Michael S. Jellinek, MD

With the changing leaves and cooling temperatures, early autumn also brings the excitement of the new school year. While returning to sports, mastering new subjects, and spending time with old and new friends is exhilarating, this season can also be a time of intense stress.

For those high school students who are especially ambitious, the school year presents the challenge of a very high stakes performance, one whose success will be measured by admission to a prized college. Not only are there classes to study for, but schedules are packed with a maximum number of subjects, a maximum number of Advanced Placement courses and a maximum number of impressive extra-curricular activities. Varsity sports practice, SAT prep, Debate Club, volunteer hours, and on and on.

What is often missing is enough time for sleep, socializing, exploring new interests, and unwinding. When you hear your patients (or parents) describing the intense stress of their overloaded schedules compounded by a sense that “I have no choice,” you have an opportunity to complicate their thinking. Introduce the idea that there are smart approaches to performing your best under stress. Like professional athletes, those experiencing stress can think about their time as being their most precious resource and be intentional about how they can best balance preparation, performance, resting, and recharging. Pushing themselves relentlessly will inevitably lead to burnout and exhaustion. This approach will help them learn to make wise choices and will better serve their healthy development.

Start by acknowledging the stress of high-stakes performance. Telling your patients that they need to lower the temperature by not putting so much pressure on themselves is likely to be experienced as a lack of confidence in them and is unlikely to get any traction. Instead, ask your patients what matters to them the most: Is it admission to the college of their choice? Achieving a certain score or GPA? Is it their competitiveness and drive to win? There is no wrong answer, but it is helpful for them to be able to reflect on what matters to them. Are they hoping to impress someone else? Are they worried about their future financial health and convinced that getting into a certain college will secure their financial success? Do they think this matters more to their parents than to themselves? Or have they discovered an intense interest in theoretical physics and want to be able to study at Caltech? If their ambition is meaningfully connected to an authentic interest or to their emerging identity, their sense of purpose will be much deeper and able to sustain them.

Even with talent and a strong sense of purpose, performing well is very difficult and demanding. It is important to consider the cycle of performance as including preparation, performance itself, and effective rest and recovery, just as with athletic performance. Whether the performance is the SATs, an AP test, a debate or big game, there were probably hours of preparation for every hour of performance. Help them to consider the importance of this practice or preparation time, and how to use that time effectively. Are they able to work in environments where there are few distractions? Do they have the support or useful feedback they need? How are they able to know when it is time for a break or when they are ready? It can be helpful for them to appreciate whether preparation or performance is more challenging for them, as the former requires focus and patience, while the latter requires courage and tenacity. If they are aware of which is harder for them, they can be thoughtful about how to effectively handle those challenges.

What can be most valuable for your patients is hearing from their pediatricians that they need to have time protected for rest and recharging, and not only for preparation and performance. Any athlete knows that failing to do so will lead to exhaustion and injury, and performance inevitably suffers. Rest is unwinding and slowing down, and a restful activity will leave them feeling calm, relaxed, and ready for sleep. A recharging activity is one that leaves them feeling refreshed and energized. Some common restful activities are a hot bath or shower, a distracting activity such as watching a show or surfing the web, playing a simple video game or puzzle or listening to music. Some recharging activities are creative ones (making art or music), engaging in hobbies, reading, or talking with a good friend. A few activities — sleep, exercise, and mindfulness meditation, are powerful in that they pack both rest and recharge into the same activity. Your patients should be discovering and learning which activities they find restful or recharging. The college application process or preparing for a varsity tryout will both add stress and give them an opportunity to learn what rests and recharges them. They should aim to have a list of at least five effective strategies that they can turn to when it’s time to rest or to recharge. Help them turn their work ethic to building a deeper well of self-knowledge that will serve them when they face challenges in high school or when they are on their own in college. This time of stress can be a time of growth, too.

Of course, remind your patients that this is a critical time to focus on basic self-care: They need consistently adequate, restful sleep, good nutrition, and physical activity. They will benefit from regular time in nature and time spent with friends that nourish them. They can find ways to compound these activities: Go for a walk with a friend, eat dinner with family, play a relaxing game while enjoying music. Lastly, ask your patients what is the last new thing they tried. It is easy to become so focused on an ambitious project that there is no time for exploration and play. Play is important throughout life, but adolescents are actively discovering their interests, talents, tastes, and values. To do this they need to be trying things that are new and maybe less purpose-driven. I call this type of activity “senseless fun.” Splashing in the pool is senseless fun, swimming laps is purposeful exercise that my contribute to recharging, and competing in a swim meet is often more on the stressful side. As they discover new talents, deeply engaging interests, what relaxes and recharges them, they will be learning who they are. Regardless of the outcome of a test, a big game, or where they go to college, it is this emerging knowledge about themselves that will carry them into adulthood. The pediatrician’s goal: Encouraging aspiration, exploration, and self-awareness in the context of giving permission for rest, recharging, and senseless fun.

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

With the changing leaves and cooling temperatures, early autumn also brings the excitement of the new school year. While returning to sports, mastering new subjects, and spending time with old and new friends is exhilarating, this season can also be a time of intense stress.

For those high school students who are especially ambitious, the school year presents the challenge of a very high stakes performance, one whose success will be measured by admission to a prized college. Not only are there classes to study for, but schedules are packed with a maximum number of subjects, a maximum number of Advanced Placement courses and a maximum number of impressive extra-curricular activities. Varsity sports practice, SAT prep, Debate Club, volunteer hours, and on and on.

What is often missing is enough time for sleep, socializing, exploring new interests, and unwinding. When you hear your patients (or parents) describing the intense stress of their overloaded schedules compounded by a sense that “I have no choice,” you have an opportunity to complicate their thinking. Introduce the idea that there are smart approaches to performing your best under stress. Like professional athletes, those experiencing stress can think about their time as being their most precious resource and be intentional about how they can best balance preparation, performance, resting, and recharging. Pushing themselves relentlessly will inevitably lead to burnout and exhaustion. This approach will help them learn to make wise choices and will better serve their healthy development.

Start by acknowledging the stress of high-stakes performance. Telling your patients that they need to lower the temperature by not putting so much pressure on themselves is likely to be experienced as a lack of confidence in them and is unlikely to get any traction. Instead, ask your patients what matters to them the most: Is it admission to the college of their choice? Achieving a certain score or GPA? Is it their competitiveness and drive to win? There is no wrong answer, but it is helpful for them to be able to reflect on what matters to them. Are they hoping to impress someone else? Are they worried about their future financial health and convinced that getting into a certain college will secure their financial success? Do they think this matters more to their parents than to themselves? Or have they discovered an intense interest in theoretical physics and want to be able to study at Caltech? If their ambition is meaningfully connected to an authentic interest or to their emerging identity, their sense of purpose will be much deeper and able to sustain them.

Even with talent and a strong sense of purpose, performing well is very difficult and demanding. It is important to consider the cycle of performance as including preparation, performance itself, and effective rest and recovery, just as with athletic performance. Whether the performance is the SATs, an AP test, a debate or big game, there were probably hours of preparation for every hour of performance. Help them to consider the importance of this practice or preparation time, and how to use that time effectively. Are they able to work in environments where there are few distractions? Do they have the support or useful feedback they need? How are they able to know when it is time for a break or when they are ready? It can be helpful for them to appreciate whether preparation or performance is more challenging for them, as the former requires focus and patience, while the latter requires courage and tenacity. If they are aware of which is harder for them, they can be thoughtful about how to effectively handle those challenges.

What can be most valuable for your patients is hearing from their pediatricians that they need to have time protected for rest and recharging, and not only for preparation and performance. Any athlete knows that failing to do so will lead to exhaustion and injury, and performance inevitably suffers. Rest is unwinding and slowing down, and a restful activity will leave them feeling calm, relaxed, and ready for sleep. A recharging activity is one that leaves them feeling refreshed and energized. Some common restful activities are a hot bath or shower, a distracting activity such as watching a show or surfing the web, playing a simple video game or puzzle or listening to music. Some recharging activities are creative ones (making art or music), engaging in hobbies, reading, or talking with a good friend. A few activities — sleep, exercise, and mindfulness meditation, are powerful in that they pack both rest and recharge into the same activity. Your patients should be discovering and learning which activities they find restful or recharging. The college application process or preparing for a varsity tryout will both add stress and give them an opportunity to learn what rests and recharges them. They should aim to have a list of at least five effective strategies that they can turn to when it’s time to rest or to recharge. Help them turn their work ethic to building a deeper well of self-knowledge that will serve them when they face challenges in high school or when they are on their own in college. This time of stress can be a time of growth, too.

Of course, remind your patients that this is a critical time to focus on basic self-care: They need consistently adequate, restful sleep, good nutrition, and physical activity. They will benefit from regular time in nature and time spent with friends that nourish them. They can find ways to compound these activities: Go for a walk with a friend, eat dinner with family, play a relaxing game while enjoying music. Lastly, ask your patients what is the last new thing they tried. It is easy to become so focused on an ambitious project that there is no time for exploration and play. Play is important throughout life, but adolescents are actively discovering their interests, talents, tastes, and values. To do this they need to be trying things that are new and maybe less purpose-driven. I call this type of activity “senseless fun.” Splashing in the pool is senseless fun, swimming laps is purposeful exercise that my contribute to recharging, and competing in a swim meet is often more on the stressful side. As they discover new talents, deeply engaging interests, what relaxes and recharges them, they will be learning who they are. Regardless of the outcome of a test, a big game, or where they go to college, it is this emerging knowledge about themselves that will carry them into adulthood. The pediatrician’s goal: Encouraging aspiration, exploration, and self-awareness in the context of giving permission for rest, recharging, and senseless fun.

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

With the changing leaves and cooling temperatures, early autumn also brings the excitement of the new school year. While returning to sports, mastering new subjects, and spending time with old and new friends is exhilarating, this season can also be a time of intense stress.

For those high school students who are especially ambitious, the school year presents the challenge of a very high stakes performance, one whose success will be measured by admission to a prized college. Not only are there classes to study for, but schedules are packed with a maximum number of subjects, a maximum number of Advanced Placement courses and a maximum number of impressive extra-curricular activities. Varsity sports practice, SAT prep, Debate Club, volunteer hours, and on and on.

What is often missing is enough time for sleep, socializing, exploring new interests, and unwinding. When you hear your patients (or parents) describing the intense stress of their overloaded schedules compounded by a sense that “I have no choice,” you have an opportunity to complicate their thinking. Introduce the idea that there are smart approaches to performing your best under stress. Like professional athletes, those experiencing stress can think about their time as being their most precious resource and be intentional about how they can best balance preparation, performance, resting, and recharging. Pushing themselves relentlessly will inevitably lead to burnout and exhaustion. This approach will help them learn to make wise choices and will better serve their healthy development.

Start by acknowledging the stress of high-stakes performance. Telling your patients that they need to lower the temperature by not putting so much pressure on themselves is likely to be experienced as a lack of confidence in them and is unlikely to get any traction. Instead, ask your patients what matters to them the most: Is it admission to the college of their choice? Achieving a certain score or GPA? Is it their competitiveness and drive to win? There is no wrong answer, but it is helpful for them to be able to reflect on what matters to them. Are they hoping to impress someone else? Are they worried about their future financial health and convinced that getting into a certain college will secure their financial success? Do they think this matters more to their parents than to themselves? Or have they discovered an intense interest in theoretical physics and want to be able to study at Caltech? If their ambition is meaningfully connected to an authentic interest or to their emerging identity, their sense of purpose will be much deeper and able to sustain them.

Even with talent and a strong sense of purpose, performing well is very difficult and demanding. It is important to consider the cycle of performance as including preparation, performance itself, and effective rest and recovery, just as with athletic performance. Whether the performance is the SATs, an AP test, a debate or big game, there were probably hours of preparation for every hour of performance. Help them to consider the importance of this practice or preparation time, and how to use that time effectively. Are they able to work in environments where there are few distractions? Do they have the support or useful feedback they need? How are they able to know when it is time for a break or when they are ready? It can be helpful for them to appreciate whether preparation or performance is more challenging for them, as the former requires focus and patience, while the latter requires courage and tenacity. If they are aware of which is harder for them, they can be thoughtful about how to effectively handle those challenges.

What can be most valuable for your patients is hearing from their pediatricians that they need to have time protected for rest and recharging, and not only for preparation and performance. Any athlete knows that failing to do so will lead to exhaustion and injury, and performance inevitably suffers. Rest is unwinding and slowing down, and a restful activity will leave them feeling calm, relaxed, and ready for sleep. A recharging activity is one that leaves them feeling refreshed and energized. Some common restful activities are a hot bath or shower, a distracting activity such as watching a show or surfing the web, playing a simple video game or puzzle or listening to music. Some recharging activities are creative ones (making art or music), engaging in hobbies, reading, or talking with a good friend. A few activities — sleep, exercise, and mindfulness meditation, are powerful in that they pack both rest and recharge into the same activity. Your patients should be discovering and learning which activities they find restful or recharging. The college application process or preparing for a varsity tryout will both add stress and give them an opportunity to learn what rests and recharges them. They should aim to have a list of at least five effective strategies that they can turn to when it’s time to rest or to recharge. Help them turn their work ethic to building a deeper well of self-knowledge that will serve them when they face challenges in high school or when they are on their own in college. This time of stress can be a time of growth, too.

Of course, remind your patients that this is a critical time to focus on basic self-care: They need consistently adequate, restful sleep, good nutrition, and physical activity. They will benefit from regular time in nature and time spent with friends that nourish them. They can find ways to compound these activities: Go for a walk with a friend, eat dinner with family, play a relaxing game while enjoying music. Lastly, ask your patients what is the last new thing they tried. It is easy to become so focused on an ambitious project that there is no time for exploration and play. Play is important throughout life, but adolescents are actively discovering their interests, talents, tastes, and values. To do this they need to be trying things that are new and maybe less purpose-driven. I call this type of activity “senseless fun.” Splashing in the pool is senseless fun, swimming laps is purposeful exercise that my contribute to recharging, and competing in a swim meet is often more on the stressful side. As they discover new talents, deeply engaging interests, what relaxes and recharges them, they will be learning who they are. Regardless of the outcome of a test, a big game, or where they go to college, it is this emerging knowledge about themselves that will carry them into adulthood. The pediatrician’s goal: Encouraging aspiration, exploration, and self-awareness in the context of giving permission for rest, recharging, and senseless fun.

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

The start of the school year is a time that is always full of anticipation and even anxiety. Who will my teachers be? Will I be in classes with friends? Have some of my friends changed over the summer? Will the work be too hard? For some children this anxiety will be so intense that they will resist going back to school. School avoidance is very important to identify and address quickly, as it can intensify and threaten development. Each day of school missed due to accommodating to a child’s anxiety makes a return to school more difficult and less likely. Days can easily become weeks and even months of missed school. A child who misses a substantial amount of school is inevitably going to face developmental delays: academic, social, behavioral and emotional. The pediatrician is often brought into these situations early, as when a child complains of vague physical symptoms that are keeping him or her from school or when a previously calm child becomes inconsolable about going to school in the mornings. With a thoughtful assessment of the potential causes of school avoidance, you can help almost all children return to school successfully.

School Refusal

Sustained school avoidance is now called “school refusal,” a term coined in the late 1990s to describe a school attendance problem driven by emotional distress, as opposed to truancy. It affects up to 15% of children (depending on the operational definition) and seems to peak in the earliest years of elementary school and again in early high school. These are not occasional absences, but missing over 80% of classroom time in a 2-week period. It is also marked by the presence of an anxiety disorder and the absence of conduct disorder. Often in such cases the parents are aware of their child’s whereabouts and motivated to return them to school. Youth with school refusal experience social and academic consequences in the short term and, over the long term, have shown problems with social, family, and professional performance, along with higher rates of major depressive disorder than is seen in the general population. Early identification of these children can make addressing the underlying distress and return to school much easier than attempts to treat after weeks or months out of school.

Identifying the Problem

With younger children, school avoidance is most commonly associated with an anxious temperament or an underlying anxiety disorder, such as separation anxiety disorder or social phobia. A family history of anxiety may contribute or impact a parent’s approach to the issue. Children often present with vague somatic concerns that are genuine symptoms of anxiety (upset stomach, headache). A screening instrument such as the Screen for Child Anxiety Related Disorders (SCARED) can be helpful, but so is inquiring about sleep and other anxiety symptoms. Do the symptoms remit on weekends or in after-school hours? Are there other environmental factors that may be stressing younger children: Are they being teased or bullied at school? Are they struggling to find friends in a new classroom? Might they be having trouble with reading or other new tasks? Perhaps they are afraid of walking to school alone. Has there been a recent change or stress at home, such as a move or parental illness? Younger children may feel more anxious about separating from parents in the face of stress. But when parents accommodate a child’s wish to avoid school, the child’s anxiety, briefly relieved, grows more persistent, gets rewarded by parental attention, and reinforces their reluctance to try new things.

Adolescents may be facing more complex challenges that lead to school avoidance. They may have an undiagnosed anxiety or mood disorder, perhaps complicated by substance abuse that is presenting as an inability to perform at school or to manage the challenge of keeping up with higher workloads. They may be facing complex situations with friends, bullying, or rejection. Those adolescents who are prone to procrastination may avoid school to manage their workload and their distress, which can then become tangled up with symptoms of anxiety and dysphoria. Missing school compounds this problem rather than solving it. Adolescents outside of the structure of school, hungry for socializing and new experiences, often turn to social media for entertainment. Days without exercise and nights without adequate sleep can make mood, attention, and anxiety symptoms worse while overdue work grows. Parents often fear that setting limits or “pushing” their stuck and miserable child may make them more depressed or even suicidal.
 

Accommodating the Problem Will Likely Make It Worse

It is worth noting that children with a genuine medical illness can also experience school avoidance. Temperamentally anxious children who stay home for several days with a febrile illness may find it overwhelming to return to school as they have become so comfortable at home. Adolescents may have fallen behind with work and find themselves unable to set a schedule and return to more structure. Youth who are managing a known mood or anxiety disorder often have low motivation or high anxiety and want to wait to feel entirely better before returning to school. Youth with a chronic condition such as severe allergies or a sustained viral infection may be anxious about managing symptoms at school. Their parents may have kept them home to be safe or until they feel better, unwittingly making the school avoidance worse.

Formulating a Management Plan

When you suspect school avoidance is present, the critical first step is to engage the parents alongside their child. Without their understanding of the nature of this behavior, it will continue. Start by acknowledging the real physical and emotional symptoms their child is experiencing; it is important that parents and patients not feel that they are being told this is “just” a psychological problem. Children rarely feign illness or manipulate; they genuinely feel bad enough to stay home. It is important that they understand this is a common problem that will get worse unless it is addressed directly. If you believe they are suffering from a mood or anxiety disorder, talk about treatment options and consider getting started with treatment while finding a therapist to participate in their care. Help everyone listen to the child or teenager to understand any realistic basis for anxiety and attempt to address it (e.g. address bullying, provide a tutor, support a parent dependent on the child, etc.)

You can partner with parents and the school to provide the child with structure and support to make the return to school manageable. Frame the challenge of “demagnetizing” home and “remagnetizing” school. When they are at home, there should be no screen time except to catch up or keep up with homework. The child should not be in bed all day unless he or she has a fever. There needs to be close attention paid to maintaining a regular routine, with bedtime and wake time, meals with family, and regular exercise. This may mean turning off the Wi-Fi while a child is at home and parents are at work and providing them with books.

Work with the school to make getting into school and staying there as easy as possible. If a child has very high distress or has been out of school for a long time, he or she may need to return gradually; perhaps aim for the child to spend an hour at school for the first few days and then gradually work up to half and full days. Younger children may benefit from having a “buddy” who meets them outside and enters school with them. This can help avoid intense emotional scenes with parents that heighten distress and lead to accommodation. The child can identify a preferred teacher (or librarian, coach, or school nurse). When they feel overwhelmed, they can have a “break” with that teacher to avoid leaving school altogether. If they enjoy sports, music, or art, emphasize these classes or practices as part of their return to school.

Remind parents and your patients that it is not a matter of making the distress better first and then returning to school. They can be in treatment for an illness and manage returning to school at the same time. Indeed, the distress around school will only get better by getting back to school. This is hard! Ask about previous challenges they have managed or mastered and remind them that this is no different. Providing parents with knowledge and support will help them to be validating of their children without accommodating their wish to avoid discomfort. This support of your patient and the parents is the first step in helping them manage a difficult period and stay on their healthiest developmental trajectory.

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

The start of the school year is a time that is always full of anticipation and even anxiety. Who will my teachers be? Will I be in classes with friends? Have some of my friends changed over the summer? Will the work be too hard? For some children this anxiety will be so intense that they will resist going back to school. School avoidance is very important to identify and address quickly, as it can intensify and threaten development. Each day of school missed due to accommodating to a child’s anxiety makes a return to school more difficult and less likely. Days can easily become weeks and even months of missed school. A child who misses a substantial amount of school is inevitably going to face developmental delays: academic, social, behavioral and emotional. The pediatrician is often brought into these situations early, as when a child complains of vague physical symptoms that are keeping him or her from school or when a previously calm child becomes inconsolable about going to school in the mornings. With a thoughtful assessment of the potential causes of school avoidance, you can help almost all children return to school successfully.

School Refusal

Sustained school avoidance is now called “school refusal,” a term coined in the late 1990s to describe a school attendance problem driven by emotional distress, as opposed to truancy. It affects up to 15% of children (depending on the operational definition) and seems to peak in the earliest years of elementary school and again in early high school. These are not occasional absences, but missing over 80% of classroom time in a 2-week period. It is also marked by the presence of an anxiety disorder and the absence of conduct disorder. Often in such cases the parents are aware of their child’s whereabouts and motivated to return them to school. Youth with school refusal experience social and academic consequences in the short term and, over the long term, have shown problems with social, family, and professional performance, along with higher rates of major depressive disorder than is seen in the general population. Early identification of these children can make addressing the underlying distress and return to school much easier than attempts to treat after weeks or months out of school.

Identifying the Problem

With younger children, school avoidance is most commonly associated with an anxious temperament or an underlying anxiety disorder, such as separation anxiety disorder or social phobia. A family history of anxiety may contribute or impact a parent’s approach to the issue. Children often present with vague somatic concerns that are genuine symptoms of anxiety (upset stomach, headache). A screening instrument such as the Screen for Child Anxiety Related Disorders (SCARED) can be helpful, but so is inquiring about sleep and other anxiety symptoms. Do the symptoms remit on weekends or in after-school hours? Are there other environmental factors that may be stressing younger children: Are they being teased or bullied at school? Are they struggling to find friends in a new classroom? Might they be having trouble with reading or other new tasks? Perhaps they are afraid of walking to school alone. Has there been a recent change or stress at home, such as a move or parental illness? Younger children may feel more anxious about separating from parents in the face of stress. But when parents accommodate a child’s wish to avoid school, the child’s anxiety, briefly relieved, grows more persistent, gets rewarded by parental attention, and reinforces their reluctance to try new things.

Adolescents may be facing more complex challenges that lead to school avoidance. They may have an undiagnosed anxiety or mood disorder, perhaps complicated by substance abuse that is presenting as an inability to perform at school or to manage the challenge of keeping up with higher workloads. They may be facing complex situations with friends, bullying, or rejection. Those adolescents who are prone to procrastination may avoid school to manage their workload and their distress, which can then become tangled up with symptoms of anxiety and dysphoria. Missing school compounds this problem rather than solving it. Adolescents outside of the structure of school, hungry for socializing and new experiences, often turn to social media for entertainment. Days without exercise and nights without adequate sleep can make mood, attention, and anxiety symptoms worse while overdue work grows. Parents often fear that setting limits or “pushing” their stuck and miserable child may make them more depressed or even suicidal.
 

Accommodating the Problem Will Likely Make It Worse

It is worth noting that children with a genuine medical illness can also experience school avoidance. Temperamentally anxious children who stay home for several days with a febrile illness may find it overwhelming to return to school as they have become so comfortable at home. Adolescents may have fallen behind with work and find themselves unable to set a schedule and return to more structure. Youth who are managing a known mood or anxiety disorder often have low motivation or high anxiety and want to wait to feel entirely better before returning to school. Youth with a chronic condition such as severe allergies or a sustained viral infection may be anxious about managing symptoms at school. Their parents may have kept them home to be safe or until they feel better, unwittingly making the school avoidance worse.

