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Me? Address social determinants of health? How?
When I heard the American Academy of Pediatrics call for pediatricians to address poverty and social determinants of health, I – and maybe you, too – thought, “Great idea. But how am I, as a practicing pediatrician, supposed to help with such overwhelming and socially determined factors?”
It seems that the best way to reduce poverty, homelessness, and inadequate education is to advocate and vote to maintain or expand proven social programs. But there are also more proximal “relational” (relationship) factors we can address. The Adverse Childhood Experiences (ACE) study showed that the number of ACEs reported in their pasts by adults has a nearly linear relationship to long-term morbidities, including suicide, depression, obesity, smoking, substance abuse, heart disease, and early death. The ACE events during childhood – besides lack of food – came from the child’s relationships: abuse (emotional, physical, or sexual) and family dysfunction (mother abused; loss of a caregiver through divorce, separation, or death; household members with alcohol or substance abuse, mental illness, or time in prison).
The most important step you can take to prevent your patients from ACEs is detection. You have to ask parents, either verbally or with a screening tool about current factors that could be harmful to the child. You may think, “My patients don’t have these problems,” but abuse, intimate partner violence (IPV), depression, substance use, and loss occur in families of all kinds and means. Even the presence of food insecurity and imprisonment in some of my “put together” families has surprised me.
There are a number of tools available to screen for individual factors such as parental depression (Edinburgh Postnatal Screening, Patient Health Questionnaire-2 and -4), IPV, substance use (CRAFFT, which stands for Car, Relax, Alone, Forget, Friends, Trouble), and food insecurity. Tools covering multiple risk factors also are available on paper (Safe Environment for Every Kid [SEEK], Survey of Well-being of Young Children [SWYC]) or online (CHADIS). Rather than being overly intrusive, parents report accepting these questions as representing your caring about them as well as their child.
Coverage for screening and counseling for depression and IPV is mandated by the Affordable Care Act. As of July 2016, screening for maternal depression by pediatricians is paid for by Medicaid and many other insurers, often as part of the well-child visit, according to the Center for Medicaid and CHIP Services’ Informational Bulletin of May 11, 2016. For patient-centered medical homes, there is a mandate for referral and care coordination (AHRQ Publication No.11-M005-EF, December 2010). New value-based payment mechanisms are likely to pay you based on such screening and referral processes (e.g. New York), so we had best prepare (“Value-Based Payment Models for Medicaid Child Health Services,” Report to the Schuyler Center for Analysis and Advocacy and the United Hospital Fund, July 13, 2016).
But what to do when the screen or questions reveal a problem? Your first impulse is likely to be to refer. But unlike referrals for a physical health issue such as severe anemia for which the parent calls the hematologist immediately, in the case of these touchy, embarrassing, or emotionally charged problems, accepting help may not be so easy. It may be the financially critical partner who is the substance user or the mother herself who is too depressed to move towards help. For problems such as lack of food or the need to get a GED (general education development), the referral may be successful by supplying phone numbers. Referrals for IPV, one of the most common (greater than 29%) and damaging ACEs to the child, who is exposed to violence and often abused, have been found to mainly fail from simply making a referral.
Just as for a positive blood screen, for a referral to be effective more information is needed. In the case of a family stressor, you need to find out the nature and extent of the problem, the immediacy of the danger, and what has been done so far to reduce it. Research now shows that the most effective way to collect this information is using motivational interviewing (MI) techniques that nonjudgmentally determine not just the facts, but engage parents in weighing the pros and cons of changing the status quo, their readiness to change, the types of interventions that might be acceptable, and what would tell them that it was time to act. When using MI, you are actually doing more than making a referral, you are beginning to address the problem you uncovered.
The MI process strengthens the trust in your relationship with the parent, starting with reflecting on the issue (“It sounds as though you don’t always feel safe at home”), empathizing (“That must be really scary. I am sorry you are going through that”), and assessing (“May I try to help you with this?”).
After collecting the pros and cons for making a change, either in the interview or via the screening tool SEEK Plus in CHADIS, your job is to help the parent weigh them (“On the one hand you love him and need his income, but on the other hand you are so afraid that you can’t sleep and your children are too nervous to concentrate in school.”) Then you need to elicit what would be enough to move them (“How will you know when it is time to act?”) and to assess readiness to change (“What kinds of help would you be open to?”), then offer that kind of help (“I would like to connect you to a professional who has a lot of experience helping people in your situation. Is it okay if we call her right now?”). Provide written contact information, of course, but actually assisting by calling the appropriate resource or even doing a “warm handoff” in person is more effective.
Obviously, to make an effective referral, we need resources assembled in advance for the most common issues. UnitedWay.org is a good place to include on your list.
Our job, however, is not over with an “accepted” referral. Most referrals are not kept, help is never received, and risk to the child is not averted. There are many potential barriers to families’ accessing help – time off work, money, transportation, or child care – but difficulty generating the courage to change is understandable and may resolve only gradually with your work and support. It is wise to tell the parent that “I (or someone on your staff) will check in on how this goes, okay?”
Making a follow-up appointment with you is important, even if you feel helpless to do more than refer. Why? A return visit is a chance to show that you care, to be sure they went, and to get information on the quality and appropriateness of the care provided so you can support it or refer elsewhere. Perhaps most importantly, it shows that you do not reject them for revealing what they may see as personal failure or immoral behavior so that you can continue caring for and monitoring their at-risk child.
What if they decline help, no resources are to be found, or the damage has already occurred? You still have valuable help to provide. Our goal is to ameliorate the impact of the stressors on the child now and in the future. Just as relational factors can stress the child, improving supportive relationships is key to reducing their effects. Parents with ACE risk factors are often self-absorbed in their pain, using smoking, substances, or alcohol to dampen it and moving from one troubled relationship to another in response to past trauma; thus they are emotionally unavailable to the child.
You can help them by focusing on the wonders of their child, encouraging daily individual time for play, and modeling Reach Out and Read as a supportive, calm activity they can do even when stressed. You can encourage the practice of mindfulness – an exercise of letting thoughts pass over them without judgment while breathing rhythmically – for stressed parents and school-aged children. It has been shown to be an effective intervention for recovering from past as well as current stress. Children also should receive any needed mental health care.
An emotionally available, supportive, nurturing parent is the most important protective factor for the child’s development of emotion regulation, resilience, and the ability to cope with adversity throughout their life. Referring parents to services such as home visiting, Healthy Steps, or parent-child therapy to build these skills has evidence for improving relational health. Helping the parents avoid ACEs for their children and assisting them in ameliorating them, if they occur, are important investments in long-term health that you can provide.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at pdnews@frontlinemedcom.com.
When I heard the American Academy of Pediatrics call for pediatricians to address poverty and social determinants of health, I – and maybe you, too – thought, “Great idea. But how am I, as a practicing pediatrician, supposed to help with such overwhelming and socially determined factors?”
It seems that the best way to reduce poverty, homelessness, and inadequate education is to advocate and vote to maintain or expand proven social programs. But there are also more proximal “relational” (relationship) factors we can address. The Adverse Childhood Experiences (ACE) study showed that the number of ACEs reported in their pasts by adults has a nearly linear relationship to long-term morbidities, including suicide, depression, obesity, smoking, substance abuse, heart disease, and early death. The ACE events during childhood – besides lack of food – came from the child’s relationships: abuse (emotional, physical, or sexual) and family dysfunction (mother abused; loss of a caregiver through divorce, separation, or death; household members with alcohol or substance abuse, mental illness, or time in prison).
The most important step you can take to prevent your patients from ACEs is detection. You have to ask parents, either verbally or with a screening tool about current factors that could be harmful to the child. You may think, “My patients don’t have these problems,” but abuse, intimate partner violence (IPV), depression, substance use, and loss occur in families of all kinds and means. Even the presence of food insecurity and imprisonment in some of my “put together” families has surprised me.
There are a number of tools available to screen for individual factors such as parental depression (Edinburgh Postnatal Screening, Patient Health Questionnaire-2 and -4), IPV, substance use (CRAFFT, which stands for Car, Relax, Alone, Forget, Friends, Trouble), and food insecurity. Tools covering multiple risk factors also are available on paper (Safe Environment for Every Kid [SEEK], Survey of Well-being of Young Children [SWYC]) or online (CHADIS). Rather than being overly intrusive, parents report accepting these questions as representing your caring about them as well as their child.
Coverage for screening and counseling for depression and IPV is mandated by the Affordable Care Act. As of July 2016, screening for maternal depression by pediatricians is paid for by Medicaid and many other insurers, often as part of the well-child visit, according to the Center for Medicaid and CHIP Services’ Informational Bulletin of May 11, 2016. For patient-centered medical homes, there is a mandate for referral and care coordination (AHRQ Publication No.11-M005-EF, December 2010). New value-based payment mechanisms are likely to pay you based on such screening and referral processes (e.g. New York), so we had best prepare (“Value-Based Payment Models for Medicaid Child Health Services,” Report to the Schuyler Center for Analysis and Advocacy and the United Hospital Fund, July 13, 2016).
But what to do when the screen or questions reveal a problem? Your first impulse is likely to be to refer. But unlike referrals for a physical health issue such as severe anemia for which the parent calls the hematologist immediately, in the case of these touchy, embarrassing, or emotionally charged problems, accepting help may not be so easy. It may be the financially critical partner who is the substance user or the mother herself who is too depressed to move towards help. For problems such as lack of food or the need to get a GED (general education development), the referral may be successful by supplying phone numbers. Referrals for IPV, one of the most common (greater than 29%) and damaging ACEs to the child, who is exposed to violence and often abused, have been found to mainly fail from simply making a referral.
Just as for a positive blood screen, for a referral to be effective more information is needed. In the case of a family stressor, you need to find out the nature and extent of the problem, the immediacy of the danger, and what has been done so far to reduce it. Research now shows that the most effective way to collect this information is using motivational interviewing (MI) techniques that nonjudgmentally determine not just the facts, but engage parents in weighing the pros and cons of changing the status quo, their readiness to change, the types of interventions that might be acceptable, and what would tell them that it was time to act. When using MI, you are actually doing more than making a referral, you are beginning to address the problem you uncovered.
The MI process strengthens the trust in your relationship with the parent, starting with reflecting on the issue (“It sounds as though you don’t always feel safe at home”), empathizing (“That must be really scary. I am sorry you are going through that”), and assessing (“May I try to help you with this?”).
After collecting the pros and cons for making a change, either in the interview or via the screening tool SEEK Plus in CHADIS, your job is to help the parent weigh them (“On the one hand you love him and need his income, but on the other hand you are so afraid that you can’t sleep and your children are too nervous to concentrate in school.”) Then you need to elicit what would be enough to move them (“How will you know when it is time to act?”) and to assess readiness to change (“What kinds of help would you be open to?”), then offer that kind of help (“I would like to connect you to a professional who has a lot of experience helping people in your situation. Is it okay if we call her right now?”). Provide written contact information, of course, but actually assisting by calling the appropriate resource or even doing a “warm handoff” in person is more effective.
Obviously, to make an effective referral, we need resources assembled in advance for the most common issues. UnitedWay.org is a good place to include on your list.
Our job, however, is not over with an “accepted” referral. Most referrals are not kept, help is never received, and risk to the child is not averted. There are many potential barriers to families’ accessing help – time off work, money, transportation, or child care – but difficulty generating the courage to change is understandable and may resolve only gradually with your work and support. It is wise to tell the parent that “I (or someone on your staff) will check in on how this goes, okay?”
Making a follow-up appointment with you is important, even if you feel helpless to do more than refer. Why? A return visit is a chance to show that you care, to be sure they went, and to get information on the quality and appropriateness of the care provided so you can support it or refer elsewhere. Perhaps most importantly, it shows that you do not reject them for revealing what they may see as personal failure or immoral behavior so that you can continue caring for and monitoring their at-risk child.
What if they decline help, no resources are to be found, or the damage has already occurred? You still have valuable help to provide. Our goal is to ameliorate the impact of the stressors on the child now and in the future. Just as relational factors can stress the child, improving supportive relationships is key to reducing their effects. Parents with ACE risk factors are often self-absorbed in their pain, using smoking, substances, or alcohol to dampen it and moving from one troubled relationship to another in response to past trauma; thus they are emotionally unavailable to the child.
You can help them by focusing on the wonders of their child, encouraging daily individual time for play, and modeling Reach Out and Read as a supportive, calm activity they can do even when stressed. You can encourage the practice of mindfulness – an exercise of letting thoughts pass over them without judgment while breathing rhythmically – for stressed parents and school-aged children. It has been shown to be an effective intervention for recovering from past as well as current stress. Children also should receive any needed mental health care.
An emotionally available, supportive, nurturing parent is the most important protective factor for the child’s development of emotion regulation, resilience, and the ability to cope with adversity throughout their life. Referring parents to services such as home visiting, Healthy Steps, or parent-child therapy to build these skills has evidence for improving relational health. Helping the parents avoid ACEs for their children and assisting them in ameliorating them, if they occur, are important investments in long-term health that you can provide.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at pdnews@frontlinemedcom.com.
When I heard the American Academy of Pediatrics call for pediatricians to address poverty and social determinants of health, I – and maybe you, too – thought, “Great idea. But how am I, as a practicing pediatrician, supposed to help with such overwhelming and socially determined factors?”
It seems that the best way to reduce poverty, homelessness, and inadequate education is to advocate and vote to maintain or expand proven social programs. But there are also more proximal “relational” (relationship) factors we can address. The Adverse Childhood Experiences (ACE) study showed that the number of ACEs reported in their pasts by adults has a nearly linear relationship to long-term morbidities, including suicide, depression, obesity, smoking, substance abuse, heart disease, and early death. The ACE events during childhood – besides lack of food – came from the child’s relationships: abuse (emotional, physical, or sexual) and family dysfunction (mother abused; loss of a caregiver through divorce, separation, or death; household members with alcohol or substance abuse, mental illness, or time in prison).
The most important step you can take to prevent your patients from ACEs is detection. You have to ask parents, either verbally or with a screening tool about current factors that could be harmful to the child. You may think, “My patients don’t have these problems,” but abuse, intimate partner violence (IPV), depression, substance use, and loss occur in families of all kinds and means. Even the presence of food insecurity and imprisonment in some of my “put together” families has surprised me.
There are a number of tools available to screen for individual factors such as parental depression (Edinburgh Postnatal Screening, Patient Health Questionnaire-2 and -4), IPV, substance use (CRAFFT, which stands for Car, Relax, Alone, Forget, Friends, Trouble), and food insecurity. Tools covering multiple risk factors also are available on paper (Safe Environment for Every Kid [SEEK], Survey of Well-being of Young Children [SWYC]) or online (CHADIS). Rather than being overly intrusive, parents report accepting these questions as representing your caring about them as well as their child.
Coverage for screening and counseling for depression and IPV is mandated by the Affordable Care Act. As of July 2016, screening for maternal depression by pediatricians is paid for by Medicaid and many other insurers, often as part of the well-child visit, according to the Center for Medicaid and CHIP Services’ Informational Bulletin of May 11, 2016. For patient-centered medical homes, there is a mandate for referral and care coordination (AHRQ Publication No.11-M005-EF, December 2010). New value-based payment mechanisms are likely to pay you based on such screening and referral processes (e.g. New York), so we had best prepare (“Value-Based Payment Models for Medicaid Child Health Services,” Report to the Schuyler Center for Analysis and Advocacy and the United Hospital Fund, July 13, 2016).
But what to do when the screen or questions reveal a problem? Your first impulse is likely to be to refer. But unlike referrals for a physical health issue such as severe anemia for which the parent calls the hematologist immediately, in the case of these touchy, embarrassing, or emotionally charged problems, accepting help may not be so easy. It may be the financially critical partner who is the substance user or the mother herself who is too depressed to move towards help. For problems such as lack of food or the need to get a GED (general education development), the referral may be successful by supplying phone numbers. Referrals for IPV, one of the most common (greater than 29%) and damaging ACEs to the child, who is exposed to violence and often abused, have been found to mainly fail from simply making a referral.
Just as for a positive blood screen, for a referral to be effective more information is needed. In the case of a family stressor, you need to find out the nature and extent of the problem, the immediacy of the danger, and what has been done so far to reduce it. Research now shows that the most effective way to collect this information is using motivational interviewing (MI) techniques that nonjudgmentally determine not just the facts, but engage parents in weighing the pros and cons of changing the status quo, their readiness to change, the types of interventions that might be acceptable, and what would tell them that it was time to act. When using MI, you are actually doing more than making a referral, you are beginning to address the problem you uncovered.
The MI process strengthens the trust in your relationship with the parent, starting with reflecting on the issue (“It sounds as though you don’t always feel safe at home”), empathizing (“That must be really scary. I am sorry you are going through that”), and assessing (“May I try to help you with this?”).
After collecting the pros and cons for making a change, either in the interview or via the screening tool SEEK Plus in CHADIS, your job is to help the parent weigh them (“On the one hand you love him and need his income, but on the other hand you are so afraid that you can’t sleep and your children are too nervous to concentrate in school.”) Then you need to elicit what would be enough to move them (“How will you know when it is time to act?”) and to assess readiness to change (“What kinds of help would you be open to?”), then offer that kind of help (“I would like to connect you to a professional who has a lot of experience helping people in your situation. Is it okay if we call her right now?”). Provide written contact information, of course, but actually assisting by calling the appropriate resource or even doing a “warm handoff” in person is more effective.
Obviously, to make an effective referral, we need resources assembled in advance for the most common issues. UnitedWay.org is a good place to include on your list.
Our job, however, is not over with an “accepted” referral. Most referrals are not kept, help is never received, and risk to the child is not averted. There are many potential barriers to families’ accessing help – time off work, money, transportation, or child care – but difficulty generating the courage to change is understandable and may resolve only gradually with your work and support. It is wise to tell the parent that “I (or someone on your staff) will check in on how this goes, okay?”
Making a follow-up appointment with you is important, even if you feel helpless to do more than refer. Why? A return visit is a chance to show that you care, to be sure they went, and to get information on the quality and appropriateness of the care provided so you can support it or refer elsewhere. Perhaps most importantly, it shows that you do not reject them for revealing what they may see as personal failure or immoral behavior so that you can continue caring for and monitoring their at-risk child.
What if they decline help, no resources are to be found, or the damage has already occurred? You still have valuable help to provide. Our goal is to ameliorate the impact of the stressors on the child now and in the future. Just as relational factors can stress the child, improving supportive relationships is key to reducing their effects. Parents with ACE risk factors are often self-absorbed in their pain, using smoking, substances, or alcohol to dampen it and moving from one troubled relationship to another in response to past trauma; thus they are emotionally unavailable to the child.
You can help them by focusing on the wonders of their child, encouraging daily individual time for play, and modeling Reach Out and Read as a supportive, calm activity they can do even when stressed. You can encourage the practice of mindfulness – an exercise of letting thoughts pass over them without judgment while breathing rhythmically – for stressed parents and school-aged children. It has been shown to be an effective intervention for recovering from past as well as current stress. Children also should receive any needed mental health care.
An emotionally available, supportive, nurturing parent is the most important protective factor for the child’s development of emotion regulation, resilience, and the ability to cope with adversity throughout their life. Referring parents to services such as home visiting, Healthy Steps, or parent-child therapy to build these skills has evidence for improving relational health. Helping the parents avoid ACEs for their children and assisting them in ameliorating them, if they occur, are important investments in long-term health that you can provide.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at pdnews@frontlinemedcom.com.
Don’t touch that! You’ll get hurt! Fear in childhood
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 pdnews@frontlinemedcom.com.
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 pdnews@frontlinemedcom.com.
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 pdnews@frontlinemedcom.com.
Value of the prebaby visit
Will you get paid for conducting a prebaby visit in your practice? Probably not in income, but certainly in long-term benefits to your care of the incoming child and family.
While parents are coached by websites to determine such things as your fees, what insurance you take, your credentials, age, gender, practice structure, hours, and availability, all these questions can be handled by your front desk or nursing staff or a handout. The really valuable conversations are the ones that you have that help the imminent parents begin to understand the sometimes subtle factors influencing the parenting they will undertake.
Pregnancy brings mental and emotional changes in a predicable pattern that is useful to understand. In the first trimester, the prospective parents become aware of their gender and sexuality in a new way, usually with pride and confirmation. For teenagers, this may not be welcomed by the family and may even place them at risk for being put out of the house. The fetus, however, is not very real to the parents at this point, except through the morning sickness that mothers – and even some empathetic fathers – experience. You are not likely to see the family in the first trimester unless an early ultrasound or genetic test raises concerns that require decisions.
In the second trimester, the gender is often revealed, making the child seem much more real. Men may spend a lot of time thinking about finances and how to support the upcoming demands. Some men deal with the impending departure of their freedom by taking up a new hobby, making the mother nervous about their commitment to helping with the baby in the future. In these months, prospective parents often have dreams of a deformed infant or other scary imaginings about forgetting or harming the baby. Older parents or those with a history of miscarriage or infertility may be particularly worried about possible abnormalities, but these fears are quite common among all parents. You can reassure parents that these dreams may be a way of helping them “be ready for anything.” The responsibility of parenting already has begun in needing to avoid medications, alcohol, and smoking – at least for the mother. While the father also may be abstaining in support, he may be oblivious, and the mother may be suffering alone and concerned about his future support in parenting.
