Michael S. Jellinek, MD

As your patients return to your offices for annual exams and sports physicals before the school year starts, everyone will still be processing the challenges, losses, and grief that have marked end of the COVID experience. There will be questions about the safety of vaccines for younger children, whether foreign travel is now a reasonable option, and about how best to help children – school age and teenagers, vulnerable and secure – get their footing socially and academically in the new school year. But dig a little, and you may hear about the silver linings of this past year: children who enjoyed having more time with their parents, parents who were with their families rather than in a car commuting for hours a day or traveling many days a month, grocery deliveries that eased the parent’s workload, adolescents who were able to pull back from overscheduled days, and opportunities for calm conversations that occurred quite naturally during nightly family dinners. Office visits present a dual opportunity to review – what were the psychological costs of COVID and what were positive personal and family adaptations to COVID they may want to continue as the pandemic ends?

Family dinner: Whether because sports practice was suspended, schooling was virtual, or working was at home, many families returned to eating dinner together during the pandemic year. Nightly dinners are a simple but powerful routine allowing all members of a family to reconnect and recharge together, and they are often the first things to disappear in the face of school, sports, and work demands. Research over the past several decades has demonstrated that regular family dinners are associated with better academic performance and higher self-esteem in children. They are also associated with lower rates of depression, substance abuse, eating disorders, and pregnancy in adolescents. Finally, they are associated with better cardiovascular health and lower rates of obesity in both youth and parents. The response is dose dependent, with more regular dinners leading to better outcomes. The food can be simple, what matters most is that the tone is warm, sharing, and curious, not rigid and controlling. Families can be an essential source of support as they help put events and feelings into context, giving them meaning or a framework based on the parents’ past, values, or perspective and on the family’s cultural history. Everyone benefits as family members cope with small and large setbacks, share values, and celebrate one another’s small and large successes. The return of the family dinner table, as often as is reasonable, is one “consequence” of COVID that families should try to preserve.

Consistent virtual family visits: Many families managed the cancellation of holiday visits or supported elderly relatives by connecting with family virtually. For some families, a weekly Zoom call came to function like a weekly family dinner with cousins and grandparents. Not only do these regular video calls protect elderly relatives from loneliness and isolation, but they also made it very easy for extended families to stay connected. Children cannot have too many caring adults around them, and regular calls mean that aunts, uncles, and grandparents can be an enthusiastic audience for their achievements and can offer perspective and guidance when needed. Staying connected without having to manage hours of travel makes it easy to build and maintain these family connections, creating bonds that will be deeper and stronger. Like family dinner, regular virtual gatherings with extended family are unequivocally beneficial for younger and older children and a valuable legacy of COVID.

Lowering the pressure: Many children struggled to stay engaged with virtual school and deeply missed time with friends or in activities like woodshop, soccer, or theater. But many other children had a chance to slow down from a relentless schedule of school, homework, sports, clubs, music lessons, tutoring, and on and on. For these children, many of whom are intensely ambitious and were not willing to voluntarily give up any activities, the forced slowdown of COVID has offered a new perspective on how they might manage their time. The COVID slowdown shone a light on the value of spending enough time in an activity to really learn it, and then choosing which activities to continue to explore and master, while opening time to explore new activities. There was also more time for “senseless fun,” activities that do not lead to achievement or recognition, but are simply fun, e.g., playing video games, splashing in a pool, or surfing the web. This process is critical to healthy development in early and later adolescence, and for many driven teenagers, it has been replaced by a tightly packed schedule of activities they felt they “should” be doing. If these young people hear from you that not only does the COVID pace feel better, but it can also contribute to better health and more meaningful learning and engagement, they may adopt a more thoughtful and intentional approach to managing their most precious asset – their time. Your discussion about prioritizing healthy exercise, virtual visits with friends, hobbies, or even senseless fun might reset the pressure gauge from high to moderate.

Homework help: Many children (and teenagers) found that their parents became an important source of academic support during the year of virtual school. While few parents welcomed the chance to master calculus, it is powerful for parents to know what their children are facing at school and for children to know that their parents are available to help them when they face a challenge. When parents can bear uncertainty, frustration, and even failure alongside their children, they help their children to cultivate tenacity and resilience, whether or not they can help them with a chemistry problem. Some parents will have special skills like knowing a language, being a good writer, or an academic expertise related to their work. But what matters more is working out how to help, not pressure or argue – how to share knowledge in a pleasurable manner. While it is important for children to have access to teachers and tutors with the knowledge and skills to help them learn specific subjects, the positive presence and involvement of their parents can make a valuable contribution to their psychological and educational development.

New ritual: Over the past 16 months, families found many creative ways to pass time together, from evening walks to reading aloud, listening to music, and even mastering new card games. The family evenings of a century earlier, when family members listened together to radio programs, practiced music, or played board games, seemed to have returned. While everyone could still escape to their own space to be on a screen activity alone, solitary computer time was leavened by collective time. Families may have rediscovered joy in shared recreation, exploration, or diversion. This kind of family time is a reward in itself, but it also deepens a child’s connections to everyone in their family. Such time provides lessons in how to turn boredom into something meaningful and even fun. COVID forced families inward and gave them more time. There were many costs including illness, deaths of friends and relatives, loss of time with peers, missed activities and milestones, and an impaired education. However, many of the coerced adaptations had a silver lining or unanticipated benefit. Keeping some of those benefits post COVID could enhance the lives of every member of the family.

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

As your patients return to your offices for annual exams and sports physicals before the school year starts, everyone will still be processing the challenges, losses, and grief that have marked end of the COVID experience. There will be questions about the safety of vaccines for younger children, whether foreign travel is now a reasonable option, and about how best to help children – school age and teenagers, vulnerable and secure – get their footing socially and academically in the new school year. But dig a little, and you may hear about the silver linings of this past year: children who enjoyed having more time with their parents, parents who were with their families rather than in a car commuting for hours a day or traveling many days a month, grocery deliveries that eased the parent’s workload, adolescents who were able to pull back from overscheduled days, and opportunities for calm conversations that occurred quite naturally during nightly family dinners. Office visits present a dual opportunity to review – what were the psychological costs of COVID and what were positive personal and family adaptations to COVID they may want to continue as the pandemic ends?

Family dinner: Whether because sports practice was suspended, schooling was virtual, or working was at home, many families returned to eating dinner together during the pandemic year. Nightly dinners are a simple but powerful routine allowing all members of a family to reconnect and recharge together, and they are often the first things to disappear in the face of school, sports, and work demands. Research over the past several decades has demonstrated that regular family dinners are associated with better academic performance and higher self-esteem in children. They are also associated with lower rates of depression, substance abuse, eating disorders, and pregnancy in adolescents. Finally, they are associated with better cardiovascular health and lower rates of obesity in both youth and parents. The response is dose dependent, with more regular dinners leading to better outcomes. The food can be simple, what matters most is that the tone is warm, sharing, and curious, not rigid and controlling. Families can be an essential source of support as they help put events and feelings into context, giving them meaning or a framework based on the parents’ past, values, or perspective and on the family’s cultural history. Everyone benefits as family members cope with small and large setbacks, share values, and celebrate one another’s small and large successes. The return of the family dinner table, as often as is reasonable, is one “consequence” of COVID that families should try to preserve.

Consistent virtual family visits: Many families managed the cancellation of holiday visits or supported elderly relatives by connecting with family virtually. For some families, a weekly Zoom call came to function like a weekly family dinner with cousins and grandparents. Not only do these regular video calls protect elderly relatives from loneliness and isolation, but they also made it very easy for extended families to stay connected. Children cannot have too many caring adults around them, and regular calls mean that aunts, uncles, and grandparents can be an enthusiastic audience for their achievements and can offer perspective and guidance when needed. Staying connected without having to manage hours of travel makes it easy to build and maintain these family connections, creating bonds that will be deeper and stronger. Like family dinner, regular virtual gatherings with extended family are unequivocally beneficial for younger and older children and a valuable legacy of COVID.

Lowering the pressure: Many children struggled to stay engaged with virtual school and deeply missed time with friends or in activities like woodshop, soccer, or theater. But many other children had a chance to slow down from a relentless schedule of school, homework, sports, clubs, music lessons, tutoring, and on and on. For these children, many of whom are intensely ambitious and were not willing to voluntarily give up any activities, the forced slowdown of COVID has offered a new perspective on how they might manage their time. The COVID slowdown shone a light on the value of spending enough time in an activity to really learn it, and then choosing which activities to continue to explore and master, while opening time to explore new activities. There was also more time for “senseless fun,” activities that do not lead to achievement or recognition, but are simply fun, e.g., playing video games, splashing in a pool, or surfing the web. This process is critical to healthy development in early and later adolescence, and for many driven teenagers, it has been replaced by a tightly packed schedule of activities they felt they “should” be doing. If these young people hear from you that not only does the COVID pace feel better, but it can also contribute to better health and more meaningful learning and engagement, they may adopt a more thoughtful and intentional approach to managing their most precious asset – their time. Your discussion about prioritizing healthy exercise, virtual visits with friends, hobbies, or even senseless fun might reset the pressure gauge from high to moderate.

Homework help: Many children (and teenagers) found that their parents became an important source of academic support during the year of virtual school. While few parents welcomed the chance to master calculus, it is powerful for parents to know what their children are facing at school and for children to know that their parents are available to help them when they face a challenge. When parents can bear uncertainty, frustration, and even failure alongside their children, they help their children to cultivate tenacity and resilience, whether or not they can help them with a chemistry problem. Some parents will have special skills like knowing a language, being a good writer, or an academic expertise related to their work. But what matters more is working out how to help, not pressure or argue – how to share knowledge in a pleasurable manner. While it is important for children to have access to teachers and tutors with the knowledge and skills to help them learn specific subjects, the positive presence and involvement of their parents can make a valuable contribution to their psychological and educational development.

New ritual: Over the past 16 months, families found many creative ways to pass time together, from evening walks to reading aloud, listening to music, and even mastering new card games. The family evenings of a century earlier, when family members listened together to radio programs, practiced music, or played board games, seemed to have returned. While everyone could still escape to their own space to be on a screen activity alone, solitary computer time was leavened by collective time. Families may have rediscovered joy in shared recreation, exploration, or diversion. This kind of family time is a reward in itself, but it also deepens a child’s connections to everyone in their family. Such time provides lessons in how to turn boredom into something meaningful and even fun. COVID forced families inward and gave them more time. There were many costs including illness, deaths of friends and relatives, loss of time with peers, missed activities and milestones, and an impaired education. However, many of the coerced adaptations had a silver lining or unanticipated benefit. Keeping some of those benefits post COVID could enhance the lives of every member of the family.

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

As your patients return to your offices for annual exams and sports physicals before the school year starts, everyone will still be processing the challenges, losses, and grief that have marked end of the COVID experience. There will be questions about the safety of vaccines for younger children, whether foreign travel is now a reasonable option, and about how best to help children – school age and teenagers, vulnerable and secure – get their footing socially and academically in the new school year. But dig a little, and you may hear about the silver linings of this past year: children who enjoyed having more time with their parents, parents who were with their families rather than in a car commuting for hours a day or traveling many days a month, grocery deliveries that eased the parent’s workload, adolescents who were able to pull back from overscheduled days, and opportunities for calm conversations that occurred quite naturally during nightly family dinners. Office visits present a dual opportunity to review – what were the psychological costs of COVID and what were positive personal and family adaptations to COVID they may want to continue as the pandemic ends?

Family dinner: Whether because sports practice was suspended, schooling was virtual, or working was at home, many families returned to eating dinner together during the pandemic year. Nightly dinners are a simple but powerful routine allowing all members of a family to reconnect and recharge together, and they are often the first things to disappear in the face of school, sports, and work demands. Research over the past several decades has demonstrated that regular family dinners are associated with better academic performance and higher self-esteem in children. They are also associated with lower rates of depression, substance abuse, eating disorders, and pregnancy in adolescents. Finally, they are associated with better cardiovascular health and lower rates of obesity in both youth and parents. The response is dose dependent, with more regular dinners leading to better outcomes. The food can be simple, what matters most is that the tone is warm, sharing, and curious, not rigid and controlling. Families can be an essential source of support as they help put events and feelings into context, giving them meaning or a framework based on the parents’ past, values, or perspective and on the family’s cultural history. Everyone benefits as family members cope with small and large setbacks, share values, and celebrate one another’s small and large successes. The return of the family dinner table, as often as is reasonable, is one “consequence” of COVID that families should try to preserve.

Consistent virtual family visits: Many families managed the cancellation of holiday visits or supported elderly relatives by connecting with family virtually. For some families, a weekly Zoom call came to function like a weekly family dinner with cousins and grandparents. Not only do these regular video calls protect elderly relatives from loneliness and isolation, but they also made it very easy for extended families to stay connected. Children cannot have too many caring adults around them, and regular calls mean that aunts, uncles, and grandparents can be an enthusiastic audience for their achievements and can offer perspective and guidance when needed. Staying connected without having to manage hours of travel makes it easy to build and maintain these family connections, creating bonds that will be deeper and stronger. Like family dinner, regular virtual gatherings with extended family are unequivocally beneficial for younger and older children and a valuable legacy of COVID.

Lowering the pressure: Many children struggled to stay engaged with virtual school and deeply missed time with friends or in activities like woodshop, soccer, or theater. But many other children had a chance to slow down from a relentless schedule of school, homework, sports, clubs, music lessons, tutoring, and on and on. For these children, many of whom are intensely ambitious and were not willing to voluntarily give up any activities, the forced slowdown of COVID has offered a new perspective on how they might manage their time. The COVID slowdown shone a light on the value of spending enough time in an activity to really learn it, and then choosing which activities to continue to explore and master, while opening time to explore new activities. There was also more time for “senseless fun,” activities that do not lead to achievement or recognition, but are simply fun, e.g., playing video games, splashing in a pool, or surfing the web. This process is critical to healthy development in early and later adolescence, and for many driven teenagers, it has been replaced by a tightly packed schedule of activities they felt they “should” be doing. If these young people hear from you that not only does the COVID pace feel better, but it can also contribute to better health and more meaningful learning and engagement, they may adopt a more thoughtful and intentional approach to managing their most precious asset – their time. Your discussion about prioritizing healthy exercise, virtual visits with friends, hobbies, or even senseless fun might reset the pressure gauge from high to moderate.

Homework help: Many children (and teenagers) found that their parents became an important source of academic support during the year of virtual school. While few parents welcomed the chance to master calculus, it is powerful for parents to know what their children are facing at school and for children to know that their parents are available to help them when they face a challenge. When parents can bear uncertainty, frustration, and even failure alongside their children, they help their children to cultivate tenacity and resilience, whether or not they can help them with a chemistry problem. Some parents will have special skills like knowing a language, being a good writer, or an academic expertise related to their work. But what matters more is working out how to help, not pressure or argue – how to share knowledge in a pleasurable manner. While it is important for children to have access to teachers and tutors with the knowledge and skills to help them learn specific subjects, the positive presence and involvement of their parents can make a valuable contribution to their psychological and educational development.

New ritual: Over the past 16 months, families found many creative ways to pass time together, from evening walks to reading aloud, listening to music, and even mastering new card games. The family evenings of a century earlier, when family members listened together to radio programs, practiced music, or played board games, seemed to have returned. While everyone could still escape to their own space to be on a screen activity alone, solitary computer time was leavened by collective time. Families may have rediscovered joy in shared recreation, exploration, or diversion. This kind of family time is a reward in itself, but it also deepens a child’s connections to everyone in their family. Such time provides lessons in how to turn boredom into something meaningful and even fun. COVID forced families inward and gave them more time. There were many costs including illness, deaths of friends and relatives, loss of time with peers, missed activities and milestones, and an impaired education. However, many of the coerced adaptations had a silver lining or unanticipated benefit. Keeping some of those benefits post COVID could enhance the lives of every member of the family.

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

Postpartum depression (PPD) is a common and treatable problem affecting over 10% of all pregnant women. Without routine use of a screening questionnaire, many women go undiagnosed and without treatment. The risks of untreated PPD in a new mother are the risks of depression tripled: to her health and to the health of her new infant and their whole family. Although pediatricians treat children, they take care of the whole family. They appreciate their role in offering support and guidance to new parents, and in the case of PPD, they are in a unique position. The American Academy of Pediatrics recognized this when they issued their policy statement, “Incorporating Recognition and Management of Perinatal Depression into Pediatric Practice,” in January 2019. By screening, tracking, and connecting affected mothers to care and services, you can truly provide “two-generational care” for your youngest patients.

PPD affects an estimated one in seven women (13%) globally. In one large retrospective study that looked at the 39 weeks before and after delivery, 15.4% of mothers received a diagnosis of PPD and a second study indicated that 22% of new mothers had depressive symptoms that were persistent for 6 months.¹ The pathways to PPD include prior personal or family history of depression, stressors in the family (connected to social determinants of health), previous miscarriage or serious complications in a previous pregnancy, and sensitivity to hormonal changes. Indeed, PPD is the most common complication of childbirth.² Although as many as half of all women eventually diagnosed with PPD had symptoms during their pregnancy, the misperception that PPD is only post partum leads to it being mistaken for the normal process of adjustment to parenthood. PPD is particularly insidious as new mothers are likely to be silent if they feel shame for not enjoying what they have been told will be a special and happy time, and those around them may mistake symptoms for the normal “baby blues” that will resolve quickly and with routine supports.

Untreated PPD, creates risks for mother, infant, and family as she manages needless suffering during a critical period for her new baby. While depression may remit over months without treatment, suicide is a real risk, and accounts for 20% of postpartum deaths.³ Infants face serious developmental consequences when their mothers are withdrawn and disconnected from them during the first months of life, including impaired social development, physical growth, and cognitive development. This impairment persists. Exposure to maternal depression during infancy is associated with lower IQ, attentional problems, and special educational needs by elementary school,⁴ and is a risk factor for psychiatric illnesses in childhood and adolescence.^5,6 PPD has a broad range of severity, including psychosis that may include paranoia with the rare risk of infanticide. And maternal depression can add to the strains in a vulnerable caregiver relationship that can raise the risk for neglect or abuse of the mother, children, or both.

It is important to note that anxiety is often the presenting problem in perinatal mood disorders, with mothers experiencing intense morbid worries about their infant’s safety and health, and fear of inadequacy, criticism, and even infant removal. These fears may reinforce silence and isolation. But pediatricians are one group that these mothers are most likely to share their anxieties with as they look for reassurance. It can be challenging to distinguish PPD from obsessive-compulsive disorder or PTSD. The critical work of the pediatrician is not specific diagnosis and treatment. Instead, your task is to provide screening and support, to create a safe place to overcome silence and shame.

There are many reliable and valid screening instruments available for depression, but the Edinburgh Postnatal Depression Scale (EDPS) has been specially developed for and tested in this population. It is a 10-item scale that is easy to complete and to score. Scores range from 0 to 30 and a score of 10 is considered a cutoff for depression. It can be used to track symptoms and is free and widely available online and in multiple languages. Ideally, this scale can be administered as part of a previsit, automatically entered into an electronic medical record and given at regular intervals during the infant’s first year of primary care. Some new mothers, especially if they are suffering from depression, may feel anxious about filling this out. It is important that your staff tell them that you screen all new mothers in your practice, and that PPD is common and treatable and the pediatrician’s office is committed to the health of the whole family.

If a new mother screens positive, you might consider yourself to have three tasks: Reassure her that she is a wonderful mother and this is a treatable illness, not a cause for guilt, shame, or alarm; expand her support and decrease her isolation by helping her to communicate with her family; and identify treatment resources for her. Start by being curious about some of her specific worries or feelings, her energy level, feelings of isolation or trouble with sleep. Offer compassion and validation around the pain of these experiences in the midst of so much transition. Only after hearing a little detail about her experience, then you may offer that such feelings are common, but when they are persistent or severe, they often indicate PPD, and that her screening test suggests they do for her. Offer that this form of depression is very treatable, with both pharmacologic and psychotherapy interventions. And if she is resistant, gently offer that treatment will be very protective of her new infant’s physical, social, and cognitive growth and development. Hearing this from a pediatrician is powerful for a new mother, even if depressed. Finally, ask if you might help her bring other important adults in her family into an understanding of this. Could she tell her spouse? Her sister? Her best friend? Perhaps she could bring one of them to the next weekly visit, so you can all speak together. This intervention greatly improves the likelihood of her engaging in treatment, and strong interpersonal connections are therapeutic in and of themselves.

For treatment, the easier your office can make it, the more likely she is to follow up. Identify local resources, perhaps through connected community organizations such as Jewish Family and Children’s Services or through a public program like California’s First Five. Connect with the local obstetric practice, which may already have a referral process in place. If you can connect with her primary care provider, they may take on the referral process or may even have integrated capacity for treatment. Identify strategies that may support her restful sleep, including realistic daily exercise, sharing infant care, and being cautious with caffeine and screen time. Identify ways for her to meet other new mothers or reconnect with friends. Reassure her that easy attachment activities, such as reading a book or singing to her baby can be good for both of them without requiring much energy. This may sound like a daunting task, but the conversation will only take a few minutes. Helping an isolated new parent recognize that their feelings of fear, inadequacy, and guilt are not facts, offering some simple immediate strategies and facilitating a referral can be lifesaving.

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

References

1. Dietz PM et al. Am J Psychiatry. 2007;164(10):1515-20.

2. Hanusa BH et al. J Women’s Health (Larchmt) 2008;17(4):585-96.

3. Lindahl V et al. Arch Womens Ment Health. 2005;8(2):77-87.

4. Hay DF et al. J Child Psychol Psychiatry. 2001;42(7):871-89.

5. Tully EC et al. Am J Psychiatry. 2008:165(9):1148-54.

6. Maternal depression and child development. Paediatr. Child Health 2004;9(8):575-98.

Postpartum depression (PPD) is a common and treatable problem affecting over 10% of all pregnant women. Without routine use of a screening questionnaire, many women go undiagnosed and without treatment. The risks of untreated PPD in a new mother are the risks of depression tripled: to her health and to the health of her new infant and their whole family. Although pediatricians treat children, they take care of the whole family. They appreciate their role in offering support and guidance to new parents, and in the case of PPD, they are in a unique position. The American Academy of Pediatrics recognized this when they issued their policy statement, “Incorporating Recognition and Management of Perinatal Depression into Pediatric Practice,” in January 2019. By screening, tracking, and connecting affected mothers to care and services, you can truly provide “two-generational care” for your youngest patients.

PPD affects an estimated one in seven women (13%) globally. In one large retrospective study that looked at the 39 weeks before and after delivery, 15.4% of mothers received a diagnosis of PPD and a second study indicated that 22% of new mothers had depressive symptoms that were persistent for 6 months.¹ The pathways to PPD include prior personal or family history of depression, stressors in the family (connected to social determinants of health), previous miscarriage or serious complications in a previous pregnancy, and sensitivity to hormonal changes. Indeed, PPD is the most common complication of childbirth.² Although as many as half of all women eventually diagnosed with PPD had symptoms during their pregnancy, the misperception that PPD is only post partum leads to it being mistaken for the normal process of adjustment to parenthood. PPD is particularly insidious as new mothers are likely to be silent if they feel shame for not enjoying what they have been told will be a special and happy time, and those around them may mistake symptoms for the normal “baby blues” that will resolve quickly and with routine supports.