Formulating a Management Plan

When you suspect school avoidance is present, the critical first step is to engage the parents alongside their child. Without their understanding of the nature of this behavior, it will continue. Start by acknowledging the real physical and emotional symptoms their child is experiencing; it is important that parents and patients not feel that they are being told this is “just” a psychological problem. Children rarely feign illness or manipulate; they genuinely feel bad enough to stay home. It is important that they understand this is a common problem that will get worse unless it is addressed directly. If you believe they are suffering from a mood or anxiety disorder, talk about treatment options and consider getting started with treatment while finding a therapist to participate in their care. Help everyone listen to the child or teenager to understand any realistic basis for anxiety and attempt to address it (e.g. address bullying, provide a tutor, support a parent dependent on the child, etc.)

You can partner with parents and the school to provide the child with structure and support to make the return to school manageable. Frame the challenge of “demagnetizing” home and “remagnetizing” school. When they are at home, there should be no screen time except to catch up or keep up with homework. The child should not be in bed all day unless he or she has a fever. There needs to be close attention paid to maintaining a regular routine, with bedtime and wake time, meals with family, and regular exercise. This may mean turning off the Wi-Fi while a child is at home and parents are at work and providing them with books.

Work with the school to make getting into school and staying there as easy as possible. If a child has very high distress or has been out of school for a long time, he or she may need to return gradually; perhaps aim for the child to spend an hour at school for the first few days and then gradually work up to half and full days. Younger children may benefit from having a “buddy” who meets them outside and enters school with them. This can help avoid intense emotional scenes with parents that heighten distress and lead to accommodation. The child can identify a preferred teacher (or librarian, coach, or school nurse). When they feel overwhelmed, they can have a “break” with that teacher to avoid leaving school altogether. If they enjoy sports, music, or art, emphasize these classes or practices as part of their return to school.

Remind parents and your patients that it is not a matter of making the distress better first and then returning to school. They can be in treatment for an illness and manage returning to school at the same time. Indeed, the distress around school will only get better by getting back to school. This is hard! Ask about previous challenges they have managed or mastered and remind them that this is no different. Providing parents with knowledge and support will help them to be validating of their children without accommodating their wish to avoid discomfort. This support of your patient and the parents is the first step in helping them manage a difficult period and stay on their healthiest developmental trajectory.

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

The start of the school year is a time that is always full of anticipation and even anxiety. Who will my teachers be? Will I be in classes with friends? Have some of my friends changed over the summer? Will the work be too hard? For some children this anxiety will be so intense that they will resist going back to school. School avoidance is very important to identify and address quickly, as it can intensify and threaten development. Each day of school missed due to accommodating to a child’s anxiety makes a return to school more difficult and less likely. Days can easily become weeks and even months of missed school. A child who misses a substantial amount of school is inevitably going to face developmental delays: academic, social, behavioral and emotional. The pediatrician is often brought into these situations early, as when a child complains of vague physical symptoms that are keeping him or her from school or when a previously calm child becomes inconsolable about going to school in the mornings. With a thoughtful assessment of the potential causes of school avoidance, you can help almost all children return to school successfully.

School Refusal

Sustained school avoidance is now called “school refusal,” a term coined in the late 1990s to describe a school attendance problem driven by emotional distress, as opposed to truancy. It affects up to 15% of children (depending on the operational definition) and seems to peak in the earliest years of elementary school and again in early high school. These are not occasional absences, but missing over 80% of classroom time in a 2-week period. It is also marked by the presence of an anxiety disorder and the absence of conduct disorder. Often in such cases the parents are aware of their child’s whereabouts and motivated to return them to school. Youth with school refusal experience social and academic consequences in the short term and, over the long term, have shown problems with social, family, and professional performance, along with higher rates of major depressive disorder than is seen in the general population. Early identification of these children can make addressing the underlying distress and return to school much easier than attempts to treat after weeks or months out of school.

Identifying the Problem

With younger children, school avoidance is most commonly associated with an anxious temperament or an underlying anxiety disorder, such as separation anxiety disorder or social phobia. A family history of anxiety may contribute or impact a parent’s approach to the issue. Children often present with vague somatic concerns that are genuine symptoms of anxiety (upset stomach, headache). A screening instrument such as the Screen for Child Anxiety Related Disorders (SCARED) can be helpful, but so is inquiring about sleep and other anxiety symptoms. Do the symptoms remit on weekends or in after-school hours? Are there other environmental factors that may be stressing younger children: Are they being teased or bullied at school? Are they struggling to find friends in a new classroom? Might they be having trouble with reading or other new tasks? Perhaps they are afraid of walking to school alone. Has there been a recent change or stress at home, such as a move or parental illness? Younger children may feel more anxious about separating from parents in the face of stress. But when parents accommodate a child’s wish to avoid school, the child’s anxiety, briefly relieved, grows more persistent, gets rewarded by parental attention, and reinforces their reluctance to try new things.

Adolescents may be facing more complex challenges that lead to school avoidance. They may have an undiagnosed anxiety or mood disorder, perhaps complicated by substance abuse that is presenting as an inability to perform at school or to manage the challenge of keeping up with higher workloads. They may be facing complex situations with friends, bullying, or rejection. Those adolescents who are prone to procrastination may avoid school to manage their workload and their distress, which can then become tangled up with symptoms of anxiety and dysphoria. Missing school compounds this problem rather than solving it. Adolescents outside of the structure of school, hungry for socializing and new experiences, often turn to social media for entertainment. Days without exercise and nights without adequate sleep can make mood, attention, and anxiety symptoms worse while overdue work grows. Parents often fear that setting limits or “pushing” their stuck and miserable child may make them more depressed or even suicidal.
 

Accommodating the Problem Will Likely Make It Worse

It is worth noting that children with a genuine medical illness can also experience school avoidance. Temperamentally anxious children who stay home for several days with a febrile illness may find it overwhelming to return to school as they have become so comfortable at home. Adolescents may have fallen behind with work and find themselves unable to set a schedule and return to more structure. Youth who are managing a known mood or anxiety disorder often have low motivation or high anxiety and want to wait to feel entirely better before returning to school. Youth with a chronic condition such as severe allergies or a sustained viral infection may be anxious about managing symptoms at school. Their parents may have kept them home to be safe or until they feel better, unwittingly making the school avoidance worse.

Formulating a Management Plan

When you suspect school avoidance is present, the critical first step is to engage the parents alongside their child. Without their understanding of the nature of this behavior, it will continue. Start by acknowledging the real physical and emotional symptoms their child is experiencing; it is important that parents and patients not feel that they are being told this is “just” a psychological problem. Children rarely feign illness or manipulate; they genuinely feel bad enough to stay home. It is important that they understand this is a common problem that will get worse unless it is addressed directly. If you believe they are suffering from a mood or anxiety disorder, talk about treatment options and consider getting started with treatment while finding a therapist to participate in their care. Help everyone listen to the child or teenager to understand any realistic basis for anxiety and attempt to address it (e.g. address bullying, provide a tutor, support a parent dependent on the child, etc.)

You can partner with parents and the school to provide the child with structure and support to make the return to school manageable. Frame the challenge of “demagnetizing” home and “remagnetizing” school. When they are at home, there should be no screen time except to catch up or keep up with homework. The child should not be in bed all day unless he or she has a fever. There needs to be close attention paid to maintaining a regular routine, with bedtime and wake time, meals with family, and regular exercise. This may mean turning off the Wi-Fi while a child is at home and parents are at work and providing them with books.

Work with the school to make getting into school and staying there as easy as possible. If a child has very high distress or has been out of school for a long time, he or she may need to return gradually; perhaps aim for the child to spend an hour at school for the first few days and then gradually work up to half and full days. Younger children may benefit from having a “buddy” who meets them outside and enters school with them. This can help avoid intense emotional scenes with parents that heighten distress and lead to accommodation. The child can identify a preferred teacher (or librarian, coach, or school nurse). When they feel overwhelmed, they can have a “break” with that teacher to avoid leaving school altogether. If they enjoy sports, music, or art, emphasize these classes or practices as part of their return to school.

Remind parents and your patients that it is not a matter of making the distress better first and then returning to school. They can be in treatment for an illness and manage returning to school at the same time. Indeed, the distress around school will only get better by getting back to school. This is hard! Ask about previous challenges they have managed or mastered and remind them that this is no different. Providing parents with knowledge and support will help them to be validating of their children without accommodating their wish to avoid discomfort. This support of your patient and the parents is the first step in helping them manage a difficult period and stay on their healthiest developmental trajectory.

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

Amid the declarations about the current mental health crisis among youth, it has become increasingly common to link rising rates of anxiety and depression among youth to screen time, and more specifically to hours spent on social media. But in truth, this matter is far from settled. The evidence linking mood and anxiety disorders to social media use is inconsistent. And where the evidence is stronger, causality has not been established. Does screen time precipitate an episode of depression or does a preteen at risk for depression, in the midst of a divorce or burdened by learning problems, use screen time excessively as a solution to these problems? There is also substantial variation across age groups, genders, and other factors that suggests that time spent on smartphone apps may not be the primary factor creating risk. Indeed, there is growing uncertainty about whether the climbing rates of anxiety and mood disorders among youth reflect yet to be identified factors increasing the burden of mental illness or the altered screening and tracking landscape in the United States after COVID and the Affordable Care Act. This uncertainty does not mean that we cannot make recommendations about how to guide patients and their families. Smartphones (and watches, glasses, etc) are here to stay. We can help young people and their families to be smart users of their smartphones and social media as we learn more detail about risk and vulnerability.

Start by asking your patients how much time they spend on screens of all sorts and on social media in particular. Find out if there are rules at school or at home limiting screen time or social media. Are there disagreements about screen time? Are patients frustrated with their parents’ use of screens? What are their favorite apps to use? How much time do they think they spend on them? If they don’t know, point out how they can track it on their phone directly. Is it painful to be separated from their phone? Do they have interests or hobbies that are not screen-based? What would they do if the power or Wi-Fi was out for a week? These questions can be the start of an ongoing project for screen time and social media literacy.

Recognize That Apps Are Designed to Be Addictive

Smartphones are useful tools designed to help people stay connected, manage their bank accounts, keep up with current events, access entertainment, and much more. It is easy to spend more time than one intended on them. The applications developed for smartphones promise, and often deliver, efficiency and ease, including staying connected to friends and families. But social media applications have been developed to make their parent companies profit from ad revenue or selling user data. They are designed to encourage more and more use, and for some may become addictive. Start the literacy course with a clear statement of this fact. Remind teenagers that they are often the target audience for the corporations making money from these apps. They are especially sensitive to the likes and followers that can be the currency of social media. For every minute they spend on the apps, a corporation is profiting. It can be helpful to remind teenagers to bring their healthy skepticism of authority to their use of these corporate products.

Develop Awareness of Their Time, Energy, and Mood

Time is our most precious commodity, and most teenagers are stressed by not having enough of it. Ask your patients about the variety of things they need to do and want to do each day. Do they have enough time to do the things they want beyond their smartphones? Is the time on their smartphones more or less than they want? How do they feel when they finish with different activities? Energized? Engaged? Exhilarated? Drained? Irritable? Sad? Do they feel connected? Lonely? Loved? Left out? Suggest that they pay attention to how they feel after engaging in all kinds of activities (including homework, sports, hobbies, and time with friends), as these are the types of choices they will make throughout their adult lives. Some tasks are simply required (homework), some are relaxing (leaving us feeling calm and even sleepy), and some are recharging (leaving us feeling focused and energized). If an activity consistently leaves them drained and irritable, sad, and lonely or discouraged and insecure, they need to step back and ask themselves why they are making this choice and if that is the choice they want to make. Support their developing self-awareness, activating their sense of agency and independence in making choices that will serve them.

Develop Awareness of Their Sense of Connection to Others

As your patients are paying attention to their mood, focus, interest, and energy, they can also pay attention to these components of their social life. How do they feel with individual friends? With different groups? In different settings? How does this compare with how they feel when engaged with social media? In general, when technology is supporting strong connections with friends, it can enhance their health and well-being. When it helps youth isolated by interests or identity to become connected to supportive youth who are physically far away, it can be a social lifeline. But sometimes, social media exploits youth sensitivity to peer opinions and social comparison to keep their attention without the payoff of deepened or new relationships. Do they know the youth they are chatting with or following? Could they spend 2 hours with them offline? How do they feel after spending 2 hours “with” them online? Once again, the goal is to develop teens’ awareness of the quality of their relationships and of their control over how to manage this.

Acknowledge Their Own Vulnerabilities

Does your patient have attention-deficit/hyperactivity disorder (ADHD)? Are they being treated for depression? An anxiety disorder? An eating disorder? While we cannot say whether excessive use of social media can cause these problems, we know that it can be counterproductive to their treatment. Youth with ADHD have great difficulty switching their cognitive focus away from something rewarding, so are particularly prone to spending excessive time in addictive apps. Those with depression often have low energy and initiative alongside feelings of worthlessness that can make engaging in physical, in-person activities challenging. Those with anxiety disorders are prone to rumination and avoidance. The possibility of escaping into virtual social activities or distractions can be very hard to resist and counter-therapeutic for these youth (and adults). Those with eating disorders are vulnerable to comparing themselves with idealized (airbrushed) images online, which can intensify the body image distortion and competitiveness that are common in eating disorders. While there may be helpful information about diagnoses, treatment, and support, there is also troubling information about self-injury, restrictive eating, and even suicide that can increase the risk for these behaviors in vulnerable youth. You can help your patients cultivate awareness of how to take good care of themselves.

Create Habits That Support Sleep, Exercise, and Relationships

Talk with your patients and their parents about strategies to set habits that will make it easier for them to be smart users of their smartphones. Can they explore new apps or games together? Can they talk together about how each of them relaxes and recharges? Then they can work together on how this tool (and toy) can fit into a healthy life. The task is to prioritize sleep, exercise, and live, in-person social time, so virtual activities don’t take over the time needed for them. This can be as simple as consistent bed and waking times and ensuring that smartphones are not at the dining table or in bedrooms at night. Having dinner together as a family most nights (an especially positive habit), going for walks, runs, or hikes together, or doing activities that everyone enjoys (playing music or board games, making cookies or art, gardening) are beneficial for every family member’s physical and mental health and ensure that screen time is not at the expense of real connection. Invite your patients to tell you how they practice putting their smartphones away, getting their homework done, or making time for activities that matter to them. And find out how they relax and recharge beyond using their smartphones. Healthy habits evolve over a lifetime, and there will surely be new technologies that require new limits in the coming years. Helping your patients to make good choices will serve them well as they enter adulthood and throughout their lives.

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

Amid the declarations about the current mental health crisis among youth, it has become increasingly common to link rising rates of anxiety and depression among youth to screen time, and more specifically to hours spent on social media. But in truth, this matter is far from settled. The evidence linking mood and anxiety disorders to social media use is inconsistent. And where the evidence is stronger, causality has not been established. Does screen time precipitate an episode of depression or does a preteen at risk for depression, in the midst of a divorce or burdened by learning problems, use screen time excessively as a solution to these problems? There is also substantial variation across age groups, genders, and other factors that suggests that time spent on smartphone apps may not be the primary factor creating risk. Indeed, there is growing uncertainty about whether the climbing rates of anxiety and mood disorders among youth reflect yet to be identified factors increasing the burden of mental illness or the altered screening and tracking landscape in the United States after COVID and the Affordable Care Act. This uncertainty does not mean that we cannot make recommendations about how to guide patients and their families. Smartphones (and watches, glasses, etc) are here to stay. We can help young people and their families to be smart users of their smartphones and social media as we learn more detail about risk and vulnerability.

Start by asking your patients how much time they spend on screens of all sorts and on social media in particular. Find out if there are rules at school or at home limiting screen time or social media. Are there disagreements about screen time? Are patients frustrated with their parents’ use of screens? What are their favorite apps to use? How much time do they think they spend on them? If they don’t know, point out how they can track it on their phone directly. Is it painful to be separated from their phone? Do they have interests or hobbies that are not screen-based? What would they do if the power or Wi-Fi was out for a week? These questions can be the start of an ongoing project for screen time and social media literacy.

Recognize That Apps Are Designed to Be Addictive

Smartphones are useful tools designed to help people stay connected, manage their bank accounts, keep up with current events, access entertainment, and much more. It is easy to spend more time than one intended on them. The applications developed for smartphones promise, and often deliver, efficiency and ease, including staying connected to friends and families. But social media applications have been developed to make their parent companies profit from ad revenue or selling user data. They are designed to encourage more and more use, and for some may become addictive. Start the literacy course with a clear statement of this fact. Remind teenagers that they are often the target audience for the corporations making money from these apps. They are especially sensitive to the likes and followers that can be the currency of social media. For every minute they spend on the apps, a corporation is profiting. It can be helpful to remind teenagers to bring their healthy skepticism of authority to their use of these corporate products.

Develop Awareness of Their Time, Energy, and Mood

Time is our most precious commodity, and most teenagers are stressed by not having enough of it. Ask your patients about the variety of things they need to do and want to do each day. Do they have enough time to do the things they want beyond their smartphones? Is the time on their smartphones more or less than they want? How do they feel when they finish with different activities? Energized? Engaged? Exhilarated? Drained? Irritable? Sad? Do they feel connected? Lonely? Loved? Left out? Suggest that they pay attention to how they feel after engaging in all kinds of activities (including homework, sports, hobbies, and time with friends), as these are the types of choices they will make throughout their adult lives. Some tasks are simply required (homework), some are relaxing (leaving us feeling calm and even sleepy), and some are recharging (leaving us feeling focused and energized). If an activity consistently leaves them drained and irritable, sad, and lonely or discouraged and insecure, they need to step back and ask themselves why they are making this choice and if that is the choice they want to make. Support their developing self-awareness, activating their sense of agency and independence in making choices that will serve them.

Develop Awareness of Their Sense of Connection to Others

As your patients are paying attention to their mood, focus, interest, and energy, they can also pay attention to these components of their social life. How do they feel with individual friends? With different groups? In different settings? How does this compare with how they feel when engaged with social media? In general, when technology is supporting strong connections with friends, it can enhance their health and well-being. When it helps youth isolated by interests or identity to become connected to supportive youth who are physically far away, it can be a social lifeline. But sometimes, social media exploits youth sensitivity to peer opinions and social comparison to keep their attention without the payoff of deepened or new relationships. Do they know the youth they are chatting with or following? Could they spend 2 hours with them offline? How do they feel after spending 2 hours “with” them online? Once again, the goal is to develop teens’ awareness of the quality of their relationships and of their control over how to manage this.

Acknowledge Their Own Vulnerabilities

Does your patient have attention-deficit/hyperactivity disorder (ADHD)? Are they being treated for depression? An anxiety disorder? An eating disorder? While we cannot say whether excessive use of social media can cause these problems, we know that it can be counterproductive to their treatment. Youth with ADHD have great difficulty switching their cognitive focus away from something rewarding, so are particularly prone to spending excessive time in addictive apps. Those with depression often have low energy and initiative alongside feelings of worthlessness that can make engaging in physical, in-person activities challenging. Those with anxiety disorders are prone to rumination and avoidance. The possibility of escaping into virtual social activities or distractions can be very hard to resist and counter-therapeutic for these youth (and adults). Those with eating disorders are vulnerable to comparing themselves with idealized (airbrushed) images online, which can intensify the body image distortion and competitiveness that are common in eating disorders. While there may be helpful information about diagnoses, treatment, and support, there is also troubling information about self-injury, restrictive eating, and even suicide that can increase the risk for these behaviors in vulnerable youth. You can help your patients cultivate awareness of how to take good care of themselves.

Create Habits That Support Sleep, Exercise, and Relationships

Talk with your patients and their parents about strategies to set habits that will make it easier for them to be smart users of their smartphones. Can they explore new apps or games together? Can they talk together about how each of them relaxes and recharges? Then they can work together on how this tool (and toy) can fit into a healthy life. The task is to prioritize sleep, exercise, and live, in-person social time, so virtual activities don’t take over the time needed for them. This can be as simple as consistent bed and waking times and ensuring that smartphones are not at the dining table or in bedrooms at night. Having dinner together as a family most nights (an especially positive habit), going for walks, runs, or hikes together, or doing activities that everyone enjoys (playing music or board games, making cookies or art, gardening) are beneficial for every family member’s physical and mental health and ensure that screen time is not at the expense of real connection. Invite your patients to tell you how they practice putting their smartphones away, getting their homework done, or making time for activities that matter to them. And find out how they relax and recharge beyond using their smartphones. Healthy habits evolve over a lifetime, and there will surely be new technologies that require new limits in the coming years. Helping your patients to make good choices will serve them well as they enter adulthood and throughout their lives.

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

Amid the declarations about the current mental health crisis among youth, it has become increasingly common to link rising rates of anxiety and depression among youth to screen time, and more specifically to hours spent on social media. But in truth, this matter is far from settled. The evidence linking mood and anxiety disorders to social media use is inconsistent. And where the evidence is stronger, causality has not been established. Does screen time precipitate an episode of depression or does a preteen at risk for depression, in the midst of a divorce or burdened by learning problems, use screen time excessively as a solution to these problems? There is also substantial variation across age groups, genders, and other factors that suggests that time spent on smartphone apps may not be the primary factor creating risk. Indeed, there is growing uncertainty about whether the climbing rates of anxiety and mood disorders among youth reflect yet to be identified factors increasing the burden of mental illness or the altered screening and tracking landscape in the United States after COVID and the Affordable Care Act. This uncertainty does not mean that we cannot make recommendations about how to guide patients and their families. Smartphones (and watches, glasses, etc) are here to stay. We can help young people and their families to be smart users of their smartphones and social media as we learn more detail about risk and vulnerability.

Start by asking your patients how much time they spend on screens of all sorts and on social media in particular. Find out if there are rules at school or at home limiting screen time or social media. Are there disagreements about screen time? Are patients frustrated with their parents’ use of screens? What are their favorite apps to use? How much time do they think they spend on them? If they don’t know, point out how they can track it on their phone directly. Is it painful to be separated from their phone? Do they have interests or hobbies that are not screen-based? What would they do if the power or Wi-Fi was out for a week? These questions can be the start of an ongoing project for screen time and social media literacy.

Recognize That Apps Are Designed to Be Addictive

Smartphones are useful tools designed to help people stay connected, manage their bank accounts, keep up with current events, access entertainment, and much more. It is easy to spend more time than one intended on them. The applications developed for smartphones promise, and often deliver, efficiency and ease, including staying connected to friends and families. But social media applications have been developed to make their parent companies profit from ad revenue or selling user data. They are designed to encourage more and more use, and for some may become addictive. Start the literacy course with a clear statement of this fact. Remind teenagers that they are often the target audience for the corporations making money from these apps. They are especially sensitive to the likes and followers that can be the currency of social media. For every minute they spend on the apps, a corporation is profiting. It can be helpful to remind teenagers to bring their healthy skepticism of authority to their use of these corporate products.

Develop Awareness of Their Time, Energy, and Mood

Time is our most precious commodity, and most teenagers are stressed by not having enough of it. Ask your patients about the variety of things they need to do and want to do each day. Do they have enough time to do the things they want beyond their smartphones? Is the time on their smartphones more or less than they want? How do they feel when they finish with different activities? Energized? Engaged? Exhilarated? Drained? Irritable? Sad? Do they feel connected? Lonely? Loved? Left out? Suggest that they pay attention to how they feel after engaging in all kinds of activities (including homework, sports, hobbies, and time with friends), as these are the types of choices they will make throughout their adult lives. Some tasks are simply required (homework), some are relaxing (leaving us feeling calm and even sleepy), and some are recharging (leaving us feeling focused and energized). If an activity consistently leaves them drained and irritable, sad, and lonely or discouraged and insecure, they need to step back and ask themselves why they are making this choice and if that is the choice they want to make. Support their developing self-awareness, activating their sense of agency and independence in making choices that will serve them.

