Behavioral Consult

As clinicians trained in the care of children, we have struggled in recent years with how much care is appropriate to provide to the parents of our young charges.

Ridofranz/Thinkstock

Gradual progression has occurred from recognizing postpartum depression as affecting infants, to recommending screening, to creation of a billing code for screening as “for the benefit of” the child, and increasingly even being paid for that code. We now see referral of depressed parents as within our scope of practice with the goal of protecting the child’s emotional development from the caregiver’s altered mental condition, as well as relieving the parent’s suffering. Some of us even provide treatment ourselves.

While the family history has been our standard way of assessing “transgenerational transmission” of risk for physical and mental health conditions, parenting practices are a more direct transmission threat, and one more amenable to our intervention.

Aversive parenting acts happen to many people growing up, but how the parent thinks about these seems to make the difference between consciously protecting the child from similar experiences or unconsciously playing them out in the child’s life. With 64% of U.S. adults reporting at least one adverse childhood experience (ACE), many of which were acts or omissions by their parents, we need to be vigilant to track their translation of past events, “the ghosts,” into present parenting.
 

Just ask

“I barely have time to talk about the child,” you may be saying, “how can I have time to dig into the parent’s issues, much less know what to do?” Exploring for connections to the parent’s past in primary care is most crucial when the parent-child relationship is strained, or the parent’s handling of typical or problematic child behaviors is abnormal, clinically symptomatic, or dangerous. Nonetheless, helping all parents make these connections enriches life and meaning for families, and dramatically strengthens the doctor-family relationship. Then all of our care is more effective.

In my experience, this valuable connection is not difficult to make – it lives just below the surface for most parents. We may want to ask permission first, noting that “our ideas about how to parent tend to be shaped by how we were parented.” By simply asking, “May I ask how your parents would have handled this [behavior or situation]?” we may hear a description of a reasonable approach (sent to my room), denial that this ever came up (I was never as hardheaded as this kid!), blanking out (Things were tough. I have tried to block it all out), or clues to a pattern better not repeated (Oh, my father would have beat me ...). This question also may be useful in elucidating cultural or generational differences between what was done to them and their own intentions that can be hard to bridge. All of these are opportunities for promoting positive parenting by creating empathy for that child of the past to carry forward to the own child in the present.

While we may be lucky to have even one parent at the visit, we should ask the one present the equivalent question of the partner’s past. Even if one parent had a model that he or she wanted to emulate or a ghost to bust, the other may not agree. Conflict between partners undermines management and can create harmful tension. If the parent does not know, this is an important homework assignment to being collaborative coparents.
 

Empathize

After hearing about the past experiences, we should empathize with the parent regarding pain experienced as a child in the past (“That would be very scary for any child”) and ask “How much is this a burden for you now?” to see if help is needed. But this is a key educational moment for us as child development experts to suggest how children of the age they were then might process the events. For example, one might explain reaction to abandonment by a father by saying, “Any 6-year-old whose father left would feel sad and mad, but also might think he had done something wrong or wasn’t worth staying around for.” One might react to a story of abusive discipline by saying, “Children need to feel safe and protected at home. Not knowing when your parent is going to hurt you could produce lifelong anxiety and trouble trusting your closest relationships.” Watch to see if this connects for them.

Selma Fraiberg, in the classic article “Ghosts in the Nursery,”¹ noted that if parents have come to empathize with their past hurting selves, they will work to prevent similar pain for their own children. If they have dealt with these experiences by identifying with the aggressive or neglectful adult or blanking the memory, they are more likely to act out similar practices with their children.

For some, being able to tolerate reviewing these painful times enough to experience empathy for the child may require years of work with a trusted therapist. We should be prepared to refer if the parents are in distress. But for many, getting our help to understand how a child might feel and later act after these experiences may be enough to interrupt the transmission. We can try to elicit current impact of the past (“How are those experiences affecting your parenting now?”). This question, expecting impact, often causes parents to stop short and think. While at first denying impact, if I have been compassionate and nonjudgmental in asking, they often return with more insight.
 

Help with parenting issues

After eliciting perceptions of the past, I find it useful to ask, “So, what have (the two of) you decided” about how to manage [the problematic parenting situation]?” The implication is that parenting actions are decisions. Making this decision process overt may reveal that they are having blank out moments of impulsive action, or ambivalence with thoughts and feelings in conflict, or arguments resulting in standoffs. A common reaction to hurts in the past is for parents to strongly avoid doing as their own parents did, but then have no plan at all, get increasingly emotional, and finally blow up and scream or hit or storm off ineffectually. We can help them pick out one or two stressful situations, often perceived disrespect or defiance by the child, and plan steps for when it comes up again – as hot-button issues always do. It is important to let them know that their “emotion brain” is likely to speak up first under stress and the “thinking brain” takes longer. We, and they, need to be patient and congratulate them for little bits of progress in having rationality win.

Don’t forget that children adapt to the parenting they receive and develop reactions that may interfere with seeing their parents in a new mode of trust and kindness. A child may have defended him/herself from the emotional pain of not feeling safe or protected by the parent who is acting out a ghost and may react by laughing, running, spitting, hitting, shutting down, pushing the parent away, or saying “I don’t care.” The child’s reaction, too, takes time and consistent responsiveness to change to accept new parenting patterns. It can be painful to the newly-aware parents to recognize these behaviors are caused, at least in part, by their own actions, especially when it is a repetition of their own childhood experiences. We can be the patient, empathic coach – believing in their good intentions as they develop as parents – just as they would have wanted from their parents when they were growing up.



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 for MDedge News. E-mail her at [email protected].


Reference

1. “Ghosts in the Nursery: A Psychoanalytic Approach to the Problems of Impaired Infant-Mother Relationships,” J Am Acad Child Psychiatry. 1975 Summer;14(3);387-421.

As clinicians trained in the care of children, we have struggled in recent years with how much care is appropriate to provide to the parents of our young charges.

Ridofranz/Thinkstock

Gradual progression has occurred from recognizing postpartum depression as affecting infants, to recommending screening, to creation of a billing code for screening as “for the benefit of” the child, and increasingly even being paid for that code. We now see referral of depressed parents as within our scope of practice with the goal of protecting the child’s emotional development from the caregiver’s altered mental condition, as well as relieving the parent’s suffering. Some of us even provide treatment ourselves.

While the family history has been our standard way of assessing “transgenerational transmission” of risk for physical and mental health conditions, parenting practices are a more direct transmission threat, and one more amenable to our intervention.

Aversive parenting acts happen to many people growing up, but how the parent thinks about these seems to make the difference between consciously protecting the child from similar experiences or unconsciously playing them out in the child’s life. With 64% of U.S. adults reporting at least one adverse childhood experience (ACE), many of which were acts or omissions by their parents, we need to be vigilant to track their translation of past events, “the ghosts,” into present parenting.
 

Just ask

“I barely have time to talk about the child,” you may be saying, “how can I have time to dig into the parent’s issues, much less know what to do?” Exploring for connections to the parent’s past in primary care is most crucial when the parent-child relationship is strained, or the parent’s handling of typical or problematic child behaviors is abnormal, clinically symptomatic, or dangerous. Nonetheless, helping all parents make these connections enriches life and meaning for families, and dramatically strengthens the doctor-family relationship. Then all of our care is more effective.

In my experience, this valuable connection is not difficult to make – it lives just below the surface for most parents. We may want to ask permission first, noting that “our ideas about how to parent tend to be shaped by how we were parented.” By simply asking, “May I ask how your parents would have handled this [behavior or situation]?” we may hear a description of a reasonable approach (sent to my room), denial that this ever came up (I was never as hardheaded as this kid!), blanking out (Things were tough. I have tried to block it all out), or clues to a pattern better not repeated (Oh, my father would have beat me ...). This question also may be useful in elucidating cultural or generational differences between what was done to them and their own intentions that can be hard to bridge. All of these are opportunities for promoting positive parenting by creating empathy for that child of the past to carry forward to the own child in the present.

While we may be lucky to have even one parent at the visit, we should ask the one present the equivalent question of the partner’s past. Even if one parent had a model that he or she wanted to emulate or a ghost to bust, the other may not agree. Conflict between partners undermines management and can create harmful tension. If the parent does not know, this is an important homework assignment to being collaborative coparents.
 

Empathize

After hearing about the past experiences, we should empathize with the parent regarding pain experienced as a child in the past (“That would be very scary for any child”) and ask “How much is this a burden for you now?” to see if help is needed. But this is a key educational moment for us as child development experts to suggest how children of the age they were then might process the events. For example, one might explain reaction to abandonment by a father by saying, “Any 6-year-old whose father left would feel sad and mad, but also might think he had done something wrong or wasn’t worth staying around for.” One might react to a story of abusive discipline by saying, “Children need to feel safe and protected at home. Not knowing when your parent is going to hurt you could produce lifelong anxiety and trouble trusting your closest relationships.” Watch to see if this connects for them.

Selma Fraiberg, in the classic article “Ghosts in the Nursery,”¹ noted that if parents have come to empathize with their past hurting selves, they will work to prevent similar pain for their own children. If they have dealt with these experiences by identifying with the aggressive or neglectful adult or blanking the memory, they are more likely to act out similar practices with their children.

For some, being able to tolerate reviewing these painful times enough to experience empathy for the child may require years of work with a trusted therapist. We should be prepared to refer if the parents are in distress. But for many, getting our help to understand how a child might feel and later act after these experiences may be enough to interrupt the transmission. We can try to elicit current impact of the past (“How are those experiences affecting your parenting now?”). This question, expecting impact, often causes parents to stop short and think. While at first denying impact, if I have been compassionate and nonjudgmental in asking, they often return with more insight.
 

Help with parenting issues

After eliciting perceptions of the past, I find it useful to ask, “So, what have (the two of) you decided” about how to manage [the problematic parenting situation]?” The implication is that parenting actions are decisions. Making this decision process overt may reveal that they are having blank out moments of impulsive action, or ambivalence with thoughts and feelings in conflict, or arguments resulting in standoffs. A common reaction to hurts in the past is for parents to strongly avoid doing as their own parents did, but then have no plan at all, get increasingly emotional, and finally blow up and scream or hit or storm off ineffectually. We can help them pick out one or two stressful situations, often perceived disrespect or defiance by the child, and plan steps for when it comes up again – as hot-button issues always do. It is important to let them know that their “emotion brain” is likely to speak up first under stress and the “thinking brain” takes longer. We, and they, need to be patient and congratulate them for little bits of progress in having rationality win.

Don’t forget that children adapt to the parenting they receive and develop reactions that may interfere with seeing their parents in a new mode of trust and kindness. A child may have defended him/herself from the emotional pain of not feeling safe or protected by the parent who is acting out a ghost and may react by laughing, running, spitting, hitting, shutting down, pushing the parent away, or saying “I don’t care.” The child’s reaction, too, takes time and consistent responsiveness to change to accept new parenting patterns. It can be painful to the newly-aware parents to recognize these behaviors are caused, at least in part, by their own actions, especially when it is a repetition of their own childhood experiences. We can be the patient, empathic coach – believing in their good intentions as they develop as parents – just as they would have wanted from their parents when they were growing up.



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 for MDedge News. E-mail her at [email protected].


Reference

1. “Ghosts in the Nursery: A Psychoanalytic Approach to the Problems of Impaired Infant-Mother Relationships,” J Am Acad Child Psychiatry. 1975 Summer;14(3);387-421.

As clinicians trained in the care of children, we have struggled in recent years with how much care is appropriate to provide to the parents of our young charges.

Ridofranz/Thinkstock

Gradual progression has occurred from recognizing postpartum depression as affecting infants, to recommending screening, to creation of a billing code for screening as “for the benefit of” the child, and increasingly even being paid for that code. We now see referral of depressed parents as within our scope of practice with the goal of protecting the child’s emotional development from the caregiver’s altered mental condition, as well as relieving the parent’s suffering. Some of us even provide treatment ourselves.

While the family history has been our standard way of assessing “transgenerational transmission” of risk for physical and mental health conditions, parenting practices are a more direct transmission threat, and one more amenable to our intervention.

Aversive parenting acts happen to many people growing up, but how the parent thinks about these seems to make the difference between consciously protecting the child from similar experiences or unconsciously playing them out in the child’s life. With 64% of U.S. adults reporting at least one adverse childhood experience (ACE), many of which were acts or omissions by their parents, we need to be vigilant to track their translation of past events, “the ghosts,” into present parenting.
 

Just ask

“I barely have time to talk about the child,” you may be saying, “how can I have time to dig into the parent’s issues, much less know what to do?” Exploring for connections to the parent’s past in primary care is most crucial when the parent-child relationship is strained, or the parent’s handling of typical or problematic child behaviors is abnormal, clinically symptomatic, or dangerous. Nonetheless, helping all parents make these connections enriches life and meaning for families, and dramatically strengthens the doctor-family relationship. Then all of our care is more effective.

In my experience, this valuable connection is not difficult to make – it lives just below the surface for most parents. We may want to ask permission first, noting that “our ideas about how to parent tend to be shaped by how we were parented.” By simply asking, “May I ask how your parents would have handled this [behavior or situation]?” we may hear a description of a reasonable approach (sent to my room), denial that this ever came up (I was never as hardheaded as this kid!), blanking out (Things were tough. I have tried to block it all out), or clues to a pattern better not repeated (Oh, my father would have beat me ...). This question also may be useful in elucidating cultural or generational differences between what was done to them and their own intentions that can be hard to bridge. All of these are opportunities for promoting positive parenting by creating empathy for that child of the past to carry forward to the own child in the present.

While we may be lucky to have even one parent at the visit, we should ask the one present the equivalent question of the partner’s past. Even if one parent had a model that he or she wanted to emulate or a ghost to bust, the other may not agree. Conflict between partners undermines management and can create harmful tension. If the parent does not know, this is an important homework assignment to being collaborative coparents.
 

Empathize

After hearing about the past experiences, we should empathize with the parent regarding pain experienced as a child in the past (“That would be very scary for any child”) and ask “How much is this a burden for you now?” to see if help is needed. But this is a key educational moment for us as child development experts to suggest how children of the age they were then might process the events. For example, one might explain reaction to abandonment by a father by saying, “Any 6-year-old whose father left would feel sad and mad, but also might think he had done something wrong or wasn’t worth staying around for.” One might react to a story of abusive discipline by saying, “Children need to feel safe and protected at home. Not knowing when your parent is going to hurt you could produce lifelong anxiety and trouble trusting your closest relationships.” Watch to see if this connects for them.

Selma Fraiberg, in the classic article “Ghosts in the Nursery,”¹ noted that if parents have come to empathize with their past hurting selves, they will work to prevent similar pain for their own children. If they have dealt with these experiences by identifying with the aggressive or neglectful adult or blanking the memory, they are more likely to act out similar practices with their children.

For some, being able to tolerate reviewing these painful times enough to experience empathy for the child may require years of work with a trusted therapist. We should be prepared to refer if the parents are in distress. But for many, getting our help to understand how a child might feel and later act after these experiences may be enough to interrupt the transmission. We can try to elicit current impact of the past (“How are those experiences affecting your parenting now?”). This question, expecting impact, often causes parents to stop short and think. While at first denying impact, if I have been compassionate and nonjudgmental in asking, they often return with more insight.
 

