Michael S. Jellinek, MD

Parents want to raise their children to be happy and successful in childhood and through adulthood. For many parents, this means giving their children as many opportunities to learn, practice, and master a wide variety of skills outside of school as they possibly can. These activities often include the study of a musical instrument, a sport, an activity in the arts, religious study, and even extra academic work such as math, computer science, or a second language. Each one of these activities can mean many classes or practices outside of the home each week and additional practice time at home.

When you combine these activities with school and homework, children can be busier than most professional adults. And their parents can feel like managing their child’s schedule is another full-time job. By asking parents how many afternoons and evenings are scheduled (or how many hours of down time their children have) each week, you begin a conversation that may help parents determine the right balance for each child and the family.

Without a doubt, there can be tremendous value in making time for extracurricular activities for children. School alone usually does not offer much exposure to music education and the arts, and a daily gym class is sadly a thing of the past for most children. There is a growing body of evidence that daily vigorous exercise in childhood not only promotes good physical health and restorative sleep, and fights obesity, but that it also promotes strong cognitive development and can prevent anxiety and mood symptoms. Sustained experience with a team sport cultivates discipline, frustration tolerance, and resilience alongside friendships and fun. Likewise, there is a growing body of evidence that learning to play a musical instrument contributes in broader ways to healthy cognitive development, cultivates discipline and frustration tolerance, and improves executive function and the attention and self-regulation skills that all school-age children need to develop. Exposure to the arts, to trade skills, or to rare languages may help children discover a unique interest or passion that will draw them through their adolescence. Discovering an area of passionate interest is one of the essential goals of childhood; it can help teens feel good about themselves, and is especially meaningful in children who may not be gaining a lot of self-esteem in other areas, such as schoolwork.

But the well-meant intentions of parents (or interests of children) sometimes can lead to so many extracurricular activities that children barely have time for homework, play, or relaxation. From kindergarten through middle school, children are at the perfect age to be exploring multiple activities as they learn about their own abilities, strengths, and interests. But it is a developmental period in which there also should be plenty of open, free creative play, often with a social component. This is where children not only learn about their own talents, but also try things they might fail at, developing their curiosity, social skills, self-awareness, and resilience. While it can be wonderful to have a weekly music lesson and a team sport at this age, it is critical that there also be protected free play or down time. During this developmental period, children may switch sports, instruments, or hobbies, and it is healthy that they have the time and space to do so. Parents will say that every hour of activity is "fun." But fun with a purpose is different from "senseless fun," which is just fun without an achievement goal. Adults may have "fun" working out, but also have senseless fun playing golf, having a drink with friends, or going to a movie.

Adolescents are more likely to be "pruning" their interests as they figure out where their passions lie. Teenagers may do fewer activities overall, but spend more time on each of them. Of course, many teens will be experiencing great pressure (internal, external or both) to build the strongest possible college applications with the "right" mix of extracurricular activities, which may not line up with their actual interests. They will face the pressure also to be performing at a very high level academically. Some may have jobs, as they seek to build independence. Then add to this the fact that many will be driving themselves to each activity and wanting to spend time with friends and romantic interests, and you have a recipe for adolescents whose every moment is accounted for, to the point that they may skimp on sleep and mealtimes and feel overwhelmed. In choosing how to manage their schedules, adolescents also should be learning about the value of self-care, protecting time to relax, exercise, and sleep adequately (with a good measure of senseless fun texting as they build their identity).

So how do you help your patients and their parents reestablish some balance? You can start by figuring out if they are overscheduled. Ask if their school-age children have as many free afternoons as scheduled ones? Do they have recurring play dates as well as Russian and math classes? Do they have time for senseless fun with friends, siblings, and parents? Ask teenagers how much sleep they are getting? How often is the family able to have dinner together? When is the last time they had time to read a book for pleasure or to explore a new interest? Some children and teenagers may be very busy, but will report feeling like their battery is charged by all of their activities. Although they are busy, their schedule may be a good balance for them. But when children or teens report feeling drained by the end (or middle) of their week, they are likely overscheduled.

If parents resist some easing, you should begin to wonder if the child is the one who chose the activity or it represents a parent’s interests instead? Some parents may have strong feelings about what activities made a difference in their lives, and may not be paying attention to how their child’s temperament is different from their own. Sometimes, parents who are working might feel guilty that they are not as available as they’d like to be. They may sign their child up for many activities, hoping to make up for what they worry they are failing to directly provide their child. Parents may need a gentle reminder that a happy, calm dinner with mom and dad often is more developmentally productive than a rushed drive between two practices and a violin lesson.

Find out if specific activities are born of interest or obligation. Demanding obligatory activities should have important meaning for the child, such as Hebrew lessons prior to a Bar Mitzvah. There should be only one demanding activity that is not fun for a child at a time, though. The balance may come from fun or less-structured activities. Asking a child in front of the parents what activities are (or would be) the most fun or interesting for them can help the family to think through how to prune activities when a child is overscheduled, and remind parents of the value of play.

It also can be helpful to consider a child’s temperament when talking with a family about finding greater balance. If a child is very shy, there can be greater developmental value in activities that promote social skills, even though that child might not naturally seek those activities out. Teens who are struggling to fulfill basic responsibilities may need to have their schedules streamlined, but it is important to preserve an activity that may aid in cultivating their discipline and organization (such as a sports team or a job they value). Highly driven, ambitious adolescents sleeping only 4 hours a night to fulfill their many responsibilities would benefit from making time for relaxation and sleep, and hearing this from a pediatrician may be the critical factor in making it happen.

Finally, ask parents how drained they feel by facilitating their child’s (or children’s) schedule. When parents are so busy with their children’s activities that family time is nonexistent, or one child is receiving a greatly disproportionate share of the parents’ time, it is worth examining. Reminding parents that time spent together around the dinner table and helping with homework or in a shared activity – time that may leave them feeling more charged than drained as parents – is critical for the well-being of the whole family.

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

Parents want to raise their children to be happy and successful in childhood and through adulthood. For many parents, this means giving their children as many opportunities to learn, practice, and master a wide variety of skills outside of school as they possibly can. These activities often include the study of a musical instrument, a sport, an activity in the arts, religious study, and even extra academic work such as math, computer science, or a second language. Each one of these activities can mean many classes or practices outside of the home each week and additional practice time at home.

When you combine these activities with school and homework, children can be busier than most professional adults. And their parents can feel like managing their child’s schedule is another full-time job. By asking parents how many afternoons and evenings are scheduled (or how many hours of down time their children have) each week, you begin a conversation that may help parents determine the right balance for each child and the family.

Without a doubt, there can be tremendous value in making time for extracurricular activities for children. School alone usually does not offer much exposure to music education and the arts, and a daily gym class is sadly a thing of the past for most children. There is a growing body of evidence that daily vigorous exercise in childhood not only promotes good physical health and restorative sleep, and fights obesity, but that it also promotes strong cognitive development and can prevent anxiety and mood symptoms. Sustained experience with a team sport cultivates discipline, frustration tolerance, and resilience alongside friendships and fun. Likewise, there is a growing body of evidence that learning to play a musical instrument contributes in broader ways to healthy cognitive development, cultivates discipline and frustration tolerance, and improves executive function and the attention and self-regulation skills that all school-age children need to develop. Exposure to the arts, to trade skills, or to rare languages may help children discover a unique interest or passion that will draw them through their adolescence. Discovering an area of passionate interest is one of the essential goals of childhood; it can help teens feel good about themselves, and is especially meaningful in children who may not be gaining a lot of self-esteem in other areas, such as schoolwork.

But the well-meant intentions of parents (or interests of children) sometimes can lead to so many extracurricular activities that children barely have time for homework, play, or relaxation. From kindergarten through middle school, children are at the perfect age to be exploring multiple activities as they learn about their own abilities, strengths, and interests. But it is a developmental period in which there also should be plenty of open, free creative play, often with a social component. This is where children not only learn about their own talents, but also try things they might fail at, developing their curiosity, social skills, self-awareness, and resilience. While it can be wonderful to have a weekly music lesson and a team sport at this age, it is critical that there also be protected free play or down time. During this developmental period, children may switch sports, instruments, or hobbies, and it is healthy that they have the time and space to do so. Parents will say that every hour of activity is "fun." But fun with a purpose is different from "senseless fun," which is just fun without an achievement goal. Adults may have "fun" working out, but also have senseless fun playing golf, having a drink with friends, or going to a movie.

Adolescents are more likely to be "pruning" their interests as they figure out where their passions lie. Teenagers may do fewer activities overall, but spend more time on each of them. Of course, many teens will be experiencing great pressure (internal, external or both) to build the strongest possible college applications with the "right" mix of extracurricular activities, which may not line up with their actual interests. They will face the pressure also to be performing at a very high level academically. Some may have jobs, as they seek to build independence. Then add to this the fact that many will be driving themselves to each activity and wanting to spend time with friends and romantic interests, and you have a recipe for adolescents whose every moment is accounted for, to the point that they may skimp on sleep and mealtimes and feel overwhelmed. In choosing how to manage their schedules, adolescents also should be learning about the value of self-care, protecting time to relax, exercise, and sleep adequately (with a good measure of senseless fun texting as they build their identity).

So how do you help your patients and their parents reestablish some balance? You can start by figuring out if they are overscheduled. Ask if their school-age children have as many free afternoons as scheduled ones? Do they have recurring play dates as well as Russian and math classes? Do they have time for senseless fun with friends, siblings, and parents? Ask teenagers how much sleep they are getting? How often is the family able to have dinner together? When is the last time they had time to read a book for pleasure or to explore a new interest? Some children and teenagers may be very busy, but will report feeling like their battery is charged by all of their activities. Although they are busy, their schedule may be a good balance for them. But when children or teens report feeling drained by the end (or middle) of their week, they are likely overscheduled.

If parents resist some easing, you should begin to wonder if the child is the one who chose the activity or it represents a parent’s interests instead? Some parents may have strong feelings about what activities made a difference in their lives, and may not be paying attention to how their child’s temperament is different from their own. Sometimes, parents who are working might feel guilty that they are not as available as they’d like to be. They may sign their child up for many activities, hoping to make up for what they worry they are failing to directly provide their child. Parents may need a gentle reminder that a happy, calm dinner with mom and dad often is more developmentally productive than a rushed drive between two practices and a violin lesson.

Find out if specific activities are born of interest or obligation. Demanding obligatory activities should have important meaning for the child, such as Hebrew lessons prior to a Bar Mitzvah. There should be only one demanding activity that is not fun for a child at a time, though. The balance may come from fun or less-structured activities. Asking a child in front of the parents what activities are (or would be) the most fun or interesting for them can help the family to think through how to prune activities when a child is overscheduled, and remind parents of the value of play.

It also can be helpful to consider a child’s temperament when talking with a family about finding greater balance. If a child is very shy, there can be greater developmental value in activities that promote social skills, even though that child might not naturally seek those activities out. Teens who are struggling to fulfill basic responsibilities may need to have their schedules streamlined, but it is important to preserve an activity that may aid in cultivating their discipline and organization (such as a sports team or a job they value). Highly driven, ambitious adolescents sleeping only 4 hours a night to fulfill their many responsibilities would benefit from making time for relaxation and sleep, and hearing this from a pediatrician may be the critical factor in making it happen.

Finally, ask parents how drained they feel by facilitating their child’s (or children’s) schedule. When parents are so busy with their children’s activities that family time is nonexistent, or one child is receiving a greatly disproportionate share of the parents’ time, it is worth examining. Reminding parents that time spent together around the dinner table and helping with homework or in a shared activity – time that may leave them feeling more charged than drained as parents – is critical for the well-being of the whole family.

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

Parents want to raise their children to be happy and successful in childhood and through adulthood. For many parents, this means giving their children as many opportunities to learn, practice, and master a wide variety of skills outside of school as they possibly can. These activities often include the study of a musical instrument, a sport, an activity in the arts, religious study, and even extra academic work such as math, computer science, or a second language. Each one of these activities can mean many classes or practices outside of the home each week and additional practice time at home.

When you combine these activities with school and homework, children can be busier than most professional adults. And their parents can feel like managing their child’s schedule is another full-time job. By asking parents how many afternoons and evenings are scheduled (or how many hours of down time their children have) each week, you begin a conversation that may help parents determine the right balance for each child and the family.

Without a doubt, there can be tremendous value in making time for extracurricular activities for children. School alone usually does not offer much exposure to music education and the arts, and a daily gym class is sadly a thing of the past for most children. There is a growing body of evidence that daily vigorous exercise in childhood not only promotes good physical health and restorative sleep, and fights obesity, but that it also promotes strong cognitive development and can prevent anxiety and mood symptoms. Sustained experience with a team sport cultivates discipline, frustration tolerance, and resilience alongside friendships and fun. Likewise, there is a growing body of evidence that learning to play a musical instrument contributes in broader ways to healthy cognitive development, cultivates discipline and frustration tolerance, and improves executive function and the attention and self-regulation skills that all school-age children need to develop. Exposure to the arts, to trade skills, or to rare languages may help children discover a unique interest or passion that will draw them through their adolescence. Discovering an area of passionate interest is one of the essential goals of childhood; it can help teens feel good about themselves, and is especially meaningful in children who may not be gaining a lot of self-esteem in other areas, such as schoolwork.

But the well-meant intentions of parents (or interests of children) sometimes can lead to so many extracurricular activities that children barely have time for homework, play, or relaxation. From kindergarten through middle school, children are at the perfect age to be exploring multiple activities as they learn about their own abilities, strengths, and interests. But it is a developmental period in which there also should be plenty of open, free creative play, often with a social component. This is where children not only learn about their own talents, but also try things they might fail at, developing their curiosity, social skills, self-awareness, and resilience. While it can be wonderful to have a weekly music lesson and a team sport at this age, it is critical that there also be protected free play or down time. During this developmental period, children may switch sports, instruments, or hobbies, and it is healthy that they have the time and space to do so. Parents will say that every hour of activity is "fun." But fun with a purpose is different from "senseless fun," which is just fun without an achievement goal. Adults may have "fun" working out, but also have senseless fun playing golf, having a drink with friends, or going to a movie.

Adolescents are more likely to be "pruning" their interests as they figure out where their passions lie. Teenagers may do fewer activities overall, but spend more time on each of them. Of course, many teens will be experiencing great pressure (internal, external or both) to build the strongest possible college applications with the "right" mix of extracurricular activities, which may not line up with their actual interests. They will face the pressure also to be performing at a very high level academically. Some may have jobs, as they seek to build independence. Then add to this the fact that many will be driving themselves to each activity and wanting to spend time with friends and romantic interests, and you have a recipe for adolescents whose every moment is accounted for, to the point that they may skimp on sleep and mealtimes and feel overwhelmed. In choosing how to manage their schedules, adolescents also should be learning about the value of self-care, protecting time to relax, exercise, and sleep adequately (with a good measure of senseless fun texting as they build their identity).

So how do you help your patients and their parents reestablish some balance? You can start by figuring out if they are overscheduled. Ask if their school-age children have as many free afternoons as scheduled ones? Do they have recurring play dates as well as Russian and math classes? Do they have time for senseless fun with friends, siblings, and parents? Ask teenagers how much sleep they are getting? How often is the family able to have dinner together? When is the last time they had time to read a book for pleasure or to explore a new interest? Some children and teenagers may be very busy, but will report feeling like their battery is charged by all of their activities. Although they are busy, their schedule may be a good balance for them. But when children or teens report feeling drained by the end (or middle) of their week, they are likely overscheduled.

If parents resist some easing, you should begin to wonder if the child is the one who chose the activity or it represents a parent’s interests instead? Some parents may have strong feelings about what activities made a difference in their lives, and may not be paying attention to how their child’s temperament is different from their own. Sometimes, parents who are working might feel guilty that they are not as available as they’d like to be. They may sign their child up for many activities, hoping to make up for what they worry they are failing to directly provide their child. Parents may need a gentle reminder that a happy, calm dinner with mom and dad often is more developmentally productive than a rushed drive between two practices and a violin lesson.

Find out if specific activities are born of interest or obligation. Demanding obligatory activities should have important meaning for the child, such as Hebrew lessons prior to a Bar Mitzvah. There should be only one demanding activity that is not fun for a child at a time, though. The balance may come from fun or less-structured activities. Asking a child in front of the parents what activities are (or would be) the most fun or interesting for them can help the family to think through how to prune activities when a child is overscheduled, and remind parents of the value of play.

It also can be helpful to consider a child’s temperament when talking with a family about finding greater balance. If a child is very shy, there can be greater developmental value in activities that promote social skills, even though that child might not naturally seek those activities out. Teens who are struggling to fulfill basic responsibilities may need to have their schedules streamlined, but it is important to preserve an activity that may aid in cultivating their discipline and organization (such as a sports team or a job they value). Highly driven, ambitious adolescents sleeping only 4 hours a night to fulfill their many responsibilities would benefit from making time for relaxation and sleep, and hearing this from a pediatrician may be the critical factor in making it happen.

