Behavioral Consult

Fear is an intrinsic reaction evolved to protect us from harm. Unsurprisingly, anxiety disorders are common, affecting as many as 25% of children. On average, children have 2-14 fears typical for thinking at their age, from separation (1 year), animals (6 years), environment (dark or storms), medical intrusions or injury (9 years) to social disgrace (16 years). But about one-fifth of children with typical fear topics qualify as having a disorder; that is, they have impairment in functioning.

I wonder daily in my care of anxious children: Is this amount of fear really inevitable? Are there things we can do to avoid this burden on children?

For everyone, genetics predispose fear of things that are dangerous, such as snakes. (Tell me that they don’t make you startle!) Genetic influences account for about 50% of the variance in significant fearfulness as evidenced by parent-child patterns, and the fact that monozygotic twins are more highly concordant in fearfulness than dizygotic. Not much we can do about that!

So, if evolution armed humans with fear for protection, how is it that everyone is not impaired?

In combination with genetic vulnerabilities, fears are learned in three ways: experiential conditioning, modeling, and threat information transmission. These frequently co-occur because bad things happen, genetically anxious parents show a fear reaction, and the same parents warn their children frequently and expressively about potential dangers.

As for avoiding fear conditioning, all parents want to protect their children from scary experiences, but it is not always possible. Car crashes and other bad things happen. Even viewing events that threaten injury or death, such as 9/11, can be sufficient to induce post-traumatic stress disorder (18% of children in New York City). The closer and more severe a scary event is, the more it injures or has potential to injure the child or the child’s loved ones; the more expressive the family members are and the more it is repeated (abuse, for example), the greater the likelihood of it lasting and having impairing effects.

Conditioned fears from real experiences are not entirely random. Low-income children are more likely to experience frightening events from rat bites to house fires to domestic violence to gunshots. Asking about environmental factors or using screening tools such as Safe Environment for Every Kid to evaluate the home environment, and referring families for assistance are steps relevant to every child, but especially anxious ones.

You and I need to continue to advocate for safer communities for all children. In the meantime, it is important to know that encouraging a child to describe in detail to a caring adult – verbally and/or by drawing – traumas they experienced is significantly therapeutic. It might not seem intuitive to parents to promote “reliving the experience,” especially because they may have been traumatized themselves. So providing this opportunity ourselves or through a friend, teacher, or counselor who can calmly answer questions and put the event in perspective, is important advice.

But even simply viewing disasters, violence, or artificial frightening events on television or film can produce lasting fears. While inherently anxious children are more vulnerable to fears induced by media, 90% of undergraduates report at least one enduring fear that started this way, and 26% report persistence to the present. At least one-third of youth have fear reactions to media. Simply the number of hours watching television is associated with a child’s increased perception of personal vulnerability. While 8- to 10-year-olds had reduced fear when parents explained news events, more realistic and serious coverage (the Iraq War, for example) and older age predicted more severe fear reactions not similarly reassured. With this high prevalence of anxiety, I encourage parents to avoid media whose content is not known to them for all children, but especially for those already anxious or traumatized. It amazes me how many families of anxious children have the Weather Channel on constantly, showing devastation all over the world, oblivious that the child is internalizing the risk as though it was outside their window! When media trauma exposure can’t be avoided, parents need to show calm and provide explanation to the child to put it in perspective, as we saw the father do on TV after the Paris massacre.

Modeling of fearful reactions is the second powerful influence on the development of fears. How caregivers react when they encounter a situation such as an approaching dog is quickly modeled by the child. This vicarious learning by watching others’ reactions evolved as preferable to having to chance it yourself. Mothers’ voices and actions are especially salient to children, compared with fathers’ voices and actions. Unfortunately, females tend to be both more fearful and more expressive of fear than males. Some approaches you can suggest regarding modeling include coaching parents (sometimes even sitters) to dampen or mask their reactions, provide other adults without a similar fear to model for the child, or at least not tell the child why they are walking a different route to avoid a dog!

How information about threats is transmitted is the third and perhaps most modifiable influence on a child’s development of fears. Parents talk to children constantly, and a lot of it is warnings! This too may be genetic/cultural as evidenced by the 41% of nursery rhymes across cultures that include violence! Children who have been told potentially bad things about an animal, person, or event show a stronger fear response as measured by self-report, physiological reaction, and behavioral avoidance than when not primed. Conversely, children told positive things react with less fear immediately and are less likely to learn a fear response at later exposures. Once fear has been promoted by negative information, the child’s actual ways of thinking (cognitive biases) are shifted. Attention to forewarned stimuli is increased, the use of reasoning is limited to verifying that fear was warranted rather than alternatively looking for evidence against it, and over estimation of the likelihood of bad outcomes occurs. Children with an overly aroused brain behavioral inhibition system (inherent tendency to react to novelty with physiological arousal and fear) are more influenced by negative verbal information to have fear, cognitive distortions, and avoidance.¹

Not surprisingly, anxious parents give more negative information, particularly about ambiguous situations, than other parents. Children living in homes with more negative interactions with fathers or more punitive or neglectful mothers also are more susceptible to increased fears from verbal threat information. Unfortunately, parents generally do not perceive their own role in transmitting threat information. In contrast, one-quarter to one-third of children with significant fears relate onset or intensification of their fears to things they heard. While possibly not relevant for innate fears such as of spiders, this is important information for prevention of fears in general. A child’s development of excessive fear can be somewhat dampened by adult verbal explanations, a focus on the positives, and reassurance, especially if this is done routinely.

The “30 Million Word Gap”² in total word exposure before age 3 years of children in families on welfare vs. professionals found that higher-income parents provided far more words of praise and six encouragements for every discouragement vs. more total negative vocabulary and two discouragements for every encouragement. The same children more likely to be exposed to trauma also may have less positive preparation to reduce their development of significant fears with the associated stress effects. You and I see this during visits – take the opportunity to discuss and model an alternative.

References

1. Clin Child Fam Psychol Rev. 2010 Jun;13(2):129-50.

2. “The Early Catastrophe: The 30 Million Word Gap by Age 3” (Washington: American Educator, Spring 2003).

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at [email protected].

Fear is an intrinsic reaction evolved to protect us from harm. Unsurprisingly, anxiety disorders are common, affecting as many as 25% of children. On average, children have 2-14 fears typical for thinking at their age, from separation (1 year), animals (6 years), environment (dark or storms), medical intrusions or injury (9 years) to social disgrace (16 years). But about one-fifth of children with typical fear topics qualify as having a disorder; that is, they have impairment in functioning.

I wonder daily in my care of anxious children: Is this amount of fear really inevitable? Are there things we can do to avoid this burden on children?

For everyone, genetics predispose fear of things that are dangerous, such as snakes. (Tell me that they don’t make you startle!) Genetic influences account for about 50% of the variance in significant fearfulness as evidenced by parent-child patterns, and the fact that monozygotic twins are more highly concordant in fearfulness than dizygotic. Not much we can do about that!

So, if evolution armed humans with fear for protection, how is it that everyone is not impaired?

In combination with genetic vulnerabilities, fears are learned in three ways: experiential conditioning, modeling, and threat information transmission. These frequently co-occur because bad things happen, genetically anxious parents show a fear reaction, and the same parents warn their children frequently and expressively about potential dangers.

As for avoiding fear conditioning, all parents want to protect their children from scary experiences, but it is not always possible. Car crashes and other bad things happen. Even viewing events that threaten injury or death, such as 9/11, can be sufficient to induce post-traumatic stress disorder (18% of children in New York City). The closer and more severe a scary event is, the more it injures or has potential to injure the child or the child’s loved ones; the more expressive the family members are and the more it is repeated (abuse, for example), the greater the likelihood of it lasting and having impairing effects.

Conditioned fears from real experiences are not entirely random. Low-income children are more likely to experience frightening events from rat bites to house fires to domestic violence to gunshots. Asking about environmental factors or using screening tools such as Safe Environment for Every Kid to evaluate the home environment, and referring families for assistance are steps relevant to every child, but especially anxious ones.

You and I need to continue to advocate for safer communities for all children. In the meantime, it is important to know that encouraging a child to describe in detail to a caring adult – verbally and/or by drawing – traumas they experienced is significantly therapeutic. It might not seem intuitive to parents to promote “reliving the experience,” especially because they may have been traumatized themselves. So providing this opportunity ourselves or through a friend, teacher, or counselor who can calmly answer questions and put the event in perspective, is important advice.

But even simply viewing disasters, violence, or artificial frightening events on television or film can produce lasting fears. While inherently anxious children are more vulnerable to fears induced by media, 90% of undergraduates report at least one enduring fear that started this way, and 26% report persistence to the present. At least one-third of youth have fear reactions to media. Simply the number of hours watching television is associated with a child’s increased perception of personal vulnerability. While 8- to 10-year-olds had reduced fear when parents explained news events, more realistic and serious coverage (the Iraq War, for example) and older age predicted more severe fear reactions not similarly reassured. With this high prevalence of anxiety, I encourage parents to avoid media whose content is not known to them for all children, but especially for those already anxious or traumatized. It amazes me how many families of anxious children have the Weather Channel on constantly, showing devastation all over the world, oblivious that the child is internalizing the risk as though it was outside their window! When media trauma exposure can’t be avoided, parents need to show calm and provide explanation to the child to put it in perspective, as we saw the father do on TV after the Paris massacre.

Modeling of fearful reactions is the second powerful influence on the development of fears. How caregivers react when they encounter a situation such as an approaching dog is quickly modeled by the child. This vicarious learning by watching others’ reactions evolved as preferable to having to chance it yourself. Mothers’ voices and actions are especially salient to children, compared with fathers’ voices and actions. Unfortunately, females tend to be both more fearful and more expressive of fear than males. Some approaches you can suggest regarding modeling include coaching parents (sometimes even sitters) to dampen or mask their reactions, provide other adults without a similar fear to model for the child, or at least not tell the child why they are walking a different route to avoid a dog!

How information about threats is transmitted is the third and perhaps most modifiable influence on a child’s development of fears. Parents talk to children constantly, and a lot of it is warnings! This too may be genetic/cultural as evidenced by the 41% of nursery rhymes across cultures that include violence! Children who have been told potentially bad things about an animal, person, or event show a stronger fear response as measured by self-report, physiological reaction, and behavioral avoidance than when not primed. Conversely, children told positive things react with less fear immediately and are less likely to learn a fear response at later exposures. Once fear has been promoted by negative information, the child’s actual ways of thinking (cognitive biases) are shifted. Attention to forewarned stimuli is increased, the use of reasoning is limited to verifying that fear was warranted rather than alternatively looking for evidence against it, and over estimation of the likelihood of bad outcomes occurs. Children with an overly aroused brain behavioral inhibition system (inherent tendency to react to novelty with physiological arousal and fear) are more influenced by negative verbal information to have fear, cognitive distortions, and avoidance.¹

Not surprisingly, anxious parents give more negative information, particularly about ambiguous situations, than other parents. Children living in homes with more negative interactions with fathers or more punitive or neglectful mothers also are more susceptible to increased fears from verbal threat information. Unfortunately, parents generally do not perceive their own role in transmitting threat information. In contrast, one-quarter to one-third of children with significant fears relate onset or intensification of their fears to things they heard. While possibly not relevant for innate fears such as of spiders, this is important information for prevention of fears in general. A child’s development of excessive fear can be somewhat dampened by adult verbal explanations, a focus on the positives, and reassurance, especially if this is done routinely.

The “30 Million Word Gap”² in total word exposure before age 3 years of children in families on welfare vs. professionals found that higher-income parents provided far more words of praise and six encouragements for every discouragement vs. more total negative vocabulary and two discouragements for every encouragement. The same children more likely to be exposed to trauma also may have less positive preparation to reduce their development of significant fears with the associated stress effects. You and I see this during visits – take the opportunity to discuss and model an alternative.

References

1. Clin Child Fam Psychol Rev. 2010 Jun;13(2):129-50.

2. “The Early Catastrophe: The 30 Million Word Gap by Age 3” (Washington: American Educator, Spring 2003).

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at [email protected].

Fear is an intrinsic reaction evolved to protect us from harm. Unsurprisingly, anxiety disorders are common, affecting as many as 25% of children. On average, children have 2-14 fears typical for thinking at their age, from separation (1 year), animals (6 years), environment (dark or storms), medical intrusions or injury (9 years) to social disgrace (16 years). But about one-fifth of children with typical fear topics qualify as having a disorder; that is, they have impairment in functioning.

I wonder daily in my care of anxious children: Is this amount of fear really inevitable? Are there things we can do to avoid this burden on children?

For everyone, genetics predispose fear of things that are dangerous, such as snakes. (Tell me that they don’t make you startle!) Genetic influences account for about 50% of the variance in significant fearfulness as evidenced by parent-child patterns, and the fact that monozygotic twins are more highly concordant in fearfulness than dizygotic. Not much we can do about that!

So, if evolution armed humans with fear for protection, how is it that everyone is not impaired?

In combination with genetic vulnerabilities, fears are learned in three ways: experiential conditioning, modeling, and threat information transmission. These frequently co-occur because bad things happen, genetically anxious parents show a fear reaction, and the same parents warn their children frequently and expressively about potential dangers.

As for avoiding fear conditioning, all parents want to protect their children from scary experiences, but it is not always possible. Car crashes and other bad things happen. Even viewing events that threaten injury or death, such as 9/11, can be sufficient to induce post-traumatic stress disorder (18% of children in New York City). The closer and more severe a scary event is, the more it injures or has potential to injure the child or the child’s loved ones; the more expressive the family members are and the more it is repeated (abuse, for example), the greater the likelihood of it lasting and having impairing effects.

Conditioned fears from real experiences are not entirely random. Low-income children are more likely to experience frightening events from rat bites to house fires to domestic violence to gunshots. Asking about environmental factors or using screening tools such as Safe Environment for Every Kid to evaluate the home environment, and referring families for assistance are steps relevant to every child, but especially anxious ones.

You and I need to continue to advocate for safer communities for all children. In the meantime, it is important to know that encouraging a child to describe in detail to a caring adult – verbally and/or by drawing – traumas they experienced is significantly therapeutic. It might not seem intuitive to parents to promote “reliving the experience,” especially because they may have been traumatized themselves. So providing this opportunity ourselves or through a friend, teacher, or counselor who can calmly answer questions and put the event in perspective, is important advice.

But even simply viewing disasters, violence, or artificial frightening events on television or film can produce lasting fears. While inherently anxious children are more vulnerable to fears induced by media, 90% of undergraduates report at least one enduring fear that started this way, and 26% report persistence to the present. At least one-third of youth have fear reactions to media. Simply the number of hours watching television is associated with a child’s increased perception of personal vulnerability. While 8- to 10-year-olds had reduced fear when parents explained news events, more realistic and serious coverage (the Iraq War, for example) and older age predicted more severe fear reactions not similarly reassured. With this high prevalence of anxiety, I encourage parents to avoid media whose content is not known to them for all children, but especially for those already anxious or traumatized. It amazes me how many families of anxious children have the Weather Channel on constantly, showing devastation all over the world, oblivious that the child is internalizing the risk as though it was outside their window! When media trauma exposure can’t be avoided, parents need to show calm and provide explanation to the child to put it in perspective, as we saw the father do on TV after the Paris massacre.

Modeling of fearful reactions is the second powerful influence on the development of fears. How caregivers react when they encounter a situation such as an approaching dog is quickly modeled by the child. This vicarious learning by watching others’ reactions evolved as preferable to having to chance it yourself. Mothers’ voices and actions are especially salient to children, compared with fathers’ voices and actions. Unfortunately, females tend to be both more fearful and more expressive of fear than males. Some approaches you can suggest regarding modeling include coaching parents (sometimes even sitters) to dampen or mask their reactions, provide other adults without a similar fear to model for the child, or at least not tell the child why they are walking a different route to avoid a dog!

How information about threats is transmitted is the third and perhaps most modifiable influence on a child’s development of fears. Parents talk to children constantly, and a lot of it is warnings! This too may be genetic/cultural as evidenced by the 41% of nursery rhymes across cultures that include violence! Children who have been told potentially bad things about an animal, person, or event show a stronger fear response as measured by self-report, physiological reaction, and behavioral avoidance than when not primed. Conversely, children told positive things react with less fear immediately and are less likely to learn a fear response at later exposures. Once fear has been promoted by negative information, the child’s actual ways of thinking (cognitive biases) are shifted. Attention to forewarned stimuli is increased, the use of reasoning is limited to verifying that fear was warranted rather than alternatively looking for evidence against it, and over estimation of the likelihood of bad outcomes occurs. Children with an overly aroused brain behavioral inhibition system (inherent tendency to react to novelty with physiological arousal and fear) are more influenced by negative verbal information to have fear, cognitive distortions, and avoidance.¹

Not surprisingly, anxious parents give more negative information, particularly about ambiguous situations, than other parents. Children living in homes with more negative interactions with fathers or more punitive or neglectful mothers also are more susceptible to increased fears from verbal threat information. Unfortunately, parents generally do not perceive their own role in transmitting threat information. In contrast, one-quarter to one-third of children with significant fears relate onset or intensification of their fears to things they heard. While possibly not relevant for innate fears such as of spiders, this is important information for prevention of fears in general. A child’s development of excessive fear can be somewhat dampened by adult verbal explanations, a focus on the positives, and reassurance, especially if this is done routinely.

The “30 Million Word Gap”² in total word exposure before age 3 years of children in families on welfare vs. professionals found that higher-income parents provided far more words of praise and six encouragements for every discouragement vs. more total negative vocabulary and two discouragements for every encouragement. The same children more likely to be exposed to trauma also may have less positive preparation to reduce their development of significant fears with the associated stress effects. You and I see this during visits – take the opportunity to discuss and model an alternative.

References

1. Clin Child Fam Psychol Rev. 2010 Jun;13(2):129-50.

2. “The Early Catastrophe: The 30 Million Word Gap by Age 3” (Washington: American Educator, Spring 2003).

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at [email protected].

The term “psychotherapy” describes a variety of talk-based treatments for psychiatric illnesses. Its fundamental premise is that there are determinants of mood, anxiety, and behavior that are not fully in our conscious awareness. By becoming more aware or by developing skills in managing thoughts and feelings, patients can get relief from symptoms that often impair functioning. The focus on unconscious thoughts, feelings, and behaviors is the central principle of dynamic psychotherapy in which the therapist listens to the patients speak freely about important people and events in their day-to-day lives and takes note of themes that emerge. Eventually they offer “interpretations” to their patients about these patterns, and ways that current problems may connect to powerful experiences from their earlier lives.

Dynamic psychotherapy is often contrasted with supportive psychotherapy. This is not cheerleading, but instead refers to supporting the healthy ability to think about oneself, one’s thoughts and emotions, and one’s needs, and the tension that these can create with the expectations of society. In working with children and adolescents, therapists are almost always supporting the age-appropriate development of some of these skills, particularly if a child has gotten developmentally stuck because of depressive, anxious, or attentional symptoms. There are almost always supportive elements in psychotherapy with a school-age or teenage child.

For children with anxiety disorders or mild to moderate depression, cognitive-behavioral therapy (CBT) is an evidence-based first-line treatment. CBT is a structured psychotherapy that helps patients to identify specific thoughts that trigger or follow their mood or anxiety symptoms, and then sets about establishing new (less-distorted) thoughts or practicing avoided behaviors to help learn new responses. It appears to be especially effective for anxiety disorders (such as social phobia, panic disorder, and generalized anxiety disorder) and for obsessive-compulsive disorder. There are specialized types of CBT that can be offered to patients (including children) who have been exposed to trauma and even for teenagers experiencing psychotic symptoms. It should be noted that one of the reasons that CBT has a robust evidence base supporting its use is that it is one of the most structured types of psychotherapy. It is standardized, reproducible, and easier to study than most other varieties of psychotherapy. Practicing CBT requires specific training, so in looking for a CBT therapist, one needs to ask whether she is CBT trained, and even whether she is trained in the type of CBT specific for the disorder you are treating.

A relative of CBT is dialectical behavioral therapy or DBT, developed to treat borderline personality disorder, a maladaptive pattern of identity uncertainty, emotional instability, and impulsivity that often starts in adolescence, causing stormy relationships and poor self-regulation that can contribute to self-injury, substance abuse, and chronic suicidality. DBT focuses on cognitive patterns, and utilizes a patient’s strengths to build new skills at managing challenging thoughts and feelings. The “dialectic” relates to interpersonal relationships, as this is where these patients often have great difficulty. High-quality DBT is often done with both individual and group therapy sessions. There is substantial evidence supporting the efficacy of this therapy in patients with borderline personality disorder.

Play therapy generally refers to the use of play (with toys, dolls, art, or games) in therapy with the youngest children. Such young children are unlikely to speak in a fluid manner about their relationships or struggles, as they may lack some of the cognitive means to be self-reflective. So instead, a therapist will watch for themes in their play (aggression, cheating, repetitive stories with dolls or art) that may reflect important themes, that they will then work on in play or in speaking, as tolerated. Therapists of older children also may use play to help these children feel more comfortable as they proceed with CBT or another talk therapy.

While gathering data from parents is always part of therapy for children, family therapy brings the whole family into a room with the therapist, who focuses on the roles each person may play in the family and patterns of communication (verbal and otherwise) that may be contributing to a young person’s symptoms. Family therapy can be very important in treating anorexia nervosa, somatoform illnesses, and conduct disorder in children and adolescents. While it can be a complex type of therapy to study, there is significant evidence supporting its efficacy in these very challenging disorders of youth.

There is a growing body of evidence in adults demonstrating neuroimaging changes after effective psychotherapies. Several studies of patients with OCD who were successfully treated with CBT have demonstrated decreased metabolism in the right caudate nucleus, and those treated effectively for phobias showed decreased activity in the limbic and paralimbic areas. Interestingly, patients with OCD and phobias who were effectively treated with selective serotonin reuptake inhibitors demonstrated these same changes on functional neuroimaging (Mol Psychiatry. 2006 Jun;11[6]:528-38.). An Italian meta-analysis of patients treated for major depression with medications (usually selective serotonin reuptake inhibitors) or with psychotherapy (usually CBT) demonstrated different, and possibly complementary brain changes in the two treatment groups (Brain Imaging Behav. 2015 Jul 12. [Epub ahead of print]). With time, these studies may help us to better understand the nature of specific illnesses and more about neuroplasticity, and may even help us to understand when medications, therapy, or both are indicated.

©AlexRaths/Thinkstock

Finally, it is worth noting that multiple studies indicate that one of the most consistent predictors of a positive outcome in psychotherapy is the presence of a strong treatment alliance between the therapist and the patient. Studies have demonstrated that a strong alliance was a better predictor of positive outcomes than type of psychotherapy, and seemed to be a strong predictor of positive outcomes even in cases where the treatment was pharmacologic. This makes it critical that when you are trying to help your patient find a “good therapist,” you consider whether the patient may need a specialized therapy (CBT, DBT, or family therapy). But you should also instruct your patient and their parents that it is very important that they like their therapist, that after several meetings they should feel comfortable meeting and talking honestly with him, and that they should feel that the therapist cares about them and is committed to their health and well-being.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. Email them at [email protected].

The term “psychotherapy” describes a variety of talk-based treatments for psychiatric illnesses. Its fundamental premise is that there are determinants of mood, anxiety, and behavior that are not fully in our conscious awareness. By becoming more aware or by developing skills in managing thoughts and feelings, patients can get relief from symptoms that often impair functioning. The focus on unconscious thoughts, feelings, and behaviors is the central principle of dynamic psychotherapy in which the therapist listens to the patients speak freely about important people and events in their day-to-day lives and takes note of themes that emerge. Eventually they offer “interpretations” to their patients about these patterns, and ways that current problems may connect to powerful experiences from their earlier lives.