Help with parenting issues

After eliciting perceptions of the past, I find it useful to ask, “So, what have (the two of) you decided” about how to manage [the problematic parenting situation]?” The implication is that parenting actions are decisions. Making this decision process overt may reveal that they are having blank out moments of impulsive action, or ambivalence with thoughts and feelings in conflict, or arguments resulting in standoffs. A common reaction to hurts in the past is for parents to strongly avoid doing as their own parents did, but then have no plan at all, get increasingly emotional, and finally blow up and scream or hit or storm off ineffectually. We can help them pick out one or two stressful situations, often perceived disrespect or defiance by the child, and plan steps for when it comes up again – as hot-button issues always do. It is important to let them know that their “emotion brain” is likely to speak up first under stress and the “thinking brain” takes longer. We, and they, need to be patient and congratulate them for little bits of progress in having rationality win.

Don’t forget that children adapt to the parenting they receive and develop reactions that may interfere with seeing their parents in a new mode of trust and kindness. A child may have defended him/herself from the emotional pain of not feeling safe or protected by the parent who is acting out a ghost and may react by laughing, running, spitting, hitting, shutting down, pushing the parent away, or saying “I don’t care.” The child’s reaction, too, takes time and consistent responsiveness to change to accept new parenting patterns. It can be painful to the newly-aware parents to recognize these behaviors are caused, at least in part, by their own actions, especially when it is a repetition of their own childhood experiences. We can be the patient, empathic coach – believing in their good intentions as they develop as parents – just as they would have wanted from their parents when they were growing up.



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 for MDedge News. E-mail her at [email protected].


Reference

1. “Ghosts in the Nursery: A Psychoanalytic Approach to the Problems of Impaired Infant-Mother Relationships,” J Am Acad Child Psychiatry. 1975 Summer;14(3);387-421.

It has been 2 years since we last wrote about the potential risks to children and adolescents of spending too much time on screens. While there have been studies in the interval that offer us more information about the effects of heavy screen use and the developing brain, there is little certainty about what is optimal for children and adolescents, and less still on how parents might effectively equip their children to make good use of screens without suffering ill effects.

monkeybusinessimages/iStock/Getty Images Plus

You might recall that back in October of 2016, the American Academy of Pediatrics published screen time guidelines: recommending no screen time for infants and children up to 18 months old, limiting all screen time to 1 hour per day for children up to 5 years old, and 2 hours daily for older children (up to 11 years old), so that it would not interfere with homework, social time, exercise, and sleep. At the time, data suggested that children from 2 to 11 years old were spending an average of 4.5 hours per day on screens (TV, computer, tablets, or smartphones, not counting homework).

The Adolescent Brain Cognitive Development Study began in September 2016 to evaluate the effects of Canadian recommendations for 8- to 11-year-olds (9-11 hours sleep nightly, 1 hour of exercise daily, and 2 hours or less of screen time daily; the study subjects are in the United States). This fall they published their initial results, demonstrating that only 51% get the recommended amount of sleep, only 37% kept their daily screen time to under 2 hours, and only 18% were getting the recommended amount of exercise. Only 5% of children consistently met all three recommendations while 29% of children didn’t meet any of the recommendations.

The researchers assessed the children’s cognitive development and found that after 1 year, those children who met the screen time recommendations, both screen time and sleep, or all three recommendations demonstrated “superior global cognition.” Children were spending an average of 3.7 hours daily on screens, and those children who were spending 2 hours or less on screens performed 4% better on tests of cognitive function than did children spending the average amount of time. Sleep and exercise differences alone did not contribute to significant differences in cognitive function. This study will continue for another 10 years.¹

In a much smaller study out of Cincinnati Children’s Hospital, researchers asked parents to describe the amount of time a child spent on reading and in screen-based media activities, then completed MRI scans of the children’s brains.² They found a strong association between reading time and higher functional connectivity between the parts of the brain responsible for visual word formation and those responsible for language and cognitive control, with a negative correlation between functional connectivity and time spent in screen-based media activities.

While these studies are important pieces of data as we build a deeper understanding about the effects of screen-based media use on children’s cognitive and behavioral development, they do not offer certainty about causality. These studies do not yet clarify whether certain children are especially vulnerable to the untoward effects of heavy screen-based media use. Perhaps the research will someday offer guidelines with certainty, but families need guidance now. Without doubt, digital devices are here to stay, are important to homework, and can facilitate independence, long-distance connections, important technical work-skills, and even senseless fun and relaxation. So we will focus on offering some principles to help you guide young people (or their parents) in approaching screen time thoughtfully.

While recommending no more than 2 hours of daily screen time seems reasonable, it may be more useful to focus on what young people are doing with the rest of their time. Are they getting adequate, restful sleep? Are they able to exercise most days? Do they have enough time for homework? Do they have time for friends (time actually together, not just texting)? What about time for hobbies? When parents focus on the precious resource of time and all of the activities their children both need and want to do, it sets the frame for them to say that their children are allowed to have time to relax with screen-based media as long as it does not take away from these other priorities. Ensuring that the child has at least 8 hours of sleep, after homework and sports, also will set natural limits on screen time.

Parents also can use the frame of development to guide their rules about screen time. If use of an electronic device serves a developmental task, then it is reasonable. If it interferes with a developmental task, then it should be limited. Adolescents (ages 12-20) should be exploring their own identities, establishing independence, deepening social relationships, and learning to manage their impulses. Some interests can be most easily explored with the aid of a computer (such as with programming, art history, or astronomy). Use of cellphones can facilitate teenagers’ being more independent with plans or transportation. Social connections can be supported by texting or FaceTime. Some close friends may be in a different sport or live far away, and it is possible to stay connected only virtually. However, when use of electronic devices keeps the child from engaging with new friends and new interests or from getting into the world to establish real independence (i.e., a job), then there should be limits. In all of these cases, it is critical that adults explain to teenagers what is guiding their thinking about limits on screen time. Open discussions about the great utility and fun that screens can provide, as well as the challenge of keeping those activities in balance with other important activities, helps adolescents set the frame for that rapidly approaching time when they will be making those choices without adult supervision.

Younger children (ages 8-11) should be sampling a wide array of activities and interests and experiencing challenges and eventual mastery across domains. Video games can be very compelling for this age group because they appeal to exactly this drive to master a challenge. Parents want to ensure that their children can have senseless fun, and still have enough time to explore actual activities: social, athletic, creative, and academic. They can be ready to explain the why of rules, but consistent rules, enforced for everyone at home, are most helpful for this age group.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
 

References

1. Lancet Child Adolesc Health. 2018 Nov 1;2(11):783-91.

2. Acta Paediatra. 2018 Apr;107(4):685-93

It has been 2 years since we last wrote about the potential risks to children and adolescents of spending too much time on screens. While there have been studies in the interval that offer us more information about the effects of heavy screen use and the developing brain, there is little certainty about what is optimal for children and adolescents, and less still on how parents might effectively equip their children to make good use of screens without suffering ill effects.

monkeybusinessimages/iStock/Getty Images Plus

You might recall that back in October of 2016, the American Academy of Pediatrics published screen time guidelines: recommending no screen time for infants and children up to 18 months old, limiting all screen time to 1 hour per day for children up to 5 years old, and 2 hours daily for older children (up to 11 years old), so that it would not interfere with homework, social time, exercise, and sleep. At the time, data suggested that children from 2 to 11 years old were spending an average of 4.5 hours per day on screens (TV, computer, tablets, or smartphones, not counting homework).

The Adolescent Brain Cognitive Development Study began in September 2016 to evaluate the effects of Canadian recommendations for 8- to 11-year-olds (9-11 hours sleep nightly, 1 hour of exercise daily, and 2 hours or less of screen time daily; the study subjects are in the United States). This fall they published their initial results, demonstrating that only 51% get the recommended amount of sleep, only 37% kept their daily screen time to under 2 hours, and only 18% were getting the recommended amount of exercise. Only 5% of children consistently met all three recommendations while 29% of children didn’t meet any of the recommendations.

The researchers assessed the children’s cognitive development and found that after 1 year, those children who met the screen time recommendations, both screen time and sleep, or all three recommendations demonstrated “superior global cognition.” Children were spending an average of 3.7 hours daily on screens, and those children who were spending 2 hours or less on screens performed 4% better on tests of cognitive function than did children spending the average amount of time. Sleep and exercise differences alone did not contribute to significant differences in cognitive function. This study will continue for another 10 years.¹

In a much smaller study out of Cincinnati Children’s Hospital, researchers asked parents to describe the amount of time a child spent on reading and in screen-based media activities, then completed MRI scans of the children’s brains.² They found a strong association between reading time and higher functional connectivity between the parts of the brain responsible for visual word formation and those responsible for language and cognitive control, with a negative correlation between functional connectivity and time spent in screen-based media activities.

While these studies are important pieces of data as we build a deeper understanding about the effects of screen-based media use on children’s cognitive and behavioral development, they do not offer certainty about causality. These studies do not yet clarify whether certain children are especially vulnerable to the untoward effects of heavy screen-based media use. Perhaps the research will someday offer guidelines with certainty, but families need guidance now. Without doubt, digital devices are here to stay, are important to homework, and can facilitate independence, long-distance connections, important technical work-skills, and even senseless fun and relaxation. So we will focus on offering some principles to help you guide young people (or their parents) in approaching screen time thoughtfully.

While recommending no more than 2 hours of daily screen time seems reasonable, it may be more useful to focus on what young people are doing with the rest of their time. Are they getting adequate, restful sleep? Are they able to exercise most days? Do they have enough time for homework? Do they have time for friends (time actually together, not just texting)? What about time for hobbies? When parents focus on the precious resource of time and all of the activities their children both need and want to do, it sets the frame for them to say that their children are allowed to have time to relax with screen-based media as long as it does not take away from these other priorities. Ensuring that the child has at least 8 hours of sleep, after homework and sports, also will set natural limits on screen time.

Parents also can use the frame of development to guide their rules about screen time. If use of an electronic device serves a developmental task, then it is reasonable. If it interferes with a developmental task, then it should be limited. Adolescents (ages 12-20) should be exploring their own identities, establishing independence, deepening social relationships, and learning to manage their impulses. Some interests can be most easily explored with the aid of a computer (such as with programming, art history, or astronomy). Use of cellphones can facilitate teenagers’ being more independent with plans or transportation. Social connections can be supported by texting or FaceTime. Some close friends may be in a different sport or live far away, and it is possible to stay connected only virtually. However, when use of electronic devices keeps the child from engaging with new friends and new interests or from getting into the world to establish real independence (i.e., a job), then there should be limits. In all of these cases, it is critical that adults explain to teenagers what is guiding their thinking about limits on screen time. Open discussions about the great utility and fun that screens can provide, as well as the challenge of keeping those activities in balance with other important activities, helps adolescents set the frame for that rapidly approaching time when they will be making those choices without adult supervision.

Younger children (ages 8-11) should be sampling a wide array of activities and interests and experiencing challenges and eventual mastery across domains. Video games can be very compelling for this age group because they appeal to exactly this drive to master a challenge. Parents want to ensure that their children can have senseless fun, and still have enough time to explore actual activities: social, athletic, creative, and academic. They can be ready to explain the why of rules, but consistent rules, enforced for everyone at home, are most helpful for this age group.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
 

References

1. Lancet Child Adolesc Health. 2018 Nov 1;2(11):783-91.

2. Acta Paediatra. 2018 Apr;107(4):685-93

It has been 2 years since we last wrote about the potential risks to children and adolescents of spending too much time on screens. While there have been studies in the interval that offer us more information about the effects of heavy screen use and the developing brain, there is little certainty about what is optimal for children and adolescents, and less still on how parents might effectively equip their children to make good use of screens without suffering ill effects.

monkeybusinessimages/iStock/Getty Images Plus

You might recall that back in October of 2016, the American Academy of Pediatrics published screen time guidelines: recommending no screen time for infants and children up to 18 months old, limiting all screen time to 1 hour per day for children up to 5 years old, and 2 hours daily for older children (up to 11 years old), so that it would not interfere with homework, social time, exercise, and sleep. At the time, data suggested that children from 2 to 11 years old were spending an average of 4.5 hours per day on screens (TV, computer, tablets, or smartphones, not counting homework).

The Adolescent Brain Cognitive Development Study began in September 2016 to evaluate the effects of Canadian recommendations for 8- to 11-year-olds (9-11 hours sleep nightly, 1 hour of exercise daily, and 2 hours or less of screen time daily; the study subjects are in the United States). This fall they published their initial results, demonstrating that only 51% get the recommended amount of sleep, only 37% kept their daily screen time to under 2 hours, and only 18% were getting the recommended amount of exercise. Only 5% of children consistently met all three recommendations while 29% of children didn’t meet any of the recommendations.

The researchers assessed the children’s cognitive development and found that after 1 year, those children who met the screen time recommendations, both screen time and sleep, or all three recommendations demonstrated “superior global cognition.” Children were spending an average of 3.7 hours daily on screens, and those children who were spending 2 hours or less on screens performed 4% better on tests of cognitive function than did children spending the average amount of time. Sleep and exercise differences alone did not contribute to significant differences in cognitive function. This study will continue for another 10 years.¹

In a much smaller study out of Cincinnati Children’s Hospital, researchers asked parents to describe the amount of time a child spent on reading and in screen-based media activities, then completed MRI scans of the children’s brains.² They found a strong association between reading time and higher functional connectivity between the parts of the brain responsible for visual word formation and those responsible for language and cognitive control, with a negative correlation between functional connectivity and time spent in screen-based media activities.

While these studies are important pieces of data as we build a deeper understanding about the effects of screen-based media use on children’s cognitive and behavioral development, they do not offer certainty about causality. These studies do not yet clarify whether certain children are especially vulnerable to the untoward effects of heavy screen-based media use. Perhaps the research will someday offer guidelines with certainty, but families need guidance now. Without doubt, digital devices are here to stay, are important to homework, and can facilitate independence, long-distance connections, important technical work-skills, and even senseless fun and relaxation. So we will focus on offering some principles to help you guide young people (or their parents) in approaching screen time thoughtfully.

While recommending no more than 2 hours of daily screen time seems reasonable, it may be more useful to focus on what young people are doing with the rest of their time. Are they getting adequate, restful sleep? Are they able to exercise most days? Do they have enough time for homework? Do they have time for friends (time actually together, not just texting)? What about time for hobbies? When parents focus on the precious resource of time and all of the activities their children both need and want to do, it sets the frame for them to say that their children are allowed to have time to relax with screen-based media as long as it does not take away from these other priorities. Ensuring that the child has at least 8 hours of sleep, after homework and sports, also will set natural limits on screen time.

Parents also can use the frame of development to guide their rules about screen time. If use of an electronic device serves a developmental task, then it is reasonable. If it interferes with a developmental task, then it should be limited. Adolescents (ages 12-20) should be exploring their own identities, establishing independence, deepening social relationships, and learning to manage their impulses. Some interests can be most easily explored with the aid of a computer (such as with programming, art history, or astronomy). Use of cellphones can facilitate teenagers’ being more independent with plans or transportation. Social connections can be supported by texting or FaceTime. Some close friends may be in a different sport or live far away, and it is possible to stay connected only virtually. However, when use of electronic devices keeps the child from engaging with new friends and new interests or from getting into the world to establish real independence (i.e., a job), then there should be limits. In all of these cases, it is critical that adults explain to teenagers what is guiding their thinking about limits on screen time. Open discussions about the great utility and fun that screens can provide, as well as the challenge of keeping those activities in balance with other important activities, helps adolescents set the frame for that rapidly approaching time when they will be making those choices without adult supervision.