Finally, ask parents how drained they feel by facilitating their child’s (or children’s) schedule. When parents are so busy with their children’s activities that family time is nonexistent, or one child is receiving a greatly disproportionate share of the parents’ time, it is worth examining. Reminding parents that time spent together around the dinner table and helping with homework or in a shared activity – time that may leave them feeling more charged than drained as parents – is critical for the well-being of the whole family.

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

Questions about sleep – from newborns to teenagers – are among the most common in pediatric practice. A good night’s sleep is in everyone’s best interest for daily functioning and healthy development. Asking about sleep also provides a window into the family’s perspectives on discipline, parental cooperation, family stresses, and views on a child’s developing autonomy.

During their first year, infants may need as many as 18 hours of sleep daily, and the duration of sleep gradually declines thereafter to 8-10 hours nightly in adolescence. Sleep plays an essential role in consolidating memories, attention, and other cognitive functions; the immune system; and metabolism. Additionally, developing healthy sleep habits is one of the first and most profound ways that children learn to expect consistency from their parents, to soothe themselves, and to manage limits. As a child grows, her ability to plan, manage anxiety, and exercise discipline is cultivated through managing her sleep with increasing independence.

Preschoolers who are not getting adequate sleep may have behavioral problems, particularly in new settings (like school) or at transitional times (like bedtime). When a preschooler presents with hyperactivity, irritability, and tantrums, or failure to keep up with developmental expectations, asking about sleep patterns is a good early step. Although sleep disruption may be symptomatic of psychiatric disorders related to mood, anxiety, or attention, before you consider a disorder and treatment make sure that tensions at bedtime and poor sleeping habits are not a major factor.

How do you help tired, stressed parents encourage or enforce healthy sleep habits? Does the family have a routine after dinner that allows a child to settle down (such as taking a bath and then a quiet activity like reading a book with a parent)? Are the parents able to enforce this routine consistently, or does bedtime get dragged out for hours? And if so, why? In addition to ensuring that a child gets enough exercise during the day (but not in the hour before bed), parents will need to turn off the lights at a reasonably early hour so that a child may get adequate sleep before they will awaken with daylight.

Many parents will delay sleep until later as children push to stay awake and play. Sometimes, if both parents work and feel their only time with their children is after they return from work well into the evening, they may want more time with their children or feel guilty about having a strict, early bedtime routine. Reassure parents that even a short stretch of quality time with their children (reading to them, snuggling, asking about their day) is enough to nurture a profound connection.

"Screen time" merits special mention, especially in younger children. Letting children watch television or play on computers in order to "unwind" at the end of a long day is common, but in the time before bed, screen content can be very disruptive to restful sleep. Parents should assess if "screen time" is helping or hurting their child’s ability to fall asleep. Some families have found it helpful to have no screen time (any screen: television, computer, tablet, or cell phone) within 1 hour of lights going out: back-lit screens suppress endogenous melatonin release and can delay sleep. With school-age children, reading at bedtime is certainly preferable to an additional hour of computer time.

It is also worth asking where a child is sleeping. Do they have their own bed? Are they alone in their room? Is their room on the same level of the house as their parents’ room? Children who are anxious may sleep better if they share a room with a sibling or are close to their parents’ room. On the other hand, if they sleep with a sibling who is waking often during the night, they may have disrupted sleep.

It is worth finding out if a child is able to sleep through the night in their own bed. Many children have their own bed and room, but have a routine of sleeping in their parents’ bed. This usually results in inadequate sleep for both child and parents, and a child who does not learn how to appropriately soothe himself. Is it permissible for a child to climb into their parents’ bed in the middle of the night once in a while, if they have a bad dream, do not feel well, or have faced a stressful day? Yes. Is a child arguing to go to sleep in their parents’ bed, refusing to sleep in their own bed, with their parents "giving in"? Then it is a habit worth undoing.

School-age children who are not getting adequate sleep also may appear more irritable, forgetful, and inattentive, and they may have problems with academic, athletic, and social performance. These are years in which children start to have more independence and responsibility for their bedtime routines. They may have greater access to screens in the evening, and may be in charge of setting an alarm or turning their light out. These are also years in which children are more likely to experience anxiety, as they face and manage a host of new challenges. Anxiety can be very disruptive of restful sleep, and will in turn cause more problems about which these children get anxious. Alongside their greater responsibility, school-age children still need basic and consistently enforced ground rules about sleep in order to build independence. Clearly at this age, reading before bedtime is a good option.

Parents should help their school-age children to start their homework early, and to enjoy screen time, but not within an hour of bedtime, and to follow a consistent (and more independent) routine before bed. Do they have a consistent bedtime? Do they take a shower or bath each night? (A hot shower or bath naturally cues the body that it is time for sleep as the body’s core temperature rises and then drops.) Do they read before lights out? Is the house quiet at their bedtime? Parents should also find out if their children have worries that are making it difficult to go to sleep. Are they worried about a test or big game? Or about bigger issues of safety? Parents can help a child to discuss their worries and address those that are addressable; usually, this is enough to help children learn to master their worries. When a school-age child’s anxiety does not improve with open discussion, then it may be helpful to have a more formal evaluation for anxiety with a mental health clinician.

Adolescence is a time in which sleep patterns naturally shift, while the need for sleep remains robust. Teenagers become tired later and need to sleep in until later in the morning, just at the same time that school demands impinge on sleep with an earlier start to the day and more extensive homework at night. Older adolescents may go out with friends on weekends and shift their bedtime routine by 4 or more hours for two nights out of every seven, which is as profoundly disruptive to restful sleep as traveling across four time zones and back every week. These are years in which more independence can again lead to more screen use in the evening, whether for writing a paper on a computer or texting a friend late into the night.

An adolescent who is sleep deprived may have low energy, be forgetful and distractible, and see their academic and athletic performance suffer. They may appear more withdrawn or moody. This is an age in which serious mood problems, such as depression, are more likely to emerge, and are associated with sleep problems. But these problems will not improve with simple sleep hygiene interventions; thus, the teens who do not get better after these interventions may need a psychiatric evaluation.

The strategies that might help adolescents are not much different from those for younger children. It is important with adolescents, however, to explain why they should exercise regularly, have a consistent bedtime routine, and not bring their cell phone to bed. While parents should still be able to set and enforce ground rules, they also need to be equipping their adolescents to understand and manage their sleep independently, which they will need to do soon enough. Encouraging self-regulation between ages 13 and 17 is essential as college or independence approaches, and efforts at control are hard to enforce and send the wrong message.

Inconsistent, inadequate sleep often reflects what has been a frustrating struggle for parents. Asking questions about sleep gives parents the supportive message that sleep is challenging and important, and may empower them to approach it with renewed firmness and clarity. When you help parents to set routines and limits that support consistent, adequate sleep, their children will be on a path to healthy development.

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

Questions about sleep – from newborns to teenagers – are among the most common in pediatric practice. A good night’s sleep is in everyone’s best interest for daily functioning and healthy development. Asking about sleep also provides a window into the family’s perspectives on discipline, parental cooperation, family stresses, and views on a child’s developing autonomy.

During their first year, infants may need as many as 18 hours of sleep daily, and the duration of sleep gradually declines thereafter to 8-10 hours nightly in adolescence. Sleep plays an essential role in consolidating memories, attention, and other cognitive functions; the immune system; and metabolism. Additionally, developing healthy sleep habits is one of the first and most profound ways that children learn to expect consistency from their parents, to soothe themselves, and to manage limits. As a child grows, her ability to plan, manage anxiety, and exercise discipline is cultivated through managing her sleep with increasing independence.

Preschoolers who are not getting adequate sleep may have behavioral problems, particularly in new settings (like school) or at transitional times (like bedtime). When a preschooler presents with hyperactivity, irritability, and tantrums, or failure to keep up with developmental expectations, asking about sleep patterns is a good early step. Although sleep disruption may be symptomatic of psychiatric disorders related to mood, anxiety, or attention, before you consider a disorder and treatment make sure that tensions at bedtime and poor sleeping habits are not a major factor.

How do you help tired, stressed parents encourage or enforce healthy sleep habits? Does the family have a routine after dinner that allows a child to settle down (such as taking a bath and then a quiet activity like reading a book with a parent)? Are the parents able to enforce this routine consistently, or does bedtime get dragged out for hours? And if so, why? In addition to ensuring that a child gets enough exercise during the day (but not in the hour before bed), parents will need to turn off the lights at a reasonably early hour so that a child may get adequate sleep before they will awaken with daylight.

Many parents will delay sleep until later as children push to stay awake and play. Sometimes, if both parents work and feel their only time with their children is after they return from work well into the evening, they may want more time with their children or feel guilty about having a strict, early bedtime routine. Reassure parents that even a short stretch of quality time with their children (reading to them, snuggling, asking about their day) is enough to nurture a profound connection.

"Screen time" merits special mention, especially in younger children. Letting children watch television or play on computers in order to "unwind" at the end of a long day is common, but in the time before bed, screen content can be very disruptive to restful sleep. Parents should assess if "screen time" is helping or hurting their child’s ability to fall asleep. Some families have found it helpful to have no screen time (any screen: television, computer, tablet, or cell phone) within 1 hour of lights going out: back-lit screens suppress endogenous melatonin release and can delay sleep. With school-age children, reading at bedtime is certainly preferable to an additional hour of computer time.

It is also worth asking where a child is sleeping. Do they have their own bed? Are they alone in their room? Is their room on the same level of the house as their parents’ room? Children who are anxious may sleep better if they share a room with a sibling or are close to their parents’ room. On the other hand, if they sleep with a sibling who is waking often during the night, they may have disrupted sleep.

It is worth finding out if a child is able to sleep through the night in their own bed. Many children have their own bed and room, but have a routine of sleeping in their parents’ bed. This usually results in inadequate sleep for both child and parents, and a child who does not learn how to appropriately soothe himself. Is it permissible for a child to climb into their parents’ bed in the middle of the night once in a while, if they have a bad dream, do not feel well, or have faced a stressful day? Yes. Is a child arguing to go to sleep in their parents’ bed, refusing to sleep in their own bed, with their parents "giving in"? Then it is a habit worth undoing.

School-age children who are not getting adequate sleep also may appear more irritable, forgetful, and inattentive, and they may have problems with academic, athletic, and social performance. These are years in which children start to have more independence and responsibility for their bedtime routines. They may have greater access to screens in the evening, and may be in charge of setting an alarm or turning their light out. These are also years in which children are more likely to experience anxiety, as they face and manage a host of new challenges. Anxiety can be very disruptive of restful sleep, and will in turn cause more problems about which these children get anxious. Alongside their greater responsibility, school-age children still need basic and consistently enforced ground rules about sleep in order to build independence. Clearly at this age, reading before bedtime is a good option.

Parents should help their school-age children to start their homework early, and to enjoy screen time, but not within an hour of bedtime, and to follow a consistent (and more independent) routine before bed. Do they have a consistent bedtime? Do they take a shower or bath each night? (A hot shower or bath naturally cues the body that it is time for sleep as the body’s core temperature rises and then drops.) Do they read before lights out? Is the house quiet at their bedtime? Parents should also find out if their children have worries that are making it difficult to go to sleep. Are they worried about a test or big game? Or about bigger issues of safety? Parents can help a child to discuss their worries and address those that are addressable; usually, this is enough to help children learn to master their worries. When a school-age child’s anxiety does not improve with open discussion, then it may be helpful to have a more formal evaluation for anxiety with a mental health clinician.

Adolescence is a time in which sleep patterns naturally shift, while the need for sleep remains robust. Teenagers become tired later and need to sleep in until later in the morning, just at the same time that school demands impinge on sleep with an earlier start to the day and more extensive homework at night. Older adolescents may go out with friends on weekends and shift their bedtime routine by 4 or more hours for two nights out of every seven, which is as profoundly disruptive to restful sleep as traveling across four time zones and back every week. These are years in which more independence can again lead to more screen use in the evening, whether for writing a paper on a computer or texting a friend late into the night.

An adolescent who is sleep deprived may have low energy, be forgetful and distractible, and see their academic and athletic performance suffer. They may appear more withdrawn or moody. This is an age in which serious mood problems, such as depression, are more likely to emerge, and are associated with sleep problems. But these problems will not improve with simple sleep hygiene interventions; thus, the teens who do not get better after these interventions may need a psychiatric evaluation.

The strategies that might help adolescents are not much different from those for younger children. It is important with adolescents, however, to explain why they should exercise regularly, have a consistent bedtime routine, and not bring their cell phone to bed. While parents should still be able to set and enforce ground rules, they also need to be equipping their adolescents to understand and manage their sleep independently, which they will need to do soon enough. Encouraging self-regulation between ages 13 and 17 is essential as college or independence approaches, and efforts at control are hard to enforce and send the wrong message.

Inconsistent, inadequate sleep often reflects what has been a frustrating struggle for parents. Asking questions about sleep gives parents the supportive message that sleep is challenging and important, and may empower them to approach it with renewed firmness and clarity. When you help parents to set routines and limits that support consistent, adequate sleep, their children will be on a path to healthy development.

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

Questions about sleep – from newborns to teenagers – are among the most common in pediatric practice. A good night’s sleep is in everyone’s best interest for daily functioning and healthy development. Asking about sleep also provides a window into the family’s perspectives on discipline, parental cooperation, family stresses, and views on a child’s developing autonomy.

During their first year, infants may need as many as 18 hours of sleep daily, and the duration of sleep gradually declines thereafter to 8-10 hours nightly in adolescence. Sleep plays an essential role in consolidating memories, attention, and other cognitive functions; the immune system; and metabolism. Additionally, developing healthy sleep habits is one of the first and most profound ways that children learn to expect consistency from their parents, to soothe themselves, and to manage limits. As a child grows, her ability to plan, manage anxiety, and exercise discipline is cultivated through managing her sleep with increasing independence.

Preschoolers who are not getting adequate sleep may have behavioral problems, particularly in new settings (like school) or at transitional times (like bedtime). When a preschooler presents with hyperactivity, irritability, and tantrums, or failure to keep up with developmental expectations, asking about sleep patterns is a good early step. Although sleep disruption may be symptomatic of psychiatric disorders related to mood, anxiety, or attention, before you consider a disorder and treatment make sure that tensions at bedtime and poor sleeping habits are not a major factor.

How do you help tired, stressed parents encourage or enforce healthy sleep habits? Does the family have a routine after dinner that allows a child to settle down (such as taking a bath and then a quiet activity like reading a book with a parent)? Are the parents able to enforce this routine consistently, or does bedtime get dragged out for hours? And if so, why? In addition to ensuring that a child gets enough exercise during the day (but not in the hour before bed), parents will need to turn off the lights at a reasonably early hour so that a child may get adequate sleep before they will awaken with daylight.

Many parents will delay sleep until later as children push to stay awake and play. Sometimes, if both parents work and feel their only time with their children is after they return from work well into the evening, they may want more time with their children or feel guilty about having a strict, early bedtime routine. Reassure parents that even a short stretch of quality time with their children (reading to them, snuggling, asking about their day) is enough to nurture a profound connection.

"Screen time" merits special mention, especially in younger children. Letting children watch television or play on computers in order to "unwind" at the end of a long day is common, but in the time before bed, screen content can be very disruptive to restful sleep. Parents should assess if "screen time" is helping or hurting their child’s ability to fall asleep. Some families have found it helpful to have no screen time (any screen: television, computer, tablet, or cell phone) within 1 hour of lights going out: back-lit screens suppress endogenous melatonin release and can delay sleep. With school-age children, reading at bedtime is certainly preferable to an additional hour of computer time.

It is also worth asking where a child is sleeping. Do they have their own bed? Are they alone in their room? Is their room on the same level of the house as their parents’ room? Children who are anxious may sleep better if they share a room with a sibling or are close to their parents’ room. On the other hand, if they sleep with a sibling who is waking often during the night, they may have disrupted sleep.

It is worth finding out if a child is able to sleep through the night in their own bed. Many children have their own bed and room, but have a routine of sleeping in their parents’ bed. This usually results in inadequate sleep for both child and parents, and a child who does not learn how to appropriately soothe himself. Is it permissible for a child to climb into their parents’ bed in the middle of the night once in a while, if they have a bad dream, do not feel well, or have faced a stressful day? Yes. Is a child arguing to go to sleep in their parents’ bed, refusing to sleep in their own bed, with their parents "giving in"? Then it is a habit worth undoing.

