Child Psychiatry Consult

Case vignette: A 16-year-old Nepali-born English-speaking adolescent presents for a well-child visit and notes concerns for anxiety, depression, and a history of trauma. She resides with her parents who work in hospitality with limited time off, and thus she presented for the initial office visit with a neighbor. Parents were not readily available to discuss treatment recommendations, including medication options. The teen shares a number of challenges that makes coming to appointments difficult. You also notice that the patient currently is not enrolled in insurance, though she appears eligible.

The above vignette highlights various social issues and concerns that impact access to healthcare and overall health/well-being. Social determinants of health (SDOH) and factors centered on mental health are now widely known to impact pediatric health and wellbeing. The Office of Disease Prevention and Health Promotion defines SDOH as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” SDOH can be grouped into five domains: Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment, and Social and Community Context.¹

Dr. Abdul-Karim

Additionally, when considering determinants that impact the mental health of children, it is prudent to consider parental psychosocial factors and adverse childhood experiences (ACEs), such as witnessing interpersonal violence, child abuse, parental substance use, and parental depression.² All these factors have been shown to impact an individual’s mental and physical health not only contemporaneously but also later in life.³

Screening Tool for Pediatric Social Histories

One screening tool to assist with gathering an expanded pediatric social history is called IHELP, developed by Kenyon et al,⁴ with further derivations from Colvin et al.⁵ Utilizing this tool can assist providers with identifying social needs.

The tool begins with a framing statement — “Let me ask you some questions I ask every family” — then proceeds to discuss relevant topics as shared below:

I: Income; Insurance

• Do you have any concerns about making ends meet?
• Do you have any concerns about your child’s health insurance?

H: Hunger, Housing Conditions; Homeless

• Do you have any concerns about having enough food?
• Have you ever been worried whether your food would run out before you got money to buy more?
• Within the past year has the food you bought ever not lasted, and you didn’t have money to get more?
• Do you have any concerns about poor housing conditions like mice, mold, or cockroaches?
• Do you have any concerns about being evicted or not being able to pay the rent?
• Do you have any concerns about not being able to pay your mortgage?

E: Education; Ensuring Safety (Violence)

• Do you have any concerns about your child’s educational needs?
• [DO NOT ASK IN FRONT OF CHILD 3 OR OLDER OR IN FRONT OF OTHER PARTNER] “From speaking to families, I have learned that violence in the home is common and now I ask all families about violence in the home. Do you have any concerns about violence in your home?”

L: Legal status (Immigration)

• What hospital was your child born in?
• If not in the United States: “Are you aware that your child may be eligible for benefits even though they were not born in the US? If you would like, I can have a social worker come talk to you about some possible benefits your child may be eligible for. Would you like me to do that?”

P: Power of Attorney; Guardianship

• Are you the biological mother or father of this child?
• [If not] “Can you show me the power of attorney or guardianship document you have?”
• **PATIENTS >17+ with Mental Incapacity: Ask for Guardianship.

This tool can help with identifying families with significant social needs so that one can attain further historical information and subsequently share resources to assist with any challenges.
 

Consider the Role of Adverse Childhood Experiences

Additionally, as noted, ACEs often play an important role in overall health and well-being; they include experiencing childhood abuse, neglect, and/or household dysfunction. The impact of these early exposures can lead to toxic stress that can negatively alter the brain and the body’s response to stress over time.³ There are various tools readily available online that can assist with identifying ACEs and interpreting their prevalence. The American Academy of Pediatrics has an updated page of commonly used screening tools. Early identification and intervention can help mitigate the impact of these experiences on long-term outcomes.

Important Considerations Regarding Screening for SDOH and/or ACEs:

• Please consider if screening is helpful in your space, recognizing that there are benefits and potential ethical considerations to screen or not. Ensure an interdisciplinary approach if screening is implemented to ensure that the patient’s experience and well-being is prioritized.
• Try to be intentional in your communication with parents. The patient and family are our teachers and know best what they need.
• Consider what is available in your community and what can be offered to ensure that parents and families are appropriate and eligible for a particular resource.
• Encourage continuous collaboration and partnership with community providers who offer resources that a family may benefit from to ensure that the resource continues to be available.

Returning to the Vignette

Administering the IHELP tool has led to identifying that the adolescent’s insurance has lapsed, but she remains eligible, and the family seeks support to re-enroll. The family shares concerns regarding educational needs, as the child has not attended school for the past year and is not on track to graduate. The IHELP tool also helps you identify inconsistent transportation availability. Ultimately, a social work consultation is placed which assists with re-enrolling in insurance for the child and obtaining a bus pass for in-person visits. The patient is also supported in enrolling in the use of a videoconferencing platform for virtual visits. You and your team reach out to the school, which provides valuable information regarding the child’s status and how best to support re-engagement. On follow-up, she is now readily engaged in appointments and shares she is no longer worrying about transportation, which has been helpful. She has started initial conversations with the school and has a condensed schedule for reintegration.

Dr. Abdul-Karim, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at [email protected].

References

1. Office of Disease Prevention and Health Promotion, US Department of Health & Human Services. Social Determinants of Health. https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health

2. Cotton N and Shim R. J Am Acad Child Adolesc Psychiatry. 2022 Nov;61(11):1385-1389. doi: 10.1016/j.jaac.2022.04.020.

3. US Centers for Disease Control and Prevention. Adverse Childhood Experiences (ACEs): Preventing Early Trauma to Improve Adult Health. https://www.cdc.gov/vitalsigns/aces/index.html.

4. Kenyon C et al. Pediatrics. 2007 Sep;120(3):e734-e738. doi: 10.1542/peds.2006-2495.

5. Colvin JD et al. Acad Pediatr. 2016 Mar;16(2):168-174. doi: 10.1016/j.acap.2015.06.001.

Case vignette: A 16-year-old Nepali-born English-speaking adolescent presents for a well-child visit and notes concerns for anxiety, depression, and a history of trauma. She resides with her parents who work in hospitality with limited time off, and thus she presented for the initial office visit with a neighbor. Parents were not readily available to discuss treatment recommendations, including medication options. The teen shares a number of challenges that makes coming to appointments difficult. You also notice that the patient currently is not enrolled in insurance, though she appears eligible.

The above vignette highlights various social issues and concerns that impact access to healthcare and overall health/well-being. Social determinants of health (SDOH) and factors centered on mental health are now widely known to impact pediatric health and wellbeing. The Office of Disease Prevention and Health Promotion defines SDOH as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” SDOH can be grouped into five domains: Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment, and Social and Community Context.¹

Dr. Abdul-Karim

Additionally, when considering determinants that impact the mental health of children, it is prudent to consider parental psychosocial factors and adverse childhood experiences (ACEs), such as witnessing interpersonal violence, child abuse, parental substance use, and parental depression.² All these factors have been shown to impact an individual’s mental and physical health not only contemporaneously but also later in life.³

Screening Tool for Pediatric Social Histories

One screening tool to assist with gathering an expanded pediatric social history is called IHELP, developed by Kenyon et al,⁴ with further derivations from Colvin et al.⁵ Utilizing this tool can assist providers with identifying social needs.

The tool begins with a framing statement — “Let me ask you some questions I ask every family” — then proceeds to discuss relevant topics as shared below:

I: Income; Insurance

• Do you have any concerns about making ends meet?
• Do you have any concerns about your child’s health insurance?

H: Hunger, Housing Conditions; Homeless

• Do you have any concerns about having enough food?
• Have you ever been worried whether your food would run out before you got money to buy more?
• Within the past year has the food you bought ever not lasted, and you didn’t have money to get more?
• Do you have any concerns about poor housing conditions like mice, mold, or cockroaches?
• Do you have any concerns about being evicted or not being able to pay the rent?
• Do you have any concerns about not being able to pay your mortgage?

E: Education; Ensuring Safety (Violence)

• Do you have any concerns about your child’s educational needs?
• [DO NOT ASK IN FRONT OF CHILD 3 OR OLDER OR IN FRONT OF OTHER PARTNER] “From speaking to families, I have learned that violence in the home is common and now I ask all families about violence in the home. Do you have any concerns about violence in your home?”

L: Legal status (Immigration)

• What hospital was your child born in?
• If not in the United States: “Are you aware that your child may be eligible for benefits even though they were not born in the US? If you would like, I can have a social worker come talk to you about some possible benefits your child may be eligible for. Would you like me to do that?”

P: Power of Attorney; Guardianship

• Are you the biological mother or father of this child?
• [If not] “Can you show me the power of attorney or guardianship document you have?”
• **PATIENTS >17+ with Mental Incapacity: Ask for Guardianship.

This tool can help with identifying families with significant social needs so that one can attain further historical information and subsequently share resources to assist with any challenges.
 

Consider the Role of Adverse Childhood Experiences

Additionally, as noted, ACEs often play an important role in overall health and well-being; they include experiencing childhood abuse, neglect, and/or household dysfunction. The impact of these early exposures can lead to toxic stress that can negatively alter the brain and the body’s response to stress over time.³ There are various tools readily available online that can assist with identifying ACEs and interpreting their prevalence. The American Academy of Pediatrics has an updated page of commonly used screening tools. Early identification and intervention can help mitigate the impact of these experiences on long-term outcomes.

Important Considerations Regarding Screening for SDOH and/or ACEs:

• Please consider if screening is helpful in your space, recognizing that there are benefits and potential ethical considerations to screen or not. Ensure an interdisciplinary approach if screening is implemented to ensure that the patient’s experience and well-being is prioritized.
• Try to be intentional in your communication with parents. The patient and family are our teachers and know best what they need.
• Consider what is available in your community and what can be offered to ensure that parents and families are appropriate and eligible for a particular resource.
• Encourage continuous collaboration and partnership with community providers who offer resources that a family may benefit from to ensure that the resource continues to be available.

Returning to the Vignette

Administering the IHELP tool has led to identifying that the adolescent’s insurance has lapsed, but she remains eligible, and the family seeks support to re-enroll. The family shares concerns regarding educational needs, as the child has not attended school for the past year and is not on track to graduate. The IHELP tool also helps you identify inconsistent transportation availability. Ultimately, a social work consultation is placed which assists with re-enrolling in insurance for the child and obtaining a bus pass for in-person visits. The patient is also supported in enrolling in the use of a videoconferencing platform for virtual visits. You and your team reach out to the school, which provides valuable information regarding the child’s status and how best to support re-engagement. On follow-up, she is now readily engaged in appointments and shares she is no longer worrying about transportation, which has been helpful. She has started initial conversations with the school and has a condensed schedule for reintegration.

Dr. Abdul-Karim, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at [email protected].

References

1. Office of Disease Prevention and Health Promotion, US Department of Health & Human Services. Social Determinants of Health. https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health

2. Cotton N and Shim R. J Am Acad Child Adolesc Psychiatry. 2022 Nov;61(11):1385-1389. doi: 10.1016/j.jaac.2022.04.020.

3. US Centers for Disease Control and Prevention. Adverse Childhood Experiences (ACEs): Preventing Early Trauma to Improve Adult Health. https://www.cdc.gov/vitalsigns/aces/index.html.

4. Kenyon C et al. Pediatrics. 2007 Sep;120(3):e734-e738. doi: 10.1542/peds.2006-2495.

5. Colvin JD et al. Acad Pediatr. 2016 Mar;16(2):168-174. doi: 10.1016/j.acap.2015.06.001.

Case vignette: A 16-year-old Nepali-born English-speaking adolescent presents for a well-child visit and notes concerns for anxiety, depression, and a history of trauma. She resides with her parents who work in hospitality with limited time off, and thus she presented for the initial office visit with a neighbor. Parents were not readily available to discuss treatment recommendations, including medication options. The teen shares a number of challenges that makes coming to appointments difficult. You also notice that the patient currently is not enrolled in insurance, though she appears eligible.

The above vignette highlights various social issues and concerns that impact access to healthcare and overall health/well-being. Social determinants of health (SDOH) and factors centered on mental health are now widely known to impact pediatric health and wellbeing. The Office of Disease Prevention and Health Promotion defines SDOH as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” SDOH can be grouped into five domains: Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment, and Social and Community Context.¹

Dr. Abdul-Karim

Additionally, when considering determinants that impact the mental health of children, it is prudent to consider parental psychosocial factors and adverse childhood experiences (ACEs), such as witnessing interpersonal violence, child abuse, parental substance use, and parental depression.² All these factors have been shown to impact an individual’s mental and physical health not only contemporaneously but also later in life.³

Screening Tool for Pediatric Social Histories

One screening tool to assist with gathering an expanded pediatric social history is called IHELP, developed by Kenyon et al,⁴ with further derivations from Colvin et al.⁵ Utilizing this tool can assist providers with identifying social needs.

The tool begins with a framing statement — “Let me ask you some questions I ask every family” — then proceeds to discuss relevant topics as shared below:

I: Income; Insurance

• Do you have any concerns about making ends meet?
• Do you have any concerns about your child’s health insurance?

H: Hunger, Housing Conditions; Homeless

• Do you have any concerns about having enough food?
• Have you ever been worried whether your food would run out before you got money to buy more?
• Within the past year has the food you bought ever not lasted, and you didn’t have money to get more?
• Do you have any concerns about poor housing conditions like mice, mold, or cockroaches?
• Do you have any concerns about being evicted or not being able to pay the rent?
• Do you have any concerns about not being able to pay your mortgage?

E: Education; Ensuring Safety (Violence)

• Do you have any concerns about your child’s educational needs?
• [DO NOT ASK IN FRONT OF CHILD 3 OR OLDER OR IN FRONT OF OTHER PARTNER] “From speaking to families, I have learned that violence in the home is common and now I ask all families about violence in the home. Do you have any concerns about violence in your home?”

L: Legal status (Immigration)

• What hospital was your child born in?
• If not in the United States: “Are you aware that your child may be eligible for benefits even though they were not born in the US? If you would like, I can have a social worker come talk to you about some possible benefits your child may be eligible for. Would you like me to do that?”

P: Power of Attorney; Guardianship

• Are you the biological mother or father of this child?
• [If not] “Can you show me the power of attorney or guardianship document you have?”
• **PATIENTS >17+ with Mental Incapacity: Ask for Guardianship.

This tool can help with identifying families with significant social needs so that one can attain further historical information and subsequently share resources to assist with any challenges.
 

Consider the Role of Adverse Childhood Experiences

Additionally, as noted, ACEs often play an important role in overall health and well-being; they include experiencing childhood abuse, neglect, and/or household dysfunction. The impact of these early exposures can lead to toxic stress that can negatively alter the brain and the body’s response to stress over time.³ There are various tools readily available online that can assist with identifying ACEs and interpreting their prevalence. The American Academy of Pediatrics has an updated page of commonly used screening tools. Early identification and intervention can help mitigate the impact of these experiences on long-term outcomes.

Important Considerations Regarding Screening for SDOH and/or ACEs:

• Please consider if screening is helpful in your space, recognizing that there are benefits and potential ethical considerations to screen or not. Ensure an interdisciplinary approach if screening is implemented to ensure that the patient’s experience and well-being is prioritized.
• Try to be intentional in your communication with parents. The patient and family are our teachers and know best what they need.
• Consider what is available in your community and what can be offered to ensure that parents and families are appropriate and eligible for a particular resource.
• Encourage continuous collaboration and partnership with community providers who offer resources that a family may benefit from to ensure that the resource continues to be available.

Returning to the Vignette

Administering the IHELP tool has led to identifying that the adolescent’s insurance has lapsed, but she remains eligible, and the family seeks support to re-enroll. The family shares concerns regarding educational needs, as the child has not attended school for the past year and is not on track to graduate. The IHELP tool also helps you identify inconsistent transportation availability. Ultimately, a social work consultation is placed which assists with re-enrolling in insurance for the child and obtaining a bus pass for in-person visits. The patient is also supported in enrolling in the use of a videoconferencing platform for virtual visits. You and your team reach out to the school, which provides valuable information regarding the child’s status and how best to support re-engagement. On follow-up, she is now readily engaged in appointments and shares she is no longer worrying about transportation, which has been helpful. She has started initial conversations with the school and has a condensed schedule for reintegration.

Dr. Abdul-Karim, a child and adolescent psychiatrist, is assistant professor of psychiatry at the University of Vermont, Burlington. She said she had no relevant financial disclosures. Email her at [email protected].

References

1. Office of Disease Prevention and Health Promotion, US Department of Health & Human Services. Social Determinants of Health. https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health

2. Cotton N and Shim R. J Am Acad Child Adolesc Psychiatry. 2022 Nov;61(11):1385-1389. doi: 10.1016/j.jaac.2022.04.020.

3. US Centers for Disease Control and Prevention. Adverse Childhood Experiences (ACEs): Preventing Early Trauma to Improve Adult Health. https://www.cdc.gov/vitalsigns/aces/index.html.

4. Kenyon C et al. Pediatrics. 2007 Sep;120(3):e734-e738. doi: 10.1542/peds.2006-2495.

5. Colvin JD et al. Acad Pediatr. 2016 Mar;16(2):168-174. doi: 10.1016/j.acap.2015.06.001.

A 3-year-old presents to my clinic for evaluation of a possible autism spectrum disorder/difference. He has a history of severe emotional dysregulation, as well as reduced social skills and multiple sensory sensitivities. When I enter the exam room he is watching videos on his mom’s phone, and has some difficulty transitioning to play with toys when I encourage him to do so. He is eventually able to cooperate with my testing, though a bit reluctantly, and scores within the low average range for both language and pre-academic skills. His neurologic exam is within normal limits. He utilizes reasonably well-modulated eye contact paired with some typical use of gestures, and his affect is moderately directed and reactive. He displays typical intonation and prosody of speech, though engages in less spontaneous, imaginative, and reciprocal play than would be expected for his age. His mother reports decreased pretend play at home, minimal interest in toys, and difficulty playing cooperatively with other children.

Upon further history, it becomes apparent that the child spends a majority of his time on electronic devices, and has done so since early toddlerhood. Further dialogue suggests that the family became isolated during the COVID-19 pandemic, and has not yet re-engaged with the community in a meaningful way. The child has had rare opportunity for social interactions with other children, and minimal access to outdoor play. His most severe meltdowns generally involve transitions away from screens, and his overwhelmed parents often resort to use of additional screens to calm him once he is dysregulated.

Oregon Health & Science University (OHSU)

At the end of the visit, through shared decision making, we agree that enrolling the child in a high-quality public preschool will help parents make a concerted effort towards a significant reduction in the hours per day in which the child utilizes electronic devices, while also providing him more exposure to peers. We plan for the child to return in 6 months for a re-evaluation around social-emotional skills, given his current limited exposure to peers and limited “unplugged” play-time.
 

Overutilization of Electronic Devices

As clinicians, we can all see how pervasive the use of electronic devices has become in the lives of the families we care for, as well as in our own lives, and how challenging some aspects of modern parenting have become. The developmental impact of early and excessive use of screens in young children is well documented,¹ but as clinicians it can be tricky to help empower parents to find ways to limit screen time. When parents use screens to comfort and amuse their children during a clinic visit, this situation may serve as an excellent opportunity for a meaningful and respectful conversation around skill deficits which can result from overutilization of electronic devices in young children.

One scenario I often encounter during my patient evaluations as a developmental and behavioral pediatrician is children begging their parents for use of their phone throughout their visits with me. Not infrequently, a child is already on a screen when I enter the exam room, even when there has been a minimal wait time, which often leads to some resistance on behalf of the child as I explain to the family that a significant portion of the visit involves my interactions with the child, testing the child, and observing their child at play. I always provide ample amounts of age-appropriate art supplies, puzzles, fidgets, building toys, and imaginative play items to children during their 30 to 90 minute evaluations, but these are often not appealing to children when they have been very recently engaged with an electronic device. At times I also need to ask caretakers themselves to please disengage from their own electronic devices during the visit so that I can involve them in a detailed discussion about their child.

One challenge with the practice of allowing children access to entertainment on their parent’s smartphones in particular, lies in the fact that these devices are almost always present, meaning there is no natural boundary to inhibit access, in contrast to a television set or stationary computer parked in the family living room. Not dissimilar to candy visible in a parent’s purse, a cell phone becomes a constant temptation for children accustomed to utilizing them at home and public venues, and the incessant begging can wear down already stressed parents.

Children can become conditioned to utilize the distraction of screens to avoid feelings of discomfort or stress, and so can be very persistent and emotional when asking for the use of screens in public settings. Out in the community, I very frequently see young children and toddlers quietly staring at their phones and tablets while at restaurants and stores. While I have empathy for exhausted parents desperate for a moment of quiet, if this type of screen use is the rule rather than the exception for a child, there is risk for missed opportunities for the development of self-regulation skills.

Additionally, I have seen very young children present to my clinic with poor posture and neck pain secondary to chronic smartphone use, and young children who are getting minimal exercise or outdoor time due to excessive screen use, leading to concerns around fine and gross motor skills as well.

While allowing a child to stay occupied with or be soothed by a highly interesting digital experience can create a more calm environment for all, if habitual, this use can come at a cost regarding opportunities for the growth of executive functioning skills, general coping skills, general situational awareness, and experiential learning. Reliance on screens to decrease uncomfortable experiences decreases the opportunity for building distress tolerance, patience, and coping skills.

Of course there are times of extreme distress where a lollipop or bit of screen time might be reasonable to help keep a child safe or further avoid emotional trauma, but in general, other methods of soothing can very often be utilized, and in the long run would serve to increase the child’s general adaptive functioning.
 

A Teachable Moment

When clinicians encounter screens being used by parents to entertain their kids in clinic, it provides a valuable teaching moment around the risks of using screens to keep kids regulated and occupied during life’s less interesting or more anxiety provoking experiences. Having a meaningful conversation about the use of electronic devices with caregivers by clinicians in the exam room can be a delicate dance between providing supportive education while avoiding judgmental tones or verbiage. Normalizing and sympathizing with the difficulty of managing challenging behaviors from children in public spaces can help parents feel less desperate to keep their child quiet at all costs, and thus allow for greater development of coping skills.

Some parents may benefit from learning simple ideas for keeping a child regulated and occupied during times of waiting such as silly songs and dances, verbal games like “I spy,” and clapping routines. For a child with additional sensory or developmental needs, a referral to an occupational therapist to work on emotional regulation by way of specific sensory tools can be helpful. Parent-Child Interaction Therapy for kids ages 2 to 7 can also help build some relational activities and skills that can be utilized during trying situations to help keep a child settled and occupied.

If a child has qualified for Developmental Disability Services (DDS), medical providers can also write “prescriptions’ for sensory calming items which are often covered financially by DDS, such as chewies, weighted vests, stuffed animals, and fidgets. While vilification of all screen time for children is not necessary or helpful, supporting parents as they navigate and implement appropriate boundaries is important for optimizing child development. Encouraging parents to schedule allowed screen time at home in a very predictable and controlled manner is one method to help limit excessive use, as well as it’s utilization as an emotional regulation tool.

For public outings with children with special needs, and in particular in situations where meltdowns are likely to occur, some families find it helpful to dress their children in clothing or accessories that increase community awareness about their child’s condition (such as an autism awareness t-shirt). This effort can also help deflect unhelpful attention or advice from the public. Some parents choose to carry small cards explaining the child’s developmental differences, which can then be easily handed to unsupportive strangers in community settings during trying moments.