The third trimester is the time parents come up with names, prep the bedroom, pack the suitcase, and make concrete plans for the delivery but also face the reality that delivering a baby has huge potential dangers as well as joys.
The third trimester is the most common time for a visit to interview pediatricians, and these issues are not far from the surface – if you ask. The goal of a prebaby visit – of forming a supportive relationship with the parents without a baby yet present – is multifactorial. It is best approached by:
• Asking about the history of previous pregnancies and the course of the current pregnancy so far.
• Asking whether flu and Tdap vaccines were given.
• Asking whether there have there been any complications or exposures to infections, medications, smoke, alcohol, or drugs.
• Congratulating abstinence and acknowledging all the ways that the parents have been “taking good care of this baby already.”
More parents are questioning the use of vaccines and antibiotics these days, and they may want to discuss your views or policies on these. Having handouts available on these plus ones on car seats, smoke exposure, supine sleeping position, safe crib accessories, and the expected newborn tests is important for all parents because these standards keep changing. While most practices want to attract new patients, be honest because sometimes parents are not a good fit!
Delivery method is not completely a choice, but put in a word about avoiding general anesthesia for the sake of the baby, which is not likely to have been on the parents’ minds. This is the chance to get them excited about the unique alertness their newborn will have in the first hour after birth under the influence of labor stress, giving them the chance to lock gaze in a moment they will never forget!
Asking “How do you plan to feed the baby?” rather than just “breast or bottle” gives you a chance to inform them of your team’s expertise and your support for their choice, but may also reveal ambivalences worth exploring. The prospect of breastfeeding often brings out fears of failure from the mother, but surprisingly, some fathers are possessive about their partner’s breasts and not willing to share. Some mothers are so modest that breastfeeding is taboo. A motivational interviewing style “pros and cons” discussion of nursing is in order, but may not budge those beliefs. In this age of safe formula, you need not strain your relationship to convince them. Such extremes in the family are quite likely to reemerge as issues later in the need to “surrender” to the requirements of childrearing, however.
You may think that taking a family history to understand health risks will soon be obviated by genomic testing or a shared electronic medical record. I believe that it will always have special value at the prebaby visit, whether that information is available or not. In eliciting a history of any potentially hereditary conditions, the key is to assure families that you will be on their team to provide the best medical care for any eventuality. But this is also the time to ask about each family member, their education, employment, and medical conditions, including mental health and substance use. In the process, you are likely to hear about any estrangements, abuse, divorces, dependent relatives, and just plain family stress that will impact on this newly forming family. The question, “Who will you have to help you with the baby?” will elicit social support, but also concerns about fears of intrusive relatives or demands of dependent family members. Parents will thank you later for suggesting a doula, inviting relatives to takes turns coming to help after the first 2 “settling in” weeks when the father has to go back to work, or arranging a sitter for older siblings even though mother is home! This is a good moment to discuss prebaby classes and strategies for supporting any siblings at this big transition with daily special time. It is a valuable service to have resource listings for child care as this may be a bigger stress than concerns about delivery!
Even if they already know the baby’s sex, I like to ask, “Were you hoping for a girl or a boy?” (and why) as a way to elicit gender bias, in addition to finding out about risk for genetic conditions. Such bias may later become relevant, especially for toddler discipline, which presents as the “prejudiced parent syndrome” of overly lax or overly strong punishment. Turning to the father and asking, “What are your ideas about circumcision?” is sure to engage his attention and show that you expect him to be an active participant in decisions in what may have seemed a female process so far. If they have not decided or are actively disagreeing, you may express curiosity about “how they usually decide things together.” Be sure to recommend local anesthesia for circumcision, if planned!
Parental bias about gender also may come from negative experiences when the parent was growing up, such as a whiny sister or hyperactive cousin. Verbalizing that “everyone has memories from how we were raised that we may or may not want to repeat” is a great opener for asking, “What was it like when you were growing up? What would you like to do the same way and what differently?” This is an appropriate time to ask about their marriage and whether this was “a good time to have a baby.” Although most pregnancies are unplanned, it is the norm for parents to have come to an acceptance and excitement about the pregnancy by the second trimester. If you detect marital discord or depression, making a referral now is very important, rather than waiting in hopes it will resolve when the baby comes. With all its joys, studies show that the arrival of a baby is a huge stress that tends to worsen the parental relationship. Plus, they have more time to get to help now than they will after delivery!
Having a baby is life’s biggest commitment, adventure, and joy. Showing parents in the prebaby visit that you care about them, their values, and questions, and not just the medical care of their child can quickly establish a deep understanding that will inform all future contacts – making communication easier, more effective, and more meaningful.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication is as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
Will you get paid for conducting a prebaby visit in your practice? Probably not in income, but certainly in long-term benefits to your care of the incoming child and family.
While parents are coached by websites to determine such things as your fees, what insurance you take, your credentials, age, gender, practice structure, hours, and availability, all these questions can be handled by your front desk or nursing staff or a handout. The really valuable conversations are the ones that you have that help the imminent parents begin to understand the sometimes subtle factors influencing the parenting they will undertake.
Pregnancy brings mental and emotional changes in a predicable pattern that is useful to understand. In the first trimester, the prospective parents become aware of their gender and sexuality in a new way, usually with pride and confirmation. For teenagers, this may not be welcomed by the family and may even place them at risk for being put out of the house. The fetus, however, is not very real to the parents at this point, except through the morning sickness that mothers – and even some empathetic fathers – experience. You are not likely to see the family in the first trimester unless an early ultrasound or genetic test raises concerns that require decisions.
In the second trimester, the gender is often revealed, making the child seem much more real. Men may spend a lot of time thinking about finances and how to support the upcoming demands. Some men deal with the impending departure of their freedom by taking up a new hobby, making the mother nervous about their commitment to helping with the baby in the future. In these months, prospective parents often have dreams of a deformed infant or other scary imaginings about forgetting or harming the baby. Older parents or those with a history of miscarriage or infertility may be particularly worried about possible abnormalities, but these fears are quite common among all parents. You can reassure parents that these dreams may be a way of helping them “be ready for anything.” The responsibility of parenting already has begun in needing to avoid medications, alcohol, and smoking – at least for the mother. While the father also may be abstaining in support, he may be oblivious, and the mother may be suffering alone and concerned about his future support in parenting.
The third trimester is the time parents come up with names, prep the bedroom, pack the suitcase, and make concrete plans for the delivery but also face the reality that delivering a baby has huge potential dangers as well as joys.
The third trimester is the most common time for a visit to interview pediatricians, and these issues are not far from the surface – if you ask. The goal of a prebaby visit – of forming a supportive relationship with the parents without a baby yet present – is multifactorial. It is best approached by:
• Asking about the history of previous pregnancies and the course of the current pregnancy so far.
• Asking whether flu and Tdap vaccines were given.
• Asking whether there have there been any complications or exposures to infections, medications, smoke, alcohol, or drugs.
• Congratulating abstinence and acknowledging all the ways that the parents have been “taking good care of this baby already.”
More parents are questioning the use of vaccines and antibiotics these days, and they may want to discuss your views or policies on these. Having handouts available on these plus ones on car seats, smoke exposure, supine sleeping position, safe crib accessories, and the expected newborn tests is important for all parents because these standards keep changing. While most practices want to attract new patients, be honest because sometimes parents are not a good fit!
Delivery method is not completely a choice, but put in a word about avoiding general anesthesia for the sake of the baby, which is not likely to have been on the parents’ minds. This is the chance to get them excited about the unique alertness their newborn will have in the first hour after birth under the influence of labor stress, giving them the chance to lock gaze in a moment they will never forget!
Asking “How do you plan to feed the baby?” rather than just “breast or bottle” gives you a chance to inform them of your team’s expertise and your support for their choice, but may also reveal ambivalences worth exploring. The prospect of breastfeeding often brings out fears of failure from the mother, but surprisingly, some fathers are possessive about their partner’s breasts and not willing to share. Some mothers are so modest that breastfeeding is taboo. A motivational interviewing style “pros and cons” discussion of nursing is in order, but may not budge those beliefs. In this age of safe formula, you need not strain your relationship to convince them. Such extremes in the family are quite likely to reemerge as issues later in the need to “surrender” to the requirements of childrearing, however.
You may think that taking a family history to understand health risks will soon be obviated by genomic testing or a shared electronic medical record. I believe that it will always have special value at the prebaby visit, whether that information is available or not. In eliciting a history of any potentially hereditary conditions, the key is to assure families that you will be on their team to provide the best medical care for any eventuality. But this is also the time to ask about each family member, their education, employment, and medical conditions, including mental health and substance use. In the process, you are likely to hear about any estrangements, abuse, divorces, dependent relatives, and just plain family stress that will impact on this newly forming family. The question, “Who will you have to help you with the baby?” will elicit social support, but also concerns about fears of intrusive relatives or demands of dependent family members. Parents will thank you later for suggesting a doula, inviting relatives to takes turns coming to help after the first 2 “settling in” weeks when the father has to go back to work, or arranging a sitter for older siblings even though mother is home! This is a good moment to discuss prebaby classes and strategies for supporting any siblings at this big transition with daily special time. It is a valuable service to have resource listings for child care as this may be a bigger stress than concerns about delivery!
Even if they already know the baby’s sex, I like to ask, “Were you hoping for a girl or a boy?” (and why) as a way to elicit gender bias, in addition to finding out about risk for genetic conditions. Such bias may later become relevant, especially for toddler discipline, which presents as the “prejudiced parent syndrome” of overly lax or overly strong punishment. Turning to the father and asking, “What are your ideas about circumcision?” is sure to engage his attention and show that you expect him to be an active participant in decisions in what may have seemed a female process so far. If they have not decided or are actively disagreeing, you may express curiosity about “how they usually decide things together.” Be sure to recommend local anesthesia for circumcision, if planned!
Parental bias about gender also may come from negative experiences when the parent was growing up, such as a whiny sister or hyperactive cousin. Verbalizing that “everyone has memories from how we were raised that we may or may not want to repeat” is a great opener for asking, “What was it like when you were growing up? What would you like to do the same way and what differently?” This is an appropriate time to ask about their marriage and whether this was “a good time to have a baby.” Although most pregnancies are unplanned, it is the norm for parents to have come to an acceptance and excitement about the pregnancy by the second trimester. If you detect marital discord or depression, making a referral now is very important, rather than waiting in hopes it will resolve when the baby comes. With all its joys, studies show that the arrival of a baby is a huge stress that tends to worsen the parental relationship. Plus, they have more time to get to help now than they will after delivery!
Having a baby is life’s biggest commitment, adventure, and joy. Showing parents in the prebaby visit that you care about them, their values, and questions, and not just the medical care of their child can quickly establish a deep understanding that will inform all future contacts – making communication easier, more effective, and more meaningful.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication is as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
Will you get paid for conducting a prebaby visit in your practice? Probably not in income, but certainly in long-term benefits to your care of the incoming child and family.
While parents are coached by websites to determine such things as your fees, what insurance you take, your credentials, age, gender, practice structure, hours, and availability, all these questions can be handled by your front desk or nursing staff or a handout. The really valuable conversations are the ones that you have that help the imminent parents begin to understand the sometimes subtle factors influencing the parenting they will undertake.
Pregnancy brings mental and emotional changes in a predicable pattern that is useful to understand. In the first trimester, the prospective parents become aware of their gender and sexuality in a new way, usually with pride and confirmation. For teenagers, this may not be welcomed by the family and may even place them at risk for being put out of the house. The fetus, however, is not very real to the parents at this point, except through the morning sickness that mothers – and even some empathetic fathers – experience. You are not likely to see the family in the first trimester unless an early ultrasound or genetic test raises concerns that require decisions.
In the second trimester, the gender is often revealed, making the child seem much more real. Men may spend a lot of time thinking about finances and how to support the upcoming demands. Some men deal with the impending departure of their freedom by taking up a new hobby, making the mother nervous about their commitment to helping with the baby in the future. In these months, prospective parents often have dreams of a deformed infant or other scary imaginings about forgetting or harming the baby. Older parents or those with a history of miscarriage or infertility may be particularly worried about possible abnormalities, but these fears are quite common among all parents. You can reassure parents that these dreams may be a way of helping them “be ready for anything.” The responsibility of parenting already has begun in needing to avoid medications, alcohol, and smoking – at least for the mother. While the father also may be abstaining in support, he may be oblivious, and the mother may be suffering alone and concerned about his future support in parenting.
The third trimester is the time parents come up with names, prep the bedroom, pack the suitcase, and make concrete plans for the delivery but also face the reality that delivering a baby has huge potential dangers as well as joys.
The third trimester is the most common time for a visit to interview pediatricians, and these issues are not far from the surface – if you ask. The goal of a prebaby visit – of forming a supportive relationship with the parents without a baby yet present – is multifactorial. It is best approached by:
• Asking about the history of previous pregnancies and the course of the current pregnancy so far.
• Asking whether flu and Tdap vaccines were given.
• Asking whether there have there been any complications or exposures to infections, medications, smoke, alcohol, or drugs.
• Congratulating abstinence and acknowledging all the ways that the parents have been “taking good care of this baby already.”
More parents are questioning the use of vaccines and antibiotics these days, and they may want to discuss your views or policies on these. Having handouts available on these plus ones on car seats, smoke exposure, supine sleeping position, safe crib accessories, and the expected newborn tests is important for all parents because these standards keep changing. While most practices want to attract new patients, be honest because sometimes parents are not a good fit!
Delivery method is not completely a choice, but put in a word about avoiding general anesthesia for the sake of the baby, which is not likely to have been on the parents’ minds. This is the chance to get them excited about the unique alertness their newborn will have in the first hour after birth under the influence of labor stress, giving them the chance to lock gaze in a moment they will never forget!
Asking “How do you plan to feed the baby?” rather than just “breast or bottle” gives you a chance to inform them of your team’s expertise and your support for their choice, but may also reveal ambivalences worth exploring. The prospect of breastfeeding often brings out fears of failure from the mother, but surprisingly, some fathers are possessive about their partner’s breasts and not willing to share. Some mothers are so modest that breastfeeding is taboo. A motivational interviewing style “pros and cons” discussion of nursing is in order, but may not budge those beliefs. In this age of safe formula, you need not strain your relationship to convince them. Such extremes in the family are quite likely to reemerge as issues later in the need to “surrender” to the requirements of childrearing, however.
You may think that taking a family history to understand health risks will soon be obviated by genomic testing or a shared electronic medical record. I believe that it will always have special value at the prebaby visit, whether that information is available or not. In eliciting a history of any potentially hereditary conditions, the key is to assure families that you will be on their team to provide the best medical care for any eventuality. But this is also the time to ask about each family member, their education, employment, and medical conditions, including mental health and substance use. In the process, you are likely to hear about any estrangements, abuse, divorces, dependent relatives, and just plain family stress that will impact on this newly forming family. The question, “Who will you have to help you with the baby?” will elicit social support, but also concerns about fears of intrusive relatives or demands of dependent family members. Parents will thank you later for suggesting a doula, inviting relatives to takes turns coming to help after the first 2 “settling in” weeks when the father has to go back to work, or arranging a sitter for older siblings even though mother is home! This is a good moment to discuss prebaby classes and strategies for supporting any siblings at this big transition with daily special time. It is a valuable service to have resource listings for child care as this may be a bigger stress than concerns about delivery!
Even if they already know the baby’s sex, I like to ask, “Were you hoping for a girl or a boy?” (and why) as a way to elicit gender bias, in addition to finding out about risk for genetic conditions. Such bias may later become relevant, especially for toddler discipline, which presents as the “prejudiced parent syndrome” of overly lax or overly strong punishment. Turning to the father and asking, “What are your ideas about circumcision?” is sure to engage his attention and show that you expect him to be an active participant in decisions in what may have seemed a female process so far. If they have not decided or are actively disagreeing, you may express curiosity about “how they usually decide things together.” Be sure to recommend local anesthesia for circumcision, if planned!
Parental bias about gender also may come from negative experiences when the parent was growing up, such as a whiny sister or hyperactive cousin. Verbalizing that “everyone has memories from how we were raised that we may or may not want to repeat” is a great opener for asking, “What was it like when you were growing up? What would you like to do the same way and what differently?” This is an appropriate time to ask about their marriage and whether this was “a good time to have a baby.” Although most pregnancies are unplanned, it is the norm for parents to have come to an acceptance and excitement about the pregnancy by the second trimester. If you detect marital discord or depression, making a referral now is very important, rather than waiting in hopes it will resolve when the baby comes. With all its joys, studies show that the arrival of a baby is a huge stress that tends to worsen the parental relationship. Plus, they have more time to get to help now than they will after delivery!
Having a baby is life’s biggest commitment, adventure, and joy. Showing parents in the prebaby visit that you care about them, their values, and questions, and not just the medical care of their child can quickly establish a deep understanding that will inform all future contacts – making communication easier, more effective, and more meaningful.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication is as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
The newest ‘rage’: disruptive mood dysregulation disorder
Outbursts by children when frustrated or when asked to “do something they don’t want to do” are among the most common behavioral complaints voiced by parents. But behavioral outbursts, beyond the typical tantrums of children up to age 4 years, can be signs of very severe mental health disorders and are the most common reason for psychiatric admission (50%-60%).
While behavioral dysregulation is undeniably a huge problem for families, there has been an unreasonable 40-fold rise in diagnosis of bipolar disorder from 1994 to 2003, and 48% were prescribed atypical neuroleptics – medications with serious side effects. In response to this overdiagnosis as bipolar disorder, in 2013 the DSM-5 created a new diagnosis called disruptive mood dysregulation disorder (DMDD) to differentiate children who experience explosive outbursts who have a different outcome. This new classification includes children aged 6-12 years with persistent irritability most of the time, nearly every day, lasting at least 12 months and starting before age 10 years. DMDD diagnosis is not used after age 18 years.
To be diagnosed, the child has to have frequent, severe temper outbursts “grossly out of proportion” to the situation, averaging at least three times per week. The outbursts can be verbal or physical aggression to people, things, or themselves. While tantrums can be severe in children with delayed development, for the DMDD diagnosis these behaviors must be inconsistent with developmental level and must occur in at least two settings, and in one setting it must be severe. While outbursts are common, only half of children in one study of severe tantrum behavior in 5- to 9-year-olds also had the required persistent irritability.
If this does sound a lot like bipolar disorder so far, you are right. So what is different? DMDD has a prevalence of 2%-5% and occurs mostly in boys, whereas bipolar disorder affects boys and girls equally and affects less than 1% prior to adolescence.
The key features distinguishing DMDD from bipolar disorder are lack of an episodic nature to the irritability and lack of mania. Irritability in DMDD has to be persistently present with breaks of no more than 3 consecutive months in the defining 12-month period. There also cannot be any more than 1 day of the elevated mood features of mania or hypomania. Identifying mania is the hardest part, even in diagnosing adult bipolar, where it occurs only 1% of the year, much less in children who are generally lively! Hypomania, while less intense than mania, is when the person is energetic, talkative, and confident to an extreme extent, often with a flight of creative ideas. Excitement over birthdays or Christmas specifically does not count! So getting this history has to be done carefully, generally by a mental health professional, to make the distinction.
Interestingly, DMDD is not diagnosed when outbursts and irritability are better explained by autism spectrum disorder, separation anxiety disorder, or PTSD. To me, these exclusions point out the importance of sorting out the “set conditions” for all problematic behaviors, not always an easy task. Symptoms of autism in high functioning individuals can be quite subtle. Was the upset from change in a rigid routine known only to the child? Were sensory stimuli such as loud noises intolerable to this child? Was a nonverbal signal of a peer mistaken as a threat? While violent outbursts precipitated by these factors would still be considered “grossly out of proportion to the situation” for a typical child, they are not uncommon in atypical children. Similarly, children with separation anxiety disorder experience a high level of threat from even thinking about being apart from their caregivers, setting them up for alarm by situations other children would not find difficult.
The American Academy of Pediatrics emphasizes the need to assess all children for a history of psychological trauma. Traumas are quite common, and their sequelae affect many aspects of the child’s life; in the case of outbursts, it is emotional resilience that is impaired. As for all DSM-5 diagnoses, DMDD is not diagnosed when the irritability is due to physiological effects of a substance (e.g. steroids) or another medical or neurological disorder. Children with chronic pain conditions such as rheumatoid arthritis or sickle cell usually cope remarkably well, but when they don’t, their irritability should not be considered a mental health disorder. More commonly, sleep debt can produce chronic irritability and always should be assessed.
When coaching families about outbursts, I work to help them recognize that the child is not just angry, but very distressed. While “typical” tantrums last 1-5 minutes and show a rise then decline in intensity of the anger and distress, anger outbursts are longer and have an initial short and rapid burst of anger that then declines over the duration of the outburst, and with a steady but lower level of distress throughout.
The option to hug and verbally console the child’s distress is sometimes effective and does not reinforce the behavior unless the parent also yields to demands. But once outbursts begin, I liken them to a bomb going off – there is no intervention possible then. Instead, the task of the family, and over time that of the child, is to recognize and better manage the triggers.
