Michael S. Jellinek

pdnews@elsevier.com

Some parents of very young children – those 6 years old and younger – will come to you exhausted, feeling inadequate as parents, and even angry at their children.

Parents will report that their children with attention-deficit/hyperactivity disorder are very difficult at home and in preschool. Probably when their children were around age 2, 3, or 4 years old, their parents began wondering if the youngsters were immature, were more impulsive, and had a shorter attention span, compared with peers.

Pediatricians will recognize this pattern as likely ADHD and, in addition to making an accurate diagnosis, know that much is at stake in guiding and supporting parents. A critical relationship is at risk as the child's behavior evokes criticism and a negative tone from parents. Pediatricians should help parents set reasonable expectations and focus on behaviors and activities that build self-esteem. For some families, this work can be difficult and time consuming, requiring counseling and behavioral reward training – probably better delegated to a mental health specialist.

Attention span, impulsivity, and motoric hyperactivity are active concerns every waking hour of the child's day. Certain demands in preschool, at a longer dinner, or in church may exacerbate the symptoms, whereas playing in the park or playing a fun-filled computer game may ease the symptoms. The pediatrician can sort through a typical day and recommend approaches that are consistent with developmentally reasonable expectations, and modified for the child's ADHD symptoms.

Family history is another consideration. About 30% of children with ADHD come from fathers who had or have the disorder. Reminding a father of his difficulties growing up or any ongoing ADHD symptoms can be helpful in eliciting some empathy from him for his child's suffering.

Beyond family life, ADHD will affect the choice of school and activities. Based on what works for the child, consider how many hours a child should spend in preschool and how much structure is helpful. How will the culture of the school fit the child's style? Remember that the last thing a child with ADHD needs is an early school experience characterized by criticism and a sense of not being able to please teachers. A school with more recess and activity opportunities, as well as after-school programs, might be a good choice, and might offer some respite for parents.

As part of building self-esteem, ask parents if there is anything the child is really good at. For example, I treated a 6-year-old with ADHD who was gifted with computers. He was able to teach his peers and play games with friends, and he felt genuine pride working with a machine that was tolerant and nonjudgmental, and could be reset as needed. Might this not lead to a path of an after-school computer club or computer summer camp (that of course would include other activities)? Other young children may show strength in music, art, or a sport, and these activities are at least as important as remediating weaknesses.

Awareness of the different ADHD subtypes is important in general, but also can guide you in when to refer these children. Some kids with ADHD are more moody or depressed, some are more anxious, and others are more physically aggressive. Consider referral to a child and adolescent psychiatrist if one of these subtypes becomes more difficult to manage. A mental health consultation can help these higher-risk children.

Some children with ADHD also have learning disabilities, and diagnosis at a young age, before school failure, is invaluable. If you suspect this in a particular patient, you might want to recommend some early testing through the schools to avoid creation of unrealistic expectations in the classroom.

Parents may tell you their children are impulsive. While other kids are more predictable when playing in the sandbox, their children with ADHD may do something unpredictable. They might jump out of the sandbox or grab a toy from another child, for example. A mother of a 3-year-old with ADHD will stay closer to the sandbox because she doesn't know what that child is going to do next.

Typically, the child also will have a shorter attention span. The parents cannot relax because they know the sandbox, or a particular project in the sandbox, won't hold their child as long. Other children may be occupied for 15, 20, or even 30 minutes, but their young child with ADHD might last only 3 or 4 minutes and then need to move on. That, as you can imagine, is going to make the parenting demands much higher. Remember this doesn't happen for just 1 or 2 hours per day; children with true ADHD are going to be like this from the time they get up until the time they go to sleep.

All these behaviors associated with ADHD set these children up for a fair amount of criticism. The parents are tempted, especially if they don't understand the disorder, to say: “Don't do that!”; “Put that down!”; “I just bought you this – why don't you want to play with it?”; “Why can't you play like your friend Johnny does?”; “Why can't you sit still for a minute while Mommy fixes dinner?”

These children are subject to a lot of negative feedback from their environment. The world is not very tolerant of a young child, or even an older child, with ADHD. My guess is if these children are in preschool, the teacher is having the same issues with their behaviors. They may get criticized during circle time or while doing a certain project. Except for recess and lunch, they are going to be under a lot of scrutiny and most of the feedback is going to be negative.

We can see how children with ADHD, in a typical day, can hear 10, if not 25, negative comments. That is about two to three per hour. That degree of criticism begins to become part of how they see themselves, and they become fairly self-critical.

One of the key risks from ADHD at this young age is that it's hard for these children to differentiate if what they are doing is bad or if they are bad. Their self-esteem is very vulnerable. One principle that guides a lot of my management of these youngsters with ADHD is figuring out how to protect or enhance their self-esteem. Therefore, one of the initial things I ask parents to do is to think about how much negative criticism their child is hearing. Next, I ask them to think about what are reasonable expectations for that particular child.

Any opportunity to build self-esteem and build a sense of success based on reasonable expectations is worthwhile. A lot of parents will start sports for their children when they are 4 or 5. Kids with ADHD don't do very well in the outfield of T-ball because they are distracted. They don't stand out there waiting for the hit, and then they get yelled at for missing the ball. Help parents choose a sport that fits their children. I've seen some ADHD kids be goalies because they have to pay attention for a few seconds when the ball is coming, and then when the ball is somewhere else they can daydream with impunity. A lot of children with ADHD do well with swimming, for example, because there are fewer rules and they have a little more freedom. Others thrive with the structure and sense of accomplishment that comes from the “belt” system of karate.

Clearly one of the most effective treatments for the symptoms of ADHD is medication. Medication will increase attention span in school, church, or at dinner. Of course, every parent has concerns about how young to start children on medication, or whether to use medication at all. For those families, the first set of efforts may be directed to setting reasonable expectations and reviewing daily activities.

This focus will help, but will not be enough, and medication will be a critical part of treatment. Medication adds some risk, but the benefits to the child's functioning and self-esteem often outweigh these risks.

One of the things that medication probably does best is reduce the amount of negative feedback because the child will not be as impulsive and will appear to have a longer attention span. Again, you can ask too much of a child, but you will see higher expectations if the child is taking medication that is working correctly. Once ADHD is diagnosed in a young child, the pediatrician has a key role in trying to protect and enhance the child's self-esteem, advising on the child's day-to-day functioning, and supporting the overall care with appropriate use of medications.

pdnews@elsevier.com

Some parents of very young children – those 6 years old and younger – will come to you exhausted, feeling inadequate as parents, and even angry at their children.

Parents will report that their children with attention-deficit/hyperactivity disorder are very difficult at home and in preschool. Probably when their children were around age 2, 3, or 4 years old, their parents began wondering if the youngsters were immature, were more impulsive, and had a shorter attention span, compared with peers.

Pediatricians will recognize this pattern as likely ADHD and, in addition to making an accurate diagnosis, know that much is at stake in guiding and supporting parents. A critical relationship is at risk as the child's behavior evokes criticism and a negative tone from parents. Pediatricians should help parents set reasonable expectations and focus on behaviors and activities that build self-esteem. For some families, this work can be difficult and time consuming, requiring counseling and behavioral reward training – probably better delegated to a mental health specialist.

Attention span, impulsivity, and motoric hyperactivity are active concerns every waking hour of the child's day. Certain demands in preschool, at a longer dinner, or in church may exacerbate the symptoms, whereas playing in the park or playing a fun-filled computer game may ease the symptoms. The pediatrician can sort through a typical day and recommend approaches that are consistent with developmentally reasonable expectations, and modified for the child's ADHD symptoms.

Family history is another consideration. About 30% of children with ADHD come from fathers who had or have the disorder. Reminding a father of his difficulties growing up or any ongoing ADHD symptoms can be helpful in eliciting some empathy from him for his child's suffering.

Beyond family life, ADHD will affect the choice of school and activities. Based on what works for the child, consider how many hours a child should spend in preschool and how much structure is helpful. How will the culture of the school fit the child's style? Remember that the last thing a child with ADHD needs is an early school experience characterized by criticism and a sense of not being able to please teachers. A school with more recess and activity opportunities, as well as after-school programs, might be a good choice, and might offer some respite for parents.

As part of building self-esteem, ask parents if there is anything the child is really good at. For example, I treated a 6-year-old with ADHD who was gifted with computers. He was able to teach his peers and play games with friends, and he felt genuine pride working with a machine that was tolerant and nonjudgmental, and could be reset as needed. Might this not lead to a path of an after-school computer club or computer summer camp (that of course would include other activities)? Other young children may show strength in music, art, or a sport, and these activities are at least as important as remediating weaknesses.

Awareness of the different ADHD subtypes is important in general, but also can guide you in when to refer these children. Some kids with ADHD are more moody or depressed, some are more anxious, and others are more physically aggressive. Consider referral to a child and adolescent psychiatrist if one of these subtypes becomes more difficult to manage. A mental health consultation can help these higher-risk children.

Some children with ADHD also have learning disabilities, and diagnosis at a young age, before school failure, is invaluable. If you suspect this in a particular patient, you might want to recommend some early testing through the schools to avoid creation of unrealistic expectations in the classroom.

Parents may tell you their children are impulsive. While other kids are more predictable when playing in the sandbox, their children with ADHD may do something unpredictable. They might jump out of the sandbox or grab a toy from another child, for example. A mother of a 3-year-old with ADHD will stay closer to the sandbox because she doesn't know what that child is going to do next.

