Behavioral Consult

To weary parents, the fact that their child does not want to go to bed at night is both puzzling and exasperating. No matter what age, it is important to have a healthy bedtime for the child’s well-being as well as their caregiver’s!

Sleep, like the “canary in the mine,” is vulnerable to disruption by anything from minor illness to changes in schedule, things viewed on media, or emotions in the home, to life changes such as a new sibling, toilet training, or a new school year. In patients on stimulant medicine resisting bedtime, consider the need to finally eat. Asking about these specifically will help you plan an appropriate time to successfully address bedtime conflicts.

Knowing some basic principles about falling asleep can help your counseling. “Sleep drive” builds up over the day like a coiled spring, making falling asleep easier initially than for wakings later in the night. It also means that a nap too close to bedtime reduces the drive. Avoiding any naps (after age 4 years) and naps lasting past 4 p.m. for children under 4, even in car rides, is crucial. Beware of teens “having trouble falling asleep” who have sneaked in a nap after school!

To optimize sleep drive, calculate age-related sleep needs and, ideally, ask parents to keep a sleep diary for 1-2 weeks, especially checking on naps at daycare. Updated sleep duration standards (preschool 10-13 hours; school age 9-11 hours; teens 8-10 hours (see sleepfoundation.org) show that ranges of total sleep are remarkably stable, but may not meet parents’ ideals for time “off duty.”

If placed in bed when not yet tired, anyone will have trouble falling asleep (phase shift). For a child, lying awake in the dark alone is time for active imaginations to conjure fear of separation (> 4-6 months), monsters (for preschoolers), burglars (for anxious school-aged children), or the next day’s social or academic stresses (for school-aged children to teens). Children with anxiety disorders even worry that they may not get enough sleep! A soothing routine with a story in their bed (not media), a spritzing of “monster spray” or a “bedtime ticket” to cash in for “one more thing” (for those who beg) will usually suffice for preschoolers. A “magic flashlight” lends the child some control to check for monsters, but an “exorcism ritual” by the all-powerful parent can be added if needed. Teens are never too old for a chance to talk or even a story read by the parent (but they won’t ask for this).

A secret to managing bedtime struggles is to start the routine at the time the child is now falling asleep to avoid resistance, and keeping wake-up time appropriate to the new schedule. Once falling asleep within 10 minutes, move bedtime 15 minutes earlier each night to reach the schedule, then maintain 7 days per week (or within 1 hour) to prevent resetting the biological clock. Sorry, no movie nights until 2 a.m. or “sleeping in” on weekends! Teens who resist bedtime may be napping, socializing at the “only time” peers are up, addicted to media, or avoiding family. Their cooperation must be engaged to make a change by staying up all night once, then setting a new schedule, or staying up 1 hour later each night until the desired bedtime is reached.

©deyangeorgiev/thinkstockphotos.com

Because sleep includes being paralyzed (REM stages), evolution encourages animals to sleep together to protect from predators. Sleeping alone requires a great deal of reassurance, such as from a friendly atmosphere, favorite stuffed toy, and familiar routine that implies safety. Children could use a toy, pet, or even a sibling to feel safe. While body contact is the most reassuring, children may not return to sleep from the many normal night wakings without it. Most can be weaned from this dependence by the parent sitting by the bed silently, moving one foot closer to the door each night. A promise to “check on you” in 5 minutes also helps.

Other factors making sleep easier include avoiding caffeine, stimulating medicines, or nicotine as well as exciting games, media, or exercise within 2 hours of bedtime. A quiet, dark, cool but not damp location used only for sleeping is helpful, but not always possible. A white noise generator, fan, or radio on static can help.

Many parents strangely expect their child to give up the pleasures of the day and take themselves to bed! As for other kinds of limit setting, parental company is typically needed for brushing teeth, pajamas, and a story. Ideally, it can be fun as a race or with songs, not a yelling match, which undermines the sense of safety. Setting rules about no electronics in the bedroom, even for charging, after a certain hour is often the only solution (even for adults) to the common struggle over ending media.

Often the bedtime complaint is “curtain calls” after being settled in bed. For children who call out, advise parents wait a few moments before responding, then reassure verbally without entering their room, waiting longer each time. For the child getting out of bed, one parent should lead them back without talking at all as many times as necessary. A reward for staying in bed without calling or coming out can be an extra story the next night and/or a morning reward. Alternatively, close the door and turn off the light if they come out or call out. After a few moments in the dark, give a “second chance” as long as they are quietly in bed. Gating the doorway works well for toddlers – sleeping on the floor is not dangerous!

Families often are ambivalent about asking for bedtime advice, thinking your solutions might be stressful, harmful to their relationship, or will take up their own precious sleep. For many, a prolonged bedtime is the best part of their day. Special Time earlier is often key to enforcing a healthy bedtime. Reassure them that these solutions usually take less than 3 weeks!

For the child, bedtime means giving up on fun but, more importantly, separation from the parent. This separation is harder if negative emotions are left from a day of behavior struggles or parents are even subtly angry at each other. For parents, bedtime means separating from their main pleasure in life. They also may be regretting their interactions during the day. Ambivalence about parting also may come from fears of being alone with their partner due to marital discord, intimate partner violence, chronic arguing, substance use, or simply depression. When simple advice fails, it is important to explore these meanings with families, encourage positive daytime behavior management methods, and avoid conflict in front of the children to resolve bedtime struggles.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.

To weary parents, the fact that their child does not want to go to bed at night is both puzzling and exasperating. No matter what age, it is important to have a healthy bedtime for the child’s well-being as well as their caregiver’s!

Sleep, like the “canary in the mine,” is vulnerable to disruption by anything from minor illness to changes in schedule, things viewed on media, or emotions in the home, to life changes such as a new sibling, toilet training, or a new school year. In patients on stimulant medicine resisting bedtime, consider the need to finally eat. Asking about these specifically will help you plan an appropriate time to successfully address bedtime conflicts.

Knowing some basic principles about falling asleep can help your counseling. “Sleep drive” builds up over the day like a coiled spring, making falling asleep easier initially than for wakings later in the night. It also means that a nap too close to bedtime reduces the drive. Avoiding any naps (after age 4 years) and naps lasting past 4 p.m. for children under 4, even in car rides, is crucial. Beware of teens “having trouble falling asleep” who have sneaked in a nap after school!

To optimize sleep drive, calculate age-related sleep needs and, ideally, ask parents to keep a sleep diary for 1-2 weeks, especially checking on naps at daycare. Updated sleep duration standards (preschool 10-13 hours; school age 9-11 hours; teens 8-10 hours (see sleepfoundation.org) show that ranges of total sleep are remarkably stable, but may not meet parents’ ideals for time “off duty.”

If placed in bed when not yet tired, anyone will have trouble falling asleep (phase shift). For a child, lying awake in the dark alone is time for active imaginations to conjure fear of separation (> 4-6 months), monsters (for preschoolers), burglars (for anxious school-aged children), or the next day’s social or academic stresses (for school-aged children to teens). Children with anxiety disorders even worry that they may not get enough sleep! A soothing routine with a story in their bed (not media), a spritzing of “monster spray” or a “bedtime ticket” to cash in for “one more thing” (for those who beg) will usually suffice for preschoolers. A “magic flashlight” lends the child some control to check for monsters, but an “exorcism ritual” by the all-powerful parent can be added if needed. Teens are never too old for a chance to talk or even a story read by the parent (but they won’t ask for this).

A secret to managing bedtime struggles is to start the routine at the time the child is now falling asleep to avoid resistance, and keeping wake-up time appropriate to the new schedule. Once falling asleep within 10 minutes, move bedtime 15 minutes earlier each night to reach the schedule, then maintain 7 days per week (or within 1 hour) to prevent resetting the biological clock. Sorry, no movie nights until 2 a.m. or “sleeping in” on weekends! Teens who resist bedtime may be napping, socializing at the “only time” peers are up, addicted to media, or avoiding family. Their cooperation must be engaged to make a change by staying up all night once, then setting a new schedule, or staying up 1 hour later each night until the desired bedtime is reached.

©deyangeorgiev/thinkstockphotos.com

Because sleep includes being paralyzed (REM stages), evolution encourages animals to sleep together to protect from predators. Sleeping alone requires a great deal of reassurance, such as from a friendly atmosphere, favorite stuffed toy, and familiar routine that implies safety. Children could use a toy, pet, or even a sibling to feel safe. While body contact is the most reassuring, children may not return to sleep from the many normal night wakings without it. Most can be weaned from this dependence by the parent sitting by the bed silently, moving one foot closer to the door each night. A promise to “check on you” in 5 minutes also helps.

Other factors making sleep easier include avoiding caffeine, stimulating medicines, or nicotine as well as exciting games, media, or exercise within 2 hours of bedtime. A quiet, dark, cool but not damp location used only for sleeping is helpful, but not always possible. A white noise generator, fan, or radio on static can help.

Many parents strangely expect their child to give up the pleasures of the day and take themselves to bed! As for other kinds of limit setting, parental company is typically needed for brushing teeth, pajamas, and a story. Ideally, it can be fun as a race or with songs, not a yelling match, which undermines the sense of safety. Setting rules about no electronics in the bedroom, even for charging, after a certain hour is often the only solution (even for adults) to the common struggle over ending media.

Often the bedtime complaint is “curtain calls” after being settled in bed. For children who call out, advise parents wait a few moments before responding, then reassure verbally without entering their room, waiting longer each time. For the child getting out of bed, one parent should lead them back without talking at all as many times as necessary. A reward for staying in bed without calling or coming out can be an extra story the next night and/or a morning reward. Alternatively, close the door and turn off the light if they come out or call out. After a few moments in the dark, give a “second chance” as long as they are quietly in bed. Gating the doorway works well for toddlers – sleeping on the floor is not dangerous!

Families often are ambivalent about asking for bedtime advice, thinking your solutions might be stressful, harmful to their relationship, or will take up their own precious sleep. For many, a prolonged bedtime is the best part of their day. Special Time earlier is often key to enforcing a healthy bedtime. Reassure them that these solutions usually take less than 3 weeks!

For the child, bedtime means giving up on fun but, more importantly, separation from the parent. This separation is harder if negative emotions are left from a day of behavior struggles or parents are even subtly angry at each other. For parents, bedtime means separating from their main pleasure in life. They also may be regretting their interactions during the day. Ambivalence about parting also may come from fears of being alone with their partner due to marital discord, intimate partner violence, chronic arguing, substance use, or simply depression. When simple advice fails, it is important to explore these meanings with families, encourage positive daytime behavior management methods, and avoid conflict in front of the children to resolve bedtime struggles.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.

To weary parents, the fact that their child does not want to go to bed at night is both puzzling and exasperating. No matter what age, it is important to have a healthy bedtime for the child’s well-being as well as their caregiver’s!

Sleep, like the “canary in the mine,” is vulnerable to disruption by anything from minor illness to changes in schedule, things viewed on media, or emotions in the home, to life changes such as a new sibling, toilet training, or a new school year. In patients on stimulant medicine resisting bedtime, consider the need to finally eat. Asking about these specifically will help you plan an appropriate time to successfully address bedtime conflicts.

Knowing some basic principles about falling asleep can help your counseling. “Sleep drive” builds up over the day like a coiled spring, making falling asleep easier initially than for wakings later in the night. It also means that a nap too close to bedtime reduces the drive. Avoiding any naps (after age 4 years) and naps lasting past 4 p.m. for children under 4, even in car rides, is crucial. Beware of teens “having trouble falling asleep” who have sneaked in a nap after school!

To optimize sleep drive, calculate age-related sleep needs and, ideally, ask parents to keep a sleep diary for 1-2 weeks, especially checking on naps at daycare. Updated sleep duration standards (preschool 10-13 hours; school age 9-11 hours; teens 8-10 hours (see sleepfoundation.org) show that ranges of total sleep are remarkably stable, but may not meet parents’ ideals for time “off duty.”

If placed in bed when not yet tired, anyone will have trouble falling asleep (phase shift). For a child, lying awake in the dark alone is time for active imaginations to conjure fear of separation (> 4-6 months), monsters (for preschoolers), burglars (for anxious school-aged children), or the next day’s social or academic stresses (for school-aged children to teens). Children with anxiety disorders even worry that they may not get enough sleep! A soothing routine with a story in their bed (not media), a spritzing of “monster spray” or a “bedtime ticket” to cash in for “one more thing” (for those who beg) will usually suffice for preschoolers. A “magic flashlight” lends the child some control to check for monsters, but an “exorcism ritual” by the all-powerful parent can be added if needed. Teens are never too old for a chance to talk or even a story read by the parent (but they won’t ask for this).

A secret to managing bedtime struggles is to start the routine at the time the child is now falling asleep to avoid resistance, and keeping wake-up time appropriate to the new schedule. Once falling asleep within 10 minutes, move bedtime 15 minutes earlier each night to reach the schedule, then maintain 7 days per week (or within 1 hour) to prevent resetting the biological clock. Sorry, no movie nights until 2 a.m. or “sleeping in” on weekends! Teens who resist bedtime may be napping, socializing at the “only time” peers are up, addicted to media, or avoiding family. Their cooperation must be engaged to make a change by staying up all night once, then setting a new schedule, or staying up 1 hour later each night until the desired bedtime is reached.

©deyangeorgiev/thinkstockphotos.com

Because sleep includes being paralyzed (REM stages), evolution encourages animals to sleep together to protect from predators. Sleeping alone requires a great deal of reassurance, such as from a friendly atmosphere, favorite stuffed toy, and familiar routine that implies safety. Children could use a toy, pet, or even a sibling to feel safe. While body contact is the most reassuring, children may not return to sleep from the many normal night wakings without it. Most can be weaned from this dependence by the parent sitting by the bed silently, moving one foot closer to the door each night. A promise to “check on you” in 5 minutes also helps.

Other factors making sleep easier include avoiding caffeine, stimulating medicines, or nicotine as well as exciting games, media, or exercise within 2 hours of bedtime. A quiet, dark, cool but not damp location used only for sleeping is helpful, but not always possible. A white noise generator, fan, or radio on static can help.

Many parents strangely expect their child to give up the pleasures of the day and take themselves to bed! As for other kinds of limit setting, parental company is typically needed for brushing teeth, pajamas, and a story. Ideally, it can be fun as a race or with songs, not a yelling match, which undermines the sense of safety. Setting rules about no electronics in the bedroom, even for charging, after a certain hour is often the only solution (even for adults) to the common struggle over ending media.

Often the bedtime complaint is “curtain calls” after being settled in bed. For children who call out, advise parents wait a few moments before responding, then reassure verbally without entering their room, waiting longer each time. For the child getting out of bed, one parent should lead them back without talking at all as many times as necessary. A reward for staying in bed without calling or coming out can be an extra story the next night and/or a morning reward. Alternatively, close the door and turn off the light if they come out or call out. After a few moments in the dark, give a “second chance” as long as they are quietly in bed. Gating the doorway works well for toddlers – sleeping on the floor is not dangerous!

Families often are ambivalent about asking for bedtime advice, thinking your solutions might be stressful, harmful to their relationship, or will take up their own precious sleep. For many, a prolonged bedtime is the best part of their day. Special Time earlier is often key to enforcing a healthy bedtime. Reassure them that these solutions usually take less than 3 weeks!

For the child, bedtime means giving up on fun but, more importantly, separation from the parent. This separation is harder if negative emotions are left from a day of behavior struggles or parents are even subtly angry at each other. For parents, bedtime means separating from their main pleasure in life. They also may be regretting their interactions during the day. Ambivalence about parting also may come from fears of being alone with their partner due to marital discord, intimate partner violence, chronic arguing, substance use, or simply depression. When simple advice fails, it is important to explore these meanings with families, encourage positive daytime behavior management methods, and avoid conflict in front of the children to resolve bedtime struggles.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.

