Commentary

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

Going to the movies is something I have always enjoyed. What I don’t always enjoy is waiting in line to use the bathroom after the movie is over and invariably picking a stall that has run out of toilet paper or that is in need of cleaning. These minor inconveniences in no way compare to the experiences some of my transgender patients have shared with me. Many of my patients tell me that they avoid using bathrooms in public places because of the anxiety they feel at having to pick a bathroom. Do they use the one that matches their sex assigned at birth or the one that matches their gender identity? Will they be safe and free from harassment in either bathroom? Some of my patients tell me they avoid drinking water at school just so they do not have to deal with going to the bathroom there.

Recently there have been bills introduced in several states that seek to deny transgender youth access to sex-segregated spaces including restrooms and locker rooms. These bills stigmatize an already vulnerable population, potentially increasing their risk of negative health outcomes. In a survey of transgender people in Massachusetts, 65% of respondents reported being discriminated against in public accommodations, and this discrimination was associated with poorer mental and physical health outcomes.¹

In February of 2016, the American Academy of Pediatrics and several other organizations dedicated to the health and welfare of children came out with a letter to state governors in opposition to these bills.² It states: “Transgender kids are already at heightened risk for violence, bullying, and harassment, and these bills exacerbate those risks by creating a hostile environment. … In addition, students who would be affected by these bills are among our most vulnerable to experiencing depression and engaging in self-harm, including suicide.”

On May 13, 2016, the U.S. Department of Justice and the U.S. Department of Education jointly issued a letter directing public schools to allow transgender students to use bathrooms that correspond with their gender identity.³ The letter was accompanied by a 25-page document with examples of policies and emerging practices to support transgender students.⁴

Proponents of these bills state that their purpose is to increase public safety and protect privacy. There are concerns that individuals may take advantage of these policies to sexually harass people in sex-segregated spaces. To date, there are no data to support these claims. In interviews conducted with heads of state police departments in 12 states that have nondiscrimination laws to protect transgender people in public settings, not one of the participants indicated any increase in sexual harassment or abuse in connection with these laws.¹ In addition, should any type of harassment occur, it would not be protected under antidiscrimination laws, and perpetrators would be subject to criminal penalties.

What can we do as health care providers to support our patients?

•  Educate ourselves. Keep up to date with best practice guidelines and evidence on how to promote the health and well-being of all children. The National LGBT Health Education Center has many educational resources to help health care providers provide quality care to LGBT patients and families. It is important to be aware of resources to help patients and families be aware of their rights and advocate for themselves in other settings such as school and work. Two organizations that provide this support and information are Trans Youth Family Allies and Lambda Legal.

•  Create safe spaces. Create spaces in our practice settings where children and youth can safely explore their gender identity and gender expression. This can be done by providing access to gender-neutral bathrooms, prominently displaying nondiscrimination policies that are inclusive of gender identity, and modeling recognition of the variety of ways gender can be experienced by asking and using patients’ preferred names and pronouns.

•  Advocate. Advocate for gender-inclusive environments within local youth-serving organizations including schools, medical facilities, and child welfare agencies. Share available information about the potential negative health effects of stigmatization and discrimination in transgender youth.

Together we can work to promote the well-being of all children.

Resources

•  The National LGBT Health Education Center (www.lgbthealtheducation.org/).

•  Trans Youth Family Allies (www.imatyfa.org/).

•  Lambda Legal (www.lambdalegal.org/know-your-rights/youth).

References

1. Policy Brief: State Anti-transgender Bathroom Bills Threaten Transgender People’s Health and Participation in Public Life. Fenway Institute and Center for American Progress, 2016.

2. American Academy of Pediatrics letter on sex-segregated spaces (www.aap.org/en-us/advocacy-and-policy/state-advocacy/Documents/AAP_HRCLetter.pdf).

3. Department of Justice and Department of Education Dear Colleague Letter on Transgender Students (www.justice.gov/opa/file/850996/download).

4. Department of Education Examples of Policies and Emerging Practices for Supporting Transgender Students (www2.ed.gov/about/offices/list/oese/oshs/emergingpractices.pdf).

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Going to the movies is something I have always enjoyed. What I don’t always enjoy is waiting in line to use the bathroom after the movie is over and invariably picking a stall that has run out of toilet paper or that is in need of cleaning. These minor inconveniences in no way compare to the experiences some of my transgender patients have shared with me. Many of my patients tell me that they avoid using bathrooms in public places because of the anxiety they feel at having to pick a bathroom. Do they use the one that matches their sex assigned at birth or the one that matches their gender identity? Will they be safe and free from harassment in either bathroom? Some of my patients tell me they avoid drinking water at school just so they do not have to deal with going to the bathroom there.

Recently there have been bills introduced in several states that seek to deny transgender youth access to sex-segregated spaces including restrooms and locker rooms. These bills stigmatize an already vulnerable population, potentially increasing their risk of negative health outcomes. In a survey of transgender people in Massachusetts, 65% of respondents reported being discriminated against in public accommodations, and this discrimination was associated with poorer mental and physical health outcomes.¹

In February of 2016, the American Academy of Pediatrics and several other organizations dedicated to the health and welfare of children came out with a letter to state governors in opposition to these bills.² It states: “Transgender kids are already at heightened risk for violence, bullying, and harassment, and these bills exacerbate those risks by creating a hostile environment. … In addition, students who would be affected by these bills are among our most vulnerable to experiencing depression and engaging in self-harm, including suicide.”

On May 13, 2016, the U.S. Department of Justice and the U.S. Department of Education jointly issued a letter directing public schools to allow transgender students to use bathrooms that correspond with their gender identity.³ The letter was accompanied by a 25-page document with examples of policies and emerging practices to support transgender students.⁴

Proponents of these bills state that their purpose is to increase public safety and protect privacy. There are concerns that individuals may take advantage of these policies to sexually harass people in sex-segregated spaces. To date, there are no data to support these claims. In interviews conducted with heads of state police departments in 12 states that have nondiscrimination laws to protect transgender people in public settings, not one of the participants indicated any increase in sexual harassment or abuse in connection with these laws.¹ In addition, should any type of harassment occur, it would not be protected under antidiscrimination laws, and perpetrators would be subject to criminal penalties.

What can we do as health care providers to support our patients?

•  Educate ourselves. Keep up to date with best practice guidelines and evidence on how to promote the health and well-being of all children. The National LGBT Health Education Center has many educational resources to help health care providers provide quality care to LGBT patients and families. It is important to be aware of resources to help patients and families be aware of their rights and advocate for themselves in other settings such as school and work. Two organizations that provide this support and information are Trans Youth Family Allies and Lambda Legal.

•  Create safe spaces. Create spaces in our practice settings where children and youth can safely explore their gender identity and gender expression. This can be done by providing access to gender-neutral bathrooms, prominently displaying nondiscrimination policies that are inclusive of gender identity, and modeling recognition of the variety of ways gender can be experienced by asking and using patients’ preferred names and pronouns.

•  Advocate. Advocate for gender-inclusive environments within local youth-serving organizations including schools, medical facilities, and child welfare agencies. Share available information about the potential negative health effects of stigmatization and discrimination in transgender youth.

Together we can work to promote the well-being of all children.

Resources

•  The National LGBT Health Education Center (www.lgbthealtheducation.org/).

•  Trans Youth Family Allies (www.imatyfa.org/).

•  Lambda Legal (www.lambdalegal.org/know-your-rights/youth).

References

1. Policy Brief: State Anti-transgender Bathroom Bills Threaten Transgender People’s Health and Participation in Public Life. Fenway Institute and Center for American Progress, 2016.

2. American Academy of Pediatrics letter on sex-segregated spaces (www.aap.org/en-us/advocacy-and-policy/state-advocacy/Documents/AAP_HRCLetter.pdf).

3. Department of Justice and Department of Education Dear Colleague Letter on Transgender Students (www.justice.gov/opa/file/850996/download).

4. Department of Education Examples of Policies and Emerging Practices for Supporting Transgender Students (www2.ed.gov/about/offices/list/oese/oshs/emergingpractices.pdf).