Typically, the child also will have a shorter attention span. The parents cannot relax because they know the sandbox, or a particular project in the sandbox, won't hold their child as long. Other children may be occupied for 15, 20, or even 30 minutes, but their young child with ADHD might last only 3 or 4 minutes and then need to move on. That, as you can imagine, is going to make the parenting demands much higher. Remember this doesn't happen for just 1 or 2 hours per day; children with true ADHD are going to be like this from the time they get up until the time they go to sleep.

All these behaviors associated with ADHD set these children up for a fair amount of criticism. The parents are tempted, especially if they don't understand the disorder, to say: “Don't do that!”; “Put that down!”; “I just bought you this – why don't you want to play with it?”; “Why can't you play like your friend Johnny does?”; “Why can't you sit still for a minute while Mommy fixes dinner?”

These children are subject to a lot of negative feedback from their environment. The world is not very tolerant of a young child, or even an older child, with ADHD. My guess is if these children are in preschool, the teacher is having the same issues with their behaviors. They may get criticized during circle time or while doing a certain project. Except for recess and lunch, they are going to be under a lot of scrutiny and most of the feedback is going to be negative.

We can see how children with ADHD, in a typical day, can hear 10, if not 25, negative comments. That is about two to three per hour. That degree of criticism begins to become part of how they see themselves, and they become fairly self-critical.

One of the key risks from ADHD at this young age is that it's hard for these children to differentiate if what they are doing is bad or if they are bad. Their self-esteem is very vulnerable. One principle that guides a lot of my management of these youngsters with ADHD is figuring out how to protect or enhance their self-esteem. Therefore, one of the initial things I ask parents to do is to think about how much negative criticism their child is hearing. Next, I ask them to think about what are reasonable expectations for that particular child.

Any opportunity to build self-esteem and build a sense of success based on reasonable expectations is worthwhile. A lot of parents will start sports for their children when they are 4 or 5. Kids with ADHD don't do very well in the outfield of T-ball because they are distracted. They don't stand out there waiting for the hit, and then they get yelled at for missing the ball. Help parents choose a sport that fits their children. I've seen some ADHD kids be goalies because they have to pay attention for a few seconds when the ball is coming, and then when the ball is somewhere else they can daydream with impunity. A lot of children with ADHD do well with swimming, for example, because there are fewer rules and they have a little more freedom. Others thrive with the structure and sense of accomplishment that comes from the “belt” system of karate.

Clearly one of the most effective treatments for the symptoms of ADHD is medication. Medication will increase attention span in school, church, or at dinner. Of course, every parent has concerns about how young to start children on medication, or whether to use medication at all. For those families, the first set of efforts may be directed to setting reasonable expectations and reviewing daily activities.

This focus will help, but will not be enough, and medication will be a critical part of treatment. Medication adds some risk, but the benefits to the child's functioning and self-esteem often outweigh these risks.

One of the things that medication probably does best is reduce the amount of negative feedback because the child will not be as impulsive and will appear to have a longer attention span. Again, you can ask too much of a child, but you will see higher expectations if the child is taking medication that is working correctly. Once ADHD is diagnosed in a young child, the pediatrician has a key role in trying to protect and enhance the child's self-esteem, advising on the child's day-to-day functioning, and supporting the overall care with appropriate use of medications.

pdnews@elsevier.com

Some parents of very young children – those 6 years old and younger – will come to you exhausted, feeling inadequate as parents, and even angry at their children.

Parents will report that their children with attention-deficit/hyperactivity disorder are very difficult at home and in preschool. Probably when their children were around age 2, 3, or 4 years old, their parents began wondering if the youngsters were immature, were more impulsive, and had a shorter attention span, compared with peers.

Pediatricians will recognize this pattern as likely ADHD and, in addition to making an accurate diagnosis, know that much is at stake in guiding and supporting parents. A critical relationship is at risk as the child's behavior evokes criticism and a negative tone from parents. Pediatricians should help parents set reasonable expectations and focus on behaviors and activities that build self-esteem. For some families, this work can be difficult and time consuming, requiring counseling and behavioral reward training – probably better delegated to a mental health specialist.

Attention span, impulsivity, and motoric hyperactivity are active concerns every waking hour of the child's day. Certain demands in preschool, at a longer dinner, or in church may exacerbate the symptoms, whereas playing in the park or playing a fun-filled computer game may ease the symptoms. The pediatrician can sort through a typical day and recommend approaches that are consistent with developmentally reasonable expectations, and modified for the child's ADHD symptoms.

Family history is another consideration. About 30% of children with ADHD come from fathers who had or have the disorder. Reminding a father of his difficulties growing up or any ongoing ADHD symptoms can be helpful in eliciting some empathy from him for his child's suffering.

Beyond family life, ADHD will affect the choice of school and activities. Based on what works for the child, consider how many hours a child should spend in preschool and how much structure is helpful. How will the culture of the school fit the child's style? Remember that the last thing a child with ADHD needs is an early school experience characterized by criticism and a sense of not being able to please teachers. A school with more recess and activity opportunities, as well as after-school programs, might be a good choice, and might offer some respite for parents.

As part of building self-esteem, ask parents if there is anything the child is really good at. For example, I treated a 6-year-old with ADHD who was gifted with computers. He was able to teach his peers and play games with friends, and he felt genuine pride working with a machine that was tolerant and nonjudgmental, and could be reset as needed. Might this not lead to a path of an after-school computer club or computer summer camp (that of course would include other activities)? Other young children may show strength in music, art, or a sport, and these activities are at least as important as remediating weaknesses.

Awareness of the different ADHD subtypes is important in general, but also can guide you in when to refer these children. Some kids with ADHD are more moody or depressed, some are more anxious, and others are more physically aggressive. Consider referral to a child and adolescent psychiatrist if one of these subtypes becomes more difficult to manage. A mental health consultation can help these higher-risk children.

Some children with ADHD also have learning disabilities, and diagnosis at a young age, before school failure, is invaluable. If you suspect this in a particular patient, you might want to recommend some early testing through the schools to avoid creation of unrealistic expectations in the classroom.

Parents may tell you their children are impulsive. While other kids are more predictable when playing in the sandbox, their children with ADHD may do something unpredictable. They might jump out of the sandbox or grab a toy from another child, for example. A mother of a 3-year-old with ADHD will stay closer to the sandbox because she doesn't know what that child is going to do next.

Typically, the child also will have a shorter attention span. The parents cannot relax because they know the sandbox, or a particular project in the sandbox, won't hold their child as long. Other children may be occupied for 15, 20, or even 30 minutes, but their young child with ADHD might last only 3 or 4 minutes and then need to move on. That, as you can imagine, is going to make the parenting demands much higher. Remember this doesn't happen for just 1 or 2 hours per day; children with true ADHD are going to be like this from the time they get up until the time they go to sleep.

All these behaviors associated with ADHD set these children up for a fair amount of criticism. The parents are tempted, especially if they don't understand the disorder, to say: “Don't do that!”; “Put that down!”; “I just bought you this – why don't you want to play with it?”; “Why can't you play like your friend Johnny does?”; “Why can't you sit still for a minute while Mommy fixes dinner?”

These children are subject to a lot of negative feedback from their environment. The world is not very tolerant of a young child, or even an older child, with ADHD. My guess is if these children are in preschool, the teacher is having the same issues with their behaviors. They may get criticized during circle time or while doing a certain project. Except for recess and lunch, they are going to be under a lot of scrutiny and most of the feedback is going to be negative.

We can see how children with ADHD, in a typical day, can hear 10, if not 25, negative comments. That is about two to three per hour. That degree of criticism begins to become part of how they see themselves, and they become fairly self-critical.

One of the key risks from ADHD at this young age is that it's hard for these children to differentiate if what they are doing is bad or if they are bad. Their self-esteem is very vulnerable. One principle that guides a lot of my management of these youngsters with ADHD is figuring out how to protect or enhance their self-esteem. Therefore, one of the initial things I ask parents to do is to think about how much negative criticism their child is hearing. Next, I ask them to think about what are reasonable expectations for that particular child.

Any opportunity to build self-esteem and build a sense of success based on reasonable expectations is worthwhile. A lot of parents will start sports for their children when they are 4 or 5. Kids with ADHD don't do very well in the outfield of T-ball because they are distracted. They don't stand out there waiting for the hit, and then they get yelled at for missing the ball. Help parents choose a sport that fits their children. I've seen some ADHD kids be goalies because they have to pay attention for a few seconds when the ball is coming, and then when the ball is somewhere else they can daydream with impunity. A lot of children with ADHD do well with swimming, for example, because there are fewer rules and they have a little more freedom. Others thrive with the structure and sense of accomplishment that comes from the “belt” system of karate.

Clearly one of the most effective treatments for the symptoms of ADHD is medication. Medication will increase attention span in school, church, or at dinner. Of course, every parent has concerns about how young to start children on medication, or whether to use medication at all. For those families, the first set of efforts may be directed to setting reasonable expectations and reviewing daily activities.

This focus will help, but will not be enough, and medication will be a critical part of treatment. Medication adds some risk, but the benefits to the child's functioning and self-esteem often outweigh these risks.

One of the things that medication probably does best is reduce the amount of negative feedback because the child will not be as impulsive and will appear to have a longer attention span. Again, you can ask too much of a child, but you will see higher expectations if the child is taking medication that is working correctly. Once ADHD is diagnosed in a young child, the pediatrician has a key role in trying to protect and enhance the child's self-esteem, advising on the child's day-to-day functioning, and supporting the overall care with appropriate use of medications.

pdnews@elsevier.com

Different forms of trauma can cause posttraumatic stress disorder in children, whether from an objective event like a car crash or sports injury to trauma involving loved ones, such as domestic violence, abuse, or neglect.