For you, the first visits with a newborn are a busy balancing act of gentle physical exam and empathic parent reassurance and education. It’s difficult to imagine that much else could fit into these visits. But your providing weekly and then monthly checks on a newborn puts you in a unique position to detect postpartum depression in that baby’s mother (as are obstetricians at the 6-week follow up). Postpartum depression is relatively common and very treatable, but it can go untreated because of the silence that is often grounded in shame and stigma. A few days of “baby blues” secondary to being tired and hormonal changes is quite different from persistent postpartum depression. Early detection of postpartum depression and referral to a psychiatrist can relieve extraordinary suffering in a parent and stress in a family, and can protect the critical relationship developing between mother and baby.

Postpartum depression was rarely discussed as recently as 30 years ago; it was not formally recognized by psychiatrists as a distinct illness in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until its fourth edition, released in 1994. It is only slightly more common than depression in nonpregnant women of childbearing age: the Centers for Disease Control and Prevention estimated that depression affects 13% of women in the postpartum period, compared with 11% of age-matched controls. It is, however, more likely to be severe than depression in the nonperipartum woman (Gen. Hosp. Psychiatry 2004;26:289-95).Teenage mothers, women with a personal or family history of depression, women giving birth to twins or triplets, women with a history of miscarriage or stillbirth, and women who experienced premature labor and delivery all appear to be at elevated risk for postpartum depression. While other stressors such as marital conflict, single parenthood, or financial strain are challenging for new mothers, they have not been shown to significantly increase the risk of postpartum depression. It also should be noted that a history of previous deliveries without a postpartum mood disorder is not protective or predictive.

The diagnostic criteria for postpartum depression are the same as for a major depressive episode, except that symptoms start in the 4 weeks after the delivery of a baby (although they may be present during the pregnancy or may not be noted until weeks or months later). This can make it easy to mistake depression for the “baby blues” – a period of weepiness, anxiety, moodiness, and exhaustion that commonly occurs to new mothers. These symptoms affect as many as 75% of mothers in the first few days after delivery and can be very unsettling, but the symptoms always improve within 2 weeks, whereas postpartum depression will persist or worsen. Although it can be severe, postpartum depression will improve with treatment, typically psychotherapy and possibly medication. Without treatment, postpartum depression can persist for months. It may remit spontaneously after a substantial period, but it also may worsen. Untreated postpartum depression can (rarely) deteriorate into postpartum psychosis, which usually requires hospitalization and more significant psychopharmacologic intervention. Failure to detect and treat depression in new mothers can lead to a number of complications for the mother, ranging from difficulty with breastfeeding and forming an attachment with her newborn to an inability to return to work. It also raises the risk for suicide, which accounts for 20% of all deaths in the postpartum population (Arch. Womens Ment. Health 2005;8:77-87).The catastrophe of infanticide is diminishingly rare, but almost always associated with untreated postpartum depression or psychosis.

The complications of untreated depression do not affect only the symptomatic mother. There have been many studies that have demonstrated the negative developmental effects of maternal depression on children of all ages, from infancy through adolescence. Maternal depression in the newborn period can be especially disruptive of development, as it can interfere with healthy attachment and an infant’s development of the fundamentals of self-regulation. Infants of depressed mothers are more likely to be passive, withdrawn, and dysregulated. Cognitive development in infants and toddlers of depressed mothers is frequently delayed. Toddler children of depressed mothers more frequently display internalizing (depressed and anxious) and externalizing (disruptive) behavioral symptoms. Mood, anxiety, conduct disorders, and attention-deficit/hyperactivity disorder are more common in the school-age and adolescent children of depressed mothers than in peers whose mothers are not depressed (Paediatr. Child Health 2004;9:575-83). Clearly, the consequences of untreated depression in a mother on even the youngest children can be profound and persistent. And, most importantly, they are preventable.

Why would new mothers experiencing such uncomfortable symptoms fail to actively seek help? There are many reasons for their silent suffering. Many new mothers assume that their symptoms are the “baby blues,” a normal part of the monumental adjustment from pregnancy to motherhood. When their symptoms fail to improve in the first few weeks as promised by friends or clinicians, they often assume that they are personally inadequate, not up to the task of parenting. Such feelings of worthlessness and guilt are actually common symptoms of depression, and contribute to the shame and silence that accompany depressive disorders. (This is one of the reasons depression is described as an “internalizing” disorder.) These feelings (or symptoms) of guilt often are heightened by popular expectations that new mothers should be experiencing delight and joy in the new child. While all of the attention was on the mother during her pregnancy, the focus of friends, family, and clinicians usually shifts entirely to the infant after delivery. Although the reality of postpartum depression is more comfortably and openly discussed now than a generation ago, these forces continue to compel most women suffering from depression to remain silent.

This is where you are in a unique position to facilitate the recognition and treatment of postpartum depression. While a new mother may have one follow-up visit with her obstetrician, she often will visit you weekly for the first month and monthly for the first 6 months of her infant’s life. These visits are structured around questions about routines of sleeping and eating, the mechanics of breastfeeding, and growing connection with the newborn. You are in a natural position to ask nonjudgmentally about these things, and to follow-up on suggestions that a mother’s sleep, appetite, and energy are problematic with a few screening questions. If it sounds to you like there may be postpartum depression, you are in a powerful position to point out that these feelings do not reflect inadequacy, but rather a common and treatable problem in new mothers. You are uniquely qualified to suggest to the guilt-ridden mother that it is not selfish to seek her own treatment, but it is critical to the healthy development of her newborn and other children, much like the routine airline warning that parents must put on their own oxygen masks before attempting to place the masks on their children. Indeed, the American Academy of Pediatrics recommended in a 2010 report that pediatricians screen new mothers for postpartum depression at the 1-, 2-, and 4-month check-ups of their newborns (Pediatrics 2010;126:1032).

So how best to screen during a busy check-up? The AAP recommends the Edinburgh Postnatal Depression Screen (EPDS), an extensively validated 10-item questionnaire that a mother can fill out in the waiting room. Scoring is relatively fast and a cut-off at or above 10 points suggests a high risk of depression. The AAP also suggests using a “yes” answer to either of the following questions as a positive screen:

1. Over the past 2 weeks have you ever felt down, depressed, or hopeless?

2. Over the past 2 weeks have you felt little interest or pleasure in doing things?

Even without using specific questions or instruments, you can be vigilant for certain red flags. If a new mother reports that she is having difficulty falling asleep (despite the sleep deprivation that usually accompanies life with a newborn); if her appetite is decreasing despite breastfeeding; if she describes intense worries or doubts about the baby or motherhood that have persisted for more than a few days or that interfere with her function; if she reports that she is experiencing no feelings of happiness or pleasure with her infant; or if she describes feelings of hopelessness or recurring thoughts about death and dying, then you should be concerned that she may be suffering from postpartum depression. You might then suggest to the mother that these feelings may reflect postpartum depression, reassuring her that this is a common and treatable condition. When you calmly and comfortably discusses this topic, you provide hope and relief, dissolving some of the stigma that can surround psychiatric illness for mothers.

What to do once you have noted that a new mother may be suffering from postpartum depression? The problem is common enough that you may want to find a psychiatrist with an interest in postpartum depression and develop a collegial working relationship. It can be helpful to find out if the mother has ever seen a psychiatrist or therapist, as this can be an easy and effective referral for a comprehensive evaluation. If she does not already have a mental health provider, referring her to her primary care provider can be an efficient way to access a psychiatric evaluation. Many mothers will want to have more specialized treatment, especially as they consider the safety of medications while breastfeeding. Many academic medical centers will have psychiatrists who specialize in women’s health. Some states have created programs to facilitate access to treatment for mothers, such as Massachusetts Child Psychiatry Access Project (MCPAP) for Moms. There are several national organizations that provide online information about clinicians and other resources, such as Postpartum Support International, the American Psychological Association, and the CDC.

Finally, we have addressed depression in new mothers. But the rates of depression in new fathers also are higher than in age-matched controls. When a father is the primary parent and suggests problems with sleep and mood, asking the same questions, showing concern, and providing referral information can be just as important.

Remember, 13% of new mothers have postpartum depression, and the suffering of parent, family, and newborn is treatable. Unfortunately, many mothers do not get the help they need, as this condition has not been a priority of our health care system. You, the pediatrician or family physician, are in a unique position to make this a priority. You can detect depression in new parents, providing a critical link to treatment and relief for them, and protecting their children from potentially serious and preventable complications.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) program at the Vernon Cancer Center, Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at pdnews@frontlinemedcom.com.

For you, the first visits with a newborn are a busy balancing act of gentle physical exam and empathic parent reassurance and education. It’s difficult to imagine that much else could fit into these visits. But your providing weekly and then monthly checks on a newborn puts you in a unique position to detect postpartum depression in that baby’s mother (as are obstetricians at the 6-week follow up). Postpartum depression is relatively common and very treatable, but it can go untreated because of the silence that is often grounded in shame and stigma. A few days of “baby blues” secondary to being tired and hormonal changes is quite different from persistent postpartum depression. Early detection of postpartum depression and referral to a psychiatrist can relieve extraordinary suffering in a parent and stress in a family, and can protect the critical relationship developing between mother and baby.

Postpartum depression was rarely discussed as recently as 30 years ago; it was not formally recognized by psychiatrists as a distinct illness in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until its fourth edition, released in 1994. It is only slightly more common than depression in nonpregnant women of childbearing age: the Centers for Disease Control and Prevention estimated that depression affects 13% of women in the postpartum period, compared with 11% of age-matched controls. It is, however, more likely to be severe than depression in the nonperipartum woman (Gen. Hosp. Psychiatry 2004;26:289-95).Teenage mothers, women with a personal or family history of depression, women giving birth to twins or triplets, women with a history of miscarriage or stillbirth, and women who experienced premature labor and delivery all appear to be at elevated risk for postpartum depression. While other stressors such as marital conflict, single parenthood, or financial strain are challenging for new mothers, they have not been shown to significantly increase the risk of postpartum depression. It also should be noted that a history of previous deliveries without a postpartum mood disorder is not protective or predictive.

The diagnostic criteria for postpartum depression are the same as for a major depressive episode, except that symptoms start in the 4 weeks after the delivery of a baby (although they may be present during the pregnancy or may not be noted until weeks or months later). This can make it easy to mistake depression for the “baby blues” – a period of weepiness, anxiety, moodiness, and exhaustion that commonly occurs to new mothers. These symptoms affect as many as 75% of mothers in the first few days after delivery and can be very unsettling, but the symptoms always improve within 2 weeks, whereas postpartum depression will persist or worsen. Although it can be severe, postpartum depression will improve with treatment, typically psychotherapy and possibly medication. Without treatment, postpartum depression can persist for months. It may remit spontaneously after a substantial period, but it also may worsen. Untreated postpartum depression can (rarely) deteriorate into postpartum psychosis, which usually requires hospitalization and more significant psychopharmacologic intervention. Failure to detect and treat depression in new mothers can lead to a number of complications for the mother, ranging from difficulty with breastfeeding and forming an attachment with her newborn to an inability to return to work. It also raises the risk for suicide, which accounts for 20% of all deaths in the postpartum population (Arch. Womens Ment. Health 2005;8:77-87).The catastrophe of infanticide is diminishingly rare, but almost always associated with untreated postpartum depression or psychosis.

The complications of untreated depression do not affect only the symptomatic mother. There have been many studies that have demonstrated the negative developmental effects of maternal depression on children of all ages, from infancy through adolescence. Maternal depression in the newborn period can be especially disruptive of development, as it can interfere with healthy attachment and an infant’s development of the fundamentals of self-regulation. Infants of depressed mothers are more likely to be passive, withdrawn, and dysregulated. Cognitive development in infants and toddlers of depressed mothers is frequently delayed. Toddler children of depressed mothers more frequently display internalizing (depressed and anxious) and externalizing (disruptive) behavioral symptoms. Mood, anxiety, conduct disorders, and attention-deficit/hyperactivity disorder are more common in the school-age and adolescent children of depressed mothers than in peers whose mothers are not depressed (Paediatr. Child Health 2004;9:575-83). Clearly, the consequences of untreated depression in a mother on even the youngest children can be profound and persistent. And, most importantly, they are preventable.

Why would new mothers experiencing such uncomfortable symptoms fail to actively seek help? There are many reasons for their silent suffering. Many new mothers assume that their symptoms are the “baby blues,” a normal part of the monumental adjustment from pregnancy to motherhood. When their symptoms fail to improve in the first few weeks as promised by friends or clinicians, they often assume that they are personally inadequate, not up to the task of parenting. Such feelings of worthlessness and guilt are actually common symptoms of depression, and contribute to the shame and silence that accompany depressive disorders. (This is one of the reasons depression is described as an “internalizing” disorder.) These feelings (or symptoms) of guilt often are heightened by popular expectations that new mothers should be experiencing delight and joy in the new child. While all of the attention was on the mother during her pregnancy, the focus of friends, family, and clinicians usually shifts entirely to the infant after delivery. Although the reality of postpartum depression is more comfortably and openly discussed now than a generation ago, these forces continue to compel most women suffering from depression to remain silent.

This is where you are in a unique position to facilitate the recognition and treatment of postpartum depression. While a new mother may have one follow-up visit with her obstetrician, she often will visit you weekly for the first month and monthly for the first 6 months of her infant’s life. These visits are structured around questions about routines of sleeping and eating, the mechanics of breastfeeding, and growing connection with the newborn. You are in a natural position to ask nonjudgmentally about these things, and to follow-up on suggestions that a mother’s sleep, appetite, and energy are problematic with a few screening questions. If it sounds to you like there may be postpartum depression, you are in a powerful position to point out that these feelings do not reflect inadequacy, but rather a common and treatable problem in new mothers. You are uniquely qualified to suggest to the guilt-ridden mother that it is not selfish to seek her own treatment, but it is critical to the healthy development of her newborn and other children, much like the routine airline warning that parents must put on their own oxygen masks before attempting to place the masks on their children. Indeed, the American Academy of Pediatrics recommended in a 2010 report that pediatricians screen new mothers for postpartum depression at the 1-, 2-, and 4-month check-ups of their newborns (Pediatrics 2010;126:1032).

So how best to screen during a busy check-up? The AAP recommends the Edinburgh Postnatal Depression Screen (EPDS), an extensively validated 10-item questionnaire that a mother can fill out in the waiting room. Scoring is relatively fast and a cut-off at or above 10 points suggests a high risk of depression. The AAP also suggests using a “yes” answer to either of the following questions as a positive screen:

1. Over the past 2 weeks have you ever felt down, depressed, or hopeless?

2. Over the past 2 weeks have you felt little interest or pleasure in doing things?

Even without using specific questions or instruments, you can be vigilant for certain red flags. If a new mother reports that she is having difficulty falling asleep (despite the sleep deprivation that usually accompanies life with a newborn); if her appetite is decreasing despite breastfeeding; if she describes intense worries or doubts about the baby or motherhood that have persisted for more than a few days or that interfere with her function; if she reports that she is experiencing no feelings of happiness or pleasure with her infant; or if she describes feelings of hopelessness or recurring thoughts about death and dying, then you should be concerned that she may be suffering from postpartum depression. You might then suggest to the mother that these feelings may reflect postpartum depression, reassuring her that this is a common and treatable condition. When you calmly and comfortably discusses this topic, you provide hope and relief, dissolving some of the stigma that can surround psychiatric illness for mothers.