Untreated PPD, creates risks for mother, infant, and family as she manages needless suffering during a critical period for her new baby. While depression may remit over months without treatment, suicide is a real risk, and accounts for 20% of postpartum deaths.³ Infants face serious developmental consequences when their mothers are withdrawn and disconnected from them during the first months of life, including impaired social development, physical growth, and cognitive development. This impairment persists. Exposure to maternal depression during infancy is associated with lower IQ, attentional problems, and special educational needs by elementary school,⁴ and is a risk factor for psychiatric illnesses in childhood and adolescence.^5,6 PPD has a broad range of severity, including psychosis that may include paranoia with the rare risk of infanticide. And maternal depression can add to the strains in a vulnerable caregiver relationship that can raise the risk for neglect or abuse of the mother, children, or both.

It is important to note that anxiety is often the presenting problem in perinatal mood disorders, with mothers experiencing intense morbid worries about their infant’s safety and health, and fear of inadequacy, criticism, and even infant removal. These fears may reinforce silence and isolation. But pediatricians are one group that these mothers are most likely to share their anxieties with as they look for reassurance. It can be challenging to distinguish PPD from obsessive-compulsive disorder or PTSD. The critical work of the pediatrician is not specific diagnosis and treatment. Instead, your task is to provide screening and support, to create a safe place to overcome silence and shame.

There are many reliable and valid screening instruments available for depression, but the Edinburgh Postnatal Depression Scale (EDPS) has been specially developed for and tested in this population. It is a 10-item scale that is easy to complete and to score. Scores range from 0 to 30 and a score of 10 is considered a cutoff for depression. It can be used to track symptoms and is free and widely available online and in multiple languages. Ideally, this scale can be administered as part of a previsit, automatically entered into an electronic medical record and given at regular intervals during the infant’s first year of primary care. Some new mothers, especially if they are suffering from depression, may feel anxious about filling this out. It is important that your staff tell them that you screen all new mothers in your practice, and that PPD is common and treatable and the pediatrician’s office is committed to the health of the whole family.

If a new mother screens positive, you might consider yourself to have three tasks: Reassure her that she is a wonderful mother and this is a treatable illness, not a cause for guilt, shame, or alarm; expand her support and decrease her isolation by helping her to communicate with her family; and identify treatment resources for her. Start by being curious about some of her specific worries or feelings, her energy level, feelings of isolation or trouble with sleep. Offer compassion and validation around the pain of these experiences in the midst of so much transition. Only after hearing a little detail about her experience, then you may offer that such feelings are common, but when they are persistent or severe, they often indicate PPD, and that her screening test suggests they do for her. Offer that this form of depression is very treatable, with both pharmacologic and psychotherapy interventions. And if she is resistant, gently offer that treatment will be very protective of her new infant’s physical, social, and cognitive growth and development. Hearing this from a pediatrician is powerful for a new mother, even if depressed. Finally, ask if you might help her bring other important adults in her family into an understanding of this. Could she tell her spouse? Her sister? Her best friend? Perhaps she could bring one of them to the next weekly visit, so you can all speak together. This intervention greatly improves the likelihood of her engaging in treatment, and strong interpersonal connections are therapeutic in and of themselves.

For treatment, the easier your office can make it, the more likely she is to follow up. Identify local resources, perhaps through connected community organizations such as Jewish Family and Children’s Services or through a public program like California’s First Five. Connect with the local obstetric practice, which may already have a referral process in place. If you can connect with her primary care provider, they may take on the referral process or may even have integrated capacity for treatment. Identify strategies that may support her restful sleep, including realistic daily exercise, sharing infant care, and being cautious with caffeine and screen time. Identify ways for her to meet other new mothers or reconnect with friends. Reassure her that easy attachment activities, such as reading a book or singing to her baby can be good for both of them without requiring much energy. This may sound like a daunting task, but the conversation will only take a few minutes. Helping an isolated new parent recognize that their feelings of fear, inadequacy, and guilt are not facts, offering some simple immediate strategies and facilitating a referral can be lifesaving.

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

References

1. Dietz PM et al. Am J Psychiatry. 2007;164(10):1515-20.

2. Hanusa BH et al. J Women’s Health (Larchmt) 2008;17(4):585-96.

3. Lindahl V et al. Arch Womens Ment Health. 2005;8(2):77-87.

4. Hay DF et al. J Child Psychol Psychiatry. 2001;42(7):871-89.

5. Tully EC et al. Am J Psychiatry. 2008:165(9):1148-54.

6. Maternal depression and child development. Paediatr. Child Health 2004;9(8):575-98.

Postpartum depression (PPD) is a common and treatable problem affecting over 10% of all pregnant women. Without routine use of a screening questionnaire, many women go undiagnosed and without treatment. The risks of untreated PPD in a new mother are the risks of depression tripled: to her health and to the health of her new infant and their whole family. Although pediatricians treat children, they take care of the whole family. They appreciate their role in offering support and guidance to new parents, and in the case of PPD, they are in a unique position. The American Academy of Pediatrics recognized this when they issued their policy statement, “Incorporating Recognition and Management of Perinatal Depression into Pediatric Practice,” in January 2019. By screening, tracking, and connecting affected mothers to care and services, you can truly provide “two-generational care” for your youngest patients.

PPD affects an estimated one in seven women (13%) globally. In one large retrospective study that looked at the 39 weeks before and after delivery, 15.4% of mothers received a diagnosis of PPD and a second study indicated that 22% of new mothers had depressive symptoms that were persistent for 6 months.¹ The pathways to PPD include prior personal or family history of depression, stressors in the family (connected to social determinants of health), previous miscarriage or serious complications in a previous pregnancy, and sensitivity to hormonal changes. Indeed, PPD is the most common complication of childbirth.² Although as many as half of all women eventually diagnosed with PPD had symptoms during their pregnancy, the misperception that PPD is only post partum leads to it being mistaken for the normal process of adjustment to parenthood. PPD is particularly insidious as new mothers are likely to be silent if they feel shame for not enjoying what they have been told will be a special and happy time, and those around them may mistake symptoms for the normal “baby blues” that will resolve quickly and with routine supports.

Untreated PPD, creates risks for mother, infant, and family as she manages needless suffering during a critical period for her new baby. While depression may remit over months without treatment, suicide is a real risk, and accounts for 20% of postpartum deaths.³ Infants face serious developmental consequences when their mothers are withdrawn and disconnected from them during the first months of life, including impaired social development, physical growth, and cognitive development. This impairment persists. Exposure to maternal depression during infancy is associated with lower IQ, attentional problems, and special educational needs by elementary school,⁴ and is a risk factor for psychiatric illnesses in childhood and adolescence.^5,6 PPD has a broad range of severity, including psychosis that may include paranoia with the rare risk of infanticide. And maternal depression can add to the strains in a vulnerable caregiver relationship that can raise the risk for neglect or abuse of the mother, children, or both.

It is important to note that anxiety is often the presenting problem in perinatal mood disorders, with mothers experiencing intense morbid worries about their infant’s safety and health, and fear of inadequacy, criticism, and even infant removal. These fears may reinforce silence and isolation. But pediatricians are one group that these mothers are most likely to share their anxieties with as they look for reassurance. It can be challenging to distinguish PPD from obsessive-compulsive disorder or PTSD. The critical work of the pediatrician is not specific diagnosis and treatment. Instead, your task is to provide screening and support, to create a safe place to overcome silence and shame.

There are many reliable and valid screening instruments available for depression, but the Edinburgh Postnatal Depression Scale (EDPS) has been specially developed for and tested in this population. It is a 10-item scale that is easy to complete and to score. Scores range from 0 to 30 and a score of 10 is considered a cutoff for depression. It can be used to track symptoms and is free and widely available online and in multiple languages. Ideally, this scale can be administered as part of a previsit, automatically entered into an electronic medical record and given at regular intervals during the infant’s first year of primary care. Some new mothers, especially if they are suffering from depression, may feel anxious about filling this out. It is important that your staff tell them that you screen all new mothers in your practice, and that PPD is common and treatable and the pediatrician’s office is committed to the health of the whole family.

If a new mother screens positive, you might consider yourself to have three tasks: Reassure her that she is a wonderful mother and this is a treatable illness, not a cause for guilt, shame, or alarm; expand her support and decrease her isolation by helping her to communicate with her family; and identify treatment resources for her. Start by being curious about some of her specific worries or feelings, her energy level, feelings of isolation or trouble with sleep. Offer compassion and validation around the pain of these experiences in the midst of so much transition. Only after hearing a little detail about her experience, then you may offer that such feelings are common, but when they are persistent or severe, they often indicate PPD, and that her screening test suggests they do for her. Offer that this form of depression is very treatable, with both pharmacologic and psychotherapy interventions. And if she is resistant, gently offer that treatment will be very protective of her new infant’s physical, social, and cognitive growth and development. Hearing this from a pediatrician is powerful for a new mother, even if depressed. Finally, ask if you might help her bring other important adults in her family into an understanding of this. Could she tell her spouse? Her sister? Her best friend? Perhaps she could bring one of them to the next weekly visit, so you can all speak together. This intervention greatly improves the likelihood of her engaging in treatment, and strong interpersonal connections are therapeutic in and of themselves.

For treatment, the easier your office can make it, the more likely she is to follow up. Identify local resources, perhaps through connected community organizations such as Jewish Family and Children’s Services or through a public program like California’s First Five. Connect with the local obstetric practice, which may already have a referral process in place. If you can connect with her primary care provider, they may take on the referral process or may even have integrated capacity for treatment. Identify strategies that may support her restful sleep, including realistic daily exercise, sharing infant care, and being cautious with caffeine and screen time. Identify ways for her to meet other new mothers or reconnect with friends. Reassure her that easy attachment activities, such as reading a book or singing to her baby can be good for both of them without requiring much energy. This may sound like a daunting task, but the conversation will only take a few minutes. Helping an isolated new parent recognize that their feelings of fear, inadequacy, and guilt are not facts, offering some simple immediate strategies and facilitating a referral can be lifesaving.

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

References

1. Dietz PM et al. Am J Psychiatry. 2007;164(10):1515-20.

2. Hanusa BH et al. J Women’s Health (Larchmt) 2008;17(4):585-96.

3. Lindahl V et al. Arch Womens Ment Health. 2005;8(2):77-87.

4. Hay DF et al. J Child Psychol Psychiatry. 2001;42(7):871-89.

5. Tully EC et al. Am J Psychiatry. 2008:165(9):1148-54.

6. Maternal depression and child development. Paediatr. Child Health 2004;9(8):575-98.

This spring may bring an unusual transition for families: a return to in-person school after nearly a year in a virtual classroom. This will undoubtedly come as a welcome relief to many parents worried about their children’s education and development and struggling with running school from home. But it is important for parents to remember that transitions, even happy ones, are difficult. You can help parents to anticipate what may be challenging about this transition for their children so that they are all prepared and can diminish struggles and support their children’s mastery.

Be curious about their children’s thoughts and feelings

Parents should adopt a truly curious and open-minded approach with their children. Remind parents that, while they are experts on their own children, they should not assume they know what their children are thinking or feeling about the return to school. Some children, especially ones struggling with learning problems or difficulty with peers, will have grown very comfortable being at home with parents or siblings. Some children, especially pre- and early teens, may have changed substantially in the year and might feel uncertain about returning to a prior team or group of friends. Some children may feel concerned about leaving a pet at home alone. Some children may be going to a new school and be anxious about facing such a big transition without the usual planning and supports. Those on a college track may be worried they are “behind” academically or in college preparation.

Parents can show up when and where their children are most likely to talk, perhaps bath time or bedtime for younger children or in the car together with their adolescents. They can ask: “Have you been thinking about what it might be like to go back to school? Have your friends been chatting about it?” They might be curious together about what might have changed in a year. What might be really great about being back in a classroom? What might they miss about home school? And what might be new? Are you worried about the work, any of your friends, or not being home? If children can begin to anticipate both the good and the difficult, they will be better equipped to face and manage the challenges and appreciate the delights.

Children in elementary school are built to master new situations but are also prone to anxiety about new expectations and demands. Parents can be calmly curious about what their thoughts, feelings, and questions are and look for answers together. Often all they need is to see parents being calm in the face of uncertainty, bearing the strong feelings that may come, and preserving curiosity and compassion. Adolescents may be grieving the things they have missed, or they may have concerns about relationships and practical matters such as the implications for applying to college. Parents can offer compassion and validation and help them to devise their own strategies to face the practical challenges they are concerned about.
 

Be mindful of their children’s vulnerabilities

While most children will find the transition back to school easier than they may anticipate, there will be some for whom the transition will be very challenging. Children who have been bullied at school may have found themselves able to concentrate and learn free of the fear and stress of a classmate’s taunts or stares. Children with learning disabilities or ADHD have probably struggled with online school, but they have also likely established strategies and supports during the year that have enabled them to get enough individualized help to get their work done. These children are vulnerable to falling behind and getting discouraged when these supports are lost, and possibly not replaced with new ones in the chaos of transition. Parents should reassure their children that they will work with the school to make sure that they can succeed in the classroom as they did at home.

Children with an inhibited or shy temperament might have found that it was easier to focus and listen in the comfortable setting of home than in a busy, stimulating classroom. Children who suffer from anxiety disorders that may make separating from parents or managing the performance and social demands of school extra difficult will find the return to school especially challenging. Some younger children may have experienced the emergence of an anxiety disorder during the past year, and the return to school may mark the challenge that brings heretofore quiet symptoms into full relief.

These children have all enjoyed being able to avoid the discomfort of certain anxiety-provoking situations, and they may be particularly stressed by anticipating a return to school. Younger children may begin to have stomach aches and other physical complaints as the return to school gets close, older children may seem more withdrawn or irritable or begin discussing ways to continue school from home. Parents should help their children try to identify and describe their worries. For anxious children, having a chance to practice may be very helpful. Visiting their school, especially if it is a new school, or having a planned hangout with a friend (with appropriate precautions) is the kind of exposure that can lessen anticipatory anxiety. If this is not enough, parents should not hesitate to bring in other caring, supportive adults, such as school counselors or therapists that may be essential to helping their children face and manage what may be intense anxiety.
 

Consider routines to support their transition

Just as parents begin to return their children to an earlier bedtime toward the end of summer, it will be helpful to consider how changing certain routines will support their children now. If children will need to get up earlier to be ready for a bus or a team practice, they should start moving bedtime and wake-up time earlier gradually. Uniforms or backpacks that have not been seen for a year should be dug out. Children who are planning a return to a sport may benefit from gradually increasing their exercise or starting training now. This will have the added benefit of improving sleep and energy and fortifying children for the challenges of change. Parents might consider reaching out to other parents in the same class as their children and having a virtual conversation to share their thoughts.

If their family has developed some new “COVID routines” that they have come to enjoy, they should find a way to preserve them. Perhaps they are having dinner together more often or have established a family game night or Netflix night. Help parents consider how to avoid falling back into overscheduling their children and themselves. If they created a time to Zoom with distant or vulnerable loved ones, they might decide to continue this. School may determine some of their routines, but they should also prioritize their family connections and well-being in deciding how to schedule their days.
 

Find opportunity for mastery and meaning

As parents are listening, validating, and planning with their children, they might use this time to reflect on valuable lessons. They might point out the value of patience: Adjusting to change takes time and happens in fits and starts. It has been 12 months since many of the pandemic changes started and it will take more than a few days to adjust as schools reopen. They might point out how proud they are of what their children have been able to learn, build, or do during this year, what they admire about them. It may be a time to consider what their family may have lost and gained during the past year, what they are eager to leave behind, and what they might like to keep. And it is also a chance for parents to observe that change is an inevitable part of life (especially when growing up). It is always challenging, and often brings loss and sadness. But if we pay attention, there are also the green shoots of what is new and possible.

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

This spring may bring an unusual transition for families: a return to in-person school after nearly a year in a virtual classroom. This will undoubtedly come as a welcome relief to many parents worried about their children’s education and development and struggling with running school from home. But it is important for parents to remember that transitions, even happy ones, are difficult. You can help parents to anticipate what may be challenging about this transition for their children so that they are all prepared and can diminish struggles and support their children’s mastery.

Be curious about their children’s thoughts and feelings

Parents should adopt a truly curious and open-minded approach with their children. Remind parents that, while they are experts on their own children, they should not assume they know what their children are thinking or feeling about the return to school. Some children, especially ones struggling with learning problems or difficulty with peers, will have grown very comfortable being at home with parents or siblings. Some children, especially pre- and early teens, may have changed substantially in the year and might feel uncertain about returning to a prior team or group of friends. Some children may feel concerned about leaving a pet at home alone. Some children may be going to a new school and be anxious about facing such a big transition without the usual planning and supports. Those on a college track may be worried they are “behind” academically or in college preparation.

Parents can show up when and where their children are most likely to talk, perhaps bath time or bedtime for younger children or in the car together with their adolescents. They can ask: “Have you been thinking about what it might be like to go back to school? Have your friends been chatting about it?” They might be curious together about what might have changed in a year. What might be really great about being back in a classroom? What might they miss about home school? And what might be new? Are you worried about the work, any of your friends, or not being home? If children can begin to anticipate both the good and the difficult, they will be better equipped to face and manage the challenges and appreciate the delights.

Children in elementary school are built to master new situations but are also prone to anxiety about new expectations and demands. Parents can be calmly curious about what their thoughts, feelings, and questions are and look for answers together. Often all they need is to see parents being calm in the face of uncertainty, bearing the strong feelings that may come, and preserving curiosity and compassion. Adolescents may be grieving the things they have missed, or they may have concerns about relationships and practical matters such as the implications for applying to college. Parents can offer compassion and validation and help them to devise their own strategies to face the practical challenges they are concerned about.
 

Be mindful of their children’s vulnerabilities

While most children will find the transition back to school easier than they may anticipate, there will be some for whom the transition will be very challenging. Children who have been bullied at school may have found themselves able to concentrate and learn free of the fear and stress of a classmate’s taunts or stares. Children with learning disabilities or ADHD have probably struggled with online school, but they have also likely established strategies and supports during the year that have enabled them to get enough individualized help to get their work done. These children are vulnerable to falling behind and getting discouraged when these supports are lost, and possibly not replaced with new ones in the chaos of transition. Parents should reassure their children that they will work with the school to make sure that they can succeed in the classroom as they did at home.

Children with an inhibited or shy temperament might have found that it was easier to focus and listen in the comfortable setting of home than in a busy, stimulating classroom. Children who suffer from anxiety disorders that may make separating from parents or managing the performance and social demands of school extra difficult will find the return to school especially challenging. Some younger children may have experienced the emergence of an anxiety disorder during the past year, and the return to school may mark the challenge that brings heretofore quiet symptoms into full relief.

These children have all enjoyed being able to avoid the discomfort of certain anxiety-provoking situations, and they may be particularly stressed by anticipating a return to school. Younger children may begin to have stomach aches and other physical complaints as the return to school gets close, older children may seem more withdrawn or irritable or begin discussing ways to continue school from home. Parents should help their children try to identify and describe their worries. For anxious children, having a chance to practice may be very helpful. Visiting their school, especially if it is a new school, or having a planned hangout with a friend (with appropriate precautions) is the kind of exposure that can lessen anticipatory anxiety. If this is not enough, parents should not hesitate to bring in other caring, supportive adults, such as school counselors or therapists that may be essential to helping their children face and manage what may be intense anxiety.
 

Consider routines to support their transition

Just as parents begin to return their children to an earlier bedtime toward the end of summer, it will be helpful to consider how changing certain routines will support their children now. If children will need to get up earlier to be ready for a bus or a team practice, they should start moving bedtime and wake-up time earlier gradually. Uniforms or backpacks that have not been seen for a year should be dug out. Children who are planning a return to a sport may benefit from gradually increasing their exercise or starting training now. This will have the added benefit of improving sleep and energy and fortifying children for the challenges of change. Parents might consider reaching out to other parents in the same class as their children and having a virtual conversation to share their thoughts.

If their family has developed some new “COVID routines” that they have come to enjoy, they should find a way to preserve them. Perhaps they are having dinner together more often or have established a family game night or Netflix night. Help parents consider how to avoid falling back into overscheduling their children and themselves. If they created a time to Zoom with distant or vulnerable loved ones, they might decide to continue this. School may determine some of their routines, but they should also prioritize their family connections and well-being in deciding how to schedule their days.
 

Find opportunity for mastery and meaning

As parents are listening, validating, and planning with their children, they might use this time to reflect on valuable lessons. They might point out the value of patience: Adjusting to change takes time and happens in fits and starts. It has been 12 months since many of the pandemic changes started and it will take more than a few days to adjust as schools reopen. They might point out how proud they are of what their children have been able to learn, build, or do during this year, what they admire about them. It may be a time to consider what their family may have lost and gained during the past year, what they are eager to leave behind, and what they might like to keep. And it is also a chance for parents to observe that change is an inevitable part of life (especially when growing up). It is always challenging, and often brings loss and sadness. But if we pay attention, there are also the green shoots of what is new and possible.

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

This spring may bring an unusual transition for families: a return to in-person school after nearly a year in a virtual classroom. This will undoubtedly come as a welcome relief to many parents worried about their children’s education and development and struggling with running school from home. But it is important for parents to remember that transitions, even happy ones, are difficult. You can help parents to anticipate what may be challenging about this transition for their children so that they are all prepared and can diminish struggles and support their children’s mastery.

Be curious about their children’s thoughts and feelings

Parents should adopt a truly curious and open-minded approach with their children. Remind parents that, while they are experts on their own children, they should not assume they know what their children are thinking or feeling about the return to school. Some children, especially ones struggling with learning problems or difficulty with peers, will have grown very comfortable being at home with parents or siblings. Some children, especially pre- and early teens, may have changed substantially in the year and might feel uncertain about returning to a prior team or group of friends. Some children may feel concerned about leaving a pet at home alone. Some children may be going to a new school and be anxious about facing such a big transition without the usual planning and supports. Those on a college track may be worried they are “behind” academically or in college preparation.

Parents can show up when and where their children are most likely to talk, perhaps bath time or bedtime for younger children or in the car together with their adolescents. They can ask: “Have you been thinking about what it might be like to go back to school? Have your friends been chatting about it?” They might be curious together about what might have changed in a year. What might be really great about being back in a classroom? What might they miss about home school? And what might be new? Are you worried about the work, any of your friends, or not being home? If children can begin to anticipate both the good and the difficult, they will be better equipped to face and manage the challenges and appreciate the delights.

Children in elementary school are built to master new situations but are also prone to anxiety about new expectations and demands. Parents can be calmly curious about what their thoughts, feelings, and questions are and look for answers together. Often all they need is to see parents being calm in the face of uncertainty, bearing the strong feelings that may come, and preserving curiosity and compassion. Adolescents may be grieving the things they have missed, or they may have concerns about relationships and practical matters such as the implications for applying to college. Parents can offer compassion and validation and help them to devise their own strategies to face the practical challenges they are concerned about.
 