Pediatricians can help by routinely screening for dysfunction and by asking questions at annual well-child visits. Overt symptoms include fear related to the trauma such as avoiding the traumatic setting or activity. Less specific symptoms include anxiety, avoidance, social isolation, depression, and low self-esteem.

If a standard screen such as the Pediatric Symptom Checklist or another instrument reveals psychosocial dysfunction, you have to determine the cause of dysfunction, and PTSD should certainly be considered.

Is there family discord leading to violence in the home? If you suspect PTSD, ask a child what happened and why he or she thinks it happened. Determine if the child is blaming himself or herself in any way. Is the child grieving following a permanent injury and/or loss of a loved one? How have the parents discussed any traumatic event with the child? Do the parents feel traumatized by the child's experience?

If PTSD is a possibility, ask if the child is experiencing flashbacks, intrusive thoughts, and/or any related anxiety.

Some symptoms are expected after a traumatic event or following cancer or critical care treatment experienced as traumatic. Most children and adolescents overcome the fear of riding in a car or playing the sport that resulted in the trauma.

However, symptoms that persist for a month or more, with avoidance and associated anxiety, are core to the diagnosis of PTSD. The anxiety can build and be self-reinforcing so as to interfere with daily functioning. At this point, consider referral to a mental health specialist, preferably one with some experience in PTSD treatment. A specialist can help the patient overcome his or her anxiety and return to functioning through cognitive and behavioral techniques such as reframing the events, dealing with any guilt, and staged exposure to the anxiety.

If one of your patients experienced a car crash or other major trauma, you will likely know about it, already be treating the child, and should be planning to monitor them for signs of PTSD. In contrast, detection of subtle PTSD is more challenging, particularly if the trauma is unknown or occurred years ago. Trauma related to domestic violence or sexual abuse first requires consideration of this possibility and then gentle, empathic, and persistent questioning.

Triggers for reliving/reexperiencing the trauma also can be straightforward. For example, a child who gets into a car with a similar interior design years after a crash can immediately experience and emotionally return to the trauma. Other triggers are less obvious, such as a teenage girl who was held down and forced to have sex against her will, who later feels constrained by tight clothing and immediately relives the fear and anguish.

Like many presentations in pediatrics, management of PTSD depends on the developmental stage of the child, including his or her cognitive abilities and emotional state. For example, infants or toddlers might not be able to make much sense of what is happening when they witness domestic violence. Terror, fear, and confusion are their most likely reactions.

School-age children aged 5–8 years would not fully understand either, but they will try to make some sense of the domestic violence. Assuming no one reassures them otherwise, they also may feel that something they did sparked or contributed to the violence. For example, if they overhear arguments around issues in the family and hear their name mentioned, they may quickly assume that they are the cause of the domestic violence. This can lead to feelings of guilt, self-criticism, and unworthiness.

Adolescents will experience some of the same reactions as younger children. They will still experience shock, even if they are better equipped to conceptualize the domestic violence. Some will feel powerless because they cannot end the strife, particularly at a time when they are supposed to have more control over the real world. Teens might feel they have not lived up to expectations and perceive some blame. Others may choose to flee, find support through friends, and/or may deal with their feelings using substances.

Act when you encounter a patient who feels very guilty about parental fighting or who justifies abuse because he feels worthless or was told repeatedly he was a bad child. Help him realize he was not responsible for the conflict and that no one deserves abuse. Discuss other, more realistic possibilities for the family paradigm.

These are not easy conversations. Some pediatricians will feel comfortable working at this depth, others will prefer to refer.

Healing from PTSD related to family violence, sexual abuse, or criminal activity is a several-step process. As one's sense of guilt diminishes, other emotions such as anger at not being better protected or valued need to be addressed. Finally, there needs to be some grieving for what was lacking and some acceptance of what was possible. This is not a simple process; however, it is worthwhile because if their PTSD remains untreated, there is a greater likelihood they will continue to relive traumatic memories as adults.

There is some controversy as to whether talking through the traumatic event over and over truly helps. Some clinicians feel that a certain amount of supportive discussion in a calm way makes sense, especially early. But solely repeating the details of the event may re-traumatize the child and intensify negative feelings, especially if the memories are very vivid.

Cognitive and behavioral approaches can help the child reframe their trauma. An example is exposure therapy, where the child is carefully reexposed to the trauma in stages while they learn to reframe and diminish the intensity of the experience. Often, ideas about the trauma come out that can be examined objectively to try to lessen some of those traumatic feelings.

Exposure therapy also can incorporate gradual steps to help the child overcome their fear. If a person survived a plane crash, the first step might be to take him or her to the airport, then to board an airplane without taking off, and so forth. This approach reintroduces the trauma without eliciting a full response. You don't want the brain to go on “red alert” again. In a state of hyperarousal, reliving the trauma may do more harm than good.

The terrified moments that children experience during a traumatic sequence tend to get burned into their memories much more strongly than everyday events. A school-age child might remember nothing about an uneventful trip in the car, but if a traumatic accident happens, often she remembers almost every detail. She recalls descriptive elements of what happened as well as the emotional fright or anguish very vividly.

Sometimes vivid, traumatic memories will enter your patient's mind spontaneously without him knowing why. In other cases, there are triggers. Sometimes these flashbacks arise shortly following trauma and sometimes they take years.

Pediatricians can do their patients and families a service if they are aware of PTSD either after an overt event like a car accident or by considering trauma in an anxious or dysfunctional child.

pdnews@elsevier.com

Different forms of trauma can cause posttraumatic stress disorder in children, whether from an objective event like a car crash or sports injury to trauma involving loved ones, such as domestic violence, abuse, or neglect.

Pediatricians can help by routinely screening for dysfunction and by asking questions at annual well-child visits. Overt symptoms include fear related to the trauma such as avoiding the traumatic setting or activity. Less specific symptoms include anxiety, avoidance, social isolation, depression, and low self-esteem.

If a standard screen such as the Pediatric Symptom Checklist or another instrument reveals psychosocial dysfunction, you have to determine the cause of dysfunction, and PTSD should certainly be considered.

Is there family discord leading to violence in the home? If you suspect PTSD, ask a child what happened and why he or she thinks it happened. Determine if the child is blaming himself or herself in any way. Is the child grieving following a permanent injury and/or loss of a loved one? How have the parents discussed any traumatic event with the child? Do the parents feel traumatized by the child's experience?

If PTSD is a possibility, ask if the child is experiencing flashbacks, intrusive thoughts, and/or any related anxiety.

Some symptoms are expected after a traumatic event or following cancer or critical care treatment experienced as traumatic. Most children and adolescents overcome the fear of riding in a car or playing the sport that resulted in the trauma.

However, symptoms that persist for a month or more, with avoidance and associated anxiety, are core to the diagnosis of PTSD. The anxiety can build and be self-reinforcing so as to interfere with daily functioning. At this point, consider referral to a mental health specialist, preferably one with some experience in PTSD treatment. A specialist can help the patient overcome his or her anxiety and return to functioning through cognitive and behavioral techniques such as reframing the events, dealing with any guilt, and staged exposure to the anxiety.

If one of your patients experienced a car crash or other major trauma, you will likely know about it, already be treating the child, and should be planning to monitor them for signs of PTSD. In contrast, detection of subtle PTSD is more challenging, particularly if the trauma is unknown or occurred years ago. Trauma related to domestic violence or sexual abuse first requires consideration of this possibility and then gentle, empathic, and persistent questioning.

Triggers for reliving/reexperiencing the trauma also can be straightforward. For example, a child who gets into a car with a similar interior design years after a crash can immediately experience and emotionally return to the trauma. Other triggers are less obvious, such as a teenage girl who was held down and forced to have sex against her will, who later feels constrained by tight clothing and immediately relives the fear and anguish.

Like many presentations in pediatrics, management of PTSD depends on the developmental stage of the child, including his or her cognitive abilities and emotional state. For example, infants or toddlers might not be able to make much sense of what is happening when they witness domestic violence. Terror, fear, and confusion are their most likely reactions.

School-age children aged 5–8 years would not fully understand either, but they will try to make some sense of the domestic violence. Assuming no one reassures them otherwise, they also may feel that something they did sparked or contributed to the violence. For example, if they overhear arguments around issues in the family and hear their name mentioned, they may quickly assume that they are the cause of the domestic violence. This can lead to feelings of guilt, self-criticism, and unworthiness.

Adolescents will experience some of the same reactions as younger children. They will still experience shock, even if they are better equipped to conceptualize the domestic violence. Some will feel powerless because they cannot end the strife, particularly at a time when they are supposed to have more control over the real world. Teens might feel they have not lived up to expectations and perceive some blame. Others may choose to flee, find support through friends, and/or may deal with their feelings using substances.

Act when you encounter a patient who feels very guilty about parental fighting or who justifies abuse because he feels worthless or was told repeatedly he was a bad child. Help him realize he was not responsible for the conflict and that no one deserves abuse. Discuss other, more realistic possibilities for the family paradigm.

These are not easy conversations. Some pediatricians will feel comfortable working at this depth, others will prefer to refer.

Healing from PTSD related to family violence, sexual abuse, or criminal activity is a several-step process. As one's sense of guilt diminishes, other emotions such as anger at not being better protected or valued need to be addressed. Finally, there needs to be some grieving for what was lacking and some acceptance of what was possible. This is not a simple process; however, it is worthwhile because if their PTSD remains untreated, there is a greater likelihood they will continue to relive traumatic memories as adults.

There is some controversy as to whether talking through the traumatic event over and over truly helps. Some clinicians feel that a certain amount of supportive discussion in a calm way makes sense, especially early. But solely repeating the details of the event may re-traumatize the child and intensify negative feelings, especially if the memories are very vivid.