Dynamic psychotherapy is often contrasted with supportive psychotherapy. This is not cheerleading, but instead refers to supporting the healthy ability to think about oneself, one’s thoughts and emotions, and one’s needs, and the tension that these can create with the expectations of society. In working with children and adolescents, therapists are almost always supporting the age-appropriate development of some of these skills, particularly if a child has gotten developmentally stuck because of depressive, anxious, or attentional symptoms. There are almost always supportive elements in psychotherapy with a school-age or teenage child.

For children with anxiety disorders or mild to moderate depression, cognitive-behavioral therapy (CBT) is an evidence-based first-line treatment. CBT is a structured psychotherapy that helps patients to identify specific thoughts that trigger or follow their mood or anxiety symptoms, and then sets about establishing new (less-distorted) thoughts or practicing avoided behaviors to help learn new responses. It appears to be especially effective for anxiety disorders (such as social phobia, panic disorder, and generalized anxiety disorder) and for obsessive-compulsive disorder. There are specialized types of CBT that can be offered to patients (including children) who have been exposed to trauma and even for teenagers experiencing psychotic symptoms. It should be noted that one of the reasons that CBT has a robust evidence base supporting its use is that it is one of the most structured types of psychotherapy. It is standardized, reproducible, and easier to study than most other varieties of psychotherapy. Practicing CBT requires specific training, so in looking for a CBT therapist, one needs to ask whether she is CBT trained, and even whether she is trained in the type of CBT specific for the disorder you are treating.

A relative of CBT is dialectical behavioral therapy or DBT, developed to treat borderline personality disorder, a maladaptive pattern of identity uncertainty, emotional instability, and impulsivity that often starts in adolescence, causing stormy relationships and poor self-regulation that can contribute to self-injury, substance abuse, and chronic suicidality. DBT focuses on cognitive patterns, and utilizes a patient’s strengths to build new skills at managing challenging thoughts and feelings. The “dialectic” relates to interpersonal relationships, as this is where these patients often have great difficulty. High-quality DBT is often done with both individual and group therapy sessions. There is substantial evidence supporting the efficacy of this therapy in patients with borderline personality disorder.

Play therapy generally refers to the use of play (with toys, dolls, art, or games) in therapy with the youngest children. Such young children are unlikely to speak in a fluid manner about their relationships or struggles, as they may lack some of the cognitive means to be self-reflective. So instead, a therapist will watch for themes in their play (aggression, cheating, repetitive stories with dolls or art) that may reflect important themes, that they will then work on in play or in speaking, as tolerated. Therapists of older children also may use play to help these children feel more comfortable as they proceed with CBT or another talk therapy.

While gathering data from parents is always part of therapy for children, family therapy brings the whole family into a room with the therapist, who focuses on the roles each person may play in the family and patterns of communication (verbal and otherwise) that may be contributing to a young person’s symptoms. Family therapy can be very important in treating anorexia nervosa, somatoform illnesses, and conduct disorder in children and adolescents. While it can be a complex type of therapy to study, there is significant evidence supporting its efficacy in these very challenging disorders of youth.

There is a growing body of evidence in adults demonstrating neuroimaging changes after effective psychotherapies. Several studies of patients with OCD who were successfully treated with CBT have demonstrated decreased metabolism in the right caudate nucleus, and those treated effectively for phobias showed decreased activity in the limbic and paralimbic areas. Interestingly, patients with OCD and phobias who were effectively treated with selective serotonin reuptake inhibitors demonstrated these same changes on functional neuroimaging (Mol Psychiatry. 2006 Jun;11[6]:528-38.). An Italian meta-analysis of patients treated for major depression with medications (usually selective serotonin reuptake inhibitors) or with psychotherapy (usually CBT) demonstrated different, and possibly complementary brain changes in the two treatment groups (Brain Imaging Behav. 2015 Jul 12. [Epub ahead of print]). With time, these studies may help us to better understand the nature of specific illnesses and more about neuroplasticity, and may even help us to understand when medications, therapy, or both are indicated.

©AlexRaths/Thinkstock

Finally, it is worth noting that multiple studies indicate that one of the most consistent predictors of a positive outcome in psychotherapy is the presence of a strong treatment alliance between the therapist and the patient. Studies have demonstrated that a strong alliance was a better predictor of positive outcomes than type of psychotherapy, and seemed to be a strong predictor of positive outcomes even in cases where the treatment was pharmacologic. This makes it critical that when you are trying to help your patient find a “good therapist,” you consider whether the patient may need a specialized therapy (CBT, DBT, or family therapy). But you should also instruct your patient and their parents that it is very important that they like their therapist, that after several meetings they should feel comfortable meeting and talking honestly with him, and that they should feel that the therapist cares about them and is committed to their health and well-being.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. Email them at [email protected].

The term “psychotherapy” describes a variety of talk-based treatments for psychiatric illnesses. Its fundamental premise is that there are determinants of mood, anxiety, and behavior that are not fully in our conscious awareness. By becoming more aware or by developing skills in managing thoughts and feelings, patients can get relief from symptoms that often impair functioning. The focus on unconscious thoughts, feelings, and behaviors is the central principle of dynamic psychotherapy in which the therapist listens to the patients speak freely about important people and events in their day-to-day lives and takes note of themes that emerge. Eventually they offer “interpretations” to their patients about these patterns, and ways that current problems may connect to powerful experiences from their earlier lives.

Dynamic psychotherapy is often contrasted with supportive psychotherapy. This is not cheerleading, but instead refers to supporting the healthy ability to think about oneself, one’s thoughts and emotions, and one’s needs, and the tension that these can create with the expectations of society. In working with children and adolescents, therapists are almost always supporting the age-appropriate development of some of these skills, particularly if a child has gotten developmentally stuck because of depressive, anxious, or attentional symptoms. There are almost always supportive elements in psychotherapy with a school-age or teenage child.

For children with anxiety disorders or mild to moderate depression, cognitive-behavioral therapy (CBT) is an evidence-based first-line treatment. CBT is a structured psychotherapy that helps patients to identify specific thoughts that trigger or follow their mood or anxiety symptoms, and then sets about establishing new (less-distorted) thoughts or practicing avoided behaviors to help learn new responses. It appears to be especially effective for anxiety disorders (such as social phobia, panic disorder, and generalized anxiety disorder) and for obsessive-compulsive disorder. There are specialized types of CBT that can be offered to patients (including children) who have been exposed to trauma and even for teenagers experiencing psychotic symptoms. It should be noted that one of the reasons that CBT has a robust evidence base supporting its use is that it is one of the most structured types of psychotherapy. It is standardized, reproducible, and easier to study than most other varieties of psychotherapy. Practicing CBT requires specific training, so in looking for a CBT therapist, one needs to ask whether she is CBT trained, and even whether she is trained in the type of CBT specific for the disorder you are treating.

A relative of CBT is dialectical behavioral therapy or DBT, developed to treat borderline personality disorder, a maladaptive pattern of identity uncertainty, emotional instability, and impulsivity that often starts in adolescence, causing stormy relationships and poor self-regulation that can contribute to self-injury, substance abuse, and chronic suicidality. DBT focuses on cognitive patterns, and utilizes a patient’s strengths to build new skills at managing challenging thoughts and feelings. The “dialectic” relates to interpersonal relationships, as this is where these patients often have great difficulty. High-quality DBT is often done with both individual and group therapy sessions. There is substantial evidence supporting the efficacy of this therapy in patients with borderline personality disorder.

Play therapy generally refers to the use of play (with toys, dolls, art, or games) in therapy with the youngest children. Such young children are unlikely to speak in a fluid manner about their relationships or struggles, as they may lack some of the cognitive means to be self-reflective. So instead, a therapist will watch for themes in their play (aggression, cheating, repetitive stories with dolls or art) that may reflect important themes, that they will then work on in play or in speaking, as tolerated. Therapists of older children also may use play to help these children feel more comfortable as they proceed with CBT or another talk therapy.

While gathering data from parents is always part of therapy for children, family therapy brings the whole family into a room with the therapist, who focuses on the roles each person may play in the family and patterns of communication (verbal and otherwise) that may be contributing to a young person’s symptoms. Family therapy can be very important in treating anorexia nervosa, somatoform illnesses, and conduct disorder in children and adolescents. While it can be a complex type of therapy to study, there is significant evidence supporting its efficacy in these very challenging disorders of youth.

There is a growing body of evidence in adults demonstrating neuroimaging changes after effective psychotherapies. Several studies of patients with OCD who were successfully treated with CBT have demonstrated decreased metabolism in the right caudate nucleus, and those treated effectively for phobias showed decreased activity in the limbic and paralimbic areas. Interestingly, patients with OCD and phobias who were effectively treated with selective serotonin reuptake inhibitors demonstrated these same changes on functional neuroimaging (Mol Psychiatry. 2006 Jun;11[6]:528-38.). An Italian meta-analysis of patients treated for major depression with medications (usually selective serotonin reuptake inhibitors) or with psychotherapy (usually CBT) demonstrated different, and possibly complementary brain changes in the two treatment groups (Brain Imaging Behav. 2015 Jul 12. [Epub ahead of print]). With time, these studies may help us to better understand the nature of specific illnesses and more about neuroplasticity, and may even help us to understand when medications, therapy, or both are indicated.

©AlexRaths/Thinkstock

Finally, it is worth noting that multiple studies indicate that one of the most consistent predictors of a positive outcome in psychotherapy is the presence of a strong treatment alliance between the therapist and the patient. Studies have demonstrated that a strong alliance was a better predictor of positive outcomes than type of psychotherapy, and seemed to be a strong predictor of positive outcomes even in cases where the treatment was pharmacologic. This makes it critical that when you are trying to help your patient find a “good therapist,” you consider whether the patient may need a specialized therapy (CBT, DBT, or family therapy). But you should also instruct your patient and their parents that it is very important that they like their therapist, that after several meetings they should feel comfortable meeting and talking honestly with him, and that they should feel that the therapist cares about them and is committed to their health and well-being.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. Email them at [email protected].

Lead poisoning is a well-established cause of serious and permanent neurological, cognitive, and behavioral problems, particularly in exposed children.

Children can be exposed to lead from ingesting paint chips in their homes, when old paint is scrapped from the exterior of houses or bridges, and through the water they drink. The damage caused by lead poisoning was first recognized in the United States in the early 20th century, although lead was added to gasoline and paint until the 1970’s. Since then, regulations for lead in consumer products have become increasingly strict, and the Centers for Disease Control and Prevention’s definition of a toxic lead level has shifted from 60 micrograms/deciliter (mcg/dL) in 1970 to 5 mcg/dL in 2012. In many communities, removing lead paint up to the height of a young child is a requirement whenever an older home is sold.

Unfortunately, these regulations did not protect the families in Flint, Michigan from being exposed to high levels of lead when a change in water supply and inadequate water treatment allowed lead to enter the system from decaying water pipes. It is worth reviewing what is known about the short- and long-term consequences of lead exposure, and what lies ahead for the children of Flint.

Lead is a naturally occurring element that is not metabolized, but rather absorbed, distributed to tissues, and excreted. Lead can be inhaled (with 100% absorption) and introduced through the GI tract (with about 70% absorption in children and 20% absorption in adults). GI absorption is enhanced by calcium or iron deficiency, both conditions that are relatively common, especially in poor children and can lead to pica (or eating of non-nutritious materials), further increasing the chances of lead exposure. Absorbed lead is distributed to blood (for 28-36 days), soft tissue, including the nervous system (40 days), and to bone (where it lasts for over 25 years). Blood that is retained in growing bones can be mobilized during periods of physiologic stress (such as illness, injury, or pregnancy), meaning children exposed to lead during a period of rapid bone growth are at long-term risk for acute lead poisoning from their endogenous reservoir without a new exposure. What lead is not retained by tissues is excreted by the kidneys, with adults retaining about 1% of absorbed lead, while children younger than 2 years retain over 30% of absorbed lead. So children, especially toddlers, have a greater likelihood to absorb lead from the GI tract and to retain lead in their tissues, both due to active mineralization of bone and the permeability of the blood brain barrier, primarily in children under 3 years old. This is why we are addressing what will happen to the children of Flint and not to all the residents of Flint.

Lead competitively inhibits interactions between cations and sulfhydryl groups, which are present in most human biochemical reactions. This leads to irreversible cell damage and often cell death, especially within the central nervous system. Lead exposure is associated with particular dysfunction within dopaminergic pathways within the brain, and has been associated in a dose-dependent fashion with decreased prefrontal gray matter volume. Lead poisoning also has hematologic consequences (anemia), renal consequences (interstitial nephritis), gastrointestinal symptoms (vomiting, constipation), and endocrine consequences (reversible inhibition of Vitamin D metabolism and permanently short stature). But the CNS consequences of lead exposure are particularly devastating, as they appear to have no threshold and are permanent. Their incidence is the driving force for the CDC’s lowering of the official toxic lead level and the public health efforts to screen children and educate parents about the risk of lead exposure.

So what do these serious consequences look like? People with severe lead intoxication (blood lead levels greater than 70 mcg/dL) typically present with signs of acute encephalopathy (headache, vomiting, seizures, or coma) and require intensive medical management including chelation therapy. More typically, exposed children have low but accumulating levels of lead and present with nonspecific symptoms, including lost appetite, fatigue, irritability, and insomnia, which gradually worsen.

Behavior

High levels of impulsivity, aggression, and impaired attention are the prototypical sequelae of lead poisoning (following recovery from the acute intoxication). Multiple studies have demonstrated these high levels of aggressive and impulsive behaviors in preschoolers who were exposed to lead, and these behaviors appear to continue into adolescence and adulthood. Indeed, one study found that compared with children with the lowest measurable blood lead levels (0.2-0.7 mcg/dL), those children who were in the next two quartiles had seven and twelve times the odds of meeting diagnostic criteria for conduct disorder.¹ There have even been studies which correlated atmospheric lead levels (when leaded gasoline was common) with crime rates 20 years later, which supported an association between childhood lead exposure and adult criminal activity.^2-4.

Multiple studies have demonstrated higher rates of inattention, distractibility, and impulsivity in lead-exposed children than would be expected given the prevalence of attention-deficit/hyperactivity disorder (ADHD) in the general population. The incidence of these symptoms goes up in a dose-dependent fashion and appears to have no threshold (so they occur at even the lowest measurable blood lead levels). In a 2006 study of nearly 5,000 children between ages 4-15 years, those with blood lead levels greater than 2 mcg/dL (still below the level the CDC deems toxic) were four times more likely to be carrying a diagnosis of ADHD and be on stimulant medication than their peers with blood lead levels less than 0.8mcg/dL.

Cognition

Closely related to impulse control and attention, the cognitive domains of intelligence and executive function are clearly damaged by lead exposure. Poor performance on tasks requiring focus, cognitive flexibility, and inhibition of automatic responses was directly associated with higher blood lead levels in a group of preschoolers with levels between 0 and 13 mcg/dL.⁵

IQ has been found to be so consistently diminished by increasing blood lead levels that it is used as an overall index of neurodevelopmental morbidity of lead exposure, leading to the CDC’s adoption of a lower standard definition of toxic lead levels. Even very low blood lead levels are associated with decrements in IQ: children with blood lead levels less than 7.5 mcg/dL lost an average of 3 IQ points for every 1 mcg/dL increase in blood lead levels.⁶ In a study of 57,000 elementary school students in 2009, Miranda et al. found that those who had a blood lead level of 4 mcg/dL at 3 years old were significantly more likely to be diagnosed with a learning disability in elementary school. Another study of 48,000 children who had a blood lead level of 5 mcg/dL were 30% more likely to fail third grade reading and math tests than their peers without measurable lead levels.

Speech and language

More recent studies have demonstrated that children with higher bone lead concentrations had poorer performance on several language-processing measures, suggesting that childhood lead exposure damages language processing and function as the young people grow. These deficits in language processing can make social development and self-regulation much more challenging in adolescence, and make school and work settings much more challenging. These findings also have implications for the utility of psychotherapy, a language-based treatment, for the other behavioral problems of lead exposure.

Motor skills

Several recent studies have assessed both fine and gross motor skills in lead-exposed children. Findings have demonstrated that balance, coordination, gross motor and fine motor skills all appear to be compromised in a dose-dependent fashion by childhood lead exposure. These findings suggest that not only are children at greater risk for accident and injury through childhood and into adulthood, a risk already increased by their compromised attention and impulse control. But they also are likely to be physically clumsy, compromising an opportunity to cultivate strengths or experience mastery when cognitive tasks may prove frustrating for them.

With deficits in such fundamental cognitive, motor, and behavioral processes, exposed children are clearly vulnerable to more than ADHD, conduct disorder, and learning disabilities. These struggles may lead to secondary vulnerabilities to anxiety or mood symptoms or substance abuse as these children grow into teenagers who face frustration at every turn. In addition to treatment for their deficits in attention and executive function, these children will ideally receive specialized supports in school and at home, to be able to master cognitive tasks, manage new social circumstances and make friends, discover their interests and talents, and generally stay on their best developmental trajectories. Lastly, the specific consequences of lead exposure will vary for any individual child, so parents will have to deal with the uncertainty of their child’s behavior and development over many years. Clearly, the children of Flint face a long road that has been substantially impacted by their lead exposure. The only good that can come from the exposure in Flint is to heighten efforts to ensure that it never happens again.

1. Environ Health Perspect. 2008 Jul;116(7):956-62.

2. Environ Res. 2000 May;83(1):1-22.

3. Environ Res. 2007 Jul;104(3):315-36.

4. Arch Pediatr Adolesc Med. 2001 May;155(5):579-82.

5. Dev Neuropsychol. 2004;26(1):513-40.

6. Environ Health Perspect. 2005 Jul;113(7):894-9.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston.

Lead poisoning is a well-established cause of serious and permanent neurological, cognitive, and behavioral problems, particularly in exposed children.

Children can be exposed to lead from ingesting paint chips in their homes, when old paint is scrapped from the exterior of houses or bridges, and through the water they drink. The damage caused by lead poisoning was first recognized in the United States in the early 20th century, although lead was added to gasoline and paint until the 1970’s. Since then, regulations for lead in consumer products have become increasingly strict, and the Centers for Disease Control and Prevention’s definition of a toxic lead level has shifted from 60 micrograms/deciliter (mcg/dL) in 1970 to 5 mcg/dL in 2012. In many communities, removing lead paint up to the height of a young child is a requirement whenever an older home is sold.

Unfortunately, these regulations did not protect the families in Flint, Michigan from being exposed to high levels of lead when a change in water supply and inadequate water treatment allowed lead to enter the system from decaying water pipes. It is worth reviewing what is known about the short- and long-term consequences of lead exposure, and what lies ahead for the children of Flint.

Lead is a naturally occurring element that is not metabolized, but rather absorbed, distributed to tissues, and excreted. Lead can be inhaled (with 100% absorption) and introduced through the GI tract (with about 70% absorption in children and 20% absorption in adults). GI absorption is enhanced by calcium or iron deficiency, both conditions that are relatively common, especially in poor children and can lead to pica (or eating of non-nutritious materials), further increasing the chances of lead exposure. Absorbed lead is distributed to blood (for 28-36 days), soft tissue, including the nervous system (40 days), and to bone (where it lasts for over 25 years). Blood that is retained in growing bones can be mobilized during periods of physiologic stress (such as illness, injury, or pregnancy), meaning children exposed to lead during a period of rapid bone growth are at long-term risk for acute lead poisoning from their endogenous reservoir without a new exposure. What lead is not retained by tissues is excreted by the kidneys, with adults retaining about 1% of absorbed lead, while children younger than 2 years retain over 30% of absorbed lead. So children, especially toddlers, have a greater likelihood to absorb lead from the GI tract and to retain lead in their tissues, both due to active mineralization of bone and the permeability of the blood brain barrier, primarily in children under 3 years old. This is why we are addressing what will happen to the children of Flint and not to all the residents of Flint.

Lead competitively inhibits interactions between cations and sulfhydryl groups, which are present in most human biochemical reactions. This leads to irreversible cell damage and often cell death, especially within the central nervous system. Lead exposure is associated with particular dysfunction within dopaminergic pathways within the brain, and has been associated in a dose-dependent fashion with decreased prefrontal gray matter volume. Lead poisoning also has hematologic consequences (anemia), renal consequences (interstitial nephritis), gastrointestinal symptoms (vomiting, constipation), and endocrine consequences (reversible inhibition of Vitamin D metabolism and permanently short stature). But the CNS consequences of lead exposure are particularly devastating, as they appear to have no threshold and are permanent. Their incidence is the driving force for the CDC’s lowering of the official toxic lead level and the public health efforts to screen children and educate parents about the risk of lead exposure.

So what do these serious consequences look like? People with severe lead intoxication (blood lead levels greater than 70 mcg/dL) typically present with signs of acute encephalopathy (headache, vomiting, seizures, or coma) and require intensive medical management including chelation therapy. More typically, exposed children have low but accumulating levels of lead and present with nonspecific symptoms, including lost appetite, fatigue, irritability, and insomnia, which gradually worsen.

Behavior

High levels of impulsivity, aggression, and impaired attention are the prototypical sequelae of lead poisoning (following recovery from the acute intoxication). Multiple studies have demonstrated these high levels of aggressive and impulsive behaviors in preschoolers who were exposed to lead, and these behaviors appear to continue into adolescence and adulthood. Indeed, one study found that compared with children with the lowest measurable blood lead levels (0.2-0.7 mcg/dL), those children who were in the next two quartiles had seven and twelve times the odds of meeting diagnostic criteria for conduct disorder.¹ There have even been studies which correlated atmospheric lead levels (when leaded gasoline was common) with crime rates 20 years later, which supported an association between childhood lead exposure and adult criminal activity.^2-4.

Multiple studies have demonstrated higher rates of inattention, distractibility, and impulsivity in lead-exposed children than would be expected given the prevalence of attention-deficit/hyperactivity disorder (ADHD) in the general population. The incidence of these symptoms goes up in a dose-dependent fashion and appears to have no threshold (so they occur at even the lowest measurable blood lead levels). In a 2006 study of nearly 5,000 children between ages 4-15 years, those with blood lead levels greater than 2 mcg/dL (still below the level the CDC deems toxic) were four times more likely to be carrying a diagnosis of ADHD and be on stimulant medication than their peers with blood lead levels less than 0.8mcg/dL.

Cognition

Closely related to impulse control and attention, the cognitive domains of intelligence and executive function are clearly damaged by lead exposure. Poor performance on tasks requiring focus, cognitive flexibility, and inhibition of automatic responses was directly associated with higher blood lead levels in a group of preschoolers with levels between 0 and 13 mcg/dL.⁵

IQ has been found to be so consistently diminished by increasing blood lead levels that it is used as an overall index of neurodevelopmental morbidity of lead exposure, leading to the CDC’s adoption of a lower standard definition of toxic lead levels. Even very low blood lead levels are associated with decrements in IQ: children with blood lead levels less than 7.5 mcg/dL lost an average of 3 IQ points for every 1 mcg/dL increase in blood lead levels.⁶ In a study of 57,000 elementary school students in 2009, Miranda et al. found that those who had a blood lead level of 4 mcg/dL at 3 years old were significantly more likely to be diagnosed with a learning disability in elementary school. Another study of 48,000 children who had a blood lead level of 5 mcg/dL were 30% more likely to fail third grade reading and math tests than their peers without measurable lead levels.