What to do once you have noted that a new mother may be suffering from postpartum depression? The problem is common enough that you may want to find a psychiatrist with an interest in postpartum depression and develop a collegial working relationship. It can be helpful to find out if the mother has ever seen a psychiatrist or therapist, as this can be an easy and effective referral for a comprehensive evaluation. If she does not already have a mental health provider, referring her to her primary care provider can be an efficient way to access a psychiatric evaluation. Many mothers will want to have more specialized treatment, especially as they consider the safety of medications while breastfeeding. Many academic medical centers will have psychiatrists who specialize in women’s health. Some states have created programs to facilitate access to treatment for mothers, such as Massachusetts Child Psychiatry Access Project (MCPAP) for Moms. There are several national organizations that provide online information about clinicians and other resources, such as Postpartum Support International, the American Psychological Association, and the CDC.

Finally, we have addressed depression in new mothers. But the rates of depression in new fathers also are higher than in age-matched controls. When a father is the primary parent and suggests problems with sleep and mood, asking the same questions, showing concern, and providing referral information can be just as important.

Remember, 13% of new mothers have postpartum depression, and the suffering of parent, family, and newborn is treatable. Unfortunately, many mothers do not get the help they need, as this condition has not been a priority of our health care system. You, the pediatrician or family physician, are in a unique position to make this a priority. You can detect depression in new parents, providing a critical link to treatment and relief for them, and protecting their children from potentially serious and preventable complications.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) program at the Vernon Cancer Center, Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at pdnews@frontlinemedcom.com.

For you, the first visits with a newborn are a busy balancing act of gentle physical exam and empathic parent reassurance and education. It’s difficult to imagine that much else could fit into these visits. But your providing weekly and then monthly checks on a newborn puts you in a unique position to detect postpartum depression in that baby’s mother (as are obstetricians at the 6-week follow up). Postpartum depression is relatively common and very treatable, but it can go untreated because of the silence that is often grounded in shame and stigma. A few days of “baby blues” secondary to being tired and hormonal changes is quite different from persistent postpartum depression. Early detection of postpartum depression and referral to a psychiatrist can relieve extraordinary suffering in a parent and stress in a family, and can protect the critical relationship developing between mother and baby.

Postpartum depression was rarely discussed as recently as 30 years ago; it was not formally recognized by psychiatrists as a distinct illness in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until its fourth edition, released in 1994. It is only slightly more common than depression in nonpregnant women of childbearing age: the Centers for Disease Control and Prevention estimated that depression affects 13% of women in the postpartum period, compared with 11% of age-matched controls. It is, however, more likely to be severe than depression in the nonperipartum woman (Gen. Hosp. Psychiatry 2004;26:289-95).Teenage mothers, women with a personal or family history of depression, women giving birth to twins or triplets, women with a history of miscarriage or stillbirth, and women who experienced premature labor and delivery all appear to be at elevated risk for postpartum depression. While other stressors such as marital conflict, single parenthood, or financial strain are challenging for new mothers, they have not been shown to significantly increase the risk of postpartum depression. It also should be noted that a history of previous deliveries without a postpartum mood disorder is not protective or predictive.

The diagnostic criteria for postpartum depression are the same as for a major depressive episode, except that symptoms start in the 4 weeks after the delivery of a baby (although they may be present during the pregnancy or may not be noted until weeks or months later). This can make it easy to mistake depression for the “baby blues” – a period of weepiness, anxiety, moodiness, and exhaustion that commonly occurs to new mothers. These symptoms affect as many as 75% of mothers in the first few days after delivery and can be very unsettling, but the symptoms always improve within 2 weeks, whereas postpartum depression will persist or worsen. Although it can be severe, postpartum depression will improve with treatment, typically psychotherapy and possibly medication. Without treatment, postpartum depression can persist for months. It may remit spontaneously after a substantial period, but it also may worsen. Untreated postpartum depression can (rarely) deteriorate into postpartum psychosis, which usually requires hospitalization and more significant psychopharmacologic intervention. Failure to detect and treat depression in new mothers can lead to a number of complications for the mother, ranging from difficulty with breastfeeding and forming an attachment with her newborn to an inability to return to work. It also raises the risk for suicide, which accounts for 20% of all deaths in the postpartum population (Arch. Womens Ment. Health 2005;8:77-87).The catastrophe of infanticide is diminishingly rare, but almost always associated with untreated postpartum depression or psychosis.

The complications of untreated depression do not affect only the symptomatic mother. There have been many studies that have demonstrated the negative developmental effects of maternal depression on children of all ages, from infancy through adolescence. Maternal depression in the newborn period can be especially disruptive of development, as it can interfere with healthy attachment and an infant’s development of the fundamentals of self-regulation. Infants of depressed mothers are more likely to be passive, withdrawn, and dysregulated. Cognitive development in infants and toddlers of depressed mothers is frequently delayed. Toddler children of depressed mothers more frequently display internalizing (depressed and anxious) and externalizing (disruptive) behavioral symptoms. Mood, anxiety, conduct disorders, and attention-deficit/hyperactivity disorder are more common in the school-age and adolescent children of depressed mothers than in peers whose mothers are not depressed (Paediatr. Child Health 2004;9:575-83). Clearly, the consequences of untreated depression in a mother on even the youngest children can be profound and persistent. And, most importantly, they are preventable.

Why would new mothers experiencing such uncomfortable symptoms fail to actively seek help? There are many reasons for their silent suffering. Many new mothers assume that their symptoms are the “baby blues,” a normal part of the monumental adjustment from pregnancy to motherhood. When their symptoms fail to improve in the first few weeks as promised by friends or clinicians, they often assume that they are personally inadequate, not up to the task of parenting. Such feelings of worthlessness and guilt are actually common symptoms of depression, and contribute to the shame and silence that accompany depressive disorders. (This is one of the reasons depression is described as an “internalizing” disorder.) These feelings (or symptoms) of guilt often are heightened by popular expectations that new mothers should be experiencing delight and joy in the new child. While all of the attention was on the mother during her pregnancy, the focus of friends, family, and clinicians usually shifts entirely to the infant after delivery. Although the reality of postpartum depression is more comfortably and openly discussed now than a generation ago, these forces continue to compel most women suffering from depression to remain silent.

This is where you are in a unique position to facilitate the recognition and treatment of postpartum depression. While a new mother may have one follow-up visit with her obstetrician, she often will visit you weekly for the first month and monthly for the first 6 months of her infant’s life. These visits are structured around questions about routines of sleeping and eating, the mechanics of breastfeeding, and growing connection with the newborn. You are in a natural position to ask nonjudgmentally about these things, and to follow-up on suggestions that a mother’s sleep, appetite, and energy are problematic with a few screening questions. If it sounds to you like there may be postpartum depression, you are in a powerful position to point out that these feelings do not reflect inadequacy, but rather a common and treatable problem in new mothers. You are uniquely qualified to suggest to the guilt-ridden mother that it is not selfish to seek her own treatment, but it is critical to the healthy development of her newborn and other children, much like the routine airline warning that parents must put on their own oxygen masks before attempting to place the masks on their children. Indeed, the American Academy of Pediatrics recommended in a 2010 report that pediatricians screen new mothers for postpartum depression at the 1-, 2-, and 4-month check-ups of their newborns (Pediatrics 2010;126:1032).

So how best to screen during a busy check-up? The AAP recommends the Edinburgh Postnatal Depression Screen (EPDS), an extensively validated 10-item questionnaire that a mother can fill out in the waiting room. Scoring is relatively fast and a cut-off at or above 10 points suggests a high risk of depression. The AAP also suggests using a “yes” answer to either of the following questions as a positive screen:

1. Over the past 2 weeks have you ever felt down, depressed, or hopeless?

2. Over the past 2 weeks have you felt little interest or pleasure in doing things?

Even without using specific questions or instruments, you can be vigilant for certain red flags. If a new mother reports that she is having difficulty falling asleep (despite the sleep deprivation that usually accompanies life with a newborn); if her appetite is decreasing despite breastfeeding; if she describes intense worries or doubts about the baby or motherhood that have persisted for more than a few days or that interfere with her function; if she reports that she is experiencing no feelings of happiness or pleasure with her infant; or if she describes feelings of hopelessness or recurring thoughts about death and dying, then you should be concerned that she may be suffering from postpartum depression. You might then suggest to the mother that these feelings may reflect postpartum depression, reassuring her that this is a common and treatable condition. When you calmly and comfortably discusses this topic, you provide hope and relief, dissolving some of the stigma that can surround psychiatric illness for mothers.

What to do once you have noted that a new mother may be suffering from postpartum depression? The problem is common enough that you may want to find a psychiatrist with an interest in postpartum depression and develop a collegial working relationship. It can be helpful to find out if the mother has ever seen a psychiatrist or therapist, as this can be an easy and effective referral for a comprehensive evaluation. If she does not already have a mental health provider, referring her to her primary care provider can be an efficient way to access a psychiatric evaluation. Many mothers will want to have more specialized treatment, especially as they consider the safety of medications while breastfeeding. Many academic medical centers will have psychiatrists who specialize in women’s health. Some states have created programs to facilitate access to treatment for mothers, such as Massachusetts Child Psychiatry Access Project (MCPAP) for Moms. There are several national organizations that provide online information about clinicians and other resources, such as Postpartum Support International, the American Psychological Association, and the CDC.

Finally, we have addressed depression in new mothers. But the rates of depression in new fathers also are higher than in age-matched controls. When a father is the primary parent and suggests problems with sleep and mood, asking the same questions, showing concern, and providing referral information can be just as important.

Remember, 13% of new mothers have postpartum depression, and the suffering of parent, family, and newborn is treatable. Unfortunately, many mothers do not get the help they need, as this condition has not been a priority of our health care system. You, the pediatrician or family physician, are in a unique position to make this a priority. You can detect depression in new parents, providing a critical link to treatment and relief for them, and protecting their children from potentially serious and preventable complications.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) program at the Vernon Cancer Center, Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at pdnews@frontlinemedcom.com.

Concerns about tantrums come up a lot in pediatric care. We all know about telling parents to ignore tantrums in toddlers and not to give in. But what about when this advice does not work?

I like to think of tantrums as emotions that go beyond the child’s control. This reframing helps families consider that not all tantrums are an attempt by the child to manipulate them. That is an important first step in avoiding a solely punitive response and instead encouraging parents to look for the source of the imbalance.

Temper tantrums are most common when a child is making developmental spurts in abilities or thinking that are typically unevenly matched with self-control. There is a lot of unevenness in children’s ability to do, say, or tolerate feelings between the early tantrums of the 9-month-old until the greater coping of the 6-year-old. For example, 87% of 18- to 24-month-olds have tantrums just as they acquire autonomy and some language, yet can’t really speak their feelings, while 91% of 30- to 36-month-olds have tantrums because they can imagine big things, but are only capable of or allowed small ones. Even at 42-48 months, more than half have tantrums, which often are associated with the stress and fatigue from dropping their nap.

Life is frustrating for kids. Young children want to try to use their new skills such as climbing, opening things, or scribbling, but parents – at first delighted – suddenly want them to stop! At first, every new word is celebrated, but then toddler talk gets routine, and toddlers may be ignored or even shushed. When the child has a strong desire, the words may not be there, or emotions may make it hard to talk at all, leading to frustration.

With the development of a sense of self, the song is “I want,” “mine,” and “no!” Sharing is not in the child’s repertoire until age 3 years or older. Temperamentally more intense children give up less easily or are not readily distracted.

The threshold for frustration depends on the child’s overall state. Is the child hungry? Tired? Stressed? In pain? Here is where the differential diagnosis of excessive tantrums needs to also include pain from a medical condition such as celiac disease, arthritis, migraine, or sickle cell disease. Children under age 7 years commonly have a low tolerance for sensations as simple as loud noises and elastic waistbands, but those with sensory integration disorder are at the extreme in what sounds, feelings, or motions they cannot bear at any age and may need specific intervention by occupational or physical therapists. Mental health conditions such as attention-deficit/hyperactivity disorder, depression, anxiety, and bipolar disorder also predispose to irritable responses to even normal stresses, often in combination with lagging skills and poor sleep. Consider these when tantrums are extreme.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications.

Concerns about tantrums come up a lot in pediatric care. We all know about telling parents to ignore tantrums in toddlers and not to give in. But what about when this advice does not work?

I like to think of tantrums as emotions that go beyond the child’s control. This reframing helps families consider that not all tantrums are an attempt by the child to manipulate them. That is an important first step in avoiding a solely punitive response and instead encouraging parents to look for the source of the imbalance.

Temper tantrums are most common when a child is making developmental spurts in abilities or thinking that are typically unevenly matched with self-control. There is a lot of unevenness in children’s ability to do, say, or tolerate feelings between the early tantrums of the 9-month-old until the greater coping of the 6-year-old. For example, 87% of 18- to 24-month-olds have tantrums just as they acquire autonomy and some language, yet can’t really speak their feelings, while 91% of 30- to 36-month-olds have tantrums because they can imagine big things, but are only capable of or allowed small ones. Even at 42-48 months, more than half have tantrums, which often are associated with the stress and fatigue from dropping their nap.

Life is frustrating for kids. Young children want to try to use their new skills such as climbing, opening things, or scribbling, but parents – at first delighted – suddenly want them to stop! At first, every new word is celebrated, but then toddler talk gets routine, and toddlers may be ignored or even shushed. When the child has a strong desire, the words may not be there, or emotions may make it hard to talk at all, leading to frustration.

With the development of a sense of self, the song is “I want,” “mine,” and “no!” Sharing is not in the child’s repertoire until age 3 years or older. Temperamentally more intense children give up less easily or are not readily distracted.

The threshold for frustration depends on the child’s overall state. Is the child hungry? Tired? Stressed? In pain? Here is where the differential diagnosis of excessive tantrums needs to also include pain from a medical condition such as celiac disease, arthritis, migraine, or sickle cell disease. Children under age 7 years commonly have a low tolerance for sensations as simple as loud noises and elastic waistbands, but those with sensory integration disorder are at the extreme in what sounds, feelings, or motions they cannot bear at any age and may need specific intervention by occupational or physical therapists. Mental health conditions such as attention-deficit/hyperactivity disorder, depression, anxiety, and bipolar disorder also predispose to irritable responses to even normal stresses, often in combination with lagging skills and poor sleep. Consider these when tantrums are extreme.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications.

Concerns about tantrums come up a lot in pediatric care. We all know about telling parents to ignore tantrums in toddlers and not to give in. But what about when this advice does not work?

I like to think of tantrums as emotions that go beyond the child’s control. This reframing helps families consider that not all tantrums are an attempt by the child to manipulate them. That is an important first step in avoiding a solely punitive response and instead encouraging parents to look for the source of the imbalance.

Temper tantrums are most common when a child is making developmental spurts in abilities or thinking that are typically unevenly matched with self-control. There is a lot of unevenness in children’s ability to do, say, or tolerate feelings between the early tantrums of the 9-month-old until the greater coping of the 6-year-old. For example, 87% of 18- to 24-month-olds have tantrums just as they acquire autonomy and some language, yet can’t really speak their feelings, while 91% of 30- to 36-month-olds have tantrums because they can imagine big things, but are only capable of or allowed small ones. Even at 42-48 months, more than half have tantrums, which often are associated with the stress and fatigue from dropping their nap.

Life is frustrating for kids. Young children want to try to use their new skills such as climbing, opening things, or scribbling, but parents – at first delighted – suddenly want them to stop! At first, every new word is celebrated, but then toddler talk gets routine, and toddlers may be ignored or even shushed. When the child has a strong desire, the words may not be there, or emotions may make it hard to talk at all, leading to frustration.

With the development of a sense of self, the song is “I want,” “mine,” and “no!” Sharing is not in the child’s repertoire until age 3 years or older. Temperamentally more intense children give up less easily or are not readily distracted.