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

Going to the movies is something I have always enjoyed. What I don’t always enjoy is waiting in line to use the bathroom after the movie is over and invariably picking a stall that has run out of toilet paper or that is in need of cleaning. These minor inconveniences in no way compare to the experiences some of my transgender patients have shared with me. Many of my patients tell me that they avoid using bathrooms in public places because of the anxiety they feel at having to pick a bathroom. Do they use the one that matches their sex assigned at birth or the one that matches their gender identity? Will they be safe and free from harassment in either bathroom? Some of my patients tell me they avoid drinking water at school just so they do not have to deal with going to the bathroom there.

Recently there have been bills introduced in several states that seek to deny transgender youth access to sex-segregated spaces including restrooms and locker rooms. These bills stigmatize an already vulnerable population, potentially increasing their risk of negative health outcomes. In a survey of transgender people in Massachusetts, 65% of respondents reported being discriminated against in public accommodations, and this discrimination was associated with poorer mental and physical health outcomes.¹

In February of 2016, the American Academy of Pediatrics and several other organizations dedicated to the health and welfare of children came out with a letter to state governors in opposition to these bills.² It states: “Transgender kids are already at heightened risk for violence, bullying, and harassment, and these bills exacerbate those risks by creating a hostile environment. … In addition, students who would be affected by these bills are among our most vulnerable to experiencing depression and engaging in self-harm, including suicide.”

On May 13, 2016, the U.S. Department of Justice and the U.S. Department of Education jointly issued a letter directing public schools to allow transgender students to use bathrooms that correspond with their gender identity.³ The letter was accompanied by a 25-page document with examples of policies and emerging practices to support transgender students.⁴

Proponents of these bills state that their purpose is to increase public safety and protect privacy. There are concerns that individuals may take advantage of these policies to sexually harass people in sex-segregated spaces. To date, there are no data to support these claims. In interviews conducted with heads of state police departments in 12 states that have nondiscrimination laws to protect transgender people in public settings, not one of the participants indicated any increase in sexual harassment or abuse in connection with these laws.¹ In addition, should any type of harassment occur, it would not be protected under antidiscrimination laws, and perpetrators would be subject to criminal penalties.

What can we do as health care providers to support our patients?

•  Educate ourselves. Keep up to date with best practice guidelines and evidence on how to promote the health and well-being of all children. The National LGBT Health Education Center has many educational resources to help health care providers provide quality care to LGBT patients and families. It is important to be aware of resources to help patients and families be aware of their rights and advocate for themselves in other settings such as school and work. Two organizations that provide this support and information are Trans Youth Family Allies and Lambda Legal.

•  Create safe spaces. Create spaces in our practice settings where children and youth can safely explore their gender identity and gender expression. This can be done by providing access to gender-neutral bathrooms, prominently displaying nondiscrimination policies that are inclusive of gender identity, and modeling recognition of the variety of ways gender can be experienced by asking and using patients’ preferred names and pronouns.

•  Advocate. Advocate for gender-inclusive environments within local youth-serving organizations including schools, medical facilities, and child welfare agencies. Share available information about the potential negative health effects of stigmatization and discrimination in transgender youth.

Together we can work to promote the well-being of all children.

Resources

•  The National LGBT Health Education Center (www.lgbthealtheducation.org/).

•  Trans Youth Family Allies (www.imatyfa.org/).

•  Lambda Legal (www.lambdalegal.org/know-your-rights/youth).

References

1. Policy Brief: State Anti-transgender Bathroom Bills Threaten Transgender People’s Health and Participation in Public Life. Fenway Institute and Center for American Progress, 2016.

2. American Academy of Pediatrics letter on sex-segregated spaces (www.aap.org/en-us/advocacy-and-policy/state-advocacy/Documents/AAP_HRCLetter.pdf).

3. Department of Justice and Department of Education Dear Colleague Letter on Transgender Students (www.justice.gov/opa/file/850996/download).

4. Department of Education Examples of Policies and Emerging Practices for Supporting Transgender Students (www2.ed.gov/about/offices/list/oese/oshs/emergingpractices.pdf).

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

We found the case report “Unresponsive and mute after he smoked ‘Spice’” (Cases That Test Your Skills, Current Psychiatry. March 2016 p. 65-70) intriguing because we recently published an article that discusses 3 similar cases of DSM-5 unspecified catatonia.¹ The diagnosis of unspecified catatonia applies to catatonia that does not fully meet criteria for either catatonic disorder associated with another mental disorder or catatonic disorder associated with another medical disorder.

In Case 3 of our article, we described a patient who presented with unspecified catatonia after smoking a synthetic cannabinoid. The patient had been diagnosed with schizophrenia 4 years prior, but had not been adherent to treatment with an antipsychotic regimen since his diagnosis. His companion reported he had been smoking “K2” before he presented to the hospital. He was admitted to acute psychiatry, treated with oral lorazepam, 1 mg, 3 times a day, and improved within 3 days. He did not require electroconvulsive therapy (ECT). We have followed this patient through electronic medical records for 2.5 years after this hospitalization. He has not presented with re-emergent signs or symptoms of catatonia.

We also have conducted a literature review of synthetic cannabinoids and catatonia. As synthetic cannabinoids are a relatively recent phenomena, we recognize that reviews on catatonia might not include such substances.² Our literature review shows there are no other published cases of patients who returned to baseline functioning after treat<hl name="3"/>ment with benzodiazepine (ie, lorazepam) monotherapy.

It appears that, in similar cases of Cannabis-induced or synthetic cannabinoid-induced catatonia, return to baseline level of functioning before hospitalization required ECT in addition to benzodiazepines. Therefore, we feel it is important to note that in some cases, such as with our patient, Cannabis-induced catatonia might resolve with benzodiazepine monotherapy.

Shannon M. O’Connell, DO
PGY-3 Psychiatry Resident

Brendan T. Carroll, MD
Clinical Assistant Professor
Ohio University Heritage College of Osteopathic Medicine
Athens, Ohio
Chillicothe Veterans Affairs Medical Center
Chillicothe, Ohio

We found the case report “Unresponsive and mute after he smoked ‘Spice’” (Cases That Test Your Skills, Current Psychiatry. March 2016 p. 65-70) intriguing because we recently published an article that discusses 3 similar cases of DSM-5 unspecified catatonia.¹ The diagnosis of unspecified catatonia applies to catatonia that does not fully meet criteria for either catatonic disorder associated with another mental disorder or catatonic disorder associated with another medical disorder.

In Case 3 of our article, we described a patient who presented with unspecified catatonia after smoking a synthetic cannabinoid. The patient had been diagnosed with schizophrenia 4 years prior, but had not been adherent to treatment with an antipsychotic regimen since his diagnosis. His companion reported he had been smoking “K2” before he presented to the hospital. He was admitted to acute psychiatry, treated with oral lorazepam, 1 mg, 3 times a day, and improved within 3 days. He did not require electroconvulsive therapy (ECT). We have followed this patient through electronic medical records for 2.5 years after this hospitalization. He has not presented with re-emergent signs or symptoms of catatonia.

We also have conducted a literature review of synthetic cannabinoids and catatonia. As synthetic cannabinoids are a relatively recent phenomena, we recognize that reviews on catatonia might not include such substances.² Our literature review shows there are no other published cases of patients who returned to baseline functioning after treat<hl name="3"/>ment with benzodiazepine (ie, lorazepam) monotherapy.

It appears that, in similar cases of Cannabis-induced or synthetic cannabinoid-induced catatonia, return to baseline level of functioning before hospitalization required ECT in addition to benzodiazepines. Therefore, we feel it is important to note that in some cases, such as with our patient, Cannabis-induced catatonia might resolve with benzodiazepine monotherapy.

Shannon M. O’Connell, DO
PGY-3 Psychiatry Resident

Brendan T. Carroll, MD
Clinical Assistant Professor
Ohio University Heritage College of Osteopathic Medicine
Athens, Ohio
Chillicothe Veterans Affairs Medical Center
Chillicothe, Ohio

We found the case report “Unresponsive and mute after he smoked ‘Spice’” (Cases That Test Your Skills, Current Psychiatry. March 2016 p. 65-70) intriguing because we recently published an article that discusses 3 similar cases of DSM-5 unspecified catatonia.¹ The diagnosis of unspecified catatonia applies to catatonia that does not fully meet criteria for either catatonic disorder associated with another mental disorder or catatonic disorder associated with another medical disorder.