Speech and language

More recent studies have demonstrated that children with higher bone lead concentrations had poorer performance on several language-processing measures, suggesting that childhood lead exposure damages language processing and function as the young people grow. These deficits in language processing can make social development and self-regulation much more challenging in adolescence, and make school and work settings much more challenging. These findings also have implications for the utility of psychotherapy, a language-based treatment, for the other behavioral problems of lead exposure.

Motor skills

Several recent studies have assessed both fine and gross motor skills in lead-exposed children. Findings have demonstrated that balance, coordination, gross motor and fine motor skills all appear to be compromised in a dose-dependent fashion by childhood lead exposure. These findings suggest that not only are children at greater risk for accident and injury through childhood and into adulthood, a risk already increased by their compromised attention and impulse control. But they also are likely to be physically clumsy, compromising an opportunity to cultivate strengths or experience mastery when cognitive tasks may prove frustrating for them.

With deficits in such fundamental cognitive, motor, and behavioral processes, exposed children are clearly vulnerable to more than ADHD, conduct disorder, and learning disabilities. These struggles may lead to secondary vulnerabilities to anxiety or mood symptoms or substance abuse as these children grow into teenagers who face frustration at every turn. In addition to treatment for their deficits in attention and executive function, these children will ideally receive specialized supports in school and at home, to be able to master cognitive tasks, manage new social circumstances and make friends, discover their interests and talents, and generally stay on their best developmental trajectories. Lastly, the specific consequences of lead exposure will vary for any individual child, so parents will have to deal with the uncertainty of their child’s behavior and development over many years. Clearly, the children of Flint face a long road that has been substantially impacted by their lead exposure. The only good that can come from the exposure in Flint is to heighten efforts to ensure that it never happens again.

1. Environ Health Perspect. 2008 Jul;116(7):956-62.

2. Environ Res. 2000 May;83(1):1-22.

3. Environ Res. 2007 Jul;104(3):315-36.

4. Arch Pediatr Adolesc Med. 2001 May;155(5):579-82.

5. Dev Neuropsychol. 2004;26(1):513-40.

6. Environ Health Perspect. 2005 Jul;113(7):894-9.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston.

Lead poisoning is a well-established cause of serious and permanent neurological, cognitive, and behavioral problems, particularly in exposed children.

Children can be exposed to lead from ingesting paint chips in their homes, when old paint is scrapped from the exterior of houses or bridges, and through the water they drink. The damage caused by lead poisoning was first recognized in the United States in the early 20th century, although lead was added to gasoline and paint until the 1970’s. Since then, regulations for lead in consumer products have become increasingly strict, and the Centers for Disease Control and Prevention’s definition of a toxic lead level has shifted from 60 micrograms/deciliter (mcg/dL) in 1970 to 5 mcg/dL in 2012. In many communities, removing lead paint up to the height of a young child is a requirement whenever an older home is sold.

Unfortunately, these regulations did not protect the families in Flint, Michigan from being exposed to high levels of lead when a change in water supply and inadequate water treatment allowed lead to enter the system from decaying water pipes. It is worth reviewing what is known about the short- and long-term consequences of lead exposure, and what lies ahead for the children of Flint.

Lead is a naturally occurring element that is not metabolized, but rather absorbed, distributed to tissues, and excreted. Lead can be inhaled (with 100% absorption) and introduced through the GI tract (with about 70% absorption in children and 20% absorption in adults). GI absorption is enhanced by calcium or iron deficiency, both conditions that are relatively common, especially in poor children and can lead to pica (or eating of non-nutritious materials), further increasing the chances of lead exposure. Absorbed lead is distributed to blood (for 28-36 days), soft tissue, including the nervous system (40 days), and to bone (where it lasts for over 25 years). Blood that is retained in growing bones can be mobilized during periods of physiologic stress (such as illness, injury, or pregnancy), meaning children exposed to lead during a period of rapid bone growth are at long-term risk for acute lead poisoning from their endogenous reservoir without a new exposure. What lead is not retained by tissues is excreted by the kidneys, with adults retaining about 1% of absorbed lead, while children younger than 2 years retain over 30% of absorbed lead. So children, especially toddlers, have a greater likelihood to absorb lead from the GI tract and to retain lead in their tissues, both due to active mineralization of bone and the permeability of the blood brain barrier, primarily in children under 3 years old. This is why we are addressing what will happen to the children of Flint and not to all the residents of Flint.

Lead competitively inhibits interactions between cations and sulfhydryl groups, which are present in most human biochemical reactions. This leads to irreversible cell damage and often cell death, especially within the central nervous system. Lead exposure is associated with particular dysfunction within dopaminergic pathways within the brain, and has been associated in a dose-dependent fashion with decreased prefrontal gray matter volume. Lead poisoning also has hematologic consequences (anemia), renal consequences (interstitial nephritis), gastrointestinal symptoms (vomiting, constipation), and endocrine consequences (reversible inhibition of Vitamin D metabolism and permanently short stature). But the CNS consequences of lead exposure are particularly devastating, as they appear to have no threshold and are permanent. Their incidence is the driving force for the CDC’s lowering of the official toxic lead level and the public health efforts to screen children and educate parents about the risk of lead exposure.

So what do these serious consequences look like? People with severe lead intoxication (blood lead levels greater than 70 mcg/dL) typically present with signs of acute encephalopathy (headache, vomiting, seizures, or coma) and require intensive medical management including chelation therapy. More typically, exposed children have low but accumulating levels of lead and present with nonspecific symptoms, including lost appetite, fatigue, irritability, and insomnia, which gradually worsen.

Behavior

High levels of impulsivity, aggression, and impaired attention are the prototypical sequelae of lead poisoning (following recovery from the acute intoxication). Multiple studies have demonstrated these high levels of aggressive and impulsive behaviors in preschoolers who were exposed to lead, and these behaviors appear to continue into adolescence and adulthood. Indeed, one study found that compared with children with the lowest measurable blood lead levels (0.2-0.7 mcg/dL), those children who were in the next two quartiles had seven and twelve times the odds of meeting diagnostic criteria for conduct disorder.¹ There have even been studies which correlated atmospheric lead levels (when leaded gasoline was common) with crime rates 20 years later, which supported an association between childhood lead exposure and adult criminal activity.^2-4.

Multiple studies have demonstrated higher rates of inattention, distractibility, and impulsivity in lead-exposed children than would be expected given the prevalence of attention-deficit/hyperactivity disorder (ADHD) in the general population. The incidence of these symptoms goes up in a dose-dependent fashion and appears to have no threshold (so they occur at even the lowest measurable blood lead levels). In a 2006 study of nearly 5,000 children between ages 4-15 years, those with blood lead levels greater than 2 mcg/dL (still below the level the CDC deems toxic) were four times more likely to be carrying a diagnosis of ADHD and be on stimulant medication than their peers with blood lead levels less than 0.8mcg/dL.

Cognition

Closely related to impulse control and attention, the cognitive domains of intelligence and executive function are clearly damaged by lead exposure. Poor performance on tasks requiring focus, cognitive flexibility, and inhibition of automatic responses was directly associated with higher blood lead levels in a group of preschoolers with levels between 0 and 13 mcg/dL.⁵

IQ has been found to be so consistently diminished by increasing blood lead levels that it is used as an overall index of neurodevelopmental morbidity of lead exposure, leading to the CDC’s adoption of a lower standard definition of toxic lead levels. Even very low blood lead levels are associated with decrements in IQ: children with blood lead levels less than 7.5 mcg/dL lost an average of 3 IQ points for every 1 mcg/dL increase in blood lead levels.⁶ In a study of 57,000 elementary school students in 2009, Miranda et al. found that those who had a blood lead level of 4 mcg/dL at 3 years old were significantly more likely to be diagnosed with a learning disability in elementary school. Another study of 48,000 children who had a blood lead level of 5 mcg/dL were 30% more likely to fail third grade reading and math tests than their peers without measurable lead levels.

Speech and language

More recent studies have demonstrated that children with higher bone lead concentrations had poorer performance on several language-processing measures, suggesting that childhood lead exposure damages language processing and function as the young people grow. These deficits in language processing can make social development and self-regulation much more challenging in adolescence, and make school and work settings much more challenging. These findings also have implications for the utility of psychotherapy, a language-based treatment, for the other behavioral problems of lead exposure.

Motor skills

Several recent studies have assessed both fine and gross motor skills in lead-exposed children. Findings have demonstrated that balance, coordination, gross motor and fine motor skills all appear to be compromised in a dose-dependent fashion by childhood lead exposure. These findings suggest that not only are children at greater risk for accident and injury through childhood and into adulthood, a risk already increased by their compromised attention and impulse control. But they also are likely to be physically clumsy, compromising an opportunity to cultivate strengths or experience mastery when cognitive tasks may prove frustrating for them.

With deficits in such fundamental cognitive, motor, and behavioral processes, exposed children are clearly vulnerable to more than ADHD, conduct disorder, and learning disabilities. These struggles may lead to secondary vulnerabilities to anxiety or mood symptoms or substance abuse as these children grow into teenagers who face frustration at every turn. In addition to treatment for their deficits in attention and executive function, these children will ideally receive specialized supports in school and at home, to be able to master cognitive tasks, manage new social circumstances and make friends, discover their interests and talents, and generally stay on their best developmental trajectories. Lastly, the specific consequences of lead exposure will vary for any individual child, so parents will have to deal with the uncertainty of their child’s behavior and development over many years. Clearly, the children of Flint face a long road that has been substantially impacted by their lead exposure. The only good that can come from the exposure in Flint is to heighten efforts to ensure that it never happens again.

1. Environ Health Perspect. 2008 Jul;116(7):956-62.

2. Environ Res. 2000 May;83(1):1-22.

3. Environ Res. 2007 Jul;104(3):315-36.

4. Arch Pediatr Adolesc Med. 2001 May;155(5):579-82.

5. Dev Neuropsychol. 2004;26(1):513-40.

6. Environ Health Perspect. 2005 Jul;113(7):894-9.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston.

Outbursts by children when frustrated or when asked to “do something they don’t want to do” are among the most common behavioral complaints voiced by parents. But behavioral outbursts, beyond the typical tantrums of children up to age 4 years, can be signs of very severe mental health disorders and are the most common reason for psychiatric admission (50%-60%).

While behavioral dysregulation is undeniably a huge problem for families, there has been an unreasonable 40-fold rise in diagnosis of bipolar disorder from 1994 to 2003, and 48% were prescribed atypical neuroleptics – medications with serious side effects. In response to this overdiagnosis as bipolar disorder, in 2013 the DSM-5 created a new diagnosis called disruptive mood dysregulation disorder (DMDD) to differentiate children who experience explosive outbursts who have a different outcome. This new classification includes children aged 6-12 years with persistent irritability most of the time, nearly every day, lasting at least 12 months and starting before age 10 years. DMDD diagnosis is not used after age 18 years.

To be diagnosed, the child has to have frequent, severe temper outbursts “grossly out of proportion” to the situation, averaging at least three times per week. The outbursts can be verbal or physical aggression to people, things, or themselves. While tantrums can be severe in children with delayed development, for the DMDD diagnosis these behaviors must be inconsistent with developmental level and must occur in at least two settings, and in one setting it must be severe. While outbursts are common, only half of children in one study of severe tantrum behavior in 5- to 9-year-olds also had the required persistent irritability.

If this does sound a lot like bipolar disorder so far, you are right. So what is different? DMDD has a prevalence of 2%-5% and occurs mostly in boys, whereas bipolar disorder affects boys and girls equally and affects less than 1% prior to adolescence.

The key features distinguishing DMDD from bipolar disorder are lack of an episodic nature to the irritability and lack of mania. Irritability in DMDD has to be persistently present with breaks of no more than 3 consecutive months in the defining 12-month period. There also cannot be any more than 1 day of the elevated mood features of mania or hypomania. Identifying mania is the hardest part, even in diagnosing adult bipolar, where it occurs only 1% of the year, much less in children who are generally lively! Hypomania, while less intense than mania, is when the person is energetic, talkative, and confident to an extreme extent, often with a flight of creative ideas. Excitement over birthdays or Christmas specifically does not count! So getting this history has to be done carefully, generally by a mental health professional, to make the distinction.

Interestingly, DMDD is not diagnosed when outbursts and irritability are better explained by autism spectrum disorder, separation anxiety disorder, or PTSD. To me, these exclusions point out the importance of sorting out the “set conditions” for all problematic behaviors, not always an easy task. Symptoms of autism in high functioning individuals can be quite subtle. Was the upset from change in a rigid routine known only to the child? Were sensory stimuli such as loud noises intolerable to this child? Was a nonverbal signal of a peer mistaken as a threat? While violent outbursts precipitated by these factors would still be considered “grossly out of proportion to the situation” for a typical child, they are not uncommon in atypical children. Similarly, children with separation anxiety disorder experience a high level of threat from even thinking about being apart from their caregivers, setting them up for alarm by situations other children would not find difficult.

The American Academy of Pediatrics emphasizes the need to assess all children for a history of psychological trauma. Traumas are quite common, and their sequelae affect many aspects of the child’s life; in the case of outbursts, it is emotional resilience that is impaired. As for all DSM-5 diagnoses, DMDD is not diagnosed when the irritability is due to physiological effects of a substance (e.g. steroids) or another medical or neurological disorder. Children with chronic pain conditions such as rheumatoid arthritis or sickle cell usually cope remarkably well, but when they don’t, their irritability should not be considered a mental health disorder. More commonly, sleep debt can produce chronic irritability and always should be assessed.

When coaching families about outbursts, I work to help them recognize that the child is not just angry, but very distressed. While “typical” tantrums last 1-5 minutes and show a rise then decline in intensity of the anger and distress, anger outbursts are longer and have an initial short and rapid burst of anger that then declines over the duration of the outburst, and with a steady but lower level of distress throughout.

The option to hug and verbally console the child’s distress is sometimes effective and does not reinforce the behavior unless the parent also yields to demands. But once outbursts begin, I liken them to a bomb going off – there is no intervention possible then. Instead, the task of the family, and over time that of the child, is to recognize and better manage the triggers.

Dr. Ross Greene, in his book, “The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children,” asserts that the child’s anger and distress can be interpreted as frustration from a gap in skills. This has treatment implications for identifying, educating about, and ameliorating the child’s weaknesses (deficits in understanding, communication, emotion regulation, flexibility or performance; or excess jealousy or hypersensitivity), and coaching parents to recognize, acknowledge, and avoid stressing these areas, if possible. I coach families to give points to the child for progressive little steps toward being able to recognize, verbalize, and inhibit outbursts with a reward system for the points. This helps put the parents and child “on the same team” in working on improving these skills.

Research on children with DMDD indicates that they show less positive affect when winning a “fixed” video game and are less able to suppress negative affect when losing. (Don’t forget to examine the role of real video games as precipitants of tantrums and contingently remove them!) Threshold for upset is lower and the degree of the upsets less well handled by children with DMDD.

In another study, when presented with a series of ambiguous facial expressions, children with DMDD were more likely to see anger in the faces than were controls. One hopeful result was that they could be taught to shift their perceptions significantly away from seeing anger, also reducing irritability and resulting in functional MRI changes. Such hostile bias attribution (tending to see threat) is well known to predispose to aggression. Cognitive behavioral therapy, the most effective counseling intervention, similarly teaches children to rethink their own negative thoughts before acting.

If irritability and rages were not enough, most children with DMDD have other psychiatric disorders; 39% having two, and 51% three or more (J Child Adolesc Psychopharmacol. 2013 Nov;23[9]:588-96). If not for the DMDD diagnosis, 82% would meet criteria for oppositional defiant disorder (ODD). The other common comorbidities are attention-deficit/hyperactivity disorder (ADHD) (74.5%), anxiety disorders (49.0%), and depression that is not major depressive disorder (MDD)(33.3%). When MDD is present, that diagnosis takes precedence. One cannot diagnose ODD, intermittent explosive disorder, or bipolar disorder along with DMDD, conditions from which it is intended to differentiate. Each of these comorbid disorders can be difficult to manage alone much less in combination, making DMDD a disorder deserving diagnosis and treatment by a mental health professional.

One of the main reasons DMDD was created is that children with these features go on to depressive or anxiety disorder in adolescence, not bipolar disorder.

While there is no treatment specific to DMDD, the depression component and prognosis suggest use of SSRIs, in addition to psychosocial therapies, and stimulants for the comorbid ADHD. Unfortunately, these two classes of medication are relatively contraindicated in bipolar disorder because they can lead to treatment-induced episodic mania (TEM). TEM occurs twice as often with antidepressants compared with stimulants (44% vs. 18%) in children with bipolar disorder (J Affect Disord. 2004 Oct 1;82[1]:149-58). Getting the diagnosis correct is, therefore, of great importance when medication is considered.

Approaches such as behavior modification, family therapy, and inpatient treatment can be effective for chronic irritability and aggression. Stimulant treatment of comorbid ADHD can decrease aggression and irritability. Alpha agonists such as guanfacine or clonidine also can help. In cases of partial improvement, adding either risperidone or divalproex may further decrease aggression in ADHD. In refractory aggression, risperidone has the best evidence. The Affective Reactivity Index or Outburst Monitoring Scale can be helpful in assessing severity and monitoring outcomes.

While a prognosis for depression rather than bipolar disorder sounds like a plus, in a longitudinal study, adults who had DMDD as children had worse outcomes, including being more likely to have adverse health outcomes (smoking, sexually transmitted infection), police contact, and low educational attainment, and being more likely to live in poverty, compared with controls who had other psychiatric disorders. While DMDD is a new and different diagnosis, it is similar to bipolar in having a potential course of life disruption, dangerous behaviors, suicide risk, and hospitalization.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at [email protected].

Outbursts by children when frustrated or when asked to “do something they don’t want to do” are among the most common behavioral complaints voiced by parents. But behavioral outbursts, beyond the typical tantrums of children up to age 4 years, can be signs of very severe mental health disorders and are the most common reason for psychiatric admission (50%-60%).

While behavioral dysregulation is undeniably a huge problem for families, there has been an unreasonable 40-fold rise in diagnosis of bipolar disorder from 1994 to 2003, and 48% were prescribed atypical neuroleptics – medications with serious side effects. In response to this overdiagnosis as bipolar disorder, in 2013 the DSM-5 created a new diagnosis called disruptive mood dysregulation disorder (DMDD) to differentiate children who experience explosive outbursts who have a different outcome. This new classification includes children aged 6-12 years with persistent irritability most of the time, nearly every day, lasting at least 12 months and starting before age 10 years. DMDD diagnosis is not used after age 18 years.

To be diagnosed, the child has to have frequent, severe temper outbursts “grossly out of proportion” to the situation, averaging at least three times per week. The outbursts can be verbal or physical aggression to people, things, or themselves. While tantrums can be severe in children with delayed development, for the DMDD diagnosis these behaviors must be inconsistent with developmental level and must occur in at least two settings, and in one setting it must be severe. While outbursts are common, only half of children in one study of severe tantrum behavior in 5- to 9-year-olds also had the required persistent irritability.

If this does sound a lot like bipolar disorder so far, you are right. So what is different? DMDD has a prevalence of 2%-5% and occurs mostly in boys, whereas bipolar disorder affects boys and girls equally and affects less than 1% prior to adolescence.

The key features distinguishing DMDD from bipolar disorder are lack of an episodic nature to the irritability and lack of mania. Irritability in DMDD has to be persistently present with breaks of no more than 3 consecutive months in the defining 12-month period. There also cannot be any more than 1 day of the elevated mood features of mania or hypomania. Identifying mania is the hardest part, even in diagnosing adult bipolar, where it occurs only 1% of the year, much less in children who are generally lively! Hypomania, while less intense than mania, is when the person is energetic, talkative, and confident to an extreme extent, often with a flight of creative ideas. Excitement over birthdays or Christmas specifically does not count! So getting this history has to be done carefully, generally by a mental health professional, to make the distinction.

Interestingly, DMDD is not diagnosed when outbursts and irritability are better explained by autism spectrum disorder, separation anxiety disorder, or PTSD. To me, these exclusions point out the importance of sorting out the “set conditions” for all problematic behaviors, not always an easy task. Symptoms of autism in high functioning individuals can be quite subtle. Was the upset from change in a rigid routine known only to the child? Were sensory stimuli such as loud noises intolerable to this child? Was a nonverbal signal of a peer mistaken as a threat? While violent outbursts precipitated by these factors would still be considered “grossly out of proportion to the situation” for a typical child, they are not uncommon in atypical children. Similarly, children with separation anxiety disorder experience a high level of threat from even thinking about being apart from their caregivers, setting them up for alarm by situations other children would not find difficult.

The American Academy of Pediatrics emphasizes the need to assess all children for a history of psychological trauma. Traumas are quite common, and their sequelae affect many aspects of the child’s life; in the case of outbursts, it is emotional resilience that is impaired. As for all DSM-5 diagnoses, DMDD is not diagnosed when the irritability is due to physiological effects of a substance (e.g. steroids) or another medical or neurological disorder. Children with chronic pain conditions such as rheumatoid arthritis or sickle cell usually cope remarkably well, but when they don’t, their irritability should not be considered a mental health disorder. More commonly, sleep debt can produce chronic irritability and always should be assessed.

When coaching families about outbursts, I work to help them recognize that the child is not just angry, but very distressed. While “typical” tantrums last 1-5 minutes and show a rise then decline in intensity of the anger and distress, anger outbursts are longer and have an initial short and rapid burst of anger that then declines over the duration of the outburst, and with a steady but lower level of distress throughout.

The option to hug and verbally console the child’s distress is sometimes effective and does not reinforce the behavior unless the parent also yields to demands. But once outbursts begin, I liken them to a bomb going off – there is no intervention possible then. Instead, the task of the family, and over time that of the child, is to recognize and better manage the triggers.

Dr. Ross Greene, in his book, “The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children,” asserts that the child’s anger and distress can be interpreted as frustration from a gap in skills. This has treatment implications for identifying, educating about, and ameliorating the child’s weaknesses (deficits in understanding, communication, emotion regulation, flexibility or performance; or excess jealousy or hypersensitivity), and coaching parents to recognize, acknowledge, and avoid stressing these areas, if possible. I coach families to give points to the child for progressive little steps toward being able to recognize, verbalize, and inhibit outbursts with a reward system for the points. This helps put the parents and child “on the same team” in working on improving these skills.

Research on children with DMDD indicates that they show less positive affect when winning a “fixed” video game and are less able to suppress negative affect when losing. (Don’t forget to examine the role of real video games as precipitants of tantrums and contingently remove them!) Threshold for upset is lower and the degree of the upsets less well handled by children with DMDD.

In another study, when presented with a series of ambiguous facial expressions, children with DMDD were more likely to see anger in the faces than were controls. One hopeful result was that they could be taught to shift their perceptions significantly away from seeing anger, also reducing irritability and resulting in functional MRI changes. Such hostile bias attribution (tending to see threat) is well known to predispose to aggression. Cognitive behavioral therapy, the most effective counseling intervention, similarly teaches children to rethink their own negative thoughts before acting.