School-age children who are not getting adequate sleep also may appear more irritable, forgetful, and inattentive, and they may have problems with academic, athletic, and social performance. These are years in which children start to have more independence and responsibility for their bedtime routines. They may have greater access to screens in the evening, and may be in charge of setting an alarm or turning their light out. These are also years in which children are more likely to experience anxiety, as they face and manage a host of new challenges. Anxiety can be very disruptive of restful sleep, and will in turn cause more problems about which these children get anxious. Alongside their greater responsibility, school-age children still need basic and consistently enforced ground rules about sleep in order to build independence. Clearly at this age, reading before bedtime is a good option.

Parents should help their school-age children to start their homework early, and to enjoy screen time, but not within an hour of bedtime, and to follow a consistent (and more independent) routine before bed. Do they have a consistent bedtime? Do they take a shower or bath each night? (A hot shower or bath naturally cues the body that it is time for sleep as the body’s core temperature rises and then drops.) Do they read before lights out? Is the house quiet at their bedtime? Parents should also find out if their children have worries that are making it difficult to go to sleep. Are they worried about a test or big game? Or about bigger issues of safety? Parents can help a child to discuss their worries and address those that are addressable; usually, this is enough to help children learn to master their worries. When a school-age child’s anxiety does not improve with open discussion, then it may be helpful to have a more formal evaluation for anxiety with a mental health clinician.

Adolescence is a time in which sleep patterns naturally shift, while the need for sleep remains robust. Teenagers become tired later and need to sleep in until later in the morning, just at the same time that school demands impinge on sleep with an earlier start to the day and more extensive homework at night. Older adolescents may go out with friends on weekends and shift their bedtime routine by 4 or more hours for two nights out of every seven, which is as profoundly disruptive to restful sleep as traveling across four time zones and back every week. These are years in which more independence can again lead to more screen use in the evening, whether for writing a paper on a computer or texting a friend late into the night.

An adolescent who is sleep deprived may have low energy, be forgetful and distractible, and see their academic and athletic performance suffer. They may appear more withdrawn or moody. This is an age in which serious mood problems, such as depression, are more likely to emerge, and are associated with sleep problems. But these problems will not improve with simple sleep hygiene interventions; thus, the teens who do not get better after these interventions may need a psychiatric evaluation.

The strategies that might help adolescents are not much different from those for younger children. It is important with adolescents, however, to explain why they should exercise regularly, have a consistent bedtime routine, and not bring their cell phone to bed. While parents should still be able to set and enforce ground rules, they also need to be equipping their adolescents to understand and manage their sleep independently, which they will need to do soon enough. Encouraging self-regulation between ages 13 and 17 is essential as college or independence approaches, and efforts at control are hard to enforce and send the wrong message.

Inconsistent, inadequate sleep often reflects what has been a frustrating struggle for parents. Asking questions about sleep gives parents the supportive message that sleep is challenging and important, and may empower them to approach it with renewed firmness and clarity. When you help parents to set routines and limits that support consistent, adequate sleep, their children will be on a path to healthy development.

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

If you ask the parents in your practice what their most important task is with their children, they will probably say something about keeping their child safe and developing their child’s character. They might speak about wanting to raise children who are ready to live independently, happily, and successfully. Beyond independence, they may also observe that they want to raise children of good character, with a deeply held value system that reflects their own core principles. The details of such a value system will vary from family to family, but often will include descriptive ideals such as being ethical, empathic, courageous, generous, ambitious, responsible, and having integrity. Because the everyday tasks of life with children can be so demanding, this larger task often does not get much direct attention from physicians and may not even be explicitly discussed between parents. A few questions from their physician can be profoundly helpful to parents as they reflect on practical strategies to cultivate the qualities of character that will prepare their children to live independent, happy, purposeful, and meaningful adult lives.

One way to get a sense of how parents are preparing their children for independence is to ask how they are they teaching their children about the value of money. Do they give their children a predictable allowance? Is it contingent on chores or responsibilities? Do their children have a bank account or a piggy bank? Do they spend time talking with their children about how they manage their money or plan for large purchases? Money is often a charged subject for families. Asking about it explicitly can help support open, thoughtful communication within the family. Parents will be very interested to learn that such discussions and efforts can powerfully support the development of independence, self-confidence, patience, good judgment, and responsibility in their children. You might inform parents that they can consider their child’s natural temperament when having these discussions. An anxious child, who may be prone to worries about poverty and perfection, might benefit from hearing that money is something that everyone needs to learn how to manage, and it is a tool that can make life easier, but it is not a measure of a person’s worth. On the other hand, a very easygoing child may benefit from having an allowance that is contingent on chores or an adolescent could be urged to get a job rather than depend on allowance. This is how they will learn the real value of work and will cultivate discipline, planning, and the meaningful confidence that they know how to work hard. Whether a family is struggling or can afford more than they choose to spend, the values inherent in financial decisions will be very meaningful for the preadolescent or teenager.

While all parents would likely agree that they hope to raise children who are disciplined, responsible, and independent, the other values that they hope their children appreciate and integrate will cover a wider territory. If you understand what the parents in your practice consider to be their most important values, it also will enhance your understanding of that family’s priorities and how they will manage challenges. You might ask them, "What three values, such as caring about others, honesty, or bravery, would you most like to cultivate in your children?" For those parents that have not actively reflected on their values and behavior or where there are differences between parents concerning values, this may be the start of an important conversation at home.

With ethical qualities that are interpersonal, such as empathy or generosity, there is a growing body of evidence in the psychological literature that suggests that children are much more likely to emulate their parents’ behavior than to follow their suggestions. In a classic experiment published in 1975, the psychologist J. Philippe Rushton observed how school-age children’s generous behaviors correspond with the generous (or selfish) behaviors or suggestions of parents and teachers. Rushton found that there was a very robust relationship between what the adults did and what the children did, one that could powerfully counteract what the adults said (when they disagreed). It seems actions truly do speak louder than words.

Clearly, parents should actively pay attention to how they are living their values, demonstrating them to their children in choices they make, both large and small. Then they can consider what experiences might encourage these values for their children. If they value empathy, what sorts of experiences will give their children the chance to experience and develop empathy for others? They might think about school-based activities or hobbies that can foster empathy. Is there an activity dedicated to helping children in need or to partnering with children with physical disabilities? Perhaps there is a group of children that work toward a chosen public service. If there is not such a group at their children’s school, they should consider starting one. By living these values, by doing it in a way that teaches these values to other children, and by being involved in their children’s school experience, parents can very powerfully nourish the development of these values and behaviors in their children.

Parents also might keep these important values in mind as they are helping their older children choose extracurricular activities or apply for summer jobs. While their children are considering what is most interesting to them, what will "look good" on a college application, or how to make the most money, parents might keep in mind how important values, such as empathy, generosity, bravery, discipline, or patience might be nurtured by the various experiences. Ultimately, these will be their teenager’s choices to make, but parents can still have a powerful influence by showing an interest and highlighting the importance of principles beyond dollars or college ambitions.

Emphasizing the potency of modeling treasured values does not mean that parents shouldn’t also talk about these values and even mixed feelings as they approach difficult, value-laden decisions in their own lives. What matters is how such values are discussed. Praise is powerful, and it appears that when parents praise a child’s character, it is even more powerful than when they praise a behavior. This is especially true for younger children (6- to 12-year-olds), when children lightly try on many different behaviors but are considering the kinds of people they wish to be. Likewise, when children fail to live up to their parents’ values, it is effective for parents to share their disappointment, but they should take care not to shame their children, which leave children feeling discouraged and powerless to change.

Beyond praise and reproach, when parents talk openly and with curiosity about these complex, nuanced topics, and genuinely listen to their children’s questions, thoughts, and opinions about them, they are communicating that their child’s thinking, feelings, and character are valued. Parents should look for opportunities to discuss values one step removed from their children. They could discuss characters’ choices in a movie or book, issues faced by their or their children’s friends, challenges managed by a celebrated athlete or celebrity or even events in a reality television show they have watched together. With these conversations, they are helping their children nurture their own ideas about values and demonstrating genuine confidence that their children can develop their own opinions about such complex matters. They also contribute to a climate in which their children appreciate that values should be carefully considered and may evolve over time. These conversations will be most helpful as their teenagers become more autonomous and face choices on their own in late high school, college, and young adulthood. They will build a strong foundation on which their children will gradually construct their own considered, individual value system, one they can reflect upon and modify over their lifetime.

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

If you ask the parents in your practice what their most important task is with their children, they will probably say something about keeping their child safe and developing their child’s character. They might speak about wanting to raise children who are ready to live independently, happily, and successfully. Beyond independence, they may also observe that they want to raise children of good character, with a deeply held value system that reflects their own core principles. The details of such a value system will vary from family to family, but often will include descriptive ideals such as being ethical, empathic, courageous, generous, ambitious, responsible, and having integrity. Because the everyday tasks of life with children can be so demanding, this larger task often does not get much direct attention from physicians and may not even be explicitly discussed between parents. A few questions from their physician can be profoundly helpful to parents as they reflect on practical strategies to cultivate the qualities of character that will prepare their children to live independent, happy, purposeful, and meaningful adult lives.

One way to get a sense of how parents are preparing their children for independence is to ask how they are they teaching their children about the value of money. Do they give their children a predictable allowance? Is it contingent on chores or responsibilities? Do their children have a bank account or a piggy bank? Do they spend time talking with their children about how they manage their money or plan for large purchases? Money is often a charged subject for families. Asking about it explicitly can help support open, thoughtful communication within the family. Parents will be very interested to learn that such discussions and efforts can powerfully support the development of independence, self-confidence, patience, good judgment, and responsibility in their children. You might inform parents that they can consider their child’s natural temperament when having these discussions. An anxious child, who may be prone to worries about poverty and perfection, might benefit from hearing that money is something that everyone needs to learn how to manage, and it is a tool that can make life easier, but it is not a measure of a person’s worth. On the other hand, a very easygoing child may benefit from having an allowance that is contingent on chores or an adolescent could be urged to get a job rather than depend on allowance. This is how they will learn the real value of work and will cultivate discipline, planning, and the meaningful confidence that they know how to work hard. Whether a family is struggling or can afford more than they choose to spend, the values inherent in financial decisions will be very meaningful for the preadolescent or teenager.

While all parents would likely agree that they hope to raise children who are disciplined, responsible, and independent, the other values that they hope their children appreciate and integrate will cover a wider territory. If you understand what the parents in your practice consider to be their most important values, it also will enhance your understanding of that family’s priorities and how they will manage challenges. You might ask them, "What three values, such as caring about others, honesty, or bravery, would you most like to cultivate in your children?" For those parents that have not actively reflected on their values and behavior or where there are differences between parents concerning values, this may be the start of an important conversation at home.

With ethical qualities that are interpersonal, such as empathy or generosity, there is a growing body of evidence in the psychological literature that suggests that children are much more likely to emulate their parents’ behavior than to follow their suggestions. In a classic experiment published in 1975, the psychologist J. Philippe Rushton observed how school-age children’s generous behaviors correspond with the generous (or selfish) behaviors or suggestions of parents and teachers. Rushton found that there was a very robust relationship between what the adults did and what the children did, one that could powerfully counteract what the adults said (when they disagreed). It seems actions truly do speak louder than words.

Clearly, parents should actively pay attention to how they are living their values, demonstrating them to their children in choices they make, both large and small. Then they can consider what experiences might encourage these values for their children. If they value empathy, what sorts of experiences will give their children the chance to experience and develop empathy for others? They might think about school-based activities or hobbies that can foster empathy. Is there an activity dedicated to helping children in need or to partnering with children with physical disabilities? Perhaps there is a group of children that work toward a chosen public service. If there is not such a group at their children’s school, they should consider starting one. By living these values, by doing it in a way that teaches these values to other children, and by being involved in their children’s school experience, parents can very powerfully nourish the development of these values and behaviors in their children.

Parents also might keep these important values in mind as they are helping their older children choose extracurricular activities or apply for summer jobs. While their children are considering what is most interesting to them, what will "look good" on a college application, or how to make the most money, parents might keep in mind how important values, such as empathy, generosity, bravery, discipline, or patience might be nurtured by the various experiences. Ultimately, these will be their teenager’s choices to make, but parents can still have a powerful influence by showing an interest and highlighting the importance of principles beyond dollars or college ambitions.

Emphasizing the potency of modeling treasured values does not mean that parents shouldn’t also talk about these values and even mixed feelings as they approach difficult, value-laden decisions in their own lives. What matters is how such values are discussed. Praise is powerful, and it appears that when parents praise a child’s character, it is even more powerful than when they praise a behavior. This is especially true for younger children (6- to 12-year-olds), when children lightly try on many different behaviors but are considering the kinds of people they wish to be. Likewise, when children fail to live up to their parents’ values, it is effective for parents to share their disappointment, but they should take care not to shame their children, which leave children feeling discouraged and powerless to change.

Beyond praise and reproach, when parents talk openly and with curiosity about these complex, nuanced topics, and genuinely listen to their children’s questions, thoughts, and opinions about them, they are communicating that their child’s thinking, feelings, and character are valued. Parents should look for opportunities to discuss values one step removed from their children. They could discuss characters’ choices in a movie or book, issues faced by their or their children’s friends, challenges managed by a celebrated athlete or celebrity or even events in a reality television show they have watched together. With these conversations, they are helping their children nurture their own ideas about values and demonstrating genuine confidence that their children can develop their own opinions about such complex matters. They also contribute to a climate in which their children appreciate that values should be carefully considered and may evolve over time. These conversations will be most helpful as their teenagers become more autonomous and face choices on their own in late high school, college, and young adulthood. They will build a strong foundation on which their children will gradually construct their own considered, individual value system, one they can reflect upon and modify over their lifetime.

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

If you ask the parents in your practice what their most important task is with their children, they will probably say something about keeping their child safe and developing their child’s character. They might speak about wanting to raise children who are ready to live independently, happily, and successfully. Beyond independence, they may also observe that they want to raise children of good character, with a deeply held value system that reflects their own core principles. The details of such a value system will vary from family to family, but often will include descriptive ideals such as being ethical, empathic, courageous, generous, ambitious, responsible, and having integrity. Because the everyday tasks of life with children can be so demanding, this larger task often does not get much direct attention from physicians and may not even be explicitly discussed between parents. A few questions from their physician can be profoundly helpful to parents as they reflect on practical strategies to cultivate the qualities of character that will prepare their children to live independent, happy, purposeful, and meaningful adult lives.

One way to get a sense of how parents are preparing their children for independence is to ask how they are they teaching their children about the value of money. Do they give their children a predictable allowance? Is it contingent on chores or responsibilities? Do their children have a bank account or a piggy bank? Do they spend time talking with their children about how they manage their money or plan for large purchases? Money is often a charged subject for families. Asking about it explicitly can help support open, thoughtful communication within the family. Parents will be very interested to learn that such discussions and efforts can powerfully support the development of independence, self-confidence, patience, good judgment, and responsibility in their children. You might inform parents that they can consider their child’s natural temperament when having these discussions. An anxious child, who may be prone to worries about poverty and perfection, might benefit from hearing that money is something that everyone needs to learn how to manage, and it is a tool that can make life easier, but it is not a measure of a person’s worth. On the other hand, a very easygoing child may benefit from having an allowance that is contingent on chores or an adolescent could be urged to get a job rather than depend on allowance. This is how they will learn the real value of work and will cultivate discipline, planning, and the meaningful confidence that they know how to work hard. Whether a family is struggling or can afford more than they choose to spend, the values inherent in financial decisions will be very meaningful for the preadolescent or teenager.

While all parents would likely agree that they hope to raise children who are disciplined, responsible, and independent, the other values that they hope their children appreciate and integrate will cover a wider territory. If you understand what the parents in your practice consider to be their most important values, it also will enhance your understanding of that family’s priorities and how they will manage challenges. You might ask them, "What three values, such as caring about others, honesty, or bravery, would you most like to cultivate in your children?" For those parents that have not actively reflected on their values and behavior or where there are differences between parents concerning values, this may be the start of an important conversation at home.

With ethical qualities that are interpersonal, such as empathy or generosity, there is a growing body of evidence in the psychological literature that suggests that children are much more likely to emulate their parents’ behavior than to follow their suggestions. In a classic experiment published in 1975, the psychologist J. Philippe Rushton observed how school-age children’s generous behaviors correspond with the generous (or selfish) behaviors or suggestions of parents and teachers. Rushton found that there was a very robust relationship between what the adults did and what the children did, one that could powerfully counteract what the adults said (when they disagreed). It seems actions truly do speak louder than words.

Clearly, parents should actively pay attention to how they are living their values, demonstrating them to their children in choices they make, both large and small. Then they can consider what experiences might encourage these values for their children. If they value empathy, what sorts of experiences will give their children the chance to experience and develop empathy for others? They might think about school-based activities or hobbies that can foster empathy. Is there an activity dedicated to helping children in need or to partnering with children with physical disabilities? Perhaps there is a group of children that work toward a chosen public service. If there is not such a group at their children’s school, they should consider starting one. By living these values, by doing it in a way that teaches these values to other children, and by being involved in their children’s school experience, parents can very powerfully nourish the development of these values and behaviors in their children.

