. He said he had no relevant financial disclosures. Email Dr. Jackson at [email protected].
References
1. MMWR Morb Mortal Wkly Rep. 2018;67:1276-7.
2. e-cigarettes.surgeongeneral.gov
3. N Engl J Med 2019;380:629-37.
4. Pediatrics. 2018 Dec; 142(6):e20180486.
5. MMWR Morb Mortal Wkly Rep 2018;67:196-200.
6. JAMA Pediatr. 2017 Aug 1;171(8):788-97.
7. “Public health consequences of e-cigarettes” (Washington, DC: National Academies Press, January 2018).
8. N Engl J Med 2014;371:932-43.
9. N Engl J Med 2019;380:689-90.
10. MMWR Morb Mortal Wkly Rep. 2016 Jan 8;64(52):1403-8.
11. Pediatrics. 2019 Feb;143(2). pii: e20183652.
‘You’re not going to tell my parents about this are you?’
You are on the front lines of the prevention, screening, and treatment decisions for adolescent substance use disorders. You often must choose whether to disclose information about substance use to parents and other concerned adults.
The risk of developing a substance use disorder increases dramatically the earlier an individual begins using a given substance.1 The neurobiology behind this risk is becoming increasingly clear. Young brains are undergoing crucial developmental processes, including synaptic pruning and myelination. The brain increasingly becomes more efficient in a staggered pattern, with limbic regions preceding frontal and executive regions, so we see adolescents with “more gas than brakes.” This has wisely been identified as developmentally appropriate, and even beneficial, rather than evidence that adolescents are somehow broken.2
Age-appropriate screening for substance use should occur as early as the preteen years and continue throughout adolescence. The most widely studied screening tools include the CRAFFT screening instrument and the Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach.3,4 During formal and informal screening, you should lead with genuine concern for the well-being of the adolescent. Beginning a discussion with open-ended questions about substance use in the school and home is a way to build understanding of an adolescent’s environment prior to asking about personal use. While screening, consider well known risk factors including family history of substance use disorders, poor parental supervision, childhood maltreatment or abuse, low academic achievement, and untreated psychiatric disorders such as ADHD, depression, or anxiety, which may contribute to a higher likelihood or more rapid progression of a substance use disorder. Adolescents are more likely to disclose substance use when screening is done in private, rather than in the presence of a parent.5
Discussing the limits of confidentiality (generally when there is substantial risk of harm to self or others) with an adolescent shows respect and can be an expression of genuine care and concern. Once substance use or other risk-associated behaviors and choices are disclosed, you often may be asked not to share the information with parents. In some instances, privacy cannot be broken without consent. Be aware of your state laws governing parental and adolescent rights related to confidentiality.
You should strongly consider discussing substance use with the concerned adults when there are these red flags: daily use of any substance, any intravenous substance use, a score of 2 or higher on the CRAFFT, prescription medication misuse, or any change in medical status resulting from substance use, such as alcohol-related blackouts.
In most cases, adolescents should be informed of a decision to disclose substance use to their parents. Inviting adolescents to discuss how this will be done, including if the adolescent will be present, and whether you or the adolescent will disclose the use can be an opportunity to discuss their concerns. You should seek to understand if an adolescent has specific fears related to such a disclosure including careful consideration of any history of domestic violence or abuse.
Although adolescents increasingly identify with the opinions and values of their peers, it is a mistake to assume that they therefore do not value the opinions of their parents and the concerned adults in their lives. Parents play an integral role in preventing and treating adolescent substance use disorders. Except in rare instances of severe parent-child relationship problems or abuse, parents can and should be engaged as invaluable participants
Being aware of the legal and ethical obligations in treatment of adolescents presenting with any level of substance use, you can improve outcomes by thoughtfully inviting the participation of parents and other concerned adults into the prevention, screening, and treatment of adolescent substance use disorders.
Dr. Jackson is a child and adolescent psychiatrist at the University of Vermont, Burlington.
References
1. “Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings.” NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. (Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013).