Develop Awareness of Their Sense of Connection to Others

As your patients are paying attention to their mood, focus, interest, and energy, they can also pay attention to these components of their social life. How do they feel with individual friends? With different groups? In different settings? How does this compare with how they feel when engaged with social media? In general, when technology is supporting strong connections with friends, it can enhance their health and well-being. When it helps youth isolated by interests or identity to become connected to supportive youth who are physically far away, it can be a social lifeline. But sometimes, social media exploits youth sensitivity to peer opinions and social comparison to keep their attention without the payoff of deepened or new relationships. Do they know the youth they are chatting with or following? Could they spend 2 hours with them offline? How do they feel after spending 2 hours “with” them online? Once again, the goal is to develop teens’ awareness of the quality of their relationships and of their control over how to manage this.

Acknowledge Their Own Vulnerabilities

Does your patient have attention-deficit/hyperactivity disorder (ADHD)? Are they being treated for depression? An anxiety disorder? An eating disorder? While we cannot say whether excessive use of social media can cause these problems, we know that it can be counterproductive to their treatment. Youth with ADHD have great difficulty switching their cognitive focus away from something rewarding, so are particularly prone to spending excessive time in addictive apps. Those with depression often have low energy and initiative alongside feelings of worthlessness that can make engaging in physical, in-person activities challenging. Those with anxiety disorders are prone to rumination and avoidance. The possibility of escaping into virtual social activities or distractions can be very hard to resist and counter-therapeutic for these youth (and adults). Those with eating disorders are vulnerable to comparing themselves with idealized (airbrushed) images online, which can intensify the body image distortion and competitiveness that are common in eating disorders. While there may be helpful information about diagnoses, treatment, and support, there is also troubling information about self-injury, restrictive eating, and even suicide that can increase the risk for these behaviors in vulnerable youth. You can help your patients cultivate awareness of how to take good care of themselves.

Create Habits That Support Sleep, Exercise, and Relationships

Talk with your patients and their parents about strategies to set habits that will make it easier for them to be smart users of their smartphones. Can they explore new apps or games together? Can they talk together about how each of them relaxes and recharges? Then they can work together on how this tool (and toy) can fit into a healthy life. The task is to prioritize sleep, exercise, and live, in-person social time, so virtual activities don’t take over the time needed for them. This can be as simple as consistent bed and waking times and ensuring that smartphones are not at the dining table or in bedrooms at night. Having dinner together as a family most nights (an especially positive habit), going for walks, runs, or hikes together, or doing activities that everyone enjoys (playing music or board games, making cookies or art, gardening) are beneficial for every family member’s physical and mental health and ensure that screen time is not at the expense of real connection. Invite your patients to tell you how they practice putting their smartphones away, getting their homework done, or making time for activities that matter to them. And find out how they relax and recharge beyond using their smartphones. Healthy habits evolve over a lifetime, and there will surely be new technologies that require new limits in the coming years. Helping your patients to make good choices will serve them well as they enter adulthood and throughout their lives.

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

Bullying, heavy social media use, experimentation with drugs and alcohol: These are the well-described hazards of adolescence. We have growing knowledge of the risks associated with these experiences and which youth are more vulnerable to these risks. Developmentally, adolescence is a time of critical brain development marked by heightened sensitivity to social approval and limited impulse control. Adolescents also have growing autonomy from parents alongside a stronger need for time with friends (the new peer home away from the parental home). These factors alone make adolescence a period of heightened sensitivity to these experiences, but some youth have greater vulnerability to develop psychopathology such as anxiety, depression, eating disorders, or addiction after exposure to these common experiences. Pediatricians can assess these broader vulnerabilities during well child visits of pre- and early teens and offer patients and their parents strategies for minimizing risk and cultivating resilience.

Bullying

Bullying, both verbal and physical, has long been an unwelcome part of youth. Cellphones and social media have brought bullying into the 21st century. Cyberbullying has meant that targeted youth are no longer safe after school and it carries higher risk of self-harm and suicidality than the analog version. No child benefits from bullying, but some children are more vulnerable to develop an anxiety or mood disorder, self-injury, or suicidality, whereas others experience stress and distress, but are able to adaptively seek support from friends and adults and stay on track developmentally, even to flourish. There is evidence that girls and LGBTQ youth are more commonly bullied and at higher risk for depression, self-harm, and suicidality as a consequence of cyberbullying. Youth already suffering from a psychiatric illness or substance abuse who are bullied are at higher risk for self-harm and suicidality than that of their bullied peers. Youth whose parents score high on measures of distress and family dysfunction also face higher risk of self-harm and suicidality after bullying.¹

Social Media

Unlike bullying, social media has been a force only in 21st century life, with Facebook starting in 2004 and cellphones in common use by adolescents in the past 2 decades. While there are potential benefits of social media use, such as stronger connections to supportive peers for isolated LGBTQ youth or youth who live in rural areas, there are also risks. Of course, social media carries the risk of cyberbullying. It also carries the risk for very heavy patterns of use that can interfere with physical activity, adequate sleep, academic performance, and healthy in-person social activities. There is robust emerging evidence that heavy users have higher rates of mood disorders and anxiety symptoms, although it is unclear whether social media exacerbates, or more social media use is the result of depression and/or anxiety. Adolescents’ desire for social acceptance makes them especially sensitive to the social rewards of “likes” and they are thus vulnerable to becoming heavy users. Adolescent girls who are heavy users are vulnerable to developing a disordered body image and eating disorders. Those youth with especially low levels of impulse control, such as those with ADHD, have greater risk of developing problematic use.^2-4

Substance Use and Abuse

Exploration of alcohol and drug use has been a common experience, and hazard, of adolescence for many generations. As a result, we have richer knowledge of those factors that are associated with risk of and protection against that use progressing to a use disorder. Earlier age at first experimentation appears to be independently correlated with increased risk of developing a substance use disorder. Every pediatrician should be aware of a family history of substance use disorders, especially alcohol, as they are strongly associated with higher risk. Youth with temperaments that are sensation seeking, externalizing and impulsive are at higher risk. Youth with anxiety and mood disorders and untreated attention deficit disorders are at higher risk. Youth whose parents have high levels of conflict or “permissive” parenting styles are at higher risk as are those who as children experienced abuse or neglect.^5-7

Minimizing Risk and Cultivating Resilience

Protective factors balance these risks: adequate sleep; positive relationships with friends and parents; and confidence in their academic, athletic, or social abilities all are correlated with good outcomes after bullying, drug and alcohol use, and social media use. These teenagers are meaningfully connected to caring adults and peers, have a future orientation, and typically have higher self-esteem. Youth whose parents balance attunement with rules and expectations (“authoritative” parenting) appear to be at lower risk of poor mental health outcomes associated with heavy social media use as well as other risk behaviors. These parents have clear rules and expectations, including about drugs and alcohol, and enforce rules reasonably calmly and consistently. Youth whose families eat dinner together at least three times weekly, who attend schools that offer a wide range of after-school activities, and who learn to use problem-focused coping skills rather than emotion-focused coping skills are protected against poor mental health outcomes in the face of these challenges.

While bullying is a stressor, social media and substances may seem like ways of managing stress and connecting with peers. There are youth with clear vulnerabilities to the risks associated with each of them. Shared factors include vulnerable temperaments, high conflict or permissive parenting, family history of substance use disorders or preexisting psychiatric illness. Pediatricians are in a unique position to raise teenagers’ awareness of their specific vulnerabilities. Talk about the heightened risk of experimentation with alcohol or drugs in your patients who are in treatment for an anxiety or mood disorder. Help them cultivate critical thinking — an adolescent specialty — around marketing and peer pressure. Remind them that social media companies make money from keeping them online longer. Then help them identify what strategies are in their control, such as limiting their time online. What else could they be doing with their time that they actually enjoy? Remind them about the value of protecting time for adequate sleep, regular exercise, and sitting down for dinner with their family. Ask about their nourishing relationships with peers and adults and talk about the value of protecting time for them. Ask your patients and their parents about how they face stress, emphasizing their ability to locate what is within their control. While awareness of feelings is important, learning to manage intense emotions is more connected to healthy habits of sleep and exercise and strategies to get support or pivot to engaging activities. Discussing this openly models for parents how to bear difficulty alongside their children without becoming distressed or punitive themselves. Talk with worried parents about the value of regular meals together, shared physical activities, and supporting time for their children’s emerging interests and hobbies. Equipping your patients and their parents with knowledge about their particular vulnerabilities, reminders about what is known about these risks, and all that is in their power to build resilience, may be as meaningful a public health intervention as asking them about biking with helmets and using seat belts.

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

References

1. Zych I et al. Protective Factors Against Bullying and Cyberbullying: A Systematic Review of Meta-Analyses. Aggress Violent Behav. 2019;45:4-19. doi: 10.1016/j.avb.2018.06.008.

2. Office of the Surgeon General. Social Media and Youth Mental Health: The U.S. Surgeon General’s Advisory. 2023. https://www.ncbi.nlm.nih.gov/books/NBK594761/.

3. Uhls Y et al. Benefits and Costs of Social Media in Adolescence. Pediatrics. 2017 Nov;140(Suppl 2):S67-S70. doi: 10.1542/peds.2016-1758E.

4. Health Advisory on Social Media Use in Adolescence. American Psychological Association (2023).

5. Sloboda Z et al. Revisiting the Concepts of Risk and Protective Factors for Understanding the Etiology and Development of Substance Use and Substance Use Disorders: Implications for Prevention, Substance Use and Misuse, Subst Use Misuse. 2012 Jun-Jul;47(8-9):944-62. doi: 10.3109/10826084.2012.663280.

6. O’Connell M et al. Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Washington, DC: The National Academies Press and US Department of Health and Human Services, Substance Abuse and Mental Health Administration. 2009 (https://nap.nationalacademies.org/catalog/12480/preventing-mental-emotional-and-behavioral-disorders-among-young-people-progress).

7. Staiger P et al. Can Emotion-Focused Coping Help Explain the Link Between Posttraumatic Stress Disorder Severity and Triggers for Substance Use in Young Adults? J Subst Abuse Treat. 2009 Mar;36(2):220-6. doi: 10.1016/j.jsat.2008.05.008.

Bullying, heavy social media use, experimentation with drugs and alcohol: These are the well-described hazards of adolescence. We have growing knowledge of the risks associated with these experiences and which youth are more vulnerable to these risks. Developmentally, adolescence is a time of critical brain development marked by heightened sensitivity to social approval and limited impulse control. Adolescents also have growing autonomy from parents alongside a stronger need for time with friends (the new peer home away from the parental home). These factors alone make adolescence a period of heightened sensitivity to these experiences, but some youth have greater vulnerability to develop psychopathology such as anxiety, depression, eating disorders, or addiction after exposure to these common experiences. Pediatricians can assess these broader vulnerabilities during well child visits of pre- and early teens and offer patients and their parents strategies for minimizing risk and cultivating resilience.

Bullying

Bullying, both verbal and physical, has long been an unwelcome part of youth. Cellphones and social media have brought bullying into the 21st century. Cyberbullying has meant that targeted youth are no longer safe after school and it carries higher risk of self-harm and suicidality than the analog version. No child benefits from bullying, but some children are more vulnerable to develop an anxiety or mood disorder, self-injury, or suicidality, whereas others experience stress and distress, but are able to adaptively seek support from friends and adults and stay on track developmentally, even to flourish. There is evidence that girls and LGBTQ youth are more commonly bullied and at higher risk for depression, self-harm, and suicidality as a consequence of cyberbullying. Youth already suffering from a psychiatric illness or substance abuse who are bullied are at higher risk for self-harm and suicidality than that of their bullied peers. Youth whose parents score high on measures of distress and family dysfunction also face higher risk of self-harm and suicidality after bullying.¹

Social Media

Unlike bullying, social media has been a force only in 21st century life, with Facebook starting in 2004 and cellphones in common use by adolescents in the past 2 decades. While there are potential benefits of social media use, such as stronger connections to supportive peers for isolated LGBTQ youth or youth who live in rural areas, there are also risks. Of course, social media carries the risk of cyberbullying. It also carries the risk for very heavy patterns of use that can interfere with physical activity, adequate sleep, academic performance, and healthy in-person social activities. There is robust emerging evidence that heavy users have higher rates of mood disorders and anxiety symptoms, although it is unclear whether social media exacerbates, or more social media use is the result of depression and/or anxiety. Adolescents’ desire for social acceptance makes them especially sensitive to the social rewards of “likes” and they are thus vulnerable to becoming heavy users. Adolescent girls who are heavy users are vulnerable to developing a disordered body image and eating disorders. Those youth with especially low levels of impulse control, such as those with ADHD, have greater risk of developing problematic use.^2-4

Substance Use and Abuse

Exploration of alcohol and drug use has been a common experience, and hazard, of adolescence for many generations. As a result, we have richer knowledge of those factors that are associated with risk of and protection against that use progressing to a use disorder. Earlier age at first experimentation appears to be independently correlated with increased risk of developing a substance use disorder. Every pediatrician should be aware of a family history of substance use disorders, especially alcohol, as they are strongly associated with higher risk. Youth with temperaments that are sensation seeking, externalizing and impulsive are at higher risk. Youth with anxiety and mood disorders and untreated attention deficit disorders are at higher risk. Youth whose parents have high levels of conflict or “permissive” parenting styles are at higher risk as are those who as children experienced abuse or neglect.^5-7

Minimizing Risk and Cultivating Resilience

Protective factors balance these risks: adequate sleep; positive relationships with friends and parents; and confidence in their academic, athletic, or social abilities all are correlated with good outcomes after bullying, drug and alcohol use, and social media use. These teenagers are meaningfully connected to caring adults and peers, have a future orientation, and typically have higher self-esteem. Youth whose parents balance attunement with rules and expectations (“authoritative” parenting) appear to be at lower risk of poor mental health outcomes associated with heavy social media use as well as other risk behaviors. These parents have clear rules and expectations, including about drugs and alcohol, and enforce rules reasonably calmly and consistently. Youth whose families eat dinner together at least three times weekly, who attend schools that offer a wide range of after-school activities, and who learn to use problem-focused coping skills rather than emotion-focused coping skills are protected against poor mental health outcomes in the face of these challenges.

While bullying is a stressor, social media and substances may seem like ways of managing stress and connecting with peers. There are youth with clear vulnerabilities to the risks associated with each of them. Shared factors include vulnerable temperaments, high conflict or permissive parenting, family history of substance use disorders or preexisting psychiatric illness. Pediatricians are in a unique position to raise teenagers’ awareness of their specific vulnerabilities. Talk about the heightened risk of experimentation with alcohol or drugs in your patients who are in treatment for an anxiety or mood disorder. Help them cultivate critical thinking — an adolescent specialty — around marketing and peer pressure. Remind them that social media companies make money from keeping them online longer. Then help them identify what strategies are in their control, such as limiting their time online. What else could they be doing with their time that they actually enjoy? Remind them about the value of protecting time for adequate sleep, regular exercise, and sitting down for dinner with their family. Ask about their nourishing relationships with peers and adults and talk about the value of protecting time for them. Ask your patients and their parents about how they face stress, emphasizing their ability to locate what is within their control. While awareness of feelings is important, learning to manage intense emotions is more connected to healthy habits of sleep and exercise and strategies to get support or pivot to engaging activities. Discussing this openly models for parents how to bear difficulty alongside their children without becoming distressed or punitive themselves. Talk with worried parents about the value of regular meals together, shared physical activities, and supporting time for their children’s emerging interests and hobbies. Equipping your patients and their parents with knowledge about their particular vulnerabilities, reminders about what is known about these risks, and all that is in their power to build resilience, may be as meaningful a public health intervention as asking them about biking with helmets and using seat belts.

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

References

1. Zych I et al. Protective Factors Against Bullying and Cyberbullying: A Systematic Review of Meta-Analyses. Aggress Violent Behav. 2019;45:4-19. doi: 10.1016/j.avb.2018.06.008.

2. Office of the Surgeon General. Social Media and Youth Mental Health: The U.S. Surgeon General’s Advisory. 2023. https://www.ncbi.nlm.nih.gov/books/NBK594761/.

3. Uhls Y et al. Benefits and Costs of Social Media in Adolescence. Pediatrics. 2017 Nov;140(Suppl 2):S67-S70. doi: 10.1542/peds.2016-1758E.

4. Health Advisory on Social Media Use in Adolescence. American Psychological Association (2023).

5. Sloboda Z et al. Revisiting the Concepts of Risk and Protective Factors for Understanding the Etiology and Development of Substance Use and Substance Use Disorders: Implications for Prevention, Substance Use and Misuse, Subst Use Misuse. 2012 Jun-Jul;47(8-9):944-62. doi: 10.3109/10826084.2012.663280.

6. O’Connell M et al. Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Washington, DC: The National Academies Press and US Department of Health and Human Services, Substance Abuse and Mental Health Administration. 2009 (https://nap.nationalacademies.org/catalog/12480/preventing-mental-emotional-and-behavioral-disorders-among-young-people-progress).

7. Staiger P et al. Can Emotion-Focused Coping Help Explain the Link Between Posttraumatic Stress Disorder Severity and Triggers for Substance Use in Young Adults? J Subst Abuse Treat. 2009 Mar;36(2):220-6. doi: 10.1016/j.jsat.2008.05.008.

Bullying, heavy social media use, experimentation with drugs and alcohol: These are the well-described hazards of adolescence. We have growing knowledge of the risks associated with these experiences and which youth are more vulnerable to these risks. Developmentally, adolescence is a time of critical brain development marked by heightened sensitivity to social approval and limited impulse control. Adolescents also have growing autonomy from parents alongside a stronger need for time with friends (the new peer home away from the parental home). These factors alone make adolescence a period of heightened sensitivity to these experiences, but some youth have greater vulnerability to develop psychopathology such as anxiety, depression, eating disorders, or addiction after exposure to these common experiences. Pediatricians can assess these broader vulnerabilities during well child visits of pre- and early teens and offer patients and their parents strategies for minimizing risk and cultivating resilience.

Bullying

Bullying, both verbal and physical, has long been an unwelcome part of youth. Cellphones and social media have brought bullying into the 21st century. Cyberbullying has meant that targeted youth are no longer safe after school and it carries higher risk of self-harm and suicidality than the analog version. No child benefits from bullying, but some children are more vulnerable to develop an anxiety or mood disorder, self-injury, or suicidality, whereas others experience stress and distress, but are able to adaptively seek support from friends and adults and stay on track developmentally, even to flourish. There is evidence that girls and LGBTQ youth are more commonly bullied and at higher risk for depression, self-harm, and suicidality as a consequence of cyberbullying. Youth already suffering from a psychiatric illness or substance abuse who are bullied are at higher risk for self-harm and suicidality than that of their bullied peers. Youth whose parents score high on measures of distress and family dysfunction also face higher risk of self-harm and suicidality after bullying.¹

Social Media

Unlike bullying, social media has been a force only in 21st century life, with Facebook starting in 2004 and cellphones in common use by adolescents in the past 2 decades. While there are potential benefits of social media use, such as stronger connections to supportive peers for isolated LGBTQ youth or youth who live in rural areas, there are also risks. Of course, social media carries the risk of cyberbullying. It also carries the risk for very heavy patterns of use that can interfere with physical activity, adequate sleep, academic performance, and healthy in-person social activities. There is robust emerging evidence that heavy users have higher rates of mood disorders and anxiety symptoms, although it is unclear whether social media exacerbates, or more social media use is the result of depression and/or anxiety. Adolescents’ desire for social acceptance makes them especially sensitive to the social rewards of “likes” and they are thus vulnerable to becoming heavy users. Adolescent girls who are heavy users are vulnerable to developing a disordered body image and eating disorders. Those youth with especially low levels of impulse control, such as those with ADHD, have greater risk of developing problematic use.^2-4

Substance Use and Abuse

Exploration of alcohol and drug use has been a common experience, and hazard, of adolescence for many generations. As a result, we have richer knowledge of those factors that are associated with risk of and protection against that use progressing to a use disorder. Earlier age at first experimentation appears to be independently correlated with increased risk of developing a substance use disorder. Every pediatrician should be aware of a family history of substance use disorders, especially alcohol, as they are strongly associated with higher risk. Youth with temperaments that are sensation seeking, externalizing and impulsive are at higher risk. Youth with anxiety and mood disorders and untreated attention deficit disorders are at higher risk. Youth whose parents have high levels of conflict or “permissive” parenting styles are at higher risk as are those who as children experienced abuse or neglect.^5-7

Minimizing Risk and Cultivating Resilience

Protective factors balance these risks: adequate sleep; positive relationships with friends and parents; and confidence in their academic, athletic, or social abilities all are correlated with good outcomes after bullying, drug and alcohol use, and social media use. These teenagers are meaningfully connected to caring adults and peers, have a future orientation, and typically have higher self-esteem. Youth whose parents balance attunement with rules and expectations (“authoritative” parenting) appear to be at lower risk of poor mental health outcomes associated with heavy social media use as well as other risk behaviors. These parents have clear rules and expectations, including about drugs and alcohol, and enforce rules reasonably calmly and consistently. Youth whose families eat dinner together at least three times weekly, who attend schools that offer a wide range of after-school activities, and who learn to use problem-focused coping skills rather than emotion-focused coping skills are protected against poor mental health outcomes in the face of these challenges.

While bullying is a stressor, social media and substances may seem like ways of managing stress and connecting with peers. There are youth with clear vulnerabilities to the risks associated with each of them. Shared factors include vulnerable temperaments, high conflict or permissive parenting, family history of substance use disorders or preexisting psychiatric illness. Pediatricians are in a unique position to raise teenagers’ awareness of their specific vulnerabilities. Talk about the heightened risk of experimentation with alcohol or drugs in your patients who are in treatment for an anxiety or mood disorder. Help them cultivate critical thinking — an adolescent specialty — around marketing and peer pressure. Remind them that social media companies make money from keeping them online longer. Then help them identify what strategies are in their control, such as limiting their time online. What else could they be doing with their time that they actually enjoy? Remind them about the value of protecting time for adequate sleep, regular exercise, and sitting down for dinner with their family. Ask about their nourishing relationships with peers and adults and talk about the value of protecting time for them. Ask your patients and their parents about how they face stress, emphasizing their ability to locate what is within their control. While awareness of feelings is important, learning to manage intense emotions is more connected to healthy habits of sleep and exercise and strategies to get support or pivot to engaging activities. Discussing this openly models for parents how to bear difficulty alongside their children without becoming distressed or punitive themselves. Talk with worried parents about the value of regular meals together, shared physical activities, and supporting time for their children’s emerging interests and hobbies. Equipping your patients and their parents with knowledge about their particular vulnerabilities, reminders about what is known about these risks, and all that is in their power to build resilience, may be as meaningful a public health intervention as asking them about biking with helmets and using seat belts.

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

References

1. Zych I et al. Protective Factors Against Bullying and Cyberbullying: A Systematic Review of Meta-Analyses. Aggress Violent Behav. 2019;45:4-19. doi: 10.1016/j.avb.2018.06.008.

2. Office of the Surgeon General. Social Media and Youth Mental Health: The U.S. Surgeon General’s Advisory. 2023. https://www.ncbi.nlm.nih.gov/books/NBK594761/.

3. Uhls Y et al. Benefits and Costs of Social Media in Adolescence. Pediatrics. 2017 Nov;140(Suppl 2):S67-S70. doi: 10.1542/peds.2016-1758E.

4. Health Advisory on Social Media Use in Adolescence. American Psychological Association (2023).

5. Sloboda Z et al. Revisiting the Concepts of Risk and Protective Factors for Understanding the Etiology and Development of Substance Use and Substance Use Disorders: Implications for Prevention, Substance Use and Misuse, Subst Use Misuse. 2012 Jun-Jul;47(8-9):944-62. doi: 10.3109/10826084.2012.663280.

6. O’Connell M et al. Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Washington, DC: The National Academies Press and US Department of Health and Human Services, Substance Abuse and Mental Health Administration. 2009 (https://nap.nationalacademies.org/catalog/12480/preventing-mental-emotional-and-behavioral-disorders-among-young-people-progress).

7. Staiger P et al. Can Emotion-Focused Coping Help Explain the Link Between Posttraumatic Stress Disorder Severity and Triggers for Substance Use in Young Adults? J Subst Abuse Treat. 2009 Mar;36(2):220-6. doi: 10.1016/j.jsat.2008.05.008.

How might you discuss a suicidal ideation, an anxiety-provoking topic, with your patients and their parents? After a positive screen, there will be times when you decide your patient should go to an emergency department for an urgent evaluation. However, most of the time you will be able to help the family identify strategies to lower risk and improve safety and resilience, while waiting for a thorough psychiatric evaluation.