Parents also might keep these important values in mind as they are helping their older children choose extracurricular activities or apply for summer jobs. While their children are considering what is most interesting to them, what will "look good" on a college application, or how to make the most money, parents might keep in mind how important values, such as empathy, generosity, bravery, discipline, or patience might be nurtured by the various experiences. Ultimately, these will be their teenager’s choices to make, but parents can still have a powerful influence by showing an interest and highlighting the importance of principles beyond dollars or college ambitions.

Emphasizing the potency of modeling treasured values does not mean that parents shouldn’t also talk about these values and even mixed feelings as they approach difficult, value-laden decisions in their own lives. What matters is how such values are discussed. Praise is powerful, and it appears that when parents praise a child’s character, it is even more powerful than when they praise a behavior. This is especially true for younger children (6- to 12-year-olds), when children lightly try on many different behaviors but are considering the kinds of people they wish to be. Likewise, when children fail to live up to their parents’ values, it is effective for parents to share their disappointment, but they should take care not to shame their children, which leave children feeling discouraged and powerless to change.

Beyond praise and reproach, when parents talk openly and with curiosity about these complex, nuanced topics, and genuinely listen to their children’s questions, thoughts, and opinions about them, they are communicating that their child’s thinking, feelings, and character are valued. Parents should look for opportunities to discuss values one step removed from their children. They could discuss characters’ choices in a movie or book, issues faced by their or their children’s friends, challenges managed by a celebrated athlete or celebrity or even events in a reality television show they have watched together. With these conversations, they are helping their children nurture their own ideas about values and demonstrating genuine confidence that their children can develop their own opinions about such complex matters. They also contribute to a climate in which their children appreciate that values should be carefully considered and may evolve over time. These conversations will be most helpful as their teenagers become more autonomous and face choices on their own in late high school, college, and young adulthood. They will build a strong foundation on which their children will gradually construct their own considered, individual value system, one they can reflect upon and modify over their lifetime.

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

Technology and social media now occupy a central place in the lives of our children and adolescents. According to data from the Pew Research Center in 2012, 75% of U.S. adolescents text. Texting has far outpaced phone calls and e-mail among adolescents as the primary means of (electronic) communication with family and friends. The number of texts they send has grown dramatically over the last few years, with a median of 100 texts sent daily among older adolescent girls in 2012. And it is increasingly challenging to distinguish texting from communication via other social media platforms: Flickr, Tumblr, Snapchat, Instagram, and Twitter. The new technology has augmented the local park or hangout as an essential aspect of adolescents developing their identity through intense interaction with peers.

We physicians who orbit the lives of adolescents may have difficulty keeping up with these developments, but we have a responsibility to be curious with our patients and their parents about the use of social media. We appreciate the developmental forces in adolescence that lead to new independence, heightened impulsivity, the intense importance of friendships, and sexual curiosity. When these developmental forces play out online rather than in high school hallways, there are new risks of unexpected consequences, serious psychological and even legal complications. In the same way that we speak with our patients and their parents about other risky behaviors, we should be curious about patients’ online behaviors and be prepared to offer them guidance as to how to lower risk and offer their parents guidance in establishing and enforcing reasonable rules and boundaries.

Texting is an increasingly commonplace means of communication. Many families will provide a new sixth grader with a cell phone to help the child manage a new bus route or a solo walk home, and texting can be an efficient way to stay connected.

But texting can pose a particular problem when it includes sexual material, or "sexting." Definitions vary, but sexting is most consistently defined as the taking of an explicit photograph of oneself and sending it to another via text or e-mail. There have been few controlled studies, but smaller surveys have suggested that between 20% and 30% of older adolescents have sent a sext, and a higher percentage have received them. Most of those sending these explicit photos are girls, and more than half of them report having been pressured to do so by a boy. While the likelihood of sending and receiving sexts is greatest among older adolescents, it can be a red flag for low self-esteem or social insecurity if a school-age or young teen is sending sexts.

More trouble can arise if these explicit photographs are shared with a wider audience, as can sometimes happen. This can lead to intense shame and psychological distress, bullying, and isolation; the subsequent stress can cause depression, anxiety, or even suicidality. Even without the shame of wide distribution, several studies have found a correlation between sexting and impulsivity and substance use in adolescents. Then there are child pornography statutes that can find 18-year-olds charged with a felony for sharing a photo of someone under 18. Beyond sexting, the circulating of other personal photos or posts (about drinking at a party, for example) can seem a harmless impulse, but these are often permanent and might haunt adolescents as they apply to college or for jobs. The consequences of an impulsive photo shared online can be unexpected, enduring, and occasionally devastating, and, like other teenage behavior, long-term consequences are rarely a top priority.

Although the value of staying connected so easily and frequently is enormous, these platforms also bring the possibility of predators who are looking to make more than a virtual connection with children and teens. The potential anonymity of these platforms also can make for group exchanges that can become mean spirited or abusive, and quickly deteriorate into cyberbullying. It can be difficult to find actual adults to supervise or manage these situations, and the risks for depression, anxiety, school avoidance, and suicidality among bullied adolescents (and among the bulliers) is well established.

Among other risks associated with extensive amounts of time spent virtually connected is the difficulty some adolescents have in shutting off or even silencing their phone; what precious little sleep they are getting is further squeezed by texts throughout the night. For those adolescents who have difficulty getting off of their phone or the computer, they can fall behind in school work or spend less time in the wide range of physical, intellectual, and creative activities that should be a part of a healthy adolescence. When too many relationships are managed virtually, teens can struggle with the nuances of communication and emotional understanding that happen in live exchanges. The abilities to be patient, to tolerate frustration or uncertainty, and to defer gratification are essential life skills, and are not cultivated in time spent tending virtual connections. These subtler risks of online activity may be especially pronounced for young people with problems with attention, impulsivity, mood, or developmental issues.

So how much time do your patients spend online every day? Does it interfere with getting their homework done? Have they withdrawn from prior hobbies? Would they rather text their friends or hang out with them? Do they have their own phone? Have they ever seen a sext? Have they felt pressure to send one? Do they turn their phone off at night? Have they ever been involved in texts that felt cruel?

These questions are similar to ones that arose when day to day life was face to face; they flow from expected adolescent development, but are now worth considering for both the real and the virtual world. And if, as a pediatrician, you can ask these questions of your patients directly and warmly, you will likely get honest answers. Most young people, although nimble with these technologies, are happy to have your interest in this area and even your advice about their use of these technologies.

It can be equally powerful to speak with parents about this to find out what their concerns are, whether they understand the role of this technology as part of adolescent development, and whether they know the answers to questions about their child’s use of technology. It can help to ask whether they find themselves on their smartphones when they are with their children and are supposed to be watching them play soccer or are eating dinner together.

Parents need to be mindful of what they are modeling if they hope to help their children better control their use of technology. It can be powerful for parents to hear that it is reasonable for them to set firm, clear rules around technology use, and enforce those rules. Parents can explain warmly and clearly that phones and computers go off at a certain time or are taken away, that they don’t belong at the dinner table, and that their children should imagine that every text they send or photo they post could be seen by their parents, teachers, or college admissions committee before they hit send.

As technology changes and the teenager matures, sharing some of the dilemmas or challenges of current technology and negotiating expectations and enforcing rules, in the context of ongoing, honest communication, is likely the best path. When the teenager’s use of the technology reflects poor judgment, rigid overuse, or serious risk taking, mental health referral is indicated.

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

Technology and social media now occupy a central place in the lives of our children and adolescents. According to data from the Pew Research Center in 2012, 75% of U.S. adolescents text. Texting has far outpaced phone calls and e-mail among adolescents as the primary means of (electronic) communication with family and friends. The number of texts they send has grown dramatically over the last few years, with a median of 100 texts sent daily among older adolescent girls in 2012. And it is increasingly challenging to distinguish texting from communication via other social media platforms: Flickr, Tumblr, Snapchat, Instagram, and Twitter. The new technology has augmented the local park or hangout as an essential aspect of adolescents developing their identity through intense interaction with peers.

We physicians who orbit the lives of adolescents may have difficulty keeping up with these developments, but we have a responsibility to be curious with our patients and their parents about the use of social media. We appreciate the developmental forces in adolescence that lead to new independence, heightened impulsivity, the intense importance of friendships, and sexual curiosity. When these developmental forces play out online rather than in high school hallways, there are new risks of unexpected consequences, serious psychological and even legal complications. In the same way that we speak with our patients and their parents about other risky behaviors, we should be curious about patients’ online behaviors and be prepared to offer them guidance as to how to lower risk and offer their parents guidance in establishing and enforcing reasonable rules and boundaries.

Texting is an increasingly commonplace means of communication. Many families will provide a new sixth grader with a cell phone to help the child manage a new bus route or a solo walk home, and texting can be an efficient way to stay connected.

But texting can pose a particular problem when it includes sexual material, or "sexting." Definitions vary, but sexting is most consistently defined as the taking of an explicit photograph of oneself and sending it to another via text or e-mail. There have been few controlled studies, but smaller surveys have suggested that between 20% and 30% of older adolescents have sent a sext, and a higher percentage have received them. Most of those sending these explicit photos are girls, and more than half of them report having been pressured to do so by a boy. While the likelihood of sending and receiving sexts is greatest among older adolescents, it can be a red flag for low self-esteem or social insecurity if a school-age or young teen is sending sexts.

More trouble can arise if these explicit photographs are shared with a wider audience, as can sometimes happen. This can lead to intense shame and psychological distress, bullying, and isolation; the subsequent stress can cause depression, anxiety, or even suicidality. Even without the shame of wide distribution, several studies have found a correlation between sexting and impulsivity and substance use in adolescents. Then there are child pornography statutes that can find 18-year-olds charged with a felony for sharing a photo of someone under 18. Beyond sexting, the circulating of other personal photos or posts (about drinking at a party, for example) can seem a harmless impulse, but these are often permanent and might haunt adolescents as they apply to college or for jobs. The consequences of an impulsive photo shared online can be unexpected, enduring, and occasionally devastating, and, like other teenage behavior, long-term consequences are rarely a top priority.

Although the value of staying connected so easily and frequently is enormous, these platforms also bring the possibility of predators who are looking to make more than a virtual connection with children and teens. The potential anonymity of these platforms also can make for group exchanges that can become mean spirited or abusive, and quickly deteriorate into cyberbullying. It can be difficult to find actual adults to supervise or manage these situations, and the risks for depression, anxiety, school avoidance, and suicidality among bullied adolescents (and among the bulliers) is well established.

Among other risks associated with extensive amounts of time spent virtually connected is the difficulty some adolescents have in shutting off or even silencing their phone; what precious little sleep they are getting is further squeezed by texts throughout the night. For those adolescents who have difficulty getting off of their phone or the computer, they can fall behind in school work or spend less time in the wide range of physical, intellectual, and creative activities that should be a part of a healthy adolescence. When too many relationships are managed virtually, teens can struggle with the nuances of communication and emotional understanding that happen in live exchanges. The abilities to be patient, to tolerate frustration or uncertainty, and to defer gratification are essential life skills, and are not cultivated in time spent tending virtual connections. These subtler risks of online activity may be especially pronounced for young people with problems with attention, impulsivity, mood, or developmental issues.

So how much time do your patients spend online every day? Does it interfere with getting their homework done? Have they withdrawn from prior hobbies? Would they rather text their friends or hang out with them? Do they have their own phone? Have they ever seen a sext? Have they felt pressure to send one? Do they turn their phone off at night? Have they ever been involved in texts that felt cruel?

These questions are similar to ones that arose when day to day life was face to face; they flow from expected adolescent development, but are now worth considering for both the real and the virtual world. And if, as a pediatrician, you can ask these questions of your patients directly and warmly, you will likely get honest answers. Most young people, although nimble with these technologies, are happy to have your interest in this area and even your advice about their use of these technologies.

It can be equally powerful to speak with parents about this to find out what their concerns are, whether they understand the role of this technology as part of adolescent development, and whether they know the answers to questions about their child’s use of technology. It can help to ask whether they find themselves on their smartphones when they are with their children and are supposed to be watching them play soccer or are eating dinner together.

Parents need to be mindful of what they are modeling if they hope to help their children better control their use of technology. It can be powerful for parents to hear that it is reasonable for them to set firm, clear rules around technology use, and enforce those rules. Parents can explain warmly and clearly that phones and computers go off at a certain time or are taken away, that they don’t belong at the dinner table, and that their children should imagine that every text they send or photo they post could be seen by their parents, teachers, or college admissions committee before they hit send.

As technology changes and the teenager matures, sharing some of the dilemmas or challenges of current technology and negotiating expectations and enforcing rules, in the context of ongoing, honest communication, is likely the best path. When the teenager’s use of the technology reflects poor judgment, rigid overuse, or serious risk taking, mental health referral is indicated.

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

Technology and social media now occupy a central place in the lives of our children and adolescents. According to data from the Pew Research Center in 2012, 75% of U.S. adolescents text. Texting has far outpaced phone calls and e-mail among adolescents as the primary means of (electronic) communication with family and friends. The number of texts they send has grown dramatically over the last few years, with a median of 100 texts sent daily among older adolescent girls in 2012. And it is increasingly challenging to distinguish texting from communication via other social media platforms: Flickr, Tumblr, Snapchat, Instagram, and Twitter. The new technology has augmented the local park or hangout as an essential aspect of adolescents developing their identity through intense interaction with peers.

We physicians who orbit the lives of adolescents may have difficulty keeping up with these developments, but we have a responsibility to be curious with our patients and their parents about the use of social media. We appreciate the developmental forces in adolescence that lead to new independence, heightened impulsivity, the intense importance of friendships, and sexual curiosity. When these developmental forces play out online rather than in high school hallways, there are new risks of unexpected consequences, serious psychological and even legal complications. In the same way that we speak with our patients and their parents about other risky behaviors, we should be curious about patients’ online behaviors and be prepared to offer them guidance as to how to lower risk and offer their parents guidance in establishing and enforcing reasonable rules and boundaries.

Texting is an increasingly commonplace means of communication. Many families will provide a new sixth grader with a cell phone to help the child manage a new bus route or a solo walk home, and texting can be an efficient way to stay connected.

But texting can pose a particular problem when it includes sexual material, or "sexting." Definitions vary, but sexting is most consistently defined as the taking of an explicit photograph of oneself and sending it to another via text or e-mail. There have been few controlled studies, but smaller surveys have suggested that between 20% and 30% of older adolescents have sent a sext, and a higher percentage have received them. Most of those sending these explicit photos are girls, and more than half of them report having been pressured to do so by a boy. While the likelihood of sending and receiving sexts is greatest among older adolescents, it can be a red flag for low self-esteem or social insecurity if a school-age or young teen is sending sexts.

More trouble can arise if these explicit photographs are shared with a wider audience, as can sometimes happen. This can lead to intense shame and psychological distress, bullying, and isolation; the subsequent stress can cause depression, anxiety, or even suicidality. Even without the shame of wide distribution, several studies have found a correlation between sexting and impulsivity and substance use in adolescents. Then there are child pornography statutes that can find 18-year-olds charged with a felony for sharing a photo of someone under 18. Beyond sexting, the circulating of other personal photos or posts (about drinking at a party, for example) can seem a harmless impulse, but these are often permanent and might haunt adolescents as they apply to college or for jobs. The consequences of an impulsive photo shared online can be unexpected, enduring, and occasionally devastating, and, like other teenage behavior, long-term consequences are rarely a top priority.

Although the value of staying connected so easily and frequently is enormous, these platforms also bring the possibility of predators who are looking to make more than a virtual connection with children and teens. The potential anonymity of these platforms also can make for group exchanges that can become mean spirited or abusive, and quickly deteriorate into cyberbullying. It can be difficult to find actual adults to supervise or manage these situations, and the risks for depression, anxiety, school avoidance, and suicidality among bullied adolescents (and among the bulliers) is well established.

Among other risks associated with extensive amounts of time spent virtually connected is the difficulty some adolescents have in shutting off or even silencing their phone; what precious little sleep they are getting is further squeezed by texts throughout the night. For those adolescents who have difficulty getting off of their phone or the computer, they can fall behind in school work or spend less time in the wide range of physical, intellectual, and creative activities that should be a part of a healthy adolescence. When too many relationships are managed virtually, teens can struggle with the nuances of communication and emotional understanding that happen in live exchanges. The abilities to be patient, to tolerate frustration or uncertainty, and to defer gratification are essential life skills, and are not cultivated in time spent tending virtual connections. These subtler risks of online activity may be especially pronounced for young people with problems with attention, impulsivity, mood, or developmental issues.