Dr. Ross Greene, in his book, “The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children,” asserts that the child’s anger and distress can be interpreted as frustration from a gap in skills. This has treatment implications for identifying, educating about, and ameliorating the child’s weaknesses (deficits in understanding, communication, emotion regulation, flexibility or performance; or excess jealousy or hypersensitivity), and coaching parents to recognize, acknowledge, and avoid stressing these areas, if possible. I coach families to give points to the child for progressive little steps toward being able to recognize, verbalize, and inhibit outbursts with a reward system for the points. This helps put the parents and child “on the same team” in working on improving these skills.
Research on children with DMDD indicates that they show less positive affect when winning a “fixed” video game and are less able to suppress negative affect when losing. (Don’t forget to examine the role of real video games as precipitants of tantrums and contingently remove them!) Threshold for upset is lower and the degree of the upsets less well handled by children with DMDD.
In another study, when presented with a series of ambiguous facial expressions, children with DMDD were more likely to see anger in the faces than were controls. One hopeful result was that they could be taught to shift their perceptions significantly away from seeing anger, also reducing irritability and resulting in functional MRI changes. Such hostile bias attribution (tending to see threat) is well known to predispose to aggression. Cognitive behavioral therapy, the most effective counseling intervention, similarly teaches children to rethink their own negative thoughts before acting.
If irritability and rages were not enough, most children with DMDD have other psychiatric disorders; 39% having two, and 51% three or more (J Child Adolesc Psychopharmacol. 2013 Nov;23[9]:588-96). If not for the DMDD diagnosis, 82% would meet criteria for oppositional defiant disorder (ODD). The other common comorbidities are attention-deficit/hyperactivity disorder (ADHD) (74.5%), anxiety disorders (49.0%), and depression that is not major depressive disorder (MDD)(33.3%). When MDD is present, that diagnosis takes precedence. One cannot diagnose ODD, intermittent explosive disorder, or bipolar disorder along with DMDD, conditions from which it is intended to differentiate. Each of these comorbid disorders can be difficult to manage alone much less in combination, making DMDD a disorder deserving diagnosis and treatment by a mental health professional.
One of the main reasons DMDD was created is that children with these features go on to depressive or anxiety disorder in adolescence, not bipolar disorder.
While there is no treatment specific to DMDD, the depression component and prognosis suggest use of SSRIs, in addition to psychosocial therapies, and stimulants for the comorbid ADHD. Unfortunately, these two classes of medication are relatively contraindicated in bipolar disorder because they can lead to treatment-induced episodic mania (TEM). TEM occurs twice as often with antidepressants compared with stimulants (44% vs. 18%) in children with bipolar disorder (J Affect Disord. 2004 Oct 1;82[1]:149-58). Getting the diagnosis correct is, therefore, of great importance when medication is considered.
Approaches such as behavior modification, family therapy, and inpatient treatment can be effective for chronic irritability and aggression. Stimulant treatment of comorbid ADHD can decrease aggression and irritability. Alpha agonists such as guanfacine or clonidine also can help. In cases of partial improvement, adding either risperidone or divalproex may further decrease aggression in ADHD. In refractory aggression, risperidone has the best evidence. The Affective Reactivity Index or Outburst Monitoring Scale can be helpful in assessing severity and monitoring outcomes.
While a prognosis for depression rather than bipolar disorder sounds like a plus, in a longitudinal study, adults who had DMDD as children had worse outcomes, including being more likely to have adverse health outcomes (smoking, sexually transmitted infection), police contact, and low educational attainment, and being more likely to live in poverty, compared with controls who had other psychiatric disorders. While DMDD is a new and different diagnosis, it is similar to bipolar in having a potential course of life disruption, dangerous behaviors, suicide risk, and hospitalization.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.
Outbursts by children when frustrated or when asked to “do something they don’t want to do” are among the most common behavioral complaints voiced by parents. But behavioral outbursts, beyond the typical tantrums of children up to age 4 years, can be signs of very severe mental health disorders and are the most common reason for psychiatric admission (50%-60%).
While behavioral dysregulation is undeniably a huge problem for families, there has been an unreasonable 40-fold rise in diagnosis of bipolar disorder from 1994 to 2003, and 48% were prescribed atypical neuroleptics – medications with serious side effects. In response to this overdiagnosis as bipolar disorder, in 2013 the DSM-5 created a new diagnosis called disruptive mood dysregulation disorder (DMDD) to differentiate children who experience explosive outbursts who have a different outcome. This new classification includes children aged 6-12 years with persistent irritability most of the time, nearly every day, lasting at least 12 months and starting before age 10 years. DMDD diagnosis is not used after age 18 years.
To be diagnosed, the child has to have frequent, severe temper outbursts “grossly out of proportion” to the situation, averaging at least three times per week. The outbursts can be verbal or physical aggression to people, things, or themselves. While tantrums can be severe in children with delayed development, for the DMDD diagnosis these behaviors must be inconsistent with developmental level and must occur in at least two settings, and in one setting it must be severe. While outbursts are common, only half of children in one study of severe tantrum behavior in 5- to 9-year-olds also had the required persistent irritability.
If this does sound a lot like bipolar disorder so far, you are right. So what is different? DMDD has a prevalence of 2%-5% and occurs mostly in boys, whereas bipolar disorder affects boys and girls equally and affects less than 1% prior to adolescence.
The key features distinguishing DMDD from bipolar disorder are lack of an episodic nature to the irritability and lack of mania. Irritability in DMDD has to be persistently present with breaks of no more than 3 consecutive months in the defining 12-month period. There also cannot be any more than 1 day of the elevated mood features of mania or hypomania. Identifying mania is the hardest part, even in diagnosing adult bipolar, where it occurs only 1% of the year, much less in children who are generally lively! Hypomania, while less intense than mania, is when the person is energetic, talkative, and confident to an extreme extent, often with a flight of creative ideas. Excitement over birthdays or Christmas specifically does not count! So getting this history has to be done carefully, generally by a mental health professional, to make the distinction.
Interestingly, DMDD is not diagnosed when outbursts and irritability are better explained by autism spectrum disorder, separation anxiety disorder, or PTSD. To me, these exclusions point out the importance of sorting out the “set conditions” for all problematic behaviors, not always an easy task. Symptoms of autism in high functioning individuals can be quite subtle. Was the upset from change in a rigid routine known only to the child? Were sensory stimuli such as loud noises intolerable to this child? Was a nonverbal signal of a peer mistaken as a threat? While violent outbursts precipitated by these factors would still be considered “grossly out of proportion to the situation” for a typical child, they are not uncommon in atypical children. Similarly, children with separation anxiety disorder experience a high level of threat from even thinking about being apart from their caregivers, setting them up for alarm by situations other children would not find difficult.
The American Academy of Pediatrics emphasizes the need to assess all children for a history of psychological trauma. Traumas are quite common, and their sequelae affect many aspects of the child’s life; in the case of outbursts, it is emotional resilience that is impaired. As for all DSM-5 diagnoses, DMDD is not diagnosed when the irritability is due to physiological effects of a substance (e.g. steroids) or another medical or neurological disorder. Children with chronic pain conditions such as rheumatoid arthritis or sickle cell usually cope remarkably well, but when they don’t, their irritability should not be considered a mental health disorder. More commonly, sleep debt can produce chronic irritability and always should be assessed.
When coaching families about outbursts, I work to help them recognize that the child is not just angry, but very distressed. While “typical” tantrums last 1-5 minutes and show a rise then decline in intensity of the anger and distress, anger outbursts are longer and have an initial short and rapid burst of anger that then declines over the duration of the outburst, and with a steady but lower level of distress throughout.
The option to hug and verbally console the child’s distress is sometimes effective and does not reinforce the behavior unless the parent also yields to demands. But once outbursts begin, I liken them to a bomb going off – there is no intervention possible then. Instead, the task of the family, and over time that of the child, is to recognize and better manage the triggers.
Dr. Ross Greene, in his book, “The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children,” asserts that the child’s anger and distress can be interpreted as frustration from a gap in skills. This has treatment implications for identifying, educating about, and ameliorating the child’s weaknesses (deficits in understanding, communication, emotion regulation, flexibility or performance; or excess jealousy or hypersensitivity), and coaching parents to recognize, acknowledge, and avoid stressing these areas, if possible. I coach families to give points to the child for progressive little steps toward being able to recognize, verbalize, and inhibit outbursts with a reward system for the points. This helps put the parents and child “on the same team” in working on improving these skills.
Research on children with DMDD indicates that they show less positive affect when winning a “fixed” video game and are less able to suppress negative affect when losing. (Don’t forget to examine the role of real video games as precipitants of tantrums and contingently remove them!) Threshold for upset is lower and the degree of the upsets less well handled by children with DMDD.
In another study, when presented with a series of ambiguous facial expressions, children with DMDD were more likely to see anger in the faces than were controls. One hopeful result was that they could be taught to shift their perceptions significantly away from seeing anger, also reducing irritability and resulting in functional MRI changes. Such hostile bias attribution (tending to see threat) is well known to predispose to aggression. Cognitive behavioral therapy, the most effective counseling intervention, similarly teaches children to rethink their own negative thoughts before acting.
If irritability and rages were not enough, most children with DMDD have other psychiatric disorders; 39% having two, and 51% three or more (J Child Adolesc Psychopharmacol. 2013 Nov;23[9]:588-96). If not for the DMDD diagnosis, 82% would meet criteria for oppositional defiant disorder (ODD). The other common comorbidities are attention-deficit/hyperactivity disorder (ADHD) (74.5%), anxiety disorders (49.0%), and depression that is not major depressive disorder (MDD)(33.3%). When MDD is present, that diagnosis takes precedence. One cannot diagnose ODD, intermittent explosive disorder, or bipolar disorder along with DMDD, conditions from which it is intended to differentiate. Each of these comorbid disorders can be difficult to manage alone much less in combination, making DMDD a disorder deserving diagnosis and treatment by a mental health professional.
One of the main reasons DMDD was created is that children with these features go on to depressive or anxiety disorder in adolescence, not bipolar disorder.
While there is no treatment specific to DMDD, the depression component and prognosis suggest use of SSRIs, in addition to psychosocial therapies, and stimulants for the comorbid ADHD. Unfortunately, these two classes of medication are relatively contraindicated in bipolar disorder because they can lead to treatment-induced episodic mania (TEM). TEM occurs twice as often with antidepressants compared with stimulants (44% vs. 18%) in children with bipolar disorder (J Affect Disord. 2004 Oct 1;82[1]:149-58). Getting the diagnosis correct is, therefore, of great importance when medication is considered.
Approaches such as behavior modification, family therapy, and inpatient treatment can be effective for chronic irritability and aggression. Stimulant treatment of comorbid ADHD can decrease aggression and irritability. Alpha agonists such as guanfacine or clonidine also can help. In cases of partial improvement, adding either risperidone or divalproex may further decrease aggression in ADHD. In refractory aggression, risperidone has the best evidence. The Affective Reactivity Index or Outburst Monitoring Scale can be helpful in assessing severity and monitoring outcomes.
While a prognosis for depression rather than bipolar disorder sounds like a plus, in a longitudinal study, adults who had DMDD as children had worse outcomes, including being more likely to have adverse health outcomes (smoking, sexually transmitted infection), police contact, and low educational attainment, and being more likely to live in poverty, compared with controls who had other psychiatric disorders. While DMDD is a new and different diagnosis, it is similar to bipolar in having a potential course of life disruption, dangerous behaviors, suicide risk, and hospitalization.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.
Outbursts by children when frustrated or when asked to “do something they don’t want to do” are among the most common behavioral complaints voiced by parents. But behavioral outbursts, beyond the typical tantrums of children up to age 4 years, can be signs of very severe mental health disorders and are the most common reason for psychiatric admission (50%-60%).
While behavioral dysregulation is undeniably a huge problem for families, there has been an unreasonable 40-fold rise in diagnosis of bipolar disorder from 1994 to 2003, and 48% were prescribed atypical neuroleptics – medications with serious side effects. In response to this overdiagnosis as bipolar disorder, in 2013 the DSM-5 created a new diagnosis called disruptive mood dysregulation disorder (DMDD) to differentiate children who experience explosive outbursts who have a different outcome. This new classification includes children aged 6-12 years with persistent irritability most of the time, nearly every day, lasting at least 12 months and starting before age 10 years. DMDD diagnosis is not used after age 18 years.
To be diagnosed, the child has to have frequent, severe temper outbursts “grossly out of proportion” to the situation, averaging at least three times per week. The outbursts can be verbal or physical aggression to people, things, or themselves. While tantrums can be severe in children with delayed development, for the DMDD diagnosis these behaviors must be inconsistent with developmental level and must occur in at least two settings, and in one setting it must be severe. While outbursts are common, only half of children in one study of severe tantrum behavior in 5- to 9-year-olds also had the required persistent irritability.
If this does sound a lot like bipolar disorder so far, you are right. So what is different? DMDD has a prevalence of 2%-5% and occurs mostly in boys, whereas bipolar disorder affects boys and girls equally and affects less than 1% prior to adolescence.
The key features distinguishing DMDD from bipolar disorder are lack of an episodic nature to the irritability and lack of mania. Irritability in DMDD has to be persistently present with breaks of no more than 3 consecutive months in the defining 12-month period. There also cannot be any more than 1 day of the elevated mood features of mania or hypomania. Identifying mania is the hardest part, even in diagnosing adult bipolar, where it occurs only 1% of the year, much less in children who are generally lively! Hypomania, while less intense than mania, is when the person is energetic, talkative, and confident to an extreme extent, often with a flight of creative ideas. Excitement over birthdays or Christmas specifically does not count! So getting this history has to be done carefully, generally by a mental health professional, to make the distinction.
Interestingly, DMDD is not diagnosed when outbursts and irritability are better explained by autism spectrum disorder, separation anxiety disorder, or PTSD. To me, these exclusions point out the importance of sorting out the “set conditions” for all problematic behaviors, not always an easy task. Symptoms of autism in high functioning individuals can be quite subtle. Was the upset from change in a rigid routine known only to the child? Were sensory stimuli such as loud noises intolerable to this child? Was a nonverbal signal of a peer mistaken as a threat? While violent outbursts precipitated by these factors would still be considered “grossly out of proportion to the situation” for a typical child, they are not uncommon in atypical children. Similarly, children with separation anxiety disorder experience a high level of threat from even thinking about being apart from their caregivers, setting them up for alarm by situations other children would not find difficult.
The American Academy of Pediatrics emphasizes the need to assess all children for a history of psychological trauma. Traumas are quite common, and their sequelae affect many aspects of the child’s life; in the case of outbursts, it is emotional resilience that is impaired. As for all DSM-5 diagnoses, DMDD is not diagnosed when the irritability is due to physiological effects of a substance (e.g. steroids) or another medical or neurological disorder. Children with chronic pain conditions such as rheumatoid arthritis or sickle cell usually cope remarkably well, but when they don’t, their irritability should not be considered a mental health disorder. More commonly, sleep debt can produce chronic irritability and always should be assessed.
When coaching families about outbursts, I work to help them recognize that the child is not just angry, but very distressed. While “typical” tantrums last 1-5 minutes and show a rise then decline in intensity of the anger and distress, anger outbursts are longer and have an initial short and rapid burst of anger that then declines over the duration of the outburst, and with a steady but lower level of distress throughout.
The option to hug and verbally console the child’s distress is sometimes effective and does not reinforce the behavior unless the parent also yields to demands. But once outbursts begin, I liken them to a bomb going off – there is no intervention possible then. Instead, the task of the family, and over time that of the child, is to recognize and better manage the triggers.
Dr. Ross Greene, in his book, “The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children,” asserts that the child’s anger and distress can be interpreted as frustration from a gap in skills. This has treatment implications for identifying, educating about, and ameliorating the child’s weaknesses (deficits in understanding, communication, emotion regulation, flexibility or performance; or excess jealousy or hypersensitivity), and coaching parents to recognize, acknowledge, and avoid stressing these areas, if possible. I coach families to give points to the child for progressive little steps toward being able to recognize, verbalize, and inhibit outbursts with a reward system for the points. This helps put the parents and child “on the same team” in working on improving these skills.
Research on children with DMDD indicates that they show less positive affect when winning a “fixed” video game and are less able to suppress negative affect when losing. (Don’t forget to examine the role of real video games as precipitants of tantrums and contingently remove them!) Threshold for upset is lower and the degree of the upsets less well handled by children with DMDD.
In another study, when presented with a series of ambiguous facial expressions, children with DMDD were more likely to see anger in the faces than were controls. One hopeful result was that they could be taught to shift their perceptions significantly away from seeing anger, also reducing irritability and resulting in functional MRI changes. Such hostile bias attribution (tending to see threat) is well known to predispose to aggression. Cognitive behavioral therapy, the most effective counseling intervention, similarly teaches children to rethink their own negative thoughts before acting.
If irritability and rages were not enough, most children with DMDD have other psychiatric disorders; 39% having two, and 51% three or more (J Child Adolesc Psychopharmacol. 2013 Nov;23[9]:588-96). If not for the DMDD diagnosis, 82% would meet criteria for oppositional defiant disorder (ODD). The other common comorbidities are attention-deficit/hyperactivity disorder (ADHD) (74.5%), anxiety disorders (49.0%), and depression that is not major depressive disorder (MDD)(33.3%). When MDD is present, that diagnosis takes precedence. One cannot diagnose ODD, intermittent explosive disorder, or bipolar disorder along with DMDD, conditions from which it is intended to differentiate. Each of these comorbid disorders can be difficult to manage alone much less in combination, making DMDD a disorder deserving diagnosis and treatment by a mental health professional.
One of the main reasons DMDD was created is that children with these features go on to depressive or anxiety disorder in adolescence, not bipolar disorder.
While there is no treatment specific to DMDD, the depression component and prognosis suggest use of SSRIs, in addition to psychosocial therapies, and stimulants for the comorbid ADHD. Unfortunately, these two classes of medication are relatively contraindicated in bipolar disorder because they can lead to treatment-induced episodic mania (TEM). TEM occurs twice as often with antidepressants compared with stimulants (44% vs. 18%) in children with bipolar disorder (J Affect Disord. 2004 Oct 1;82[1]:149-58). Getting the diagnosis correct is, therefore, of great importance when medication is considered.
Approaches such as behavior modification, family therapy, and inpatient treatment can be effective for chronic irritability and aggression. Stimulant treatment of comorbid ADHD can decrease aggression and irritability. Alpha agonists such as guanfacine or clonidine also can help. In cases of partial improvement, adding either risperidone or divalproex may further decrease aggression in ADHD. In refractory aggression, risperidone has the best evidence. The Affective Reactivity Index or Outburst Monitoring Scale can be helpful in assessing severity and monitoring outcomes.
While a prognosis for depression rather than bipolar disorder sounds like a plus, in a longitudinal study, adults who had DMDD as children had worse outcomes, including being more likely to have adverse health outcomes (smoking, sexually transmitted infection), police contact, and low educational attainment, and being more likely to live in poverty, compared with controls who had other psychiatric disorders. While DMDD is a new and different diagnosis, it is similar to bipolar in having a potential course of life disruption, dangerous behaviors, suicide risk, and hospitalization.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.
Supporting siblings of children with special needs
Even the name “special needs” gives a clue about what it can be like to be a sibling of a child with a chronic condition. When a sibling has special needs, from a child’s perspective, that sibling can seem to be regarded as more special than me!
Whether parents are caring for a child with a physical or mental condition, the amount of attention required almost inevitably consumes some of the time the siblings might otherwise access. There are more visits to doctors and other professionals, hospitalizations with one parent staying overnight, more tests, and sometimes even therapists coming into the family’s home for monitoring or care giving. If the primary issue is mental health that takes attention, too! Sometimes even routine health care for the sibling falls behind.
When the special needs child is acutely ill, or a time-sensitive need or crisis occurs, everything planned for the family that day can go out the window. There is hardly an adult who would not resent always being second fiddle, much less a child with less maturity.
There are more subtle reasons for potential resentment that come from having a special sibling. Although federal regulations now mandate accessibility, often the kinds of outings typical families enjoy are too much hassle to arrange when there is equipment to haul, there are medicines to refrigerate, or there are toileting requirements such as for catheter care. Travel team soccer is out. So these events just don’t happen for the family as a whole.
Even with greater community awareness of different special needs conditions such as autism, stigma still exists. Siblings already are embarrassed about behaviors of typically developing children who pick their noses, laugh too loudly, or slurp their milkshake! It is not hard to see how being in public with a sibling who is shouting, rocking, or having tantrums could be mortifying. Children often choose playdates at someone else’s house to avoid having to explain or deal with their special sibling. This creates a kind of uneven relationship with peers and also deprives parents from being involved.
Siblings of children with special needs are often asked to help out. They have to answer the door when the parent is suctioning, babysit that child or siblings, feed them, or even provide direct care for the child’s medical needs. Household chores that would have been shared with a typically developing child may fall on the sibling.
Finances often add another constraint on the opportunities for a sibling of a child with special needs. Even really good insurance does not cover all the extra costs associated with chronic conditions. Babysitters may need extra skills; vehicles may need lifts or extra space; the home may need structural changes. Paying all these costs means other things don’t fit the budget. Even for a family of means, for the sibling this may result in public school rather than an elite private school, no music lessons, or no overnight camp. For families of lesser means, even life’s basics are hard to afford.
As children get older, they begin to worry about their future options. Will there be enough money for college? Will I have to live at home to help out? What if my parents die and I am the only one left to care for my special sibling? How will I ever get a date or get married?