The threshold for frustration depends on the child’s overall state. Is the child hungry? Tired? Stressed? In pain? Here is where the differential diagnosis of excessive tantrums needs to also include pain from a medical condition such as celiac disease, arthritis, migraine, or sickle cell disease. Children under age 7 years commonly have a low tolerance for sensations as simple as loud noises and elastic waistbands, but those with sensory integration disorder are at the extreme in what sounds, feelings, or motions they cannot bear at any age and may need specific intervention by occupational or physical therapists. Mental health conditions such as attention-deficit/hyperactivity disorder, depression, anxiety, and bipolar disorder also predispose to irritable responses to even normal stresses, often in combination with lagging skills and poor sleep. Consider these when tantrums are extreme.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical Communications.

A major challenge faced by parents is the task of setting basic ground rules and expectations for their children, and then enforcing these with limits, rewards, and consequences. This task is made far more difficult when parents are separated or divorced. Agreeing upon and enforcing rules in separate homes often becomes burdened by the angry baggage that led to the divorce. When a family in your practice is going through a divorce, you have an opportunity to provide the parents with valuable strategies to manage rules effectively so that conflict is minimized.

Many happily married parents who communicate very well on most matters struggle to get on the same page when negotiating rules and limits. One parent’s sense of what is an appropriate bedtime, how children should help with chores, or even how often they can have sweets can become a deeply held belief and might be very different than their spouse’s opinions. Sometimes, a parent has old anger about how they were raised and finds it hard to distinguish what might have been better for them, compared with what is best for their own child. Cultural and family differences on how much choice children should have at different ages, criteria and severity of any consequences for misbehavior, and opportunities for redemption or amnesty all add complexity to the discussion. Once they have found common ground on what makes sense for their joint rules, values, and needs of their child, they have to manage enforcing rules and limits, agreeing upon appropriate rewards and punishments, and bearing the inevitable distress of their children when facing a limit or consequence. And, of course, once parents think they have it all figured out, their children react and grow, and they must reset the rules, expectations, and consequences.

When parents get separated or divorced, this process becomes considerably more difficult. Negotiating new rules or limits is very difficult when communication is hampered by conflict. Parental guilt about the divorce itself, anger at old hurts or disputes about money and custody, missing the child between visits, and remarriages all add baggage to the discussion of a reasonable bedtime or consequences for a poor grade at school. If the divorce required aggressive negotiation between lawyers, appointment of a guardian ad Litem to manage ongoing disputes involving the children, or a court case to reach resolution, the tensions between parents can be intense, enduring, and with no issue too small to add fuel to the arguments. Enforcing limits is much harder for a single parent than when there are two parents doing the enforcement. And divorced parents, already feeling guilty and insecure, are more likely to suspend rules or limits so that they don’t have to be the “bad parent.” For the child or children, the stress and disruptions that come with divorce can cause an increase in regressed or disrespectful behavior. While it can be a time when limits are increasingly tested, being reasonable and consistent in enforcing limits becomes more important, as it provides reassuring steadiness in the midst of turbulent change.

Let’s take the example of a 12-year-old coming home from school with poor grades. One parent may see the need for a tutor, but might be using that approach as part of a financial attack if the other parent has to pay for it. The other parent may want to limit the use of computer games or access to television until the grades go up. And one may expect movement from a D to a C average while the other may expect A’s, period. Is the poor grade based on lack of ability, effort, an attempt to get attention, a reaction to the divorce, or preoccupation with ongoing parental discord? What is the impact on the child if in one home there is a tutor and a C expectation, and in the other there is no tutor, no computer use, no TV... and these change every time the child moves from one home to the other? A child striving to overcome a poor grade needs calm, consistent, patient, and optimistic support, rather than managing the increased tension across two homes or feeling like the cause of increased conflict. Virtually any reasonable approach is better for the child than each parent doing something different as a reflection of ongoing tension. Pediatricians can be extraordinarily helpful to their patient if they can get divorced parents to agree on a single approach that is based on their child’s needs rather than past and ongoing angers. The emotional damage of ongoing discord is far worse than any C average.

As the pediatrician to a family managing divorce, you may be one of the few authority figures whom both parents and the children all still respect and trust. You are in a strong position to ask a parent during an appointment how rules and limits are being managed across two homes. Find out if they have a clear plan for handling routine communication about the children, whether about summer camps or a new curfew, so that they don’t default to communicating only once there is a crisis. See if rules are a vehicle for ongoing parental fighting so that a minor difference (an 8 o’clock bedtime in one house versus 9 o’clock in the other) carries a high emotional charge. Find out if there are certain rules that have become very hard to enforce, or if their child has been testing limits more. Ask if there has been a consequence enforced in one home, but not in another. Often simply providing a calm affirmation that increased limit testing is normal in children after a divorce is very reassuring for parents. Remind them that providing reasonably consistent rules and limits will be very helpful to their children during this period, the opposite of making them a “bad parent.”

Some divorced parents will become more rigid about rules, managing any infraction or extenuating circumstance more like a contract negotiation. These parents might benefit from a suggestion that consistency and simplicity are the keys to effective rules across two households. Rules also provide an opportunity to listen to their children’s thoughts and feelings and share the family’s values that are the basis for the rules. Parents should be curious about their children’s opinions and be ready to show thoughtful flexibility when rules become outdated or special circumstances exist.

You can suggest a rule the parents should follow. While they can talk honestly about what each parent may struggle with or acknowledge clear differences in style or personality, they should strive to never vilify the other parent. Even in circumstances in which it is very difficult for two parents to collaborate, sharing grievances with the children will only be painful and confusing for them.

Lastly, pediatricians can discuss the long-term goals that all parents, even those alienated from each other, share. Children will do best when they have a positive, honest, warm relationship with each parent, and do not carry responsibility for negotiating conflict between their parents. Ultimately, more autonomy and fewer rules will be an important part of the child’s adolescence. Discord between parents, sabotaging of rules and consequences, and explicit contempt for their children’s other parent all will lead to children feeling burdened, having lower self-esteem, and being at greater risk for serious problems in school, emotionally or with substances as they grow into adolescents and young adults. If you are frustrated in your effort to protect children from ongoing discord, suggest a referral to a mental health clinician with expertise helping parents after a divorce.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at pdnews@frontlinemedcom.com.

A major challenge faced by parents is the task of setting basic ground rules and expectations for their children, and then enforcing these with limits, rewards, and consequences. This task is made far more difficult when parents are separated or divorced. Agreeing upon and enforcing rules in separate homes often becomes burdened by the angry baggage that led to the divorce. When a family in your practice is going through a divorce, you have an opportunity to provide the parents with valuable strategies to manage rules effectively so that conflict is minimized.

Many happily married parents who communicate very well on most matters struggle to get on the same page when negotiating rules and limits. One parent’s sense of what is an appropriate bedtime, how children should help with chores, or even how often they can have sweets can become a deeply held belief and might be very different than their spouse’s opinions. Sometimes, a parent has old anger about how they were raised and finds it hard to distinguish what might have been better for them, compared with what is best for their own child. Cultural and family differences on how much choice children should have at different ages, criteria and severity of any consequences for misbehavior, and opportunities for redemption or amnesty all add complexity to the discussion. Once they have found common ground on what makes sense for their joint rules, values, and needs of their child, they have to manage enforcing rules and limits, agreeing upon appropriate rewards and punishments, and bearing the inevitable distress of their children when facing a limit or consequence. And, of course, once parents think they have it all figured out, their children react and grow, and they must reset the rules, expectations, and consequences.

When parents get separated or divorced, this process becomes considerably more difficult. Negotiating new rules or limits is very difficult when communication is hampered by conflict. Parental guilt about the divorce itself, anger at old hurts or disputes about money and custody, missing the child between visits, and remarriages all add baggage to the discussion of a reasonable bedtime or consequences for a poor grade at school. If the divorce required aggressive negotiation between lawyers, appointment of a guardian ad Litem to manage ongoing disputes involving the children, or a court case to reach resolution, the tensions between parents can be intense, enduring, and with no issue too small to add fuel to the arguments. Enforcing limits is much harder for a single parent than when there are two parents doing the enforcement. And divorced parents, already feeling guilty and insecure, are more likely to suspend rules or limits so that they don’t have to be the “bad parent.” For the child or children, the stress and disruptions that come with divorce can cause an increase in regressed or disrespectful behavior. While it can be a time when limits are increasingly tested, being reasonable and consistent in enforcing limits becomes more important, as it provides reassuring steadiness in the midst of turbulent change.

Let’s take the example of a 12-year-old coming home from school with poor grades. One parent may see the need for a tutor, but might be using that approach as part of a financial attack if the other parent has to pay for it. The other parent may want to limit the use of computer games or access to television until the grades go up. And one may expect movement from a D to a C average while the other may expect A’s, period. Is the poor grade based on lack of ability, effort, an attempt to get attention, a reaction to the divorce, or preoccupation with ongoing parental discord? What is the impact on the child if in one home there is a tutor and a C expectation, and in the other there is no tutor, no computer use, no TV... and these change every time the child moves from one home to the other? A child striving to overcome a poor grade needs calm, consistent, patient, and optimistic support, rather than managing the increased tension across two homes or feeling like the cause of increased conflict. Virtually any reasonable approach is better for the child than each parent doing something different as a reflection of ongoing tension. Pediatricians can be extraordinarily helpful to their patient if they can get divorced parents to agree on a single approach that is based on their child’s needs rather than past and ongoing angers. The emotional damage of ongoing discord is far worse than any C average.

As the pediatrician to a family managing divorce, you may be one of the few authority figures whom both parents and the children all still respect and trust. You are in a strong position to ask a parent during an appointment how rules and limits are being managed across two homes. Find out if they have a clear plan for handling routine communication about the children, whether about summer camps or a new curfew, so that they don’t default to communicating only once there is a crisis. See if rules are a vehicle for ongoing parental fighting so that a minor difference (an 8 o’clock bedtime in one house versus 9 o’clock in the other) carries a high emotional charge. Find out if there are certain rules that have become very hard to enforce, or if their child has been testing limits more. Ask if there has been a consequence enforced in one home, but not in another. Often simply providing a calm affirmation that increased limit testing is normal in children after a divorce is very reassuring for parents. Remind them that providing reasonably consistent rules and limits will be very helpful to their children during this period, the opposite of making them a “bad parent.”

Some divorced parents will become more rigid about rules, managing any infraction or extenuating circumstance more like a contract negotiation. These parents might benefit from a suggestion that consistency and simplicity are the keys to effective rules across two households. Rules also provide an opportunity to listen to their children’s thoughts and feelings and share the family’s values that are the basis for the rules. Parents should be curious about their children’s opinions and be ready to show thoughtful flexibility when rules become outdated or special circumstances exist.

You can suggest a rule the parents should follow. While they can talk honestly about what each parent may struggle with or acknowledge clear differences in style or personality, they should strive to never vilify the other parent. Even in circumstances in which it is very difficult for two parents to collaborate, sharing grievances with the children will only be painful and confusing for them.

Lastly, pediatricians can discuss the long-term goals that all parents, even those alienated from each other, share. Children will do best when they have a positive, honest, warm relationship with each parent, and do not carry responsibility for negotiating conflict between their parents. Ultimately, more autonomy and fewer rules will be an important part of the child’s adolescence. Discord between parents, sabotaging of rules and consequences, and explicit contempt for their children’s other parent all will lead to children feeling burdened, having lower self-esteem, and being at greater risk for serious problems in school, emotionally or with substances as they grow into adolescents and young adults. If you are frustrated in your effort to protect children from ongoing discord, suggest a referral to a mental health clinician with expertise helping parents after a divorce.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at pdnews@frontlinemedcom.com.

A major challenge faced by parents is the task of setting basic ground rules and expectations for their children, and then enforcing these with limits, rewards, and consequences. This task is made far more difficult when parents are separated or divorced. Agreeing upon and enforcing rules in separate homes often becomes burdened by the angry baggage that led to the divorce. When a family in your practice is going through a divorce, you have an opportunity to provide the parents with valuable strategies to manage rules effectively so that conflict is minimized.

Many happily married parents who communicate very well on most matters struggle to get on the same page when negotiating rules and limits. One parent’s sense of what is an appropriate bedtime, how children should help with chores, or even how often they can have sweets can become a deeply held belief and might be very different than their spouse’s opinions. Sometimes, a parent has old anger about how they were raised and finds it hard to distinguish what might have been better for them, compared with what is best for their own child. Cultural and family differences on how much choice children should have at different ages, criteria and severity of any consequences for misbehavior, and opportunities for redemption or amnesty all add complexity to the discussion. Once they have found common ground on what makes sense for their joint rules, values, and needs of their child, they have to manage enforcing rules and limits, agreeing upon appropriate rewards and punishments, and bearing the inevitable distress of their children when facing a limit or consequence. And, of course, once parents think they have it all figured out, their children react and grow, and they must reset the rules, expectations, and consequences.

When parents get separated or divorced, this process becomes considerably more difficult. Negotiating new rules or limits is very difficult when communication is hampered by conflict. Parental guilt about the divorce itself, anger at old hurts or disputes about money and custody, missing the child between visits, and remarriages all add baggage to the discussion of a reasonable bedtime or consequences for a poor grade at school. If the divorce required aggressive negotiation between lawyers, appointment of a guardian ad Litem to manage ongoing disputes involving the children, or a court case to reach resolution, the tensions between parents can be intense, enduring, and with no issue too small to add fuel to the arguments. Enforcing limits is much harder for a single parent than when there are two parents doing the enforcement. And divorced parents, already feeling guilty and insecure, are more likely to suspend rules or limits so that they don’t have to be the “bad parent.” For the child or children, the stress and disruptions that come with divorce can cause an increase in regressed or disrespectful behavior. While it can be a time when limits are increasingly tested, being reasonable and consistent in enforcing limits becomes more important, as it provides reassuring steadiness in the midst of turbulent change.

Let’s take the example of a 12-year-old coming home from school with poor grades. One parent may see the need for a tutor, but might be using that approach as part of a financial attack if the other parent has to pay for it. The other parent may want to limit the use of computer games or access to television until the grades go up. And one may expect movement from a D to a C average while the other may expect A’s, period. Is the poor grade based on lack of ability, effort, an attempt to get attention, a reaction to the divorce, or preoccupation with ongoing parental discord? What is the impact on the child if in one home there is a tutor and a C expectation, and in the other there is no tutor, no computer use, no TV... and these change every time the child moves from one home to the other? A child striving to overcome a poor grade needs calm, consistent, patient, and optimistic support, rather than managing the increased tension across two homes or feeling like the cause of increased conflict. Virtually any reasonable approach is better for the child than each parent doing something different as a reflection of ongoing tension. Pediatricians can be extraordinarily helpful to their patient if they can get divorced parents to agree on a single approach that is based on their child’s needs rather than past and ongoing angers. The emotional damage of ongoing discord is far worse than any C average.

As the pediatrician to a family managing divorce, you may be one of the few authority figures whom both parents and the children all still respect and trust. You are in a strong position to ask a parent during an appointment how rules and limits are being managed across two homes. Find out if they have a clear plan for handling routine communication about the children, whether about summer camps or a new curfew, so that they don’t default to communicating only once there is a crisis. See if rules are a vehicle for ongoing parental fighting so that a minor difference (an 8 o’clock bedtime in one house versus 9 o’clock in the other) carries a high emotional charge. Find out if there are certain rules that have become very hard to enforce, or if their child has been testing limits more. Ask if there has been a consequence enforced in one home, but not in another. Often simply providing a calm affirmation that increased limit testing is normal in children after a divorce is very reassuring for parents. Remind them that providing reasonably consistent rules and limits will be very helpful to their children during this period, the opposite of making them a “bad parent.”

Some divorced parents will become more rigid about rules, managing any infraction or extenuating circumstance more like a contract negotiation. These parents might benefit from a suggestion that consistency and simplicity are the keys to effective rules across two households. Rules also provide an opportunity to listen to their children’s thoughts and feelings and share the family’s values that are the basis for the rules. Parents should be curious about their children’s opinions and be ready to show thoughtful flexibility when rules become outdated or special circumstances exist.

