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Why screen if there are no services?
Do you remember the discussion of the ethical dilemma of Huntington’s disease you probably participated in during medical school? The question was whether you would want to know that you were at risk for a chronic debilitating condition that would develop at some later age if there was nothing that could be done about it. In that discussion, you also may have heard about individuals who, after hearing about their risk status, become depressed or suicidal, depending on the story line.
Some pediatricians seem to have taken this example too far in arguing that there is no point in screening for issues of development, autism, maternal depression, or child mental health because “there are no services” available to treat them.
Despair is understandable. Physicians’ lack of knowledge about resources in the community is often a sore point among local agencies, parents, and even pediatricians themselves. In spite of United Way, state 3-1-1 programs ,and the occasionally available social worker, the resources with which we are familiar sometimes come from hard-working parents telling us about a program they found on their own. It also seems that, just when we hit upon a valuable resource, it runs out of funding, changes eligibility requirements, or loses key staff. Worse yet, we may rely on resources we know about because of our own children’s problems, activities, or friends. While the Internet is an increasingly valuable method of finding resources, there is no filter of the evidence-basis of the care provided, and the process of searching, vetting, and informing your patients is extremely time consuming, and often the patient is not eligible or has a long waiting period after all that.
There are important reasons not to succumb to throwing up one’s hands about service availability. And more important reasons to still screen even if you do not know where to refer.
Screening using validated tools is recommended by the American Academy of Pediatrics because parent concern and even clinical observation are not adequately sensitive to detect significant problems of development and mental health, even when done by experienced physicians who know families well. The process of screening sends an important message to the parents – that you care about the child’s progress and are using proven methods to ensure that it is going well and consider it part of complete medical care.
And families often already think that their child may have a problem, even when they don’t bring it up. Perhaps deep down they are afraid that somehow raising the question of autism will make it true. They may be in denial, are feeling guilty, or are under pressure from their spouse, relatives, or friends not to worry, that “he will grow out” of it, that better discipline will fix the problem, etc. They may even care so much about your positive regard that they do not want to seem overly anxious, obsessive, or be regarded as a failure for having a “defective” child. They, like you, also may be in despair about finding effective help.
But there can be serious consequences to not screening, even when you are not sure what you will do with the results. The family may push the child with delays or mental health problems beyond his abilities, and even become negative and punitive in trying to make him succeed, in the process promoting unnecessary behavior problems, discouragement, and even defiance in the child. Failure to detect also means failure to list the child on a registry for follow-up to determine progress or refer when resources become available. Some problems of development or mental health that are detected by screening may have medical causes that you can treat, even though counseling or therapy interventions are not available. Examples include hearing or vision deficits causing delays or anemia, sleep apnea, or hypothyroidism or maternal depression or attention-deficit/hyperactivity disorder (ADHD). For issues with a genetic basis, siblings may be born with same problem during the period of delay in making a diagnosis, a prime example being Fragile X. In untold cases, the family loses trust in you and in the medical system for not acknowledging a problem.
In many cases, your acknowledgment, explanation, sympathy, and advice can help enormously. Families can cope better, garner support from family or friends, deal with the child’s behavior better, and find steps to take to help their child in their own ways, even without formal services, once told that their child has a specific problem.
On a system level, it is important to realize that how services are established and maintained is far less rational than might be imagined. State programs, schools, hospitals, and insurers all have legal requirements to provide services within a certain time frame once referred. Even if the services are not there to help a your child or family right now, the referral itself adds to the data used to determine if services are adequate and to plan for additional service types or capacity. The Autism Waiver is one such example where waits are years long, but getting on the list is crucial to the future of the program.
Until you screen and give parents information – especially middle-class parents – we will never have the resources. As it was for lead paint, until we identified prevalence of elevated lead levels and the harm associated, we got no action on lead paint removal policies. Another example where complaints about access made a difference, is the relatively new Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 that requires health insurers and health plans to guarantee that financial requirements on benefits for mental health, such as copays, deductibles, and limitations on treatment benefits, are not more restrictive than those that are for medical benefits. This does not guarantee that services will be available or of high quality, but is a step toward accessibility.
You may be one of the many pediatricians who consider advocacy a basic component of your professional responsibilities. If you cannot advocate for services that you see your patients in need of, you can pass your concerns onto a group that does. Many American Academy of Pediatrics state chapters have so-called Pediatric Councils that receive ideas about system problems and put group pressure on leaders in the state to address them.
As in the historic painting of the physician leaning over the ill child whom he could not cure, after detection through screening our thoughtful evaluation, explanations, shared concern, and our patients’ advocacy have great value even when specific services are not yet available.
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 Medical News. E-mail her at pdnews@frontlinemedcom.com.
Do you remember the discussion of the ethical dilemma of Huntington’s disease you probably participated in during medical school? The question was whether you would want to know that you were at risk for a chronic debilitating condition that would develop at some later age if there was nothing that could be done about it. In that discussion, you also may have heard about individuals who, after hearing about their risk status, become depressed or suicidal, depending on the story line.
Some pediatricians seem to have taken this example too far in arguing that there is no point in screening for issues of development, autism, maternal depression, or child mental health because “there are no services” available to treat them.
Despair is understandable. Physicians’ lack of knowledge about resources in the community is often a sore point among local agencies, parents, and even pediatricians themselves. In spite of United Way, state 3-1-1 programs ,and the occasionally available social worker, the resources with which we are familiar sometimes come from hard-working parents telling us about a program they found on their own. It also seems that, just when we hit upon a valuable resource, it runs out of funding, changes eligibility requirements, or loses key staff. Worse yet, we may rely on resources we know about because of our own children’s problems, activities, or friends. While the Internet is an increasingly valuable method of finding resources, there is no filter of the evidence-basis of the care provided, and the process of searching, vetting, and informing your patients is extremely time consuming, and often the patient is not eligible or has a long waiting period after all that.
There are important reasons not to succumb to throwing up one’s hands about service availability. And more important reasons to still screen even if you do not know where to refer.
Screening using validated tools is recommended by the American Academy of Pediatrics because parent concern and even clinical observation are not adequately sensitive to detect significant problems of development and mental health, even when done by experienced physicians who know families well. The process of screening sends an important message to the parents – that you care about the child’s progress and are using proven methods to ensure that it is going well and consider it part of complete medical care.
And families often already think that their child may have a problem, even when they don’t bring it up. Perhaps deep down they are afraid that somehow raising the question of autism will make it true. They may be in denial, are feeling guilty, or are under pressure from their spouse, relatives, or friends not to worry, that “he will grow out” of it, that better discipline will fix the problem, etc. They may even care so much about your positive regard that they do not want to seem overly anxious, obsessive, or be regarded as a failure for having a “defective” child. They, like you, also may be in despair about finding effective help.
But there can be serious consequences to not screening, even when you are not sure what you will do with the results. The family may push the child with delays or mental health problems beyond his abilities, and even become negative and punitive in trying to make him succeed, in the process promoting unnecessary behavior problems, discouragement, and even defiance in the child. Failure to detect also means failure to list the child on a registry for follow-up to determine progress or refer when resources become available. Some problems of development or mental health that are detected by screening may have medical causes that you can treat, even though counseling or therapy interventions are not available. Examples include hearing or vision deficits causing delays or anemia, sleep apnea, or hypothyroidism or maternal depression or attention-deficit/hyperactivity disorder (ADHD). For issues with a genetic basis, siblings may be born with same problem during the period of delay in making a diagnosis, a prime example being Fragile X. In untold cases, the family loses trust in you and in the medical system for not acknowledging a problem.
In many cases, your acknowledgment, explanation, sympathy, and advice can help enormously. Families can cope better, garner support from family or friends, deal with the child’s behavior better, and find steps to take to help their child in their own ways, even without formal services, once told that their child has a specific problem.
On a system level, it is important to realize that how services are established and maintained is far less rational than might be imagined. State programs, schools, hospitals, and insurers all have legal requirements to provide services within a certain time frame once referred. Even if the services are not there to help a your child or family right now, the referral itself adds to the data used to determine if services are adequate and to plan for additional service types or capacity. The Autism Waiver is one such example where waits are years long, but getting on the list is crucial to the future of the program.
Until you screen and give parents information – especially middle-class parents – we will never have the resources. As it was for lead paint, until we identified prevalence of elevated lead levels and the harm associated, we got no action on lead paint removal policies. Another example where complaints about access made a difference, is the relatively new Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 that requires health insurers and health plans to guarantee that financial requirements on benefits for mental health, such as copays, deductibles, and limitations on treatment benefits, are not more restrictive than those that are for medical benefits. This does not guarantee that services will be available or of high quality, but is a step toward accessibility.
You may be one of the many pediatricians who consider advocacy a basic component of your professional responsibilities. If you cannot advocate for services that you see your patients in need of, you can pass your concerns onto a group that does. Many American Academy of Pediatrics state chapters have so-called Pediatric Councils that receive ideas about system problems and put group pressure on leaders in the state to address them.
As in the historic painting of the physician leaning over the ill child whom he could not cure, after detection through screening our thoughtful evaluation, explanations, shared concern, and our patients’ advocacy have great value even when specific services are not yet available.
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 Medical News. E-mail her at pdnews@frontlinemedcom.com.
Do you remember the discussion of the ethical dilemma of Huntington’s disease you probably participated in during medical school? The question was whether you would want to know that you were at risk for a chronic debilitating condition that would develop at some later age if there was nothing that could be done about it. In that discussion, you also may have heard about individuals who, after hearing about their risk status, become depressed or suicidal, depending on the story line.
Some pediatricians seem to have taken this example too far in arguing that there is no point in screening for issues of development, autism, maternal depression, or child mental health because “there are no services” available to treat them.
Despair is understandable. Physicians’ lack of knowledge about resources in the community is often a sore point among local agencies, parents, and even pediatricians themselves. In spite of United Way, state 3-1-1 programs ,and the occasionally available social worker, the resources with which we are familiar sometimes come from hard-working parents telling us about a program they found on their own. It also seems that, just when we hit upon a valuable resource, it runs out of funding, changes eligibility requirements, or loses key staff. Worse yet, we may rely on resources we know about because of our own children’s problems, activities, or friends. While the Internet is an increasingly valuable method of finding resources, there is no filter of the evidence-basis of the care provided, and the process of searching, vetting, and informing your patients is extremely time consuming, and often the patient is not eligible or has a long waiting period after all that.
There are important reasons not to succumb to throwing up one’s hands about service availability. And more important reasons to still screen even if you do not know where to refer.
Screening using validated tools is recommended by the American Academy of Pediatrics because parent concern and even clinical observation are not adequately sensitive to detect significant problems of development and mental health, even when done by experienced physicians who know families well. The process of screening sends an important message to the parents – that you care about the child’s progress and are using proven methods to ensure that it is going well and consider it part of complete medical care.
And families often already think that their child may have a problem, even when they don’t bring it up. Perhaps deep down they are afraid that somehow raising the question of autism will make it true. They may be in denial, are feeling guilty, or are under pressure from their spouse, relatives, or friends not to worry, that “he will grow out” of it, that better discipline will fix the problem, etc. They may even care so much about your positive regard that they do not want to seem overly anxious, obsessive, or be regarded as a failure for having a “defective” child. They, like you, also may be in despair about finding effective help.
But there can be serious consequences to not screening, even when you are not sure what you will do with the results. The family may push the child with delays or mental health problems beyond his abilities, and even become negative and punitive in trying to make him succeed, in the process promoting unnecessary behavior problems, discouragement, and even defiance in the child. Failure to detect also means failure to list the child on a registry for follow-up to determine progress or refer when resources become available. Some problems of development or mental health that are detected by screening may have medical causes that you can treat, even though counseling or therapy interventions are not available. Examples include hearing or vision deficits causing delays or anemia, sleep apnea, or hypothyroidism or maternal depression or attention-deficit/hyperactivity disorder (ADHD). For issues with a genetic basis, siblings may be born with same problem during the period of delay in making a diagnosis, a prime example being Fragile X. In untold cases, the family loses trust in you and in the medical system for not acknowledging a problem.
In many cases, your acknowledgment, explanation, sympathy, and advice can help enormously. Families can cope better, garner support from family or friends, deal with the child’s behavior better, and find steps to take to help their child in their own ways, even without formal services, once told that their child has a specific problem.
On a system level, it is important to realize that how services are established and maintained is far less rational than might be imagined. State programs, schools, hospitals, and insurers all have legal requirements to provide services within a certain time frame once referred. Even if the services are not there to help a your child or family right now, the referral itself adds to the data used to determine if services are adequate and to plan for additional service types or capacity. The Autism Waiver is one such example where waits are years long, but getting on the list is crucial to the future of the program.
Until you screen and give parents information – especially middle-class parents – we will never have the resources. As it was for lead paint, until we identified prevalence of elevated lead levels and the harm associated, we got no action on lead paint removal policies. Another example where complaints about access made a difference, is the relatively new Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 that requires health insurers and health plans to guarantee that financial requirements on benefits for mental health, such as copays, deductibles, and limitations on treatment benefits, are not more restrictive than those that are for medical benefits. This does not guarantee that services will be available or of high quality, but is a step toward accessibility.
You may be one of the many pediatricians who consider advocacy a basic component of your professional responsibilities. If you cannot advocate for services that you see your patients in need of, you can pass your concerns onto a group that does. Many American Academy of Pediatrics state chapters have so-called Pediatric Councils that receive ideas about system problems and put group pressure on leaders in the state to address them.
As in the historic painting of the physician leaning over the ill child whom he could not cure, after detection through screening our thoughtful evaluation, explanations, shared concern, and our patients’ advocacy have great value even when specific services are not yet available.
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 Medical News. E-mail her at pdnews@frontlinemedcom.com.
Overscheduled children
Parents want to raise their children to be happy and successful in childhood and through adulthood. For many parents, this means giving their children as many opportunities to learn, practice, and master a wide variety of skills outside of school as they possibly can. These activities often include the study of a musical instrument, a sport, an activity in the arts, religious study, and even extra academic work such as math, computer science, or a second language. Each one of these activities can mean many classes or practices outside of the home each week and additional practice time at home.
When you combine these activities with school and homework, children can be busier than most professional adults. And their parents can feel like managing their child’s schedule is another full-time job. By asking parents how many afternoons and evenings are scheduled (or how many hours of down time their children have) each week, you begin a conversation that may help parents determine the right balance for each child and the family.
Without a doubt, there can be tremendous value in making time for extracurricular activities for children. School alone usually does not offer much exposure to music education and the arts, and a daily gym class is sadly a thing of the past for most children. There is a growing body of evidence that daily vigorous exercise in childhood not only promotes good physical health and restorative sleep, and fights obesity, but that it also promotes strong cognitive development and can prevent anxiety and mood symptoms. Sustained experience with a team sport cultivates discipline, frustration tolerance, and resilience alongside friendships and fun. Likewise, there is a growing body of evidence that learning to play a musical instrument contributes in broader ways to healthy cognitive development, cultivates discipline and frustration tolerance, and improves executive function and the attention and self-regulation skills that all school-age children need to develop. Exposure to the arts, to trade skills, or to rare languages may help children discover a unique interest or passion that will draw them through their adolescence. Discovering an area of passionate interest is one of the essential goals of childhood; it can help teens feel good about themselves, and is especially meaningful in children who may not be gaining a lot of self-esteem in other areas, such as schoolwork.
But the well-meant intentions of parents (or interests of children) sometimes can lead to so many extracurricular activities that children barely have time for homework, play, or relaxation. From kindergarten through middle school, children are at the perfect age to be exploring multiple activities as they learn about their own abilities, strengths, and interests. But it is a developmental period in which there also should be plenty of open, free creative play, often with a social component. This is where children not only learn about their own talents, but also try things they might fail at, developing their curiosity, social skills, self-awareness, and resilience. While it can be wonderful to have a weekly music lesson and a team sport at this age, it is critical that there also be protected free play or down time. During this developmental period, children may switch sports, instruments, or hobbies, and it is healthy that they have the time and space to do so. Parents will say that every hour of activity is "fun." But fun with a purpose is different from "senseless fun," which is just fun without an achievement goal. Adults may have "fun" working out, but also have senseless fun playing golf, having a drink with friends, or going to a movie.
Adolescents are more likely to be "pruning" their interests as they figure out where their passions lie. Teenagers may do fewer activities overall, but spend more time on each of them. Of course, many teens will be experiencing great pressure (internal, external or both) to build the strongest possible college applications with the "right" mix of extracurricular activities, which may not line up with their actual interests. They will face the pressure also to be performing at a very high level academically. Some may have jobs, as they seek to build independence. Then add to this the fact that many will be driving themselves to each activity and wanting to spend time with friends and romantic interests, and you have a recipe for adolescents whose every moment is accounted for, to the point that they may skimp on sleep and mealtimes and feel overwhelmed. In choosing how to manage their schedules, adolescents also should be learning about the value of self-care, protecting time to relax, exercise, and sleep adequately (with a good measure of senseless fun texting as they build their identity).
So how do you help your patients and their parents reestablish some balance? You can start by figuring out if they are overscheduled. Ask if their school-age children have as many free afternoons as scheduled ones? Do they have recurring play dates as well as Russian and math classes? Do they have time for senseless fun with friends, siblings, and parents? Ask teenagers how much sleep they are getting? How often is the family able to have dinner together? When is the last time they had time to read a book for pleasure or to explore a new interest? Some children and teenagers may be very busy, but will report feeling like their battery is charged by all of their activities. Although they are busy, their schedule may be a good balance for them. But when children or teens report feeling drained by the end (or middle) of their week, they are likely overscheduled.
If parents resist some easing, you should begin to wonder if the child is the one who chose the activity or it represents a parent’s interests instead? Some parents may have strong feelings about what activities made a difference in their lives, and may not be paying attention to how their child’s temperament is different from their own. Sometimes, parents who are working might feel guilty that they are not as available as they’d like to be. They may sign their child up for many activities, hoping to make up for what they worry they are failing to directly provide their child. Parents may need a gentle reminder that a happy, calm dinner with mom and dad often is more developmentally productive than a rushed drive between two practices and a violin lesson.
Find out if specific activities are born of interest or obligation. Demanding obligatory activities should have important meaning for the child, such as Hebrew lessons prior to a Bar Mitzvah. There should be only one demanding activity that is not fun for a child at a time, though. The balance may come from fun or less-structured activities. Asking a child in front of the parents what activities are (or would be) the most fun or interesting for them can help the family to think through how to prune activities when a child is overscheduled, and remind parents of the value of play.
It also can be helpful to consider a child’s temperament when talking with a family about finding greater balance. If a child is very shy, there can be greater developmental value in activities that promote social skills, even though that child might not naturally seek those activities out. Teens who are struggling to fulfill basic responsibilities may need to have their schedules streamlined, but it is important to preserve an activity that may aid in cultivating their discipline and organization (such as a sports team or a job they value). Highly driven, ambitious adolescents sleeping only 4 hours a night to fulfill their many responsibilities would benefit from making time for relaxation and sleep, and hearing this from a pediatrician may be the critical factor in making it happen.
Finally, ask parents how drained they feel by facilitating their child’s (or children’s) schedule. When parents are so busy with their children’s activities that family time is nonexistent, or one child is receiving a greatly disproportionate share of the parents’ time, it is worth examining. Reminding parents that time spent together around the dinner table and helping with homework or in a shared activity – time that may leave them feeling more charged than drained as parents – is critical for the well-being of the whole family.
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.
Parents want to raise their children to be happy and successful in childhood and through adulthood. For many parents, this means giving their children as many opportunities to learn, practice, and master a wide variety of skills outside of school as they possibly can. These activities often include the study of a musical instrument, a sport, an activity in the arts, religious study, and even extra academic work such as math, computer science, or a second language. Each one of these activities can mean many classes or practices outside of the home each week and additional practice time at home.
When you combine these activities with school and homework, children can be busier than most professional adults. And their parents can feel like managing their child’s schedule is another full-time job. By asking parents how many afternoons and evenings are scheduled (or how many hours of down time their children have) each week, you begin a conversation that may help parents determine the right balance for each child and the family.
Without a doubt, there can be tremendous value in making time for extracurricular activities for children. School alone usually does not offer much exposure to music education and the arts, and a daily gym class is sadly a thing of the past for most children. There is a growing body of evidence that daily vigorous exercise in childhood not only promotes good physical health and restorative sleep, and fights obesity, but that it also promotes strong cognitive development and can prevent anxiety and mood symptoms. Sustained experience with a team sport cultivates discipline, frustration tolerance, and resilience alongside friendships and fun. Likewise, there is a growing body of evidence that learning to play a musical instrument contributes in broader ways to healthy cognitive development, cultivates discipline and frustration tolerance, and improves executive function and the attention and self-regulation skills that all school-age children need to develop. Exposure to the arts, to trade skills, or to rare languages may help children discover a unique interest or passion that will draw them through their adolescence. Discovering an area of passionate interest is one of the essential goals of childhood; it can help teens feel good about themselves, and is especially meaningful in children who may not be gaining a lot of self-esteem in other areas, such as schoolwork.