While all of these factors are stresses, studies have shown being a sibling of a special needs child promotes greater compassion and maturity. Being of real help in the family and to a beloved sibling gives meaning to a child’s life that may be hard to come by during more typical circumstances of growing up. Certainly you have seen in your practice how siblings of special needs children disproportionately aim for careers in health care, psychology, social work, or other helping professions. This may even have been a factor in your own life.
But some siblings of children with special needs become depressed, develop hardened resentment, or take a defiant, acting-out stance. How can you support siblings so that this is not the outcome?
The first step is to ask about their well-being at every visit for the child with special needs. When parents respond with a balanced expression of the positive and the problematic, you can be reassured. If they seem immune to the difficulties the sibling must be experiencing or interpret jealous or attention-seeking behaviors as being solely “bad,” then more discussion or even referral for counseling may be needed. A parent who ordinarily might have understood may not when overburdened or depressed. The siblings with greater maturity and compassion were likely raised by parents who made sure that the point of view and positive attributes of every child in the family were voiced, and that each had opportunities to contribute to the family in meaningful ways as well as express themselves.
“Strong empathic talk” about the sibling’s feelings has been shown to be one of the best ways to build all positive sibling relationships starting in infancy. Acknowledging jealousy and providing individual attention come next. When things aren’t “fair” (which they often cannot be), token fairness helps. For the sake of the sibling, a child with special needs should still have “chores” (such as pulling sheets out of the dryer) and consequences for misbehavior (such as time out), whether the child understands or not.
At their own health supervision visit, I ask siblings about their relationship with the child with special needs, what is fun for them together and what is the hardest part about living with them. The aim is to assess their attitudes and also give them permission to complain. I almost always do this interview with the parents present, giving them a chance to hear those views (although private time may be needed as well). It often is hard for parents and the child himself or herself to express negative feelings because the special needs situation was no one’s fault and everyone has to work hard to be optimistic and to cope. You can then model a sympathetic ear plus assist in coming up with solutions, when possible. The interventions I suggest are often “tokens” to address the family dynamics rather than solutions to the problem. For example, a teen sibling of a child with autism under my care showed depression. Although for fun he played video games with his brother with autism, the hardest part was the lack of an age-appropriate social life. He had to make breakfast and get the special needs sibling off to school every morning as well as care for him after school while their single mother worked. We discussed this, and their mother determined to pay the teen for child care plus loosen her restrictions on his bedtime so that he could go out with friends.
Simply allowing the sibling expression that it can be hard is helpful. Many times stress is denied. To open up discussion, ask such questions as, “How is it having friends over?” or “Do you get enough time with your mom, just you and her?” or “Are there things you miss out on because you have a sister with special needs?”. These same topics are relevant for the parents themselves, too. Protecting the sibling’s privacy during playdates, having 10 minutes daily alone with the sibling to talk or play cards, or setting some family savings goals for the missing privileges are possible solutions that parents could implement. I suggest regular family meetings at home to ensure that these discussions occur and that the solutions are maintained or refined over time.
There are services available for some special needs conditions that are helpful in supporting siblings. Wraparound services may include respite care to allow family vacations, babysitters with needed skills, or payment for summer camp for children with special needs. Summer camps specific to siblings of children with special needs exist as well.
When free services are not available or finances are tight, you can encourage families to think outside the box. Maybe they can trade child care with another family with a child with special needs – each taking both kids for weekly breaks for the other family. Both condition-specific and general parent support groups often are helpful for coming up with ideas and making friendships that can lead to this kind of exchange.
When parents do not have a sitter they trust to manage care for the child with special needs, I often suggest getting a less-skilled (and less expensive) sitter (an 11-year old-works) to mind the child, but then the parent can stay in the house or yard to allow for individual time with the sibling without having to worry. (This is a good tip for time alone for spouses, too!)
The long-term questions that older siblings will have are best addressed by making a plan with a financial adviser. Organizations such as the Arc of the United States (www.thearc.org) and lawyers specializing in disabilities can provide this kind of advice. A trust fund, an up-to-date will, and a written plan for care giving long term are important to reduce worries parents have and can be communicated to the siblings when the time is right.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline.
Even the name “special needs” gives a clue about what it can be like to be a sibling of a child with a chronic condition. When a sibling has special needs, from a child’s perspective, that sibling can seem to be regarded as more special than me!
Whether parents are caring for a child with a physical or mental condition, the amount of attention required almost inevitably consumes some of the time the siblings might otherwise access. There are more visits to doctors and other professionals, hospitalizations with one parent staying overnight, more tests, and sometimes even therapists coming into the family’s home for monitoring or care giving. If the primary issue is mental health that takes attention, too! Sometimes even routine health care for the sibling falls behind.
When the special needs child is acutely ill, or a time-sensitive need or crisis occurs, everything planned for the family that day can go out the window. There is hardly an adult who would not resent always being second fiddle, much less a child with less maturity.
There are more subtle reasons for potential resentment that come from having a special sibling. Although federal regulations now mandate accessibility, often the kinds of outings typical families enjoy are too much hassle to arrange when there is equipment to haul, there are medicines to refrigerate, or there are toileting requirements such as for catheter care. Travel team soccer is out. So these events just don’t happen for the family as a whole.
Even with greater community awareness of different special needs conditions such as autism, stigma still exists. Siblings already are embarrassed about behaviors of typically developing children who pick their noses, laugh too loudly, or slurp their milkshake! It is not hard to see how being in public with a sibling who is shouting, rocking, or having tantrums could be mortifying. Children often choose playdates at someone else’s house to avoid having to explain or deal with their special sibling. This creates a kind of uneven relationship with peers and also deprives parents from being involved.
Siblings of children with special needs are often asked to help out. They have to answer the door when the parent is suctioning, babysit that child or siblings, feed them, or even provide direct care for the child’s medical needs. Household chores that would have been shared with a typically developing child may fall on the sibling.
Finances often add another constraint on the opportunities for a sibling of a child with special needs. Even really good insurance does not cover all the extra costs associated with chronic conditions. Babysitters may need extra skills; vehicles may need lifts or extra space; the home may need structural changes. Paying all these costs means other things don’t fit the budget. Even for a family of means, for the sibling this may result in public school rather than an elite private school, no music lessons, or no overnight camp. For families of lesser means, even life’s basics are hard to afford.
As children get older, they begin to worry about their future options. Will there be enough money for college? Will I have to live at home to help out? What if my parents die and I am the only one left to care for my special sibling? How will I ever get a date or get married?
While all of these factors are stresses, studies have shown being a sibling of a special needs child promotes greater compassion and maturity. Being of real help in the family and to a beloved sibling gives meaning to a child’s life that may be hard to come by during more typical circumstances of growing up. Certainly you have seen in your practice how siblings of special needs children disproportionately aim for careers in health care, psychology, social work, or other helping professions. This may even have been a factor in your own life.
But some siblings of children with special needs become depressed, develop hardened resentment, or take a defiant, acting-out stance. How can you support siblings so that this is not the outcome?
The first step is to ask about their well-being at every visit for the child with special needs. When parents respond with a balanced expression of the positive and the problematic, you can be reassured. If they seem immune to the difficulties the sibling must be experiencing or interpret jealous or attention-seeking behaviors as being solely “bad,” then more discussion or even referral for counseling may be needed. A parent who ordinarily might have understood may not when overburdened or depressed. The siblings with greater maturity and compassion were likely raised by parents who made sure that the point of view and positive attributes of every child in the family were voiced, and that each had opportunities to contribute to the family in meaningful ways as well as express themselves.
“Strong empathic talk” about the sibling’s feelings has been shown to be one of the best ways to build all positive sibling relationships starting in infancy. Acknowledging jealousy and providing individual attention come next. When things aren’t “fair” (which they often cannot be), token fairness helps. For the sake of the sibling, a child with special needs should still have “chores” (such as pulling sheets out of the dryer) and consequences for misbehavior (such as time out), whether the child understands or not.
At their own health supervision visit, I ask siblings about their relationship with the child with special needs, what is fun for them together and what is the hardest part about living with them. The aim is to assess their attitudes and also give them permission to complain. I almost always do this interview with the parents present, giving them a chance to hear those views (although private time may be needed as well). It often is hard for parents and the child himself or herself to express negative feelings because the special needs situation was no one’s fault and everyone has to work hard to be optimistic and to cope. You can then model a sympathetic ear plus assist in coming up with solutions, when possible. The interventions I suggest are often “tokens” to address the family dynamics rather than solutions to the problem. For example, a teen sibling of a child with autism under my care showed depression. Although for fun he played video games with his brother with autism, the hardest part was the lack of an age-appropriate social life. He had to make breakfast and get the special needs sibling off to school every morning as well as care for him after school while their single mother worked. We discussed this, and their mother determined to pay the teen for child care plus loosen her restrictions on his bedtime so that he could go out with friends.
Simply allowing the sibling expression that it can be hard is helpful. Many times stress is denied. To open up discussion, ask such questions as, “How is it having friends over?” or “Do you get enough time with your mom, just you and her?” or “Are there things you miss out on because you have a sister with special needs?”. These same topics are relevant for the parents themselves, too. Protecting the sibling’s privacy during playdates, having 10 minutes daily alone with the sibling to talk or play cards, or setting some family savings goals for the missing privileges are possible solutions that parents could implement. I suggest regular family meetings at home to ensure that these discussions occur and that the solutions are maintained or refined over time.
There are services available for some special needs conditions that are helpful in supporting siblings. Wraparound services may include respite care to allow family vacations, babysitters with needed skills, or payment for summer camp for children with special needs. Summer camps specific to siblings of children with special needs exist as well.
When free services are not available or finances are tight, you can encourage families to think outside the box. Maybe they can trade child care with another family with a child with special needs – each taking both kids for weekly breaks for the other family. Both condition-specific and general parent support groups often are helpful for coming up with ideas and making friendships that can lead to this kind of exchange.
When parents do not have a sitter they trust to manage care for the child with special needs, I often suggest getting a less-skilled (and less expensive) sitter (an 11-year old-works) to mind the child, but then the parent can stay in the house or yard to allow for individual time with the sibling without having to worry. (This is a good tip for time alone for spouses, too!)
The long-term questions that older siblings will have are best addressed by making a plan with a financial adviser. Organizations such as the Arc of the United States (www.thearc.org) and lawyers specializing in disabilities can provide this kind of advice. A trust fund, an up-to-date will, and a written plan for care giving long term are important to reduce worries parents have and can be communicated to the siblings when the time is right.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline.
Even the name “special needs” gives a clue about what it can be like to be a sibling of a child with a chronic condition. When a sibling has special needs, from a child’s perspective, that sibling can seem to be regarded as more special than me!
Whether parents are caring for a child with a physical or mental condition, the amount of attention required almost inevitably consumes some of the time the siblings might otherwise access. There are more visits to doctors and other professionals, hospitalizations with one parent staying overnight, more tests, and sometimes even therapists coming into the family’s home for monitoring or care giving. If the primary issue is mental health that takes attention, too! Sometimes even routine health care for the sibling falls behind.
When the special needs child is acutely ill, or a time-sensitive need or crisis occurs, everything planned for the family that day can go out the window. There is hardly an adult who would not resent always being second fiddle, much less a child with less maturity.
There are more subtle reasons for potential resentment that come from having a special sibling. Although federal regulations now mandate accessibility, often the kinds of outings typical families enjoy are too much hassle to arrange when there is equipment to haul, there are medicines to refrigerate, or there are toileting requirements such as for catheter care. Travel team soccer is out. So these events just don’t happen for the family as a whole.
Even with greater community awareness of different special needs conditions such as autism, stigma still exists. Siblings already are embarrassed about behaviors of typically developing children who pick their noses, laugh too loudly, or slurp their milkshake! It is not hard to see how being in public with a sibling who is shouting, rocking, or having tantrums could be mortifying. Children often choose playdates at someone else’s house to avoid having to explain or deal with their special sibling. This creates a kind of uneven relationship with peers and also deprives parents from being involved.
Siblings of children with special needs are often asked to help out. They have to answer the door when the parent is suctioning, babysit that child or siblings, feed them, or even provide direct care for the child’s medical needs. Household chores that would have been shared with a typically developing child may fall on the sibling.
Finances often add another constraint on the opportunities for a sibling of a child with special needs. Even really good insurance does not cover all the extra costs associated with chronic conditions. Babysitters may need extra skills; vehicles may need lifts or extra space; the home may need structural changes. Paying all these costs means other things don’t fit the budget. Even for a family of means, for the sibling this may result in public school rather than an elite private school, no music lessons, or no overnight camp. For families of lesser means, even life’s basics are hard to afford.
As children get older, they begin to worry about their future options. Will there be enough money for college? Will I have to live at home to help out? What if my parents die and I am the only one left to care for my special sibling? How will I ever get a date or get married?
While all of these factors are stresses, studies have shown being a sibling of a special needs child promotes greater compassion and maturity. Being of real help in the family and to a beloved sibling gives meaning to a child’s life that may be hard to come by during more typical circumstances of growing up. Certainly you have seen in your practice how siblings of special needs children disproportionately aim for careers in health care, psychology, social work, or other helping professions. This may even have been a factor in your own life.
But some siblings of children with special needs become depressed, develop hardened resentment, or take a defiant, acting-out stance. How can you support siblings so that this is not the outcome?
The first step is to ask about their well-being at every visit for the child with special needs. When parents respond with a balanced expression of the positive and the problematic, you can be reassured. If they seem immune to the difficulties the sibling must be experiencing or interpret jealous or attention-seeking behaviors as being solely “bad,” then more discussion or even referral for counseling may be needed. A parent who ordinarily might have understood may not when overburdened or depressed. The siblings with greater maturity and compassion were likely raised by parents who made sure that the point of view and positive attributes of every child in the family were voiced, and that each had opportunities to contribute to the family in meaningful ways as well as express themselves.
“Strong empathic talk” about the sibling’s feelings has been shown to be one of the best ways to build all positive sibling relationships starting in infancy. Acknowledging jealousy and providing individual attention come next. When things aren’t “fair” (which they often cannot be), token fairness helps. For the sake of the sibling, a child with special needs should still have “chores” (such as pulling sheets out of the dryer) and consequences for misbehavior (such as time out), whether the child understands or not.
At their own health supervision visit, I ask siblings about their relationship with the child with special needs, what is fun for them together and what is the hardest part about living with them. The aim is to assess their attitudes and also give them permission to complain. I almost always do this interview with the parents present, giving them a chance to hear those views (although private time may be needed as well). It often is hard for parents and the child himself or herself to express negative feelings because the special needs situation was no one’s fault and everyone has to work hard to be optimistic and to cope. You can then model a sympathetic ear plus assist in coming up with solutions, when possible. The interventions I suggest are often “tokens” to address the family dynamics rather than solutions to the problem. For example, a teen sibling of a child with autism under my care showed depression. Although for fun he played video games with his brother with autism, the hardest part was the lack of an age-appropriate social life. He had to make breakfast and get the special needs sibling off to school every morning as well as care for him after school while their single mother worked. We discussed this, and their mother determined to pay the teen for child care plus loosen her restrictions on his bedtime so that he could go out with friends.
Simply allowing the sibling expression that it can be hard is helpful. Many times stress is denied. To open up discussion, ask such questions as, “How is it having friends over?” or “Do you get enough time with your mom, just you and her?” or “Are there things you miss out on because you have a sister with special needs?”. These same topics are relevant for the parents themselves, too. Protecting the sibling’s privacy during playdates, having 10 minutes daily alone with the sibling to talk or play cards, or setting some family savings goals for the missing privileges are possible solutions that parents could implement. I suggest regular family meetings at home to ensure that these discussions occur and that the solutions are maintained or refined over time.
There are services available for some special needs conditions that are helpful in supporting siblings. Wraparound services may include respite care to allow family vacations, babysitters with needed skills, or payment for summer camp for children with special needs. Summer camps specific to siblings of children with special needs exist as well.
When free services are not available or finances are tight, you can encourage families to think outside the box. Maybe they can trade child care with another family with a child with special needs – each taking both kids for weekly breaks for the other family. Both condition-specific and general parent support groups often are helpful for coming up with ideas and making friendships that can lead to this kind of exchange.
When parents do not have a sitter they trust to manage care for the child with special needs, I often suggest getting a less-skilled (and less expensive) sitter (an 11-year old-works) to mind the child, but then the parent can stay in the house or yard to allow for individual time with the sibling without having to worry. (This is a good tip for time alone for spouses, too!)
The long-term questions that older siblings will have are best addressed by making a plan with a financial adviser. Organizations such as the Arc of the United States (www.thearc.org) and lawyers specializing in disabilities can provide this kind of advice. A trust fund, an up-to-date will, and a written plan for care giving long term are important to reduce worries parents have and can be communicated to the siblings when the time is right.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline.
ADHD and comorbidities
No pediatrician thinks caring for children with attention-deficit/hyperactivity disorder (ADHD) is easy, but some of these patients are far easier than others! The difference between your patients with ADHD who give you nightmares and those you are eager to see at return visits is usually the presence of comorbidities (not counting parent issues!).
Comorbidities are very common with ADHD, occurring in nearly half of all patients. One of the tricky things about comorbidities in ADHD is that several of them, or medicines used to treat them, also are potential explanations for the ADHD symptoms themselves.
The most common comorbid conditions are learning disabilities, which are present in 12% when narrowly defined, but school underachievement occurs in up to 60% of children with ADHD. Children with learning difficulties that are not adequately accommodated can present with “ADHD symptoms.” These children can be inattentive, fidgety, or out of their seats; may do classwork slowly or poorly; and may ultimately be disruptive in class. What child wouldn’t act this way if he or she couldn’t understand the work? Remember that a child will do anything to “save face.” Acting up and getting sent out of class is a last resort, but not a bad option over being humiliated by looking dumb, being teased, or being embarrassed in front of peers.
Some clues that learning disabilities are responsible for symptoms include behaviors that occur selectively during specific subjects, reports of disliking the subject, or refusal to do homework for certain subjects. One would think that poor grades would point to learning disabilities, but this is not always true either because the teacher is not that discerning or because a bright child compensates while still struggling. Be sure to have some grade-level assessment you can administer yourself such as the Einstein Evaluation of School-Related Skills or the WRAT (Wide Range Achievement Test). A large proportion of children with ADHD have a reading disability so having standard paragraphs available is important in deciding who needs complete psychological testing.
With this high prevalence of reading disabilities, it should not surprise you that language disorders also are comorbid with ADHD, occurring in 4% of these children. Because language disorder is among the developmental issues most amenable to intervention, detection and referral are especially important. If a child does not answer your questions with the grammar, vocabulary, or flow of ideas you expect at a particular age, consider using the Sentence Repetition Test to check for understanding. There are no easy screens for the complex language expected of school-aged children, so consider referral to a speech-language pathologist if you are suspicious.
Anxiety is comorbid with ADHD in 21% of children, but most importantly, it the most-often-missed diagnosis causing ADHD symptoms. Consider anxiety when a child is too nervous to pay attention, is distracted by worry, is concerned about what peers think to the point of having to listen in on their conversations, is unable to come up with an answer for a teacher that is perceived as critical, or is perfectionistic about work so it never gets done on time. Although children with ADHD are rather poor observers of their own symptoms, I always ask, “Is it hard to pay attention in class?” and follow up on a “yes” by asking, “What is going through your mind when you are not paying attention?” Reports of daydreams about skateboarding are one thing, but if children say they are thinking about their mother or worrying about an upcoming test, then further evaluation for anxiety is in order. Using a screening self-report tool such as the SCARED (Screen for Childhood Anxiety and Related Disorders) or the Pediatric Anxiety Rating Scale have rather low sensitivity, but can help the conversation to define anxiety symptoms, something children do not find easy to do if asked directly.
Remember that anxiety disorders do not “fly alone” either: Children with one anxiety disorder have a greater than 60% chance of having two, and children with two have a 30% chance of having three or more anxiety disorders. That means that children with generalized anxiety disorder may well have obsessive-compulsive disorder or a specific phobia as well. Just watching for general worrying is not enough. Add to this that the parent coming in worried about their child may be the genetic source with an anxiety disorder themselves, potentially contributing to the child’s distress and making it harder for you to assess the severity of either the anxiety or the ADHD symptoms!
I am sometimes grateful that a child with ADHD has excessive anxiety because it may protect him from jumping out of windows! But the combination has downsides in making the child even less preferred by peers and more likely to have hostile bias attribution – the tendency to see others as a threat. This combination can result in impulsive proactive aggression. Recognizing the role of anxiety in the aggressive episodes, and helping the child and parent to identify it, also is crucial to successful management. Anxiety is rarely perceived by parents, teachers, or children themselves as a cause of oppositional or aggressive behavior, so you need to probe for this connection. There is no substitute for debriefing a specific example of aggression and asking the child, “What were you thinking right before this happened?” You may suspect anxiety simply by watching the child’s reaction to what the parent says in the interview. Having the child draw a picture of a child, tell a story about “What happens next?” and then “How does the story end?” can be another adjunct to detecting anxiety.