You can suggest a rule the parents should follow. While they can talk honestly about what each parent may struggle with or acknowledge clear differences in style or personality, they should strive to never vilify the other parent. Even in circumstances in which it is very difficult for two parents to collaborate, sharing grievances with the children will only be painful and confusing for them.

Lastly, pediatricians can discuss the long-term goals that all parents, even those alienated from each other, share. Children will do best when they have a positive, honest, warm relationship with each parent, and do not carry responsibility for negotiating conflict between their parents. Ultimately, more autonomy and fewer rules will be an important part of the child’s adolescence. Discord between parents, sabotaging of rules and consequences, and explicit contempt for their children’s other parent all will lead to children feeling burdened, having lower self-esteem, and being at greater risk for serious problems in school, emotionally or with substances as they grow into adolescents and young adults. If you are frustrated in your effort to protect children from ongoing discord, suggest a referral to a mental health clinician with expertise helping parents after a divorce.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at pdnews@frontlinemedcom.com.

As an experienced clinician who has seen tics and habits in your patients come and go, you may be surprised by the amount of concern parents express about them. At times, it seems, and may be, that the parent’s attention to the habit actually keeps it going! This does not always mean that the child keeps doing the habit to aggravate the parent, as parental correction may amp up the child’s anxiety, which may make the habit worse.

As with other parent concerns, both empathizing with their worry and providing evidence-based information is helpful in relieving their distress.

Habits are complex behaviors done the same way repeatedly. Habits can have a strong protective effect on our lives and be a foundation for success when they ensure that we wash our hands (protection from infection), help us know where the keys are (efficiency), or soothe us to sleep (bedtime routines).

Tics are “involuntary” (meaning often, but not always, suppressible), brief, abrupt, repeated movements usually of the face, head, or neck. More complex, apparently meaningless movements may fall into the category of stereotypies. If they last more than 4 weeks, are driven, and cause marked dysfunction or significant self-injury, they may even qualify as stereotypic movement disorder.

It is good to know that repeated behaviors such as thumb sucking, nail/lip biting, hair twirling, body rocking, self biting, and head banging are relatively common in childhood, and often (but not mostly) disappear after age 4. I like to set the expectation that one habit or tic often evolves to another to reduce panic when this happens. Thumb and hand sucking at a younger developmental age may be replaced by body rocking and head banging, and later by nail biting and finger and foot tapping.

Even in college, habits are common and stress-related such as touching the face; playing with hair, pens, or jewelry; shaking a leg; tapping fingers; or scratching the head. Parents may connect some of these to acne or poor hygiene (a good opening for coaching!) but more importantly they may be accompanied by general distress, anxiety, obsessive-compulsive symptoms, and impulsive aggressive symptoms, which need to be looked for and addressed.

Stereotypies occur in about 20% of typically developing children (called “primary”) and are classified into:

• Common behaviors (such as, rocking, head banging, finger drumming, pencil tapping, hair twisting),

• Head nodding.

• Complex motor movements (such as hand and arm flapping/waving).

Habits – including nail biting, lip chewing, and nose picking – also may be diagnosed as stereotypic movement disorders, although ICD-10 lists includes them as “other specified behavioral and emotional disorders.”

For both conditions, the behavior must not be better accounted for by a compulsion, a tic disorder, part of autism, hair pulling (trichotillomania), or paroxysmal dyskinesias.

So what is the difference between motor stereotypies and tics (and why do you care)? Motor stereotypies begin before 3 years in more than 60%, whereas tics appear later (mean 5-7 years). Stereotypies are more fixed in their pattern, compared with tics that keep shifting form, disappearing, and reappearing. Stereotypies frequently involve the arms, hands, or the entire body, while tics involve the eyes, face, head, and shoulders. Stereotypies are more fixed, rhythmic, and prolonged (most more than 10 seconds) than tics, which are mostly brief, rapid, random, and fluctuating.

One key distinguishing factor is that tics have a premonitory urge and result in a sense of relief after the tic is performed. This also means that they can be suppressed to some extent when the situation requires. While both may occur more during anxiety, excitement, or fatigue, stereotypic movements, unlike tics, also are common when the child is engrossed.

Tics can occur as a side effect of medications such as stimulants and may decrease by lowering the dose, but tics also come and go, so the impact of a medication can be hard to sort out.

One vocal or multiple motor tics occurring many times per day starting before age 18 years and lasting more than 1 year are considered chronic; those occurring less than 1 year are transient. Chronic multiple motor tics accompanied by vocalizations, even sniffing or throat clearing, qualify as Tourette syndrome. The feared component of Tourette of coprolalia (saying bad words or gestures) is fortunately rare. These diagnoses can only be made after ruling out the effects of medication or another neurological condition such as Sydenham’s chorea (resulting from infection via group A beta-hemolytic streptococcus, the bacterium that causes rheumatic fever) or PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections).

The importance of distinguishing tics from stereotypies is in the treatment options, differential diagnosis, and prognosis. Some families (and certainly the kids themselves) do not even notice that they are moving abnormally even though 25% have at least one family member with a similar behavior. But many parents are upset about the potential for teasing and stigmatization. When you ask them directly what they are afraid of, they often admit fearing an underlying diagnosis such as intellectual disability, autism, or Tourette syndrome. The first two are straightforward to rule in or out, but Tourette can be subtle. If parents don’t bring up the possibilities, it is worth telling them directly which underlying conditions can be ruled out.

There are many conditions comorbid with tics including attention-deficit/hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), learning disorder (LD), behavioral, developmental or social problems, and mood or anxiety disorders. This clearly means that a comprehensive evaluation looking specifically for these conditions is needed when a child has chronic tics. Typically developing children with complex arm or hand movements also are more likely to have ADHD (30%), LD (20%), obsessive-compulsive behaviors (10%), or tics (18%).

Tics and stereotypies may be annoying, but generally are not harmful or progressive, although repeated movements such as skin or nose picking may result in scars or infections, and severe head banging can lead to eye injuries. Frequently repeated motor acts can cause significant muscle pain and fatigue. The most common problems are probably injury to self-esteem or oppositional behavior as a result of repeated (and fruitless) nagging or punishment by parents, even if well-meaning.

Since they occur so often along with comorbid conditions, our job includes determining the most problematic aspect before advising on a treatment. Both tics and stereotypies may be reduced by distraction, but the effect on stereotypies is faster and more certain. You can make this intervention in the office by simply asking how the child can tell when they make the movement and have them plan out what they could do instead. An example might be to shift a hand flapping movement (that makes peers think of autism) into more acceptable fist clenching. Habit reversal training or differential reinforcement based on a functional analysis can be taught by psychologists when this simple suggestion is not effective. When tics are severe, teacher education and school accommodations (504 Plan with extended time, scribe, private location for tic breaks) may be needed.

Medication is not indicated for most tics because most are mild. If ADHD is present, tics may actually be reduced by stimulants or atomoxetine rather than worsened. If the tic is severe and habit reversal training has not been successful, alpha agonists such as clonidine or guanfacine, or typical or atypical neuroleptics may be helpful. Even baclofen, benzodiazepines, anticonvulsants, nicotine, and Botox have been used. These require consultation with a specialist.

As for other chronic medical conditions, tics and persisting stereotypies deserve a comprehensive approach, including repeated education of the parent and child, evaluation for comorbidity, school accommodations, building other strengths and social support, and only rarely pulling out your prescription pad.

Dr. Howard is an assistant professor of pediatrics at The Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.

As an experienced clinician who has seen tics and habits in your patients come and go, you may be surprised by the amount of concern parents express about them. At times, it seems, and may be, that the parent’s attention to the habit actually keeps it going! This does not always mean that the child keeps doing the habit to aggravate the parent, as parental correction may amp up the child’s anxiety, which may make the habit worse.

As with other parent concerns, both empathizing with their worry and providing evidence-based information is helpful in relieving their distress.

Habits are complex behaviors done the same way repeatedly. Habits can have a strong protective effect on our lives and be a foundation for success when they ensure that we wash our hands (protection from infection), help us know where the keys are (efficiency), or soothe us to sleep (bedtime routines).

Tics are “involuntary” (meaning often, but not always, suppressible), brief, abrupt, repeated movements usually of the face, head, or neck. More complex, apparently meaningless movements may fall into the category of stereotypies. If they last more than 4 weeks, are driven, and cause marked dysfunction or significant self-injury, they may even qualify as stereotypic movement disorder.

It is good to know that repeated behaviors such as thumb sucking, nail/lip biting, hair twirling, body rocking, self biting, and head banging are relatively common in childhood, and often (but not mostly) disappear after age 4. I like to set the expectation that one habit or tic often evolves to another to reduce panic when this happens. Thumb and hand sucking at a younger developmental age may be replaced by body rocking and head banging, and later by nail biting and finger and foot tapping.

Even in college, habits are common and stress-related such as touching the face; playing with hair, pens, or jewelry; shaking a leg; tapping fingers; or scratching the head. Parents may connect some of these to acne or poor hygiene (a good opening for coaching!) but more importantly they may be accompanied by general distress, anxiety, obsessive-compulsive symptoms, and impulsive aggressive symptoms, which need to be looked for and addressed.

Stereotypies occur in about 20% of typically developing children (called “primary”) and are classified into:

• Common behaviors (such as, rocking, head banging, finger drumming, pencil tapping, hair twisting),

• Head nodding.

• Complex motor movements (such as hand and arm flapping/waving).

Habits – including nail biting, lip chewing, and nose picking – also may be diagnosed as stereotypic movement disorders, although ICD-10 lists includes them as “other specified behavioral and emotional disorders.”

For both conditions, the behavior must not be better accounted for by a compulsion, a tic disorder, part of autism, hair pulling (trichotillomania), or paroxysmal dyskinesias.

So what is the difference between motor stereotypies and tics (and why do you care)? Motor stereotypies begin before 3 years in more than 60%, whereas tics appear later (mean 5-7 years). Stereotypies are more fixed in their pattern, compared with tics that keep shifting form, disappearing, and reappearing. Stereotypies frequently involve the arms, hands, or the entire body, while tics involve the eyes, face, head, and shoulders. Stereotypies are more fixed, rhythmic, and prolonged (most more than 10 seconds) than tics, which are mostly brief, rapid, random, and fluctuating.

One key distinguishing factor is that tics have a premonitory urge and result in a sense of relief after the tic is performed. This also means that they can be suppressed to some extent when the situation requires. While both may occur more during anxiety, excitement, or fatigue, stereotypic movements, unlike tics, also are common when the child is engrossed.

Tics can occur as a side effect of medications such as stimulants and may decrease by lowering the dose, but tics also come and go, so the impact of a medication can be hard to sort out.

One vocal or multiple motor tics occurring many times per day starting before age 18 years and lasting more than 1 year are considered chronic; those occurring less than 1 year are transient. Chronic multiple motor tics accompanied by vocalizations, even sniffing or throat clearing, qualify as Tourette syndrome. The feared component of Tourette of coprolalia (saying bad words or gestures) is fortunately rare. These diagnoses can only be made after ruling out the effects of medication or another neurological condition such as Sydenham’s chorea (resulting from infection via group A beta-hemolytic streptococcus, the bacterium that causes rheumatic fever) or PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections).

The importance of distinguishing tics from stereotypies is in the treatment options, differential diagnosis, and prognosis. Some families (and certainly the kids themselves) do not even notice that they are moving abnormally even though 25% have at least one family member with a similar behavior. But many parents are upset about the potential for teasing and stigmatization. When you ask them directly what they are afraid of, they often admit fearing an underlying diagnosis such as intellectual disability, autism, or Tourette syndrome. The first two are straightforward to rule in or out, but Tourette can be subtle. If parents don’t bring up the possibilities, it is worth telling them directly which underlying conditions can be ruled out.

There are many conditions comorbid with tics including attention-deficit/hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), learning disorder (LD), behavioral, developmental or social problems, and mood or anxiety disorders. This clearly means that a comprehensive evaluation looking specifically for these conditions is needed when a child has chronic tics. Typically developing children with complex arm or hand movements also are more likely to have ADHD (30%), LD (20%), obsessive-compulsive behaviors (10%), or tics (18%).

Tics and stereotypies may be annoying, but generally are not harmful or progressive, although repeated movements such as skin or nose picking may result in scars or infections, and severe head banging can lead to eye injuries. Frequently repeated motor acts can cause significant muscle pain and fatigue. The most common problems are probably injury to self-esteem or oppositional behavior as a result of repeated (and fruitless) nagging or punishment by parents, even if well-meaning.

Since they occur so often along with comorbid conditions, our job includes determining the most problematic aspect before advising on a treatment. Both tics and stereotypies may be reduced by distraction, but the effect on stereotypies is faster and more certain. You can make this intervention in the office by simply asking how the child can tell when they make the movement and have them plan out what they could do instead. An example might be to shift a hand flapping movement (that makes peers think of autism) into more acceptable fist clenching. Habit reversal training or differential reinforcement based on a functional analysis can be taught by psychologists when this simple suggestion is not effective. When tics are severe, teacher education and school accommodations (504 Plan with extended time, scribe, private location for tic breaks) may be needed.

Medication is not indicated for most tics because most are mild. If ADHD is present, tics may actually be reduced by stimulants or atomoxetine rather than worsened. If the tic is severe and habit reversal training has not been successful, alpha agonists such as clonidine or guanfacine, or typical or atypical neuroleptics may be helpful. Even baclofen, benzodiazepines, anticonvulsants, nicotine, and Botox have been used. These require consultation with a specialist.

As for other chronic medical conditions, tics and persisting stereotypies deserve a comprehensive approach, including repeated education of the parent and child, evaluation for comorbidity, school accommodations, building other strengths and social support, and only rarely pulling out your prescription pad.

Dr. Howard is an assistant professor of pediatrics at The Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.

As an experienced clinician who has seen tics and habits in your patients come and go, you may be surprised by the amount of concern parents express about them. At times, it seems, and may be, that the parent’s attention to the habit actually keeps it going! This does not always mean that the child keeps doing the habit to aggravate the parent, as parental correction may amp up the child’s anxiety, which may make the habit worse.

As with other parent concerns, both empathizing with their worry and providing evidence-based information is helpful in relieving their distress.

Habits are complex behaviors done the same way repeatedly. Habits can have a strong protective effect on our lives and be a foundation for success when they ensure that we wash our hands (protection from infection), help us know where the keys are (efficiency), or soothe us to sleep (bedtime routines).

Tics are “involuntary” (meaning often, but not always, suppressible), brief, abrupt, repeated movements usually of the face, head, or neck. More complex, apparently meaningless movements may fall into the category of stereotypies. If they last more than 4 weeks, are driven, and cause marked dysfunction or significant self-injury, they may even qualify as stereotypic movement disorder.

It is good to know that repeated behaviors such as thumb sucking, nail/lip biting, hair twirling, body rocking, self biting, and head banging are relatively common in childhood, and often (but not mostly) disappear after age 4. I like to set the expectation that one habit or tic often evolves to another to reduce panic when this happens. Thumb and hand sucking at a younger developmental age may be replaced by body rocking and head banging, and later by nail biting and finger and foot tapping.

Even in college, habits are common and stress-related such as touching the face; playing with hair, pens, or jewelry; shaking a leg; tapping fingers; or scratching the head. Parents may connect some of these to acne or poor hygiene (a good opening for coaching!) but more importantly they may be accompanied by general distress, anxiety, obsessive-compulsive symptoms, and impulsive aggressive symptoms, which need to be looked for and addressed.

Stereotypies occur in about 20% of typically developing children (called “primary”) and are classified into:

• Common behaviors (such as, rocking, head banging, finger drumming, pencil tapping, hair twisting),

• Head nodding.

• Complex motor movements (such as hand and arm flapping/waving).