In Case 3 of our article, we described a patient who presented with unspecified catatonia after smoking a synthetic cannabinoid. The patient had been diagnosed with schizophrenia 4 years prior, but had not been adherent to treatment with an antipsychotic regimen since his diagnosis. His companion reported he had been smoking “K2” before he presented to the hospital. He was admitted to acute psychiatry, treated with oral lorazepam, 1 mg, 3 times a day, and improved within 3 days. He did not require electroconvulsive therapy (ECT). We have followed this patient through electronic medical records for 2.5 years after this hospitalization. He has not presented with re-emergent signs or symptoms of catatonia.

We also have conducted a literature review of synthetic cannabinoids and catatonia. As synthetic cannabinoids are a relatively recent phenomena, we recognize that reviews on catatonia might not include such substances.² Our literature review shows there are no other published cases of patients who returned to baseline functioning after treat<hl name="3"/>ment with benzodiazepine (ie, lorazepam) monotherapy.

It appears that, in similar cases of Cannabis-induced or synthetic cannabinoid-induced catatonia, return to baseline level of functioning before hospitalization required ECT in addition to benzodiazepines. Therefore, we feel it is important to note that in some cases, such as with our patient, Cannabis-induced catatonia might resolve with benzodiazepine monotherapy.

Shannon M. O’Connell, DO
PGY-3 Psychiatry Resident

Brendan T. Carroll, MD
Clinical Assistant Professor
Ohio University Heritage College of Osteopathic Medicine
Athens, Ohio
Chillicothe Veterans Affairs Medical Center
Chillicothe, Ohio

 Recent legislation to ban the sale of e-cigarettes to persons younger than 18 years of age, and to prevent distribution of free samples and placement in vending machines where teens may be present, was a major win for the fight for the health and well-being of our adolescents.¹

The electronic nicotine delivery system, or ENDS, was developed as an alternative to smoking cigarettes, reducing the intake of harmful fumes that lead to lung cancer. It was a great idea for those wishing to decrease or completely stop smoking. Its sleek design and flavor assortment made it very appealing, not only to adults, but to teenagers as well.

The history of e-cigs goes back to the 1960s when first developed, but because smoking was so socially acceptable the idea did not take hold. It wasn’t until 2003 when they started to become popular. Initially, e-cigs were met with resistance from the Food and Drug Administration, which stated that they were dangerous. But as the need for an alternative to smoking increased and preventable deaths continued to rise, there was more pressure to make them available. In 2013, sales started to skyrocket, but no restrictions for sale or product information was required. This made them readily available to teens and heralded the start of a whole new crisis. The Centers for Disease Control and Prevention reported that between 2011 and 2014, e-cig use rose from 0.6% to 5.3% among middle schoolers and from 1.5% to 16% among high school students.²

Because the marketing for e-cigs suggests they carry a reduced risk for cancer and are a healthier alternative to cigarettes, the perception is that they are not harmful. But research shows the contrary. Nicotine exposure of any level to the developing brain has been found to have negative effects, particularly in the prefrontal cortex where altered synapses have been identified.³ Symptoms of nicotine dependence at lower doses of nicotine is evident in adolescents. Long-term effects in adolescents are reported in working memory, attention, and predilection to major depressive disorder, panic disorder, academic problems, and addiction to other substances.³

The American Academy of Pediatrics 2015 statement on e-cigarettes stated increasing use by teens “threatens 5 decades of public health gains in successfully deglamorizing, restricting, and decreasing the use of tobacco products” and called for an FDA ban on the products.⁴ Although the FDA recently did place new restrictions, it will take several years for them to go fully into effect. A recent incident where a toddler ingested the liquid nicotine from an e-cig and died also brought to light other dangers of nicotine.⁵ These nicotine solutions come in colors and a variety of flavors, which makes them even more desirable to toddlers.Just one confirmed death has been reported from e-cig solution ingestion, but there has been a significant jump in calls to poison control centers associated with the liquids. Nicotine from these solutions also can be absorbed through the skin.

mauro grigollo/Thinkstock.com

More than 3 million middle and high school students were current users of e-cigarettes in 2015,¹ and e-cigs were the most commonly used tobacco product among middle and high school students that year.² Early introduction of ENDS causes a combination of early dependence and addiction with long-term impairment of cognitive skills, promoting an even more grim future for the health of our teens. Education and awareness is imperative to slow the current trends and prevent an even worse crisis than the one ENDS was created to improve.

References

1. http://www.fda.gov/TobaccoProducts/Labeling/ProductsIngredientsComponents/ucm456610.htm

2. MMWR Morb Mortal Wkly Rep. 2016 Apr 15;65(14):361-7.

3. Cold Spring Harbor Perspectives in Medicine. 2012;2(12):10.1101/cshperspect.a012120 a012120.

4. Pediatrics. 2015 Nov.10.1542/peds.2015-3222.

5. healthychildren.org

Dr. Pearce is a pediatrician in Frankfort, Ill. Email her at [email protected].

 Recent legislation to ban the sale of e-cigarettes to persons younger than 18 years of age, and to prevent distribution of free samples and placement in vending machines where teens may be present, was a major win for the fight for the health and well-being of our adolescents.¹

The electronic nicotine delivery system, or ENDS, was developed as an alternative to smoking cigarettes, reducing the intake of harmful fumes that lead to lung cancer. It was a great idea for those wishing to decrease or completely stop smoking. Its sleek design and flavor assortment made it very appealing, not only to adults, but to teenagers as well.

The history of e-cigs goes back to the 1960s when first developed, but because smoking was so socially acceptable the idea did not take hold. It wasn’t until 2003 when they started to become popular. Initially, e-cigs were met with resistance from the Food and Drug Administration, which stated that they were dangerous. But as the need for an alternative to smoking increased and preventable deaths continued to rise, there was more pressure to make them available. In 2013, sales started to skyrocket, but no restrictions for sale or product information was required. This made them readily available to teens and heralded the start of a whole new crisis. The Centers for Disease Control and Prevention reported that between 2011 and 2014, e-cig use rose from 0.6% to 5.3% among middle schoolers and from 1.5% to 16% among high school students.²

Because the marketing for e-cigs suggests they carry a reduced risk for cancer and are a healthier alternative to cigarettes, the perception is that they are not harmful. But research shows the contrary. Nicotine exposure of any level to the developing brain has been found to have negative effects, particularly in the prefrontal cortex where altered synapses have been identified.³ Symptoms of nicotine dependence at lower doses of nicotine is evident in adolescents. Long-term effects in adolescents are reported in working memory, attention, and predilection to major depressive disorder, panic disorder, academic problems, and addiction to other substances.³

The American Academy of Pediatrics 2015 statement on e-cigarettes stated increasing use by teens “threatens 5 decades of public health gains in successfully deglamorizing, restricting, and decreasing the use of tobacco products” and called for an FDA ban on the products.⁴ Although the FDA recently did place new restrictions, it will take several years for them to go fully into effect. A recent incident where a toddler ingested the liquid nicotine from an e-cig and died also brought to light other dangers of nicotine.⁵ These nicotine solutions come in colors and a variety of flavors, which makes them even more desirable to toddlers.Just one confirmed death has been reported from e-cig solution ingestion, but there has been a significant jump in calls to poison control centers associated with the liquids. Nicotine from these solutions also can be absorbed through the skin.

mauro grigollo/Thinkstock.com

More than 3 million middle and high school students were current users of e-cigarettes in 2015,¹ and e-cigs were the most commonly used tobacco product among middle and high school students that year.² Early introduction of ENDS causes a combination of early dependence and addiction with long-term impairment of cognitive skills, promoting an even more grim future for the health of our teens. Education and awareness is imperative to slow the current trends and prevent an even worse crisis than the one ENDS was created to improve.

References

1. http://www.fda.gov/TobaccoProducts/Labeling/ProductsIngredientsComponents/ucm456610.htm

2. MMWR Morb Mortal Wkly Rep. 2016 Apr 15;65(14):361-7.

3. Cold Spring Harbor Perspectives in Medicine. 2012;2(12):10.1101/cshperspect.a012120 a012120.

4. Pediatrics. 2015 Nov.10.1542/peds.2015-3222.

5. healthychildren.org

Dr. Pearce is a pediatrician in Frankfort, Ill. Email her at [email protected].