Sometimes the treatment of ADHD makes the comorbid condition worse or vice versa. A prime example where treatment of one exacerbates the other is the use of stimulants, especially amphetamines, which can produce or worsen anxiety. Even though the reported side effects of stimulants do not state that there is more anxiety with amphetamines, I often prefer to prescribe dexmethylphenidate when both ADHD and anxiety coexist. The longer-acting preparations such as methylphenidate in a long-acting liquid or patch also seem to allow for finer tuning of dose with less anxiety exacerbation than shorter-acting preparations. Nonstimulants such as long-acting guanfacine or atomoxetine as treatment for the ADHD may be needed alone or in combination to allow a lower dose when the side effects of the stimulants on the anxiety outweigh their benefits. On the other hand, if the child is on selective serotonin reuptake inhibitors for anxiety (not the first-line treatment, which is cognitive-behavior therapy), he or she may experience behavioral activation that looks a lot like worsening ADHD!
Depression is “the other side” of anxiety – often developing at a later age after an earlier diagnosis of anxiety disorder – and another common comorbidity to ADHD occurring in 18% of children. Depression is less likely to masquerade as ADHD, but still may present as inattention or poor performance. Remember that children with depression may act irritable or aggressive rather than lethargic. Depression screens such as the Patient Health Questionnaire–9 can help sort this out.
Oppositional-defiant disorder (32%) and conduct disorder (25%) are more commonly comorbid with ADHD than are the conditions just discussed, but because they are “acting-out” conditions they are of great concern to parents and thus not likely to be missed in your office visits. Other medical conditions such as tics, enuresis, encopresis and even asthma also are comorbid and should be asked about.
The Vanderbilt Initial questionnaires have a few items for anxiety, depression, and conduct as well as performance items about academic functioning. A general screening tool such as the Pediatric Symptom Checklist, perhaps followed by a diagnostic tool such as the CHADIS DSM questionnaire, can be completed by parents online or on paper to detect and help diagnose any of these comorbidities before visits.
Pediatricians are the main clinicians diagnosing (for 53% of children with ADHD) and managing this condition (Natl. Health Stat Report. 2015 Sep;81:1-8). You should be proud of how well we have recently risen to the occasion and are now identifying and treating ADHD using evidence-based tools (90%) and attempting to collect data from schools (82%) as well as parents. The biggest gap in effective primary care management of ADHD now is detecting and managing its comorbidities.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
No pediatrician thinks caring for children with attention-deficit/hyperactivity disorder (ADHD) is easy, but some of these patients are far easier than others! The difference between your patients with ADHD who give you nightmares and those you are eager to see at return visits is usually the presence of comorbidities (not counting parent issues!).
Comorbidities are very common with ADHD, occurring in nearly half of all patients. One of the tricky things about comorbidities in ADHD is that several of them, or medicines used to treat them, also are potential explanations for the ADHD symptoms themselves.
The most common comorbid conditions are learning disabilities, which are present in 12% when narrowly defined, but school underachievement occurs in up to 60% of children with ADHD. Children with learning difficulties that are not adequately accommodated can present with “ADHD symptoms.” These children can be inattentive, fidgety, or out of their seats; may do classwork slowly or poorly; and may ultimately be disruptive in class. What child wouldn’t act this way if he or she couldn’t understand the work? Remember that a child will do anything to “save face.” Acting up and getting sent out of class is a last resort, but not a bad option over being humiliated by looking dumb, being teased, or being embarrassed in front of peers.
Some clues that learning disabilities are responsible for symptoms include behaviors that occur selectively during specific subjects, reports of disliking the subject, or refusal to do homework for certain subjects. One would think that poor grades would point to learning disabilities, but this is not always true either because the teacher is not that discerning or because a bright child compensates while still struggling. Be sure to have some grade-level assessment you can administer yourself such as the Einstein Evaluation of School-Related Skills or the WRAT (Wide Range Achievement Test). A large proportion of children with ADHD have a reading disability so having standard paragraphs available is important in deciding who needs complete psychological testing.
With this high prevalence of reading disabilities, it should not surprise you that language disorders also are comorbid with ADHD, occurring in 4% of these children. Because language disorder is among the developmental issues most amenable to intervention, detection and referral are especially important. If a child does not answer your questions with the grammar, vocabulary, or flow of ideas you expect at a particular age, consider using the Sentence Repetition Test to check for understanding. There are no easy screens for the complex language expected of school-aged children, so consider referral to a speech-language pathologist if you are suspicious.
Anxiety is comorbid with ADHD in 21% of children, but most importantly, it the most-often-missed diagnosis causing ADHD symptoms. Consider anxiety when a child is too nervous to pay attention, is distracted by worry, is concerned about what peers think to the point of having to listen in on their conversations, is unable to come up with an answer for a teacher that is perceived as critical, or is perfectionistic about work so it never gets done on time. Although children with ADHD are rather poor observers of their own symptoms, I always ask, “Is it hard to pay attention in class?” and follow up on a “yes” by asking, “What is going through your mind when you are not paying attention?” Reports of daydreams about skateboarding are one thing, but if children say they are thinking about their mother or worrying about an upcoming test, then further evaluation for anxiety is in order. Using a screening self-report tool such as the SCARED (Screen for Childhood Anxiety and Related Disorders) or the Pediatric Anxiety Rating Scale have rather low sensitivity, but can help the conversation to define anxiety symptoms, something children do not find easy to do if asked directly.
Remember that anxiety disorders do not “fly alone” either: Children with one anxiety disorder have a greater than 60% chance of having two, and children with two have a 30% chance of having three or more anxiety disorders. That means that children with generalized anxiety disorder may well have obsessive-compulsive disorder or a specific phobia as well. Just watching for general worrying is not enough. Add to this that the parent coming in worried about their child may be the genetic source with an anxiety disorder themselves, potentially contributing to the child’s distress and making it harder for you to assess the severity of either the anxiety or the ADHD symptoms!
I am sometimes grateful that a child with ADHD has excessive anxiety because it may protect him from jumping out of windows! But the combination has downsides in making the child even less preferred by peers and more likely to have hostile bias attribution – the tendency to see others as a threat. This combination can result in impulsive proactive aggression. Recognizing the role of anxiety in the aggressive episodes, and helping the child and parent to identify it, also is crucial to successful management. Anxiety is rarely perceived by parents, teachers, or children themselves as a cause of oppositional or aggressive behavior, so you need to probe for this connection. There is no substitute for debriefing a specific example of aggression and asking the child, “What were you thinking right before this happened?” You may suspect anxiety simply by watching the child’s reaction to what the parent says in the interview. Having the child draw a picture of a child, tell a story about “What happens next?” and then “How does the story end?” can be another adjunct to detecting anxiety.
Sometimes the treatment of ADHD makes the comorbid condition worse or vice versa. A prime example where treatment of one exacerbates the other is the use of stimulants, especially amphetamines, which can produce or worsen anxiety. Even though the reported side effects of stimulants do not state that there is more anxiety with amphetamines, I often prefer to prescribe dexmethylphenidate when both ADHD and anxiety coexist. The longer-acting preparations such as methylphenidate in a long-acting liquid or patch also seem to allow for finer tuning of dose with less anxiety exacerbation than shorter-acting preparations. Nonstimulants such as long-acting guanfacine or atomoxetine as treatment for the ADHD may be needed alone or in combination to allow a lower dose when the side effects of the stimulants on the anxiety outweigh their benefits. On the other hand, if the child is on selective serotonin reuptake inhibitors for anxiety (not the first-line treatment, which is cognitive-behavior therapy), he or she may experience behavioral activation that looks a lot like worsening ADHD!
Depression is “the other side” of anxiety – often developing at a later age after an earlier diagnosis of anxiety disorder – and another common comorbidity to ADHD occurring in 18% of children. Depression is less likely to masquerade as ADHD, but still may present as inattention or poor performance. Remember that children with depression may act irritable or aggressive rather than lethargic. Depression screens such as the Patient Health Questionnaire–9 can help sort this out.
Oppositional-defiant disorder (32%) and conduct disorder (25%) are more commonly comorbid with ADHD than are the conditions just discussed, but because they are “acting-out” conditions they are of great concern to parents and thus not likely to be missed in your office visits. Other medical conditions such as tics, enuresis, encopresis and even asthma also are comorbid and should be asked about.
The Vanderbilt Initial questionnaires have a few items for anxiety, depression, and conduct as well as performance items about academic functioning. A general screening tool such as the Pediatric Symptom Checklist, perhaps followed by a diagnostic tool such as the CHADIS DSM questionnaire, can be completed by parents online or on paper to detect and help diagnose any of these comorbidities before visits.
Pediatricians are the main clinicians diagnosing (for 53% of children with ADHD) and managing this condition (Natl. Health Stat Report. 2015 Sep;81:1-8). You should be proud of how well we have recently risen to the occasion and are now identifying and treating ADHD using evidence-based tools (90%) and attempting to collect data from schools (82%) as well as parents. The biggest gap in effective primary care management of ADHD now is detecting and managing its comorbidities.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
No pediatrician thinks caring for children with attention-deficit/hyperactivity disorder (ADHD) is easy, but some of these patients are far easier than others! The difference between your patients with ADHD who give you nightmares and those you are eager to see at return visits is usually the presence of comorbidities (not counting parent issues!).
Comorbidities are very common with ADHD, occurring in nearly half of all patients. One of the tricky things about comorbidities in ADHD is that several of them, or medicines used to treat them, also are potential explanations for the ADHD symptoms themselves.
The most common comorbid conditions are learning disabilities, which are present in 12% when narrowly defined, but school underachievement occurs in up to 60% of children with ADHD. Children with learning difficulties that are not adequately accommodated can present with “ADHD symptoms.” These children can be inattentive, fidgety, or out of their seats; may do classwork slowly or poorly; and may ultimately be disruptive in class. What child wouldn’t act this way if he or she couldn’t understand the work? Remember that a child will do anything to “save face.” Acting up and getting sent out of class is a last resort, but not a bad option over being humiliated by looking dumb, being teased, or being embarrassed in front of peers.
Some clues that learning disabilities are responsible for symptoms include behaviors that occur selectively during specific subjects, reports of disliking the subject, or refusal to do homework for certain subjects. One would think that poor grades would point to learning disabilities, but this is not always true either because the teacher is not that discerning or because a bright child compensates while still struggling. Be sure to have some grade-level assessment you can administer yourself such as the Einstein Evaluation of School-Related Skills or the WRAT (Wide Range Achievement Test). A large proportion of children with ADHD have a reading disability so having standard paragraphs available is important in deciding who needs complete psychological testing.
With this high prevalence of reading disabilities, it should not surprise you that language disorders also are comorbid with ADHD, occurring in 4% of these children. Because language disorder is among the developmental issues most amenable to intervention, detection and referral are especially important. If a child does not answer your questions with the grammar, vocabulary, or flow of ideas you expect at a particular age, consider using the Sentence Repetition Test to check for understanding. There are no easy screens for the complex language expected of school-aged children, so consider referral to a speech-language pathologist if you are suspicious.
Anxiety is comorbid with ADHD in 21% of children, but most importantly, it the most-often-missed diagnosis causing ADHD symptoms. Consider anxiety when a child is too nervous to pay attention, is distracted by worry, is concerned about what peers think to the point of having to listen in on their conversations, is unable to come up with an answer for a teacher that is perceived as critical, or is perfectionistic about work so it never gets done on time. Although children with ADHD are rather poor observers of their own symptoms, I always ask, “Is it hard to pay attention in class?” and follow up on a “yes” by asking, “What is going through your mind when you are not paying attention?” Reports of daydreams about skateboarding are one thing, but if children say they are thinking about their mother or worrying about an upcoming test, then further evaluation for anxiety is in order. Using a screening self-report tool such as the SCARED (Screen for Childhood Anxiety and Related Disorders) or the Pediatric Anxiety Rating Scale have rather low sensitivity, but can help the conversation to define anxiety symptoms, something children do not find easy to do if asked directly.
Remember that anxiety disorders do not “fly alone” either: Children with one anxiety disorder have a greater than 60% chance of having two, and children with two have a 30% chance of having three or more anxiety disorders. That means that children with generalized anxiety disorder may well have obsessive-compulsive disorder or a specific phobia as well. Just watching for general worrying is not enough. Add to this that the parent coming in worried about their child may be the genetic source with an anxiety disorder themselves, potentially contributing to the child’s distress and making it harder for you to assess the severity of either the anxiety or the ADHD symptoms!
I am sometimes grateful that a child with ADHD has excessive anxiety because it may protect him from jumping out of windows! But the combination has downsides in making the child even less preferred by peers and more likely to have hostile bias attribution – the tendency to see others as a threat. This combination can result in impulsive proactive aggression. Recognizing the role of anxiety in the aggressive episodes, and helping the child and parent to identify it, also is crucial to successful management. Anxiety is rarely perceived by parents, teachers, or children themselves as a cause of oppositional or aggressive behavior, so you need to probe for this connection. There is no substitute for debriefing a specific example of aggression and asking the child, “What were you thinking right before this happened?” You may suspect anxiety simply by watching the child’s reaction to what the parent says in the interview. Having the child draw a picture of a child, tell a story about “What happens next?” and then “How does the story end?” can be another adjunct to detecting anxiety.
Sometimes the treatment of ADHD makes the comorbid condition worse or vice versa. A prime example where treatment of one exacerbates the other is the use of stimulants, especially amphetamines, which can produce or worsen anxiety. Even though the reported side effects of stimulants do not state that there is more anxiety with amphetamines, I often prefer to prescribe dexmethylphenidate when both ADHD and anxiety coexist. The longer-acting preparations such as methylphenidate in a long-acting liquid or patch also seem to allow for finer tuning of dose with less anxiety exacerbation than shorter-acting preparations. Nonstimulants such as long-acting guanfacine or atomoxetine as treatment for the ADHD may be needed alone or in combination to allow a lower dose when the side effects of the stimulants on the anxiety outweigh their benefits. On the other hand, if the child is on selective serotonin reuptake inhibitors for anxiety (not the first-line treatment, which is cognitive-behavior therapy), he or she may experience behavioral activation that looks a lot like worsening ADHD!
Depression is “the other side” of anxiety – often developing at a later age after an earlier diagnosis of anxiety disorder – and another common comorbidity to ADHD occurring in 18% of children. Depression is less likely to masquerade as ADHD, but still may present as inattention or poor performance. Remember that children with depression may act irritable or aggressive rather than lethargic. Depression screens such as the Patient Health Questionnaire–9 can help sort this out.
Oppositional-defiant disorder (32%) and conduct disorder (25%) are more commonly comorbid with ADHD than are the conditions just discussed, but because they are “acting-out” conditions they are of great concern to parents and thus not likely to be missed in your office visits. Other medical conditions such as tics, enuresis, encopresis and even asthma also are comorbid and should be asked about.
The Vanderbilt Initial questionnaires have a few items for anxiety, depression, and conduct as well as performance items about academic functioning. A general screening tool such as the Pediatric Symptom Checklist, perhaps followed by a diagnostic tool such as the CHADIS DSM questionnaire, can be completed by parents online or on paper to detect and help diagnose any of these comorbidities before visits.
Pediatricians are the main clinicians diagnosing (for 53% of children with ADHD) and managing this condition (Natl. Health Stat Report. 2015 Sep;81:1-8). You should be proud of how well we have recently risen to the occasion and are now identifying and treating ADHD using evidence-based tools (90%) and attempting to collect data from schools (82%) as well as parents. The biggest gap in effective primary care management of ADHD now is detecting and managing its comorbidities.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications. E-mail her at pdnews@frontlinemedcom.com.
Why, oh why, won’t she go to bed?!
To weary parents, the fact that their child does not want to go to bed at night is both puzzling and exasperating. No matter what age, it is important to have a healthy bedtime for the child’s well-being as well as their caregiver’s!
Sleep, like the “canary in the mine,” is vulnerable to disruption by anything from minor illness to changes in schedule, things viewed on media, or emotions in the home, to life changes such as a new sibling, toilet training, or a new school year. In patients on stimulant medicine resisting bedtime, consider the need to finally eat. Asking about these specifically will help you plan an appropriate time to successfully address bedtime conflicts.
Knowing some basic principles about falling asleep can help your counseling. “Sleep drive” builds up over the day like a coiled spring, making falling asleep easier initially than for wakings later in the night. It also means that a nap too close to bedtime reduces the drive. Avoiding any naps (after age 4 years) and naps lasting past 4 p.m. for children under 4, even in car rides, is crucial. Beware of teens “having trouble falling asleep” who have sneaked in a nap after school!
To optimize sleep drive, calculate age-related sleep needs and, ideally, ask parents to keep a sleep diary for 1-2 weeks, especially checking on naps at daycare. Updated sleep duration standards (preschool 10-13 hours; school age 9-11 hours; teens 8-10 hours (see sleepfoundation.org) show that ranges of total sleep are remarkably stable, but may not meet parents’ ideals for time “off duty.”
If placed in bed when not yet tired, anyone will have trouble falling asleep (phase shift). For a child, lying awake in the dark alone is time for active imaginations to conjure fear of separation (> 4-6 months), monsters (for preschoolers), burglars (for anxious school-aged children), or the next day’s social or academic stresses (for school-aged children to teens). Children with anxiety disorders even worry that they may not get enough sleep! A soothing routine with a story in their bed (not media), a spritzing of “monster spray” or a “bedtime ticket” to cash in for “one more thing” (for those who beg) will usually suffice for preschoolers. A “magic flashlight” lends the child some control to check for monsters, but an “exorcism ritual” by the all-powerful parent can be added if needed. Teens are never too old for a chance to talk or even a story read by the parent (but they won’t ask for this).
A secret to managing bedtime struggles is to start the routine at the time the child is now falling asleep to avoid resistance, and keeping wake-up time appropriate to the new schedule. Once falling asleep within 10 minutes, move bedtime 15 minutes earlier each night to reach the schedule, then maintain 7 days per week (or within 1 hour) to prevent resetting the biological clock. Sorry, no movie nights until 2 a.m. or “sleeping in” on weekends! Teens who resist bedtime may be napping, socializing at the “only time” peers are up, addicted to media, or avoiding family. Their cooperation must be engaged to make a change by staying up all night once, then setting a new schedule, or staying up 1 hour later each night until the desired bedtime is reached.
Because sleep includes being paralyzed (REM stages), evolution encourages animals to sleep together to protect from predators. Sleeping alone requires a great deal of reassurance, such as from a friendly atmosphere, favorite stuffed toy, and familiar routine that implies safety. Children could use a toy, pet, or even a sibling to feel safe. While body contact is the most reassuring, children may not return to sleep from the many normal night wakings without it. Most can be weaned from this dependence by the parent sitting by the bed silently, moving one foot closer to the door each night. A promise to “check on you” in 5 minutes also helps.
Other factors making sleep easier include avoiding caffeine, stimulating medicines, or nicotine as well as exciting games, media, or exercise within 2 hours of bedtime. A quiet, dark, cool but not damp location used only for sleeping is helpful, but not always possible. A white noise generator, fan, or radio on static can help.
Many parents strangely expect their child to give up the pleasures of the day and take themselves to bed! As for other kinds of limit setting, parental company is typically needed for brushing teeth, pajamas, and a story. Ideally, it can be fun as a race or with songs, not a yelling match, which undermines the sense of safety. Setting rules about no electronics in the bedroom, even for charging, after a certain hour is often the only solution (even for adults) to the common struggle over ending media.
Often the bedtime complaint is “curtain calls” after being settled in bed. For children who call out, advise parents wait a few moments before responding, then reassure verbally without entering their room, waiting longer each time. For the child getting out of bed, one parent should lead them back without talking at all as many times as necessary. A reward for staying in bed without calling or coming out can be an extra story the next night and/or a morning reward. Alternatively, close the door and turn off the light if they come out or call out. After a few moments in the dark, give a “second chance” as long as they are quietly in bed. Gating the doorway works well for toddlers – sleeping on the floor is not dangerous!
Families often are ambivalent about asking for bedtime advice, thinking your solutions might be stressful, harmful to their relationship, or will take up their own precious sleep. For many, a prolonged bedtime is the best part of their day. Special Time earlier is often key to enforcing a healthy bedtime. Reassure them that these solutions usually take less than 3 weeks!
For the child, bedtime means giving up on fun but, more importantly, separation from the parent. This separation is harder if negative emotions are left from a day of behavior struggles or parents are even subtly angry at each other. For parents, bedtime means separating from their main pleasure in life. They also may be regretting their interactions during the day. Ambivalence about parting also may come from fears of being alone with their partner due to marital discord, intimate partner violence, chronic arguing, substance use, or simply depression. When simple advice fails, it is important to explore these meanings with families, encourage positive daytime behavior management methods, and avoid conflict in front of the children to resolve bedtime struggles.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.
To weary parents, the fact that their child does not want to go to bed at night is both puzzling and exasperating. No matter what age, it is important to have a healthy bedtime for the child’s well-being as well as their caregiver’s!
Sleep, like the “canary in the mine,” is vulnerable to disruption by anything from minor illness to changes in schedule, things viewed on media, or emotions in the home, to life changes such as a new sibling, toilet training, or a new school year. In patients on stimulant medicine resisting bedtime, consider the need to finally eat. Asking about these specifically will help you plan an appropriate time to successfully address bedtime conflicts.