Younger children (ages 8-11) should be sampling a wide array of activities and interests and experiencing challenges and eventual mastery across domains. Video games can be very compelling for this age group because they appeal to exactly this drive to master a challenge. Parents want to ensure that their children can have senseless fun, and still have enough time to explore actual activities: social, athletic, creative, and academic. They can be ready to explain the why of rules, but consistent rules, enforced for everyone at home, are most helpful for this age group.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
 

References

1. Lancet Child Adolesc Health. 2018 Nov 1;2(11):783-91.

2. Acta Paediatra. 2018 Apr;107(4):685-93

Babies evolved to cry to get their needs met and adults evolved to be aroused by the sound. Perfect match, right? But crying/fussing was rated the No. 1 hardest part of parenting for 0- to 3-year-olds in our data from more than 68,000 parents.

Petro Feketa/iStockphoto

As clinicians, we become amazingly immune to the crying in our offices, but hopefully not to crying as a concern of parents. Our training directs us to look for pathology such as under- or overfeeding, infection, gastroesophageal reflux disease (GERD), volvulus, a hair tourniquet, or an injury as causes of crying. Having ruled these out, the bigger task is making sure that parents learn to read their infants’ crying and find ways to console them. Learning to handle crying can be tense, frustrating, and upsetting for parents, but success is ultimately satisfying and an important part of the reciprocal interaction that builds attachment for both parent and child.

“Developmental crying” is a great term for explaining crying in the first 3 months to families, as it is age related. The acronym PURPLE was created to teach about this normal crying.
 

• “P” is for peak of crying – babies may cry more each week, most in month 2, then less in months 3-5.
• “U” is for unexpected – crying can come and go without explanation.
• “R” is for resists soothing – babies may not stop crying no matter what is tried.
• “P” is for pain-like face – babies appear to be in pain, even if they are not.
• “L” is for long lasting – crying can last 5 hours a day or more.
• “E” is for evening – the baby might cry more in the late afternoon and evening.

The 1- to 2-week visit is a key time to teach parents about the expected upcoming crying and ways to manage it. I lean on the evidence-based steps for soothing, using the 5 S’s described by Harvey Karp, MD, based on the wisdom of T. Berry Brazelton, MD. These include:

• Swaddling in a wrap that constrains arms and legs.
• Side or stomach holding (but not for sleeping).
• Shushing sounds of voice, radio static, fan, air conditioner, or car ride.
• Swinging gently (point out to never shake a baby).
• Sucking on a pacifier, finger, or hand.

Because babies change state slowly and also respond to high caregiver emotion such as anxiety, it is important for parents to take some deep breaths and give each “S” several minutes to have an effect.

Some of our patients will go beyond typical crying to colic, defined as crying for at least 3 hours per day, at least 3 days per week, starting before 3 months post term. While typically easing by age 3 months, colic can in nightmare cases persist to age 1 year. Needless to say, prolonged crying can be an enormous stress for families. Researchers in the Fussy Baby Network consulting on infant crying have found value in a family prescription for REST: Reassurance, Empathy, Support, and Time away. Reassurance that the child is not ill should be provided after a careful history, including asking why parents think the baby is crying, and a physical exam, even if we think we can tell at a glance that the baby is okay. Remember that every parent’s first concern is whether the baby is okay, and crying indicates otherwise. Parents are counting on us for a thorough exam before we reassure them. Exhausted new parents deserve empathy – acknowledgment of how difficult, scary, and maddening it is to not be able to console their newborns.

While friends are saying “You must be so happy!” after a child is born, ambivalence (What have I done to my life?) is very common, but not easy to admit. We can point out that the typical age at which parents report “loving” their infants is actually more like 6 weeks, when they finally smile! To acknowledge ambivalence, I may say, “When you feel like throwing him out the window, it’s okay to lay him in the crib and put on headphones for a few minutes.” Music, meditation, yoga, or exercise are break activities that also can reduce parent stress.

Support for the parents is one of the most important protections for children at all ages, but can’t be assumed. Unfortunately, crying tends to increase beginning at 2 weeks post term, right when the partner returns to work or relatives leave. It is important to ask, “Who is helping you with the baby?” Just having a partner doesn’t mean that person is taking a turn! Fathers may be afraid of holding a baby, or may have no experience and try to defer. We need to encourage fathers in all aspects of care but especially to “find at least one way to console your baby.” Sometimes mothers “rescue” dads too quickly. While mothers may have both more experience with infants and the magic of breastfeeding for consoling, depriving fathers of working through the struggle of managing crying can result in their developing less confidence in caregiving. It also can cause them to miss out on supporting the mother at this delicate time, a chance to profoundly strengthen the partnership.

Taking into account the importance for parents of finding ways to console crying babies, getting some “time away” can be helpful, especially if crying goes on for months. Maybe those friends who asked, “What can I do to help?” could come over for an hour in the evening (peak crying time) to hold the baby. This also can be a chance for parent time together, a newly rare commodity.

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

Babies evolved to cry to get their needs met and adults evolved to be aroused by the sound. Perfect match, right? But crying/fussing was rated the No. 1 hardest part of parenting for 0- to 3-year-olds in our data from more than 68,000 parents.

Petro Feketa/iStockphoto

As clinicians, we become amazingly immune to the crying in our offices, but hopefully not to crying as a concern of parents. Our training directs us to look for pathology such as under- or overfeeding, infection, gastroesophageal reflux disease (GERD), volvulus, a hair tourniquet, or an injury as causes of crying. Having ruled these out, the bigger task is making sure that parents learn to read their infants’ crying and find ways to console them. Learning to handle crying can be tense, frustrating, and upsetting for parents, but success is ultimately satisfying and an important part of the reciprocal interaction that builds attachment for both parent and child.

“Developmental crying” is a great term for explaining crying in the first 3 months to families, as it is age related. The acronym PURPLE was created to teach about this normal crying.
 

• “P” is for peak of crying – babies may cry more each week, most in month 2, then less in months 3-5.
• “U” is for unexpected – crying can come and go without explanation.
• “R” is for resists soothing – babies may not stop crying no matter what is tried.
• “P” is for pain-like face – babies appear to be in pain, even if they are not.
• “L” is for long lasting – crying can last 5 hours a day or more.
• “E” is for evening – the baby might cry more in the late afternoon and evening.

The 1- to 2-week visit is a key time to teach parents about the expected upcoming crying and ways to manage it. I lean on the evidence-based steps for soothing, using the 5 S’s described by Harvey Karp, MD, based on the wisdom of T. Berry Brazelton, MD. These include:

• Swaddling in a wrap that constrains arms and legs.
• Side or stomach holding (but not for sleeping).
• Shushing sounds of voice, radio static, fan, air conditioner, or car ride.
• Swinging gently (point out to never shake a baby).
• Sucking on a pacifier, finger, or hand.

Because babies change state slowly and also respond to high caregiver emotion such as anxiety, it is important for parents to take some deep breaths and give each “S” several minutes to have an effect.

Some of our patients will go beyond typical crying to colic, defined as crying for at least 3 hours per day, at least 3 days per week, starting before 3 months post term. While typically easing by age 3 months, colic can in nightmare cases persist to age 1 year. Needless to say, prolonged crying can be an enormous stress for families. Researchers in the Fussy Baby Network consulting on infant crying have found value in a family prescription for REST: Reassurance, Empathy, Support, and Time away. Reassurance that the child is not ill should be provided after a careful history, including asking why parents think the baby is crying, and a physical exam, even if we think we can tell at a glance that the baby is okay. Remember that every parent’s first concern is whether the baby is okay, and crying indicates otherwise. Parents are counting on us for a thorough exam before we reassure them. Exhausted new parents deserve empathy – acknowledgment of how difficult, scary, and maddening it is to not be able to console their newborns.

While friends are saying “You must be so happy!” after a child is born, ambivalence (What have I done to my life?) is very common, but not easy to admit. We can point out that the typical age at which parents report “loving” their infants is actually more like 6 weeks, when they finally smile! To acknowledge ambivalence, I may say, “When you feel like throwing him out the window, it’s okay to lay him in the crib and put on headphones for a few minutes.” Music, meditation, yoga, or exercise are break activities that also can reduce parent stress.

Support for the parents is one of the most important protections for children at all ages, but can’t be assumed. Unfortunately, crying tends to increase beginning at 2 weeks post term, right when the partner returns to work or relatives leave. It is important to ask, “Who is helping you with the baby?” Just having a partner doesn’t mean that person is taking a turn! Fathers may be afraid of holding a baby, or may have no experience and try to defer. We need to encourage fathers in all aspects of care but especially to “find at least one way to console your baby.” Sometimes mothers “rescue” dads too quickly. While mothers may have both more experience with infants and the magic of breastfeeding for consoling, depriving fathers of working through the struggle of managing crying can result in their developing less confidence in caregiving. It also can cause them to miss out on supporting the mother at this delicate time, a chance to profoundly strengthen the partnership.

Taking into account the importance for parents of finding ways to console crying babies, getting some “time away” can be helpful, especially if crying goes on for months. Maybe those friends who asked, “What can I do to help?” could come over for an hour in the evening (peak crying time) to hold the baby. This also can be a chance for parent time together, a newly rare commodity.

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

Babies evolved to cry to get their needs met and adults evolved to be aroused by the sound. Perfect match, right? But crying/fussing was rated the No. 1 hardest part of parenting for 0- to 3-year-olds in our data from more than 68,000 parents.

Petro Feketa/iStockphoto

As clinicians, we become amazingly immune to the crying in our offices, but hopefully not to crying as a concern of parents. Our training directs us to look for pathology such as under- or overfeeding, infection, gastroesophageal reflux disease (GERD), volvulus, a hair tourniquet, or an injury as causes of crying. Having ruled these out, the bigger task is making sure that parents learn to read their infants’ crying and find ways to console them. Learning to handle crying can be tense, frustrating, and upsetting for parents, but success is ultimately satisfying and an important part of the reciprocal interaction that builds attachment for both parent and child.

“Developmental crying” is a great term for explaining crying in the first 3 months to families, as it is age related. The acronym PURPLE was created to teach about this normal crying.
 

• “P” is for peak of crying – babies may cry more each week, most in month 2, then less in months 3-5.
• “U” is for unexpected – crying can come and go without explanation.
• “R” is for resists soothing – babies may not stop crying no matter what is tried.
• “P” is for pain-like face – babies appear to be in pain, even if they are not.
• “L” is for long lasting – crying can last 5 hours a day or more.
• “E” is for evening – the baby might cry more in the late afternoon and evening.

The 1- to 2-week visit is a key time to teach parents about the expected upcoming crying and ways to manage it. I lean on the evidence-based steps for soothing, using the 5 S’s described by Harvey Karp, MD, based on the wisdom of T. Berry Brazelton, MD. These include:

• Swaddling in a wrap that constrains arms and legs.
• Side or stomach holding (but not for sleeping).
• Shushing sounds of voice, radio static, fan, air conditioner, or car ride.
• Swinging gently (point out to never shake a baby).
• Sucking on a pacifier, finger, or hand.

Because babies change state slowly and also respond to high caregiver emotion such as anxiety, it is important for parents to take some deep breaths and give each “S” several minutes to have an effect.

Some of our patients will go beyond typical crying to colic, defined as crying for at least 3 hours per day, at least 3 days per week, starting before 3 months post term. While typically easing by age 3 months, colic can in nightmare cases persist to age 1 year. Needless to say, prolonged crying can be an enormous stress for families. Researchers in the Fussy Baby Network consulting on infant crying have found value in a family prescription for REST: Reassurance, Empathy, Support, and Time away. Reassurance that the child is not ill should be provided after a careful history, including asking why parents think the baby is crying, and a physical exam, even if we think we can tell at a glance that the baby is okay. Remember that every parent’s first concern is whether the baby is okay, and crying indicates otherwise. Parents are counting on us for a thorough exam before we reassure them. Exhausted new parents deserve empathy – acknowledgment of how difficult, scary, and maddening it is to not be able to console their newborns.

While friends are saying “You must be so happy!” after a child is born, ambivalence (What have I done to my life?) is very common, but not easy to admit. We can point out that the typical age at which parents report “loving” their infants is actually more like 6 weeks, when they finally smile! To acknowledge ambivalence, I may say, “When you feel like throwing him out the window, it’s okay to lay him in the crib and put on headphones for a few minutes.” Music, meditation, yoga, or exercise are break activities that also can reduce parent stress.

Support for the parents is one of the most important protections for children at all ages, but can’t be assumed. Unfortunately, crying tends to increase beginning at 2 weeks post term, right when the partner returns to work or relatives leave. It is important to ask, “Who is helping you with the baby?” Just having a partner doesn’t mean that person is taking a turn! Fathers may be afraid of holding a baby, or may have no experience and try to defer. We need to encourage fathers in all aspects of care but especially to “find at least one way to console your baby.” Sometimes mothers “rescue” dads too quickly. While mothers may have both more experience with infants and the magic of breastfeeding for consoling, depriving fathers of working through the struggle of managing crying can result in their developing less confidence in caregiving. It also can cause them to miss out on supporting the mother at this delicate time, a chance to profoundly strengthen the partnership.

Taking into account the importance for parents of finding ways to console crying babies, getting some “time away” can be helpful, especially if crying goes on for months. Maybe those friends who asked, “What can I do to help?” could come over for an hour in the evening (peak crying time) to hold the baby. This also can be a chance for parent time together, a newly rare commodity.

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

The start of the school year brings excitement and some expected anxiety, around seeing friends and undertaking new challenges. While setbacks, small failures, and disappointments are an essential part of a child’s mastery of new challenges, academic and otherwise, occasionally a child will experience school failure in many areas. When this happens, the school usually will engage parents to help understand and address what might be interfering with the child’s performance at school. Parents may turn to their trusted pediatricians for guidance in sorting out school failure, as the list of possible causes is very long. By asking the right questions and knowing your patient, you can efficiently investigate this problem so that your patient may quickly get back on track, both academically and in overall development.

dtiberio/iStock/Getty Images

Are their academic problems a striking change from prior years? If your patients previously had managed coursework with ease, then there is a new problem interfering with their performance, unless they are young enough that earlier years were not as challenging. Possibly a previous school was not as demanding or new academic expectations such as writing an essay or a dramatic increase in reading expectations have exposed a learning disability or attentional issue that is interfering with performance. This can be sorted out by asking more specific questions about their function. Do they struggle more with reading, essay writing, or math? Do they struggle with sustained attention on assignments or handing in completed work? Your patients can help answer these questions, as can as parents and teachers. Neuropsychological testing can elucidate specific learning disabilities or indicate marked problems with attention, working memory, or processing speed that may be improved with cognitive coaching, in-class strategies, and even medications. With older patients, a new problem is less likely to be the first presentation of an underlying learning or attentional issue and will need further investigation.

Do your patients still enjoy school or are they resisting attending? Students who are avoiding school may be struggling with anxiety. This may be a consequence of their academic struggles, as they try to avoid the shame, embarrassment, or discomfort of their failure to understand material, keep up, or perform. Alternately, the anxiety may have come first, leading to an inability to manage the challenges of school and then failure academically. Similarly, a mood disorder such as depression can create problems with attention, energy, interest, and motivation that make it difficult to attend and participate in school.

Ask about any family history of school problems and psychiatric disorders as these issues often run in families. Ask if there is anxiety around academic or social performance or more generalized anxiety. Are they experiencing trouble with sleep, energy, appetite? Have they withdrawn from other interests? Are they more tearful or irritable in all settings? When these symptoms are universal (i.e., occurring across settings and affecting school), there is likely an underlying psychiatric disorder driving them, and they require a full psychiatric assessment. It is worth noting that often children or adolescents with mood or anxiety disorders will experience somatic symptoms such as stomach aches or headaches alongside the loss of energy and motivation. They may come to the pediatrician first, and it is important to investigate the likely psychiatric illnesses (anxiety in prepubertal children and anxiety or depression in adolescents) as well as the more esoteric medical problems that could be causing such universal impairment in a child or teenager. Stigma still exists around psychiatric illness and it is powerful when a pediatrician can tell a family that these illnesses are common in young people (affecting nearly 20% of children by the age of 18) and very treatable.