Habits – including nail biting, lip chewing, and nose picking – also may be diagnosed as stereotypic movement disorders, although ICD-10 lists includes them as “other specified behavioral and emotional disorders.”

For both conditions, the behavior must not be better accounted for by a compulsion, a tic disorder, part of autism, hair pulling (trichotillomania), or paroxysmal dyskinesias.

So what is the difference between motor stereotypies and tics (and why do you care)? Motor stereotypies begin before 3 years in more than 60%, whereas tics appear later (mean 5-7 years). Stereotypies are more fixed in their pattern, compared with tics that keep shifting form, disappearing, and reappearing. Stereotypies frequently involve the arms, hands, or the entire body, while tics involve the eyes, face, head, and shoulders. Stereotypies are more fixed, rhythmic, and prolonged (most more than 10 seconds) than tics, which are mostly brief, rapid, random, and fluctuating.

One key distinguishing factor is that tics have a premonitory urge and result in a sense of relief after the tic is performed. This also means that they can be suppressed to some extent when the situation requires. While both may occur more during anxiety, excitement, or fatigue, stereotypic movements, unlike tics, also are common when the child is engrossed.

Tics can occur as a side effect of medications such as stimulants and may decrease by lowering the dose, but tics also come and go, so the impact of a medication can be hard to sort out.

One vocal or multiple motor tics occurring many times per day starting before age 18 years and lasting more than 1 year are considered chronic; those occurring less than 1 year are transient. Chronic multiple motor tics accompanied by vocalizations, even sniffing or throat clearing, qualify as Tourette syndrome. The feared component of Tourette of coprolalia (saying bad words or gestures) is fortunately rare. These diagnoses can only be made after ruling out the effects of medication or another neurological condition such as Sydenham’s chorea (resulting from infection via group A beta-hemolytic streptococcus, the bacterium that causes rheumatic fever) or PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections).

The importance of distinguishing tics from stereotypies is in the treatment options, differential diagnosis, and prognosis. Some families (and certainly the kids themselves) do not even notice that they are moving abnormally even though 25% have at least one family member with a similar behavior. But many parents are upset about the potential for teasing and stigmatization. When you ask them directly what they are afraid of, they often admit fearing an underlying diagnosis such as intellectual disability, autism, or Tourette syndrome. The first two are straightforward to rule in or out, but Tourette can be subtle. If parents don’t bring up the possibilities, it is worth telling them directly which underlying conditions can be ruled out.

There are many conditions comorbid with tics including attention-deficit/hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), learning disorder (LD), behavioral, developmental or social problems, and mood or anxiety disorders. This clearly means that a comprehensive evaluation looking specifically for these conditions is needed when a child has chronic tics. Typically developing children with complex arm or hand movements also are more likely to have ADHD (30%), LD (20%), obsessive-compulsive behaviors (10%), or tics (18%).

Tics and stereotypies may be annoying, but generally are not harmful or progressive, although repeated movements such as skin or nose picking may result in scars or infections, and severe head banging can lead to eye injuries. Frequently repeated motor acts can cause significant muscle pain and fatigue. The most common problems are probably injury to self-esteem or oppositional behavior as a result of repeated (and fruitless) nagging or punishment by parents, even if well-meaning.

Since they occur so often along with comorbid conditions, our job includes determining the most problematic aspect before advising on a treatment. Both tics and stereotypies may be reduced by distraction, but the effect on stereotypies is faster and more certain. You can make this intervention in the office by simply asking how the child can tell when they make the movement and have them plan out what they could do instead. An example might be to shift a hand flapping movement (that makes peers think of autism) into more acceptable fist clenching. Habit reversal training or differential reinforcement based on a functional analysis can be taught by psychologists when this simple suggestion is not effective. When tics are severe, teacher education and school accommodations (504 Plan with extended time, scribe, private location for tic breaks) may be needed.

Medication is not indicated for most tics because most are mild. If ADHD is present, tics may actually be reduced by stimulants or atomoxetine rather than worsened. If the tic is severe and habit reversal training has not been successful, alpha agonists such as clonidine or guanfacine, or typical or atypical neuroleptics may be helpful. Even baclofen, benzodiazepines, anticonvulsants, nicotine, and Botox have been used. These require consultation with a specialist.

As for other chronic medical conditions, tics and persisting stereotypies deserve a comprehensive approach, including repeated education of the parent and child, evaluation for comorbidity, school accommodations, building other strengths and social support, and only rarely pulling out your prescription pad.

Dr. Howard is an assistant professor of pediatrics at The Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.

The development of language in children is like the canary in the coal mine – problems of genetics, medical conditions, and environment all can cause it to go awry. Whatever the cause, it is very important to make sure a child with a problem in this area gets prompt assistance, because how speech and language progress also affects many aspects of the child’s success in life and what it is like to parent them.

Some of the factors known to put a child at risk for delays or deviations in speech and language development include prematurity and low birth weight; genetic conditions such as Down syndrome; physical problems such as cerebral palsy or seizure disorders; hearing impairment; and, as usual, being a boy. The most common reason for delayed language is general delay or intellectual disability. A family history of speech and language disorders also adds to the risk, and one single gene defect has even been found for a few of these. Eight percent of young children have been estimated to have a delay in speech or language. The vast majority of them have no specific risk factors.

The “language environment” of the home is critical to language learning. Compared with high-income families, parents on welfare say one-third as many words to their children and working-class parents say one-half as many in the first 3 years. Because over 85% of a child’s words at age 3 years come from words heard from their parents, this is estimated to create a 30-million-word difference between children of high- versus low-income families by age 4 years! In addition, low-income parents provide two discouragements for each one encouragement, in contrast to one correction to six encouragements in high-income homes, with the additional psychological implications.

These sad facts contributed to the creation of the Reach Out and Read program, which I hope you have joined. A free book from the doctor at every checkup visit, some modeling of how to read to the child, and information about the importance of talking with the child are things you can do to emphasize the importance of language stimulation to development and academic success.

Most parents are very motivated by the promise of better school success from better language, but it can seem far away when the child is only 1 year old! A more immediate motivator is the threat of more temper tantrums and noncompliance in children with delayed language. Almost all children with language problems understand more than they can express. When the gap between understanding and speaking is greater, so is the child’s frustration. While a large percentage of children with expressive language problems will “outgrow” them, the pattern of angry reactivity and difficult parent child interactions may continue. This is a good reason to discuss promoting language but to also suggest Baby Signs (www.babysignstoo.com) starting in the first year, especially if communication frustration starts to emerge.

School is where the big impact from language impairments appears. And it is not just the significant association between early language disorders and persistent reading disability and even written language disability that you should worry about and monitor. Children with speech and language disorders, even simply dysarticulation, can be teased, bullied, and rejected socially. As a result, children with speech and language deficits experience lower self-esteem, greater discouragement, and sometimes reactive aggression. In addition to identifying these problems and getting treatment for the issues of language, learning, and socio-emotional adjustment, it is important to find nonverbal strengths in the child such as sports or music to give them a social group where they can find success.

Language problems in older children may be subtle and not noticed or complained about by their parents, who may have the same weakness. Even teachers may not connect the student’s poor academic performance to language difficulties because they seem to have “the basics.” If you notice a schoolaged child unable to understand or answer your questions with some sentence complexity, it is important to refer to a speech pathologist for assessment. Although there should be free evaluation and treatment services at the school, the speech pathologist may not be expert at assessing more complex language disorders. In addition, the child’s difficulties may not measure up as “impairing enough” to receive those services, and private services may be needed.

But if you do not feel like a child language expert, you are not alone! Not only were you lucky if you heard one lecture on language development during training, but the younger the child, the less language you are likely to hear from him or her during brief health supervision visits. The parent is probably dominating the conversation (if you are a good listener) trying to have their agenda addressed, and the child is either excited or terrified by your office environment.

The broadband developmental screening now recommended by the American Academy of Pediatrics for all children at 9, 18, and 30 months includes language milestones or parental concern, but these have not been shown to have adequate sensitivity or specificity and will miss many affected children.

Many young children with language disorders are now or will later be on the autism spectrum. The recommended autism-specific screens at 18 and 24-30 months will detect many, but not all, of these children. It is important to realize that the most common reason for a false positive autism screen is language delay, and it deserves follow-up and treatment even though not representing autism.

What should you do given these gaps between need, tools, and knowledge? Of course, collect the general and autism screens as recommended, but also use them when you or the parent have a concern. For children under 2 years, the parent’s report is generally accurate, as expected language is fairly simple. Infants should have different cries and reactions to caregivers in the first 3 months; babble and laugh by 6 months; and imitate sounds as well as recognize a few words by 1 year. While infants typically have 1-2 words by 12 months and two-word combinations by 18 months, as a cutoff they should show 1-2 words by 18 months and either 50 words or 2 words together by 24 months. Listening to a child’s spontaneous language is the best gauge of articulation. By age 2 years, we – a stranger to the child – can only expect to understand about 25% of what they say, but by 3 years it should be 66%, and by age 4 years almost 100%.

Gestures are an important aspect of communication. Use of gestures such as raising arms to be picked up or waving bye-bye by 1 year are typical. Between 1 and 2 years, children should follow your pointing and share their interests by pointing in addition to indicating named pictures and body parts. Deficits in use of gestures should spur a language evaluation and also are part of diagnosing autism, a much more serious and specific condition defined by communication deficits. Most autism screening tools include tapping gestures as well as spoken language.

After 2 years, language assessment has to include more elements than many parents can report easily or you can observe. There is now no formal additional language screening recommendation beyond surveillance, and the general developmental and autism screens. Every state has free child development services that can assess and provide intervention for children 0-3 years if you or the parent has concerns. But you may want to do more to either reassure or clarify the need for and type of referral by using a language-specific tool. The most accurate and practical tools applicable to children 8-35 months are the MacArthur-Bates Communicative Development Inventories (CDI) and the Language Development Survey (LDS), both parent completed. The LDS assesses based on a list of vocabulary words and examples of phrases, and the CDI has three different forms using vocabulary, gestures, and sentences.

After age 3 years, language is so complex that direct testing of the child is needed. A draft report from the U.S. Preventive Services Task Force in November 2014 presents a review of all available measures.

The good news is that a variety of approaches to therapy for speech and language disorders in young children are effective in reducing impairment. The most effective ones involve the parents in learning what communication skills to observe, stimulate, and reinforce, and have an adequate number of total hours of intervention spread over several months.

As for all children and youth with special health care needs, we have the responsibility to detect, monitor, refer, track, and support families of children with speech and language disorders to assure their best outcomes. Whatever the cause, improving the communication abilities of the child can make a big difference to many aspects of their lives.

Dr. Howard is an assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.

The development of language in children is like the canary in the coal mine – problems of genetics, medical conditions, and environment all can cause it to go awry. Whatever the cause, it is very important to make sure a child with a problem in this area gets prompt assistance, because how speech and language progress also affects many aspects of the child’s success in life and what it is like to parent them.

Some of the factors known to put a child at risk for delays or deviations in speech and language development include prematurity and low birth weight; genetic conditions such as Down syndrome; physical problems such as cerebral palsy or seizure disorders; hearing impairment; and, as usual, being a boy. The most common reason for delayed language is general delay or intellectual disability. A family history of speech and language disorders also adds to the risk, and one single gene defect has even been found for a few of these. Eight percent of young children have been estimated to have a delay in speech or language. The vast majority of them have no specific risk factors.

The “language environment” of the home is critical to language learning. Compared with high-income families, parents on welfare say one-third as many words to their children and working-class parents say one-half as many in the first 3 years. Because over 85% of a child’s words at age 3 years come from words heard from their parents, this is estimated to create a 30-million-word difference between children of high- versus low-income families by age 4 years! In addition, low-income parents provide two discouragements for each one encouragement, in contrast to one correction to six encouragements in high-income homes, with the additional psychological implications.

These sad facts contributed to the creation of the Reach Out and Read program, which I hope you have joined. A free book from the doctor at every checkup visit, some modeling of how to read to the child, and information about the importance of talking with the child are things you can do to emphasize the importance of language stimulation to development and academic success.

Most parents are very motivated by the promise of better school success from better language, but it can seem far away when the child is only 1 year old! A more immediate motivator is the threat of more temper tantrums and noncompliance in children with delayed language. Almost all children with language problems understand more than they can express. When the gap between understanding and speaking is greater, so is the child’s frustration. While a large percentage of children with expressive language problems will “outgrow” them, the pattern of angry reactivity and difficult parent child interactions may continue. This is a good reason to discuss promoting language but to also suggest Baby Signs (www.babysignstoo.com) starting in the first year, especially if communication frustration starts to emerge.

School is where the big impact from language impairments appears. And it is not just the significant association between early language disorders and persistent reading disability and even written language disability that you should worry about and monitor. Children with speech and language disorders, even simply dysarticulation, can be teased, bullied, and rejected socially. As a result, children with speech and language deficits experience lower self-esteem, greater discouragement, and sometimes reactive aggression. In addition to identifying these problems and getting treatment for the issues of language, learning, and socio-emotional adjustment, it is important to find nonverbal strengths in the child such as sports or music to give them a social group where they can find success.

Language problems in older children may be subtle and not noticed or complained about by their parents, who may have the same weakness. Even teachers may not connect the student’s poor academic performance to language difficulties because they seem to have “the basics.” If you notice a schoolaged child unable to understand or answer your questions with some sentence complexity, it is important to refer to a speech pathologist for assessment. Although there should be free evaluation and treatment services at the school, the speech pathologist may not be expert at assessing more complex language disorders. In addition, the child’s difficulties may not measure up as “impairing enough” to receive those services, and private services may be needed.

But if you do not feel like a child language expert, you are not alone! Not only were you lucky if you heard one lecture on language development during training, but the younger the child, the less language you are likely to hear from him or her during brief health supervision visits. The parent is probably dominating the conversation (if you are a good listener) trying to have their agenda addressed, and the child is either excited or terrified by your office environment.

The broadband developmental screening now recommended by the American Academy of Pediatrics for all children at 9, 18, and 30 months includes language milestones or parental concern, but these have not been shown to have adequate sensitivity or specificity and will miss many affected children.

Many young children with language disorders are now or will later be on the autism spectrum. The recommended autism-specific screens at 18 and 24-30 months will detect many, but not all, of these children. It is important to realize that the most common reason for a false positive autism screen is language delay, and it deserves follow-up and treatment even though not representing autism.

What should you do given these gaps between need, tools, and knowledge? Of course, collect the general and autism screens as recommended, but also use them when you or the parent have a concern. For children under 2 years, the parent’s report is generally accurate, as expected language is fairly simple. Infants should have different cries and reactions to caregivers in the first 3 months; babble and laugh by 6 months; and imitate sounds as well as recognize a few words by 1 year. While infants typically have 1-2 words by 12 months and two-word combinations by 18 months, as a cutoff they should show 1-2 words by 18 months and either 50 words or 2 words together by 24 months. Listening to a child’s spontaneous language is the best gauge of articulation. By age 2 years, we – a stranger to the child – can only expect to understand about 25% of what they say, but by 3 years it should be 66%, and by age 4 years almost 100%.

Gestures are an important aspect of communication. Use of gestures such as raising arms to be picked up or waving bye-bye by 1 year are typical. Between 1 and 2 years, children should follow your pointing and share their interests by pointing in addition to indicating named pictures and body parts. Deficits in use of gestures should spur a language evaluation and also are part of diagnosing autism, a much more serious and specific condition defined by communication deficits. Most autism screening tools include tapping gestures as well as spoken language.