Knowing some basic principles about falling asleep can help your counseling. “Sleep drive” builds up over the day like a coiled spring, making falling asleep easier initially than for wakings later in the night. It also means that a nap too close to bedtime reduces the drive. Avoiding any naps (after age 4 years) and naps lasting past 4 p.m. for children under 4, even in car rides, is crucial. Beware of teens “having trouble falling asleep” who have sneaked in a nap after school!
To optimize sleep drive, calculate age-related sleep needs and, ideally, ask parents to keep a sleep diary for 1-2 weeks, especially checking on naps at daycare. Updated sleep duration standards (preschool 10-13 hours; school age 9-11 hours; teens 8-10 hours (see sleepfoundation.org) show that ranges of total sleep are remarkably stable, but may not meet parents’ ideals for time “off duty.”
If placed in bed when not yet tired, anyone will have trouble falling asleep (phase shift). For a child, lying awake in the dark alone is time for active imaginations to conjure fear of separation (> 4-6 months), monsters (for preschoolers), burglars (for anxious school-aged children), or the next day’s social or academic stresses (for school-aged children to teens). Children with anxiety disorders even worry that they may not get enough sleep! A soothing routine with a story in their bed (not media), a spritzing of “monster spray” or a “bedtime ticket” to cash in for “one more thing” (for those who beg) will usually suffice for preschoolers. A “magic flashlight” lends the child some control to check for monsters, but an “exorcism ritual” by the all-powerful parent can be added if needed. Teens are never too old for a chance to talk or even a story read by the parent (but they won’t ask for this).
A secret to managing bedtime struggles is to start the routine at the time the child is now falling asleep to avoid resistance, and keeping wake-up time appropriate to the new schedule. Once falling asleep within 10 minutes, move bedtime 15 minutes earlier each night to reach the schedule, then maintain 7 days per week (or within 1 hour) to prevent resetting the biological clock. Sorry, no movie nights until 2 a.m. or “sleeping in” on weekends! Teens who resist bedtime may be napping, socializing at the “only time” peers are up, addicted to media, or avoiding family. Their cooperation must be engaged to make a change by staying up all night once, then setting a new schedule, or staying up 1 hour later each night until the desired bedtime is reached.
Because sleep includes being paralyzed (REM stages), evolution encourages animals to sleep together to protect from predators. Sleeping alone requires a great deal of reassurance, such as from a friendly atmosphere, favorite stuffed toy, and familiar routine that implies safety. Children could use a toy, pet, or even a sibling to feel safe. While body contact is the most reassuring, children may not return to sleep from the many normal night wakings without it. Most can be weaned from this dependence by the parent sitting by the bed silently, moving one foot closer to the door each night. A promise to “check on you” in 5 minutes also helps.
Other factors making sleep easier include avoiding caffeine, stimulating medicines, or nicotine as well as exciting games, media, or exercise within 2 hours of bedtime. A quiet, dark, cool but not damp location used only for sleeping is helpful, but not always possible. A white noise generator, fan, or radio on static can help.
Many parents strangely expect their child to give up the pleasures of the day and take themselves to bed! As for other kinds of limit setting, parental company is typically needed for brushing teeth, pajamas, and a story. Ideally, it can be fun as a race or with songs, not a yelling match, which undermines the sense of safety. Setting rules about no electronics in the bedroom, even for charging, after a certain hour is often the only solution (even for adults) to the common struggle over ending media.
Often the bedtime complaint is “curtain calls” after being settled in bed. For children who call out, advise parents wait a few moments before responding, then reassure verbally without entering their room, waiting longer each time. For the child getting out of bed, one parent should lead them back without talking at all as many times as necessary. A reward for staying in bed without calling or coming out can be an extra story the next night and/or a morning reward. Alternatively, close the door and turn off the light if they come out or call out. After a few moments in the dark, give a “second chance” as long as they are quietly in bed. Gating the doorway works well for toddlers – sleeping on the floor is not dangerous!
Families often are ambivalent about asking for bedtime advice, thinking your solutions might be stressful, harmful to their relationship, or will take up their own precious sleep. For many, a prolonged bedtime is the best part of their day. Special Time earlier is often key to enforcing a healthy bedtime. Reassure them that these solutions usually take less than 3 weeks!
For the child, bedtime means giving up on fun but, more importantly, separation from the parent. This separation is harder if negative emotions are left from a day of behavior struggles or parents are even subtly angry at each other. For parents, bedtime means separating from their main pleasure in life. They also may be regretting their interactions during the day. Ambivalence about parting also may come from fears of being alone with their partner due to marital discord, intimate partner violence, chronic arguing, substance use, or simply depression. When simple advice fails, it is important to explore these meanings with families, encourage positive daytime behavior management methods, and avoid conflict in front of the children to resolve bedtime struggles.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.
To weary parents, the fact that their child does not want to go to bed at night is both puzzling and exasperating. No matter what age, it is important to have a healthy bedtime for the child’s well-being as well as their caregiver’s!
Sleep, like the “canary in the mine,” is vulnerable to disruption by anything from minor illness to changes in schedule, things viewed on media, or emotions in the home, to life changes such as a new sibling, toilet training, or a new school year. In patients on stimulant medicine resisting bedtime, consider the need to finally eat. Asking about these specifically will help you plan an appropriate time to successfully address bedtime conflicts.
Knowing some basic principles about falling asleep can help your counseling. “Sleep drive” builds up over the day like a coiled spring, making falling asleep easier initially than for wakings later in the night. It also means that a nap too close to bedtime reduces the drive. Avoiding any naps (after age 4 years) and naps lasting past 4 p.m. for children under 4, even in car rides, is crucial. Beware of teens “having trouble falling asleep” who have sneaked in a nap after school!
To optimize sleep drive, calculate age-related sleep needs and, ideally, ask parents to keep a sleep diary for 1-2 weeks, especially checking on naps at daycare. Updated sleep duration standards (preschool 10-13 hours; school age 9-11 hours; teens 8-10 hours (see sleepfoundation.org) show that ranges of total sleep are remarkably stable, but may not meet parents’ ideals for time “off duty.”
If placed in bed when not yet tired, anyone will have trouble falling asleep (phase shift). For a child, lying awake in the dark alone is time for active imaginations to conjure fear of separation (> 4-6 months), monsters (for preschoolers), burglars (for anxious school-aged children), or the next day’s social or academic stresses (for school-aged children to teens). Children with anxiety disorders even worry that they may not get enough sleep! A soothing routine with a story in their bed (not media), a spritzing of “monster spray” or a “bedtime ticket” to cash in for “one more thing” (for those who beg) will usually suffice for preschoolers. A “magic flashlight” lends the child some control to check for monsters, but an “exorcism ritual” by the all-powerful parent can be added if needed. Teens are never too old for a chance to talk or even a story read by the parent (but they won’t ask for this).
A secret to managing bedtime struggles is to start the routine at the time the child is now falling asleep to avoid resistance, and keeping wake-up time appropriate to the new schedule. Once falling asleep within 10 minutes, move bedtime 15 minutes earlier each night to reach the schedule, then maintain 7 days per week (or within 1 hour) to prevent resetting the biological clock. Sorry, no movie nights until 2 a.m. or “sleeping in” on weekends! Teens who resist bedtime may be napping, socializing at the “only time” peers are up, addicted to media, or avoiding family. Their cooperation must be engaged to make a change by staying up all night once, then setting a new schedule, or staying up 1 hour later each night until the desired bedtime is reached.
Because sleep includes being paralyzed (REM stages), evolution encourages animals to sleep together to protect from predators. Sleeping alone requires a great deal of reassurance, such as from a friendly atmosphere, favorite stuffed toy, and familiar routine that implies safety. Children could use a toy, pet, or even a sibling to feel safe. While body contact is the most reassuring, children may not return to sleep from the many normal night wakings without it. Most can be weaned from this dependence by the parent sitting by the bed silently, moving one foot closer to the door each night. A promise to “check on you” in 5 minutes also helps.
Other factors making sleep easier include avoiding caffeine, stimulating medicines, or nicotine as well as exciting games, media, or exercise within 2 hours of bedtime. A quiet, dark, cool but not damp location used only for sleeping is helpful, but not always possible. A white noise generator, fan, or radio on static can help.
Many parents strangely expect their child to give up the pleasures of the day and take themselves to bed! As for other kinds of limit setting, parental company is typically needed for brushing teeth, pajamas, and a story. Ideally, it can be fun as a race or with songs, not a yelling match, which undermines the sense of safety. Setting rules about no electronics in the bedroom, even for charging, after a certain hour is often the only solution (even for adults) to the common struggle over ending media.
Often the bedtime complaint is “curtain calls” after being settled in bed. For children who call out, advise parents wait a few moments before responding, then reassure verbally without entering their room, waiting longer each time. For the child getting out of bed, one parent should lead them back without talking at all as many times as necessary. A reward for staying in bed without calling or coming out can be an extra story the next night and/or a morning reward. Alternatively, close the door and turn off the light if they come out or call out. After a few moments in the dark, give a “second chance” as long as they are quietly in bed. Gating the doorway works well for toddlers – sleeping on the floor is not dangerous!
Families often are ambivalent about asking for bedtime advice, thinking your solutions might be stressful, harmful to their relationship, or will take up their own precious sleep. For many, a prolonged bedtime is the best part of their day. Special Time earlier is often key to enforcing a healthy bedtime. Reassure them that these solutions usually take less than 3 weeks!
For the child, bedtime means giving up on fun but, more importantly, separation from the parent. This separation is harder if negative emotions are left from a day of behavior struggles or parents are even subtly angry at each other. For parents, bedtime means separating from their main pleasure in life. They also may be regretting their interactions during the day. Ambivalence about parting also may come from fears of being alone with their partner due to marital discord, intimate partner violence, chronic arguing, substance use, or simply depression. When simple advice fails, it is important to explore these meanings with families, encourage positive daytime behavior management methods, and avoid conflict in front of the children to resolve bedtime struggles.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.
Tips for assessing, managing temper tantrums
Concerns about tantrums come up a lot in pediatric care. We all know about telling parents to ignore tantrums in toddlers and not to give in. But what about when this advice does not work?
I like to think of tantrums as emotions that go beyond the child’s control. This reframing helps families consider that not all tantrums are an attempt by the child to manipulate them. That is an important first step in avoiding a solely punitive response and instead encouraging parents to look for the source of the imbalance.
Temper tantrums are most common when a child is making developmental spurts in abilities or thinking that are typically unevenly matched with self-control. There is a lot of unevenness in children’s ability to do, say, or tolerate feelings between the early tantrums of the 9-month-old until the greater coping of the 6-year-old. For example, 87% of 18- to 24-month-olds have tantrums just as they acquire autonomy and some language, yet can’t really speak their feelings, while 91% of 30- to 36-month-olds have tantrums because they can imagine big things, but are only capable of or allowed small ones. Even at 42-48 months, more than half have tantrums, which often are associated with the stress and fatigue from dropping their nap.
Life is frustrating for kids. Young children want to try to use their new skills such as climbing, opening things, or scribbling, but parents – at first delighted – suddenly want them to stop! At first, every new word is celebrated, but then toddler talk gets routine, and toddlers may be ignored or even shushed. When the child has a strong desire, the words may not be there, or emotions may make it hard to talk at all, leading to frustration.
With the development of a sense of self, the song is “I want,” “mine,” and “no!” Sharing is not in the child’s repertoire until age 3 years or older. Temperamentally more intense children give up less easily or are not readily distracted.
The threshold for frustration depends on the child’s overall state. Is the child hungry? Tired? Stressed? In pain? Here is where the differential diagnosis of excessive tantrums needs to also include pain from a medical condition such as celiac disease, arthritis, migraine, or sickle cell disease. Children under age 7 years commonly have a low tolerance for sensations as simple as loud noises and elastic waistbands, but those with sensory integration disorder are at the extreme in what sounds, feelings, or motions they cannot bear at any age and may need specific intervention by occupational or physical therapists. Mental health conditions such as attention-deficit/hyperactivity disorder, depression, anxiety, and bipolar disorder also predispose to irritable responses to even normal stresses, often in combination with lagging skills and poor sleep. Consider these when tantrums are extreme.
An age period of tantrums may be expected and accepted by parents, thus the name “terrible twos,” but if tantrums persist, they can wear out even a patient parent. Signs that a child’s tantrums are beyond the usual range include a frequency of more than once a day, a duration of more than the typical 5 minutes, or persistence after age 6 years. When you are asked if a child’s tantrums are “normal,” these are useful parameters. It also helps to explain to parents the natural course of anger arousal that starts with a trigger, peaks within 3 minutes, then subsides rapidly (usually a total of 90 seconds), and although starting with anger, ends up with sadness. Asking parents to collect this information helps them avoid interfering with or reinforcing tantrums.
Understanding the child’s temperament and needs, and avoiding triggers, can prevent many tantrums. What was she doing just before the tantrum started? What were the triggers such as fatigue, hunger, inability to express herself, or a buildup of jealousy from repeated sibling intrusions? Are there skill deficits setting him off, especially fine motor or language delays? Management then needs to focus on avoiding these triggers, if possible, and diagnosing and treating developmental delays.
Next, parents can try to distract by jollying, making a joke, or singing. These are useful moments of modeling. Some parents are worried that distracting the child with something more fun to do will interfere with his learning to cope. If distraction works, they should use it!
Often nothing works, and the child has to explode and recover on her own. Talking, cajoling, or scolding during the fit is useless – like trying to squash dynamite after the flame has hit the powder.
While standing by silently ignoring tantrums is usually the fastest way to reduce them, some children calm down faster if held. This does not reinforce the fits as long as the child’s demand is not fulfilled. Instead, it lends adult “ego support” to reassure the child that all is well and life goes on. Children quickly go from angry to sad; older children are even embarrassed by their loss of control. Comfort is appropriate and kind, as long as at least one parent can do this authentically.
Point out that frustrations in small doses are crucial for learning frustration tolerance. Parents who overprotect their child from any little stress to avoid fits is doing him a disservice. Instead, attention, praise, or marks for little bits of self-control effort or for “using your words” builds self-control over time. Times of transitions such as coming for dinner or going to brush teeth are often times of tantrums; these deserve a 2-minute warning and praise or marks for success in “moving on.”(Stopping electronics without a fit is another . Hint: If the child has a fit, he gets no electronics the next day.)
Adult management may be reinforcing tantrums. When parents give the child what she was screaming for, or remove a demand – such as to take a bath – that had sparked a fit, they can count on having an even worse reaction the next time.
I coach parents to think together about the six main things that set off their child’s tantrums and decide in advance on which ones they will hold their ground. Then, when the child just begins to beg for that snack, the parent should decide instantly if this is a “yes” or a “no” (aiming for more yeses). Parental “giving in” before a tantrum starts models positive flexibility for the child and avoids reinforcement. When an event on the “no” list comes up, both parents are then better able to have an unequivocal response and then walk away.
“But when should we teach him a lesson?” parents often ask. If parents interpret a tantrum as manipulative, a moral failing, or an evil tendency, they tend to react with anger and even loss of control themselves. Be alert for risks of excessive punishment in these cases. Not only is their response a poor model and scary for the child, it can even become an exciting, reinforcing display. If parents are depressed or tend to ignore the child as a norm, it may be worth it to the child to throw a fit to bring them to life. You can emphasize that positive attention to good behavior and silent ignoring of fits is more effective and avoids these side effects.
Parents may experience tantrums as a battle of wills that they are not willing to lose, imagining a future rebellious teen. They need education on the normal imbalances of childhood and on both prevention and intervention strategies. What they can lose in the present is their child’s confidence in adult kindness, the opportunity to model flexibility and self-control, and a relationship with their child that conveys acceptance.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications.
Concerns about tantrums come up a lot in pediatric care. We all know about telling parents to ignore tantrums in toddlers and not to give in. But what about when this advice does not work?
I like to think of tantrums as emotions that go beyond the child’s control. This reframing helps families consider that not all tantrums are an attempt by the child to manipulate them. That is an important first step in avoiding a solely punitive response and instead encouraging parents to look for the source of the imbalance.
Temper tantrums are most common when a child is making developmental spurts in abilities or thinking that are typically unevenly matched with self-control. There is a lot of unevenness in children’s ability to do, say, or tolerate feelings between the early tantrums of the 9-month-old until the greater coping of the 6-year-old. For example, 87% of 18- to 24-month-olds have tantrums just as they acquire autonomy and some language, yet can’t really speak their feelings, while 91% of 30- to 36-month-olds have tantrums because they can imagine big things, but are only capable of or allowed small ones. Even at 42-48 months, more than half have tantrums, which often are associated with the stress and fatigue from dropping their nap.
Life is frustrating for kids. Young children want to try to use their new skills such as climbing, opening things, or scribbling, but parents – at first delighted – suddenly want them to stop! At first, every new word is celebrated, but then toddler talk gets routine, and toddlers may be ignored or even shushed. When the child has a strong desire, the words may not be there, or emotions may make it hard to talk at all, leading to frustration.
With the development of a sense of self, the song is “I want,” “mine,” and “no!” Sharing is not in the child’s repertoire until age 3 years or older. Temperamentally more intense children give up less easily or are not readily distracted.
The threshold for frustration depends on the child’s overall state. Is the child hungry? Tired? Stressed? In pain? Here is where the differential diagnosis of excessive tantrums needs to also include pain from a medical condition such as celiac disease, arthritis, migraine, or sickle cell disease. Children under age 7 years commonly have a low tolerance for sensations as simple as loud noises and elastic waistbands, but those with sensory integration disorder are at the extreme in what sounds, feelings, or motions they cannot bear at any age and may need specific intervention by occupational or physical therapists. Mental health conditions such as attention-deficit/hyperactivity disorder, depression, anxiety, and bipolar disorder also predispose to irritable responses to even normal stresses, often in combination with lagging skills and poor sleep. Consider these when tantrums are extreme.
An age period of tantrums may be expected and accepted by parents, thus the name “terrible twos,” but if tantrums persist, they can wear out even a patient parent. Signs that a child’s tantrums are beyond the usual range include a frequency of more than once a day, a duration of more than the typical 5 minutes, or persistence after age 6 years. When you are asked if a child’s tantrums are “normal,” these are useful parameters. It also helps to explain to parents the natural course of anger arousal that starts with a trigger, peaks within 3 minutes, then subsides rapidly (usually a total of 90 seconds), and although starting with anger, ends up with sadness. Asking parents to collect this information helps them avoid interfering with or reinforcing tantrums.
Understanding the child’s temperament and needs, and avoiding triggers, can prevent many tantrums. What was she doing just before the tantrum started? What were the triggers such as fatigue, hunger, inability to express herself, or a buildup of jealousy from repeated sibling intrusions? Are there skill deficits setting him off, especially fine motor or language delays? Management then needs to focus on avoiding these triggers, if possible, and diagnosing and treating developmental delays.
Next, parents can try to distract by jollying, making a joke, or singing. These are useful moments of modeling. Some parents are worried that distracting the child with something more fun to do will interfere with his learning to cope. If distraction works, they should use it!
Often nothing works, and the child has to explode and recover on her own. Talking, cajoling, or scolding during the fit is useless – like trying to squash dynamite after the flame has hit the powder.
While standing by silently ignoring tantrums is usually the fastest way to reduce them, some children calm down faster if held. This does not reinforce the fits as long as the child’s demand is not fulfilled. Instead, it lends adult “ego support” to reassure the child that all is well and life goes on. Children quickly go from angry to sad; older children are even embarrassed by their loss of control. Comfort is appropriate and kind, as long as at least one parent can do this authentically.
Point out that frustrations in small doses are crucial for learning frustration tolerance. Parents who overprotect their child from any little stress to avoid fits is doing him a disservice. Instead, attention, praise, or marks for little bits of self-control effort or for “using your words” builds self-control over time. Times of transitions such as coming for dinner or going to brush teeth are often times of tantrums; these deserve a 2-minute warning and praise or marks for success in “moving on.”(Stopping electronics without a fit is another . Hint: If the child has a fit, he gets no electronics the next day.)
Adult management may be reinforcing tantrums. When parents give the child what she was screaming for, or remove a demand – such as to take a bath – that had sparked a fit, they can count on having an even worse reaction the next time.
I coach parents to think together about the six main things that set off their child’s tantrums and decide in advance on which ones they will hold their ground. Then, when the child just begins to beg for that snack, the parent should decide instantly if this is a “yes” or a “no” (aiming for more yeses). Parental “giving in” before a tantrum starts models positive flexibility for the child and avoids reinforcement. When an event on the “no” list comes up, both parents are then better able to have an unequivocal response and then walk away.
“But when should we teach him a lesson?” parents often ask. If parents interpret a tantrum as manipulative, a moral failing, or an evil tendency, they tend to react with anger and even loss of control themselves. Be alert for risks of excessive punishment in these cases. Not only is their response a poor model and scary for the child, it can even become an exciting, reinforcing display. If parents are depressed or tend to ignore the child as a norm, it may be worth it to the child to throw a fit to bring them to life. You can emphasize that positive attention to good behavior and silent ignoring of fits is more effective and avoids these side effects.
Parents may experience tantrums as a battle of wills that they are not willing to lose, imagining a future rebellious teen. They need education on the normal imbalances of childhood and on both prevention and intervention strategies. What they can lose in the present is their child’s confidence in adult kindness, the opportunity to model flexibility and self-control, and a relationship with their child that conveys acceptance.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications.