If irritability and rages were not enough, most children with DMDD have other psychiatric disorders; 39% having two, and 51% three or more (J Child Adolesc Psychopharmacol. 2013 Nov;23[9]:588-96). If not for the DMDD diagnosis, 82% would meet criteria for oppositional defiant disorder (ODD). The other common comorbidities are attention-deficit/hyperactivity disorder (ADHD) (74.5%), anxiety disorders (49.0%), and depression that is not major depressive disorder (MDD)(33.3%). When MDD is present, that diagnosis takes precedence. One cannot diagnose ODD, intermittent explosive disorder, or bipolar disorder along with DMDD, conditions from which it is intended to differentiate. Each of these comorbid disorders can be difficult to manage alone much less in combination, making DMDD a disorder deserving diagnosis and treatment by a mental health professional.

One of the main reasons DMDD was created is that children with these features go on to depressive or anxiety disorder in adolescence, not bipolar disorder.

While there is no treatment specific to DMDD, the depression component and prognosis suggest use of SSRIs, in addition to psychosocial therapies, and stimulants for the comorbid ADHD. Unfortunately, these two classes of medication are relatively contraindicated in bipolar disorder because they can lead to treatment-induced episodic mania (TEM). TEM occurs twice as often with antidepressants compared with stimulants (44% vs. 18%) in children with bipolar disorder (J Affect Disord. 2004 Oct 1;82[1]:149-58). Getting the diagnosis correct is, therefore, of great importance when medication is considered.

Approaches such as behavior modification, family therapy, and inpatient treatment can be effective for chronic irritability and aggression. Stimulant treatment of comorbid ADHD can decrease aggression and irritability. Alpha agonists such as guanfacine or clonidine also can help. In cases of partial improvement, adding either risperidone or divalproex may further decrease aggression in ADHD. In refractory aggression, risperidone has the best evidence. The Affective Reactivity Index or Outburst Monitoring Scale can be helpful in assessing severity and monitoring outcomes.

While a prognosis for depression rather than bipolar disorder sounds like a plus, in a longitudinal study, adults who had DMDD as children had worse outcomes, including being more likely to have adverse health outcomes (smoking, sexually transmitted infection), police contact, and low educational attainment, and being more likely to live in poverty, compared with controls who had other psychiatric disorders. While DMDD is a new and different diagnosis, it is similar to bipolar in having a potential course of life disruption, dangerous behaviors, suicide risk, and hospitalization.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at [email protected].

Outbursts by children when frustrated or when asked to “do something they don’t want to do” are among the most common behavioral complaints voiced by parents. But behavioral outbursts, beyond the typical tantrums of children up to age 4 years, can be signs of very severe mental health disorders and are the most common reason for psychiatric admission (50%-60%).

While behavioral dysregulation is undeniably a huge problem for families, there has been an unreasonable 40-fold rise in diagnosis of bipolar disorder from 1994 to 2003, and 48% were prescribed atypical neuroleptics – medications with serious side effects. In response to this overdiagnosis as bipolar disorder, in 2013 the DSM-5 created a new diagnosis called disruptive mood dysregulation disorder (DMDD) to differentiate children who experience explosive outbursts who have a different outcome. This new classification includes children aged 6-12 years with persistent irritability most of the time, nearly every day, lasting at least 12 months and starting before age 10 years. DMDD diagnosis is not used after age 18 years.

To be diagnosed, the child has to have frequent, severe temper outbursts “grossly out of proportion” to the situation, averaging at least three times per week. The outbursts can be verbal or physical aggression to people, things, or themselves. While tantrums can be severe in children with delayed development, for the DMDD diagnosis these behaviors must be inconsistent with developmental level and must occur in at least two settings, and in one setting it must be severe. While outbursts are common, only half of children in one study of severe tantrum behavior in 5- to 9-year-olds also had the required persistent irritability.

If this does sound a lot like bipolar disorder so far, you are right. So what is different? DMDD has a prevalence of 2%-5% and occurs mostly in boys, whereas bipolar disorder affects boys and girls equally and affects less than 1% prior to adolescence.

The key features distinguishing DMDD from bipolar disorder are lack of an episodic nature to the irritability and lack of mania. Irritability in DMDD has to be persistently present with breaks of no more than 3 consecutive months in the defining 12-month period. There also cannot be any more than 1 day of the elevated mood features of mania or hypomania. Identifying mania is the hardest part, even in diagnosing adult bipolar, where it occurs only 1% of the year, much less in children who are generally lively! Hypomania, while less intense than mania, is when the person is energetic, talkative, and confident to an extreme extent, often with a flight of creative ideas. Excitement over birthdays or Christmas specifically does not count! So getting this history has to be done carefully, generally by a mental health professional, to make the distinction.

Interestingly, DMDD is not diagnosed when outbursts and irritability are better explained by autism spectrum disorder, separation anxiety disorder, or PTSD. To me, these exclusions point out the importance of sorting out the “set conditions” for all problematic behaviors, not always an easy task. Symptoms of autism in high functioning individuals can be quite subtle. Was the upset from change in a rigid routine known only to the child? Were sensory stimuli such as loud noises intolerable to this child? Was a nonverbal signal of a peer mistaken as a threat? While violent outbursts precipitated by these factors would still be considered “grossly out of proportion to the situation” for a typical child, they are not uncommon in atypical children. Similarly, children with separation anxiety disorder experience a high level of threat from even thinking about being apart from their caregivers, setting them up for alarm by situations other children would not find difficult.

The American Academy of Pediatrics emphasizes the need to assess all children for a history of psychological trauma. Traumas are quite common, and their sequelae affect many aspects of the child’s life; in the case of outbursts, it is emotional resilience that is impaired. As for all DSM-5 diagnoses, DMDD is not diagnosed when the irritability is due to physiological effects of a substance (e.g. steroids) or another medical or neurological disorder. Children with chronic pain conditions such as rheumatoid arthritis or sickle cell usually cope remarkably well, but when they don’t, their irritability should not be considered a mental health disorder. More commonly, sleep debt can produce chronic irritability and always should be assessed.

When coaching families about outbursts, I work to help them recognize that the child is not just angry, but very distressed. While “typical” tantrums last 1-5 minutes and show a rise then decline in intensity of the anger and distress, anger outbursts are longer and have an initial short and rapid burst of anger that then declines over the duration of the outburst, and with a steady but lower level of distress throughout.

The option to hug and verbally console the child’s distress is sometimes effective and does not reinforce the behavior unless the parent also yields to demands. But once outbursts begin, I liken them to a bomb going off – there is no intervention possible then. Instead, the task of the family, and over time that of the child, is to recognize and better manage the triggers.

Dr. Ross Greene, in his book, “The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children,” asserts that the child’s anger and distress can be interpreted as frustration from a gap in skills. This has treatment implications for identifying, educating about, and ameliorating the child’s weaknesses (deficits in understanding, communication, emotion regulation, flexibility or performance; or excess jealousy or hypersensitivity), and coaching parents to recognize, acknowledge, and avoid stressing these areas, if possible. I coach families to give points to the child for progressive little steps toward being able to recognize, verbalize, and inhibit outbursts with a reward system for the points. This helps put the parents and child “on the same team” in working on improving these skills.

Research on children with DMDD indicates that they show less positive affect when winning a “fixed” video game and are less able to suppress negative affect when losing. (Don’t forget to examine the role of real video games as precipitants of tantrums and contingently remove them!) Threshold for upset is lower and the degree of the upsets less well handled by children with DMDD.

In another study, when presented with a series of ambiguous facial expressions, children with DMDD were more likely to see anger in the faces than were controls. One hopeful result was that they could be taught to shift their perceptions significantly away from seeing anger, also reducing irritability and resulting in functional MRI changes. Such hostile bias attribution (tending to see threat) is well known to predispose to aggression. Cognitive behavioral therapy, the most effective counseling intervention, similarly teaches children to rethink their own negative thoughts before acting.

If irritability and rages were not enough, most children with DMDD have other psychiatric disorders; 39% having two, and 51% three or more (J Child Adolesc Psychopharmacol. 2013 Nov;23[9]:588-96). If not for the DMDD diagnosis, 82% would meet criteria for oppositional defiant disorder (ODD). The other common comorbidities are attention-deficit/hyperactivity disorder (ADHD) (74.5%), anxiety disorders (49.0%), and depression that is not major depressive disorder (MDD)(33.3%). When MDD is present, that diagnosis takes precedence. One cannot diagnose ODD, intermittent explosive disorder, or bipolar disorder along with DMDD, conditions from which it is intended to differentiate. Each of these comorbid disorders can be difficult to manage alone much less in combination, making DMDD a disorder deserving diagnosis and treatment by a mental health professional.

One of the main reasons DMDD was created is that children with these features go on to depressive or anxiety disorder in adolescence, not bipolar disorder.

While there is no treatment specific to DMDD, the depression component and prognosis suggest use of SSRIs, in addition to psychosocial therapies, and stimulants for the comorbid ADHD. Unfortunately, these two classes of medication are relatively contraindicated in bipolar disorder because they can lead to treatment-induced episodic mania (TEM). TEM occurs twice as often with antidepressants compared with stimulants (44% vs. 18%) in children with bipolar disorder (J Affect Disord. 2004 Oct 1;82[1]:149-58). Getting the diagnosis correct is, therefore, of great importance when medication is considered.

Approaches such as behavior modification, family therapy, and inpatient treatment can be effective for chronic irritability and aggression. Stimulant treatment of comorbid ADHD can decrease aggression and irritability. Alpha agonists such as guanfacine or clonidine also can help. In cases of partial improvement, adding either risperidone or divalproex may further decrease aggression in ADHD. In refractory aggression, risperidone has the best evidence. The Affective Reactivity Index or Outburst Monitoring Scale can be helpful in assessing severity and monitoring outcomes.

While a prognosis for depression rather than bipolar disorder sounds like a plus, in a longitudinal study, adults who had DMDD as children had worse outcomes, including being more likely to have adverse health outcomes (smoking, sexually transmitted infection), police contact, and low educational attainment, and being more likely to live in poverty, compared with controls who had other psychiatric disorders. While DMDD is a new and different diagnosis, it is similar to bipolar in having a potential course of life disruption, dangerous behaviors, suicide risk, and hospitalization.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at [email protected].

The annual checkup has long provided an opportunity for early adolescents to learn about the risks of alcohol and drug use from a trusted source who may be less biased than parents, teachers, or police. Parents also turn to their child’s pediatrician for guidance on how to broach this important topic with their children, or they may come with concerns about their children’s use of drugs or alcohol.

Marijuana has become an increasingly complex topic, as its legal status has rapidly changed: It’s legal to purchase marijuana in four states (Alaska, Colorado, Oregon, and Washington, as well as the District of Columbia); it is decriminalized in 20 states and the District of Columbia for certain marijuana possession offenses; and it is legal to use medical marijuana in 23 states. As its legal status changes, attitudes about its use also have shifted, and its availability, form, and potency all have changed dramatically in just the past decade. Further, we ourselves may have mixed feelings about marijuana use based on our own experience as adolescents and sampling bias. We may have seen its low-level use and minimal effects in young or mature adults, or we may have seen substantial use of marijuana have a major deleterious impact on a friend or become a gateway drug for addiction to dangerous substances.

Before addressing marijuana use with adolescent patients and dealing with their potential skepticism concerning any harm, it is worth spending a little time looking in the mirror to consider your perspective on marijuana use and your response to disbelief.

According to the National Institute on Drug Abuse’s Monitoring the Future (MTF) survey, almost 12% of 8th graders, 27% of 10th graders, and 35% of 12th graders in the United States reported having used marijuana in the past year. Among the 12th graders in that 2014 survey, almost 20% were current users of marijuana and 6% were daily users. Many surveys, including the MTF, have demonstrated that attitudes of teenagers have shifted about marijuana’s dangerousness, with a steep and steady decline in the number of teenagers believing that regular marijuana use poses a risk to their health and well-being. In 2014, less than 40% of 12th graders in the MTF survey agreed that regular use of marijuana would pose a risk to their well-being, compared with a peak of almost 80% of 12th graders in the early 1990’s.

Pediatricians have an opportunity to change their patient’s thinking about marijuana. At the checkup when you routinely ask about alcohol and drug use, ask about marijuana use in particular. You might start by asking if they have heard their friends talking about marijuana? What have they heard? Are other kids using it? Have they ever seen anyone use it? Have their friends invited them to try? You should find out if they think it is safe or dangerous, and how it compares with cigarettes, alcohol, and other drugs on this score. Then you may be able to debunk some myths you hear from them.

Myth No. 1: Marijuana is medicine

Although 23 states allow the legal sale of marijuana for “medicinal purposes,” it is important to note that there are currently no Food and Drug Administration–approved indications for medical marijuana. There is modest evidence that the active compounds in marijuana (delta-9-tetra-hydrocannabinol [THC] and other cannabinoids) can be effective in the management of the muscle spasticity associated with multiple sclerosis, the treatment of nausea associated with chemotherapy, and increasing the appetite of patients with wasting due to AIDS, and there are FDA-approved synthetic cannabinoids that can be prescribed for these symptoms. It is also important to note that there is no evidence that THC or other cannabinoids are useful in the treatment of mood or anxiety symptoms, even though these are often used as reasons for seeking medicinal marijuana. Indeed, marijuana may cause or worsen several psychiatric problems.

Myth No. 2: Marijuana is safe

Although there is consensus that moderate marijuana use in adulthood poses only limited health risks (including the known risks of smoking), there is robust evidence that marijuana use during youth (through the early 20s) causes several serious and permanent effects on the developing brain. One 2012 study showed that for youth who are dependent on marijuana before they are 18 years, there is an 8-point drop in IQ in adulthood (Proc Natl Acad Sci USA. 2012 Oct 2;109[40]:E2657-64). This IQ drop persists even if they quit smoking, and does not occur for those who first become dependent on marijuana in adulthood. A 2015 study demonstrated that even for adolescents who are light smokers (one to two times weekly) with no evidence of marijuana dependence, there are significant abnormalities in the size and shape of their amygdala and nucleus accumbens, with associated changes in their motivation, decision making, attention, functional memory, and processing of emotions(J Neurosci. 2014 Apr 16;34[16]:5529-38). These abnormalities increase with increased frequency of use, and are not seen in those who begin smoking in adulthood (mid-20s and later).

Beyond these findings of cognitive deficits, evidence is growing that adolescent marijuana use is associated with several psychiatric illnesses, including depression and anxiety. There is especially strong evidence for a causal link between marijuana use and psychotic illnesses in (genetically) vulnerable young people. Any marijuana user can experience a brief psychotic reaction if the amount ingested or smoked is great enough, but for those young people who carry a specific variant of the gene for catechol-o-methyltransferase (COMT, an enzyme that degrades neurotransmitters), smoking marijuana in adolescence nearly triples their risk of developing schizophrenia in adulthood. For youth with a variant of the AKT gene (another enzyme affecting dopamine signaling in the brain), daily use of marijuana raises their risk of developing schizophrenia sevenfold. Clearly, marijuana can be the critical environmental trigger for schizophrenia in genetically vulnerable youth. Until we have a comprehensive knowledge of the relevant genes, and routinely check every patient’s complete genetic profile, it is reasonable to assume that any young person using marijuana is significantly increasing the risk of developing schizophrenia, a chronic and disabling condition.

Myth No. 3: Marijuana has no effect on driving

©iStock/ThinkStockPhotos.com

Marijuana intoxication significantly affects motor coordination, reaction time, and judgment, and multiple studies have demonstrated a direct relationship between blood THC concentration and impaired driving ability. A recent meta-analysis demonstrated that the risk of being in a car accident doubled after marijuana use (Drug Alcohol Depend. 2004 Feb 7;73[2]:109-19). These studies usually involved adults, and it is reasonable to assume that the risks may be more pronounced in adolescents, particularly ones who are new to driving or have other problems that could affect their attention or reaction time (such as attention-deficit/hyperactivity disorder). Beyond letting patients know about the increased risks of accidents, it may be worth reminding them that driving while intoxicated – even with legal use marijuana – is a criminal offense.

Myth No. 4: Marijuana has no effect on schoolwork

Aside from the risks of causing long-term cognitive changes and psychiatric problems that can affect school performance, the direct effects of marijuana intoxication can linger and affect school performance well after its use. The “high” from marijuana typically lasts from 1 to 3 hours, but the drug’s effects on higher-level cognitive processes (mediated by the neocortex and hippocampus) can last for days. So a teenager who smokes on Saturday night may have lingering impairment of motivation, the ability to shift attention, the ability to learn complex tasks, and working memory. These are all critical cognitive abilities for learning, and can make studying on Sunday and performing well on a test on Monday much more difficult.

Myth No. 5: Marijuana is not addictive

Marijuana is addictive, with studies suggesting that nearly 9% of marijuana users will become addicted. Again, the risks are far greater for young people. Among people who begin using marijuana during adolescence, the rate of addiction climbs to 17%, and can be as high as 50% in daily users. Remember that addiction describes a pattern of continued use despite that use causing significant legal, social, or school and work problems. Users also may develop physical dependence, with a withdrawal syndrome that includes irritability, restlessness, insomnia, and appetite changes; these can last as long as 2 weeks.

Currently available forms of marijuana are much more potent than those that were studied and used in prior decades. On average, the potency of smoked marijuana has tripled, and there are concentrates (in oil form, for example) and hybrids with much higher potency still. More potent marijuana increases the high from even a small dose, and increases the likelihood of addiction and of other immediate and lingering complications of its use. So, parents who think they know what marijuana does to adolescents based on their own youthful experiences are significantly underestimating the risks.

When asking your patients explicitly about marijuana use, be curious and nonjudgmental, but also be frank and forthright about what is known about the risks associated with its use. Although the current legal and political changes around marijuana use may have given them the impression that marijuana use is safe, you want them to have the facts they need to make informed decisions. Even if you only discuss one of these myths with your patients, you will have equipped them with powerful information that they may use and share with their friends.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. Email them at [email protected].

The annual checkup has long provided an opportunity for early adolescents to learn about the risks of alcohol and drug use from a trusted source who may be less biased than parents, teachers, or police. Parents also turn to their child’s pediatrician for guidance on how to broach this important topic with their children, or they may come with concerns about their children’s use of drugs or alcohol.

Marijuana has become an increasingly complex topic, as its legal status has rapidly changed: It’s legal to purchase marijuana in four states (Alaska, Colorado, Oregon, and Washington, as well as the District of Columbia); it is decriminalized in 20 states and the District of Columbia for certain marijuana possession offenses; and it is legal to use medical marijuana in 23 states. As its legal status changes, attitudes about its use also have shifted, and its availability, form, and potency all have changed dramatically in just the past decade. Further, we ourselves may have mixed feelings about marijuana use based on our own experience as adolescents and sampling bias. We may have seen its low-level use and minimal effects in young or mature adults, or we may have seen substantial use of marijuana have a major deleterious impact on a friend or become a gateway drug for addiction to dangerous substances.

Before addressing marijuana use with adolescent patients and dealing with their potential skepticism concerning any harm, it is worth spending a little time looking in the mirror to consider your perspective on marijuana use and your response to disbelief.

According to the National Institute on Drug Abuse’s Monitoring the Future (MTF) survey, almost 12% of 8th graders, 27% of 10th graders, and 35% of 12th graders in the United States reported having used marijuana in the past year. Among the 12th graders in that 2014 survey, almost 20% were current users of marijuana and 6% were daily users. Many surveys, including the MTF, have demonstrated that attitudes of teenagers have shifted about marijuana’s dangerousness, with a steep and steady decline in the number of teenagers believing that regular marijuana use poses a risk to their health and well-being. In 2014, less than 40% of 12th graders in the MTF survey agreed that regular use of marijuana would pose a risk to their well-being, compared with a peak of almost 80% of 12th graders in the early 1990’s.

Pediatricians have an opportunity to change their patient’s thinking about marijuana. At the checkup when you routinely ask about alcohol and drug use, ask about marijuana use in particular. You might start by asking if they have heard their friends talking about marijuana? What have they heard? Are other kids using it? Have they ever seen anyone use it? Have their friends invited them to try? You should find out if they think it is safe or dangerous, and how it compares with cigarettes, alcohol, and other drugs on this score. Then you may be able to debunk some myths you hear from them.

Myth No. 1: Marijuana is medicine

Although 23 states allow the legal sale of marijuana for “medicinal purposes,” it is important to note that there are currently no Food and Drug Administration–approved indications for medical marijuana. There is modest evidence that the active compounds in marijuana (delta-9-tetra-hydrocannabinol [THC] and other cannabinoids) can be effective in the management of the muscle spasticity associated with multiple sclerosis, the treatment of nausea associated with chemotherapy, and increasing the appetite of patients with wasting due to AIDS, and there are FDA-approved synthetic cannabinoids that can be prescribed for these symptoms. It is also important to note that there is no evidence that THC or other cannabinoids are useful in the treatment of mood or anxiety symptoms, even though these are often used as reasons for seeking medicinal marijuana. Indeed, marijuana may cause or worsen several psychiatric problems.

Myth No. 2: Marijuana is safe

Although there is consensus that moderate marijuana use in adulthood poses only limited health risks (including the known risks of smoking), there is robust evidence that marijuana use during youth (through the early 20s) causes several serious and permanent effects on the developing brain. One 2012 study showed that for youth who are dependent on marijuana before they are 18 years, there is an 8-point drop in IQ in adulthood (Proc Natl Acad Sci USA. 2012 Oct 2;109[40]:E2657-64). This IQ drop persists even if they quit smoking, and does not occur for those who first become dependent on marijuana in adulthood. A 2015 study demonstrated that even for adolescents who are light smokers (one to two times weekly) with no evidence of marijuana dependence, there are significant abnormalities in the size and shape of their amygdala and nucleus accumbens, with associated changes in their motivation, decision making, attention, functional memory, and processing of emotions(J Neurosci. 2014 Apr 16;34[16]:5529-38). These abnormalities increase with increased frequency of use, and are not seen in those who begin smoking in adulthood (mid-20s and later).

Beyond these findings of cognitive deficits, evidence is growing that adolescent marijuana use is associated with several psychiatric illnesses, including depression and anxiety. There is especially strong evidence for a causal link between marijuana use and psychotic illnesses in (genetically) vulnerable young people. Any marijuana user can experience a brief psychotic reaction if the amount ingested or smoked is great enough, but for those young people who carry a specific variant of the gene for catechol-o-methyltransferase (COMT, an enzyme that degrades neurotransmitters), smoking marijuana in adolescence nearly triples their risk of developing schizophrenia in adulthood. For youth with a variant of the AKT gene (another enzyme affecting dopamine signaling in the brain), daily use of marijuana raises their risk of developing schizophrenia sevenfold. Clearly, marijuana can be the critical environmental trigger for schizophrenia in genetically vulnerable youth. Until we have a comprehensive knowledge of the relevant genes, and routinely check every patient’s complete genetic profile, it is reasonable to assume that any young person using marijuana is significantly increasing the risk of developing schizophrenia, a chronic and disabling condition.

Myth No. 3: Marijuana has no effect on driving

©iStock/ThinkStockPhotos.com

Marijuana intoxication significantly affects motor coordination, reaction time, and judgment, and multiple studies have demonstrated a direct relationship between blood THC concentration and impaired driving ability. A recent meta-analysis demonstrated that the risk of being in a car accident doubled after marijuana use (Drug Alcohol Depend. 2004 Feb 7;73[2]:109-19). These studies usually involved adults, and it is reasonable to assume that the risks may be more pronounced in adolescents, particularly ones who are new to driving or have other problems that could affect their attention or reaction time (such as attention-deficit/hyperactivity disorder). Beyond letting patients know about the increased risks of accidents, it may be worth reminding them that driving while intoxicated – even with legal use marijuana – is a criminal offense.