But the well-meant intentions of parents (or interests of children) sometimes can lead to so many extracurricular activities that children barely have time for homework, play, or relaxation. From kindergarten through middle school, children are at the perfect age to be exploring multiple activities as they learn about their own abilities, strengths, and interests. But it is a developmental period in which there also should be plenty of open, free creative play, often with a social component. This is where children not only learn about their own talents, but also try things they might fail at, developing their curiosity, social skills, self-awareness, and resilience. While it can be wonderful to have a weekly music lesson and a team sport at this age, it is critical that there also be protected free play or down time. During this developmental period, children may switch sports, instruments, or hobbies, and it is healthy that they have the time and space to do so. Parents will say that every hour of activity is "fun." But fun with a purpose is different from "senseless fun," which is just fun without an achievement goal. Adults may have "fun" working out, but also have senseless fun playing golf, having a drink with friends, or going to a movie.
Adolescents are more likely to be "pruning" their interests as they figure out where their passions lie. Teenagers may do fewer activities overall, but spend more time on each of them. Of course, many teens will be experiencing great pressure (internal, external or both) to build the strongest possible college applications with the "right" mix of extracurricular activities, which may not line up with their actual interests. They will face the pressure also to be performing at a very high level academically. Some may have jobs, as they seek to build independence. Then add to this the fact that many will be driving themselves to each activity and wanting to spend time with friends and romantic interests, and you have a recipe for adolescents whose every moment is accounted for, to the point that they may skimp on sleep and mealtimes and feel overwhelmed. In choosing how to manage their schedules, adolescents also should be learning about the value of self-care, protecting time to relax, exercise, and sleep adequately (with a good measure of senseless fun texting as they build their identity).
So how do you help your patients and their parents reestablish some balance? You can start by figuring out if they are overscheduled. Ask if their school-age children have as many free afternoons as scheduled ones? Do they have recurring play dates as well as Russian and math classes? Do they have time for senseless fun with friends, siblings, and parents? Ask teenagers how much sleep they are getting? How often is the family able to have dinner together? When is the last time they had time to read a book for pleasure or to explore a new interest? Some children and teenagers may be very busy, but will report feeling like their battery is charged by all of their activities. Although they are busy, their schedule may be a good balance for them. But when children or teens report feeling drained by the end (or middle) of their week, they are likely overscheduled.
If parents resist some easing, you should begin to wonder if the child is the one who chose the activity or it represents a parent’s interests instead? Some parents may have strong feelings about what activities made a difference in their lives, and may not be paying attention to how their child’s temperament is different from their own. Sometimes, parents who are working might feel guilty that they are not as available as they’d like to be. They may sign their child up for many activities, hoping to make up for what they worry they are failing to directly provide their child. Parents may need a gentle reminder that a happy, calm dinner with mom and dad often is more developmentally productive than a rushed drive between two practices and a violin lesson.
Find out if specific activities are born of interest or obligation. Demanding obligatory activities should have important meaning for the child, such as Hebrew lessons prior to a Bar Mitzvah. There should be only one demanding activity that is not fun for a child at a time, though. The balance may come from fun or less-structured activities. Asking a child in front of the parents what activities are (or would be) the most fun or interesting for them can help the family to think through how to prune activities when a child is overscheduled, and remind parents of the value of play.
It also can be helpful to consider a child’s temperament when talking with a family about finding greater balance. If a child is very shy, there can be greater developmental value in activities that promote social skills, even though that child might not naturally seek those activities out. Teens who are struggling to fulfill basic responsibilities may need to have their schedules streamlined, but it is important to preserve an activity that may aid in cultivating their discipline and organization (such as a sports team or a job they value). Highly driven, ambitious adolescents sleeping only 4 hours a night to fulfill their many responsibilities would benefit from making time for relaxation and sleep, and hearing this from a pediatrician may be the critical factor in making it happen.
Finally, ask parents how drained they feel by facilitating their child’s (or children’s) schedule. When parents are so busy with their children’s activities that family time is nonexistent, or one child is receiving a greatly disproportionate share of the parents’ time, it is worth examining. Reminding parents that time spent together around the dinner table and helping with homework or in a shared activity – time that may leave them feeling more charged than drained as parents – is critical for the well-being of the whole family.
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.
Parents want to raise their children to be happy and successful in childhood and through adulthood. For many parents, this means giving their children as many opportunities to learn, practice, and master a wide variety of skills outside of school as they possibly can. These activities often include the study of a musical instrument, a sport, an activity in the arts, religious study, and even extra academic work such as math, computer science, or a second language. Each one of these activities can mean many classes or practices outside of the home each week and additional practice time at home.
When you combine these activities with school and homework, children can be busier than most professional adults. And their parents can feel like managing their child’s schedule is another full-time job. By asking parents how many afternoons and evenings are scheduled (or how many hours of down time their children have) each week, you begin a conversation that may help parents determine the right balance for each child and the family.
Without a doubt, there can be tremendous value in making time for extracurricular activities for children. School alone usually does not offer much exposure to music education and the arts, and a daily gym class is sadly a thing of the past for most children. There is a growing body of evidence that daily vigorous exercise in childhood not only promotes good physical health and restorative sleep, and fights obesity, but that it also promotes strong cognitive development and can prevent anxiety and mood symptoms. Sustained experience with a team sport cultivates discipline, frustration tolerance, and resilience alongside friendships and fun. Likewise, there is a growing body of evidence that learning to play a musical instrument contributes in broader ways to healthy cognitive development, cultivates discipline and frustration tolerance, and improves executive function and the attention and self-regulation skills that all school-age children need to develop. Exposure to the arts, to trade skills, or to rare languages may help children discover a unique interest or passion that will draw them through their adolescence. Discovering an area of passionate interest is one of the essential goals of childhood; it can help teens feel good about themselves, and is especially meaningful in children who may not be gaining a lot of self-esteem in other areas, such as schoolwork.
But the well-meant intentions of parents (or interests of children) sometimes can lead to so many extracurricular activities that children barely have time for homework, play, or relaxation. From kindergarten through middle school, children are at the perfect age to be exploring multiple activities as they learn about their own abilities, strengths, and interests. But it is a developmental period in which there also should be plenty of open, free creative play, often with a social component. This is where children not only learn about their own talents, but also try things they might fail at, developing their curiosity, social skills, self-awareness, and resilience. While it can be wonderful to have a weekly music lesson and a team sport at this age, it is critical that there also be protected free play or down time. During this developmental period, children may switch sports, instruments, or hobbies, and it is healthy that they have the time and space to do so. Parents will say that every hour of activity is "fun." But fun with a purpose is different from "senseless fun," which is just fun without an achievement goal. Adults may have "fun" working out, but also have senseless fun playing golf, having a drink with friends, or going to a movie.
Adolescents are more likely to be "pruning" their interests as they figure out where their passions lie. Teenagers may do fewer activities overall, but spend more time on each of them. Of course, many teens will be experiencing great pressure (internal, external or both) to build the strongest possible college applications with the "right" mix of extracurricular activities, which may not line up with their actual interests. They will face the pressure also to be performing at a very high level academically. Some may have jobs, as they seek to build independence. Then add to this the fact that many will be driving themselves to each activity and wanting to spend time with friends and romantic interests, and you have a recipe for adolescents whose every moment is accounted for, to the point that they may skimp on sleep and mealtimes and feel overwhelmed. In choosing how to manage their schedules, adolescents also should be learning about the value of self-care, protecting time to relax, exercise, and sleep adequately (with a good measure of senseless fun texting as they build their identity).
So how do you help your patients and their parents reestablish some balance? You can start by figuring out if they are overscheduled. Ask if their school-age children have as many free afternoons as scheduled ones? Do they have recurring play dates as well as Russian and math classes? Do they have time for senseless fun with friends, siblings, and parents? Ask teenagers how much sleep they are getting? How often is the family able to have dinner together? When is the last time they had time to read a book for pleasure or to explore a new interest? Some children and teenagers may be very busy, but will report feeling like their battery is charged by all of their activities. Although they are busy, their schedule may be a good balance for them. But when children or teens report feeling drained by the end (or middle) of their week, they are likely overscheduled.
If parents resist some easing, you should begin to wonder if the child is the one who chose the activity or it represents a parent’s interests instead? Some parents may have strong feelings about what activities made a difference in their lives, and may not be paying attention to how their child’s temperament is different from their own. Sometimes, parents who are working might feel guilty that they are not as available as they’d like to be. They may sign their child up for many activities, hoping to make up for what they worry they are failing to directly provide their child. Parents may need a gentle reminder that a happy, calm dinner with mom and dad often is more developmentally productive than a rushed drive between two practices and a violin lesson.
Find out if specific activities are born of interest or obligation. Demanding obligatory activities should have important meaning for the child, such as Hebrew lessons prior to a Bar Mitzvah. There should be only one demanding activity that is not fun for a child at a time, though. The balance may come from fun or less-structured activities. Asking a child in front of the parents what activities are (or would be) the most fun or interesting for them can help the family to think through how to prune activities when a child is overscheduled, and remind parents of the value of play.
It also can be helpful to consider a child’s temperament when talking with a family about finding greater balance. If a child is very shy, there can be greater developmental value in activities that promote social skills, even though that child might not naturally seek those activities out. Teens who are struggling to fulfill basic responsibilities may need to have their schedules streamlined, but it is important to preserve an activity that may aid in cultivating their discipline and organization (such as a sports team or a job they value). Highly driven, ambitious adolescents sleeping only 4 hours a night to fulfill their many responsibilities would benefit from making time for relaxation and sleep, and hearing this from a pediatrician may be the critical factor in making it happen.
Finally, ask parents how drained they feel by facilitating their child’s (or children’s) schedule. When parents are so busy with their children’s activities that family time is nonexistent, or one child is receiving a greatly disproportionate share of the parents’ time, it is worth examining. Reminding parents that time spent together around the dinner table and helping with homework or in a shared activity – time that may leave them feeling more charged than drained as parents – is critical for the well-being of the whole family.
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.
Nurturing values: An inevitable part of parenting
If you ask the parents in your practice what their most important task is with their children, they will probably say something about keeping their child safe and developing their child’s character. They might speak about wanting to raise children who are ready to live independently, happily, and successfully. Beyond independence, they may also observe that they want to raise children of good character, with a deeply held value system that reflects their own core principles. The details of such a value system will vary from family to family, but often will include descriptive ideals such as being ethical, empathic, courageous, generous, ambitious, responsible, and having integrity. Because the everyday tasks of life with children can be so demanding, this larger task often does not get much direct attention from physicians and may not even be explicitly discussed between parents. A few questions from their physician can be profoundly helpful to parents as they reflect on practical strategies to cultivate the qualities of character that will prepare their children to live independent, happy, purposeful, and meaningful adult lives.
One way to get a sense of how parents are preparing their children for independence is to ask how they are they teaching their children about the value of money. Do they give their children a predictable allowance? Is it contingent on chores or responsibilities? Do their children have a bank account or a piggy bank? Do they spend time talking with their children about how they manage their money or plan for large purchases? Money is often a charged subject for families. Asking about it explicitly can help support open, thoughtful communication within the family. Parents will be very interested to learn that such discussions and efforts can powerfully support the development of independence, self-confidence, patience, good judgment, and responsibility in their children. You might inform parents that they can consider their child’s natural temperament when having these discussions. An anxious child, who may be prone to worries about poverty and perfection, might benefit from hearing that money is something that everyone needs to learn how to manage, and it is a tool that can make life easier, but it is not a measure of a person’s worth. On the other hand, a very easygoing child may benefit from having an allowance that is contingent on chores or an adolescent could be urged to get a job rather than depend on allowance. This is how they will learn the real value of work and will cultivate discipline, planning, and the meaningful confidence that they know how to work hard. Whether a family is struggling or can afford more than they choose to spend, the values inherent in financial decisions will be very meaningful for the preadolescent or teenager.
While all parents would likely agree that they hope to raise children who are disciplined, responsible, and independent, the other values that they hope their children appreciate and integrate will cover a wider territory. If you understand what the parents in your practice consider to be their most important values, it also will enhance your understanding of that family’s priorities and how they will manage challenges. You might ask them, "What three values, such as caring about others, honesty, or bravery, would you most like to cultivate in your children?" For those parents that have not actively reflected on their values and behavior or where there are differences between parents concerning values, this may be the start of an important conversation at home.
With ethical qualities that are interpersonal, such as empathy or generosity, there is a growing body of evidence in the psychological literature that suggests that children are much more likely to emulate their parents’ behavior than to follow their suggestions. In a classic experiment published in 1975, the psychologist J. Philippe Rushton observed how school-age children’s generous behaviors correspond with the generous (or selfish) behaviors or suggestions of parents and teachers. Rushton found that there was a very robust relationship between what the adults did and what the children did, one that could powerfully counteract what the adults said (when they disagreed). It seems actions truly do speak louder than words.
Clearly, parents should actively pay attention to how they are living their values, demonstrating them to their children in choices they make, both large and small. Then they can consider what experiences might encourage these values for their children. If they value empathy, what sorts of experiences will give their children the chance to experience and develop empathy for others? They might think about school-based activities or hobbies that can foster empathy. Is there an activity dedicated to helping children in need or to partnering with children with physical disabilities? Perhaps there is a group of children that work toward a chosen public service. If there is not such a group at their children’s school, they should consider starting one. By living these values, by doing it in a way that teaches these values to other children, and by being involved in their children’s school experience, parents can very powerfully nourish the development of these values and behaviors in their children.
Parents also might keep these important values in mind as they are helping their older children choose extracurricular activities or apply for summer jobs. While their children are considering what is most interesting to them, what will "look good" on a college application, or how to make the most money, parents might keep in mind how important values, such as empathy, generosity, bravery, discipline, or patience might be nurtured by the various experiences. Ultimately, these will be their teenager’s choices to make, but parents can still have a powerful influence by showing an interest and highlighting the importance of principles beyond dollars or college ambitions.
Emphasizing the potency of modeling treasured values does not mean that parents shouldn’t also talk about these values and even mixed feelings as they approach difficult, value-laden decisions in their own lives. What matters is how such values are discussed. Praise is powerful, and it appears that when parents praise a child’s character, it is even more powerful than when they praise a behavior. This is especially true for younger children (6- to 12-year-olds), when children lightly try on many different behaviors but are considering the kinds of people they wish to be. Likewise, when children fail to live up to their parents’ values, it is effective for parents to share their disappointment, but they should take care not to shame their children, which leave children feeling discouraged and powerless to change.
Beyond praise and reproach, when parents talk openly and with curiosity about these complex, nuanced topics, and genuinely listen to their children’s questions, thoughts, and opinions about them, they are communicating that their child’s thinking, feelings, and character are valued. Parents should look for opportunities to discuss values one step removed from their children. They could discuss characters’ choices in a movie or book, issues faced by their or their children’s friends, challenges managed by a celebrated athlete or celebrity or even events in a reality television show they have watched together. With these conversations, they are helping their children nurture their own ideas about values and demonstrating genuine confidence that their children can develop their own opinions about such complex matters. They also contribute to a climate in which their children appreciate that values should be carefully considered and may evolve over time. These conversations will be most helpful as their teenagers become more autonomous and face choices on their own in late high school, college, and young adulthood. They will build a strong foundation on which their children will gradually construct their own considered, individual value system, one they can reflect upon and modify over their lifetime.
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.
If you ask the parents in your practice what their most important task is with their children, they will probably say something about keeping their child safe and developing their child’s character. They might speak about wanting to raise children who are ready to live independently, happily, and successfully. Beyond independence, they may also observe that they want to raise children of good character, with a deeply held value system that reflects their own core principles. The details of such a value system will vary from family to family, but often will include descriptive ideals such as being ethical, empathic, courageous, generous, ambitious, responsible, and having integrity. Because the everyday tasks of life with children can be so demanding, this larger task often does not get much direct attention from physicians and may not even be explicitly discussed between parents. A few questions from their physician can be profoundly helpful to parents as they reflect on practical strategies to cultivate the qualities of character that will prepare their children to live independent, happy, purposeful, and meaningful adult lives.
One way to get a sense of how parents are preparing their children for independence is to ask how they are they teaching their children about the value of money. Do they give their children a predictable allowance? Is it contingent on chores or responsibilities? Do their children have a bank account or a piggy bank? Do they spend time talking with their children about how they manage their money or plan for large purchases? Money is often a charged subject for families. Asking about it explicitly can help support open, thoughtful communication within the family. Parents will be very interested to learn that such discussions and efforts can powerfully support the development of independence, self-confidence, patience, good judgment, and responsibility in their children. You might inform parents that they can consider their child’s natural temperament when having these discussions. An anxious child, who may be prone to worries about poverty and perfection, might benefit from hearing that money is something that everyone needs to learn how to manage, and it is a tool that can make life easier, but it is not a measure of a person’s worth. On the other hand, a very easygoing child may benefit from having an allowance that is contingent on chores or an adolescent could be urged to get a job rather than depend on allowance. This is how they will learn the real value of work and will cultivate discipline, planning, and the meaningful confidence that they know how to work hard. Whether a family is struggling or can afford more than they choose to spend, the values inherent in financial decisions will be very meaningful for the preadolescent or teenager.
While all parents would likely agree that they hope to raise children who are disciplined, responsible, and independent, the other values that they hope their children appreciate and integrate will cover a wider territory. If you understand what the parents in your practice consider to be their most important values, it also will enhance your understanding of that family’s priorities and how they will manage challenges. You might ask them, "What three values, such as caring about others, honesty, or bravery, would you most like to cultivate in your children?" For those parents that have not actively reflected on their values and behavior or where there are differences between parents concerning values, this may be the start of an important conversation at home.
With ethical qualities that are interpersonal, such as empathy or generosity, there is a growing body of evidence in the psychological literature that suggests that children are much more likely to emulate their parents’ behavior than to follow their suggestions. In a classic experiment published in 1975, the psychologist J. Philippe Rushton observed how school-age children’s generous behaviors correspond with the generous (or selfish) behaviors or suggestions of parents and teachers. Rushton found that there was a very robust relationship between what the adults did and what the children did, one that could powerfully counteract what the adults said (when they disagreed). It seems actions truly do speak louder than words.
Clearly, parents should actively pay attention to how they are living their values, demonstrating them to their children in choices they make, both large and small. Then they can consider what experiences might encourage these values for their children. If they value empathy, what sorts of experiences will give their children the chance to experience and develop empathy for others? They might think about school-based activities or hobbies that can foster empathy. Is there an activity dedicated to helping children in need or to partnering with children with physical disabilities? Perhaps there is a group of children that work toward a chosen public service. If there is not such a group at their children’s school, they should consider starting one. By living these values, by doing it in a way that teaches these values to other children, and by being involved in their children’s school experience, parents can very powerfully nourish the development of these values and behaviors in their children.
Parents also might keep these important values in mind as they are helping their older children choose extracurricular activities or apply for summer jobs. While their children are considering what is most interesting to them, what will "look good" on a college application, or how to make the most money, parents might keep in mind how important values, such as empathy, generosity, bravery, discipline, or patience might be nurtured by the various experiences. Ultimately, these will be their teenager’s choices to make, but parents can still have a powerful influence by showing an interest and highlighting the importance of principles beyond dollars or college ambitions.
Emphasizing the potency of modeling treasured values does not mean that parents shouldn’t also talk about these values and even mixed feelings as they approach difficult, value-laden decisions in their own lives. What matters is how such values are discussed. Praise is powerful, and it appears that when parents praise a child’s character, it is even more powerful than when they praise a behavior. This is especially true for younger children (6- to 12-year-olds), when children lightly try on many different behaviors but are considering the kinds of people they wish to be. Likewise, when children fail to live up to their parents’ values, it is effective for parents to share their disappointment, but they should take care not to shame their children, which leave children feeling discouraged and powerless to change.
Beyond praise and reproach, when parents talk openly and with curiosity about these complex, nuanced topics, and genuinely listen to their children’s questions, thoughts, and opinions about them, they are communicating that their child’s thinking, feelings, and character are valued. Parents should look for opportunities to discuss values one step removed from their children. They could discuss characters’ choices in a movie or book, issues faced by their or their children’s friends, challenges managed by a celebrated athlete or celebrity or even events in a reality television show they have watched together. With these conversations, they are helping their children nurture their own ideas about values and demonstrating genuine confidence that their children can develop their own opinions about such complex matters. They also contribute to a climate in which their children appreciate that values should be carefully considered and may evolve over time. These conversations will be most helpful as their teenagers become more autonomous and face choices on their own in late high school, college, and young adulthood. They will build a strong foundation on which their children will gradually construct their own considered, individual value system, one they can reflect upon and modify over their lifetime.
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.
If you ask the parents in your practice what their most important task is with their children, they will probably say something about keeping their child safe and developing their child’s character. They might speak about wanting to raise children who are ready to live independently, happily, and successfully. Beyond independence, they may also observe that they want to raise children of good character, with a deeply held value system that reflects their own core principles. The details of such a value system will vary from family to family, but often will include descriptive ideals such as being ethical, empathic, courageous, generous, ambitious, responsible, and having integrity. Because the everyday tasks of life with children can be so demanding, this larger task often does not get much direct attention from physicians and may not even be explicitly discussed between parents. A few questions from their physician can be profoundly helpful to parents as they reflect on practical strategies to cultivate the qualities of character that will prepare their children to live independent, happy, purposeful, and meaningful adult lives.