After 2 years, language assessment has to include more elements than many parents can report easily or you can observe. There is now no formal additional language screening recommendation beyond surveillance, and the general developmental and autism screens. Every state has free child development services that can assess and provide intervention for children 0-3 years if you or the parent has concerns. But you may want to do more to either reassure or clarify the need for and type of referral by using a language-specific tool. The most accurate and practical tools applicable to children 8-35 months are the MacArthur-Bates Communicative Development Inventories (CDI) and the Language Development Survey (LDS), both parent completed. The LDS assesses based on a list of vocabulary words and examples of phrases, and the CDI has three different forms using vocabulary, gestures, and sentences.

After age 3 years, language is so complex that direct testing of the child is needed. A draft report from the U.S. Preventive Services Task Force in November 2014 presents a review of all available measures.

The good news is that a variety of approaches to therapy for speech and language disorders in young children are effective in reducing impairment. The most effective ones involve the parents in learning what communication skills to observe, stimulate, and reinforce, and have an adequate number of total hours of intervention spread over several months.

As for all children and youth with special health care needs, we have the responsibility to detect, monitor, refer, track, and support families of children with speech and language disorders to assure their best outcomes. Whatever the cause, improving the communication abilities of the child can make a big difference to many aspects of their lives.

Dr. Howard is an assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.

The development of language in children is like the canary in the coal mine – problems of genetics, medical conditions, and environment all can cause it to go awry. Whatever the cause, it is very important to make sure a child with a problem in this area gets prompt assistance, because how speech and language progress also affects many aspects of the child’s success in life and what it is like to parent them.

Some of the factors known to put a child at risk for delays or deviations in speech and language development include prematurity and low birth weight; genetic conditions such as Down syndrome; physical problems such as cerebral palsy or seizure disorders; hearing impairment; and, as usual, being a boy. The most common reason for delayed language is general delay or intellectual disability. A family history of speech and language disorders also adds to the risk, and one single gene defect has even been found for a few of these. Eight percent of young children have been estimated to have a delay in speech or language. The vast majority of them have no specific risk factors.

The “language environment” of the home is critical to language learning. Compared with high-income families, parents on welfare say one-third as many words to their children and working-class parents say one-half as many in the first 3 years. Because over 85% of a child’s words at age 3 years come from words heard from their parents, this is estimated to create a 30-million-word difference between children of high- versus low-income families by age 4 years! In addition, low-income parents provide two discouragements for each one encouragement, in contrast to one correction to six encouragements in high-income homes, with the additional psychological implications.

These sad facts contributed to the creation of the Reach Out and Read program, which I hope you have joined. A free book from the doctor at every checkup visit, some modeling of how to read to the child, and information about the importance of talking with the child are things you can do to emphasize the importance of language stimulation to development and academic success.

Most parents are very motivated by the promise of better school success from better language, but it can seem far away when the child is only 1 year old! A more immediate motivator is the threat of more temper tantrums and noncompliance in children with delayed language. Almost all children with language problems understand more than they can express. When the gap between understanding and speaking is greater, so is the child’s frustration. While a large percentage of children with expressive language problems will “outgrow” them, the pattern of angry reactivity and difficult parent child interactions may continue. This is a good reason to discuss promoting language but to also suggest Baby Signs (www.babysignstoo.com) starting in the first year, especially if communication frustration starts to emerge.

School is where the big impact from language impairments appears. And it is not just the significant association between early language disorders and persistent reading disability and even written language disability that you should worry about and monitor. Children with speech and language disorders, even simply dysarticulation, can be teased, bullied, and rejected socially. As a result, children with speech and language deficits experience lower self-esteem, greater discouragement, and sometimes reactive aggression. In addition to identifying these problems and getting treatment for the issues of language, learning, and socio-emotional adjustment, it is important to find nonverbal strengths in the child such as sports or music to give them a social group where they can find success.

Language problems in older children may be subtle and not noticed or complained about by their parents, who may have the same weakness. Even teachers may not connect the student’s poor academic performance to language difficulties because they seem to have “the basics.” If you notice a schoolaged child unable to understand or answer your questions with some sentence complexity, it is important to refer to a speech pathologist for assessment. Although there should be free evaluation and treatment services at the school, the speech pathologist may not be expert at assessing more complex language disorders. In addition, the child’s difficulties may not measure up as “impairing enough” to receive those services, and private services may be needed.

But if you do not feel like a child language expert, you are not alone! Not only were you lucky if you heard one lecture on language development during training, but the younger the child, the less language you are likely to hear from him or her during brief health supervision visits. The parent is probably dominating the conversation (if you are a good listener) trying to have their agenda addressed, and the child is either excited or terrified by your office environment.

The broadband developmental screening now recommended by the American Academy of Pediatrics for all children at 9, 18, and 30 months includes language milestones or parental concern, but these have not been shown to have adequate sensitivity or specificity and will miss many affected children.

Many young children with language disorders are now or will later be on the autism spectrum. The recommended autism-specific screens at 18 and 24-30 months will detect many, but not all, of these children. It is important to realize that the most common reason for a false positive autism screen is language delay, and it deserves follow-up and treatment even though not representing autism.

What should you do given these gaps between need, tools, and knowledge? Of course, collect the general and autism screens as recommended, but also use them when you or the parent have a concern. For children under 2 years, the parent’s report is generally accurate, as expected language is fairly simple. Infants should have different cries and reactions to caregivers in the first 3 months; babble and laugh by 6 months; and imitate sounds as well as recognize a few words by 1 year. While infants typically have 1-2 words by 12 months and two-word combinations by 18 months, as a cutoff they should show 1-2 words by 18 months and either 50 words or 2 words together by 24 months. Listening to a child’s spontaneous language is the best gauge of articulation. By age 2 years, we – a stranger to the child – can only expect to understand about 25% of what they say, but by 3 years it should be 66%, and by age 4 years almost 100%.

Gestures are an important aspect of communication. Use of gestures such as raising arms to be picked up or waving bye-bye by 1 year are typical. Between 1 and 2 years, children should follow your pointing and share their interests by pointing in addition to indicating named pictures and body parts. Deficits in use of gestures should spur a language evaluation and also are part of diagnosing autism, a much more serious and specific condition defined by communication deficits. Most autism screening tools include tapping gestures as well as spoken language.

After 2 years, language assessment has to include more elements than many parents can report easily or you can observe. There is now no formal additional language screening recommendation beyond surveillance, and the general developmental and autism screens. Every state has free child development services that can assess and provide intervention for children 0-3 years if you or the parent has concerns. But you may want to do more to either reassure or clarify the need for and type of referral by using a language-specific tool. The most accurate and practical tools applicable to children 8-35 months are the MacArthur-Bates Communicative Development Inventories (CDI) and the Language Development Survey (LDS), both parent completed. The LDS assesses based on a list of vocabulary words and examples of phrases, and the CDI has three different forms using vocabulary, gestures, and sentences.

After age 3 years, language is so complex that direct testing of the child is needed. A draft report from the U.S. Preventive Services Task Force in November 2014 presents a review of all available measures.

The good news is that a variety of approaches to therapy for speech and language disorders in young children are effective in reducing impairment. The most effective ones involve the parents in learning what communication skills to observe, stimulate, and reinforce, and have an adequate number of total hours of intervention spread over several months.

As for all children and youth with special health care needs, we have the responsibility to detect, monitor, refer, track, and support families of children with speech and language disorders to assure their best outcomes. Whatever the cause, improving the communication abilities of the child can make a big difference to many aspects of their lives.

Dr. Howard is an assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at pdnews@frontlinemedcom.com.

One of the greatest challenges you may face as a pediatrician is in helping your patients and families navigate the mental health system. Nearly 20% of children will experience a psychiatric illness before they turn 18, and a quarter of those will go on to experience a persistent or severe psychiatric illness. Whether a patient is experiencing symptoms that are mild or severe, their parents are likely to come to you first for an assessment and for help in finding a referral to the appropriate specialist.

Unlike the smooth process to refer to a neurologist or orthopedist, accessing treatment for mental health problems is often confusing and frustrating. Because of reimbursement that is below the cost of providing care, many community hospitals have closed their divisions of child and adolescent psychiatry, and academic medical centers often have a long wait for a provider. If you go through a patient’s insurance, usually the list of providers is woefully out-of-date, with most of them not accepting new referrals or insurance or both. If mental health services are “carved out” to cut costs, the primary insurer has no direct control of mental health services, and the carve out company is looking for providers willing to accept lower reimbursement and limit longer-term treatments. Faced with reimbursement and administrative demands by the carve out company, child psychiatrists, psychologists, and social workers that once staffed these services have chosen fee-for-service private offices that do not accept any insurance, leaving many communities without access to adequate resources. In private practice, these providers are busy, face no administrative demands to justify their work, and earn two or three times what insurers reimburse.

So families often turn to their schools and their pediatricians when faced with a mood, anxiety, or behavioral problem. While there is no straightforward solution to this problem of access, we have put together a “road map” to what services might be available and to help you in your approach to these patients.

It is first important to consider that mental health and developmental questions are now a major part of pediatric primary care. The majority of your visits will be well child care and psychosocial. So a part, maybe a third or half of mental health concerns might now be considered a routine part of primary care. Many practices are now doing psychosocial screening and more states are mandating reimbursement of this screening. Typically screening includes a CHATfor autism (Checklist for Autism in Toddlers), a developmental screen if indicated, a Pediatric Symptom Checklist for school-age children and adolescents, a Hamilton Rating Scale for Depression in adolescents, and a CRAFFTfor adolescent substance abuse. Some practices include a Hamilton or other depression screen for mothers of newborns and toddlers as maternal depression has a serious impact on the child and is responsive to treatment. If screening is reimbursed, some of that money could go to fund an on-site social worker, who can also bill for patient contact services, and thus provide the practice with an on-site mental health presence at break-even cost. This social worker may be expert in referring to local resources, may be trained in psychotherapy, or may even lead groups for parents of recent divorce, new mothers, facing attention-deficit/hyperactivity disorder (ADHD), etc.

The best place to start for a family with psychosocial concerns is to do a brief review of your patient’s day to day functioning – school, friends, family, activities, and mood. What is your best assessment of the problem, how much of the child and family’s life is affected, and how severe is the problem? There are many mental health problems for which the first-line treatment is a trial of medication according to an algorithm that you can use following American Academy of Pediatrics guidelines. For example, if considering stimulant treatment for a 7-year-old with possible attention difficulties, you can use broad screening instruments like the Pediatric Symptom Checklist or Childhood Behavior Checklist as well as the Vanderbilt Assessment Scales or Conners questionnaire that are specific for ADHD. Many pediatricians also are comfortable treating adolescent depression with medication and with comanagement from a social worker with a master’s degree or a doctorate level psychologist. Of course, treating depression requires a more careful interview, consideration of suicide risk, and more frequent follow-up visits.

As first-line treatment for depression and anxiety usually starts with psychotherapy, it is important to consider how you will access this component of mental health care. For those that don’t have a licensed clinical social worker on-site providing cognitive-behavioral therapy, many busy pediatric practices will establish a relationship with a therapist or group that has agreed to accept their referrals and accepts insurance reimbursement. If you are not fortunate enough to already have such a relationship, it can be fruitful to speak with colleagues in a busier practice about whom they use. It also can be fruitful to reach out to the graduate programs in psychology (PhD or PsyD programs) or social work in your community, to find out if they have a referral service or would like to connect recent graduates trying to establish themselves with referring pediatricians. Having a resource located in your office (employed by you or renting space) is ideal.

When a patient is presenting with a more complex set of symptoms or fails to respond to your initial treatments, then you will want to locate an appropriate referral to a child psychiatrist. If your group is affiliated with an academic medical center, find out what the procedure is for referring to their child psychiatrists or to the child psychiatry trainees. Often there is easy availability early in the academic year (summer), when children are less likely to present with problems and a new crop of trainees has arrived. Academic medical centers also will often be a hub for a lot of research activity, and research programs are usually eager to enroll patients without regard to their insurance. Good studies will provide patients with a formalized assessment that will clarify the diagnostic picture, ensuring that a child is on the path to the right treatment. Cultivating a connection with the research coordinator can ensure that your group knows about opportunities for free care that is easier to access than most.

Many states require schools to provide testing to clarify whether psychiatric symptoms, developmental issues, or learning disabilities are affecting a student’s ability to perform in school. Your office can educate parents that they should go to the school with their concerns and request a formal assessment. If testing indicates a condition, the school system is often required to provide appropriate educational services, such as tutoring for learning disabilities, occupational therapy, and social skills support for children on the autism spectrum, and even counseling for children with anxiety, mood, and behavioral issues. Often, the school psychologist or social worker will be a valuable resource in providing direct care to children or helping you and the parents identify excellent treaters in the community. For children with severe and persistent psychiatric illness, many states require that schools provide or pay for the services that are necessary to educate each child. This can mean anything from paying for an after school social skills group to paying for a therapeutic boarding school. In these cases, it is often helpful to have established a relationship with an educational consultant. These are usually social workers with expertise in mental health issues and the state’s educational system and regulations, and they will partner with parents for a modest fee to educate and empower parents so that they might get appropriate services from their schools. Again, it can be fruitful to speak with trusted colleagues and find one who has identified a local consultant that they trust.

Some states and counties have tried to address the problem of accessing psychiatric care for children, but often these are programs that have not been adequately marketed to pediatricians or families, so they may be under utilized. In Massachusetts and Connecticut, there is the state Child Psychiatry Access Project, which provides all pediatricians with free access to a consulting child psychiatrist by phone. It requires that pediatricians are willing to treat children themselves with the support and guidance of a consulting child psychiatrist, but it will also provide a face-to-face diagnostic evaluation of that child by a child psychiatrist so that they can in turn provide the best guidance to the pediatrician. And it provides a care coordinator who will help to identify appropriate treaters, such as a cognitive-behavioral therapist or a psychopharmacologist who accept the family’s insurance, when the pediatrician is unable to provide the recommended treatment. An online investigation through your state’s or county’s Office of Mental Health or your local Medical Society can help your office identify what resources may exist in your community.

Finally, your most critical task after a parent has come to you with concerns about their child’s mood, thinking, or behavior, may be in educating and supporting those parents. Prepare the parents by explaining to them how the mental health system is more fragmented and frustrating than most other medical specialties. Remind them that psychiatric symptoms and illnesses are eminently treatable, and it will be worth patiently navigating this complex system to eventually access the right care for their child. It can be helpful to suggest to them that if they can possibly afford to pay out-of-pocket for the appropriate care, it will make excellent treatment much easier to access in a timely way. It can be meaningful for parents to hear from you that it is worthwhile for them to call or write their insurance company and complain if that company has restricted access to child psychiatric care. They are, after all, the customers of their insurance company, and it is the silence, shame, and stigma surrounding psychiatric illness that has enabled insurance companies to restrict access to effective care. Finally, it can be very powerful to connect parents with support or advocacy organizations that will help them in navigating this system and in speaking up to their insurance companies, state health, or education agencies or in the press in ways that will diminish the stigma that still surrounds these problems. The National Alliance on Mental Illness (www.nami.org), The Bazelon Center for Mental Health Law (www.bazelon.org), and the American Academy of Child and Adolescent Psychiatry (www.aacap.org) all have excellent online resources that also help identify local organizations and resources for parents. If insurance companies refused to pay for potentially life-saving chemotherapy for a pediatric cancer, you can imagine that there would be many parents protesting to those insurers, to the news, and even to their local or state governments. Mental health care should be no different, as the problems can be as disabling and life-threatening and effective treatments and even cures exist.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at pdnews@frontlinemedcom.com.

One of the greatest challenges you may face as a pediatrician is in helping your patients and families navigate the mental health system. Nearly 20% of children will experience a psychiatric illness before they turn 18, and a quarter of those will go on to experience a persistent or severe psychiatric illness. Whether a patient is experiencing symptoms that are mild or severe, their parents are likely to come to you first for an assessment and for help in finding a referral to the appropriate specialist.