Be mindful of their children’s vulnerabilities

While most children will find the transition back to school easier than they may anticipate, there will be some for whom the transition will be very challenging. Children who have been bullied at school may have found themselves able to concentrate and learn free of the fear and stress of a classmate’s taunts or stares. Children with learning disabilities or ADHD have probably struggled with online school, but they have also likely established strategies and supports during the year that have enabled them to get enough individualized help to get their work done. These children are vulnerable to falling behind and getting discouraged when these supports are lost, and possibly not replaced with new ones in the chaos of transition. Parents should reassure their children that they will work with the school to make sure that they can succeed in the classroom as they did at home.

Children with an inhibited or shy temperament might have found that it was easier to focus and listen in the comfortable setting of home than in a busy, stimulating classroom. Children who suffer from anxiety disorders that may make separating from parents or managing the performance and social demands of school extra difficult will find the return to school especially challenging. Some younger children may have experienced the emergence of an anxiety disorder during the past year, and the return to school may mark the challenge that brings heretofore quiet symptoms into full relief.

These children have all enjoyed being able to avoid the discomfort of certain anxiety-provoking situations, and they may be particularly stressed by anticipating a return to school. Younger children may begin to have stomach aches and other physical complaints as the return to school gets close, older children may seem more withdrawn or irritable or begin discussing ways to continue school from home. Parents should help their children try to identify and describe their worries. For anxious children, having a chance to practice may be very helpful. Visiting their school, especially if it is a new school, or having a planned hangout with a friend (with appropriate precautions) is the kind of exposure that can lessen anticipatory anxiety. If this is not enough, parents should not hesitate to bring in other caring, supportive adults, such as school counselors or therapists that may be essential to helping their children face and manage what may be intense anxiety.
 

Consider routines to support their transition

Just as parents begin to return their children to an earlier bedtime toward the end of summer, it will be helpful to consider how changing certain routines will support their children now. If children will need to get up earlier to be ready for a bus or a team practice, they should start moving bedtime and wake-up time earlier gradually. Uniforms or backpacks that have not been seen for a year should be dug out. Children who are planning a return to a sport may benefit from gradually increasing their exercise or starting training now. This will have the added benefit of improving sleep and energy and fortifying children for the challenges of change. Parents might consider reaching out to other parents in the same class as their children and having a virtual conversation to share their thoughts.

If their family has developed some new “COVID routines” that they have come to enjoy, they should find a way to preserve them. Perhaps they are having dinner together more often or have established a family game night or Netflix night. Help parents consider how to avoid falling back into overscheduling their children and themselves. If they created a time to Zoom with distant or vulnerable loved ones, they might decide to continue this. School may determine some of their routines, but they should also prioritize their family connections and well-being in deciding how to schedule their days.
 

Find opportunity for mastery and meaning

As parents are listening, validating, and planning with their children, they might use this time to reflect on valuable lessons. They might point out the value of patience: Adjusting to change takes time and happens in fits and starts. It has been 12 months since many of the pandemic changes started and it will take more than a few days to adjust as schools reopen. They might point out how proud they are of what their children have been able to learn, build, or do during this year, what they admire about them. It may be a time to consider what their family may have lost and gained during the past year, what they are eager to leave behind, and what they might like to keep. And it is also a chance for parents to observe that change is an inevitable part of life (especially when growing up). It is always challenging, and often brings loss and sadness. But if we pay attention, there are also the green shoots of what is new and possible.

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

The first weeks of 2021 have us considering how best to face compound challenges and we expect parents will be looking to their pediatricians for guidance. There are daily stories of the COVID-19 death toll, an abstraction made real by tragic stories of shattered families. Most families are approaching the first anniversary of their children being in virtual school, with growing concerns about the quality of virtual education, loss of socialization and group activities, and additional risks facing poor and vulnerable children. There are real concerns about the future impact of children spending so much time every day on their screens for school, extracurricular activities, social time, and relaxation. While the COVID-19 vaccines promise a return to “normal” sometime in 2021, in-person school may not return until late in the spring or next fall.

After the events of Jan. 6, families face an additional challenge: Discussing the violent invasion of the U.S. Capitol by the president’s supporters. This event was shocking, frightening, and confusing for most, and continues to be heavily covered in the news and online. There is a light in all this darkness. We have the opportunity to talk with our children – and to share explanations, perspectives, values, and even the discomfort of the unknowns – about COVID-19, use of the Internet, and the violence of Jan 6. We will consider how parents can approach this challenge for three age groups. With each group, parents will need to be calm and curious and will need time to give their children their full attention. We are all living through history. When parents can be fully present with their children, even for short periods at meals or at bedtime, it will help all to get their balance back and start to make sense of the extraordinary events we have been facing.

The youngest children (aged 3-6 years), those who were in preschool or kindergarten before the pandemic, need the most from their parents during this time. If they are attending school virtually, their online school days are likely short and challenging. Children at this age are mastering behavior rather than cognitive tasks. They are learning how to manage their bodies in space (stay in their seats!), how to be patient and kind (take turns!), and how to manage frustration (math is hard, try again!). Without the physical presence of their teacher and classmates, these lessons are tougher to internalize. Given their age-appropriate short attention spans, they often walk away from a screen, even if it’s class time. They are more likely to be paying attention to their parents, responding to the emotional climate at home. Even if they are not watching news websites themselves, they are likely to have overheard or noticed the news about recent events. Parents of young children should take care to turn off the television or their own computer, as repeated frightening videos of the insurrection can cause their children to worry that these events continue to unfold. These children need their parents’ undivided attention, even just for a little while. Play a board game with them (good chance to stay in their seats, take turns, and manage losing). Or get them outside for some physical play. While playing, parents can ask what they have seen, heard, or understand about what happened in the Capitol. Then they can correct misperceptions that might be frightening and offer reasonable reassurances in language these young children can understand. They might tell their children that sometimes people get angry when they have lost, and even adults can behave badly and make mistakes. They can focus on who the helpers are, and what they could do to help also. They could write letters of appreciation to their elected officials or to the Capitol police who were so brave in protecting others. If their children are curious, parents can find books or videos that are age appropriate about the Constitution and how elections work in a democracy. Parents don’t need to be able to answer every question, watching “Schoolhouse Rock” videos on YouTube together is a wonderful way to complement their online school and support their healthy development.

School-aged children (7-12 years) are developmentally focused on mastery experiences, whether they are social, academic, or athletic. They may be better equipped to pay attention and do homework than their younger siblings, but they will miss building friendships and having a real audience for their efforts as they build emotional maturity. They are prone to worry and distress about the big events that they can understand, at least in concrete terms, but have never faced before. These children usually have been able to use social media and online games to stay connected to friends, but they are less likely than their older siblings to independently exercise or explore new interests without a parent or teacher to guide and support them. These children are likely to be spending a lot of their time online on websites their parents don’t know about, and most likely to be curious about the events of Jan. 6. Parents should close their own device and invite their school-age children to show them what they are working on in school. Be curious about all of it, even how they are doing gym or music class. Then ask about what they have seen or heard about the election and its aftermath at school, from friends, or on their own. Let them be the teachers about what happened and how they learned about it. Parents can correct misinformation or offer reliable sources of information they can investigate together. What they will need is validation of the difficult feelings that events like these can cause; that is, acknowledgment, acceptance, and understanding of big feelings, without trying to just make those feelings go away. Parents might help them to be curious about what can make people get angry, break laws, and even hurt others, and how we protest injustices in a democracy. These children may be ready to take a deeper dive into history, via a good film or documentary, with their parents’ company for discussion afterward. Be their audience and model curiosity and patience, all the while validating the feelings that might arise.

Teenagers are developmentally focused on building their own identities, cultivating independence, and deeper relationships beyond their family. While they may be well equipped to manage online learning and to stay connected to their friends and teachers through electronic means, they are also facing considerable challenge, as their ability to explore new interests, build new relationships, and be meaningfully independent has been profoundly restrained over the past year. And they are facing other losses, as milestones like proms, performances, and competitions have been altered or missed. Parents still know when their teenager is most likely to talk, and they should check in with them during those times. They can ask them about what classes are working online and which ones aren’t, and what extracurriculars are still possible. They should not be discouraged if their teenager only offers cursory responses, it matters that they are showing up and showing interest. The election and its aftermath provide a meaningful matter to discuss; parents can find out if it is being discussed by any teachers or friends. What do they think triggered the events of Jan. 6? Who should be held responsible? How to reasonably protest injustice? What does a society do when citizens can’t agree on facts? More than offering reassurance, parents should be curious about their adolescent’s developing identity and their values, how they are thinking about complex issues around free speech and justice. It is a wonderful opportunity for parents to learn about their adolescent’s emerging identity, to be tolerant of their autonomy, and an opportunity to offer their perspective and values.

At every age, parents need to be present by listening and drawing their children out without distraction. Now is a time to build relationships and to use the difficult events of the day to shed light on deeper issues and values. This is hard, but far better than having children deal with these issues in darkness or alone.

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

The first weeks of 2021 have us considering how best to face compound challenges and we expect parents will be looking to their pediatricians for guidance. There are daily stories of the COVID-19 death toll, an abstraction made real by tragic stories of shattered families. Most families are approaching the first anniversary of their children being in virtual school, with growing concerns about the quality of virtual education, loss of socialization and group activities, and additional risks facing poor and vulnerable children. There are real concerns about the future impact of children spending so much time every day on their screens for school, extracurricular activities, social time, and relaxation. While the COVID-19 vaccines promise a return to “normal” sometime in 2021, in-person school may not return until late in the spring or next fall.

After the events of Jan. 6, families face an additional challenge: Discussing the violent invasion of the U.S. Capitol by the president’s supporters. This event was shocking, frightening, and confusing for most, and continues to be heavily covered in the news and online. There is a light in all this darkness. We have the opportunity to talk with our children – and to share explanations, perspectives, values, and even the discomfort of the unknowns – about COVID-19, use of the Internet, and the violence of Jan 6. We will consider how parents can approach this challenge for three age groups. With each group, parents will need to be calm and curious and will need time to give their children their full attention. We are all living through history. When parents can be fully present with their children, even for short periods at meals or at bedtime, it will help all to get their balance back and start to make sense of the extraordinary events we have been facing.

The youngest children (aged 3-6 years), those who were in preschool or kindergarten before the pandemic, need the most from their parents during this time. If they are attending school virtually, their online school days are likely short and challenging. Children at this age are mastering behavior rather than cognitive tasks. They are learning how to manage their bodies in space (stay in their seats!), how to be patient and kind (take turns!), and how to manage frustration (math is hard, try again!). Without the physical presence of their teacher and classmates, these lessons are tougher to internalize. Given their age-appropriate short attention spans, they often walk away from a screen, even if it’s class time. They are more likely to be paying attention to their parents, responding to the emotional climate at home. Even if they are not watching news websites themselves, they are likely to have overheard or noticed the news about recent events. Parents of young children should take care to turn off the television or their own computer, as repeated frightening videos of the insurrection can cause their children to worry that these events continue to unfold. These children need their parents’ undivided attention, even just for a little while. Play a board game with them (good chance to stay in their seats, take turns, and manage losing). Or get them outside for some physical play. While playing, parents can ask what they have seen, heard, or understand about what happened in the Capitol. Then they can correct misperceptions that might be frightening and offer reasonable reassurances in language these young children can understand. They might tell their children that sometimes people get angry when they have lost, and even adults can behave badly and make mistakes. They can focus on who the helpers are, and what they could do to help also. They could write letters of appreciation to their elected officials or to the Capitol police who were so brave in protecting others. If their children are curious, parents can find books or videos that are age appropriate about the Constitution and how elections work in a democracy. Parents don’t need to be able to answer every question, watching “Schoolhouse Rock” videos on YouTube together is a wonderful way to complement their online school and support their healthy development.

School-aged children (7-12 years) are developmentally focused on mastery experiences, whether they are social, academic, or athletic. They may be better equipped to pay attention and do homework than their younger siblings, but they will miss building friendships and having a real audience for their efforts as they build emotional maturity. They are prone to worry and distress about the big events that they can understand, at least in concrete terms, but have never faced before. These children usually have been able to use social media and online games to stay connected to friends, but they are less likely than their older siblings to independently exercise or explore new interests without a parent or teacher to guide and support them. These children are likely to be spending a lot of their time online on websites their parents don’t know about, and most likely to be curious about the events of Jan. 6. Parents should close their own device and invite their school-age children to show them what they are working on in school. Be curious about all of it, even how they are doing gym or music class. Then ask about what they have seen or heard about the election and its aftermath at school, from friends, or on their own. Let them be the teachers about what happened and how they learned about it. Parents can correct misinformation or offer reliable sources of information they can investigate together. What they will need is validation of the difficult feelings that events like these can cause; that is, acknowledgment, acceptance, and understanding of big feelings, without trying to just make those feelings go away. Parents might help them to be curious about what can make people get angry, break laws, and even hurt others, and how we protest injustices in a democracy. These children may be ready to take a deeper dive into history, via a good film or documentary, with their parents’ company for discussion afterward. Be their audience and model curiosity and patience, all the while validating the feelings that might arise.

Teenagers are developmentally focused on building their own identities, cultivating independence, and deeper relationships beyond their family. While they may be well equipped to manage online learning and to stay connected to their friends and teachers through electronic means, they are also facing considerable challenge, as their ability to explore new interests, build new relationships, and be meaningfully independent has been profoundly restrained over the past year. And they are facing other losses, as milestones like proms, performances, and competitions have been altered or missed. Parents still know when their teenager is most likely to talk, and they should check in with them during those times. They can ask them about what classes are working online and which ones aren’t, and what extracurriculars are still possible. They should not be discouraged if their teenager only offers cursory responses, it matters that they are showing up and showing interest. The election and its aftermath provide a meaningful matter to discuss; parents can find out if it is being discussed by any teachers or friends. What do they think triggered the events of Jan. 6? Who should be held responsible? How to reasonably protest injustice? What does a society do when citizens can’t agree on facts? More than offering reassurance, parents should be curious about their adolescent’s developing identity and their values, how they are thinking about complex issues around free speech and justice. It is a wonderful opportunity for parents to learn about their adolescent’s emerging identity, to be tolerant of their autonomy, and an opportunity to offer their perspective and values.

At every age, parents need to be present by listening and drawing their children out without distraction. Now is a time to build relationships and to use the difficult events of the day to shed light on deeper issues and values. This is hard, but far better than having children deal with these issues in darkness or alone.

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

The first weeks of 2021 have us considering how best to face compound challenges and we expect parents will be looking to their pediatricians for guidance. There are daily stories of the COVID-19 death toll, an abstraction made real by tragic stories of shattered families. Most families are approaching the first anniversary of their children being in virtual school, with growing concerns about the quality of virtual education, loss of socialization and group activities, and additional risks facing poor and vulnerable children. There are real concerns about the future impact of children spending so much time every day on their screens for school, extracurricular activities, social time, and relaxation. While the COVID-19 vaccines promise a return to “normal” sometime in 2021, in-person school may not return until late in the spring or next fall.

After the events of Jan. 6, families face an additional challenge: Discussing the violent invasion of the U.S. Capitol by the president’s supporters. This event was shocking, frightening, and confusing for most, and continues to be heavily covered in the news and online. There is a light in all this darkness. We have the opportunity to talk with our children – and to share explanations, perspectives, values, and even the discomfort of the unknowns – about COVID-19, use of the Internet, and the violence of Jan 6. We will consider how parents can approach this challenge for three age groups. With each group, parents will need to be calm and curious and will need time to give their children their full attention. We are all living through history. When parents can be fully present with their children, even for short periods at meals or at bedtime, it will help all to get their balance back and start to make sense of the extraordinary events we have been facing.

The youngest children (aged 3-6 years), those who were in preschool or kindergarten before the pandemic, need the most from their parents during this time. If they are attending school virtually, their online school days are likely short and challenging. Children at this age are mastering behavior rather than cognitive tasks. They are learning how to manage their bodies in space (stay in their seats!), how to be patient and kind (take turns!), and how to manage frustration (math is hard, try again!). Without the physical presence of their teacher and classmates, these lessons are tougher to internalize. Given their age-appropriate short attention spans, they often walk away from a screen, even if it’s class time. They are more likely to be paying attention to their parents, responding to the emotional climate at home. Even if they are not watching news websites themselves, they are likely to have overheard or noticed the news about recent events. Parents of young children should take care to turn off the television or their own computer, as repeated frightening videos of the insurrection can cause their children to worry that these events continue to unfold. These children need their parents’ undivided attention, even just for a little while. Play a board game with them (good chance to stay in their seats, take turns, and manage losing). Or get them outside for some physical play. While playing, parents can ask what they have seen, heard, or understand about what happened in the Capitol. Then they can correct misperceptions that might be frightening and offer reasonable reassurances in language these young children can understand. They might tell their children that sometimes people get angry when they have lost, and even adults can behave badly and make mistakes. They can focus on who the helpers are, and what they could do to help also. They could write letters of appreciation to their elected officials or to the Capitol police who were so brave in protecting others. If their children are curious, parents can find books or videos that are age appropriate about the Constitution and how elections work in a democracy. Parents don’t need to be able to answer every question, watching “Schoolhouse Rock” videos on YouTube together is a wonderful way to complement their online school and support their healthy development.

School-aged children (7-12 years) are developmentally focused on mastery experiences, whether they are social, academic, or athletic. They may be better equipped to pay attention and do homework than their younger siblings, but they will miss building friendships and having a real audience for their efforts as they build emotional maturity. They are prone to worry and distress about the big events that they can understand, at least in concrete terms, but have never faced before. These children usually have been able to use social media and online games to stay connected to friends, but they are less likely than their older siblings to independently exercise or explore new interests without a parent or teacher to guide and support them. These children are likely to be spending a lot of their time online on websites their parents don’t know about, and most likely to be curious about the events of Jan. 6. Parents should close their own device and invite their school-age children to show them what they are working on in school. Be curious about all of it, even how they are doing gym or music class. Then ask about what they have seen or heard about the election and its aftermath at school, from friends, or on their own. Let them be the teachers about what happened and how they learned about it. Parents can correct misinformation or offer reliable sources of information they can investigate together. What they will need is validation of the difficult feelings that events like these can cause; that is, acknowledgment, acceptance, and understanding of big feelings, without trying to just make those feelings go away. Parents might help them to be curious about what can make people get angry, break laws, and even hurt others, and how we protest injustices in a democracy. These children may be ready to take a deeper dive into history, via a good film or documentary, with their parents’ company for discussion afterward. Be their audience and model curiosity and patience, all the while validating the feelings that might arise.

Teenagers are developmentally focused on building their own identities, cultivating independence, and deeper relationships beyond their family. While they may be well equipped to manage online learning and to stay connected to their friends and teachers through electronic means, they are also facing considerable challenge, as their ability to explore new interests, build new relationships, and be meaningfully independent has been profoundly restrained over the past year. And they are facing other losses, as milestones like proms, performances, and competitions have been altered or missed. Parents still know when their teenager is most likely to talk, and they should check in with them during those times. They can ask them about what classes are working online and which ones aren’t, and what extracurriculars are still possible. They should not be discouraged if their teenager only offers cursory responses, it matters that they are showing up and showing interest. The election and its aftermath provide a meaningful matter to discuss; parents can find out if it is being discussed by any teachers or friends. What do they think triggered the events of Jan. 6? Who should be held responsible? How to reasonably protest injustice? What does a society do when citizens can’t agree on facts? More than offering reassurance, parents should be curious about their adolescent’s developing identity and their values, how they are thinking about complex issues around free speech and justice. It is a wonderful opportunity for parents to learn about their adolescent’s emerging identity, to be tolerant of their autonomy, and an opportunity to offer their perspective and values.

At every age, parents need to be present by listening and drawing their children out without distraction. Now is a time to build relationships and to use the difficult events of the day to shed light on deeper issues and values. This is hard, but far better than having children deal with these issues in darkness or alone.

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

The school year has begun, but for most families it is a school year without precedent. Parents have to monitor and support their children through school days that are partially or completely virtual, juggling sudden class transitions, troubleshooting technology, and trying to manage lessons and assignments. Most related activities such as sports and orchestra are cancelled. Parents themselves are anxious about completing their work, if they have jobs at all. On top of this, all of us have faced months of challenge and disruption with virtually no relief, with regard to seeing friends, traveling, or going out to dinner or a movie. For your patients with ADHD, the challenges of this school year will be even more difficult. Offering parents some guidance about how to approach and manage these challenges can support their adaptation and lessen the chances of compounded problems by the time in-person school resumes.

FatCamera/E+

Children with ADHD, particularly those in elementary school, are managing symptoms of difficulty shifting their attention, sustaining focus on less-engaging material, and motor hyperactivity. They often have difficulty with organization and planning, working memory, and impulse control. Even with effective medication management, they typically are dependent on external cues and support to manage the demands of school. They benefit from attentive teachers who can redirect their attention, offer serial prompts before transitions, and provide patient support, reassurance, and confidence when they grow frustrated. And it often is easier for teachers to do this than for parents, as they have years of experience and training, and the support of their professionals in the school setting. And of course they are less likely to personalize these challenges than are parents, who are likely to feel worried, guilty, or discouraged by the child’s persistent difficulties with attention. Parents who are stressed or who may be managing difficulties with attention themselves – as ADHD is one of the more heritable psychiatric disorders – will be vulnerable to feeling frustration and losing their temper.

Suggest to the parents of your patients with ADHD that there will be frustrations and challenges as they manage the learning curve of virtual school with their children. Increasing the dose of an effective stimulant may be tempting, but there are a few strategies that may better help the children adapt to a virtual classroom without too much distress.
 

Promote good sleep patterns

Adequate, restful sleep is critical to our physical and psychological health and to healthy development. Children with ADHD are prone to sleep difficulties, and stimulants may exacerbate these.

deyangeorgiev/thinkstockphotos.com

So, it is critical that parents prioritize setting and maintaining healthy routines around sleep. All screens should power down at least 1 hour before lights out, and parents can help their children know when to accept “good enough” homework, so they also may get good enough sleep.

Daily physical activity helps enormously with restful sleep. A warm bath or shower and quiet reading (not homework!) can help wired kids unwind and be truly ready for lights out. Bedtime may start to slide later as life’s routines are disrupted with work and school happening at home, but it is important to maintain a consistent bedtime that will allow for 8-10 hours of sleep.
 

Create routines around the “school day”

Good schools involve a predictable rhythm and a lot of caring adults engaging with children. They have very consistent routines at the start of each day, and families can create their own to offer structure and cues to their children.

Start the day with a consistent wake up time and routine plus a healthy breakfast. Take advantage of the extra time that no commute to school or bus ride allow, whether by supporting more sleep, cooking a hot breakfast together, or by letting the children engage in a beloved activity, such as listening to music, reading a comic book, or working on a craft before the computer goes on.

The routine should be centered on the rhythm of the school, and realistic for parents. It matters most that it is consistent, incorporates nutritious food and exercise, and is pleasant and even fun.
 

Set the stage

Teachers will often put their students with ADHD in the front of the class, so they can offer prompts and so the students are less distracted by peers. Consider where in the home is a good spot for the children, one that minimizes distractions and where a parent is near enough to support and monitor them.

Parents might want to avoid rooms with a lot of toys or games that may tempt children, and children will need to be apart from (noisy) siblings. If they forget to mute themselves or are tempted to open another window on their computer, it is helpful for a parent to be near enough to be unobtrusively following along. Parents will hear the sounds of trouble and be able to help if their children get lost in an assignment or are otherwise off-track.
 