Clinicians can work to utilize even quick visits with families as an opportunity to review the American Academy of Pediatrics screen time recommendations with families, and also direct them to the Family Media Plan creation resources. Parenting in the modern era presents many challenges regarding choices around the use of electronic devices with children, and using the exam room experience as a teaching opportunity may be a helpful way to decrease utilization of screens as emotional regulation tools for children, while also providing general education around healthy use of screens.
 

Dr. Roth is a developmental and behavioral pediatrician in Eugene, Oregon.

Reference

1. Takahashi I et al. Screen Time at Age 1 Year and Communication and Problem-Solving Developmental Delays at 2 and 4 years. JAMA Pediatr. 2023 Oct 1;177(10):1039-1046. doi: 10.1001/jamapediatrics.2023.3057.

A 3-year-old presents to my clinic for evaluation of a possible autism spectrum disorder/difference. He has a history of severe emotional dysregulation, as well as reduced social skills and multiple sensory sensitivities. When I enter the exam room he is watching videos on his mom’s phone, and has some difficulty transitioning to play with toys when I encourage him to do so. He is eventually able to cooperate with my testing, though a bit reluctantly, and scores within the low average range for both language and pre-academic skills. His neurologic exam is within normal limits. He utilizes reasonably well-modulated eye contact paired with some typical use of gestures, and his affect is moderately directed and reactive. He displays typical intonation and prosody of speech, though engages in less spontaneous, imaginative, and reciprocal play than would be expected for his age. His mother reports decreased pretend play at home, minimal interest in toys, and difficulty playing cooperatively with other children.

Upon further history, it becomes apparent that the child spends a majority of his time on electronic devices, and has done so since early toddlerhood. Further dialogue suggests that the family became isolated during the COVID-19 pandemic, and has not yet re-engaged with the community in a meaningful way. The child has had rare opportunity for social interactions with other children, and minimal access to outdoor play. His most severe meltdowns generally involve transitions away from screens, and his overwhelmed parents often resort to use of additional screens to calm him once he is dysregulated.

Oregon Health & Science University (OHSU)

At the end of the visit, through shared decision making, we agree that enrolling the child in a high-quality public preschool will help parents make a concerted effort towards a significant reduction in the hours per day in which the child utilizes electronic devices, while also providing him more exposure to peers. We plan for the child to return in 6 months for a re-evaluation around social-emotional skills, given his current limited exposure to peers and limited “unplugged” play-time.
 

Overutilization of Electronic Devices

As clinicians, we can all see how pervasive the use of electronic devices has become in the lives of the families we care for, as well as in our own lives, and how challenging some aspects of modern parenting have become. The developmental impact of early and excessive use of screens in young children is well documented,¹ but as clinicians it can be tricky to help empower parents to find ways to limit screen time. When parents use screens to comfort and amuse their children during a clinic visit, this situation may serve as an excellent opportunity for a meaningful and respectful conversation around skill deficits which can result from overutilization of electronic devices in young children.

One scenario I often encounter during my patient evaluations as a developmental and behavioral pediatrician is children begging their parents for use of their phone throughout their visits with me. Not infrequently, a child is already on a screen when I enter the exam room, even when there has been a minimal wait time, which often leads to some resistance on behalf of the child as I explain to the family that a significant portion of the visit involves my interactions with the child, testing the child, and observing their child at play. I always provide ample amounts of age-appropriate art supplies, puzzles, fidgets, building toys, and imaginative play items to children during their 30 to 90 minute evaluations, but these are often not appealing to children when they have been very recently engaged with an electronic device. At times I also need to ask caretakers themselves to please disengage from their own electronic devices during the visit so that I can involve them in a detailed discussion about their child.

One challenge with the practice of allowing children access to entertainment on their parent’s smartphones in particular, lies in the fact that these devices are almost always present, meaning there is no natural boundary to inhibit access, in contrast to a television set or stationary computer parked in the family living room. Not dissimilar to candy visible in a parent’s purse, a cell phone becomes a constant temptation for children accustomed to utilizing them at home and public venues, and the incessant begging can wear down already stressed parents.

Children can become conditioned to utilize the distraction of screens to avoid feelings of discomfort or stress, and so can be very persistent and emotional when asking for the use of screens in public settings. Out in the community, I very frequently see young children and toddlers quietly staring at their phones and tablets while at restaurants and stores. While I have empathy for exhausted parents desperate for a moment of quiet, if this type of screen use is the rule rather than the exception for a child, there is risk for missed opportunities for the development of self-regulation skills.

Additionally, I have seen very young children present to my clinic with poor posture and neck pain secondary to chronic smartphone use, and young children who are getting minimal exercise or outdoor time due to excessive screen use, leading to concerns around fine and gross motor skills as well.

While allowing a child to stay occupied with or be soothed by a highly interesting digital experience can create a more calm environment for all, if habitual, this use can come at a cost regarding opportunities for the growth of executive functioning skills, general coping skills, general situational awareness, and experiential learning. Reliance on screens to decrease uncomfortable experiences decreases the opportunity for building distress tolerance, patience, and coping skills.

Of course there are times of extreme distress where a lollipop or bit of screen time might be reasonable to help keep a child safe or further avoid emotional trauma, but in general, other methods of soothing can very often be utilized, and in the long run would serve to increase the child’s general adaptive functioning.
 

A Teachable Moment

When clinicians encounter screens being used by parents to entertain their kids in clinic, it provides a valuable teaching moment around the risks of using screens to keep kids regulated and occupied during life’s less interesting or more anxiety provoking experiences. Having a meaningful conversation about the use of electronic devices with caregivers by clinicians in the exam room can be a delicate dance between providing supportive education while avoiding judgmental tones or verbiage. Normalizing and sympathizing with the difficulty of managing challenging behaviors from children in public spaces can help parents feel less desperate to keep their child quiet at all costs, and thus allow for greater development of coping skills.

Some parents may benefit from learning simple ideas for keeping a child regulated and occupied during times of waiting such as silly songs and dances, verbal games like “I spy,” and clapping routines. For a child with additional sensory or developmental needs, a referral to an occupational therapist to work on emotional regulation by way of specific sensory tools can be helpful. Parent-Child Interaction Therapy for kids ages 2 to 7 can also help build some relational activities and skills that can be utilized during trying situations to help keep a child settled and occupied.

If a child has qualified for Developmental Disability Services (DDS), medical providers can also write “prescriptions’ for sensory calming items which are often covered financially by DDS, such as chewies, weighted vests, stuffed animals, and fidgets. While vilification of all screen time for children is not necessary or helpful, supporting parents as they navigate and implement appropriate boundaries is important for optimizing child development. Encouraging parents to schedule allowed screen time at home in a very predictable and controlled manner is one method to help limit excessive use, as well as it’s utilization as an emotional regulation tool.

For public outings with children with special needs, and in particular in situations where meltdowns are likely to occur, some families find it helpful to dress their children in clothing or accessories that increase community awareness about their child’s condition (such as an autism awareness t-shirt). This effort can also help deflect unhelpful attention or advice from the public. Some parents choose to carry small cards explaining the child’s developmental differences, which can then be easily handed to unsupportive strangers in community settings during trying moments.

Clinicians can work to utilize even quick visits with families as an opportunity to review the American Academy of Pediatrics screen time recommendations with families, and also direct them to the Family Media Plan creation resources. Parenting in the modern era presents many challenges regarding choices around the use of electronic devices with children, and using the exam room experience as a teaching opportunity may be a helpful way to decrease utilization of screens as emotional regulation tools for children, while also providing general education around healthy use of screens.
 

Dr. Roth is a developmental and behavioral pediatrician in Eugene, Oregon.

Reference

1. Takahashi I et al. Screen Time at Age 1 Year and Communication and Problem-Solving Developmental Delays at 2 and 4 years. JAMA Pediatr. 2023 Oct 1;177(10):1039-1046. doi: 10.1001/jamapediatrics.2023.3057.

A 3-year-old presents to my clinic for evaluation of a possible autism spectrum disorder/difference. He has a history of severe emotional dysregulation, as well as reduced social skills and multiple sensory sensitivities. When I enter the exam room he is watching videos on his mom’s phone, and has some difficulty transitioning to play with toys when I encourage him to do so. He is eventually able to cooperate with my testing, though a bit reluctantly, and scores within the low average range for both language and pre-academic skills. His neurologic exam is within normal limits. He utilizes reasonably well-modulated eye contact paired with some typical use of gestures, and his affect is moderately directed and reactive. He displays typical intonation and prosody of speech, though engages in less spontaneous, imaginative, and reciprocal play than would be expected for his age. His mother reports decreased pretend play at home, minimal interest in toys, and difficulty playing cooperatively with other children.

Upon further history, it becomes apparent that the child spends a majority of his time on electronic devices, and has done so since early toddlerhood. Further dialogue suggests that the family became isolated during the COVID-19 pandemic, and has not yet re-engaged with the community in a meaningful way. The child has had rare opportunity for social interactions with other children, and minimal access to outdoor play. His most severe meltdowns generally involve transitions away from screens, and his overwhelmed parents often resort to use of additional screens to calm him once he is dysregulated.

Oregon Health & Science University (OHSU)

At the end of the visit, through shared decision making, we agree that enrolling the child in a high-quality public preschool will help parents make a concerted effort towards a significant reduction in the hours per day in which the child utilizes electronic devices, while also providing him more exposure to peers. We plan for the child to return in 6 months for a re-evaluation around social-emotional skills, given his current limited exposure to peers and limited “unplugged” play-time.
 

Overutilization of Electronic Devices

As clinicians, we can all see how pervasive the use of electronic devices has become in the lives of the families we care for, as well as in our own lives, and how challenging some aspects of modern parenting have become. The developmental impact of early and excessive use of screens in young children is well documented,¹ but as clinicians it can be tricky to help empower parents to find ways to limit screen time. When parents use screens to comfort and amuse their children during a clinic visit, this situation may serve as an excellent opportunity for a meaningful and respectful conversation around skill deficits which can result from overutilization of electronic devices in young children.

One scenario I often encounter during my patient evaluations as a developmental and behavioral pediatrician is children begging their parents for use of their phone throughout their visits with me. Not infrequently, a child is already on a screen when I enter the exam room, even when there has been a minimal wait time, which often leads to some resistance on behalf of the child as I explain to the family that a significant portion of the visit involves my interactions with the child, testing the child, and observing their child at play. I always provide ample amounts of age-appropriate art supplies, puzzles, fidgets, building toys, and imaginative play items to children during their 30 to 90 minute evaluations, but these are often not appealing to children when they have been very recently engaged with an electronic device. At times I also need to ask caretakers themselves to please disengage from their own electronic devices during the visit so that I can involve them in a detailed discussion about their child.

One challenge with the practice of allowing children access to entertainment on their parent’s smartphones in particular, lies in the fact that these devices are almost always present, meaning there is no natural boundary to inhibit access, in contrast to a television set or stationary computer parked in the family living room. Not dissimilar to candy visible in a parent’s purse, a cell phone becomes a constant temptation for children accustomed to utilizing them at home and public venues, and the incessant begging can wear down already stressed parents.

Children can become conditioned to utilize the distraction of screens to avoid feelings of discomfort or stress, and so can be very persistent and emotional when asking for the use of screens in public settings. Out in the community, I very frequently see young children and toddlers quietly staring at their phones and tablets while at restaurants and stores. While I have empathy for exhausted parents desperate for a moment of quiet, if this type of screen use is the rule rather than the exception for a child, there is risk for missed opportunities for the development of self-regulation skills.

Additionally, I have seen very young children present to my clinic with poor posture and neck pain secondary to chronic smartphone use, and young children who are getting minimal exercise or outdoor time due to excessive screen use, leading to concerns around fine and gross motor skills as well.

While allowing a child to stay occupied with or be soothed by a highly interesting digital experience can create a more calm environment for all, if habitual, this use can come at a cost regarding opportunities for the growth of executive functioning skills, general coping skills, general situational awareness, and experiential learning. Reliance on screens to decrease uncomfortable experiences decreases the opportunity for building distress tolerance, patience, and coping skills.

Of course there are times of extreme distress where a lollipop or bit of screen time might be reasonable to help keep a child safe or further avoid emotional trauma, but in general, other methods of soothing can very often be utilized, and in the long run would serve to increase the child’s general adaptive functioning.
 

A Teachable Moment

When clinicians encounter screens being used by parents to entertain their kids in clinic, it provides a valuable teaching moment around the risks of using screens to keep kids regulated and occupied during life’s less interesting or more anxiety provoking experiences. Having a meaningful conversation about the use of electronic devices with caregivers by clinicians in the exam room can be a delicate dance between providing supportive education while avoiding judgmental tones or verbiage. Normalizing and sympathizing with the difficulty of managing challenging behaviors from children in public spaces can help parents feel less desperate to keep their child quiet at all costs, and thus allow for greater development of coping skills.

Some parents may benefit from learning simple ideas for keeping a child regulated and occupied during times of waiting such as silly songs and dances, verbal games like “I spy,” and clapping routines. For a child with additional sensory or developmental needs, a referral to an occupational therapist to work on emotional regulation by way of specific sensory tools can be helpful. Parent-Child Interaction Therapy for kids ages 2 to 7 can also help build some relational activities and skills that can be utilized during trying situations to help keep a child settled and occupied.

If a child has qualified for Developmental Disability Services (DDS), medical providers can also write “prescriptions’ for sensory calming items which are often covered financially by DDS, such as chewies, weighted vests, stuffed animals, and fidgets. While vilification of all screen time for children is not necessary or helpful, supporting parents as they navigate and implement appropriate boundaries is important for optimizing child development. Encouraging parents to schedule allowed screen time at home in a very predictable and controlled manner is one method to help limit excessive use, as well as it’s utilization as an emotional regulation tool.

For public outings with children with special needs, and in particular in situations where meltdowns are likely to occur, some families find it helpful to dress their children in clothing or accessories that increase community awareness about their child’s condition (such as an autism awareness t-shirt). This effort can also help deflect unhelpful attention or advice from the public. Some parents choose to carry small cards explaining the child’s developmental differences, which can then be easily handed to unsupportive strangers in community settings during trying moments.

Clinicians can work to utilize even quick visits with families as an opportunity to review the American Academy of Pediatrics screen time recommendations with families, and also direct them to the Family Media Plan creation resources. Parenting in the modern era presents many challenges regarding choices around the use of electronic devices with children, and using the exam room experience as a teaching opportunity may be a helpful way to decrease utilization of screens as emotional regulation tools for children, while also providing general education around healthy use of screens.
 

Dr. Roth is a developmental and behavioral pediatrician in Eugene, Oregon.

Reference

1. Takahashi I et al. Screen Time at Age 1 Year and Communication and Problem-Solving Developmental Delays at 2 and 4 years. JAMA Pediatr. 2023 Oct 1;177(10):1039-1046. doi: 10.1001/jamapediatrics.2023.3057.

As child psychiatrists and pediatricians, our mission extends beyond treating the physical health of children; it encompasses understanding the intricate web of factors that influence a child’s overall well-being. A recent advisory from U.S. Surgeon General Dr. Vivek Murthy has brought to light a critical issue that demands our attention: the declining mental health of parents and its profound impact on children. As providers who depend heavily on parental involvement to manage the needs of our pediatric patients, addressing parental mental health can be a crucial step in safeguarding the mental health of children.

The Surgeon General’s Advisory: A Call to Action

On August 28, 2024, the U.S. Surgeon General issued an advisory highlighting the significant stressors impacting parents and caregivers, and the broader implications for children’s mental health. The advisory emphasizes the bidirectional relationship between parental and child mental health, urging healthcare providers, policymakers, and communities to prioritize support for parents. It stresses that the mental health of parents is not only vital for their well-being but also plays a critical role in shaping the emotional and psychological development of their children.¹

The Link Between Parental and Child Mental Health

Research shows that a parent’s mental health directly influences the child’s emotional and behavioral outcomes. Children of parents with untreated mental health conditions, such as depression, anxiety, trauma, or chronic stress, are at a significantly higher risk of developing similar conditions. This risk is mediated through various mechanisms, including genetic predisposition, compromised parent-child interactions, and exposure to adverse environments.

1. Parental Depression and Child Outcomes: Parental depression, particularly maternal depression, has been extensively studied and is strongly associated with emotional and behavioral problems in children. Children of depressed parents are more likely to experience anxiety, depression, and resulting academic difficulties. Depressed parents may struggle with consistent and positive parenting, which can disrupt the development of secure attachments and emotional regulation in children.^2-4

2. Anxiety and Parenting Styles: Parental anxiety can influence parenting styles, often leading to overprotectiveness, inconsistency, or heightened criticism. These behaviors, in turn, can cultivate anxiety in children, creating a cycle that perpetuates mental health challenges across generations. Children raised in environments where anxiety is pervasive may learn to view the world as threatening, contributing to hypervigilance and stress.⁵

3. Impact of Chronic Stress on Parenting: Chronic stress experienced by parents, often due to financial hardship, lack of social support, or work-life imbalance, can impair their ability to engage in responsive and nurturing parenting. This, in turn, can affect children’s ability to meaningfully engage with parents to form secure attachments. Further, chronic stress can negatively impact the quality of parent-child interactions and fuel the cycle of rupture with limited opportunity for repair. The advisory stresses the need to address these systemic stressors as part of a broader public health strategy to support families.¹

Implications for Pediatric Practice

Pediatricians are often the first point of contact for families navigating mental health challenges. The Surgeon General’s advisory highlights the need for pediatricians to adopt a holistic approach that considers the mental health of the entire family, not just the child. This can be challenging with the average follow-up appointment time of 16 minutes, though many of the recommendations take this logistical hurdle into consideration:

1. Screening for Parental Mental Health: Incorporating routine screening for parental mental health into pediatric visits can be a powerful tool. Questions about parental stress, depression (especially postpartum depression), and anxiety should be integrated into well-child visits, especially in families where children present with emotional or behavioral difficulties. By identifying at-risk parents early, timely referrals to mental health services can be secured.

2. Providing Resources and Referrals: Offering resources and referrals to parents who may be struggling can positively impact the entire family. This includes connecting families with mental health professionals, parenting support groups, or community resources that can alleviate stressors such as food insecurity or lack of childcare. Having a list of local mental health resources available in your practice can empower parents to seek the help they need.

3. Promoting Positive Parenting Practices: Guidance on positive parenting practices, stress management, and self-care can make a significant difference in the mental health of parents and their children. Workshops or educational materials on topics like mindfulness, managing work-life balance, and fostering healthy communication within the family can be valuable and high-yield additions to pediatric care.

4. Collaborative Care Models: Collaborative care models, where pediatricians work closely with child psychiatrists, psychologists, and social workers, can provide comprehensive support to families. This integrated approach ensures that both children and their parents receive the care they need, promoting better outcomes for the entire family unit.
 

Addressing Broader Systemic Issues

The advisory also calls for systemic changes that extend beyond the clinic. Policy changes such as expanding access to paid family leave, affordable childcare, and mental health services are essential to creating an environment where parents can thrive. As pediatricians, advocating for these changes at the local and national level can amplify the overall impact on families.

1. Advocating for Paid Family Leave: Paid family leave allows parents to bond with their children and attend to their own mental health needs without the added pressure of financial instability. Supporting policies that provide adequate paid leave can pave the way for a successful and healthy return to work and have long-term benefits for family health.

2. Expanding Mental Health Services: Increasing access to mental health services, especially in underserved communities, is crucial. Pediatricians can play a role by partnering with local mental health providers to offer integrated care within their practices or community settings.

3. Community Support Programs: The creation of community support programs that offer parenting classes, stress management workshops, and peer support groups can help reduce the isolation and stress that many parents feel. Pediatricians can collaborate with community organizations to promote these resources to families.
 

Conclusion

The Surgeon General’s advisory serves as a timely reminder of the interconnectedness of parental and child mental health. Pediatricians have a unique opportunity to influence not only the health of their pediatric patients, but also the well-being of their families. By recognizing and addressing the mental health needs of parents, we can break the cycle of stress and mental illness that affects so many families, ensuring a healthier future for the next generation.

Let us embrace this call to action and work together to create a supportive environment where all parents and children can thrive.

Dr. Richards is assistant clinical professor in the department of psychiatry and biobehavioral sciences; program director of the child and adolescent psychiatry fellowship; and associate medical director of the perinatal program at the UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles.

References

1. American Hospital Association. Surgeon General Issues Advisory on Mental Health and Well-Being of Parents. American Hospital Association. 2024 Sep 4.

2. Goodman SH, Gotlib IH. Risk for Psychopathology in the Children of Depressed Mothers: A Developmental Model for Understanding Mechanisms of Transmission. Psychol Rev. 1999;106(3):458-490. doi: 10.1037/0033-295X.106.3.458.

3. Lovejoy MC et al. Maternal Depression and Parenting Behavior: A Meta-Analytic Review. Clin Psychol Rev. 2000;20(5):561-592. doi: 10.1016/s0272-7358(98)00100-7.

4. Weissman MM et al. Offspring of Depressed Parents: 20 Years Later. Am J Psychiatry. 2006;163(6):1001-1008. doi: 10.1176/ajp.2006.163.6.1001.

5. Smith KE, Pollak SD. Early Life Stress and Development: Potential Mechanisms for Adverse Outcomes. J Neurodev Disord. 2020;12(1):3-14. doi: 10.1186/s11689-020-09337-y.

As child psychiatrists and pediatricians, our mission extends beyond treating the physical health of children; it encompasses understanding the intricate web of factors that influence a child’s overall well-being. A recent advisory from U.S. Surgeon General Dr. Vivek Murthy has brought to light a critical issue that demands our attention: the declining mental health of parents and its profound impact on children. As providers who depend heavily on parental involvement to manage the needs of our pediatric patients, addressing parental mental health can be a crucial step in safeguarding the mental health of children.

The Surgeon General’s Advisory: A Call to Action

On August 28, 2024, the U.S. Surgeon General issued an advisory highlighting the significant stressors impacting parents and caregivers, and the broader implications for children’s mental health. The advisory emphasizes the bidirectional relationship between parental and child mental health, urging healthcare providers, policymakers, and communities to prioritize support for parents. It stresses that the mental health of parents is not only vital for their well-being but also plays a critical role in shaping the emotional and psychological development of their children.¹

The Link Between Parental and Child Mental Health

Research shows that a parent’s mental health directly influences the child’s emotional and behavioral outcomes. Children of parents with untreated mental health conditions, such as depression, anxiety, trauma, or chronic stress, are at a significantly higher risk of developing similar conditions. This risk is mediated through various mechanisms, including genetic predisposition, compromised parent-child interactions, and exposure to adverse environments.