Unlike the smooth process to refer to a neurologist or orthopedist, accessing treatment for mental health problems is often confusing and frustrating. Because of reimbursement that is below the cost of providing care, many community hospitals have closed their divisions of child and adolescent psychiatry, and academic medical centers often have a long wait for a provider. If you go through a patient’s insurance, usually the list of providers is woefully out-of-date, with most of them not accepting new referrals or insurance or both. If mental health services are “carved out” to cut costs, the primary insurer has no direct control of mental health services, and the carve out company is looking for providers willing to accept lower reimbursement and limit longer-term treatments. Faced with reimbursement and administrative demands by the carve out company, child psychiatrists, psychologists, and social workers that once staffed these services have chosen fee-for-service private offices that do not accept any insurance, leaving many communities without access to adequate resources. In private practice, these providers are busy, face no administrative demands to justify their work, and earn two or three times what insurers reimburse.

So families often turn to their schools and their pediatricians when faced with a mood, anxiety, or behavioral problem. While there is no straightforward solution to this problem of access, we have put together a “road map” to what services might be available and to help you in your approach to these patients.

It is first important to consider that mental health and developmental questions are now a major part of pediatric primary care. The majority of your visits will be well child care and psychosocial. So a part, maybe a third or half of mental health concerns might now be considered a routine part of primary care. Many practices are now doing psychosocial screening and more states are mandating reimbursement of this screening. Typically screening includes a CHATfor autism (Checklist for Autism in Toddlers), a developmental screen if indicated, a Pediatric Symptom Checklist for school-age children and adolescents, a Hamilton Rating Scale for Depression in adolescents, and a CRAFFTfor adolescent substance abuse. Some practices include a Hamilton or other depression screen for mothers of newborns and toddlers as maternal depression has a serious impact on the child and is responsive to treatment. If screening is reimbursed, some of that money could go to fund an on-site social worker, who can also bill for patient contact services, and thus provide the practice with an on-site mental health presence at break-even cost. This social worker may be expert in referring to local resources, may be trained in psychotherapy, or may even lead groups for parents of recent divorce, new mothers, facing attention-deficit/hyperactivity disorder (ADHD), etc.

The best place to start for a family with psychosocial concerns is to do a brief review of your patient’s day to day functioning – school, friends, family, activities, and mood. What is your best assessment of the problem, how much of the child and family’s life is affected, and how severe is the problem? There are many mental health problems for which the first-line treatment is a trial of medication according to an algorithm that you can use following American Academy of Pediatrics guidelines. For example, if considering stimulant treatment for a 7-year-old with possible attention difficulties, you can use broad screening instruments like the Pediatric Symptom Checklist or Childhood Behavior Checklist as well as the Vanderbilt Assessment Scales or Conners questionnaire that are specific for ADHD. Many pediatricians also are comfortable treating adolescent depression with medication and with comanagement from a social worker with a master’s degree or a doctorate level psychologist. Of course, treating depression requires a more careful interview, consideration of suicide risk, and more frequent follow-up visits.

As first-line treatment for depression and anxiety usually starts with psychotherapy, it is important to consider how you will access this component of mental health care. For those that don’t have a licensed clinical social worker on-site providing cognitive-behavioral therapy, many busy pediatric practices will establish a relationship with a therapist or group that has agreed to accept their referrals and accepts insurance reimbursement. If you are not fortunate enough to already have such a relationship, it can be fruitful to speak with colleagues in a busier practice about whom they use. It also can be fruitful to reach out to the graduate programs in psychology (PhD or PsyD programs) or social work in your community, to find out if they have a referral service or would like to connect recent graduates trying to establish themselves with referring pediatricians. Having a resource located in your office (employed by you or renting space) is ideal.

When a patient is presenting with a more complex set of symptoms or fails to respond to your initial treatments, then you will want to locate an appropriate referral to a child psychiatrist. If your group is affiliated with an academic medical center, find out what the procedure is for referring to their child psychiatrists or to the child psychiatry trainees. Often there is easy availability early in the academic year (summer), when children are less likely to present with problems and a new crop of trainees has arrived. Academic medical centers also will often be a hub for a lot of research activity, and research programs are usually eager to enroll patients without regard to their insurance. Good studies will provide patients with a formalized assessment that will clarify the diagnostic picture, ensuring that a child is on the path to the right treatment. Cultivating a connection with the research coordinator can ensure that your group knows about opportunities for free care that is easier to access than most.

Many states require schools to provide testing to clarify whether psychiatric symptoms, developmental issues, or learning disabilities are affecting a student’s ability to perform in school. Your office can educate parents that they should go to the school with their concerns and request a formal assessment. If testing indicates a condition, the school system is often required to provide appropriate educational services, such as tutoring for learning disabilities, occupational therapy, and social skills support for children on the autism spectrum, and even counseling for children with anxiety, mood, and behavioral issues. Often, the school psychologist or social worker will be a valuable resource in providing direct care to children or helping you and the parents identify excellent treaters in the community. For children with severe and persistent psychiatric illness, many states require that schools provide or pay for the services that are necessary to educate each child. This can mean anything from paying for an after school social skills group to paying for a therapeutic boarding school. In these cases, it is often helpful to have established a relationship with an educational consultant. These are usually social workers with expertise in mental health issues and the state’s educational system and regulations, and they will partner with parents for a modest fee to educate and empower parents so that they might get appropriate services from their schools. Again, it can be fruitful to speak with trusted colleagues and find one who has identified a local consultant that they trust.

Some states and counties have tried to address the problem of accessing psychiatric care for children, but often these are programs that have not been adequately marketed to pediatricians or families, so they may be under utilized. In Massachusetts and Connecticut, there is the state Child Psychiatry Access Project, which provides all pediatricians with free access to a consulting child psychiatrist by phone. It requires that pediatricians are willing to treat children themselves with the support and guidance of a consulting child psychiatrist, but it will also provide a face-to-face diagnostic evaluation of that child by a child psychiatrist so that they can in turn provide the best guidance to the pediatrician. And it provides a care coordinator who will help to identify appropriate treaters, such as a cognitive-behavioral therapist or a psychopharmacologist who accept the family’s insurance, when the pediatrician is unable to provide the recommended treatment. An online investigation through your state’s or county’s Office of Mental Health or your local Medical Society can help your office identify what resources may exist in your community.

Finally, your most critical task after a parent has come to you with concerns about their child’s mood, thinking, or behavior, may be in educating and supporting those parents. Prepare the parents by explaining to them how the mental health system is more fragmented and frustrating than most other medical specialties. Remind them that psychiatric symptoms and illnesses are eminently treatable, and it will be worth patiently navigating this complex system to eventually access the right care for their child. It can be helpful to suggest to them that if they can possibly afford to pay out-of-pocket for the appropriate care, it will make excellent treatment much easier to access in a timely way. It can be meaningful for parents to hear from you that it is worthwhile for them to call or write their insurance company and complain if that company has restricted access to child psychiatric care. They are, after all, the customers of their insurance company, and it is the silence, shame, and stigma surrounding psychiatric illness that has enabled insurance companies to restrict access to effective care. Finally, it can be very powerful to connect parents with support or advocacy organizations that will help them in navigating this system and in speaking up to their insurance companies, state health, or education agencies or in the press in ways that will diminish the stigma that still surrounds these problems. The National Alliance on Mental Illness (www.nami.org), The Bazelon Center for Mental Health Law (www.bazelon.org), and the American Academy of Child and Adolescent Psychiatry (www.aacap.org) all have excellent online resources that also help identify local organizations and resources for parents. If insurance companies refused to pay for potentially life-saving chemotherapy for a pediatric cancer, you can imagine that there would be many parents protesting to those insurers, to the news, and even to their local or state governments. Mental health care should be no different, as the problems can be as disabling and life-threatening and effective treatments and even cures exist.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at pdnews@frontlinemedcom.com.

One of the greatest challenges you may face as a pediatrician is in helping your patients and families navigate the mental health system. Nearly 20% of children will experience a psychiatric illness before they turn 18, and a quarter of those will go on to experience a persistent or severe psychiatric illness. Whether a patient is experiencing symptoms that are mild or severe, their parents are likely to come to you first for an assessment and for help in finding a referral to the appropriate specialist.

Unlike the smooth process to refer to a neurologist or orthopedist, accessing treatment for mental health problems is often confusing and frustrating. Because of reimbursement that is below the cost of providing care, many community hospitals have closed their divisions of child and adolescent psychiatry, and academic medical centers often have a long wait for a provider. If you go through a patient’s insurance, usually the list of providers is woefully out-of-date, with most of them not accepting new referrals or insurance or both. If mental health services are “carved out” to cut costs, the primary insurer has no direct control of mental health services, and the carve out company is looking for providers willing to accept lower reimbursement and limit longer-term treatments. Faced with reimbursement and administrative demands by the carve out company, child psychiatrists, psychologists, and social workers that once staffed these services have chosen fee-for-service private offices that do not accept any insurance, leaving many communities without access to adequate resources. In private practice, these providers are busy, face no administrative demands to justify their work, and earn two or three times what insurers reimburse.

So families often turn to their schools and their pediatricians when faced with a mood, anxiety, or behavioral problem. While there is no straightforward solution to this problem of access, we have put together a “road map” to what services might be available and to help you in your approach to these patients.

It is first important to consider that mental health and developmental questions are now a major part of pediatric primary care. The majority of your visits will be well child care and psychosocial. So a part, maybe a third or half of mental health concerns might now be considered a routine part of primary care. Many practices are now doing psychosocial screening and more states are mandating reimbursement of this screening. Typically screening includes a CHATfor autism (Checklist for Autism in Toddlers), a developmental screen if indicated, a Pediatric Symptom Checklist for school-age children and adolescents, a Hamilton Rating Scale for Depression in adolescents, and a CRAFFTfor adolescent substance abuse. Some practices include a Hamilton or other depression screen for mothers of newborns and toddlers as maternal depression has a serious impact on the child and is responsive to treatment. If screening is reimbursed, some of that money could go to fund an on-site social worker, who can also bill for patient contact services, and thus provide the practice with an on-site mental health presence at break-even cost. This social worker may be expert in referring to local resources, may be trained in psychotherapy, or may even lead groups for parents of recent divorce, new mothers, facing attention-deficit/hyperactivity disorder (ADHD), etc.

The best place to start for a family with psychosocial concerns is to do a brief review of your patient’s day to day functioning – school, friends, family, activities, and mood. What is your best assessment of the problem, how much of the child and family’s life is affected, and how severe is the problem? There are many mental health problems for which the first-line treatment is a trial of medication according to an algorithm that you can use following American Academy of Pediatrics guidelines. For example, if considering stimulant treatment for a 7-year-old with possible attention difficulties, you can use broad screening instruments like the Pediatric Symptom Checklist or Childhood Behavior Checklist as well as the Vanderbilt Assessment Scales or Conners questionnaire that are specific for ADHD. Many pediatricians also are comfortable treating adolescent depression with medication and with comanagement from a social worker with a master’s degree or a doctorate level psychologist. Of course, treating depression requires a more careful interview, consideration of suicide risk, and more frequent follow-up visits.

As first-line treatment for depression and anxiety usually starts with psychotherapy, it is important to consider how you will access this component of mental health care. For those that don’t have a licensed clinical social worker on-site providing cognitive-behavioral therapy, many busy pediatric practices will establish a relationship with a therapist or group that has agreed to accept their referrals and accepts insurance reimbursement. If you are not fortunate enough to already have such a relationship, it can be fruitful to speak with colleagues in a busier practice about whom they use. It also can be fruitful to reach out to the graduate programs in psychology (PhD or PsyD programs) or social work in your community, to find out if they have a referral service or would like to connect recent graduates trying to establish themselves with referring pediatricians. Having a resource located in your office (employed by you or renting space) is ideal.

When a patient is presenting with a more complex set of symptoms or fails to respond to your initial treatments, then you will want to locate an appropriate referral to a child psychiatrist. If your group is affiliated with an academic medical center, find out what the procedure is for referring to their child psychiatrists or to the child psychiatry trainees. Often there is easy availability early in the academic year (summer), when children are less likely to present with problems and a new crop of trainees has arrived. Academic medical centers also will often be a hub for a lot of research activity, and research programs are usually eager to enroll patients without regard to their insurance. Good studies will provide patients with a formalized assessment that will clarify the diagnostic picture, ensuring that a child is on the path to the right treatment. Cultivating a connection with the research coordinator can ensure that your group knows about opportunities for free care that is easier to access than most.

Many states require schools to provide testing to clarify whether psychiatric symptoms, developmental issues, or learning disabilities are affecting a student’s ability to perform in school. Your office can educate parents that they should go to the school with their concerns and request a formal assessment. If testing indicates a condition, the school system is often required to provide appropriate educational services, such as tutoring for learning disabilities, occupational therapy, and social skills support for children on the autism spectrum, and even counseling for children with anxiety, mood, and behavioral issues. Often, the school psychologist or social worker will be a valuable resource in providing direct care to children or helping you and the parents identify excellent treaters in the community. For children with severe and persistent psychiatric illness, many states require that schools provide or pay for the services that are necessary to educate each child. This can mean anything from paying for an after school social skills group to paying for a therapeutic boarding school. In these cases, it is often helpful to have established a relationship with an educational consultant. These are usually social workers with expertise in mental health issues and the state’s educational system and regulations, and they will partner with parents for a modest fee to educate and empower parents so that they might get appropriate services from their schools. Again, it can be fruitful to speak with trusted colleagues and find one who has identified a local consultant that they trust.

Some states and counties have tried to address the problem of accessing psychiatric care for children, but often these are programs that have not been adequately marketed to pediatricians or families, so they may be under utilized. In Massachusetts and Connecticut, there is the state Child Psychiatry Access Project, which provides all pediatricians with free access to a consulting child psychiatrist by phone. It requires that pediatricians are willing to treat children themselves with the support and guidance of a consulting child psychiatrist, but it will also provide a face-to-face diagnostic evaluation of that child by a child psychiatrist so that they can in turn provide the best guidance to the pediatrician. And it provides a care coordinator who will help to identify appropriate treaters, such as a cognitive-behavioral therapist or a psychopharmacologist who accept the family’s insurance, when the pediatrician is unable to provide the recommended treatment. An online investigation through your state’s or county’s Office of Mental Health or your local Medical Society can help your office identify what resources may exist in your community.

Finally, your most critical task after a parent has come to you with concerns about their child’s mood, thinking, or behavior, may be in educating and supporting those parents. Prepare the parents by explaining to them how the mental health system is more fragmented and frustrating than most other medical specialties. Remind them that psychiatric symptoms and illnesses are eminently treatable, and it will be worth patiently navigating this complex system to eventually access the right care for their child. It can be helpful to suggest to them that if they can possibly afford to pay out-of-pocket for the appropriate care, it will make excellent treatment much easier to access in a timely way. It can be meaningful for parents to hear from you that it is worthwhile for them to call or write their insurance company and complain if that company has restricted access to child psychiatric care. They are, after all, the customers of their insurance company, and it is the silence, shame, and stigma surrounding psychiatric illness that has enabled insurance companies to restrict access to effective care. Finally, it can be very powerful to connect parents with support or advocacy organizations that will help them in navigating this system and in speaking up to their insurance companies, state health, or education agencies or in the press in ways that will diminish the stigma that still surrounds these problems. The National Alliance on Mental Illness (www.nami.org), The Bazelon Center for Mental Health Law (www.bazelon.org), and the American Academy of Child and Adolescent Psychiatry (www.aacap.org) all have excellent online resources that also help identify local organizations and resources for parents. If insurance companies refused to pay for potentially life-saving chemotherapy for a pediatric cancer, you can imagine that there would be many parents protesting to those insurers, to the news, and even to their local or state governments. Mental health care should be no different, as the problems can be as disabling and life-threatening and effective treatments and even cures exist.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at pdnews@frontlinemedcom.com.