So how much time do your patients spend online every day? Does it interfere with getting their homework done? Have they withdrawn from prior hobbies? Would they rather text their friends or hang out with them? Do they have their own phone? Have they ever seen a sext? Have they felt pressure to send one? Do they turn their phone off at night? Have they ever been involved in texts that felt cruel?

These questions are similar to ones that arose when day to day life was face to face; they flow from expected adolescent development, but are now worth considering for both the real and the virtual world. And if, as a pediatrician, you can ask these questions of your patients directly and warmly, you will likely get honest answers. Most young people, although nimble with these technologies, are happy to have your interest in this area and even your advice about their use of these technologies.

It can be equally powerful to speak with parents about this to find out what their concerns are, whether they understand the role of this technology as part of adolescent development, and whether they know the answers to questions about their child’s use of technology. It can help to ask whether they find themselves on their smartphones when they are with their children and are supposed to be watching them play soccer or are eating dinner together.

Parents need to be mindful of what they are modeling if they hope to help their children better control their use of technology. It can be powerful for parents to hear that it is reasonable for them to set firm, clear rules around technology use, and enforce those rules. Parents can explain warmly and clearly that phones and computers go off at a certain time or are taken away, that they don’t belong at the dinner table, and that their children should imagine that every text they send or photo they post could be seen by their parents, teachers, or college admissions committee before they hit send.

As technology changes and the teenager matures, sharing some of the dilemmas or challenges of current technology and negotiating expectations and enforcing rules, in the context of ongoing, honest communication, is likely the best path. When the teenager’s use of the technology reflects poor judgment, rigid overuse, or serious risk taking, mental health referral is indicated.

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

Currently in the United States, less than 0.5% of the population serves in the uniformed armed services. This small sliver of the population has borne a large burden over the past dozen years, as the United States engaged in wars in both Iraq and Afghanistan. While those in the armed services have traditionally been quite young themselves, Operation Iraqi Freedom and Operation Enduring Freedom saw many more Army Reservists and National Guardsmen deployed.

Many of those deployed are parents, coming from civilian communities and jobs rather than from military bases. While combat operations in Iraq and Afghanistan have officially ceased, there are many families still living with the effects of a military deployment, whether deployment is ongoing or the deployed parent recently returned; the effects of deployment include post-traumatic stress disorder (PTSD) or traumatic brain injury (TBI) in a returning parent, or even the death of a parent.

As many as 2 million children in the United States have lived through a parent’s deployment, with more than 800,000 living through two or more deployments. Pediatricians are in a unique position to provide useful information and support to the parents of these children, especially for those not on military bases, which have all of the built-in supports such a location may provide.

Supporting resilience in the families of our military service members can begin with a simple question, "Is someone in your family serving in the military?" Simply asking this question suggests you understand the range of risks, level of stress, and potential isolation of these "single" parents. Children with a deployed parent are at greater risk for anxiety and depression than their civilian peers are, and the risk goes up with longer or multiple deployments.

Somewhat counterintuitively, the risk can be higher for adolescents than for younger children. Adolescents have more complex needs to adjust and test their emerging identities with both parents, and they are faced with greater real-world risks given their many hours of unsupervised time, access to alcohol, and, if they are old enough, the ability to drive. It can be useful to find out if the child is functioning well at school, at home, and with peers, or if there have been any changes in function since the parent was deployed. This may be an ideal time to consider using a mental health screening instrument, such as the Pediatric Symptom Checklist (PSC) to check for functional impairment that may indicate a need for a mental health referral.

It is also important to ask the remaining parent how they are managing the deployment. The combined effect of their anxiety about their partner’s safety; sudden, single parenthood; and the financial strains that deployment can bring is often profound. Families with a deployed reservist are likely to experience some social isolation as they manage these challenges outside of the structure and organization of the military community. It can be meaningful for these parents to receive support from a pediatrician, and the suggestion that they make good use of all of their available supports, whether through the military, a faith organization, family, or community-service agencies.

On a practical level, it can be very helpful to consider how the family is managing communication around the deployment. How much should their children know about the details of the parent’s deployment? How is the child or adolescent dealing with the information? How anxious are they? What questions are they asking? Do the children feel they have enough information or would they prefer to know more? Are there certain things they don’t want to know? Do they know to ask a trusted adult if they have a specific worry or hear something worrisome at school, on television, or even at home? How is the parent himself or herself adjusting? Is she able to cope with the stress? Is he depressed or overwhelmed?

Similarly, it can be powerful for a parent to hear from their pediatrician that it is protective to preserve a child’s routines, rules, and responsibilities during a parent’s deployment. Even an adolescent will find it reassuring and organizing to have consistency in her schedule. School, extracurricular activities, homework, sports, and play dates should continue whenever possible, and parents may need to use their support network to help with this. They might focus on special rituals, such as holidays or birthdays, and document them so that they can be shared with the deployed parent, either in a care package or when they return.

While a parent’s return will be eagerly anticipated, it will also be a time of some unexpected changes and challenges. During deployment, usually 8 to 12 months, their children will have grown and changed, and the at-home parent will have adjusted to a different pace and routines. Simple questions can help the other parent anticipate and prepare for the challenge of reintegration into the home and community. What have they told their children about the return? Have they talked about what might be difficult? What has been surprising or easier during the parent’s deployment? What will be easier after that parent returns? How have they changed since their parent was deployed? What are they most curious about? What are they most worried about? Reintegration takes time, but as long as there are open lines of communication during the transition and supports to turn to in case of significant difficulties, it will be successful.

If a parent has recently returned, it is reasonable to ask if there have been any unexpected problems. While some injuries are visible, many returning soldiers will experience the "invisible wounds" of TBI or PTSD. There is ample evidence that many veterans will not seek care for PTSD, and those who do may experience significant barriers to accessing treatment. These conditions will affect a whole family, so asking a parent (and your patient) about concerning behaviors, such as anxiety, anger, avoidance, withdrawal, or substance abuse in a returned parent can be the first step to helping a family. Reminding parents that there are resources available to them, whether through the Department of Veterans Affairs, community service agencies, or even online (see below), can empower them to help the returning parent get the needed treatment and support.

Finally, the death of a parent during deployment is a subject worthy of its own column. Express your condolences while acknowledging that grief is a gradual process that is different for each individual and is especially different for children and spouses. Ask if they are taking good care of themselves and have enough personal support. You might remind a parent that some regressive behaviors, moodiness, or even seeming normalcy are all typical expressions of grief in children and require patience. Increased risk-taking behaviors in an adolescent or significant dysfunction (refusing to go to school or total withdrawal from friends and extracurricular activities) are concerning, though, and should be referred for additional evaluation and support. Assess the parent’s capacity during this difficult time, and see if the surviving parent and children have access to sufficient support or whether a referral for mental health services is needed. For a child to know that she can speak to another family member, teacher, or coach can be protective and allay guilt, as she can voice her grief or worries to an adult who is not grieving as intensely as her surviving parent. Finally, you might work with parents to locate the community resources that are available to them and their children as they manage this painful adjustment while also supporting their children’s healthiest development.

Some examples of online resources for the families of deployed or returned veterans:

• The Department of Veterans Affairs Mental Health page.

• The Veteran Parenting Toolkit.

• The Home Base Program.

Most of us are isolated from the difficulties that military families routinely face, and it is easy to forget the impact and the risks to children when parents are deployed. We should not forget their service and their needs.

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

Currently in the United States, less than 0.5% of the population serves in the uniformed armed services. This small sliver of the population has borne a large burden over the past dozen years, as the United States engaged in wars in both Iraq and Afghanistan. While those in the armed services have traditionally been quite young themselves, Operation Iraqi Freedom and Operation Enduring Freedom saw many more Army Reservists and National Guardsmen deployed.

Many of those deployed are parents, coming from civilian communities and jobs rather than from military bases. While combat operations in Iraq and Afghanistan have officially ceased, there are many families still living with the effects of a military deployment, whether deployment is ongoing or the deployed parent recently returned; the effects of deployment include post-traumatic stress disorder (PTSD) or traumatic brain injury (TBI) in a returning parent, or even the death of a parent.

As many as 2 million children in the United States have lived through a parent’s deployment, with more than 800,000 living through two or more deployments. Pediatricians are in a unique position to provide useful information and support to the parents of these children, especially for those not on military bases, which have all of the built-in supports such a location may provide.

Supporting resilience in the families of our military service members can begin with a simple question, "Is someone in your family serving in the military?" Simply asking this question suggests you understand the range of risks, level of stress, and potential isolation of these "single" parents. Children with a deployed parent are at greater risk for anxiety and depression than their civilian peers are, and the risk goes up with longer or multiple deployments.

Somewhat counterintuitively, the risk can be higher for adolescents than for younger children. Adolescents have more complex needs to adjust and test their emerging identities with both parents, and they are faced with greater real-world risks given their many hours of unsupervised time, access to alcohol, and, if they are old enough, the ability to drive. It can be useful to find out if the child is functioning well at school, at home, and with peers, or if there have been any changes in function since the parent was deployed. This may be an ideal time to consider using a mental health screening instrument, such as the Pediatric Symptom Checklist (PSC) to check for functional impairment that may indicate a need for a mental health referral.

It is also important to ask the remaining parent how they are managing the deployment. The combined effect of their anxiety about their partner’s safety; sudden, single parenthood; and the financial strains that deployment can bring is often profound. Families with a deployed reservist are likely to experience some social isolation as they manage these challenges outside of the structure and organization of the military community. It can be meaningful for these parents to receive support from a pediatrician, and the suggestion that they make good use of all of their available supports, whether through the military, a faith organization, family, or community-service agencies.

On a practical level, it can be very helpful to consider how the family is managing communication around the deployment. How much should their children know about the details of the parent’s deployment? How is the child or adolescent dealing with the information? How anxious are they? What questions are they asking? Do the children feel they have enough information or would they prefer to know more? Are there certain things they don’t want to know? Do they know to ask a trusted adult if they have a specific worry or hear something worrisome at school, on television, or even at home? How is the parent himself or herself adjusting? Is she able to cope with the stress? Is he depressed or overwhelmed?

Similarly, it can be powerful for a parent to hear from their pediatrician that it is protective to preserve a child’s routines, rules, and responsibilities during a parent’s deployment. Even an adolescent will find it reassuring and organizing to have consistency in her schedule. School, extracurricular activities, homework, sports, and play dates should continue whenever possible, and parents may need to use their support network to help with this. They might focus on special rituals, such as holidays or birthdays, and document them so that they can be shared with the deployed parent, either in a care package or when they return.

While a parent’s return will be eagerly anticipated, it will also be a time of some unexpected changes and challenges. During deployment, usually 8 to 12 months, their children will have grown and changed, and the at-home parent will have adjusted to a different pace and routines. Simple questions can help the other parent anticipate and prepare for the challenge of reintegration into the home and community. What have they told their children about the return? Have they talked about what might be difficult? What has been surprising or easier during the parent’s deployment? What will be easier after that parent returns? How have they changed since their parent was deployed? What are they most curious about? What are they most worried about? Reintegration takes time, but as long as there are open lines of communication during the transition and supports to turn to in case of significant difficulties, it will be successful.

If a parent has recently returned, it is reasonable to ask if there have been any unexpected problems. While some injuries are visible, many returning soldiers will experience the "invisible wounds" of TBI or PTSD. There is ample evidence that many veterans will not seek care for PTSD, and those who do may experience significant barriers to accessing treatment. These conditions will affect a whole family, so asking a parent (and your patient) about concerning behaviors, such as anxiety, anger, avoidance, withdrawal, or substance abuse in a returned parent can be the first step to helping a family. Reminding parents that there are resources available to them, whether through the Department of Veterans Affairs, community service agencies, or even online (see below), can empower them to help the returning parent get the needed treatment and support.

Finally, the death of a parent during deployment is a subject worthy of its own column. Express your condolences while acknowledging that grief is a gradual process that is different for each individual and is especially different for children and spouses. Ask if they are taking good care of themselves and have enough personal support. You might remind a parent that some regressive behaviors, moodiness, or even seeming normalcy are all typical expressions of grief in children and require patience. Increased risk-taking behaviors in an adolescent or significant dysfunction (refusing to go to school or total withdrawal from friends and extracurricular activities) are concerning, though, and should be referred for additional evaluation and support. Assess the parent’s capacity during this difficult time, and see if the surviving parent and children have access to sufficient support or whether a referral for mental health services is needed. For a child to know that she can speak to another family member, teacher, or coach can be protective and allay guilt, as she can voice her grief or worries to an adult who is not grieving as intensely as her surviving parent. Finally, you might work with parents to locate the community resources that are available to them and their children as they manage this painful adjustment while also supporting their children’s healthiest development.

Some examples of online resources for the families of deployed or returned veterans:

• The Department of Veterans Affairs Mental Health page.

• The Veteran Parenting Toolkit.

• The Home Base Program.

Most of us are isolated from the difficulties that military families routinely face, and it is easy to forget the impact and the risks to children when parents are deployed. We should not forget their service and their needs.

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

Currently in the United States, less than 0.5% of the population serves in the uniformed armed services. This small sliver of the population has borne a large burden over the past dozen years, as the United States engaged in wars in both Iraq and Afghanistan. While those in the armed services have traditionally been quite young themselves, Operation Iraqi Freedom and Operation Enduring Freedom saw many more Army Reservists and National Guardsmen deployed.

Many of those deployed are parents, coming from civilian communities and jobs rather than from military bases. While combat operations in Iraq and Afghanistan have officially ceased, there are many families still living with the effects of a military deployment, whether deployment is ongoing or the deployed parent recently returned; the effects of deployment include post-traumatic stress disorder (PTSD) or traumatic brain injury (TBI) in a returning parent, or even the death of a parent.

As many as 2 million children in the United States have lived through a parent’s deployment, with more than 800,000 living through two or more deployments. Pediatricians are in a unique position to provide useful information and support to the parents of these children, especially for those not on military bases, which have all of the built-in supports such a location may provide.

Supporting resilience in the families of our military service members can begin with a simple question, "Is someone in your family serving in the military?" Simply asking this question suggests you understand the range of risks, level of stress, and potential isolation of these "single" parents. Children with a deployed parent are at greater risk for anxiety and depression than their civilian peers are, and the risk goes up with longer or multiple deployments.

Somewhat counterintuitively, the risk can be higher for adolescents than for younger children. Adolescents have more complex needs to adjust and test their emerging identities with both parents, and they are faced with greater real-world risks given their many hours of unsupervised time, access to alcohol, and, if they are old enough, the ability to drive. It can be useful to find out if the child is functioning well at school, at home, and with peers, or if there have been any changes in function since the parent was deployed. This may be an ideal time to consider using a mental health screening instrument, such as the Pediatric Symptom Checklist (PSC) to check for functional impairment that may indicate a need for a mental health referral.

It is also important to ask the remaining parent how they are managing the deployment. The combined effect of their anxiety about their partner’s safety; sudden, single parenthood; and the financial strains that deployment can bring is often profound. Families with a deployed reservist are likely to experience some social isolation as they manage these challenges outside of the structure and organization of the military community. It can be meaningful for these parents to receive support from a pediatrician, and the suggestion that they make good use of all of their available supports, whether through the military, a faith organization, family, or community-service agencies.

On a practical level, it can be very helpful to consider how the family is managing communication around the deployment. How much should their children know about the details of the parent’s deployment? How is the child or adolescent dealing with the information? How anxious are they? What questions are they asking? Do the children feel they have enough information or would they prefer to know more? Are there certain things they don’t want to know? Do they know to ask a trusted adult if they have a specific worry or hear something worrisome at school, on television, or even at home? How is the parent himself or herself adjusting? Is she able to cope with the stress? Is he depressed or overwhelmed?

Similarly, it can be powerful for a parent to hear from their pediatrician that it is protective to preserve a child’s routines, rules, and responsibilities during a parent’s deployment. Even an adolescent will find it reassuring and organizing to have consistency in her schedule. School, extracurricular activities, homework, sports, and play dates should continue whenever possible, and parents may need to use their support network to help with this. They might focus on special rituals, such as holidays or birthdays, and document them so that they can be shared with the deployed parent, either in a care package or when they return.

While a parent’s return will be eagerly anticipated, it will also be a time of some unexpected changes and challenges. During deployment, usually 8 to 12 months, their children will have grown and changed, and the at-home parent will have adjusted to a different pace and routines. Simple questions can help the other parent anticipate and prepare for the challenge of reintegration into the home and community. What have they told their children about the return? Have they talked about what might be difficult? What has been surprising or easier during the parent’s deployment? What will be easier after that parent returns? How have they changed since their parent was deployed? What are they most curious about? What are they most worried about? Reintegration takes time, but as long as there are open lines of communication during the transition and supports to turn to in case of significant difficulties, it will be successful.