Bring in the Parents: Modeling Validation, Structure, and Optimism

If you have identified some degree of suicide risk in your patient, either with a screening instrument or in your clinical interview, ask your patient if you can bring their parents into the conversation. They may resist, and if so, find out why they are hesitant. Are they worried about causing their parents some distress? Are they concerned their parents will be surprised? Disappointed? Scared? Angry? Acknowledge how hard it can be to find a way to talk about such emotional material with parents. What is their communication like with their parents usually? Do they talk every night at dinner or rarely? Are their interactions usually lighthearted or playful? Brief? Irritable and angry? Have they talked about or managed difficult times before as a family? How did that go? Did they feel they ended up supporting an anxious or depressed single parent? Was their parent harsh and punitive? Since involving the parent is essential, if you become concerned that a conversation with the parent would truly increase the risk of suicide, perhaps because of reports of violence at home, then you may need to send your patient to the emergency department so they can be assessed in a safe setting where a clinical team can evaluate your patient while involving more (or different) members of the family.

Most of the time, your patient will describe a situation that will simply be uncomfortable or stressful for their parent. Don’t be dismissive of their concerns. Instead, acknowledge that talking about their inner life will feel hard. Validate that their parents will be sad, worried, and stressed to hear about what they are feeling. Then offer that parents always prefer to know what is happening with their child so they can help, even if that means only being present to bear it alongside them. You can remind them that you will be there, too, to reassure their parents that this is a common problem and that you can face it and help it to get better together. Find out if they would like you to take the lead in speaking about it, but do not let them wait in the waiting room. Discussing the topic with you with both parents and patient in the room will help even those families that are not great communicators to begin to be more connected, even if you do most of the talking. While you need to bring their symptoms and suicidality to their parents’ attention, find out if there are any details they would rather not share. Perhaps they are struggling with questions of gender identity or sexual orientation, or are thinking of giving up an activity their parents may be very invested in. While any future treatment will prioritize honest communication within the family, communication about their emerging identity should not be rushed, and especially not in the setting of concerns about suicide risk.

With the information you do gather, there are often steps you can take to lower the stress level. The parents’ awareness of their suffering, perhaps acknowledging a broken heart, excessive academic pressure, or a major disappointment may suggest steps to lower the stress level. A mental health referral might introduce a sense of hope. A reminder of their meaningful connection to a parent, a team, a religion, or an activity may also remind the adolescent of a positive view of their future.
 

Introducing the Topic

When you bring parents into the room, let them know that there is something important and difficult that you need to discuss with them together. Ask if they have noted any changes in their child’s behavior, school performance, or demeanor. Have they had any worries about their teenager? If they have, affirm that they are picking up on something real, and ask more about it. If they have not, offer that their child has been doing a valiant job of soldiering through their days while managing some strong and difficult thoughts and feelings. Walk them through some of what you have learned from your patient, always inviting your patient to affirm or add to what you are detailing. Most parents are keenly aware of the prevalence of suicidal thoughts during adolescence. Bring it into the open, and offer that the next steps are going to be to add more adults to their child’s orbit to help diagnose and treat any underlying psychiatric illness. Reassure them that you are confident that psychiatric illnesses are treatable, even curable. Reassure them that one of the best safety measures is good communication and connectedness with parents.

Help Parents to Be Good Listeners

Some parents may respond with heightened anxiety and need for reassurance from their child. Others may try to talk their child out of their suicidal thoughts. But your year is going so well! You got a great grade in calculus! Gently model validation: Acknowledge to the parents that it is understandable to feel worried or to look for a rational argument against suicide. Offer that feelings don’t usually respond to logic, but do improve with support and time. It may be better for everyone to treat this topic more like the weather so it is easier to talk about and manage. No one gets defensive or distressed if it’s raining, they just put on the right gear. Has the parent ever felt depressed? Did they ever have suicidal ideation growing up? Can they agree to check in at regular times? Could the child speak up if they are feeling badly? Can all agree that parents should check in if their child seems more down? Help them to acknowledge how hard it is to bear strong feelings, but that it is always better together.

Identify Coping Strategies

In front of parents, ask your patient if anything helps when they are feeling at their worst. If they can’t identify anything, offer some possibilities: a walk outside together? making art or music? being out in nature? snuggling with a beloved pet? a set of jumping jacks to get their heart rate up? a favorite playlist? Talking to a particular friend or relative? Make a list. Prioritize activities that are healthy and connect them to others when they are feeling their worst.

Focus on the Basics

Make a concrete and practical plan for steps they can all take to improve well-being. Start with strategies to ensure restful sleep at night, regular exercise, and healthy nutrition. Depression and anxiety often interfere with these functions, so families can work together to support them even while waiting for assessment by a psychiatrist. Help them identify modest rules or routines (consistent bedtime, no screens in the bedroom, a daily walk after dinner) that parents can set that will make a difference.

Set Up Speed Bumps

Talk together about setting up some speed bumps to support their child’s safety. Find out if there are firearms in the home. Be crystal clear that they should be locked, preferably with ammunition, in a separate secure place. Their child should have no knowledge of how to access them, or they should be stored out of the home for the time being.

Parents should lock any medications that could be dangerous in overdose (including in homes if the adolescent will be visiting). Educate them about Tylenol and any prescription medications in their home that should be locked. This part of a conversation is always stressful. Acknowledge that, and remind everyone that, these are important strategies. It should be always be easier to ask their parent for help if they are feeling terrible than it is to access something dangerous.
 

Acknowledge the Strain

Finally, it is important to acknowledge how hard it is for your patient to bear these feelings, and that speaking up about them may feel like the last thing they want to do. Applaud them for their strength while reminding them that they need to share if they feel worse. Likewise, model for parents that feeling stressed and worried in this circumstance is normal. They should think about how to take good care of themselves. The same well-being strategies you reviewed for their child can work for them too! They may want to focus on sleep or exercise, enhance their nourishing social connections, protect time for beloved hobbies. Everyone should hear that they should never worry alone. If someone feels more worried, bring it to their parent, therapist, psychiatrist, spouse, or to you. They should trust their instincts if they think it is time to go to the emergency department. With supportive open communication, they will strengthen the protective connections which in turn will see the family through the course of the treatable illnesses that cause suicidal thoughts.

Lastly, this is difficult work for any physician. As psychiatrists, we worry about higher-risk teenagers when we decide that hospitalization carries a bigger risk than benefit. Pediatricians see many more teenagers with suicidal ideation and even though the statistical risk is very low, no one knows how to predict any individual teenager’s behavior. Therefore, pediatricians face the direct stress of the clinical work and the deeper stress of knowing there is always some uncertainty in medicine.

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

How might you discuss a suicidal ideation, an anxiety-provoking topic, with your patients and their parents? After a positive screen, there will be times when you decide your patient should go to an emergency department for an urgent evaluation. However, most of the time you will be able to help the family identify strategies to lower risk and improve safety and resilience, while waiting for a thorough psychiatric evaluation.

Bring in the Parents: Modeling Validation, Structure, and Optimism

If you have identified some degree of suicide risk in your patient, either with a screening instrument or in your clinical interview, ask your patient if you can bring their parents into the conversation. They may resist, and if so, find out why they are hesitant. Are they worried about causing their parents some distress? Are they concerned their parents will be surprised? Disappointed? Scared? Angry? Acknowledge how hard it can be to find a way to talk about such emotional material with parents. What is their communication like with their parents usually? Do they talk every night at dinner or rarely? Are their interactions usually lighthearted or playful? Brief? Irritable and angry? Have they talked about or managed difficult times before as a family? How did that go? Did they feel they ended up supporting an anxious or depressed single parent? Was their parent harsh and punitive? Since involving the parent is essential, if you become concerned that a conversation with the parent would truly increase the risk of suicide, perhaps because of reports of violence at home, then you may need to send your patient to the emergency department so they can be assessed in a safe setting where a clinical team can evaluate your patient while involving more (or different) members of the family.

Most of the time, your patient will describe a situation that will simply be uncomfortable or stressful for their parent. Don’t be dismissive of their concerns. Instead, acknowledge that talking about their inner life will feel hard. Validate that their parents will be sad, worried, and stressed to hear about what they are feeling. Then offer that parents always prefer to know what is happening with their child so they can help, even if that means only being present to bear it alongside them. You can remind them that you will be there, too, to reassure their parents that this is a common problem and that you can face it and help it to get better together. Find out if they would like you to take the lead in speaking about it, but do not let them wait in the waiting room. Discussing the topic with you with both parents and patient in the room will help even those families that are not great communicators to begin to be more connected, even if you do most of the talking. While you need to bring their symptoms and suicidality to their parents’ attention, find out if there are any details they would rather not share. Perhaps they are struggling with questions of gender identity or sexual orientation, or are thinking of giving up an activity their parents may be very invested in. While any future treatment will prioritize honest communication within the family, communication about their emerging identity should not be rushed, and especially not in the setting of concerns about suicide risk.

With the information you do gather, there are often steps you can take to lower the stress level. The parents’ awareness of their suffering, perhaps acknowledging a broken heart, excessive academic pressure, or a major disappointment may suggest steps to lower the stress level. A mental health referral might introduce a sense of hope. A reminder of their meaningful connection to a parent, a team, a religion, or an activity may also remind the adolescent of a positive view of their future.
 

Introducing the Topic

When you bring parents into the room, let them know that there is something important and difficult that you need to discuss with them together. Ask if they have noted any changes in their child’s behavior, school performance, or demeanor. Have they had any worries about their teenager? If they have, affirm that they are picking up on something real, and ask more about it. If they have not, offer that their child has been doing a valiant job of soldiering through their days while managing some strong and difficult thoughts and feelings. Walk them through some of what you have learned from your patient, always inviting your patient to affirm or add to what you are detailing. Most parents are keenly aware of the prevalence of suicidal thoughts during adolescence. Bring it into the open, and offer that the next steps are going to be to add more adults to their child’s orbit to help diagnose and treat any underlying psychiatric illness. Reassure them that you are confident that psychiatric illnesses are treatable, even curable. Reassure them that one of the best safety measures is good communication and connectedness with parents.

Help Parents to Be Good Listeners

Some parents may respond with heightened anxiety and need for reassurance from their child. Others may try to talk their child out of their suicidal thoughts. But your year is going so well! You got a great grade in calculus! Gently model validation: Acknowledge to the parents that it is understandable to feel worried or to look for a rational argument against suicide. Offer that feelings don’t usually respond to logic, but do improve with support and time. It may be better for everyone to treat this topic more like the weather so it is easier to talk about and manage. No one gets defensive or distressed if it’s raining, they just put on the right gear. Has the parent ever felt depressed? Did they ever have suicidal ideation growing up? Can they agree to check in at regular times? Could the child speak up if they are feeling badly? Can all agree that parents should check in if their child seems more down? Help them to acknowledge how hard it is to bear strong feelings, but that it is always better together.

Identify Coping Strategies

In front of parents, ask your patient if anything helps when they are feeling at their worst. If they can’t identify anything, offer some possibilities: a walk outside together? making art or music? being out in nature? snuggling with a beloved pet? a set of jumping jacks to get their heart rate up? a favorite playlist? Talking to a particular friend or relative? Make a list. Prioritize activities that are healthy and connect them to others when they are feeling their worst.

Focus on the Basics

Make a concrete and practical plan for steps they can all take to improve well-being. Start with strategies to ensure restful sleep at night, regular exercise, and healthy nutrition. Depression and anxiety often interfere with these functions, so families can work together to support them even while waiting for assessment by a psychiatrist. Help them identify modest rules or routines (consistent bedtime, no screens in the bedroom, a daily walk after dinner) that parents can set that will make a difference.

Set Up Speed Bumps

Talk together about setting up some speed bumps to support their child’s safety. Find out if there are firearms in the home. Be crystal clear that they should be locked, preferably with ammunition, in a separate secure place. Their child should have no knowledge of how to access them, or they should be stored out of the home for the time being.

Parents should lock any medications that could be dangerous in overdose (including in homes if the adolescent will be visiting). Educate them about Tylenol and any prescription medications in their home that should be locked. This part of a conversation is always stressful. Acknowledge that, and remind everyone that, these are important strategies. It should be always be easier to ask their parent for help if they are feeling terrible than it is to access something dangerous.
 

Acknowledge the Strain

Finally, it is important to acknowledge how hard it is for your patient to bear these feelings, and that speaking up about them may feel like the last thing they want to do. Applaud them for their strength while reminding them that they need to share if they feel worse. Likewise, model for parents that feeling stressed and worried in this circumstance is normal. They should think about how to take good care of themselves. The same well-being strategies you reviewed for their child can work for them too! They may want to focus on sleep or exercise, enhance their nourishing social connections, protect time for beloved hobbies. Everyone should hear that they should never worry alone. If someone feels more worried, bring it to their parent, therapist, psychiatrist, spouse, or to you. They should trust their instincts if they think it is time to go to the emergency department. With supportive open communication, they will strengthen the protective connections which in turn will see the family through the course of the treatable illnesses that cause suicidal thoughts.

Lastly, this is difficult work for any physician. As psychiatrists, we worry about higher-risk teenagers when we decide that hospitalization carries a bigger risk than benefit. Pediatricians see many more teenagers with suicidal ideation and even though the statistical risk is very low, no one knows how to predict any individual teenager’s behavior. Therefore, pediatricians face the direct stress of the clinical work and the deeper stress of knowing there is always some uncertainty in medicine.

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

How might you discuss a suicidal ideation, an anxiety-provoking topic, with your patients and their parents? After a positive screen, there will be times when you decide your patient should go to an emergency department for an urgent evaluation. However, most of the time you will be able to help the family identify strategies to lower risk and improve safety and resilience, while waiting for a thorough psychiatric evaluation.

Bring in the Parents: Modeling Validation, Structure, and Optimism

If you have identified some degree of suicide risk in your patient, either with a screening instrument or in your clinical interview, ask your patient if you can bring their parents into the conversation. They may resist, and if so, find out why they are hesitant. Are they worried about causing their parents some distress? Are they concerned their parents will be surprised? Disappointed? Scared? Angry? Acknowledge how hard it can be to find a way to talk about such emotional material with parents. What is their communication like with their parents usually? Do they talk every night at dinner or rarely? Are their interactions usually lighthearted or playful? Brief? Irritable and angry? Have they talked about or managed difficult times before as a family? How did that go? Did they feel they ended up supporting an anxious or depressed single parent? Was their parent harsh and punitive? Since involving the parent is essential, if you become concerned that a conversation with the parent would truly increase the risk of suicide, perhaps because of reports of violence at home, then you may need to send your patient to the emergency department so they can be assessed in a safe setting where a clinical team can evaluate your patient while involving more (or different) members of the family.

Most of the time, your patient will describe a situation that will simply be uncomfortable or stressful for their parent. Don’t be dismissive of their concerns. Instead, acknowledge that talking about their inner life will feel hard. Validate that their parents will be sad, worried, and stressed to hear about what they are feeling. Then offer that parents always prefer to know what is happening with their child so they can help, even if that means only being present to bear it alongside them. You can remind them that you will be there, too, to reassure their parents that this is a common problem and that you can face it and help it to get better together. Find out if they would like you to take the lead in speaking about it, but do not let them wait in the waiting room. Discussing the topic with you with both parents and patient in the room will help even those families that are not great communicators to begin to be more connected, even if you do most of the talking. While you need to bring their symptoms and suicidality to their parents’ attention, find out if there are any details they would rather not share. Perhaps they are struggling with questions of gender identity or sexual orientation, or are thinking of giving up an activity their parents may be very invested in. While any future treatment will prioritize honest communication within the family, communication about their emerging identity should not be rushed, and especially not in the setting of concerns about suicide risk.

With the information you do gather, there are often steps you can take to lower the stress level. The parents’ awareness of their suffering, perhaps acknowledging a broken heart, excessive academic pressure, or a major disappointment may suggest steps to lower the stress level. A mental health referral might introduce a sense of hope. A reminder of their meaningful connection to a parent, a team, a religion, or an activity may also remind the adolescent of a positive view of their future.
 

Introducing the Topic

When you bring parents into the room, let them know that there is something important and difficult that you need to discuss with them together. Ask if they have noted any changes in their child’s behavior, school performance, or demeanor. Have they had any worries about their teenager? If they have, affirm that they are picking up on something real, and ask more about it. If they have not, offer that their child has been doing a valiant job of soldiering through their days while managing some strong and difficult thoughts and feelings. Walk them through some of what you have learned from your patient, always inviting your patient to affirm or add to what you are detailing. Most parents are keenly aware of the prevalence of suicidal thoughts during adolescence. Bring it into the open, and offer that the next steps are going to be to add more adults to their child’s orbit to help diagnose and treat any underlying psychiatric illness. Reassure them that you are confident that psychiatric illnesses are treatable, even curable. Reassure them that one of the best safety measures is good communication and connectedness with parents.

Help Parents to Be Good Listeners

Some parents may respond with heightened anxiety and need for reassurance from their child. Others may try to talk their child out of their suicidal thoughts. But your year is going so well! You got a great grade in calculus! Gently model validation: Acknowledge to the parents that it is understandable to feel worried or to look for a rational argument against suicide. Offer that feelings don’t usually respond to logic, but do improve with support and time. It may be better for everyone to treat this topic more like the weather so it is easier to talk about and manage. No one gets defensive or distressed if it’s raining, they just put on the right gear. Has the parent ever felt depressed? Did they ever have suicidal ideation growing up? Can they agree to check in at regular times? Could the child speak up if they are feeling badly? Can all agree that parents should check in if their child seems more down? Help them to acknowledge how hard it is to bear strong feelings, but that it is always better together.

Identify Coping Strategies

In front of parents, ask your patient if anything helps when they are feeling at their worst. If they can’t identify anything, offer some possibilities: a walk outside together? making art or music? being out in nature? snuggling with a beloved pet? a set of jumping jacks to get their heart rate up? a favorite playlist? Talking to a particular friend or relative? Make a list. Prioritize activities that are healthy and connect them to others when they are feeling their worst.

Focus on the Basics

Make a concrete and practical plan for steps they can all take to improve well-being. Start with strategies to ensure restful sleep at night, regular exercise, and healthy nutrition. Depression and anxiety often interfere with these functions, so families can work together to support them even while waiting for assessment by a psychiatrist. Help them identify modest rules or routines (consistent bedtime, no screens in the bedroom, a daily walk after dinner) that parents can set that will make a difference.

Set Up Speed Bumps

Talk together about setting up some speed bumps to support their child’s safety. Find out if there are firearms in the home. Be crystal clear that they should be locked, preferably with ammunition, in a separate secure place. Their child should have no knowledge of how to access them, or they should be stored out of the home for the time being.

Parents should lock any medications that could be dangerous in overdose (including in homes if the adolescent will be visiting). Educate them about Tylenol and any prescription medications in their home that should be locked. This part of a conversation is always stressful. Acknowledge that, and remind everyone that, these are important strategies. It should be always be easier to ask their parent for help if they are feeling terrible than it is to access something dangerous.
 

Acknowledge the Strain

Finally, it is important to acknowledge how hard it is for your patient to bear these feelings, and that speaking up about them may feel like the last thing they want to do. Applaud them for their strength while reminding them that they need to share if they feel worse. Likewise, model for parents that feeling stressed and worried in this circumstance is normal. They should think about how to take good care of themselves. The same well-being strategies you reviewed for their child can work for them too! They may want to focus on sleep or exercise, enhance their nourishing social connections, protect time for beloved hobbies. Everyone should hear that they should never worry alone. If someone feels more worried, bring it to their parent, therapist, psychiatrist, spouse, or to you. They should trust their instincts if they think it is time to go to the emergency department. With supportive open communication, they will strengthen the protective connections which in turn will see the family through the course of the treatable illnesses that cause suicidal thoughts.

Lastly, this is difficult work for any physician. As psychiatrists, we worry about higher-risk teenagers when we decide that hospitalization carries a bigger risk than benefit. Pediatricians see many more teenagers with suicidal ideation and even though the statistical risk is very low, no one knows how to predict any individual teenager’s behavior. Therefore, pediatricians face the direct stress of the clinical work and the deeper stress of knowing there is always some uncertainty in medicine.

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

Suicide is among the top three causes of death for young people in the United States. According to the Centers for Disease Control and Prevention, the rate of suicide deaths has climbed from 4.4 per 100,000 American 12- to 17-year-olds in 2011 to 6.5 per 100,000 in 2021, an increase of almost 50%. As with accidents and homicides, we hope these are preventable deaths, although the factors contributing to them are complex.

We do know that more than half of the people who die by suicide visit a health care provider within 4 weeks of their death, highlighting an opportunity for screening and intervention.
 

Suicide screening

In 2022, the American Academy of Pediatrics (AAP) recommended that all adolescents get screened for suicide risk annually. Given that less than 1 in 10,000 adolescents commit suicide and that there is no definitive data on how to prevent suicide in any individual, the goal of suicide screening is much broader than preventing suicide. Beyond universal screening, we will review how being open and curious with all of your patients can be the most extraordinary screening instrument.

There is extensive data that tells us that far from causing suicide, asking about suicidal thoughts is protective. When you make suicidal thoughts discussable, you directly counteract the isolation, stigma, and shame that are strong predictors of actual suicide attempts. You model the value of bringing difficult or frightening thoughts to the attention of caring adults, and you model calm listening rather than emotional overreaction for their parents. The resulting connectedness can lower the risk for vulnerable patients and enhance resilience for all of your patients.
 

Who is at greater risk?

We have robust data to guide our understanding of which youth have suicidal ideation, which is distinct from those who attempt suicide, which also may be quite distinct from those who complete. The CDC reports that the rate of suicidal thoughts (“seriously considering suicide”) in high school students climbed from 16% in 2011 to 22% in 2021. In that decade, the number of high schoolers with a suicide plan climbed from 13% to 18%, and those with suicide attempts climbed from 8% to 10%. Girls are at higher risk for suicidal thoughts and attempts, but boys are at greater risk for suicide completion. Black youth were more likely to attempt suicide than were their Asian, Hispanic, or White peers and LGBTQ+ youth are at particular risk; in 2021, they were three times as likely as were their heterosexual peers to have suicidal thoughts and attempts. Youth with psychiatric illness (particularly PTSD, mood or thought disorders), a family history of suicide, a history of risk-taking behavior (including sexual activity, smoking, drinking, and drug use) and those with prior suicide attempts are at the highest risk for suicide. Adding all these risk factors together means that many, if not the majority, of teenagers have risk factors.

Focus on the patient

In your office, though, a public health approach should give way to curiosity about your individual patient. Suicidal thoughts usually follow a substantial stress. Pay attention to exceptional stresses, especially if they have a component of social stigma or isolation. Did your patient report another student for an assault? Are they now being bullied or ostracized by friends? Have they lost an especially important relationship? Some other stresses may seem minor, such as a poor grade on a test. But for a very driven, perfectionistic teenager who believes that a perfect 4.0 GPA is essential to college admission and future success and happiness, one poor grade may feel like a catastrophe.

When your patients tell you about a challenge or setback, slow down and be curious. Listen to the importance they give it. How have they managed it? Are they finding it hard to go to school or back to practice? Do they feel discouraged or even hopeless? Discouragement is a normal response to adversity, but it should be temporary. This approach can make it easy to ask if they have ever wished they were dead, or made a suicide plan or an attempt. When you calmly and supportively learn about their inner experience, it will be easy for young people to be honest with you.

There will be teenagers in your practice who are sensation-seeking and impulsive, and you should pay special attention to this group. They may not be classically depressed, but in the aftermath of a stressful experience that they find humiliating or shameful, they are at risk for an impulsive act that could still be lethal. Be curious with these patients after they feel they have let down their team or their family, or if they have been caught in a crime or cheating, or even if their girlfriend breaks up with them. Find out how they are managing, and where their support comes from. Ask them in a nonjudgmental manner about whether they are having thoughts about death or suicide, and if those thoughts are troubling, frequent, or feel like a relief. What has stopped them from acting on these thoughts? Offer your patient the perspective that such thoughts may be normal in the face of a large stress, but that the pain of stress always subsides, whereas suicide is irreversible.