Drug and alcohol abuse may be associated with another psychiatric illness or can be independent problems that interfere with the healthy development and school performance of young people, including middle school students. Find out if your patients are drinking alcohol, using marijuana, vaping, utilizing prescription medications that are not their own, or using other illegal drugs. Substance use that has led to problems at school is by definition a problem (in addition to being illegal) and will not improve without treatment. These young people need a full psychiatric evaluation, and they and their parents require specialized treatment and support to address the substance abuse problem.

Of course, school failure may represent other sources of stress. It is critical to find out from your patients if they feel safe at school. Are they being bullied or threatened? Do they have a safe way to get to and from school? Has something else occurred at the school that has left them feeling vigilant and unable to concentrate on classwork? While bullying or living in a neighborhood plagued by violence may not be easy problems to fix, it is critical to find out about them so the adults – parents, teachers, and others – can provide the students with support while directly addressing the safety issue. Do not fail to find out if the fear is at home. Children who are managing physical or sexual abuse may be too stressed to complete homework or even attend school. A caring, curious pediatrician will be a lifeline to a safer future for these children.

Similarly, it is important to find out if your patient is managing less dramatic stresses at home. Perhaps a parent has been seriously ill, working two jobs, or managing a problem with drugs or alcohol, and your patient is caring for that person, or for siblings, instead of keeping up with schoolwork. Perhaps there has been a stressful loss or transition, such as the death of a grandparent or pet, the loss of a job, or a big move, or family discord/violence that has made it difficult for your patient to focus on homework or interfered with parental supervision or homework help. Perhaps your patient has gotten a job to help the family financially and has no time for homework. Bringing such a challenge out into the open and rallying support for your patient and the family in these circumstances is often enough to foster adaptation to these stresses and a return to healthy function in school.

Finally, it is possible that school failure is a function of milder imbalances in a young person’s life. Some children may respond to the expanded independence of adolescence by making poor choices. When do they go to bed at night? Are they staying up late playing video games or surfing the web? Not all insomnia represents illness. Find out how much independence your patients have and how they are managing their time and responsibilities. Help them to think about how to protect time for both responsibilities and relaxation. You also may help the parents of these young people think about how to set expectations and basic rules while stepping back appropriately to allow for expanding independence in ways that will help their children to flourish.

Once defined, school failure should be comprehensively treated because the educational consequences and potentially lifelong damage to self-esteem can be severe. Setting reasonable expectations, curriculum adjustments, any needed psychiatric treatment, building on a child’s strengths, and paying attention to self-esteem are the hallmarks of effective interventions.
 

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

The start of the school year brings excitement and some expected anxiety, around seeing friends and undertaking new challenges. While setbacks, small failures, and disappointments are an essential part of a child’s mastery of new challenges, academic and otherwise, occasionally a child will experience school failure in many areas. When this happens, the school usually will engage parents to help understand and address what might be interfering with the child’s performance at school. Parents may turn to their trusted pediatricians for guidance in sorting out school failure, as the list of possible causes is very long. By asking the right questions and knowing your patient, you can efficiently investigate this problem so that your patient may quickly get back on track, both academically and in overall development.

dtiberio/iStock/Getty Images

Are their academic problems a striking change from prior years? If your patients previously had managed coursework with ease, then there is a new problem interfering with their performance, unless they are young enough that earlier years were not as challenging. Possibly a previous school was not as demanding or new academic expectations such as writing an essay or a dramatic increase in reading expectations have exposed a learning disability or attentional issue that is interfering with performance. This can be sorted out by asking more specific questions about their function. Do they struggle more with reading, essay writing, or math? Do they struggle with sustained attention on assignments or handing in completed work? Your patients can help answer these questions, as can as parents and teachers. Neuropsychological testing can elucidate specific learning disabilities or indicate marked problems with attention, working memory, or processing speed that may be improved with cognitive coaching, in-class strategies, and even medications. With older patients, a new problem is less likely to be the first presentation of an underlying learning or attentional issue and will need further investigation.

Do your patients still enjoy school or are they resisting attending? Students who are avoiding school may be struggling with anxiety. This may be a consequence of their academic struggles, as they try to avoid the shame, embarrassment, or discomfort of their failure to understand material, keep up, or perform. Alternately, the anxiety may have come first, leading to an inability to manage the challenges of school and then failure academically. Similarly, a mood disorder such as depression can create problems with attention, energy, interest, and motivation that make it difficult to attend and participate in school.

Ask about any family history of school problems and psychiatric disorders as these issues often run in families. Ask if there is anxiety around academic or social performance or more generalized anxiety. Are they experiencing trouble with sleep, energy, appetite? Have they withdrawn from other interests? Are they more tearful or irritable in all settings? When these symptoms are universal (i.e., occurring across settings and affecting school), there is likely an underlying psychiatric disorder driving them, and they require a full psychiatric assessment. It is worth noting that often children or adolescents with mood or anxiety disorders will experience somatic symptoms such as stomach aches or headaches alongside the loss of energy and motivation. They may come to the pediatrician first, and it is important to investigate the likely psychiatric illnesses (anxiety in prepubertal children and anxiety or depression in adolescents) as well as the more esoteric medical problems that could be causing such universal impairment in a child or teenager. Stigma still exists around psychiatric illness and it is powerful when a pediatrician can tell a family that these illnesses are common in young people (affecting nearly 20% of children by the age of 18) and very treatable.

Drug and alcohol abuse may be associated with another psychiatric illness or can be independent problems that interfere with the healthy development and school performance of young people, including middle school students. Find out if your patients are drinking alcohol, using marijuana, vaping, utilizing prescription medications that are not their own, or using other illegal drugs. Substance use that has led to problems at school is by definition a problem (in addition to being illegal) and will not improve without treatment. These young people need a full psychiatric evaluation, and they and their parents require specialized treatment and support to address the substance abuse problem.

Of course, school failure may represent other sources of stress. It is critical to find out from your patients if they feel safe at school. Are they being bullied or threatened? Do they have a safe way to get to and from school? Has something else occurred at the school that has left them feeling vigilant and unable to concentrate on classwork? While bullying or living in a neighborhood plagued by violence may not be easy problems to fix, it is critical to find out about them so the adults – parents, teachers, and others – can provide the students with support while directly addressing the safety issue. Do not fail to find out if the fear is at home. Children who are managing physical or sexual abuse may be too stressed to complete homework or even attend school. A caring, curious pediatrician will be a lifeline to a safer future for these children.

Similarly, it is important to find out if your patient is managing less dramatic stresses at home. Perhaps a parent has been seriously ill, working two jobs, or managing a problem with drugs or alcohol, and your patient is caring for that person, or for siblings, instead of keeping up with schoolwork. Perhaps there has been a stressful loss or transition, such as the death of a grandparent or pet, the loss of a job, or a big move, or family discord/violence that has made it difficult for your patient to focus on homework or interfered with parental supervision or homework help. Perhaps your patient has gotten a job to help the family financially and has no time for homework. Bringing such a challenge out into the open and rallying support for your patient and the family in these circumstances is often enough to foster adaptation to these stresses and a return to healthy function in school.

Finally, it is possible that school failure is a function of milder imbalances in a young person’s life. Some children may respond to the expanded independence of adolescence by making poor choices. When do they go to bed at night? Are they staying up late playing video games or surfing the web? Not all insomnia represents illness. Find out how much independence your patients have and how they are managing their time and responsibilities. Help them to think about how to protect time for both responsibilities and relaxation. You also may help the parents of these young people think about how to set expectations and basic rules while stepping back appropriately to allow for expanding independence in ways that will help their children to flourish.

Once defined, school failure should be comprehensively treated because the educational consequences and potentially lifelong damage to self-esteem can be severe. Setting reasonable expectations, curriculum adjustments, any needed psychiatric treatment, building on a child’s strengths, and paying attention to self-esteem are the hallmarks of effective interventions.
 

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

The start of the school year brings excitement and some expected anxiety, around seeing friends and undertaking new challenges. While setbacks, small failures, and disappointments are an essential part of a child’s mastery of new challenges, academic and otherwise, occasionally a child will experience school failure in many areas. When this happens, the school usually will engage parents to help understand and address what might be interfering with the child’s performance at school. Parents may turn to their trusted pediatricians for guidance in sorting out school failure, as the list of possible causes is very long. By asking the right questions and knowing your patient, you can efficiently investigate this problem so that your patient may quickly get back on track, both academically and in overall development.

dtiberio/iStock/Getty Images

Are their academic problems a striking change from prior years? If your patients previously had managed coursework with ease, then there is a new problem interfering with their performance, unless they are young enough that earlier years were not as challenging. Possibly a previous school was not as demanding or new academic expectations such as writing an essay or a dramatic increase in reading expectations have exposed a learning disability or attentional issue that is interfering with performance. This can be sorted out by asking more specific questions about their function. Do they struggle more with reading, essay writing, or math? Do they struggle with sustained attention on assignments or handing in completed work? Your patients can help answer these questions, as can as parents and teachers. Neuropsychological testing can elucidate specific learning disabilities or indicate marked problems with attention, working memory, or processing speed that may be improved with cognitive coaching, in-class strategies, and even medications. With older patients, a new problem is less likely to be the first presentation of an underlying learning or attentional issue and will need further investigation.

Do your patients still enjoy school or are they resisting attending? Students who are avoiding school may be struggling with anxiety. This may be a consequence of their academic struggles, as they try to avoid the shame, embarrassment, or discomfort of their failure to understand material, keep up, or perform. Alternately, the anxiety may have come first, leading to an inability to manage the challenges of school and then failure academically. Similarly, a mood disorder such as depression can create problems with attention, energy, interest, and motivation that make it difficult to attend and participate in school.

Ask about any family history of school problems and psychiatric disorders as these issues often run in families. Ask if there is anxiety around academic or social performance or more generalized anxiety. Are they experiencing trouble with sleep, energy, appetite? Have they withdrawn from other interests? Are they more tearful or irritable in all settings? When these symptoms are universal (i.e., occurring across settings and affecting school), there is likely an underlying psychiatric disorder driving them, and they require a full psychiatric assessment. It is worth noting that often children or adolescents with mood or anxiety disorders will experience somatic symptoms such as stomach aches or headaches alongside the loss of energy and motivation. They may come to the pediatrician first, and it is important to investigate the likely psychiatric illnesses (anxiety in prepubertal children and anxiety or depression in adolescents) as well as the more esoteric medical problems that could be causing such universal impairment in a child or teenager. Stigma still exists around psychiatric illness and it is powerful when a pediatrician can tell a family that these illnesses are common in young people (affecting nearly 20% of children by the age of 18) and very treatable.

Drug and alcohol abuse may be associated with another psychiatric illness or can be independent problems that interfere with the healthy development and school performance of young people, including middle school students. Find out if your patients are drinking alcohol, using marijuana, vaping, utilizing prescription medications that are not their own, or using other illegal drugs. Substance use that has led to problems at school is by definition a problem (in addition to being illegal) and will not improve without treatment. These young people need a full psychiatric evaluation, and they and their parents require specialized treatment and support to address the substance abuse problem.

Of course, school failure may represent other sources of stress. It is critical to find out from your patients if they feel safe at school. Are they being bullied or threatened? Do they have a safe way to get to and from school? Has something else occurred at the school that has left them feeling vigilant and unable to concentrate on classwork? While bullying or living in a neighborhood plagued by violence may not be easy problems to fix, it is critical to find out about them so the adults – parents, teachers, and others – can provide the students with support while directly addressing the safety issue. Do not fail to find out if the fear is at home. Children who are managing physical or sexual abuse may be too stressed to complete homework or even attend school. A caring, curious pediatrician will be a lifeline to a safer future for these children.

Similarly, it is important to find out if your patient is managing less dramatic stresses at home. Perhaps a parent has been seriously ill, working two jobs, or managing a problem with drugs or alcohol, and your patient is caring for that person, or for siblings, instead of keeping up with schoolwork. Perhaps there has been a stressful loss or transition, such as the death of a grandparent or pet, the loss of a job, or a big move, or family discord/violence that has made it difficult for your patient to focus on homework or interfered with parental supervision or homework help. Perhaps your patient has gotten a job to help the family financially and has no time for homework. Bringing such a challenge out into the open and rallying support for your patient and the family in these circumstances is often enough to foster adaptation to these stresses and a return to healthy function in school.

Finally, it is possible that school failure is a function of milder imbalances in a young person’s life. Some children may respond to the expanded independence of adolescence by making poor choices. When do they go to bed at night? Are they staying up late playing video games or surfing the web? Not all insomnia represents illness. Find out how much independence your patients have and how they are managing their time and responsibilities. Help them to think about how to protect time for both responsibilities and relaxation. You also may help the parents of these young people think about how to set expectations and basic rules while stepping back appropriately to allow for expanding independence in ways that will help their children to flourish.

Once defined, school failure should be comprehensively treated because the educational consequences and potentially lifelong damage to self-esteem can be severe. Setting reasonable expectations, curriculum adjustments, any needed psychiatric treatment, building on a child’s strengths, and paying attention to self-esteem are the hallmarks of effective interventions.
 

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

You probably think you know how to talk with a child about death. But somehow talking about a parent’s mental illness may seem more difficult. Even medical professionals, as most people, can find themselves feeling more judgmental or uneasy talking about mental illness than about physical problems. But with a prevalence of about one in four people having mental disorders, we need to be prepared for this discussion.

Steve Debenport/Getty Images

Sometimes family members, or even parents themselves, have asked me to tell a child about a parent’s mental illness or substance use. They know the child is confused and scared but don’t know what to say about this still-hushed issue. Other times, children’s behaviors show that they are struggling – by their aggression, depression, decline in school performance, anger, anxiety, or running away – and I find out only by asking that they are experiencing life with a mentally ill parent.

Both are times to get more information about the nature of the parent’s symptoms, what is being done about it; what the child has seen, heard, or experienced; the child’s safety; and what intrinsic or cultural attitudes the family has about the problem. It is best if the affected parents themselves are able to talk realistically about the illness with the child. Sometimes we, as pediatric professionals, can help get the conversation started or may need to step in.

What needs to be conveyed about parental mental illness depends on the developmental age and maturity of the child. Teens can understand the nature of mental illness as a brain disorder, but often have acquired misinformation from peers, the other parent who is hurt and angry, or the Internet that needs to be respectfully corrected. They may be less willing to have such a discussion than would younger children, as they may have experienced verbal or physical aggression from the parent, embarrassment in front of peers, or teasing by classmates. They may have developed coping strategies of writing off the parent, defiance, aggressive responses, or denial.

It is important to find a relaxed moment and begin by saying, “May I ask what you have noticed about your parent’s behavior?” and “What did you make of it?” If they do not answer, you could add, “You know, like acting different or strange.” It is very valuable to be able to name it, if you know the diagnosis, to make the illness more objective. Teens are typically egocentric and wonder if they are prone to develop a similar condition, as well as anxious about who will be there for them if the parent does not get better; both are good questions to address.