1. Parental Depression and Child Outcomes: Parental depression, particularly maternal depression, has been extensively studied and is strongly associated with emotional and behavioral problems in children. Children of depressed parents are more likely to experience anxiety, depression, and resulting academic difficulties. Depressed parents may struggle with consistent and positive parenting, which can disrupt the development of secure attachments and emotional regulation in children.^2-4

2. Anxiety and Parenting Styles: Parental anxiety can influence parenting styles, often leading to overprotectiveness, inconsistency, or heightened criticism. These behaviors, in turn, can cultivate anxiety in children, creating a cycle that perpetuates mental health challenges across generations. Children raised in environments where anxiety is pervasive may learn to view the world as threatening, contributing to hypervigilance and stress.⁵

3. Impact of Chronic Stress on Parenting: Chronic stress experienced by parents, often due to financial hardship, lack of social support, or work-life imbalance, can impair their ability to engage in responsive and nurturing parenting. This, in turn, can affect children’s ability to meaningfully engage with parents to form secure attachments. Further, chronic stress can negatively impact the quality of parent-child interactions and fuel the cycle of rupture with limited opportunity for repair. The advisory stresses the need to address these systemic stressors as part of a broader public health strategy to support families.¹

Implications for Pediatric Practice

Pediatricians are often the first point of contact for families navigating mental health challenges. The Surgeon General’s advisory highlights the need for pediatricians to adopt a holistic approach that considers the mental health of the entire family, not just the child. This can be challenging with the average follow-up appointment time of 16 minutes, though many of the recommendations take this logistical hurdle into consideration:

1. Screening for Parental Mental Health: Incorporating routine screening for parental mental health into pediatric visits can be a powerful tool. Questions about parental stress, depression (especially postpartum depression), and anxiety should be integrated into well-child visits, especially in families where children present with emotional or behavioral difficulties. By identifying at-risk parents early, timely referrals to mental health services can be secured.

2. Providing Resources and Referrals: Offering resources and referrals to parents who may be struggling can positively impact the entire family. This includes connecting families with mental health professionals, parenting support groups, or community resources that can alleviate stressors such as food insecurity or lack of childcare. Having a list of local mental health resources available in your practice can empower parents to seek the help they need.

3. Promoting Positive Parenting Practices: Guidance on positive parenting practices, stress management, and self-care can make a significant difference in the mental health of parents and their children. Workshops or educational materials on topics like mindfulness, managing work-life balance, and fostering healthy communication within the family can be valuable and high-yield additions to pediatric care.

4. Collaborative Care Models: Collaborative care models, where pediatricians work closely with child psychiatrists, psychologists, and social workers, can provide comprehensive support to families. This integrated approach ensures that both children and their parents receive the care they need, promoting better outcomes for the entire family unit.
 

Addressing Broader Systemic Issues

The advisory also calls for systemic changes that extend beyond the clinic. Policy changes such as expanding access to paid family leave, affordable childcare, and mental health services are essential to creating an environment where parents can thrive. As pediatricians, advocating for these changes at the local and national level can amplify the overall impact on families.

1. Advocating for Paid Family Leave: Paid family leave allows parents to bond with their children and attend to their own mental health needs without the added pressure of financial instability. Supporting policies that provide adequate paid leave can pave the way for a successful and healthy return to work and have long-term benefits for family health.

2. Expanding Mental Health Services: Increasing access to mental health services, especially in underserved communities, is crucial. Pediatricians can play a role by partnering with local mental health providers to offer integrated care within their practices or community settings.

3. Community Support Programs: The creation of community support programs that offer parenting classes, stress management workshops, and peer support groups can help reduce the isolation and stress that many parents feel. Pediatricians can collaborate with community organizations to promote these resources to families.
 

Conclusion

The Surgeon General’s advisory serves as a timely reminder of the interconnectedness of parental and child mental health. Pediatricians have a unique opportunity to influence not only the health of their pediatric patients, but also the well-being of their families. By recognizing and addressing the mental health needs of parents, we can break the cycle of stress and mental illness that affects so many families, ensuring a healthier future for the next generation.

Let us embrace this call to action and work together to create a supportive environment where all parents and children can thrive.

Dr. Richards is assistant clinical professor in the department of psychiatry and biobehavioral sciences; program director of the child and adolescent psychiatry fellowship; and associate medical director of the perinatal program at the UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles.

References

1. American Hospital Association. Surgeon General Issues Advisory on Mental Health and Well-Being of Parents. American Hospital Association. 2024 Sep 4.

2. Goodman SH, Gotlib IH. Risk for Psychopathology in the Children of Depressed Mothers: A Developmental Model for Understanding Mechanisms of Transmission. Psychol Rev. 1999;106(3):458-490. doi: 10.1037/0033-295X.106.3.458.

3. Lovejoy MC et al. Maternal Depression and Parenting Behavior: A Meta-Analytic Review. Clin Psychol Rev. 2000;20(5):561-592. doi: 10.1016/s0272-7358(98)00100-7.

4. Weissman MM et al. Offspring of Depressed Parents: 20 Years Later. Am J Psychiatry. 2006;163(6):1001-1008. doi: 10.1176/ajp.2006.163.6.1001.

5. Smith KE, Pollak SD. Early Life Stress and Development: Potential Mechanisms for Adverse Outcomes. J Neurodev Disord. 2020;12(1):3-14. doi: 10.1186/s11689-020-09337-y.

As child psychiatrists and pediatricians, our mission extends beyond treating the physical health of children; it encompasses understanding the intricate web of factors that influence a child’s overall well-being. A recent advisory from U.S. Surgeon General Dr. Vivek Murthy has brought to light a critical issue that demands our attention: the declining mental health of parents and its profound impact on children. As providers who depend heavily on parental involvement to manage the needs of our pediatric patients, addressing parental mental health can be a crucial step in safeguarding the mental health of children.

The Surgeon General’s Advisory: A Call to Action

On August 28, 2024, the U.S. Surgeon General issued an advisory highlighting the significant stressors impacting parents and caregivers, and the broader implications for children’s mental health. The advisory emphasizes the bidirectional relationship between parental and child mental health, urging healthcare providers, policymakers, and communities to prioritize support for parents. It stresses that the mental health of parents is not only vital for their well-being but also plays a critical role in shaping the emotional and psychological development of their children.¹

The Link Between Parental and Child Mental Health

Research shows that a parent’s mental health directly influences the child’s emotional and behavioral outcomes. Children of parents with untreated mental health conditions, such as depression, anxiety, trauma, or chronic stress, are at a significantly higher risk of developing similar conditions. This risk is mediated through various mechanisms, including genetic predisposition, compromised parent-child interactions, and exposure to adverse environments.

1. Parental Depression and Child Outcomes: Parental depression, particularly maternal depression, has been extensively studied and is strongly associated with emotional and behavioral problems in children. Children of depressed parents are more likely to experience anxiety, depression, and resulting academic difficulties. Depressed parents may struggle with consistent and positive parenting, which can disrupt the development of secure attachments and emotional regulation in children.^2-4

2. Anxiety and Parenting Styles: Parental anxiety can influence parenting styles, often leading to overprotectiveness, inconsistency, or heightened criticism. These behaviors, in turn, can cultivate anxiety in children, creating a cycle that perpetuates mental health challenges across generations. Children raised in environments where anxiety is pervasive may learn to view the world as threatening, contributing to hypervigilance and stress.⁵

3. Impact of Chronic Stress on Parenting: Chronic stress experienced by parents, often due to financial hardship, lack of social support, or work-life imbalance, can impair their ability to engage in responsive and nurturing parenting. This, in turn, can affect children’s ability to meaningfully engage with parents to form secure attachments. Further, chronic stress can negatively impact the quality of parent-child interactions and fuel the cycle of rupture with limited opportunity for repair. The advisory stresses the need to address these systemic stressors as part of a broader public health strategy to support families.¹

Implications for Pediatric Practice

Pediatricians are often the first point of contact for families navigating mental health challenges. The Surgeon General’s advisory highlights the need for pediatricians to adopt a holistic approach that considers the mental health of the entire family, not just the child. This can be challenging with the average follow-up appointment time of 16 minutes, though many of the recommendations take this logistical hurdle into consideration:

1. Screening for Parental Mental Health: Incorporating routine screening for parental mental health into pediatric visits can be a powerful tool. Questions about parental stress, depression (especially postpartum depression), and anxiety should be integrated into well-child visits, especially in families where children present with emotional or behavioral difficulties. By identifying at-risk parents early, timely referrals to mental health services can be secured.

2. Providing Resources and Referrals: Offering resources and referrals to parents who may be struggling can positively impact the entire family. This includes connecting families with mental health professionals, parenting support groups, or community resources that can alleviate stressors such as food insecurity or lack of childcare. Having a list of local mental health resources available in your practice can empower parents to seek the help they need.

3. Promoting Positive Parenting Practices: Guidance on positive parenting practices, stress management, and self-care can make a significant difference in the mental health of parents and their children. Workshops or educational materials on topics like mindfulness, managing work-life balance, and fostering healthy communication within the family can be valuable and high-yield additions to pediatric care.

4. Collaborative Care Models: Collaborative care models, where pediatricians work closely with child psychiatrists, psychologists, and social workers, can provide comprehensive support to families. This integrated approach ensures that both children and their parents receive the care they need, promoting better outcomes for the entire family unit.
 

Addressing Broader Systemic Issues

The advisory also calls for systemic changes that extend beyond the clinic. Policy changes such as expanding access to paid family leave, affordable childcare, and mental health services are essential to creating an environment where parents can thrive. As pediatricians, advocating for these changes at the local and national level can amplify the overall impact on families.

1. Advocating for Paid Family Leave: Paid family leave allows parents to bond with their children and attend to their own mental health needs without the added pressure of financial instability. Supporting policies that provide adequate paid leave can pave the way for a successful and healthy return to work and have long-term benefits for family health.

2. Expanding Mental Health Services: Increasing access to mental health services, especially in underserved communities, is crucial. Pediatricians can play a role by partnering with local mental health providers to offer integrated care within their practices or community settings.

3. Community Support Programs: The creation of community support programs that offer parenting classes, stress management workshops, and peer support groups can help reduce the isolation and stress that many parents feel. Pediatricians can collaborate with community organizations to promote these resources to families.
 

Conclusion

The Surgeon General’s advisory serves as a timely reminder of the interconnectedness of parental and child mental health. Pediatricians have a unique opportunity to influence not only the health of their pediatric patients, but also the well-being of their families. By recognizing and addressing the mental health needs of parents, we can break the cycle of stress and mental illness that affects so many families, ensuring a healthier future for the next generation.

Let us embrace this call to action and work together to create a supportive environment where all parents and children can thrive.

Dr. Richards is assistant clinical professor in the department of psychiatry and biobehavioral sciences; program director of the child and adolescent psychiatry fellowship; and associate medical director of the perinatal program at the UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles.

References

1. American Hospital Association. Surgeon General Issues Advisory on Mental Health and Well-Being of Parents. American Hospital Association. 2024 Sep 4.

2. Goodman SH, Gotlib IH. Risk for Psychopathology in the Children of Depressed Mothers: A Developmental Model for Understanding Mechanisms of Transmission. Psychol Rev. 1999;106(3):458-490. doi: 10.1037/0033-295X.106.3.458.

3. Lovejoy MC et al. Maternal Depression and Parenting Behavior: A Meta-Analytic Review. Clin Psychol Rev. 2000;20(5):561-592. doi: 10.1016/s0272-7358(98)00100-7.

4. Weissman MM et al. Offspring of Depressed Parents: 20 Years Later. Am J Psychiatry. 2006;163(6):1001-1008. doi: 10.1176/ajp.2006.163.6.1001.

5. Smith KE, Pollak SD. Early Life Stress and Development: Potential Mechanisms for Adverse Outcomes. J Neurodev Disord. 2020;12(1):3-14. doi: 10.1186/s11689-020-09337-y.

In July, the United States Senate passed the Kids Online Safety Act, which will need to be taken up and passed by the House prior to becoming law. This bill was designed based on emerging research showing how social media impacts the developing regions of the adolescent brain, including those involved in the growing “stop and think” pathways.

Whether this bill is passed or not, parents are already having conversations with their children’s primary care providers about how to navigate digital versus In Real Life (IRL) aspects of parenting. Why should families and primary care providers care about creating opportunities to put down devices together? We have few new ways of explaining social media’s impact on adolescent development. These angles can empower families and give tweens an increased sense of efficacy around family social media agreements. Dr. Mitch Prinstein (chief science officer for the American Psychological Association) explains how apps take children’s data from other apps to make a profit.¹ When kids understand what motivates technology companies, they are more likely to buy into efforts to curtail use. He also explains that adolescent brain size and function decreases with increased social media use and resulting lack of sleep.²

Prioritizing IRL togetherness is increasingly showing up in media itself. In Inside Out 2 the coach collects players’ phones at the beginning of their intensive training weekend, allowing for Riley to have IRL social successes and failures, and resulting growth. Gather, a recently published young adult novel by Kenneth M. Cadow, is written from the perspective of Ian Gray, a teen whose mother struggles with addiction. We experience Ian’s perspective at the house of a friend. This fictional family all put their devices in a basket upon entering their home, allowing the family to interact in a more present and positive way with one another.

Dr. Spottswood

Dr. Spottswood is a child psychiatrist practicing in an integrated care clinic at the Community Health Centers of Burlington, Vermont, a Federally Qualified Health Center. She is also the medical director of the Vermont Child Psychiatry Access Program and a clinical assistant professor in the department of psychiatry at the University of Vermont.

References

1. Raffoul A et al. Social media platforms generate billions of dollars in revenue from U.S. youth: Findings from a simulated revenue model. PLoS One. 2023 Dec 27;18(12):e0295337. doi: 10.1371/journal.pone.0295337.

2. Telzer EH et al. Sleep variability in adolescence is associated with altered brain development. Dev Cogn Neurosci. 2015 Aug:14:16-22. doi: 10.1016/j.dcn.2015.05.007.

3. Common Sense Family Media Agreement. https://www.commonsensemedia.org/sites/default/files/featured-content/files/common_sense_family_media_agreement.pdf.

4. Healthy Children Family Media Plan. https://www.healthychildren.org/English/fmp/Pages/MediaPlan.aspx.

5. Getz L, Prinstein M. Like Ability: The Truth About Popularity. Washington: Magination Press, 2022. https://www.apa.org/pubs/magination/like-ability.

In July, the United States Senate passed the Kids Online Safety Act, which will need to be taken up and passed by the House prior to becoming law. This bill was designed based on emerging research showing how social media impacts the developing regions of the adolescent brain, including those involved in the growing “stop and think” pathways.

Whether this bill is passed or not, parents are already having conversations with their children’s primary care providers about how to navigate digital versus In Real Life (IRL) aspects of parenting. Why should families and primary care providers care about creating opportunities to put down devices together? We have few new ways of explaining social media’s impact on adolescent development. These angles can empower families and give tweens an increased sense of efficacy around family social media agreements. Dr. Mitch Prinstein (chief science officer for the American Psychological Association) explains how apps take children’s data from other apps to make a profit.¹ When kids understand what motivates technology companies, they are more likely to buy into efforts to curtail use. He also explains that adolescent brain size and function decreases with increased social media use and resulting lack of sleep.²

Prioritizing IRL togetherness is increasingly showing up in media itself. In Inside Out 2 the coach collects players’ phones at the beginning of their intensive training weekend, allowing for Riley to have IRL social successes and failures, and resulting growth. Gather, a recently published young adult novel by Kenneth M. Cadow, is written from the perspective of Ian Gray, a teen whose mother struggles with addiction. We experience Ian’s perspective at the house of a friend. This fictional family all put their devices in a basket upon entering their home, allowing the family to interact in a more present and positive way with one another.

Dr. Spottswood

Dr. Spottswood is a child psychiatrist practicing in an integrated care clinic at the Community Health Centers of Burlington, Vermont, a Federally Qualified Health Center. She is also the medical director of the Vermont Child Psychiatry Access Program and a clinical assistant professor in the department of psychiatry at the University of Vermont.

References

1. Raffoul A et al. Social media platforms generate billions of dollars in revenue from U.S. youth: Findings from a simulated revenue model. PLoS One. 2023 Dec 27;18(12):e0295337. doi: 10.1371/journal.pone.0295337.

2. Telzer EH et al. Sleep variability in adolescence is associated with altered brain development. Dev Cogn Neurosci. 2015 Aug:14:16-22. doi: 10.1016/j.dcn.2015.05.007.

3. Common Sense Family Media Agreement. https://www.commonsensemedia.org/sites/default/files/featured-content/files/common_sense_family_media_agreement.pdf.

4. Healthy Children Family Media Plan. https://www.healthychildren.org/English/fmp/Pages/MediaPlan.aspx.

5. Getz L, Prinstein M. Like Ability: The Truth About Popularity. Washington: Magination Press, 2022. https://www.apa.org/pubs/magination/like-ability.

In July, the United States Senate passed the Kids Online Safety Act, which will need to be taken up and passed by the House prior to becoming law. This bill was designed based on emerging research showing how social media impacts the developing regions of the adolescent brain, including those involved in the growing “stop and think” pathways.

Whether this bill is passed or not, parents are already having conversations with their children’s primary care providers about how to navigate digital versus In Real Life (IRL) aspects of parenting. Why should families and primary care providers care about creating opportunities to put down devices together? We have few new ways of explaining social media’s impact on adolescent development. These angles can empower families and give tweens an increased sense of efficacy around family social media agreements. Dr. Mitch Prinstein (chief science officer for the American Psychological Association) explains how apps take children’s data from other apps to make a profit.¹ When kids understand what motivates technology companies, they are more likely to buy into efforts to curtail use. He also explains that adolescent brain size and function decreases with increased social media use and resulting lack of sleep.²

Prioritizing IRL togetherness is increasingly showing up in media itself. In Inside Out 2 the coach collects players’ phones at the beginning of their intensive training weekend, allowing for Riley to have IRL social successes and failures, and resulting growth. Gather, a recently published young adult novel by Kenneth M. Cadow, is written from the perspective of Ian Gray, a teen whose mother struggles with addiction. We experience Ian’s perspective at the house of a friend. This fictional family all put their devices in a basket upon entering their home, allowing the family to interact in a more present and positive way with one another.

Dr. Spottswood

Dr. Spottswood is a child psychiatrist practicing in an integrated care clinic at the Community Health Centers of Burlington, Vermont, a Federally Qualified Health Center. She is also the medical director of the Vermont Child Psychiatry Access Program and a clinical assistant professor in the department of psychiatry at the University of Vermont.

References

1. Raffoul A et al. Social media platforms generate billions of dollars in revenue from U.S. youth: Findings from a simulated revenue model. PLoS One. 2023 Dec 27;18(12):e0295337. doi: 10.1371/journal.pone.0295337.

2. Telzer EH et al. Sleep variability in adolescence is associated with altered brain development. Dev Cogn Neurosci. 2015 Aug:14:16-22. doi: 10.1016/j.dcn.2015.05.007.

3. Common Sense Family Media Agreement. https://www.commonsensemedia.org/sites/default/files/featured-content/files/common_sense_family_media_agreement.pdf.

4. Healthy Children Family Media Plan. https://www.healthychildren.org/English/fmp/Pages/MediaPlan.aspx.

5. Getz L, Prinstein M. Like Ability: The Truth About Popularity. Washington: Magination Press, 2022. https://www.apa.org/pubs/magination/like-ability.

Clinical Case: Sol is a 10 year-old cisgender White girl who appears sad at her annual well visit. On further inquiry she describes that her father is angry that there is no snow, her mother keeps talking about the forests disappearing, and local flooding closed down her favorite family restaurant for good. She is worried “the planet is in trouble and there’s nothing we can do” so much that she gets stomachaches when she thinks about it.

Climate Anxiety

Climate change is a complex phenomenon that has been subject to decades of political disagreement. Lobbying by groups like the fossil fuel industry, state legislation to implement recycling, oil spills and pollution disasters, and outspoken icons like former US Vice President Al Gore and Swedish activist Greta Thunberg have kept the climate crisis a hot topic. What was once a slow burn has begun to boil as climate-related disasters occur — wildfires, droughts, floods, and increasingly powerful and frequent severe weather events — alongside increasing temperatures globally. With heroic efforts, the UN-convened Paris Agreement was adopted by 196 nations in 2015 with ambitious goals to reduce global greenhouse emissions and limit Earth’s rising temperature.¹ Yet doomsday headlines on this topic remain a regular occurrence.

Between sensationalized news coverage, political controversy, and international disasters, it is no wonder some youth are overwhelmed. When it comes to the effects of climate change on youth mental health, there are direct and indirect consequences.² Direct effects could include a family losing their home to flooding or wildfires, resulting in post-traumatic stress symptoms or an anxiety disorder. Indirect effects might include a drought that results in loss of agricultural income leading to a forced migration, family stress and/or separation, and disordered substance use.

Managing Climate Anxiety

Climate anxiety presents with many of the typical features of other anxieties. These include worries that cycle repetitively and intrusively through the mind, somatic distress such as headaches or stomachaches, and avoidance of things that remind one of the uncertainty and distress associated with climate change. Because the climate crisis is so global and complex, hopelessness and fatigue are not uncommon.

However, climate anxiety can often be ameliorated with the typical approaches to treating anxiety. Borrowing from cognitive-behavioral and mindfulness-based interventions, many recommendations have been offered to help with eco-anxiety. External validation of youth’s concerns and fears is a starting point that might build a teen’s capacity to tolerate distressing emotions about global warming.

Once reactions to climate change are acknowledged and accepted, space is created for reflection. This might include a balance of hope and pragmatic action. For example, renewable energy sources have made up an increasing share of the market over time with the world adding 50% more renewable capacity in 2023.⁷ Seventy-two percent of Americans acknowledge global warming, 75% feel schools should teach about consequences and solutions for global warming, and 79% support investment in renewable energy.⁸

Climate activism itself has been shown to buffer climate anxiety, particularly when implemented collectively rather than individually.⁴ Nature connectedness, or cognitive and emotional connections with nature, not only has many direct mental health benefits, but is also associated with climate activism.⁹ Many other integrative interventions can improve well-being while reducing ecological harm. Nutrition, physical activity, mindfulness, and sleep are youth mental health interventions with a strong evidence base that also reduce the carbon footprint and pollution attributable to psychiatric pharmaceuticals. Moreover, these climate-friendly interventions can improve family-connectedness, thus boosting resilience.

Without needing to become eco-warriors, healthcare providers can model sustainable practices while caring for patients. This might include having more plants in the office, recycling and composting at work, adding solar panels to the rooftop, or joining local parks prescription programs (see mygreendoctor.org, a nonprofit owned by the Florida Medical Association).
 

Next Steps

Sol is relieved to hear that many kids her age share her family’s concerns. A conversation about how to manage distressing emotions and physical feelings leads to a referral for brief cognitive behavioral interventions. Her parents join your visit to hear her concerns. They want to begin a family plan for climate action. You recommend the books How to Change Everything: The Young Human’s Guide to Protecting the Planet and Each Other by Naomi Klein and The Parents’ Guide to Climate Revolution: 100 Ways to Build a Fossil-Free Future, Raise Empowered Kids, and Still Get a Good Night’s Sleep by Mary DeMocker.

Dr. Rosenfeld is associate professor of psychiatry and pediatrics at the University of Vermont, Burlington.

References

1. Maizland L. Global Climate Agreements: Successes and Failures. Council on Foreign Relations. https://www.cfr.org/backgrounder/paris-global-climate-change-agreements.

2. van Nieuwenhuizen A et al. The effects of climate change on child and adolescent mental health: Clinical considerations. Curr Psychiatry Rep. 2021 Dec 7;23(12):88. doi: 10.1007/s11920-021-01296-y.