Cognitive and behavioral approaches can help the child reframe their trauma. An example is exposure therapy, where the child is carefully reexposed to the trauma in stages while they learn to reframe and diminish the intensity of the experience. Often, ideas about the trauma come out that can be examined objectively to try to lessen some of those traumatic feelings.

Exposure therapy also can incorporate gradual steps to help the child overcome their fear. If a person survived a plane crash, the first step might be to take him or her to the airport, then to board an airplane without taking off, and so forth. This approach reintroduces the trauma without eliciting a full response. You don't want the brain to go on “red alert” again. In a state of hyperarousal, reliving the trauma may do more harm than good.

The terrified moments that children experience during a traumatic sequence tend to get burned into their memories much more strongly than everyday events. A school-age child might remember nothing about an uneventful trip in the car, but if a traumatic accident happens, often she remembers almost every detail. She recalls descriptive elements of what happened as well as the emotional fright or anguish very vividly.

Sometimes vivid, traumatic memories will enter your patient's mind spontaneously without him knowing why. In other cases, there are triggers. Sometimes these flashbacks arise shortly following trauma and sometimes they take years.

Pediatricians can do their patients and families a service if they are aware of PTSD either after an overt event like a car accident or by considering trauma in an anxious or dysfunctional child.

pdnews@elsevier.com

Different forms of trauma can cause posttraumatic stress disorder in children, whether from an objective event like a car crash or sports injury to trauma involving loved ones, such as domestic violence, abuse, or neglect.

Pediatricians can help by routinely screening for dysfunction and by asking questions at annual well-child visits. Overt symptoms include fear related to the trauma such as avoiding the traumatic setting or activity. Less specific symptoms include anxiety, avoidance, social isolation, depression, and low self-esteem.

If a standard screen such as the Pediatric Symptom Checklist or another instrument reveals psychosocial dysfunction, you have to determine the cause of dysfunction, and PTSD should certainly be considered.

Is there family discord leading to violence in the home? If you suspect PTSD, ask a child what happened and why he or she thinks it happened. Determine if the child is blaming himself or herself in any way. Is the child grieving following a permanent injury and/or loss of a loved one? How have the parents discussed any traumatic event with the child? Do the parents feel traumatized by the child's experience?

If PTSD is a possibility, ask if the child is experiencing flashbacks, intrusive thoughts, and/or any related anxiety.

Some symptoms are expected after a traumatic event or following cancer or critical care treatment experienced as traumatic. Most children and adolescents overcome the fear of riding in a car or playing the sport that resulted in the trauma.

However, symptoms that persist for a month or more, with avoidance and associated anxiety, are core to the diagnosis of PTSD. The anxiety can build and be self-reinforcing so as to interfere with daily functioning. At this point, consider referral to a mental health specialist, preferably one with some experience in PTSD treatment. A specialist can help the patient overcome his or her anxiety and return to functioning through cognitive and behavioral techniques such as reframing the events, dealing with any guilt, and staged exposure to the anxiety.

If one of your patients experienced a car crash or other major trauma, you will likely know about it, already be treating the child, and should be planning to monitor them for signs of PTSD. In contrast, detection of subtle PTSD is more challenging, particularly if the trauma is unknown or occurred years ago. Trauma related to domestic violence or sexual abuse first requires consideration of this possibility and then gentle, empathic, and persistent questioning.

Triggers for reliving/reexperiencing the trauma also can be straightforward. For example, a child who gets into a car with a similar interior design years after a crash can immediately experience and emotionally return to the trauma. Other triggers are less obvious, such as a teenage girl who was held down and forced to have sex against her will, who later feels constrained by tight clothing and immediately relives the fear and anguish.

Like many presentations in pediatrics, management of PTSD depends on the developmental stage of the child, including his or her cognitive abilities and emotional state. For example, infants or toddlers might not be able to make much sense of what is happening when they witness domestic violence. Terror, fear, and confusion are their most likely reactions.

School-age children aged 5–8 years would not fully understand either, but they will try to make some sense of the domestic violence. Assuming no one reassures them otherwise, they also may feel that something they did sparked or contributed to the violence. For example, if they overhear arguments around issues in the family and hear their name mentioned, they may quickly assume that they are the cause of the domestic violence. This can lead to feelings of guilt, self-criticism, and unworthiness.

Adolescents will experience some of the same reactions as younger children. They will still experience shock, even if they are better equipped to conceptualize the domestic violence. Some will feel powerless because they cannot end the strife, particularly at a time when they are supposed to have more control over the real world. Teens might feel they have not lived up to expectations and perceive some blame. Others may choose to flee, find support through friends, and/or may deal with their feelings using substances.

Act when you encounter a patient who feels very guilty about parental fighting or who justifies abuse because he feels worthless or was told repeatedly he was a bad child. Help him realize he was not responsible for the conflict and that no one deserves abuse. Discuss other, more realistic possibilities for the family paradigm.

These are not easy conversations. Some pediatricians will feel comfortable working at this depth, others will prefer to refer.

Healing from PTSD related to family violence, sexual abuse, or criminal activity is a several-step process. As one's sense of guilt diminishes, other emotions such as anger at not being better protected or valued need to be addressed. Finally, there needs to be some grieving for what was lacking and some acceptance of what was possible. This is not a simple process; however, it is worthwhile because if their PTSD remains untreated, there is a greater likelihood they will continue to relive traumatic memories as adults.

There is some controversy as to whether talking through the traumatic event over and over truly helps. Some clinicians feel that a certain amount of supportive discussion in a calm way makes sense, especially early. But solely repeating the details of the event may re-traumatize the child and intensify negative feelings, especially if the memories are very vivid.

Cognitive and behavioral approaches can help the child reframe their trauma. An example is exposure therapy, where the child is carefully reexposed to the trauma in stages while they learn to reframe and diminish the intensity of the experience. Often, ideas about the trauma come out that can be examined objectively to try to lessen some of those traumatic feelings.

Exposure therapy also can incorporate gradual steps to help the child overcome their fear. If a person survived a plane crash, the first step might be to take him or her to the airport, then to board an airplane without taking off, and so forth. This approach reintroduces the trauma without eliciting a full response. You don't want the brain to go on “red alert” again. In a state of hyperarousal, reliving the trauma may do more harm than good.

The terrified moments that children experience during a traumatic sequence tend to get burned into their memories much more strongly than everyday events. A school-age child might remember nothing about an uneventful trip in the car, but if a traumatic accident happens, often she remembers almost every detail. She recalls descriptive elements of what happened as well as the emotional fright or anguish very vividly.

Sometimes vivid, traumatic memories will enter your patient's mind spontaneously without him knowing why. In other cases, there are triggers. Sometimes these flashbacks arise shortly following trauma and sometimes they take years.

Pediatricians can do their patients and families a service if they are aware of PTSD either after an overt event like a car accident or by considering trauma in an anxious or dysfunctional child.

pdnews@elsevier.com

Adolescent substance use is a big, difficult issue. Alcohol, cigarettes, and marijuana – and to a lesser extent, cocaine – are endemic to most high schools.

It's not at all unusual for high school juniors and seniors to drink or even to binge drink. In addition, about 15%-20% of them smoke cigarettes, depending on the community, and probably more than that try or intermittently smoke marijuana.

One approach is to educate parents about which children may be at higher risk for substance use.

For example, most teenagers are at some risk and need to be watched for any high-risk activities, especially drinking and driving or riding in a car with a friend who has been drinking. If parents begin to see a serious problem – such as binge drinking every weekend, obvious use of marijuana on a regular basis, or obvious use of cocaine – take it very seriously. Talk with patients and parents, and provide a referral for services as indicated.

Other kids might be at slightly higher risk in high school, based on their achievements. A good athlete who joins the varsity team in 9th or 10th grade, or the talented 9th-grader who lands the lead in the high school play, tend to spend more time with juniors and seniors. They get invited to parties and events outside their peer groups. Without the judgment of an older child and while trying to “keep up,” they might be more vulnerable to problematic substance use. The difference between a 14-year-old and a 17-year-old is enormous, and the peer pressure of being with seniors is considerable.

Recognize that some kids start high school already predisposed and at quite high risk for substance use problems: A patient with biologic or genetic risk factors; a patient with untreated depression or anxiety; and/or an adolescent with attention-deficit/hyperactivity disorder (ADHD) are examples.

Left unaddressed, these kids are predisposed to earlier and more serious substance use. Some children with genetic and/or biological risk factors begin drinking heavily before their 14th birthday. In contrast, the typical age of onset for alcohol use includes some experimentation at 15 or 16 years that becomes binge drinking for some a year or two later.

Biology predisposes some adolescents to nicotine addiction or heavy use of marijuana or alcohol. While adolescent brains are in development and experience the expected stress of puberty and building an identity, some teenagers' brains may be more susceptible to addiction than others. In addition, genetics and environment can play a role, evidenced by the higher risks for children whose parents have a personal or family history of substance use problems. If there is a strong history of alcoholism in the family or if a parent is a recovering alcoholic, discuss with parents how their past might influence how they treat their teenager. Advise them what information should be shared to alert the teenager to the potential risks. It might help a child at age 12 or 13 to know that he or she may be especially vulnerable to the dangers of substance use, and this may well open up an avenue of communication and trust that could be helpful later.

Anxiety and depression also have genetic roots in some patients. Asking parents about their family history of substance abuse, depression, or serious mental health disorder should be a routine part of pediatric practice.