There will also be patients in your practice who cut themselves. This is sometimes called “nonsuicidal self-injury,” and it often raises concern about suicide risk. While accelerating frequency of self-injury in a teenager who is suicidal can indicate growing risk, this behavior alone is usually a mechanism for regulating emotion. Ask your patient about when they cut themselves. What are the triggers? How do they feel afterward? Are their friends all doing it? Is it only after fighting with their parents? Or does it make their parents worry instead of getting angry? As you learn about the nature of the behavior, you will be able to offer thoughtful guidance about better strategies for stress management or to pursue further assessment and support.
 

Next steps

Speaking comfortably with your patients about suicidal thoughts and behaviors requires that you also feel comfortable with what comes next. As in the ASQ screening instrument recommended by the AAP, you should always follow affirmative answers about suicidal thoughts with more questions. Do they have a plan? Do they have access to lethal means including any guns in the home? Have they ever made an attempt? Are they thinking about killing themselves now? If the thoughts are current, they have access, and they have tried before, it is clear that they need an urgent assessment, probably in an emergency department. But when the thoughts were in the past or have never been connected to plans or intent, there is an opportunity to enhance their connectedness. You can diminish the potential for shame, stigma and isolation by reminding them that such thoughts and feelings are normal in the face of difficulty. They deserve support to help them face and manage their adversity, whether that stress comes from an internal or external source. How do they feel now that they have shared these thoughts with you? Most will describe feeling better, relieved, even hopeful once they are not facing intense thoughts and feelings alone.

You should tell them that you would like to bring their parents into the conversation. You want them to know they can turn to their parents if they are having these thoughts, so they are never alone in facing them. Parents can learn from your model of calm and supportive listening to fully understand the situation before turning together to talk about what might be helpful next steps. It is always prudent to create “speed bumps” between thought and action with impulsive teens, so recommend limiting access to any lethal means (firearms especially). But the strongest protective intervention is for the child to feel confident in and connected to their support network, trusting you and their parents to listen and understand before figuring out together what else is needed to address the situation.

Lastly, recognize that talking about difficult issues with teenagers is among the most stressful and demanding aspects of pediatric primary care. Talk to colleagues, never worry alone, and recognize and manage your own stress. This is among the best ways to model for your patients and their parents that every challenge can be met, but we often need support.
 

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

Suicide is among the top three causes of death for young people in the United States. According to the Centers for Disease Control and Prevention, the rate of suicide deaths has climbed from 4.4 per 100,000 American 12- to 17-year-olds in 2011 to 6.5 per 100,000 in 2021, an increase of almost 50%. As with accidents and homicides, we hope these are preventable deaths, although the factors contributing to them are complex.

We do know that more than half of the people who die by suicide visit a health care provider within 4 weeks of their death, highlighting an opportunity for screening and intervention.
 

Suicide screening

In 2022, the American Academy of Pediatrics (AAP) recommended that all adolescents get screened for suicide risk annually. Given that less than 1 in 10,000 adolescents commit suicide and that there is no definitive data on how to prevent suicide in any individual, the goal of suicide screening is much broader than preventing suicide. Beyond universal screening, we will review how being open and curious with all of your patients can be the most extraordinary screening instrument.

There is extensive data that tells us that far from causing suicide, asking about suicidal thoughts is protective. When you make suicidal thoughts discussable, you directly counteract the isolation, stigma, and shame that are strong predictors of actual suicide attempts. You model the value of bringing difficult or frightening thoughts to the attention of caring adults, and you model calm listening rather than emotional overreaction for their parents. The resulting connectedness can lower the risk for vulnerable patients and enhance resilience for all of your patients.
 

Who is at greater risk?

We have robust data to guide our understanding of which youth have suicidal ideation, which is distinct from those who attempt suicide, which also may be quite distinct from those who complete. The CDC reports that the rate of suicidal thoughts (“seriously considering suicide”) in high school students climbed from 16% in 2011 to 22% in 2021. In that decade, the number of high schoolers with a suicide plan climbed from 13% to 18%, and those with suicide attempts climbed from 8% to 10%. Girls are at higher risk for suicidal thoughts and attempts, but boys are at greater risk for suicide completion. Black youth were more likely to attempt suicide than were their Asian, Hispanic, or White peers and LGBTQ+ youth are at particular risk; in 2021, they were three times as likely as were their heterosexual peers to have suicidal thoughts and attempts. Youth with psychiatric illness (particularly PTSD, mood or thought disorders), a family history of suicide, a history of risk-taking behavior (including sexual activity, smoking, drinking, and drug use) and those with prior suicide attempts are at the highest risk for suicide. Adding all these risk factors together means that many, if not the majority, of teenagers have risk factors.

Focus on the patient

In your office, though, a public health approach should give way to curiosity about your individual patient. Suicidal thoughts usually follow a substantial stress. Pay attention to exceptional stresses, especially if they have a component of social stigma or isolation. Did your patient report another student for an assault? Are they now being bullied or ostracized by friends? Have they lost an especially important relationship? Some other stresses may seem minor, such as a poor grade on a test. But for a very driven, perfectionistic teenager who believes that a perfect 4.0 GPA is essential to college admission and future success and happiness, one poor grade may feel like a catastrophe.

When your patients tell you about a challenge or setback, slow down and be curious. Listen to the importance they give it. How have they managed it? Are they finding it hard to go to school or back to practice? Do they feel discouraged or even hopeless? Discouragement is a normal response to adversity, but it should be temporary. This approach can make it easy to ask if they have ever wished they were dead, or made a suicide plan or an attempt. When you calmly and supportively learn about their inner experience, it will be easy for young people to be honest with you.

There will be teenagers in your practice who are sensation-seeking and impulsive, and you should pay special attention to this group. They may not be classically depressed, but in the aftermath of a stressful experience that they find humiliating or shameful, they are at risk for an impulsive act that could still be lethal. Be curious with these patients after they feel they have let down their team or their family, or if they have been caught in a crime or cheating, or even if their girlfriend breaks up with them. Find out how they are managing, and where their support comes from. Ask them in a nonjudgmental manner about whether they are having thoughts about death or suicide, and if those thoughts are troubling, frequent, or feel like a relief. What has stopped them from acting on these thoughts? Offer your patient the perspective that such thoughts may be normal in the face of a large stress, but that the pain of stress always subsides, whereas suicide is irreversible.

There will also be patients in your practice who cut themselves. This is sometimes called “nonsuicidal self-injury,” and it often raises concern about suicide risk. While accelerating frequency of self-injury in a teenager who is suicidal can indicate growing risk, this behavior alone is usually a mechanism for regulating emotion. Ask your patient about when they cut themselves. What are the triggers? How do they feel afterward? Are their friends all doing it? Is it only after fighting with their parents? Or does it make their parents worry instead of getting angry? As you learn about the nature of the behavior, you will be able to offer thoughtful guidance about better strategies for stress management or to pursue further assessment and support.
 

Next steps

Speaking comfortably with your patients about suicidal thoughts and behaviors requires that you also feel comfortable with what comes next. As in the ASQ screening instrument recommended by the AAP, you should always follow affirmative answers about suicidal thoughts with more questions. Do they have a plan? Do they have access to lethal means including any guns in the home? Have they ever made an attempt? Are they thinking about killing themselves now? If the thoughts are current, they have access, and they have tried before, it is clear that they need an urgent assessment, probably in an emergency department. But when the thoughts were in the past or have never been connected to plans or intent, there is an opportunity to enhance their connectedness. You can diminish the potential for shame, stigma and isolation by reminding them that such thoughts and feelings are normal in the face of difficulty. They deserve support to help them face and manage their adversity, whether that stress comes from an internal or external source. How do they feel now that they have shared these thoughts with you? Most will describe feeling better, relieved, even hopeful once they are not facing intense thoughts and feelings alone.

You should tell them that you would like to bring their parents into the conversation. You want them to know they can turn to their parents if they are having these thoughts, so they are never alone in facing them. Parents can learn from your model of calm and supportive listening to fully understand the situation before turning together to talk about what might be helpful next steps. It is always prudent to create “speed bumps” between thought and action with impulsive teens, so recommend limiting access to any lethal means (firearms especially). But the strongest protective intervention is for the child to feel confident in and connected to their support network, trusting you and their parents to listen and understand before figuring out together what else is needed to address the situation.

Lastly, recognize that talking about difficult issues with teenagers is among the most stressful and demanding aspects of pediatric primary care. Talk to colleagues, never worry alone, and recognize and manage your own stress. This is among the best ways to model for your patients and their parents that every challenge can be met, but we often need support.
 

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

Suicide is among the top three causes of death for young people in the United States. According to the Centers for Disease Control and Prevention, the rate of suicide deaths has climbed from 4.4 per 100,000 American 12- to 17-year-olds in 2011 to 6.5 per 100,000 in 2021, an increase of almost 50%. As with accidents and homicides, we hope these are preventable deaths, although the factors contributing to them are complex.

We do know that more than half of the people who die by suicide visit a health care provider within 4 weeks of their death, highlighting an opportunity for screening and intervention.
 

Suicide screening

In 2022, the American Academy of Pediatrics (AAP) recommended that all adolescents get screened for suicide risk annually. Given that less than 1 in 10,000 adolescents commit suicide and that there is no definitive data on how to prevent suicide in any individual, the goal of suicide screening is much broader than preventing suicide. Beyond universal screening, we will review how being open and curious with all of your patients can be the most extraordinary screening instrument.

There is extensive data that tells us that far from causing suicide, asking about suicidal thoughts is protective. When you make suicidal thoughts discussable, you directly counteract the isolation, stigma, and shame that are strong predictors of actual suicide attempts. You model the value of bringing difficult or frightening thoughts to the attention of caring adults, and you model calm listening rather than emotional overreaction for their parents. The resulting connectedness can lower the risk for vulnerable patients and enhance resilience for all of your patients.
 

Who is at greater risk?

We have robust data to guide our understanding of which youth have suicidal ideation, which is distinct from those who attempt suicide, which also may be quite distinct from those who complete. The CDC reports that the rate of suicidal thoughts (“seriously considering suicide”) in high school students climbed from 16% in 2011 to 22% in 2021. In that decade, the number of high schoolers with a suicide plan climbed from 13% to 18%, and those with suicide attempts climbed from 8% to 10%. Girls are at higher risk for suicidal thoughts and attempts, but boys are at greater risk for suicide completion. Black youth were more likely to attempt suicide than were their Asian, Hispanic, or White peers and LGBTQ+ youth are at particular risk; in 2021, they were three times as likely as were their heterosexual peers to have suicidal thoughts and attempts. Youth with psychiatric illness (particularly PTSD, mood or thought disorders), a family history of suicide, a history of risk-taking behavior (including sexual activity, smoking, drinking, and drug use) and those with prior suicide attempts are at the highest risk for suicide. Adding all these risk factors together means that many, if not the majority, of teenagers have risk factors.

Focus on the patient

In your office, though, a public health approach should give way to curiosity about your individual patient. Suicidal thoughts usually follow a substantial stress. Pay attention to exceptional stresses, especially if they have a component of social stigma or isolation. Did your patient report another student for an assault? Are they now being bullied or ostracized by friends? Have they lost an especially important relationship? Some other stresses may seem minor, such as a poor grade on a test. But for a very driven, perfectionistic teenager who believes that a perfect 4.0 GPA is essential to college admission and future success and happiness, one poor grade may feel like a catastrophe.

When your patients tell you about a challenge or setback, slow down and be curious. Listen to the importance they give it. How have they managed it? Are they finding it hard to go to school or back to practice? Do they feel discouraged or even hopeless? Discouragement is a normal response to adversity, but it should be temporary. This approach can make it easy to ask if they have ever wished they were dead, or made a suicide plan or an attempt. When you calmly and supportively learn about their inner experience, it will be easy for young people to be honest with you.

There will be teenagers in your practice who are sensation-seeking and impulsive, and you should pay special attention to this group. They may not be classically depressed, but in the aftermath of a stressful experience that they find humiliating or shameful, they are at risk for an impulsive act that could still be lethal. Be curious with these patients after they feel they have let down their team or their family, or if they have been caught in a crime or cheating, or even if their girlfriend breaks up with them. Find out how they are managing, and where their support comes from. Ask them in a nonjudgmental manner about whether they are having thoughts about death or suicide, and if those thoughts are troubling, frequent, or feel like a relief. What has stopped them from acting on these thoughts? Offer your patient the perspective that such thoughts may be normal in the face of a large stress, but that the pain of stress always subsides, whereas suicide is irreversible.

There will also be patients in your practice who cut themselves. This is sometimes called “nonsuicidal self-injury,” and it often raises concern about suicide risk. While accelerating frequency of self-injury in a teenager who is suicidal can indicate growing risk, this behavior alone is usually a mechanism for regulating emotion. Ask your patient about when they cut themselves. What are the triggers? How do they feel afterward? Are their friends all doing it? Is it only after fighting with their parents? Or does it make their parents worry instead of getting angry? As you learn about the nature of the behavior, you will be able to offer thoughtful guidance about better strategies for stress management or to pursue further assessment and support.
 

Next steps

Speaking comfortably with your patients about suicidal thoughts and behaviors requires that you also feel comfortable with what comes next. As in the ASQ screening instrument recommended by the AAP, you should always follow affirmative answers about suicidal thoughts with more questions. Do they have a plan? Do they have access to lethal means including any guns in the home? Have they ever made an attempt? Are they thinking about killing themselves now? If the thoughts are current, they have access, and they have tried before, it is clear that they need an urgent assessment, probably in an emergency department. But when the thoughts were in the past or have never been connected to plans or intent, there is an opportunity to enhance their connectedness. You can diminish the potential for shame, stigma and isolation by reminding them that such thoughts and feelings are normal in the face of difficulty. They deserve support to help them face and manage their adversity, whether that stress comes from an internal or external source. How do they feel now that they have shared these thoughts with you? Most will describe feeling better, relieved, even hopeful once they are not facing intense thoughts and feelings alone.

You should tell them that you would like to bring their parents into the conversation. You want them to know they can turn to their parents if they are having these thoughts, so they are never alone in facing them. Parents can learn from your model of calm and supportive listening to fully understand the situation before turning together to talk about what might be helpful next steps. It is always prudent to create “speed bumps” between thought and action with impulsive teens, so recommend limiting access to any lethal means (firearms especially). But the strongest protective intervention is for the child to feel confident in and connected to their support network, trusting you and their parents to listen and understand before figuring out together what else is needed to address the situation.

Lastly, recognize that talking about difficult issues with teenagers is among the most stressful and demanding aspects of pediatric primary care. Talk to colleagues, never worry alone, and recognize and manage your own stress. This is among the best ways to model for your patients and their parents that every challenge can be met, but we often need support.
 

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

This month we are following up on our previous piece on anxiety disorders. We wrote about how these disorders are common, amenable to treatment, and often curable, but are often missed as many children suffer silently or their symptoms are mistaken for signs of other problems. We reviewed the screening instruments that can help you to catch these “quiet” illnesses. Now, we are going to offer some detail about the effective treatments for the most common anxiety disorders and how to approach getting treatment started when a screen has turned up positive. If you are interested in a deeper dive, the American Academy of Child and Adolescent Psychiatry has detailed practice parameters for the disorders discussed below.

Anxiety disorders in young children

Separation anxiety disorder, specific phobia, generalized anxiety disorder, and social phobia are the anxiety disorders that most commonly affect the youngest children. Separation anxiety disorder is the most common childhood anxiety disorder and has an average age of onset of 6 years, whereas specific phobia peaks between 5 and 8 years of age, generalized anxiety disorder peaks at 8 years old and social phobia (or social anxiety disorder) has a peak age of onset of 13 years. The first-line treatment for each disorder is cognitive-behavioral therapy (CBT), and specifically a variant called exposure and response prevention. This treatment essentially helps patients to “learn” to have a different response, not anxiety, to the triggering thought or stimulus. CBT can be very effective, curative even, but these disorders can be difficult to treat when a child’s level of anxiety exceeds their ability to engage in treatment. In these cases, treatment can be facilitated by the addition of an SSRI, which is recommended by the American Academy of Child and Adolescent Psychiatry as a second-line treatment in children aged 6-18 years. Given the anxious child’s sensitivity to some side effects (such as GI distress) starting at a low dose and titrating up slowly is the recommendation, and effective dose ranges are higher than for the treatment of mood disorders. Without treatment, these disorders may become learned over years and predict complicating anxiety, mood, and substance use disorders in adolescence and adulthood. Any treatment can be helped by the addition of parent guidance, in which parents learn how to be emotionally supportive to their anxious children without accommodating to their demands or asking them to avoid of the source of anxiety.
 

Obsessive-compulsive disorder

Mild obsessive-compulsive disorder (OCD) describes what many of us do, like double-checking we have locked our door or put our work into our briefcase. OCD as a diagnosis with substantial dysfunction has a peak onset at age 10 and again at the age of 21. Over 50% of childhood-onset OCD will have a comorbid anxiety, attention, eating, or tic disorder. Without treatment, OCD is likely to become chronic, and the symptoms (intrusive thoughts, obsessive rumination, and compulsive behaviors) interfere with social and academic function. The behavioral accommodations and avoidance of distress that mark untreated OCD interfere with the healthy development of normal stress management skills that are a critical part of early and later adolescence. First-line treatment is CBT (with exposure and response prevention) with a therapist experienced in the treatment of OCD. A detailed symptom inventory (the Children’s Yale-Brown Obsessive Compulsive Scale) is relatively simple to complete, will confirm a suspected OCD diagnosis, and will create a valuable baseline by which treatment efficacy can be assessed. For those children with moderate to severe OCD, addition of an SSRI to augment and facilitate CBT therapy is recommended. Sertraline, fluvoxamine, fluoxetine, and paroxetine have all been studied and demonstrated efficacy. Clomipramine has well-established efficacy, but its more serious side effects and poorer tolerability make SSRIs the first choice. As with other anxiety disorders, starting at very low doses and titrating upward gradually is recommended. The efficacy of medication treatments is lower in those patients who have other psychiatric illnesses occurring with OCD. Again, parent guidance can be invaluable in supporting the child and improving family well-being.

PTSD

Studies have suggested that between 15% and 45% of children and adolescents in the United States experience a traumatic event, but of those children less than 15% of girls and 6% of boys will develop PTSD in the months that follow. It is important to consider other mood and anxiety disorders in assessing youth with a trauma history who present with symptoms of anxiety and impaired function more than 1 month after the traumatic event. With a history of a traumatic event, it can be helpful to use a specific screening instrument for PTSD, such as the Child PTSD Symptoms Scale or the UCLA PTSD Reaction Index. The symptoms of other disorders (including ADHD) can mimic PTSD, and these disorders may be comorbid with mood, substance use, and eating disorders. Treatment is trauma-focused CBT, with careful use of medications to manage specific symptoms (such as nightmares). Evidence has shown that inclusion of parents in the CBT treatment results in greater reduction in both mood and behavioral symptoms than treating the children alone.

Special cases: School refusal

School refusal affects between 2% and 5% of children, and it is critical to address it promptly or else it can become entrenched and much more difficult to treat. It peaks at 6 and again at 14 years old and often comes to the attention of the pediatrician as children complain of somatic concerns that prove to have no clear cause. It is important to screen for trauma, mood, and anxiety disorders so that you might make reasonable treatment recommendations. But the critical intervention is a behavioral plan that supports the child’s prompt return to school. This requires communication with school personnel and parents to create a plan for the child’s return to school (using natural rewards like friends and trusted teachers) and staying at school (with detailed contingency planning). Parents may need help finding ways to “demagnetize” home and “remagnetize” school, such as turning off the Internet at home and not allowing a child to play sports or with friends when not attending school. Psychotherapy will be helpful for an underlying anxiety or mood disorder, and medications may also be helpful, but education and support for parents to understand how to manage the distress avoidance and rewards of school refusal are generally the critical components of an effective response to this serious problem.

Special cases: Adolescents with new anxiety symptoms

Most childhood anxiety disorders occur before puberty, but anxiety is a common symptom of mood and substance use disorders in teenagers, and often the symptom that drives help-seeking. It is important to screen teens who present with anxiety for underlying mood or substance use disorders. For example, panic disorder is relatively common in young adults, while in teenagers, panic attacks are a frequent symptom of depression or of withdrawal from regular cannabis use. If anxiety has been present and untreated since childhood, adolescents may present with complex comorbid mood and anxiety disorders and struggle with distress tolerance, social difficulties, and perfectionism. Anxiety itself is a very regular developmental feature of adolescence as this is a time of navigating peer relationships, identity, gradual separation from family, and transition to college or work. Every teen would likely benefit from advice about their sleep, exercise, use of any substances, and screen time habits.

For all of your patients with anxiety (and their parents), recognize that anxiety about being liked, making a varsity team, competing for college entrance, and becoming a young adult is expected: uncomfortable, but part of life. It’s adaptive. It helps people to stay safe, get their homework done, and avoid accidents. When people have high levels of anxiety, they can learn to identify their feelings, distinguish between facts and feelings, and learn to manage the anxiety adaptively. If anxiety causes dysfunction in major areas (school, family, friends, activities, and mood), prompt attention is required.

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

This month we are following up on our previous piece on anxiety disorders. We wrote about how these disorders are common, amenable to treatment, and often curable, but are often missed as many children suffer silently or their symptoms are mistaken for signs of other problems. We reviewed the screening instruments that can help you to catch these “quiet” illnesses. Now, we are going to offer some detail about the effective treatments for the most common anxiety disorders and how to approach getting treatment started when a screen has turned up positive. If you are interested in a deeper dive, the American Academy of Child and Adolescent Psychiatry has detailed practice parameters for the disorders discussed below.

Anxiety disorders in young children

Separation anxiety disorder, specific phobia, generalized anxiety disorder, and social phobia are the anxiety disorders that most commonly affect the youngest children. Separation anxiety disorder is the most common childhood anxiety disorder and has an average age of onset of 6 years, whereas specific phobia peaks between 5 and 8 years of age, generalized anxiety disorder peaks at 8 years old and social phobia (or social anxiety disorder) has a peak age of onset of 13 years. The first-line treatment for each disorder is cognitive-behavioral therapy (CBT), and specifically a variant called exposure and response prevention. This treatment essentially helps patients to “learn” to have a different response, not anxiety, to the triggering thought or stimulus. CBT can be very effective, curative even, but these disorders can be difficult to treat when a child’s level of anxiety exceeds their ability to engage in treatment. In these cases, treatment can be facilitated by the addition of an SSRI, which is recommended by the American Academy of Child and Adolescent Psychiatry as a second-line treatment in children aged 6-18 years. Given the anxious child’s sensitivity to some side effects (such as GI distress) starting at a low dose and titrating up slowly is the recommendation, and effective dose ranges are higher than for the treatment of mood disorders. Without treatment, these disorders may become learned over years and predict complicating anxiety, mood, and substance use disorders in adolescence and adulthood. Any treatment can be helped by the addition of parent guidance, in which parents learn how to be emotionally supportive to their anxious children without accommodating to their demands or asking them to avoid of the source of anxiety.
 

Obsessive-compulsive disorder

Mild obsessive-compulsive disorder (OCD) describes what many of us do, like double-checking we have locked our door or put our work into our briefcase. OCD as a diagnosis with substantial dysfunction has a peak onset at age 10 and again at the age of 21. Over 50% of childhood-onset OCD will have a comorbid anxiety, attention, eating, or tic disorder. Without treatment, OCD is likely to become chronic, and the symptoms (intrusive thoughts, obsessive rumination, and compulsive behaviors) interfere with social and academic function. The behavioral accommodations and avoidance of distress that mark untreated OCD interfere with the healthy development of normal stress management skills that are a critical part of early and later adolescence. First-line treatment is CBT (with exposure and response prevention) with a therapist experienced in the treatment of OCD. A detailed symptom inventory (the Children’s Yale-Brown Obsessive Compulsive Scale) is relatively simple to complete, will confirm a suspected OCD diagnosis, and will create a valuable baseline by which treatment efficacy can be assessed. For those children with moderate to severe OCD, addition of an SSRI to augment and facilitate CBT therapy is recommended. Sertraline, fluvoxamine, fluoxetine, and paroxetine have all been studied and demonstrated efficacy. Clomipramine has well-established efficacy, but its more serious side effects and poorer tolerability make SSRIs the first choice. As with other anxiety disorders, starting at very low doses and titrating upward gradually is recommended. The efficacy of medication treatments is lower in those patients who have other psychiatric illnesses occurring with OCD. Again, parent guidance can be invaluable in supporting the child and improving family well-being.