 Recent legislation to ban the sale of e-cigarettes to persons younger than 18 years of age, and to prevent distribution of free samples and placement in vending machines where teens may be present, was a major win for the fight for the health and well-being of our adolescents.¹

The electronic nicotine delivery system, or ENDS, was developed as an alternative to smoking cigarettes, reducing the intake of harmful fumes that lead to lung cancer. It was a great idea for those wishing to decrease or completely stop smoking. Its sleek design and flavor assortment made it very appealing, not only to adults, but to teenagers as well.

The history of e-cigs goes back to the 1960s when first developed, but because smoking was so socially acceptable the idea did not take hold. It wasn’t until 2003 when they started to become popular. Initially, e-cigs were met with resistance from the Food and Drug Administration, which stated that they were dangerous. But as the need for an alternative to smoking increased and preventable deaths continued to rise, there was more pressure to make them available. In 2013, sales started to skyrocket, but no restrictions for sale or product information was required. This made them readily available to teens and heralded the start of a whole new crisis. The Centers for Disease Control and Prevention reported that between 2011 and 2014, e-cig use rose from 0.6% to 5.3% among middle schoolers and from 1.5% to 16% among high school students.²

Because the marketing for e-cigs suggests they carry a reduced risk for cancer and are a healthier alternative to cigarettes, the perception is that they are not harmful. But research shows the contrary. Nicotine exposure of any level to the developing brain has been found to have negative effects, particularly in the prefrontal cortex where altered synapses have been identified.³ Symptoms of nicotine dependence at lower doses of nicotine is evident in adolescents. Long-term effects in adolescents are reported in working memory, attention, and predilection to major depressive disorder, panic disorder, academic problems, and addiction to other substances.³

The American Academy of Pediatrics 2015 statement on e-cigarettes stated increasing use by teens “threatens 5 decades of public health gains in successfully deglamorizing, restricting, and decreasing the use of tobacco products” and called for an FDA ban on the products.⁴ Although the FDA recently did place new restrictions, it will take several years for them to go fully into effect. A recent incident where a toddler ingested the liquid nicotine from an e-cig and died also brought to light other dangers of nicotine.⁵ These nicotine solutions come in colors and a variety of flavors, which makes them even more desirable to toddlers.Just one confirmed death has been reported from e-cig solution ingestion, but there has been a significant jump in calls to poison control centers associated with the liquids. Nicotine from these solutions also can be absorbed through the skin.

mauro grigollo/Thinkstock.com

More than 3 million middle and high school students were current users of e-cigarettes in 2015,¹ and e-cigs were the most commonly used tobacco product among middle and high school students that year.² Early introduction of ENDS causes a combination of early dependence and addiction with long-term impairment of cognitive skills, promoting an even more grim future for the health of our teens. Education and awareness is imperative to slow the current trends and prevent an even worse crisis than the one ENDS was created to improve.

References

1. http://www.fda.gov/TobaccoProducts/Labeling/ProductsIngredientsComponents/ucm456610.htm

2. MMWR Morb Mortal Wkly Rep. 2016 Apr 15;65(14):361-7.

3. Cold Spring Harbor Perspectives in Medicine. 2012;2(12):10.1101/cshperspect.a012120 a012120.

4. Pediatrics. 2015 Nov.10.1542/peds.2015-3222.

5. healthychildren.org

Dr. Pearce is a pediatrician in Frankfort, Ill. Email her at [email protected].

There has been quite a bit of discussion and controversy lately about transgender individuals. The debate has extended to the diagnosis itself and whether it should be maintained as an official entity. The previous edition of the Diagnostic and Statistical Manual included the diagnosis of gender identity disorder, which was modified to the current diagnosis of gender dysphoria that describes individuals who show a persistent desire to be the “other” gender and/or an insistence that their gender is different from their birth sex.

One question at the heart of this discussion is the degree to which psychiatric symptoms and disorders are inherent in the gender dysphoria itself or whether most, if not all, of the noted links to things like anxiety, depression, and suicidal behavior stem from the hostility and abuse that many of these youth endure.

As has been reported in the Pediatric News column LGBT Youth Consult, research is now focusing on the mental health of transgender youth, although the data are not entirely consistent. One recent study of 298 transgender women between the ages of 16 and 29 years, of whom nearly three-quarters had received crossgender hormones, showed quite high rates of psychiatric disorders including depression (35%), anxiety (8%), and substance abuse (11%).¹ Moderate to high levels of suicidality in the past month were found in 20% of the sample. Although one cannot conclude from this study that psychopathology is intrinsic to transgender individuals, it does suggest that difficulties can certainly persist among those who have socially transitioned to their affirmed gender.

In contrast, another study from the TransYouth Project showed much more hopeful results.² In this younger sample of 73 prepubescent children, 70% of whom were natal males and all of whom had been supported in the social transition to their affirmed gender at a relatively young age, levels of depressed symptoms were no different from those in 73 controls, and scores on an anxiety scale were only slightly elevated, but did not reach clinical or even subclinical levels as a group. The authors of this study concluded that psychiatric symptoms are not “synonymous” with being transgender. They suggest that supporting youth in their transition at earlier ages could possibly prevent the occurrence of mental health problems in the future.

There is wide acknowledgment that gender-nonconforming youth are at much heightened risk from what can be vicious and cruel maltreatment from peers and the wider community. Similarly, there is good consensus that “conversion therapy” approaches that actively try to discourage youth from their affirmed gender are misguided and unethical. What remains in question among well-meaning parents and clinicians alike, however, is at what age should social transition be supported and how encompassing should it be with regard to pronoun use, bathroom and dressing room access, clothing, and so on. Studies have shown that gender atypical behavior can be quite common in young children, with the vast majority eventually developing gender identities that are in line with their natal sex. Parents may worry that promoting a premature gender transition might expose their child to bullying and harassment that could otherwise be avoided. On the other hand, parents may worry that not supporting gender transition will be experienced as rejecting and critical, which could lead to increased feelings of depression and isolation. Although both views represent valid concerns, it is probably fair to say that among clinicians and researchers who work with transgender youth, there seems to be some movement toward more active acceptance and encouragement of a child’s gender expression at the time, with the understanding that for many, there can be continued movement in one’s gender “journey” across development.

Interestingly, these studies are being published in parallel with some neuroimaging research investigating sex differences with regard to the brain. A recent study from the Proceedings of the National Academy of Sciences found that, among many different regions that are known to show some sex differences with regard to size or connectivity to other regions, the typical human brain shows a “mosaic” pattern in which some regions look more typically male while others look more typically female.³

References

1. JAMA Pediatr. 2016 May 1;170(5):481-6.
2. Pediatrics. 2016;137(3):1-8.
3. PNAS. 2015;112(50):15468-73

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @pedipsych.

There has been quite a bit of discussion and controversy lately about transgender individuals. The debate has extended to the diagnosis itself and whether it should be maintained as an official entity. The previous edition of the Diagnostic and Statistical Manual included the diagnosis of gender identity disorder, which was modified to the current diagnosis of gender dysphoria that describes individuals who show a persistent desire to be the “other” gender and/or an insistence that their gender is different from their birth sex.

One question at the heart of this discussion is the degree to which psychiatric symptoms and disorders are inherent in the gender dysphoria itself or whether most, if not all, of the noted links to things like anxiety, depression, and suicidal behavior stem from the hostility and abuse that many of these youth endure.

As has been reported in the Pediatric News column LGBT Youth Consult, research is now focusing on the mental health of transgender youth, although the data are not entirely consistent. One recent study of 298 transgender women between the ages of 16 and 29 years, of whom nearly three-quarters had received crossgender hormones, showed quite high rates of psychiatric disorders including depression (35%), anxiety (8%), and substance abuse (11%).¹ Moderate to high levels of suicidality in the past month were found in 20% of the sample. Although one cannot conclude from this study that psychopathology is intrinsic to transgender individuals, it does suggest that difficulties can certainly persist among those who have socially transitioned to their affirmed gender.

In contrast, another study from the TransYouth Project showed much more hopeful results.² In this younger sample of 73 prepubescent children, 70% of whom were natal males and all of whom had been supported in the social transition to their affirmed gender at a relatively young age, levels of depressed symptoms were no different from those in 73 controls, and scores on an anxiety scale were only slightly elevated, but did not reach clinical or even subclinical levels as a group. The authors of this study concluded that psychiatric symptoms are not “synonymous” with being transgender. They suggest that supporting youth in their transition at earlier ages could possibly prevent the occurrence of mental health problems in the future.