Myth No. 4: Marijuana has no effect on schoolwork

Aside from the risks of causing long-term cognitive changes and psychiatric problems that can affect school performance, the direct effects of marijuana intoxication can linger and affect school performance well after its use. The “high” from marijuana typically lasts from 1 to 3 hours, but the drug’s effects on higher-level cognitive processes (mediated by the neocortex and hippocampus) can last for days. So a teenager who smokes on Saturday night may have lingering impairment of motivation, the ability to shift attention, the ability to learn complex tasks, and working memory. These are all critical cognitive abilities for learning, and can make studying on Sunday and performing well on a test on Monday much more difficult.

Myth No. 5: Marijuana is not addictive

Marijuana is addictive, with studies suggesting that nearly 9% of marijuana users will become addicted. Again, the risks are far greater for young people. Among people who begin using marijuana during adolescence, the rate of addiction climbs to 17%, and can be as high as 50% in daily users. Remember that addiction describes a pattern of continued use despite that use causing significant legal, social, or school and work problems. Users also may develop physical dependence, with a withdrawal syndrome that includes irritability, restlessness, insomnia, and appetite changes; these can last as long as 2 weeks.

Currently available forms of marijuana are much more potent than those that were studied and used in prior decades. On average, the potency of smoked marijuana has tripled, and there are concentrates (in oil form, for example) and hybrids with much higher potency still. More potent marijuana increases the high from even a small dose, and increases the likelihood of addiction and of other immediate and lingering complications of its use. So, parents who think they know what marijuana does to adolescents based on their own youthful experiences are significantly underestimating the risks.

When asking your patients explicitly about marijuana use, be curious and nonjudgmental, but also be frank and forthright about what is known about the risks associated with its use. Although the current legal and political changes around marijuana use may have given them the impression that marijuana use is safe, you want them to have the facts they need to make informed decisions. Even if you only discuss one of these myths with your patients, you will have equipped them with powerful information that they may use and share with their friends.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. Email them at [email protected].

The annual checkup has long provided an opportunity for early adolescents to learn about the risks of alcohol and drug use from a trusted source who may be less biased than parents, teachers, or police. Parents also turn to their child’s pediatrician for guidance on how to broach this important topic with their children, or they may come with concerns about their children’s use of drugs or alcohol.

Marijuana has become an increasingly complex topic, as its legal status has rapidly changed: It’s legal to purchase marijuana in four states (Alaska, Colorado, Oregon, and Washington, as well as the District of Columbia); it is decriminalized in 20 states and the District of Columbia for certain marijuana possession offenses; and it is legal to use medical marijuana in 23 states. As its legal status changes, attitudes about its use also have shifted, and its availability, form, and potency all have changed dramatically in just the past decade. Further, we ourselves may have mixed feelings about marijuana use based on our own experience as adolescents and sampling bias. We may have seen its low-level use and minimal effects in young or mature adults, or we may have seen substantial use of marijuana have a major deleterious impact on a friend or become a gateway drug for addiction to dangerous substances.

Before addressing marijuana use with adolescent patients and dealing with their potential skepticism concerning any harm, it is worth spending a little time looking in the mirror to consider your perspective on marijuana use and your response to disbelief.

According to the National Institute on Drug Abuse’s Monitoring the Future (MTF) survey, almost 12% of 8th graders, 27% of 10th graders, and 35% of 12th graders in the United States reported having used marijuana in the past year. Among the 12th graders in that 2014 survey, almost 20% were current users of marijuana and 6% were daily users. Many surveys, including the MTF, have demonstrated that attitudes of teenagers have shifted about marijuana’s dangerousness, with a steep and steady decline in the number of teenagers believing that regular marijuana use poses a risk to their health and well-being. In 2014, less than 40% of 12th graders in the MTF survey agreed that regular use of marijuana would pose a risk to their well-being, compared with a peak of almost 80% of 12th graders in the early 1990’s.

Pediatricians have an opportunity to change their patient’s thinking about marijuana. At the checkup when you routinely ask about alcohol and drug use, ask about marijuana use in particular. You might start by asking if they have heard their friends talking about marijuana? What have they heard? Are other kids using it? Have they ever seen anyone use it? Have their friends invited them to try? You should find out if they think it is safe or dangerous, and how it compares with cigarettes, alcohol, and other drugs on this score. Then you may be able to debunk some myths you hear from them.

Myth No. 1: Marijuana is medicine

Although 23 states allow the legal sale of marijuana for “medicinal purposes,” it is important to note that there are currently no Food and Drug Administration–approved indications for medical marijuana. There is modest evidence that the active compounds in marijuana (delta-9-tetra-hydrocannabinol [THC] and other cannabinoids) can be effective in the management of the muscle spasticity associated with multiple sclerosis, the treatment of nausea associated with chemotherapy, and increasing the appetite of patients with wasting due to AIDS, and there are FDA-approved synthetic cannabinoids that can be prescribed for these symptoms. It is also important to note that there is no evidence that THC or other cannabinoids are useful in the treatment of mood or anxiety symptoms, even though these are often used as reasons for seeking medicinal marijuana. Indeed, marijuana may cause or worsen several psychiatric problems.

Myth No. 2: Marijuana is safe

Although there is consensus that moderate marijuana use in adulthood poses only limited health risks (including the known risks of smoking), there is robust evidence that marijuana use during youth (through the early 20s) causes several serious and permanent effects on the developing brain. One 2012 study showed that for youth who are dependent on marijuana before they are 18 years, there is an 8-point drop in IQ in adulthood (Proc Natl Acad Sci USA. 2012 Oct 2;109[40]:E2657-64). This IQ drop persists even if they quit smoking, and does not occur for those who first become dependent on marijuana in adulthood. A 2015 study demonstrated that even for adolescents who are light smokers (one to two times weekly) with no evidence of marijuana dependence, there are significant abnormalities in the size and shape of their amygdala and nucleus accumbens, with associated changes in their motivation, decision making, attention, functional memory, and processing of emotions(J Neurosci. 2014 Apr 16;34[16]:5529-38). These abnormalities increase with increased frequency of use, and are not seen in those who begin smoking in adulthood (mid-20s and later).

Beyond these findings of cognitive deficits, evidence is growing that adolescent marijuana use is associated with several psychiatric illnesses, including depression and anxiety. There is especially strong evidence for a causal link between marijuana use and psychotic illnesses in (genetically) vulnerable young people. Any marijuana user can experience a brief psychotic reaction if the amount ingested or smoked is great enough, but for those young people who carry a specific variant of the gene for catechol-o-methyltransferase (COMT, an enzyme that degrades neurotransmitters), smoking marijuana in adolescence nearly triples their risk of developing schizophrenia in adulthood. For youth with a variant of the AKT gene (another enzyme affecting dopamine signaling in the brain), daily use of marijuana raises their risk of developing schizophrenia sevenfold. Clearly, marijuana can be the critical environmental trigger for schizophrenia in genetically vulnerable youth. Until we have a comprehensive knowledge of the relevant genes, and routinely check every patient’s complete genetic profile, it is reasonable to assume that any young person using marijuana is significantly increasing the risk of developing schizophrenia, a chronic and disabling condition.

Myth No. 3: Marijuana has no effect on driving

©iStock/ThinkStockPhotos.com

Marijuana intoxication significantly affects motor coordination, reaction time, and judgment, and multiple studies have demonstrated a direct relationship between blood THC concentration and impaired driving ability. A recent meta-analysis demonstrated that the risk of being in a car accident doubled after marijuana use (Drug Alcohol Depend. 2004 Feb 7;73[2]:109-19). These studies usually involved adults, and it is reasonable to assume that the risks may be more pronounced in adolescents, particularly ones who are new to driving or have other problems that could affect their attention or reaction time (such as attention-deficit/hyperactivity disorder). Beyond letting patients know about the increased risks of accidents, it may be worth reminding them that driving while intoxicated – even with legal use marijuana – is a criminal offense.

Myth No. 4: Marijuana has no effect on schoolwork

Aside from the risks of causing long-term cognitive changes and psychiatric problems that can affect school performance, the direct effects of marijuana intoxication can linger and affect school performance well after its use. The “high” from marijuana typically lasts from 1 to 3 hours, but the drug’s effects on higher-level cognitive processes (mediated by the neocortex and hippocampus) can last for days. So a teenager who smokes on Saturday night may have lingering impairment of motivation, the ability to shift attention, the ability to learn complex tasks, and working memory. These are all critical cognitive abilities for learning, and can make studying on Sunday and performing well on a test on Monday much more difficult.

Myth No. 5: Marijuana is not addictive

Marijuana is addictive, with studies suggesting that nearly 9% of marijuana users will become addicted. Again, the risks are far greater for young people. Among people who begin using marijuana during adolescence, the rate of addiction climbs to 17%, and can be as high as 50% in daily users. Remember that addiction describes a pattern of continued use despite that use causing significant legal, social, or school and work problems. Users also may develop physical dependence, with a withdrawal syndrome that includes irritability, restlessness, insomnia, and appetite changes; these can last as long as 2 weeks.

Currently available forms of marijuana are much more potent than those that were studied and used in prior decades. On average, the potency of smoked marijuana has tripled, and there are concentrates (in oil form, for example) and hybrids with much higher potency still. More potent marijuana increases the high from even a small dose, and increases the likelihood of addiction and of other immediate and lingering complications of its use. So, parents who think they know what marijuana does to adolescents based on their own youthful experiences are significantly underestimating the risks.

When asking your patients explicitly about marijuana use, be curious and nonjudgmental, but also be frank and forthright about what is known about the risks associated with its use. Although the current legal and political changes around marijuana use may have given them the impression that marijuana use is safe, you want them to have the facts they need to make informed decisions. Even if you only discuss one of these myths with your patients, you will have equipped them with powerful information that they may use and share with their friends.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. Email them at [email protected].

Even the name “special needs” gives a clue about what it can be like to be a sibling of a child with a chronic condition. When a sibling has special needs, from a child’s perspective, that sibling can seem to be regarded as more special than me!

Whether parents are caring for a child with a physical or mental condition, the amount of attention required almost inevitably consumes some of the time the siblings might otherwise access. There are more visits to doctors and other professionals, hospitalizations with one parent staying overnight, more tests, and sometimes even therapists coming into the family’s home for monitoring or care giving. If the primary issue is mental health that takes attention, too! Sometimes even routine health care for the sibling falls behind.

When the special needs child is acutely ill, or a time-sensitive need or crisis occurs, everything planned for the family that day can go out the window. There is hardly an adult who would not resent always being second fiddle, much less a child with less maturity.

There are more subtle reasons for potential resentment that come from having a special sibling. Although federal regulations now mandate accessibility, often the kinds of outings typical families enjoy are too much hassle to arrange when there is equipment to haul, there are medicines to refrigerate, or there are toileting requirements such as for catheter care. Travel team soccer is out. So these events just don’t happen for the family as a whole.

Even with greater community awareness of different special needs conditions such as autism, stigma still exists. Siblings already are embarrassed about behaviors of typically developing children who pick their noses, laugh too loudly, or slurp their milkshake! It is not hard to see how being in public with a sibling who is shouting, rocking, or having tantrums could be mortifying. Children often choose playdates at someone else’s house to avoid having to explain or deal with their special sibling. This creates a kind of uneven relationship with peers and also deprives parents from being involved.

Siblings of children with special needs are often asked to help out. They have to answer the door when the parent is suctioning, babysit that child or siblings, feed them, or even provide direct care for the child’s medical needs. Household chores that would have been shared with a typically developing child may fall on the sibling.

Finances often add another constraint on the opportunities for a sibling of a child with special needs. Even really good insurance does not cover all the extra costs associated with chronic conditions. Babysitters may need extra skills; vehicles may need lifts or extra space; the home may need structural changes. Paying all these costs means other things don’t fit the budget. Even for a family of means, for the sibling this may result in public school rather than an elite private school, no music lessons, or no overnight camp. For families of lesser means, even life’s basics are hard to afford.

As children get older, they begin to worry about their future options. Will there be enough money for college? Will I have to live at home to help out? What if my parents die and I am the only one left to care for my special sibling? How will I ever get a date or get married?

While all of these factors are stresses, studies have shown being a sibling of a special needs child promotes greater compassion and maturity. Being of real help in the family and to a beloved sibling gives meaning to a child’s life that may be hard to come by during more typical circumstances of growing up. Certainly you have seen in your practice how siblings of special needs children disproportionately aim for careers in health care, psychology, social work, or other helping professions. This may even have been a factor in your own life.

But some siblings of children with special needs become depressed, develop hardened resentment, or take a defiant, acting-out stance. How can you support siblings so that this is not the outcome?

The first step is to ask about their well-being at every visit for the child with special needs. When parents respond with a balanced expression of the positive and the problematic, you can be reassured. If they seem immune to the difficulties the sibling must be experiencing or interpret jealous or attention-seeking behaviors as being solely “bad,” then more discussion or even referral for counseling may be needed. A parent who ordinarily might have understood may not when overburdened or depressed. The siblings with greater maturity and compassion were likely raised by parents who made sure that the point of view and positive attributes of every child in the family were voiced, and that each had opportunities to contribute to the family in meaningful ways as well as express themselves.

“Strong empathic talk” about the sibling’s feelings has been shown to be one of the best ways to build all positive sibling relationships starting in infancy. Acknowledging jealousy and providing individual attention come next. When things aren’t “fair” (which they often cannot be), token fairness helps. For the sake of the sibling, a child with special needs should still have “chores” (such as pulling sheets out of the dryer) and consequences for misbehavior (such as time out), whether the child understands or not.

At their own health supervision visit, I ask siblings about their relationship with the child with special needs, what is fun for them together and what is the hardest part about living with them. The aim is to assess their attitudes and also give them permission to complain. I almost always do this interview with the parents present, giving them a chance to hear those views (although private time may be needed as well). It often is hard for parents and the child himself or herself to express negative feelings because the special needs situation was no one’s fault and everyone has to work hard to be optimistic and to cope. You can then model a sympathetic ear plus assist in coming up with solutions, when possible. The interventions I suggest are often “tokens” to address the family dynamics rather than solutions to the problem. For example, a teen sibling of a child with autism under my care showed depression. Although for fun he played video games with his brother with autism, the hardest part was the lack of an age-appropriate social life. He had to make breakfast and get the special needs sibling off to school every morning as well as care for him after school while their single mother worked. We discussed this, and their mother determined to pay the teen for child care plus loosen her restrictions on his bedtime so that he could go out with friends.

Simply allowing the sibling expression that it can be hard is helpful. Many times stress is denied. To open up discussion, ask such questions as, “How is it having friends over?” or “Do you get enough time with your mom, just you and her?” or “Are there things you miss out on because you have a sister with special needs?”. These same topics are relevant for the parents themselves, too. Protecting the sibling’s privacy during playdates, having 10 minutes daily alone with the sibling to talk or play cards, or setting some family savings goals for the missing privileges are possible solutions that parents could implement. I suggest regular family meetings at home to ensure that these discussions occur and that the solutions are maintained or refined over time.

There are services available for some special needs conditions that are helpful in supporting siblings. Wraparound services may include respite care to allow family vacations, babysitters with needed skills, or payment for summer camp for children with special needs. Summer camps specific to siblings of children with special needs exist as well.

When free services are not available or finances are tight, you can encourage families to think outside the box. Maybe they can trade child care with another family with a child with special needs – each taking both kids for weekly breaks for the other family. Both condition-specific and general parent support groups often are helpful for coming up with ideas and making friendships that can lead to this kind of exchange.

When parents do not have a sitter they trust to manage care for the child with special needs, I often suggest getting a less-skilled (and less expensive) sitter (an 11-year old-works) to mind the child, but then the parent can stay in the house or yard to allow for individual time with the sibling without having to worry. (This is a good tip for time alone for spouses, too!)

The long-term questions that older siblings will have are best addressed by making a plan with a financial adviser. Organizations such as the Arc of the United States (www.thearc.org) and lawyers specializing in disabilities can provide this kind of advice. A trust fund, an up-to-date will, and a written plan for care giving long term are important to reduce worries parents have and can be communicated to the siblings when the time is right.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline.

Even the name “special needs” gives a clue about what it can be like to be a sibling of a child with a chronic condition. When a sibling has special needs, from a child’s perspective, that sibling can seem to be regarded as more special than me!

Whether parents are caring for a child with a physical or mental condition, the amount of attention required almost inevitably consumes some of the time the siblings might otherwise access. There are more visits to doctors and other professionals, hospitalizations with one parent staying overnight, more tests, and sometimes even therapists coming into the family’s home for monitoring or care giving. If the primary issue is mental health that takes attention, too! Sometimes even routine health care for the sibling falls behind.

When the special needs child is acutely ill, or a time-sensitive need or crisis occurs, everything planned for the family that day can go out the window. There is hardly an adult who would not resent always being second fiddle, much less a child with less maturity.

There are more subtle reasons for potential resentment that come from having a special sibling. Although federal regulations now mandate accessibility, often the kinds of outings typical families enjoy are too much hassle to arrange when there is equipment to haul, there are medicines to refrigerate, or there are toileting requirements such as for catheter care. Travel team soccer is out. So these events just don’t happen for the family as a whole.

Even with greater community awareness of different special needs conditions such as autism, stigma still exists. Siblings already are embarrassed about behaviors of typically developing children who pick their noses, laugh too loudly, or slurp their milkshake! It is not hard to see how being in public with a sibling who is shouting, rocking, or having tantrums could be mortifying. Children often choose playdates at someone else’s house to avoid having to explain or deal with their special sibling. This creates a kind of uneven relationship with peers and also deprives parents from being involved.

Siblings of children with special needs are often asked to help out. They have to answer the door when the parent is suctioning, babysit that child or siblings, feed them, or even provide direct care for the child’s medical needs. Household chores that would have been shared with a typically developing child may fall on the sibling.

Finances often add another constraint on the opportunities for a sibling of a child with special needs. Even really good insurance does not cover all the extra costs associated with chronic conditions. Babysitters may need extra skills; vehicles may need lifts or extra space; the home may need structural changes. Paying all these costs means other things don’t fit the budget. Even for a family of means, for the sibling this may result in public school rather than an elite private school, no music lessons, or no overnight camp. For families of lesser means, even life’s basics are hard to afford.

As children get older, they begin to worry about their future options. Will there be enough money for college? Will I have to live at home to help out? What if my parents die and I am the only one left to care for my special sibling? How will I ever get a date or get married?

While all of these factors are stresses, studies have shown being a sibling of a special needs child promotes greater compassion and maturity. Being of real help in the family and to a beloved sibling gives meaning to a child’s life that may be hard to come by during more typical circumstances of growing up. Certainly you have seen in your practice how siblings of special needs children disproportionately aim for careers in health care, psychology, social work, or other helping professions. This may even have been a factor in your own life.

But some siblings of children with special needs become depressed, develop hardened resentment, or take a defiant, acting-out stance. How can you support siblings so that this is not the outcome?

The first step is to ask about their well-being at every visit for the child with special needs. When parents respond with a balanced expression of the positive and the problematic, you can be reassured. If they seem immune to the difficulties the sibling must be experiencing or interpret jealous or attention-seeking behaviors as being solely “bad,” then more discussion or even referral for counseling may be needed. A parent who ordinarily might have understood may not when overburdened or depressed. The siblings with greater maturity and compassion were likely raised by parents who made sure that the point of view and positive attributes of every child in the family were voiced, and that each had opportunities to contribute to the family in meaningful ways as well as express themselves.

“Strong empathic talk” about the sibling’s feelings has been shown to be one of the best ways to build all positive sibling relationships starting in infancy. Acknowledging jealousy and providing individual attention come next. When things aren’t “fair” (which they often cannot be), token fairness helps. For the sake of the sibling, a child with special needs should still have “chores” (such as pulling sheets out of the dryer) and consequences for misbehavior (such as time out), whether the child understands or not.

At their own health supervision visit, I ask siblings about their relationship with the child with special needs, what is fun for them together and what is the hardest part about living with them. The aim is to assess their attitudes and also give them permission to complain. I almost always do this interview with the parents present, giving them a chance to hear those views (although private time may be needed as well). It often is hard for parents and the child himself or herself to express negative feelings because the special needs situation was no one’s fault and everyone has to work hard to be optimistic and to cope. You can then model a sympathetic ear plus assist in coming up with solutions, when possible. The interventions I suggest are often “tokens” to address the family dynamics rather than solutions to the problem. For example, a teen sibling of a child with autism under my care showed depression. Although for fun he played video games with his brother with autism, the hardest part was the lack of an age-appropriate social life. He had to make breakfast and get the special needs sibling off to school every morning as well as care for him after school while their single mother worked. We discussed this, and their mother determined to pay the teen for child care plus loosen her restrictions on his bedtime so that he could go out with friends.

Simply allowing the sibling expression that it can be hard is helpful. Many times stress is denied. To open up discussion, ask such questions as, “How is it having friends over?” or “Do you get enough time with your mom, just you and her?” or “Are there things you miss out on because you have a sister with special needs?”. These same topics are relevant for the parents themselves, too. Protecting the sibling’s privacy during playdates, having 10 minutes daily alone with the sibling to talk or play cards, or setting some family savings goals for the missing privileges are possible solutions that parents could implement. I suggest regular family meetings at home to ensure that these discussions occur and that the solutions are maintained or refined over time.

There are services available for some special needs conditions that are helpful in supporting siblings. Wraparound services may include respite care to allow family vacations, babysitters with needed skills, or payment for summer camp for children with special needs. Summer camps specific to siblings of children with special needs exist as well.

When free services are not available or finances are tight, you can encourage families to think outside the box. Maybe they can trade child care with another family with a child with special needs – each taking both kids for weekly breaks for the other family. Both condition-specific and general parent support groups often are helpful for coming up with ideas and making friendships that can lead to this kind of exchange.

When parents do not have a sitter they trust to manage care for the child with special needs, I often suggest getting a less-skilled (and less expensive) sitter (an 11-year old-works) to mind the child, but then the parent can stay in the house or yard to allow for individual time with the sibling without having to worry. (This is a good tip for time alone for spouses, too!)

The long-term questions that older siblings will have are best addressed by making a plan with a financial adviser. Organizations such as the Arc of the United States (www.thearc.org) and lawyers specializing in disabilities can provide this kind of advice. A trust fund, an up-to-date will, and a written plan for care giving long term are important to reduce worries parents have and can be communicated to the siblings when the time is right.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline.

Even the name “special needs” gives a clue about what it can be like to be a sibling of a child with a chronic condition. When a sibling has special needs, from a child’s perspective, that sibling can seem to be regarded as more special than me!

Whether parents are caring for a child with a physical or mental condition, the amount of attention required almost inevitably consumes some of the time the siblings might otherwise access. There are more visits to doctors and other professionals, hospitalizations with one parent staying overnight, more tests, and sometimes even therapists coming into the family’s home for monitoring or care giving. If the primary issue is mental health that takes attention, too! Sometimes even routine health care for the sibling falls behind.

When the special needs child is acutely ill, or a time-sensitive need or crisis occurs, everything planned for the family that day can go out the window. There is hardly an adult who would not resent always being second fiddle, much less a child with less maturity.

There are more subtle reasons for potential resentment that come from having a special sibling. Although federal regulations now mandate accessibility, often the kinds of outings typical families enjoy are too much hassle to arrange when there is equipment to haul, there are medicines to refrigerate, or there are toileting requirements such as for catheter care. Travel team soccer is out. So these events just don’t happen for the family as a whole.