One way to get a sense of how parents are preparing their children for independence is to ask how they are they teaching their children about the value of money. Do they give their children a predictable allowance? Is it contingent on chores or responsibilities? Do their children have a bank account or a piggy bank? Do they spend time talking with their children about how they manage their money or plan for large purchases? Money is often a charged subject for families. Asking about it explicitly can help support open, thoughtful communication within the family. Parents will be very interested to learn that such discussions and efforts can powerfully support the development of independence, self-confidence, patience, good judgment, and responsibility in their children. You might inform parents that they can consider their child’s natural temperament when having these discussions. An anxious child, who may be prone to worries about poverty and perfection, might benefit from hearing that money is something that everyone needs to learn how to manage, and it is a tool that can make life easier, but it is not a measure of a person’s worth. On the other hand, a very easygoing child may benefit from having an allowance that is contingent on chores or an adolescent could be urged to get a job rather than depend on allowance. This is how they will learn the real value of work and will cultivate discipline, planning, and the meaningful confidence that they know how to work hard. Whether a family is struggling or can afford more than they choose to spend, the values inherent in financial decisions will be very meaningful for the preadolescent or teenager.
While all parents would likely agree that they hope to raise children who are disciplined, responsible, and independent, the other values that they hope their children appreciate and integrate will cover a wider territory. If you understand what the parents in your practice consider to be their most important values, it also will enhance your understanding of that family’s priorities and how they will manage challenges. You might ask them, "What three values, such as caring about others, honesty, or bravery, would you most like to cultivate in your children?" For those parents that have not actively reflected on their values and behavior or where there are differences between parents concerning values, this may be the start of an important conversation at home.
With ethical qualities that are interpersonal, such as empathy or generosity, there is a growing body of evidence in the psychological literature that suggests that children are much more likely to emulate their parents’ behavior than to follow their suggestions. In a classic experiment published in 1975, the psychologist J. Philippe Rushton observed how school-age children’s generous behaviors correspond with the generous (or selfish) behaviors or suggestions of parents and teachers. Rushton found that there was a very robust relationship between what the adults did and what the children did, one that could powerfully counteract what the adults said (when they disagreed). It seems actions truly do speak louder than words.
Clearly, parents should actively pay attention to how they are living their values, demonstrating them to their children in choices they make, both large and small. Then they can consider what experiences might encourage these values for their children. If they value empathy, what sorts of experiences will give their children the chance to experience and develop empathy for others? They might think about school-based activities or hobbies that can foster empathy. Is there an activity dedicated to helping children in need or to partnering with children with physical disabilities? Perhaps there is a group of children that work toward a chosen public service. If there is not such a group at their children’s school, they should consider starting one. By living these values, by doing it in a way that teaches these values to other children, and by being involved in their children’s school experience, parents can very powerfully nourish the development of these values and behaviors in their children.
Parents also might keep these important values in mind as they are helping their older children choose extracurricular activities or apply for summer jobs. While their children are considering what is most interesting to them, what will "look good" on a college application, or how to make the most money, parents might keep in mind how important values, such as empathy, generosity, bravery, discipline, or patience might be nurtured by the various experiences. Ultimately, these will be their teenager’s choices to make, but parents can still have a powerful influence by showing an interest and highlighting the importance of principles beyond dollars or college ambitions.
Emphasizing the potency of modeling treasured values does not mean that parents shouldn’t also talk about these values and even mixed feelings as they approach difficult, value-laden decisions in their own lives. What matters is how such values are discussed. Praise is powerful, and it appears that when parents praise a child’s character, it is even more powerful than when they praise a behavior. This is especially true for younger children (6- to 12-year-olds), when children lightly try on many different behaviors but are considering the kinds of people they wish to be. Likewise, when children fail to live up to their parents’ values, it is effective for parents to share their disappointment, but they should take care not to shame their children, which leave children feeling discouraged and powerless to change.
Beyond praise and reproach, when parents talk openly and with curiosity about these complex, nuanced topics, and genuinely listen to their children’s questions, thoughts, and opinions about them, they are communicating that their child’s thinking, feelings, and character are valued. Parents should look for opportunities to discuss values one step removed from their children. They could discuss characters’ choices in a movie or book, issues faced by their or their children’s friends, challenges managed by a celebrated athlete or celebrity or even events in a reality television show they have watched together. With these conversations, they are helping their children nurture their own ideas about values and demonstrating genuine confidence that their children can develop their own opinions about such complex matters. They also contribute to a climate in which their children appreciate that values should be carefully considered and may evolve over time. These conversations will be most helpful as their teenagers become more autonomous and face choices on their own in late high school, college, and young adulthood. They will build a strong foundation on which their children will gradually construct their own considered, individual value system, one they can reflect upon and modify over their lifetime.
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.
Landing Helicopter Parents
The recently coined term “helicopter parents” refers to parents who hover close to their children with the impression that this will keep them safe or ensure their success. We more formally call these parents “overprotective,” “overintrusive,” or “facilitators” for their kids. The new term may make this behavior seem more normal or even more amusing than it really is.
When you see helicopter parents in your practice, it's hard to know exactly what your role should be. How intrusive should you be to try to change their ways? Is helicopter parenting just a trendy societal or cultural phenomenon? Or do you really have enough information that it is a problem to justify your offering advice?
Even though answers to those questions may still be “up in the air,” overall such overprotection can have significant side effects and should be “on our radar”!
There are some pretty obvious reasons for the increase in helicopter parenting. One is cell phones. Everybody has cell phones, even some 6-year-old children. All the calling and texting back and forth makes it too easy to know every move the child makes. These days, if the children are not out of the house with their cell phones, they likely are at home playing video games or in a sport to which they were driven by the parent.
And these activity choices are part of a vicious cycle being selected – if not to promote entry to Harvard then to keep kids busy. Once one family puts their kids in planned activities, there are fewer peers available to play with after school, so other parents do the same. Smaller family sizes also can encourage helicopter parenting. If parents have five children, there is no time for hovering! Families with fewer children also may have more psychologically invested in each child.
I think that it is no accident that helicopter parenting has emerged at the same time most women are in the workplace full time. When home, working mothers, full of guilt, “up their efforts” to make sure they are being good parents.
Other reasons for a heightened level of hovering is parents' perception that they need to keep their kids safe in what feels like a threatening world. Families also are responding to increased competitiveness for college entry and jobs by doing all they can to position their children to achieve these goals. Of course, parents also want to show their love and concern. In some cases, high levels of protectiveness are appropriate: The child may attend a school where kids are carrying knives, or Dad is coming home drunk and the child needs to be protected. Such circumstances are the exception, though. More common pathology is that a parent is overanxious in general or even has an anxiety disorder.
While overprotectiveness may be understandable, it has significant developmental consequences. When parents dictate most of the children's activities, this can preclude the children from discovering, pursuing, and “owning” their interests. Overall, it can lessen the children's self-esteem because they have fewer opportunities to achieve things they consider to be all their own. Also, when a parent participates in the child's activities, they, as adults, will likely be more competent than the child. That can make a child feel less competent, whereas a kid doing things with peers has a decent chance of being the best. Helicopter parents also typically are aiming to avoid all kinds of risk for their precious child. The protected child may be physically safe, but can become risk aversive and miss the chance to learn how to appropriately assess real dangers. If parents “helicopter” because they are always afraid something bad is going to happen – like a pedophile is going to jump out of the bushes or the child is going to be abducted – they also transmit these fears to the child.
Children who are too restricted may even have health effects from sitting at home, eating too much, and not getting enough exercise.
But what can you do when you think problems may be developing from a helicopter parent? Parents may not perceive any problem at all. In this case, motivational interviewing can help. This technique can be used to move many different types of behavior and can fit into a primary care visit.
A motivational interview is a dialogue between the clinician and patient with specific steps. First, find out if the parent or child perceives any problem at all. You might say, “Wow, you certainly have your kid in all kinds of activities and are working hard to provide all these opportunities. Is your level of involvement a problem for you or your child in any way?” Watching the child's face when you ask this can be very revealing, and can also be used as a point of reflection for the interview.
You might also say: “Have you considered whether you really need to or want to do all of these things?” or “Have you considered backing off?” If the response is, “No, I've never thought about this before,” the parent may ask you in return: “Do you think it's a problem?” Then you have the opportunity to go over the potential pros and cons I've already outlined.
You might ask: “What are the good things about being this involved with your child?” And when you ask this, push them to include not only the effects (he's learned to play the violin or is now state ranked in tennis) but the way they feel about it as well. Parents might say things that reveal their reasons such as: “It makes me feel that I'm a good parent because I've done all these things for her” or “I feel more comfortable when I'm at work because I know he is safe at his karate class.”
Then you might ask them: “Is there any downside to being so involved in all of your child's activities?” You might get this response: “I'm beginning to resent it. I signed him up for all these activities, and now I don't have any free time any more.”
The next step in motivational interviewing is to ask about their readiness for change in a gentle way. “Do you think you might consider backing off?” If they say yes, you can ask, “What would be one of the things you could back off on now?” Make sure it is specific and also includes a time frame: “When would you be able to make this change?” In one family I was helping, the child had been talking to his parents on the phone 20 times a day. For him, a goal-setting question was, “What would it take to cut that down to 15 times?” Don't set an unrealistic goal such as stopping altogether.
Some parents initially will not be amenable to changing their behavior. For example, if they say, “I don't know. I never thought about this before,” you may need to be more circumspect. You might say, “Is there something else about this way of relating to your child that is making you want to continue?” Or use other parents as an example: “Some parents find when they back off the child becomes more relaxed, gets right on his homework by himself, and is happier.”
Garnering support for a change in behavior is an important component. You might ask: “Who could help you back off?” Finding other parents to have as friends who are not so intense, who don't feel the need to have a perfect child, or who are willing to let their kids be more autonomous may be key. Some websites and social networks developing to help parents back off from helicoptering promote “slow parenting,” “free-range parenting,” or “simplicity parenting.”
One important goal of the motivational interview is to come away with a time-based action plan. For a parent who says: “I don't want to change anything” or “This is the most important thing I'm doing for my kid,” you can keep change on the agenda by saying something like: “OK, perhaps we can talk about it when you bring her back for her vaccine in 2 months” and then make a note in the chart so you remember.
Inability to follow an agreed-upon plan can reveal where the parents or child is getting stuck, so this can be subsequently addressed. On a follow-up contact ask how it went and praise them, especially if they exceeded the goal. Or the parent may say, “When I tried to do that, he had a panic attack” or “I got depressed. I felt worthless, like I was not protecting my child.” That will help you understand the barriers for these parents and help you arrange appropriate treatment.
Even though helicopter parenting sounds like something new, addressing it employs your same old clinical skills.
---Barbara J. Howard, M.D.
The recently coined term “helicopter parents” refers to parents who hover close to their children with the impression that this will keep them safe or ensure their success. We more formally call these parents “overprotective,” “overintrusive,” or “facilitators” for their kids. The new term may make this behavior seem more normal or even more amusing than it really is.
When you see helicopter parents in your practice, it's hard to know exactly what your role should be. How intrusive should you be to try to change their ways? Is helicopter parenting just a trendy societal or cultural phenomenon? Or do you really have enough information that it is a problem to justify your offering advice?
Even though answers to those questions may still be “up in the air,” overall such overprotection can have significant side effects and should be “on our radar”!
There are some pretty obvious reasons for the increase in helicopter parenting. One is cell phones. Everybody has cell phones, even some 6-year-old children. All the calling and texting back and forth makes it too easy to know every move the child makes. These days, if the children are not out of the house with their cell phones, they likely are at home playing video games or in a sport to which they were driven by the parent.
And these activity choices are part of a vicious cycle being selected – if not to promote entry to Harvard then to keep kids busy. Once one family puts their kids in planned activities, there are fewer peers available to play with after school, so other parents do the same. Smaller family sizes also can encourage helicopter parenting. If parents have five children, there is no time for hovering! Families with fewer children also may have more psychologically invested in each child.
I think that it is no accident that helicopter parenting has emerged at the same time most women are in the workplace full time. When home, working mothers, full of guilt, “up their efforts” to make sure they are being good parents.
Other reasons for a heightened level of hovering is parents' perception that they need to keep their kids safe in what feels like a threatening world. Families also are responding to increased competitiveness for college entry and jobs by doing all they can to position their children to achieve these goals. Of course, parents also want to show their love and concern. In some cases, high levels of protectiveness are appropriate: The child may attend a school where kids are carrying knives, or Dad is coming home drunk and the child needs to be protected. Such circumstances are the exception, though. More common pathology is that a parent is overanxious in general or even has an anxiety disorder.
While overprotectiveness may be understandable, it has significant developmental consequences. When parents dictate most of the children's activities, this can preclude the children from discovering, pursuing, and “owning” their interests. Overall, it can lessen the children's self-esteem because they have fewer opportunities to achieve things they consider to be all their own. Also, when a parent participates in the child's activities, they, as adults, will likely be more competent than the child. That can make a child feel less competent, whereas a kid doing things with peers has a decent chance of being the best. Helicopter parents also typically are aiming to avoid all kinds of risk for their precious child. The protected child may be physically safe, but can become risk aversive and miss the chance to learn how to appropriately assess real dangers. If parents “helicopter” because they are always afraid something bad is going to happen – like a pedophile is going to jump out of the bushes or the child is going to be abducted – they also transmit these fears to the child.
Children who are too restricted may even have health effects from sitting at home, eating too much, and not getting enough exercise.
But what can you do when you think problems may be developing from a helicopter parent? Parents may not perceive any problem at all. In this case, motivational interviewing can help. This technique can be used to move many different types of behavior and can fit into a primary care visit.
A motivational interview is a dialogue between the clinician and patient with specific steps. First, find out if the parent or child perceives any problem at all. You might say, “Wow, you certainly have your kid in all kinds of activities and are working hard to provide all these opportunities. Is your level of involvement a problem for you or your child in any way?” Watching the child's face when you ask this can be very revealing, and can also be used as a point of reflection for the interview.
You might also say: “Have you considered whether you really need to or want to do all of these things?” or “Have you considered backing off?” If the response is, “No, I've never thought about this before,” the parent may ask you in return: “Do you think it's a problem?” Then you have the opportunity to go over the potential pros and cons I've already outlined.
You might ask: “What are the good things about being this involved with your child?” And when you ask this, push them to include not only the effects (he's learned to play the violin or is now state ranked in tennis) but the way they feel about it as well. Parents might say things that reveal their reasons such as: “It makes me feel that I'm a good parent because I've done all these things for her” or “I feel more comfortable when I'm at work because I know he is safe at his karate class.”
Then you might ask them: “Is there any downside to being so involved in all of your child's activities?” You might get this response: “I'm beginning to resent it. I signed him up for all these activities, and now I don't have any free time any more.”
The next step in motivational interviewing is to ask about their readiness for change in a gentle way. “Do you think you might consider backing off?” If they say yes, you can ask, “What would be one of the things you could back off on now?” Make sure it is specific and also includes a time frame: “When would you be able to make this change?” In one family I was helping, the child had been talking to his parents on the phone 20 times a day. For him, a goal-setting question was, “What would it take to cut that down to 15 times?” Don't set an unrealistic goal such as stopping altogether.
Some parents initially will not be amenable to changing their behavior. For example, if they say, “I don't know. I never thought about this before,” you may need to be more circumspect. You might say, “Is there something else about this way of relating to your child that is making you want to continue?” Or use other parents as an example: “Some parents find when they back off the child becomes more relaxed, gets right on his homework by himself, and is happier.”
Garnering support for a change in behavior is an important component. You might ask: “Who could help you back off?” Finding other parents to have as friends who are not so intense, who don't feel the need to have a perfect child, or who are willing to let their kids be more autonomous may be key. Some websites and social networks developing to help parents back off from helicoptering promote “slow parenting,” “free-range parenting,” or “simplicity parenting.”
One important goal of the motivational interview is to come away with a time-based action plan. For a parent who says: “I don't want to change anything” or “This is the most important thing I'm doing for my kid,” you can keep change on the agenda by saying something like: “OK, perhaps we can talk about it when you bring her back for her vaccine in 2 months” and then make a note in the chart so you remember.
Inability to follow an agreed-upon plan can reveal where the parents or child is getting stuck, so this can be subsequently addressed. On a follow-up contact ask how it went and praise them, especially if they exceeded the goal. Or the parent may say, “When I tried to do that, he had a panic attack” or “I got depressed. I felt worthless, like I was not protecting my child.” That will help you understand the barriers for these parents and help you arrange appropriate treatment.
Even though helicopter parenting sounds like something new, addressing it employs your same old clinical skills.
---Barbara J. Howard, M.D.
The recently coined term “helicopter parents” refers to parents who hover close to their children with the impression that this will keep them safe or ensure their success. We more formally call these parents “overprotective,” “overintrusive,” or “facilitators” for their kids. The new term may make this behavior seem more normal or even more amusing than it really is.
When you see helicopter parents in your practice, it's hard to know exactly what your role should be. How intrusive should you be to try to change their ways? Is helicopter parenting just a trendy societal or cultural phenomenon? Or do you really have enough information that it is a problem to justify your offering advice?
Even though answers to those questions may still be “up in the air,” overall such overprotection can have significant side effects and should be “on our radar”!
There are some pretty obvious reasons for the increase in helicopter parenting. One is cell phones. Everybody has cell phones, even some 6-year-old children. All the calling and texting back and forth makes it too easy to know every move the child makes. These days, if the children are not out of the house with their cell phones, they likely are at home playing video games or in a sport to which they were driven by the parent.
And these activity choices are part of a vicious cycle being selected – if not to promote entry to Harvard then to keep kids busy. Once one family puts their kids in planned activities, there are fewer peers available to play with after school, so other parents do the same. Smaller family sizes also can encourage helicopter parenting. If parents have five children, there is no time for hovering! Families with fewer children also may have more psychologically invested in each child.
I think that it is no accident that helicopter parenting has emerged at the same time most women are in the workplace full time. When home, working mothers, full of guilt, “up their efforts” to make sure they are being good parents.
Other reasons for a heightened level of hovering is parents' perception that they need to keep their kids safe in what feels like a threatening world. Families also are responding to increased competitiveness for college entry and jobs by doing all they can to position their children to achieve these goals. Of course, parents also want to show their love and concern. In some cases, high levels of protectiveness are appropriate: The child may attend a school where kids are carrying knives, or Dad is coming home drunk and the child needs to be protected. Such circumstances are the exception, though. More common pathology is that a parent is overanxious in general or even has an anxiety disorder.
While overprotectiveness may be understandable, it has significant developmental consequences. When parents dictate most of the children's activities, this can preclude the children from discovering, pursuing, and “owning” their interests. Overall, it can lessen the children's self-esteem because they have fewer opportunities to achieve things they consider to be all their own. Also, when a parent participates in the child's activities, they, as adults, will likely be more competent than the child. That can make a child feel less competent, whereas a kid doing things with peers has a decent chance of being the best. Helicopter parents also typically are aiming to avoid all kinds of risk for their precious child. The protected child may be physically safe, but can become risk aversive and miss the chance to learn how to appropriately assess real dangers. If parents “helicopter” because they are always afraid something bad is going to happen – like a pedophile is going to jump out of the bushes or the child is going to be abducted – they also transmit these fears to the child.
Children who are too restricted may even have health effects from sitting at home, eating too much, and not getting enough exercise.
But what can you do when you think problems may be developing from a helicopter parent? Parents may not perceive any problem at all. In this case, motivational interviewing can help. This technique can be used to move many different types of behavior and can fit into a primary care visit.
A motivational interview is a dialogue between the clinician and patient with specific steps. First, find out if the parent or child perceives any problem at all. You might say, “Wow, you certainly have your kid in all kinds of activities and are working hard to provide all these opportunities. Is your level of involvement a problem for you or your child in any way?” Watching the child's face when you ask this can be very revealing, and can also be used as a point of reflection for the interview.
You might also say: “Have you considered whether you really need to or want to do all of these things?” or “Have you considered backing off?” If the response is, “No, I've never thought about this before,” the parent may ask you in return: “Do you think it's a problem?” Then you have the opportunity to go over the potential pros and cons I've already outlined.
You might ask: “What are the good things about being this involved with your child?” And when you ask this, push them to include not only the effects (he's learned to play the violin or is now state ranked in tennis) but the way they feel about it as well. Parents might say things that reveal their reasons such as: “It makes me feel that I'm a good parent because I've done all these things for her” or “I feel more comfortable when I'm at work because I know he is safe at his karate class.”
Then you might ask them: “Is there any downside to being so involved in all of your child's activities?” You might get this response: “I'm beginning to resent it. I signed him up for all these activities, and now I don't have any free time any more.”