In addition, implementing screening tests makes sense in adolescence. Such screening tests are publicly available and reviewed by the American Academy of Pediatrics Bright Futures: Mental Health effort (http://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.htmlwww.aap.org/pcorss/demos/mht.html

Children with ADHD make up another high-risk group. They also seem to be more vulnerable to cigarettes, alcohol, and marijuana. These teenagers can be driven to find relief in these substances because of brain biology and/or secondary to the stress of living with their ADHD symptoms.

On the plus side, ADHD kids treated appropriately with stimulants and support services have lower levels of substance use and probably higher self-esteem. Ensure they have the best treatment possible for their ADHD to minimize their substance use risk as much as possible.

As they become young teenagers, they should have a full review of all their ADHD treatment and how their typical day plays out at school and at home. Consider some additional preventative counseling to help these children face their substance use challenges throughout adolescence.

Offer such guidance to all children and parents, but especially to those in one of these high-risk groups. Suggest strategies that support and reinforce their resiliency. A warm, positive relationship with an adult is a protective factor. Also, kids who feel connected to a school, church, or sports team tend to be a little more resilient to some of these influences.

Facilitate open, honest communication between the parent and adolescent. Many parents might not realize that this is more effective than are attempts to control their teen's behavior 24/7. Over-control is impossible given the lifestyle of most 15-, 16- or 17-year-olds. Between cell phones, cars, and the amount of time they are out of the house, parents cannot control them to a level of stopping all substance use.

Even if more control is possible, the effort works against the adolescent's developmental trajectory toward increasing autonomy. The real goal of adolescence in our culture is to learn how to live in the real world and to prepare for autonomy as young adults. High school is a preparation for college life and adulthood where good judgment, safety, and socialization are important learned behaviors. Teaching adolescents how to navigate all this is an essential role for physicians and parents.

Part of growing autonomy is privacy. While it is tempting to invade that privacy to learn about substance use or to clarify other concerns, it is not clear that such efforts support the long-term goals of raising a teenager. Such efforts at control and investigation, including blood or urine testing, are best reserved when the benefits outweigh the risks, when there is a substance abuse problem that needs to be addressed.

pdnews@elsevier.com

Adolescent substance use is a big, difficult issue. Alcohol, cigarettes, and marijuana – and to a lesser extent, cocaine – are endemic to most high schools.

It's not at all unusual for high school juniors and seniors to drink or even to binge drink. In addition, about 15%-20% of them smoke cigarettes, depending on the community, and probably more than that try or intermittently smoke marijuana.

One approach is to educate parents about which children may be at higher risk for substance use.

For example, most teenagers are at some risk and need to be watched for any high-risk activities, especially drinking and driving or riding in a car with a friend who has been drinking. If parents begin to see a serious problem – such as binge drinking every weekend, obvious use of marijuana on a regular basis, or obvious use of cocaine – take it very seriously. Talk with patients and parents, and provide a referral for services as indicated.

Other kids might be at slightly higher risk in high school, based on their achievements. A good athlete who joins the varsity team in 9th or 10th grade, or the talented 9th-grader who lands the lead in the high school play, tend to spend more time with juniors and seniors. They get invited to parties and events outside their peer groups. Without the judgment of an older child and while trying to “keep up,” they might be more vulnerable to problematic substance use. The difference between a 14-year-old and a 17-year-old is enormous, and the peer pressure of being with seniors is considerable.

Recognize that some kids start high school already predisposed and at quite high risk for substance use problems: A patient with biologic or genetic risk factors; a patient with untreated depression or anxiety; and/or an adolescent with attention-deficit/hyperactivity disorder (ADHD) are examples.

Left unaddressed, these kids are predisposed to earlier and more serious substance use. Some children with genetic and/or biological risk factors begin drinking heavily before their 14th birthday. In contrast, the typical age of onset for alcohol use includes some experimentation at 15 or 16 years that becomes binge drinking for some a year or two later.

Biology predisposes some adolescents to nicotine addiction or heavy use of marijuana or alcohol. While adolescent brains are in development and experience the expected stress of puberty and building an identity, some teenagers' brains may be more susceptible to addiction than others. In addition, genetics and environment can play a role, evidenced by the higher risks for children whose parents have a personal or family history of substance use problems. If there is a strong history of alcoholism in the family or if a parent is a recovering alcoholic, discuss with parents how their past might influence how they treat their teenager. Advise them what information should be shared to alert the teenager to the potential risks. It might help a child at age 12 or 13 to know that he or she may be especially vulnerable to the dangers of substance use, and this may well open up an avenue of communication and trust that could be helpful later.

Anxiety and depression also have genetic roots in some patients. Asking parents about their family history of substance abuse, depression, or serious mental health disorder should be a routine part of pediatric practice.

In addition, implementing screening tests makes sense in adolescence. Such screening tests are publicly available and reviewed by the American Academy of Pediatrics Bright Futures: Mental Health effort (http://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.htmlwww.aap.org/pcorss/demos/mht.html

Children with ADHD make up another high-risk group. They also seem to be more vulnerable to cigarettes, alcohol, and marijuana. These teenagers can be driven to find relief in these substances because of brain biology and/or secondary to the stress of living with their ADHD symptoms.

On the plus side, ADHD kids treated appropriately with stimulants and support services have lower levels of substance use and probably higher self-esteem. Ensure they have the best treatment possible for their ADHD to minimize their substance use risk as much as possible.

As they become young teenagers, they should have a full review of all their ADHD treatment and how their typical day plays out at school and at home. Consider some additional preventative counseling to help these children face their substance use challenges throughout adolescence.

Offer such guidance to all children and parents, but especially to those in one of these high-risk groups. Suggest strategies that support and reinforce their resiliency. A warm, positive relationship with an adult is a protective factor. Also, kids who feel connected to a school, church, or sports team tend to be a little more resilient to some of these influences.

Facilitate open, honest communication between the parent and adolescent. Many parents might not realize that this is more effective than are attempts to control their teen's behavior 24/7. Over-control is impossible given the lifestyle of most 15-, 16- or 17-year-olds. Between cell phones, cars, and the amount of time they are out of the house, parents cannot control them to a level of stopping all substance use.

Even if more control is possible, the effort works against the adolescent's developmental trajectory toward increasing autonomy. The real goal of adolescence in our culture is to learn how to live in the real world and to prepare for autonomy as young adults. High school is a preparation for college life and adulthood where good judgment, safety, and socialization are important learned behaviors. Teaching adolescents how to navigate all this is an essential role for physicians and parents.

Part of growing autonomy is privacy. While it is tempting to invade that privacy to learn about substance use or to clarify other concerns, it is not clear that such efforts support the long-term goals of raising a teenager. Such efforts at control and investigation, including blood or urine testing, are best reserved when the benefits outweigh the risks, when there is a substance abuse problem that needs to be addressed.

pdnews@elsevier.com

Adolescent substance use is a big, difficult issue. Alcohol, cigarettes, and marijuana – and to a lesser extent, cocaine – are endemic to most high schools.

It's not at all unusual for high school juniors and seniors to drink or even to binge drink. In addition, about 15%-20% of them smoke cigarettes, depending on the community, and probably more than that try or intermittently smoke marijuana.

One approach is to educate parents about which children may be at higher risk for substance use.

For example, most teenagers are at some risk and need to be watched for any high-risk activities, especially drinking and driving or riding in a car with a friend who has been drinking. If parents begin to see a serious problem – such as binge drinking every weekend, obvious use of marijuana on a regular basis, or obvious use of cocaine – take it very seriously. Talk with patients and parents, and provide a referral for services as indicated.

Other kids might be at slightly higher risk in high school, based on their achievements. A good athlete who joins the varsity team in 9th or 10th grade, or the talented 9th-grader who lands the lead in the high school play, tend to spend more time with juniors and seniors. They get invited to parties and events outside their peer groups. Without the judgment of an older child and while trying to “keep up,” they might be more vulnerable to problematic substance use. The difference between a 14-year-old and a 17-year-old is enormous, and the peer pressure of being with seniors is considerable.

Recognize that some kids start high school already predisposed and at quite high risk for substance use problems: A patient with biologic or genetic risk factors; a patient with untreated depression or anxiety; and/or an adolescent with attention-deficit/hyperactivity disorder (ADHD) are examples.

Left unaddressed, these kids are predisposed to earlier and more serious substance use. Some children with genetic and/or biological risk factors begin drinking heavily before their 14th birthday. In contrast, the typical age of onset for alcohol use includes some experimentation at 15 or 16 years that becomes binge drinking for some a year or two later.

Biology predisposes some adolescents to nicotine addiction or heavy use of marijuana or alcohol. While adolescent brains are in development and experience the expected stress of puberty and building an identity, some teenagers' brains may be more susceptible to addiction than others. In addition, genetics and environment can play a role, evidenced by the higher risks for children whose parents have a personal or family history of substance use problems. If there is a strong history of alcoholism in the family or if a parent is a recovering alcoholic, discuss with parents how their past might influence how they treat their teenager. Advise them what information should be shared to alert the teenager to the potential risks. It might help a child at age 12 or 13 to know that he or she may be especially vulnerable to the dangers of substance use, and this may well open up an avenue of communication and trust that could be helpful later.

Anxiety and depression also have genetic roots in some patients. Asking parents about their family history of substance abuse, depression, or serious mental health disorder should be a routine part of pediatric practice.

In addition, implementing screening tests makes sense in adolescence. Such screening tests are publicly available and reviewed by the American Academy of Pediatrics Bright Futures: Mental Health effort (http://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.htmlwww.aap.org/pcorss/demos/mht.html

Children with ADHD make up another high-risk group. They also seem to be more vulnerable to cigarettes, alcohol, and marijuana. These teenagers can be driven to find relief in these substances because of brain biology and/or secondary to the stress of living with their ADHD symptoms.