3. Window to Reach Climate Goals ‘Rapidly Closing’, UN Report Warns. United Nations. https://news.un.org/en/story/2023/09/1140527.

4. Schwartz SEO et al. Climate change anxiety and mental health: Environmental activism as buffer. Curr Psychol. 2022 Feb 28:1-14. doi: 10.1007/s12144-022-02735-6.

5. Pihkala P. Anxiety and the ecological crisis: an analysis of eco-anxiety and climate anxiety. Sustainability. 2020;12:7836. doi: 10.3390/su12197836.

6. Hickman C et al. Climate Anxiety in Children and Young People and Their Beliefs About Government Responses to Climate Change: A Global Survey. Lancet Planet Health. 2021 Dec;5(12):e863-e873. doi: 10.1016/S2542-5196(21)00278-3.

7. IEA (2021), Global Energy Review 2021, IEA, Paris. https://www.iea.org/reports/global-energy-review-2021/renewables.

8. Marlon J et al. Yale Climate Opinion Maps 2023. https://climatecommunication.yale.edu/visualizations-data/ycom-us/.

9. Thomson EE, Roach SP. The Relationships Among Nature Connectedness, Climate Anxiety, Climate Action, Climate Knowledge, and Mental Health. Front Psychol. 2023 Nov 15:14:1241400. doi: 10.3389/fpsyg.2023.1241400.

Clinical Case: Sol is a 10 year-old cisgender White girl who appears sad at her annual well visit. On further inquiry she describes that her father is angry that there is no snow, her mother keeps talking about the forests disappearing, and local flooding closed down her favorite family restaurant for good. She is worried “the planet is in trouble and there’s nothing we can do” so much that she gets stomachaches when she thinks about it.

Climate Anxiety

Climate change is a complex phenomenon that has been subject to decades of political disagreement. Lobbying by groups like the fossil fuel industry, state legislation to implement recycling, oil spills and pollution disasters, and outspoken icons like former US Vice President Al Gore and Swedish activist Greta Thunberg have kept the climate crisis a hot topic. What was once a slow burn has begun to boil as climate-related disasters occur — wildfires, droughts, floods, and increasingly powerful and frequent severe weather events — alongside increasing temperatures globally. With heroic efforts, the UN-convened Paris Agreement was adopted by 196 nations in 2015 with ambitious goals to reduce global greenhouse emissions and limit Earth’s rising temperature.¹ Yet doomsday headlines on this topic remain a regular occurrence.

Between sensationalized news coverage, political controversy, and international disasters, it is no wonder some youth are overwhelmed. When it comes to the effects of climate change on youth mental health, there are direct and indirect consequences.² Direct effects could include a family losing their home to flooding or wildfires, resulting in post-traumatic stress symptoms or an anxiety disorder. Indirect effects might include a drought that results in loss of agricultural income leading to a forced migration, family stress and/or separation, and disordered substance use.

Managing Climate Anxiety

Climate anxiety presents with many of the typical features of other anxieties. These include worries that cycle repetitively and intrusively through the mind, somatic distress such as headaches or stomachaches, and avoidance of things that remind one of the uncertainty and distress associated with climate change. Because the climate crisis is so global and complex, hopelessness and fatigue are not uncommon.

However, climate anxiety can often be ameliorated with the typical approaches to treating anxiety. Borrowing from cognitive-behavioral and mindfulness-based interventions, many recommendations have been offered to help with eco-anxiety. External validation of youth’s concerns and fears is a starting point that might build a teen’s capacity to tolerate distressing emotions about global warming.

Once reactions to climate change are acknowledged and accepted, space is created for reflection. This might include a balance of hope and pragmatic action. For example, renewable energy sources have made up an increasing share of the market over time with the world adding 50% more renewable capacity in 2023.⁷ Seventy-two percent of Americans acknowledge global warming, 75% feel schools should teach about consequences and solutions for global warming, and 79% support investment in renewable energy.⁸

Climate activism itself has been shown to buffer climate anxiety, particularly when implemented collectively rather than individually.⁴ Nature connectedness, or cognitive and emotional connections with nature, not only has many direct mental health benefits, but is also associated with climate activism.⁹ Many other integrative interventions can improve well-being while reducing ecological harm. Nutrition, physical activity, mindfulness, and sleep are youth mental health interventions with a strong evidence base that also reduce the carbon footprint and pollution attributable to psychiatric pharmaceuticals. Moreover, these climate-friendly interventions can improve family-connectedness, thus boosting resilience.

Without needing to become eco-warriors, healthcare providers can model sustainable practices while caring for patients. This might include having more plants in the office, recycling and composting at work, adding solar panels to the rooftop, or joining local parks prescription programs (see mygreendoctor.org, a nonprofit owned by the Florida Medical Association).
 

Next Steps

Sol is relieved to hear that many kids her age share her family’s concerns. A conversation about how to manage distressing emotions and physical feelings leads to a referral for brief cognitive behavioral interventions. Her parents join your visit to hear her concerns. They want to begin a family plan for climate action. You recommend the books How to Change Everything: The Young Human’s Guide to Protecting the Planet and Each Other by Naomi Klein and The Parents’ Guide to Climate Revolution: 100 Ways to Build a Fossil-Free Future, Raise Empowered Kids, and Still Get a Good Night’s Sleep by Mary DeMocker.

Dr. Rosenfeld is associate professor of psychiatry and pediatrics at the University of Vermont, Burlington.

References

1. Maizland L. Global Climate Agreements: Successes and Failures. Council on Foreign Relations. https://www.cfr.org/backgrounder/paris-global-climate-change-agreements.

2. van Nieuwenhuizen A et al. The effects of climate change on child and adolescent mental health: Clinical considerations. Curr Psychiatry Rep. 2021 Dec 7;23(12):88. doi: 10.1007/s11920-021-01296-y.

3. Window to Reach Climate Goals ‘Rapidly Closing’, UN Report Warns. United Nations. https://news.un.org/en/story/2023/09/1140527.

4. Schwartz SEO et al. Climate change anxiety and mental health: Environmental activism as buffer. Curr Psychol. 2022 Feb 28:1-14. doi: 10.1007/s12144-022-02735-6.

5. Pihkala P. Anxiety and the ecological crisis: an analysis of eco-anxiety and climate anxiety. Sustainability. 2020;12:7836. doi: 10.3390/su12197836.

6. Hickman C et al. Climate Anxiety in Children and Young People and Their Beliefs About Government Responses to Climate Change: A Global Survey. Lancet Planet Health. 2021 Dec;5(12):e863-e873. doi: 10.1016/S2542-5196(21)00278-3.

7. IEA (2021), Global Energy Review 2021, IEA, Paris. https://www.iea.org/reports/global-energy-review-2021/renewables.

8. Marlon J et al. Yale Climate Opinion Maps 2023. https://climatecommunication.yale.edu/visualizations-data/ycom-us/.

9. Thomson EE, Roach SP. The Relationships Among Nature Connectedness, Climate Anxiety, Climate Action, Climate Knowledge, and Mental Health. Front Psychol. 2023 Nov 15:14:1241400. doi: 10.3389/fpsyg.2023.1241400.

Clinical Case: Sol is a 10 year-old cisgender White girl who appears sad at her annual well visit. On further inquiry she describes that her father is angry that there is no snow, her mother keeps talking about the forests disappearing, and local flooding closed down her favorite family restaurant for good. She is worried “the planet is in trouble and there’s nothing we can do” so much that she gets stomachaches when she thinks about it.

Climate Anxiety

Climate change is a complex phenomenon that has been subject to decades of political disagreement. Lobbying by groups like the fossil fuel industry, state legislation to implement recycling, oil spills and pollution disasters, and outspoken icons like former US Vice President Al Gore and Swedish activist Greta Thunberg have kept the climate crisis a hot topic. What was once a slow burn has begun to boil as climate-related disasters occur — wildfires, droughts, floods, and increasingly powerful and frequent severe weather events — alongside increasing temperatures globally. With heroic efforts, the UN-convened Paris Agreement was adopted by 196 nations in 2015 with ambitious goals to reduce global greenhouse emissions and limit Earth’s rising temperature.¹ Yet doomsday headlines on this topic remain a regular occurrence.

Between sensationalized news coverage, political controversy, and international disasters, it is no wonder some youth are overwhelmed. When it comes to the effects of climate change on youth mental health, there are direct and indirect consequences.² Direct effects could include a family losing their home to flooding or wildfires, resulting in post-traumatic stress symptoms or an anxiety disorder. Indirect effects might include a drought that results in loss of agricultural income leading to a forced migration, family stress and/or separation, and disordered substance use.

Managing Climate Anxiety

Climate anxiety presents with many of the typical features of other anxieties. These include worries that cycle repetitively and intrusively through the mind, somatic distress such as headaches or stomachaches, and avoidance of things that remind one of the uncertainty and distress associated with climate change. Because the climate crisis is so global and complex, hopelessness and fatigue are not uncommon.

However, climate anxiety can often be ameliorated with the typical approaches to treating anxiety. Borrowing from cognitive-behavioral and mindfulness-based interventions, many recommendations have been offered to help with eco-anxiety. External validation of youth’s concerns and fears is a starting point that might build a teen’s capacity to tolerate distressing emotions about global warming.

Once reactions to climate change are acknowledged and accepted, space is created for reflection. This might include a balance of hope and pragmatic action. For example, renewable energy sources have made up an increasing share of the market over time with the world adding 50% more renewable capacity in 2023.⁷ Seventy-two percent of Americans acknowledge global warming, 75% feel schools should teach about consequences and solutions for global warming, and 79% support investment in renewable energy.⁸

Climate activism itself has been shown to buffer climate anxiety, particularly when implemented collectively rather than individually.⁴ Nature connectedness, or cognitive and emotional connections with nature, not only has many direct mental health benefits, but is also associated with climate activism.⁹ Many other integrative interventions can improve well-being while reducing ecological harm. Nutrition, physical activity, mindfulness, and sleep are youth mental health interventions with a strong evidence base that also reduce the carbon footprint and pollution attributable to psychiatric pharmaceuticals. Moreover, these climate-friendly interventions can improve family-connectedness, thus boosting resilience.

Without needing to become eco-warriors, healthcare providers can model sustainable practices while caring for patients. This might include having more plants in the office, recycling and composting at work, adding solar panels to the rooftop, or joining local parks prescription programs (see mygreendoctor.org, a nonprofit owned by the Florida Medical Association).
 

Next Steps

Sol is relieved to hear that many kids her age share her family’s concerns. A conversation about how to manage distressing emotions and physical feelings leads to a referral for brief cognitive behavioral interventions. Her parents join your visit to hear her concerns. They want to begin a family plan for climate action. You recommend the books How to Change Everything: The Young Human’s Guide to Protecting the Planet and Each Other by Naomi Klein and The Parents’ Guide to Climate Revolution: 100 Ways to Build a Fossil-Free Future, Raise Empowered Kids, and Still Get a Good Night’s Sleep by Mary DeMocker.

Dr. Rosenfeld is associate professor of psychiatry and pediatrics at the University of Vermont, Burlington.

References

1. Maizland L. Global Climate Agreements: Successes and Failures. Council on Foreign Relations. https://www.cfr.org/backgrounder/paris-global-climate-change-agreements.

2. van Nieuwenhuizen A et al. The effects of climate change on child and adolescent mental health: Clinical considerations. Curr Psychiatry Rep. 2021 Dec 7;23(12):88. doi: 10.1007/s11920-021-01296-y.

3. Window to Reach Climate Goals ‘Rapidly Closing’, UN Report Warns. United Nations. https://news.un.org/en/story/2023/09/1140527.

4. Schwartz SEO et al. Climate change anxiety and mental health: Environmental activism as buffer. Curr Psychol. 2022 Feb 28:1-14. doi: 10.1007/s12144-022-02735-6.

5. Pihkala P. Anxiety and the ecological crisis: an analysis of eco-anxiety and climate anxiety. Sustainability. 2020;12:7836. doi: 10.3390/su12197836.

6. Hickman C et al. Climate Anxiety in Children and Young People and Their Beliefs About Government Responses to Climate Change: A Global Survey. Lancet Planet Health. 2021 Dec;5(12):e863-e873. doi: 10.1016/S2542-5196(21)00278-3.

7. IEA (2021), Global Energy Review 2021, IEA, Paris. https://www.iea.org/reports/global-energy-review-2021/renewables.

8. Marlon J et al. Yale Climate Opinion Maps 2023. https://climatecommunication.yale.edu/visualizations-data/ycom-us/.

9. Thomson EE, Roach SP. The Relationships Among Nature Connectedness, Climate Anxiety, Climate Action, Climate Knowledge, and Mental Health. Front Psychol. 2023 Nov 15:14:1241400. doi: 10.3389/fpsyg.2023.1241400.

Fundamentally, an immigrant parent’s traditional role as teacher of culture and social systems to their children is undermined by immigration. In their native country, they learned throughout their life cultural norms and systems that defined their environment. When these parents immigrate to a new country, their different set of knowledge may not be applicable in many ways to their new environment.

The Disruption of Social Roles

Culturally, language is one of the most important types of knowledge parents pass to their children. Nearly half of adult immigrants in the United States have limited English proficiency. ¹

Their children often learn the language faster, often placing these children in the position of interpreters for their parents. These parents can become dependent on their children to negotiate social structures instead of vice versa, potentially undermining the social hierarchy and role of parenting. ² Both Mr. Contreras and Dr. Nguyen recall that as children of immigrant parents — from Mexico and Vietnam, respectively — they commanded English better than their parents, which often made them take on more “adult roles.” For example, Dr. Nguyen recalls that his mother would solicit his help in grocery shopping because she could neither navigate the aisles effectively nor ask for help. Mr. Contreras commonly found himself acting as an impromptu medical translator for his mother on several occasions. This dependence of immigrant parents on their children for guidance in their host country can be pervasive in other social structures such as legal and academic.

Impact on School

Potentially, an immigrant parent’s lack of knowledge of the language and systems of their host country can make them ineffective advocates for their children at school. Mr. Contreras’s intervention for his patient as a medical student demonstrates this in the arena of school.

Mr. Contreras was rotating at a hospital burn unit in 2023 when R, a young middle school student, and his mother arrived in the emergency department. An incident had occurred at his school. R had been the victim of aggravated battery and assault, sustaining a 3x2 cm burn on his forearm from students placing hot glue onto a piece of cardboard then immediately onto his skin and silencing him by covering his mouth. For months the older students had been bullying R. R’s mother made multiple attempts with both the school’s front desk and counselors to address the issue, but to no avail. R himself, though encouraged to speak up, did not out of fear. As Mr. Contreras realized the situation and the impasse, he used his fluency in Spanish and English to facilitate a joint call with the school district. Within 10 minutes, they were able to connect with a student safety specialist and launch a full investigation. A language barrier and the lack of knowledge of their rights and school system had prevented R’s mother from effectively advocating for her child’s safety.

In Dr. Nguyen’s experience as a teacher, even in classrooms dominated by minority students, the advocacy for students struggling in classes was disproportionate. It favored White parents, but also generally more educated families. This is further supported by a study of 225 schools across six states of kindergarten children showing similar trends, that African American, Latino, and less-educated parents were less involved in their children’s education as reported by teachers.³ It is important to note that in this study teachers were 80% White, 9% Latino, 7% African American, 3% multiracial, and 1% Asian American, suggesting that cultural discrepancy between teachers and parents could be an important factor affecting parent-teacher communication. Dr. Nguyen also recalled trying to discipline several students who were disruptive in his class by telling them he would speak to their parents. Several times, these students would counter defiantly, “Well, good luck, they can’t speak English.” The parents’ dependency on their children to communicate with teachers undermined the abilities of both adults to manage their behaviors and promote learning.
 

The Mental Health of Immigrant Parents  

Migrants often have greater incidence of mental health problems, including depression, PTSD, and anxiety, from a combination of peri-migrational experiences. ⁴ Immigrant mothers are known to have higher rates of post-natal depression, which cause problems later with child development. ⁵ Though she warns larger studies are needed, Dr. Fazel’s review of Croatian refugees suggests that displacement from one’s native country is a risk factor for poorer mental health, namely due to difficulty in psychosocial adaptation. ⁶ The likely mechanism is that lack of access to one’s language and culture, or a language and culture that one can navigate effectively, exacerbates, even engenders mental health sequelae. Because of this, first-generation immigrant children often face harsher and more violent parenting. ^7,8 Immigrant parents also may have less access to mental health resources since they often resort to their own cultural practices. Both Mr. Contreras’s and Dr. Nguyen’s following narratives of their mothers’ struggle with mental health illustrate the causes and consequences.

Mr. Contreras, who grew up in a Mexican immigrant household in Los Angeles, saw firsthand how his mother, who faced language barriers and a distrust of Western medicine, turned to traditional healers and herbal remedies for her health needs. Accompanying her to doctor appointments as her translator, he often felt the disconnect between her cultural background and the Western medical system. For her, seeking help from traditional healers was not just about addressing physical ailments but also about finding comfort and familiarity in practices rooted in her cultural beliefs. This preference for cultural or religious methods for mental health support is not uncommon among Mexican immigrant families.

Dr. Nguyen, whose mother was a refugee from Vietnam, recalls her constant depressed mood and suicidal thoughts in the immediate years after she resettled in San Diego. This was caused mostly by the missing of her social supports in Vietnam, her difficulty adjusting to American culture and language, and her difficulty finding work. Often her depression and stress took a darker turn in terms of more violent parenting. Of course, the cause of her poor mental health is hard to parse from the traumas and violence she had faced as a refugee, but in subsequent years, her many brothers and sisters who immigrated through a more orderly process also displayed similar mental health vulnerabilities.

   

The Mental Health of Children of Immigrant Parents  

The relationship between an immigrant parent’s poor mental health and their children is difficult to parse from what we know about native parents and their children. But the primary differences appear to be a great disruption of social roles, the effects of migration itself, and the oftentimes more strict and disciplinarian parenting style as discussed above. Given this, one would expect immigrant children to suffer greater mental health difficulties. However, a recent study of almost 500,000 children in Canada revealed decreased prevalence of conduct disorder, ADHD, and mood and anxiety disorders in immigrant youth, both first- and second-generation, as compared to non-immigrants. ⁹ This perhaps surprising result highlights how much more we need to understand about the effects of culture on the mental health diagnosis of immigrant youth. It suggests differences in mental health access and use from the cultural factors we mentioned above, to problems with using Western-based mental criteria and symptomatology for diagnosing non-Western children. It can even suggest the underestimation of the protective effects of native culture such as strong ethnic identity and cultural support systems, thereby challenging a purely deficit mental health model of the immigrant experience.

Summary

Dr. Duy Nguyen and Mr. Andrew Contreras are both children of immigrant parents from Vietnam and Mexico, respectively. Dr. Nguyen spent 15 years as an English teacher at San Leandro High School, whose student body was roughly 50% Hispanic and 25% Asian, making immigrant parents a huge swath of his educational partners. Mr. Contreras founded a high school outreach program where he interacted with K-12 children of immigrant youth. In addition, he partners with Fresno’s Economic Opportunity Commission to educate immigrant Hispanic parents and their teens on having difficult conversations with their teenage children on topics such as mental and reproductive health. Dr. Duy Nguyen and Mr. Andrew Contreras will explore the differences in immigrant parent-child relationships, compared with native ones, as they relate to mental health ramifications for the child and parent. They reveal immigrant mental health disruptions regarding culture and language, familial hierarchies, parenting styles, as well as parental mental health sequelae brought about by immigration using research and their own personal experiences.

Dr. Nguyen is a second-year resident at the University of California, San Francisco, Fresno Psychiatry Residency. He was a public high school English teacher for 15 years previously. Mr. Contreras is currently a 4th-year medical student at University of California, San Francisco, and applying to Psychiatry for the 2025 match.

References  

1. Rao A et al. Five Key Facts About Immigrants With Limited English Proficiency. KFF. 2024 March 14. https://www.kff.org/racial-equity-and-health-policy/issue-brief-five-key-facts-about-immigrants-with-limited-english-proficiency .

2. Raffaetà R. Migration and Parenting: Reviewing the Debate and Calling for Future Research. International Journal of Migration, Health and Social Care. 2016;12(1):38-50. doi: 10.1108/IJMHSC-12-2014-0052/full/html .

3. Nzinga‐Johnson S et al. Teacher‐Parent Relationships and School Involvement Among Racially and Educationally Diverse Parents of Kindergartners. Elementary School Journal. 2009 Sept. doi: 10.1086/598844 .

4. Close C et al. The Mental Health and Wellbeing of First Generation Migrants: A Systematic-Narrative Review of Reviews. Global Health. 2016 Aug 25;12(1):47. doi: 10.1186/s12992-016-0187-3.

5. Collins CH et al. Refugee, Asylum Seeker, Immigrant Women and Postnatal Depression: Rates and Risk Factors. Arch Womens Ment Health. 2011 Feb;14(1):3-11. doi: 10.1007/s00737-010-0198-7 .

6. Fazel M, Betancourt TS. Preventive Mental Health Interventions for Refugee Children and Adolescents in High-Income Settings. Lancet Child Adolesc Health. 2018 Feb;2(2):121-132. doi: 10.1016/S2352-4642(17)30147-5 .

7. Pottie K et al. Do First Generation Immigrant Adolescents Face Higher Rates of Bullying, Violence and Suicidal Behaviours Than Do Third Generation and Native Born? J Immigr Minor Health. 2015 Oct;17(5):1557-1566. doi: 10.1007/s10903-014-0108-6.

8. Smokowski PR, Bacallao ML. Acculturation and Aggression in Latino Adolescents: A Structural Model Focusing on Cultural Risk Factors and Assets. J Abnorm Child Psychol. 2006 Oct;34(5):659-673. doi: 10.1007/s10802-006-9049-4 .

9. Gadermann AM et al. Prevalence of Mental Health Disorders Among Immigrant, Refugee, and Nonimmigrant Children and Youth in British Columbia, Canada. JAMA Netw Open. 2022;5(2):e2144934. doi: 10.1001/jamanetworkopen.2021.44934 .

Fundamentally, an immigrant parent’s traditional role as teacher of culture and social systems to their children is undermined by immigration. In their native country, they learned throughout their life cultural norms and systems that defined their environment. When these parents immigrate to a new country, their different set of knowledge may not be applicable in many ways to their new environment.

The Disruption of Social Roles

Culturally, language is one of the most important types of knowledge parents pass to their children. Nearly half of adult immigrants in the United States have limited English proficiency. ¹

Their children often learn the language faster, often placing these children in the position of interpreters for their parents. These parents can become dependent on their children to negotiate social structures instead of vice versa, potentially undermining the social hierarchy and role of parenting. ² Both Mr. Contreras and Dr. Nguyen recall that as children of immigrant parents — from Mexico and Vietnam, respectively — they commanded English better than their parents, which often made them take on more “adult roles.” For example, Dr. Nguyen recalls that his mother would solicit his help in grocery shopping because she could neither navigate the aisles effectively nor ask for help. Mr. Contreras commonly found himself acting as an impromptu medical translator for his mother on several occasions. This dependence of immigrant parents on their children for guidance in their host country can be pervasive in other social structures such as legal and academic.

Impact on School

Potentially, an immigrant parent’s lack of knowledge of the language and systems of their host country can make them ineffective advocates for their children at school. Mr. Contreras’s intervention for his patient as a medical student demonstrates this in the arena of school.