If a parent has recently returned, it is reasonable to ask if there have been any unexpected problems. While some injuries are visible, many returning soldiers will experience the "invisible wounds" of TBI or PTSD. There is ample evidence that many veterans will not seek care for PTSD, and those who do may experience significant barriers to accessing treatment. These conditions will affect a whole family, so asking a parent (and your patient) about concerning behaviors, such as anxiety, anger, avoidance, withdrawal, or substance abuse in a returned parent can be the first step to helping a family. Reminding parents that there are resources available to them, whether through the Department of Veterans Affairs, community service agencies, or even online (see below), can empower them to help the returning parent get the needed treatment and support.

Finally, the death of a parent during deployment is a subject worthy of its own column. Express your condolences while acknowledging that grief is a gradual process that is different for each individual and is especially different for children and spouses. Ask if they are taking good care of themselves and have enough personal support. You might remind a parent that some regressive behaviors, moodiness, or even seeming normalcy are all typical expressions of grief in children and require patience. Increased risk-taking behaviors in an adolescent or significant dysfunction (refusing to go to school or total withdrawal from friends and extracurricular activities) are concerning, though, and should be referred for additional evaluation and support. Assess the parent’s capacity during this difficult time, and see if the surviving parent and children have access to sufficient support or whether a referral for mental health services is needed. For a child to know that she can speak to another family member, teacher, or coach can be protective and allay guilt, as she can voice her grief or worries to an adult who is not grieving as intensely as her surviving parent. Finally, you might work with parents to locate the community resources that are available to them and their children as they manage this painful adjustment while also supporting their children’s healthiest development.

Some examples of online resources for the families of deployed or returned veterans:

• The Department of Veterans Affairs Mental Health page.

• The Veteran Parenting Toolkit.

• The Home Base Program.

Most of us are isolated from the difficulties that military families routinely face, and it is easy to forget the impact and the risks to children when parents are deployed. We should not forget their service and their needs.

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

Adolescence is characterized by milestone after milestone on a route that starts with early puberty and progresses to virtually complete autonomy by young adulthood. Obtaining a driver’s license is among the most meaningful steps along this path in terms of independence, responsibility, and risk. Learning to drive is a pragmatic, almost unique opportunity, as it often brings together a highly motivated teenager and concerned parents working together on a task over considerable time.

Teaching a teenager to drive encompasses teaching a skill, demonstrating an attitude, and communicating values concerning safety, peer relationships, paying for added expenses, and "adult" responsibility with rewards and consequences in the real world where not even parents can fix potential harms.

Driving is a major issue in pediatric primary care, as automobile accidents are the leading cause of morbidity and mortality in children under 18 years. Pediatricians can offer parents critical guidance about helping their children master this skill, appreciate the level of risk involved, add to their growing sense of the value of money, and balance new privileges with added expectations.

Pediatricians should be aware of their state’s laws regulating when adolescents may get a driver’s permit, what they have to do to get their driver’s license, and even additional regulations around when adolescents can drive unaccompanied or with friends. One guideline to optimize safety is for the "learner" to get as many miles of practice as possible under parental supervision. The first year or two of driving carries the highest risk of accident; extensive practice may mitigate that risk. Many adolescents take "drivers ed," but these limited hours may be more effective after many informal driving lessons with a parent or other trusted relative.

All parents have vivid memories of how they were taught to drive. Pediatricians might ask parents what learning to drive was like and what it meant to them. Do the parents want to repeat or modify their own experience when they have a "second" chance with their teenager? Parents bring unique knowledge of their child’s strengths and vulnerabilities as well as their own adolescent experiences to help guide any additional rules they may wish to put in place.

Some adolescents, because of their anxiety, will be in no hurry to get their driver’s license. If your family lives where public transportation is good, there may be no need to push him faster than he can comfortably handle. But it can be helpful for parents to wonder with these adolescents what could be helpful about driving, such as whether it might be useful for building peer relationships, commuting to a summer job, or college. And the parent can be curious about what his teenager’s greatest anxiety about driving is. It may be easily addressed ("What if I run out of gas?"), or more profound. In either case, giving an anxious adolescent a chance to articulate what he is concerned about and to consider when the advantages of driving will outweigh the risks, can help him to feel he is actively choosing when to drive, not just passively waiting to feel less scared. This is an important distinction that can have resonance with later choices that may be intimidating, but necessary to normal development.

Then there are the parents in your practice who wish their adolescent were a bit more anxious. Their child is the eager, confident, leap-before-you-look type, which poses a different set of challenges with driving. This adolescent would benefit from a more methodical, structured approach to getting her driver’s license. Extensive driving practice should help to provide enough concerning moments to temper her bravado. Stricter rules (and consequences for breaking those rules) around practicing and driving will help the intrepid adolescent develop self-control as she expands her skills gradually.

Among the most worrisome teenagers are those who are very impulsive, including those with attention-deficit/hyperactivity disorder. It may be wise to require that this teen take his ADHD medication before driving, or have additional rules about friends and phones to minimize distractions; creating more structure and rules around this privilege can make a lifesaving difference for the impulsive teenager. During extensive practice sessions, there will be clear evidence of ADHD behaviors and how they impact driving, and these are teachable moments to build the adolescent’s self-awareness.

Driving safely is hard enough, and special efforts are necessary concerning the highest-risk behaviors. Parents are both regulators and role models on driving – with speed, courtesy, seat belts, cellphones, alcohol use, etc. It is hard to stay credible when parental behavior and teaching are not consistent.

Cell phones deserve a special discussion from parents, whether or not their children are highly distractible. Adolescents tend to be more frequently on the phone, texting, or updating their Facebook status. Having a phone available while alone in the car is a great safety plan, in case there is an accident or problem with the car. But parents need to have an explicit conversation about good car habits. It may be helpful for parents to ask that their children text once before driving and then when the car is off, or to keep the phone in the glove compartment in order to resist the urge to answer or return a call or text. There should be very strict consequences for texting while driving, in addition to any legal ones, ideally losing the privilege for a long enough time to be memorable. It is not overly dramatic for parents to have a conversation with their child about the likelihood of dying or killing someone as a result of something as simple as sending a text, and to use local reports of accidents to reinforce this standard.

The conversation about good driving habits also should focus on drugs and alcohol. Parents need to be able to tell their children about the serious dangers and legal consequences of driving drunk. But they also should be clear that any drug could impair their driving skills; marijuana is no safer to use before driving than alcohol. They should have a clear plan in place that will either rigidly follow the rule concerning the "designated driver" or facilitate their child calling them or a cab if they ever have used alcohol or drugs when out driving, without fear of significant repercussions. It is critical to establish that safety always comes first, and that it will always be helpful to be honest with parents when managing difficult situations.

Parents should consider whether driving privileges should require some financial contribution from their new driver to the car, gas, or insurance payments. This is a good time to step back and consider the parents’ values concerning money, the direction of the teenager’s attitudes, and how the costs of gas, insurance, or even an additional car fit into the values and priorities of the family. Contributing to the costs of a car can be very motivating to a teenager who might otherwise not be enthusiastic about working. For a busy and productive adolescent (and where the family can afford the costs), there may be less need to use car costs as leverage. Certainly, contributing money or service to the family is all part of new adult responsibilities that come with a license. Driving is an adult responsibility, and presents an ideal opportunity to teach adolescents about the balance between privileges and responsibilities, and about the family’s values about money.

Like other milestones in adolescence, driving can be an opportunity to add to the warmth and trust of an increasingly adult relationship between parent and teenager. Alternatively, driving can become a bitter struggle between parental control and the developmental push to autonomy. There will be errors and mistakes with both the technical and judgment aspects of this new territory.

Parents’ job is to protect teens from mistakes that are irreparable, while facilitating their expanding independence. In setting rules and expectations, parents can emphasize their confidence in their adolescent’s capacity to handle all the requirements of driving, while also impressing upon their teen the seriousness of this new privilege.

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

Adolescence is characterized by milestone after milestone on a route that starts with early puberty and progresses to virtually complete autonomy by young adulthood. Obtaining a driver’s license is among the most meaningful steps along this path in terms of independence, responsibility, and risk. Learning to drive is a pragmatic, almost unique opportunity, as it often brings together a highly motivated teenager and concerned parents working together on a task over considerable time.

Teaching a teenager to drive encompasses teaching a skill, demonstrating an attitude, and communicating values concerning safety, peer relationships, paying for added expenses, and "adult" responsibility with rewards and consequences in the real world where not even parents can fix potential harms.

Driving is a major issue in pediatric primary care, as automobile accidents are the leading cause of morbidity and mortality in children under 18 years. Pediatricians can offer parents critical guidance about helping their children master this skill, appreciate the level of risk involved, add to their growing sense of the value of money, and balance new privileges with added expectations.

Pediatricians should be aware of their state’s laws regulating when adolescents may get a driver’s permit, what they have to do to get their driver’s license, and even additional regulations around when adolescents can drive unaccompanied or with friends. One guideline to optimize safety is for the "learner" to get as many miles of practice as possible under parental supervision. The first year or two of driving carries the highest risk of accident; extensive practice may mitigate that risk. Many adolescents take "drivers ed," but these limited hours may be more effective after many informal driving lessons with a parent or other trusted relative.

All parents have vivid memories of how they were taught to drive. Pediatricians might ask parents what learning to drive was like and what it meant to them. Do the parents want to repeat or modify their own experience when they have a "second" chance with their teenager? Parents bring unique knowledge of their child’s strengths and vulnerabilities as well as their own adolescent experiences to help guide any additional rules they may wish to put in place.

Some adolescents, because of their anxiety, will be in no hurry to get their driver’s license. If your family lives where public transportation is good, there may be no need to push him faster than he can comfortably handle. But it can be helpful for parents to wonder with these adolescents what could be helpful about driving, such as whether it might be useful for building peer relationships, commuting to a summer job, or college. And the parent can be curious about what his teenager’s greatest anxiety about driving is. It may be easily addressed ("What if I run out of gas?"), or more profound. In either case, giving an anxious adolescent a chance to articulate what he is concerned about and to consider when the advantages of driving will outweigh the risks, can help him to feel he is actively choosing when to drive, not just passively waiting to feel less scared. This is an important distinction that can have resonance with later choices that may be intimidating, but necessary to normal development.

Then there are the parents in your practice who wish their adolescent were a bit more anxious. Their child is the eager, confident, leap-before-you-look type, which poses a different set of challenges with driving. This adolescent would benefit from a more methodical, structured approach to getting her driver’s license. Extensive driving practice should help to provide enough concerning moments to temper her bravado. Stricter rules (and consequences for breaking those rules) around practicing and driving will help the intrepid adolescent develop self-control as she expands her skills gradually.

Among the most worrisome teenagers are those who are very impulsive, including those with attention-deficit/hyperactivity disorder. It may be wise to require that this teen take his ADHD medication before driving, or have additional rules about friends and phones to minimize distractions; creating more structure and rules around this privilege can make a lifesaving difference for the impulsive teenager. During extensive practice sessions, there will be clear evidence of ADHD behaviors and how they impact driving, and these are teachable moments to build the adolescent’s self-awareness.

Driving safely is hard enough, and special efforts are necessary concerning the highest-risk behaviors. Parents are both regulators and role models on driving – with speed, courtesy, seat belts, cellphones, alcohol use, etc. It is hard to stay credible when parental behavior and teaching are not consistent.

Cell phones deserve a special discussion from parents, whether or not their children are highly distractible. Adolescents tend to be more frequently on the phone, texting, or updating their Facebook status. Having a phone available while alone in the car is a great safety plan, in case there is an accident or problem with the car. But parents need to have an explicit conversation about good car habits. It may be helpful for parents to ask that their children text once before driving and then when the car is off, or to keep the phone in the glove compartment in order to resist the urge to answer or return a call or text. There should be very strict consequences for texting while driving, in addition to any legal ones, ideally losing the privilege for a long enough time to be memorable. It is not overly dramatic for parents to have a conversation with their child about the likelihood of dying or killing someone as a result of something as simple as sending a text, and to use local reports of accidents to reinforce this standard.

The conversation about good driving habits also should focus on drugs and alcohol. Parents need to be able to tell their children about the serious dangers and legal consequences of driving drunk. But they also should be clear that any drug could impair their driving skills; marijuana is no safer to use before driving than alcohol. They should have a clear plan in place that will either rigidly follow the rule concerning the "designated driver" or facilitate their child calling them or a cab if they ever have used alcohol or drugs when out driving, without fear of significant repercussions. It is critical to establish that safety always comes first, and that it will always be helpful to be honest with parents when managing difficult situations.

Parents should consider whether driving privileges should require some financial contribution from their new driver to the car, gas, or insurance payments. This is a good time to step back and consider the parents’ values concerning money, the direction of the teenager’s attitudes, and how the costs of gas, insurance, or even an additional car fit into the values and priorities of the family. Contributing to the costs of a car can be very motivating to a teenager who might otherwise not be enthusiastic about working. For a busy and productive adolescent (and where the family can afford the costs), there may be less need to use car costs as leverage. Certainly, contributing money or service to the family is all part of new adult responsibilities that come with a license. Driving is an adult responsibility, and presents an ideal opportunity to teach adolescents about the balance between privileges and responsibilities, and about the family’s values about money.

Like other milestones in adolescence, driving can be an opportunity to add to the warmth and trust of an increasingly adult relationship between parent and teenager. Alternatively, driving can become a bitter struggle between parental control and the developmental push to autonomy. There will be errors and mistakes with both the technical and judgment aspects of this new territory.

Parents’ job is to protect teens from mistakes that are irreparable, while facilitating their expanding independence. In setting rules and expectations, parents can emphasize their confidence in their adolescent’s capacity to handle all the requirements of driving, while also impressing upon their teen the seriousness of this new privilege.

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

Adolescence is characterized by milestone after milestone on a route that starts with early puberty and progresses to virtually complete autonomy by young adulthood. Obtaining a driver’s license is among the most meaningful steps along this path in terms of independence, responsibility, and risk. Learning to drive is a pragmatic, almost unique opportunity, as it often brings together a highly motivated teenager and concerned parents working together on a task over considerable time.

Teaching a teenager to drive encompasses teaching a skill, demonstrating an attitude, and communicating values concerning safety, peer relationships, paying for added expenses, and "adult" responsibility with rewards and consequences in the real world where not even parents can fix potential harms.

Driving is a major issue in pediatric primary care, as automobile accidents are the leading cause of morbidity and mortality in children under 18 years. Pediatricians can offer parents critical guidance about helping their children master this skill, appreciate the level of risk involved, add to their growing sense of the value of money, and balance new privileges with added expectations.

Pediatricians should be aware of their state’s laws regulating when adolescents may get a driver’s permit, what they have to do to get their driver’s license, and even additional regulations around when adolescents can drive unaccompanied or with friends. One guideline to optimize safety is for the "learner" to get as many miles of practice as possible under parental supervision. The first year or two of driving carries the highest risk of accident; extensive practice may mitigate that risk. Many adolescents take "drivers ed," but these limited hours may be more effective after many informal driving lessons with a parent or other trusted relative.

All parents have vivid memories of how they were taught to drive. Pediatricians might ask parents what learning to drive was like and what it meant to them. Do the parents want to repeat or modify their own experience when they have a "second" chance with their teenager? Parents bring unique knowledge of their child’s strengths and vulnerabilities as well as their own adolescent experiences to help guide any additional rules they may wish to put in place.

Some adolescents, because of their anxiety, will be in no hurry to get their driver’s license. If your family lives where public transportation is good, there may be no need to push him faster than he can comfortably handle. But it can be helpful for parents to wonder with these adolescents what could be helpful about driving, such as whether it might be useful for building peer relationships, commuting to a summer job, or college. And the parent can be curious about what his teenager’s greatest anxiety about driving is. It may be easily addressed ("What if I run out of gas?"), or more profound. In either case, giving an anxious adolescent a chance to articulate what he is concerned about and to consider when the advantages of driving will outweigh the risks, can help him to feel he is actively choosing when to drive, not just passively waiting to feel less scared. This is an important distinction that can have resonance with later choices that may be intimidating, but necessary to normal development.

Then there are the parents in your practice who wish their adolescent were a bit more anxious. Their child is the eager, confident, leap-before-you-look type, which poses a different set of challenges with driving. This adolescent would benefit from a more methodical, structured approach to getting her driver’s license. Extensive driving practice should help to provide enough concerning moments to temper her bravado. Stricter rules (and consequences for breaking those rules) around practicing and driving will help the intrepid adolescent develop self-control as she expands her skills gradually.