Create reasonable expectations and positive rewards

Reassure parents that this adjustment is going to be hard for all children and families. Now is not the season for perfectionism or focusing too intensely on mastering a challenging subject.

Reasonable goals for the first month might be for the child to get some enjoyment from school and to get better at specific tasks (being on time, managing the technology, asking for help when needed).

Parents may even set this goal with their children: “What do you want to be better at by the end of the first month?” If children with ADHD improve at managing the distractions of a virtual class, they will have accomplished a great deal cognitively. It will be hard work for them.

So parents should think about what reward can come at the end of each school day, whether a walk outside together, a game of Uno, or even an afterschool treat together, so children get a sense of success for even incremental adaptation.
 

Build in breaks from the screen

Spending much more than an hour in a virtual interaction is taxing even for adult attention spans. Parents should feel empowered to speak with their children’s teachers to find ways to build in regular 10- to 15-minute breaks during which their children can have a snack, take a bathroom break, or get their wiggles out.

Ensure there is some physical activity

Recess is usually the most important class of the day in elementary school, and especially for children with ADHD. If parents can make physical activity part of their children’s routines, breaks, and afterschool rewards, their attention, energy, and sleep will be improved.

FatCamera/E+

They might do a workout with the child for 20 minutes before school starts, go for a short walk, or do jumping jacks during breaks. And getting outside to kick a ball, go for a swim, or otherwise get the heart rate up in the sunshine will be the most important thing parents do for their children after protecting their sleep.
 

Know your child

Remember parents are the experts on their children. School is the setting in which children are both cultivating their strengths and facing challenges. Ask the parents what has been most challenging for their children about school and what was most cherished about it.

Parents should get creative to cultivate their children’s strengths. If a child adores art, it will be so important to try to provide that experience during this school year. There might be other virtual resources (virtual museum tours, YouTube art lessons), a local teacher who can offer socially distant lessons, or even another student who might be able to safely share a teacher – getting a creative and social outlet together.

Are there special teachers that the children are missing? Maybe there is a way to send them emails or have some virtual time with them each week.

If a child struggles with the classroom but excells on the soccer pitch, it will be critical to find a physically distant way for the child to develop that strength, whether with a small, informal practice or a new physical undertaking.

Likewise, parents may need to look elsewhere to help their children manage important challenges. Whether a child is learning how to face anxiety or improve social skills, virtual school might seem like a relief as it takes the pressure off. Help parents consider alternate ways that their children could continue to work on these developmental projects while school is virtual, so they don’t lose ground developmentally.

If parents can set reasonable goals, be patient, and focus on the daily routines, and consider the child’s individual developmental strengths and challenges, they may be better able to manage this challenging year. They may even find improved connection, patience, and perspective for both themselves and their children.
 

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Neither Dr. Swick nor Dr. Jellinek had any relevant financial disclosures. Email them at pdnews@mdedge.com.

The school year has begun, but for most families it is a school year without precedent. Parents have to monitor and support their children through school days that are partially or completely virtual, juggling sudden class transitions, troubleshooting technology, and trying to manage lessons and assignments. Most related activities such as sports and orchestra are cancelled. Parents themselves are anxious about completing their work, if they have jobs at all. On top of this, all of us have faced months of challenge and disruption with virtually no relief, with regard to seeing friends, traveling, or going out to dinner or a movie. For your patients with ADHD, the challenges of this school year will be even more difficult. Offering parents some guidance about how to approach and manage these challenges can support their adaptation and lessen the chances of compounded problems by the time in-person school resumes.

FatCamera/E+

Children with ADHD, particularly those in elementary school, are managing symptoms of difficulty shifting their attention, sustaining focus on less-engaging material, and motor hyperactivity. They often have difficulty with organization and planning, working memory, and impulse control. Even with effective medication management, they typically are dependent on external cues and support to manage the demands of school. They benefit from attentive teachers who can redirect their attention, offer serial prompts before transitions, and provide patient support, reassurance, and confidence when they grow frustrated. And it often is easier for teachers to do this than for parents, as they have years of experience and training, and the support of their professionals in the school setting. And of course they are less likely to personalize these challenges than are parents, who are likely to feel worried, guilty, or discouraged by the child’s persistent difficulties with attention. Parents who are stressed or who may be managing difficulties with attention themselves – as ADHD is one of the more heritable psychiatric disorders – will be vulnerable to feeling frustration and losing their temper.

Suggest to the parents of your patients with ADHD that there will be frustrations and challenges as they manage the learning curve of virtual school with their children. Increasing the dose of an effective stimulant may be tempting, but there are a few strategies that may better help the children adapt to a virtual classroom without too much distress.
 

Promote good sleep patterns

Adequate, restful sleep is critical to our physical and psychological health and to healthy development. Children with ADHD are prone to sleep difficulties, and stimulants may exacerbate these.

deyangeorgiev/thinkstockphotos.com

So, it is critical that parents prioritize setting and maintaining healthy routines around sleep. All screens should power down at least 1 hour before lights out, and parents can help their children know when to accept “good enough” homework, so they also may get good enough sleep.

Daily physical activity helps enormously with restful sleep. A warm bath or shower and quiet reading (not homework!) can help wired kids unwind and be truly ready for lights out. Bedtime may start to slide later as life’s routines are disrupted with work and school happening at home, but it is important to maintain a consistent bedtime that will allow for 8-10 hours of sleep.
 

Create routines around the “school day”

Good schools involve a predictable rhythm and a lot of caring adults engaging with children. They have very consistent routines at the start of each day, and families can create their own to offer structure and cues to their children.

Start the day with a consistent wake up time and routine plus a healthy breakfast. Take advantage of the extra time that no commute to school or bus ride allow, whether by supporting more sleep, cooking a hot breakfast together, or by letting the children engage in a beloved activity, such as listening to music, reading a comic book, or working on a craft before the computer goes on.

The routine should be centered on the rhythm of the school, and realistic for parents. It matters most that it is consistent, incorporates nutritious food and exercise, and is pleasant and even fun.
 

Set the stage

Teachers will often put their students with ADHD in the front of the class, so they can offer prompts and so the students are less distracted by peers. Consider where in the home is a good spot for the children, one that minimizes distractions and where a parent is near enough to support and monitor them.

Parents might want to avoid rooms with a lot of toys or games that may tempt children, and children will need to be apart from (noisy) siblings. If they forget to mute themselves or are tempted to open another window on their computer, it is helpful for a parent to be near enough to be unobtrusively following along. Parents will hear the sounds of trouble and be able to help if their children get lost in an assignment or are otherwise off-track.
 

Create reasonable expectations and positive rewards

Reassure parents that this adjustment is going to be hard for all children and families. Now is not the season for perfectionism or focusing too intensely on mastering a challenging subject.

Reasonable goals for the first month might be for the child to get some enjoyment from school and to get better at specific tasks (being on time, managing the technology, asking for help when needed).

Parents may even set this goal with their children: “What do you want to be better at by the end of the first month?” If children with ADHD improve at managing the distractions of a virtual class, they will have accomplished a great deal cognitively. It will be hard work for them.

So parents should think about what reward can come at the end of each school day, whether a walk outside together, a game of Uno, or even an afterschool treat together, so children get a sense of success for even incremental adaptation.
 

Build in breaks from the screen

Spending much more than an hour in a virtual interaction is taxing even for adult attention spans. Parents should feel empowered to speak with their children’s teachers to find ways to build in regular 10- to 15-minute breaks during which their children can have a snack, take a bathroom break, or get their wiggles out.

Ensure there is some physical activity

Recess is usually the most important class of the day in elementary school, and especially for children with ADHD. If parents can make physical activity part of their children’s routines, breaks, and afterschool rewards, their attention, energy, and sleep will be improved.

FatCamera/E+

They might do a workout with the child for 20 minutes before school starts, go for a short walk, or do jumping jacks during breaks. And getting outside to kick a ball, go for a swim, or otherwise get the heart rate up in the sunshine will be the most important thing parents do for their children after protecting their sleep.
 

Know your child

Remember parents are the experts on their children. School is the setting in which children are both cultivating their strengths and facing challenges. Ask the parents what has been most challenging for their children about school and what was most cherished about it.

Parents should get creative to cultivate their children’s strengths. If a child adores art, it will be so important to try to provide that experience during this school year. There might be other virtual resources (virtual museum tours, YouTube art lessons), a local teacher who can offer socially distant lessons, or even another student who might be able to safely share a teacher – getting a creative and social outlet together.

Are there special teachers that the children are missing? Maybe there is a way to send them emails or have some virtual time with them each week.

If a child struggles with the classroom but excells on the soccer pitch, it will be critical to find a physically distant way for the child to develop that strength, whether with a small, informal practice or a new physical undertaking.

Likewise, parents may need to look elsewhere to help their children manage important challenges. Whether a child is learning how to face anxiety or improve social skills, virtual school might seem like a relief as it takes the pressure off. Help parents consider alternate ways that their children could continue to work on these developmental projects while school is virtual, so they don’t lose ground developmentally.

If parents can set reasonable goals, be patient, and focus on the daily routines, and consider the child’s individual developmental strengths and challenges, they may be better able to manage this challenging year. They may even find improved connection, patience, and perspective for both themselves and their children.
 

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Neither Dr. Swick nor Dr. Jellinek had any relevant financial disclosures. Email them at pdnews@mdedge.com.

The school year has begun, but for most families it is a school year without precedent. Parents have to monitor and support their children through school days that are partially or completely virtual, juggling sudden class transitions, troubleshooting technology, and trying to manage lessons and assignments. Most related activities such as sports and orchestra are cancelled. Parents themselves are anxious about completing their work, if they have jobs at all. On top of this, all of us have faced months of challenge and disruption with virtually no relief, with regard to seeing friends, traveling, or going out to dinner or a movie. For your patients with ADHD, the challenges of this school year will be even more difficult. Offering parents some guidance about how to approach and manage these challenges can support their adaptation and lessen the chances of compounded problems by the time in-person school resumes.

FatCamera/E+

Children with ADHD, particularly those in elementary school, are managing symptoms of difficulty shifting their attention, sustaining focus on less-engaging material, and motor hyperactivity. They often have difficulty with organization and planning, working memory, and impulse control. Even with effective medication management, they typically are dependent on external cues and support to manage the demands of school. They benefit from attentive teachers who can redirect their attention, offer serial prompts before transitions, and provide patient support, reassurance, and confidence when they grow frustrated. And it often is easier for teachers to do this than for parents, as they have years of experience and training, and the support of their professionals in the school setting. And of course they are less likely to personalize these challenges than are parents, who are likely to feel worried, guilty, or discouraged by the child’s persistent difficulties with attention. Parents who are stressed or who may be managing difficulties with attention themselves – as ADHD is one of the more heritable psychiatric disorders – will be vulnerable to feeling frustration and losing their temper.

Suggest to the parents of your patients with ADHD that there will be frustrations and challenges as they manage the learning curve of virtual school with their children. Increasing the dose of an effective stimulant may be tempting, but there are a few strategies that may better help the children adapt to a virtual classroom without too much distress.
 

Promote good sleep patterns

Adequate, restful sleep is critical to our physical and psychological health and to healthy development. Children with ADHD are prone to sleep difficulties, and stimulants may exacerbate these.

deyangeorgiev/thinkstockphotos.com

So, it is critical that parents prioritize setting and maintaining healthy routines around sleep. All screens should power down at least 1 hour before lights out, and parents can help their children know when to accept “good enough” homework, so they also may get good enough sleep.

Daily physical activity helps enormously with restful sleep. A warm bath or shower and quiet reading (not homework!) can help wired kids unwind and be truly ready for lights out. Bedtime may start to slide later as life’s routines are disrupted with work and school happening at home, but it is important to maintain a consistent bedtime that will allow for 8-10 hours of sleep.
 

Create routines around the “school day”

Good schools involve a predictable rhythm and a lot of caring adults engaging with children. They have very consistent routines at the start of each day, and families can create their own to offer structure and cues to their children.

Start the day with a consistent wake up time and routine plus a healthy breakfast. Take advantage of the extra time that no commute to school or bus ride allow, whether by supporting more sleep, cooking a hot breakfast together, or by letting the children engage in a beloved activity, such as listening to music, reading a comic book, or working on a craft before the computer goes on.

The routine should be centered on the rhythm of the school, and realistic for parents. It matters most that it is consistent, incorporates nutritious food and exercise, and is pleasant and even fun.
 

Set the stage

Teachers will often put their students with ADHD in the front of the class, so they can offer prompts and so the students are less distracted by peers. Consider where in the home is a good spot for the children, one that minimizes distractions and where a parent is near enough to support and monitor them.

Parents might want to avoid rooms with a lot of toys or games that may tempt children, and children will need to be apart from (noisy) siblings. If they forget to mute themselves or are tempted to open another window on their computer, it is helpful for a parent to be near enough to be unobtrusively following along. Parents will hear the sounds of trouble and be able to help if their children get lost in an assignment or are otherwise off-track.
 

Create reasonable expectations and positive rewards

Reassure parents that this adjustment is going to be hard for all children and families. Now is not the season for perfectionism or focusing too intensely on mastering a challenging subject.

Reasonable goals for the first month might be for the child to get some enjoyment from school and to get better at specific tasks (being on time, managing the technology, asking for help when needed).

Parents may even set this goal with their children: “What do you want to be better at by the end of the first month?” If children with ADHD improve at managing the distractions of a virtual class, they will have accomplished a great deal cognitively. It will be hard work for them.

So parents should think about what reward can come at the end of each school day, whether a walk outside together, a game of Uno, or even an afterschool treat together, so children get a sense of success for even incremental adaptation.
 

Build in breaks from the screen

Spending much more than an hour in a virtual interaction is taxing even for adult attention spans. Parents should feel empowered to speak with their children’s teachers to find ways to build in regular 10- to 15-minute breaks during which their children can have a snack, take a bathroom break, or get their wiggles out.

Ensure there is some physical activity

Recess is usually the most important class of the day in elementary school, and especially for children with ADHD. If parents can make physical activity part of their children’s routines, breaks, and afterschool rewards, their attention, energy, and sleep will be improved.

FatCamera/E+

They might do a workout with the child for 20 minutes before school starts, go for a short walk, or do jumping jacks during breaks. And getting outside to kick a ball, go for a swim, or otherwise get the heart rate up in the sunshine will be the most important thing parents do for their children after protecting their sleep.
 

Know your child

Remember parents are the experts on their children. School is the setting in which children are both cultivating their strengths and facing challenges. Ask the parents what has been most challenging for their children about school and what was most cherished about it.

Parents should get creative to cultivate their children’s strengths. If a child adores art, it will be so important to try to provide that experience during this school year. There might be other virtual resources (virtual museum tours, YouTube art lessons), a local teacher who can offer socially distant lessons, or even another student who might be able to safely share a teacher – getting a creative and social outlet together.

Are there special teachers that the children are missing? Maybe there is a way to send them emails or have some virtual time with them each week.

If a child struggles with the classroom but excells on the soccer pitch, it will be critical to find a physically distant way for the child to develop that strength, whether with a small, informal practice or a new physical undertaking.

Likewise, parents may need to look elsewhere to help their children manage important challenges. Whether a child is learning how to face anxiety or improve social skills, virtual school might seem like a relief as it takes the pressure off. Help parents consider alternate ways that their children could continue to work on these developmental projects while school is virtual, so they don’t lose ground developmentally.

If parents can set reasonable goals, be patient, and focus on the daily routines, and consider the child’s individual developmental strengths and challenges, they may be better able to manage this challenging year. They may even find improved connection, patience, and perspective for both themselves and their children.
 

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Neither Dr. Swick nor Dr. Jellinek had any relevant financial disclosures. Email them at pdnews@mdedge.com.

We live in historic times. A worldwide pandemic is surging in the United States, with millions infected and the world’s highest death rate. Many of our hospitals are overwhelmed. Schools have been closed for months. Businesses are struggling, and unemployment is at record levels. The murder of George Floyd unleashed an outpouring of grief and rage over police brutality and structural racism.

Thinkstock

The value of knowing about these risk factors would seem self-evident; it would inform a patient’s health care from screening for cancer or heart disease, referral for mild depressive symptoms, and counseling about alcohol consumption. But this research did not lead to the establishment of routine screening for childhood adversity in primary care practices. There are multiple reasons for this, including growing pressure on physician time and discomfort with starting conversations about potentially traumatic material. But perhaps the greatest obstacle has been uncertainty about what to offer patients who screened in. What is the treatment for a high ACE score?

Even without treatments, we have learned much about childhood adversity since Dr. Anda and Dr. Felitti published their landmark study. Other more chronic adverse childhood experiences also contribute to adult health risk, such as poverty, homelessness, discrimination, community violence, parental chronic illness, or disability or placement in foster care. Having a high ACE score does not only affect health in adulthood. Children with an ACE score of 4 are 2 times as likely to have asthma^2,3 and allergies³, 2 times as likely to be obese⁴, 3 times as likely to have headaches³ and dental problems^5,6, 4 times as likely to have depression^7,8, 5 times as likely to have ADHD^8,9, 7 times as likely to have high rates of school absenteeism³ and aggression¹⁰, and over 30 times as likely to have learning or behavioral problems at school⁴. There is a growing body of knowledge about how chronic, severe stress in childhood affects can lead to pathological alterations in neuroendocrine and immune function. But this has not led to any concrete treatments that may be preventive or reparative.

Movement toward expanding screening nonetheless has accelerated. In California, Nadine Burke-Harris, MD, a pediatrician who studied ACEs and children’s health was named the state’s first Surgeon General in 2019 and spearheaded an effort to make screening for ACEs easier. Starting in 2020, MediCal will pay for annual screenings, and the state is offering training and resources on how to screen and what to do with the information to help patients and families.

The coronavirus pandemic has only highlighted the risks of childhood adversity. The burden of infection and mortality has been borne disproportionately by people of color and those with multiple chronic medical conditions (obesity, cardiovascular disease, diabetes, etc.). While viruses do not discriminate, they are more likely to infect those with higher risk of exposure and to kill those who are physiologically vulnerable.

And the pandemic increases the risk for adversity for today’s children and families. When children cannot attend school, financially vulnerable parents may have to choose between supervising them or feeding them. Families who suddenly are all in a small apartment together without school or other outside supports may be at higher risk for domestic violence and child abuse. Unemployment and financial uncertainty will increase the rates of substance abuse and depression amongst parents. And the serious illness or death of a parent will be a more common event for children in the year ahead. One of these risk factors may increase the likelihood of others.

Beyond the obvious need for substantial policy changes focused on housing, education, and health care, there are immediate and concrete strategies that can build resilience in children and their families. And resilience can build on itself, as children face subsequent challenges with the support of caring connected adults.

The critical first step is asking. Then listen calmly and supportively, normalizing for parents and children how common these experiences are. Explain how they affect health and well-being. Explain that adversity and its consequences are not their fault. Then educate them about what is in their control: the skills they can practice to buffer against the consequences of adversity and build resilience. They sound simple, but still require effort and work. And the pandemic has created some difficulty (social distancing) and opportunity (more family time, fewer school demands).
 

Sleep

Help parents establish and protect consistent, restful sleep for their children. They can set a consistent bedtime and a calm routine, with screens all off at least 30 minutes before sleep and reading before sleep. Restful sleep is physiologically and psychologically protective to everyone in a family.

Movement

Beyond directly improving physical health, establishing habits of exercise – especially outside – every day can effectively manage ongoing stress, build skills of self-regulation, and help with sleep.

Find out what parents and their children like to do together (walking the dog, shooting hoops, even dancing) and help them devise ways to create family routines around exercise.
 

Nutrition

Food should be a source of pleasure, but stress can make food into a source of comfort or escape. Help parents to create realistic ways to consistently offer healthy family meals and discourage unhealthy habits.

Even small changes like water instead of soda can help, and there are nutritional and emotional benefits to eating a healthy breakfast or dinner together as a family.
 

Connections

Nourishing social connections are protective. Help parents think about protecting time to spend with their children for talking, playing games, or even singing.

They should support their children’s connections to other caring adults, through community organizations (church, community centers, or sports), and they should know who their children’s reliable friends are. Parents will benefit from these supports for themselves, which in turn will benefit the full family.
 

Self-awareness

Activities that cultivate mindfulness are protective. Parents can simply ask how their children are feeling, physically or emotionally, and be able to bear it when it is uncomfortable. Work towards nonjudgmental awareness of how they are feeling. Learning what is relaxing or recharging for them (exercise, music, a hot bath, a good book, time with a friend) will protect against defaulting into maladaptive coping such as escape, numbing, or avoidance.

Of course, if you learn about symptoms that suggest PTSD, depression, or addiction, you should help your patient connect with effective treatment. The difficulty of referring to a mental health provider does not mean you should not try and bring as many people onto the team and into the orbit of the child and family at risk. It may be easier to access some therapy given the new availability of telemedicine visits across many more systems of care. Although the heaviest burdens of adversity are not being borne equally, the fact that adversity is currently a shared experience makes this a moment of promise.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Dr. Swick and Dr. Jellinek had no relevant financial disclosures. Email them at pdnews@mdedge.com.

References
1. Am J Prev Med. 1998 May;14(4):245-58.
2. Ann Allergy Asthma Immunol. 2015;114: 379-84.
3. BMC Public Health. 2018. doi: 10.1186/s12889-018-5699-8.
4. Child Abuse Negl. 2011 Jun;35(6):408-13.
5. Community Dent Oral Epidemiol. 2015;43:193-9.
6. Community Dent Oral Epidemiol. 2018 Oct;46(5): 442-8.
7. Pediatrics 2016 Apr. doi: 10.1542/peds.2015-4016.
8. Matern Child Health J. 2016 Apr. doi: 10.1007/s10995-015-1915-7.
9. Acad Pediatr. 2017 May-Jun. doi: 10.1016/j.acap.2016.08.013.
10. Pediatrics. 2010 Apr. doi: 10.1542/peds.2009-0597.
 

This article was updated 7/27/2020.

We live in historic times. A worldwide pandemic is surging in the United States, with millions infected and the world’s highest death rate. Many of our hospitals are overwhelmed. Schools have been closed for months. Businesses are struggling, and unemployment is at record levels. The murder of George Floyd unleashed an outpouring of grief and rage over police brutality and structural racism.

Thinkstock

The value of knowing about these risk factors would seem self-evident; it would inform a patient’s health care from screening for cancer or heart disease, referral for mild depressive symptoms, and counseling about alcohol consumption. But this research did not lead to the establishment of routine screening for childhood adversity in primary care practices. There are multiple reasons for this, including growing pressure on physician time and discomfort with starting conversations about potentially traumatic material. But perhaps the greatest obstacle has been uncertainty about what to offer patients who screened in. What is the treatment for a high ACE score?