There is wide acknowledgment that gender-nonconforming youth are at much heightened risk from what can be vicious and cruel maltreatment from peers and the wider community. Similarly, there is good consensus that “conversion therapy” approaches that actively try to discourage youth from their affirmed gender are misguided and unethical. What remains in question among well-meaning parents and clinicians alike, however, is at what age should social transition be supported and how encompassing should it be with regard to pronoun use, bathroom and dressing room access, clothing, and so on. Studies have shown that gender atypical behavior can be quite common in young children, with the vast majority eventually developing gender identities that are in line with their natal sex. Parents may worry that promoting a premature gender transition might expose their child to bullying and harassment that could otherwise be avoided. On the other hand, parents may worry that not supporting gender transition will be experienced as rejecting and critical, which could lead to increased feelings of depression and isolation. Although both views represent valid concerns, it is probably fair to say that among clinicians and researchers who work with transgender youth, there seems to be some movement toward more active acceptance and encouragement of a child’s gender expression at the time, with the understanding that for many, there can be continued movement in one’s gender “journey” across development.

Interestingly, these studies are being published in parallel with some neuroimaging research investigating sex differences with regard to the brain. A recent study from the Proceedings of the National Academy of Sciences found that, among many different regions that are known to show some sex differences with regard to size or connectivity to other regions, the typical human brain shows a “mosaic” pattern in which some regions look more typically male while others look more typically female.³

References

1. JAMA Pediatr. 2016 May 1;170(5):481-6.
2. Pediatrics. 2016;137(3):1-8.
3. PNAS. 2015;112(50):15468-73

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @pedipsych.

There has been quite a bit of discussion and controversy lately about transgender individuals. The debate has extended to the diagnosis itself and whether it should be maintained as an official entity. The previous edition of the Diagnostic and Statistical Manual included the diagnosis of gender identity disorder, which was modified to the current diagnosis of gender dysphoria that describes individuals who show a persistent desire to be the “other” gender and/or an insistence that their gender is different from their birth sex.

One question at the heart of this discussion is the degree to which psychiatric symptoms and disorders are inherent in the gender dysphoria itself or whether most, if not all, of the noted links to things like anxiety, depression, and suicidal behavior stem from the hostility and abuse that many of these youth endure.

As has been reported in the Pediatric News column LGBT Youth Consult, research is now focusing on the mental health of transgender youth, although the data are not entirely consistent. One recent study of 298 transgender women between the ages of 16 and 29 years, of whom nearly three-quarters had received crossgender hormones, showed quite high rates of psychiatric disorders including depression (35%), anxiety (8%), and substance abuse (11%).¹ Moderate to high levels of suicidality in the past month were found in 20% of the sample. Although one cannot conclude from this study that psychopathology is intrinsic to transgender individuals, it does suggest that difficulties can certainly persist among those who have socially transitioned to their affirmed gender.

In contrast, another study from the TransYouth Project showed much more hopeful results.² In this younger sample of 73 prepubescent children, 70% of whom were natal males and all of whom had been supported in the social transition to their affirmed gender at a relatively young age, levels of depressed symptoms were no different from those in 73 controls, and scores on an anxiety scale were only slightly elevated, but did not reach clinical or even subclinical levels as a group. The authors of this study concluded that psychiatric symptoms are not “synonymous” with being transgender. They suggest that supporting youth in their transition at earlier ages could possibly prevent the occurrence of mental health problems in the future.

There is wide acknowledgment that gender-nonconforming youth are at much heightened risk from what can be vicious and cruel maltreatment from peers and the wider community. Similarly, there is good consensus that “conversion therapy” approaches that actively try to discourage youth from their affirmed gender are misguided and unethical. What remains in question among well-meaning parents and clinicians alike, however, is at what age should social transition be supported and how encompassing should it be with regard to pronoun use, bathroom and dressing room access, clothing, and so on. Studies have shown that gender atypical behavior can be quite common in young children, with the vast majority eventually developing gender identities that are in line with their natal sex. Parents may worry that promoting a premature gender transition might expose their child to bullying and harassment that could otherwise be avoided. On the other hand, parents may worry that not supporting gender transition will be experienced as rejecting and critical, which could lead to increased feelings of depression and isolation. Although both views represent valid concerns, it is probably fair to say that among clinicians and researchers who work with transgender youth, there seems to be some movement toward more active acceptance and encouragement of a child’s gender expression at the time, with the understanding that for many, there can be continued movement in one’s gender “journey” across development.

Interestingly, these studies are being published in parallel with some neuroimaging research investigating sex differences with regard to the brain. A recent study from the Proceedings of the National Academy of Sciences found that, among many different regions that are known to show some sex differences with regard to size or connectivity to other regions, the typical human brain shows a “mosaic” pattern in which some regions look more typically male while others look more typically female.³

References

1. JAMA Pediatr. 2016 May 1;170(5):481-6.
2. Pediatrics. 2016;137(3):1-8.
3. PNAS. 2015;112(50):15468-73

Dr. Rettew is an associate professor of psychiatry and pediatrics at the University of Vermont, Burlington. Follow him on Twitter @pedipsych.

The most difficult decisions in neuroscience intensive care units often involve patients’ ultimate goals of care. Oftentimes, family members of a brain-injured patient with an apparently poor neurologic prognosis must weigh whether their loved one would have preferred prolongation of aggressive ICU and post-ICU care, often with little to no chance for “meaningful” recovery, or death via the institution of comfort measures only. Proper prognostication is crucial to the family when making such decisions. However, the process of formulating and talking about prognosis for our most severely affected patients is subject to physician and family biases, families’ insufficient understanding of projected outcomes, and sometimes clinical nihilism by the physicians.

The process of predicting the outcomes of patients with traumatic brain injury (TBI) serves as an example of these issues. Moderate to severe TBI continues to be a leading cause of death and disability in the United States.¹ Most deaths of patients with moderate to severe TBI follow decisions by doctors and families to pursue comfort care only. However, these decisions occur at a disconcertingly highly variable rate at different trauma centers, with the variation seemingly unrelated to patients’ disease severity, age, or previously diagnosed comorbidities.² These patients are at risk for their care being influenced by a self-fulfilling prophecy: That is, the impression of a poor prognosis communicated by clinicians to a patient’s family, whether correct or incorrect, affects the aggressiveness of the care that a patient receives and determines the patient’s outcome.³

Remedying these issues through a family or health care proxy decision support intervention (“decision aid”) that could improve and standardize the way TBI prognosis is communicated may lead to better informed decisions for these critically ill patients, with potentially less decisional regret and post-ICU stress disorders in families, and decisions more in line with the patient’s values and preferences.⁴ A recent Cochrane review showed that for a decision aid to be effective and integrated into routine clinical care, it must contain disease-specific data tailored to patients and their families/proxies, and be simple and time efficient for physicians to use.⁵ Taking these factors into account, researchers at the University of Massachusetts are developing a National Institutes of Health–funded pilot decision aid for goals-of-care decisions in critically-ill TBI patients.

While the field of TBI has tools such as the IMPACT calculator that can be used to estimate a patient’s long-term prognosis based on how patients with similar clinical characteristics in large clinical databases have done, the fundamental uncertainty of prognosis remains a difficult challenge.⁶ Arguably, this challenge is even more daunting when estimating prognosis for patients with severe ischemic stroke and intracerebral hemorrhage (ICH). The use of ischemic stroke outcome prediction tools is complicated, as many of them are based on population databases with wide variations in whether included patients received intravenous tissue plasminogen activator, endovascular therapy, both, or neither. Furthermore, a recent study comparing the accuracy of the ICH score for predicting 3-month outcome for ICH patients to the subjective predictions of clinicians made within 24 hours of patient admission found that the educated guesses of physicians and nurses overall seemed to correlate with actual outcomes more closely than the ICH score output.⁷ This finding highlights the challenge of using available outcome “calculators” for individual patients in ICUs.