Both adolescents and school-aged children are very attuned to when things in life are “unfair,” and having an ill parent certainly qualifies. It is important for whoever has this discussion to empathize, and to acknowledge that it is unfair and that feeling angry, sad, or confused is natural – without giving them permission for misbehavior. It may be easier for some children to have a journal in which to write questions to have an adult answer later. Any child can be given hope by knowing that the parent is getting help (or that you will work on this), especially if the parents themselves say they are trying to get better. The children need to know that although mental illness tends to get better and worse at unexpected times, mental health can be improved. It is essential that children of school age and older have a clear plan for what to do if the parent loses control or is in danger. This might include getting out of the house and calling the parent’s partner, a trusted neighbor, or 911.

While teens may feel guilty about their anger or things they might have said or done in reaction to the ill parent, school-aged and preschool children are more likely to feel guilty that they somehow contributed to the parent’s condition through misbehavior or some imagined influence. Eliciting these thoughts may simply require asking, “What thoughts have you had about why this happened?” or having another family member prompting them by saying, “I have been wondering if there is something I should have done. Have you wondered about that, too?”

What is harder to explain is the impression children may get that their depressed or psychotic or drug-abusing parents no longer love them; and the parents may have said hurtful things to them. School-aged children can be told and can understand an illness of “the feelings and thinking parts of the brain” as being similar to other physical illnesses, such as the flu, that “make people act tired or grouchy or say things they do not mean.” Children of all ages need to be reassured that, inside, their parents still love them, and “it is the illness talking” if they act or speak otherwise. In the case of substance abuse disorders, which might seem more of a choice by the parent than would other mental illnesses, it can be helpful to point out that “drugs and alcohol can be stronger than people and can take over their brains.” The National Alliance on Mental Illness (www.nami.org) offers support programs that may be helpful for older children.

Sometimes families may resist telling a child about parental mental illness because of personal beliefs, cultural stigma, or privacy concerns. I try to emphasize that by being honest in giving children an understanding of their parents’ mental illness, one is helping them trust the adults in their lives. They need the truth and also to practice formulating things to say to counter those who have incorrect ideas, or who insult or make fun of them. They need the truth about mental illness to make sense of their experiences so they can feel lovable and hopeful about their own futures and can recognize illness symptoms in themselves. Giving them words, ensuring their safety and support, and strengthening their coping can help buffer the impact of this common adverse childhood experience to help prevent long-term negative effects.
 

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

You probably think you know how to talk with a child about death. But somehow talking about a parent’s mental illness may seem more difficult. Even medical professionals, as most people, can find themselves feeling more judgmental or uneasy talking about mental illness than about physical problems. But with a prevalence of about one in four people having mental disorders, we need to be prepared for this discussion.

Steve Debenport/Getty Images

Sometimes family members, or even parents themselves, have asked me to tell a child about a parent’s mental illness or substance use. They know the child is confused and scared but don’t know what to say about this still-hushed issue. Other times, children’s behaviors show that they are struggling – by their aggression, depression, decline in school performance, anger, anxiety, or running away – and I find out only by asking that they are experiencing life with a mentally ill parent.

Both are times to get more information about the nature of the parent’s symptoms, what is being done about it; what the child has seen, heard, or experienced; the child’s safety; and what intrinsic or cultural attitudes the family has about the problem. It is best if the affected parents themselves are able to talk realistically about the illness with the child. Sometimes we, as pediatric professionals, can help get the conversation started or may need to step in.

What needs to be conveyed about parental mental illness depends on the developmental age and maturity of the child. Teens can understand the nature of mental illness as a brain disorder, but often have acquired misinformation from peers, the other parent who is hurt and angry, or the Internet that needs to be respectfully corrected. They may be less willing to have such a discussion than would younger children, as they may have experienced verbal or physical aggression from the parent, embarrassment in front of peers, or teasing by classmates. They may have developed coping strategies of writing off the parent, defiance, aggressive responses, or denial.

It is important to find a relaxed moment and begin by saying, “May I ask what you have noticed about your parent’s behavior?” and “What did you make of it?” If they do not answer, you could add, “You know, like acting different or strange.” It is very valuable to be able to name it, if you know the diagnosis, to make the illness more objective. Teens are typically egocentric and wonder if they are prone to develop a similar condition, as well as anxious about who will be there for them if the parent does not get better; both are good questions to address.

Both adolescents and school-aged children are very attuned to when things in life are “unfair,” and having an ill parent certainly qualifies. It is important for whoever has this discussion to empathize, and to acknowledge that it is unfair and that feeling angry, sad, or confused is natural – without giving them permission for misbehavior. It may be easier for some children to have a journal in which to write questions to have an adult answer later. Any child can be given hope by knowing that the parent is getting help (or that you will work on this), especially if the parents themselves say they are trying to get better. The children need to know that although mental illness tends to get better and worse at unexpected times, mental health can be improved. It is essential that children of school age and older have a clear plan for what to do if the parent loses control or is in danger. This might include getting out of the house and calling the parent’s partner, a trusted neighbor, or 911.

While teens may feel guilty about their anger or things they might have said or done in reaction to the ill parent, school-aged and preschool children are more likely to feel guilty that they somehow contributed to the parent’s condition through misbehavior or some imagined influence. Eliciting these thoughts may simply require asking, “What thoughts have you had about why this happened?” or having another family member prompting them by saying, “I have been wondering if there is something I should have done. Have you wondered about that, too?”

What is harder to explain is the impression children may get that their depressed or psychotic or drug-abusing parents no longer love them; and the parents may have said hurtful things to them. School-aged children can be told and can understand an illness of “the feelings and thinking parts of the brain” as being similar to other physical illnesses, such as the flu, that “make people act tired or grouchy or say things they do not mean.” Children of all ages need to be reassured that, inside, their parents still love them, and “it is the illness talking” if they act or speak otherwise. In the case of substance abuse disorders, which might seem more of a choice by the parent than would other mental illnesses, it can be helpful to point out that “drugs and alcohol can be stronger than people and can take over their brains.” The National Alliance on Mental Illness (www.nami.org) offers support programs that may be helpful for older children.

Sometimes families may resist telling a child about parental mental illness because of personal beliefs, cultural stigma, or privacy concerns. I try to emphasize that by being honest in giving children an understanding of their parents’ mental illness, one is helping them trust the adults in their lives. They need the truth and also to practice formulating things to say to counter those who have incorrect ideas, or who insult or make fun of them. They need the truth about mental illness to make sense of their experiences so they can feel lovable and hopeful about their own futures and can recognize illness symptoms in themselves. Giving them words, ensuring their safety and support, and strengthening their coping can help buffer the impact of this common adverse childhood experience to help prevent long-term negative effects.
 

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

You probably think you know how to talk with a child about death. But somehow talking about a parent’s mental illness may seem more difficult. Even medical professionals, as most people, can find themselves feeling more judgmental or uneasy talking about mental illness than about physical problems. But with a prevalence of about one in four people having mental disorders, we need to be prepared for this discussion.

Steve Debenport/Getty Images

Sometimes family members, or even parents themselves, have asked me to tell a child about a parent’s mental illness or substance use. They know the child is confused and scared but don’t know what to say about this still-hushed issue. Other times, children’s behaviors show that they are struggling – by their aggression, depression, decline in school performance, anger, anxiety, or running away – and I find out only by asking that they are experiencing life with a mentally ill parent.

Both are times to get more information about the nature of the parent’s symptoms, what is being done about it; what the child has seen, heard, or experienced; the child’s safety; and what intrinsic or cultural attitudes the family has about the problem. It is best if the affected parents themselves are able to talk realistically about the illness with the child. Sometimes we, as pediatric professionals, can help get the conversation started or may need to step in.

What needs to be conveyed about parental mental illness depends on the developmental age and maturity of the child. Teens can understand the nature of mental illness as a brain disorder, but often have acquired misinformation from peers, the other parent who is hurt and angry, or the Internet that needs to be respectfully corrected. They may be less willing to have such a discussion than would younger children, as they may have experienced verbal or physical aggression from the parent, embarrassment in front of peers, or teasing by classmates. They may have developed coping strategies of writing off the parent, defiance, aggressive responses, or denial.

It is important to find a relaxed moment and begin by saying, “May I ask what you have noticed about your parent’s behavior?” and “What did you make of it?” If they do not answer, you could add, “You know, like acting different or strange.” It is very valuable to be able to name it, if you know the diagnosis, to make the illness more objective. Teens are typically egocentric and wonder if they are prone to develop a similar condition, as well as anxious about who will be there for them if the parent does not get better; both are good questions to address.

Both adolescents and school-aged children are very attuned to when things in life are “unfair,” and having an ill parent certainly qualifies. It is important for whoever has this discussion to empathize, and to acknowledge that it is unfair and that feeling angry, sad, or confused is natural – without giving them permission for misbehavior. It may be easier for some children to have a journal in which to write questions to have an adult answer later. Any child can be given hope by knowing that the parent is getting help (or that you will work on this), especially if the parents themselves say they are trying to get better. The children need to know that although mental illness tends to get better and worse at unexpected times, mental health can be improved. It is essential that children of school age and older have a clear plan for what to do if the parent loses control or is in danger. This might include getting out of the house and calling the parent’s partner, a trusted neighbor, or 911.

While teens may feel guilty about their anger or things they might have said or done in reaction to the ill parent, school-aged and preschool children are more likely to feel guilty that they somehow contributed to the parent’s condition through misbehavior or some imagined influence. Eliciting these thoughts may simply require asking, “What thoughts have you had about why this happened?” or having another family member prompting them by saying, “I have been wondering if there is something I should have done. Have you wondered about that, too?”

What is harder to explain is the impression children may get that their depressed or psychotic or drug-abusing parents no longer love them; and the parents may have said hurtful things to them. School-aged children can be told and can understand an illness of “the feelings and thinking parts of the brain” as being similar to other physical illnesses, such as the flu, that “make people act tired or grouchy or say things they do not mean.” Children of all ages need to be reassured that, inside, their parents still love them, and “it is the illness talking” if they act or speak otherwise. In the case of substance abuse disorders, which might seem more of a choice by the parent than would other mental illnesses, it can be helpful to point out that “drugs and alcohol can be stronger than people and can take over their brains.” The National Alliance on Mental Illness (www.nami.org) offers support programs that may be helpful for older children.

Sometimes families may resist telling a child about parental mental illness because of personal beliefs, cultural stigma, or privacy concerns. I try to emphasize that by being honest in giving children an understanding of their parents’ mental illness, one is helping them trust the adults in their lives. They need the truth and also to practice formulating things to say to counter those who have incorrect ideas, or who insult or make fun of them. They need the truth about mental illness to make sense of their experiences so they can feel lovable and hopeful about their own futures and can recognize illness symptoms in themselves. Giving them words, ensuring their safety and support, and strengthening their coping can help buffer the impact of this common adverse childhood experience to help prevent long-term negative effects.
 

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

There is consensus within both the medical and public health communities that an integrated model of health care, in which behavioral health is integrated into primary care settings, is the optimal way to improve the health of a population (not just treat disease) while managing costs and improving the patient’s experience of care. Such a model is especially compelling for pediatric care.

There are 74 million children under 18 years in the United States and the prevalence of psychiatric disorders in youth is 20%, or 15 million; after vaccinations and following development, managing psychiatric symptoms is the most common issue in pediatric primary care.

While some psychiatric illnesses can be well managed by primary care clinicians alone, some illnesses require specialized therapy or more complex pharmacologic treatment. Untreated or inadequately treated childhood mental illness can lead to a longer and worse course of illness, academic difficulties, emergence of associated illnesses (such as substance use disorders), and legal problems. For those children with chronic medical conditions, emotional disorders cause distress, and affect adherence and family functioning. We will discuss some practical strategies to begin to bring behavioral health care into the pediatric primary care setting. The dream of tomorrow’s integrated behavioral health care should not preclude the possibility of coordinated or better colocated behavioral health care today.

Start by implementing behavioral health screening into annual and sick visits. Broad instruments, such as the Pediatric Symptom Checklist (PSC, 35 items) or the Child Behavior Check List (CBCL, 113 items) can be filled out by caregivers in the waiting room or online before a visit, and can suggest specific disorders or simply the need for a full psychiatric assessment. Electronic medical records may have publicly available questionnaires such as PSC built into their software, facilitating use of a tablet or home computer, and may ease scoring and downloading of results. Depending on the structure of your practice, you could have one clinician in charge of managing screening. You may become comfortable diagnosing certain disorders, such as ADHD, a major depressive episode, or an anxiety disorder, and you may begin medication treatment when appropriate. You can use instruments developed for specific disease entities (such as ADHD, obsessive compulsive disorder [OCD], anxiety, or depression) to monitor your patient’s treatment response, and they may be done virtually to minimize unnecessary visits.

Treatment algorithms for most psychiatric illnesses are available through the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry, and can guide you through the early stages of treatment. Psychotherapy is the first-line treatment for mild to moderate anxiety and mood disorders, and it is critical to the treatment of more severe disorders. Difficulty in finding a therapist who is skilled in a specific treatment, is a good fit, and accepts insurance can be a significant barrier to care. Establishing a coordinated relationship with a team of therapists can facilitate referrals. Some states have programs in which primary care physicians can have telephone consultations with mental health clinicians or to access referral services for therapy, such as the Massachusetts Child Psychiatry Access Project.

If you have a busy enough practice, consider bringing a social worker or psychologist to work with you. Such a clinician could perform diagnostic assessments, ongoing therapy, parent guidance, family work, or care coordination. Consider how to make it cost-effective for this clinician and your group, whether by inviting that person to sublet one of your offices, or having that person directly employed by you and benefiting from your office staff and patient flow. Many states now reimburse for screening and these funds could contribute to the expense of a social worker. This approach would bring you from coordination to true colocation, which greatly improves the likelihood of compliance with therapy, enhances coordination of a patient’s care, creates opportunities for ongoing education between disciplines, and diminishes stigma of acknowledging a mental illness. Anxiety disorders are the most common illnesses of youth, with mood disorders emerging in adolescence, and substance use disorders in later adolescence. Consider this in seeking a clinician with a specific interest or skill set (such as cognitive behavioral therapy for anxiety or mood problems, dialectical behavior therapy for chronic suicidality, or motivational interviewing for substance abuse).

KatarzynaBialasiewicz/Thinkstock

There may be funds available to support your investment in integrated care. Under the Affordable Care Act, Medicaid enhanced funding for Health Homes for enrolled children. There have been federal grants for primary care offices to engage in different levels of integration and measure outcomes (Project LAUNCH – Linking Actions for Unmet Needs in Children’s Health). There may be funding at the state level or from private foundations dedicated to public health research and initiatives. Even if you do not invest in procuring outside funding, you should consider how to measure patient outcomes once you are making any efforts at integrating behavioral health care into your practice. Outcome measures include questionnaire scores, treatment adherence, number of school absences, number of office or ED visits, or global measurements, such as the Child Global Assessment Scale (CGAS). Such data can inform you about how to adjust your approach, and could contribute to the larger effort to understand what strategies are most effective and feasible. Addressing the behavioral health needs of your patients could meaningfully contribute to the efforts to make the vision of integrated care – that which truly promotes health in our young people – a reality.

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

There is consensus within both the medical and public health communities that an integrated model of health care, in which behavioral health is integrated into primary care settings, is the optimal way to improve the health of a population (not just treat disease) while managing costs and improving the patient’s experience of care. Such a model is especially compelling for pediatric care.

There are 74 million children under 18 years in the United States and the prevalence of psychiatric disorders in youth is 20%, or 15 million; after vaccinations and following development, managing psychiatric symptoms is the most common issue in pediatric primary care.