Even without treatments, we have learned much about childhood adversity since Dr. Anda and Dr. Felitti published their landmark study. Other more chronic adverse childhood experiences also contribute to adult health risk, such as poverty, homelessness, discrimination, community violence, parental chronic illness, or disability or placement in foster care. Having a high ACE score does not only affect health in adulthood. Children with an ACE score of 4 are 2 times as likely to have asthma^2,3 and allergies³, 2 times as likely to be obese⁴, 3 times as likely to have headaches³ and dental problems^5,6, 4 times as likely to have depression^7,8, 5 times as likely to have ADHD^8,9, 7 times as likely to have high rates of school absenteeism³ and aggression¹⁰, and over 30 times as likely to have learning or behavioral problems at school⁴. There is a growing body of knowledge about how chronic, severe stress in childhood affects can lead to pathological alterations in neuroendocrine and immune function. But this has not led to any concrete treatments that may be preventive or reparative.

Movement toward expanding screening nonetheless has accelerated. In California, Nadine Burke-Harris, MD, a pediatrician who studied ACEs and children’s health was named the state’s first Surgeon General in 2019 and spearheaded an effort to make screening for ACEs easier. Starting in 2020, MediCal will pay for annual screenings, and the state is offering training and resources on how to screen and what to do with the information to help patients and families.

The coronavirus pandemic has only highlighted the risks of childhood adversity. The burden of infection and mortality has been borne disproportionately by people of color and those with multiple chronic medical conditions (obesity, cardiovascular disease, diabetes, etc.). While viruses do not discriminate, they are more likely to infect those with higher risk of exposure and to kill those who are physiologically vulnerable.

And the pandemic increases the risk for adversity for today’s children and families. When children cannot attend school, financially vulnerable parents may have to choose between supervising them or feeding them. Families who suddenly are all in a small apartment together without school or other outside supports may be at higher risk for domestic violence and child abuse. Unemployment and financial uncertainty will increase the rates of substance abuse and depression amongst parents. And the serious illness or death of a parent will be a more common event for children in the year ahead. One of these risk factors may increase the likelihood of others.

Beyond the obvious need for substantial policy changes focused on housing, education, and health care, there are immediate and concrete strategies that can build resilience in children and their families. And resilience can build on itself, as children face subsequent challenges with the support of caring connected adults.

The critical first step is asking. Then listen calmly and supportively, normalizing for parents and children how common these experiences are. Explain how they affect health and well-being. Explain that adversity and its consequences are not their fault. Then educate them about what is in their control: the skills they can practice to buffer against the consequences of adversity and build resilience. They sound simple, but still require effort and work. And the pandemic has created some difficulty (social distancing) and opportunity (more family time, fewer school demands).
 

Sleep

Help parents establish and protect consistent, restful sleep for their children. They can set a consistent bedtime and a calm routine, with screens all off at least 30 minutes before sleep and reading before sleep. Restful sleep is physiologically and psychologically protective to everyone in a family.

Movement

Beyond directly improving physical health, establishing habits of exercise – especially outside – every day can effectively manage ongoing stress, build skills of self-regulation, and help with sleep.

Find out what parents and their children like to do together (walking the dog, shooting hoops, even dancing) and help them devise ways to create family routines around exercise.
 

Nutrition

Food should be a source of pleasure, but stress can make food into a source of comfort or escape. Help parents to create realistic ways to consistently offer healthy family meals and discourage unhealthy habits.

Even small changes like water instead of soda can help, and there are nutritional and emotional benefits to eating a healthy breakfast or dinner together as a family.
 

Connections

Nourishing social connections are protective. Help parents think about protecting time to spend with their children for talking, playing games, or even singing.

They should support their children’s connections to other caring adults, through community organizations (church, community centers, or sports), and they should know who their children’s reliable friends are. Parents will benefit from these supports for themselves, which in turn will benefit the full family.
 

Self-awareness

Activities that cultivate mindfulness are protective. Parents can simply ask how their children are feeling, physically or emotionally, and be able to bear it when it is uncomfortable. Work towards nonjudgmental awareness of how they are feeling. Learning what is relaxing or recharging for them (exercise, music, a hot bath, a good book, time with a friend) will protect against defaulting into maladaptive coping such as escape, numbing, or avoidance.

Of course, if you learn about symptoms that suggest PTSD, depression, or addiction, you should help your patient connect with effective treatment. The difficulty of referring to a mental health provider does not mean you should not try and bring as many people onto the team and into the orbit of the child and family at risk. It may be easier to access some therapy given the new availability of telemedicine visits across many more systems of care. Although the heaviest burdens of adversity are not being borne equally, the fact that adversity is currently a shared experience makes this a moment of promise.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Dr. Swick and Dr. Jellinek had no relevant financial disclosures. Email them at pdnews@mdedge.com.

References
1. Am J Prev Med. 1998 May;14(4):245-58.
2. Ann Allergy Asthma Immunol. 2015;114: 379-84.
3. BMC Public Health. 2018. doi: 10.1186/s12889-018-5699-8.
4. Child Abuse Negl. 2011 Jun;35(6):408-13.
5. Community Dent Oral Epidemiol. 2015;43:193-9.
6. Community Dent Oral Epidemiol. 2018 Oct;46(5): 442-8.
7. Pediatrics 2016 Apr. doi: 10.1542/peds.2015-4016.
8. Matern Child Health J. 2016 Apr. doi: 10.1007/s10995-015-1915-7.
9. Acad Pediatr. 2017 May-Jun. doi: 10.1016/j.acap.2016.08.013.
10. Pediatrics. 2010 Apr. doi: 10.1542/peds.2009-0597.
 

This article was updated 7/27/2020.

We live in historic times. A worldwide pandemic is surging in the United States, with millions infected and the world’s highest death rate. Many of our hospitals are overwhelmed. Schools have been closed for months. Businesses are struggling, and unemployment is at record levels. The murder of George Floyd unleashed an outpouring of grief and rage over police brutality and structural racism.

Thinkstock

The value of knowing about these risk factors would seem self-evident; it would inform a patient’s health care from screening for cancer or heart disease, referral for mild depressive symptoms, and counseling about alcohol consumption. But this research did not lead to the establishment of routine screening for childhood adversity in primary care practices. There are multiple reasons for this, including growing pressure on physician time and discomfort with starting conversations about potentially traumatic material. But perhaps the greatest obstacle has been uncertainty about what to offer patients who screened in. What is the treatment for a high ACE score?

Even without treatments, we have learned much about childhood adversity since Dr. Anda and Dr. Felitti published their landmark study. Other more chronic adverse childhood experiences also contribute to adult health risk, such as poverty, homelessness, discrimination, community violence, parental chronic illness, or disability or placement in foster care. Having a high ACE score does not only affect health in adulthood. Children with an ACE score of 4 are 2 times as likely to have asthma^2,3 and allergies³, 2 times as likely to be obese⁴, 3 times as likely to have headaches³ and dental problems^5,6, 4 times as likely to have depression^7,8, 5 times as likely to have ADHD^8,9, 7 times as likely to have high rates of school absenteeism³ and aggression¹⁰, and over 30 times as likely to have learning or behavioral problems at school⁴. There is a growing body of knowledge about how chronic, severe stress in childhood affects can lead to pathological alterations in neuroendocrine and immune function. But this has not led to any concrete treatments that may be preventive or reparative.

Movement toward expanding screening nonetheless has accelerated. In California, Nadine Burke-Harris, MD, a pediatrician who studied ACEs and children’s health was named the state’s first Surgeon General in 2019 and spearheaded an effort to make screening for ACEs easier. Starting in 2020, MediCal will pay for annual screenings, and the state is offering training and resources on how to screen and what to do with the information to help patients and families.

The coronavirus pandemic has only highlighted the risks of childhood adversity. The burden of infection and mortality has been borne disproportionately by people of color and those with multiple chronic medical conditions (obesity, cardiovascular disease, diabetes, etc.). While viruses do not discriminate, they are more likely to infect those with higher risk of exposure and to kill those who are physiologically vulnerable.

And the pandemic increases the risk for adversity for today’s children and families. When children cannot attend school, financially vulnerable parents may have to choose between supervising them or feeding them. Families who suddenly are all in a small apartment together without school or other outside supports may be at higher risk for domestic violence and child abuse. Unemployment and financial uncertainty will increase the rates of substance abuse and depression amongst parents. And the serious illness or death of a parent will be a more common event for children in the year ahead. One of these risk factors may increase the likelihood of others.

Beyond the obvious need for substantial policy changes focused on housing, education, and health care, there are immediate and concrete strategies that can build resilience in children and their families. And resilience can build on itself, as children face subsequent challenges with the support of caring connected adults.

The critical first step is asking. Then listen calmly and supportively, normalizing for parents and children how common these experiences are. Explain how they affect health and well-being. Explain that adversity and its consequences are not their fault. Then educate them about what is in their control: the skills they can practice to buffer against the consequences of adversity and build resilience. They sound simple, but still require effort and work. And the pandemic has created some difficulty (social distancing) and opportunity (more family time, fewer school demands).
 

Sleep

Help parents establish and protect consistent, restful sleep for their children. They can set a consistent bedtime and a calm routine, with screens all off at least 30 minutes before sleep and reading before sleep. Restful sleep is physiologically and psychologically protective to everyone in a family.

Movement

Beyond directly improving physical health, establishing habits of exercise – especially outside – every day can effectively manage ongoing stress, build skills of self-regulation, and help with sleep.

Find out what parents and their children like to do together (walking the dog, shooting hoops, even dancing) and help them devise ways to create family routines around exercise.
 

Nutrition

Food should be a source of pleasure, but stress can make food into a source of comfort or escape. Help parents to create realistic ways to consistently offer healthy family meals and discourage unhealthy habits.

Even small changes like water instead of soda can help, and there are nutritional and emotional benefits to eating a healthy breakfast or dinner together as a family.
 

Connections

Nourishing social connections are protective. Help parents think about protecting time to spend with their children for talking, playing games, or even singing.

They should support their children’s connections to other caring adults, through community organizations (church, community centers, or sports), and they should know who their children’s reliable friends are. Parents will benefit from these supports for themselves, which in turn will benefit the full family.
 

Self-awareness

Activities that cultivate mindfulness are protective. Parents can simply ask how their children are feeling, physically or emotionally, and be able to bear it when it is uncomfortable. Work towards nonjudgmental awareness of how they are feeling. Learning what is relaxing or recharging for them (exercise, music, a hot bath, a good book, time with a friend) will protect against defaulting into maladaptive coping such as escape, numbing, or avoidance.

Of course, if you learn about symptoms that suggest PTSD, depression, or addiction, you should help your patient connect with effective treatment. The difficulty of referring to a mental health provider does not mean you should not try and bring as many people onto the team and into the orbit of the child and family at risk. It may be easier to access some therapy given the new availability of telemedicine visits across many more systems of care. Although the heaviest burdens of adversity are not being borne equally, the fact that adversity is currently a shared experience makes this a moment of promise.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Dr. Swick and Dr. Jellinek had no relevant financial disclosures. Email them at pdnews@mdedge.com.

References
1. Am J Prev Med. 1998 May;14(4):245-58.
2. Ann Allergy Asthma Immunol. 2015;114: 379-84.
3. BMC Public Health. 2018. doi: 10.1186/s12889-018-5699-8.
4. Child Abuse Negl. 2011 Jun;35(6):408-13.
5. Community Dent Oral Epidemiol. 2015;43:193-9.
6. Community Dent Oral Epidemiol. 2018 Oct;46(5): 442-8.
7. Pediatrics 2016 Apr. doi: 10.1542/peds.2015-4016.
8. Matern Child Health J. 2016 Apr. doi: 10.1007/s10995-015-1915-7.
9. Acad Pediatr. 2017 May-Jun. doi: 10.1016/j.acap.2016.08.013.
10. Pediatrics. 2010 Apr. doi: 10.1542/peds.2009-0597.
 

This article was updated 7/27/2020.

We are living through unprecedented challenges, faced with profound uncertainties about the public health, the economy, the safety of our workplaces, the risks of gathering with friends and family, and even about the rhythm of the school year. Parents always have sought guidance from their pediatric providers when they are uncertain about their children’s health, behavior, and development. We want to share some guidance with you about several of the most common questions we have been hearing in the past few months, in the hope that it may prove useful in your conversations with patients and families.

ArtMarie/E+

What happens when we are so busy at home that our 2-year-old is ignored for much of the day?

If they are fortunate enough to be able to work from home, but have lost their child care, many parents are suddenly facing the sustained challenge of parenting while working. Even older children will have a tough time remembering that home is now a workplace, and they can’t interrupt their parents during a Zoom meeting. But older children will understand. Younger children (preschoolers) simply will not be able to understand that their parents are in sight but not fully available to them. They are exquisitely sensitive to their parents’ attention. If they are consistently ignored, behavioral problems can emerge. If both parents are at home, they should try to arrange a schedule taking turns so that one of them could turn their full attention to their kids if need be. If a working parent can be out of sight (i.e., in another room), it makes the situation easier for everyone.

If there is only one parent at home, that mom or dad should consider arranging a babysitter or sharing child care with a friend, with some reasonable safety provisions in place. The small risk of exposure to the virus is balanced by the risk of sustained invalidation in a developing child. Help parents set reasonable expectations for how productive they can be at home. If possible, they can manage their employer’s expectations, so that they do not find themselves in the impossible bind of choosing between a crying child and a crucial deadline. If they can work near the child (and be prepared for interruptions) when reading emails or writing, that may be enough availability for the child. And parents should not be discouraged when they have to repeatedly remind their children that they adore them, but also have to work while they are at home right now. Using age-appropriate screen time as a babysitter for a few hours each day is a perfectly acceptable part of a plan. Simply planning regular breaks when their children can have their attention will make the day easier for everyone at home.
 

What can I do about my 13-year-old who is lying around the house all day?

This is a time to pick your battles. If children can keep their regular sleep schedule, get their schoolwork done, and do some physical exercise every day, they are doing great. And if parents are continuously complaining that they are being lazy, it will probably cease to mean much to them. Instead, focus on clear, simple expectations, and parents should live by them, too. If parents can exercise with them, or try a new activity, that is a wonderful way to model self-care and trying new things. It is important to remember that the developmental task for a 13-year-old is to establish new avenues of independence that they will drive down further with each passing year. Give them some leeway to experiment and figure out their own way of handling this challenge, although it is bound to create some tension. Parents should always acknowledge how hard it is to stick with schoolwork without school, exercise without a team, practice music without a band, or do your work without an office!

What do we do about our 16-year-old who is staying up all night and sleeping until the late afternoon?

Adolescents naturally have their sleep cycle shift, so they are sleepy later and sleep longer. But staying up all night is usually about texting with friends or playing video games. The problem is that their sleep schedule can flip. They will not be able to participate in online class or enjoy exercise in the sun, and they rarely get enough sleep during the daytime, making them more irritable, anxious, inattentive, and tired. This will only make managing their schoolwork harder and increase the chances of conflict at home. So it is important to preserve rules around sleep. You might extend bedtime by an hour or so, but preserve rules and bedtime routines. Sleep is essential to health, well-being, and resilience, and all are critical during times of uncertainty and change.

We think our 17-year-old is using marijuana, and it might be a problem.

When parents think their children may have a problem with drugs, the children almost certainly do, as parents are typically the last to know about the extent of their use. Sheltering in place together may make their drug use much more apparent, and offer an opportunity for parents to respond. Talk with them about it. Let them know what you have noticed. See if they can tell you honestly about their drug use. Kids who are only experimenting socially are unlikely to be using drugs at home under quarantine. If you are truly calm and curious, they are more likely to be honest, and it could be a relief for them to discuss it with you. Find out what they think it helps, and what – if anything – they are worried about. Then share your concerns about marijuana use and the developing brain, and the risk of addiction. If they think it is “medical” use, remind them that anxiety or mood symptoms get better with therapy, whereas drugs (including marijuana) and alcohol actually worsen those problems. It is also a time to establish home rules, explain them, and enforce them. They will have your support while stopping and may learn that they are actually sleeping and feeling better after a few weeks without marijuana.

Parents should not hesitate to reach out to pediatric providers for guidance on local resources for assessment and treatment for substance abuse and addiction. These are medical problems, and they can become serious if untreated.

My 12-year-old perfectionist is very stressed about getting her work done well now that she is home schooling. How do I help her relax?

Some children, especially our anxious perfectionists, may respond to the switch to home school with great effort and organization. These kids usually are not the ones parents worry about. But they are very prone to expanding anxiety without the regular support and feedback of teachers. The school environment naturally encourages their taking chances and normalizes the setbacks and failures that are an essential part of learning something new. At home, parents are inclined to let these kids work independently. But they benefit from regular check-ins that are not focused on work completion or scores. Instead, ask about what they are doing that is hardest, and let them teach you about it. Model how you approach a new challenge, and how you regroup and try again when you don’t get it right. Finally, this is a good age to start discussing “reasonable expectations.” No one can “do their best” all the time; not parents, not professional athletes, not even machines can sustain long bursts of maximum speed without problems. Help them to start experimenting with different speeds and levels of effort, and see how it feels.

My 10-year-old is very anxious about catching coronavirus or one of us catching it. How do I help ease her anxiety when there is no certainty about how to prevent it?

Anxiety is a normal response to a situation with as much uncertainty as this one. But some are prone to more profound anxiety, and parents may find they are doing a lot of reassuring throughout the day. For especially anxious children (and adults), accommodating the anxiety by avoiding the stressful situation is a common response that provides temporary relief. But accommodation and avoidance actually fuel anxiety, and make it harder and harder to manage. It is important to talk about the “accommodations” we all are doing, how masks are recommended to protect others (not ourselves) and to slow down the spread of a new illness so our hospitals aren’t overwhelmed. It can seem counterintuitive, but rather than jumping to reassurance or dismissing their sense of risk, ask your children to play the full movie of what they are most worried about. What happens if they get sick? If you get sick? If they are worried about dying, go ahead and ask what they think happens then. You are demonstrating that you have confidence they can handle these feelings, and you are modeling curiosity – not avoidance – yourself. Correct any misunderstandings, check on facts together, acknowledge uncertainty. It also is very important for parents to assess whether their own anxiety level makes this task especially hard or may even be contributing to their children’s level of worry. Each of us is managing anxiety right now, and this moment presents an opportunity for all of us to learn about how we can face and bear it, learn to manage, and even master it.

We are all getting cabin fever at home and snapping at each other constantly. How do we keep the peace without just hiding in our rooms all day?

Cabin fever seems inevitable when a family is suddenly at home together all day every day with no end in sight. But if we establish some simple and realistic routines and preserve some structure without being rigid, it can go a long way to helping each member of a family to find their equilibrium in this new normal. Structure can be about preserving normal sleep and meal times. Ensuring everyone is getting adequate, restful sleep and is not hungry is probably the most powerful way to keep irritability and conflict low. It is also helpful to establish some new routines. These should be simple enough to be memorable and should be realistic. You might identify predictable blocks of time that are dedicated to school (or work), exercise, creative time, and family time. While much of the day may find each family member doing some independent activity, it helps when these “blocks” are the same for everybody. Try to consistently do one or two things together, like a walk after the family dinner or family game time. And also remember that everyone needs some alone time. Respect their need for this, and it will help you to explain when you need it. If someone wants to sit out the family Yahtzee tournament, don’t shame or punish them. Just invite them again the next night!

What are going to be the consequences of all this screen time?

The great majority of kids (and parents) will not suffer any adverse consequences from the increased amount of time spent in front of screens when these activities are varied and serve a useful purpose – including distraction, senseless fun, and social time. Beyond letter or email writing, screen and phone time are the only ways to stay socially connected while physically distant. But parents are the experts on their kids. Youth who are depressed and have in the past wanted to escape into long hours of video games or YouTube videos should not be allowed to do that now. Youth with attentional issues who have a hard time stopping video games will still have that difficulty. If they are getting adequate sleep and regular exercise, and are doing most of their school work and staying socially connected, screens are not dangerous. They are proving to be a wonderful tool to help us visit libraries and museums, take dance classes, learn new languages, follow the news, order groceries, or enjoy a movie together. If we stay connected to those we care about and to the world, then this time – although marked by profound suffering and loss – may prove to be a time when we were able to slow down and remember what truly matters in our lives.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. They have no relevant financial disclosures. Email them at pdnews@mdedge.com.

We are living through unprecedented challenges, faced with profound uncertainties about the public health, the economy, the safety of our workplaces, the risks of gathering with friends and family, and even about the rhythm of the school year. Parents always have sought guidance from their pediatric providers when they are uncertain about their children’s health, behavior, and development. We want to share some guidance with you about several of the most common questions we have been hearing in the past few months, in the hope that it may prove useful in your conversations with patients and families.

ArtMarie/E+

What happens when we are so busy at home that our 2-year-old is ignored for much of the day?

If they are fortunate enough to be able to work from home, but have lost their child care, many parents are suddenly facing the sustained challenge of parenting while working. Even older children will have a tough time remembering that home is now a workplace, and they can’t interrupt their parents during a Zoom meeting. But older children will understand. Younger children (preschoolers) simply will not be able to understand that their parents are in sight but not fully available to them. They are exquisitely sensitive to their parents’ attention. If they are consistently ignored, behavioral problems can emerge. If both parents are at home, they should try to arrange a schedule taking turns so that one of them could turn their full attention to their kids if need be. If a working parent can be out of sight (i.e., in another room), it makes the situation easier for everyone.

If there is only one parent at home, that mom or dad should consider arranging a babysitter or sharing child care with a friend, with some reasonable safety provisions in place. The small risk of exposure to the virus is balanced by the risk of sustained invalidation in a developing child. Help parents set reasonable expectations for how productive they can be at home. If possible, they can manage their employer’s expectations, so that they do not find themselves in the impossible bind of choosing between a crying child and a crucial deadline. If they can work near the child (and be prepared for interruptions) when reading emails or writing, that may be enough availability for the child. And parents should not be discouraged when they have to repeatedly remind their children that they adore them, but also have to work while they are at home right now. Using age-appropriate screen time as a babysitter for a few hours each day is a perfectly acceptable part of a plan. Simply planning regular breaks when their children can have their attention will make the day easier for everyone at home.
 

What can I do about my 13-year-old who is lying around the house all day?

This is a time to pick your battles. If children can keep their regular sleep schedule, get their schoolwork done, and do some physical exercise every day, they are doing great. And if parents are continuously complaining that they are being lazy, it will probably cease to mean much to them. Instead, focus on clear, simple expectations, and parents should live by them, too. If parents can exercise with them, or try a new activity, that is a wonderful way to model self-care and trying new things. It is important to remember that the developmental task for a 13-year-old is to establish new avenues of independence that they will drive down further with each passing year. Give them some leeway to experiment and figure out their own way of handling this challenge, although it is bound to create some tension. Parents should always acknowledge how hard it is to stick with schoolwork without school, exercise without a team, practice music without a band, or do your work without an office!

What do we do about our 16-year-old who is staying up all night and sleeping until the late afternoon?

Adolescents naturally have their sleep cycle shift, so they are sleepy later and sleep longer. But staying up all night is usually about texting with friends or playing video games. The problem is that their sleep schedule can flip. They will not be able to participate in online class or enjoy exercise in the sun, and they rarely get enough sleep during the daytime, making them more irritable, anxious, inattentive, and tired. This will only make managing their schoolwork harder and increase the chances of conflict at home. So it is important to preserve rules around sleep. You might extend bedtime by an hour or so, but preserve rules and bedtime routines. Sleep is essential to health, well-being, and resilience, and all are critical during times of uncertainty and change.

We think our 17-year-old is using marijuana, and it might be a problem.