On the plus side, ADHD kids treated appropriately with stimulants and support services have lower levels of substance use and probably higher self-esteem. Ensure they have the best treatment possible for their ADHD to minimize their substance use risk as much as possible.

As they become young teenagers, they should have a full review of all their ADHD treatment and how their typical day plays out at school and at home. Consider some additional preventative counseling to help these children face their substance use challenges throughout adolescence.

Offer such guidance to all children and parents, but especially to those in one of these high-risk groups. Suggest strategies that support and reinforce their resiliency. A warm, positive relationship with an adult is a protective factor. Also, kids who feel connected to a school, church, or sports team tend to be a little more resilient to some of these influences.

Facilitate open, honest communication between the parent and adolescent. Many parents might not realize that this is more effective than are attempts to control their teen's behavior 24/7. Over-control is impossible given the lifestyle of most 15-, 16- or 17-year-olds. Between cell phones, cars, and the amount of time they are out of the house, parents cannot control them to a level of stopping all substance use.

Even if more control is possible, the effort works against the adolescent's developmental trajectory toward increasing autonomy. The real goal of adolescence in our culture is to learn how to live in the real world and to prepare for autonomy as young adults. High school is a preparation for college life and adulthood where good judgment, safety, and socialization are important learned behaviors. Teaching adolescents how to navigate all this is an essential role for physicians and parents.

Part of growing autonomy is privacy. While it is tempting to invade that privacy to learn about substance use or to clarify other concerns, it is not clear that such efforts support the long-term goals of raising a teenager. Such efforts at control and investigation, including blood or urine testing, are best reserved when the benefits outweigh the risks, when there is a substance abuse problem that needs to be addressed.

pdnews@elsevier.com

Divorce is so common in the United States – ending about half of all marriages – that it will affect many patients and families in your practice. If your practice has about 2,000 children and adolescents from about 1,500 families, for example, hundreds of families will be dealing with predivorce marital tension, the divorce itself, or postdivorce concerns.

Start by screening for family functioning at every annual visit. Specifically, try to identify strife and stress early on, at a time when your inventions have the greatest preventive impact. Ask open-ended questions such as, “How are things going in the family?” or “Is there any tension or discord in the family or in the marriage?”

I recommend using the broader term “discord” because it will pick up a pending divorce and also identify other family stressors for the child. For example, research indicates that the years of arguing and fighting that often precede divorce may be more damaging to the child in the long term than the divorce itself.

Once you identify marital or family stress, strive for the following three long-term goals to optimize a healthy outcome for the child.

▸ First, make sure the child continues to function well in school, with peers, in activities, and in areas of self-esteem. The firr certain key signs that a child is not functioning well. Persistently lower school performance is one sign. Most children are't concentrate or perform as well at school in the year of the divorce, but it is a warning sign if the problems persist. Determine whether the child is still having difficulty adjusting to the divorce, and assess if there is ongoing discord or fighting about visitation, custody, child rearing, or finances after the divorce. Another warning sign is the child who drops an after-school activity during a divorce crisis, and fails to retume itin the next school year.

How a child relates to friends after the divorce can be important. In particular, ascertain how young or midadolescents treat members of the opposite sex. Look for patterns in their relationships that repeat some of the dysfunctional behaviors of their parents' marriage. Keep in mind that children are often unaware that they are repeating these family patterns.

For example, are girls who are adversely affected by divorce especially vulnerable to getting involved with older teenagers who might take advantage of them? Do you see any evidence of longing in the girls, or signs that they are seeking to replace something missing in their paternal relationship? This type of behavior is much less likely if the girl has had a good relationship with her father before, during, and after the divorce.

With teenage boys, consider how they treat their girlfriends. Is the boy supportive in his relationships, or does he have girlfriend after girlfriend because of a callous or insensitive attitude?

Referral for a mental health evaluation might be appropriate if you see a pattern of continuing dysfunction in a major area of the child's life or of unsatisfactory relationships as these younger teenagers enter high school, particularly if they are alienated from a parent.

▸ Second, ensure that parents are open and willing to answer the child's questions as the child tries to make sense of the divorce at each developmental stage. Help postdivorce families encourage the child to ask questions on an ongoing basis. If divorce happened when the child was a toddler, for example, they are going to have questions 5, 10, and 15 years later that they could not conceptualize until they reached the appropriate developmental point.

Parents may need your advice on how best to talk to their 5- or 8-year-old, a time when information should be concrete and straightforward. In contrast, a 14-year-old may be able to understand more conceptual and nuanced answers to their questions. For example, a younger child is unlikely to think about the divorce in terms of an extramarital affair or the impact on their college finances, but that may not be the case when the child is 14 or 15 years old. Keep in mind that many adolescents do not ask parents such difficult questions unless they are given permission in advance, and it's at a time when they feel safe and at ease.

▸ Third, counsel the family to facilitate a good relationship between the child and each parent over the long term. When families come to me and there is a lot of tension about visitation, custody, and money, I often focus them on the long-term goals. I ask, “What kind of relationship do you want with your child 10 and 15 years from now?”; “What is likely to result in a good long-term relationship with them?”; “Do you want to be able to be at their wedding?”; “Do you want to be close to your grandchildren?” Going all out for an extra few hours of visitation or not paying a bill is not likely to help achieve these long-term goals.

Again, early screening and intervention make your job easier. If a patient or family comes to you after years of negativity and a court fight over a bitter divorce, your ability to intervene effectively is already very limited.

Divorce is often an angry and divisive time. You can advise parents not to act out of anger by offering examples of divorcing parents who invested a lot of time and energy into winning short-term victories, only to see their efforts backfire later. Some parents believe that the child will be closer to them if they can make the child angry at the spouse. But children who feel they have to betray one parent to please the other often become resentful of this role over time.

In contrast, children who observe their parents working together with a sense of harmony and cooperation to make the custody, visitation, financial, and other arrangements successful are much less likely to blame themselves for the divorce. They also are much less likely to feel guilty when they connect more to one parent or the other at different points in their development.

It is important to monitor your patients for long-term effects of divorce up to and including the time you transition them to an adult care provider. Ask the older adolescent questions such as, “How do you feel about the divorce now, looking back on it [5, 10, or 15] years later?”; “How do you think it's affected you?”; and “Are there any things you'd like to change?”

If you do a review of how they integrated the divorce when they are in 10th or 11th grade, you will still have time to address any unresolved issues. If the child is distant with one parent, you can at least wonder if this is a point in time to reconnect and repair that relationship before the teenager goes to work or college and moves to being fully independent.

Pediatricians often have limited time to intervene. Some find this work very gratifying and feel comfortable with divorce-related issues. Others may choose to refer the patient to a social worker, psychologist, or child and adolescent psychiatrist, according to the severity of the situation. Some pediatric practices are fortunate to have a full- or part-time social worker.

If you want to counsel but your time is limited, consider offering a divorced-parent discussion and education group in your practice. You and/or a social worker could facilitate this forum. This resource can help parents share their experiences and strategies to ensure that children emerge as happy and healthy as possible after a divorce. In addition, this intervention can be cost-neutral if you charge parents a nominal fee.

pdnews@elsevier.com

Divorce is so common in the United States – ending about half of all marriages – that it will affect many patients and families in your practice. If your practice has about 2,000 children and adolescents from about 1,500 families, for example, hundreds of families will be dealing with predivorce marital tension, the divorce itself, or postdivorce concerns.

Start by screening for family functioning at every annual visit. Specifically, try to identify strife and stress early on, at a time when your inventions have the greatest preventive impact. Ask open-ended questions such as, “How are things going in the family?” or “Is there any tension or discord in the family or in the marriage?”

I recommend using the broader term “discord” because it will pick up a pending divorce and also identify other family stressors for the child. For example, research indicates that the years of arguing and fighting that often precede divorce may be more damaging to the child in the long term than the divorce itself.

Once you identify marital or family stress, strive for the following three long-term goals to optimize a healthy outcome for the child.

▸ First, make sure the child continues to function well in school, with peers, in activities, and in areas of self-esteem. The firr certain key signs that a child is not functioning well. Persistently lower school performance is one sign. Most children are't concentrate or perform as well at school in the year of the divorce, but it is a warning sign if the problems persist. Determine whether the child is still having difficulty adjusting to the divorce, and assess if there is ongoing discord or fighting about visitation, custody, child rearing, or finances after the divorce. Another warning sign is the child who drops an after-school activity during a divorce crisis, and fails to retume itin the next school year.

How a child relates to friends after the divorce can be important. In particular, ascertain how young or midadolescents treat members of the opposite sex. Look for patterns in their relationships that repeat some of the dysfunctional behaviors of their parents' marriage. Keep in mind that children are often unaware that they are repeating these family patterns.

For example, are girls who are adversely affected by divorce especially vulnerable to getting involved with older teenagers who might take advantage of them? Do you see any evidence of longing in the girls, or signs that they are seeking to replace something missing in their paternal relationship? This type of behavior is much less likely if the girl has had a good relationship with her father before, during, and after the divorce.

With teenage boys, consider how they treat their girlfriends. Is the boy supportive in his relationships, or does he have girlfriend after girlfriend because of a callous or insensitive attitude?

Referral for a mental health evaluation might be appropriate if you see a pattern of continuing dysfunction in a major area of the child's life or of unsatisfactory relationships as these younger teenagers enter high school, particularly if they are alienated from a parent.

▸ Second, ensure that parents are open and willing to answer the child's questions as the child tries to make sense of the divorce at each developmental stage. Help postdivorce families encourage the child to ask questions on an ongoing basis. If divorce happened when the child was a toddler, for example, they are going to have questions 5, 10, and 15 years later that they could not conceptualize until they reached the appropriate developmental point.