Mr. Contreras was rotating at a hospital burn unit in 2023 when R, a young middle school student, and his mother arrived in the emergency department. An incident had occurred at his school. R had been the victim of aggravated battery and assault, sustaining a 3x2 cm burn on his forearm from students placing hot glue onto a piece of cardboard then immediately onto his skin and silencing him by covering his mouth. For months the older students had been bullying R. R’s mother made multiple attempts with both the school’s front desk and counselors to address the issue, but to no avail. R himself, though encouraged to speak up, did not out of fear. As Mr. Contreras realized the situation and the impasse, he used his fluency in Spanish and English to facilitate a joint call with the school district. Within 10 minutes, they were able to connect with a student safety specialist and launch a full investigation. A language barrier and the lack of knowledge of their rights and school system had prevented R’s mother from effectively advocating for her child’s safety.

In Dr. Nguyen’s experience as a teacher, even in classrooms dominated by minority students, the advocacy for students struggling in classes was disproportionate. It favored White parents, but also generally more educated families. This is further supported by a study of 225 schools across six states of kindergarten children showing similar trends, that African American, Latino, and less-educated parents were less involved in their children’s education as reported by teachers.³ It is important to note that in this study teachers were 80% White, 9% Latino, 7% African American, 3% multiracial, and 1% Asian American, suggesting that cultural discrepancy between teachers and parents could be an important factor affecting parent-teacher communication. Dr. Nguyen also recalled trying to discipline several students who were disruptive in his class by telling them he would speak to their parents. Several times, these students would counter defiantly, “Well, good luck, they can’t speak English.” The parents’ dependency on their children to communicate with teachers undermined the abilities of both adults to manage their behaviors and promote learning.
 

The Mental Health of Immigrant Parents  

Migrants often have greater incidence of mental health problems, including depression, PTSD, and anxiety, from a combination of peri-migrational experiences. ⁴ Immigrant mothers are known to have higher rates of post-natal depression, which cause problems later with child development. ⁵ Though she warns larger studies are needed, Dr. Fazel’s review of Croatian refugees suggests that displacement from one’s native country is a risk factor for poorer mental health, namely due to difficulty in psychosocial adaptation. ⁶ The likely mechanism is that lack of access to one’s language and culture, or a language and culture that one can navigate effectively, exacerbates, even engenders mental health sequelae. Because of this, first-generation immigrant children often face harsher and more violent parenting. ^7,8 Immigrant parents also may have less access to mental health resources since they often resort to their own cultural practices. Both Mr. Contreras’s and Dr. Nguyen’s following narratives of their mothers’ struggle with mental health illustrate the causes and consequences.

Mr. Contreras, who grew up in a Mexican immigrant household in Los Angeles, saw firsthand how his mother, who faced language barriers and a distrust of Western medicine, turned to traditional healers and herbal remedies for her health needs. Accompanying her to doctor appointments as her translator, he often felt the disconnect between her cultural background and the Western medical system. For her, seeking help from traditional healers was not just about addressing physical ailments but also about finding comfort and familiarity in practices rooted in her cultural beliefs. This preference for cultural or religious methods for mental health support is not uncommon among Mexican immigrant families.

Dr. Nguyen, whose mother was a refugee from Vietnam, recalls her constant depressed mood and suicidal thoughts in the immediate years after she resettled in San Diego. This was caused mostly by the missing of her social supports in Vietnam, her difficulty adjusting to American culture and language, and her difficulty finding work. Often her depression and stress took a darker turn in terms of more violent parenting. Of course, the cause of her poor mental health is hard to parse from the traumas and violence she had faced as a refugee, but in subsequent years, her many brothers and sisters who immigrated through a more orderly process also displayed similar mental health vulnerabilities.

   

The Mental Health of Children of Immigrant Parents  

The relationship between an immigrant parent’s poor mental health and their children is difficult to parse from what we know about native parents and their children. But the primary differences appear to be a great disruption of social roles, the effects of migration itself, and the oftentimes more strict and disciplinarian parenting style as discussed above. Given this, one would expect immigrant children to suffer greater mental health difficulties. However, a recent study of almost 500,000 children in Canada revealed decreased prevalence of conduct disorder, ADHD, and mood and anxiety disorders in immigrant youth, both first- and second-generation, as compared to non-immigrants. ⁹ This perhaps surprising result highlights how much more we need to understand about the effects of culture on the mental health diagnosis of immigrant youth. It suggests differences in mental health access and use from the cultural factors we mentioned above, to problems with using Western-based mental criteria and symptomatology for diagnosing non-Western children. It can even suggest the underestimation of the protective effects of native culture such as strong ethnic identity and cultural support systems, thereby challenging a purely deficit mental health model of the immigrant experience.

Summary

Dr. Duy Nguyen and Mr. Andrew Contreras are both children of immigrant parents from Vietnam and Mexico, respectively. Dr. Nguyen spent 15 years as an English teacher at San Leandro High School, whose student body was roughly 50% Hispanic and 25% Asian, making immigrant parents a huge swath of his educational partners. Mr. Contreras founded a high school outreach program where he interacted with K-12 children of immigrant youth. In addition, he partners with Fresno’s Economic Opportunity Commission to educate immigrant Hispanic parents and their teens on having difficult conversations with their teenage children on topics such as mental and reproductive health. Dr. Duy Nguyen and Mr. Andrew Contreras will explore the differences in immigrant parent-child relationships, compared with native ones, as they relate to mental health ramifications for the child and parent. They reveal immigrant mental health disruptions regarding culture and language, familial hierarchies, parenting styles, as well as parental mental health sequelae brought about by immigration using research and their own personal experiences.

Dr. Nguyen is a second-year resident at the University of California, San Francisco, Fresno Psychiatry Residency. He was a public high school English teacher for 15 years previously. Mr. Contreras is currently a 4th-year medical student at University of California, San Francisco, and applying to Psychiatry for the 2025 match.

References  

1. Rao A et al. Five Key Facts About Immigrants With Limited English Proficiency. KFF. 2024 March 14. https://www.kff.org/racial-equity-and-health-policy/issue-brief-five-key-facts-about-immigrants-with-limited-english-proficiency .

2. Raffaetà R. Migration and Parenting: Reviewing the Debate and Calling for Future Research. International Journal of Migration, Health and Social Care. 2016;12(1):38-50. doi: 10.1108/IJMHSC-12-2014-0052/full/html .

3. Nzinga‐Johnson S et al. Teacher‐Parent Relationships and School Involvement Among Racially and Educationally Diverse Parents of Kindergartners. Elementary School Journal. 2009 Sept. doi: 10.1086/598844 .

4. Close C et al. The Mental Health and Wellbeing of First Generation Migrants: A Systematic-Narrative Review of Reviews. Global Health. 2016 Aug 25;12(1):47. doi: 10.1186/s12992-016-0187-3.

5. Collins CH et al. Refugee, Asylum Seeker, Immigrant Women and Postnatal Depression: Rates and Risk Factors. Arch Womens Ment Health. 2011 Feb;14(1):3-11. doi: 10.1007/s00737-010-0198-7 .

6. Fazel M, Betancourt TS. Preventive Mental Health Interventions for Refugee Children and Adolescents in High-Income Settings. Lancet Child Adolesc Health. 2018 Feb;2(2):121-132. doi: 10.1016/S2352-4642(17)30147-5 .

7. Pottie K et al. Do First Generation Immigrant Adolescents Face Higher Rates of Bullying, Violence and Suicidal Behaviours Than Do Third Generation and Native Born? J Immigr Minor Health. 2015 Oct;17(5):1557-1566. doi: 10.1007/s10903-014-0108-6.

8. Smokowski PR, Bacallao ML. Acculturation and Aggression in Latino Adolescents: A Structural Model Focusing on Cultural Risk Factors and Assets. J Abnorm Child Psychol. 2006 Oct;34(5):659-673. doi: 10.1007/s10802-006-9049-4 .

9. Gadermann AM et al. Prevalence of Mental Health Disorders Among Immigrant, Refugee, and Nonimmigrant Children and Youth in British Columbia, Canada. JAMA Netw Open. 2022;5(2):e2144934. doi: 10.1001/jamanetworkopen.2021.44934 .

Fundamentally, an immigrant parent’s traditional role as teacher of culture and social systems to their children is undermined by immigration. In their native country, they learned throughout their life cultural norms and systems that defined their environment. When these parents immigrate to a new country, their different set of knowledge may not be applicable in many ways to their new environment.

The Disruption of Social Roles

Culturally, language is one of the most important types of knowledge parents pass to their children. Nearly half of adult immigrants in the United States have limited English proficiency. ¹

Their children often learn the language faster, often placing these children in the position of interpreters for their parents. These parents can become dependent on their children to negotiate social structures instead of vice versa, potentially undermining the social hierarchy and role of parenting. ² Both Mr. Contreras and Dr. Nguyen recall that as children of immigrant parents — from Mexico and Vietnam, respectively — they commanded English better than their parents, which often made them take on more “adult roles.” For example, Dr. Nguyen recalls that his mother would solicit his help in grocery shopping because she could neither navigate the aisles effectively nor ask for help. Mr. Contreras commonly found himself acting as an impromptu medical translator for his mother on several occasions. This dependence of immigrant parents on their children for guidance in their host country can be pervasive in other social structures such as legal and academic.

Impact on School

Potentially, an immigrant parent’s lack of knowledge of the language and systems of their host country can make them ineffective advocates for their children at school. Mr. Contreras’s intervention for his patient as a medical student demonstrates this in the arena of school.

Mr. Contreras was rotating at a hospital burn unit in 2023 when R, a young middle school student, and his mother arrived in the emergency department. An incident had occurred at his school. R had been the victim of aggravated battery and assault, sustaining a 3x2 cm burn on his forearm from students placing hot glue onto a piece of cardboard then immediately onto his skin and silencing him by covering his mouth. For months the older students had been bullying R. R’s mother made multiple attempts with both the school’s front desk and counselors to address the issue, but to no avail. R himself, though encouraged to speak up, did not out of fear. As Mr. Contreras realized the situation and the impasse, he used his fluency in Spanish and English to facilitate a joint call with the school district. Within 10 minutes, they were able to connect with a student safety specialist and launch a full investigation. A language barrier and the lack of knowledge of their rights and school system had prevented R’s mother from effectively advocating for her child’s safety.

In Dr. Nguyen’s experience as a teacher, even in classrooms dominated by minority students, the advocacy for students struggling in classes was disproportionate. It favored White parents, but also generally more educated families. This is further supported by a study of 225 schools across six states of kindergarten children showing similar trends, that African American, Latino, and less-educated parents were less involved in their children’s education as reported by teachers.³ It is important to note that in this study teachers were 80% White, 9% Latino, 7% African American, 3% multiracial, and 1% Asian American, suggesting that cultural discrepancy between teachers and parents could be an important factor affecting parent-teacher communication. Dr. Nguyen also recalled trying to discipline several students who were disruptive in his class by telling them he would speak to their parents. Several times, these students would counter defiantly, “Well, good luck, they can’t speak English.” The parents’ dependency on their children to communicate with teachers undermined the abilities of both adults to manage their behaviors and promote learning.
 

The Mental Health of Immigrant Parents  

Migrants often have greater incidence of mental health problems, including depression, PTSD, and anxiety, from a combination of peri-migrational experiences. ⁴ Immigrant mothers are known to have higher rates of post-natal depression, which cause problems later with child development. ⁵ Though she warns larger studies are needed, Dr. Fazel’s review of Croatian refugees suggests that displacement from one’s native country is a risk factor for poorer mental health, namely due to difficulty in psychosocial adaptation. ⁶ The likely mechanism is that lack of access to one’s language and culture, or a language and culture that one can navigate effectively, exacerbates, even engenders mental health sequelae. Because of this, first-generation immigrant children often face harsher and more violent parenting. ^7,8 Immigrant parents also may have less access to mental health resources since they often resort to their own cultural practices. Both Mr. Contreras’s and Dr. Nguyen’s following narratives of their mothers’ struggle with mental health illustrate the causes and consequences.

Mr. Contreras, who grew up in a Mexican immigrant household in Los Angeles, saw firsthand how his mother, who faced language barriers and a distrust of Western medicine, turned to traditional healers and herbal remedies for her health needs. Accompanying her to doctor appointments as her translator, he often felt the disconnect between her cultural background and the Western medical system. For her, seeking help from traditional healers was not just about addressing physical ailments but also about finding comfort and familiarity in practices rooted in her cultural beliefs. This preference for cultural or religious methods for mental health support is not uncommon among Mexican immigrant families.

Dr. Nguyen, whose mother was a refugee from Vietnam, recalls her constant depressed mood and suicidal thoughts in the immediate years after she resettled in San Diego. This was caused mostly by the missing of her social supports in Vietnam, her difficulty adjusting to American culture and language, and her difficulty finding work. Often her depression and stress took a darker turn in terms of more violent parenting. Of course, the cause of her poor mental health is hard to parse from the traumas and violence she had faced as a refugee, but in subsequent years, her many brothers and sisters who immigrated through a more orderly process also displayed similar mental health vulnerabilities.

   

The Mental Health of Children of Immigrant Parents  

The relationship between an immigrant parent’s poor mental health and their children is difficult to parse from what we know about native parents and their children. But the primary differences appear to be a great disruption of social roles, the effects of migration itself, and the oftentimes more strict and disciplinarian parenting style as discussed above. Given this, one would expect immigrant children to suffer greater mental health difficulties. However, a recent study of almost 500,000 children in Canada revealed decreased prevalence of conduct disorder, ADHD, and mood and anxiety disorders in immigrant youth, both first- and second-generation, as compared to non-immigrants. ⁹ This perhaps surprising result highlights how much more we need to understand about the effects of culture on the mental health diagnosis of immigrant youth. It suggests differences in mental health access and use from the cultural factors we mentioned above, to problems with using Western-based mental criteria and symptomatology for diagnosing non-Western children. It can even suggest the underestimation of the protective effects of native culture such as strong ethnic identity and cultural support systems, thereby challenging a purely deficit mental health model of the immigrant experience.

Summary

Dr. Duy Nguyen and Mr. Andrew Contreras are both children of immigrant parents from Vietnam and Mexico, respectively. Dr. Nguyen spent 15 years as an English teacher at San Leandro High School, whose student body was roughly 50% Hispanic and 25% Asian, making immigrant parents a huge swath of his educational partners. Mr. Contreras founded a high school outreach program where he interacted with K-12 children of immigrant youth. In addition, he partners with Fresno’s Economic Opportunity Commission to educate immigrant Hispanic parents and their teens on having difficult conversations with their teenage children on topics such as mental and reproductive health. Dr. Duy Nguyen and Mr. Andrew Contreras will explore the differences in immigrant parent-child relationships, compared with native ones, as they relate to mental health ramifications for the child and parent. They reveal immigrant mental health disruptions regarding culture and language, familial hierarchies, parenting styles, as well as parental mental health sequelae brought about by immigration using research and their own personal experiences.

Dr. Nguyen is a second-year resident at the University of California, San Francisco, Fresno Psychiatry Residency. He was a public high school English teacher for 15 years previously. Mr. Contreras is currently a 4th-year medical student at University of California, San Francisco, and applying to Psychiatry for the 2025 match.

References  

1. Rao A et al. Five Key Facts About Immigrants With Limited English Proficiency. KFF. 2024 March 14. https://www.kff.org/racial-equity-and-health-policy/issue-brief-five-key-facts-about-immigrants-with-limited-english-proficiency .

2. Raffaetà R. Migration and Parenting: Reviewing the Debate and Calling for Future Research. International Journal of Migration, Health and Social Care. 2016;12(1):38-50. doi: 10.1108/IJMHSC-12-2014-0052/full/html .

3. Nzinga‐Johnson S et al. Teacher‐Parent Relationships and School Involvement Among Racially and Educationally Diverse Parents of Kindergartners. Elementary School Journal. 2009 Sept. doi: 10.1086/598844 .

4. Close C et al. The Mental Health and Wellbeing of First Generation Migrants: A Systematic-Narrative Review of Reviews. Global Health. 2016 Aug 25;12(1):47. doi: 10.1186/s12992-016-0187-3.

5. Collins CH et al. Refugee, Asylum Seeker, Immigrant Women and Postnatal Depression: Rates and Risk Factors. Arch Womens Ment Health. 2011 Feb;14(1):3-11. doi: 10.1007/s00737-010-0198-7 .

6. Fazel M, Betancourt TS. Preventive Mental Health Interventions for Refugee Children and Adolescents in High-Income Settings. Lancet Child Adolesc Health. 2018 Feb;2(2):121-132. doi: 10.1016/S2352-4642(17)30147-5 .

7. Pottie K et al. Do First Generation Immigrant Adolescents Face Higher Rates of Bullying, Violence and Suicidal Behaviours Than Do Third Generation and Native Born? J Immigr Minor Health. 2015 Oct;17(5):1557-1566. doi: 10.1007/s10903-014-0108-6.

8. Smokowski PR, Bacallao ML. Acculturation and Aggression in Latino Adolescents: A Structural Model Focusing on Cultural Risk Factors and Assets. J Abnorm Child Psychol. 2006 Oct;34(5):659-673. doi: 10.1007/s10802-006-9049-4 .

9. Gadermann AM et al. Prevalence of Mental Health Disorders Among Immigrant, Refugee, and Nonimmigrant Children and Youth in British Columbia, Canada. JAMA Netw Open. 2022;5(2):e2144934. doi: 10.1001/jamanetworkopen.2021.44934 .

Recent newspaper headlines have focused almost exclusively on gender-affirming medical interventions for transgender youth (eg, puberty blockers and gender-affirming hormones like estrogen and testosterone). It is true that these are important treatments that are consistently tied to improvements in mental health. However, an additional powerful predictor of good mental health outcomes for transgender youth is parental support and acceptance.

It is essential that clinicians consider this when creating treatment plans for transgender youth. While transgender young people are struggling with gender dysphoria, their parents are often struggling as well. Sadly, they are often afraid to share their own struggles, despite working through these being essential for their children’s thriving and well-being. I have a few key tips for combating this issue. My upcoming book Free to Be: Understanding Kids & Gender Identity provides much more context for parents and providers, but I will highlight a few big takeaways here.

Stanford Lucille Packard Children's Hospital.

Give Parents Their Own Space

Many parents have never encountered a transgender person in their life and have a lot of questions. At times, they may be “thinking out loud” and say things in passing that aren’t their final thoughts or opinions on a matter. This can, unfortunately, be damaging to their children. I often speak with adult transgender people whose parents said something they no longer believe (eg, “being trans is just a mental illness – you need therapy to fix it”), but these comments stick in the person’s mind and drive shame and self-esteem challenges later in life, sometimes for decades. Parents need to have a safe space, with a trained professional with expertise in gender, to work through their concerns and questions away from their children, so that when they talk to their kids about gender, they are presenting their fully formed thoughts.

Validate Parents’ Difficult Experiences

As pediatric providers, we are often focused on the difficult experiences of our transgender pediatric patients. However, their parents tend to be struggling as well, and that struggling predicts adverse mental health outcomes for their children.

The most common reaction a parent has upon learning their child is transgender is fear. It’s important to validate this fear (and other feelings that come out), so that parents know they can share with you what’s really going on in their minds.

There are some common themes we see for parents. Some are big fears: fear that their child will be victimized or fear that their child will later regret taking gender-affirming hormones and blame the parents for giving permission to take them. Parents often say they had a gendered vision for what their child’s future would be like, and their child coming out as transgender changes that (it can be helpful to gently remind parents that children almost never grow up exactly how we predict).

Some themes are more mundane but nonetheless distressing for parents, such as not wanting to throw away meaningful souvenirs from past vacations that have their child’s birth name on them. Clinicians can and should validate these thoughts and feelings, while also providing additional context and education. I often recommend the book Found in Transition by Pariah Hassouri, a pediatrician who goes through many of these common struggles after her daughter comes out as transgender.

 

Take a Three-Stage Approach When Adolescents Are Considering Gender-Affirming Medical Interventions

We recently outlined our process for conducting a biopsychosocial assessment for adolescents considering pubertal suppression for adolescent gender dysphoria in The Journal of the American Academy of Child & Adolescent Psychiatry, for those who want more detail on how to conduct these assessments. On the theme of supporting parents, I would highlight the value of taking a three-stage approach. In the first stage, a clinician meets with an adolescent alone to collect their gender history and discuss important considerations regarding the medical intervention. In stage two, the same information about the medical intervention is shared with parents, along with a summary of what the adolescent shared with the clinician (with the adolescent’s consent, of course). Often there will be some areas of disconnect. We make a list of these areas of disconnect that are addressed in stage three, in which the full family is brought together to get everyone on the same page and understanding each other’s perspectives.

Common disconnects include gender dysphoria seeming to “come out of nowhere” from the parents’ perspective, necessitating the young person to recount an early life experience in which they were harassed for expressing gender nonconformity, leading them to act stereotypically in line with their sex assigned at birth for years to avoid being “outed” and harassed more. Conversations around fertility preservation can be particularly complex. Young people and their parents also sometimes have different conceptualizations of gender identity and require a shared framework for talking about gender identity (which I offer in my forthcoming book). This list of family therapy topics can be diverse and highly dependent on the family. An additional resource for this phase of the family therapy is The Family Acceptance Project, which has created culturally tailored materials to help parents understand their sexual and gender minority children.

In summary, fostering healthy family functioning is essential for the care of transgender and gender diverse youth, and parents require support in addition to their children needing support. I encourage all gender providers to incorporate the vital element of family therapy into their practice.

 

Dr. Turban is director of the Gender Psychiatry Program at the University of California, San Francisco, where he is an assistant professor of child & adolescent psychiatry and affiliate faculty at the Philip R. Lee Institute for Health Policy Studies. He is on X @jack_turban.

Recent newspaper headlines have focused almost exclusively on gender-affirming medical interventions for transgender youth (eg, puberty blockers and gender-affirming hormones like estrogen and testosterone). It is true that these are important treatments that are consistently tied to improvements in mental health. However, an additional powerful predictor of good mental health outcomes for transgender youth is parental support and acceptance.

It is essential that clinicians consider this when creating treatment plans for transgender youth. While transgender young people are struggling with gender dysphoria, their parents are often struggling as well. Sadly, they are often afraid to share their own struggles, despite working through these being essential for their children’s thriving and well-being. I have a few key tips for combating this issue. My upcoming book Free to Be: Understanding Kids & Gender Identity provides much more context for parents and providers, but I will highlight a few big takeaways here.

Stanford Lucille Packard Children's Hospital.

Give Parents Their Own Space

Many parents have never encountered a transgender person in their life and have a lot of questions. At times, they may be “thinking out loud” and say things in passing that aren’t their final thoughts or opinions on a matter. This can, unfortunately, be damaging to their children. I often speak with adult transgender people whose parents said something they no longer believe (eg, “being trans is just a mental illness – you need therapy to fix it”), but these comments stick in the person’s mind and drive shame and self-esteem challenges later in life, sometimes for decades. Parents need to have a safe space, with a trained professional with expertise in gender, to work through their concerns and questions away from their children, so that when they talk to their kids about gender, they are presenting their fully formed thoughts.