Ultimately, the decisions made about the goals of care for ICU patients come down not only to what their expected outcomes are, but also whether their surrogate decision makers believe that those outcomes would be acceptable to the patient.⁸ Potential pitfalls abound with regard to this issue as well. Decision makers are often not made aware of the fact that many times patients with significant disability may nevertheless report a reasonable quality of life. By their very nature, conversations regarding patient prognosis inevitably focus on what future disabilities one might expect; accounting for a patient’s possible adaptation to disability is both easy to overlook and hard to accomplish even when given adequate attention.⁹ Improvements in the field of neuroprognostication may not only depend on the development of new shared decision making tools for physicians and families but also on increasing awareness of the limitations of prognostic scales and the cognitive biases that may exist when discussing the possibilities of future disability.

References

1. Traumatic Brain Injury Statistics [online]. Available at: http://www.cdc.gov/traumaticbraininjury/statistics.html. Accessed Nov. 1.

2. CMAJ. 2011;183:1581-8.

3. Neurocrit Care. 2013;19:347-63.

4. Col NF. Chapter 17: Shared Decision Making. In: Communicating Risks and Benefits: An Evidence-Based User’s Guide [online]. Available at http://www.fda.gov/downloads/AboutFDA/ReportsManualsForms/Reports/UCM268069.pdf.

5. Cochrane Database Syst Rev. 2011 Oct 5;(10):CD001431.

6. PLoS Med. 2008 Aug;5(8):e165; discussion e168.

7. Neurology. 2016;86:126-33.

8. Neurocrit Care. 2015;23:131-41.

9. Stroke. 2012;43:3405-8.

Dr. Muehlschlegel is associate professor of neurology (neurocritical care), anesthesia/critical care, and surgery at the University of Massachusetts, Worcester. Dr. Hwang is assistant professor of neurology in the division of neurocritical care and emergency neurology at Yale University, New Haven, Conn. Dr. Muehlschlegel reported receiving a grant from the National Institutes of Health for her research in developing a pilot decision aid for goals-of-care decisions in critically-ill TBI patients. Dr. Hwang reported receiving research funding from the American Brain Foundation, the Apple Pickers Foundation, the National Institute on Aging, and the Neurocritical Care Society.

The most difficult decisions in neuroscience intensive care units often involve patients’ ultimate goals of care. Oftentimes, family members of a brain-injured patient with an apparently poor neurologic prognosis must weigh whether their loved one would have preferred prolongation of aggressive ICU and post-ICU care, often with little to no chance for “meaningful” recovery, or death via the institution of comfort measures only. Proper prognostication is crucial to the family when making such decisions. However, the process of formulating and talking about prognosis for our most severely affected patients is subject to physician and family biases, families’ insufficient understanding of projected outcomes, and sometimes clinical nihilism by the physicians.

The process of predicting the outcomes of patients with traumatic brain injury (TBI) serves as an example of these issues. Moderate to severe TBI continues to be a leading cause of death and disability in the United States.¹ Most deaths of patients with moderate to severe TBI follow decisions by doctors and families to pursue comfort care only. However, these decisions occur at a disconcertingly highly variable rate at different trauma centers, with the variation seemingly unrelated to patients’ disease severity, age, or previously diagnosed comorbidities.² These patients are at risk for their care being influenced by a self-fulfilling prophecy: That is, the impression of a poor prognosis communicated by clinicians to a patient’s family, whether correct or incorrect, affects the aggressiveness of the care that a patient receives and determines the patient’s outcome.³

Remedying these issues through a family or health care proxy decision support intervention (“decision aid”) that could improve and standardize the way TBI prognosis is communicated may lead to better informed decisions for these critically ill patients, with potentially less decisional regret and post-ICU stress disorders in families, and decisions more in line with the patient’s values and preferences.⁴ A recent Cochrane review showed that for a decision aid to be effective and integrated into routine clinical care, it must contain disease-specific data tailored to patients and their families/proxies, and be simple and time efficient for physicians to use.⁵ Taking these factors into account, researchers at the University of Massachusetts are developing a National Institutes of Health–funded pilot decision aid for goals-of-care decisions in critically-ill TBI patients.

While the field of TBI has tools such as the IMPACT calculator that can be used to estimate a patient’s long-term prognosis based on how patients with similar clinical characteristics in large clinical databases have done, the fundamental uncertainty of prognosis remains a difficult challenge.⁶ Arguably, this challenge is even more daunting when estimating prognosis for patients with severe ischemic stroke and intracerebral hemorrhage (ICH). The use of ischemic stroke outcome prediction tools is complicated, as many of them are based on population databases with wide variations in whether included patients received intravenous tissue plasminogen activator, endovascular therapy, both, or neither. Furthermore, a recent study comparing the accuracy of the ICH score for predicting 3-month outcome for ICH patients to the subjective predictions of clinicians made within 24 hours of patient admission found that the educated guesses of physicians and nurses overall seemed to correlate with actual outcomes more closely than the ICH score output.⁷ This finding highlights the challenge of using available outcome “calculators” for individual patients in ICUs.

Ultimately, the decisions made about the goals of care for ICU patients come down not only to what their expected outcomes are, but also whether their surrogate decision makers believe that those outcomes would be acceptable to the patient.⁸ Potential pitfalls abound with regard to this issue as well. Decision makers are often not made aware of the fact that many times patients with significant disability may nevertheless report a reasonable quality of life. By their very nature, conversations regarding patient prognosis inevitably focus on what future disabilities one might expect; accounting for a patient’s possible adaptation to disability is both easy to overlook and hard to accomplish even when given adequate attention.⁹ Improvements in the field of neuroprognostication may not only depend on the development of new shared decision making tools for physicians and families but also on increasing awareness of the limitations of prognostic scales and the cognitive biases that may exist when discussing the possibilities of future disability.

References

1. Traumatic Brain Injury Statistics [online]. Available at: http://www.cdc.gov/traumaticbraininjury/statistics.html. Accessed Nov. 1.

2. CMAJ. 2011;183:1581-8.

3. Neurocrit Care. 2013;19:347-63.

4. Col NF. Chapter 17: Shared Decision Making. In: Communicating Risks and Benefits: An Evidence-Based User’s Guide [online]. Available at http://www.fda.gov/downloads/AboutFDA/ReportsManualsForms/Reports/UCM268069.pdf.

5. Cochrane Database Syst Rev. 2011 Oct 5;(10):CD001431.

6. PLoS Med. 2008 Aug;5(8):e165; discussion e168.

7. Neurology. 2016;86:126-33.

8. Neurocrit Care. 2015;23:131-41.

9. Stroke. 2012;43:3405-8.

Dr. Muehlschlegel is associate professor of neurology (neurocritical care), anesthesia/critical care, and surgery at the University of Massachusetts, Worcester. Dr. Hwang is assistant professor of neurology in the division of neurocritical care and emergency neurology at Yale University, New Haven, Conn. Dr. Muehlschlegel reported receiving a grant from the National Institutes of Health for her research in developing a pilot decision aid for goals-of-care decisions in critically-ill TBI patients. Dr. Hwang reported receiving research funding from the American Brain Foundation, the Apple Pickers Foundation, the National Institute on Aging, and the Neurocritical Care Society.

The most difficult decisions in neuroscience intensive care units often involve patients’ ultimate goals of care. Oftentimes, family members of a brain-injured patient with an apparently poor neurologic prognosis must weigh whether their loved one would have preferred prolongation of aggressive ICU and post-ICU care, often with little to no chance for “meaningful” recovery, or death via the institution of comfort measures only. Proper prognostication is crucial to the family when making such decisions. However, the process of formulating and talking about prognosis for our most severely affected patients is subject to physician and family biases, families’ insufficient understanding of projected outcomes, and sometimes clinical nihilism by the physicians.

The process of predicting the outcomes of patients with traumatic brain injury (TBI) serves as an example of these issues. Moderate to severe TBI continues to be a leading cause of death and disability in the United States.¹ Most deaths of patients with moderate to severe TBI follow decisions by doctors and families to pursue comfort care only. However, these decisions occur at a disconcertingly highly variable rate at different trauma centers, with the variation seemingly unrelated to patients’ disease severity, age, or previously diagnosed comorbidities.² These patients are at risk for their care being influenced by a self-fulfilling prophecy: That is, the impression of a poor prognosis communicated by clinicians to a patient’s family, whether correct or incorrect, affects the aggressiveness of the care that a patient receives and determines the patient’s outcome.³

Remedying these issues through a family or health care proxy decision support intervention (“decision aid”) that could improve and standardize the way TBI prognosis is communicated may lead to better informed decisions for these critically ill patients, with potentially less decisional regret and post-ICU stress disorders in families, and decisions more in line with the patient’s values and preferences.⁴ A recent Cochrane review showed that for a decision aid to be effective and integrated into routine clinical care, it must contain disease-specific data tailored to patients and their families/proxies, and be simple and time efficient for physicians to use.⁵ Taking these factors into account, researchers at the University of Massachusetts are developing a National Institutes of Health–funded pilot decision aid for goals-of-care decisions in critically-ill TBI patients.