Parents may need your advice on how best to talk to their 5- or 8-year-old, a time when information should be concrete and straightforward. In contrast, a 14-year-old may be able to understand more conceptual and nuanced answers to their questions. For example, a younger child is unlikely to think about the divorce in terms of an extramarital affair or the impact on their college finances, but that may not be the case when the child is 14 or 15 years old. Keep in mind that many adolescents do not ask parents such difficult questions unless they are given permission in advance, and it's at a time when they feel safe and at ease.

▸ Third, counsel the family to facilitate a good relationship between the child and each parent over the long term. When families come to me and there is a lot of tension about visitation, custody, and money, I often focus them on the long-term goals. I ask, “What kind of relationship do you want with your child 10 and 15 years from now?”; “What is likely to result in a good long-term relationship with them?”; “Do you want to be able to be at their wedding?”; “Do you want to be close to your grandchildren?” Going all out for an extra few hours of visitation or not paying a bill is not likely to help achieve these long-term goals.

Again, early screening and intervention make your job easier. If a patient or family comes to you after years of negativity and a court fight over a bitter divorce, your ability to intervene effectively is already very limited.

Divorce is often an angry and divisive time. You can advise parents not to act out of anger by offering examples of divorcing parents who invested a lot of time and energy into winning short-term victories, only to see their efforts backfire later. Some parents believe that the child will be closer to them if they can make the child angry at the spouse. But children who feel they have to betray one parent to please the other often become resentful of this role over time.

In contrast, children who observe their parents working together with a sense of harmony and cooperation to make the custody, visitation, financial, and other arrangements successful are much less likely to blame themselves for the divorce. They also are much less likely to feel guilty when they connect more to one parent or the other at different points in their development.

It is important to monitor your patients for long-term effects of divorce up to and including the time you transition them to an adult care provider. Ask the older adolescent questions such as, “How do you feel about the divorce now, looking back on it [5, 10, or 15] years later?”; “How do you think it's affected you?”; and “Are there any things you'd like to change?”

If you do a review of how they integrated the divorce when they are in 10th or 11th grade, you will still have time to address any unresolved issues. If the child is distant with one parent, you can at least wonder if this is a point in time to reconnect and repair that relationship before the teenager goes to work or college and moves to being fully independent.

Pediatricians often have limited time to intervene. Some find this work very gratifying and feel comfortable with divorce-related issues. Others may choose to refer the patient to a social worker, psychologist, or child and adolescent psychiatrist, according to the severity of the situation. Some pediatric practices are fortunate to have a full- or part-time social worker.

If you want to counsel but your time is limited, consider offering a divorced-parent discussion and education group in your practice. You and/or a social worker could facilitate this forum. This resource can help parents share their experiences and strategies to ensure that children emerge as happy and healthy as possible after a divorce. In addition, this intervention can be cost-neutral if you charge parents a nominal fee.

pdnews@elsevier.com

Divorce is so common in the United States – ending about half of all marriages – that it will affect many patients and families in your practice. If your practice has about 2,000 children and adolescents from about 1,500 families, for example, hundreds of families will be dealing with predivorce marital tension, the divorce itself, or postdivorce concerns.

Start by screening for family functioning at every annual visit. Specifically, try to identify strife and stress early on, at a time when your inventions have the greatest preventive impact. Ask open-ended questions such as, “How are things going in the family?” or “Is there any tension or discord in the family or in the marriage?”

I recommend using the broader term “discord” because it will pick up a pending divorce and also identify other family stressors for the child. For example, research indicates that the years of arguing and fighting that often precede divorce may be more damaging to the child in the long term than the divorce itself.

Once you identify marital or family stress, strive for the following three long-term goals to optimize a healthy outcome for the child.

▸ First, make sure the child continues to function well in school, with peers, in activities, and in areas of self-esteem. The firr certain key signs that a child is not functioning well. Persistently lower school performance is one sign. Most children are't concentrate or perform as well at school in the year of the divorce, but it is a warning sign if the problems persist. Determine whether the child is still having difficulty adjusting to the divorce, and assess if there is ongoing discord or fighting about visitation, custody, child rearing, or finances after the divorce. Another warning sign is the child who drops an after-school activity during a divorce crisis, and fails to retume itin the next school year.

How a child relates to friends after the divorce can be important. In particular, ascertain how young or midadolescents treat members of the opposite sex. Look for patterns in their relationships that repeat some of the dysfunctional behaviors of their parents' marriage. Keep in mind that children are often unaware that they are repeating these family patterns.

For example, are girls who are adversely affected by divorce especially vulnerable to getting involved with older teenagers who might take advantage of them? Do you see any evidence of longing in the girls, or signs that they are seeking to replace something missing in their paternal relationship? This type of behavior is much less likely if the girl has had a good relationship with her father before, during, and after the divorce.

With teenage boys, consider how they treat their girlfriends. Is the boy supportive in his relationships, or does he have girlfriend after girlfriend because of a callous or insensitive attitude?

Referral for a mental health evaluation might be appropriate if you see a pattern of continuing dysfunction in a major area of the child's life or of unsatisfactory relationships as these younger teenagers enter high school, particularly if they are alienated from a parent.

▸ Second, ensure that parents are open and willing to answer the child's questions as the child tries to make sense of the divorce at each developmental stage. Help postdivorce families encourage the child to ask questions on an ongoing basis. If divorce happened when the child was a toddler, for example, they are going to have questions 5, 10, and 15 years later that they could not conceptualize until they reached the appropriate developmental point.

Parents may need your advice on how best to talk to their 5- or 8-year-old, a time when information should be concrete and straightforward. In contrast, a 14-year-old may be able to understand more conceptual and nuanced answers to their questions. For example, a younger child is unlikely to think about the divorce in terms of an extramarital affair or the impact on their college finances, but that may not be the case when the child is 14 or 15 years old. Keep in mind that many adolescents do not ask parents such difficult questions unless they are given permission in advance, and it's at a time when they feel safe and at ease.

▸ Third, counsel the family to facilitate a good relationship between the child and each parent over the long term. When families come to me and there is a lot of tension about visitation, custody, and money, I often focus them on the long-term goals. I ask, “What kind of relationship do you want with your child 10 and 15 years from now?”; “What is likely to result in a good long-term relationship with them?”; “Do you want to be able to be at their wedding?”; “Do you want to be close to your grandchildren?” Going all out for an extra few hours of visitation or not paying a bill is not likely to help achieve these long-term goals.

Again, early screening and intervention make your job easier. If a patient or family comes to you after years of negativity and a court fight over a bitter divorce, your ability to intervene effectively is already very limited.

Divorce is often an angry and divisive time. You can advise parents not to act out of anger by offering examples of divorcing parents who invested a lot of time and energy into winning short-term victories, only to see their efforts backfire later. Some parents believe that the child will be closer to them if they can make the child angry at the spouse. But children who feel they have to betray one parent to please the other often become resentful of this role over time.

In contrast, children who observe their parents working together with a sense of harmony and cooperation to make the custody, visitation, financial, and other arrangements successful are much less likely to blame themselves for the divorce. They also are much less likely to feel guilty when they connect more to one parent or the other at different points in their development.

It is important to monitor your patients for long-term effects of divorce up to and including the time you transition them to an adult care provider. Ask the older adolescent questions such as, “How do you feel about the divorce now, looking back on it [5, 10, or 15] years later?”; “How do you think it's affected you?”; and “Are there any things you'd like to change?”

If you do a review of how they integrated the divorce when they are in 10th or 11th grade, you will still have time to address any unresolved issues. If the child is distant with one parent, you can at least wonder if this is a point in time to reconnect and repair that relationship before the teenager goes to work or college and moves to being fully independent.

Pediatricians often have limited time to intervene. Some find this work very gratifying and feel comfortable with divorce-related issues. Others may choose to refer the patient to a social worker, psychologist, or child and adolescent psychiatrist, according to the severity of the situation. Some pediatric practices are fortunate to have a full- or part-time social worker.

If you want to counsel but your time is limited, consider offering a divorced-parent discussion and education group in your practice. You and/or a social worker could facilitate this forum. This resource can help parents share their experiences and strategies to ensure that children emerge as happy and healthy as possible after a divorce. In addition, this intervention can be cost-neutral if you charge parents a nominal fee.

pdnews@elsevier.com

Stress is nothing new to American families, who—over the generations—have endured wars, epidemics, natural disasters, and numerous economic downturns.

Today's dismal economic climate with continuing unemployment poses real challenges for families.

You should be especially attuned to warning signs that more children in your practice may be at risk for hunger, displacement from their homes and schools, and poverty-associated trauma, both physical and psychological.

The statistics are sobering.

In June 2010, unemployment stood at 14.6 million people, or 9.5% of the working-age population nationwide. Even more people are jobless in some unfortunate states and cities—more than 14% in Nevada, for instance; 14.5% in Las Vegas, Nev.; and 27.6% in tiny El Centro, Calif.

Homelessness among American families is growing, with 170,000 families seeking shelter in 2009, up from 159,000 the year before, according to the U.S. Department of Housing and Urban Development.

Every 3 months, another 250,000 families' homes enter foreclosure, putting one child in every classroom at risk of losing his or her home, according to the Mortgage Bankers Association. That statistic is so stunning—home foreclosures impacting one child in every classroom—that it bears repeating as it indicates every pediatric practice has more red flags in terms of psychosocial stressors then at any time in most pediatrician's career.

Families, as always, face crises unrelated to the economy as well: illness, marital discord, substance abuse, and intergenerational pressures, but economic downturns increase the prevalence of almost all of the crises on this list.