Validate Parents’ Difficult Experiences

As pediatric providers, we are often focused on the difficult experiences of our transgender pediatric patients. However, their parents tend to be struggling as well, and that struggling predicts adverse mental health outcomes for their children.

The most common reaction a parent has upon learning their child is transgender is fear. It’s important to validate this fear (and other feelings that come out), so that parents know they can share with you what’s really going on in their minds.

There are some common themes we see for parents. Some are big fears: fear that their child will be victimized or fear that their child will later regret taking gender-affirming hormones and blame the parents for giving permission to take them. Parents often say they had a gendered vision for what their child’s future would be like, and their child coming out as transgender changes that (it can be helpful to gently remind parents that children almost never grow up exactly how we predict).

Some themes are more mundane but nonetheless distressing for parents, such as not wanting to throw away meaningful souvenirs from past vacations that have their child’s birth name on them. Clinicians can and should validate these thoughts and feelings, while also providing additional context and education. I often recommend the book Found in Transition by Pariah Hassouri, a pediatrician who goes through many of these common struggles after her daughter comes out as transgender.

 

Take a Three-Stage Approach When Adolescents Are Considering Gender-Affirming Medical Interventions

We recently outlined our process for conducting a biopsychosocial assessment for adolescents considering pubertal suppression for adolescent gender dysphoria in The Journal of the American Academy of Child & Adolescent Psychiatry, for those who want more detail on how to conduct these assessments. On the theme of supporting parents, I would highlight the value of taking a three-stage approach. In the first stage, a clinician meets with an adolescent alone to collect their gender history and discuss important considerations regarding the medical intervention. In stage two, the same information about the medical intervention is shared with parents, along with a summary of what the adolescent shared with the clinician (with the adolescent’s consent, of course). Often there will be some areas of disconnect. We make a list of these areas of disconnect that are addressed in stage three, in which the full family is brought together to get everyone on the same page and understanding each other’s perspectives.

Common disconnects include gender dysphoria seeming to “come out of nowhere” from the parents’ perspective, necessitating the young person to recount an early life experience in which they were harassed for expressing gender nonconformity, leading them to act stereotypically in line with their sex assigned at birth for years to avoid being “outed” and harassed more. Conversations around fertility preservation can be particularly complex. Young people and their parents also sometimes have different conceptualizations of gender identity and require a shared framework for talking about gender identity (which I offer in my forthcoming book). This list of family therapy topics can be diverse and highly dependent on the family. An additional resource for this phase of the family therapy is The Family Acceptance Project, which has created culturally tailored materials to help parents understand their sexual and gender minority children.

In summary, fostering healthy family functioning is essential for the care of transgender and gender diverse youth, and parents require support in addition to their children needing support. I encourage all gender providers to incorporate the vital element of family therapy into their practice.

 

Dr. Turban is director of the Gender Psychiatry Program at the University of California, San Francisco, where he is an assistant professor of child & adolescent psychiatry and affiliate faculty at the Philip R. Lee Institute for Health Policy Studies. He is on X @jack_turban.

Recent newspaper headlines have focused almost exclusively on gender-affirming medical interventions for transgender youth (eg, puberty blockers and gender-affirming hormones like estrogen and testosterone). It is true that these are important treatments that are consistently tied to improvements in mental health. However, an additional powerful predictor of good mental health outcomes for transgender youth is parental support and acceptance.

It is essential that clinicians consider this when creating treatment plans for transgender youth. While transgender young people are struggling with gender dysphoria, their parents are often struggling as well. Sadly, they are often afraid to share their own struggles, despite working through these being essential for their children’s thriving and well-being. I have a few key tips for combating this issue. My upcoming book Free to Be: Understanding Kids & Gender Identity provides much more context for parents and providers, but I will highlight a few big takeaways here.

Stanford Lucille Packard Children's Hospital.

Give Parents Their Own Space

Many parents have never encountered a transgender person in their life and have a lot of questions. At times, they may be “thinking out loud” and say things in passing that aren’t their final thoughts or opinions on a matter. This can, unfortunately, be damaging to their children. I often speak with adult transgender people whose parents said something they no longer believe (eg, “being trans is just a mental illness – you need therapy to fix it”), but these comments stick in the person’s mind and drive shame and self-esteem challenges later in life, sometimes for decades. Parents need to have a safe space, with a trained professional with expertise in gender, to work through their concerns and questions away from their children, so that when they talk to their kids about gender, they are presenting their fully formed thoughts.

Validate Parents’ Difficult Experiences

As pediatric providers, we are often focused on the difficult experiences of our transgender pediatric patients. However, their parents tend to be struggling as well, and that struggling predicts adverse mental health outcomes for their children.

The most common reaction a parent has upon learning their child is transgender is fear. It’s important to validate this fear (and other feelings that come out), so that parents know they can share with you what’s really going on in their minds.

There are some common themes we see for parents. Some are big fears: fear that their child will be victimized or fear that their child will later regret taking gender-affirming hormones and blame the parents for giving permission to take them. Parents often say they had a gendered vision for what their child’s future would be like, and their child coming out as transgender changes that (it can be helpful to gently remind parents that children almost never grow up exactly how we predict).

Some themes are more mundane but nonetheless distressing for parents, such as not wanting to throw away meaningful souvenirs from past vacations that have their child’s birth name on them. Clinicians can and should validate these thoughts and feelings, while also providing additional context and education. I often recommend the book Found in Transition by Pariah Hassouri, a pediatrician who goes through many of these common struggles after her daughter comes out as transgender.

 

Take a Three-Stage Approach When Adolescents Are Considering Gender-Affirming Medical Interventions

We recently outlined our process for conducting a biopsychosocial assessment for adolescents considering pubertal suppression for adolescent gender dysphoria in The Journal of the American Academy of Child & Adolescent Psychiatry, for those who want more detail on how to conduct these assessments. On the theme of supporting parents, I would highlight the value of taking a three-stage approach. In the first stage, a clinician meets with an adolescent alone to collect their gender history and discuss important considerations regarding the medical intervention. In stage two, the same information about the medical intervention is shared with parents, along with a summary of what the adolescent shared with the clinician (with the adolescent’s consent, of course). Often there will be some areas of disconnect. We make a list of these areas of disconnect that are addressed in stage three, in which the full family is brought together to get everyone on the same page and understanding each other’s perspectives.

Common disconnects include gender dysphoria seeming to “come out of nowhere” from the parents’ perspective, necessitating the young person to recount an early life experience in which they were harassed for expressing gender nonconformity, leading them to act stereotypically in line with their sex assigned at birth for years to avoid being “outed” and harassed more. Conversations around fertility preservation can be particularly complex. Young people and their parents also sometimes have different conceptualizations of gender identity and require a shared framework for talking about gender identity (which I offer in my forthcoming book). This list of family therapy topics can be diverse and highly dependent on the family. An additional resource for this phase of the family therapy is The Family Acceptance Project, which has created culturally tailored materials to help parents understand their sexual and gender minority children.

In summary, fostering healthy family functioning is essential for the care of transgender and gender diverse youth, and parents require support in addition to their children needing support. I encourage all gender providers to incorporate the vital element of family therapy into their practice.

 

Dr. Turban is director of the Gender Psychiatry Program at the University of California, San Francisco, where he is an assistant professor of child & adolescent psychiatry and affiliate faculty at the Philip R. Lee Institute for Health Policy Studies. He is on X @jack_turban.

Psychiatry, like all medical disciplines, changes over time. For many decades, psychiatrists were primarily psychotherapists. As medications slowly became available, these became a second tool for treatment — so much so that by the 21st century many, if not most, psychiatrists saw themselves primarily as psychopharmacologists and diagnosticians who were skilled at identifying various forms of mental illness and using medications in the hopes of inducing a clinically meaningful “response” in symptoms. While still belonging to the umbrella category of a mental health professional, more and more psychiatrists trained and practiced as mental illness professionals.

Slowly, however, there have been stirrings within the field by many who have found the identity of the psychiatrist as a “prescriber” to be too narrow, and the current “med check” model of treatment too confining. This change was partly inspired by our colleagues in clinical psychology who were challenged in the 1990s by then American Psychological Association President Martin Seligman, PhD, to develop knowledge and expertise not only in alleviating mental suffering but also in promoting true mental well-being, a construct that still was often vaguely defined. One framework of well-being that was advanced at the time was the PERMA model, representing the five well-being dimensions of Positive emotions, Engagement, Relationships, Meaning, and Accomplishment.¹

Dr. Rettew

While there have always been those in psychiatry who have advocated for a broad emphasis that incorporates the full spectrum of mental health, there has been a surge of interest in the past 10-15 years, urging a focus on well-being and the tools that can help a person achieve it. This trend has variably been referred to as positive psychiatry, lifestyle psychiatry, and other terms.² As one might expect, child and adolescent psychiatry has been particularly fertile ground for such principles, and models such as the Vermont Family Based Approach have expanded the concept beyond the individual to the family and even community.³

It is important to note here that embracing the concept of well-being in treatment does not in any way require one to abandon the idea that genetic or environmental factors can lead to negative outcomes in brain development, nor does it mandate that one leaves behind important treatment modalities such as traditional psychotherapy and medication treatment. Further, this approach should not be confused with some “wellness” activities that offer quick fixes and lack scientific rigor. Positive psychiatry does, however, offer a third pathway to advance positive emotional behavioral growth, namely through health promotion activities ranging from exercise to good nutrition to positive parenting in ways that have been shown to benefit both those who are already doing fairly well as well as those who are actively struggling with significant psychiatric disorders.⁴

Primary care clinicians already have extensive familiarity talking about these kinds of health promoting activities with families. That said, it’s been my observation from many years of doing consultations and reviewing notes that these conversations happen almost exclusively during well-check visits and can get forgotten when a child presents with emotional behavioral challenges.

So how can the primary care clinician who is interested in more fully incorporating the burgeoning science on well-being work these principles into routine practice? Here are three suggestions.
 

Ask Some New Questions

It’s difficult to treat things that aren’t assessed. To best incorporate true mental health within one’s work with families, it can be very helpful to expand the regular questions one asks to include those that address some of the PERMA and health promotion areas described above. Some examples could include the following:

• Hopes. What would a perfect life look like for you when you’re older?
• Connection. Is there anything that you just love doing, so much so that time sometimes just seems to go away?
• Strengths. What are you good at? What good things would your friends say about you?
• Parenting. What are you most proud of as a parent, and where are your biggest challenges?
• Nutrition. What does a typical school day breakfast look like for you?
• Screens. Do you have any restrictions related to what you do on screens?
• Sleep. Tell me about your typical bedtime routine.

Add Some New Interventions

Counseling and medications can be powerful ways to bring improvement in a child’s life, but thinking about health promotion opens up a whole new avenue for intervention. This domain includes areas like physical activity, nutrition, sleep practices, parenting, participation in music and the arts, practicing kindness towards others, and mindfulness, among others.

For someone newly diagnosed with ADHD, for example, consider expanding your treatment plan to include not only medications but also specific guidance to exercise more, limit screen usage, practice good bedtime routines, eat a real breakfast, and reduce the helicopter parenting. Monitor these areas over time.

Another example relates to common sleep problems. Before making that melatonin recommendation, ask yourself if you understand what is happening in that child’s environment at night. Are they allowed to play video games until 2 a.m.? Are they taking naps during the day because they have nothing to do? Are they downing caffeinated drinks with dinner? Does the child get zero physical activity outside of the PE class? Maybe you still will need the melatonin, but perhaps other areas need to be addressed first.
 

Find Some New Colleagues

While it can be challenging sometimes to find anyone in mental health who sees new patients, there is value is finding out the approach and methodology that psychiatric clinicians and therapists apply in their practice. Working collaboratively with those who value a well-being orientation and who can work productively with the whole family to increase health promotion can yield benefits for a patient’s long-term physical and mental health.

The renewed interest and attention on well-being and health promotion activities that can optimize brain growth are a welcome and overdue development in mental health treatment. Pediatricians and other primary care clinicians can be a critical part of this growing initiative by gaining knowledge about youth well-being, applying this knowledge in day-to-day practice, and working collaboratively with those who share a similar perspective.
 

Dr. Rettew is a child & adolescent psychiatrist and medical director of Lane County Behavioral Health in Eugene, Oregon. He is on the psychiatry faculty at Oregon Health & Science University. You can follow him on Facebook and X @PediPsych. His latest book is Parenting Made Complicated: What Science Really Knows about the Greatest Debates of Early Childhood.

References

1. Seligman, MEP. Flourish: a visionary new understanding of happiness and well-being. New York: Simon & Schuster; 2011.

2. Jeste DV, Palmer BW. (Eds.). Positive psychiatry: a clinical handbook. Washington DC: American Psychiatric Publishing; 2015. doi: 10.1176/appi.books.9781615370818.

3. Hudziak J, Ivanova MY. The Vermont family based approach: Family based health promotion, illness prevention, and intervention. Child Adolesc Psychiatr Clin N Am. 2016 Apr;25(2):167-78. doi: 10.1016/j.chc.2015.11.002.

4. Rettew DC. Incorporating positive psychiatry with children and adolescents. Current Psychiatry. 2022 November;21(11):12-16,45. doi: 10.12788/cp.0303.

Psychiatry, like all medical disciplines, changes over time. For many decades, psychiatrists were primarily psychotherapists. As medications slowly became available, these became a second tool for treatment — so much so that by the 21st century many, if not most, psychiatrists saw themselves primarily as psychopharmacologists and diagnosticians who were skilled at identifying various forms of mental illness and using medications in the hopes of inducing a clinically meaningful “response” in symptoms. While still belonging to the umbrella category of a mental health professional, more and more psychiatrists trained and practiced as mental illness professionals.

Slowly, however, there have been stirrings within the field by many who have found the identity of the psychiatrist as a “prescriber” to be too narrow, and the current “med check” model of treatment too confining. This change was partly inspired by our colleagues in clinical psychology who were challenged in the 1990s by then American Psychological Association President Martin Seligman, PhD, to develop knowledge and expertise not only in alleviating mental suffering but also in promoting true mental well-being, a construct that still was often vaguely defined. One framework of well-being that was advanced at the time was the PERMA model, representing the five well-being dimensions of Positive emotions, Engagement, Relationships, Meaning, and Accomplishment.¹

Dr. Rettew

While there have always been those in psychiatry who have advocated for a broad emphasis that incorporates the full spectrum of mental health, there has been a surge of interest in the past 10-15 years, urging a focus on well-being and the tools that can help a person achieve it. This trend has variably been referred to as positive psychiatry, lifestyle psychiatry, and other terms.² As one might expect, child and adolescent psychiatry has been particularly fertile ground for such principles, and models such as the Vermont Family Based Approach have expanded the concept beyond the individual to the family and even community.³

It is important to note here that embracing the concept of well-being in treatment does not in any way require one to abandon the idea that genetic or environmental factors can lead to negative outcomes in brain development, nor does it mandate that one leaves behind important treatment modalities such as traditional psychotherapy and medication treatment. Further, this approach should not be confused with some “wellness” activities that offer quick fixes and lack scientific rigor. Positive psychiatry does, however, offer a third pathway to advance positive emotional behavioral growth, namely through health promotion activities ranging from exercise to good nutrition to positive parenting in ways that have been shown to benefit both those who are already doing fairly well as well as those who are actively struggling with significant psychiatric disorders.⁴

Primary care clinicians already have extensive familiarity talking about these kinds of health promoting activities with families. That said, it’s been my observation from many years of doing consultations and reviewing notes that these conversations happen almost exclusively during well-check visits and can get forgotten when a child presents with emotional behavioral challenges.

So how can the primary care clinician who is interested in more fully incorporating the burgeoning science on well-being work these principles into routine practice? Here are three suggestions.
 

Ask Some New Questions

It’s difficult to treat things that aren’t assessed. To best incorporate true mental health within one’s work with families, it can be very helpful to expand the regular questions one asks to include those that address some of the PERMA and health promotion areas described above. Some examples could include the following:

• Hopes. What would a perfect life look like for you when you’re older?
• Connection. Is there anything that you just love doing, so much so that time sometimes just seems to go away?
• Strengths. What are you good at? What good things would your friends say about you?
• Parenting. What are you most proud of as a parent, and where are your biggest challenges?
• Nutrition. What does a typical school day breakfast look like for you?
• Screens. Do you have any restrictions related to what you do on screens?
• Sleep. Tell me about your typical bedtime routine.

Add Some New Interventions

Counseling and medications can be powerful ways to bring improvement in a child’s life, but thinking about health promotion opens up a whole new avenue for intervention. This domain includes areas like physical activity, nutrition, sleep practices, parenting, participation in music and the arts, practicing kindness towards others, and mindfulness, among others.

For someone newly diagnosed with ADHD, for example, consider expanding your treatment plan to include not only medications but also specific guidance to exercise more, limit screen usage, practice good bedtime routines, eat a real breakfast, and reduce the helicopter parenting. Monitor these areas over time.

Another example relates to common sleep problems. Before making that melatonin recommendation, ask yourself if you understand what is happening in that child’s environment at night. Are they allowed to play video games until 2 a.m.? Are they taking naps during the day because they have nothing to do? Are they downing caffeinated drinks with dinner? Does the child get zero physical activity outside of the PE class? Maybe you still will need the melatonin, but perhaps other areas need to be addressed first.
 

Find Some New Colleagues

While it can be challenging sometimes to find anyone in mental health who sees new patients, there is value is finding out the approach and methodology that psychiatric clinicians and therapists apply in their practice. Working collaboratively with those who value a well-being orientation and who can work productively with the whole family to increase health promotion can yield benefits for a patient’s long-term physical and mental health.

The renewed interest and attention on well-being and health promotion activities that can optimize brain growth are a welcome and overdue development in mental health treatment. Pediatricians and other primary care clinicians can be a critical part of this growing initiative by gaining knowledge about youth well-being, applying this knowledge in day-to-day practice, and working collaboratively with those who share a similar perspective.
 

Dr. Rettew is a child & adolescent psychiatrist and medical director of Lane County Behavioral Health in Eugene, Oregon. He is on the psychiatry faculty at Oregon Health & Science University. You can follow him on Facebook and X @PediPsych. His latest book is Parenting Made Complicated: What Science Really Knows about the Greatest Debates of Early Childhood.

References

1. Seligman, MEP. Flourish: a visionary new understanding of happiness and well-being. New York: Simon & Schuster; 2011.

2. Jeste DV, Palmer BW. (Eds.). Positive psychiatry: a clinical handbook. Washington DC: American Psychiatric Publishing; 2015. doi: 10.1176/appi.books.9781615370818.

3. Hudziak J, Ivanova MY. The Vermont family based approach: Family based health promotion, illness prevention, and intervention. Child Adolesc Psychiatr Clin N Am. 2016 Apr;25(2):167-78. doi: 10.1016/j.chc.2015.11.002.

4. Rettew DC. Incorporating positive psychiatry with children and adolescents. Current Psychiatry. 2022 November;21(11):12-16,45. doi: 10.12788/cp.0303.

Psychiatry, like all medical disciplines, changes over time. For many decades, psychiatrists were primarily psychotherapists. As medications slowly became available, these became a second tool for treatment — so much so that by the 21st century many, if not most, psychiatrists saw themselves primarily as psychopharmacologists and diagnosticians who were skilled at identifying various forms of mental illness and using medications in the hopes of inducing a clinically meaningful “response” in symptoms. While still belonging to the umbrella category of a mental health professional, more and more psychiatrists trained and practiced as mental illness professionals.

Slowly, however, there have been stirrings within the field by many who have found the identity of the psychiatrist as a “prescriber” to be too narrow, and the current “med check” model of treatment too confining. This change was partly inspired by our colleagues in clinical psychology who were challenged in the 1990s by then American Psychological Association President Martin Seligman, PhD, to develop knowledge and expertise not only in alleviating mental suffering but also in promoting true mental well-being, a construct that still was often vaguely defined. One framework of well-being that was advanced at the time was the PERMA model, representing the five well-being dimensions of Positive emotions, Engagement, Relationships, Meaning, and Accomplishment.¹

Dr. Rettew

While there have always been those in psychiatry who have advocated for a broad emphasis that incorporates the full spectrum of mental health, there has been a surge of interest in the past 10-15 years, urging a focus on well-being and the tools that can help a person achieve it. This trend has variably been referred to as positive psychiatry, lifestyle psychiatry, and other terms.² As one might expect, child and adolescent psychiatry has been particularly fertile ground for such principles, and models such as the Vermont Family Based Approach have expanded the concept beyond the individual to the family and even community.³

It is important to note here that embracing the concept of well-being in treatment does not in any way require one to abandon the idea that genetic or environmental factors can lead to negative outcomes in brain development, nor does it mandate that one leaves behind important treatment modalities such as traditional psychotherapy and medication treatment. Further, this approach should not be confused with some “wellness” activities that offer quick fixes and lack scientific rigor. Positive psychiatry does, however, offer a third pathway to advance positive emotional behavioral growth, namely through health promotion activities ranging from exercise to good nutrition to positive parenting in ways that have been shown to benefit both those who are already doing fairly well as well as those who are actively struggling with significant psychiatric disorders.⁴

Primary care clinicians already have extensive familiarity talking about these kinds of health promoting activities with families. That said, it’s been my observation from many years of doing consultations and reviewing notes that these conversations happen almost exclusively during well-check visits and can get forgotten when a child presents with emotional behavioral challenges.

So how can the primary care clinician who is interested in more fully incorporating the burgeoning science on well-being work these principles into routine practice? Here are three suggestions.
 

Ask Some New Questions

It’s difficult to treat things that aren’t assessed. To best incorporate true mental health within one’s work with families, it can be very helpful to expand the regular questions one asks to include those that address some of the PERMA and health promotion areas described above. Some examples could include the following:

• Hopes. What would a perfect life look like for you when you’re older?
• Connection. Is there anything that you just love doing, so much so that time sometimes just seems to go away?
• Strengths. What are you good at? What good things would your friends say about you?
• Parenting. What are you most proud of as a parent, and where are your biggest challenges?
• Nutrition. What does a typical school day breakfast look like for you?
• Screens. Do you have any restrictions related to what you do on screens?
• Sleep. Tell me about your typical bedtime routine.

Add Some New Interventions

Counseling and medications can be powerful ways to bring improvement in a child’s life, but thinking about health promotion opens up a whole new avenue for intervention. This domain includes areas like physical activity, nutrition, sleep practices, parenting, participation in music and the arts, practicing kindness towards others, and mindfulness, among others.

For someone newly diagnosed with ADHD, for example, consider expanding your treatment plan to include not only medications but also specific guidance to exercise more, limit screen usage, practice good bedtime routines, eat a real breakfast, and reduce the helicopter parenting. Monitor these areas over time.

Another example relates to common sleep problems. Before making that melatonin recommendation, ask yourself if you understand what is happening in that child’s environment at night. Are they allowed to play video games until 2 a.m.? Are they taking naps during the day because they have nothing to do? Are they downing caffeinated drinks with dinner? Does the child get zero physical activity outside of the PE class? Maybe you still will need the melatonin, but perhaps other areas need to be addressed first.
 

Find Some New Colleagues

While it can be challenging sometimes to find anyone in mental health who sees new patients, there is value is finding out the approach and methodology that psychiatric clinicians and therapists apply in their practice. Working collaboratively with those who value a well-being orientation and who can work productively with the whole family to increase health promotion can yield benefits for a patient’s long-term physical and mental health.