When parents think their children may have a problem with drugs, the children almost certainly do, as parents are typically the last to know about the extent of their use. Sheltering in place together may make their drug use much more apparent, and offer an opportunity for parents to respond. Talk with them about it. Let them know what you have noticed. See if they can tell you honestly about their drug use. Kids who are only experimenting socially are unlikely to be using drugs at home under quarantine. If you are truly calm and curious, they are more likely to be honest, and it could be a relief for them to discuss it with you. Find out what they think it helps, and what – if anything – they are worried about. Then share your concerns about marijuana use and the developing brain, and the risk of addiction. If they think it is “medical” use, remind them that anxiety or mood symptoms get better with therapy, whereas drugs (including marijuana) and alcohol actually worsen those problems. It is also a time to establish home rules, explain them, and enforce them. They will have your support while stopping and may learn that they are actually sleeping and feeling better after a few weeks without marijuana.

Parents should not hesitate to reach out to pediatric providers for guidance on local resources for assessment and treatment for substance abuse and addiction. These are medical problems, and they can become serious if untreated.

My 12-year-old perfectionist is very stressed about getting her work done well now that she is home schooling. How do I help her relax?

Some children, especially our anxious perfectionists, may respond to the switch to home school with great effort and organization. These kids usually are not the ones parents worry about. But they are very prone to expanding anxiety without the regular support and feedback of teachers. The school environment naturally encourages their taking chances and normalizes the setbacks and failures that are an essential part of learning something new. At home, parents are inclined to let these kids work independently. But they benefit from regular check-ins that are not focused on work completion or scores. Instead, ask about what they are doing that is hardest, and let them teach you about it. Model how you approach a new challenge, and how you regroup and try again when you don’t get it right. Finally, this is a good age to start discussing “reasonable expectations.” No one can “do their best” all the time; not parents, not professional athletes, not even machines can sustain long bursts of maximum speed without problems. Help them to start experimenting with different speeds and levels of effort, and see how it feels.

My 10-year-old is very anxious about catching coronavirus or one of us catching it. How do I help ease her anxiety when there is no certainty about how to prevent it?

Anxiety is a normal response to a situation with as much uncertainty as this one. But some are prone to more profound anxiety, and parents may find they are doing a lot of reassuring throughout the day. For especially anxious children (and adults), accommodating the anxiety by avoiding the stressful situation is a common response that provides temporary relief. But accommodation and avoidance actually fuel anxiety, and make it harder and harder to manage. It is important to talk about the “accommodations” we all are doing, how masks are recommended to protect others (not ourselves) and to slow down the spread of a new illness so our hospitals aren’t overwhelmed. It can seem counterintuitive, but rather than jumping to reassurance or dismissing their sense of risk, ask your children to play the full movie of what they are most worried about. What happens if they get sick? If you get sick? If they are worried about dying, go ahead and ask what they think happens then. You are demonstrating that you have confidence they can handle these feelings, and you are modeling curiosity – not avoidance – yourself. Correct any misunderstandings, check on facts together, acknowledge uncertainty. It also is very important for parents to assess whether their own anxiety level makes this task especially hard or may even be contributing to their children’s level of worry. Each of us is managing anxiety right now, and this moment presents an opportunity for all of us to learn about how we can face and bear it, learn to manage, and even master it.

We are all getting cabin fever at home and snapping at each other constantly. How do we keep the peace without just hiding in our rooms all day?

Cabin fever seems inevitable when a family is suddenly at home together all day every day with no end in sight. But if we establish some simple and realistic routines and preserve some structure without being rigid, it can go a long way to helping each member of a family to find their equilibrium in this new normal. Structure can be about preserving normal sleep and meal times. Ensuring everyone is getting adequate, restful sleep and is not hungry is probably the most powerful way to keep irritability and conflict low. It is also helpful to establish some new routines. These should be simple enough to be memorable and should be realistic. You might identify predictable blocks of time that are dedicated to school (or work), exercise, creative time, and family time. While much of the day may find each family member doing some independent activity, it helps when these “blocks” are the same for everybody. Try to consistently do one or two things together, like a walk after the family dinner or family game time. And also remember that everyone needs some alone time. Respect their need for this, and it will help you to explain when you need it. If someone wants to sit out the family Yahtzee tournament, don’t shame or punish them. Just invite them again the next night!

What are going to be the consequences of all this screen time?

The great majority of kids (and parents) will not suffer any adverse consequences from the increased amount of time spent in front of screens when these activities are varied and serve a useful purpose – including distraction, senseless fun, and social time. Beyond letter or email writing, screen and phone time are the only ways to stay socially connected while physically distant. But parents are the experts on their kids. Youth who are depressed and have in the past wanted to escape into long hours of video games or YouTube videos should not be allowed to do that now. Youth with attentional issues who have a hard time stopping video games will still have that difficulty. If they are getting adequate sleep and regular exercise, and are doing most of their school work and staying socially connected, screens are not dangerous. They are proving to be a wonderful tool to help us visit libraries and museums, take dance classes, learn new languages, follow the news, order groceries, or enjoy a movie together. If we stay connected to those we care about and to the world, then this time – although marked by profound suffering and loss – may prove to be a time when we were able to slow down and remember what truly matters in our lives.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. They have no relevant financial disclosures. Email them at pdnews@mdedge.com.

We are living through unprecedented challenges, faced with profound uncertainties about the public health, the economy, the safety of our workplaces, the risks of gathering with friends and family, and even about the rhythm of the school year. Parents always have sought guidance from their pediatric providers when they are uncertain about their children’s health, behavior, and development. We want to share some guidance with you about several of the most common questions we have been hearing in the past few months, in the hope that it may prove useful in your conversations with patients and families.

ArtMarie/E+

What happens when we are so busy at home that our 2-year-old is ignored for much of the day?

If they are fortunate enough to be able to work from home, but have lost their child care, many parents are suddenly facing the sustained challenge of parenting while working. Even older children will have a tough time remembering that home is now a workplace, and they can’t interrupt their parents during a Zoom meeting. But older children will understand. Younger children (preschoolers) simply will not be able to understand that their parents are in sight but not fully available to them. They are exquisitely sensitive to their parents’ attention. If they are consistently ignored, behavioral problems can emerge. If both parents are at home, they should try to arrange a schedule taking turns so that one of them could turn their full attention to their kids if need be. If a working parent can be out of sight (i.e., in another room), it makes the situation easier for everyone.

If there is only one parent at home, that mom or dad should consider arranging a babysitter or sharing child care with a friend, with some reasonable safety provisions in place. The small risk of exposure to the virus is balanced by the risk of sustained invalidation in a developing child. Help parents set reasonable expectations for how productive they can be at home. If possible, they can manage their employer’s expectations, so that they do not find themselves in the impossible bind of choosing between a crying child and a crucial deadline. If they can work near the child (and be prepared for interruptions) when reading emails or writing, that may be enough availability for the child. And parents should not be discouraged when they have to repeatedly remind their children that they adore them, but also have to work while they are at home right now. Using age-appropriate screen time as a babysitter for a few hours each day is a perfectly acceptable part of a plan. Simply planning regular breaks when their children can have their attention will make the day easier for everyone at home.
 

What can I do about my 13-year-old who is lying around the house all day?

This is a time to pick your battles. If children can keep their regular sleep schedule, get their schoolwork done, and do some physical exercise every day, they are doing great. And if parents are continuously complaining that they are being lazy, it will probably cease to mean much to them. Instead, focus on clear, simple expectations, and parents should live by them, too. If parents can exercise with them, or try a new activity, that is a wonderful way to model self-care and trying new things. It is important to remember that the developmental task for a 13-year-old is to establish new avenues of independence that they will drive down further with each passing year. Give them some leeway to experiment and figure out their own way of handling this challenge, although it is bound to create some tension. Parents should always acknowledge how hard it is to stick with schoolwork without school, exercise without a team, practice music without a band, or do your work without an office!

What do we do about our 16-year-old who is staying up all night and sleeping until the late afternoon?

Adolescents naturally have their sleep cycle shift, so they are sleepy later and sleep longer. But staying up all night is usually about texting with friends or playing video games. The problem is that their sleep schedule can flip. They will not be able to participate in online class or enjoy exercise in the sun, and they rarely get enough sleep during the daytime, making them more irritable, anxious, inattentive, and tired. This will only make managing their schoolwork harder and increase the chances of conflict at home. So it is important to preserve rules around sleep. You might extend bedtime by an hour or so, but preserve rules and bedtime routines. Sleep is essential to health, well-being, and resilience, and all are critical during times of uncertainty and change.

We think our 17-year-old is using marijuana, and it might be a problem.

When parents think their children may have a problem with drugs, the children almost certainly do, as parents are typically the last to know about the extent of their use. Sheltering in place together may make their drug use much more apparent, and offer an opportunity for parents to respond. Talk with them about it. Let them know what you have noticed. See if they can tell you honestly about their drug use. Kids who are only experimenting socially are unlikely to be using drugs at home under quarantine. If you are truly calm and curious, they are more likely to be honest, and it could be a relief for them to discuss it with you. Find out what they think it helps, and what – if anything – they are worried about. Then share your concerns about marijuana use and the developing brain, and the risk of addiction. If they think it is “medical” use, remind them that anxiety or mood symptoms get better with therapy, whereas drugs (including marijuana) and alcohol actually worsen those problems. It is also a time to establish home rules, explain them, and enforce them. They will have your support while stopping and may learn that they are actually sleeping and feeling better after a few weeks without marijuana.

Parents should not hesitate to reach out to pediatric providers for guidance on local resources for assessment and treatment for substance abuse and addiction. These are medical problems, and they can become serious if untreated.

My 12-year-old perfectionist is very stressed about getting her work done well now that she is home schooling. How do I help her relax?

Some children, especially our anxious perfectionists, may respond to the switch to home school with great effort and organization. These kids usually are not the ones parents worry about. But they are very prone to expanding anxiety without the regular support and feedback of teachers. The school environment naturally encourages their taking chances and normalizes the setbacks and failures that are an essential part of learning something new. At home, parents are inclined to let these kids work independently. But they benefit from regular check-ins that are not focused on work completion or scores. Instead, ask about what they are doing that is hardest, and let them teach you about it. Model how you approach a new challenge, and how you regroup and try again when you don’t get it right. Finally, this is a good age to start discussing “reasonable expectations.” No one can “do their best” all the time; not parents, not professional athletes, not even machines can sustain long bursts of maximum speed without problems. Help them to start experimenting with different speeds and levels of effort, and see how it feels.

My 10-year-old is very anxious about catching coronavirus or one of us catching it. How do I help ease her anxiety when there is no certainty about how to prevent it?

Anxiety is a normal response to a situation with as much uncertainty as this one. But some are prone to more profound anxiety, and parents may find they are doing a lot of reassuring throughout the day. For especially anxious children (and adults), accommodating the anxiety by avoiding the stressful situation is a common response that provides temporary relief. But accommodation and avoidance actually fuel anxiety, and make it harder and harder to manage. It is important to talk about the “accommodations” we all are doing, how masks are recommended to protect others (not ourselves) and to slow down the spread of a new illness so our hospitals aren’t overwhelmed. It can seem counterintuitive, but rather than jumping to reassurance or dismissing their sense of risk, ask your children to play the full movie of what they are most worried about. What happens if they get sick? If you get sick? If they are worried about dying, go ahead and ask what they think happens then. You are demonstrating that you have confidence they can handle these feelings, and you are modeling curiosity – not avoidance – yourself. Correct any misunderstandings, check on facts together, acknowledge uncertainty. It also is very important for parents to assess whether their own anxiety level makes this task especially hard or may even be contributing to their children’s level of worry. Each of us is managing anxiety right now, and this moment presents an opportunity for all of us to learn about how we can face and bear it, learn to manage, and even master it.

We are all getting cabin fever at home and snapping at each other constantly. How do we keep the peace without just hiding in our rooms all day?

Cabin fever seems inevitable when a family is suddenly at home together all day every day with no end in sight. But if we establish some simple and realistic routines and preserve some structure without being rigid, it can go a long way to helping each member of a family to find their equilibrium in this new normal. Structure can be about preserving normal sleep and meal times. Ensuring everyone is getting adequate, restful sleep and is not hungry is probably the most powerful way to keep irritability and conflict low. It is also helpful to establish some new routines. These should be simple enough to be memorable and should be realistic. You might identify predictable blocks of time that are dedicated to school (or work), exercise, creative time, and family time. While much of the day may find each family member doing some independent activity, it helps when these “blocks” are the same for everybody. Try to consistently do one or two things together, like a walk after the family dinner or family game time. And also remember that everyone needs some alone time. Respect their need for this, and it will help you to explain when you need it. If someone wants to sit out the family Yahtzee tournament, don’t shame or punish them. Just invite them again the next night!

What are going to be the consequences of all this screen time?

The great majority of kids (and parents) will not suffer any adverse consequences from the increased amount of time spent in front of screens when these activities are varied and serve a useful purpose – including distraction, senseless fun, and social time. Beyond letter or email writing, screen and phone time are the only ways to stay socially connected while physically distant. But parents are the experts on their kids. Youth who are depressed and have in the past wanted to escape into long hours of video games or YouTube videos should not be allowed to do that now. Youth with attentional issues who have a hard time stopping video games will still have that difficulty. If they are getting adequate sleep and regular exercise, and are doing most of their school work and staying socially connected, screens are not dangerous. They are proving to be a wonderful tool to help us visit libraries and museums, take dance classes, learn new languages, follow the news, order groceries, or enjoy a movie together. If we stay connected to those we care about and to the world, then this time – although marked by profound suffering and loss – may prove to be a time when we were able to slow down and remember what truly matters in our lives.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. They have no relevant financial disclosures. Email them at pdnews@mdedge.com.

We are in uncharted waters with national and local states of emergency, schools and most activities being shut down, and rapidly evolving strategies on managing the COVID-19 outbreak. Everyone’s anxiety is appropriately high. As health care providers for children, you are facing changes in your personal life at home and in practice, likely including setting up televisits, trying to assess which patients to see, managing staffing challenges, and facing potential cash flow issues as expenses continue but revenue may fall short. And, of course, you will address a host of novel questions and concerns from the families you care for.

Ryan McVay/ThinkStock

Your top priorities are to stay calm while offering clear recommendations on testing, quarantine, and treatment with guidance from our federal and local public health agencies. By providing clear guidance on the medical issues, you will offer substantial reassurance to families. But even with a medical plan in place, this remains a confusing and anxiety-provoking moment, one without much precedent in most people’s lives or in our national experience. Our aim is to complement that guidance by offering you some principles to help families manage the stress and anxiety that the disruptions and uncertainties that this public health emergency has created.
 

Offer clear, open, regular, and child-centered communication

Accurate information calmly delivered is the antidote to anxiety or panic in a stressful situation. If you have an email mailing list of your parents, you may want to summarize information you are gathering with a note they can expect at a specified time each day. You could request them to email you questions that then can be included as an FAQ (frequently asked questions).

Most children will have noticed people wearing face masks, or dramatic scenes on the news with hospital workers in full protective gear, breathlessly reporting growing numbers of the infected and the deceased. At a minimum, they are being commanded to wash hands and to not touch their faces (which is challenging enough for adults!), and are probably overhearing conversations about quarantines and contagion as well as family concerns about jobs and family finances. Many children are managing extended school closures and some are even managing the quarantine or serious illness of a loved one. When children overhear frightening news from distressed adults, they are going to become anxious and afraid themselves. Parents should remember to find out what their children have seen, heard, or understood about what is going on, and they should correct misinformation or misunderstandings with clear explanations. They also should find out what their children are curious about. “What has you wondering about that?” is a great response when children have questions, in order to make sure you get at any underlying worry.

It is fine to not have an answer to every question. It is difficult to offer clear explanations about something that we don’t yet fully understand, and it is fine to acknowledge what we don’t know. “That’s a great question. Let’s look together at the CDC [Centers for Disease Control and Prevention] website.” Offering to look for answers or information together can be a powerful way to model how to handle uncertainty. And always couch answers with appropriate (not false) reassurance: “Children and young adults appear to be very safe from this illness, but we want to take care to protect those that are older or already sick.”

Remember most children set their anxiety level based on their parent’s anxiety, and part of being child centered in your communication includes offering information in an age-appropriate manner. Preschool-aged children (up to 5 years) still have magical thinking. They are prone to finding masks and gowns scary and to assume that school stopping may be because they did something wrong. Tell them about the new illness, and about the doctors and officials working hard to keep people safe. Reassure them about all of the adults working hard together to understand the illness and take care of people who are sick. Their sense of time is less logical, so you may have to tell them more than once. Reassure them that children do not get very sick from this illness, but they can carry and spread it, like having paint on their hands, so they need to wash their hands often to take good care of other people.

monkeybusinessimages/thinkstockphotos.com

School-age children (aged roughly 5-12 years) are better equipped cognitively to understand the seriousness of this outbreak. They are built to master new situations, but are prone to anxiety as they don’t yet have the emotional maturity to tolerate uncertainty or unfairness. Explain what is known without euphemisms, be truly curious about what their questions are, and look for answers together. Often what they need is to see you being calm in the face of uncertainty, bearing the strong feelings that may come, and preserving curiosity and compassion for others.

Adolescents also will need all of this support, and can be curious about more abstract implications (political, ethical, financial). Do not be surprised when they ask sophisticated questions, but still are focused on the personal disruptions or sacrifices (a canceled dance or sports meet, concerns about academic performance). Adolescence is a time of intense preoccupation with their emerging identity and relationships; it is normal for them to experience events in a way that may seem selfish, especially if it disrupts their time with friends. Remind parents to offer compassion and validation, while acknowledging that shared sacrifice and discomfort are a part of every individual’s experience when a society must respond to such a large challenge.
 

Be mindful of children’s vulnerabilities

Being child centered goes beyond thinking about their age and developmental stage. Parents are the experts on their children and will know about any particular vulnerabilities to the stresses of this serious outbreak. Children who are prone to anxiety or suffer from anxiety disorders may be more prone to silent worry. It is especially important to check in with them often, find out what they know and what they are worried about, and remind them to “never worry alone.” It also is important to continue with any recommended treatment, avoiding accommodation of their anxieties, except when it is required by public health protocols (i.e., staying home from school). Children with developmental disabilities may require additional support to change behaviors (hand washing) and may be more sensitive to changes in routine. And children with learning disabilities or special services in school may require additional support or structure during a prolonged period at home.

Preserve routines and structure

Routines and predictability are important to the sense of stability and well-being of most children (and adults). While disruptions are unavoidable, preserve what routines you can, and establish some new ones. For children who are out of school for several weeks, set up a consistent home routine, with a similar wake-up and bedtime, and a “school schedule.” There may be academic activities like reading or work sheets. If the parents’ work is disrupted, they can homeschool, shoring up weak academic areas or enhancing areas of interest. Be sure to preserve time for physical activity and social connections within this new framework. Social time does not require physical proximity, and can happen by screen or phone. Physical activity should be outside if at all possible. Predictability, preserved expectations (academic and otherwise), physical exercise, social connection, and consistent sleep will go a long way in protecting everyone’s ability to manage the disruptions of this epidemic.

Find opportunity in the disruption

Many families have been on a treadmill of work, school, and activities that have left little unscheduled time or spontaneity. Recommend looking at this disruption as a rare opportunity to slow down, spend time together, listen, learn more about one another, and even to have fun. Families could play board games, card games, watch movies together, or even read aloud. They might discover it is the time to try new hobbies (knitting, learning a new language or instrument), or to teach each other new skills. You might learn something new, or something new about your children. You also will offer a model of finding the opportunity in adversity, and even offer them some wonderful memories from a difficult time.

Take care of the vulnerable and ease others’ hardships

Without a doubt, this will be a difficult time for many people, medically, financially, and emotionally. One powerful strategy to build resilience in our children and strengthen our communities is to think with children about ways to help those who are most at risk or burdened by this challenge. Perhaps they want to make cards or FaceTime calls to older relatives who may be otherwise isolated. They may want to consider ways to support the work of first responders, even just with appreciation. They may want to reach out to elderly neighbors and offer to get groceries or other needed supplies for them. Balancing appropriate self-care with a focus on the needs of those who are more vulnerable or burdened than ourselves is a powerful way to show our children how communities pull together in a challenging time; enhance their feeling of connectedness; and build resilience in them, in our families, and in our communities.

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

We are in uncharted waters with national and local states of emergency, schools and most activities being shut down, and rapidly evolving strategies on managing the COVID-19 outbreak. Everyone’s anxiety is appropriately high. As health care providers for children, you are facing changes in your personal life at home and in practice, likely including setting up televisits, trying to assess which patients to see, managing staffing challenges, and facing potential cash flow issues as expenses continue but revenue may fall short. And, of course, you will address a host of novel questions and concerns from the families you care for.

Ryan McVay/ThinkStock

Your top priorities are to stay calm while offering clear recommendations on testing, quarantine, and treatment with guidance from our federal and local public health agencies. By providing clear guidance on the medical issues, you will offer substantial reassurance to families. But even with a medical plan in place, this remains a confusing and anxiety-provoking moment, one without much precedent in most people’s lives or in our national experience. Our aim is to complement that guidance by offering you some principles to help families manage the stress and anxiety that the disruptions and uncertainties that this public health emergency has created.
 

Offer clear, open, regular, and child-centered communication

Accurate information calmly delivered is the antidote to anxiety or panic in a stressful situation. If you have an email mailing list of your parents, you may want to summarize information you are gathering with a note they can expect at a specified time each day. You could request them to email you questions that then can be included as an FAQ (frequently asked questions).

Most children will have noticed people wearing face masks, or dramatic scenes on the news with hospital workers in full protective gear, breathlessly reporting growing numbers of the infected and the deceased. At a minimum, they are being commanded to wash hands and to not touch their faces (which is challenging enough for adults!), and are probably overhearing conversations about quarantines and contagion as well as family concerns about jobs and family finances. Many children are managing extended school closures and some are even managing the quarantine or serious illness of a loved one. When children overhear frightening news from distressed adults, they are going to become anxious and afraid themselves. Parents should remember to find out what their children have seen, heard, or understood about what is going on, and they should correct misinformation or misunderstandings with clear explanations. They also should find out what their children are curious about. “What has you wondering about that?” is a great response when children have questions, in order to make sure you get at any underlying worry.

It is fine to not have an answer to every question. It is difficult to offer clear explanations about something that we don’t yet fully understand, and it is fine to acknowledge what we don’t know. “That’s a great question. Let’s look together at the CDC [Centers for Disease Control and Prevention] website.” Offering to look for answers or information together can be a powerful way to model how to handle uncertainty. And always couch answers with appropriate (not false) reassurance: “Children and young adults appear to be very safe from this illness, but we want to take care to protect those that are older or already sick.”