PTSD

Studies have suggested that between 15% and 45% of children and adolescents in the United States experience a traumatic event, but of those children less than 15% of girls and 6% of boys will develop PTSD in the months that follow. It is important to consider other mood and anxiety disorders in assessing youth with a trauma history who present with symptoms of anxiety and impaired function more than 1 month after the traumatic event. With a history of a traumatic event, it can be helpful to use a specific screening instrument for PTSD, such as the Child PTSD Symptoms Scale or the UCLA PTSD Reaction Index. The symptoms of other disorders (including ADHD) can mimic PTSD, and these disorders may be comorbid with mood, substance use, and eating disorders. Treatment is trauma-focused CBT, with careful use of medications to manage specific symptoms (such as nightmares). Evidence has shown that inclusion of parents in the CBT treatment results in greater reduction in both mood and behavioral symptoms than treating the children alone.

Special cases: School refusal

School refusal affects between 2% and 5% of children, and it is critical to address it promptly or else it can become entrenched and much more difficult to treat. It peaks at 6 and again at 14 years old and often comes to the attention of the pediatrician as children complain of somatic concerns that prove to have no clear cause. It is important to screen for trauma, mood, and anxiety disorders so that you might make reasonable treatment recommendations. But the critical intervention is a behavioral plan that supports the child’s prompt return to school. This requires communication with school personnel and parents to create a plan for the child’s return to school (using natural rewards like friends and trusted teachers) and staying at school (with detailed contingency planning). Parents may need help finding ways to “demagnetize” home and “remagnetize” school, such as turning off the Internet at home and not allowing a child to play sports or with friends when not attending school. Psychotherapy will be helpful for an underlying anxiety or mood disorder, and medications may also be helpful, but education and support for parents to understand how to manage the distress avoidance and rewards of school refusal are generally the critical components of an effective response to this serious problem.

Special cases: Adolescents with new anxiety symptoms

Most childhood anxiety disorders occur before puberty, but anxiety is a common symptom of mood and substance use disorders in teenagers, and often the symptom that drives help-seeking. It is important to screen teens who present with anxiety for underlying mood or substance use disorders. For example, panic disorder is relatively common in young adults, while in teenagers, panic attacks are a frequent symptom of depression or of withdrawal from regular cannabis use. If anxiety has been present and untreated since childhood, adolescents may present with complex comorbid mood and anxiety disorders and struggle with distress tolerance, social difficulties, and perfectionism. Anxiety itself is a very regular developmental feature of adolescence as this is a time of navigating peer relationships, identity, gradual separation from family, and transition to college or work. Every teen would likely benefit from advice about their sleep, exercise, use of any substances, and screen time habits.

For all of your patients with anxiety (and their parents), recognize that anxiety about being liked, making a varsity team, competing for college entrance, and becoming a young adult is expected: uncomfortable, but part of life. It’s adaptive. It helps people to stay safe, get their homework done, and avoid accidents. When people have high levels of anxiety, they can learn to identify their feelings, distinguish between facts and feelings, and learn to manage the anxiety adaptively. If anxiety causes dysfunction in major areas (school, family, friends, activities, and mood), prompt attention is required.

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

This month we are following up on our previous piece on anxiety disorders. We wrote about how these disorders are common, amenable to treatment, and often curable, but are often missed as many children suffer silently or their symptoms are mistaken for signs of other problems. We reviewed the screening instruments that can help you to catch these “quiet” illnesses. Now, we are going to offer some detail about the effective treatments for the most common anxiety disorders and how to approach getting treatment started when a screen has turned up positive. If you are interested in a deeper dive, the American Academy of Child and Adolescent Psychiatry has detailed practice parameters for the disorders discussed below.

Anxiety disorders in young children

Separation anxiety disorder, specific phobia, generalized anxiety disorder, and social phobia are the anxiety disorders that most commonly affect the youngest children. Separation anxiety disorder is the most common childhood anxiety disorder and has an average age of onset of 6 years, whereas specific phobia peaks between 5 and 8 years of age, generalized anxiety disorder peaks at 8 years old and social phobia (or social anxiety disorder) has a peak age of onset of 13 years. The first-line treatment for each disorder is cognitive-behavioral therapy (CBT), and specifically a variant called exposure and response prevention. This treatment essentially helps patients to “learn” to have a different response, not anxiety, to the triggering thought or stimulus. CBT can be very effective, curative even, but these disorders can be difficult to treat when a child’s level of anxiety exceeds their ability to engage in treatment. In these cases, treatment can be facilitated by the addition of an SSRI, which is recommended by the American Academy of Child and Adolescent Psychiatry as a second-line treatment in children aged 6-18 years. Given the anxious child’s sensitivity to some side effects (such as GI distress) starting at a low dose and titrating up slowly is the recommendation, and effective dose ranges are higher than for the treatment of mood disorders. Without treatment, these disorders may become learned over years and predict complicating anxiety, mood, and substance use disorders in adolescence and adulthood. Any treatment can be helped by the addition of parent guidance, in which parents learn how to be emotionally supportive to their anxious children without accommodating to their demands or asking them to avoid of the source of anxiety.
 

Obsessive-compulsive disorder

Mild obsessive-compulsive disorder (OCD) describes what many of us do, like double-checking we have locked our door or put our work into our briefcase. OCD as a diagnosis with substantial dysfunction has a peak onset at age 10 and again at the age of 21. Over 50% of childhood-onset OCD will have a comorbid anxiety, attention, eating, or tic disorder. Without treatment, OCD is likely to become chronic, and the symptoms (intrusive thoughts, obsessive rumination, and compulsive behaviors) interfere with social and academic function. The behavioral accommodations and avoidance of distress that mark untreated OCD interfere with the healthy development of normal stress management skills that are a critical part of early and later adolescence. First-line treatment is CBT (with exposure and response prevention) with a therapist experienced in the treatment of OCD. A detailed symptom inventory (the Children’s Yale-Brown Obsessive Compulsive Scale) is relatively simple to complete, will confirm a suspected OCD diagnosis, and will create a valuable baseline by which treatment efficacy can be assessed. For those children with moderate to severe OCD, addition of an SSRI to augment and facilitate CBT therapy is recommended. Sertraline, fluvoxamine, fluoxetine, and paroxetine have all been studied and demonstrated efficacy. Clomipramine has well-established efficacy, but its more serious side effects and poorer tolerability make SSRIs the first choice. As with other anxiety disorders, starting at very low doses and titrating upward gradually is recommended. The efficacy of medication treatments is lower in those patients who have other psychiatric illnesses occurring with OCD. Again, parent guidance can be invaluable in supporting the child and improving family well-being.

PTSD

Studies have suggested that between 15% and 45% of children and adolescents in the United States experience a traumatic event, but of those children less than 15% of girls and 6% of boys will develop PTSD in the months that follow. It is important to consider other mood and anxiety disorders in assessing youth with a trauma history who present with symptoms of anxiety and impaired function more than 1 month after the traumatic event. With a history of a traumatic event, it can be helpful to use a specific screening instrument for PTSD, such as the Child PTSD Symptoms Scale or the UCLA PTSD Reaction Index. The symptoms of other disorders (including ADHD) can mimic PTSD, and these disorders may be comorbid with mood, substance use, and eating disorders. Treatment is trauma-focused CBT, with careful use of medications to manage specific symptoms (such as nightmares). Evidence has shown that inclusion of parents in the CBT treatment results in greater reduction in both mood and behavioral symptoms than treating the children alone.

Special cases: School refusal

School refusal affects between 2% and 5% of children, and it is critical to address it promptly or else it can become entrenched and much more difficult to treat. It peaks at 6 and again at 14 years old and often comes to the attention of the pediatrician as children complain of somatic concerns that prove to have no clear cause. It is important to screen for trauma, mood, and anxiety disorders so that you might make reasonable treatment recommendations. But the critical intervention is a behavioral plan that supports the child’s prompt return to school. This requires communication with school personnel and parents to create a plan for the child’s return to school (using natural rewards like friends and trusted teachers) and staying at school (with detailed contingency planning). Parents may need help finding ways to “demagnetize” home and “remagnetize” school, such as turning off the Internet at home and not allowing a child to play sports or with friends when not attending school. Psychotherapy will be helpful for an underlying anxiety or mood disorder, and medications may also be helpful, but education and support for parents to understand how to manage the distress avoidance and rewards of school refusal are generally the critical components of an effective response to this serious problem.

Special cases: Adolescents with new anxiety symptoms

Most childhood anxiety disorders occur before puberty, but anxiety is a common symptom of mood and substance use disorders in teenagers, and often the symptom that drives help-seeking. It is important to screen teens who present with anxiety for underlying mood or substance use disorders. For example, panic disorder is relatively common in young adults, while in teenagers, panic attacks are a frequent symptom of depression or of withdrawal from regular cannabis use. If anxiety has been present and untreated since childhood, adolescents may present with complex comorbid mood and anxiety disorders and struggle with distress tolerance, social difficulties, and perfectionism. Anxiety itself is a very regular developmental feature of adolescence as this is a time of navigating peer relationships, identity, gradual separation from family, and transition to college or work. Every teen would likely benefit from advice about their sleep, exercise, use of any substances, and screen time habits.

For all of your patients with anxiety (and their parents), recognize that anxiety about being liked, making a varsity team, competing for college entrance, and becoming a young adult is expected: uncomfortable, but part of life. It’s adaptive. It helps people to stay safe, get their homework done, and avoid accidents. When people have high levels of anxiety, they can learn to identify their feelings, distinguish between facts and feelings, and learn to manage the anxiety adaptively. If anxiety causes dysfunction in major areas (school, family, friends, activities, and mood), prompt attention is required.

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

Anxiety symptoms in children are common, ranging from a toddler’s fear of the dark to an adolescent worrying about a major exam. Anxiety disorders, symptoms that are persistent and impact functioning, are the most common psychiatric illnesses of childhood. The good news is that, if they are detected early and treated appropriately, they are curable. Unfortunately, they are often silent, or present with misleading symptoms. Screening for anxiety disorders, especially in the presence of the most common presenting concerns, can illuminate the true nature of a child’s challenge and point the way forward. In this month’s article, we will provide details on the prevalence of anxiety disorders in children, how they typically present, and how best to screen for them. We will offer some strategies for speaking about them with your patients and their parents, as well as introduce some of the strategies that can improve mild to moderate anxiety disorders. We will follow up with another piece on the evidence-based treatments for these common disorders, how to find appropriate referrals, and what you can do in your office to get treatment started.

Anxiety disorders: Common and treatable

Anxiety disorders – including separation anxiety disorder, social phobia, simple phobias, generalized anxiety disorder, panic disorder, and PTSD – affect between 15% and 20% of children before the age of 18, with some recent estimates as high as 31.9% of youth being affected. Indeed, the mean age of onset for most anxiety disorders (excluding panic disorder and PTSD) is between 5 and 9 years of age. Despite being so common, many anxiety disorders in childhood are never properly diagnosed, and most (as many as 80%) do not receive treatment from a mental health professional. With early diagnosis and evidence-based treatment, most anxiety disorders can be “cured” and no longer impair functioning. Untreated, anxiety disorders usually have a chronic course, causing significant behavioral problems and disruption of a child’s critical social, emotional, and identity development and their academic function. Untreated, they are frequently complicated in adolescence by mood, substance use, and eating disorders. With the passage of time, developmental consequences and comorbid illnesses, a curable childhood anxiety disorder can become a complex and entrenched psychiatric syndrome in young adulthood.

One of the reasons these illnesses frequently go unrecognized is that states of fearful distress, such as separation anxiety or social anxiety, are developmentally normal at different stages of childhood, and it can be difficult to discriminate between normal and pathological anxiety. Anxiety itself is an “internalizing” symptom, and is invisible except for the behaviors that can accompany it. Some behaviors suggest anxiety, such as fearful expressions, clinginess, excessive need for reassurance, or avoidance. But anxiety can also lead to obstinate refusal to do certain things. It might lead to explosive tantrums when a child is pushed to do something that makes them intensely anxious. It can lead to irritability and moody tantrums for a child exhausted after a long school day spent managing high levels of anxiety by themselves. Anxious children often appear inattentive in school. Anxiety disorders frequently disrupt restful sleep, leading to children who are irritable and moody as well as inattentive. These children may present to the pediatrician with frustrated parents concerned that they are oppositional or explosive, or because their teachers are concerned about ADHD, when the culprit is actually anxiety.

While anxiety is uncomfortable, these children are unlikely to experience their anxiety as unusual and foreign, like a sudden toothache. Instead, it feels to them like they are fearful for good reason, responding appropriately to something real. These children are more likely to respond to a novel or uncertain situation with worry rather than curiosity, and to a new challenge as a threat. For children who are managing their anxiety more internally, their parents are often unaware of their degree of distress. Indeed, these children are often careful, thoughtful, and attentive to detail. Parents and teachers may think they are doing wonderfully. They are typically very sensitive to physical discomforts, which are heightened by an anxious state. These are likely to present to the pediatrician’s office with parents very worried about a cluster of vague physical complaints (stomach ache, headache, “just not feeling good”), which coincides with a change, challenge, or anxious stimulus. In this situation, the parents may dismiss the possibility of anxiety, and the child may not even be aware of it. But it will get worse if they are pushed to bear the source of anxiety (going to school, sports practice, etc.).
 

Anxiety screening and treatment

When a child presents for a sick visit with vague symptoms, or a negative workup for specific ones, you should screen them for an anxiety disorder. When they present with concerns about inattention, insomnia, moodiness, obstinacy, and even explosive behaviors, you should screen them for an anxiety disorder. This is especially true if they are prepubertal, when anxiety disorders are far more common than mood disorders. But you should consider anxiety disorders alongside mood disorders in adolescents presenting with these complaints. While parents may be unaware of the presence of anxiety in their child, explain to them that anxiety disorders are very common and treatable in childhood to help them understand the value of screening. Asking children directly about their internal experience can also be helpful. Avoid asking about “anxiety,” instead asking if they ever worry about specific things, such as “talking to kids you don’t know at recess,” “being alone at home,” “getting robbed or kidnapped,” or “something bad happening to your parents.” Just asking helps children pay attention to their thoughts and feelings, and is a powerful screening instrument.

There are also real screening instruments that you might use routinely for sick visits in prepubertal children or when anxiety should be in the differential. These instruments can be prone to recall bias, but generally make it easier for (anxious) children to accurately describe their internal experience. An instrument like the GAD7 is brief, free, and sensitive, but not very specific. If it is positive, you can then offer a longer screen such as the SCARED, also free, which indicates likely diagnoses such as generalized anxiety disorder, separation anxiety disorder, panic disorder, and social phobia. There is a parent version and a self-report, and it is validated for youths 8-18 years old and takes approximately 20 minutes to complete and score.

A positive screen should lead to a more nuanced conversation with your patient and their parents about their anxiety symptoms. You may feel comfortable doing a more extensive interview to make the likely diagnosis or may prefer to refer to a psychiatrist or psychologist to assist with diagnosis and treatment recommendations. In either case, you can offer your patient and their parents meaningful reassurance that the intense discomfort of their anxiety will get better with effective treatment. In this visit, you can get treatment started by identifying what parents and their children can do right away to begin addressing anxiety symptoms. Offer strategies to protect and promote restful sleep and daily vigorous exercise, both of which can directly improve mild to moderate anxiety symptoms. Suggest to parents that they should help their children to notice what they are feeling, rather than rushing in to remove a source of anxiety. These measures can help their child to identify what is a thought, a feeling, a physical sensation, or a fact. They can offer support and validation around how uncomfortable these feelings are, but just being curious will reassure their child that they will be able to manage and master this feeling. This “practice” is akin to what their child will do in most effective treatments, and will have the added benefit of helping them to build skills that all children need to manage the challenges and worries that are a normal, but difficult part of growing up and of adult life. Finally, you can tell them that anxious temperaments come with advantages also, such as great powers of observation, attention to detail, and thoroughness, high levels of empathy, drive, and tenacity. By learning to manage anxiety early, these children can grow up to be engaged, resilient, successful, and satisfied adults.

Once identified, the range of effective treatments available include cognitive-behavioral therapy, graduated exposure, mindfulness/relaxation techniques, and medication, and we will discuss these in our next article.

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

Reference

Beesdo K et al. Anxiety and anxiety disorders in children and adolescents: developmental issues and implications for DSM-V. Psychiatr Clin North Am. 2009 Sep. doi: 10.1016/j.psc.2009.06.002.

Anxiety symptoms in children are common, ranging from a toddler’s fear of the dark to an adolescent worrying about a major exam. Anxiety disorders, symptoms that are persistent and impact functioning, are the most common psychiatric illnesses of childhood. The good news is that, if they are detected early and treated appropriately, they are curable. Unfortunately, they are often silent, or present with misleading symptoms. Screening for anxiety disorders, especially in the presence of the most common presenting concerns, can illuminate the true nature of a child’s challenge and point the way forward. In this month’s article, we will provide details on the prevalence of anxiety disorders in children, how they typically present, and how best to screen for them. We will offer some strategies for speaking about them with your patients and their parents, as well as introduce some of the strategies that can improve mild to moderate anxiety disorders. We will follow up with another piece on the evidence-based treatments for these common disorders, how to find appropriate referrals, and what you can do in your office to get treatment started.

Anxiety disorders: Common and treatable

Anxiety disorders – including separation anxiety disorder, social phobia, simple phobias, generalized anxiety disorder, panic disorder, and PTSD – affect between 15% and 20% of children before the age of 18, with some recent estimates as high as 31.9% of youth being affected. Indeed, the mean age of onset for most anxiety disorders (excluding panic disorder and PTSD) is between 5 and 9 years of age. Despite being so common, many anxiety disorders in childhood are never properly diagnosed, and most (as many as 80%) do not receive treatment from a mental health professional. With early diagnosis and evidence-based treatment, most anxiety disorders can be “cured” and no longer impair functioning. Untreated, anxiety disorders usually have a chronic course, causing significant behavioral problems and disruption of a child’s critical social, emotional, and identity development and their academic function. Untreated, they are frequently complicated in adolescence by mood, substance use, and eating disorders. With the passage of time, developmental consequences and comorbid illnesses, a curable childhood anxiety disorder can become a complex and entrenched psychiatric syndrome in young adulthood.

One of the reasons these illnesses frequently go unrecognized is that states of fearful distress, such as separation anxiety or social anxiety, are developmentally normal at different stages of childhood, and it can be difficult to discriminate between normal and pathological anxiety. Anxiety itself is an “internalizing” symptom, and is invisible except for the behaviors that can accompany it. Some behaviors suggest anxiety, such as fearful expressions, clinginess, excessive need for reassurance, or avoidance. But anxiety can also lead to obstinate refusal to do certain things. It might lead to explosive tantrums when a child is pushed to do something that makes them intensely anxious. It can lead to irritability and moody tantrums for a child exhausted after a long school day spent managing high levels of anxiety by themselves. Anxious children often appear inattentive in school. Anxiety disorders frequently disrupt restful sleep, leading to children who are irritable and moody as well as inattentive. These children may present to the pediatrician with frustrated parents concerned that they are oppositional or explosive, or because their teachers are concerned about ADHD, when the culprit is actually anxiety.

While anxiety is uncomfortable, these children are unlikely to experience their anxiety as unusual and foreign, like a sudden toothache. Instead, it feels to them like they are fearful for good reason, responding appropriately to something real. These children are more likely to respond to a novel or uncertain situation with worry rather than curiosity, and to a new challenge as a threat. For children who are managing their anxiety more internally, their parents are often unaware of their degree of distress. Indeed, these children are often careful, thoughtful, and attentive to detail. Parents and teachers may think they are doing wonderfully. They are typically very sensitive to physical discomforts, which are heightened by an anxious state. These are likely to present to the pediatrician’s office with parents very worried about a cluster of vague physical complaints (stomach ache, headache, “just not feeling good”), which coincides with a change, challenge, or anxious stimulus. In this situation, the parents may dismiss the possibility of anxiety, and the child may not even be aware of it. But it will get worse if they are pushed to bear the source of anxiety (going to school, sports practice, etc.).
 

Anxiety screening and treatment

When a child presents for a sick visit with vague symptoms, or a negative workup for specific ones, you should screen them for an anxiety disorder. When they present with concerns about inattention, insomnia, moodiness, obstinacy, and even explosive behaviors, you should screen them for an anxiety disorder. This is especially true if they are prepubertal, when anxiety disorders are far more common than mood disorders. But you should consider anxiety disorders alongside mood disorders in adolescents presenting with these complaints. While parents may be unaware of the presence of anxiety in their child, explain to them that anxiety disorders are very common and treatable in childhood to help them understand the value of screening. Asking children directly about their internal experience can also be helpful. Avoid asking about “anxiety,” instead asking if they ever worry about specific things, such as “talking to kids you don’t know at recess,” “being alone at home,” “getting robbed or kidnapped,” or “something bad happening to your parents.” Just asking helps children pay attention to their thoughts and feelings, and is a powerful screening instrument.

There are also real screening instruments that you might use routinely for sick visits in prepubertal children or when anxiety should be in the differential. These instruments can be prone to recall bias, but generally make it easier for (anxious) children to accurately describe their internal experience. An instrument like the GAD7 is brief, free, and sensitive, but not very specific. If it is positive, you can then offer a longer screen such as the SCARED, also free, which indicates likely diagnoses such as generalized anxiety disorder, separation anxiety disorder, panic disorder, and social phobia. There is a parent version and a self-report, and it is validated for youths 8-18 years old and takes approximately 20 minutes to complete and score.

A positive screen should lead to a more nuanced conversation with your patient and their parents about their anxiety symptoms. You may feel comfortable doing a more extensive interview to make the likely diagnosis or may prefer to refer to a psychiatrist or psychologist to assist with diagnosis and treatment recommendations. In either case, you can offer your patient and their parents meaningful reassurance that the intense discomfort of their anxiety will get better with effective treatment. In this visit, you can get treatment started by identifying what parents and their children can do right away to begin addressing anxiety symptoms. Offer strategies to protect and promote restful sleep and daily vigorous exercise, both of which can directly improve mild to moderate anxiety symptoms. Suggest to parents that they should help their children to notice what they are feeling, rather than rushing in to remove a source of anxiety. These measures can help their child to identify what is a thought, a feeling, a physical sensation, or a fact. They can offer support and validation around how uncomfortable these feelings are, but just being curious will reassure their child that they will be able to manage and master this feeling. This “practice” is akin to what their child will do in most effective treatments, and will have the added benefit of helping them to build skills that all children need to manage the challenges and worries that are a normal, but difficult part of growing up and of adult life. Finally, you can tell them that anxious temperaments come with advantages also, such as great powers of observation, attention to detail, and thoroughness, high levels of empathy, drive, and tenacity. By learning to manage anxiety early, these children can grow up to be engaged, resilient, successful, and satisfied adults.

Once identified, the range of effective treatments available include cognitive-behavioral therapy, graduated exposure, mindfulness/relaxation techniques, and medication, and we will discuss these in our next article.

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

Reference

Beesdo K et al. Anxiety and anxiety disorders in children and adolescents: developmental issues and implications for DSM-V. Psychiatr Clin North Am. 2009 Sep. doi: 10.1016/j.psc.2009.06.002.

Anxiety symptoms in children are common, ranging from a toddler’s fear of the dark to an adolescent worrying about a major exam. Anxiety disorders, symptoms that are persistent and impact functioning, are the most common psychiatric illnesses of childhood. The good news is that, if they are detected early and treated appropriately, they are curable. Unfortunately, they are often silent, or present with misleading symptoms. Screening for anxiety disorders, especially in the presence of the most common presenting concerns, can illuminate the true nature of a child’s challenge and point the way forward. In this month’s article, we will provide details on the prevalence of anxiety disorders in children, how they typically present, and how best to screen for them. We will offer some strategies for speaking about them with your patients and their parents, as well as introduce some of the strategies that can improve mild to moderate anxiety disorders. We will follow up with another piece on the evidence-based treatments for these common disorders, how to find appropriate referrals, and what you can do in your office to get treatment started.