The renewed interest and attention on well-being and health promotion activities that can optimize brain growth are a welcome and overdue development in mental health treatment. Pediatricians and other primary care clinicians can be a critical part of this growing initiative by gaining knowledge about youth well-being, applying this knowledge in day-to-day practice, and working collaboratively with those who share a similar perspective.
 

Dr. Rettew is a child & adolescent psychiatrist and medical director of Lane County Behavioral Health in Eugene, Oregon. He is on the psychiatry faculty at Oregon Health & Science University. You can follow him on Facebook and X @PediPsych. His latest book is Parenting Made Complicated: What Science Really Knows about the Greatest Debates of Early Childhood.

References

1. Seligman, MEP. Flourish: a visionary new understanding of happiness and well-being. New York: Simon & Schuster; 2011.

2. Jeste DV, Palmer BW. (Eds.). Positive psychiatry: a clinical handbook. Washington DC: American Psychiatric Publishing; 2015. doi: 10.1176/appi.books.9781615370818.

3. Hudziak J, Ivanova MY. The Vermont family based approach: Family based health promotion, illness prevention, and intervention. Child Adolesc Psychiatr Clin N Am. 2016 Apr;25(2):167-78. doi: 10.1016/j.chc.2015.11.002.

4. Rettew DC. Incorporating positive psychiatry with children and adolescents. Current Psychiatry. 2022 November;21(11):12-16,45. doi: 10.12788/cp.0303.

Maternal mental health has a profound impact on the health and wellbeing of the child. Since the onset of the pandemic, rates of postpartum depression have increased, affecting an estimated 1 in 5 women.¹ Numerous studies show the impact of postpartum depression on the newborn child across multiple domains, from bonding to healthy weight gain to meeting developmental milestones.

While new medications are being studied and approved to specifically target postpartum depression, these treatments are inaccessible to many because of high costs and long wait lists. Beyond medication, structural changes such as paid parental leave have been shown to have a substantial impact on maternal mental health, thus impacting the health of children as well. As physicians, it is imperative that we advocate for systems-level policy changes that have been shown to improve the health of both parent and child.

Implications for Mothers and Children

Psychiatric diagnoses such as postpartum depression are on the rise.^1,2 This is likely attributable to a combination of factors, including increased isolation since the start of the pandemic, worsening health inequities across race and socioeconomic status, and difficulty accessing mental health care.^3-5 The effect that postpartum depression has on the family is significant for the newborn as well as other children in the home.

Data suggest that postpartum depression impacts both the physical and mental health of the child. Infants of mothers with postpartum depression may experience challenges with weight gain, decreased breastfeeding, sleep disruptions, and delays in achieving developmental milestones.^6-9 They may also show decreased maternal infant bonding, challenges with cognitive development including language and IQ, and increased risk of behavioral disturbances.^10,11 These effects are likely attributable to a combination of factors, including decreased maternal responsiveness to infant cues.^7,12 Many of these effects are mediated by the chronicity and severity of depressive symptoms, suggesting the importance of screening and treatment of postpartum depression.^10,11 However, treatment for postpartum depression can be difficult to access, particularly given the increased level of need.

It is therefore critical to consider what structural interventions and policy changes can decrease the risk of developing postpartum depression. Data consistently show that access to paid parental leave improves maternal mental health outcomes. Among patients with access to parental leave, research shows that paid leave of longer duration, at least 2-3 months, is the most protective.¹³ Studies have identified decreased depressive symptoms, decreased stress, decreased use of mental health services, and decreased hospital admissions among women with longer parental leave.¹³ The positive effects of paid parental leave on maternal mental health can extend beyond the postpartum period, solidifying its impact on the long-term health outcomes of both mother and child.¹³
 

Advocacy Is Imperative

In 2024, the United States is the only high-income country, and one of only seven countries in the world, that does not guarantee access to paid parental leave. The Family Medical Leave Act is a 31-year-old federal law that requires some employers to provide unpaid leave to eligible employees. It is narrow in scope, and it excludes many low-wage workers and LGBTQ+ families. Thirteen states — California, Colorado, Connecticut, Delaware, Maine, Massachusetts, Maryland, Minnesota, New Jersey, New York, Oregon, Rhode Island, and Washington — as well as the District of Columbia, have enacted their own paid leave policies. However, there are no federal laws requiring access to paid parental leave. As of 2023, fewer than 30% of workers in the United States have access to paid parental leave, and only 16% of employees in the service industry have access to paid parental leave.¹⁴ This disproportionately affects families from lower income backgrounds, and further exacerbates socioeconomic, racial, and gender inequities. From a health systems lens, this increases risk of adverse maternal mental health outcomes among those who already have decreased access to mental health services, worsening health disparities.

Paid parental leave has strong public support across party lines, with polls showing the majority of Americans support comprehensive paid family and medical leave.¹⁵ Despite this, the United States has failed to enact legislation on this issue since 1993. Multiple attempts at expanding leave have not come to fruition. In the past year, both the house and the senate have announced bipartisan efforts to expand access to paid parental leave. However, legislative frameworks are still in early stages.

As physicians, it is crucial that we advocate for expanded access to paid parental leave. We must use our expertise to speak to the impact that paid parental leave can have on the mental and physical health of parents, children, and families. By advocating for paid parental leave, we can help create a more just and equitable healthcare system.
 

Dr. Shannon is a second-year psychiatry resident at University of California, Los Angeles. She attended Stanford University for her undergraduate degree and Dartmouth Geisel School of Medicine for medical school. Her interests include perinatal psychiatry, health systems research, and mental health policy advocacy. Dr. Richards is assistant clinical professor in the department of psychiatry and biobehavioral sciences; program director of the child and adolescent psychiatry fellowship; and associate medical director of the perinatal program at the UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles.

References

1. Wang Z et al. Mapping Global Prevalence of Depression Among Postpartum Women. Transl Psychiatry. 2021 Oct 20. doi: 10.1038/s41398-021-01663-6.

2. Iyengar U et al. One Year Into the Pandemic: A Systematic Review of Perinatal Mental Health Outcomes During COVID-19. Front Psychiatry. 2021 Jun 24. doi: 10.3389/fpsyt.2021.674194.

3. World Health Organization. Mental Health and COVID-19: Early Evidence of the Pandemic’s Impact: Scientific Brief. 2022 Mar 2. www.who.int/publications/i/item/WHO-2019-nCoV-Sci_Brief-Mental_health-2022.1.

4. Masters GA et al. Impact of the COVID-19 Pandemic on Mental Health, Access to Care, and Health Disparities in the Perinatal Period. J Psychiatr Res. 2021 May. doi: 10.1016/j.jpsychires.2021.02.056.

5. Shuffrey LC et al. Improving Perinatal Maternal Mental Health Starts With Addressing Structural Inequities. JAMA Psychiatry. 2022 May 1. doi: 10.1001/jamapsychiatry.2022.0097.

6. Lubotzky-Gete S et al. Postpartum Depression and Infant Development Up to 24 months: A Nationwide Population-Based Study. J Affect Disord. 2021 Apr 15. doi: 10.1016/j.jad.2021.02.042.

7. Saharoy R et al. Postpartum Depression and Maternal Care: Exploring the Complex Effects on Mothers and Infants. Cureus. 2023 Jul 4. doi: 10.7759/cureus.41381..

8. Gress-Smith JL et al. Postpartum Depression Prevalence and Impact on Infant Health, Weight, and Sleep in Low-Income and Ethnic Minority Women and Infants. Matern Child Health J. 2012 May. doi: 10.1007/s10995-011-0812-y.

9. Kim S et al. The Impact of Antepartum Depression and Postpartum Depression on Exclusive Breastfeeding: A Systematic Review and Meta-Analysis. Clin Nurs Res. 2022 Jun. doi: 10.1177/10547738211053507.

10. Mirhosseini H et al. Cognitive Behavioral Development in Children Following Maternal Postpartum Depression: A Review Article. Electron Physician. 2015 Dec 20. doi: 10.19082/1673.

11. Grace SL et al. The Effect of Postpartum Depression on Child Cognitive Development and Behavior: A Review and Critical Analysis of the Literature. Arch Womens Ment Health. 2003 Nov. doi: 10.1007/s00737-003-0024-6.

12. Milgrom J et al. The Mediating Role of Maternal Responsiveness in Some Longer Term Effects of Postnatal Depression on Infant Development. Infant Behavior and Development. 2004 Sep 11. doi.org/10.1016/j.infbeh.2004.03.003.

13. Heshmati A et al. The Effect of Parental Leave on Parents’ Mental Health: A Systematic Review. Lancet Public Health. 2023 Jan. doi: 10.1016/S2468-2667(22)00311-5.

14. U.S. Bureau of Labor Statistics, What Data Does the BLS Publish on Family Leave? 2023 Sept 21. www.bls.gov/ebs/factsheets/family-leave-benefits-fact-sheet.htm.

15. Horowitz JM et al. Americans Widely Support Paid Family and Medical Leave, But Differ Over Specific Policies. Pew Research Center’s Social & Demographic Trends Project, Pew Research Center. 2017 Mar 23. www.pewresearch.org/social-trends/2017/03/23/americans-widely-support-paid-family-and-medical-leave-but-differ-over-specific-policies/.

Maternal mental health has a profound impact on the health and wellbeing of the child. Since the onset of the pandemic, rates of postpartum depression have increased, affecting an estimated 1 in 5 women.¹ Numerous studies show the impact of postpartum depression on the newborn child across multiple domains, from bonding to healthy weight gain to meeting developmental milestones.

While new medications are being studied and approved to specifically target postpartum depression, these treatments are inaccessible to many because of high costs and long wait lists. Beyond medication, structural changes such as paid parental leave have been shown to have a substantial impact on maternal mental health, thus impacting the health of children as well. As physicians, it is imperative that we advocate for systems-level policy changes that have been shown to improve the health of both parent and child.

Implications for Mothers and Children

Psychiatric diagnoses such as postpartum depression are on the rise.^1,2 This is likely attributable to a combination of factors, including increased isolation since the start of the pandemic, worsening health inequities across race and socioeconomic status, and difficulty accessing mental health care.^3-5 The effect that postpartum depression has on the family is significant for the newborn as well as other children in the home.

Data suggest that postpartum depression impacts both the physical and mental health of the child. Infants of mothers with postpartum depression may experience challenges with weight gain, decreased breastfeeding, sleep disruptions, and delays in achieving developmental milestones.^6-9 They may also show decreased maternal infant bonding, challenges with cognitive development including language and IQ, and increased risk of behavioral disturbances.^10,11 These effects are likely attributable to a combination of factors, including decreased maternal responsiveness to infant cues.^7,12 Many of these effects are mediated by the chronicity and severity of depressive symptoms, suggesting the importance of screening and treatment of postpartum depression.^10,11 However, treatment for postpartum depression can be difficult to access, particularly given the increased level of need.

It is therefore critical to consider what structural interventions and policy changes can decrease the risk of developing postpartum depression. Data consistently show that access to paid parental leave improves maternal mental health outcomes. Among patients with access to parental leave, research shows that paid leave of longer duration, at least 2-3 months, is the most protective.¹³ Studies have identified decreased depressive symptoms, decreased stress, decreased use of mental health services, and decreased hospital admissions among women with longer parental leave.¹³ The positive effects of paid parental leave on maternal mental health can extend beyond the postpartum period, solidifying its impact on the long-term health outcomes of both mother and child.¹³
 

Advocacy Is Imperative

In 2024, the United States is the only high-income country, and one of only seven countries in the world, that does not guarantee access to paid parental leave. The Family Medical Leave Act is a 31-year-old federal law that requires some employers to provide unpaid leave to eligible employees. It is narrow in scope, and it excludes many low-wage workers and LGBTQ+ families. Thirteen states — California, Colorado, Connecticut, Delaware, Maine, Massachusetts, Maryland, Minnesota, New Jersey, New York, Oregon, Rhode Island, and Washington — as well as the District of Columbia, have enacted their own paid leave policies. However, there are no federal laws requiring access to paid parental leave. As of 2023, fewer than 30% of workers in the United States have access to paid parental leave, and only 16% of employees in the service industry have access to paid parental leave.¹⁴ This disproportionately affects families from lower income backgrounds, and further exacerbates socioeconomic, racial, and gender inequities. From a health systems lens, this increases risk of adverse maternal mental health outcomes among those who already have decreased access to mental health services, worsening health disparities.

Paid parental leave has strong public support across party lines, with polls showing the majority of Americans support comprehensive paid family and medical leave.¹⁵ Despite this, the United States has failed to enact legislation on this issue since 1993. Multiple attempts at expanding leave have not come to fruition. In the past year, both the house and the senate have announced bipartisan efforts to expand access to paid parental leave. However, legislative frameworks are still in early stages.

As physicians, it is crucial that we advocate for expanded access to paid parental leave. We must use our expertise to speak to the impact that paid parental leave can have on the mental and physical health of parents, children, and families. By advocating for paid parental leave, we can help create a more just and equitable healthcare system.
 

Dr. Shannon is a second-year psychiatry resident at University of California, Los Angeles. She attended Stanford University for her undergraduate degree and Dartmouth Geisel School of Medicine for medical school. Her interests include perinatal psychiatry, health systems research, and mental health policy advocacy. Dr. Richards is assistant clinical professor in the department of psychiatry and biobehavioral sciences; program director of the child and adolescent psychiatry fellowship; and associate medical director of the perinatal program at the UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles.

References

1. Wang Z et al. Mapping Global Prevalence of Depression Among Postpartum Women. Transl Psychiatry. 2021 Oct 20. doi: 10.1038/s41398-021-01663-6.

2. Iyengar U et al. One Year Into the Pandemic: A Systematic Review of Perinatal Mental Health Outcomes During COVID-19. Front Psychiatry. 2021 Jun 24. doi: 10.3389/fpsyt.2021.674194.

3. World Health Organization. Mental Health and COVID-19: Early Evidence of the Pandemic’s Impact: Scientific Brief. 2022 Mar 2. www.who.int/publications/i/item/WHO-2019-nCoV-Sci_Brief-Mental_health-2022.1.

4. Masters GA et al. Impact of the COVID-19 Pandemic on Mental Health, Access to Care, and Health Disparities in the Perinatal Period. J Psychiatr Res. 2021 May. doi: 10.1016/j.jpsychires.2021.02.056.

5. Shuffrey LC et al. Improving Perinatal Maternal Mental Health Starts With Addressing Structural Inequities. JAMA Psychiatry. 2022 May 1. doi: 10.1001/jamapsychiatry.2022.0097.

6. Lubotzky-Gete S et al. Postpartum Depression and Infant Development Up to 24 months: A Nationwide Population-Based Study. J Affect Disord. 2021 Apr 15. doi: 10.1016/j.jad.2021.02.042.

7. Saharoy R et al. Postpartum Depression and Maternal Care: Exploring the Complex Effects on Mothers and Infants. Cureus. 2023 Jul 4. doi: 10.7759/cureus.41381..

8. Gress-Smith JL et al. Postpartum Depression Prevalence and Impact on Infant Health, Weight, and Sleep in Low-Income and Ethnic Minority Women and Infants. Matern Child Health J. 2012 May. doi: 10.1007/s10995-011-0812-y.

9. Kim S et al. The Impact of Antepartum Depression and Postpartum Depression on Exclusive Breastfeeding: A Systematic Review and Meta-Analysis. Clin Nurs Res. 2022 Jun. doi: 10.1177/10547738211053507.

10. Mirhosseini H et al. Cognitive Behavioral Development in Children Following Maternal Postpartum Depression: A Review Article. Electron Physician. 2015 Dec 20. doi: 10.19082/1673.

11. Grace SL et al. The Effect of Postpartum Depression on Child Cognitive Development and Behavior: A Review and Critical Analysis of the Literature. Arch Womens Ment Health. 2003 Nov. doi: 10.1007/s00737-003-0024-6.

12. Milgrom J et al. The Mediating Role of Maternal Responsiveness in Some Longer Term Effects of Postnatal Depression on Infant Development. Infant Behavior and Development. 2004 Sep 11. doi.org/10.1016/j.infbeh.2004.03.003.

13. Heshmati A et al. The Effect of Parental Leave on Parents’ Mental Health: A Systematic Review. Lancet Public Health. 2023 Jan. doi: 10.1016/S2468-2667(22)00311-5.

14. U.S. Bureau of Labor Statistics, What Data Does the BLS Publish on Family Leave? 2023 Sept 21. www.bls.gov/ebs/factsheets/family-leave-benefits-fact-sheet.htm.

15. Horowitz JM et al. Americans Widely Support Paid Family and Medical Leave, But Differ Over Specific Policies. Pew Research Center’s Social & Demographic Trends Project, Pew Research Center. 2017 Mar 23. www.pewresearch.org/social-trends/2017/03/23/americans-widely-support-paid-family-and-medical-leave-but-differ-over-specific-policies/.

Maternal mental health has a profound impact on the health and wellbeing of the child. Since the onset of the pandemic, rates of postpartum depression have increased, affecting an estimated 1 in 5 women.¹ Numerous studies show the impact of postpartum depression on the newborn child across multiple domains, from bonding to healthy weight gain to meeting developmental milestones.

While new medications are being studied and approved to specifically target postpartum depression, these treatments are inaccessible to many because of high costs and long wait lists. Beyond medication, structural changes such as paid parental leave have been shown to have a substantial impact on maternal mental health, thus impacting the health of children as well. As physicians, it is imperative that we advocate for systems-level policy changes that have been shown to improve the health of both parent and child.

Implications for Mothers and Children

Psychiatric diagnoses such as postpartum depression are on the rise.^1,2 This is likely attributable to a combination of factors, including increased isolation since the start of the pandemic, worsening health inequities across race and socioeconomic status, and difficulty accessing mental health care.^3-5 The effect that postpartum depression has on the family is significant for the newborn as well as other children in the home.

Data suggest that postpartum depression impacts both the physical and mental health of the child. Infants of mothers with postpartum depression may experience challenges with weight gain, decreased breastfeeding, sleep disruptions, and delays in achieving developmental milestones.^6-9 They may also show decreased maternal infant bonding, challenges with cognitive development including language and IQ, and increased risk of behavioral disturbances.^10,11 These effects are likely attributable to a combination of factors, including decreased maternal responsiveness to infant cues.^7,12 Many of these effects are mediated by the chronicity and severity of depressive symptoms, suggesting the importance of screening and treatment of postpartum depression.^10,11 However, treatment for postpartum depression can be difficult to access, particularly given the increased level of need.

It is therefore critical to consider what structural interventions and policy changes can decrease the risk of developing postpartum depression. Data consistently show that access to paid parental leave improves maternal mental health outcomes. Among patients with access to parental leave, research shows that paid leave of longer duration, at least 2-3 months, is the most protective.¹³ Studies have identified decreased depressive symptoms, decreased stress, decreased use of mental health services, and decreased hospital admissions among women with longer parental leave.¹³ The positive effects of paid parental leave on maternal mental health can extend beyond the postpartum period, solidifying its impact on the long-term health outcomes of both mother and child.¹³
 

Advocacy Is Imperative

In 2024, the United States is the only high-income country, and one of only seven countries in the world, that does not guarantee access to paid parental leave. The Family Medical Leave Act is a 31-year-old federal law that requires some employers to provide unpaid leave to eligible employees. It is narrow in scope, and it excludes many low-wage workers and LGBTQ+ families. Thirteen states — California, Colorado, Connecticut, Delaware, Maine, Massachusetts, Maryland, Minnesota, New Jersey, New York, Oregon, Rhode Island, and Washington — as well as the District of Columbia, have enacted their own paid leave policies. However, there are no federal laws requiring access to paid parental leave. As of 2023, fewer than 30% of workers in the United States have access to paid parental leave, and only 16% of employees in the service industry have access to paid parental leave.¹⁴ This disproportionately affects families from lower income backgrounds, and further exacerbates socioeconomic, racial, and gender inequities. From a health systems lens, this increases risk of adverse maternal mental health outcomes among those who already have decreased access to mental health services, worsening health disparities.

Paid parental leave has strong public support across party lines, with polls showing the majority of Americans support comprehensive paid family and medical leave.¹⁵ Despite this, the United States has failed to enact legislation on this issue since 1993. Multiple attempts at expanding leave have not come to fruition. In the past year, both the house and the senate have announced bipartisan efforts to expand access to paid parental leave. However, legislative frameworks are still in early stages.

As physicians, it is crucial that we advocate for expanded access to paid parental leave. We must use our expertise to speak to the impact that paid parental leave can have on the mental and physical health of parents, children, and families. By advocating for paid parental leave, we can help create a more just and equitable healthcare system.
 

Dr. Shannon is a second-year psychiatry resident at University of California, Los Angeles. She attended Stanford University for her undergraduate degree and Dartmouth Geisel School of Medicine for medical school. Her interests include perinatal psychiatry, health systems research, and mental health policy advocacy. Dr. Richards is assistant clinical professor in the department of psychiatry and biobehavioral sciences; program director of the child and adolescent psychiatry fellowship; and associate medical director of the perinatal program at the UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles.

References

1. Wang Z et al. Mapping Global Prevalence of Depression Among Postpartum Women. Transl Psychiatry. 2021 Oct 20. doi: 10.1038/s41398-021-01663-6.

2. Iyengar U et al. One Year Into the Pandemic: A Systematic Review of Perinatal Mental Health Outcomes During COVID-19. Front Psychiatry. 2021 Jun 24. doi: 10.3389/fpsyt.2021.674194.

3. World Health Organization. Mental Health and COVID-19: Early Evidence of the Pandemic’s Impact: Scientific Brief. 2022 Mar 2. www.who.int/publications/i/item/WHO-2019-nCoV-Sci_Brief-Mental_health-2022.1.

4. Masters GA et al. Impact of the COVID-19 Pandemic on Mental Health, Access to Care, and Health Disparities in the Perinatal Period. J Psychiatr Res. 2021 May. doi: 10.1016/j.jpsychires.2021.02.056.

5. Shuffrey LC et al. Improving Perinatal Maternal Mental Health Starts With Addressing Structural Inequities. JAMA Psychiatry. 2022 May 1. doi: 10.1001/jamapsychiatry.2022.0097.

6. Lubotzky-Gete S et al. Postpartum Depression and Infant Development Up to 24 months: A Nationwide Population-Based Study. J Affect Disord. 2021 Apr 15. doi: 10.1016/j.jad.2021.02.042.

7. Saharoy R et al. Postpartum Depression and Maternal Care: Exploring the Complex Effects on Mothers and Infants. Cureus. 2023 Jul 4. doi: 10.7759/cureus.41381..

8. Gress-Smith JL et al. Postpartum Depression Prevalence and Impact on Infant Health, Weight, and Sleep in Low-Income and Ethnic Minority Women and Infants. Matern Child Health J. 2012 May. doi: 10.1007/s10995-011-0812-y.

9. Kim S et al. The Impact of Antepartum Depression and Postpartum Depression on Exclusive Breastfeeding: A Systematic Review and Meta-Analysis. Clin Nurs Res. 2022 Jun. doi: 10.1177/10547738211053507.