Poverty is the elephant in the room, exposing children to a host of contributors to an unstable environment that sets the stage for poor academic performance, increased mental health disorders, conduct problems, substance abuse, and difficulties in relationships.

The first red flag raised by a family in economic trouble probably isn't even seen in the examining room, but in your billing department, where reimbursements are likely down and delinquent accounts are likely up.

A family may be unable to produce a copay for a visit, or may have lost health insurance along with mom or dad's job. They may report multiple changes in their address. Mail from your office may be returned as undeliverable.

This is, of course, an economic problem for you and your practice, but it likely heralds medical and psychosocial problems as well. A child whose family cannot pay for your services may be twice as likely as a financially secure child to have depression, anxiety, and learning problems at school.

Your office staff may want to alert you to financial red flags not only as they appear on the office balance sheet, but as they relate to your care of the child as well.

Moving, for example, has many implications for a child's development and well-being.

A new address may mean changes in a child's school and after-school activities, the loss of friends and close access to extended family members, and a shattering of the security of familiar places and routines. If the move was involuntary, say, a forced exit from a foreclosed home, parents may be so distracted and emotionally spent, they may not have devoted time to calmly explaining to the child what will change and what will stay the same.

I always think it's a good idea, but especially so in hard times, for you to ask one screening question of every family during routine office visits.

That bushel basket question is, “Are there any ongoing tensions affecting the family?”

Answers can potentially cover a lot of ground, and may open the door to a family sharing financial concerns, as well as any other issues that may be troubling them: a recent move, concern about a family member, or signs of domestic strife.

Red flags may appear during your examination as well. Immunizations may not be up to date, problems are suddenly arising at school, or a there may be a change in trajectory of the child's weight curve due to a lack of nutritious food.

Fatigue and stress associated with family troubles may be cloaked in somatic diagnoses: headaches, stomachaches, chest pain, weakness, or dizziness in a child who never had such complaints before or where these symptoms previously have signaled stress.

Take a good look at the parent accompanying your patient as well. Does the mother or father seem more withdrawn, sadder, or more anxious than expected?

Often, you have an internal red flag, a vaguely unsettled feeling that something is not right. Do not underestimate the value of this clinical sixth sense. Listen to it. It may not be anything specific that you can put your finger on or diagnose, but if you're getting that signal from within, sit down and take the pulse of the family in these troubling times.

pdnews@elsevier.com

Stress is nothing new to American families, who—over the generations—have endured wars, epidemics, natural disasters, and numerous economic downturns.

Today's dismal economic climate with continuing unemployment poses real challenges for families.

You should be especially attuned to warning signs that more children in your practice may be at risk for hunger, displacement from their homes and schools, and poverty-associated trauma, both physical and psychological.

The statistics are sobering.

In June 2010, unemployment stood at 14.6 million people, or 9.5% of the working-age population nationwide. Even more people are jobless in some unfortunate states and cities—more than 14% in Nevada, for instance; 14.5% in Las Vegas, Nev.; and 27.6% in tiny El Centro, Calif.

Homelessness among American families is growing, with 170,000 families seeking shelter in 2009, up from 159,000 the year before, according to the U.S. Department of Housing and Urban Development.

Every 3 months, another 250,000 families' homes enter foreclosure, putting one child in every classroom at risk of losing his or her home, according to the Mortgage Bankers Association. That statistic is so stunning—home foreclosures impacting one child in every classroom—that it bears repeating as it indicates every pediatric practice has more red flags in terms of psychosocial stressors then at any time in most pediatrician's career.

Families, as always, face crises unrelated to the economy as well: illness, marital discord, substance abuse, and intergenerational pressures, but economic downturns increase the prevalence of almost all of the crises on this list.

Poverty is the elephant in the room, exposing children to a host of contributors to an unstable environment that sets the stage for poor academic performance, increased mental health disorders, conduct problems, substance abuse, and difficulties in relationships.

The first red flag raised by a family in economic trouble probably isn't even seen in the examining room, but in your billing department, where reimbursements are likely down and delinquent accounts are likely up.

A family may be unable to produce a copay for a visit, or may have lost health insurance along with mom or dad's job. They may report multiple changes in their address. Mail from your office may be returned as undeliverable.

This is, of course, an economic problem for you and your practice, but it likely heralds medical and psychosocial problems as well. A child whose family cannot pay for your services may be twice as likely as a financially secure child to have depression, anxiety, and learning problems at school.

Your office staff may want to alert you to financial red flags not only as they appear on the office balance sheet, but as they relate to your care of the child as well.

Moving, for example, has many implications for a child's development and well-being.

A new address may mean changes in a child's school and after-school activities, the loss of friends and close access to extended family members, and a shattering of the security of familiar places and routines. If the move was involuntary, say, a forced exit from a foreclosed home, parents may be so distracted and emotionally spent, they may not have devoted time to calmly explaining to the child what will change and what will stay the same.

I always think it's a good idea, but especially so in hard times, for you to ask one screening question of every family during routine office visits.

That bushel basket question is, “Are there any ongoing tensions affecting the family?”

Answers can potentially cover a lot of ground, and may open the door to a family sharing financial concerns, as well as any other issues that may be troubling them: a recent move, concern about a family member, or signs of domestic strife.

Red flags may appear during your examination as well. Immunizations may not be up to date, problems are suddenly arising at school, or a there may be a change in trajectory of the child's weight curve due to a lack of nutritious food.

Fatigue and stress associated with family troubles may be cloaked in somatic diagnoses: headaches, stomachaches, chest pain, weakness, or dizziness in a child who never had such complaints before or where these symptoms previously have signaled stress.

Take a good look at the parent accompanying your patient as well. Does the mother or father seem more withdrawn, sadder, or more anxious than expected?

Often, you have an internal red flag, a vaguely unsettled feeling that something is not right. Do not underestimate the value of this clinical sixth sense. Listen to it. It may not be anything specific that you can put your finger on or diagnose, but if you're getting that signal from within, sit down and take the pulse of the family in these troubling times.

pdnews@elsevier.com

Stress is nothing new to American families, who—over the generations—have endured wars, epidemics, natural disasters, and numerous economic downturns.

Today's dismal economic climate with continuing unemployment poses real challenges for families.

You should be especially attuned to warning signs that more children in your practice may be at risk for hunger, displacement from their homes and schools, and poverty-associated trauma, both physical and psychological.

The statistics are sobering.

In June 2010, unemployment stood at 14.6 million people, or 9.5% of the working-age population nationwide. Even more people are jobless in some unfortunate states and cities—more than 14% in Nevada, for instance; 14.5% in Las Vegas, Nev.; and 27.6% in tiny El Centro, Calif.

Homelessness among American families is growing, with 170,000 families seeking shelter in 2009, up from 159,000 the year before, according to the U.S. Department of Housing and Urban Development.

Every 3 months, another 250,000 families' homes enter foreclosure, putting one child in every classroom at risk of losing his or her home, according to the Mortgage Bankers Association. That statistic is so stunning—home foreclosures impacting one child in every classroom—that it bears repeating as it indicates every pediatric practice has more red flags in terms of psychosocial stressors then at any time in most pediatrician's career.

Families, as always, face crises unrelated to the economy as well: illness, marital discord, substance abuse, and intergenerational pressures, but economic downturns increase the prevalence of almost all of the crises on this list.

Poverty is the elephant in the room, exposing children to a host of contributors to an unstable environment that sets the stage for poor academic performance, increased mental health disorders, conduct problems, substance abuse, and difficulties in relationships.

The first red flag raised by a family in economic trouble probably isn't even seen in the examining room, but in your billing department, where reimbursements are likely down and delinquent accounts are likely up.

A family may be unable to produce a copay for a visit, or may have lost health insurance along with mom or dad's job. They may report multiple changes in their address. Mail from your office may be returned as undeliverable.

This is, of course, an economic problem for you and your practice, but it likely heralds medical and psychosocial problems as well. A child whose family cannot pay for your services may be twice as likely as a financially secure child to have depression, anxiety, and learning problems at school.

Your office staff may want to alert you to financial red flags not only as they appear on the office balance sheet, but as they relate to your care of the child as well.

Moving, for example, has many implications for a child's development and well-being.

A new address may mean changes in a child's school and after-school activities, the loss of friends and close access to extended family members, and a shattering of the security of familiar places and routines. If the move was involuntary, say, a forced exit from a foreclosed home, parents may be so distracted and emotionally spent, they may not have devoted time to calmly explaining to the child what will change and what will stay the same.

I always think it's a good idea, but especially so in hard times, for you to ask one screening question of every family during routine office visits.

That bushel basket question is, “Are there any ongoing tensions affecting the family?”

Answers can potentially cover a lot of ground, and may open the door to a family sharing financial concerns, as well as any other issues that may be troubling them: a recent move, concern about a family member, or signs of domestic strife.

Red flags may appear during your examination as well. Immunizations may not be up to date, problems are suddenly arising at school, or a there may be a change in trajectory of the child's weight curve due to a lack of nutritious food.

Fatigue and stress associated with family troubles may be cloaked in somatic diagnoses: headaches, stomachaches, chest pain, weakness, or dizziness in a child who never had such complaints before or where these symptoms previously have signaled stress.

Take a good look at the parent accompanying your patient as well. Does the mother or father seem more withdrawn, sadder, or more anxious than expected?

Often, you have an internal red flag, a vaguely unsettled feeling that something is not right. Do not underestimate the value of this clinical sixth sense. Listen to it. It may not be anything specific that you can put your finger on or diagnose, but if you're getting that signal from within, sit down and take the pulse of the family in these troubling times.