The next step in motivational interviewing is to ask about their readiness for change in a gentle way. “Do you think you might consider backing off?” If they say yes, you can ask, “What would be one of the things you could back off on now?” Make sure it is specific and also includes a time frame: “When would you be able to make this change?” In one family I was helping, the child had been talking to his parents on the phone 20 times a day. For him, a goal-setting question was, “What would it take to cut that down to 15 times?” Don't set an unrealistic goal such as stopping altogether.
Some parents initially will not be amenable to changing their behavior. For example, if they say, “I don't know. I never thought about this before,” you may need to be more circumspect. You might say, “Is there something else about this way of relating to your child that is making you want to continue?” Or use other parents as an example: “Some parents find when they back off the child becomes more relaxed, gets right on his homework by himself, and is happier.”
Garnering support for a change in behavior is an important component. You might ask: “Who could help you back off?” Finding other parents to have as friends who are not so intense, who don't feel the need to have a perfect child, or who are willing to let their kids be more autonomous may be key. Some websites and social networks developing to help parents back off from helicoptering promote “slow parenting,” “free-range parenting,” or “simplicity parenting.”
One important goal of the motivational interview is to come away with a time-based action plan. For a parent who says: “I don't want to change anything” or “This is the most important thing I'm doing for my kid,” you can keep change on the agenda by saying something like: “OK, perhaps we can talk about it when you bring her back for her vaccine in 2 months” and then make a note in the chart so you remember.
Inability to follow an agreed-upon plan can reveal where the parents or child is getting stuck, so this can be subsequently addressed. On a follow-up contact ask how it went and praise them, especially if they exceeded the goal. Or the parent may say, “When I tried to do that, he had a panic attack” or “I got depressed. I felt worthless, like I was not protecting my child.” That will help you understand the barriers for these parents and help you arrange appropriate treatment.
Even though helicopter parenting sounds like something new, addressing it employs your same old clinical skills.
---Barbara J. Howard, M.D.
Managing ADHD in a Young Child
Some parents of very young children – those 6 years old and younger – will come to you exhausted, feeling inadequate as parents, and even angry at their children.
Parents will report that their children with attention-deficit/hyperactivity disorder are very difficult at home and in preschool. Probably when their children were around age 2, 3, or 4 years old, their parents began wondering if the youngsters were immature, were more impulsive, and had a shorter attention span, compared with peers.
Pediatricians will recognize this pattern as likely ADHD and, in addition to making an accurate diagnosis, know that much is at stake in guiding and supporting parents. A critical relationship is at risk as the child's behavior evokes criticism and a negative tone from parents. Pediatricians should help parents set reasonable expectations and focus on behaviors and activities that build self-esteem. For some families, this work can be difficult and time consuming, requiring counseling and behavioral reward training – probably better delegated to a mental health specialist.
Attention span, impulsivity, and motoric hyperactivity are active concerns every waking hour of the child's day. Certain demands in preschool, at a longer dinner, or in church may exacerbate the symptoms, whereas playing in the park or playing a fun-filled computer game may ease the symptoms. The pediatrician can sort through a typical day and recommend approaches that are consistent with developmentally reasonable expectations, and modified for the child's ADHD symptoms.
Family history is another consideration. About 30% of children with ADHD come from fathers who had or have the disorder. Reminding a father of his difficulties growing up or any ongoing ADHD symptoms can be helpful in eliciting some empathy from him for his child's suffering.
Beyond family life, ADHD will affect the choice of school and activities. Based on what works for the child, consider how many hours a child should spend in preschool and how much structure is helpful. How will the culture of the school fit the child's style? Remember that the last thing a child with ADHD needs is an early school experience characterized by criticism and a sense of not being able to please teachers. A school with more recess and activity opportunities, as well as after-school programs, might be a good choice, and might offer some respite for parents.
As part of building self-esteem, ask parents if there is anything the child is really good at. For example, I treated a 6-year-old with ADHD who was gifted with computers. He was able to teach his peers and play games with friends, and he felt genuine pride working with a machine that was tolerant and nonjudgmental, and could be reset as needed. Might this not lead to a path of an after-school computer club or computer summer camp (that of course would include other activities)? Other young children may show strength in music, art, or a sport, and these activities are at least as important as remediating weaknesses.
Awareness of the different ADHD subtypes is important in general, but also can guide you in when to refer these children. Some kids with ADHD are more moody or depressed, some are more anxious, and others are more physically aggressive. Consider referral to a child and adolescent psychiatrist if one of these subtypes becomes more difficult to manage. A mental health consultation can help these higher-risk children.
Some children with ADHD also have learning disabilities, and diagnosis at a young age, before school failure, is invaluable. If you suspect this in a particular patient, you might want to recommend some early testing through the schools to avoid creation of unrealistic expectations in the classroom.
Parents may tell you their children are impulsive. While other kids are more predictable when playing in the sandbox, their children with ADHD may do something unpredictable. They might jump out of the sandbox or grab a toy from another child, for example. A mother of a 3-year-old with ADHD will stay closer to the sandbox because she doesn't know what that child is going to do next.
Typically, the child also will have a shorter attention span. The parents cannot relax because they know the sandbox, or a particular project in the sandbox, won't hold their child as long. Other children may be occupied for 15, 20, or even 30 minutes, but their young child with ADHD might last only 3 or 4 minutes and then need to move on. That, as you can imagine, is going to make the parenting demands much higher. Remember this doesn't happen for just 1 or 2 hours per day; children with true ADHD are going to be like this from the time they get up until the time they go to sleep.
All these behaviors associated with ADHD set these children up for a fair amount of criticism. The parents are tempted, especially if they don't understand the disorder, to say: “Don't do that!”; “Put that down!”; “I just bought you this – why don't you want to play with it?”; “Why can't you play like your friend Johnny does?”; “Why can't you sit still for a minute while Mommy fixes dinner?”
These children are subject to a lot of negative feedback from their environment. The world is not very tolerant of a young child, or even an older child, with ADHD. My guess is if these children are in preschool, the teacher is having the same issues with their behaviors. They may get criticized during circle time or while doing a certain project. Except for recess and lunch, they are going to be under a lot of scrutiny and most of the feedback is going to be negative.
We can see how children with ADHD, in a typical day, can hear 10, if not 25, negative comments. That is about two to three per hour. That degree of criticism begins to become part of how they see themselves, and they become fairly self-critical.
One of the key risks from ADHD at this young age is that it's hard for these children to differentiate if what they are doing is bad or if they are bad. Their self-esteem is very vulnerable. One principle that guides a lot of my management of these youngsters with ADHD is figuring out how to protect or enhance their self-esteem. Therefore, one of the initial things I ask parents to do is to think about how much negative criticism their child is hearing. Next, I ask them to think about what are reasonable expectations for that particular child.
Any opportunity to build self-esteem and build a sense of success based on reasonable expectations is worthwhile. A lot of parents will start sports for their children when they are 4 or 5. Kids with ADHD don't do very well in the outfield of T-ball because they are distracted. They don't stand out there waiting for the hit, and then they get yelled at for missing the ball. Help parents choose a sport that fits their children. I've seen some ADHD kids be goalies because they have to pay attention for a few seconds when the ball is coming, and then when the ball is somewhere else they can daydream with impunity. A lot of children with ADHD do well with swimming, for example, because there are fewer rules and they have a little more freedom. Others thrive with the structure and sense of accomplishment that comes from the “belt” system of karate.
Clearly one of the most effective treatments for the symptoms of ADHD is medication. Medication will increase attention span in school, church, or at dinner. Of course, every parent has concerns about how young to start children on medication, or whether to use medication at all. For those families, the first set of efforts may be directed to setting reasonable expectations and reviewing daily activities.
This focus will help, but will not be enough, and medication will be a critical part of treatment. Medication adds some risk, but the benefits to the child's functioning and self-esteem often outweigh these risks.
One of the things that medication probably does best is reduce the amount of negative feedback because the child will not be as impulsive and will appear to have a longer attention span. Again, you can ask too much of a child, but you will see higher expectations if the child is taking medication that is working correctly. Once ADHD is diagnosed in a young child, the pediatrician has a key role in trying to protect and enhance the child's self-esteem, advising on the child's day-to-day functioning, and supporting the overall care with appropriate use of medications.
Some parents of very young children – those 6 years old and younger – will come to you exhausted, feeling inadequate as parents, and even angry at their children.
Parents will report that their children with attention-deficit/hyperactivity disorder are very difficult at home and in preschool. Probably when their children were around age 2, 3, or 4 years old, their parents began wondering if the youngsters were immature, were more impulsive, and had a shorter attention span, compared with peers.
Pediatricians will recognize this pattern as likely ADHD and, in addition to making an accurate diagnosis, know that much is at stake in guiding and supporting parents. A critical relationship is at risk as the child's behavior evokes criticism and a negative tone from parents. Pediatricians should help parents set reasonable expectations and focus on behaviors and activities that build self-esteem. For some families, this work can be difficult and time consuming, requiring counseling and behavioral reward training – probably better delegated to a mental health specialist.
Attention span, impulsivity, and motoric hyperactivity are active concerns every waking hour of the child's day. Certain demands in preschool, at a longer dinner, or in church may exacerbate the symptoms, whereas playing in the park or playing a fun-filled computer game may ease the symptoms. The pediatrician can sort through a typical day and recommend approaches that are consistent with developmentally reasonable expectations, and modified for the child's ADHD symptoms.
Family history is another consideration. About 30% of children with ADHD come from fathers who had or have the disorder. Reminding a father of his difficulties growing up or any ongoing ADHD symptoms can be helpful in eliciting some empathy from him for his child's suffering.
Beyond family life, ADHD will affect the choice of school and activities. Based on what works for the child, consider how many hours a child should spend in preschool and how much structure is helpful. How will the culture of the school fit the child's style? Remember that the last thing a child with ADHD needs is an early school experience characterized by criticism and a sense of not being able to please teachers. A school with more recess and activity opportunities, as well as after-school programs, might be a good choice, and might offer some respite for parents.
As part of building self-esteem, ask parents if there is anything the child is really good at. For example, I treated a 6-year-old with ADHD who was gifted with computers. He was able to teach his peers and play games with friends, and he felt genuine pride working with a machine that was tolerant and nonjudgmental, and could be reset as needed. Might this not lead to a path of an after-school computer club or computer summer camp (that of course would include other activities)? Other young children may show strength in music, art, or a sport, and these activities are at least as important as remediating weaknesses.
Awareness of the different ADHD subtypes is important in general, but also can guide you in when to refer these children. Some kids with ADHD are more moody or depressed, some are more anxious, and others are more physically aggressive. Consider referral to a child and adolescent psychiatrist if one of these subtypes becomes more difficult to manage. A mental health consultation can help these higher-risk children.
Some children with ADHD also have learning disabilities, and diagnosis at a young age, before school failure, is invaluable. If you suspect this in a particular patient, you might want to recommend some early testing through the schools to avoid creation of unrealistic expectations in the classroom.
Parents may tell you their children are impulsive. While other kids are more predictable when playing in the sandbox, their children with ADHD may do something unpredictable. They might jump out of the sandbox or grab a toy from another child, for example. A mother of a 3-year-old with ADHD will stay closer to the sandbox because she doesn't know what that child is going to do next.
Typically, the child also will have a shorter attention span. The parents cannot relax because they know the sandbox, or a particular project in the sandbox, won't hold their child as long. Other children may be occupied for 15, 20, or even 30 minutes, but their young child with ADHD might last only 3 or 4 minutes and then need to move on. That, as you can imagine, is going to make the parenting demands much higher. Remember this doesn't happen for just 1 or 2 hours per day; children with true ADHD are going to be like this from the time they get up until the time they go to sleep.
All these behaviors associated with ADHD set these children up for a fair amount of criticism. The parents are tempted, especially if they don't understand the disorder, to say: “Don't do that!”; “Put that down!”; “I just bought you this – why don't you want to play with it?”; “Why can't you play like your friend Johnny does?”; “Why can't you sit still for a minute while Mommy fixes dinner?”
These children are subject to a lot of negative feedback from their environment. The world is not very tolerant of a young child, or even an older child, with ADHD. My guess is if these children are in preschool, the teacher is having the same issues with their behaviors. They may get criticized during circle time or while doing a certain project. Except for recess and lunch, they are going to be under a lot of scrutiny and most of the feedback is going to be negative.
We can see how children with ADHD, in a typical day, can hear 10, if not 25, negative comments. That is about two to three per hour. That degree of criticism begins to become part of how they see themselves, and they become fairly self-critical.
One of the key risks from ADHD at this young age is that it's hard for these children to differentiate if what they are doing is bad or if they are bad. Their self-esteem is very vulnerable. One principle that guides a lot of my management of these youngsters with ADHD is figuring out how to protect or enhance their self-esteem. Therefore, one of the initial things I ask parents to do is to think about how much negative criticism their child is hearing. Next, I ask them to think about what are reasonable expectations for that particular child.
Any opportunity to build self-esteem and build a sense of success based on reasonable expectations is worthwhile. A lot of parents will start sports for their children when they are 4 or 5. Kids with ADHD don't do very well in the outfield of T-ball because they are distracted. They don't stand out there waiting for the hit, and then they get yelled at for missing the ball. Help parents choose a sport that fits their children. I've seen some ADHD kids be goalies because they have to pay attention for a few seconds when the ball is coming, and then when the ball is somewhere else they can daydream with impunity. A lot of children with ADHD do well with swimming, for example, because there are fewer rules and they have a little more freedom. Others thrive with the structure and sense of accomplishment that comes from the “belt” system of karate.
Clearly one of the most effective treatments for the symptoms of ADHD is medication. Medication will increase attention span in school, church, or at dinner. Of course, every parent has concerns about how young to start children on medication, or whether to use medication at all. For those families, the first set of efforts may be directed to setting reasonable expectations and reviewing daily activities.
This focus will help, but will not be enough, and medication will be a critical part of treatment. Medication adds some risk, but the benefits to the child's functioning and self-esteem often outweigh these risks.
One of the things that medication probably does best is reduce the amount of negative feedback because the child will not be as impulsive and will appear to have a longer attention span. Again, you can ask too much of a child, but you will see higher expectations if the child is taking medication that is working correctly. Once ADHD is diagnosed in a young child, the pediatrician has a key role in trying to protect and enhance the child's self-esteem, advising on the child's day-to-day functioning, and supporting the overall care with appropriate use of medications.
Some parents of very young children – those 6 years old and younger – will come to you exhausted, feeling inadequate as parents, and even angry at their children.
Parents will report that their children with attention-deficit/hyperactivity disorder are very difficult at home and in preschool. Probably when their children were around age 2, 3, or 4 years old, their parents began wondering if the youngsters were immature, were more impulsive, and had a shorter attention span, compared with peers.
Pediatricians will recognize this pattern as likely ADHD and, in addition to making an accurate diagnosis, know that much is at stake in guiding and supporting parents. A critical relationship is at risk as the child's behavior evokes criticism and a negative tone from parents. Pediatricians should help parents set reasonable expectations and focus on behaviors and activities that build self-esteem. For some families, this work can be difficult and time consuming, requiring counseling and behavioral reward training – probably better delegated to a mental health specialist.
Attention span, impulsivity, and motoric hyperactivity are active concerns every waking hour of the child's day. Certain demands in preschool, at a longer dinner, or in church may exacerbate the symptoms, whereas playing in the park or playing a fun-filled computer game may ease the symptoms. The pediatrician can sort through a typical day and recommend approaches that are consistent with developmentally reasonable expectations, and modified for the child's ADHD symptoms.
Family history is another consideration. About 30% of children with ADHD come from fathers who had or have the disorder. Reminding a father of his difficulties growing up or any ongoing ADHD symptoms can be helpful in eliciting some empathy from him for his child's suffering.
Beyond family life, ADHD will affect the choice of school and activities. Based on what works for the child, consider how many hours a child should spend in preschool and how much structure is helpful. How will the culture of the school fit the child's style? Remember that the last thing a child with ADHD needs is an early school experience characterized by criticism and a sense of not being able to please teachers. A school with more recess and activity opportunities, as well as after-school programs, might be a good choice, and might offer some respite for parents.
As part of building self-esteem, ask parents if there is anything the child is really good at. For example, I treated a 6-year-old with ADHD who was gifted with computers. He was able to teach his peers and play games with friends, and he felt genuine pride working with a machine that was tolerant and nonjudgmental, and could be reset as needed. Might this not lead to a path of an after-school computer club or computer summer camp (that of course would include other activities)? Other young children may show strength in music, art, or a sport, and these activities are at least as important as remediating weaknesses.
Awareness of the different ADHD subtypes is important in general, but also can guide you in when to refer these children. Some kids with ADHD are more moody or depressed, some are more anxious, and others are more physically aggressive. Consider referral to a child and adolescent psychiatrist if one of these subtypes becomes more difficult to manage. A mental health consultation can help these higher-risk children.
Some children with ADHD also have learning disabilities, and diagnosis at a young age, before school failure, is invaluable. If you suspect this in a particular patient, you might want to recommend some early testing through the schools to avoid creation of unrealistic expectations in the classroom.
Parents may tell you their children are impulsive. While other kids are more predictable when playing in the sandbox, their children with ADHD may do something unpredictable. They might jump out of the sandbox or grab a toy from another child, for example. A mother of a 3-year-old with ADHD will stay closer to the sandbox because she doesn't know what that child is going to do next.
Typically, the child also will have a shorter attention span. The parents cannot relax because they know the sandbox, or a particular project in the sandbox, won't hold their child as long. Other children may be occupied for 15, 20, or even 30 minutes, but their young child with ADHD might last only 3 or 4 minutes and then need to move on. That, as you can imagine, is going to make the parenting demands much higher. Remember this doesn't happen for just 1 or 2 hours per day; children with true ADHD are going to be like this from the time they get up until the time they go to sleep.
All these behaviors associated with ADHD set these children up for a fair amount of criticism. The parents are tempted, especially if they don't understand the disorder, to say: “Don't do that!”; “Put that down!”; “I just bought you this – why don't you want to play with it?”; “Why can't you play like your friend Johnny does?”; “Why can't you sit still for a minute while Mommy fixes dinner?”
These children are subject to a lot of negative feedback from their environment. The world is not very tolerant of a young child, or even an older child, with ADHD. My guess is if these children are in preschool, the teacher is having the same issues with their behaviors. They may get criticized during circle time or while doing a certain project. Except for recess and lunch, they are going to be under a lot of scrutiny and most of the feedback is going to be negative.
We can see how children with ADHD, in a typical day, can hear 10, if not 25, negative comments. That is about two to three per hour. That degree of criticism begins to become part of how they see themselves, and they become fairly self-critical.
One of the key risks from ADHD at this young age is that it's hard for these children to differentiate if what they are doing is bad or if they are bad. Their self-esteem is very vulnerable. One principle that guides a lot of my management of these youngsters with ADHD is figuring out how to protect or enhance their self-esteem. Therefore, one of the initial things I ask parents to do is to think about how much negative criticism their child is hearing. Next, I ask them to think about what are reasonable expectations for that particular child.
Any opportunity to build self-esteem and build a sense of success based on reasonable expectations is worthwhile. A lot of parents will start sports for their children when they are 4 or 5. Kids with ADHD don't do very well in the outfield of T-ball because they are distracted. They don't stand out there waiting for the hit, and then they get yelled at for missing the ball. Help parents choose a sport that fits their children. I've seen some ADHD kids be goalies because they have to pay attention for a few seconds when the ball is coming, and then when the ball is somewhere else they can daydream with impunity. A lot of children with ADHD do well with swimming, for example, because there are fewer rules and they have a little more freedom. Others thrive with the structure and sense of accomplishment that comes from the “belt” system of karate.
Clearly one of the most effective treatments for the symptoms of ADHD is medication. Medication will increase attention span in school, church, or at dinner. Of course, every parent has concerns about how young to start children on medication, or whether to use medication at all. For those families, the first set of efforts may be directed to setting reasonable expectations and reviewing daily activities.
This focus will help, but will not be enough, and medication will be a critical part of treatment. Medication adds some risk, but the benefits to the child's functioning and self-esteem often outweigh these risks.
One of the things that medication probably does best is reduce the amount of negative feedback because the child will not be as impulsive and will appear to have a longer attention span. Again, you can ask too much of a child, but you will see higher expectations if the child is taking medication that is working correctly. Once ADHD is diagnosed in a young child, the pediatrician has a key role in trying to protect and enhance the child's self-esteem, advising on the child's day-to-day functioning, and supporting the overall care with appropriate use of medications.
Helping Children With PTSD
Different forms of trauma can cause posttraumatic stress disorder in children, whether from an objective event like a car crash or sports injury to trauma involving loved ones, such as domestic violence, abuse, or neglect.
Pediatricians can help by routinely screening for dysfunction and by asking questions at annual well-child visits. Overt symptoms include fear related to the trauma such as avoiding the traumatic setting or activity. Less specific symptoms include anxiety, avoidance, social isolation, depression, and low self-esteem.
If a standard screen such as the Pediatric Symptom Checklist or another instrument reveals psychosocial dysfunction, you have to determine the cause of dysfunction, and PTSD should certainly be considered.