Remember most children set their anxiety level based on their parent’s anxiety, and part of being child centered in your communication includes offering information in an age-appropriate manner. Preschool-aged children (up to 5 years) still have magical thinking. They are prone to finding masks and gowns scary and to assume that school stopping may be because they did something wrong. Tell them about the new illness, and about the doctors and officials working hard to keep people safe. Reassure them about all of the adults working hard together to understand the illness and take care of people who are sick. Their sense of time is less logical, so you may have to tell them more than once. Reassure them that children do not get very sick from this illness, but they can carry and spread it, like having paint on their hands, so they need to wash their hands often to take good care of other people.

monkeybusinessimages/thinkstockphotos.com

School-age children (aged roughly 5-12 years) are better equipped cognitively to understand the seriousness of this outbreak. They are built to master new situations, but are prone to anxiety as they don’t yet have the emotional maturity to tolerate uncertainty or unfairness. Explain what is known without euphemisms, be truly curious about what their questions are, and look for answers together. Often what they need is to see you being calm in the face of uncertainty, bearing the strong feelings that may come, and preserving curiosity and compassion for others.

Adolescents also will need all of this support, and can be curious about more abstract implications (political, ethical, financial). Do not be surprised when they ask sophisticated questions, but still are focused on the personal disruptions or sacrifices (a canceled dance or sports meet, concerns about academic performance). Adolescence is a time of intense preoccupation with their emerging identity and relationships; it is normal for them to experience events in a way that may seem selfish, especially if it disrupts their time with friends. Remind parents to offer compassion and validation, while acknowledging that shared sacrifice and discomfort are a part of every individual’s experience when a society must respond to such a large challenge.
 

Be mindful of children’s vulnerabilities

Being child centered goes beyond thinking about their age and developmental stage. Parents are the experts on their children and will know about any particular vulnerabilities to the stresses of this serious outbreak. Children who are prone to anxiety or suffer from anxiety disorders may be more prone to silent worry. It is especially important to check in with them often, find out what they know and what they are worried about, and remind them to “never worry alone.” It also is important to continue with any recommended treatment, avoiding accommodation of their anxieties, except when it is required by public health protocols (i.e., staying home from school). Children with developmental disabilities may require additional support to change behaviors (hand washing) and may be more sensitive to changes in routine. And children with learning disabilities or special services in school may require additional support or structure during a prolonged period at home.

Preserve routines and structure

Routines and predictability are important to the sense of stability and well-being of most children (and adults). While disruptions are unavoidable, preserve what routines you can, and establish some new ones. For children who are out of school for several weeks, set up a consistent home routine, with a similar wake-up and bedtime, and a “school schedule.” There may be academic activities like reading or work sheets. If the parents’ work is disrupted, they can homeschool, shoring up weak academic areas or enhancing areas of interest. Be sure to preserve time for physical activity and social connections within this new framework. Social time does not require physical proximity, and can happen by screen or phone. Physical activity should be outside if at all possible. Predictability, preserved expectations (academic and otherwise), physical exercise, social connection, and consistent sleep will go a long way in protecting everyone’s ability to manage the disruptions of this epidemic.

Find opportunity in the disruption

Many families have been on a treadmill of work, school, and activities that have left little unscheduled time or spontaneity. Recommend looking at this disruption as a rare opportunity to slow down, spend time together, listen, learn more about one another, and even to have fun. Families could play board games, card games, watch movies together, or even read aloud. They might discover it is the time to try new hobbies (knitting, learning a new language or instrument), or to teach each other new skills. You might learn something new, or something new about your children. You also will offer a model of finding the opportunity in adversity, and even offer them some wonderful memories from a difficult time.

Take care of the vulnerable and ease others’ hardships

Without a doubt, this will be a difficult time for many people, medically, financially, and emotionally. One powerful strategy to build resilience in our children and strengthen our communities is to think with children about ways to help those who are most at risk or burdened by this challenge. Perhaps they want to make cards or FaceTime calls to older relatives who may be otherwise isolated. They may want to consider ways to support the work of first responders, even just with appreciation. They may want to reach out to elderly neighbors and offer to get groceries or other needed supplies for them. Balancing appropriate self-care with a focus on the needs of those who are more vulnerable or burdened than ourselves is a powerful way to show our children how communities pull together in a challenging time; enhance their feeling of connectedness; and build resilience in them, in our families, and in our communities.

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

We are in uncharted waters with national and local states of emergency, schools and most activities being shut down, and rapidly evolving strategies on managing the COVID-19 outbreak. Everyone’s anxiety is appropriately high. As health care providers for children, you are facing changes in your personal life at home and in practice, likely including setting up televisits, trying to assess which patients to see, managing staffing challenges, and facing potential cash flow issues as expenses continue but revenue may fall short. And, of course, you will address a host of novel questions and concerns from the families you care for.

Ryan McVay/ThinkStock

Your top priorities are to stay calm while offering clear recommendations on testing, quarantine, and treatment with guidance from our federal and local public health agencies. By providing clear guidance on the medical issues, you will offer substantial reassurance to families. But even with a medical plan in place, this remains a confusing and anxiety-provoking moment, one without much precedent in most people’s lives or in our national experience. Our aim is to complement that guidance by offering you some principles to help families manage the stress and anxiety that the disruptions and uncertainties that this public health emergency has created.
 

Offer clear, open, regular, and child-centered communication

Accurate information calmly delivered is the antidote to anxiety or panic in a stressful situation. If you have an email mailing list of your parents, you may want to summarize information you are gathering with a note they can expect at a specified time each day. You could request them to email you questions that then can be included as an FAQ (frequently asked questions).

Most children will have noticed people wearing face masks, or dramatic scenes on the news with hospital workers in full protective gear, breathlessly reporting growing numbers of the infected and the deceased. At a minimum, they are being commanded to wash hands and to not touch their faces (which is challenging enough for adults!), and are probably overhearing conversations about quarantines and contagion as well as family concerns about jobs and family finances. Many children are managing extended school closures and some are even managing the quarantine or serious illness of a loved one. When children overhear frightening news from distressed adults, they are going to become anxious and afraid themselves. Parents should remember to find out what their children have seen, heard, or understood about what is going on, and they should correct misinformation or misunderstandings with clear explanations. They also should find out what their children are curious about. “What has you wondering about that?” is a great response when children have questions, in order to make sure you get at any underlying worry.

It is fine to not have an answer to every question. It is difficult to offer clear explanations about something that we don’t yet fully understand, and it is fine to acknowledge what we don’t know. “That’s a great question. Let’s look together at the CDC [Centers for Disease Control and Prevention] website.” Offering to look for answers or information together can be a powerful way to model how to handle uncertainty. And always couch answers with appropriate (not false) reassurance: “Children and young adults appear to be very safe from this illness, but we want to take care to protect those that are older or already sick.”

Remember most children set their anxiety level based on their parent’s anxiety, and part of being child centered in your communication includes offering information in an age-appropriate manner. Preschool-aged children (up to 5 years) still have magical thinking. They are prone to finding masks and gowns scary and to assume that school stopping may be because they did something wrong. Tell them about the new illness, and about the doctors and officials working hard to keep people safe. Reassure them about all of the adults working hard together to understand the illness and take care of people who are sick. Their sense of time is less logical, so you may have to tell them more than once. Reassure them that children do not get very sick from this illness, but they can carry and spread it, like having paint on their hands, so they need to wash their hands often to take good care of other people.

monkeybusinessimages/thinkstockphotos.com

School-age children (aged roughly 5-12 years) are better equipped cognitively to understand the seriousness of this outbreak. They are built to master new situations, but are prone to anxiety as they don’t yet have the emotional maturity to tolerate uncertainty or unfairness. Explain what is known without euphemisms, be truly curious about what their questions are, and look for answers together. Often what they need is to see you being calm in the face of uncertainty, bearing the strong feelings that may come, and preserving curiosity and compassion for others.

Adolescents also will need all of this support, and can be curious about more abstract implications (political, ethical, financial). Do not be surprised when they ask sophisticated questions, but still are focused on the personal disruptions or sacrifices (a canceled dance or sports meet, concerns about academic performance). Adolescence is a time of intense preoccupation with their emerging identity and relationships; it is normal for them to experience events in a way that may seem selfish, especially if it disrupts their time with friends. Remind parents to offer compassion and validation, while acknowledging that shared sacrifice and discomfort are a part of every individual’s experience when a society must respond to such a large challenge.
 

Be mindful of children’s vulnerabilities

Being child centered goes beyond thinking about their age and developmental stage. Parents are the experts on their children and will know about any particular vulnerabilities to the stresses of this serious outbreak. Children who are prone to anxiety or suffer from anxiety disorders may be more prone to silent worry. It is especially important to check in with them often, find out what they know and what they are worried about, and remind them to “never worry alone.” It also is important to continue with any recommended treatment, avoiding accommodation of their anxieties, except when it is required by public health protocols (i.e., staying home from school). Children with developmental disabilities may require additional support to change behaviors (hand washing) and may be more sensitive to changes in routine. And children with learning disabilities or special services in school may require additional support or structure during a prolonged period at home.

Preserve routines and structure

Routines and predictability are important to the sense of stability and well-being of most children (and adults). While disruptions are unavoidable, preserve what routines you can, and establish some new ones. For children who are out of school for several weeks, set up a consistent home routine, with a similar wake-up and bedtime, and a “school schedule.” There may be academic activities like reading or work sheets. If the parents’ work is disrupted, they can homeschool, shoring up weak academic areas or enhancing areas of interest. Be sure to preserve time for physical activity and social connections within this new framework. Social time does not require physical proximity, and can happen by screen or phone. Physical activity should be outside if at all possible. Predictability, preserved expectations (academic and otherwise), physical exercise, social connection, and consistent sleep will go a long way in protecting everyone’s ability to manage the disruptions of this epidemic.

Find opportunity in the disruption

Many families have been on a treadmill of work, school, and activities that have left little unscheduled time or spontaneity. Recommend looking at this disruption as a rare opportunity to slow down, spend time together, listen, learn more about one another, and even to have fun. Families could play board games, card games, watch movies together, or even read aloud. They might discover it is the time to try new hobbies (knitting, learning a new language or instrument), or to teach each other new skills. You might learn something new, or something new about your children. You also will offer a model of finding the opportunity in adversity, and even offer them some wonderful memories from a difficult time.

Take care of the vulnerable and ease others’ hardships

Without a doubt, this will be a difficult time for many people, medically, financially, and emotionally. One powerful strategy to build resilience in our children and strengthen our communities is to think with children about ways to help those who are most at risk or burdened by this challenge. Perhaps they want to make cards or FaceTime calls to older relatives who may be otherwise isolated. They may want to consider ways to support the work of first responders, even just with appreciation. They may want to reach out to elderly neighbors and offer to get groceries or other needed supplies for them. Balancing appropriate self-care with a focus on the needs of those who are more vulnerable or burdened than ourselves is a powerful way to show our children how communities pull together in a challenging time; enhance their feeling of connectedness; and build resilience in them, in our families, and in our communities.

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

Anxiety is probably the most common behavioral health complaint that presents in the pediatrician’s office. The prevalence of anxiety is going up every year, and we do not have a good understanding why. Is it the pressure to perform at earlier and earlier ages? Is it the press of information or rapid communication of every disaster on Earth? Or are children not developing appropriate coping skills for the expectable challenges and stresses they will face through development? We do not know.

Anxiety disorders are most likely to present in the early school years – latency – between the ages of 6 and 12 years. Teenagers may present with new anxiety disorders or may disclose symptoms that they have been quietly managing since they were younger, when they were thought to be “shy.” These disorders include separation anxiety disorder, social phobia, selective mutism, specific phobia, and generalized anxiety disorder. This age period also is marked by high levels of normal anxiety because children’s cognitive development has advanced beyond their emotional development. They are capable of logic, can understand cause and effect, and can appreciate the passage of time and serious matters such as the permanence of death. Gone is the magical thinking of the preschool years! When an elementary student learns about global warming or a refugee crisis, they can fully appreciate the serious implications of the subject. What they lack is experience with tolerating uncertainty and worry and proceeding with life, focusing on what they might address or even bearing the fact that life is sometimes unfair. This mismatch of relative cognitive maturity with emotional immaturity can lead to anxiety and distress. This is particularly true as they face these challenges while they have new independence, spending longer days at school and less time with parents. Bearing this distress with caring adults, learning to focus on what they can do, and discovering that they and the world can go on even when something very unfair has happened is central to how they develop emotional maturity.

How a child learns to manage anxiety is very much determined by how their parents manage anxiety and how well their parents can tolerate their children’s distress. A parent who becomes overwhelmed when their child is upset about missing a goal in soccer will have a difficult time helping their child learn how to manage distress. And children who are facing chronic severe stress, such as poverty, domestic violence, or chronic illness in a parent, are facing the double challenge of managing persistent anxiety that may be impairing their parents’ ability to support them. When the child and their family are connected to a community that has not been able to effectively respond to larger problems, such as creating safe schools or neighborhoods, anxiety can become entrenched in despair.

So where to begin when your patient comes to an appointment reporting high levels of anxiety? Start by remaining calm and being curious for more details. It often is tempting to jump in with reassurance when your patient or their parents present with anxiety. But when you calmly show curiosity, you model tolerance of their distress. Are they fearful about very specific situations, such as being called on in class? Or do they become dysregulated when facing a separation from their parents, such as at bedtime or before school, seeking contact with their parents with endless questions? Find out how the parents are managing separations and whether they may be inadvertently rewarding by staying with them to negotiate or answer endless questions. Find out if parents may be accommodating anxiety by allowing their children to avoid normal situations that are stirring anxiety. Do they give in anytime their child shows resistance or have they learned to pick their battles and help their children face more-modest stress while avoiding only the most intensely anxious situations? Are the parents able to speak calmly and with good humor about these challenges or do they become very stressed and defensive? Is there a family history of anxiety? Managing a child’s anxiety every day can be exhausting, and parents might need a referral in addition to a discussion about how anxiety is developmentally normal.

For those parents that can manage this discussion, suggest that, like you, if they can remain calm during these times with their child (even if they don’t feel calm), it will help their child get better at managing anxiety, even if their child has an anxiety disorder. They also should be curious about their child’s worries, learning about the details and scenarios their children may be anticipating. They should express compassion about how uncomfortable anxiety is, coupled with their confident belief that the child will be able to tolerate and manage the situation even though it’s uncomfortable. This acknowledgment should not be a dismissal of the anxiety, instead it should be confidence that the child will learn to bear it.

When your patient is a teenager describing anxiety, unpack. Are they anxious about their performance on their five Advanced Placement exams? If their anxiety sounds more like appropriate stress, be compassionate and then curious about how they are learning to relax. Are they using drugs and alcohol? Or have they found healthy ways to unwind and recharge? Focusing on ways in which they are learning to care for themselves, making time for sleep and exercise, live time with friends, and senseless fun is therapeutic. Find out if their parents are supportive of their self-care. You might even give them a prescription!

Anxiety is often a private experience, and parents might not know about it until it presents with an explosion of distress or obstinacy when an anxious child is pushed into scary territory. Asking questions about specific worries (something happening to parents, germs, weather events) can illuminate the extent of anxiety. It also is worth exploring if there are rituals that help them manage their worries, whether they are common (finding a parent, hugging a pet, prayer) or more compulsive (repetitive undoing, hair pulling). Find out if there has recently been any serious stress or change for the family, such as the loss of a job or illness in a grandparent, that may be contributing to a child’s anxiety.

Anytime you see anxieties that are broad or extreme, disrupt their ability to function (go to school, participate in activities, build friendships), or if their parents are clearly struggling with managing their child’s distress, it is worthwhile to find a referral to a psychiatrist or psychologist for evaluation and further treatment. School avoidance constitutes an urgent need for evaluation, as every day of school missed makes it harder for the child to return to school. For all of your anxious patients, even when you make a referral to a psychiatrist for evaluation, teach your patients and parents about how critical adequate sleep and regular exercise are to managing anxiety. Remind them that an appropriate level of anxiety is normal and promotes performance and grit, despite the discomfort, and that learning how to manage anxiety is essential to growing up and building mental health.

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

Anxiety is probably the most common behavioral health complaint that presents in the pediatrician’s office. The prevalence of anxiety is going up every year, and we do not have a good understanding why. Is it the pressure to perform at earlier and earlier ages? Is it the press of information or rapid communication of every disaster on Earth? Or are children not developing appropriate coping skills for the expectable challenges and stresses they will face through development? We do not know.

Anxiety disorders are most likely to present in the early school years – latency – between the ages of 6 and 12 years. Teenagers may present with new anxiety disorders or may disclose symptoms that they have been quietly managing since they were younger, when they were thought to be “shy.” These disorders include separation anxiety disorder, social phobia, selective mutism, specific phobia, and generalized anxiety disorder. This age period also is marked by high levels of normal anxiety because children’s cognitive development has advanced beyond their emotional development. They are capable of logic, can understand cause and effect, and can appreciate the passage of time and serious matters such as the permanence of death. Gone is the magical thinking of the preschool years! When an elementary student learns about global warming or a refugee crisis, they can fully appreciate the serious implications of the subject. What they lack is experience with tolerating uncertainty and worry and proceeding with life, focusing on what they might address or even bearing the fact that life is sometimes unfair. This mismatch of relative cognitive maturity with emotional immaturity can lead to anxiety and distress. This is particularly true as they face these challenges while they have new independence, spending longer days at school and less time with parents. Bearing this distress with caring adults, learning to focus on what they can do, and discovering that they and the world can go on even when something very unfair has happened is central to how they develop emotional maturity.

How a child learns to manage anxiety is very much determined by how their parents manage anxiety and how well their parents can tolerate their children’s distress. A parent who becomes overwhelmed when their child is upset about missing a goal in soccer will have a difficult time helping their child learn how to manage distress. And children who are facing chronic severe stress, such as poverty, domestic violence, or chronic illness in a parent, are facing the double challenge of managing persistent anxiety that may be impairing their parents’ ability to support them. When the child and their family are connected to a community that has not been able to effectively respond to larger problems, such as creating safe schools or neighborhoods, anxiety can become entrenched in despair.

So where to begin when your patient comes to an appointment reporting high levels of anxiety? Start by remaining calm and being curious for more details. It often is tempting to jump in with reassurance when your patient or their parents present with anxiety. But when you calmly show curiosity, you model tolerance of their distress. Are they fearful about very specific situations, such as being called on in class? Or do they become dysregulated when facing a separation from their parents, such as at bedtime or before school, seeking contact with their parents with endless questions? Find out how the parents are managing separations and whether they may be inadvertently rewarding by staying with them to negotiate or answer endless questions. Find out if parents may be accommodating anxiety by allowing their children to avoid normal situations that are stirring anxiety. Do they give in anytime their child shows resistance or have they learned to pick their battles and help their children face more-modest stress while avoiding only the most intensely anxious situations? Are the parents able to speak calmly and with good humor about these challenges or do they become very stressed and defensive? Is there a family history of anxiety? Managing a child’s anxiety every day can be exhausting, and parents might need a referral in addition to a discussion about how anxiety is developmentally normal.

For those parents that can manage this discussion, suggest that, like you, if they can remain calm during these times with their child (even if they don’t feel calm), it will help their child get better at managing anxiety, even if their child has an anxiety disorder. They also should be curious about their child’s worries, learning about the details and scenarios their children may be anticipating. They should express compassion about how uncomfortable anxiety is, coupled with their confident belief that the child will be able to tolerate and manage the situation even though it’s uncomfortable. This acknowledgment should not be a dismissal of the anxiety, instead it should be confidence that the child will learn to bear it.

When your patient is a teenager describing anxiety, unpack. Are they anxious about their performance on their five Advanced Placement exams? If their anxiety sounds more like appropriate stress, be compassionate and then curious about how they are learning to relax. Are they using drugs and alcohol? Or have they found healthy ways to unwind and recharge? Focusing on ways in which they are learning to care for themselves, making time for sleep and exercise, live time with friends, and senseless fun is therapeutic. Find out if their parents are supportive of their self-care. You might even give them a prescription!

Anxiety is often a private experience, and parents might not know about it until it presents with an explosion of distress or obstinacy when an anxious child is pushed into scary territory. Asking questions about specific worries (something happening to parents, germs, weather events) can illuminate the extent of anxiety. It also is worth exploring if there are rituals that help them manage their worries, whether they are common (finding a parent, hugging a pet, prayer) or more compulsive (repetitive undoing, hair pulling). Find out if there has recently been any serious stress or change for the family, such as the loss of a job or illness in a grandparent, that may be contributing to a child’s anxiety.

Anytime you see anxieties that are broad or extreme, disrupt their ability to function (go to school, participate in activities, build friendships), or if their parents are clearly struggling with managing their child’s distress, it is worthwhile to find a referral to a psychiatrist or psychologist for evaluation and further treatment. School avoidance constitutes an urgent need for evaluation, as every day of school missed makes it harder for the child to return to school. For all of your anxious patients, even when you make a referral to a psychiatrist for evaluation, teach your patients and parents about how critical adequate sleep and regular exercise are to managing anxiety. Remind them that an appropriate level of anxiety is normal and promotes performance and grit, despite the discomfort, and that learning how to manage anxiety is essential to growing up and building mental health.

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

Anxiety is probably the most common behavioral health complaint that presents in the pediatrician’s office. The prevalence of anxiety is going up every year, and we do not have a good understanding why. Is it the pressure to perform at earlier and earlier ages? Is it the press of information or rapid communication of every disaster on Earth? Or are children not developing appropriate coping skills for the expectable challenges and stresses they will face through development? We do not know.

Anxiety disorders are most likely to present in the early school years – latency – between the ages of 6 and 12 years. Teenagers may present with new anxiety disorders or may disclose symptoms that they have been quietly managing since they were younger, when they were thought to be “shy.” These disorders include separation anxiety disorder, social phobia, selective mutism, specific phobia, and generalized anxiety disorder. This age period also is marked by high levels of normal anxiety because children’s cognitive development has advanced beyond their emotional development. They are capable of logic, can understand cause and effect, and can appreciate the passage of time and serious matters such as the permanence of death. Gone is the magical thinking of the preschool years! When an elementary student learns about global warming or a refugee crisis, they can fully appreciate the serious implications of the subject. What they lack is experience with tolerating uncertainty and worry and proceeding with life, focusing on what they might address or even bearing the fact that life is sometimes unfair. This mismatch of relative cognitive maturity with emotional immaturity can lead to anxiety and distress. This is particularly true as they face these challenges while they have new independence, spending longer days at school and less time with parents. Bearing this distress with caring adults, learning to focus on what they can do, and discovering that they and the world can go on even when something very unfair has happened is central to how they develop emotional maturity.

How a child learns to manage anxiety is very much determined by how their parents manage anxiety and how well their parents can tolerate their children’s distress. A parent who becomes overwhelmed when their child is upset about missing a goal in soccer will have a difficult time helping their child learn how to manage distress. And children who are facing chronic severe stress, such as poverty, domestic violence, or chronic illness in a parent, are facing the double challenge of managing persistent anxiety that may be impairing their parents’ ability to support them. When the child and their family are connected to a community that has not been able to effectively respond to larger problems, such as creating safe schools or neighborhoods, anxiety can become entrenched in despair.