Among the most worrisome teenagers are those who are very impulsive, including those with attention-deficit/hyperactivity disorder. It may be wise to require that this teen take his ADHD medication before driving, or have additional rules about friends and phones to minimize distractions; creating more structure and rules around this privilege can make a lifesaving difference for the impulsive teenager. During extensive practice sessions, there will be clear evidence of ADHD behaviors and how they impact driving, and these are teachable moments to build the adolescent’s self-awareness.

Driving safely is hard enough, and special efforts are necessary concerning the highest-risk behaviors. Parents are both regulators and role models on driving – with speed, courtesy, seat belts, cellphones, alcohol use, etc. It is hard to stay credible when parental behavior and teaching are not consistent.

Cell phones deserve a special discussion from parents, whether or not their children are highly distractible. Adolescents tend to be more frequently on the phone, texting, or updating their Facebook status. Having a phone available while alone in the car is a great safety plan, in case there is an accident or problem with the car. But parents need to have an explicit conversation about good car habits. It may be helpful for parents to ask that their children text once before driving and then when the car is off, or to keep the phone in the glove compartment in order to resist the urge to answer or return a call or text. There should be very strict consequences for texting while driving, in addition to any legal ones, ideally losing the privilege for a long enough time to be memorable. It is not overly dramatic for parents to have a conversation with their child about the likelihood of dying or killing someone as a result of something as simple as sending a text, and to use local reports of accidents to reinforce this standard.

The conversation about good driving habits also should focus on drugs and alcohol. Parents need to be able to tell their children about the serious dangers and legal consequences of driving drunk. But they also should be clear that any drug could impair their driving skills; marijuana is no safer to use before driving than alcohol. They should have a clear plan in place that will either rigidly follow the rule concerning the "designated driver" or facilitate their child calling them or a cab if they ever have used alcohol or drugs when out driving, without fear of significant repercussions. It is critical to establish that safety always comes first, and that it will always be helpful to be honest with parents when managing difficult situations.

Parents should consider whether driving privileges should require some financial contribution from their new driver to the car, gas, or insurance payments. This is a good time to step back and consider the parents’ values concerning money, the direction of the teenager’s attitudes, and how the costs of gas, insurance, or even an additional car fit into the values and priorities of the family. Contributing to the costs of a car can be very motivating to a teenager who might otherwise not be enthusiastic about working. For a busy and productive adolescent (and where the family can afford the costs), there may be less need to use car costs as leverage. Certainly, contributing money or service to the family is all part of new adult responsibilities that come with a license. Driving is an adult responsibility, and presents an ideal opportunity to teach adolescents about the balance between privileges and responsibilities, and about the family’s values about money.

Like other milestones in adolescence, driving can be an opportunity to add to the warmth and trust of an increasingly adult relationship between parent and teenager. Alternatively, driving can become a bitter struggle between parental control and the developmental push to autonomy. There will be errors and mistakes with both the technical and judgment aspects of this new territory.

Parents’ job is to protect teens from mistakes that are irreparable, while facilitating their expanding independence. In setting rules and expectations, parents can emphasize their confidence in their adolescent’s capacity to handle all the requirements of driving, while also impressing upon their teen the seriousness of this new privilege.

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

A challenge unique to the practice of pediatrics is that it is not enough to know your patient well. To be an effective pediatrician, you must know the family well.

This may seem obvious, but it is so essential that it is worthy of some discussion. When your patient is young, all problems will be presented by the parents and will reflect the parents’ own values and anxieties as well as straightforward physical symptoms. Almost every intervention you offer will have to be accepted and managed by the parents. As your patients grow older, you may find that some families serve as a useful buffer to stress and others seem to amplify distress.

Every pediatrician knows that families differ in their self-awareness. Some know their biases and perspectives, some even know that how they were raised or their wishes might distort their view of a given situation. But there are other families that deny even the possibility of any distortion.

Over the years that you work with a family, you will come to know their personality, their unique areas of strength and strain, talent and vulnerability. But early in working with a family, you might pay attention to a few areas to help you learn quickly about a family’s style. With this understanding, you will better understand the context for certain complaints or concerns, and you will be better able to help parents help their children.

There need not be a major illness or serious problem for you to learn about a family’s style and perspective. The daily routines of most families offer rich and nuanced illustrations of their styles, and you might learn about them efficiently with only a few specific questions. One especially useful approach is to ask about a family’s mealtime routine.

Even with very young children, does the family eat together most nights? Do they cook or order in or eat out? Who cooks the food and do the children participate? Do they eat at a consistent time on most nights? Does the family sit down together and how long does the mealtime last? Is it chaotic or rushed? Is it generally pleasant and fun, or is there tension or conflict?

A portrait of mealtime will give you a sense of the parents’ abilities to plan and collaborate, and to stick with a plan even when it is challenging. It illustrates the value they may have placed on spending time consistently with their children as well as providing them with nourishing meals. It might also illustrate how much stress they are facing as a family, due to finances or busy schedules. You could ask if the current dinnertime routine is to their liking – is it what they want for the family? If this seems like a sensitive topic, you could go further and ask what dinnertime was like for them when they were growing up. You might be amazed at what you learn from this simple discussion.

Another daily ritual that can offer a vivid portrait of a family’s style is their children’s bedtime routine. Invite parents to tell you how bedtime goes in their home. Often, you won’t need to ask for any more than that, and you will get a lot of detail.

But if needed, ask about what time bedtime starts, and how consistent is the routine from night to night. Does the child get to bed by an appropriate time? Are parents able to enforce a bedtime or is there a lot of struggle over lights going out each night? Does the child stay in their bed or come into their parents’ room? Is there time for snuggling or talking before lights out?

Again, you will learn about parents’ ability to plan and collaborate with one another. You will learn a lot about parents’ ability to tolerate higher levels of stress, as bedtimes are typically charged by exhaustion (in both children and parents), excitement (as everyone is together), and even anxiety.

You also will learn a lot about how well attuned the parents are to their children’s moods, temperaments, and needs (as opposed to their wants). Bedtime is full of opportunities for parents to pick up on their children’s physical and emotional needs without their children’s help. How parents are managing this task, all while tolerating the roller coaster of their children’s and their own fatigue, tells you a great deal about their ability to bear a child’s distress. A capacity to bear and manage their child’s distress is an essential skill in parenting, often one that develops over time. When it is lacking, home can become a place of very intense and unremitting anxiety and distress, and children will have difficulty learning to soothe themselves. All of this can provide helpful context when that parent is calling you with a concern about that child.

When a family is facing a child’s illness or a challenging condition, such as a learning disability, it can be helpful to ask how they have managed other problems in the past. While the problem they are now facing may feel unprecedented or overwhelming, they have usually managed other challenges, such as moves, changes in employment or financial setbacks. Perhaps there has been a parent’s broken leg, Alzheimer’s disease in a grandparent, or even the loss of a beloved pet. Find out how the family has managed communication in these circumstances, have they been clear and honest, in age-appropriate ways with their children? Have they been attuned to their children’s questions and concerns, and available to really listen? Have they tried to focus on protecting essential family time (remember mealtimes?) and their children’s routines both in and out of school? Listening to these past situations and responses is caring, respectful, and in and of itself supportive. As their pediatrician, you needn’t teach them these skills, but merely remind them of those that they already have.

If you have asked about mealtime and bedtime, you will have a clinical sense of what life is like for your patient and this family. You will look for patterns that generally support development – thoughtful planning, patience, empathy, and connectedness – and you will intuitively know whether this family would benefit from some health promotion. What you learn may be directly helpful concerning mealtimes or bedtime. Asking the questions communicates a precedent that you are interested in the family and how it functions. With experience, you also will be able to make inferences about the relationship between the parents, how the family handles stress, and what are the family’s expectations. All of this information will build attunement and trust. It will enable you to ask the right questions and make more effective interventions throughout your work with your patient and their family.

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

This column, "Behavioral Consult," appears regularly in Pediatric News, a publication of IMNG Medical Media.

A challenge unique to the practice of pediatrics is that it is not enough to know your patient well. To be an effective pediatrician, you must know the family well.

This may seem obvious, but it is so essential that it is worthy of some discussion. When your patient is young, all problems will be presented by the parents and will reflect the parents’ own values and anxieties as well as straightforward physical symptoms. Almost every intervention you offer will have to be accepted and managed by the parents. As your patients grow older, you may find that some families serve as a useful buffer to stress and others seem to amplify distress.

Every pediatrician knows that families differ in their self-awareness. Some know their biases and perspectives, some even know that how they were raised or their wishes might distort their view of a given situation. But there are other families that deny even the possibility of any distortion.

Over the years that you work with a family, you will come to know their personality, their unique areas of strength and strain, talent and vulnerability. But early in working with a family, you might pay attention to a few areas to help you learn quickly about a family’s style. With this understanding, you will better understand the context for certain complaints or concerns, and you will be better able to help parents help their children.

There need not be a major illness or serious problem for you to learn about a family’s style and perspective. The daily routines of most families offer rich and nuanced illustrations of their styles, and you might learn about them efficiently with only a few specific questions. One especially useful approach is to ask about a family’s mealtime routine.

Even with very young children, does the family eat together most nights? Do they cook or order in or eat out? Who cooks the food and do the children participate? Do they eat at a consistent time on most nights? Does the family sit down together and how long does the mealtime last? Is it chaotic or rushed? Is it generally pleasant and fun, or is there tension or conflict?

A portrait of mealtime will give you a sense of the parents’ abilities to plan and collaborate, and to stick with a plan even when it is challenging. It illustrates the value they may have placed on spending time consistently with their children as well as providing them with nourishing meals. It might also illustrate how much stress they are facing as a family, due to finances or busy schedules. You could ask if the current dinnertime routine is to their liking – is it what they want for the family? If this seems like a sensitive topic, you could go further and ask what dinnertime was like for them when they were growing up. You might be amazed at what you learn from this simple discussion.

Another daily ritual that can offer a vivid portrait of a family’s style is their children’s bedtime routine. Invite parents to tell you how bedtime goes in their home. Often, you won’t need to ask for any more than that, and you will get a lot of detail.

But if needed, ask about what time bedtime starts, and how consistent is the routine from night to night. Does the child get to bed by an appropriate time? Are parents able to enforce a bedtime or is there a lot of struggle over lights going out each night? Does the child stay in their bed or come into their parents’ room? Is there time for snuggling or talking before lights out?

Again, you will learn about parents’ ability to plan and collaborate with one another. You will learn a lot about parents’ ability to tolerate higher levels of stress, as bedtimes are typically charged by exhaustion (in both children and parents), excitement (as everyone is together), and even anxiety.

You also will learn a lot about how well attuned the parents are to their children’s moods, temperaments, and needs (as opposed to their wants). Bedtime is full of opportunities for parents to pick up on their children’s physical and emotional needs without their children’s help. How parents are managing this task, all while tolerating the roller coaster of their children’s and their own fatigue, tells you a great deal about their ability to bear a child’s distress. A capacity to bear and manage their child’s distress is an essential skill in parenting, often one that develops over time. When it is lacking, home can become a place of very intense and unremitting anxiety and distress, and children will have difficulty learning to soothe themselves. All of this can provide helpful context when that parent is calling you with a concern about that child.

When a family is facing a child’s illness or a challenging condition, such as a learning disability, it can be helpful to ask how they have managed other problems in the past. While the problem they are now facing may feel unprecedented or overwhelming, they have usually managed other challenges, such as moves, changes in employment or financial setbacks. Perhaps there has been a parent’s broken leg, Alzheimer’s disease in a grandparent, or even the loss of a beloved pet. Find out how the family has managed communication in these circumstances, have they been clear and honest, in age-appropriate ways with their children? Have they been attuned to their children’s questions and concerns, and available to really listen? Have they tried to focus on protecting essential family time (remember mealtimes?) and their children’s routines both in and out of school? Listening to these past situations and responses is caring, respectful, and in and of itself supportive. As their pediatrician, you needn’t teach them these skills, but merely remind them of those that they already have.

If you have asked about mealtime and bedtime, you will have a clinical sense of what life is like for your patient and this family. You will look for patterns that generally support development – thoughtful planning, patience, empathy, and connectedness – and you will intuitively know whether this family would benefit from some health promotion. What you learn may be directly helpful concerning mealtimes or bedtime. Asking the questions communicates a precedent that you are interested in the family and how it functions. With experience, you also will be able to make inferences about the relationship between the parents, how the family handles stress, and what are the family’s expectations. All of this information will build attunement and trust. It will enable you to ask the right questions and make more effective interventions throughout your work with your patient and their family.

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

This column, "Behavioral Consult," appears regularly in Pediatric News, a publication of IMNG Medical Media.

A challenge unique to the practice of pediatrics is that it is not enough to know your patient well. To be an effective pediatrician, you must know the family well.

This may seem obvious, but it is so essential that it is worthy of some discussion. When your patient is young, all problems will be presented by the parents and will reflect the parents’ own values and anxieties as well as straightforward physical symptoms. Almost every intervention you offer will have to be accepted and managed by the parents. As your patients grow older, you may find that some families serve as a useful buffer to stress and others seem to amplify distress.

Every pediatrician knows that families differ in their self-awareness. Some know their biases and perspectives, some even know that how they were raised or their wishes might distort their view of a given situation. But there are other families that deny even the possibility of any distortion.

Over the years that you work with a family, you will come to know their personality, their unique areas of strength and strain, talent and vulnerability. But early in working with a family, you might pay attention to a few areas to help you learn quickly about a family’s style. With this understanding, you will better understand the context for certain complaints or concerns, and you will be better able to help parents help their children.

There need not be a major illness or serious problem for you to learn about a family’s style and perspective. The daily routines of most families offer rich and nuanced illustrations of their styles, and you might learn about them efficiently with only a few specific questions. One especially useful approach is to ask about a family’s mealtime routine.

Even with very young children, does the family eat together most nights? Do they cook or order in or eat out? Who cooks the food and do the children participate? Do they eat at a consistent time on most nights? Does the family sit down together and how long does the mealtime last? Is it chaotic or rushed? Is it generally pleasant and fun, or is there tension or conflict?

A portrait of mealtime will give you a sense of the parents’ abilities to plan and collaborate, and to stick with a plan even when it is challenging. It illustrates the value they may have placed on spending time consistently with their children as well as providing them with nourishing meals. It might also illustrate how much stress they are facing as a family, due to finances or busy schedules. You could ask if the current dinnertime routine is to their liking – is it what they want for the family? If this seems like a sensitive topic, you could go further and ask what dinnertime was like for them when they were growing up. You might be amazed at what you learn from this simple discussion.

Another daily ritual that can offer a vivid portrait of a family’s style is their children’s bedtime routine. Invite parents to tell you how bedtime goes in their home. Often, you won’t need to ask for any more than that, and you will get a lot of detail.

But if needed, ask about what time bedtime starts, and how consistent is the routine from night to night. Does the child get to bed by an appropriate time? Are parents able to enforce a bedtime or is there a lot of struggle over lights going out each night? Does the child stay in their bed or come into their parents’ room? Is there time for snuggling or talking before lights out?

Again, you will learn about parents’ ability to plan and collaborate with one another. You will learn a lot about parents’ ability to tolerate higher levels of stress, as bedtimes are typically charged by exhaustion (in both children and parents), excitement (as everyone is together), and even anxiety.

You also will learn a lot about how well attuned the parents are to their children’s moods, temperaments, and needs (as opposed to their wants). Bedtime is full of opportunities for parents to pick up on their children’s physical and emotional needs without their children’s help. How parents are managing this task, all while tolerating the roller coaster of their children’s and their own fatigue, tells you a great deal about their ability to bear a child’s distress. A capacity to bear and manage their child’s distress is an essential skill in parenting, often one that develops over time. When it is lacking, home can become a place of very intense and unremitting anxiety and distress, and children will have difficulty learning to soothe themselves. All of this can provide helpful context when that parent is calling you with a concern about that child.

When a family is facing a child’s illness or a challenging condition, such as a learning disability, it can be helpful to ask how they have managed other problems in the past. While the problem they are now facing may feel unprecedented or overwhelming, they have usually managed other challenges, such as moves, changes in employment or financial setbacks. Perhaps there has been a parent’s broken leg, Alzheimer’s disease in a grandparent, or even the loss of a beloved pet. Find out how the family has managed communication in these circumstances, have they been clear and honest, in age-appropriate ways with their children? Have they been attuned to their children’s questions and concerns, and available to really listen? Have they tried to focus on protecting essential family time (remember mealtimes?) and their children’s routines both in and out of school? Listening to these past situations and responses is caring, respectful, and in and of itself supportive. As their pediatrician, you needn’t teach them these skills, but merely remind them of those that they already have.