10. Mirhosseini H et al. Cognitive Behavioral Development in Children Following Maternal Postpartum Depression: A Review Article. Electron Physician. 2015 Dec 20. doi: 10.19082/1673.

11. Grace SL et al. The Effect of Postpartum Depression on Child Cognitive Development and Behavior: A Review and Critical Analysis of the Literature. Arch Womens Ment Health. 2003 Nov. doi: 10.1007/s00737-003-0024-6.

12. Milgrom J et al. The Mediating Role of Maternal Responsiveness in Some Longer Term Effects of Postnatal Depression on Infant Development. Infant Behavior and Development. 2004 Sep 11. doi.org/10.1016/j.infbeh.2004.03.003.

13. Heshmati A et al. The Effect of Parental Leave on Parents’ Mental Health: A Systematic Review. Lancet Public Health. 2023 Jan. doi: 10.1016/S2468-2667(22)00311-5.

14. U.S. Bureau of Labor Statistics, What Data Does the BLS Publish on Family Leave? 2023 Sept 21. www.bls.gov/ebs/factsheets/family-leave-benefits-fact-sheet.htm.

15. Horowitz JM et al. Americans Widely Support Paid Family and Medical Leave, But Differ Over Specific Policies. Pew Research Center’s Social & Demographic Trends Project, Pew Research Center. 2017 Mar 23. www.pewresearch.org/social-trends/2017/03/23/americans-widely-support-paid-family-and-medical-leave-but-differ-over-specific-policies/.

In my previous article, “Mental Health Characteristics of Refugee Children,” we learned that in recent decades, refugeeism has become a growing problem that disproportionately affects children. Refugee children and their families experience a variety of traumas, often sustained across years and even decades, because of armed conflict, persecution, social upheavals, or environmental disasters. Refugees are at greater risks for PTSD and affective and psychotic disorders presumably due to increased traumatic life events before, during, and after migration. I used my own experience as a child refugee from Vietnam to elucidate the stressors evident in various phases of forced displacement.¹

Risk Factors and Protective Factors

To a certain extent, the experiences of refugees are universal. All refugees experience some sort of humanitarian crisis that forces an emergent escape from their home across international borders to a new resettlement area. It is important to note that internally displaced people do not meet the United Nations’ (UN) official designation of refugee status; however, some agencies use a broader definition where they are designated as such.^2,3 We will refer to those not meeting the UN criteria as displaced people, while refugees are those that do meet the UN criteria. Dr. Mina Fazel’s 2012 systematic review in The Lancet of mental health risk factors and protective factors for displaced and refugee children is the most comprehensive of its kind.⁴ It will be summarized in this section with some relevant personal reflection.

In terms of risk factors, external displacement likely results in additional stress and trauma, presumably from the lack of assess to one’s culture and the host country’s language. Understandably, this makes rebuilding of one’s life more difficult. Several studies show that displaced/refugee children experience more difficulty with psychosocial adaptation than non-displaced children. Violence, directly experienced or indirectly feared, both to the child and their parents, was the strongest predictor of mental health problems and withdrawn behavior. Children who were separated from their parents clearly fared worst in their mental health than those who did not, which is not surprising given the nature of their dependence on caregivers for protection and guidance. During resettlement, experienced or perceived discrimination from the host country was also a risk factor, as well as instability in housing and a drawn-out resettlement process. Female sex was a risk factor mainly for emotional problems. Poor financial support post-migration is associated with depression, but it is unclear whether pre-migration financial status was protective. From my own experience, it is likely not, given that once one becomes a refugee one does not have access to one’s wealth, except that which could be hidden on one’s body. Another risk factor was also if one’s parent had psychiatric problems or was single. Due to the migration, my mother was separated permanently from her husband, which caused her extraordinary isolation and loneliness, something that was palpably felt by myself as I grew up.

In terms of protective factors, family cohesion and cultural continuity appear critical. For myself, not only would I not have survived without my mother and aunt, but they constantly protected me from the harsh realities. My mother would distract me with seemingly trivial goals once we got to America, like finally tasting a hamburger, or talking about school and being reunited with my uncle. This is in line with another finding — that children have better mental health outcomes when their parents do not talk about their hardships. Once my family was resettled with my uncle and his family, they played a critical role in smoothing our transition, not only by providing us with housing, but also cultural knowledge. Cultural havens can restore some of the social position and way of life that refugees lose when they are able to reconnect with a society that recognizes their previous achievements and status. Finally, religion also seemed to be a protective factor.
 

Mental Health Interventions

In 2018, Dr. Fazel identified mental health interventions for refugee children in a narrative review.⁵ She acknowledged that these conclusions are limited by the paucity of preventive mental health research in children in general, as well as the mobile nature and complex cultural differences of refugee children. This is exacerbated by the small evidence base. Given that, she makes these recommendations for varying levels of interventions: individual, group, family, living circumstances, social interactions, and school.

On an individual level, effective interventions developed to address PTSD include narrative exposure therapy, trauma-focused cognitive behavior therapy, and eye-movement and desensitization therapy. Group-based interventions for trauma, for example school-based PTSD intervention programs in conflicted areas, have either been shown to not be effective, or only effective for reducing depression. The mental health of unaccompanied children separated from family fare better when placed in foster care, rather than other types of social support. This is further enhanced if the foster family is the same ethnicity.

On a family level, improvements in parenting style and parental mental health, family engagement with local culture and structures, and family-based mental health interventions all positively impact refugee children. Not surprisingly, refugee parents have a greater prevalence of mental health conditions. Several studies on refugeeism point out a greater occurrence of intimate partner violence (that negatively affects children) as well has harsher discipline and maltreatment of refugee children. Thus, mental health treatment for parents also directly improves the well-being of their children. Teaching parenting skills to mitigate the violent effect of their PTSD symptoms, as well as parenting classes that teach gentler styles, have been shown to reduce harsh parenting and mitigate aggressive behaviors in these children. These improvements are enhanced when these classes are taught by other refugees themselves.

School is key for helping refugee children since it is a site where they can access language proficiency, successful acculturation, and medical and mental health services. Several studies have identified the positive effects of better parental engagement with school, resulting in improved academic performance and reduced levels of depressive and PTSD symptoms. A review of learning problems in refugee children identified several factors for success. These include high academic and life ambition, parental involvement in education, accurate educational assessment and grade placement, teacher understanding of linguistic and cultural heritage, culturally appropriate school transition, supportive peer relationships, and successful acculturation. School certainly was key for my acculturation and language proficiency. When I arrived at 6 years old I was selectively mute for my year in first grade, namely because I did not know how to speak English and because I did not share the culture. However, my teacher correctly identified my deficiency and chose to place me in kindergarten, which allowed me the time to gain English proficiency. Though I was always the oldest one in class, that remediation was key in allowing eventual success in school leading up to my admission to UC Berkeley.
 

Summary

In recent decades, refugeeism has become a growing problem that disproportionately affects children leading to traumas sustained across years and even decades, and greater risks for PTSD, as well as affective and psychotic disorders. Risk factors include the experience of violence, the separation from family, female gender, discrimination in the host country, unstable housing, and a drawn-out resettlement process. Protective factors consist of family cohesion, cultural continuity, support at schools, being protected from the truth of their harsh reality, stable housing, language acquisition, and quick resettlement. From these factors, effective mental interventions have been found to be the promotion of these protective factors as well as support for parental mental health and parenting skills, better parental engagement at school, and schools that correctly identify and address these children’s educational needs.

Dr. Nguyen is a second-year resident at UCSF Fresno Psychiatry Residency. He was a public high school English teacher for 15 years previously.*

References

1. Nguyen D. Mental Health Characteristics of Refugee Children. Pediatric News. 2023 Nov. 14. https://www.mdedge.com/pediatrics/article/266518/mental-health/mental-health-characteristics-refugee-children.

2. Office of the United Nations High Commissioner for Refugees. The Refugee Concept Under International Law. Global Compact for Safe, Orderly and Regular Migration. 2018 March 8. https://www.unhcr.org/sites/default/files/legacy-pdf/5aa290937.pdf.

3. Winer JP. Mental Health Practice with Immigrant and Refugee Youth [Power Point Slides]. Michigan Medicine. 2021 June 24. https://www.youtube.com/watch?v=ICkg4132SQY

4. Fazel M et al. Mental Health of Displaced and Refugee Children Resettled in High-Income Countries: Risk and Protective Factors. Lancet. 2012 Jan 21;379(9812):266-282. doi: 10.1016/S0140-6736(11)60051-2.

5. Fazel M, Betancourt TS. Preventive Mental Health Interventions for Refugee Children and Adolescents in High-Income Settings. Lancet Child Adolesc Health. 2018 Feb;2(2):121-132. doi: 10.1016/S2352-4642(17)30147-5.

*Correction, 2/27: An earlier version of this article misstated Dr. Nguyen's affiliation.

In my previous article, “Mental Health Characteristics of Refugee Children,” we learned that in recent decades, refugeeism has become a growing problem that disproportionately affects children. Refugee children and their families experience a variety of traumas, often sustained across years and even decades, because of armed conflict, persecution, social upheavals, or environmental disasters. Refugees are at greater risks for PTSD and affective and psychotic disorders presumably due to increased traumatic life events before, during, and after migration. I used my own experience as a child refugee from Vietnam to elucidate the stressors evident in various phases of forced displacement.¹

Risk Factors and Protective Factors

To a certain extent, the experiences of refugees are universal. All refugees experience some sort of humanitarian crisis that forces an emergent escape from their home across international borders to a new resettlement area. It is important to note that internally displaced people do not meet the United Nations’ (UN) official designation of refugee status; however, some agencies use a broader definition where they are designated as such.^2,3 We will refer to those not meeting the UN criteria as displaced people, while refugees are those that do meet the UN criteria. Dr. Mina Fazel’s 2012 systematic review in The Lancet of mental health risk factors and protective factors for displaced and refugee children is the most comprehensive of its kind.⁴ It will be summarized in this section with some relevant personal reflection.

In terms of risk factors, external displacement likely results in additional stress and trauma, presumably from the lack of assess to one’s culture and the host country’s language. Understandably, this makes rebuilding of one’s life more difficult. Several studies show that displaced/refugee children experience more difficulty with psychosocial adaptation than non-displaced children. Violence, directly experienced or indirectly feared, both to the child and their parents, was the strongest predictor of mental health problems and withdrawn behavior. Children who were separated from their parents clearly fared worst in their mental health than those who did not, which is not surprising given the nature of their dependence on caregivers for protection and guidance. During resettlement, experienced or perceived discrimination from the host country was also a risk factor, as well as instability in housing and a drawn-out resettlement process. Female sex was a risk factor mainly for emotional problems. Poor financial support post-migration is associated with depression, but it is unclear whether pre-migration financial status was protective. From my own experience, it is likely not, given that once one becomes a refugee one does not have access to one’s wealth, except that which could be hidden on one’s body. Another risk factor was also if one’s parent had psychiatric problems or was single. Due to the migration, my mother was separated permanently from her husband, which caused her extraordinary isolation and loneliness, something that was palpably felt by myself as I grew up.

In terms of protective factors, family cohesion and cultural continuity appear critical. For myself, not only would I not have survived without my mother and aunt, but they constantly protected me from the harsh realities. My mother would distract me with seemingly trivial goals once we got to America, like finally tasting a hamburger, or talking about school and being reunited with my uncle. This is in line with another finding — that children have better mental health outcomes when their parents do not talk about their hardships. Once my family was resettled with my uncle and his family, they played a critical role in smoothing our transition, not only by providing us with housing, but also cultural knowledge. Cultural havens can restore some of the social position and way of life that refugees lose when they are able to reconnect with a society that recognizes their previous achievements and status. Finally, religion also seemed to be a protective factor.
 

Mental Health Interventions

In 2018, Dr. Fazel identified mental health interventions for refugee children in a narrative review.⁵ She acknowledged that these conclusions are limited by the paucity of preventive mental health research in children in general, as well as the mobile nature and complex cultural differences of refugee children. This is exacerbated by the small evidence base. Given that, she makes these recommendations for varying levels of interventions: individual, group, family, living circumstances, social interactions, and school.

On an individual level, effective interventions developed to address PTSD include narrative exposure therapy, trauma-focused cognitive behavior therapy, and eye-movement and desensitization therapy. Group-based interventions for trauma, for example school-based PTSD intervention programs in conflicted areas, have either been shown to not be effective, or only effective for reducing depression. The mental health of unaccompanied children separated from family fare better when placed in foster care, rather than other types of social support. This is further enhanced if the foster family is the same ethnicity.

On a family level, improvements in parenting style and parental mental health, family engagement with local culture and structures, and family-based mental health interventions all positively impact refugee children. Not surprisingly, refugee parents have a greater prevalence of mental health conditions. Several studies on refugeeism point out a greater occurrence of intimate partner violence (that negatively affects children) as well has harsher discipline and maltreatment of refugee children. Thus, mental health treatment for parents also directly improves the well-being of their children. Teaching parenting skills to mitigate the violent effect of their PTSD symptoms, as well as parenting classes that teach gentler styles, have been shown to reduce harsh parenting and mitigate aggressive behaviors in these children. These improvements are enhanced when these classes are taught by other refugees themselves.

School is key for helping refugee children since it is a site where they can access language proficiency, successful acculturation, and medical and mental health services. Several studies have identified the positive effects of better parental engagement with school, resulting in improved academic performance and reduced levels of depressive and PTSD symptoms. A review of learning problems in refugee children identified several factors for success. These include high academic and life ambition, parental involvement in education, accurate educational assessment and grade placement, teacher understanding of linguistic and cultural heritage, culturally appropriate school transition, supportive peer relationships, and successful acculturation. School certainly was key for my acculturation and language proficiency. When I arrived at 6 years old I was selectively mute for my year in first grade, namely because I did not know how to speak English and because I did not share the culture. However, my teacher correctly identified my deficiency and chose to place me in kindergarten, which allowed me the time to gain English proficiency. Though I was always the oldest one in class, that remediation was key in allowing eventual success in school leading up to my admission to UC Berkeley.
 

Summary

In recent decades, refugeeism has become a growing problem that disproportionately affects children leading to traumas sustained across years and even decades, and greater risks for PTSD, as well as affective and psychotic disorders. Risk factors include the experience of violence, the separation from family, female gender, discrimination in the host country, unstable housing, and a drawn-out resettlement process. Protective factors consist of family cohesion, cultural continuity, support at schools, being protected from the truth of their harsh reality, stable housing, language acquisition, and quick resettlement. From these factors, effective mental interventions have been found to be the promotion of these protective factors as well as support for parental mental health and parenting skills, better parental engagement at school, and schools that correctly identify and address these children’s educational needs.

Dr. Nguyen is a second-year resident at UCSF Fresno Psychiatry Residency. He was a public high school English teacher for 15 years previously.*

References

1. Nguyen D. Mental Health Characteristics of Refugee Children. Pediatric News. 2023 Nov. 14. https://www.mdedge.com/pediatrics/article/266518/mental-health/mental-health-characteristics-refugee-children.

2. Office of the United Nations High Commissioner for Refugees. The Refugee Concept Under International Law. Global Compact for Safe, Orderly and Regular Migration. 2018 March 8. https://www.unhcr.org/sites/default/files/legacy-pdf/5aa290937.pdf.

3. Winer JP. Mental Health Practice with Immigrant and Refugee Youth [Power Point Slides]. Michigan Medicine. 2021 June 24. https://www.youtube.com/watch?v=ICkg4132SQY

4. Fazel M et al. Mental Health of Displaced and Refugee Children Resettled in High-Income Countries: Risk and Protective Factors. Lancet. 2012 Jan 21;379(9812):266-282. doi: 10.1016/S0140-6736(11)60051-2.

5. Fazel M, Betancourt TS. Preventive Mental Health Interventions for Refugee Children and Adolescents in High-Income Settings. Lancet Child Adolesc Health. 2018 Feb;2(2):121-132. doi: 10.1016/S2352-4642(17)30147-5.

*Correction, 2/27: An earlier version of this article misstated Dr. Nguyen's affiliation.

In my previous article, “Mental Health Characteristics of Refugee Children,” we learned that in recent decades, refugeeism has become a growing problem that disproportionately affects children. Refugee children and their families experience a variety of traumas, often sustained across years and even decades, because of armed conflict, persecution, social upheavals, or environmental disasters. Refugees are at greater risks for PTSD and affective and psychotic disorders presumably due to increased traumatic life events before, during, and after migration. I used my own experience as a child refugee from Vietnam to elucidate the stressors evident in various phases of forced displacement.¹

Risk Factors and Protective Factors

To a certain extent, the experiences of refugees are universal. All refugees experience some sort of humanitarian crisis that forces an emergent escape from their home across international borders to a new resettlement area. It is important to note that internally displaced people do not meet the United Nations’ (UN) official designation of refugee status; however, some agencies use a broader definition where they are designated as such.^2,3 We will refer to those not meeting the UN criteria as displaced people, while refugees are those that do meet the UN criteria. Dr. Mina Fazel’s 2012 systematic review in The Lancet of mental health risk factors and protective factors for displaced and refugee children is the most comprehensive of its kind.⁴ It will be summarized in this section with some relevant personal reflection.

In terms of risk factors, external displacement likely results in additional stress and trauma, presumably from the lack of assess to one’s culture and the host country’s language. Understandably, this makes rebuilding of one’s life more difficult. Several studies show that displaced/refugee children experience more difficulty with psychosocial adaptation than non-displaced children. Violence, directly experienced or indirectly feared, both to the child and their parents, was the strongest predictor of mental health problems and withdrawn behavior. Children who were separated from their parents clearly fared worst in their mental health than those who did not, which is not surprising given the nature of their dependence on caregivers for protection and guidance. During resettlement, experienced or perceived discrimination from the host country was also a risk factor, as well as instability in housing and a drawn-out resettlement process. Female sex was a risk factor mainly for emotional problems. Poor financial support post-migration is associated with depression, but it is unclear whether pre-migration financial status was protective. From my own experience, it is likely not, given that once one becomes a refugee one does not have access to one’s wealth, except that which could be hidden on one’s body. Another risk factor was also if one’s parent had psychiatric problems or was single. Due to the migration, my mother was separated permanently from her husband, which caused her extraordinary isolation and loneliness, something that was palpably felt by myself as I grew up.

In terms of protective factors, family cohesion and cultural continuity appear critical. For myself, not only would I not have survived without my mother and aunt, but they constantly protected me from the harsh realities. My mother would distract me with seemingly trivial goals once we got to America, like finally tasting a hamburger, or talking about school and being reunited with my uncle. This is in line with another finding — that children have better mental health outcomes when their parents do not talk about their hardships. Once my family was resettled with my uncle and his family, they played a critical role in smoothing our transition, not only by providing us with housing, but also cultural knowledge. Cultural havens can restore some of the social position and way of life that refugees lose when they are able to reconnect with a society that recognizes their previous achievements and status. Finally, religion also seemed to be a protective factor.
 

Mental Health Interventions

In 2018, Dr. Fazel identified mental health interventions for refugee children in a narrative review.⁵ She acknowledged that these conclusions are limited by the paucity of preventive mental health research in children in general, as well as the mobile nature and complex cultural differences of refugee children. This is exacerbated by the small evidence base. Given that, she makes these recommendations for varying levels of interventions: individual, group, family, living circumstances, social interactions, and school.

On an individual level, effective interventions developed to address PTSD include narrative exposure therapy, trauma-focused cognitive behavior therapy, and eye-movement and desensitization therapy. Group-based interventions for trauma, for example school-based PTSD intervention programs in conflicted areas, have either been shown to not be effective, or only effective for reducing depression. The mental health of unaccompanied children separated from family fare better when placed in foster care, rather than other types of social support. This is further enhanced if the foster family is the same ethnicity.

On a family level, improvements in parenting style and parental mental health, family engagement with local culture and structures, and family-based mental health interventions all positively impact refugee children. Not surprisingly, refugee parents have a greater prevalence of mental health conditions. Several studies on refugeeism point out a greater occurrence of intimate partner violence (that negatively affects children) as well has harsher discipline and maltreatment of refugee children. Thus, mental health treatment for parents also directly improves the well-being of their children. Teaching parenting skills to mitigate the violent effect of their PTSD symptoms, as well as parenting classes that teach gentler styles, have been shown to reduce harsh parenting and mitigate aggressive behaviors in these children. These improvements are enhanced when these classes are taught by other refugees themselves.

School is key for helping refugee children since it is a site where they can access language proficiency, successful acculturation, and medical and mental health services. Several studies have identified the positive effects of better parental engagement with school, resulting in improved academic performance and reduced levels of depressive and PTSD symptoms. A review of learning problems in refugee children identified several factors for success. These include high academic and life ambition, parental involvement in education, accurate educational assessment and grade placement, teacher understanding of linguistic and cultural heritage, culturally appropriate school transition, supportive peer relationships, and successful acculturation. School certainly was key for my acculturation and language proficiency. When I arrived at 6 years old I was selectively mute for my year in first grade, namely because I did not know how to speak English and because I did not share the culture. However, my teacher correctly identified my deficiency and chose to place me in kindergarten, which allowed me the time to gain English proficiency. Though I was always the oldest one in class, that remediation was key in allowing eventual success in school leading up to my admission to UC Berkeley.
 

Summary

In recent decades, refugeeism has become a growing problem that disproportionately affects children leading to traumas sustained across years and even decades, and greater risks for PTSD, as well as affective and psychotic disorders. Risk factors include the experience of violence, the separation from family, female gender, discrimination in the host country, unstable housing, and a drawn-out resettlement process. Protective factors consist of family cohesion, cultural continuity, support at schools, being protected from the truth of their harsh reality, stable housing, language acquisition, and quick resettlement. From these factors, effective mental interventions have been found to be the promotion of these protective factors as well as support for parental mental health and parenting skills, better parental engagement at school, and schools that correctly identify and address these children’s educational needs.

Dr. Nguyen is a second-year resident at UCSF Fresno Psychiatry Residency. He was a public high school English teacher for 15 years previously.*

References

1. Nguyen D. Mental Health Characteristics of Refugee Children. Pediatric News. 2023 Nov. 14. https://www.mdedge.com/pediatrics/article/266518/mental-health/mental-health-characteristics-refugee-children.

2. Office of the United Nations High Commissioner for Refugees. The Refugee Concept Under International Law. Global Compact for Safe, Orderly and Regular Migration. 2018 March 8. https://www.unhcr.org/sites/default/files/legacy-pdf/5aa290937.pdf.

3. Winer JP. Mental Health Practice with Immigrant and Refugee Youth [Power Point Slides]. Michigan Medicine. 2021 June 24. https://www.youtube.com/watch?v=ICkg4132SQY

4. Fazel M et al. Mental Health of Displaced and Refugee Children Resettled in High-Income Countries: Risk and Protective Factors. Lancet. 2012 Jan 21;379(9812):266-282. doi: 10.1016/S0140-6736(11)60051-2.

5. Fazel M, Betancourt TS. Preventive Mental Health Interventions for Refugee Children and Adolescents in High-Income Settings. Lancet Child Adolesc Health. 2018 Feb;2(2):121-132. doi: 10.1016/S2352-4642(17)30147-5.

*Correction, 2/27: An earlier version of this article misstated Dr. Nguyen's affiliation.