While the field of TBI has tools such as the IMPACT calculator that can be used to estimate a patient’s long-term prognosis based on how patients with similar clinical characteristics in large clinical databases have done, the fundamental uncertainty of prognosis remains a difficult challenge.⁶ Arguably, this challenge is even more daunting when estimating prognosis for patients with severe ischemic stroke and intracerebral hemorrhage (ICH). The use of ischemic stroke outcome prediction tools is complicated, as many of them are based on population databases with wide variations in whether included patients received intravenous tissue plasminogen activator, endovascular therapy, both, or neither. Furthermore, a recent study comparing the accuracy of the ICH score for predicting 3-month outcome for ICH patients to the subjective predictions of clinicians made within 24 hours of patient admission found that the educated guesses of physicians and nurses overall seemed to correlate with actual outcomes more closely than the ICH score output.⁷ This finding highlights the challenge of using available outcome “calculators” for individual patients in ICUs.

Ultimately, the decisions made about the goals of care for ICU patients come down not only to what their expected outcomes are, but also whether their surrogate decision makers believe that those outcomes would be acceptable to the patient.⁸ Potential pitfalls abound with regard to this issue as well. Decision makers are often not made aware of the fact that many times patients with significant disability may nevertheless report a reasonable quality of life. By their very nature, conversations regarding patient prognosis inevitably focus on what future disabilities one might expect; accounting for a patient’s possible adaptation to disability is both easy to overlook and hard to accomplish even when given adequate attention.⁹ Improvements in the field of neuroprognostication may not only depend on the development of new shared decision making tools for physicians and families but also on increasing awareness of the limitations of prognostic scales and the cognitive biases that may exist when discussing the possibilities of future disability.

References

1. Traumatic Brain Injury Statistics [online]. Available at: http://www.cdc.gov/traumaticbraininjury/statistics.html. Accessed Nov. 1.

2. CMAJ. 2011;183:1581-8.

3. Neurocrit Care. 2013;19:347-63.

4. Col NF. Chapter 17: Shared Decision Making. In: Communicating Risks and Benefits: An Evidence-Based User’s Guide [online]. Available at http://www.fda.gov/downloads/AboutFDA/ReportsManualsForms/Reports/UCM268069.pdf.

5. Cochrane Database Syst Rev. 2011 Oct 5;(10):CD001431.

6. PLoS Med. 2008 Aug;5(8):e165; discussion e168.

7. Neurology. 2016;86:126-33.

8. Neurocrit Care. 2015;23:131-41.

9. Stroke. 2012;43:3405-8.

Dr. Muehlschlegel is associate professor of neurology (neurocritical care), anesthesia/critical care, and surgery at the University of Massachusetts, Worcester. Dr. Hwang is assistant professor of neurology in the division of neurocritical care and emergency neurology at Yale University, New Haven, Conn. Dr. Muehlschlegel reported receiving a grant from the National Institutes of Health for her research in developing a pilot decision aid for goals-of-care decisions in critically-ill TBI patients. Dr. Hwang reported receiving research funding from the American Brain Foundation, the Apple Pickers Foundation, the National Institute on Aging, and the Neurocritical Care Society.

At 6 a.m., after eight admissions back to back, I feel like I can’t stay awake any longer. I desperately need a nap. I have 30 minutes before my next admission, but I know I’m not going to rest. I close my eyes, and I only see charts. I’m trying not to collapse, but I still have three more patients to admit before I go home. And I can’t rest.

I’m scared that I’ll make a mistake. While I write my history of presenting illness, I imagine the day team reading my notes and hoping they don’t notice that I was about to crash on the desk. I check my documentation multiple times to make sure I don’t miss anything, and I know that won’t relieve my anxiety. When I leave, I will still feel the failure of not being able to give my best for my patient or for my night team, because I’m too tired. I know this frustration is going to give room to the emptiness – that indifference of being so beaten up that you can’t feel anymore.

And eventually, shame comes in. I’m ashamed of how I feel, because somehow, it means I am weak. All these feelings threaten to cripple me. Then I get home and cry till I fall asleep.

Recently, I read an article about a young physician contemplating suicide in her first year of practice. She described the dread of going into work and the emptiness left at the end of the day. Halfway through my second year of residency, I could relate to those feelings. I dealt with the anxiety of wondering what type of shift I was going to walk into, and experienced the stress of not wanting to disappoint the team, my peers, the patient, or myself.

Being constantly afraid of making a mistake is tiring. Sometimes, I get the pat on the back from senior physicians, saying I will survive. But it’s not enough. I can’t blame them. It’s human nature to forget how bad it hurt and just remember being strong enough to bear it. I count the days til I have a day off or the weeks til my next vacation. I try not to complain as much because nobody wants to hear it, and nothing is going to change. I feel deeply alone, like nobody cares.

And in the end I put myself onto this path. I knew what I was getting myself into. And I get myself out of it. I hold on to the smiles my staff give me when I walk in. I experience that 10-minute interview with someone whose thought process was so disorganized, and I realize that it took some skill to connect with that patient.

I am heartened by my ability to deescalate a patient who was about to become violent because I know Spanish. I notice that I am able to work faster than I did just a year ago. So I hold on. The trick was to find what made me want to hold on and what motivates me.

I’m not going to write about socializing or finding a hobby outside of medicine. But I must acknowledge that I have a wonderful book club, supportive boyfriend, and family. I lose myself in books, TV shows, cooking. I even started reading comic books. Plenty of articles are out there about how to beat physician burnout. They all help. I tried knitting, coloring, you name it, but for me, those activities were just not enough. I had to try to find meaning behind the work I do. I had to grab all those small moments during a shift and knit them together to build a bridge to where my passion lies. Then I started by reminding myself why I wanted to practice medicine and why psychiatry.

What inspires me is learning how to decipher what hides behind a symptom – why patient A’s anxiety is different from patient B’s. I find psychodynamics fascinating, so I read. I read literature, articles, and books with subjects around my interests. So when I see a patient at 4 a.m. for 5 minutes, I can knit it together with what I read. So it has meaning. And then it’s easier to hold on. Because the 12-hour overnight shift becomes hours of learning about my passion. Because I feel a step closer. And even though last night’s shift was so hard, I’m happy to be back at work today. When I read about the psychopathology of depression and then admit five patients with suicidal ideation, it stops being the same story over and over. It turns into an exploration, and it becomes fascinating. I won’t hear the same story again. So many times, attendings told me to read, and I had to be at my breaking point to understand why it was so essential. Now I’m motivated, and I plan to keep pushing myself to the limit to find a new challenge and to surprise myself in the middle of my beat-up tiredness when I see something in my patient that so many have written about. The adrenaline rush comes on the path of becoming that psychiatrist I aim to be, not in the diploma I will get 2 years from now.

I am racing against burnout, but I’m winning. And I wanted to share my experience to remind others that we are not alone on this path, and we should not have higher suicide rates than other professional groups.

If you are a resident or more experienced physician, know that you are not alone. Many others just like you are stretching themselves thin. Follow the tips of how to beat burnout that you’ve seen around. Find what works for you and dig into yourself, into what drove you in this direction, into where your passion lies. Find the meaning behind this hard work, and connect it to the passion that motivates you. Think of what made you want to become a doctor! I’m not sure it works 100% of the time.

Ask me again in 6 months.

Dr. Serrano is a PGY2 psychiatry resident at the Einstein Medical Center in Philadelphia.

At 6 a.m., after eight admissions back to back, I feel like I can’t stay awake any longer. I desperately need a nap. I have 30 minutes before my next admission, but I know I’m not going to rest. I close my eyes, and I only see charts. I’m trying not to collapse, but I still have three more patients to admit before I go home. And I can’t rest.