Anxiety disorders: Common and treatable

Anxiety disorders – including separation anxiety disorder, social phobia, simple phobias, generalized anxiety disorder, panic disorder, and PTSD – affect between 15% and 20% of children before the age of 18, with some recent estimates as high as 31.9% of youth being affected. Indeed, the mean age of onset for most anxiety disorders (excluding panic disorder and PTSD) is between 5 and 9 years of age. Despite being so common, many anxiety disorders in childhood are never properly diagnosed, and most (as many as 80%) do not receive treatment from a mental health professional. With early diagnosis and evidence-based treatment, most anxiety disorders can be “cured” and no longer impair functioning. Untreated, anxiety disorders usually have a chronic course, causing significant behavioral problems and disruption of a child’s critical social, emotional, and identity development and their academic function. Untreated, they are frequently complicated in adolescence by mood, substance use, and eating disorders. With the passage of time, developmental consequences and comorbid illnesses, a curable childhood anxiety disorder can become a complex and entrenched psychiatric syndrome in young adulthood.

One of the reasons these illnesses frequently go unrecognized is that states of fearful distress, such as separation anxiety or social anxiety, are developmentally normal at different stages of childhood, and it can be difficult to discriminate between normal and pathological anxiety. Anxiety itself is an “internalizing” symptom, and is invisible except for the behaviors that can accompany it. Some behaviors suggest anxiety, such as fearful expressions, clinginess, excessive need for reassurance, or avoidance. But anxiety can also lead to obstinate refusal to do certain things. It might lead to explosive tantrums when a child is pushed to do something that makes them intensely anxious. It can lead to irritability and moody tantrums for a child exhausted after a long school day spent managing high levels of anxiety by themselves. Anxious children often appear inattentive in school. Anxiety disorders frequently disrupt restful sleep, leading to children who are irritable and moody as well as inattentive. These children may present to the pediatrician with frustrated parents concerned that they are oppositional or explosive, or because their teachers are concerned about ADHD, when the culprit is actually anxiety.

While anxiety is uncomfortable, these children are unlikely to experience their anxiety as unusual and foreign, like a sudden toothache. Instead, it feels to them like they are fearful for good reason, responding appropriately to something real. These children are more likely to respond to a novel or uncertain situation with worry rather than curiosity, and to a new challenge as a threat. For children who are managing their anxiety more internally, their parents are often unaware of their degree of distress. Indeed, these children are often careful, thoughtful, and attentive to detail. Parents and teachers may think they are doing wonderfully. They are typically very sensitive to physical discomforts, which are heightened by an anxious state. These are likely to present to the pediatrician’s office with parents very worried about a cluster of vague physical complaints (stomach ache, headache, “just not feeling good”), which coincides with a change, challenge, or anxious stimulus. In this situation, the parents may dismiss the possibility of anxiety, and the child may not even be aware of it. But it will get worse if they are pushed to bear the source of anxiety (going to school, sports practice, etc.).
 

Anxiety screening and treatment

When a child presents for a sick visit with vague symptoms, or a negative workup for specific ones, you should screen them for an anxiety disorder. When they present with concerns about inattention, insomnia, moodiness, obstinacy, and even explosive behaviors, you should screen them for an anxiety disorder. This is especially true if they are prepubertal, when anxiety disorders are far more common than mood disorders. But you should consider anxiety disorders alongside mood disorders in adolescents presenting with these complaints. While parents may be unaware of the presence of anxiety in their child, explain to them that anxiety disorders are very common and treatable in childhood to help them understand the value of screening. Asking children directly about their internal experience can also be helpful. Avoid asking about “anxiety,” instead asking if they ever worry about specific things, such as “talking to kids you don’t know at recess,” “being alone at home,” “getting robbed or kidnapped,” or “something bad happening to your parents.” Just asking helps children pay attention to their thoughts and feelings, and is a powerful screening instrument.

There are also real screening instruments that you might use routinely for sick visits in prepubertal children or when anxiety should be in the differential. These instruments can be prone to recall bias, but generally make it easier for (anxious) children to accurately describe their internal experience. An instrument like the GAD7 is brief, free, and sensitive, but not very specific. If it is positive, you can then offer a longer screen such as the SCARED, also free, which indicates likely diagnoses such as generalized anxiety disorder, separation anxiety disorder, panic disorder, and social phobia. There is a parent version and a self-report, and it is validated for youths 8-18 years old and takes approximately 20 minutes to complete and score.

A positive screen should lead to a more nuanced conversation with your patient and their parents about their anxiety symptoms. You may feel comfortable doing a more extensive interview to make the likely diagnosis or may prefer to refer to a psychiatrist or psychologist to assist with diagnosis and treatment recommendations. In either case, you can offer your patient and their parents meaningful reassurance that the intense discomfort of their anxiety will get better with effective treatment. In this visit, you can get treatment started by identifying what parents and their children can do right away to begin addressing anxiety symptoms. Offer strategies to protect and promote restful sleep and daily vigorous exercise, both of which can directly improve mild to moderate anxiety symptoms. Suggest to parents that they should help their children to notice what they are feeling, rather than rushing in to remove a source of anxiety. These measures can help their child to identify what is a thought, a feeling, a physical sensation, or a fact. They can offer support and validation around how uncomfortable these feelings are, but just being curious will reassure their child that they will be able to manage and master this feeling. This “practice” is akin to what their child will do in most effective treatments, and will have the added benefit of helping them to build skills that all children need to manage the challenges and worries that are a normal, but difficult part of growing up and of adult life. Finally, you can tell them that anxious temperaments come with advantages also, such as great powers of observation, attention to detail, and thoroughness, high levels of empathy, drive, and tenacity. By learning to manage anxiety early, these children can grow up to be engaged, resilient, successful, and satisfied adults.

Once identified, the range of effective treatments available include cognitive-behavioral therapy, graduated exposure, mindfulness/relaxation techniques, and medication, and we will discuss these in our next article.

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

Reference

Beesdo K et al. Anxiety and anxiety disorders in children and adolescents: developmental issues and implications for DSM-V. Psychiatr Clin North Am. 2009 Sep. doi: 10.1016/j.psc.2009.06.002.

May is Mental Health Awareness Month, providing us a chance to go beyond discussing the screening, diagnosis, and evidence-based treatments for the mental illnesses of youth. Just as children are developing physical health, they are similarly establishing the foundations for their mental health. The World Health Organization defines good mental health as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her own community.” While the science of mental health promotion and disease prevention in childhood and adolescence is relatively young, there are several discrete domains in which you can follow and support your patient’s developing mental health. This begins with the well-being of new parents, and then moves into how parents are helping their children to develop skills to manage their basic daily needs and impulses, their thoughts and feelings, their stresses and their relationships. With a little support from you, parents can confidently help their children develop the foundations for good mental health.

First year of life: Parental mental health

Perhaps the strongest risk factor for serious mental illness in childhood and adulthood is parental neglect during the first year of life, and neglect in the first several months of life is the most commonly reported form of child abuse. Infant neglect is associated with parental depression (and other mental illnesses), parental substance use, and a parent’s own experience of childhood abuse or neglect. Neglect is more common with teenaged parents and parents living in poverty. Pediatricians are uniquely connected to families during the first year of a child’s life. The American Academy of Pediatrics recommends screening new mothers for depression at 1-, 2-, 4-, and 6-month infant check-ups with the Edinburgh Postnatal Depression Screen. Even without a positive screen, new parents may need the fortifications of extra community support to adapt to the changes parenthood brings.

At checkups, ask (both) parents how they are managing the stresses of a new baby. Are they getting restful sleep? Do they have social supports? Are they connected to a community (friends, extended family, faith) or isolated? Are they developing confidence as parents or feeling overwhelmed? Simple guidance, such as “sleep when the baby sleeps” and reassurance that taking good care of themselves is taking good care of the baby is always helpful. Sometimes you will need to refer for treatment or to community supports. Have your list of online and in-person resources at the ready to provide parents with these prescriptions. Supporting parental mental health and adjustment in the first year of life is possibly the most important building block for their child’s future mental health.
 

Toddlers and up: Emotional literacy

Emotional literacy (sometimes called “emotional intelligence”) is the capacity to recognize, identify, and manage feelings in oneself and in others. This skill begins to develop in infancy when parents respond to their baby’s cries with attunement, feeding or changing them if needed, and at other times simply reflecting their feelings and soothing them with movement, singing, or quiet talking. As children grow, so does their range of feelings, and their (cognitive) capacity to identify and manage them. Parents support this development by being available whenever their young children experience strong emotions, calmly listening, and acknowledging their discomfort. Parents can offer words for describing those feelings, and even be curious with their young children where in their bodies they are feeling them, how they can stay patient while the feeling passes or things they might be able to do to feel better. Parents may want to remove their child’s distress, but staying calm, curious, and present while helping their child to manage it will build their child’s emotional health. Parents can nurture this development in a less intense way by reading books about feelings together and noticing and identifying feelings in other children or in cartoon characters.

School-age children: Adding mindfulness

While a child’s cognitive development unfolds naturally, school-age children can cultivate awareness of their thoughts. This becomes possible after awareness of feelings and parents can help their older children consider whether something they are experiencing is a thought, a feeling, or a fact. They do so in the same way they helped their child develop emotional literacy: By responding with calm, curiosity, and confidence every time their child comes to them in distress (especially mild distress, like boredom!) or with a challenge or a question. With a difficult situation, parents start by helping their child to identify thoughts and feelings before impulsively acting on them. Parents can help children identify what’s in their control, try different approaches, and be flexible if their first efforts don’t work. Children need to learn that failing at things is how we learn and grow. Just like learning to ride a bike, it builds their frustration tolerance, their knowledge that they can do difficult things, and that distress subsides. These are critical building blocks for adolescence, when the challenges become greater and they manage them more independently.

Learning “mindfulness” (a practice that cultivates nonjudgmental awareness of one’s own thoughts, feelings, and sensations) can help children (and parents) to cultivate quiet self-awareness outside of moments of difficulty. “Stop, Breathe, and Think” and “Mindful gNATs” are two free apps that are recommended by the American Academy of Child and Adolescent Psychiatry for children (and their parents) to use to practice this awareness of thoughts and feelings.
 

Early and later adolescence: Stress management skills

Building on this awareness of thoughts and emotions, adolescents develop adaptive coping skills by facing challenges with the support of their parents nearby. Parents should still be ready to respond to charged emotional moments with calm and curiosity, validating their child’s distress while helping them to consider healthy responses. Helping their teenager to describe their experience, differentiating feelings from thoughts (and facts), and considering different choices within their control is foundational to resilience in adulthood. Parents also help their teenagers by reminding them of the need for good self-care (sleep, exercise, nutrition), nourishing social relationships, and protecting time for rest and recharging activities. Sometimes, parents will think with their teenager about why they are engaged in an activity that is stressful, whether it is authentically important to them, and why. Adolescents should be deepening their sense of identity, interests, talents, and even values, and stressful moments are rich opportunities to do so, with the support of caring adults. Without intentionally building these skills, adolescents will be more prone to managing stress with avoidance or unhealthy coping, such as excessive eating, video gaming, drugs, or alcohol.

Infancy and up: Behavioral healthy habits (sleep, physical activity, nutrition, and screen time)

Healthy habits sound simple, but establishing them is not always easy. The idea of a habit is that it makes managing something challenging or important more automatic, and thus easier and more reliable. Many of the same habits that promote physical health in adulthood also promote mental health: adequate, restful sleep; daily physical activity; a nutritious diet and a healthy relationship with food; and managing screen time in a developmentally appropriate way. Infants depend entirely on their parents for regulation of these behaviors. As their children grow, parents will adapt these routines so that their children are gradually regulating these needs and activities more independently. In each of these areas, children need clear expectations and routines, consistent consequences and positive feedback, and the modeling and patient support of their parents. Educate parents about what good sleep hygiene looks like at each age. Discuss ways to support regular physical activity, especially as a family. Ask the parents about nutrition, including how they manage picky eating; how many family meals they enjoy together; and whether food is ever used to manage boredom or distress. Finally, talk with parents about a developmentally appropriate approach to rules and expectations around screen time and the importance of using family-based rules. Establishing expectations and routines during early childhood means children learn how good it feels to have restful sleep, regular exercise, and happy, healthy family meals. In adolescence, parents can then focus on helping their children to manage temptation, challenge, disappointment, and frustration more independently.

Infancy and up: Relational health

Children develop the skills needed for healthy relationships at home, and they are connected to all of the skills described above. Children need attuned, responsive, and reliable parenting to build a capacity for trust of others, to learn how to communicate honestly and effectively, to learn to expect and offer compassion and respect, and to learn how to handle disagreement and conflict. They learn these skills by watching their parents and by developing the emotional, cognitive, and behavioral healthy habits with their parents’ help. They need a consistently safe and responsive environment at home. They need parents who are attuned and flexible, while maintaining routines and high expectations. They need parents who make time for them when they are sad or struggling, and make time for joy, play, and mindless fun. While a detailed assessment of how the family is functioning may go beyond a check-up, you can ask about those routines that build healthy habits (family mealtime, sleep routines, screen time rules), communication style, and what the family enjoys doing together. Learning about how a family is building these healthy habits and how connected they are to one another can give you a clear snapshot of how well a child may be doing on their mental health growth curve, and what areas might benefit from more active guidance and support.

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

May is Mental Health Awareness Month, providing us a chance to go beyond discussing the screening, diagnosis, and evidence-based treatments for the mental illnesses of youth. Just as children are developing physical health, they are similarly establishing the foundations for their mental health. The World Health Organization defines good mental health as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her own community.” While the science of mental health promotion and disease prevention in childhood and adolescence is relatively young, there are several discrete domains in which you can follow and support your patient’s developing mental health. This begins with the well-being of new parents, and then moves into how parents are helping their children to develop skills to manage their basic daily needs and impulses, their thoughts and feelings, their stresses and their relationships. With a little support from you, parents can confidently help their children develop the foundations for good mental health.

First year of life: Parental mental health

Perhaps the strongest risk factor for serious mental illness in childhood and adulthood is parental neglect during the first year of life, and neglect in the first several months of life is the most commonly reported form of child abuse. Infant neglect is associated with parental depression (and other mental illnesses), parental substance use, and a parent’s own experience of childhood abuse or neglect. Neglect is more common with teenaged parents and parents living in poverty. Pediatricians are uniquely connected to families during the first year of a child’s life. The American Academy of Pediatrics recommends screening new mothers for depression at 1-, 2-, 4-, and 6-month infant check-ups with the Edinburgh Postnatal Depression Screen. Even without a positive screen, new parents may need the fortifications of extra community support to adapt to the changes parenthood brings.

At checkups, ask (both) parents how they are managing the stresses of a new baby. Are they getting restful sleep? Do they have social supports? Are they connected to a community (friends, extended family, faith) or isolated? Are they developing confidence as parents or feeling overwhelmed? Simple guidance, such as “sleep when the baby sleeps” and reassurance that taking good care of themselves is taking good care of the baby is always helpful. Sometimes you will need to refer for treatment or to community supports. Have your list of online and in-person resources at the ready to provide parents with these prescriptions. Supporting parental mental health and adjustment in the first year of life is possibly the most important building block for their child’s future mental health.
 

Toddlers and up: Emotional literacy

Emotional literacy (sometimes called “emotional intelligence”) is the capacity to recognize, identify, and manage feelings in oneself and in others. This skill begins to develop in infancy when parents respond to their baby’s cries with attunement, feeding or changing them if needed, and at other times simply reflecting their feelings and soothing them with movement, singing, or quiet talking. As children grow, so does their range of feelings, and their (cognitive) capacity to identify and manage them. Parents support this development by being available whenever their young children experience strong emotions, calmly listening, and acknowledging their discomfort. Parents can offer words for describing those feelings, and even be curious with their young children where in their bodies they are feeling them, how they can stay patient while the feeling passes or things they might be able to do to feel better. Parents may want to remove their child’s distress, but staying calm, curious, and present while helping their child to manage it will build their child’s emotional health. Parents can nurture this development in a less intense way by reading books about feelings together and noticing and identifying feelings in other children or in cartoon characters.

School-age children: Adding mindfulness

While a child’s cognitive development unfolds naturally, school-age children can cultivate awareness of their thoughts. This becomes possible after awareness of feelings and parents can help their older children consider whether something they are experiencing is a thought, a feeling, or a fact. They do so in the same way they helped their child develop emotional literacy: By responding with calm, curiosity, and confidence every time their child comes to them in distress (especially mild distress, like boredom!) or with a challenge or a question. With a difficult situation, parents start by helping their child to identify thoughts and feelings before impulsively acting on them. Parents can help children identify what’s in their control, try different approaches, and be flexible if their first efforts don’t work. Children need to learn that failing at things is how we learn and grow. Just like learning to ride a bike, it builds their frustration tolerance, their knowledge that they can do difficult things, and that distress subsides. These are critical building blocks for adolescence, when the challenges become greater and they manage them more independently.

Learning “mindfulness” (a practice that cultivates nonjudgmental awareness of one’s own thoughts, feelings, and sensations) can help children (and parents) to cultivate quiet self-awareness outside of moments of difficulty. “Stop, Breathe, and Think” and “Mindful gNATs” are two free apps that are recommended by the American Academy of Child and Adolescent Psychiatry for children (and their parents) to use to practice this awareness of thoughts and feelings.
 

Early and later adolescence: Stress management skills

Building on this awareness of thoughts and emotions, adolescents develop adaptive coping skills by facing challenges with the support of their parents nearby. Parents should still be ready to respond to charged emotional moments with calm and curiosity, validating their child’s distress while helping them to consider healthy responses. Helping their teenager to describe their experience, differentiating feelings from thoughts (and facts), and considering different choices within their control is foundational to resilience in adulthood. Parents also help their teenagers by reminding them of the need for good self-care (sleep, exercise, nutrition), nourishing social relationships, and protecting time for rest and recharging activities. Sometimes, parents will think with their teenager about why they are engaged in an activity that is stressful, whether it is authentically important to them, and why. Adolescents should be deepening their sense of identity, interests, talents, and even values, and stressful moments are rich opportunities to do so, with the support of caring adults. Without intentionally building these skills, adolescents will be more prone to managing stress with avoidance or unhealthy coping, such as excessive eating, video gaming, drugs, or alcohol.

Infancy and up: Behavioral healthy habits (sleep, physical activity, nutrition, and screen time)

Healthy habits sound simple, but establishing them is not always easy. The idea of a habit is that it makes managing something challenging or important more automatic, and thus easier and more reliable. Many of the same habits that promote physical health in adulthood also promote mental health: adequate, restful sleep; daily physical activity; a nutritious diet and a healthy relationship with food; and managing screen time in a developmentally appropriate way. Infants depend entirely on their parents for regulation of these behaviors. As their children grow, parents will adapt these routines so that their children are gradually regulating these needs and activities more independently. In each of these areas, children need clear expectations and routines, consistent consequences and positive feedback, and the modeling and patient support of their parents. Educate parents about what good sleep hygiene looks like at each age. Discuss ways to support regular physical activity, especially as a family. Ask the parents about nutrition, including how they manage picky eating; how many family meals they enjoy together; and whether food is ever used to manage boredom or distress. Finally, talk with parents about a developmentally appropriate approach to rules and expectations around screen time and the importance of using family-based rules. Establishing expectations and routines during early childhood means children learn how good it feels to have restful sleep, regular exercise, and happy, healthy family meals. In adolescence, parents can then focus on helping their children to manage temptation, challenge, disappointment, and frustration more independently.

Infancy and up: Relational health

Children develop the skills needed for healthy relationships at home, and they are connected to all of the skills described above. Children need attuned, responsive, and reliable parenting to build a capacity for trust of others, to learn how to communicate honestly and effectively, to learn to expect and offer compassion and respect, and to learn how to handle disagreement and conflict. They learn these skills by watching their parents and by developing the emotional, cognitive, and behavioral healthy habits with their parents’ help. They need a consistently safe and responsive environment at home. They need parents who are attuned and flexible, while maintaining routines and high expectations. They need parents who make time for them when they are sad or struggling, and make time for joy, play, and mindless fun. While a detailed assessment of how the family is functioning may go beyond a check-up, you can ask about those routines that build healthy habits (family mealtime, sleep routines, screen time rules), communication style, and what the family enjoys doing together. Learning about how a family is building these healthy habits and how connected they are to one another can give you a clear snapshot of how well a child may be doing on their mental health growth curve, and what areas might benefit from more active guidance and support.

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

May is Mental Health Awareness Month, providing us a chance to go beyond discussing the screening, diagnosis, and evidence-based treatments for the mental illnesses of youth. Just as children are developing physical health, they are similarly establishing the foundations for their mental health. The World Health Organization defines good mental health as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her own community.” While the science of mental health promotion and disease prevention in childhood and adolescence is relatively young, there are several discrete domains in which you can follow and support your patient’s developing mental health. This begins with the well-being of new parents, and then moves into how parents are helping their children to develop skills to manage their basic daily needs and impulses, their thoughts and feelings, their stresses and their relationships. With a little support from you, parents can confidently help their children develop the foundations for good mental health.

First year of life: Parental mental health

Perhaps the strongest risk factor for serious mental illness in childhood and adulthood is parental neglect during the first year of life, and neglect in the first several months of life is the most commonly reported form of child abuse. Infant neglect is associated with parental depression (and other mental illnesses), parental substance use, and a parent’s own experience of childhood abuse or neglect. Neglect is more common with teenaged parents and parents living in poverty. Pediatricians are uniquely connected to families during the first year of a child’s life. The American Academy of Pediatrics recommends screening new mothers for depression at 1-, 2-, 4-, and 6-month infant check-ups with the Edinburgh Postnatal Depression Screen. Even without a positive screen, new parents may need the fortifications of extra community support to adapt to the changes parenthood brings.

At checkups, ask (both) parents how they are managing the stresses of a new baby. Are they getting restful sleep? Do they have social supports? Are they connected to a community (friends, extended family, faith) or isolated? Are they developing confidence as parents or feeling overwhelmed? Simple guidance, such as “sleep when the baby sleeps” and reassurance that taking good care of themselves is taking good care of the baby is always helpful. Sometimes you will need to refer for treatment or to community supports. Have your list of online and in-person resources at the ready to provide parents with these prescriptions. Supporting parental mental health and adjustment in the first year of life is possibly the most important building block for their child’s future mental health.
 

Toddlers and up: Emotional literacy

Emotional literacy (sometimes called “emotional intelligence”) is the capacity to recognize, identify, and manage feelings in oneself and in others. This skill begins to develop in infancy when parents respond to their baby’s cries with attunement, feeding or changing them if needed, and at other times simply reflecting their feelings and soothing them with movement, singing, or quiet talking. As children grow, so does their range of feelings, and their (cognitive) capacity to identify and manage them. Parents support this development by being available whenever their young children experience strong emotions, calmly listening, and acknowledging their discomfort. Parents can offer words for describing those feelings, and even be curious with their young children where in their bodies they are feeling them, how they can stay patient while the feeling passes or things they might be able to do to feel better. Parents may want to remove their child’s distress, but staying calm, curious, and present while helping their child to manage it will build their child’s emotional health. Parents can nurture this development in a less intense way by reading books about feelings together and noticing and identifying feelings in other children or in cartoon characters.

School-age children: Adding mindfulness

While a child’s cognitive development unfolds naturally, school-age children can cultivate awareness of their thoughts. This becomes possible after awareness of feelings and parents can help their older children consider whether something they are experiencing is a thought, a feeling, or a fact. They do so in the same way they helped their child develop emotional literacy: By responding with calm, curiosity, and confidence every time their child comes to them in distress (especially mild distress, like boredom!) or with a challenge or a question. With a difficult situation, parents start by helping their child to identify thoughts and feelings before impulsively acting on them. Parents can help children identify what’s in their control, try different approaches, and be flexible if their first efforts don’t work. Children need to learn that failing at things is how we learn and grow. Just like learning to ride a bike, it builds their frustration tolerance, their knowledge that they can do difficult things, and that distress subsides. These are critical building blocks for adolescence, when the challenges become greater and they manage them more independently.

Learning “mindfulness” (a practice that cultivates nonjudgmental awareness of one’s own thoughts, feelings, and sensations) can help children (and parents) to cultivate quiet self-awareness outside of moments of difficulty. “Stop, Breathe, and Think” and “Mindful gNATs” are two free apps that are recommended by the American Academy of Child and Adolescent Psychiatry for children (and their parents) to use to practice this awareness of thoughts and feelings.
 