Is there family discord leading to violence in the home? If you suspect PTSD, ask a child what happened and why he or she thinks it happened. Determine if the child is blaming himself or herself in any way. Is the child grieving following a permanent injury and/or loss of a loved one? How have the parents discussed any traumatic event with the child? Do the parents feel traumatized by the child's experience?
If PTSD is a possibility, ask if the child is experiencing flashbacks, intrusive thoughts, and/or any related anxiety.
Some symptoms are expected after a traumatic event or following cancer or critical care treatment experienced as traumatic. Most children and adolescents overcome the fear of riding in a car or playing the sport that resulted in the trauma.
However, symptoms that persist for a month or more, with avoidance and associated anxiety, are core to the diagnosis of PTSD. The anxiety can build and be self-reinforcing so as to interfere with daily functioning. At this point, consider referral to a mental health specialist, preferably one with some experience in PTSD treatment. A specialist can help the patient overcome his or her anxiety and return to functioning through cognitive and behavioral techniques such as reframing the events, dealing with any guilt, and staged exposure to the anxiety.
If one of your patients experienced a car crash or other major trauma, you will likely know about it, already be treating the child, and should be planning to monitor them for signs of PTSD. In contrast, detection of subtle PTSD is more challenging, particularly if the trauma is unknown or occurred years ago. Trauma related to domestic violence or sexual abuse first requires consideration of this possibility and then gentle, empathic, and persistent questioning.
Triggers for reliving/reexperiencing the trauma also can be straightforward. For example, a child who gets into a car with a similar interior design years after a crash can immediately experience and emotionally return to the trauma. Other triggers are less obvious, such as a teenage girl who was held down and forced to have sex against her will, who later feels constrained by tight clothing and immediately relives the fear and anguish.
Like many presentations in pediatrics, management of PTSD depends on the developmental stage of the child, including his or her cognitive abilities and emotional state. For example, infants or toddlers might not be able to make much sense of what is happening when they witness domestic violence. Terror, fear, and confusion are their most likely reactions.
School-age children aged 5–8 years would not fully understand either, but they will try to make some sense of the domestic violence. Assuming no one reassures them otherwise, they also may feel that something they did sparked or contributed to the violence. For example, if they overhear arguments around issues in the family and hear their name mentioned, they may quickly assume that they are the cause of the domestic violence. This can lead to feelings of guilt, self-criticism, and unworthiness.
Adolescents will experience some of the same reactions as younger children. They will still experience shock, even if they are better equipped to conceptualize the domestic violence. Some will feel powerless because they cannot end the strife, particularly at a time when they are supposed to have more control over the real world. Teens might feel they have not lived up to expectations and perceive some blame. Others may choose to flee, find support through friends, and/or may deal with their feelings using substances.
Act when you encounter a patient who feels very guilty about parental fighting or who justifies abuse because he feels worthless or was told repeatedly he was a bad child. Help him realize he was not responsible for the conflict and that no one deserves abuse. Discuss other, more realistic possibilities for the family paradigm.
These are not easy conversations. Some pediatricians will feel comfortable working at this depth, others will prefer to refer.
Healing from PTSD related to family violence, sexual abuse, or criminal activity is a several-step process. As one's sense of guilt diminishes, other emotions such as anger at not being better protected or valued need to be addressed. Finally, there needs to be some grieving for what was lacking and some acceptance of what was possible. This is not a simple process; however, it is worthwhile because if their PTSD remains untreated, there is a greater likelihood they will continue to relive traumatic memories as adults.
There is some controversy as to whether talking through the traumatic event over and over truly helps. Some clinicians feel that a certain amount of supportive discussion in a calm way makes sense, especially early. But solely repeating the details of the event may re-traumatize the child and intensify negative feelings, especially if the memories are very vivid.
Cognitive and behavioral approaches can help the child reframe their trauma. An example is exposure therapy, where the child is carefully reexposed to the trauma in stages while they learn to reframe and diminish the intensity of the experience. Often, ideas about the trauma come out that can be examined objectively to try to lessen some of those traumatic feelings.
Exposure therapy also can incorporate gradual steps to help the child overcome their fear. If a person survived a plane crash, the first step might be to take him or her to the airport, then to board an airplane without taking off, and so forth. This approach reintroduces the trauma without eliciting a full response. You don't want the brain to go on “red alert” again. In a state of hyperarousal, reliving the trauma may do more harm than good.
The terrified moments that children experience during a traumatic sequence tend to get burned into their memories much more strongly than everyday events. A school-age child might remember nothing about an uneventful trip in the car, but if a traumatic accident happens, often she remembers almost every detail. She recalls descriptive elements of what happened as well as the emotional fright or anguish very vividly.
Sometimes vivid, traumatic memories will enter your patient's mind spontaneously without him knowing why. In other cases, there are triggers. Sometimes these flashbacks arise shortly following trauma and sometimes they take years.
Pediatricians can do their patients and families a service if they are aware of PTSD either after an overt event like a car accident or by considering trauma in an anxious or dysfunctional child.
Different forms of trauma can cause posttraumatic stress disorder in children, whether from an objective event like a car crash or sports injury to trauma involving loved ones, such as domestic violence, abuse, or neglect.
Pediatricians can help by routinely screening for dysfunction and by asking questions at annual well-child visits. Overt symptoms include fear related to the trauma such as avoiding the traumatic setting or activity. Less specific symptoms include anxiety, avoidance, social isolation, depression, and low self-esteem.
If a standard screen such as the Pediatric Symptom Checklist or another instrument reveals psychosocial dysfunction, you have to determine the cause of dysfunction, and PTSD should certainly be considered.
Is there family discord leading to violence in the home? If you suspect PTSD, ask a child what happened and why he or she thinks it happened. Determine if the child is blaming himself or herself in any way. Is the child grieving following a permanent injury and/or loss of a loved one? How have the parents discussed any traumatic event with the child? Do the parents feel traumatized by the child's experience?
If PTSD is a possibility, ask if the child is experiencing flashbacks, intrusive thoughts, and/or any related anxiety.
Some symptoms are expected after a traumatic event or following cancer or critical care treatment experienced as traumatic. Most children and adolescents overcome the fear of riding in a car or playing the sport that resulted in the trauma.
However, symptoms that persist for a month or more, with avoidance and associated anxiety, are core to the diagnosis of PTSD. The anxiety can build and be self-reinforcing so as to interfere with daily functioning. At this point, consider referral to a mental health specialist, preferably one with some experience in PTSD treatment. A specialist can help the patient overcome his or her anxiety and return to functioning through cognitive and behavioral techniques such as reframing the events, dealing with any guilt, and staged exposure to the anxiety.
If one of your patients experienced a car crash or other major trauma, you will likely know about it, already be treating the child, and should be planning to monitor them for signs of PTSD. In contrast, detection of subtle PTSD is more challenging, particularly if the trauma is unknown or occurred years ago. Trauma related to domestic violence or sexual abuse first requires consideration of this possibility and then gentle, empathic, and persistent questioning.
Triggers for reliving/reexperiencing the trauma also can be straightforward. For example, a child who gets into a car with a similar interior design years after a crash can immediately experience and emotionally return to the trauma. Other triggers are less obvious, such as a teenage girl who was held down and forced to have sex against her will, who later feels constrained by tight clothing and immediately relives the fear and anguish.
Like many presentations in pediatrics, management of PTSD depends on the developmental stage of the child, including his or her cognitive abilities and emotional state. For example, infants or toddlers might not be able to make much sense of what is happening when they witness domestic violence. Terror, fear, and confusion are their most likely reactions.
School-age children aged 5–8 years would not fully understand either, but they will try to make some sense of the domestic violence. Assuming no one reassures them otherwise, they also may feel that something they did sparked or contributed to the violence. For example, if they overhear arguments around issues in the family and hear their name mentioned, they may quickly assume that they are the cause of the domestic violence. This can lead to feelings of guilt, self-criticism, and unworthiness.
Adolescents will experience some of the same reactions as younger children. They will still experience shock, even if they are better equipped to conceptualize the domestic violence. Some will feel powerless because they cannot end the strife, particularly at a time when they are supposed to have more control over the real world. Teens might feel they have not lived up to expectations and perceive some blame. Others may choose to flee, find support through friends, and/or may deal with their feelings using substances.
Act when you encounter a patient who feels very guilty about parental fighting or who justifies abuse because he feels worthless or was told repeatedly he was a bad child. Help him realize he was not responsible for the conflict and that no one deserves abuse. Discuss other, more realistic possibilities for the family paradigm.
These are not easy conversations. Some pediatricians will feel comfortable working at this depth, others will prefer to refer.
Healing from PTSD related to family violence, sexual abuse, or criminal activity is a several-step process. As one's sense of guilt diminishes, other emotions such as anger at not being better protected or valued need to be addressed. Finally, there needs to be some grieving for what was lacking and some acceptance of what was possible. This is not a simple process; however, it is worthwhile because if their PTSD remains untreated, there is a greater likelihood they will continue to relive traumatic memories as adults.
There is some controversy as to whether talking through the traumatic event over and over truly helps. Some clinicians feel that a certain amount of supportive discussion in a calm way makes sense, especially early. But solely repeating the details of the event may re-traumatize the child and intensify negative feelings, especially if the memories are very vivid.
Cognitive and behavioral approaches can help the child reframe their trauma. An example is exposure therapy, where the child is carefully reexposed to the trauma in stages while they learn to reframe and diminish the intensity of the experience. Often, ideas about the trauma come out that can be examined objectively to try to lessen some of those traumatic feelings.
Exposure therapy also can incorporate gradual steps to help the child overcome their fear. If a person survived a plane crash, the first step might be to take him or her to the airport, then to board an airplane without taking off, and so forth. This approach reintroduces the trauma without eliciting a full response. You don't want the brain to go on “red alert” again. In a state of hyperarousal, reliving the trauma may do more harm than good.
The terrified moments that children experience during a traumatic sequence tend to get burned into their memories much more strongly than everyday events. A school-age child might remember nothing about an uneventful trip in the car, but if a traumatic accident happens, often she remembers almost every detail. She recalls descriptive elements of what happened as well as the emotional fright or anguish very vividly.
Sometimes vivid, traumatic memories will enter your patient's mind spontaneously without him knowing why. In other cases, there are triggers. Sometimes these flashbacks arise shortly following trauma and sometimes they take years.
Pediatricians can do their patients and families a service if they are aware of PTSD either after an overt event like a car accident or by considering trauma in an anxious or dysfunctional child.
Different forms of trauma can cause posttraumatic stress disorder in children, whether from an objective event like a car crash or sports injury to trauma involving loved ones, such as domestic violence, abuse, or neglect.
Pediatricians can help by routinely screening for dysfunction and by asking questions at annual well-child visits. Overt symptoms include fear related to the trauma such as avoiding the traumatic setting or activity. Less specific symptoms include anxiety, avoidance, social isolation, depression, and low self-esteem.
If a standard screen such as the Pediatric Symptom Checklist or another instrument reveals psychosocial dysfunction, you have to determine the cause of dysfunction, and PTSD should certainly be considered.
Is there family discord leading to violence in the home? If you suspect PTSD, ask a child what happened and why he or she thinks it happened. Determine if the child is blaming himself or herself in any way. Is the child grieving following a permanent injury and/or loss of a loved one? How have the parents discussed any traumatic event with the child? Do the parents feel traumatized by the child's experience?
If PTSD is a possibility, ask if the child is experiencing flashbacks, intrusive thoughts, and/or any related anxiety.
Some symptoms are expected after a traumatic event or following cancer or critical care treatment experienced as traumatic. Most children and adolescents overcome the fear of riding in a car or playing the sport that resulted in the trauma.
However, symptoms that persist for a month or more, with avoidance and associated anxiety, are core to the diagnosis of PTSD. The anxiety can build and be self-reinforcing so as to interfere with daily functioning. At this point, consider referral to a mental health specialist, preferably one with some experience in PTSD treatment. A specialist can help the patient overcome his or her anxiety and return to functioning through cognitive and behavioral techniques such as reframing the events, dealing with any guilt, and staged exposure to the anxiety.
If one of your patients experienced a car crash or other major trauma, you will likely know about it, already be treating the child, and should be planning to monitor them for signs of PTSD. In contrast, detection of subtle PTSD is more challenging, particularly if the trauma is unknown or occurred years ago. Trauma related to domestic violence or sexual abuse first requires consideration of this possibility and then gentle, empathic, and persistent questioning.
Triggers for reliving/reexperiencing the trauma also can be straightforward. For example, a child who gets into a car with a similar interior design years after a crash can immediately experience and emotionally return to the trauma. Other triggers are less obvious, such as a teenage girl who was held down and forced to have sex against her will, who later feels constrained by tight clothing and immediately relives the fear and anguish.
Like many presentations in pediatrics, management of PTSD depends on the developmental stage of the child, including his or her cognitive abilities and emotional state. For example, infants or toddlers might not be able to make much sense of what is happening when they witness domestic violence. Terror, fear, and confusion are their most likely reactions.
School-age children aged 5–8 years would not fully understand either, but they will try to make some sense of the domestic violence. Assuming no one reassures them otherwise, they also may feel that something they did sparked or contributed to the violence. For example, if they overhear arguments around issues in the family and hear their name mentioned, they may quickly assume that they are the cause of the domestic violence. This can lead to feelings of guilt, self-criticism, and unworthiness.
Adolescents will experience some of the same reactions as younger children. They will still experience shock, even if they are better equipped to conceptualize the domestic violence. Some will feel powerless because they cannot end the strife, particularly at a time when they are supposed to have more control over the real world. Teens might feel they have not lived up to expectations and perceive some blame. Others may choose to flee, find support through friends, and/or may deal with their feelings using substances.
Act when you encounter a patient who feels very guilty about parental fighting or who justifies abuse because he feels worthless or was told repeatedly he was a bad child. Help him realize he was not responsible for the conflict and that no one deserves abuse. Discuss other, more realistic possibilities for the family paradigm.
These are not easy conversations. Some pediatricians will feel comfortable working at this depth, others will prefer to refer.
Healing from PTSD related to family violence, sexual abuse, or criminal activity is a several-step process. As one's sense of guilt diminishes, other emotions such as anger at not being better protected or valued need to be addressed. Finally, there needs to be some grieving for what was lacking and some acceptance of what was possible. This is not a simple process; however, it is worthwhile because if their PTSD remains untreated, there is a greater likelihood they will continue to relive traumatic memories as adults.
There is some controversy as to whether talking through the traumatic event over and over truly helps. Some clinicians feel that a certain amount of supportive discussion in a calm way makes sense, especially early. But solely repeating the details of the event may re-traumatize the child and intensify negative feelings, especially if the memories are very vivid.
Cognitive and behavioral approaches can help the child reframe their trauma. An example is exposure therapy, where the child is carefully reexposed to the trauma in stages while they learn to reframe and diminish the intensity of the experience. Often, ideas about the trauma come out that can be examined objectively to try to lessen some of those traumatic feelings.
Exposure therapy also can incorporate gradual steps to help the child overcome their fear. If a person survived a plane crash, the first step might be to take him or her to the airport, then to board an airplane without taking off, and so forth. This approach reintroduces the trauma without eliciting a full response. You don't want the brain to go on “red alert” again. In a state of hyperarousal, reliving the trauma may do more harm than good.
The terrified moments that children experience during a traumatic sequence tend to get burned into their memories much more strongly than everyday events. A school-age child might remember nothing about an uneventful trip in the car, but if a traumatic accident happens, often she remembers almost every detail. She recalls descriptive elements of what happened as well as the emotional fright or anguish very vividly.
Sometimes vivid, traumatic memories will enter your patient's mind spontaneously without him knowing why. In other cases, there are triggers. Sometimes these flashbacks arise shortly following trauma and sometimes they take years.
Pediatricians can do their patients and families a service if they are aware of PTSD either after an overt event like a car accident or by considering trauma in an anxious or dysfunctional child.
Substance Use in Teens
Adolescent substance use is a big, difficult issue. Alcohol, cigarettes, and marijuana – and to a lesser extent, cocaine – are endemic to most high schools.
It's not at all unusual for high school juniors and seniors to drink or even to binge drink. In addition, about 15%-20% of them smoke cigarettes, depending on the community, and probably more than that try or intermittently smoke marijuana.
One approach is to educate parents about which children may be at higher risk for substance use.
For example, most teenagers are at some risk and need to be watched for any high-risk activities, especially drinking and driving or riding in a car with a friend who has been drinking. If parents begin to see a serious problem – such as binge drinking every weekend, obvious use of marijuana on a regular basis, or obvious use of cocaine – take it very seriously. Talk with patients and parents, and provide a referral for services as indicated.
Other kids might be at slightly higher risk in high school, based on their achievements. A good athlete who joins the varsity team in 9th or 10th grade, or the talented 9th-grader who lands the lead in the high school play, tend to spend more time with juniors and seniors. They get invited to parties and events outside their peer groups. Without the judgment of an older child and while trying to “keep up,” they might be more vulnerable to problematic substance use. The difference between a 14-year-old and a 17-year-old is enormous, and the peer pressure of being with seniors is considerable.
Recognize that some kids start high school already predisposed and at quite high risk for substance use problems: A patient with biologic or genetic risk factors; a patient with untreated depression or anxiety; and/or an adolescent with attention-deficit/hyperactivity disorder (ADHD) are examples.
Left unaddressed, these kids are predisposed to earlier and more serious substance use. Some children with genetic and/or biological risk factors begin drinking heavily before their 14th birthday. In contrast, the typical age of onset for alcohol use includes some experimentation at 15 or 16 years that becomes binge drinking for some a year or two later.
Biology predisposes some adolescents to nicotine addiction or heavy use of marijuana or alcohol. While adolescent brains are in development and experience the expected stress of puberty and building an identity, some teenagers' brains may be more susceptible to addiction than others. In addition, genetics and environment can play a role, evidenced by the higher risks for children whose parents have a personal or family history of substance use problems. If there is a strong history of alcoholism in the family or if a parent is a recovering alcoholic, discuss with parents how their past might influence how they treat their teenager. Advise them what information should be shared to alert the teenager to the potential risks. It might help a child at age 12 or 13 to know that he or she may be especially vulnerable to the dangers of substance use, and this may well open up an avenue of communication and trust that could be helpful later.
Anxiety and depression also have genetic roots in some patients. Asking parents about their family history of substance abuse, depression, or serious mental health disorder should be a routine part of pediatric practice.
In addition, implementing screening tests makes sense in adolescence. Such screening tests are publicly available and reviewed by the American Academy of Pediatrics Bright Futures: Mental Health effort (http://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.htmlwww.aap.org/pcorss/demos/mht.html
Children with ADHD make up another high-risk group. They also seem to be more vulnerable to cigarettes, alcohol, and marijuana. These teenagers can be driven to find relief in these substances because of brain biology and/or secondary to the stress of living with their ADHD symptoms.
On the plus side, ADHD kids treated appropriately with stimulants and support services have lower levels of substance use and probably higher self-esteem. Ensure they have the best treatment possible for their ADHD to minimize their substance use risk as much as possible.
As they become young teenagers, they should have a full review of all their ADHD treatment and how their typical day plays out at school and at home. Consider some additional preventative counseling to help these children face their substance use challenges throughout adolescence.
Offer such guidance to all children and parents, but especially to those in one of these high-risk groups. Suggest strategies that support and reinforce their resiliency. A warm, positive relationship with an adult is a protective factor. Also, kids who feel connected to a school, church, or sports team tend to be a little more resilient to some of these influences.
Facilitate open, honest communication between the parent and adolescent. Many parents might not realize that this is more effective than are attempts to control their teen's behavior 24/7. Over-control is impossible given the lifestyle of most 15-, 16- or 17-year-olds. Between cell phones, cars, and the amount of time they are out of the house, parents cannot control them to a level of stopping all substance use.
Even if more control is possible, the effort works against the adolescent's developmental trajectory toward increasing autonomy. The real goal of adolescence in our culture is to learn how to live in the real world and to prepare for autonomy as young adults. High school is a preparation for college life and adulthood where good judgment, safety, and socialization are important learned behaviors. Teaching adolescents how to navigate all this is an essential role for physicians and parents.
Part of growing autonomy is privacy. While it is tempting to invade that privacy to learn about substance use or to clarify other concerns, it is not clear that such efforts support the long-term goals of raising a teenager. Such efforts at control and investigation, including blood or urine testing, are best reserved when the benefits outweigh the risks, when there is a substance abuse problem that needs to be addressed.
Adolescent substance use is a big, difficult issue. Alcohol, cigarettes, and marijuana – and to a lesser extent, cocaine – are endemic to most high schools.
It's not at all unusual for high school juniors and seniors to drink or even to binge drink. In addition, about 15%-20% of them smoke cigarettes, depending on the community, and probably more than that try or intermittently smoke marijuana.
One approach is to educate parents about which children may be at higher risk for substance use.