2. “The Amazing Teen Brain,” Jay N. Geidd, Scientific American, May 2016.
3. Pediatrics 2011 Oct. doi: 10.1542/peds.2011-1754.
4. Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide.
5. Pediatrics. 2016 Jul 1. doi: 10.1542/peds.2016-1211.
6. J Fam Commun. 2014 Jan 1:14(4):328-51.
7. J Clin Child Adolesc. Psychol. 2008;37(1):236-59.
8. J Child Adolesc Subst Abuse. 2015 May 4;24(3):155-65.
9. Arch Pediatr Adolesc Med. 2012;166(12):1132-9.
You are on the front lines of the prevention, screening, and treatment decisions for adolescent substance use disorders. You often must choose whether to disclose information about substance use to parents and other concerned adults.
The risk of developing a substance use disorder increases dramatically the earlier an individual begins using a given substance.1 The neurobiology behind this risk is becoming increasingly clear. Young brains are undergoing crucial developmental processes, including synaptic pruning and myelination. The brain increasingly becomes more efficient in a staggered pattern, with limbic regions preceding frontal and executive regions, so we see adolescents with “more gas than brakes.” This has wisely been identified as developmentally appropriate, and even beneficial, rather than evidence that adolescents are somehow broken.2
Age-appropriate screening for substance use should occur as early as the preteen years and continue throughout adolescence. The most widely studied screening tools include the CRAFFT screening instrument and the Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach.3,4 During formal and informal screening, you should lead with genuine concern for the well-being of the adolescent. Beginning a discussion with open-ended questions about substance use in the school and home is a way to build understanding of an adolescent’s environment prior to asking about personal use. While screening, consider well known risk factors including family history of substance use disorders, poor parental supervision, childhood maltreatment or abuse, low academic achievement, and untreated psychiatric disorders such as ADHD, depression, or anxiety, which may contribute to a higher likelihood or more rapid progression of a substance use disorder. Adolescents are more likely to disclose substance use when screening is done in private, rather than in the presence of a parent.5
Discussing the limits of confidentiality (generally when there is substantial risk of harm to self or others) with an adolescent shows respect and can be an expression of genuine care and concern. Once substance use or other risk-associated behaviors and choices are disclosed, you often may be asked not to share the information with parents. In some instances, privacy cannot be broken without consent. Be aware of your state laws governing parental and adolescent rights related to confidentiality.
You should strongly consider discussing substance use with the concerned adults when there are these red flags: daily use of any substance, any intravenous substance use, a score of 2 or higher on the CRAFFT, prescription medication misuse, or any change in medical status resulting from substance use, such as alcohol-related blackouts.
In most cases, adolescents should be informed of a decision to disclose substance use to their parents. Inviting adolescents to discuss how this will be done, including if the adolescent will be present, and whether you or the adolescent will disclose the use can be an opportunity to discuss their concerns. You should seek to understand if an adolescent has specific fears related to such a disclosure including careful consideration of any history of domestic violence or abuse.
Although adolescents increasingly identify with the opinions and values of their peers, it is a mistake to assume that they therefore do not value the opinions of their parents and the concerned adults in their lives. Parents play an integral role in preventing and treating adolescent substance use disorders. Except in rare instances of severe parent-child relationship problems or abuse, parents can and should be engaged as invaluable participants
Being aware of the legal and ethical obligations in treatment of adolescents presenting with any level of substance use, you can improve outcomes by thoughtfully inviting the participation of parents and other concerned adults into the prevention, screening, and treatment of adolescent substance use disorders.
Dr. Jackson is a child and adolescent psychiatrist at the University of Vermont, Burlington.
References
1. “Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings.” NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. (Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013).
2. “The Amazing Teen Brain,” Jay N. Geidd, Scientific American, May 2016.
3. Pediatrics 2011 Oct. doi: 10.1542/peds.2011-1754.
4. Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide.