Concerns about tantrums come up a lot in pediatric care. We all know about telling parents to ignore tantrums in toddlers and not to give in. But what about when this advice does not work?
I like to think of tantrums as emotions that go beyond the child’s control. This reframing helps families consider that not all tantrums are an attempt by the child to manipulate them. That is an important first step in avoiding a solely punitive response and instead encouraging parents to look for the source of the imbalance.
Temper tantrums are most common when a child is making developmental spurts in abilities or thinking that are typically unevenly matched with self-control. There is a lot of unevenness in children’s ability to do, say, or tolerate feelings between the early tantrums of the 9-month-old until the greater coping of the 6-year-old. For example, 87% of 18- to 24-month-olds have tantrums just as they acquire autonomy and some language, yet can’t really speak their feelings, while 91% of 30- to 36-month-olds have tantrums because they can imagine big things, but are only capable of or allowed small ones. Even at 42-48 months, more than half have tantrums, which often are associated with the stress and fatigue from dropping their nap.
Life is frustrating for kids. Young children want to try to use their new skills such as climbing, opening things, or scribbling, but parents – at first delighted – suddenly want them to stop! At first, every new word is celebrated, but then toddler talk gets routine, and toddlers may be ignored or even shushed. When the child has a strong desire, the words may not be there, or emotions may make it hard to talk at all, leading to frustration.
With the development of a sense of self, the song is “I want,” “mine,” and “no!” Sharing is not in the child’s repertoire until age 3 years or older. Temperamentally more intense children give up less easily or are not readily distracted.
The threshold for frustration depends on the child’s overall state. Is the child hungry? Tired? Stressed? In pain? Here is where the differential diagnosis of excessive tantrums needs to also include pain from a medical condition such as celiac disease, arthritis, migraine, or sickle cell disease. Children under age 7 years commonly have a low tolerance for sensations as simple as loud noises and elastic waistbands, but those with sensory integration disorder are at the extreme in what sounds, feelings, or motions they cannot bear at any age and may need specific intervention by occupational or physical therapists. Mental health conditions such as attention-deficit/hyperactivity disorder, depression, anxiety, and bipolar disorder also predispose to irritable responses to even normal stresses, often in combination with lagging skills and poor sleep. Consider these when tantrums are extreme.
An age period of tantrums may be expected and accepted by parents, thus the name “terrible twos,” but if tantrums persist, they can wear out even a patient parent. Signs that a child’s tantrums are beyond the usual range include a frequency of more than once a day, a duration of more than the typical 5 minutes, or persistence after age 6 years. When you are asked if a child’s tantrums are “normal,” these are useful parameters. It also helps to explain to parents the natural course of anger arousal that starts with a trigger, peaks within 3 minutes, then subsides rapidly (usually a total of 90 seconds), and although starting with anger, ends up with sadness. Asking parents to collect this information helps them avoid interfering with or reinforcing tantrums.
Understanding the child’s temperament and needs, and avoiding triggers, can prevent many tantrums. What was she doing just before the tantrum started? What were the triggers such as fatigue, hunger, inability to express herself, or a buildup of jealousy from repeated sibling intrusions? Are there skill deficits setting him off, especially fine motor or language delays? Management then needs to focus on avoiding these triggers, if possible, and diagnosing and treating developmental delays.
Next, parents can try to distract by jollying, making a joke, or singing. These are useful moments of modeling. Some parents are worried that distracting the child with something more fun to do will interfere with his learning to cope. If distraction works, they should use it!
Often nothing works, and the child has to explode and recover on her own. Talking, cajoling, or scolding during the fit is useless – like trying to squash dynamite after the flame has hit the powder.
While standing by silently ignoring tantrums is usually the fastest way to reduce them, some children calm down faster if held. This does not reinforce the fits as long as the child’s demand is not fulfilled. Instead, it lends adult “ego support” to reassure the child that all is well and life goes on. Children quickly go from angry to sad; older children are even embarrassed by their loss of control. Comfort is appropriate and kind, as long as at least one parent can do this authentically.
Point out that frustrations in small doses are crucial for learning frustration tolerance. Parents who overprotect their child from any little stress to avoid fits is doing him a disservice. Instead, attention, praise, or marks for little bits of self-control effort or for “using your words” builds self-control over time. Times of transitions such as coming for dinner or going to brush teeth are often times of tantrums; these deserve a 2-minute warning and praise or marks for success in “moving on.”(Stopping electronics without a fit is another . Hint: If the child has a fit, he gets no electronics the next day.)
Adult management may be reinforcing tantrums. When parents give the child what she was screaming for, or remove a demand – such as to take a bath – that had sparked a fit, they can count on having an even worse reaction the next time.
I coach parents to think together about the six main things that set off their child’s tantrums and decide in advance on which ones they will hold their ground. Then, when the child just begins to beg for that snack, the parent should decide instantly if this is a “yes” or a “no” (aiming for more yeses). Parental “giving in” before a tantrum starts models positive flexibility for the child and avoids reinforcement. When an event on the “no” list comes up, both parents are then better able to have an unequivocal response and then walk away.
“But when should we teach him a lesson?” parents often ask. If parents interpret a tantrum as manipulative, a moral failing, or an evil tendency, they tend to react with anger and even loss of control themselves. Be alert for risks of excessive punishment in these cases. Not only is their response a poor model and scary for the child, it can even become an exciting, reinforcing display. If parents are depressed or tend to ignore the child as a norm, it may be worth it to the child to throw a fit to bring them to life. You can emphasize that positive attention to good behavior and silent ignoring of fits is more effective and avoids these side effects.
Parents may experience tantrums as a battle of wills that they are not willing to lose, imagining a future rebellious teen. They need education on the normal imbalances of childhood and on both prevention and intervention strategies. What they can lose in the present is their child’s confidence in adult kindness, the opportunity to model flexibility and self-control, and a relationship with their child that conveys acceptance.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications.
Tips for assessing, managing temper tantrums
Concerns about tantrums come up a lot in pediatric care. We all know about telling parents to ignore tantrums in toddlers and not to give in. But what about when this advice does not work?
I like to think of tantrums as emotions that go beyond the child’s control. This reframing helps families consider that not all tantrums are an attempt by the child to manipulate them. That is an important first step in avoiding a solely punitive response and instead encouraging parents to look for the source of the imbalance.
Temper tantrums are most common when a child is making developmental spurts in abilities or thinking that are typically unevenly matched with self-control. There is a lot of unevenness in children’s ability to do, say, or tolerate feelings between the early tantrums of the 9-month-old until the greater coping of the 6-year-old. For example, 87% of 18- to 24-month-olds have tantrums just as they acquire autonomy and some language, yet can’t really speak their feelings, while 91% of 30- to 36-month-olds have tantrums because they can imagine big things, but are only capable of or allowed small ones. Even at 42-48 months, more than half have tantrums, which often are associated with the stress and fatigue from dropping their nap.
Life is frustrating for kids. Young children want to try to use their new skills such as climbing, opening things, or scribbling, but parents – at first delighted – suddenly want them to stop! At first, every new word is celebrated, but then toddler talk gets routine, and toddlers may be ignored or even shushed. When the child has a strong desire, the words may not be there, or emotions may make it hard to talk at all, leading to frustration.
With the development of a sense of self, the song is “I want,” “mine,” and “no!” Sharing is not in the child’s repertoire until age 3 years or older. Temperamentally more intense children give up less easily or are not readily distracted.
The threshold for frustration depends on the child’s overall state. Is the child hungry? Tired? Stressed? In pain? Here is where the differential diagnosis of excessive tantrums needs to also include pain from a medical condition such as celiac disease, arthritis, migraine, or sickle cell disease. Children under age 7 years commonly have a low tolerance for sensations as simple as loud noises and elastic waistbands, but those with sensory integration disorder are at the extreme in what sounds, feelings, or motions they cannot bear at any age and may need specific intervention by occupational or physical therapists. Mental health conditions such as attention-deficit/hyperactivity disorder, depression, anxiety, and bipolar disorder also predispose to irritable responses to even normal stresses, often in combination with lagging skills and poor sleep. Consider these when tantrums are extreme.
An age period of tantrums may be expected and accepted by parents, thus the name “terrible twos,” but if tantrums persist, they can wear out even a patient parent. Signs that a child’s tantrums are beyond the usual range include a frequency of more than once a day, a duration of more than the typical 5 minutes, or persistence after age 6 years. When you are asked if a child’s tantrums are “normal,” these are useful parameters. It also helps to explain to parents the natural course of anger arousal that starts with a trigger, peaks within 3 minutes, then subsides rapidly (usually a total of 90 seconds), and although starting with anger, ends up with sadness. Asking parents to collect this information helps them avoid interfering with or reinforcing tantrums.
Understanding the child’s temperament and needs, and avoiding triggers, can prevent many tantrums. What was she doing just before the tantrum started? What were the triggers such as fatigue, hunger, inability to express herself, or a buildup of jealousy from repeated sibling intrusions? Are there skill deficits setting him off, especially fine motor or language delays? Management then needs to focus on avoiding these triggers, if possible, and diagnosing and treating developmental delays.
Next, parents can try to distract by jollying, making a joke, or singing. These are useful moments of modeling. Some parents are worried that distracting the child with something more fun to do will interfere with his learning to cope. If distraction works, they should use it!
Often nothing works, and the child has to explode and recover on her own. Talking, cajoling, or scolding during the fit is useless – like trying to squash dynamite after the flame has hit the powder.
While standing by silently ignoring tantrums is usually the fastest way to reduce them, some children calm down faster if held. This does not reinforce the fits as long as the child’s demand is not fulfilled. Instead, it lends adult “ego support” to reassure the child that all is well and life goes on. Children quickly go from angry to sad; older children are even embarrassed by their loss of control. Comfort is appropriate and kind, as long as at least one parent can do this authentically.
Point out that frustrations in small doses are crucial for learning frustration tolerance. Parents who overprotect their child from any little stress to avoid fits is doing him a disservice. Instead, attention, praise, or marks for little bits of self-control effort or for “using your words” builds self-control over time. Times of transitions such as coming for dinner or going to brush teeth are often times of tantrums; these deserve a 2-minute warning and praise or marks for success in “moving on.”(Stopping electronics without a fit is another . Hint: If the child has a fit, he gets no electronics the next day.)
Adult management may be reinforcing tantrums. When parents give the child what she was screaming for, or remove a demand – such as to take a bath – that had sparked a fit, they can count on having an even worse reaction the next time.
I coach parents to think together about the six main things that set off their child’s tantrums and decide in advance on which ones they will hold their ground. Then, when the child just begins to beg for that snack, the parent should decide instantly if this is a “yes” or a “no” (aiming for more yeses). Parental “giving in” before a tantrum starts models positive flexibility for the child and avoids reinforcement. When an event on the “no” list comes up, both parents are then better able to have an unequivocal response and then walk away.
“But when should we teach him a lesson?” parents often ask. If parents interpret a tantrum as manipulative, a moral failing, or an evil tendency, they tend to react with anger and even loss of control themselves. Be alert for risks of excessive punishment in these cases. Not only is their response a poor model and scary for the child, it can even become an exciting, reinforcing display. If parents are depressed or tend to ignore the child as a norm, it may be worth it to the child to throw a fit to bring them to life. You can emphasize that positive attention to good behavior and silent ignoring of fits is more effective and avoids these side effects.
Parents may experience tantrums as a battle of wills that they are not willing to lose, imagining a future rebellious teen. They need education on the normal imbalances of childhood and on both prevention and intervention strategies. What they can lose in the present is their child’s confidence in adult kindness, the opportunity to model flexibility and self-control, and a relationship with their child that conveys acceptance.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications.
Concerns about tantrums come up a lot in pediatric care. We all know about telling parents to ignore tantrums in toddlers and not to give in. But what about when this advice does not work?
I like to think of tantrums as emotions that go beyond the child’s control. This reframing helps families consider that not all tantrums are an attempt by the child to manipulate them. That is an important first step in avoiding a solely punitive response and instead encouraging parents to look for the source of the imbalance.
Temper tantrums are most common when a child is making developmental spurts in abilities or thinking that are typically unevenly matched with self-control. There is a lot of unevenness in children’s ability to do, say, or tolerate feelings between the early tantrums of the 9-month-old until the greater coping of the 6-year-old. For example, 87% of 18- to 24-month-olds have tantrums just as they acquire autonomy and some language, yet can’t really speak their feelings, while 91% of 30- to 36-month-olds have tantrums because they can imagine big things, but are only capable of or allowed small ones. Even at 42-48 months, more than half have tantrums, which often are associated with the stress and fatigue from dropping their nap.
Life is frustrating for kids. Young children want to try to use their new skills such as climbing, opening things, or scribbling, but parents – at first delighted – suddenly want them to stop! At first, every new word is celebrated, but then toddler talk gets routine, and toddlers may be ignored or even shushed. When the child has a strong desire, the words may not be there, or emotions may make it hard to talk at all, leading to frustration.
With the development of a sense of self, the song is “I want,” “mine,” and “no!” Sharing is not in the child’s repertoire until age 3 years or older. Temperamentally more intense children give up less easily or are not readily distracted.
The threshold for frustration depends on the child’s overall state. Is the child hungry? Tired? Stressed? In pain? Here is where the differential diagnosis of excessive tantrums needs to also include pain from a medical condition such as celiac disease, arthritis, migraine, or sickle cell disease. Children under age 7 years commonly have a low tolerance for sensations as simple as loud noises and elastic waistbands, but those with sensory integration disorder are at the extreme in what sounds, feelings, or motions they cannot bear at any age and may need specific intervention by occupational or physical therapists. Mental health conditions such as attention-deficit/hyperactivity disorder, depression, anxiety, and bipolar disorder also predispose to irritable responses to even normal stresses, often in combination with lagging skills and poor sleep. Consider these when tantrums are extreme.
An age period of tantrums may be expected and accepted by parents, thus the name “terrible twos,” but if tantrums persist, they can wear out even a patient parent. Signs that a child’s tantrums are beyond the usual range include a frequency of more than once a day, a duration of more than the typical 5 minutes, or persistence after age 6 years. When you are asked if a child’s tantrums are “normal,” these are useful parameters. It also helps to explain to parents the natural course of anger arousal that starts with a trigger, peaks within 3 minutes, then subsides rapidly (usually a total of 90 seconds), and although starting with anger, ends up with sadness. Asking parents to collect this information helps them avoid interfering with or reinforcing tantrums.
Understanding the child’s temperament and needs, and avoiding triggers, can prevent many tantrums. What was she doing just before the tantrum started? What were the triggers such as fatigue, hunger, inability to express herself, or a buildup of jealousy from repeated sibling intrusions? Are there skill deficits setting him off, especially fine motor or language delays? Management then needs to focus on avoiding these triggers, if possible, and diagnosing and treating developmental delays.
Next, parents can try to distract by jollying, making a joke, or singing. These are useful moments of modeling. Some parents are worried that distracting the child with something more fun to do will interfere with his learning to cope. If distraction works, they should use it!
Often nothing works, and the child has to explode and recover on her own. Talking, cajoling, or scolding during the fit is useless – like trying to squash dynamite after the flame has hit the powder.
While standing by silently ignoring tantrums is usually the fastest way to reduce them, some children calm down faster if held. This does not reinforce the fits as long as the child’s demand is not fulfilled. Instead, it lends adult “ego support” to reassure the child that all is well and life goes on. Children quickly go from angry to sad; older children are even embarrassed by their loss of control. Comfort is appropriate and kind, as long as at least one parent can do this authentically.
Point out that frustrations in small doses are crucial for learning frustration tolerance. Parents who overprotect their child from any little stress to avoid fits is doing him a disservice. Instead, attention, praise, or marks for little bits of self-control effort or for “using your words” builds self-control over time. Times of transitions such as coming for dinner or going to brush teeth are often times of tantrums; these deserve a 2-minute warning and praise or marks for success in “moving on.”(Stopping electronics without a fit is another . Hint: If the child has a fit, he gets no electronics the next day.)
Adult management may be reinforcing tantrums. When parents give the child what she was screaming for, or remove a demand – such as to take a bath – that had sparked a fit, they can count on having an even worse reaction the next time.
I coach parents to think together about the six main things that set off their child’s tantrums and decide in advance on which ones they will hold their ground. Then, when the child just begins to beg for that snack, the parent should decide instantly if this is a “yes” or a “no” (aiming for more yeses). Parental “giving in” before a tantrum starts models positive flexibility for the child and avoids reinforcement. When an event on the “no” list comes up, both parents are then better able to have an unequivocal response and then walk away.
“But when should we teach him a lesson?” parents often ask. If parents interpret a tantrum as manipulative, a moral failing, or an evil tendency, they tend to react with anger and even loss of control themselves. Be alert for risks of excessive punishment in these cases. Not only is their response a poor model and scary for the child, it can even become an exciting, reinforcing display. If parents are depressed or tend to ignore the child as a norm, it may be worth it to the child to throw a fit to bring them to life. You can emphasize that positive attention to good behavior and silent ignoring of fits is more effective and avoids these side effects.
Parents may experience tantrums as a battle of wills that they are not willing to lose, imagining a future rebellious teen. They need education on the normal imbalances of childhood and on both prevention and intervention strategies. What they can lose in the present is their child’s confidence in adult kindness, the opportunity to model flexibility and self-control, and a relationship with their child that conveys acceptance.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications.
Concerns about tantrums come up a lot in pediatric care. We all know about telling parents to ignore tantrums in toddlers and not to give in. But what about when this advice does not work?
I like to think of tantrums as emotions that go beyond the child’s control. This reframing helps families consider that not all tantrums are an attempt by the child to manipulate them. That is an important first step in avoiding a solely punitive response and instead encouraging parents to look for the source of the imbalance.
Temper tantrums are most common when a child is making developmental spurts in abilities or thinking that are typically unevenly matched with self-control. There is a lot of unevenness in children’s ability to do, say, or tolerate feelings between the early tantrums of the 9-month-old until the greater coping of the 6-year-old. For example, 87% of 18- to 24-month-olds have tantrums just as they acquire autonomy and some language, yet can’t really speak their feelings, while 91% of 30- to 36-month-olds have tantrums because they can imagine big things, but are only capable of or allowed small ones. Even at 42-48 months, more than half have tantrums, which often are associated with the stress and fatigue from dropping their nap.
Life is frustrating for kids. Young children want to try to use their new skills such as climbing, opening things, or scribbling, but parents – at first delighted – suddenly want them to stop! At first, every new word is celebrated, but then toddler talk gets routine, and toddlers may be ignored or even shushed. When the child has a strong desire, the words may not be there, or emotions may make it hard to talk at all, leading to frustration.
With the development of a sense of self, the song is “I want,” “mine,” and “no!” Sharing is not in the child’s repertoire until age 3 years or older. Temperamentally more intense children give up less easily or are not readily distracted.
The threshold for frustration depends on the child’s overall state. Is the child hungry? Tired? Stressed? In pain? Here is where the differential diagnosis of excessive tantrums needs to also include pain from a medical condition such as celiac disease, arthritis, migraine, or sickle cell disease. Children under age 7 years commonly have a low tolerance for sensations as simple as loud noises and elastic waistbands, but those with sensory integration disorder are at the extreme in what sounds, feelings, or motions they cannot bear at any age and may need specific intervention by occupational or physical therapists. Mental health conditions such as attention-deficit/hyperactivity disorder, depression, anxiety, and bipolar disorder also predispose to irritable responses to even normal stresses, often in combination with lagging skills and poor sleep. Consider these when tantrums are extreme.
An age period of tantrums may be expected and accepted by parents, thus the name “terrible twos,” but if tantrums persist, they can wear out even a patient parent. Signs that a child’s tantrums are beyond the usual range include a frequency of more than once a day, a duration of more than the typical 5 minutes, or persistence after age 6 years. When you are asked if a child’s tantrums are “normal,” these are useful parameters. It also helps to explain to parents the natural course of anger arousal that starts with a trigger, peaks within 3 minutes, then subsides rapidly (usually a total of 90 seconds), and although starting with anger, ends up with sadness. Asking parents to collect this information helps them avoid interfering with or reinforcing tantrums.
Understanding the child’s temperament and needs, and avoiding triggers, can prevent many tantrums. What was she doing just before the tantrum started? What were the triggers such as fatigue, hunger, inability to express herself, or a buildup of jealousy from repeated sibling intrusions? Are there skill deficits setting him off, especially fine motor or language delays? Management then needs to focus on avoiding these triggers, if possible, and diagnosing and treating developmental delays.
Next, parents can try to distract by jollying, making a joke, or singing. These are useful moments of modeling. Some parents are worried that distracting the child with something more fun to do will interfere with his learning to cope. If distraction works, they should use it!
Often nothing works, and the child has to explode and recover on her own. Talking, cajoling, or scolding during the fit is useless – like trying to squash dynamite after the flame has hit the powder.
While standing by silently ignoring tantrums is usually the fastest way to reduce them, some children calm down faster if held. This does not reinforce the fits as long as the child’s demand is not fulfilled. Instead, it lends adult “ego support” to reassure the child that all is well and life goes on. Children quickly go from angry to sad; older children are even embarrassed by their loss of control. Comfort is appropriate and kind, as long as at least one parent can do this authentically.