While some psychiatric illnesses can be well managed by primary care clinicians alone, some illnesses require specialized therapy or more complex pharmacologic treatment. Untreated or inadequately treated childhood mental illness can lead to a longer and worse course of illness, academic difficulties, emergence of associated illnesses (such as substance use disorders), and legal problems. For those children with chronic medical conditions, emotional disorders cause distress, and affect adherence and family functioning. We will discuss some practical strategies to begin to bring behavioral health care into the pediatric primary care setting. The dream of tomorrow’s integrated behavioral health care should not preclude the possibility of coordinated or better colocated behavioral health care today.

Start by implementing behavioral health screening into annual and sick visits. Broad instruments, such as the Pediatric Symptom Checklist (PSC, 35 items) or the Child Behavior Check List (CBCL, 113 items) can be filled out by caregivers in the waiting room or online before a visit, and can suggest specific disorders or simply the need for a full psychiatric assessment. Electronic medical records may have publicly available questionnaires such as PSC built into their software, facilitating use of a tablet or home computer, and may ease scoring and downloading of results. Depending on the structure of your practice, you could have one clinician in charge of managing screening. You may become comfortable diagnosing certain disorders, such as ADHD, a major depressive episode, or an anxiety disorder, and you may begin medication treatment when appropriate. You can use instruments developed for specific disease entities (such as ADHD, obsessive compulsive disorder [OCD], anxiety, or depression) to monitor your patient’s treatment response, and they may be done virtually to minimize unnecessary visits.

Treatment algorithms for most psychiatric illnesses are available through the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry, and can guide you through the early stages of treatment. Psychotherapy is the first-line treatment for mild to moderate anxiety and mood disorders, and it is critical to the treatment of more severe disorders. Difficulty in finding a therapist who is skilled in a specific treatment, is a good fit, and accepts insurance can be a significant barrier to care. Establishing a coordinated relationship with a team of therapists can facilitate referrals. Some states have programs in which primary care physicians can have telephone consultations with mental health clinicians or to access referral services for therapy, such as the Massachusetts Child Psychiatry Access Project.

If you have a busy enough practice, consider bringing a social worker or psychologist to work with you. Such a clinician could perform diagnostic assessments, ongoing therapy, parent guidance, family work, or care coordination. Consider how to make it cost-effective for this clinician and your group, whether by inviting that person to sublet one of your offices, or having that person directly employed by you and benefiting from your office staff and patient flow. Many states now reimburse for screening and these funds could contribute to the expense of a social worker. This approach would bring you from coordination to true colocation, which greatly improves the likelihood of compliance with therapy, enhances coordination of a patient’s care, creates opportunities for ongoing education between disciplines, and diminishes stigma of acknowledging a mental illness. Anxiety disorders are the most common illnesses of youth, with mood disorders emerging in adolescence, and substance use disorders in later adolescence. Consider this in seeking a clinician with a specific interest or skill set (such as cognitive behavioral therapy for anxiety or mood problems, dialectical behavior therapy for chronic suicidality, or motivational interviewing for substance abuse).

KatarzynaBialasiewicz/Thinkstock

There may be funds available to support your investment in integrated care. Under the Affordable Care Act, Medicaid enhanced funding for Health Homes for enrolled children. There have been federal grants for primary care offices to engage in different levels of integration and measure outcomes (Project LAUNCH – Linking Actions for Unmet Needs in Children’s Health). There may be funding at the state level or from private foundations dedicated to public health research and initiatives. Even if you do not invest in procuring outside funding, you should consider how to measure patient outcomes once you are making any efforts at integrating behavioral health care into your practice. Outcome measures include questionnaire scores, treatment adherence, number of school absences, number of office or ED visits, or global measurements, such as the Child Global Assessment Scale (CGAS). Such data can inform you about how to adjust your approach, and could contribute to the larger effort to understand what strategies are most effective and feasible. Addressing the behavioral health needs of your patients could meaningfully contribute to the efforts to make the vision of integrated care – that which truly promotes health in our young people – a reality.

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

There is consensus within both the medical and public health communities that an integrated model of health care, in which behavioral health is integrated into primary care settings, is the optimal way to improve the health of a population (not just treat disease) while managing costs and improving the patient’s experience of care. Such a model is especially compelling for pediatric care.

There are 74 million children under 18 years in the United States and the prevalence of psychiatric disorders in youth is 20%, or 15 million; after vaccinations and following development, managing psychiatric symptoms is the most common issue in pediatric primary care.

While some psychiatric illnesses can be well managed by primary care clinicians alone, some illnesses require specialized therapy or more complex pharmacologic treatment. Untreated or inadequately treated childhood mental illness can lead to a longer and worse course of illness, academic difficulties, emergence of associated illnesses (such as substance use disorders), and legal problems. For those children with chronic medical conditions, emotional disorders cause distress, and affect adherence and family functioning. We will discuss some practical strategies to begin to bring behavioral health care into the pediatric primary care setting. The dream of tomorrow’s integrated behavioral health care should not preclude the possibility of coordinated or better colocated behavioral health care today.

Start by implementing behavioral health screening into annual and sick visits. Broad instruments, such as the Pediatric Symptom Checklist (PSC, 35 items) or the Child Behavior Check List (CBCL, 113 items) can be filled out by caregivers in the waiting room or online before a visit, and can suggest specific disorders or simply the need for a full psychiatric assessment. Electronic medical records may have publicly available questionnaires such as PSC built into their software, facilitating use of a tablet or home computer, and may ease scoring and downloading of results. Depending on the structure of your practice, you could have one clinician in charge of managing screening. You may become comfortable diagnosing certain disorders, such as ADHD, a major depressive episode, or an anxiety disorder, and you may begin medication treatment when appropriate. You can use instruments developed for specific disease entities (such as ADHD, obsessive compulsive disorder [OCD], anxiety, or depression) to monitor your patient’s treatment response, and they may be done virtually to minimize unnecessary visits.

Treatment algorithms for most psychiatric illnesses are available through the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry, and can guide you through the early stages of treatment. Psychotherapy is the first-line treatment for mild to moderate anxiety and mood disorders, and it is critical to the treatment of more severe disorders. Difficulty in finding a therapist who is skilled in a specific treatment, is a good fit, and accepts insurance can be a significant barrier to care. Establishing a coordinated relationship with a team of therapists can facilitate referrals. Some states have programs in which primary care physicians can have telephone consultations with mental health clinicians or to access referral services for therapy, such as the Massachusetts Child Psychiatry Access Project.

If you have a busy enough practice, consider bringing a social worker or psychologist to work with you. Such a clinician could perform diagnostic assessments, ongoing therapy, parent guidance, family work, or care coordination. Consider how to make it cost-effective for this clinician and your group, whether by inviting that person to sublet one of your offices, or having that person directly employed by you and benefiting from your office staff and patient flow. Many states now reimburse for screening and these funds could contribute to the expense of a social worker. This approach would bring you from coordination to true colocation, which greatly improves the likelihood of compliance with therapy, enhances coordination of a patient’s care, creates opportunities for ongoing education between disciplines, and diminishes stigma of acknowledging a mental illness. Anxiety disorders are the most common illnesses of youth, with mood disorders emerging in adolescence, and substance use disorders in later adolescence. Consider this in seeking a clinician with a specific interest or skill set (such as cognitive behavioral therapy for anxiety or mood problems, dialectical behavior therapy for chronic suicidality, or motivational interviewing for substance abuse).

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There may be funds available to support your investment in integrated care. Under the Affordable Care Act, Medicaid enhanced funding for Health Homes for enrolled children. There have been federal grants for primary care offices to engage in different levels of integration and measure outcomes (Project LAUNCH – Linking Actions for Unmet Needs in Children’s Health). There may be funding at the state level or from private foundations dedicated to public health research and initiatives. Even if you do not invest in procuring outside funding, you should consider how to measure patient outcomes once you are making any efforts at integrating behavioral health care into your practice. Outcome measures include questionnaire scores, treatment adherence, number of school absences, number of office or ED visits, or global measurements, such as the Child Global Assessment Scale (CGAS). Such data can inform you about how to adjust your approach, and could contribute to the larger effort to understand what strategies are most effective and feasible. Addressing the behavioral health needs of your patients could meaningfully contribute to the efforts to make the vision of integrated care – that which truly promotes health in our young people – a reality.

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

Life is full of traumas, large and small. You know this for yourself as well as for the families and children under your care. The American Academy of Pediatrics provides screening tools for trauma, also called adverse childhood experiences (ACEs). But with 68% of children exposed to a traumatic event before the age of 16 years (Arch Gen Psychiatry. 2007 May; 64[5]:577-84), what is it we should do if we find it?

Smaller traumas, such as a power outage, may frighten but be growth promoting for most children – so called “eustress” – as they see adults bring out flashlights and serve tuna from a can and learn that one can cope with scary, unfamiliar situations. Even with smaller threats some children may have intense fear, especially those already anxiety prone or with developmental differences such as autism or sensory processing disorders.

I suggest that our role when we uncover trauma is to determine if there is current danger (and take action), or if the past trauma is affecting the child’s or parent’s functioning or producing distress. Most people recover from trauma with support from family or community but without formal help.

But we can’t assume a child will recover without help as individual, family, cultural, and historical factors affect a person’s response. Someone with an anxiety disorder, or a victim of war or assault may react disproportionately to even small events. A parent with such sensitizing factors may model poor coping, increase the child’s fear, and fail to provide the support that could buffer development of sequelae. We need to check.

Larger traumas that a child is exposed to or learns about, which threatened or resulted in death or injury – such as a destructive tornado – or sexual violence can produce lasting effects, and 25%-69% develop posttraumatic stress disorder (PTSD). For preschoolers, car crashes, dog bites, and medical procedures can also be causative. To be diagnosed with PTSD, a combination and number of symptoms must appear as a result of the trauma, including: re-experiencing the event (1); avoidance of things that remind one of the event (1); arousal or reactivity (2); and negative change in thoughts or feelings (2).

“PTSD in preschool children” (DMS-5) requires 0 re-experiencing, and only 1 avoidance or negative thoughts/feelings symptom as it is harder to discern at this age. The jumpiness of reactivity can disrupt activities and often sleep. The cognitive changes can include forgetting details about the event, decline in ability to pay attention or do school work, or distorted or negative thoughts such as feeling blame. Besides anxiety or depression, mood changes can include dulled emotions or social withdrawal. These symptoms are important for us to recognize.

To be diagnosed, PTSD symptoms must impair functioning and last more than 1 month. So why are families not telling us? While symptoms usually appear within 3 months, it may be months or even years, especially for early traumas such as sexual abuse as the child cannot put the experience into context until later when sexuality becomes relevant. This delay in onset is one reason parents may not report a trauma when complaining about a behavior change. When the trauma also affected them, common in both natural disasters and psychosocial events such as partner violence, the parent may have the related forgetting or depression focusing them on their own pain rather than their child’s pain. These are important reasons to ask about possible traumas of child and parent, giving examples, when a child presents with a behavior, emotional, learning, or somatic complaint.

Pixland/Thinkstock

Traumatized children, as adolescents, are at risk for coping with this pain by cutting, or abusing substances or alcohol (other signs suggesting trauma). These harmful strategies contribute to the adult morbidity now recognized from Adverse Childhood Experiences. Fortunately, we can refer to effective parent-child therapies, such as Circle of Security and play therapy for children less than 3 years old, trauma-focused cognitive behavioral therapy for those over 3 years, and even video training such as trust-based relational intervention, as well as monitor well-being.
 

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

Life is full of traumas, large and small. You know this for yourself as well as for the families and children under your care. The American Academy of Pediatrics provides screening tools for trauma, also called adverse childhood experiences (ACEs). But with 68% of children exposed to a traumatic event before the age of 16 years (Arch Gen Psychiatry. 2007 May; 64[5]:577-84), what is it we should do if we find it?

Smaller traumas, such as a power outage, may frighten but be growth promoting for most children – so called “eustress” – as they see adults bring out flashlights and serve tuna from a can and learn that one can cope with scary, unfamiliar situations. Even with smaller threats some children may have intense fear, especially those already anxiety prone or with developmental differences such as autism or sensory processing disorders.

I suggest that our role when we uncover trauma is to determine if there is current danger (and take action), or if the past trauma is affecting the child’s or parent’s functioning or producing distress. Most people recover from trauma with support from family or community but without formal help.

But we can’t assume a child will recover without help as individual, family, cultural, and historical factors affect a person’s response. Someone with an anxiety disorder, or a victim of war or assault may react disproportionately to even small events. A parent with such sensitizing factors may model poor coping, increase the child’s fear, and fail to provide the support that could buffer development of sequelae. We need to check.

Larger traumas that a child is exposed to or learns about, which threatened or resulted in death or injury – such as a destructive tornado – or sexual violence can produce lasting effects, and 25%-69% develop posttraumatic stress disorder (PTSD). For preschoolers, car crashes, dog bites, and medical procedures can also be causative. To be diagnosed with PTSD, a combination and number of symptoms must appear as a result of the trauma, including: re-experiencing the event (1); avoidance of things that remind one of the event (1); arousal or reactivity (2); and negative change in thoughts or feelings (2).

“PTSD in preschool children” (DMS-5) requires 0 re-experiencing, and only 1 avoidance or negative thoughts/feelings symptom as it is harder to discern at this age. The jumpiness of reactivity can disrupt activities and often sleep. The cognitive changes can include forgetting details about the event, decline in ability to pay attention or do school work, or distorted or negative thoughts such as feeling blame. Besides anxiety or depression, mood changes can include dulled emotions or social withdrawal. These symptoms are important for us to recognize.

To be diagnosed, PTSD symptoms must impair functioning and last more than 1 month. So why are families not telling us? While symptoms usually appear within 3 months, it may be months or even years, especially for early traumas such as sexual abuse as the child cannot put the experience into context until later when sexuality becomes relevant. This delay in onset is one reason parents may not report a trauma when complaining about a behavior change. When the trauma also affected them, common in both natural disasters and psychosocial events such as partner violence, the parent may have the related forgetting or depression focusing them on their own pain rather than their child’s pain. These are important reasons to ask about possible traumas of child and parent, giving examples, when a child presents with a behavior, emotional, learning, or somatic complaint.

Pixland/Thinkstock

Traumatized children, as adolescents, are at risk for coping with this pain by cutting, or abusing substances or alcohol (other signs suggesting trauma). These harmful strategies contribute to the adult morbidity now recognized from Adverse Childhood Experiences. Fortunately, we can refer to effective parent-child therapies, such as Circle of Security and play therapy for children less than 3 years old, trauma-focused cognitive behavioral therapy for those over 3 years, and even video training such as trust-based relational intervention, as well as monitor well-being.
 

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

Life is full of traumas, large and small. You know this for yourself as well as for the families and children under your care. The American Academy of Pediatrics provides screening tools for trauma, also called adverse childhood experiences (ACEs). But with 68% of children exposed to a traumatic event before the age of 16 years (Arch Gen Psychiatry. 2007 May; 64[5]:577-84), what is it we should do if we find it?

Smaller traumas, such as a power outage, may frighten but be growth promoting for most children – so called “eustress” – as they see adults bring out flashlights and serve tuna from a can and learn that one can cope with scary, unfamiliar situations. Even with smaller threats some children may have intense fear, especially those already anxiety prone or with developmental differences such as autism or sensory processing disorders.

I suggest that our role when we uncover trauma is to determine if there is current danger (and take action), or if the past trauma is affecting the child’s or parent’s functioning or producing distress. Most people recover from trauma with support from family or community but without formal help.