For example, most teenagers are at some risk and need to be watched for any high-risk activities, especially drinking and driving or riding in a car with a friend who has been drinking. If parents begin to see a serious problem – such as binge drinking every weekend, obvious use of marijuana on a regular basis, or obvious use of cocaine – take it very seriously. Talk with patients and parents, and provide a referral for services as indicated.
Other kids might be at slightly higher risk in high school, based on their achievements. A good athlete who joins the varsity team in 9th or 10th grade, or the talented 9th-grader who lands the lead in the high school play, tend to spend more time with juniors and seniors. They get invited to parties and events outside their peer groups. Without the judgment of an older child and while trying to “keep up,” they might be more vulnerable to problematic substance use. The difference between a 14-year-old and a 17-year-old is enormous, and the peer pressure of being with seniors is considerable.
Recognize that some kids start high school already predisposed and at quite high risk for substance use problems: A patient with biologic or genetic risk factors; a patient with untreated depression or anxiety; and/or an adolescent with attention-deficit/hyperactivity disorder (ADHD) are examples.
Left unaddressed, these kids are predisposed to earlier and more serious substance use. Some children with genetic and/or biological risk factors begin drinking heavily before their 14th birthday. In contrast, the typical age of onset for alcohol use includes some experimentation at 15 or 16 years that becomes binge drinking for some a year or two later.
Biology predisposes some adolescents to nicotine addiction or heavy use of marijuana or alcohol. While adolescent brains are in development and experience the expected stress of puberty and building an identity, some teenagers' brains may be more susceptible to addiction than others. In addition, genetics and environment can play a role, evidenced by the higher risks for children whose parents have a personal or family history of substance use problems. If there is a strong history of alcoholism in the family or if a parent is a recovering alcoholic, discuss with parents how their past might influence how they treat their teenager. Advise them what information should be shared to alert the teenager to the potential risks. It might help a child at age 12 or 13 to know that he or she may be especially vulnerable to the dangers of substance use, and this may well open up an avenue of communication and trust that could be helpful later.
Anxiety and depression also have genetic roots in some patients. Asking parents about their family history of substance abuse, depression, or serious mental health disorder should be a routine part of pediatric practice.
In addition, implementing screening tests makes sense in adolescence. Such screening tests are publicly available and reviewed by the American Academy of Pediatrics Bright Futures: Mental Health effort (http://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.htmlwww.aap.org/pcorss/demos/mht.html
Children with ADHD make up another high-risk group. They also seem to be more vulnerable to cigarettes, alcohol, and marijuana. These teenagers can be driven to find relief in these substances because of brain biology and/or secondary to the stress of living with their ADHD symptoms.
On the plus side, ADHD kids treated appropriately with stimulants and support services have lower levels of substance use and probably higher self-esteem. Ensure they have the best treatment possible for their ADHD to minimize their substance use risk as much as possible.
As they become young teenagers, they should have a full review of all their ADHD treatment and how their typical day plays out at school and at home. Consider some additional preventative counseling to help these children face their substance use challenges throughout adolescence.
Offer such guidance to all children and parents, but especially to those in one of these high-risk groups. Suggest strategies that support and reinforce their resiliency. A warm, positive relationship with an adult is a protective factor. Also, kids who feel connected to a school, church, or sports team tend to be a little more resilient to some of these influences.
Facilitate open, honest communication between the parent and adolescent. Many parents might not realize that this is more effective than are attempts to control their teen's behavior 24/7. Over-control is impossible given the lifestyle of most 15-, 16- or 17-year-olds. Between cell phones, cars, and the amount of time they are out of the house, parents cannot control them to a level of stopping all substance use.
Even if more control is possible, the effort works against the adolescent's developmental trajectory toward increasing autonomy. The real goal of adolescence in our culture is to learn how to live in the real world and to prepare for autonomy as young adults. High school is a preparation for college life and adulthood where good judgment, safety, and socialization are important learned behaviors. Teaching adolescents how to navigate all this is an essential role for physicians and parents.
Part of growing autonomy is privacy. While it is tempting to invade that privacy to learn about substance use or to clarify other concerns, it is not clear that such efforts support the long-term goals of raising a teenager. Such efforts at control and investigation, including blood or urine testing, are best reserved when the benefits outweigh the risks, when there is a substance abuse problem that needs to be addressed.
Adolescent substance use is a big, difficult issue. Alcohol, cigarettes, and marijuana – and to a lesser extent, cocaine – are endemic to most high schools.
It's not at all unusual for high school juniors and seniors to drink or even to binge drink. In addition, about 15%-20% of them smoke cigarettes, depending on the community, and probably more than that try or intermittently smoke marijuana.
One approach is to educate parents about which children may be at higher risk for substance use.
For example, most teenagers are at some risk and need to be watched for any high-risk activities, especially drinking and driving or riding in a car with a friend who has been drinking. If parents begin to see a serious problem – such as binge drinking every weekend, obvious use of marijuana on a regular basis, or obvious use of cocaine – take it very seriously. Talk with patients and parents, and provide a referral for services as indicated.
Other kids might be at slightly higher risk in high school, based on their achievements. A good athlete who joins the varsity team in 9th or 10th grade, or the talented 9th-grader who lands the lead in the high school play, tend to spend more time with juniors and seniors. They get invited to parties and events outside their peer groups. Without the judgment of an older child and while trying to “keep up,” they might be more vulnerable to problematic substance use. The difference between a 14-year-old and a 17-year-old is enormous, and the peer pressure of being with seniors is considerable.
Recognize that some kids start high school already predisposed and at quite high risk for substance use problems: A patient with biologic or genetic risk factors; a patient with untreated depression or anxiety; and/or an adolescent with attention-deficit/hyperactivity disorder (ADHD) are examples.
Left unaddressed, these kids are predisposed to earlier and more serious substance use. Some children with genetic and/or biological risk factors begin drinking heavily before their 14th birthday. In contrast, the typical age of onset for alcohol use includes some experimentation at 15 or 16 years that becomes binge drinking for some a year or two later.
Biology predisposes some adolescents to nicotine addiction or heavy use of marijuana or alcohol. While adolescent brains are in development and experience the expected stress of puberty and building an identity, some teenagers' brains may be more susceptible to addiction than others. In addition, genetics and environment can play a role, evidenced by the higher risks for children whose parents have a personal or family history of substance use problems. If there is a strong history of alcoholism in the family or if a parent is a recovering alcoholic, discuss with parents how their past might influence how they treat their teenager. Advise them what information should be shared to alert the teenager to the potential risks. It might help a child at age 12 or 13 to know that he or she may be especially vulnerable to the dangers of substance use, and this may well open up an avenue of communication and trust that could be helpful later.
Anxiety and depression also have genetic roots in some patients. Asking parents about their family history of substance abuse, depression, or serious mental health disorder should be a routine part of pediatric practice.
In addition, implementing screening tests makes sense in adolescence. Such screening tests are publicly available and reviewed by the American Academy of Pediatrics Bright Futures: Mental Health effort (http://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.htmlwww.aap.org/pcorss/demos/mht.html
Children with ADHD make up another high-risk group. They also seem to be more vulnerable to cigarettes, alcohol, and marijuana. These teenagers can be driven to find relief in these substances because of brain biology and/or secondary to the stress of living with their ADHD symptoms.
On the plus side, ADHD kids treated appropriately with stimulants and support services have lower levels of substance use and probably higher self-esteem. Ensure they have the best treatment possible for their ADHD to minimize their substance use risk as much as possible.
As they become young teenagers, they should have a full review of all their ADHD treatment and how their typical day plays out at school and at home. Consider some additional preventative counseling to help these children face their substance use challenges throughout adolescence.
Offer such guidance to all children and parents, but especially to those in one of these high-risk groups. Suggest strategies that support and reinforce their resiliency. A warm, positive relationship with an adult is a protective factor. Also, kids who feel connected to a school, church, or sports team tend to be a little more resilient to some of these influences.
Facilitate open, honest communication between the parent and adolescent. Many parents might not realize that this is more effective than are attempts to control their teen's behavior 24/7. Over-control is impossible given the lifestyle of most 15-, 16- or 17-year-olds. Between cell phones, cars, and the amount of time they are out of the house, parents cannot control them to a level of stopping all substance use.
Even if more control is possible, the effort works against the adolescent's developmental trajectory toward increasing autonomy. The real goal of adolescence in our culture is to learn how to live in the real world and to prepare for autonomy as young adults. High school is a preparation for college life and adulthood where good judgment, safety, and socialization are important learned behaviors. Teaching adolescents how to navigate all this is an essential role for physicians and parents.
Part of growing autonomy is privacy. While it is tempting to invade that privacy to learn about substance use or to clarify other concerns, it is not clear that such efforts support the long-term goals of raising a teenager. Such efforts at control and investigation, including blood or urine testing, are best reserved when the benefits outweigh the risks, when there is a substance abuse problem that needs to be addressed.
Are We Pandering to Peer Problems in Preschool?
www.CHADIS.compdnews@elsevier.com
“The preschool just called for the second time about Jason's behavior! What can I do?” This plea to you the pediatrician makes your stomach turn upside down. “What am I supposed to do about that?” you ask yourself. You're not there to see what is happening, and the parent isn't either.
This scenario is made even more difficult because the parents can be desperate for advice and quick solutions. It is incredibly inconvenient when a child is thrown out of child care or preschool for bad behavior, especially for parents who both work. Parents may even get hysterical because they immediately envision their darling failing to get into Harvard based on an inability to interact properly in preschool.
The differential diagnosis of this complaint takes some good sleuthing, but can make a big difference in the life of a young child.
Young children deal with social interaction issues that also confront grown-ups, but without the skills to navigate and manage them.
Learning social skills is a major benefit of preschool and kindergarten, particularly for children with few siblings or siblings of much different ages. The poem “All I Need to Know I Learned in Kindergarten” describes many of these social benefits, including learning to share, take turns, act kindly, and use manners. The poem does not mention some of the other less poetic skills developed at this age, however: learning how to tease successfully, pull your punches, stand tall when there is a bully, bounce back when people insult you or after you wet your pants, tell if someone is a real friend, and deal with a critical teacher who is screaming all the time.
Young children normally practice a social interaction known as “inclusion/exclusion,” where one day they say, “Oh, you're my best friend. Let's go have our secret club.” But the next day they say, “You're not my friend anymore. I've got a new best friend. You can't play with me.” In general, the best short- and long-term outcomes occur when children work out minor interaction problems on their own, with a little teacher support, but serious problems are handled privately by the adults.
Ask for specific information about one of the incidents from both the child and the parent. If a child comes home from school and says, “This kid called me names,” parents can ask, “What kind of names?” to distinguish normal teasing from a toxic environment that needs to be changed. Abnormal teasing is more vicious and adultlike, for example, a peer calling the child a “whore” or using a racial epithet.
Don't forget to suggest ways to pump up resilience such as getting sufficient sleep and proper nutrition.
Next, assess the child with problematic peer behavior for skill deficits. A child with a gap may act up to distract others from noticing, out of frustration or as result of discrimination the child experiences. Often children this age who are aggressive have shortcomings in language. They may speak a different language at home or still communicate only in two- or three-word phrases, and therefore are unable to keep up with others and feel – or actually are – left out. They don't have the repartee to negotiate social situations and can become the victim of taunting and teasing, a specialty of girls.
Children with gross motor skill deficits, particularly boys, also may experience difficulty keeping up with their peers. In some cases, they are rejected by the group for being unable to kick a soccer ball or to climb a jungle gym as well as others can, and they are angry as a result.
Check fine motor skills as well. A child with poor coordination may be slow to finish work and/or be ashamed of what they do produce. Children can be very self-critical at this age and even tear up their papers. If the teacher asks everyone to draw a truck, and another student pointedly says, 'That doesn't look like a truck,” the child might punch in return. The child is acting up in frustration.
While children at this age are just on the edge of acquiring “perspective taking” (considering another's point of view), in the most severe form, difficulty in doing this can be a sign of autism spectrum disorder. Peers quickly pick up on this and may tease them, call them names, and/or reject their awkward attempts to engage. Try telling them a joke or asking them to tell one, and you may see why.
You can help by addressing any detected skill deficits with language therapy or physical therapy. Importantly, suggest ways to build their skills while allowing them to bypass social humiliation. Let children who are not athletic skip recess, assigning them the task of getting out the snacks to avoid further humiliation. Then work on their motor skills through after-school karate instead.
Anxiety can spark aggression, too. If you are afraid, it seems better to strike first. If anxiety seems key, the parents and school will need to soften their handling of the child and help him or her put feelings into words to assist the child in not acting out.
Since some children will misbehave to get a teacher's attention, recommend that the parents drop in unannounced. Often the way a classroom appears (or is staffed) at 8 a.m. drop-off time is not the same way it operates at 10:30 a.m. Suggest a parent watch the part of the day their child complains about the most, which is frequently recess.
Even though there are bad situations and bad schools, most schools have great teachers and other professionals from whom parents can gain valuable information and advice.
Generally teachers can explain the timing of a child's troubles, for example, during circle time he cannot sit still or during craft time because his fine motor skills are not well developed. Having parents seek out these examples is the most efficient way to identify deficits in need of help.
Suggest parents speak to their child empathically instead of giving instructions. In this culture, boys especially are told to “keep a stiff upper lip” or “be a big soldier.” A better approach is to say, “Yes, it's tough when kids talk to you like that” or “I understand this really makes you sad and you feel like crying.”
It also helps when parents share a similar experience from their own childhood. For example, parents can say, “You know, when I was your age, I had an experience like this – I had a kid who was always on my case.”
Parents can promote social development as well. For example, role playing can clearly help a child develop appropriate socioemotional skills. Parents can use this strategy either before an incident – for example, to rehearse how a child might react to a bully in class – or afterward, to help the child determine what he or she might have said or done differently and prepare for the next time. Use of social stories can foster these skills (see www.socialstories.com
Parents who experienced a bad peer interaction as a preschooler or kindergartener may project their concerns on their child who may be doing just fine. The parents might be supersensitive to teasing, for example, and bring an otherwise minor incident to your attention and/or become overintrusive at school. Asking, “How was it for you when you were little? Did you ever run into anything like this?” may bring out past experiences as an important factor predisposing to overreaction. If they wet their pants in kindergarten and never got over it, realizing this connection makes it possible for them to back off and let the school and child handle the current problem.
Watch for red flags or warning signs that problematic behaviors are not within the range of normal stress. The child initially doing well at school who suddenly does not want to return is one example.
Sadly, you need to always consider whether there is abuse going on at school, including sexual abuse. Sudden adjustment problems at home, such as trouble sleeping, nightmares, or bed-wetting, also should raise your level of concern.
Also ask parents if their preschooler suddenly became more difficult to manage at home. Some children who experience negative peer interactions will cling to parents, but oppositional or defiant behavior is more common. Of course, 4-year-old children are notoriously brassy, so you cannot consider back talk a warning sign unless it is part of a sudden change in the normal flow of the child's behavior.
A child this stressed over school may need to be cared for at home or moved to a family day care situation
Unfortunately, the modern practice of grouping of kids of the same age together in a classroom increases the likelihood of interactions going badly. Ten 2-year-old children are not necessarily capable of peacefully spending hours together at a time. When a serious behavioral problem arises in this kind of setting, I frequently recommend family-based day care instead of center-based day care because children will be with others of different ages and different skill levels, and hopefully some of them will be more mature.
Support parents in deciding to pull the child out of a school if the situation is bad. If, for example, the school administration is unresponsive to or dismissive of a parent, removal of the child may be the best option. A new parent recently came to the parent group at our clinic. She reported that a teacher responded to her child's behavior problem by putting him in a closet, which would have been egregious enough, but the teacher also said that there were spiders and bugs in the closet that were going to get him before closing the door. I was flabbergasted. The school tried to defend the teacher for doing this, and my final advice was to “pull the kid.” Any school that ignorant of normal child development cannot be fixed.
www.CHADIS.compdnews@elsevier.com
“The preschool just called for the second time about Jason's behavior! What can I do?” This plea to you the pediatrician makes your stomach turn upside down. “What am I supposed to do about that?” you ask yourself. You're not there to see what is happening, and the parent isn't either.
This scenario is made even more difficult because the parents can be desperate for advice and quick solutions. It is incredibly inconvenient when a child is thrown out of child care or preschool for bad behavior, especially for parents who both work. Parents may even get hysterical because they immediately envision their darling failing to get into Harvard based on an inability to interact properly in preschool.
The differential diagnosis of this complaint takes some good sleuthing, but can make a big difference in the life of a young child.
Young children deal with social interaction issues that also confront grown-ups, but without the skills to navigate and manage them.
Learning social skills is a major benefit of preschool and kindergarten, particularly for children with few siblings or siblings of much different ages. The poem “All I Need to Know I Learned in Kindergarten” describes many of these social benefits, including learning to share, take turns, act kindly, and use manners. The poem does not mention some of the other less poetic skills developed at this age, however: learning how to tease successfully, pull your punches, stand tall when there is a bully, bounce back when people insult you or after you wet your pants, tell if someone is a real friend, and deal with a critical teacher who is screaming all the time.
Young children normally practice a social interaction known as “inclusion/exclusion,” where one day they say, “Oh, you're my best friend. Let's go have our secret club.” But the next day they say, “You're not my friend anymore. I've got a new best friend. You can't play with me.” In general, the best short- and long-term outcomes occur when children work out minor interaction problems on their own, with a little teacher support, but serious problems are handled privately by the adults.
Ask for specific information about one of the incidents from both the child and the parent. If a child comes home from school and says, “This kid called me names,” parents can ask, “What kind of names?” to distinguish normal teasing from a toxic environment that needs to be changed. Abnormal teasing is more vicious and adultlike, for example, a peer calling the child a “whore” or using a racial epithet.
Don't forget to suggest ways to pump up resilience such as getting sufficient sleep and proper nutrition.
Next, assess the child with problematic peer behavior for skill deficits. A child with a gap may act up to distract others from noticing, out of frustration or as result of discrimination the child experiences. Often children this age who are aggressive have shortcomings in language. They may speak a different language at home or still communicate only in two- or three-word phrases, and therefore are unable to keep up with others and feel – or actually are – left out. They don't have the repartee to negotiate social situations and can become the victim of taunting and teasing, a specialty of girls.
Children with gross motor skill deficits, particularly boys, also may experience difficulty keeping up with their peers. In some cases, they are rejected by the group for being unable to kick a soccer ball or to climb a jungle gym as well as others can, and they are angry as a result.
Check fine motor skills as well. A child with poor coordination may be slow to finish work and/or be ashamed of what they do produce. Children can be very self-critical at this age and even tear up their papers. If the teacher asks everyone to draw a truck, and another student pointedly says, 'That doesn't look like a truck,” the child might punch in return. The child is acting up in frustration.
While children at this age are just on the edge of acquiring “perspective taking” (considering another's point of view), in the most severe form, difficulty in doing this can be a sign of autism spectrum disorder. Peers quickly pick up on this and may tease them, call them names, and/or reject their awkward attempts to engage. Try telling them a joke or asking them to tell one, and you may see why.
You can help by addressing any detected skill deficits with language therapy or physical therapy. Importantly, suggest ways to build their skills while allowing them to bypass social humiliation. Let children who are not athletic skip recess, assigning them the task of getting out the snacks to avoid further humiliation. Then work on their motor skills through after-school karate instead.
Anxiety can spark aggression, too. If you are afraid, it seems better to strike first. If anxiety seems key, the parents and school will need to soften their handling of the child and help him or her put feelings into words to assist the child in not acting out.
Since some children will misbehave to get a teacher's attention, recommend that the parents drop in unannounced. Often the way a classroom appears (or is staffed) at 8 a.m. drop-off time is not the same way it operates at 10:30 a.m. Suggest a parent watch the part of the day their child complains about the most, which is frequently recess.
Even though there are bad situations and bad schools, most schools have great teachers and other professionals from whom parents can gain valuable information and advice.
Generally teachers can explain the timing of a child's troubles, for example, during circle time he cannot sit still or during craft time because his fine motor skills are not well developed. Having parents seek out these examples is the most efficient way to identify deficits in need of help.
Suggest parents speak to their child empathically instead of giving instructions. In this culture, boys especially are told to “keep a stiff upper lip” or “be a big soldier.” A better approach is to say, “Yes, it's tough when kids talk to you like that” or “I understand this really makes you sad and you feel like crying.”
It also helps when parents share a similar experience from their own childhood. For example, parents can say, “You know, when I was your age, I had an experience like this – I had a kid who was always on my case.”
Parents can promote social development as well. For example, role playing can clearly help a child develop appropriate socioemotional skills. Parents can use this strategy either before an incident – for example, to rehearse how a child might react to a bully in class – or afterward, to help the child determine what he or she might have said or done differently and prepare for the next time. Use of social stories can foster these skills (see www.socialstories.com
Parents who experienced a bad peer interaction as a preschooler or kindergartener may project their concerns on their child who may be doing just fine. The parents might be supersensitive to teasing, for example, and bring an otherwise minor incident to your attention and/or become overintrusive at school. Asking, “How was it for you when you were little? Did you ever run into anything like this?” may bring out past experiences as an important factor predisposing to overreaction. If they wet their pants in kindergarten and never got over it, realizing this connection makes it possible for them to back off and let the school and child handle the current problem.