I’m scared that I’ll make a mistake. While I write my history of presenting illness, I imagine the day team reading my notes and hoping they don’t notice that I was about to crash on the desk. I check my documentation multiple times to make sure I don’t miss anything, and I know that won’t relieve my anxiety. When I leave, I will still feel the failure of not being able to give my best for my patient or for my night team, because I’m too tired. I know this frustration is going to give room to the emptiness – that indifference of being so beaten up that you can’t feel anymore.

And eventually, shame comes in. I’m ashamed of how I feel, because somehow, it means I am weak. All these feelings threaten to cripple me. Then I get home and cry till I fall asleep.

Recently, I read an article about a young physician contemplating suicide in her first year of practice. She described the dread of going into work and the emptiness left at the end of the day. Halfway through my second year of residency, I could relate to those feelings. I dealt with the anxiety of wondering what type of shift I was going to walk into, and experienced the stress of not wanting to disappoint the team, my peers, the patient, or myself.

Being constantly afraid of making a mistake is tiring. Sometimes, I get the pat on the back from senior physicians, saying I will survive. But it’s not enough. I can’t blame them. It’s human nature to forget how bad it hurt and just remember being strong enough to bear it. I count the days til I have a day off or the weeks til my next vacation. I try not to complain as much because nobody wants to hear it, and nothing is going to change. I feel deeply alone, like nobody cares.

And in the end I put myself onto this path. I knew what I was getting myself into. And I get myself out of it. I hold on to the smiles my staff give me when I walk in. I experience that 10-minute interview with someone whose thought process was so disorganized, and I realize that it took some skill to connect with that patient.

I am heartened by my ability to deescalate a patient who was about to become violent because I know Spanish. I notice that I am able to work faster than I did just a year ago. So I hold on. The trick was to find what made me want to hold on and what motivates me.

I’m not going to write about socializing or finding a hobby outside of medicine. But I must acknowledge that I have a wonderful book club, supportive boyfriend, and family. I lose myself in books, TV shows, cooking. I even started reading comic books. Plenty of articles are out there about how to beat physician burnout. They all help. I tried knitting, coloring, you name it, but for me, those activities were just not enough. I had to try to find meaning behind the work I do. I had to grab all those small moments during a shift and knit them together to build a bridge to where my passion lies. Then I started by reminding myself why I wanted to practice medicine and why psychiatry.

What inspires me is learning how to decipher what hides behind a symptom – why patient A’s anxiety is different from patient B’s. I find psychodynamics fascinating, so I read. I read literature, articles, and books with subjects around my interests. So when I see a patient at 4 a.m. for 5 minutes, I can knit it together with what I read. So it has meaning. And then it’s easier to hold on. Because the 12-hour overnight shift becomes hours of learning about my passion. Because I feel a step closer. And even though last night’s shift was so hard, I’m happy to be back at work today. When I read about the psychopathology of depression and then admit five patients with suicidal ideation, it stops being the same story over and over. It turns into an exploration, and it becomes fascinating. I won’t hear the same story again. So many times, attendings told me to read, and I had to be at my breaking point to understand why it was so essential. Now I’m motivated, and I plan to keep pushing myself to the limit to find a new challenge and to surprise myself in the middle of my beat-up tiredness when I see something in my patient that so many have written about. The adrenaline rush comes on the path of becoming that psychiatrist I aim to be, not in the diploma I will get 2 years from now.

I am racing against burnout, but I’m winning. And I wanted to share my experience to remind others that we are not alone on this path, and we should not have higher suicide rates than other professional groups.

If you are a resident or more experienced physician, know that you are not alone. Many others just like you are stretching themselves thin. Follow the tips of how to beat burnout that you’ve seen around. Find what works for you and dig into yourself, into what drove you in this direction, into where your passion lies. Find the meaning behind this hard work, and connect it to the passion that motivates you. Think of what made you want to become a doctor! I’m not sure it works 100% of the time.

Ask me again in 6 months.

Dr. Serrano is a PGY2 psychiatry resident at the Einstein Medical Center in Philadelphia.

At 6 a.m., after eight admissions back to back, I feel like I can’t stay awake any longer. I desperately need a nap. I have 30 minutes before my next admission, but I know I’m not going to rest. I close my eyes, and I only see charts. I’m trying not to collapse, but I still have three more patients to admit before I go home. And I can’t rest.

I’m scared that I’ll make a mistake. While I write my history of presenting illness, I imagine the day team reading my notes and hoping they don’t notice that I was about to crash on the desk. I check my documentation multiple times to make sure I don’t miss anything, and I know that won’t relieve my anxiety. When I leave, I will still feel the failure of not being able to give my best for my patient or for my night team, because I’m too tired. I know this frustration is going to give room to the emptiness – that indifference of being so beaten up that you can’t feel anymore.

And eventually, shame comes in. I’m ashamed of how I feel, because somehow, it means I am weak. All these feelings threaten to cripple me. Then I get home and cry till I fall asleep.

Recently, I read an article about a young physician contemplating suicide in her first year of practice. She described the dread of going into work and the emptiness left at the end of the day. Halfway through my second year of residency, I could relate to those feelings. I dealt with the anxiety of wondering what type of shift I was going to walk into, and experienced the stress of not wanting to disappoint the team, my peers, the patient, or myself.

Being constantly afraid of making a mistake is tiring. Sometimes, I get the pat on the back from senior physicians, saying I will survive. But it’s not enough. I can’t blame them. It’s human nature to forget how bad it hurt and just remember being strong enough to bear it. I count the days til I have a day off or the weeks til my next vacation. I try not to complain as much because nobody wants to hear it, and nothing is going to change. I feel deeply alone, like nobody cares.

And in the end I put myself onto this path. I knew what I was getting myself into. And I get myself out of it. I hold on to the smiles my staff give me when I walk in. I experience that 10-minute interview with someone whose thought process was so disorganized, and I realize that it took some skill to connect with that patient.

I am heartened by my ability to deescalate a patient who was about to become violent because I know Spanish. I notice that I am able to work faster than I did just a year ago. So I hold on. The trick was to find what made me want to hold on and what motivates me.

I’m not going to write about socializing or finding a hobby outside of medicine. But I must acknowledge that I have a wonderful book club, supportive boyfriend, and family. I lose myself in books, TV shows, cooking. I even started reading comic books. Plenty of articles are out there about how to beat physician burnout. They all help. I tried knitting, coloring, you name it, but for me, those activities were just not enough. I had to try to find meaning behind the work I do. I had to grab all those small moments during a shift and knit them together to build a bridge to where my passion lies. Then I started by reminding myself why I wanted to practice medicine and why psychiatry.

What inspires me is learning how to decipher what hides behind a symptom – why patient A’s anxiety is different from patient B’s. I find psychodynamics fascinating, so I read. I read literature, articles, and books with subjects around my interests. So when I see a patient at 4 a.m. for 5 minutes, I can knit it together with what I read. So it has meaning. And then it’s easier to hold on. Because the 12-hour overnight shift becomes hours of learning about my passion. Because I feel a step closer. And even though last night’s shift was so hard, I’m happy to be back at work today. When I read about the psychopathology of depression and then admit five patients with suicidal ideation, it stops being the same story over and over. It turns into an exploration, and it becomes fascinating. I won’t hear the same story again. So many times, attendings told me to read, and I had to be at my breaking point to understand why it was so essential. Now I’m motivated, and I plan to keep pushing myself to the limit to find a new challenge and to surprise myself in the middle of my beat-up tiredness when I see something in my patient that so many have written about. The adrenaline rush comes on the path of becoming that psychiatrist I aim to be, not in the diploma I will get 2 years from now.

I am racing against burnout, but I’m winning. And I wanted to share my experience to remind others that we are not alone on this path, and we should not have higher suicide rates than other professional groups.

If you are a resident or more experienced physician, know that you are not alone. Many others just like you are stretching themselves thin. Follow the tips of how to beat burnout that you’ve seen around. Find what works for you and dig into yourself, into what drove you in this direction, into where your passion lies. Find the meaning behind this hard work, and connect it to the passion that motivates you. Think of what made you want to become a doctor! I’m not sure it works 100% of the time.

Ask me again in 6 months.

Dr. Serrano is a PGY2 psychiatry resident at the Einstein Medical Center in Philadelphia.