So where to begin when your patient comes to an appointment reporting high levels of anxiety? Start by remaining calm and being curious for more details. It often is tempting to jump in with reassurance when your patient or their parents present with anxiety. But when you calmly show curiosity, you model tolerance of their distress. Are they fearful about very specific situations, such as being called on in class? Or do they become dysregulated when facing a separation from their parents, such as at bedtime or before school, seeking contact with their parents with endless questions? Find out how the parents are managing separations and whether they may be inadvertently rewarding by staying with them to negotiate or answer endless questions. Find out if parents may be accommodating anxiety by allowing their children to avoid normal situations that are stirring anxiety. Do they give in anytime their child shows resistance or have they learned to pick their battles and help their children face more-modest stress while avoiding only the most intensely anxious situations? Are the parents able to speak calmly and with good humor about these challenges or do they become very stressed and defensive? Is there a family history of anxiety? Managing a child’s anxiety every day can be exhausting, and parents might need a referral in addition to a discussion about how anxiety is developmentally normal.

For those parents that can manage this discussion, suggest that, like you, if they can remain calm during these times with their child (even if they don’t feel calm), it will help their child get better at managing anxiety, even if their child has an anxiety disorder. They also should be curious about their child’s worries, learning about the details and scenarios their children may be anticipating. They should express compassion about how uncomfortable anxiety is, coupled with their confident belief that the child will be able to tolerate and manage the situation even though it’s uncomfortable. This acknowledgment should not be a dismissal of the anxiety, instead it should be confidence that the child will learn to bear it.

When your patient is a teenager describing anxiety, unpack. Are they anxious about their performance on their five Advanced Placement exams? If their anxiety sounds more like appropriate stress, be compassionate and then curious about how they are learning to relax. Are they using drugs and alcohol? Or have they found healthy ways to unwind and recharge? Focusing on ways in which they are learning to care for themselves, making time for sleep and exercise, live time with friends, and senseless fun is therapeutic. Find out if their parents are supportive of their self-care. You might even give them a prescription!

Anxiety is often a private experience, and parents might not know about it until it presents with an explosion of distress or obstinacy when an anxious child is pushed into scary territory. Asking questions about specific worries (something happening to parents, germs, weather events) can illuminate the extent of anxiety. It also is worth exploring if there are rituals that help them manage their worries, whether they are common (finding a parent, hugging a pet, prayer) or more compulsive (repetitive undoing, hair pulling). Find out if there has recently been any serious stress or change for the family, such as the loss of a job or illness in a grandparent, that may be contributing to a child’s anxiety.

Anytime you see anxieties that are broad or extreme, disrupt their ability to function (go to school, participate in activities, build friendships), or if their parents are clearly struggling with managing their child’s distress, it is worthwhile to find a referral to a psychiatrist or psychologist for evaluation and further treatment. School avoidance constitutes an urgent need for evaluation, as every day of school missed makes it harder for the child to return to school. For all of your anxious patients, even when you make a referral to a psychiatrist for evaluation, teach your patients and parents about how critical adequate sleep and regular exercise are to managing anxiety. Remind them that an appropriate level of anxiety is normal and promotes performance and grit, despite the discomfort, and that learning how to manage anxiety is essential to growing up and building mental health.

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

Strong feelings – such as intense anxiety, irritability, or depressed mood – may affect every child for brief periods of time during their development. Parents and pediatricians are wise to not treat them as psychiatric disorders unless they persist for weeks, impair functioning, or are dramatically severe. Psychosis – marked by hallucinations, perceptual distortions, or profoundly disorganized thinking and behavior – typically looks dramatically severe. Even when psychotic symptoms are mild or brief, they can cause very serious distress for parents and clinicians. The worry is that they may represent a “first break,” a psychotic episode that requires much work for recovery, or the beginning of a lifelong struggle with schizophrenia or other chronic psychotic illness.

KatarzynaBialasiewicz/iStock/Getty Images Plus

While it is important to recognize schizophrenia early – because early interventions are thought to improve the course of the disease – schizophrenia in childhood is rare. It is not commonly recognized that psychotic or psychoticlike symptoms are much more common than schizophrenia. In childhood, psychosis is three times more common than in adults, and can indicate a number of different psychiatric or medical problems. While it is important to begin a thoughtful evaluation when a child or teenager presents with psychosis, it also is important to know that the majority of young people who experience psychotic symptoms do not have schizophrenia or other psychotic illness.

Psychosis describes symptoms in which there has been some “break with reality,” often in the form of hallucinations (seeing or hearing things which are not objectively present) or of distorted perceptions (such as paranoia or grandiosity). “Subsyndromal psychotic symptoms” occur when a person experiences these perceptual disturbances but has doubt about whether or not they are real. In frank psychosis, patients have a “fixed and firm” belief in the truth or accuracy of their perceptions, no matter the evidence against them. The voices they hear or hallucinations they see are “real” and there is a wholehearted belief that what the voice says or what they are seeing is as true as what you or I see and hear.

Schizophrenia is a diagnosis that requires the presence of both these “positive” psychotic symptoms and “negative” symptoms of flat affect; loss of motivation, social, or motor abilities; and cognitive impairment. These symptoms typically emerge in late adolescence (median age, 18 years) in males and early adulthood (median age, 25 years) in females, with another (smaller) peak in incidence in middle age. Importantly, the negative symptoms often emerge first so there often is a history of subtle cognitive decline and social withdrawal, one of the most common patterns in children, before psychosis emerges. Schizophrenia is quite rare, with a prevalence of slightly under 1% of the global population, an annual incidence of approximately 15 people per 100,000, and 1 in 40,000 in children under 13 years old, according to the National Institute of Mental Health. Psychotic symptoms are much more common than schizophrenia, affecting approximately 5% of the adult population at any point in time. They are even more common in children and adolescents. A meta-analysis of population-based studies of psychotic symptoms in youth demonstrated a median prevalence of 17% in children aged 9-12 years and 7.5% in adolescents aged 13-18 years.¹ Of course, as with all statistics, much depends on the definitions used to identify this high prevalence rate.

Children and adolescents who report psychotic symptoms are at increased risk for developing schizophrenia, compared with the general population, but most youth with psychotic symptoms will not go on to develop schizophrenia. They are more likely to indicate other, nonpsychotic psychiatric illnesses, such as anxiety or mood disorders, including depression, obsessive compulsive disorder (OCD), and PTSD. In younger children, these symptoms may prove to be benign, but in adolescents they usually indicate the presence of a psychiatric illness. In one study, 57% of children aged 11-13 years with psychotic symptoms were found to have a nonpsychotic psychiatric illness, but the rate jumped to 80% for those aged 13-15 years with psychotic symptoms.² So while psychosis in teenagers only rarely indicates schizophrenia, these symptoms usually indicate the presence of a psychiatric illness, and a psychiatric evaluation should be initiated.

If a child in your practice presents with psychotic symptoms, it is appropriate to assess their safety and then start a medical work-up. Find out from your patient or their parents if their behavior has been affected by their perceptual disturbances. Are they frightened and avoiding school? Are they withdrawing from social relationships? Is their sleep disrupted? Have they been more impulsive or unpredictable? If their behavior has been affected, you should refer to a child psychiatrist to perform a full diagnostic evaluation and help with management of these symptoms.

Your medical work-up should include a drug screen, blood count, metabolic panel, and thyroid function test. Medications, particularly stimulants, steroids, and anticholinergics can cause psychotic symptoms in high doses or vulnerable patients (such as those with a developmental disorder or traumatic brain injury). If the physical or neurologic exam are suggestive, further investigation of the many potential medical sources of psychotic symptoms in youth can be pursued to rule out autoimmune illnesses, endocrine disorders, metabolic illnesses, heavy metal poisoning, neurologic diseases, infectious diseases, and nutritional deficits. It is worth noting that childhood sleep disorders also can present with psychosis. Persistent psychotic symptoms in children are very hard to evaluate and may be the harbinger of a serious psychiatric disorder, so even if the medical work-up is negative and the persistent symptoms are mild and not causing a safety concern, a referral to a child psychiatrist for a full mental health evaluation is appropriate.

Psychotic symptoms in an adolescent sometimes are easier to assess, more worrisome for serious mental illness, and are a high-risk category for self-destructive behavior and substance use. Before you begin a medical work-up, you always should assess for safety, including suicide risk, if your adolescent patient presents with psychotic symptoms. Screening for symptoms of mood, anxiety, and substance use disorders also can help reveal the nature of their presenting problem. If your adolescent patient is using drugs, that does not rule out the possibility of an underlying mood, anxiety, or thought disorder. While intoxication with many drugs may precipitate psychotic symptoms (including stimulants, hallucinogens, and marijuana), others may precipitate psychosis in withdrawal states (alcohol, benzodiazepines, and other CNS depressants). It also is important to note that adolescents with emerging schizophrenia have very high rates of comorbid substance abuse (as high as 60%), so their drug use may not be the cause of their psychotic symptoms. There also is emerging evidence that use of certain drugs during sensitive developmental periods can significantly increase the likelihood of developing schizophrenia in vulnerable populations, such as with regular marijuana use in adolescents who have a family history of schizophrenia.

For those rare pediatric patients who present with both negative and positive symptoms of emerging schizophrenia, early diagnosis and treatment has shown promise in improving the course of the disease. Cognitive-behavioral therapy (CBT) for psychosis has shown promise in lowering the rates of conversion to schizophrenia in select patient populations. This therapy teaches strategies for improving reality testing, cognitive flexibility, and social skills. The social skills appear to be especially important for improving adaptive function, even in those patients who progress to schizophrenia. Family therapies, focused on improving family cohesion, communication, and adaptive functioning, appear to improve family well-being and the course of the patient’s illness (such as fewer and less severe psychotic episodes and improved mood and adaptive function). Early use of antipsychotic medications also appears to improve the course of the illness.

While schizophrenia is not curable, early detection (perhaps by a pediatrician), referral, and treatment can be powerfully protective for patients and their families.
 

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

References

1. Psychol Med. 2012 Sep;42(9):1857-63.

2. Br J Psychiatry. 2012 Jul;201(1):26-32.

Strong feelings – such as intense anxiety, irritability, or depressed mood – may affect every child for brief periods of time during their development. Parents and pediatricians are wise to not treat them as psychiatric disorders unless they persist for weeks, impair functioning, or are dramatically severe. Psychosis – marked by hallucinations, perceptual distortions, or profoundly disorganized thinking and behavior – typically looks dramatically severe. Even when psychotic symptoms are mild or brief, they can cause very serious distress for parents and clinicians. The worry is that they may represent a “first break,” a psychotic episode that requires much work for recovery, or the beginning of a lifelong struggle with schizophrenia or other chronic psychotic illness.

KatarzynaBialasiewicz/iStock/Getty Images Plus

While it is important to recognize schizophrenia early – because early interventions are thought to improve the course of the disease – schizophrenia in childhood is rare. It is not commonly recognized that psychotic or psychoticlike symptoms are much more common than schizophrenia. In childhood, psychosis is three times more common than in adults, and can indicate a number of different psychiatric or medical problems. While it is important to begin a thoughtful evaluation when a child or teenager presents with psychosis, it also is important to know that the majority of young people who experience psychotic symptoms do not have schizophrenia or other psychotic illness.

Psychosis describes symptoms in which there has been some “break with reality,” often in the form of hallucinations (seeing or hearing things which are not objectively present) or of distorted perceptions (such as paranoia or grandiosity). “Subsyndromal psychotic symptoms” occur when a person experiences these perceptual disturbances but has doubt about whether or not they are real. In frank psychosis, patients have a “fixed and firm” belief in the truth or accuracy of their perceptions, no matter the evidence against them. The voices they hear or hallucinations they see are “real” and there is a wholehearted belief that what the voice says or what they are seeing is as true as what you or I see and hear.

Schizophrenia is a diagnosis that requires the presence of both these “positive” psychotic symptoms and “negative” symptoms of flat affect; loss of motivation, social, or motor abilities; and cognitive impairment. These symptoms typically emerge in late adolescence (median age, 18 years) in males and early adulthood (median age, 25 years) in females, with another (smaller) peak in incidence in middle age. Importantly, the negative symptoms often emerge first so there often is a history of subtle cognitive decline and social withdrawal, one of the most common patterns in children, before psychosis emerges. Schizophrenia is quite rare, with a prevalence of slightly under 1% of the global population, an annual incidence of approximately 15 people per 100,000, and 1 in 40,000 in children under 13 years old, according to the National Institute of Mental Health. Psychotic symptoms are much more common than schizophrenia, affecting approximately 5% of the adult population at any point in time. They are even more common in children and adolescents. A meta-analysis of population-based studies of psychotic symptoms in youth demonstrated a median prevalence of 17% in children aged 9-12 years and 7.5% in adolescents aged 13-18 years.¹ Of course, as with all statistics, much depends on the definitions used to identify this high prevalence rate.

Children and adolescents who report psychotic symptoms are at increased risk for developing schizophrenia, compared with the general population, but most youth with psychotic symptoms will not go on to develop schizophrenia. They are more likely to indicate other, nonpsychotic psychiatric illnesses, such as anxiety or mood disorders, including depression, obsessive compulsive disorder (OCD), and PTSD. In younger children, these symptoms may prove to be benign, but in adolescents they usually indicate the presence of a psychiatric illness. In one study, 57% of children aged 11-13 years with psychotic symptoms were found to have a nonpsychotic psychiatric illness, but the rate jumped to 80% for those aged 13-15 years with psychotic symptoms.² So while psychosis in teenagers only rarely indicates schizophrenia, these symptoms usually indicate the presence of a psychiatric illness, and a psychiatric evaluation should be initiated.

If a child in your practice presents with psychotic symptoms, it is appropriate to assess their safety and then start a medical work-up. Find out from your patient or their parents if their behavior has been affected by their perceptual disturbances. Are they frightened and avoiding school? Are they withdrawing from social relationships? Is their sleep disrupted? Have they been more impulsive or unpredictable? If their behavior has been affected, you should refer to a child psychiatrist to perform a full diagnostic evaluation and help with management of these symptoms.

Your medical work-up should include a drug screen, blood count, metabolic panel, and thyroid function test. Medications, particularly stimulants, steroids, and anticholinergics can cause psychotic symptoms in high doses or vulnerable patients (such as those with a developmental disorder or traumatic brain injury). If the physical or neurologic exam are suggestive, further investigation of the many potential medical sources of psychotic symptoms in youth can be pursued to rule out autoimmune illnesses, endocrine disorders, metabolic illnesses, heavy metal poisoning, neurologic diseases, infectious diseases, and nutritional deficits. It is worth noting that childhood sleep disorders also can present with psychosis. Persistent psychotic symptoms in children are very hard to evaluate and may be the harbinger of a serious psychiatric disorder, so even if the medical work-up is negative and the persistent symptoms are mild and not causing a safety concern, a referral to a child psychiatrist for a full mental health evaluation is appropriate.

Psychotic symptoms in an adolescent sometimes are easier to assess, more worrisome for serious mental illness, and are a high-risk category for self-destructive behavior and substance use. Before you begin a medical work-up, you always should assess for safety, including suicide risk, if your adolescent patient presents with psychotic symptoms. Screening for symptoms of mood, anxiety, and substance use disorders also can help reveal the nature of their presenting problem. If your adolescent patient is using drugs, that does not rule out the possibility of an underlying mood, anxiety, or thought disorder. While intoxication with many drugs may precipitate psychotic symptoms (including stimulants, hallucinogens, and marijuana), others may precipitate psychosis in withdrawal states (alcohol, benzodiazepines, and other CNS depressants). It also is important to note that adolescents with emerging schizophrenia have very high rates of comorbid substance abuse (as high as 60%), so their drug use may not be the cause of their psychotic symptoms. There also is emerging evidence that use of certain drugs during sensitive developmental periods can significantly increase the likelihood of developing schizophrenia in vulnerable populations, such as with regular marijuana use in adolescents who have a family history of schizophrenia.

For those rare pediatric patients who present with both negative and positive symptoms of emerging schizophrenia, early diagnosis and treatment has shown promise in improving the course of the disease. Cognitive-behavioral therapy (CBT) for psychosis has shown promise in lowering the rates of conversion to schizophrenia in select patient populations. This therapy teaches strategies for improving reality testing, cognitive flexibility, and social skills. The social skills appear to be especially important for improving adaptive function, even in those patients who progress to schizophrenia. Family therapies, focused on improving family cohesion, communication, and adaptive functioning, appear to improve family well-being and the course of the patient’s illness (such as fewer and less severe psychotic episodes and improved mood and adaptive function). Early use of antipsychotic medications also appears to improve the course of the illness.

While schizophrenia is not curable, early detection (perhaps by a pediatrician), referral, and treatment can be powerfully protective for patients and their families.
 

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

References

1. Psychol Med. 2012 Sep;42(9):1857-63.

2. Br J Psychiatry. 2012 Jul;201(1):26-32.

Strong feelings – such as intense anxiety, irritability, or depressed mood – may affect every child for brief periods of time during their development. Parents and pediatricians are wise to not treat them as psychiatric disorders unless they persist for weeks, impair functioning, or are dramatically severe. Psychosis – marked by hallucinations, perceptual distortions, or profoundly disorganized thinking and behavior – typically looks dramatically severe. Even when psychotic symptoms are mild or brief, they can cause very serious distress for parents and clinicians. The worry is that they may represent a “first break,” a psychotic episode that requires much work for recovery, or the beginning of a lifelong struggle with schizophrenia or other chronic psychotic illness.

KatarzynaBialasiewicz/iStock/Getty Images Plus

While it is important to recognize schizophrenia early – because early interventions are thought to improve the course of the disease – schizophrenia in childhood is rare. It is not commonly recognized that psychotic or psychoticlike symptoms are much more common than schizophrenia. In childhood, psychosis is three times more common than in adults, and can indicate a number of different psychiatric or medical problems. While it is important to begin a thoughtful evaluation when a child or teenager presents with psychosis, it also is important to know that the majority of young people who experience psychotic symptoms do not have schizophrenia or other psychotic illness.

Psychosis describes symptoms in which there has been some “break with reality,” often in the form of hallucinations (seeing or hearing things which are not objectively present) or of distorted perceptions (such as paranoia or grandiosity). “Subsyndromal psychotic symptoms” occur when a person experiences these perceptual disturbances but has doubt about whether or not they are real. In frank psychosis, patients have a “fixed and firm” belief in the truth or accuracy of their perceptions, no matter the evidence against them. The voices they hear or hallucinations they see are “real” and there is a wholehearted belief that what the voice says or what they are seeing is as true as what you or I see and hear.

Schizophrenia is a diagnosis that requires the presence of both these “positive” psychotic symptoms and “negative” symptoms of flat affect; loss of motivation, social, or motor abilities; and cognitive impairment. These symptoms typically emerge in late adolescence (median age, 18 years) in males and early adulthood (median age, 25 years) in females, with another (smaller) peak in incidence in middle age. Importantly, the negative symptoms often emerge first so there often is a history of subtle cognitive decline and social withdrawal, one of the most common patterns in children, before psychosis emerges. Schizophrenia is quite rare, with a prevalence of slightly under 1% of the global population, an annual incidence of approximately 15 people per 100,000, and 1 in 40,000 in children under 13 years old, according to the National Institute of Mental Health. Psychotic symptoms are much more common than schizophrenia, affecting approximately 5% of the adult population at any point in time. They are even more common in children and adolescents. A meta-analysis of population-based studies of psychotic symptoms in youth demonstrated a median prevalence of 17% in children aged 9-12 years and 7.5% in adolescents aged 13-18 years.¹ Of course, as with all statistics, much depends on the definitions used to identify this high prevalence rate.

Children and adolescents who report psychotic symptoms are at increased risk for developing schizophrenia, compared with the general population, but most youth with psychotic symptoms will not go on to develop schizophrenia. They are more likely to indicate other, nonpsychotic psychiatric illnesses, such as anxiety or mood disorders, including depression, obsessive compulsive disorder (OCD), and PTSD. In younger children, these symptoms may prove to be benign, but in adolescents they usually indicate the presence of a psychiatric illness. In one study, 57% of children aged 11-13 years with psychotic symptoms were found to have a nonpsychotic psychiatric illness, but the rate jumped to 80% for those aged 13-15 years with psychotic symptoms.² So while psychosis in teenagers only rarely indicates schizophrenia, these symptoms usually indicate the presence of a psychiatric illness, and a psychiatric evaluation should be initiated.

If a child in your practice presents with psychotic symptoms, it is appropriate to assess their safety and then start a medical work-up. Find out from your patient or their parents if their behavior has been affected by their perceptual disturbances. Are they frightened and avoiding school? Are they withdrawing from social relationships? Is their sleep disrupted? Have they been more impulsive or unpredictable? If their behavior has been affected, you should refer to a child psychiatrist to perform a full diagnostic evaluation and help with management of these symptoms.

Your medical work-up should include a drug screen, blood count, metabolic panel, and thyroid function test. Medications, particularly stimulants, steroids, and anticholinergics can cause psychotic symptoms in high doses or vulnerable patients (such as those with a developmental disorder or traumatic brain injury). If the physical or neurologic exam are suggestive, further investigation of the many potential medical sources of psychotic symptoms in youth can be pursued to rule out autoimmune illnesses, endocrine disorders, metabolic illnesses, heavy metal poisoning, neurologic diseases, infectious diseases, and nutritional deficits. It is worth noting that childhood sleep disorders also can present with psychosis. Persistent psychotic symptoms in children are very hard to evaluate and may be the harbinger of a serious psychiatric disorder, so even if the medical work-up is negative and the persistent symptoms are mild and not causing a safety concern, a referral to a child psychiatrist for a full mental health evaluation is appropriate.

Psychotic symptoms in an adolescent sometimes are easier to assess, more worrisome for serious mental illness, and are a high-risk category for self-destructive behavior and substance use. Before you begin a medical work-up, you always should assess for safety, including suicide risk, if your adolescent patient presents with psychotic symptoms. Screening for symptoms of mood, anxiety, and substance use disorders also can help reveal the nature of their presenting problem. If your adolescent patient is using drugs, that does not rule out the possibility of an underlying mood, anxiety, or thought disorder. While intoxication with many drugs may precipitate psychotic symptoms (including stimulants, hallucinogens, and marijuana), others may precipitate psychosis in withdrawal states (alcohol, benzodiazepines, and other CNS depressants). It also is important to note that adolescents with emerging schizophrenia have very high rates of comorbid substance abuse (as high as 60%), so their drug use may not be the cause of their psychotic symptoms. There also is emerging evidence that use of certain drugs during sensitive developmental periods can significantly increase the likelihood of developing schizophrenia in vulnerable populations, such as with regular marijuana use in adolescents who have a family history of schizophrenia.

For those rare pediatric patients who present with both negative and positive symptoms of emerging schizophrenia, early diagnosis and treatment has shown promise in improving the course of the disease. Cognitive-behavioral therapy (CBT) for psychosis has shown promise in lowering the rates of conversion to schizophrenia in select patient populations. This therapy teaches strategies for improving reality testing, cognitive flexibility, and social skills. The social skills appear to be especially important for improving adaptive function, even in those patients who progress to schizophrenia. Family therapies, focused on improving family cohesion, communication, and adaptive functioning, appear to improve family well-being and the course of the patient’s illness (such as fewer and less severe psychotic episodes and improved mood and adaptive function). Early use of antipsychotic medications also appears to improve the course of the illness.

While schizophrenia is not curable, early detection (perhaps by a pediatrician), referral, and treatment can be powerfully protective for patients and their families.
 

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

References

1. Psychol Med. 2012 Sep;42(9):1857-63.

2. Br J Psychiatry. 2012 Jul;201(1):26-32.