Even with greater community awareness of different special needs conditions such as autism, stigma still exists. Siblings already are embarrassed about behaviors of typically developing children who pick their noses, laugh too loudly, or slurp their milkshake! It is not hard to see how being in public with a sibling who is shouting, rocking, or having tantrums could be mortifying. Children often choose playdates at someone else’s house to avoid having to explain or deal with their special sibling. This creates a kind of uneven relationship with peers and also deprives parents from being involved.

Siblings of children with special needs are often asked to help out. They have to answer the door when the parent is suctioning, babysit that child or siblings, feed them, or even provide direct care for the child’s medical needs. Household chores that would have been shared with a typically developing child may fall on the sibling.

Finances often add another constraint on the opportunities for a sibling of a child with special needs. Even really good insurance does not cover all the extra costs associated with chronic conditions. Babysitters may need extra skills; vehicles may need lifts or extra space; the home may need structural changes. Paying all these costs means other things don’t fit the budget. Even for a family of means, for the sibling this may result in public school rather than an elite private school, no music lessons, or no overnight camp. For families of lesser means, even life’s basics are hard to afford.

As children get older, they begin to worry about their future options. Will there be enough money for college? Will I have to live at home to help out? What if my parents die and I am the only one left to care for my special sibling? How will I ever get a date or get married?

While all of these factors are stresses, studies have shown being a sibling of a special needs child promotes greater compassion and maturity. Being of real help in the family and to a beloved sibling gives meaning to a child’s life that may be hard to come by during more typical circumstances of growing up. Certainly you have seen in your practice how siblings of special needs children disproportionately aim for careers in health care, psychology, social work, or other helping professions. This may even have been a factor in your own life.

But some siblings of children with special needs become depressed, develop hardened resentment, or take a defiant, acting-out stance. How can you support siblings so that this is not the outcome?

The first step is to ask about their well-being at every visit for the child with special needs. When parents respond with a balanced expression of the positive and the problematic, you can be reassured. If they seem immune to the difficulties the sibling must be experiencing or interpret jealous or attention-seeking behaviors as being solely “bad,” then more discussion or even referral for counseling may be needed. A parent who ordinarily might have understood may not when overburdened or depressed. The siblings with greater maturity and compassion were likely raised by parents who made sure that the point of view and positive attributes of every child in the family were voiced, and that each had opportunities to contribute to the family in meaningful ways as well as express themselves.

“Strong empathic talk” about the sibling’s feelings has been shown to be one of the best ways to build all positive sibling relationships starting in infancy. Acknowledging jealousy and providing individual attention come next. When things aren’t “fair” (which they often cannot be), token fairness helps. For the sake of the sibling, a child with special needs should still have “chores” (such as pulling sheets out of the dryer) and consequences for misbehavior (such as time out), whether the child understands or not.

At their own health supervision visit, I ask siblings about their relationship with the child with special needs, what is fun for them together and what is the hardest part about living with them. The aim is to assess their attitudes and also give them permission to complain. I almost always do this interview with the parents present, giving them a chance to hear those views (although private time may be needed as well). It often is hard for parents and the child himself or herself to express negative feelings because the special needs situation was no one’s fault and everyone has to work hard to be optimistic and to cope. You can then model a sympathetic ear plus assist in coming up with solutions, when possible. The interventions I suggest are often “tokens” to address the family dynamics rather than solutions to the problem. For example, a teen sibling of a child with autism under my care showed depression. Although for fun he played video games with his brother with autism, the hardest part was the lack of an age-appropriate social life. He had to make breakfast and get the special needs sibling off to school every morning as well as care for him after school while their single mother worked. We discussed this, and their mother determined to pay the teen for child care plus loosen her restrictions on his bedtime so that he could go out with friends.

Simply allowing the sibling expression that it can be hard is helpful. Many times stress is denied. To open up discussion, ask such questions as, “How is it having friends over?” or “Do you get enough time with your mom, just you and her?” or “Are there things you miss out on because you have a sister with special needs?”. These same topics are relevant for the parents themselves, too. Protecting the sibling’s privacy during playdates, having 10 minutes daily alone with the sibling to talk or play cards, or setting some family savings goals for the missing privileges are possible solutions that parents could implement. I suggest regular family meetings at home to ensure that these discussions occur and that the solutions are maintained or refined over time.

There are services available for some special needs conditions that are helpful in supporting siblings. Wraparound services may include respite care to allow family vacations, babysitters with needed skills, or payment for summer camp for children with special needs. Summer camps specific to siblings of children with special needs exist as well.

When free services are not available or finances are tight, you can encourage families to think outside the box. Maybe they can trade child care with another family with a child with special needs – each taking both kids for weekly breaks for the other family. Both condition-specific and general parent support groups often are helpful for coming up with ideas and making friendships that can lead to this kind of exchange.

When parents do not have a sitter they trust to manage care for the child with special needs, I often suggest getting a less-skilled (and less expensive) sitter (an 11-year old-works) to mind the child, but then the parent can stay in the house or yard to allow for individual time with the sibling without having to worry. (This is a good tip for time alone for spouses, too!)

The long-term questions that older siblings will have are best addressed by making a plan with a financial adviser. Organizations such as the Arc of the United States (www.thearc.org) and lawyers specializing in disabilities can provide this kind of advice. A trust fund, an up-to-date will, and a written plan for care giving long term are important to reduce worries parents have and can be communicated to the siblings when the time is right.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline.

The biological transition to puberty has always marked a critical point in a primary care pediatrician’s relationship to a patient. Adolescents’ capacity for abstract reasoning, their movement to autonomy, their nuanced sense of identity, their need for privacy, and their emerging sexuality together give the pediatrician an opportunity and a responsibility to create a safe place to talk. Your office can be an oasis from parents, peers, and a society that seems saturated with sexuality. You can be trusted more than the Internet and offer discussions that are leavened by your long-standing relationship with the patient.

The growing public awareness, acceptance, and legal standing given to gay, lesbian, bisexual, and transgender individuals represents welcome societal progress, and we sense that amidst this richer public conversation, a growing number of children and adolescents are presenting with questions or worries about their own emerging sexual orientation or gender identity. We would like to start with our key takeaway: Discussions about sexual orientation and gender identity do not require that you give answers or predict the future. Focus instead on being a curious, compassionate, and nonjudgmental listener, and you will be effective at helping your patient to better manage new, uncertain, and possibly stressful feelings.

Our focus today is how to create a safe setting and specifically how to ask about and discuss sexual orientation. Most teenagers will wonder at some point about their orientation. Studies suggest that among adults, 5%-10% are attracted to the same sex and 3% describe themselves as gay or bisexual. Such surveys are very challenging, though, and in our experience, these percentages are higher. Sexual orientation is believed to exist on a continuum rather than in a simple binary state – some people identify as purely homosexual or heterosexual, and the rest exist somewhere in the middle. Sharing this fact alone can offer a very helpful perspective to young people who are feeling pressure to “figure out” if they are gay or straight.

While sexual orientation describes whom a person is attracted to, gender identity is a person’s internal sense of his or her own gender. It emerges in childhood and becomes more rich and nuanced in adolescence and adulthood, and, like sexual orientation, it is also believed to exist on a continuum rather than in a simple binary state. Less than 0.1% of youth will experience gender dysphoria, or the pressing feeling that their gender identity is not the same as their phenotypic sex. While questions about gender identity should be approached with the same curious, compassionate, and nonjudgmental style, we will not discuss the management of patients with gender dysphoria here. It is a very complex (and controversial) topic. And, as a practical matter, sexual orientation will likely be a more common issue with your patients, whereas questions about gender identity will come up much less frequently.

It is worth knowing that there is a range of mental health issues that are associated with the stress of feeling comfortable with one’s sexual identity. There is some evidence that young people who identify as gay or bisexual have elevated risk for mood disorders (depression), anxiety disorders, conduct disorder, and substance use disorders, but this finding has not been consistent (Am J Public Health. 2010:100[12]; 2426-32). However, there is unequivocal evidence that there is an elevated risk for suicide attempts in lesbian, gay, or bisexual (LGB) youth above their heterosexual peers. One survey found that 9th-12th grade students who identified as LGB were up to seven times as likely to have a suicide attempt as were their peers who identify as heterosexual. This risk is especially pronounced in male adolescents and continues into adulthood, when there is an elevated risk for suicide completion among adult males who identify as homosexual, although not in adult females (J Homosex. 2011 Jan;58[1]:10-51). Importantly, the risk for suicide attempt in LGB adolescents remains elevated even in those adolescents without any diagnosable mental illness, likely attributable to the stresses of isolation, family conflict, stigmatization, or bullying that LGB adolescents are likely to experience.

Asking your early-adolescent patients in a calm and comfortable manner about sexual feelings builds an environment in which thoughts, feelings, and questions about sex and sexuality are more easily shared. It is important to find language that feels like yours, which you can use with ease. Perhaps starting with, “At about your age, I ask every patient of mine whether they are beginning to have sexual feelings. This is when you really want to be around someone, in a way that’s more powerful and different from even your favorite friend. Some people call it getting butterflies in your stomach.” If your patient recognizes what you are talking about, you might continue, “Do you feel attracted to boys or girls or both? Do you have those feelings about kids in your class or people you know, like a teacher? Perhaps about a celebrity in a TV show or a band?” You should absolutely reassure them, “You don’t have to talk about anything you do not want to, but you should know that this is a normal part of becoming a teenager. I talk about this a lot with patients who are younger and older than you are. I keep what we talk about very private, and sometimes this is the only place a teenager feels safe to ask questions.” If you start this process early enough – by the start of middle school – the patient will probably be a bit embarrassed or giggle and not talk much. But, by the next annual physical or the one after that, the issue will be more familiar and less charged. A meaningful discussion may start.

With patients who do describe feeling attracted to people of the same sex, more specific questions may be appropriate. You should expect these feelings to exist on a continuum: You may encounter a school-age child with great clarity about exactly whom she is attracted to and what that means, or an older teenager who is far less certain, responding to a less intense interest or having been told by a peer that he is probably gay. It can be powerfully reassuring to remind your patient that adolescence is when we start to figure out to whom we are attracted. They don’t have to decide, but just be aware of these feelings as they emerge, essentially getting to know themselves without any feelings of urgency or pressure. You might ask, “Have you wondered if you were gay or bisexual? Have you spoken to any friends about your feelings or have you experimented with a boy or girl to try and figure this out?” It’s very helpful if you ask if they are worried or stressed by these feelings. Some young people will suffer from internalized homophobia, which may be helped by your accepting stance or may require a referral for more ongoing support. It can be valuable to find out if they are dating people of the same sex, or if their “relationships” have all been online. While this “virtual” dating may seem safer, it may not help them better understand themselves and may expose them to exploitation or predatory behavior. If your patient is sexually active, you should be comfortable talking with them about the risks of unprotected sex and same-sex safe-sex practices.

It is particularly important to ask your adolescent LGB patient about whom they have told, and what responses have they gotten. The presence of good friends and loving family members is critical to all adolescents’ emotional well-being. If they have talked about their sexual orientation with their peers, have their friends been supportive, or has it left them more isolated at school? You should find out if they have been teased or bullied, and ask specifically about online teasing or harassment. If they are being bullied, how have they handled that? Find out also if they feel free to ask or talk about this subject with their parents. If not, try to understand if they are simply embarrassed and unsure how to bring it up, or if there is a strong sense that they will be shamed or even rejected by their parents. If the parents are truly shaming or rejecting, it will be critical to consider what kind of support may be necessary. Teens who are facing isolation or bullying at school may benefit from resources such as a gay-straight student alliance or a community organization dedicated to issues facing LGB youth. For patients who are facing hostile or rejecting parents, it can be protective to connect them with a therapist as well, as you are mindful of their marked isolation and subsequently heightened risk for mood problems and even suicide attempts.

Along a similar vein, it is very important that you are aware of your own comfort level with these issues. While discussing sexual orientation may feel awkward if it is new for you, it is important to be realistic if you cannot be supportive of your patients who are gay. If for religious or other reasons you are not comfortable talking about sexual orientation in an accepting, nonjudgmental manner, you should seek guidance on how to thoughtfully care for your LGB patients or appropriately refer them to someone who can provide a more-supportive treatment setting.

When you create an office that makes sexuality a safe topic for discussion, you should expect that you will hear questions or concerns about which you yourself may not know the answers. Do not panic, just maintain your posture of being a curious, compassionate, and nonjudgmental listener, and then look for the answers. We are delighted this news organization has devoted a column to the optimal care of LGBT youth (LGBT Youth Consult) and encourage the primary care pediatrician to “never to worry alone,” and instead get some advice and expert teammates when dealing with these complex and important issues.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, in Newton, Mass. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston.

The biological transition to puberty has always marked a critical point in a primary care pediatrician’s relationship to a patient. Adolescents’ capacity for abstract reasoning, their movement to autonomy, their nuanced sense of identity, their need for privacy, and their emerging sexuality together give the pediatrician an opportunity and a responsibility to create a safe place to talk. Your office can be an oasis from parents, peers, and a society that seems saturated with sexuality. You can be trusted more than the Internet and offer discussions that are leavened by your long-standing relationship with the patient.

The growing public awareness, acceptance, and legal standing given to gay, lesbian, bisexual, and transgender individuals represents welcome societal progress, and we sense that amidst this richer public conversation, a growing number of children and adolescents are presenting with questions or worries about their own emerging sexual orientation or gender identity. We would like to start with our key takeaway: Discussions about sexual orientation and gender identity do not require that you give answers or predict the future. Focus instead on being a curious, compassionate, and nonjudgmental listener, and you will be effective at helping your patient to better manage new, uncertain, and possibly stressful feelings.

Our focus today is how to create a safe setting and specifically how to ask about and discuss sexual orientation. Most teenagers will wonder at some point about their orientation. Studies suggest that among adults, 5%-10% are attracted to the same sex and 3% describe themselves as gay or bisexual. Such surveys are very challenging, though, and in our experience, these percentages are higher. Sexual orientation is believed to exist on a continuum rather than in a simple binary state – some people identify as purely homosexual or heterosexual, and the rest exist somewhere in the middle. Sharing this fact alone can offer a very helpful perspective to young people who are feeling pressure to “figure out” if they are gay or straight.

While sexual orientation describes whom a person is attracted to, gender identity is a person’s internal sense of his or her own gender. It emerges in childhood and becomes more rich and nuanced in adolescence and adulthood, and, like sexual orientation, it is also believed to exist on a continuum rather than in a simple binary state. Less than 0.1% of youth will experience gender dysphoria, or the pressing feeling that their gender identity is not the same as their phenotypic sex. While questions about gender identity should be approached with the same curious, compassionate, and nonjudgmental style, we will not discuss the management of patients with gender dysphoria here. It is a very complex (and controversial) topic. And, as a practical matter, sexual orientation will likely be a more common issue with your patients, whereas questions about gender identity will come up much less frequently.

It is worth knowing that there is a range of mental health issues that are associated with the stress of feeling comfortable with one’s sexual identity. There is some evidence that young people who identify as gay or bisexual have elevated risk for mood disorders (depression), anxiety disorders, conduct disorder, and substance use disorders, but this finding has not been consistent (Am J Public Health. 2010:100[12]; 2426-32). However, there is unequivocal evidence that there is an elevated risk for suicide attempts in lesbian, gay, or bisexual (LGB) youth above their heterosexual peers. One survey found that 9th-12th grade students who identified as LGB were up to seven times as likely to have a suicide attempt as were their peers who identify as heterosexual. This risk is especially pronounced in male adolescents and continues into adulthood, when there is an elevated risk for suicide completion among adult males who identify as homosexual, although not in adult females (J Homosex. 2011 Jan;58[1]:10-51). Importantly, the risk for suicide attempt in LGB adolescents remains elevated even in those adolescents without any diagnosable mental illness, likely attributable to the stresses of isolation, family conflict, stigmatization, or bullying that LGB adolescents are likely to experience.

Asking your early-adolescent patients in a calm and comfortable manner about sexual feelings builds an environment in which thoughts, feelings, and questions about sex and sexuality are more easily shared. It is important to find language that feels like yours, which you can use with ease. Perhaps starting with, “At about your age, I ask every patient of mine whether they are beginning to have sexual feelings. This is when you really want to be around someone, in a way that’s more powerful and different from even your favorite friend. Some people call it getting butterflies in your stomach.” If your patient recognizes what you are talking about, you might continue, “Do you feel attracted to boys or girls or both? Do you have those feelings about kids in your class or people you know, like a teacher? Perhaps about a celebrity in a TV show or a band?” You should absolutely reassure them, “You don’t have to talk about anything you do not want to, but you should know that this is a normal part of becoming a teenager. I talk about this a lot with patients who are younger and older than you are. I keep what we talk about very private, and sometimes this is the only place a teenager feels safe to ask questions.” If you start this process early enough – by the start of middle school – the patient will probably be a bit embarrassed or giggle and not talk much. But, by the next annual physical or the one after that, the issue will be more familiar and less charged. A meaningful discussion may start.

With patients who do describe feeling attracted to people of the same sex, more specific questions may be appropriate. You should expect these feelings to exist on a continuum: You may encounter a school-age child with great clarity about exactly whom she is attracted to and what that means, or an older teenager who is far less certain, responding to a less intense interest or having been told by a peer that he is probably gay. It can be powerfully reassuring to remind your patient that adolescence is when we start to figure out to whom we are attracted. They don’t have to decide, but just be aware of these feelings as they emerge, essentially getting to know themselves without any feelings of urgency or pressure. You might ask, “Have you wondered if you were gay or bisexual? Have you spoken to any friends about your feelings or have you experimented with a boy or girl to try and figure this out?” It’s very helpful if you ask if they are worried or stressed by these feelings. Some young people will suffer from internalized homophobia, which may be helped by your accepting stance or may require a referral for more ongoing support. It can be valuable to find out if they are dating people of the same sex, or if their “relationships” have all been online. While this “virtual” dating may seem safer, it may not help them better understand themselves and may expose them to exploitation or predatory behavior. If your patient is sexually active, you should be comfortable talking with them about the risks of unprotected sex and same-sex safe-sex practices.

It is particularly important to ask your adolescent LGB patient about whom they have told, and what responses have they gotten. The presence of good friends and loving family members is critical to all adolescents’ emotional well-being. If they have talked about their sexual orientation with their peers, have their friends been supportive, or has it left them more isolated at school? You should find out if they have been teased or bullied, and ask specifically about online teasing or harassment. If they are being bullied, how have they handled that? Find out also if they feel free to ask or talk about this subject with their parents. If not, try to understand if they are simply embarrassed and unsure how to bring it up, or if there is a strong sense that they will be shamed or even rejected by their parents. If the parents are truly shaming or rejecting, it will be critical to consider what kind of support may be necessary. Teens who are facing isolation or bullying at school may benefit from resources such as a gay-straight student alliance or a community organization dedicated to issues facing LGB youth. For patients who are facing hostile or rejecting parents, it can be protective to connect them with a therapist as well, as you are mindful of their marked isolation and subsequently heightened risk for mood problems and even suicide attempts.

Along a similar vein, it is very important that you are aware of your own comfort level with these issues. While discussing sexual orientation may feel awkward if it is new for you, it is important to be realistic if you cannot be supportive of your patients who are gay. If for religious or other reasons you are not comfortable talking about sexual orientation in an accepting, nonjudgmental manner, you should seek guidance on how to thoughtfully care for your LGB patients or appropriately refer them to someone who can provide a more-supportive treatment setting.

When you create an office that makes sexuality a safe topic for discussion, you should expect that you will hear questions or concerns about which you yourself may not know the answers. Do not panic, just maintain your posture of being a curious, compassionate, and nonjudgmental listener, and then look for the answers. We are delighted this news organization has devoted a column to the optimal care of LGBT youth (LGBT Youth Consult) and encourage the primary care pediatrician to “never to worry alone,” and instead get some advice and expert teammates when dealing with these complex and important issues.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, in Newton, Mass. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston.

The biological transition to puberty has always marked a critical point in a primary care pediatrician’s relationship to a patient. Adolescents’ capacity for abstract reasoning, their movement to autonomy, their nuanced sense of identity, their need for privacy, and their emerging sexuality together give the pediatrician an opportunity and a responsibility to create a safe place to talk. Your office can be an oasis from parents, peers, and a society that seems saturated with sexuality. You can be trusted more than the Internet and offer discussions that are leavened by your long-standing relationship with the patient.

The growing public awareness, acceptance, and legal standing given to gay, lesbian, bisexual, and transgender individuals represents welcome societal progress, and we sense that amidst this richer public conversation, a growing number of children and adolescents are presenting with questions or worries about their own emerging sexual orientation or gender identity. We would like to start with our key takeaway: Discussions about sexual orientation and gender identity do not require that you give answers or predict the future. Focus instead on being a curious, compassionate, and nonjudgmental listener, and you will be effective at helping your patient to better manage new, uncertain, and possibly stressful feelings.

Our focus today is how to create a safe setting and specifically how to ask about and discuss sexual orientation. Most teenagers will wonder at some point about their orientation. Studies suggest that among adults, 5%-10% are attracted to the same sex and 3% describe themselves as gay or bisexual. Such surveys are very challenging, though, and in our experience, these percentages are higher. Sexual orientation is believed to exist on a continuum rather than in a simple binary state – some people identify as purely homosexual or heterosexual, and the rest exist somewhere in the middle. Sharing this fact alone can offer a very helpful perspective to young people who are feeling pressure to “figure out” if they are gay or straight.

While sexual orientation describes whom a person is attracted to, gender identity is a person’s internal sense of his or her own gender. It emerges in childhood and becomes more rich and nuanced in adolescence and adulthood, and, like sexual orientation, it is also believed to exist on a continuum rather than in a simple binary state. Less than 0.1% of youth will experience gender dysphoria, or the pressing feeling that their gender identity is not the same as their phenotypic sex. While questions about gender identity should be approached with the same curious, compassionate, and nonjudgmental style, we will not discuss the management of patients with gender dysphoria here. It is a very complex (and controversial) topic. And, as a practical matter, sexual orientation will likely be a more common issue with your patients, whereas questions about gender identity will come up much less frequently.

It is worth knowing that there is a range of mental health issues that are associated with the stress of feeling comfortable with one’s sexual identity. There is some evidence that young people who identify as gay or bisexual have elevated risk for mood disorders (depression), anxiety disorders, conduct disorder, and substance use disorders, but this finding has not been consistent (Am J Public Health. 2010:100[12]; 2426-32). However, there is unequivocal evidence that there is an elevated risk for suicide attempts in lesbian, gay, or bisexual (LGB) youth above their heterosexual peers. One survey found that 9th-12th grade students who identified as LGB were up to seven times as likely to have a suicide attempt as were their peers who identify as heterosexual. This risk is especially pronounced in male adolescents and continues into adulthood, when there is an elevated risk for suicide completion among adult males who identify as homosexual, although not in adult females (J Homosex. 2011 Jan;58[1]:10-51). Importantly, the risk for suicide attempt in LGB adolescents remains elevated even in those adolescents without any diagnosable mental illness, likely attributable to the stresses of isolation, family conflict, stigmatization, or bullying that LGB adolescents are likely to experience.