Point out that frustrations in small doses are crucial for learning frustration tolerance. Parents who overprotect their child from any little stress to avoid fits is doing him a disservice. Instead, attention, praise, or marks for little bits of self-control effort or for “using your words” builds self-control over time. Times of transitions such as coming for dinner or going to brush teeth are often times of tantrums; these deserve a 2-minute warning and praise or marks for success in “moving on.”(Stopping electronics without a fit is another . Hint: If the child has a fit, he gets no electronics the next day.)
Adult management may be reinforcing tantrums. When parents give the child what she was screaming for, or remove a demand – such as to take a bath – that had sparked a fit, they can count on having an even worse reaction the next time.
I coach parents to think together about the six main things that set off their child’s tantrums and decide in advance on which ones they will hold their ground. Then, when the child just begins to beg for that snack, the parent should decide instantly if this is a “yes” or a “no” (aiming for more yeses). Parental “giving in” before a tantrum starts models positive flexibility for the child and avoids reinforcement. When an event on the “no” list comes up, both parents are then better able to have an unequivocal response and then walk away.
“But when should we teach him a lesson?” parents often ask. If parents interpret a tantrum as manipulative, a moral failing, or an evil tendency, they tend to react with anger and even loss of control themselves. Be alert for risks of excessive punishment in these cases. Not only is their response a poor model and scary for the child, it can even become an exciting, reinforcing display. If parents are depressed or tend to ignore the child as a norm, it may be worth it to the child to throw a fit to bring them to life. You can emphasize that positive attention to good behavior and silent ignoring of fits is more effective and avoids these side effects.
Parents may experience tantrums as a battle of wills that they are not willing to lose, imagining a future rebellious teen. They need education on the normal imbalances of childhood and on both prevention and intervention strategies. What they can lose in the present is their child’s confidence in adult kindness, the opportunity to model flexibility and self-control, and a relationship with their child that conveys acceptance.
Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications.
Staying fit or fearing fat?
In these days of struggles over obesity, it may be hard to remember that being too thin may be a bigger health threat than being too fat. Anorexia nervosa is a very serious but hidden disorder in which the person has a relentless pursuit of thinness, is unwilling to maintain a healthy weight, has distorted body image and intense fear of gaining weight, disturbed eating behavior, and, in girls, amenorrhea.
Anorexia nervosa is actually the third-leading chronic illness in adolescent females and has a mortality rate as high as 20% – one-third by suicide. Boys are not only not immune, but also are even more difficult to suspect and detect. While most affected children improve with behavioral treatment, anorexia nervosa severe enough to warrant hospitalization can result in permanent damage to bones, heart, and brain.
I refer to these patients as “children” here, but you may rightly associate anorexia with adolescents: 43% of those affected had onset at 16-20 years and 86% by 20 years. But listen to this disturbing statistic: 42% of 1st-3rd grade girls report that they want to be thinner and 81% of 10-year-olds are “afraid” of being fat. Over half of teen girls and one-third of boys skip meals, fast, smoke cigarettes, vomit, or take laxatives to control weight – ineffective practices that can lead to eating disorders. Healthy foods and exercise may seem too slow or difficult ways to control weight.
Even with a prevalence of 0.5% you may be wondering, “Gee, I haven’t seen anyone with that for years!” But you probably have been seeing children with the most common presentations of anorexia, which are concerns over complications rather than a request for help with excess weight loss. These are usually complaints about abdominal pain, bloating, or constipation, but may be about headaches, amenorrhea, or feeling faint. You may see them for the first time after an intercurrent illness such as viral gastroenteritis or mononucleosis that sends their emaciated bodies over the edge. Do those patients sound more familiar?
Anorexia nervosa works its damage from starvation and purging behaviors. Any system of the body can be affected from starvation, ranging from suppression of bone marrow with anemia, low white count, and low platelets; endocrine suppression with low TSH and T4 and amenorrhea; cardiomyopathy with resulting mitral valve prolapse, arrhythmias, and syncope; or even seizures and brain atrophy. Depression and anxiety are pretty inevitable when one is starving but, while comorbid, their primacy or severity really can’t be assessed until the starvation state is resolved.
Why aren’t the affected children worried about these serious complications? Actually, they may be worried when they find out about them, but their first fear is about getting fat. Characteristic of anorexia is a distorted body image that nags at them incessantly to lose weight. In U.S. culture, weight loss and fitness ads are all around us, making this concern seem quite normal or even more urgent. They may even panic and get angry if their excessive exercise routine is interrupted. The missing link is that they can’t see that they are not overweight, instead fearing being fat.
Many children with anorexia have tried to stop their dieting but failed. They may be ashamed, embarrassed, or worried about being stigmatized if they are found out. But they often feel that they are on the right path for themselves. At best they are ambivalent about being detected and pushed into treatment. So they get really good at hiding their condition, sometimes getting new ideas online. Common strategies to evade detection include eating apart from the family, saying they are “not hungry now” or even cooking for others but not eating themselves. They wear baggy clothes to hide their emaciation. They often exercise to an extreme, in any weather, whether sick or well. When it is time to be weighed they may drink quarts of water and fill pockets with stones so their true weight loss is not evident.
Actions children take for weight control or loss create much of the morbidity. Most common are use of laxatives and diuretics that can result in fatal electrolyte imbalances and arrhythmias. Purging in anorexia and also in bulimia nervosa can result in gastroesophageal reflux disease, esophageal tears, and bleeding. Self-induced vomiting also destroys tooth enamel, fosters cavities, and can cause scars of palate or knuckles from forcing their hand down their throat. Hypoglycemia from severe restriction can even result in seizures.
When your patients have those metabolic and physical signs, you are not likely to be tricked into thinking all is well. But those athletes in your practice, of whom you and the parents are so proud, can sneak up on you. Those participating in individual “aesthetic” sports such as dance, figure skating, and gymnastics are especially vulnerable to (and rewarded by) extreme thinness. They have been coached to be slim. But to make it worse, the most elite athletes also often have personalities that make extreme weight control possible including perfectionism, competitiveness, compulsiveness, drive, and high activity level.
Parents of children with anorexia may be ambivalent, also, as they see their child eating healthy foods and exercising as they have encouraged them to do. It is not so clear when they have gone too far. But 35% of “normal dieters” go on to pathological dieting and, of those, 20%-25% develop eating disorders of varying degree.
As with most disorders, earlier detection of anorexia symptoms can allow for an easier treatment course and fewer long-term complications. So, when should you be thinking and asking about abnormal eating? Certainly, it is time to ask questions when a child is not gaining weight appropriately, is losing weight to below 15% of appropriate weight for height, or has 3 or more months of amenorrhea. But also consider it when you hear complaints of abdominal pain, headache, or feeling faint that you can’t explain. Ask directly “What would you like to weigh?” A desired weight that would give a body mass index (BMI) of <19 kg/m2 is nearly diagnostic. Also ask them to, “Tell me what you eat at each meal on a typical day,” looking for extremely low-calorie bizarre choices such as all lettuce, and “How much exercise do you do daily?” Be specific in collecting information about dieting, binging, self-induced vomiting, and use of laxatives, diuretics, or diet pills for weight control. Asking family members what they have observed about the child’s exercise, dieting, and statements about body image gives even more objective information that the child may try to obscure.
Specific screening self report tools such as the SCOFF questionnaire and Patient Health Questionnaire – Adolescents (PHQ-A) used for all teens or those with signs of weight loss are both a way to get more accurate information and a valuable point of conversation.
When you detect signs and symptoms, the initial work up should include complete blood count, electrolytes, liver function, thyroid-stimulating hormone, and urinalysis, but most importantly an accurate height, weight, and BMI measured in underwear in a gown. Amenorrhea may require endocrine tests as well. While malignancy, endocrine and gastrointestinal disorders are in the differential, characteristic history, physical exam, and lab results will point to the diagnosis. If there is bradycardia or low potassium, chloride, or sodium, an electrocardiogram and hospitalization are urgent as these are the harbingers of life-threatening arrhythmias that are the most common cause of death.
So when you suspect anorexia, you may be facing a difficult-to-detect, life-threatening condition with resistant patients and even reluctant parents. While you may be able to make a contract for biweekly weigh-ins and coaching for subclinical anorexia not otherwise specified, a team will be needed in most full-blown cases. Eating disorder programs are often part of departments of psychiatry, but adolescent specialists also may have assembled needed teams.
Dr. Howard is assistant professor of pediatrics at the 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. E-mail her at pdnews@frontlinemedcom.com.
In these days of struggles over obesity, it may be hard to remember that being too thin may be a bigger health threat than being too fat. Anorexia nervosa is a very serious but hidden disorder in which the person has a relentless pursuit of thinness, is unwilling to maintain a healthy weight, has distorted body image and intense fear of gaining weight, disturbed eating behavior, and, in girls, amenorrhea.
Anorexia nervosa is actually the third-leading chronic illness in adolescent females and has a mortality rate as high as 20% – one-third by suicide. Boys are not only not immune, but also are even more difficult to suspect and detect. While most affected children improve with behavioral treatment, anorexia nervosa severe enough to warrant hospitalization can result in permanent damage to bones, heart, and brain.
I refer to these patients as “children” here, but you may rightly associate anorexia with adolescents: 43% of those affected had onset at 16-20 years and 86% by 20 years. But listen to this disturbing statistic: 42% of 1st-3rd grade girls report that they want to be thinner and 81% of 10-year-olds are “afraid” of being fat. Over half of teen girls and one-third of boys skip meals, fast, smoke cigarettes, vomit, or take laxatives to control weight – ineffective practices that can lead to eating disorders. Healthy foods and exercise may seem too slow or difficult ways to control weight.
Even with a prevalence of 0.5% you may be wondering, “Gee, I haven’t seen anyone with that for years!” But you probably have been seeing children with the most common presentations of anorexia, which are concerns over complications rather than a request for help with excess weight loss. These are usually complaints about abdominal pain, bloating, or constipation, but may be about headaches, amenorrhea, or feeling faint. You may see them for the first time after an intercurrent illness such as viral gastroenteritis or mononucleosis that sends their emaciated bodies over the edge. Do those patients sound more familiar?
Anorexia nervosa works its damage from starvation and purging behaviors. Any system of the body can be affected from starvation, ranging from suppression of bone marrow with anemia, low white count, and low platelets; endocrine suppression with low TSH and T4 and amenorrhea; cardiomyopathy with resulting mitral valve prolapse, arrhythmias, and syncope; or even seizures and brain atrophy. Depression and anxiety are pretty inevitable when one is starving but, while comorbid, their primacy or severity really can’t be assessed until the starvation state is resolved.
Why aren’t the affected children worried about these serious complications? Actually, they may be worried when they find out about them, but their first fear is about getting fat. Characteristic of anorexia is a distorted body image that nags at them incessantly to lose weight. In U.S. culture, weight loss and fitness ads are all around us, making this concern seem quite normal or even more urgent. They may even panic and get angry if their excessive exercise routine is interrupted. The missing link is that they can’t see that they are not overweight, instead fearing being fat.
Many children with anorexia have tried to stop their dieting but failed. They may be ashamed, embarrassed, or worried about being stigmatized if they are found out. But they often feel that they are on the right path for themselves. At best they are ambivalent about being detected and pushed into treatment. So they get really good at hiding their condition, sometimes getting new ideas online. Common strategies to evade detection include eating apart from the family, saying they are “not hungry now” or even cooking for others but not eating themselves. They wear baggy clothes to hide their emaciation. They often exercise to an extreme, in any weather, whether sick or well. When it is time to be weighed they may drink quarts of water and fill pockets with stones so their true weight loss is not evident.
Actions children take for weight control or loss create much of the morbidity. Most common are use of laxatives and diuretics that can result in fatal electrolyte imbalances and arrhythmias. Purging in anorexia and also in bulimia nervosa can result in gastroesophageal reflux disease, esophageal tears, and bleeding. Self-induced vomiting also destroys tooth enamel, fosters cavities, and can cause scars of palate or knuckles from forcing their hand down their throat. Hypoglycemia from severe restriction can even result in seizures.
When your patients have those metabolic and physical signs, you are not likely to be tricked into thinking all is well. But those athletes in your practice, of whom you and the parents are so proud, can sneak up on you. Those participating in individual “aesthetic” sports such as dance, figure skating, and gymnastics are especially vulnerable to (and rewarded by) extreme thinness. They have been coached to be slim. But to make it worse, the most elite athletes also often have personalities that make extreme weight control possible including perfectionism, competitiveness, compulsiveness, drive, and high activity level.
Parents of children with anorexia may be ambivalent, also, as they see their child eating healthy foods and exercising as they have encouraged them to do. It is not so clear when they have gone too far. But 35% of “normal dieters” go on to pathological dieting and, of those, 20%-25% develop eating disorders of varying degree.
As with most disorders, earlier detection of anorexia symptoms can allow for an easier treatment course and fewer long-term complications. So, when should you be thinking and asking about abnormal eating? Certainly, it is time to ask questions when a child is not gaining weight appropriately, is losing weight to below 15% of appropriate weight for height, or has 3 or more months of amenorrhea. But also consider it when you hear complaints of abdominal pain, headache, or feeling faint that you can’t explain. Ask directly “What would you like to weigh?” A desired weight that would give a body mass index (BMI) of <19 kg/m2 is nearly diagnostic. Also ask them to, “Tell me what you eat at each meal on a typical day,” looking for extremely low-calorie bizarre choices such as all lettuce, and “How much exercise do you do daily?” Be specific in collecting information about dieting, binging, self-induced vomiting, and use of laxatives, diuretics, or diet pills for weight control. Asking family members what they have observed about the child’s exercise, dieting, and statements about body image gives even more objective information that the child may try to obscure.
Specific screening self report tools such as the SCOFF questionnaire and Patient Health Questionnaire – Adolescents (PHQ-A) used for all teens or those with signs of weight loss are both a way to get more accurate information and a valuable point of conversation.
When you detect signs and symptoms, the initial work up should include complete blood count, electrolytes, liver function, thyroid-stimulating hormone, and urinalysis, but most importantly an accurate height, weight, and BMI measured in underwear in a gown. Amenorrhea may require endocrine tests as well. While malignancy, endocrine and gastrointestinal disorders are in the differential, characteristic history, physical exam, and lab results will point to the diagnosis. If there is bradycardia or low potassium, chloride, or sodium, an electrocardiogram and hospitalization are urgent as these are the harbingers of life-threatening arrhythmias that are the most common cause of death.
So when you suspect anorexia, you may be facing a difficult-to-detect, life-threatening condition with resistant patients and even reluctant parents. While you may be able to make a contract for biweekly weigh-ins and coaching for subclinical anorexia not otherwise specified, a team will be needed in most full-blown cases. Eating disorder programs are often part of departments of psychiatry, but adolescent specialists also may have assembled needed teams.
Dr. Howard is assistant professor of pediatrics at the 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. E-mail her at pdnews@frontlinemedcom.com.
In these days of struggles over obesity, it may be hard to remember that being too thin may be a bigger health threat than being too fat. Anorexia nervosa is a very serious but hidden disorder in which the person has a relentless pursuit of thinness, is unwilling to maintain a healthy weight, has distorted body image and intense fear of gaining weight, disturbed eating behavior, and, in girls, amenorrhea.
Anorexia nervosa is actually the third-leading chronic illness in adolescent females and has a mortality rate as high as 20% – one-third by suicide. Boys are not only not immune, but also are even more difficult to suspect and detect. While most affected children improve with behavioral treatment, anorexia nervosa severe enough to warrant hospitalization can result in permanent damage to bones, heart, and brain.
I refer to these patients as “children” here, but you may rightly associate anorexia with adolescents: 43% of those affected had onset at 16-20 years and 86% by 20 years. But listen to this disturbing statistic: 42% of 1st-3rd grade girls report that they want to be thinner and 81% of 10-year-olds are “afraid” of being fat. Over half of teen girls and one-third of boys skip meals, fast, smoke cigarettes, vomit, or take laxatives to control weight – ineffective practices that can lead to eating disorders. Healthy foods and exercise may seem too slow or difficult ways to control weight.
Even with a prevalence of 0.5% you may be wondering, “Gee, I haven’t seen anyone with that for years!” But you probably have been seeing children with the most common presentations of anorexia, which are concerns over complications rather than a request for help with excess weight loss. These are usually complaints about abdominal pain, bloating, or constipation, but may be about headaches, amenorrhea, or feeling faint. You may see them for the first time after an intercurrent illness such as viral gastroenteritis or mononucleosis that sends their emaciated bodies over the edge. Do those patients sound more familiar?
Anorexia nervosa works its damage from starvation and purging behaviors. Any system of the body can be affected from starvation, ranging from suppression of bone marrow with anemia, low white count, and low platelets; endocrine suppression with low TSH and T4 and amenorrhea; cardiomyopathy with resulting mitral valve prolapse, arrhythmias, and syncope; or even seizures and brain atrophy. Depression and anxiety are pretty inevitable when one is starving but, while comorbid, their primacy or severity really can’t be assessed until the starvation state is resolved.
Why aren’t the affected children worried about these serious complications? Actually, they may be worried when they find out about them, but their first fear is about getting fat. Characteristic of anorexia is a distorted body image that nags at them incessantly to lose weight. In U.S. culture, weight loss and fitness ads are all around us, making this concern seem quite normal or even more urgent. They may even panic and get angry if their excessive exercise routine is interrupted. The missing link is that they can’t see that they are not overweight, instead fearing being fat.
Many children with anorexia have tried to stop their dieting but failed. They may be ashamed, embarrassed, or worried about being stigmatized if they are found out. But they often feel that they are on the right path for themselves. At best they are ambivalent about being detected and pushed into treatment. So they get really good at hiding their condition, sometimes getting new ideas online. Common strategies to evade detection include eating apart from the family, saying they are “not hungry now” or even cooking for others but not eating themselves. They wear baggy clothes to hide their emaciation. They often exercise to an extreme, in any weather, whether sick or well. When it is time to be weighed they may drink quarts of water and fill pockets with stones so their true weight loss is not evident.
Actions children take for weight control or loss create much of the morbidity. Most common are use of laxatives and diuretics that can result in fatal electrolyte imbalances and arrhythmias. Purging in anorexia and also in bulimia nervosa can result in gastroesophageal reflux disease, esophageal tears, and bleeding. Self-induced vomiting also destroys tooth enamel, fosters cavities, and can cause scars of palate or knuckles from forcing their hand down their throat. Hypoglycemia from severe restriction can even result in seizures.
When your patients have those metabolic and physical signs, you are not likely to be tricked into thinking all is well. But those athletes in your practice, of whom you and the parents are so proud, can sneak up on you. Those participating in individual “aesthetic” sports such as dance, figure skating, and gymnastics are especially vulnerable to (and rewarded by) extreme thinness. They have been coached to be slim. But to make it worse, the most elite athletes also often have personalities that make extreme weight control possible including perfectionism, competitiveness, compulsiveness, drive, and high activity level.
Parents of children with anorexia may be ambivalent, also, as they see their child eating healthy foods and exercising as they have encouraged them to do. It is not so clear when they have gone too far. But 35% of “normal dieters” go on to pathological dieting and, of those, 20%-25% develop eating disorders of varying degree.
As with most disorders, earlier detection of anorexia symptoms can allow for an easier treatment course and fewer long-term complications. So, when should you be thinking and asking about abnormal eating? Certainly, it is time to ask questions when a child is not gaining weight appropriately, is losing weight to below 15% of appropriate weight for height, or has 3 or more months of amenorrhea. But also consider it when you hear complaints of abdominal pain, headache, or feeling faint that you can’t explain. Ask directly “What would you like to weigh?” A desired weight that would give a body mass index (BMI) of <19 kg/m2 is nearly diagnostic. Also ask them to, “Tell me what you eat at each meal on a typical day,” looking for extremely low-calorie bizarre choices such as all lettuce, and “How much exercise do you do daily?” Be specific in collecting information about dieting, binging, self-induced vomiting, and use of laxatives, diuretics, or diet pills for weight control. Asking family members what they have observed about the child’s exercise, dieting, and statements about body image gives even more objective information that the child may try to obscure.
Specific screening self report tools such as the SCOFF questionnaire and Patient Health Questionnaire – Adolescents (PHQ-A) used for all teens or those with signs of weight loss are both a way to get more accurate information and a valuable point of conversation.
When you detect signs and symptoms, the initial work up should include complete blood count, electrolytes, liver function, thyroid-stimulating hormone, and urinalysis, but most importantly an accurate height, weight, and BMI measured in underwear in a gown. Amenorrhea may require endocrine tests as well. While malignancy, endocrine and gastrointestinal disorders are in the differential, characteristic history, physical exam, and lab results will point to the diagnosis. If there is bradycardia or low potassium, chloride, or sodium, an electrocardiogram and hospitalization are urgent as these are the harbingers of life-threatening arrhythmias that are the most common cause of death.
So when you suspect anorexia, you may be facing a difficult-to-detect, life-threatening condition with resistant patients and even reluctant parents. While you may be able to make a contract for biweekly weigh-ins and coaching for subclinical anorexia not otherwise specified, a team will be needed in most full-blown cases. Eating disorder programs are often part of departments of psychiatry, but adolescent specialists also may have assembled needed teams.
Dr. Howard is assistant professor of pediatrics at the 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. E-mail her at pdnews@frontlinemedcom.com.