Watch for red flags or warning signs that problematic behaviors are not within the range of normal stress. The child initially doing well at school who suddenly does not want to return is one example.
Sadly, you need to always consider whether there is abuse going on at school, including sexual abuse. Sudden adjustment problems at home, such as trouble sleeping, nightmares, or bed-wetting, also should raise your level of concern.
Also ask parents if their preschooler suddenly became more difficult to manage at home. Some children who experience negative peer interactions will cling to parents, but oppositional or defiant behavior is more common. Of course, 4-year-old children are notoriously brassy, so you cannot consider back talk a warning sign unless it is part of a sudden change in the normal flow of the child's behavior.
A child this stressed over school may need to be cared for at home or moved to a family day care situation
Unfortunately, the modern practice of grouping of kids of the same age together in a classroom increases the likelihood of interactions going badly. Ten 2-year-old children are not necessarily capable of peacefully spending hours together at a time. When a serious behavioral problem arises in this kind of setting, I frequently recommend family-based day care instead of center-based day care because children will be with others of different ages and different skill levels, and hopefully some of them will be more mature.
Support parents in deciding to pull the child out of a school if the situation is bad. If, for example, the school administration is unresponsive to or dismissive of a parent, removal of the child may be the best option. A new parent recently came to the parent group at our clinic. She reported that a teacher responded to her child's behavior problem by putting him in a closet, which would have been egregious enough, but the teacher also said that there were spiders and bugs in the closet that were going to get him before closing the door. I was flabbergasted. The school tried to defend the teacher for doing this, and my final advice was to “pull the kid.” Any school that ignorant of normal child development cannot be fixed.
www.CHADIS.compdnews@elsevier.com
“The preschool just called for the second time about Jason's behavior! What can I do?” This plea to you the pediatrician makes your stomach turn upside down. “What am I supposed to do about that?” you ask yourself. You're not there to see what is happening, and the parent isn't either.
This scenario is made even more difficult because the parents can be desperate for advice and quick solutions. It is incredibly inconvenient when a child is thrown out of child care or preschool for bad behavior, especially for parents who both work. Parents may even get hysterical because they immediately envision their darling failing to get into Harvard based on an inability to interact properly in preschool.
The differential diagnosis of this complaint takes some good sleuthing, but can make a big difference in the life of a young child.
Young children deal with social interaction issues that also confront grown-ups, but without the skills to navigate and manage them.
Learning social skills is a major benefit of preschool and kindergarten, particularly for children with few siblings or siblings of much different ages. The poem “All I Need to Know I Learned in Kindergarten” describes many of these social benefits, including learning to share, take turns, act kindly, and use manners. The poem does not mention some of the other less poetic skills developed at this age, however: learning how to tease successfully, pull your punches, stand tall when there is a bully, bounce back when people insult you or after you wet your pants, tell if someone is a real friend, and deal with a critical teacher who is screaming all the time.
Young children normally practice a social interaction known as “inclusion/exclusion,” where one day they say, “Oh, you're my best friend. Let's go have our secret club.” But the next day they say, “You're not my friend anymore. I've got a new best friend. You can't play with me.” In general, the best short- and long-term outcomes occur when children work out minor interaction problems on their own, with a little teacher support, but serious problems are handled privately by the adults.
Ask for specific information about one of the incidents from both the child and the parent. If a child comes home from school and says, “This kid called me names,” parents can ask, “What kind of names?” to distinguish normal teasing from a toxic environment that needs to be changed. Abnormal teasing is more vicious and adultlike, for example, a peer calling the child a “whore” or using a racial epithet.
Don't forget to suggest ways to pump up resilience such as getting sufficient sleep and proper nutrition.
Next, assess the child with problematic peer behavior for skill deficits. A child with a gap may act up to distract others from noticing, out of frustration or as result of discrimination the child experiences. Often children this age who are aggressive have shortcomings in language. They may speak a different language at home or still communicate only in two- or three-word phrases, and therefore are unable to keep up with others and feel – or actually are – left out. They don't have the repartee to negotiate social situations and can become the victim of taunting and teasing, a specialty of girls.
Children with gross motor skill deficits, particularly boys, also may experience difficulty keeping up with their peers. In some cases, they are rejected by the group for being unable to kick a soccer ball or to climb a jungle gym as well as others can, and they are angry as a result.
Check fine motor skills as well. A child with poor coordination may be slow to finish work and/or be ashamed of what they do produce. Children can be very self-critical at this age and even tear up their papers. If the teacher asks everyone to draw a truck, and another student pointedly says, 'That doesn't look like a truck,” the child might punch in return. The child is acting up in frustration.
While children at this age are just on the edge of acquiring “perspective taking” (considering another's point of view), in the most severe form, difficulty in doing this can be a sign of autism spectrum disorder. Peers quickly pick up on this and may tease them, call them names, and/or reject their awkward attempts to engage. Try telling them a joke or asking them to tell one, and you may see why.
You can help by addressing any detected skill deficits with language therapy or physical therapy. Importantly, suggest ways to build their skills while allowing them to bypass social humiliation. Let children who are not athletic skip recess, assigning them the task of getting out the snacks to avoid further humiliation. Then work on their motor skills through after-school karate instead.
Anxiety can spark aggression, too. If you are afraid, it seems better to strike first. If anxiety seems key, the parents and school will need to soften their handling of the child and help him or her put feelings into words to assist the child in not acting out.
Since some children will misbehave to get a teacher's attention, recommend that the parents drop in unannounced. Often the way a classroom appears (or is staffed) at 8 a.m. drop-off time is not the same way it operates at 10:30 a.m. Suggest a parent watch the part of the day their child complains about the most, which is frequently recess.
Even though there are bad situations and bad schools, most schools have great teachers and other professionals from whom parents can gain valuable information and advice.
Generally teachers can explain the timing of a child's troubles, for example, during circle time he cannot sit still or during craft time because his fine motor skills are not well developed. Having parents seek out these examples is the most efficient way to identify deficits in need of help.
Suggest parents speak to their child empathically instead of giving instructions. In this culture, boys especially are told to “keep a stiff upper lip” or “be a big soldier.” A better approach is to say, “Yes, it's tough when kids talk to you like that” or “I understand this really makes you sad and you feel like crying.”
It also helps when parents share a similar experience from their own childhood. For example, parents can say, “You know, when I was your age, I had an experience like this – I had a kid who was always on my case.”
Parents can promote social development as well. For example, role playing can clearly help a child develop appropriate socioemotional skills. Parents can use this strategy either before an incident – for example, to rehearse how a child might react to a bully in class – or afterward, to help the child determine what he or she might have said or done differently and prepare for the next time. Use of social stories can foster these skills (see www.socialstories.com
Parents who experienced a bad peer interaction as a preschooler or kindergartener may project their concerns on their child who may be doing just fine. The parents might be supersensitive to teasing, for example, and bring an otherwise minor incident to your attention and/or become overintrusive at school. Asking, “How was it for you when you were little? Did you ever run into anything like this?” may bring out past experiences as an important factor predisposing to overreaction. If they wet their pants in kindergarten and never got over it, realizing this connection makes it possible for them to back off and let the school and child handle the current problem.
Watch for red flags or warning signs that problematic behaviors are not within the range of normal stress. The child initially doing well at school who suddenly does not want to return is one example.
Sadly, you need to always consider whether there is abuse going on at school, including sexual abuse. Sudden adjustment problems at home, such as trouble sleeping, nightmares, or bed-wetting, also should raise your level of concern.
Also ask parents if their preschooler suddenly became more difficult to manage at home. Some children who experience negative peer interactions will cling to parents, but oppositional or defiant behavior is more common. Of course, 4-year-old children are notoriously brassy, so you cannot consider back talk a warning sign unless it is part of a sudden change in the normal flow of the child's behavior.
A child this stressed over school may need to be cared for at home or moved to a family day care situation
Unfortunately, the modern practice of grouping of kids of the same age together in a classroom increases the likelihood of interactions going badly. Ten 2-year-old children are not necessarily capable of peacefully spending hours together at a time. When a serious behavioral problem arises in this kind of setting, I frequently recommend family-based day care instead of center-based day care because children will be with others of different ages and different skill levels, and hopefully some of them will be more mature.
Support parents in deciding to pull the child out of a school if the situation is bad. If, for example, the school administration is unresponsive to or dismissive of a parent, removal of the child may be the best option. A new parent recently came to the parent group at our clinic. She reported that a teacher responded to her child's behavior problem by putting him in a closet, which would have been egregious enough, but the teacher also said that there were spiders and bugs in the closet that were going to get him before closing the door. I was flabbergasted. The school tried to defend the teacher for doing this, and my final advice was to “pull the kid.” Any school that ignorant of normal child development cannot be fixed.
Kids and Divorce: A Long-Term Commitment
Divorce is so common in the United States – ending about half of all marriages – that it will affect many patients and families in your practice. If your practice has about 2,000 children and adolescents from about 1,500 families, for example, hundreds of families will be dealing with predivorce marital tension, the divorce itself, or postdivorce concerns.
Start by screening for family functioning at every annual visit. Specifically, try to identify strife and stress early on, at a time when your inventions have the greatest preventive impact. Ask open-ended questions such as, “How are things going in the family?” or “Is there any tension or discord in the family or in the marriage?”
I recommend using the broader term “discord” because it will pick up a pending divorce and also identify other family stressors for the child. For example, research indicates that the years of arguing and fighting that often precede divorce may be more damaging to the child in the long term than the divorce itself.
Once you identify marital or family stress, strive for the following three long-term goals to optimize a healthy outcome for the child.
▸ First, make sure the child continues to function well in school, with peers, in activities, and in areas of self-esteem. The firr certain key signs that a child is not functioning well. Persistently lower school performance is one sign. Most children are't concentrate or perform as well at school in the year of the divorce, but it is a warning sign if the problems persist. Determine whether the child is still having difficulty adjusting to the divorce, and assess if there is ongoing discord or fighting about visitation, custody, child rearing, or finances after the divorce. Another warning sign is the child who drops an after-school activity during a divorce crisis, and fails to retume itin the next school year.
How a child relates to friends after the divorce can be important. In particular, ascertain how young or midadolescents treat members of the opposite sex. Look for patterns in their relationships that repeat some of the dysfunctional behaviors of their parents' marriage. Keep in mind that children are often unaware that they are repeating these family patterns.
For example, are girls who are adversely affected by divorce especially vulnerable to getting involved with older teenagers who might take advantage of them? Do you see any evidence of longing in the girls, or signs that they are seeking to replace something missing in their paternal relationship? This type of behavior is much less likely if the girl has had a good relationship with her father before, during, and after the divorce.
With teenage boys, consider how they treat their girlfriends. Is the boy supportive in his relationships, or does he have girlfriend after girlfriend because of a callous or insensitive attitude?
Referral for a mental health evaluation might be appropriate if you see a pattern of continuing dysfunction in a major area of the child's life or of unsatisfactory relationships as these younger teenagers enter high school, particularly if they are alienated from a parent.
▸ Second, ensure that parents are open and willing to answer the child's questions as the child tries to make sense of the divorce at each developmental stage. Help postdivorce families encourage the child to ask questions on an ongoing basis. If divorce happened when the child was a toddler, for example, they are going to have questions 5, 10, and 15 years later that they could not conceptualize until they reached the appropriate developmental point.
Parents may need your advice on how best to talk to their 5- or 8-year-old, a time when information should be concrete and straightforward. In contrast, a 14-year-old may be able to understand more conceptual and nuanced answers to their questions. For example, a younger child is unlikely to think about the divorce in terms of an extramarital affair or the impact on their college finances, but that may not be the case when the child is 14 or 15 years old. Keep in mind that many adolescents do not ask parents such difficult questions unless they are given permission in advance, and it's at a time when they feel safe and at ease.
▸ Third, counsel the family to facilitate a good relationship between the child and each parent over the long term. When families come to me and there is a lot of tension about visitation, custody, and money, I often focus them on the long-term goals. I ask, “What kind of relationship do you want with your child 10 and 15 years from now?”; “What is likely to result in a good long-term relationship with them?”; “Do you want to be able to be at their wedding?”; “Do you want to be close to your grandchildren?” Going all out for an extra few hours of visitation or not paying a bill is not likely to help achieve these long-term goals.
Again, early screening and intervention make your job easier. If a patient or family comes to you after years of negativity and a court fight over a bitter divorce, your ability to intervene effectively is already very limited.
Divorce is often an angry and divisive time. You can advise parents not to act out of anger by offering examples of divorcing parents who invested a lot of time and energy into winning short-term victories, only to see their efforts backfire later. Some parents believe that the child will be closer to them if they can make the child angry at the spouse. But children who feel they have to betray one parent to please the other often become resentful of this role over time.
In contrast, children who observe their parents working together with a sense of harmony and cooperation to make the custody, visitation, financial, and other arrangements successful are much less likely to blame themselves for the divorce. They also are much less likely to feel guilty when they connect more to one parent or the other at different points in their development.
It is important to monitor your patients for long-term effects of divorce up to and including the time you transition them to an adult care provider. Ask the older adolescent questions such as, “How do you feel about the divorce now, looking back on it [5, 10, or 15] years later?”; “How do you think it's affected you?”; and “Are there any things you'd like to change?”
If you do a review of how they integrated the divorce when they are in 10th or 11th grade, you will still have time to address any unresolved issues. If the child is distant with one parent, you can at least wonder if this is a point in time to reconnect and repair that relationship before the teenager goes to work or college and moves to being fully independent.
Pediatricians often have limited time to intervene. Some find this work very gratifying and feel comfortable with divorce-related issues. Others may choose to refer the patient to a social worker, psychologist, or child and adolescent psychiatrist, according to the severity of the situation. Some pediatric practices are fortunate to have a full- or part-time social worker.
If you want to counsel but your time is limited, consider offering a divorced-parent discussion and education group in your practice. You and/or a social worker could facilitate this forum. This resource can help parents share their experiences and strategies to ensure that children emerge as happy and healthy as possible after a divorce. In addition, this intervention can be cost-neutral if you charge parents a nominal fee.
Divorce is so common in the United States – ending about half of all marriages – that it will affect many patients and families in your practice. If your practice has about 2,000 children and adolescents from about 1,500 families, for example, hundreds of families will be dealing with predivorce marital tension, the divorce itself, or postdivorce concerns.
Start by screening for family functioning at every annual visit. Specifically, try to identify strife and stress early on, at a time when your inventions have the greatest preventive impact. Ask open-ended questions such as, “How are things going in the family?” or “Is there any tension or discord in the family or in the marriage?”
I recommend using the broader term “discord” because it will pick up a pending divorce and also identify other family stressors for the child. For example, research indicates that the years of arguing and fighting that often precede divorce may be more damaging to the child in the long term than the divorce itself.
Once you identify marital or family stress, strive for the following three long-term goals to optimize a healthy outcome for the child.
▸ First, make sure the child continues to function well in school, with peers, in activities, and in areas of self-esteem. The firr certain key signs that a child is not functioning well. Persistently lower school performance is one sign. Most children are't concentrate or perform as well at school in the year of the divorce, but it is a warning sign if the problems persist. Determine whether the child is still having difficulty adjusting to the divorce, and assess if there is ongoing discord or fighting about visitation, custody, child rearing, or finances after the divorce. Another warning sign is the child who drops an after-school activity during a divorce crisis, and fails to retume itin the next school year.
How a child relates to friends after the divorce can be important. In particular, ascertain how young or midadolescents treat members of the opposite sex. Look for patterns in their relationships that repeat some of the dysfunctional behaviors of their parents' marriage. Keep in mind that children are often unaware that they are repeating these family patterns.
For example, are girls who are adversely affected by divorce especially vulnerable to getting involved with older teenagers who might take advantage of them? Do you see any evidence of longing in the girls, or signs that they are seeking to replace something missing in their paternal relationship? This type of behavior is much less likely if the girl has had a good relationship with her father before, during, and after the divorce.
With teenage boys, consider how they treat their girlfriends. Is the boy supportive in his relationships, or does he have girlfriend after girlfriend because of a callous or insensitive attitude?
Referral for a mental health evaluation might be appropriate if you see a pattern of continuing dysfunction in a major area of the child's life or of unsatisfactory relationships as these younger teenagers enter high school, particularly if they are alienated from a parent.
▸ Second, ensure that parents are open and willing to answer the child's questions as the child tries to make sense of the divorce at each developmental stage. Help postdivorce families encourage the child to ask questions on an ongoing basis. If divorce happened when the child was a toddler, for example, they are going to have questions 5, 10, and 15 years later that they could not conceptualize until they reached the appropriate developmental point.
Parents may need your advice on how best to talk to their 5- or 8-year-old, a time when information should be concrete and straightforward. In contrast, a 14-year-old may be able to understand more conceptual and nuanced answers to their questions. For example, a younger child is unlikely to think about the divorce in terms of an extramarital affair or the impact on their college finances, but that may not be the case when the child is 14 or 15 years old. Keep in mind that many adolescents do not ask parents such difficult questions unless they are given permission in advance, and it's at a time when they feel safe and at ease.
▸ Third, counsel the family to facilitate a good relationship between the child and each parent over the long term. When families come to me and there is a lot of tension about visitation, custody, and money, I often focus them on the long-term goals. I ask, “What kind of relationship do you want with your child 10 and 15 years from now?”; “What is likely to result in a good long-term relationship with them?”; “Do you want to be able to be at their wedding?”; “Do you want to be close to your grandchildren?” Going all out for an extra few hours of visitation or not paying a bill is not likely to help achieve these long-term goals.
Again, early screening and intervention make your job easier. If a patient or family comes to you after years of negativity and a court fight over a bitter divorce, your ability to intervene effectively is already very limited.
Divorce is often an angry and divisive time. You can advise parents not to act out of anger by offering examples of divorcing parents who invested a lot of time and energy into winning short-term victories, only to see their efforts backfire later. Some parents believe that the child will be closer to them if they can make the child angry at the spouse. But children who feel they have to betray one parent to please the other often become resentful of this role over time.
In contrast, children who observe their parents working together with a sense of harmony and cooperation to make the custody, visitation, financial, and other arrangements successful are much less likely to blame themselves for the divorce. They also are much less likely to feel guilty when they connect more to one parent or the other at different points in their development.
It is important to monitor your patients for long-term effects of divorce up to and including the time you transition them to an adult care provider. Ask the older adolescent questions such as, “How do you feel about the divorce now, looking back on it [5, 10, or 15] years later?”; “How do you think it's affected you?”; and “Are there any things you'd like to change?”
If you do a review of how they integrated the divorce when they are in 10th or 11th grade, you will still have time to address any unresolved issues. If the child is distant with one parent, you can at least wonder if this is a point in time to reconnect and repair that relationship before the teenager goes to work or college and moves to being fully independent.
Pediatricians often have limited time to intervene. Some find this work very gratifying and feel comfortable with divorce-related issues. Others may choose to refer the patient to a social worker, psychologist, or child and adolescent psychiatrist, according to the severity of the situation. Some pediatric practices are fortunate to have a full- or part-time social worker.
If you want to counsel but your time is limited, consider offering a divorced-parent discussion and education group in your practice. You and/or a social worker could facilitate this forum. This resource can help parents share their experiences and strategies to ensure that children emerge as happy and healthy as possible after a divorce. In addition, this intervention can be cost-neutral if you charge parents a nominal fee.
Divorce is so common in the United States – ending about half of all marriages – that it will affect many patients and families in your practice. If your practice has about 2,000 children and adolescents from about 1,500 families, for example, hundreds of families will be dealing with predivorce marital tension, the divorce itself, or postdivorce concerns.
Start by screening for family functioning at every annual visit. Specifically, try to identify strife and stress early on, at a time when your inventions have the greatest preventive impact. Ask open-ended questions such as, “How are things going in the family?” or “Is there any tension or discord in the family or in the marriage?”
I recommend using the broader term “discord” because it will pick up a pending divorce and also identify other family stressors for the child. For example, research indicates that the years of arguing and fighting that often precede divorce may be more damaging to the child in the long term than the divorce itself.
Once you identify marital or family stress, strive for the following three long-term goals to optimize a healthy outcome for the child.
▸ First, make sure the child continues to function well in school, with peers, in activities, and in areas of self-esteem. The firr certain key signs that a child is not functioning well. Persistently lower school performance is one sign. Most children are't concentrate or perform as well at school in the year of the divorce, but it is a warning sign if the problems persist. Determine whether the child is still having difficulty adjusting to the divorce, and assess if there is ongoing discord or fighting about visitation, custody, child rearing, or finances after the divorce. Another warning sign is the child who drops an after-school activity during a divorce crisis, and fails to retume itin the next school year.
How a child relates to friends after the divorce can be important. In particular, ascertain how young or midadolescents treat members of the opposite sex. Look for patterns in their relationships that repeat some of the dysfunctional behaviors of their parents' marriage. Keep in mind that children are often unaware that they are repeating these family patterns.