Asking your early-adolescent patients in a calm and comfortable manner about sexual feelings builds an environment in which thoughts, feelings, and questions about sex and sexuality are more easily shared. It is important to find language that feels like yours, which you can use with ease. Perhaps starting with, “At about your age, I ask every patient of mine whether they are beginning to have sexual feelings. This is when you really want to be around someone, in a way that’s more powerful and different from even your favorite friend. Some people call it getting butterflies in your stomach.” If your patient recognizes what you are talking about, you might continue, “Do you feel attracted to boys or girls or both? Do you have those feelings about kids in your class or people you know, like a teacher? Perhaps about a celebrity in a TV show or a band?” You should absolutely reassure them, “You don’t have to talk about anything you do not want to, but you should know that this is a normal part of becoming a teenager. I talk about this a lot with patients who are younger and older than you are. I keep what we talk about very private, and sometimes this is the only place a teenager feels safe to ask questions.” If you start this process early enough – by the start of middle school – the patient will probably be a bit embarrassed or giggle and not talk much. But, by the next annual physical or the one after that, the issue will be more familiar and less charged. A meaningful discussion may start.

With patients who do describe feeling attracted to people of the same sex, more specific questions may be appropriate. You should expect these feelings to exist on a continuum: You may encounter a school-age child with great clarity about exactly whom she is attracted to and what that means, or an older teenager who is far less certain, responding to a less intense interest or having been told by a peer that he is probably gay. It can be powerfully reassuring to remind your patient that adolescence is when we start to figure out to whom we are attracted. They don’t have to decide, but just be aware of these feelings as they emerge, essentially getting to know themselves without any feelings of urgency or pressure. You might ask, “Have you wondered if you were gay or bisexual? Have you spoken to any friends about your feelings or have you experimented with a boy or girl to try and figure this out?” It’s very helpful if you ask if they are worried or stressed by these feelings. Some young people will suffer from internalized homophobia, which may be helped by your accepting stance or may require a referral for more ongoing support. It can be valuable to find out if they are dating people of the same sex, or if their “relationships” have all been online. While this “virtual” dating may seem safer, it may not help them better understand themselves and may expose them to exploitation or predatory behavior. If your patient is sexually active, you should be comfortable talking with them about the risks of unprotected sex and same-sex safe-sex practices.

It is particularly important to ask your adolescent LGB patient about whom they have told, and what responses have they gotten. The presence of good friends and loving family members is critical to all adolescents’ emotional well-being. If they have talked about their sexual orientation with their peers, have their friends been supportive, or has it left them more isolated at school? You should find out if they have been teased or bullied, and ask specifically about online teasing or harassment. If they are being bullied, how have they handled that? Find out also if they feel free to ask or talk about this subject with their parents. If not, try to understand if they are simply embarrassed and unsure how to bring it up, or if there is a strong sense that they will be shamed or even rejected by their parents. If the parents are truly shaming or rejecting, it will be critical to consider what kind of support may be necessary. Teens who are facing isolation or bullying at school may benefit from resources such as a gay-straight student alliance or a community organization dedicated to issues facing LGB youth. For patients who are facing hostile or rejecting parents, it can be protective to connect them with a therapist as well, as you are mindful of their marked isolation and subsequently heightened risk for mood problems and even suicide attempts.

Along a similar vein, it is very important that you are aware of your own comfort level with these issues. While discussing sexual orientation may feel awkward if it is new for you, it is important to be realistic if you cannot be supportive of your patients who are gay. If for religious or other reasons you are not comfortable talking about sexual orientation in an accepting, nonjudgmental manner, you should seek guidance on how to thoughtfully care for your LGB patients or appropriately refer them to someone who can provide a more-supportive treatment setting.

When you create an office that makes sexuality a safe topic for discussion, you should expect that you will hear questions or concerns about which you yourself may not know the answers. Do not panic, just maintain your posture of being a curious, compassionate, and nonjudgmental listener, and then look for the answers. We are delighted this news organization has devoted a column to the optimal care of LGBT youth (LGBT Youth Consult) and encourage the primary care pediatrician to “never to worry alone,” and instead get some advice and expert teammates when dealing with these complex and important issues.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, in Newton, Mass. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston.

No pediatrician thinks caring for children with attention-deficit/hyperactivity disorder (ADHD) is easy, but some of these patients are far easier than others! The difference between your patients with ADHD who give you nightmares and those you are eager to see at return visits is usually the presence of comorbidities (not counting parent issues!).

Comorbidities are very common with ADHD, occurring in nearly half of all patients. One of the tricky things about comorbidities in ADHD is that several of them, or medicines used to treat them, also are potential explanations for the ADHD symptoms themselves.

The most common comorbid conditions are learning disabilities, which are present in 12% when narrowly defined, but school underachievement occurs in up to 60% of children with ADHD. Children with learning difficulties that are not adequately accommodated can present with “ADHD symptoms.” These children can be inattentive, fidgety, or out of their seats; may do classwork slowly or poorly; and may ultimately be disruptive in class. What child wouldn’t act this way if he or she couldn’t understand the work? Remember that a child will do anything to “save face.” Acting up and getting sent out of class is a last resort, but not a bad option over being humiliated by looking dumb, being teased, or being embarrassed in front of peers.

Some clues that learning disabilities are responsible for symptoms include behaviors that occur selectively during specific subjects, reports of disliking the subject, or refusal to do homework for certain subjects. One would think that poor grades would point to learning disabilities, but this is not always true either because the teacher is not that discerning or because a bright child compensates while still struggling. Be sure to have some grade-level assessment you can administer yourself such as the Einstein Evaluation of School-Related Skills or the WRAT (Wide Range Achievement Test). A large proportion of children with ADHD have a reading disability so having standard paragraphs available is important in deciding who needs complete psychological testing.

With this high prevalence of reading disabilities, it should not surprise you that language disorders also are comorbid with ADHD, occurring in 4% of these children. Because language disorder is among the developmental issues most amenable to intervention, detection and referral are especially important. If a child does not answer your questions with the grammar, vocabulary, or flow of ideas you expect at a particular age, consider using the Sentence Repetition Test to check for understanding. There are no easy screens for the complex language expected of school-aged children, so consider referral to a speech-language pathologist if you are suspicious.

Anxiety is comorbid with ADHD in 21% of children, but most importantly, it the most-often-missed diagnosis causing ADHD symptoms. Consider anxiety when a child is too nervous to pay attention, is distracted by worry, is concerned about what peers think to the point of having to listen in on their conversations, is unable to come up with an answer for a teacher that is perceived as critical, or is perfectionistic about work so it never gets done on time. Although children with ADHD are rather poor observers of their own symptoms, I always ask, “Is it hard to pay attention in class?” and follow up on a “yes” by asking, “What is going through your mind when you are not paying attention?” Reports of daydreams about skateboarding are one thing, but if children say they are thinking about their mother or worrying about an upcoming test, then further evaluation for anxiety is in order. Using a screening self-report tool such as the SCARED (Screen for Childhood Anxiety and Related Disorders) or the Pediatric Anxiety Rating Scale have rather low sensitivity, but can help the conversation to define anxiety symptoms, something children do not find easy to do if asked directly.

Remember that anxiety disorders do not “fly alone” either: Children with one anxiety disorder have a greater than 60% chance of having two, and children with two have a 30% chance of having three or more anxiety disorders. That means that children with generalized anxiety disorder may well have obsessive-compulsive disorder or a specific phobia as well. Just watching for general worrying is not enough. Add to this that the parent coming in worried about their child may be the genetic source with an anxiety disorder themselves, potentially contributing to the child’s distress and making it harder for you to assess the severity of either the anxiety or the ADHD symptoms!

I am sometimes grateful that a child with ADHD has excessive anxiety because it may protect him from jumping out of windows! But the combination has downsides in making the child even less preferred by peers and more likely to have hostile bias attribution – the tendency to see others as a threat. This combination can result in impulsive proactive aggression. Recognizing the role of anxiety in the aggressive episodes, and helping the child and parent to identify it, also is crucial to successful management. Anxiety is rarely perceived by parents, teachers, or children themselves as a cause of oppositional or aggressive behavior, so you need to probe for this connection. There is no substitute for debriefing a specific example of aggression and asking the child, “What were you thinking right before this happened?” You may suspect anxiety simply by watching the child’s reaction to what the parent says in the interview. Having the child draw a picture of a child, tell a story about “What happens next?” and then “How does the story end?” can be another adjunct to detecting anxiety.

Sometimes the treatment of ADHD makes the comorbid condition worse or vice versa. A prime example where treatment of one exacerbates the other is the use of stimulants, especially amphetamines, which can produce or worsen anxiety. Even though the reported side effects of stimulants do not state that there is more anxiety with amphetamines, I often prefer to prescribe dexmethylphenidate when both ADHD and anxiety coexist. The longer-acting preparations such as methylphenidate in a long-acting liquid or patch also seem to allow for finer tuning of dose with less anxiety exacerbation than shorter-acting preparations. Nonstimulants such as long-acting guanfacine or atomoxetine as treatment for the ADHD may be needed alone or in combination to allow a lower dose when the side effects of the stimulants on the anxiety outweigh their benefits. On the other hand, if the child is on selective serotonin reuptake inhibitors for anxiety (not the first-line treatment, which is cognitive-behavior therapy), he or she may experience behavioral activation that looks a lot like worsening ADHD!

Depression is “the other side” of anxiety – often developing at a later age after an earlier diagnosis of anxiety disorder – and another common comorbidity to ADHD occurring in 18% of children. Depression is less likely to masquerade as ADHD, but still may present as inattention or poor performance. Remember that children with depression may act irritable or aggressive rather than lethargic. Depression screens such as the Patient Health Questionnaire–9 can help sort this out.

Oppositional-defiant disorder (32%) and conduct disorder (25%) are more commonly comorbid with ADHD than are the conditions just discussed, but because they are “acting-out” conditions they are of great concern to parents and thus not likely to be missed in your office visits. Other medical conditions such as tics, enuresis, encopresis and even asthma also are comorbid and should be asked about.

The Vanderbilt Initial questionnaires have a few items for anxiety, depression, and conduct as well as performance items about academic functioning. A general screening tool such as the Pediatric Symptom Checklist, perhaps followed by a diagnostic tool such as the CHADIS DSM questionnaire, can be completed by parents online or on paper to detect and help diagnose any of these comorbidities before visits.

Pediatricians are the main clinicians diagnosing (for 53% of children with ADHD) and managing this condition (Natl. Health Stat Report. 2015 Sep;81:1-8). You should be proud of how well we have recently risen to the occasion and are now identifying and treating ADHD using evidence-based tools (90%) and attempting to collect data from schools (82%) as well as parents. The biggest gap in effective primary care management of ADHD now is detecting and managing its comorbidities.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at [email protected].

No pediatrician thinks caring for children with attention-deficit/hyperactivity disorder (ADHD) is easy, but some of these patients are far easier than others! The difference between your patients with ADHD who give you nightmares and those you are eager to see at return visits is usually the presence of comorbidities (not counting parent issues!).

Comorbidities are very common with ADHD, occurring in nearly half of all patients. One of the tricky things about comorbidities in ADHD is that several of them, or medicines used to treat them, also are potential explanations for the ADHD symptoms themselves.

The most common comorbid conditions are learning disabilities, which are present in 12% when narrowly defined, but school underachievement occurs in up to 60% of children with ADHD. Children with learning difficulties that are not adequately accommodated can present with “ADHD symptoms.” These children can be inattentive, fidgety, or out of their seats; may do classwork slowly or poorly; and may ultimately be disruptive in class. What child wouldn’t act this way if he or she couldn’t understand the work? Remember that a child will do anything to “save face.” Acting up and getting sent out of class is a last resort, but not a bad option over being humiliated by looking dumb, being teased, or being embarrassed in front of peers.

Some clues that learning disabilities are responsible for symptoms include behaviors that occur selectively during specific subjects, reports of disliking the subject, or refusal to do homework for certain subjects. One would think that poor grades would point to learning disabilities, but this is not always true either because the teacher is not that discerning or because a bright child compensates while still struggling. Be sure to have some grade-level assessment you can administer yourself such as the Einstein Evaluation of School-Related Skills or the WRAT (Wide Range Achievement Test). A large proportion of children with ADHD have a reading disability so having standard paragraphs available is important in deciding who needs complete psychological testing.

With this high prevalence of reading disabilities, it should not surprise you that language disorders also are comorbid with ADHD, occurring in 4% of these children. Because language disorder is among the developmental issues most amenable to intervention, detection and referral are especially important. If a child does not answer your questions with the grammar, vocabulary, or flow of ideas you expect at a particular age, consider using the Sentence Repetition Test to check for understanding. There are no easy screens for the complex language expected of school-aged children, so consider referral to a speech-language pathologist if you are suspicious.

Anxiety is comorbid with ADHD in 21% of children, but most importantly, it the most-often-missed diagnosis causing ADHD symptoms. Consider anxiety when a child is too nervous to pay attention, is distracted by worry, is concerned about what peers think to the point of having to listen in on their conversations, is unable to come up with an answer for a teacher that is perceived as critical, or is perfectionistic about work so it never gets done on time. Although children with ADHD are rather poor observers of their own symptoms, I always ask, “Is it hard to pay attention in class?” and follow up on a “yes” by asking, “What is going through your mind when you are not paying attention?” Reports of daydreams about skateboarding are one thing, but if children say they are thinking about their mother or worrying about an upcoming test, then further evaluation for anxiety is in order. Using a screening self-report tool such as the SCARED (Screen for Childhood Anxiety and Related Disorders) or the Pediatric Anxiety Rating Scale have rather low sensitivity, but can help the conversation to define anxiety symptoms, something children do not find easy to do if asked directly.

Remember that anxiety disorders do not “fly alone” either: Children with one anxiety disorder have a greater than 60% chance of having two, and children with two have a 30% chance of having three or more anxiety disorders. That means that children with generalized anxiety disorder may well have obsessive-compulsive disorder or a specific phobia as well. Just watching for general worrying is not enough. Add to this that the parent coming in worried about their child may be the genetic source with an anxiety disorder themselves, potentially contributing to the child’s distress and making it harder for you to assess the severity of either the anxiety or the ADHD symptoms!

I am sometimes grateful that a child with ADHD has excessive anxiety because it may protect him from jumping out of windows! But the combination has downsides in making the child even less preferred by peers and more likely to have hostile bias attribution – the tendency to see others as a threat. This combination can result in impulsive proactive aggression. Recognizing the role of anxiety in the aggressive episodes, and helping the child and parent to identify it, also is crucial to successful management. Anxiety is rarely perceived by parents, teachers, or children themselves as a cause of oppositional or aggressive behavior, so you need to probe for this connection. There is no substitute for debriefing a specific example of aggression and asking the child, “What were you thinking right before this happened?” You may suspect anxiety simply by watching the child’s reaction to what the parent says in the interview. Having the child draw a picture of a child, tell a story about “What happens next?” and then “How does the story end?” can be another adjunct to detecting anxiety.

Sometimes the treatment of ADHD makes the comorbid condition worse or vice versa. A prime example where treatment of one exacerbates the other is the use of stimulants, especially amphetamines, which can produce or worsen anxiety. Even though the reported side effects of stimulants do not state that there is more anxiety with amphetamines, I often prefer to prescribe dexmethylphenidate when both ADHD and anxiety coexist. The longer-acting preparations such as methylphenidate in a long-acting liquid or patch also seem to allow for finer tuning of dose with less anxiety exacerbation than shorter-acting preparations. Nonstimulants such as long-acting guanfacine or atomoxetine as treatment for the ADHD may be needed alone or in combination to allow a lower dose when the side effects of the stimulants on the anxiety outweigh their benefits. On the other hand, if the child is on selective serotonin reuptake inhibitors for anxiety (not the first-line treatment, which is cognitive-behavior therapy), he or she may experience behavioral activation that looks a lot like worsening ADHD!

Depression is “the other side” of anxiety – often developing at a later age after an earlier diagnosis of anxiety disorder – and another common comorbidity to ADHD occurring in 18% of children. Depression is less likely to masquerade as ADHD, but still may present as inattention or poor performance. Remember that children with depression may act irritable or aggressive rather than lethargic. Depression screens such as the Patient Health Questionnaire–9 can help sort this out.

Oppositional-defiant disorder (32%) and conduct disorder (25%) are more commonly comorbid with ADHD than are the conditions just discussed, but because they are “acting-out” conditions they are of great concern to parents and thus not likely to be missed in your office visits. Other medical conditions such as tics, enuresis, encopresis and even asthma also are comorbid and should be asked about.

The Vanderbilt Initial questionnaires have a few items for anxiety, depression, and conduct as well as performance items about academic functioning. A general screening tool such as the Pediatric Symptom Checklist, perhaps followed by a diagnostic tool such as the CHADIS DSM questionnaire, can be completed by parents online or on paper to detect and help diagnose any of these comorbidities before visits.

Pediatricians are the main clinicians diagnosing (for 53% of children with ADHD) and managing this condition (Natl. Health Stat Report. 2015 Sep;81:1-8). You should be proud of how well we have recently risen to the occasion and are now identifying and treating ADHD using evidence-based tools (90%) and attempting to collect data from schools (82%) as well as parents. The biggest gap in effective primary care management of ADHD now is detecting and managing its comorbidities.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at [email protected].

No pediatrician thinks caring for children with attention-deficit/hyperactivity disorder (ADHD) is easy, but some of these patients are far easier than others! The difference between your patients with ADHD who give you nightmares and those you are eager to see at return visits is usually the presence of comorbidities (not counting parent issues!).

Comorbidities are very common with ADHD, occurring in nearly half of all patients. One of the tricky things about comorbidities in ADHD is that several of them, or medicines used to treat them, also are potential explanations for the ADHD symptoms themselves.

The most common comorbid conditions are learning disabilities, which are present in 12% when narrowly defined, but school underachievement occurs in up to 60% of children with ADHD. Children with learning difficulties that are not adequately accommodated can present with “ADHD symptoms.” These children can be inattentive, fidgety, or out of their seats; may do classwork slowly or poorly; and may ultimately be disruptive in class. What child wouldn’t act this way if he or she couldn’t understand the work? Remember that a child will do anything to “save face.” Acting up and getting sent out of class is a last resort, but not a bad option over being humiliated by looking dumb, being teased, or being embarrassed in front of peers.

Some clues that learning disabilities are responsible for symptoms include behaviors that occur selectively during specific subjects, reports of disliking the subject, or refusal to do homework for certain subjects. One would think that poor grades would point to learning disabilities, but this is not always true either because the teacher is not that discerning or because a bright child compensates while still struggling. Be sure to have some grade-level assessment you can administer yourself such as the Einstein Evaluation of School-Related Skills or the WRAT (Wide Range Achievement Test). A large proportion of children with ADHD have a reading disability so having standard paragraphs available is important in deciding who needs complete psychological testing.

With this high prevalence of reading disabilities, it should not surprise you that language disorders also are comorbid with ADHD, occurring in 4% of these children. Because language disorder is among the developmental issues most amenable to intervention, detection and referral are especially important. If a child does not answer your questions with the grammar, vocabulary, or flow of ideas you expect at a particular age, consider using the Sentence Repetition Test to check for understanding. There are no easy screens for the complex language expected of school-aged children, so consider referral to a speech-language pathologist if you are suspicious.

Anxiety is comorbid with ADHD in 21% of children, but most importantly, it the most-often-missed diagnosis causing ADHD symptoms. Consider anxiety when a child is too nervous to pay attention, is distracted by worry, is concerned about what peers think to the point of having to listen in on their conversations, is unable to come up with an answer for a teacher that is perceived as critical, or is perfectionistic about work so it never gets done on time. Although children with ADHD are rather poor observers of their own symptoms, I always ask, “Is it hard to pay attention in class?” and follow up on a “yes” by asking, “What is going through your mind when you are not paying attention?” Reports of daydreams about skateboarding are one thing, but if children say they are thinking about their mother or worrying about an upcoming test, then further evaluation for anxiety is in order. Using a screening self-report tool such as the SCARED (Screen for Childhood Anxiety and Related Disorders) or the Pediatric Anxiety Rating Scale have rather low sensitivity, but can help the conversation to define anxiety symptoms, something children do not find easy to do if asked directly.

Remember that anxiety disorders do not “fly alone” either: Children with one anxiety disorder have a greater than 60% chance of having two, and children with two have a 30% chance of having three or more anxiety disorders. That means that children with generalized anxiety disorder may well have obsessive-compulsive disorder or a specific phobia as well. Just watching for general worrying is not enough. Add to this that the parent coming in worried about their child may be the genetic source with an anxiety disorder themselves, potentially contributing to the child’s distress and making it harder for you to assess the severity of either the anxiety or the ADHD symptoms!

I am sometimes grateful that a child with ADHD has excessive anxiety because it may protect him from jumping out of windows! But the combination has downsides in making the child even less preferred by peers and more likely to have hostile bias attribution – the tendency to see others as a threat. This combination can result in impulsive proactive aggression. Recognizing the role of anxiety in the aggressive episodes, and helping the child and parent to identify it, also is crucial to successful management. Anxiety is rarely perceived by parents, teachers, or children themselves as a cause of oppositional or aggressive behavior, so you need to probe for this connection. There is no substitute for debriefing a specific example of aggression and asking the child, “What were you thinking right before this happened?” You may suspect anxiety simply by watching the child’s reaction to what the parent says in the interview. Having the child draw a picture of a child, tell a story about “What happens next?” and then “How does the story end?” can be another adjunct to detecting anxiety.

Sometimes the treatment of ADHD makes the comorbid condition worse or vice versa. A prime example where treatment of one exacerbates the other is the use of stimulants, especially amphetamines, which can produce or worsen anxiety. Even though the reported side effects of stimulants do not state that there is more anxiety with amphetamines, I often prefer to prescribe dexmethylphenidate when both ADHD and anxiety coexist. The longer-acting preparations such as methylphenidate in a long-acting liquid or patch also seem to allow for finer tuning of dose with less anxiety exacerbation than shorter-acting preparations. Nonstimulants such as long-acting guanfacine or atomoxetine as treatment for the ADHD may be needed alone or in combination to allow a lower dose when the side effects of the stimulants on the anxiety outweigh their benefits. On the other hand, if the child is on selective serotonin reuptake inhibitors for anxiety (not the first-line treatment, which is cognitive-behavior therapy), he or she may experience behavioral activation that looks a lot like worsening ADHD!

Depression is “the other side” of anxiety – often developing at a later age after an earlier diagnosis of anxiety disorder – and another common comorbidity to ADHD occurring in 18% of children. Depression is less likely to masquerade as ADHD, but still may present as inattention or poor performance. Remember that children with depression may act irritable or aggressive rather than lethargic. Depression screens such as the Patient Health Questionnaire–9 can help sort this out.

Oppositional-defiant disorder (32%) and conduct disorder (25%) are more commonly comorbid with ADHD than are the conditions just discussed, but because they are “acting-out” conditions they are of great concern to parents and thus not likely to be missed in your office visits. Other medical conditions such as tics, enuresis, encopresis and even asthma also are comorbid and should be asked about.

The Vanderbilt Initial questionnaires have a few items for anxiety, depression, and conduct as well as performance items about academic functioning. A general screening tool such as the Pediatric Symptom Checklist, perhaps followed by a diagnostic tool such as the CHADIS DSM questionnaire, can be completed by parents online or on paper to detect and help diagnose any of these comorbidities before visits.

Pediatricians are the main clinicians diagnosing (for 53% of children with ADHD) and managing this condition (Natl. Health Stat Report. 2015 Sep;81:1-8). You should be proud of how well we have recently risen to the occasion and are now identifying and treating ADHD using evidence-based tools (90%) and attempting to collect data from schools (82%) as well as parents. The biggest gap in effective primary care management of ADHD now is detecting and managing its comorbidities.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at [email protected].