But we can’t assume a child will recover without help as individual, family, cultural, and historical factors affect a person’s response. Someone with an anxiety disorder, or a victim of war or assault may react disproportionately to even small events. A parent with such sensitizing factors may model poor coping, increase the child’s fear, and fail to provide the support that could buffer development of sequelae. We need to check.

Larger traumas that a child is exposed to or learns about, which threatened or resulted in death or injury – such as a destructive tornado – or sexual violence can produce lasting effects, and 25%-69% develop posttraumatic stress disorder (PTSD). For preschoolers, car crashes, dog bites, and medical procedures can also be causative. To be diagnosed with PTSD, a combination and number of symptoms must appear as a result of the trauma, including: re-experiencing the event (1); avoidance of things that remind one of the event (1); arousal or reactivity (2); and negative change in thoughts or feelings (2).

“PTSD in preschool children” (DMS-5) requires 0 re-experiencing, and only 1 avoidance or negative thoughts/feelings symptom as it is harder to discern at this age. The jumpiness of reactivity can disrupt activities and often sleep. The cognitive changes can include forgetting details about the event, decline in ability to pay attention or do school work, or distorted or negative thoughts such as feeling blame. Besides anxiety or depression, mood changes can include dulled emotions or social withdrawal. These symptoms are important for us to recognize.

To be diagnosed, PTSD symptoms must impair functioning and last more than 1 month. So why are families not telling us? While symptoms usually appear within 3 months, it may be months or even years, especially for early traumas such as sexual abuse as the child cannot put the experience into context until later when sexuality becomes relevant. This delay in onset is one reason parents may not report a trauma when complaining about a behavior change. When the trauma also affected them, common in both natural disasters and psychosocial events such as partner violence, the parent may have the related forgetting or depression focusing them on their own pain rather than their child’s pain. These are important reasons to ask about possible traumas of child and parent, giving examples, when a child presents with a behavior, emotional, learning, or somatic complaint.

Pixland/Thinkstock

Traumatized children, as adolescents, are at risk for coping with this pain by cutting, or abusing substances or alcohol (other signs suggesting trauma). These harmful strategies contribute to the adult morbidity now recognized from Adverse Childhood Experiences. Fortunately, we can refer to effective parent-child therapies, such as Circle of Security and play therapy for children less than 3 years old, trauma-focused cognitive behavioral therapy for those over 3 years, and even video training such as trust-based relational intervention, as well as monitor well-being.
 

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

While most of the parents you will see in your office will be thoughtful, engaged, and even anxious, occasionally you will encounter parents who seem detached from their children. Spending just a few extra minutes to understand this detachment could mean an enormous difference in the psychological health and developmental well-being of your patient.

It is striking when you see it: Flat affect, little eye contact, no questions or comments. If the parents seem unconnected to their children, it is worth being curious about it. Whether they are constantly on their phones or just disengaged, you should start by directing a question straight to them. Perhaps a question about the child’s sleep, appetite, or school performance is a good place to start. You would like to assess their knowledge of the child’s development, performance at school, friendships, and interests, to ensure that they are up to date and paying attention.

javi_indy/ Thinkstock

Depression

Ask about how they are sleeping. If the child is very young or the parents have a difficult work schedule, they might simply be sleep deprived, which you might help them address. Difficulty sleeping also can be a symptom of depression. Have they noticed any changes in their appetite or energy? Is it harder to concentrate? Have they felt more tearful, sad, or irritable? Have they noticed that they don’t get as much pleasure from things that usually bring them joy? Do they worry about being a burden to others? Major depressive disorder is relatively common, affecting as many as one in five women in the postpartum period and one in ten women generally.

Men experience depression at about half that rate, according the Centers for Disease Control and Prevention. It is a condition that can cause feelings of guilt and shame, so many suffer silently, missing the chance for treatment and raising the risk for suicide. Infants of depressed mothers often appear listless and may be fussier about sleeping and eating, which can exacerbate poor attachment with their parents, and lead to problems in later years, including anxiety, mood, or behavioral problems. A parent’s depression, particularly in the postpartum period, represents a serious threat to the child’s healthy development and well-being.

Tell the parents that what they have described to you sounds like it could be a depressive episode and that depression has a serious impact on the whole family. Offer that their primary care physicians can evaluate and treat depression, or learn about other resources in your community that you can refer them to for accessible care.

Is the newborn or special needs child feeling like more responsibility than the parents can handle? Where do the parents find support? Has there been a recent job loss or has there been a financial setback for the family? Is a spouse ill, or are they also caring for an aging parent? Has there been a separation from the spouse? Many adults face multiple significant stresses at the same time. It is not uncommon for working parents to be in “soldiering on” mode, just surviving. But this takes a toll on being present and engaged with the children, and puts them at risk for depression and substance abuse.

Traumatic stress

Have they recently experienced a crime or accident, the unexpected loss of a loved one, or threats or abuse at home? They may be grieving, or may be experiencing symptoms of posttraumatic stress disorder that lead them to appear distant and detached. Grief will improve with time, but they may benefit from extra support or from assistance with their responsibilities (a leave from work or more child care). If they have experienced a traumatic stress, they will need a clinical evaluation for potential treatment options. If they are being threatened or abused at home, you need to find out if their children have witnessed the abuse or may be victims as well. You can offer these parents resources for survivors of domestic abuse and speak with them about your obligation to file with your state’s agency responsible for children’s welfare. It is critical that you listen to any concerns they may have about this filing, from losing their children to enraging their abusers.

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

While most of the parents you will see in your office will be thoughtful, engaged, and even anxious, occasionally you will encounter parents who seem detached from their children. Spending just a few extra minutes to understand this detachment could mean an enormous difference in the psychological health and developmental well-being of your patient.

It is striking when you see it: Flat affect, little eye contact, no questions or comments. If the parents seem unconnected to their children, it is worth being curious about it. Whether they are constantly on their phones or just disengaged, you should start by directing a question straight to them. Perhaps a question about the child’s sleep, appetite, or school performance is a good place to start. You would like to assess their knowledge of the child’s development, performance at school, friendships, and interests, to ensure that they are up to date and paying attention.

javi_indy/ Thinkstock

Depression

Ask about how they are sleeping. If the child is very young or the parents have a difficult work schedule, they might simply be sleep deprived, which you might help them address. Difficulty sleeping also can be a symptom of depression. Have they noticed any changes in their appetite or energy? Is it harder to concentrate? Have they felt more tearful, sad, or irritable? Have they noticed that they don’t get as much pleasure from things that usually bring them joy? Do they worry about being a burden to others? Major depressive disorder is relatively common, affecting as many as one in five women in the postpartum period and one in ten women generally.

Men experience depression at about half that rate, according the Centers for Disease Control and Prevention. It is a condition that can cause feelings of guilt and shame, so many suffer silently, missing the chance for treatment and raising the risk for suicide. Infants of depressed mothers often appear listless and may be fussier about sleeping and eating, which can exacerbate poor attachment with their parents, and lead to problems in later years, including anxiety, mood, or behavioral problems. A parent’s depression, particularly in the postpartum period, represents a serious threat to the child’s healthy development and well-being.

Tell the parents that what they have described to you sounds like it could be a depressive episode and that depression has a serious impact on the whole family. Offer that their primary care physicians can evaluate and treat depression, or learn about other resources in your community that you can refer them to for accessible care.

Is the newborn or special needs child feeling like more responsibility than the parents can handle? Where do the parents find support? Has there been a recent job loss or has there been a financial setback for the family? Is a spouse ill, or are they also caring for an aging parent? Has there been a separation from the spouse? Many adults face multiple significant stresses at the same time. It is not uncommon for working parents to be in “soldiering on” mode, just surviving. But this takes a toll on being present and engaged with the children, and puts them at risk for depression and substance abuse.

Traumatic stress

Have they recently experienced a crime or accident, the unexpected loss of a loved one, or threats or abuse at home? They may be grieving, or may be experiencing symptoms of posttraumatic stress disorder that lead them to appear distant and detached. Grief will improve with time, but they may benefit from extra support or from assistance with their responsibilities (a leave from work or more child care). If they have experienced a traumatic stress, they will need a clinical evaluation for potential treatment options. If they are being threatened or abused at home, you need to find out if their children have witnessed the abuse or may be victims as well. You can offer these parents resources for survivors of domestic abuse and speak with them about your obligation to file with your state’s agency responsible for children’s welfare. It is critical that you listen to any concerns they may have about this filing, from losing their children to enraging their abusers.

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

While most of the parents you will see in your office will be thoughtful, engaged, and even anxious, occasionally you will encounter parents who seem detached from their children. Spending just a few extra minutes to understand this detachment could mean an enormous difference in the psychological health and developmental well-being of your patient.

It is striking when you see it: Flat affect, little eye contact, no questions or comments. If the parents seem unconnected to their children, it is worth being curious about it. Whether they are constantly on their phones or just disengaged, you should start by directing a question straight to them. Perhaps a question about the child’s sleep, appetite, or school performance is a good place to start. You would like to assess their knowledge of the child’s development, performance at school, friendships, and interests, to ensure that they are up to date and paying attention.

javi_indy/ Thinkstock

Depression

Ask about how they are sleeping. If the child is very young or the parents have a difficult work schedule, they might simply be sleep deprived, which you might help them address. Difficulty sleeping also can be a symptom of depression. Have they noticed any changes in their appetite or energy? Is it harder to concentrate? Have they felt more tearful, sad, or irritable? Have they noticed that they don’t get as much pleasure from things that usually bring them joy? Do they worry about being a burden to others? Major depressive disorder is relatively common, affecting as many as one in five women in the postpartum period and one in ten women generally.

Men experience depression at about half that rate, according the Centers for Disease Control and Prevention. It is a condition that can cause feelings of guilt and shame, so many suffer silently, missing the chance for treatment and raising the risk for suicide. Infants of depressed mothers often appear listless and may be fussier about sleeping and eating, which can exacerbate poor attachment with their parents, and lead to problems in later years, including anxiety, mood, or behavioral problems. A parent’s depression, particularly in the postpartum period, represents a serious threat to the child’s healthy development and well-being.

Tell the parents that what they have described to you sounds like it could be a depressive episode and that depression has a serious impact on the whole family. Offer that their primary care physicians can evaluate and treat depression, or learn about other resources in your community that you can refer them to for accessible care.

Is the newborn or special needs child feeling like more responsibility than the parents can handle? Where do the parents find support? Has there been a recent job loss or has there been a financial setback for the family? Is a spouse ill, or are they also caring for an aging parent? Has there been a separation from the spouse? Many adults face multiple significant stresses at the same time. It is not uncommon for working parents to be in “soldiering on” mode, just surviving. But this takes a toll on being present and engaged with the children, and puts them at risk for depression and substance abuse.

Traumatic stress

Have they recently experienced a crime or accident, the unexpected loss of a loved one, or threats or abuse at home? They may be grieving, or may be experiencing symptoms of posttraumatic stress disorder that lead them to appear distant and detached. Grief will improve with time, but they may benefit from extra support or from assistance with their responsibilities (a leave from work or more child care). If they have experienced a traumatic stress, they will need a clinical evaluation for potential treatment options. If they are being threatened or abused at home, you need to find out if their children have witnessed the abuse or may be victims as well. You can offer these parents resources for survivors of domestic abuse and speak with them about your obligation to file with your state’s agency responsible for children’s welfare. It is critical that you listen to any concerns they may have about this filing, from losing their children to enraging their abusers.

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

Diagnosing and initiating treatment for bipolar disorders in children deserve the skills of a child psychiatrist. So why do we really need to know about these complicated conditions as pediatricians?

Although the prevalence of bipolar disorder is about 4% of the adult population, first presentation of significant symptoms usually occurs in adolescence (1% prevalence) with many affected adults recalling symptoms in childhood. To be called a disorder, symptoms have to significantly impact daily functioning. That means these children and their families – and often their schoolmates and teachers – are struggling, whether a diagnosis has been made or not. While bipolar disorder is clearly heritable (emerging in 10% of children of affected adults), environmental stresses such as trauma, family discord, life transitions, academic pressure, illness, puberty, and even lack of sleep can bring out a cycle of symptoms. There also is evidence that earlier treatment may reduce symptoms long term. These factors mean that we need to be vigilant for signs that behavior or mood problems actually are symptoms of bipolar disorder and take action.

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While uncommon, medical conditions such as epilepsy, hyperthyroidism, multiple sclerosis, strokes, tumors, and infections are in the differential we are best positioned to consider. Prescribed medications such as steroids, Singulair, Accutane and, of course, illicit drugs such as cocaine and misused amphetamines also can cause severe mood changes. The psychiatric differential includes depression, ADHD, oppositional defiant disorder or conduct disorder, disruptive mood dysregulation disorder, generalized anxiety disorder, autism, substance use, and personality disorder.

Now that routine screening for depression is recommended for all children, the need to recognize bipolar disorder is even greater. The first thing you need to understand is the signs of mania, the feature that distinguishes depression (unipolar) from manic-depressive disorder (now called bipolar disorder). Walking into the chaos of a pediatric office, one might think all the patients have mania! In fact, it is now a common joke for ordinary people say their erratic or silly behavior is caused by “being bipolar.” As for all mental disorders, milder forms of the same behaviors that constitute mania may happen to any of us at times: elation often mixed with irritability, unrealistic beliefs about one’s abilities, racing thoughts or speech, trouble concentrating, acting with poor judgment for age, having a decreased need for sleep, and inappropriate sexual behaviors. To be considered mania, though, the child must have five of these behaviors with one being elation or irritability; have behavior distinctly different from usual behavior, and have behaviors that last at least 7 days or require hospitalization. Having the child or parent complete the Mood Disorders Questionnaire or the parent version of the Young Mania Rating Scale can help, but is not definitive. When mania has occurred and there is also a period of depression lasting 2 weeks, the condition is called Bipolar I. If the mania symptoms do not meet criteria or only irritability is present in distinct periods (hypomania), Bipolar II is diagnosed. In children there can be more rapid cycling than in adults, even four to five cycles per day, as well as briefer (1-2 days) or more persistent periods. Mania may manifest as irritability, aggression, rages, or inconsolability. Children with either Bipolar I or II (not otherwise specified or NOS) should be referred to a mental health specialist.

In addition to cueing the need for a referral, recognizing bipolar disorder is critical because some medications we may ordinarily feel comfortable prescribing, notably antidepressants and stimulants, can activate mania if given in the absence of mood stabilizing medications. While such activation can be reversible, the associated behaviors may be difficult to endure for everyone, and frighten parents and children so they won’t try needed treatments in the future. We must be vigilant for signs of bipolar in all children presenting with symptoms of ADHD, because more than 50% of children with bipolar disorder have comorbid ADHD, often as the presenting sign. Children with only ADHD, in contrast, do not have reduced sleep needs, hypersexuality, hallucinations, or suicidality. Similarly, depression is common, and a condition that we should diagnose and treat. About 20% of depressed children will go on to bipolar disorder. When starting medication for either ADHD or depression, we need to advise families of the signs of activation and monitor them closely, not only to optimize treatment for the condition we believe is present, but also for the possibility that our treatment could make them worse. We also need to advise that suicide is always a risk of bipolar disorder (33%-44% attempt if untreated).