5. Pediatrics. 2016 Jul 1. doi: 10.1542/peds.2016-1211.
6. J Fam Commun. 2014 Jan 1:14(4):328-51.
7. J Clin Child Adolesc. Psychol. 2008;37(1):236-59.
8. J Child Adolesc Subst Abuse. 2015 May 4;24(3):155-65.
9. Arch Pediatr Adolesc Med. 2012;166(12):1132-9.
You are on the front lines of the prevention, screening, and treatment decisions for adolescent substance use disorders. You often must choose whether to disclose information about substance use to parents and other concerned adults.
The risk of developing a substance use disorder increases dramatically the earlier an individual begins using a given substance.1 The neurobiology behind this risk is becoming increasingly clear. Young brains are undergoing crucial developmental processes, including synaptic pruning and myelination. The brain increasingly becomes more efficient in a staggered pattern, with limbic regions preceding frontal and executive regions, so we see adolescents with “more gas than brakes.” This has wisely been identified as developmentally appropriate, and even beneficial, rather than evidence that adolescents are somehow broken.2
Age-appropriate screening for substance use should occur as early as the preteen years and continue throughout adolescence. The most widely studied screening tools include the CRAFFT screening instrument and the Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach.3,4 During formal and informal screening, you should lead with genuine concern for the well-being of the adolescent. Beginning a discussion with open-ended questions about substance use in the school and home is a way to build understanding of an adolescent’s environment prior to asking about personal use. While screening, consider well known risk factors including family history of substance use disorders, poor parental supervision, childhood maltreatment or abuse, low academic achievement, and untreated psychiatric disorders such as ADHD, depression, or anxiety, which may contribute to a higher likelihood or more rapid progression of a substance use disorder. Adolescents are more likely to disclose substance use when screening is done in private, rather than in the presence of a parent.5
Discussing the limits of confidentiality (generally when there is substantial risk of harm to self or others) with an adolescent shows respect and can be an expression of genuine care and concern. Once substance use or other risk-associated behaviors and choices are disclosed, you often may be asked not to share the information with parents. In some instances, privacy cannot be broken without consent. Be aware of your state laws governing parental and adolescent rights related to confidentiality.
You should strongly consider discussing substance use with the concerned adults when there are these red flags: daily use of any substance, any intravenous substance use, a score of 2 or higher on the CRAFFT, prescription medication misuse, or any change in medical status resulting from substance use, such as alcohol-related blackouts.
In most cases, adolescents should be informed of a decision to disclose substance use to their parents. Inviting adolescents to discuss how this will be done, including if the adolescent will be present, and whether you or the adolescent will disclose the use can be an opportunity to discuss their concerns. You should seek to understand if an adolescent has specific fears related to such a disclosure including careful consideration of any history of domestic violence or abuse.
Although adolescents increasingly identify with the opinions and values of their peers, it is a mistake to assume that they therefore do not value the opinions of their parents and the concerned adults in their lives. Parents play an integral role in preventing and treating adolescent substance use disorders. Except in rare instances of severe parent-child relationship problems or abuse, parents can and should be engaged as invaluable participants
Being aware of the legal and ethical obligations in treatment of adolescents presenting with any level of substance use, you can improve outcomes by thoughtfully inviting the participation of parents and other concerned adults into the prevention, screening, and treatment of adolescent substance use disorders.
Dr. Jackson is a child and adolescent psychiatrist at the University of Vermont, Burlington.
References
1. “Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings.” NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. (Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013).
2. “The Amazing Teen Brain,” Jay N. Geidd, Scientific American, May 2016.
3. Pediatrics 2011 Oct. doi: 10.1542/peds.2011-1754.
4. Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide.
5. Pediatrics. 2016 Jul 1. doi: 10.1542/peds.2016-1211.
6. J Fam Commun. 2014 Jan 1:14(4):328-51.
7. J Clin Child Adolesc. Psychol. 2008;37(1):236-59.
8. J Child Adolesc Subst Abuse. 2015 May 4;24(3):155-65.
9. Arch Pediatr Adolesc Med. 2012;166(12):1132-9.