A couple having a baby brings together two family traditions that themselves blended the previous generations’ experiences and perspectives. Each of the new parents has been raised by two parents with their own histories, values, successes, and crises all available and potentially playing a part in the new baby’s future. A baby’s arrival can call forth memories of past successes, failures, hopes, and dreams – some fulfilled and some not.

As the pediatrician, you serve as an authority and a resource for the new parents. You will hear questions that have roots that may go back one, two, or more generations. Some may involve discipline, approaches to food, religious issues, or more subtle concerns relating to control and autonomy. And you may find that they will bring you the challenge of managing the beliefs, values, and expectations of the new grandparents. You may even find these new grandparents in your office! You have a unique opportunity to help new parents set a course with their own parents or in-laws that can promote family cohesion and honor family traditions or values, while empowering parents to trust themselves and truly be in charge of raising their own children.

Imagine this scenario: A young couple has just had their first baby, a son. The paternal grandfather, who played soccer in high school and college, presents his first grandchild with his own college soccer ball, proclaiming with great emotion that soccer will certainly be a part of his grandson’s future.

While this simple act may seem touching, it might also be perceived by the new parents as intrusive or controlling. How does the new father (who was maybe more bookish than athletic) feel the burden of this expectation? Perhaps the mother may wish her son to be more of a scholar than an athlete, or may want no expectation set, but may feel uncomfortable speaking honestly with her father-in-law. And this scenario is just about the gift of a soccer ball!

Grandparents (like parents) come with expectations, with beliefs about what practices worked and what failed over a wide range of areas from child rearing to managing finances to career to marriage. The arrival of a new grandchild will likely prompt them to share these beliefs, and do so in the way they usually communicate with their own children, be it blunt, emotional, indirect, or mute. These views might be forcefully presented, if a grandparent feels guilty or unfulfilled because a meaningful hope for their own child did not materialize: The new grandchild is their “last chance.” While their love and interest, their experience and wisdom can be invaluable, they might also arouse insecurity in a new parent or be disruptive. If they share opinions in a way that is stressful, devaluing, or confusing for new parents, that can translate into anxious, uncertain interactions with their new baby or a climate at home that is full of conflict instead of calm.

Parents are already blending their two styles and values, challenging enough before also trying to blend the elements of four grandparents.

The first weeks after the arrival of the new baby is a crucial time in the baby’s development, as well as in the development of the new parents, as all are rapidly acquiring new skills, adjusting to a new schedule, and learning how to understand and respond to each other. During these hard early days, grandparents often will be present, staying in the home or nearby to offer support to their children. Very commonly, they will share their opinions about such basics as nutrition and sleep. These are areas that are fundamentally important for a baby’s healthy development, but can be mysterious and challenging for new parents. They may seek out guidance from friends, books, websites, and pediatricians, as well as the new grandparents.

While their accumulated wisdom may be as helpful as their helping with laundry or meal preparation (think, “sleep when the baby sleeps”), it also might not. Perhaps the opinions are misguided (think, “sleeping on the tummy was always fine in my day”). And grandparents who are inadvertently undermining (“I don’t understand the difficulty, nursing was so easy for me”), or highly anxious might add to the new parents’ stress and uncertainty rather than alleviate it.

Grandparents also may come with strong cultural beliefs about child rearing. In families that are only one or two generations removed from immigration to this country, there may be powerfully held ideas about newborns, ones that might be inextricably linked for the grandparents with their drive to preserve their own cultural background. These may include ideas about when a child can eat solid food or what he or she should start eating. They may include beliefs that a child should never be put down or should be left to cry for long periods, lest they be “spoiled.” They might include ideas about when a baby can swim or how best to bathe them, what sorts of toys are appropriate or when their hair can be cut. While many of these beliefs have cultural value and no medical implications (like the timing of the first haircut), some may fly in the face of current scientific evidence (such as eating solids before they are able). And even when they are “safe,” new parents may experience these beliefs as fraught directives: ones that they may not believe in, but which will make them guilty of some cultural betrayal if they do not follow them.

Along a similar vein, grandparents may enter the home of their new grandchild with passionately held religious beliefs. While few of these may have direct medical implications for the new baby (such as circumcision), they can still have profound implications for life in the family’s home. When parents and grandparents all share the same religious beliefs, there is less possibility of conflict. But when new parents come from different religious traditions or no longer share their parents’ faith, there is high potential for emotionally charged differences. And if the new parents have not anticipated these conversations (say, whether or not to circumcise a baby boy when one parent is Jewish and the other is Protestant), trying to sort out these matters while also learning to change diapers or nurse a colicky baby can make a challenging situation into an overwhelming one.

Lastly, about 1% of all households have same-sex partners or marriages and about one in four are raising children. While same-sex parenthood has rapidly gained cultural acceptance over the past decade, it is possible that some grandparents will not have fully accepted the reality of their own child’s sexual orientation and committed relationship. If the parents speak to you about such a fraught situation, listen supportively.  When it sounds like there is ambivalence in the grandparents, the new parents can try to nurture the love that is there and be patient when their own parents still struggle. They should nurture the connections with those in their families that offer unconditional support and who can model love and acceptance for the new grandparents. In situations in which there is deeper alienation and little or no contact, offer that they might want to find a way to share photos and stories through one who remains close to their parents and periodically offer opportunities to rebuild relationships. A new grandchild can be a loving moment to take a fresh look at unresolved anger and loss, and as clinicians we have seen families resolve differences as they look to a new baby’s future.

Pediatricians are in a unique position of both neutrality and authority with their new patient’s parents and grandparents. When parents come to a newborn check or well-baby check, it can be invaluable to determine “who else is helping you?” After finding out about nursing or feeding the baby and about sleep, inquire about where they are getting any guidance or support. Friends or siblings with children? Books or websites? Grandparents? What has been helpful and what has not? When you hear about grandparents and see an eye-roll or hear a deep sigh, be curious about what has been helpful and what has been challenging. It is vitally helpful to first-time parents to be validated in their feeling that their own parents are a valuable resource, but not without their challenges.

While it may be important to offer a “medical” opinion about certain matters (back-sleeping, cosleeping, and introducing solids, for example), on most matters, the pediatrician’s role will be to help parents set a framework that will help them to cultivate what is precious and helpful from grandparents while minimizing conflict or unnecessary stress. For new parents, this may be as simple as reminding them that while this is an vital time for the baby’s development, it is also a big transition for them into parenthood and a significant transition for their parents or in-laws into grandparenthood. Help the new parents to understand that there is sometimes no one “right” way to handle certain decisions or challenges, and they will have to try a variety of strategies before finding the one that fits them as parents to this particular child. Remind them that parenting is a learning curve and it is common to feel stressed in new territory with high stakes. But they will find the right rhythm with being attuned to their new baby and eventually managing routines and limits. They are allowed to embrace the support that they find helpful and limit that which they experience as deeply undermining, dismissive, or judgmental.

When you notice that parents sound very angry at or alienated from grandparents, particularly when it is causing some marital conflict, it can be powerful for you to suggest that they should sort out their wishes and beliefs as parents first and then find a clear and loving way to communicate these to the grandparents. Remind them that they are becoming the experts on their children and that they will best be able to set appropriate routines and expectations. But remind them also that grandparents are potentially a treasure to their grandchildren, beyond the help with laundry and meal preparation at the very start of a child’s life.

There can never be enough loving, interested adults in a child’s orbit or a big enough cheering section. And grandparents can be uniquely passionate, patient, curious, and supportive to their growing grandchildren. They bring perspective on a family’s history, wonderful as a growing child builds a story about who they are and where they come from. And their interest and love will help a growing child build a sense of what characteristics make them a treasure to others. Few people can do this as well as grandparents, and letting them begin this involvement at the start of their grandchild’s life only supports this role.

While the arrival of a new baby will be a joyful event for a family, it will also be emotionally complex. Providing your patient’s parents with support and even some language that may help them cultivate the grandparents’ interest and love, while building healthy boundaries around their own parenting, may help set the stage for the healthiest development of your very young patient.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].

A couple having a baby brings together two family traditions that themselves blended the previous generations’ experiences and perspectives. Each of the new parents has been raised by two parents with their own histories, values, successes, and crises all available and potentially playing a part in the new baby’s future. A baby’s arrival can call forth memories of past successes, failures, hopes, and dreams – some fulfilled and some not.

As the pediatrician, you serve as an authority and a resource for the new parents. You will hear questions that have roots that may go back one, two, or more generations. Some may involve discipline, approaches to food, religious issues, or more subtle concerns relating to control and autonomy. And you may find that they will bring you the challenge of managing the beliefs, values, and expectations of the new grandparents. You may even find these new grandparents in your office! You have a unique opportunity to help new parents set a course with their own parents or in-laws that can promote family cohesion and honor family traditions or values, while empowering parents to trust themselves and truly be in charge of raising their own children.

Imagine this scenario: A young couple has just had their first baby, a son. The paternal grandfather, who played soccer in high school and college, presents his first grandchild with his own college soccer ball, proclaiming with great emotion that soccer will certainly be a part of his grandson’s future.

While this simple act may seem touching, it might also be perceived by the new parents as intrusive or controlling. How does the new father (who was maybe more bookish than athletic) feel the burden of this expectation? Perhaps the mother may wish her son to be more of a scholar than an athlete, or may want no expectation set, but may feel uncomfortable speaking honestly with her father-in-law. And this scenario is just about the gift of a soccer ball!

Grandparents (like parents) come with expectations, with beliefs about what practices worked and what failed over a wide range of areas from child rearing to managing finances to career to marriage. The arrival of a new grandchild will likely prompt them to share these beliefs, and do so in the way they usually communicate with their own children, be it blunt, emotional, indirect, or mute. These views might be forcefully presented, if a grandparent feels guilty or unfulfilled because a meaningful hope for their own child did not materialize: The new grandchild is their “last chance.” While their love and interest, their experience and wisdom can be invaluable, they might also arouse insecurity in a new parent or be disruptive. If they share opinions in a way that is stressful, devaluing, or confusing for new parents, that can translate into anxious, uncertain interactions with their new baby or a climate at home that is full of conflict instead of calm.

Parents are already blending their two styles and values, challenging enough before also trying to blend the elements of four grandparents.

The first weeks after the arrival of the new baby is a crucial time in the baby’s development, as well as in the development of the new parents, as all are rapidly acquiring new skills, adjusting to a new schedule, and learning how to understand and respond to each other. During these hard early days, grandparents often will be present, staying in the home or nearby to offer support to their children. Very commonly, they will share their opinions about such basics as nutrition and sleep. These are areas that are fundamentally important for a baby’s healthy development, but can be mysterious and challenging for new parents. They may seek out guidance from friends, books, websites, and pediatricians, as well as the new grandparents.

While their accumulated wisdom may be as helpful as their helping with laundry or meal preparation (think, “sleep when the baby sleeps”), it also might not. Perhaps the opinions are misguided (think, “sleeping on the tummy was always fine in my day”). And grandparents who are inadvertently undermining (“I don’t understand the difficulty, nursing was so easy for me”), or highly anxious might add to the new parents’ stress and uncertainty rather than alleviate it.

Grandparents also may come with strong cultural beliefs about child rearing. In families that are only one or two generations removed from immigration to this country, there may be powerfully held ideas about newborns, ones that might be inextricably linked for the grandparents with their drive to preserve their own cultural background. These may include ideas about when a child can eat solid food or what he or she should start eating. They may include beliefs that a child should never be put down or should be left to cry for long periods, lest they be “spoiled.” They might include ideas about when a baby can swim or how best to bathe them, what sorts of toys are appropriate or when their hair can be cut. While many of these beliefs have cultural value and no medical implications (like the timing of the first haircut), some may fly in the face of current scientific evidence (such as eating solids before they are able). And even when they are “safe,” new parents may experience these beliefs as fraught directives: ones that they may not believe in, but which will make them guilty of some cultural betrayal if they do not follow them.

Along a similar vein, grandparents may enter the home of their new grandchild with passionately held religious beliefs. While few of these may have direct medical implications for the new baby (such as circumcision), they can still have profound implications for life in the family’s home. When parents and grandparents all share the same religious beliefs, there is less possibility of conflict. But when new parents come from different religious traditions or no longer share their parents’ faith, there is high potential for emotionally charged differences. And if the new parents have not anticipated these conversations (say, whether or not to circumcise a baby boy when one parent is Jewish and the other is Protestant), trying to sort out these matters while also learning to change diapers or nurse a colicky baby can make a challenging situation into an overwhelming one.

Lastly, about 1% of all households have same-sex partners or marriages and about one in four are raising children. While same-sex parenthood has rapidly gained cultural acceptance over the past decade, it is possible that some grandparents will not have fully accepted the reality of their own child’s sexual orientation and committed relationship. If the parents speak to you about such a fraught situation, listen supportively.  When it sounds like there is ambivalence in the grandparents, the new parents can try to nurture the love that is there and be patient when their own parents still struggle. They should nurture the connections with those in their families that offer unconditional support and who can model love and acceptance for the new grandparents. In situations in which there is deeper alienation and little or no contact, offer that they might want to find a way to share photos and stories through one who remains close to their parents and periodically offer opportunities to rebuild relationships. A new grandchild can be a loving moment to take a fresh look at unresolved anger and loss, and as clinicians we have seen families resolve differences as they look to a new baby’s future.

Pediatricians are in a unique position of both neutrality and authority with their new patient’s parents and grandparents. When parents come to a newborn check or well-baby check, it can be invaluable to determine “who else is helping you?” After finding out about nursing or feeding the baby and about sleep, inquire about where they are getting any guidance or support. Friends or siblings with children? Books or websites? Grandparents? What has been helpful and what has not? When you hear about grandparents and see an eye-roll or hear a deep sigh, be curious about what has been helpful and what has been challenging. It is vitally helpful to first-time parents to be validated in their feeling that their own parents are a valuable resource, but not without their challenges.

While it may be important to offer a “medical” opinion about certain matters (back-sleeping, cosleeping, and introducing solids, for example), on most matters, the pediatrician’s role will be to help parents set a framework that will help them to cultivate what is precious and helpful from grandparents while minimizing conflict or unnecessary stress. For new parents, this may be as simple as reminding them that while this is an vital time for the baby’s development, it is also a big transition for them into parenthood and a significant transition for their parents or in-laws into grandparenthood. Help the new parents to understand that there is sometimes no one “right” way to handle certain decisions or challenges, and they will have to try a variety of strategies before finding the one that fits them as parents to this particular child. Remind them that parenting is a learning curve and it is common to feel stressed in new territory with high stakes. But they will find the right rhythm with being attuned to their new baby and eventually managing routines and limits. They are allowed to embrace the support that they find helpful and limit that which they experience as deeply undermining, dismissive, or judgmental.

When you notice that parents sound very angry at or alienated from grandparents, particularly when it is causing some marital conflict, it can be powerful for you to suggest that they should sort out their wishes and beliefs as parents first and then find a clear and loving way to communicate these to the grandparents. Remind them that they are becoming the experts on their children and that they will best be able to set appropriate routines and expectations. But remind them also that grandparents are potentially a treasure to their grandchildren, beyond the help with laundry and meal preparation at the very start of a child’s life.

There can never be enough loving, interested adults in a child’s orbit or a big enough cheering section. And grandparents can be uniquely passionate, patient, curious, and supportive to their growing grandchildren. They bring perspective on a family’s history, wonderful as a growing child builds a story about who they are and where they come from. And their interest and love will help a growing child build a sense of what characteristics make them a treasure to others. Few people can do this as well as grandparents, and letting them begin this involvement at the start of their grandchild’s life only supports this role.

While the arrival of a new baby will be a joyful event for a family, it will also be emotionally complex. Providing your patient’s parents with support and even some language that may help them cultivate the grandparents’ interest and love, while building healthy boundaries around their own parenting, may help set the stage for the healthiest development of your very young patient.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].

A couple having a baby brings together two family traditions that themselves blended the previous generations’ experiences and perspectives. Each of the new parents has been raised by two parents with their own histories, values, successes, and crises all available and potentially playing a part in the new baby’s future. A baby’s arrival can call forth memories of past successes, failures, hopes, and dreams – some fulfilled and some not.

As the pediatrician, you serve as an authority and a resource for the new parents. You will hear questions that have roots that may go back one, two, or more generations. Some may involve discipline, approaches to food, religious issues, or more subtle concerns relating to control and autonomy. And you may find that they will bring you the challenge of managing the beliefs, values, and expectations of the new grandparents. You may even find these new grandparents in your office! You have a unique opportunity to help new parents set a course with their own parents or in-laws that can promote family cohesion and honor family traditions or values, while empowering parents to trust themselves and truly be in charge of raising their own children.

Imagine this scenario: A young couple has just had their first baby, a son. The paternal grandfather, who played soccer in high school and college, presents his first grandchild with his own college soccer ball, proclaiming with great emotion that soccer will certainly be a part of his grandson’s future.

While this simple act may seem touching, it might also be perceived by the new parents as intrusive or controlling. How does the new father (who was maybe more bookish than athletic) feel the burden of this expectation? Perhaps the mother may wish her son to be more of a scholar than an athlete, or may want no expectation set, but may feel uncomfortable speaking honestly with her father-in-law. And this scenario is just about the gift of a soccer ball!

Grandparents (like parents) come with expectations, with beliefs about what practices worked and what failed over a wide range of areas from child rearing to managing finances to career to marriage. The arrival of a new grandchild will likely prompt them to share these beliefs, and do so in the way they usually communicate with their own children, be it blunt, emotional, indirect, or mute. These views might be forcefully presented, if a grandparent feels guilty or unfulfilled because a meaningful hope for their own child did not materialize: The new grandchild is their “last chance.” While their love and interest, their experience and wisdom can be invaluable, they might also arouse insecurity in a new parent or be disruptive. If they share opinions in a way that is stressful, devaluing, or confusing for new parents, that can translate into anxious, uncertain interactions with their new baby or a climate at home that is full of conflict instead of calm.

Parents are already blending their two styles and values, challenging enough before also trying to blend the elements of four grandparents.

The first weeks after the arrival of the new baby is a crucial time in the baby’s development, as well as in the development of the new parents, as all are rapidly acquiring new skills, adjusting to a new schedule, and learning how to understand and respond to each other. During these hard early days, grandparents often will be present, staying in the home or nearby to offer support to their children. Very commonly, they will share their opinions about such basics as nutrition and sleep. These are areas that are fundamentally important for a baby’s healthy development, but can be mysterious and challenging for new parents. They may seek out guidance from friends, books, websites, and pediatricians, as well as the new grandparents.

While their accumulated wisdom may be as helpful as their helping with laundry or meal preparation (think, “sleep when the baby sleeps”), it also might not. Perhaps the opinions are misguided (think, “sleeping on the tummy was always fine in my day”). And grandparents who are inadvertently undermining (“I don’t understand the difficulty, nursing was so easy for me”), or highly anxious might add to the new parents’ stress and uncertainty rather than alleviate it.

Grandparents also may come with strong cultural beliefs about child rearing. In families that are only one or two generations removed from immigration to this country, there may be powerfully held ideas about newborns, ones that might be inextricably linked for the grandparents with their drive to preserve their own cultural background. These may include ideas about when a child can eat solid food or what he or she should start eating. They may include beliefs that a child should never be put down or should be left to cry for long periods, lest they be “spoiled.” They might include ideas about when a baby can swim or how best to bathe them, what sorts of toys are appropriate or when their hair can be cut. While many of these beliefs have cultural value and no medical implications (like the timing of the first haircut), some may fly in the face of current scientific evidence (such as eating solids before they are able). And even when they are “safe,” new parents may experience these beliefs as fraught directives: ones that they may not believe in, but which will make them guilty of some cultural betrayal if they do not follow them.

Along a similar vein, grandparents may enter the home of their new grandchild with passionately held religious beliefs. While few of these may have direct medical implications for the new baby (such as circumcision), they can still have profound implications for life in the family’s home. When parents and grandparents all share the same religious beliefs, there is less possibility of conflict. But when new parents come from different religious traditions or no longer share their parents’ faith, there is high potential for emotionally charged differences. And if the new parents have not anticipated these conversations (say, whether or not to circumcise a baby boy when one parent is Jewish and the other is Protestant), trying to sort out these matters while also learning to change diapers or nurse a colicky baby can make a challenging situation into an overwhelming one.

Lastly, about 1% of all households have same-sex partners or marriages and about one in four are raising children. While same-sex parenthood has rapidly gained cultural acceptance over the past decade, it is possible that some grandparents will not have fully accepted the reality of their own child’s sexual orientation and committed relationship. If the parents speak to you about such a fraught situation, listen supportively.  When it sounds like there is ambivalence in the grandparents, the new parents can try to nurture the love that is there and be patient when their own parents still struggle. They should nurture the connections with those in their families that offer unconditional support and who can model love and acceptance for the new grandparents. In situations in which there is deeper alienation and little or no contact, offer that they might want to find a way to share photos and stories through one who remains close to their parents and periodically offer opportunities to rebuild relationships. A new grandchild can be a loving moment to take a fresh look at unresolved anger and loss, and as clinicians we have seen families resolve differences as they look to a new baby’s future.

Pediatricians are in a unique position of both neutrality and authority with their new patient’s parents and grandparents. When parents come to a newborn check or well-baby check, it can be invaluable to determine “who else is helping you?” After finding out about nursing or feeding the baby and about sleep, inquire about where they are getting any guidance or support. Friends or siblings with children? Books or websites? Grandparents? What has been helpful and what has not? When you hear about grandparents and see an eye-roll or hear a deep sigh, be curious about what has been helpful and what has been challenging. It is vitally helpful to first-time parents to be validated in their feeling that their own parents are a valuable resource, but not without their challenges.

While it may be important to offer a “medical” opinion about certain matters (back-sleeping, cosleeping, and introducing solids, for example), on most matters, the pediatrician’s role will be to help parents set a framework that will help them to cultivate what is precious and helpful from grandparents while minimizing conflict or unnecessary stress. For new parents, this may be as simple as reminding them that while this is an vital time for the baby’s development, it is also a big transition for them into parenthood and a significant transition for their parents or in-laws into grandparenthood. Help the new parents to understand that there is sometimes no one “right” way to handle certain decisions or challenges, and they will have to try a variety of strategies before finding the one that fits them as parents to this particular child. Remind them that parenting is a learning curve and it is common to feel stressed in new territory with high stakes. But they will find the right rhythm with being attuned to their new baby and eventually managing routines and limits. They are allowed to embrace the support that they find helpful and limit that which they experience as deeply undermining, dismissive, or judgmental.

When you notice that parents sound very angry at or alienated from grandparents, particularly when it is causing some marital conflict, it can be powerful for you to suggest that they should sort out their wishes and beliefs as parents first and then find a clear and loving way to communicate these to the grandparents. Remind them that they are becoming the experts on their children and that they will best be able to set appropriate routines and expectations. But remind them also that grandparents are potentially a treasure to their grandchildren, beyond the help with laundry and meal preparation at the very start of a child’s life.

There can never be enough loving, interested adults in a child’s orbit or a big enough cheering section. And grandparents can be uniquely passionate, patient, curious, and supportive to their growing grandchildren. They bring perspective on a family’s history, wonderful as a growing child builds a story about who they are and where they come from. And their interest and love will help a growing child build a sense of what characteristics make them a treasure to others. Few people can do this as well as grandparents, and letting them begin this involvement at the start of their grandchild’s life only supports this role.

While the arrival of a new baby will be a joyful event for a family, it will also be emotionally complex. Providing your patient’s parents with support and even some language that may help them cultivate the grandparents’ interest and love, while building healthy boundaries around their own parenting, may help set the stage for the healthiest development of your very young patient.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].