Early and later adolescence: Stress management skills

Building on this awareness of thoughts and emotions, adolescents develop adaptive coping skills by facing challenges with the support of their parents nearby. Parents should still be ready to respond to charged emotional moments with calm and curiosity, validating their child’s distress while helping them to consider healthy responses. Helping their teenager to describe their experience, differentiating feelings from thoughts (and facts), and considering different choices within their control is foundational to resilience in adulthood. Parents also help their teenagers by reminding them of the need for good self-care (sleep, exercise, nutrition), nourishing social relationships, and protecting time for rest and recharging activities. Sometimes, parents will think with their teenager about why they are engaged in an activity that is stressful, whether it is authentically important to them, and why. Adolescents should be deepening their sense of identity, interests, talents, and even values, and stressful moments are rich opportunities to do so, with the support of caring adults. Without intentionally building these skills, adolescents will be more prone to managing stress with avoidance or unhealthy coping, such as excessive eating, video gaming, drugs, or alcohol.

Infancy and up: Behavioral healthy habits (sleep, physical activity, nutrition, and screen time)

Healthy habits sound simple, but establishing them is not always easy. The idea of a habit is that it makes managing something challenging or important more automatic, and thus easier and more reliable. Many of the same habits that promote physical health in adulthood also promote mental health: adequate, restful sleep; daily physical activity; a nutritious diet and a healthy relationship with food; and managing screen time in a developmentally appropriate way. Infants depend entirely on their parents for regulation of these behaviors. As their children grow, parents will adapt these routines so that their children are gradually regulating these needs and activities more independently. In each of these areas, children need clear expectations and routines, consistent consequences and positive feedback, and the modeling and patient support of their parents. Educate parents about what good sleep hygiene looks like at each age. Discuss ways to support regular physical activity, especially as a family. Ask the parents about nutrition, including how they manage picky eating; how many family meals they enjoy together; and whether food is ever used to manage boredom or distress. Finally, talk with parents about a developmentally appropriate approach to rules and expectations around screen time and the importance of using family-based rules. Establishing expectations and routines during early childhood means children learn how good it feels to have restful sleep, regular exercise, and happy, healthy family meals. In adolescence, parents can then focus on helping their children to manage temptation, challenge, disappointment, and frustration more independently.

Infancy and up: Relational health

Children develop the skills needed for healthy relationships at home, and they are connected to all of the skills described above. Children need attuned, responsive, and reliable parenting to build a capacity for trust of others, to learn how to communicate honestly and effectively, to learn to expect and offer compassion and respect, and to learn how to handle disagreement and conflict. They learn these skills by watching their parents and by developing the emotional, cognitive, and behavioral healthy habits with their parents’ help. They need a consistently safe and responsive environment at home. They need parents who are attuned and flexible, while maintaining routines and high expectations. They need parents who make time for them when they are sad or struggling, and make time for joy, play, and mindless fun. While a detailed assessment of how the family is functioning may go beyond a check-up, you can ask about those routines that build healthy habits (family mealtime, sleep routines, screen time rules), communication style, and what the family enjoys doing together. Learning about how a family is building these healthy habits and how connected they are to one another can give you a clear snapshot of how well a child may be doing on their mental health growth curve, and what areas might benefit from more active guidance and support.

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

The Centers for Disease Control and Prevention recently released results of the most recent Youth Risk Behavior Survey, their once-a-decade survey of youth mental health and risk-taking behaviors. The headlines aren’t good: Self-reported rates of anxiety, depression, suicidal thoughts, and suicide attempts in adolescents have increased substantially from 2011 to 2021. This echoes epidemiologic data showing increasing rates of anxiety and depression over the last decade in 12- to 24-year-olds, but not in older age cohorts.

This trend started well before COVID, coinciding with the explosive growth in use of smartphones, apps, and social media platforms. Facebook launched in 2004, the iPhone in 2007, Instagram in 2010, and TikTok in 2016. A 2018 Pew Research survey of 13- to 17-year-olds found that 97% of them used at least one social media platform and 45% described themselves as online “almost constantly.” Social media does have great potential benefits for adolescents.

We all experienced how it supported relationships during COVID. It can provide supportive networks for teenagers isolated by exclusion, illness, or disability. It can support exploration of esoteric interests, expression of identity, entertainment, and relaxation. But certain children, as was true before social media, seem vulnerable to the bullying, loneliness, isolation, and disengagement that social media may exacerbate.

Several studies have shown an association between high daily screen time and adolescent anxiety and depression. These findings have not been consistently duplicated, and those that were could not establish causality. There appears to be a strong link between certain illnesses (ADHD, depression, anorexia nervosa) and excessive screen use, which can in turn worsen symptoms. But it is hard to know which came first or how they are related.

Now, a very large long-term observational study has suggested that there may be critical windows in adolescence (11-13 years in girls and 14-16 in boys and again at 19 years for both) during which time excessive screen time can put that child’s developing mental health at risk. This is nuanced and interesting progress, but you don’t have to wait another decade to offer the families in your practice some common sense guidance when they are asking how to balance their children’s needs to be independent and socially connected (and the fact that smartphones and social media are pervasive) with the risks of overuse. Equipped with these guiding principles, parents can set individualized, flexible ground rules, and adjust them as their children grow into young adults.
 

First: Know your child

Parents are, of course, the experts on their own child – their talents, interests, challenges, vulnerabilities, and developmental progress. Children with poor impulse control (including those with ADHD) are going to have greater difficulty turning away from highly addictive activities on their devices. Children who are anxious and shy may be prone to avoiding the stress of real-life situations, preferring virtual ones. Children with a history of depression may be vulnerable to relapse if their sleep and exercise routines are disrupted by excessive use. And children with eating disorders are especially vulnerable to the superficial social comparisons and “likes” that Instagram offers. Children with these vulnerabilities will benefit if their parents are aware of and can talk about these vulnerabilities, ideally with their child. They should be prepared to work with their teens to develop strategies that can help them learn how to manage their social media usage. These might include stopping screen use after a certain hour, leaving devices outside of bedrooms at night, and setting up apps that monitor and alert them about excessive use. They might use resources such as the AAP’s Family Media Plan (Media and Children [aap.org]), but simply taking the time to have regular, open, honest conversations about what is known and unknown about the potential risks of social media use is very protective.

Second: Use adolescent development as your guide

For those children who do not have a known vulnerability to overuse, consider the following areas that are essential to healthy development in adolescence as guideposts to help parents in setting reasonable ground rules: building independence, cultivating healthy social relationships, learning about their identity, managing their strong emotions, and developing the skills of self-care. If screen time supports these developmental areas, then it’s probably healthy. If it interferes with them, then not. And remember, parents should routinely discuss these principles with their children as well.

Independence

Key questions. Does their use of a device enable them to function more independently – that is, to arrange for rides, manage their schedules, homework, shifts, and so forth – on their own? Could it be done with a “dumb” device (text/call only)?

Social relationships

One-way viewing (Instagram, Facebook) with superficial acquaintances may promote isolation, anxiety, and depression, does not facilitate deepened relationships, and may be using up time that they could be investing in genuine social connections. But if they are using their devices to stay connected to good friends who live far away or just have different schedules, they can promote genuine, satisfying, bilateral social connections.

Key questions. Are they engaged in two-way communication with their devices? Are they staying connected to friends with whom they have a genuine, substantial relationship?
 

Investigating and experimenting with interests (identity)

Teenagers are supposed to be learning in deep and nuanced ways about their own interests and abilities during these years. This requires a lot of time invested in exploration and experimentation and a considerable amount of failure. Any activity that consumes a lot of their time without deepening meaningful knowledge of their interests and abilities (that is, activity that is only an escape or distraction) will interfere with their discovering their authentic identity.

Key questions. Is their use of devices facilitating this genuine exploration (setting up internships, practicing programming, or exploring interests that must be virtual)? Or is their device use just consuming precious time they could be using to genuinely explore potential interests?
 

Managing anxiety or distress

Exploring their identity and building social connections will involve a lot of stress, failure, disappointment, and even heartbreak. Learning to manage these uncomfortable feelings is an important part of adolescence. Distraction with a diverting entertainment can be one of several strategies for managing stress and distress. But if it becomes the only strategy, it can keep teens from getting “back in the game” and experiencing the fun, success, meaning, and joy that are also a big part of this exploration.

Key questions. Do they turn to their devices first when sad or stressed? Are they also able to use other strategies, such as talking with friends/family, exercising, or engaging in a meaningful pursuit to help them manage stress? Do they feel better after a little time spent on their device, or as if they will only feel good if they can stay on the device?
 

Self-care

Getting adequate, restful sleep (8-10 hours/night), finding regular time for exercise, cultivating healthy eating habits, and discovering what healthy strategies help them to unwind or relax is critical to a teenager’s healthiest development, and to healthy adult life. Some screens may help with motivating and tracking exercise, but screens in the bedroom interfere with going to bed, and with falling and staying asleep. Most teenagers are very busy and managing a lot of (normal) stress; the senseless fun or relaxation that are part of video games or surfing the Web are quick, practical, and effective ways to unwind. Don’t discourage your teenager from enjoying them. Instead, focus on also helping them to find other healthy ways to relax: hot baths, exercise, time with pets, crafts, reading, and listening to music are just a few examples. As they are building their identity, they should also be discovering how they best slow down and calm down.

Key questions. How many hours of sleep do they usually get on a school night? Is their phone (or other screen) in their bedroom during sleep? How do they relax? Do they have several strategies that do not require screens? Do they exercise regularly (3-5 times weekly)? Do they complain that they do not have enough time for exercise?
 

Third: Be mindful of what you model

Many of these principles can apply to our own use of smartphones, computers, and so on. Remind parents that their teenager will ultimately consider and follow their example much more than their commands. They should be prepared to talk about how they are thinking about the risks and benefits of social media use, how they are developing rules and expectations, and why they decided on them. These conversations model thoughtful and flexible decision-making.

It is critical that parents acknowledge that there are wonderful benefits to technology, including senseless fun. Then, it is easier to discuss how escaping into screen use can be hard to resist, and why it is important to practice resisting some temptations. Parents should find ways to follow the same rules they set for their teenager, or making them “family rules.” It’s important for our teenagers to learn about how to set these limits, as eventually they will be setting their own!
 

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

The Centers for Disease Control and Prevention recently released results of the most recent Youth Risk Behavior Survey, their once-a-decade survey of youth mental health and risk-taking behaviors. The headlines aren’t good: Self-reported rates of anxiety, depression, suicidal thoughts, and suicide attempts in adolescents have increased substantially from 2011 to 2021. This echoes epidemiologic data showing increasing rates of anxiety and depression over the last decade in 12- to 24-year-olds, but not in older age cohorts.

This trend started well before COVID, coinciding with the explosive growth in use of smartphones, apps, and social media platforms. Facebook launched in 2004, the iPhone in 2007, Instagram in 2010, and TikTok in 2016. A 2018 Pew Research survey of 13- to 17-year-olds found that 97% of them used at least one social media platform and 45% described themselves as online “almost constantly.” Social media does have great potential benefits for adolescents.

We all experienced how it supported relationships during COVID. It can provide supportive networks for teenagers isolated by exclusion, illness, or disability. It can support exploration of esoteric interests, expression of identity, entertainment, and relaxation. But certain children, as was true before social media, seem vulnerable to the bullying, loneliness, isolation, and disengagement that social media may exacerbate.

Several studies have shown an association between high daily screen time and adolescent anxiety and depression. These findings have not been consistently duplicated, and those that were could not establish causality. There appears to be a strong link between certain illnesses (ADHD, depression, anorexia nervosa) and excessive screen use, which can in turn worsen symptoms. But it is hard to know which came first or how they are related.

Now, a very large long-term observational study has suggested that there may be critical windows in adolescence (11-13 years in girls and 14-16 in boys and again at 19 years for both) during which time excessive screen time can put that child’s developing mental health at risk. This is nuanced and interesting progress, but you don’t have to wait another decade to offer the families in your practice some common sense guidance when they are asking how to balance their children’s needs to be independent and socially connected (and the fact that smartphones and social media are pervasive) with the risks of overuse. Equipped with these guiding principles, parents can set individualized, flexible ground rules, and adjust them as their children grow into young adults.
 

First: Know your child

Parents are, of course, the experts on their own child – their talents, interests, challenges, vulnerabilities, and developmental progress. Children with poor impulse control (including those with ADHD) are going to have greater difficulty turning away from highly addictive activities on their devices. Children who are anxious and shy may be prone to avoiding the stress of real-life situations, preferring virtual ones. Children with a history of depression may be vulnerable to relapse if their sleep and exercise routines are disrupted by excessive use. And children with eating disorders are especially vulnerable to the superficial social comparisons and “likes” that Instagram offers. Children with these vulnerabilities will benefit if their parents are aware of and can talk about these vulnerabilities, ideally with their child. They should be prepared to work with their teens to develop strategies that can help them learn how to manage their social media usage. These might include stopping screen use after a certain hour, leaving devices outside of bedrooms at night, and setting up apps that monitor and alert them about excessive use. They might use resources such as the AAP’s Family Media Plan (Media and Children [aap.org]), but simply taking the time to have regular, open, honest conversations about what is known and unknown about the potential risks of social media use is very protective.

Second: Use adolescent development as your guide

For those children who do not have a known vulnerability to overuse, consider the following areas that are essential to healthy development in adolescence as guideposts to help parents in setting reasonable ground rules: building independence, cultivating healthy social relationships, learning about their identity, managing their strong emotions, and developing the skills of self-care. If screen time supports these developmental areas, then it’s probably healthy. If it interferes with them, then not. And remember, parents should routinely discuss these principles with their children as well.

Independence

Key questions. Does their use of a device enable them to function more independently – that is, to arrange for rides, manage their schedules, homework, shifts, and so forth – on their own? Could it be done with a “dumb” device (text/call only)?

Social relationships

One-way viewing (Instagram, Facebook) with superficial acquaintances may promote isolation, anxiety, and depression, does not facilitate deepened relationships, and may be using up time that they could be investing in genuine social connections. But if they are using their devices to stay connected to good friends who live far away or just have different schedules, they can promote genuine, satisfying, bilateral social connections.

Key questions. Are they engaged in two-way communication with their devices? Are they staying connected to friends with whom they have a genuine, substantial relationship?
 

Investigating and experimenting with interests (identity)

Teenagers are supposed to be learning in deep and nuanced ways about their own interests and abilities during these years. This requires a lot of time invested in exploration and experimentation and a considerable amount of failure. Any activity that consumes a lot of their time without deepening meaningful knowledge of their interests and abilities (that is, activity that is only an escape or distraction) will interfere with their discovering their authentic identity.

Key questions. Is their use of devices facilitating this genuine exploration (setting up internships, practicing programming, or exploring interests that must be virtual)? Or is their device use just consuming precious time they could be using to genuinely explore potential interests?
 

Managing anxiety or distress

Exploring their identity and building social connections will involve a lot of stress, failure, disappointment, and even heartbreak. Learning to manage these uncomfortable feelings is an important part of adolescence. Distraction with a diverting entertainment can be one of several strategies for managing stress and distress. But if it becomes the only strategy, it can keep teens from getting “back in the game” and experiencing the fun, success, meaning, and joy that are also a big part of this exploration.

Key questions. Do they turn to their devices first when sad or stressed? Are they also able to use other strategies, such as talking with friends/family, exercising, or engaging in a meaningful pursuit to help them manage stress? Do they feel better after a little time spent on their device, or as if they will only feel good if they can stay on the device?
 

Self-care

Getting adequate, restful sleep (8-10 hours/night), finding regular time for exercise, cultivating healthy eating habits, and discovering what healthy strategies help them to unwind or relax is critical to a teenager’s healthiest development, and to healthy adult life. Some screens may help with motivating and tracking exercise, but screens in the bedroom interfere with going to bed, and with falling and staying asleep. Most teenagers are very busy and managing a lot of (normal) stress; the senseless fun or relaxation that are part of video games or surfing the Web are quick, practical, and effective ways to unwind. Don’t discourage your teenager from enjoying them. Instead, focus on also helping them to find other healthy ways to relax: hot baths, exercise, time with pets, crafts, reading, and listening to music are just a few examples. As they are building their identity, they should also be discovering how they best slow down and calm down.

Key questions. How many hours of sleep do they usually get on a school night? Is their phone (or other screen) in their bedroom during sleep? How do they relax? Do they have several strategies that do not require screens? Do they exercise regularly (3-5 times weekly)? Do they complain that they do not have enough time for exercise?
 

Third: Be mindful of what you model

Many of these principles can apply to our own use of smartphones, computers, and so on. Remind parents that their teenager will ultimately consider and follow their example much more than their commands. They should be prepared to talk about how they are thinking about the risks and benefits of social media use, how they are developing rules and expectations, and why they decided on them. These conversations model thoughtful and flexible decision-making.

It is critical that parents acknowledge that there are wonderful benefits to technology, including senseless fun. Then, it is easier to discuss how escaping into screen use can be hard to resist, and why it is important to practice resisting some temptations. Parents should find ways to follow the same rules they set for their teenager, or making them “family rules.” It’s important for our teenagers to learn about how to set these limits, as eventually they will be setting their own!
 

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

The Centers for Disease Control and Prevention recently released results of the most recent Youth Risk Behavior Survey, their once-a-decade survey of youth mental health and risk-taking behaviors. The headlines aren’t good: Self-reported rates of anxiety, depression, suicidal thoughts, and suicide attempts in adolescents have increased substantially from 2011 to 2021. This echoes epidemiologic data showing increasing rates of anxiety and depression over the last decade in 12- to 24-year-olds, but not in older age cohorts.

This trend started well before COVID, coinciding with the explosive growth in use of smartphones, apps, and social media platforms. Facebook launched in 2004, the iPhone in 2007, Instagram in 2010, and TikTok in 2016. A 2018 Pew Research survey of 13- to 17-year-olds found that 97% of them used at least one social media platform and 45% described themselves as online “almost constantly.” Social media does have great potential benefits for adolescents.

We all experienced how it supported relationships during COVID. It can provide supportive networks for teenagers isolated by exclusion, illness, or disability. It can support exploration of esoteric interests, expression of identity, entertainment, and relaxation. But certain children, as was true before social media, seem vulnerable to the bullying, loneliness, isolation, and disengagement that social media may exacerbate.

Several studies have shown an association between high daily screen time and adolescent anxiety and depression. These findings have not been consistently duplicated, and those that were could not establish causality. There appears to be a strong link between certain illnesses (ADHD, depression, anorexia nervosa) and excessive screen use, which can in turn worsen symptoms. But it is hard to know which came first or how they are related.

Now, a very large long-term observational study has suggested that there may be critical windows in adolescence (11-13 years in girls and 14-16 in boys and again at 19 years for both) during which time excessive screen time can put that child’s developing mental health at risk. This is nuanced and interesting progress, but you don’t have to wait another decade to offer the families in your practice some common sense guidance when they are asking how to balance their children’s needs to be independent and socially connected (and the fact that smartphones and social media are pervasive) with the risks of overuse. Equipped with these guiding principles, parents can set individualized, flexible ground rules, and adjust them as their children grow into young adults.
 

First: Know your child

Parents are, of course, the experts on their own child – their talents, interests, challenges, vulnerabilities, and developmental progress. Children with poor impulse control (including those with ADHD) are going to have greater difficulty turning away from highly addictive activities on their devices. Children who are anxious and shy may be prone to avoiding the stress of real-life situations, preferring virtual ones. Children with a history of depression may be vulnerable to relapse if their sleep and exercise routines are disrupted by excessive use. And children with eating disorders are especially vulnerable to the superficial social comparisons and “likes” that Instagram offers. Children with these vulnerabilities will benefit if their parents are aware of and can talk about these vulnerabilities, ideally with their child. They should be prepared to work with their teens to develop strategies that can help them learn how to manage their social media usage. These might include stopping screen use after a certain hour, leaving devices outside of bedrooms at night, and setting up apps that monitor and alert them about excessive use. They might use resources such as the AAP’s Family Media Plan (Media and Children [aap.org]), but simply taking the time to have regular, open, honest conversations about what is known and unknown about the potential risks of social media use is very protective.

Second: Use adolescent development as your guide

For those children who do not have a known vulnerability to overuse, consider the following areas that are essential to healthy development in adolescence as guideposts to help parents in setting reasonable ground rules: building independence, cultivating healthy social relationships, learning about their identity, managing their strong emotions, and developing the skills of self-care. If screen time supports these developmental areas, then it’s probably healthy. If it interferes with them, then not. And remember, parents should routinely discuss these principles with their children as well.

Independence

Key questions. Does their use of a device enable them to function more independently – that is, to arrange for rides, manage their schedules, homework, shifts, and so forth – on their own? Could it be done with a “dumb” device (text/call only)?

Social relationships

One-way viewing (Instagram, Facebook) with superficial acquaintances may promote isolation, anxiety, and depression, does not facilitate deepened relationships, and may be using up time that they could be investing in genuine social connections. But if they are using their devices to stay connected to good friends who live far away or just have different schedules, they can promote genuine, satisfying, bilateral social connections.

Key questions. Are they engaged in two-way communication with their devices? Are they staying connected to friends with whom they have a genuine, substantial relationship?
 

Investigating and experimenting with interests (identity)

Teenagers are supposed to be learning in deep and nuanced ways about their own interests and abilities during these years. This requires a lot of time invested in exploration and experimentation and a considerable amount of failure. Any activity that consumes a lot of their time without deepening meaningful knowledge of their interests and abilities (that is, activity that is only an escape or distraction) will interfere with their discovering their authentic identity.

Key questions. Is their use of devices facilitating this genuine exploration (setting up internships, practicing programming, or exploring interests that must be virtual)? Or is their device use just consuming precious time they could be using to genuinely explore potential interests?
 

Managing anxiety or distress

Exploring their identity and building social connections will involve a lot of stress, failure, disappointment, and even heartbreak. Learning to manage these uncomfortable feelings is an important part of adolescence. Distraction with a diverting entertainment can be one of several strategies for managing stress and distress. But if it becomes the only strategy, it can keep teens from getting “back in the game” and experiencing the fun, success, meaning, and joy that are also a big part of this exploration.

Key questions. Do they turn to their devices first when sad or stressed? Are they also able to use other strategies, such as talking with friends/family, exercising, or engaging in a meaningful pursuit to help them manage stress? Do they feel better after a little time spent on their device, or as if they will only feel good if they can stay on the device?
 

Self-care

Getting adequate, restful sleep (8-10 hours/night), finding regular time for exercise, cultivating healthy eating habits, and discovering what healthy strategies help them to unwind or relax is critical to a teenager’s healthiest development, and to healthy adult life. Some screens may help with motivating and tracking exercise, but screens in the bedroom interfere with going to bed, and with falling and staying asleep. Most teenagers are very busy and managing a lot of (normal) stress; the senseless fun or relaxation that are part of video games or surfing the Web are quick, practical, and effective ways to unwind. Don’t discourage your teenager from enjoying them. Instead, focus on also helping them to find other healthy ways to relax: hot baths, exercise, time with pets, crafts, reading, and listening to music are just a few examples. As they are building their identity, they should also be discovering how they best slow down and calm down.

Key questions. How many hours of sleep do they usually get on a school night? Is their phone (or other screen) in their bedroom during sleep? How do they relax? Do they have several strategies that do not require screens? Do they exercise regularly (3-5 times weekly)? Do they complain that they do not have enough time for exercise?
 

Third: Be mindful of what you model

Many of these principles can apply to our own use of smartphones, computers, and so on. Remind parents that their teenager will ultimately consider and follow their example much more than their commands. They should be prepared to talk about how they are thinking about the risks and benefits of social media use, how they are developing rules and expectations, and why they decided on them. These conversations model thoughtful and flexible decision-making.

It is critical that parents acknowledge that there are wonderful benefits to technology, including senseless fun. Then, it is easier to discuss how escaping into screen use can be hard to resist, and why it is important to practice resisting some temptations. Parents should find ways to follow the same rules they set for their teenager, or making them “family rules.” It’s important for our teenagers to learn about how to set these limits, as eventually they will be setting their own!
 

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