You often may be asked to refill medications prescribed by specialists for a child’s bipolar disorder. It is important to become familiar with both the common and rare but dangerous side effects. Patients taking lithium need regular blood levels taken for dose adjustments as well as monitoring for renal, thyroid, and parathyroid insults. Atypical antipsychotics can raise lipid levels and prolactin, as well as cause diabetes, rapid weight gain, and tardive dyskinesia. Although neuroleptic malignant syndrome is a rare and reversible side effect, if undetected it can be fatal. Antiepileptic mood stabilizers can cause low platelets or white counts, and the potentially fatal Stevens-Johnson syndrome presenting as rash. Hydration is especially important, as well as watching for hyperthermia and hypothermia as temperature regulation is affected by these medicines. Drug interactions are common and must be anticipated, such as NSAIDs increase lithium levels; OTC cold and allergy medications increase sedation; and caffeine and smoking reduce effects of atypical antipsychotics.

You are crucial for communicating the expected recurring cyclic nature of episodes of depression and mania or hypomania, and the need for maintenance medication. Recovery from an episode is common (81%) within 2.5 years, but 62% recur within the next 1.5 years. Vigilance is needed, especially from parents, because the affected child is unlikely to be able to tell when a new cycle is starting. Establishing healthy routines of eating, sleep, and exercise, and learning stress-reduction strategies as well as avoiding pregnancy, smoking, and drugs (there is a sixfold risk of abuse) is important to lessen risk of recurrence, buffer stress, and optimize outcomes. We need to counsel or refer to help families learn to manage behaviors using transition reminders, positive reinforcers rather than punishment, and sometimes reduced expectations. We may be the best ones to educate schools and request emotion-based Individualized Education Program (IEP) and 504 accommodations. Cognitive impairment during cycles of bipolar disorder may require reduced workload, extended time, or breaks for support. It can be helpful to reflect on the high energy, creativity, and innovative thinking found in many people with bipolar disorder, including Van Gogh (artist), Sir Isaac Newton (scientist), Ted Turner (founder of CNN), and Mariah Carey (singer)! Children need our honesty and help accepting this chronic disorder with optimism about their futures, which, with good medical management, can be bright.
 

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

Diagnosing and initiating treatment for bipolar disorders in children deserve the skills of a child psychiatrist. So why do we really need to know about these complicated conditions as pediatricians?

Although the prevalence of bipolar disorder is about 4% of the adult population, first presentation of significant symptoms usually occurs in adolescence (1% prevalence) with many affected adults recalling symptoms in childhood. To be called a disorder, symptoms have to significantly impact daily functioning. That means these children and their families – and often their schoolmates and teachers – are struggling, whether a diagnosis has been made or not. While bipolar disorder is clearly heritable (emerging in 10% of children of affected adults), environmental stresses such as trauma, family discord, life transitions, academic pressure, illness, puberty, and even lack of sleep can bring out a cycle of symptoms. There also is evidence that earlier treatment may reduce symptoms long term. These factors mean that we need to be vigilant for signs that behavior or mood problems actually are symptoms of bipolar disorder and take action.

KatarzynaBialasiewicz/Getty Images

While uncommon, medical conditions such as epilepsy, hyperthyroidism, multiple sclerosis, strokes, tumors, and infections are in the differential we are best positioned to consider. Prescribed medications such as steroids, Singulair, Accutane and, of course, illicit drugs such as cocaine and misused amphetamines also can cause severe mood changes. The psychiatric differential includes depression, ADHD, oppositional defiant disorder or conduct disorder, disruptive mood dysregulation disorder, generalized anxiety disorder, autism, substance use, and personality disorder.

Now that routine screening for depression is recommended for all children, the need to recognize bipolar disorder is even greater. The first thing you need to understand is the signs of mania, the feature that distinguishes depression (unipolar) from manic-depressive disorder (now called bipolar disorder). Walking into the chaos of a pediatric office, one might think all the patients have mania! In fact, it is now a common joke for ordinary people say their erratic or silly behavior is caused by “being bipolar.” As for all mental disorders, milder forms of the same behaviors that constitute mania may happen to any of us at times: elation often mixed with irritability, unrealistic beliefs about one’s abilities, racing thoughts or speech, trouble concentrating, acting with poor judgment for age, having a decreased need for sleep, and inappropriate sexual behaviors. To be considered mania, though, the child must have five of these behaviors with one being elation or irritability; have behavior distinctly different from usual behavior, and have behaviors that last at least 7 days or require hospitalization. Having the child or parent complete the Mood Disorders Questionnaire or the parent version of the Young Mania Rating Scale can help, but is not definitive. When mania has occurred and there is also a period of depression lasting 2 weeks, the condition is called Bipolar I. If the mania symptoms do not meet criteria or only irritability is present in distinct periods (hypomania), Bipolar II is diagnosed. In children there can be more rapid cycling than in adults, even four to five cycles per day, as well as briefer (1-2 days) or more persistent periods. Mania may manifest as irritability, aggression, rages, or inconsolability. Children with either Bipolar I or II (not otherwise specified or NOS) should be referred to a mental health specialist.

In addition to cueing the need for a referral, recognizing bipolar disorder is critical because some medications we may ordinarily feel comfortable prescribing, notably antidepressants and stimulants, can activate mania if given in the absence of mood stabilizing medications. While such activation can be reversible, the associated behaviors may be difficult to endure for everyone, and frighten parents and children so they won’t try needed treatments in the future. We must be vigilant for signs of bipolar in all children presenting with symptoms of ADHD, because more than 50% of children with bipolar disorder have comorbid ADHD, often as the presenting sign. Children with only ADHD, in contrast, do not have reduced sleep needs, hypersexuality, hallucinations, or suicidality. Similarly, depression is common, and a condition that we should diagnose and treat. About 20% of depressed children will go on to bipolar disorder. When starting medication for either ADHD or depression, we need to advise families of the signs of activation and monitor them closely, not only to optimize treatment for the condition we believe is present, but also for the possibility that our treatment could make them worse. We also need to advise that suicide is always a risk of bipolar disorder (33%-44% attempt if untreated).

You often may be asked to refill medications prescribed by specialists for a child’s bipolar disorder. It is important to become familiar with both the common and rare but dangerous side effects. Patients taking lithium need regular blood levels taken for dose adjustments as well as monitoring for renal, thyroid, and parathyroid insults. Atypical antipsychotics can raise lipid levels and prolactin, as well as cause diabetes, rapid weight gain, and tardive dyskinesia. Although neuroleptic malignant syndrome is a rare and reversible side effect, if undetected it can be fatal. Antiepileptic mood stabilizers can cause low platelets or white counts, and the potentially fatal Stevens-Johnson syndrome presenting as rash. Hydration is especially important, as well as watching for hyperthermia and hypothermia as temperature regulation is affected by these medicines. Drug interactions are common and must be anticipated, such as NSAIDs increase lithium levels; OTC cold and allergy medications increase sedation; and caffeine and smoking reduce effects of atypical antipsychotics.

You are crucial for communicating the expected recurring cyclic nature of episodes of depression and mania or hypomania, and the need for maintenance medication. Recovery from an episode is common (81%) within 2.5 years, but 62% recur within the next 1.5 years. Vigilance is needed, especially from parents, because the affected child is unlikely to be able to tell when a new cycle is starting. Establishing healthy routines of eating, sleep, and exercise, and learning stress-reduction strategies as well as avoiding pregnancy, smoking, and drugs (there is a sixfold risk of abuse) is important to lessen risk of recurrence, buffer stress, and optimize outcomes. We need to counsel or refer to help families learn to manage behaviors using transition reminders, positive reinforcers rather than punishment, and sometimes reduced expectations. We may be the best ones to educate schools and request emotion-based Individualized Education Program (IEP) and 504 accommodations. Cognitive impairment during cycles of bipolar disorder may require reduced workload, extended time, or breaks for support. It can be helpful to reflect on the high energy, creativity, and innovative thinking found in many people with bipolar disorder, including Van Gogh (artist), Sir Isaac Newton (scientist), Ted Turner (founder of CNN), and Mariah Carey (singer)! Children need our honesty and help accepting this chronic disorder with optimism about their futures, which, with good medical management, can be bright.
 

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

Diagnosing and initiating treatment for bipolar disorders in children deserve the skills of a child psychiatrist. So why do we really need to know about these complicated conditions as pediatricians?

Although the prevalence of bipolar disorder is about 4% of the adult population, first presentation of significant symptoms usually occurs in adolescence (1% prevalence) with many affected adults recalling symptoms in childhood. To be called a disorder, symptoms have to significantly impact daily functioning. That means these children and their families – and often their schoolmates and teachers – are struggling, whether a diagnosis has been made or not. While bipolar disorder is clearly heritable (emerging in 10% of children of affected adults), environmental stresses such as trauma, family discord, life transitions, academic pressure, illness, puberty, and even lack of sleep can bring out a cycle of symptoms. There also is evidence that earlier treatment may reduce symptoms long term. These factors mean that we need to be vigilant for signs that behavior or mood problems actually are symptoms of bipolar disorder and take action.

KatarzynaBialasiewicz/Getty Images

While uncommon, medical conditions such as epilepsy, hyperthyroidism, multiple sclerosis, strokes, tumors, and infections are in the differential we are best positioned to consider. Prescribed medications such as steroids, Singulair, Accutane and, of course, illicit drugs such as cocaine and misused amphetamines also can cause severe mood changes. The psychiatric differential includes depression, ADHD, oppositional defiant disorder or conduct disorder, disruptive mood dysregulation disorder, generalized anxiety disorder, autism, substance use, and personality disorder.

Now that routine screening for depression is recommended for all children, the need to recognize bipolar disorder is even greater. The first thing you need to understand is the signs of mania, the feature that distinguishes depression (unipolar) from manic-depressive disorder (now called bipolar disorder). Walking into the chaos of a pediatric office, one might think all the patients have mania! In fact, it is now a common joke for ordinary people say their erratic or silly behavior is caused by “being bipolar.” As for all mental disorders, milder forms of the same behaviors that constitute mania may happen to any of us at times: elation often mixed with irritability, unrealistic beliefs about one’s abilities, racing thoughts or speech, trouble concentrating, acting with poor judgment for age, having a decreased need for sleep, and inappropriate sexual behaviors. To be considered mania, though, the child must have five of these behaviors with one being elation or irritability; have behavior distinctly different from usual behavior, and have behaviors that last at least 7 days or require hospitalization. Having the child or parent complete the Mood Disorders Questionnaire or the parent version of the Young Mania Rating Scale can help, but is not definitive. When mania has occurred and there is also a period of depression lasting 2 weeks, the condition is called Bipolar I. If the mania symptoms do not meet criteria or only irritability is present in distinct periods (hypomania), Bipolar II is diagnosed. In children there can be more rapid cycling than in adults, even four to five cycles per day, as well as briefer (1-2 days) or more persistent periods. Mania may manifest as irritability, aggression, rages, or inconsolability. Children with either Bipolar I or II (not otherwise specified or NOS) should be referred to a mental health specialist.

In addition to cueing the need for a referral, recognizing bipolar disorder is critical because some medications we may ordinarily feel comfortable prescribing, notably antidepressants and stimulants, can activate mania if given in the absence of mood stabilizing medications. While such activation can be reversible, the associated behaviors may be difficult to endure for everyone, and frighten parents and children so they won’t try needed treatments in the future. We must be vigilant for signs of bipolar in all children presenting with symptoms of ADHD, because more than 50% of children with bipolar disorder have comorbid ADHD, often as the presenting sign. Children with only ADHD, in contrast, do not have reduced sleep needs, hypersexuality, hallucinations, or suicidality. Similarly, depression is common, and a condition that we should diagnose and treat. About 20% of depressed children will go on to bipolar disorder. When starting medication for either ADHD or depression, we need to advise families of the signs of activation and monitor them closely, not only to optimize treatment for the condition we believe is present, but also for the possibility that our treatment could make them worse. We also need to advise that suicide is always a risk of bipolar disorder (33%-44% attempt if untreated).

You often may be asked to refill medications prescribed by specialists for a child’s bipolar disorder. It is important to become familiar with both the common and rare but dangerous side effects. Patients taking lithium need regular blood levels taken for dose adjustments as well as monitoring for renal, thyroid, and parathyroid insults. Atypical antipsychotics can raise lipid levels and prolactin, as well as cause diabetes, rapid weight gain, and tardive dyskinesia. Although neuroleptic malignant syndrome is a rare and reversible side effect, if undetected it can be fatal. Antiepileptic mood stabilizers can cause low platelets or white counts, and the potentially fatal Stevens-Johnson syndrome presenting as rash. Hydration is especially important, as well as watching for hyperthermia and hypothermia as temperature regulation is affected by these medicines. Drug interactions are common and must be anticipated, such as NSAIDs increase lithium levels; OTC cold and allergy medications increase sedation; and caffeine and smoking reduce effects of atypical antipsychotics.

You are crucial for communicating the expected recurring cyclic nature of episodes of depression and mania or hypomania, and the need for maintenance medication. Recovery from an episode is common (81%) within 2.5 years, but 62% recur within the next 1.5 years. Vigilance is needed, especially from parents, because the affected child is unlikely to be able to tell when a new cycle is starting. Establishing healthy routines of eating, sleep, and exercise, and learning stress-reduction strategies as well as avoiding pregnancy, smoking, and drugs (there is a sixfold risk of abuse) is important to lessen risk of recurrence, buffer stress, and optimize outcomes. We need to counsel or refer to help families learn to manage behaviors using transition reminders, positive reinforcers rather than punishment, and sometimes reduced expectations. We may be the best ones to educate schools and request emotion-based Individualized Education Program (IEP) and 504 accommodations. Cognitive impairment during cycles of bipolar disorder may require reduced workload, extended time, or breaks for support. It can be helpful to reflect on the high energy, creativity, and innovative thinking found in many people with bipolar disorder, including Van Gogh (artist), Sir Isaac Newton (scientist), Ted Turner (founder of CNN), and Mariah Carey (singer)! Children need our honesty and help accepting this chronic disorder with optimism about their futures, which, with good medical management, can be bright.
 

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

While every day seems to bring extraordinary new advances in science – robotic surgery, individually targeted medications, and even gene therapy – there are many people who currently approach the science of medicine with skepticism.

While it is the right of legally competent adults in a free society to chose how best to care for their own health, to explore holistic or alternative therapies, or avoid medicine altogether, it is more complex when they are skeptical of accepted medical practice in managing the health of their children. For those parents who trust you enough to bring their children to you for care but remain skeptical of vaccines or other treatments, you have an opportunity to work with that trust and engage in a discussion so that they might reconsider their position on valuable and even life-saving treatments for their children.

Wavebreakmedia/Thinkstock

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

While every day seems to bring extraordinary new advances in science – robotic surgery, individually targeted medications, and even gene therapy – there are many people who currently approach the science of medicine with skepticism.

While it is the right of legally competent adults in a free society to chose how best to care for their own health, to explore holistic or alternative therapies, or avoid medicine altogether, it is more complex when they are skeptical of accepted medical practice in managing the health of their children. For those parents who trust you enough to bring their children to you for care but remain skeptical of vaccines or other treatments, you have an opportunity to work with that trust and engage in a discussion so that they might reconsider their position on valuable and even life-saving treatments for their children.

Wavebreakmedia/Thinkstock

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

While every day seems to bring extraordinary new advances in science – robotic surgery, individually targeted medications, and even gene therapy – there are many people who currently approach the science of medicine with skepticism.

While it is the right of legally competent adults in a free society to chose how best to care for their own health, to explore holistic or alternative therapies, or avoid medicine altogether, it is more complex when they are skeptical of accepted medical practice in managing the health of their children. For those parents who trust you enough to bring their children to you for care but remain skeptical of vaccines or other treatments, you have an opportunity to work with that trust and engage in a discussion so that they might reconsider their position on valuable and even life-saving treatments for their children.

Wavebreakmedia/Thinkstock

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