For example, are girls who are adversely affected by divorce especially vulnerable to getting involved with older teenagers who might take advantage of them? Do you see any evidence of longing in the girls, or signs that they are seeking to replace something missing in their paternal relationship? This type of behavior is much less likely if the girl has had a good relationship with her father before, during, and after the divorce.
With teenage boys, consider how they treat their girlfriends. Is the boy supportive in his relationships, or does he have girlfriend after girlfriend because of a callous or insensitive attitude?
Referral for a mental health evaluation might be appropriate if you see a pattern of continuing dysfunction in a major area of the child's life or of unsatisfactory relationships as these younger teenagers enter high school, particularly if they are alienated from a parent.
▸ Second, ensure that parents are open and willing to answer the child's questions as the child tries to make sense of the divorce at each developmental stage. Help postdivorce families encourage the child to ask questions on an ongoing basis. If divorce happened when the child was a toddler, for example, they are going to have questions 5, 10, and 15 years later that they could not conceptualize until they reached the appropriate developmental point.
Parents may need your advice on how best to talk to their 5- or 8-year-old, a time when information should be concrete and straightforward. In contrast, a 14-year-old may be able to understand more conceptual and nuanced answers to their questions. For example, a younger child is unlikely to think about the divorce in terms of an extramarital affair or the impact on their college finances, but that may not be the case when the child is 14 or 15 years old. Keep in mind that many adolescents do not ask parents such difficult questions unless they are given permission in advance, and it's at a time when they feel safe and at ease.
▸ Third, counsel the family to facilitate a good relationship between the child and each parent over the long term. When families come to me and there is a lot of tension about visitation, custody, and money, I often focus them on the long-term goals. I ask, “What kind of relationship do you want with your child 10 and 15 years from now?”; “What is likely to result in a good long-term relationship with them?”; “Do you want to be able to be at their wedding?”; “Do you want to be close to your grandchildren?” Going all out for an extra few hours of visitation or not paying a bill is not likely to help achieve these long-term goals.
Again, early screening and intervention make your job easier. If a patient or family comes to you after years of negativity and a court fight over a bitter divorce, your ability to intervene effectively is already very limited.
Divorce is often an angry and divisive time. You can advise parents not to act out of anger by offering examples of divorcing parents who invested a lot of time and energy into winning short-term victories, only to see their efforts backfire later. Some parents believe that the child will be closer to them if they can make the child angry at the spouse. But children who feel they have to betray one parent to please the other often become resentful of this role over time.
In contrast, children who observe their parents working together with a sense of harmony and cooperation to make the custody, visitation, financial, and other arrangements successful are much less likely to blame themselves for the divorce. They also are much less likely to feel guilty when they connect more to one parent or the other at different points in their development.
It is important to monitor your patients for long-term effects of divorce up to and including the time you transition them to an adult care provider. Ask the older adolescent questions such as, “How do you feel about the divorce now, looking back on it [5, 10, or 15] years later?”; “How do you think it's affected you?”; and “Are there any things you'd like to change?”
If you do a review of how they integrated the divorce when they are in 10th or 11th grade, you will still have time to address any unresolved issues. If the child is distant with one parent, you can at least wonder if this is a point in time to reconnect and repair that relationship before the teenager goes to work or college and moves to being fully independent.
Pediatricians often have limited time to intervene. Some find this work very gratifying and feel comfortable with divorce-related issues. Others may choose to refer the patient to a social worker, psychologist, or child and adolescent psychiatrist, according to the severity of the situation. Some pediatric practices are fortunate to have a full- or part-time social worker.
If you want to counsel but your time is limited, consider offering a divorced-parent discussion and education group in your practice. You and/or a social worker could facilitate this forum. This resource can help parents share their experiences and strategies to ensure that children emerge as happy and healthy as possible after a divorce. In addition, this intervention can be cost-neutral if you charge parents a nominal fee.
Help Parents Change Style for Raising Teens
www.CHADIS.compdnews@elsevier.com
Adolescents are often the most intimidating of our patients. Let's face it: Most of us chose pediatrics because we like little kids. If a 15-minute office visit with a sullen teenager can be so difficult, imagine living with one 24/7. Actually, many of us won't have to imagine—we ourselves are the parents of adolescents, and we know just how challenging that can be.
Despite our own feelings of inadequacy, we can help parents make the transition from raising the innocent younger child to guiding the testy teen into adulthood. A failure to make that transition in parenting style can contribute greatly to a suboptimal outcome.
But your guidance needs to start early. When a parent comes into the office demanding that you administer a drug test or a pregnancy test, you have probably missed the window for effective action. The horse is well out of the barn.
The time to start is earlier—much earlier. All of parenting involves the balancing act between supporting dependency and promoting independence. When people first become parents, they are consumed with accepting the huge dependency of their baby. As the child gets older, parents must allow the child more independence for things to go smoothly.
But adolescence is a time when that balancing act requires truly skilled acrobatics. Teens and their parents need to negotiate the “Four I's” of adolescent development: Initiative, Individuation, Independence, and Intimacy.
Adolescents clearly need to take the initiative in their activities, including when they do their chores and how they manage homework. If parents get in the way and try to structure all of that, they're going to get a lot of pushback.
In terms of individuation—discovering who they are—teenagers are highly sensitive to the standards of peers. They're more interested in what their peers think they should do than what their parents think they should do. On one level, this includes how many ear piercings they have and how they dress. But on a broader level, they need to think their parents are wrong about most things in order to feel “like their own person.” Offering an opinion can be beneficial in giving the adolescent something to counter, but ideally save consequences for more substantial failings. In terms of independence, teenagers are better educated by learning from the consequences of their own actions when those actions are not harmful to their futures.
And in terms of intimacy, teens want and need privacy for their budding relationships. Parents need to learn how to be available to talk about relationships, but not ask too many questions.
Different teens move through these changes at different times. And on top of that, the transition may not always go in one direction. A teen may want to be very independent in choosing her clothes. But the same teen may want a lot of parental help on getting her homework done and on handling peer situations. That's part of what makes parenting adolescents so difficult.
Parents need to gradually release control and let their teens exert more independence. But the key word in that sentence is “gradually,” and parents need to be alert for signs that the child is not ready or has not yet earned that freedom.
Let's say the parents have allowed their 13-year-old to have a cell phone. Let's say that a few weeks later, the child hurls the phone against the wall in anger, shattering it beyond repair. Some parents might be tempted to say: “That's it. I'm not buying you another cell phone until you're in college,” but that is unlikely to be the most educational solution. The time frame should be measured in days or weeks, not in months or years. If consequences are too severe, kids tend to write their parents off completely and feel they have been written off.
Instead, the parents should give the teen a clear path to re-earning the privilege, negotiating the terms. Maybe he has to contribute 80% of his allowance and do some extra chores until the phone is paid for. Showing that they're reasonable and willing to negotiate is a model of adult behavior, and it's also their key to success.
The older the child, the more important it is to negotiate what the rules are to be, and also what exceptions there might be. It's fine if there's a general rule that they can't stay out after 11 o'clock. But if a special event comes along that starts at 10 o'clock and won't end until 2 a.m., it's best to be flexible about the curfew this one time. When teens and parents negotiate one-time exceptions as needed, there is structure but rebellion or sneaking is not brought out.
Negotiation is important. A 30-year longitudinal study from the University of California, Berkeley, demonstrated that parents who managed to negotiate the rules with their children had more harmonious relationships with them later (New Dir. Child Adolesc. Dev. 2005;108:61–9). Often a dynamic arises in families where the parents are so generally annoyed with their teen that they reflexively answer, “No!” to any request. That can be really counterproductive when it comes to parenting adolescents. The first response should be: “Yes, if at all possible. Let's talk about it.”
I recommend that parents explicitly discuss the request using the following six points in deciding with the adolescent on their request. Posting these on the refrigerator and making discussing them a routine lets the teen know they are being taken seriously, slows the reflex to say “no,” and may help install them as a mantra in the teen's brain for future decision making:
Six Guides for Decision Making
1. Is it safe?
2. Is it legal?
3. Does it conflict with responsibilities?
4. Does it meet a developmental need?
5. Does it interfere with others?
6. Could it harm his/her development?
Anyone who's read “The Catcher in the Rye” (New York: Little, Brown and Co., 1951) by J.D. Salinger knows that teenagers are especially sensitive to hypocrisy. Parents often talk about the importance of being a moral person, but the teen is aware that they're cheating on their income taxes. They will reject their parents' moral code if they see them being hypocritical.
Clearly, the best way for the parent to encourage their offspring to uphold good moral standards is to actually live those standards 24/7. But almost everyone fails to live up to those standards from time to time, and if they're parents of an adolescent, the teen is sure to be right there when they do. Adolescents appreciate and learn from honesty when that happens. The parent could admit, “Yes, I know I said that you should never curse another driver, but I was so angry that I forgot my own rule.”
In these days of one- and two-child families, where parents often depend on their own children for friendship and companionship, it can be especially devastating to hear a teen say: “I hate you. You're the worst parents ever.” When that happens—and it's almost certain to happen, since it's the rare child who never utters such a sentiment—the parent's best response is not to rise to the bait of an angry teenager. They don't really mean it. And if the parent shows too much visible distress, or starts to punish them for saying those things, there won't be as much opportunity to recover. A simple “I am sorry you feel that way right now. I can see that you are really angry about [my decision, your curfew, what I said].”
And when the teen notices that the parent has not reacted to such provocation, that in itself is a valuable life lesson. The next time a street tough tosses off an insult, he'll be more likely to simply shrug his shoulders and walk away. For additional information on dealing with adolescents, the American Academy of Pediatrics maintains a particularly good collection of resources for parents at www.healthychildren.org
www.CHADIS.compdnews@elsevier.com
Adolescents are often the most intimidating of our patients. Let's face it: Most of us chose pediatrics because we like little kids. If a 15-minute office visit with a sullen teenager can be so difficult, imagine living with one 24/7. Actually, many of us won't have to imagine—we ourselves are the parents of adolescents, and we know just how challenging that can be.
Despite our own feelings of inadequacy, we can help parents make the transition from raising the innocent younger child to guiding the testy teen into adulthood. A failure to make that transition in parenting style can contribute greatly to a suboptimal outcome.
But your guidance needs to start early. When a parent comes into the office demanding that you administer a drug test or a pregnancy test, you have probably missed the window for effective action. The horse is well out of the barn.
The time to start is earlier—much earlier. All of parenting involves the balancing act between supporting dependency and promoting independence. When people first become parents, they are consumed with accepting the huge dependency of their baby. As the child gets older, parents must allow the child more independence for things to go smoothly.
But adolescence is a time when that balancing act requires truly skilled acrobatics. Teens and their parents need to negotiate the “Four I's” of adolescent development: Initiative, Individuation, Independence, and Intimacy.
Adolescents clearly need to take the initiative in their activities, including when they do their chores and how they manage homework. If parents get in the way and try to structure all of that, they're going to get a lot of pushback.
In terms of individuation—discovering who they are—teenagers are highly sensitive to the standards of peers. They're more interested in what their peers think they should do than what their parents think they should do. On one level, this includes how many ear piercings they have and how they dress. But on a broader level, they need to think their parents are wrong about most things in order to feel “like their own person.” Offering an opinion can be beneficial in giving the adolescent something to counter, but ideally save consequences for more substantial failings. In terms of independence, teenagers are better educated by learning from the consequences of their own actions when those actions are not harmful to their futures.
And in terms of intimacy, teens want and need privacy for their budding relationships. Parents need to learn how to be available to talk about relationships, but not ask too many questions.
Different teens move through these changes at different times. And on top of that, the transition may not always go in one direction. A teen may want to be very independent in choosing her clothes. But the same teen may want a lot of parental help on getting her homework done and on handling peer situations. That's part of what makes parenting adolescents so difficult.
Parents need to gradually release control and let their teens exert more independence. But the key word in that sentence is “gradually,” and parents need to be alert for signs that the child is not ready or has not yet earned that freedom.
Let's say the parents have allowed their 13-year-old to have a cell phone. Let's say that a few weeks later, the child hurls the phone against the wall in anger, shattering it beyond repair. Some parents might be tempted to say: “That's it. I'm not buying you another cell phone until you're in college,” but that is unlikely to be the most educational solution. The time frame should be measured in days or weeks, not in months or years. If consequences are too severe, kids tend to write their parents off completely and feel they have been written off.
Instead, the parents should give the teen a clear path to re-earning the privilege, negotiating the terms. Maybe he has to contribute 80% of his allowance and do some extra chores until the phone is paid for. Showing that they're reasonable and willing to negotiate is a model of adult behavior, and it's also their key to success.
The older the child, the more important it is to negotiate what the rules are to be, and also what exceptions there might be. It's fine if there's a general rule that they can't stay out after 11 o'clock. But if a special event comes along that starts at 10 o'clock and won't end until 2 a.m., it's best to be flexible about the curfew this one time. When teens and parents negotiate one-time exceptions as needed, there is structure but rebellion or sneaking is not brought out.
Negotiation is important. A 30-year longitudinal study from the University of California, Berkeley, demonstrated that parents who managed to negotiate the rules with their children had more harmonious relationships with them later (New Dir. Child Adolesc. Dev. 2005;108:61–9). Often a dynamic arises in families where the parents are so generally annoyed with their teen that they reflexively answer, “No!” to any request. That can be really counterproductive when it comes to parenting adolescents. The first response should be: “Yes, if at all possible. Let's talk about it.”
I recommend that parents explicitly discuss the request using the following six points in deciding with the adolescent on their request. Posting these on the refrigerator and making discussing them a routine lets the teen know they are being taken seriously, slows the reflex to say “no,” and may help install them as a mantra in the teen's brain for future decision making:
Six Guides for Decision Making
1. Is it safe?
2. Is it legal?
3. Does it conflict with responsibilities?
4. Does it meet a developmental need?
5. Does it interfere with others?
6. Could it harm his/her development?
Anyone who's read “The Catcher in the Rye” (New York: Little, Brown and Co., 1951) by J.D. Salinger knows that teenagers are especially sensitive to hypocrisy. Parents often talk about the importance of being a moral person, but the teen is aware that they're cheating on their income taxes. They will reject their parents' moral code if they see them being hypocritical.
Clearly, the best way for the parent to encourage their offspring to uphold good moral standards is to actually live those standards 24/7. But almost everyone fails to live up to those standards from time to time, and if they're parents of an adolescent, the teen is sure to be right there when they do. Adolescents appreciate and learn from honesty when that happens. The parent could admit, “Yes, I know I said that you should never curse another driver, but I was so angry that I forgot my own rule.”
In these days of one- and two-child families, where parents often depend on their own children for friendship and companionship, it can be especially devastating to hear a teen say: “I hate you. You're the worst parents ever.” When that happens—and it's almost certain to happen, since it's the rare child who never utters such a sentiment—the parent's best response is not to rise to the bait of an angry teenager. They don't really mean it. And if the parent shows too much visible distress, or starts to punish them for saying those things, there won't be as much opportunity to recover. A simple “I am sorry you feel that way right now. I can see that you are really angry about [my decision, your curfew, what I said].”
And when the teen notices that the parent has not reacted to such provocation, that in itself is a valuable life lesson. The next time a street tough tosses off an insult, he'll be more likely to simply shrug his shoulders and walk away. For additional information on dealing with adolescents, the American Academy of Pediatrics maintains a particularly good collection of resources for parents at www.healthychildren.org
www.CHADIS.compdnews@elsevier.com
Adolescents are often the most intimidating of our patients. Let's face it: Most of us chose pediatrics because we like little kids. If a 15-minute office visit with a sullen teenager can be so difficult, imagine living with one 24/7. Actually, many of us won't have to imagine—we ourselves are the parents of adolescents, and we know just how challenging that can be.
Despite our own feelings of inadequacy, we can help parents make the transition from raising the innocent younger child to guiding the testy teen into adulthood. A failure to make that transition in parenting style can contribute greatly to a suboptimal outcome.
But your guidance needs to start early. When a parent comes into the office demanding that you administer a drug test or a pregnancy test, you have probably missed the window for effective action. The horse is well out of the barn.
The time to start is earlier—much earlier. All of parenting involves the balancing act between supporting dependency and promoting independence. When people first become parents, they are consumed with accepting the huge dependency of their baby. As the child gets older, parents must allow the child more independence for things to go smoothly.
But adolescence is a time when that balancing act requires truly skilled acrobatics. Teens and their parents need to negotiate the “Four I's” of adolescent development: Initiative, Individuation, Independence, and Intimacy.
Adolescents clearly need to take the initiative in their activities, including when they do their chores and how they manage homework. If parents get in the way and try to structure all of that, they're going to get a lot of pushback.
In terms of individuation—discovering who they are—teenagers are highly sensitive to the standards of peers. They're more interested in what their peers think they should do than what their parents think they should do. On one level, this includes how many ear piercings they have and how they dress. But on a broader level, they need to think their parents are wrong about most things in order to feel “like their own person.” Offering an opinion can be beneficial in giving the adolescent something to counter, but ideally save consequences for more substantial failings. In terms of independence, teenagers are better educated by learning from the consequences of their own actions when those actions are not harmful to their futures.
And in terms of intimacy, teens want and need privacy for their budding relationships. Parents need to learn how to be available to talk about relationships, but not ask too many questions.
Different teens move through these changes at different times. And on top of that, the transition may not always go in one direction. A teen may want to be very independent in choosing her clothes. But the same teen may want a lot of parental help on getting her homework done and on handling peer situations. That's part of what makes parenting adolescents so difficult.
Parents need to gradually release control and let their teens exert more independence. But the key word in that sentence is “gradually,” and parents need to be alert for signs that the child is not ready or has not yet earned that freedom.
Let's say the parents have allowed their 13-year-old to have a cell phone. Let's say that a few weeks later, the child hurls the phone against the wall in anger, shattering it beyond repair. Some parents might be tempted to say: “That's it. I'm not buying you another cell phone until you're in college,” but that is unlikely to be the most educational solution. The time frame should be measured in days or weeks, not in months or years. If consequences are too severe, kids tend to write their parents off completely and feel they have been written off.
Instead, the parents should give the teen a clear path to re-earning the privilege, negotiating the terms. Maybe he has to contribute 80% of his allowance and do some extra chores until the phone is paid for. Showing that they're reasonable and willing to negotiate is a model of adult behavior, and it's also their key to success.
The older the child, the more important it is to negotiate what the rules are to be, and also what exceptions there might be. It's fine if there's a general rule that they can't stay out after 11 o'clock. But if a special event comes along that starts at 10 o'clock and won't end until 2 a.m., it's best to be flexible about the curfew this one time. When teens and parents negotiate one-time exceptions as needed, there is structure but rebellion or sneaking is not brought out.
Negotiation is important. A 30-year longitudinal study from the University of California, Berkeley, demonstrated that parents who managed to negotiate the rules with their children had more harmonious relationships with them later (New Dir. Child Adolesc. Dev. 2005;108:61–9). Often a dynamic arises in families where the parents are so generally annoyed with their teen that they reflexively answer, “No!” to any request. That can be really counterproductive when it comes to parenting adolescents. The first response should be: “Yes, if at all possible. Let's talk about it.”
I recommend that parents explicitly discuss the request using the following six points in deciding with the adolescent on their request. Posting these on the refrigerator and making discussing them a routine lets the teen know they are being taken seriously, slows the reflex to say “no,” and may help install them as a mantra in the teen's brain for future decision making:
Six Guides for Decision Making
1. Is it safe?
2. Is it legal?
3. Does it conflict with responsibilities?
4. Does it meet a developmental need?
5. Does it interfere with others?
6. Could it harm his/her development?
Anyone who's read “The Catcher in the Rye” (New York: Little, Brown and Co., 1951) by J.D. Salinger knows that teenagers are especially sensitive to hypocrisy. Parents often talk about the importance of being a moral person, but the teen is aware that they're cheating on their income taxes. They will reject their parents' moral code if they see them being hypocritical.
Clearly, the best way for the parent to encourage their offspring to uphold good moral standards is to actually live those standards 24/7. But almost everyone fails to live up to those standards from time to time, and if they're parents of an adolescent, the teen is sure to be right there when they do. Adolescents appreciate and learn from honesty when that happens. The parent could admit, “Yes, I know I said that you should never curse another driver, but I was so angry that I forgot my own rule.”
In these days of one- and two-child families, where parents often depend on their own children for friendship and companionship, it can be especially devastating to hear a teen say: “I hate you. You're the worst parents ever.” When that happens—and it's almost certain to happen, since it's the rare child who never utters such a sentiment—the parent's best response is not to rise to the bait of an angry teenager. They don't really mean it. And if the parent shows too much visible distress, or starts to punish them for saying those things, there won't be as much opportunity to recover. A simple “I am sorry you feel that way right now. I can see that you are really angry about [my decision, your curfew, what I said].”
And when the teen notices that the parent has not reacted to such provocation, that in itself is a valuable life lesson. The next time a street tough tosses off an insult, he'll be more likely to simply shrug his shoulders and walk away. For additional information on dealing with adolescents, the American Academy of Pediatrics maintains a particularly good collection of resources for parents at www.healthychildren.org