If you have asked about mealtime and bedtime, you will have a clinical sense of what life is like for your patient and this family. You will look for patterns that generally support development – thoughtful planning, patience, empathy, and connectedness – and you will intuitively know whether this family would benefit from some health promotion. What you learn may be directly helpful concerning mealtimes or bedtime. Asking the questions communicates a precedent that you are interested in the family and how it functions. With experience, you also will be able to make inferences about the relationship between the parents, how the family handles stress, and what are the family’s expectations. All of this information will build attunement and trust. It will enable you to ask the right questions and make more effective interventions throughout your work with your patient and their family.

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

This column, "Behavioral Consult," appears regularly in Pediatric News, a publication of IMNG Medical Media.

With the summer approaching, you are likely getting bombarded with health forms to fill out for summer camps, and fielding questions from parents like, "What age is best for sleepaway camp?"

In addition to simply filling out forms, consider taking the opportunity to help parents in the summer-planning process. Summer planning should be used as an opportunity to do much more for children than just fill their days or augment their college applications. You can help parents bring a developmental perspective to their planning by encouraging them to use the summer experience to help build their child’s self-esteem and autonomy.

© diego_cervo/iStockphoto.com

Encourage parents to step back and assess their child’s strengths and weaknesses and consider what experience might make a difference in their child’s life. For instance, the summer can be used to help a shy child feel more comfortable with peers, to encourage a fair athlete to become a better athlete or help a passionate athlete compete at a higher level, to encourage a child with a budding interest in theater to give it a try, to help an obese child lose weight or a weak child gain strength, or to help an adolescent with learning problems and low self-esteem gain confidence by succeeding in a summer job.

Taking it a step further, you can encourage parents to consider the quality of the child’s friendships during summer planning. Consider asking parents the following questions: Does your child have a group of more superficial friends but struggle with the competitiveness and compromises of a one-on-one friendship? Does your child have only one close friend and no others? Could the appropriate friend facilitate or enrich the summer experience? For a child with a math disability, what is the relative gain of a summer spent with a math tutor instead of friends? The answer: It will probably feel like punishment. Instead, encourage parents to focus on cultivating skills such as initiative, discipline, patience, and frustration tolerance through enhancing an academic strength (like computers or theater), instead of focusing on a weakness.

While some of these options seem obvious, setting reasonable expectations, fitting the experience into the child’s personality, and finding the right setting take good judgment and effort, and taking a developmental perspective is key.

• Young school-age children. At this age, the central task is mastery of relatively new cognitive abilities. Giving these kids an opportunity to stretch their skills across several domains – in a sports camp that has a strong social component or a day camp with mixed activities – can be just right.

• Older school-age children (aged 9-12). These children can benefit from a camp experience that provides an opportunity for self-direction and independence, as they prepare for middle school. Sleepaway camps can help some children develop lifelong skills, such as camping, woodworking, or canoeing, and help foster friendships. Sleepaway camps also give children a chance to get away from a discordant home situation or from school cliques that have been rejecting.

• Young adolescents (aged 13-15). At this age, adolescents benefit from an opportunity to focus on a single area of interest, as they are in the process of deepening their sense of identity. A summer experience that allows them to engage in one enterprise can make a great difference in their growing ability to discern between their abilities and their interests.

• Older adolescents (aged 16-19). Older adolescents will continue to cultivate their individual identities, while managing greater independence, developing better impulse control, and learning to cultivate relationships with other adults. These teenagers may benefit from summer plans that promote these skills in ways that are genuine and instructive, but relatively low risk. They may want to consider a structured experience living with a family in another country and studying the language, or a residential work experience, such as on a cooperative farm.

• College. Once teenagers have gone to college, they may want to rest during the summer. A vacation is valuable, but 3 uninterrupted months is a precious resource to spend solely on relaxation. Internships can help with the career decision-making process, and could help them land a job after college. But it is hard to overstate the value of young adults having a paid job in the summer. A genuine work experience during the summer can be a laboratory for them to develop responsibility, become aware of their strengths and weaknesses, develop independence and patience, and help them decide what career they may eventually pursue.

Enjoyment is the fuel that drives the developmental engine, and may be what distinguishes it from children’s experiences at school. Imagine a 10-year-old child who has struggled (or maybe just straggled) socially due to shyness, but who has an encyclopedic knowledge (and love) of computer programming. If there was a day camp that grouped children into teams that would then design a new computer programming language over the course of a week, that could be a great fit for this child. The child’s interest in and self-confidence about computer programming would engage him or her in the project, while allowing the child to work on social skills. The fact that the other children have a shared interest further tips the scales in favor of social success. Social success reinforces healthy skill development, which will make it easier for the child to face a social situation in less-favorable circumstances, perhaps at school. The great thing about development is that mastery often begets mastery.

We appreciate that economic limitations can limit summer planning. Sleepaway camps can be expensive, and a teenager taking on a job may be essential for the family budget. However, even within these constraints, there may be creative options through local organizations like the Boys and Girls Clubs of America and through extended family. And for most, summers well spent (a dozen or so opportunities, each 2-3 months long) are terrific ways to enhance self-esteem and broaden experiences.

 Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also chief clinical officer at Partners HealthCare, also in Boston. 

With the summer approaching, you are likely getting bombarded with health forms to fill out for summer camps, and fielding questions from parents like, "What age is best for sleepaway camp?"

In addition to simply filling out forms, consider taking the opportunity to help parents in the summer-planning process. Summer planning should be used as an opportunity to do much more for children than just fill their days or augment their college applications. You can help parents bring a developmental perspective to their planning by encouraging them to use the summer experience to help build their child’s self-esteem and autonomy.

© diego_cervo/iStockphoto.com

Encourage parents to step back and assess their child’s strengths and weaknesses and consider what experience might make a difference in their child’s life. For instance, the summer can be used to help a shy child feel more comfortable with peers, to encourage a fair athlete to become a better athlete or help a passionate athlete compete at a higher level, to encourage a child with a budding interest in theater to give it a try, to help an obese child lose weight or a weak child gain strength, or to help an adolescent with learning problems and low self-esteem gain confidence by succeeding in a summer job.

Taking it a step further, you can encourage parents to consider the quality of the child’s friendships during summer planning. Consider asking parents the following questions: Does your child have a group of more superficial friends but struggle with the competitiveness and compromises of a one-on-one friendship? Does your child have only one close friend and no others? Could the appropriate friend facilitate or enrich the summer experience? For a child with a math disability, what is the relative gain of a summer spent with a math tutor instead of friends? The answer: It will probably feel like punishment. Instead, encourage parents to focus on cultivating skills such as initiative, discipline, patience, and frustration tolerance through enhancing an academic strength (like computers or theater), instead of focusing on a weakness.

While some of these options seem obvious, setting reasonable expectations, fitting the experience into the child’s personality, and finding the right setting take good judgment and effort, and taking a developmental perspective is key.

• Young school-age children. At this age, the central task is mastery of relatively new cognitive abilities. Giving these kids an opportunity to stretch their skills across several domains – in a sports camp that has a strong social component or a day camp with mixed activities – can be just right.

• Older school-age children (aged 9-12). These children can benefit from a camp experience that provides an opportunity for self-direction and independence, as they prepare for middle school. Sleepaway camps can help some children develop lifelong skills, such as camping, woodworking, or canoeing, and help foster friendships. Sleepaway camps also give children a chance to get away from a discordant home situation or from school cliques that have been rejecting.

• Young adolescents (aged 13-15). At this age, adolescents benefit from an opportunity to focus on a single area of interest, as they are in the process of deepening their sense of identity. A summer experience that allows them to engage in one enterprise can make a great difference in their growing ability to discern between their abilities and their interests.

• Older adolescents (aged 16-19). Older adolescents will continue to cultivate their individual identities, while managing greater independence, developing better impulse control, and learning to cultivate relationships with other adults. These teenagers may benefit from summer plans that promote these skills in ways that are genuine and instructive, but relatively low risk. They may want to consider a structured experience living with a family in another country and studying the language, or a residential work experience, such as on a cooperative farm.

• College. Once teenagers have gone to college, they may want to rest during the summer. A vacation is valuable, but 3 uninterrupted months is a precious resource to spend solely on relaxation. Internships can help with the career decision-making process, and could help them land a job after college. But it is hard to overstate the value of young adults having a paid job in the summer. A genuine work experience during the summer can be a laboratory for them to develop responsibility, become aware of their strengths and weaknesses, develop independence and patience, and help them decide what career they may eventually pursue.

Enjoyment is the fuel that drives the developmental engine, and may be what distinguishes it from children’s experiences at school. Imagine a 10-year-old child who has struggled (or maybe just straggled) socially due to shyness, but who has an encyclopedic knowledge (and love) of computer programming. If there was a day camp that grouped children into teams that would then design a new computer programming language over the course of a week, that could be a great fit for this child. The child’s interest in and self-confidence about computer programming would engage him or her in the project, while allowing the child to work on social skills. The fact that the other children have a shared interest further tips the scales in favor of social success. Social success reinforces healthy skill development, which will make it easier for the child to face a social situation in less-favorable circumstances, perhaps at school. The great thing about development is that mastery often begets mastery.

We appreciate that economic limitations can limit summer planning. Sleepaway camps can be expensive, and a teenager taking on a job may be essential for the family budget. However, even within these constraints, there may be creative options through local organizations like the Boys and Girls Clubs of America and through extended family. And for most, summers well spent (a dozen or so opportunities, each 2-3 months long) are terrific ways to enhance self-esteem and broaden experiences.

 Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also chief clinical officer at Partners HealthCare, also in Boston. 

With the summer approaching, you are likely getting bombarded with health forms to fill out for summer camps, and fielding questions from parents like, "What age is best for sleepaway camp?"

In addition to simply filling out forms, consider taking the opportunity to help parents in the summer-planning process. Summer planning should be used as an opportunity to do much more for children than just fill their days or augment their college applications. You can help parents bring a developmental perspective to their planning by encouraging them to use the summer experience to help build their child’s self-esteem and autonomy.

© diego_cervo/iStockphoto.com

Encourage parents to step back and assess their child’s strengths and weaknesses and consider what experience might make a difference in their child’s life. For instance, the summer can be used to help a shy child feel more comfortable with peers, to encourage a fair athlete to become a better athlete or help a passionate athlete compete at a higher level, to encourage a child with a budding interest in theater to give it a try, to help an obese child lose weight or a weak child gain strength, or to help an adolescent with learning problems and low self-esteem gain confidence by succeeding in a summer job.

Taking it a step further, you can encourage parents to consider the quality of the child’s friendships during summer planning. Consider asking parents the following questions: Does your child have a group of more superficial friends but struggle with the competitiveness and compromises of a one-on-one friendship? Does your child have only one close friend and no others? Could the appropriate friend facilitate or enrich the summer experience? For a child with a math disability, what is the relative gain of a summer spent with a math tutor instead of friends? The answer: It will probably feel like punishment. Instead, encourage parents to focus on cultivating skills such as initiative, discipline, patience, and frustration tolerance through enhancing an academic strength (like computers or theater), instead of focusing on a weakness.

While some of these options seem obvious, setting reasonable expectations, fitting the experience into the child’s personality, and finding the right setting take good judgment and effort, and taking a developmental perspective is key.

• Young school-age children. At this age, the central task is mastery of relatively new cognitive abilities. Giving these kids an opportunity to stretch their skills across several domains – in a sports camp that has a strong social component or a day camp with mixed activities – can be just right.

• Older school-age children (aged 9-12). These children can benefit from a camp experience that provides an opportunity for self-direction and independence, as they prepare for middle school. Sleepaway camps can help some children develop lifelong skills, such as camping, woodworking, or canoeing, and help foster friendships. Sleepaway camps also give children a chance to get away from a discordant home situation or from school cliques that have been rejecting.

• Young adolescents (aged 13-15). At this age, adolescents benefit from an opportunity to focus on a single area of interest, as they are in the process of deepening their sense of identity. A summer experience that allows them to engage in one enterprise can make a great difference in their growing ability to discern between their abilities and their interests.

• Older adolescents (aged 16-19). Older adolescents will continue to cultivate their individual identities, while managing greater independence, developing better impulse control, and learning to cultivate relationships with other adults. These teenagers may benefit from summer plans that promote these skills in ways that are genuine and instructive, but relatively low risk. They may want to consider a structured experience living with a family in another country and studying the language, or a residential work experience, such as on a cooperative farm.

• College. Once teenagers have gone to college, they may want to rest during the summer. A vacation is valuable, but 3 uninterrupted months is a precious resource to spend solely on relaxation. Internships can help with the career decision-making process, and could help them land a job after college. But it is hard to overstate the value of young adults having a paid job in the summer. A genuine work experience during the summer can be a laboratory for them to develop responsibility, become aware of their strengths and weaknesses, develop independence and patience, and help them decide what career they may eventually pursue.

Enjoyment is the fuel that drives the developmental engine, and may be what distinguishes it from children’s experiences at school. Imagine a 10-year-old child who has struggled (or maybe just straggled) socially due to shyness, but who has an encyclopedic knowledge (and love) of computer programming. If there was a day camp that grouped children into teams that would then design a new computer programming language over the course of a week, that could be a great fit for this child. The child’s interest in and self-confidence about computer programming would engage him or her in the project, while allowing the child to work on social skills. The fact that the other children have a shared interest further tips the scales in favor of social success. Social success reinforces healthy skill development, which will make it easier for the child to face a social situation in less-favorable circumstances, perhaps at school. The great thing about development is that mastery often begets mastery.

We appreciate that economic limitations can limit summer planning. Sleepaway camps can be expensive, and a teenager taking on a job may be essential for the family budget. However, even within these constraints, there may be creative options through local organizations like the Boys and Girls Clubs of America and through extended family. And for most, summers well spent (a dozen or so opportunities, each 2-3 months long) are terrific ways to enhance self-esteem and broaden experiences.

 Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also chief clinical officer at Partners HealthCare, also in Boston. 

When is anxiety a normal, healthy part of a child’s development and when is it a psychiatric symptom that needs treatment? This question is likely to come up at many outpatient pediatric visits, as parents will be understandably concerned when faced with a child’s tears and fears.

It may help to discuss what we mean by anxiety. In child psychiatry, we consider anxiety to be a child’s normal subjective response to an internal or external event that causes concern, worry, or alarm. We also consider anxiety as an aspect of a child’s temperament, whether he or she has a highly anxious temperament, an easygoing one, or something in between. Anxiety can describe a patient’s ongoing, significant experience of concern, worry, or fear that may not be tied to any known cause and may lead to avoidance or dysfunction. Therefore, the extent and nature of a child’s anxiety requires the pediatrician’s understanding and differential assessment.

Anxiety also is a routine and, at times, motivating emotion experienced by children and adults, and the experience of anxiety serves a critical role in healthy development as it prepares or protects the body and mind. In younger children, anxiety protects against risky or dangerous forays without parents, whether toward unknown adults, new foods, or unfamiliar places. The experience of anxiety in a new setting confers a survival advantage on the smallest children, who are otherwise vulnerable without their parents to protect them. This anxiety also is an essential part of the earliest attachment between parents and their infants and toddlers, as parents are trained and rewarded to be present and vigilant about their young children’s location or needs.

From the ages of 7-12 years, anxiety often contributes to better or optimal cognitive, intellectual, social, and physical performance. As school-age children face new challenges, they worry about succeeding and work harder to master tasks. Ideally, the anxiety can be adaptive, supporting focus, attention, tenacity, and preparation. In this way, it supports learning and mastery, the central tasks of school-age children. Emotional maturity hinges on their experiencing, tolerating, and mastering anxiety.

Adolescents face many tasks, increasingly without direct parental presence or involvement. While teens should be developing their identity, intimacy in their relationships outside the home, independence, and better impulse control, they also need to be engaged in sustained hard work at school, activities, and athletics to prepare for the expectations and responsibilities they will face in college. Normal anxiety about whether they will be ready for a test, an independent project, or a college interview helps to fuel the focus and sustained effort they will need to prepare themselves (with little or no adult involvement). Appropriate anxiety about health, safety, or trouble with authority can counterbalance impulsivity, peer pressure, and even hormones as adolescents make choices of great consequence on their own and without experience or parents to guide them.

Although the parents of adolescents may be relieved to know that their teens are anxious about studying enough for a test or getting home safely from a cast party, most parents find it distressing to watch their children face and cope with anxiety. It is natural for parents to want to help their children with this distress, even protect them from it. And, of course, some parents may have more anxious temperaments or even anxiety disorders themselves. These parents may be highly sensitive to anxiety and, at the same time, have limited ability to help their children tolerate and learn to manage their own anxiety. For these families, reframing the value of anxiety may provide reassurance.

There are, however, some red flags that will indicate to the clinician that a referral and further evaluation, rather than reassurance, is critical. Even without understanding the subtleties of a child’s anxiety, any worry that causes a significant impairment in a child’s functioning should be referred for psychiatric evaluation. When a child refuses to attend school, even just for a few days, this is considered to be a psychiatric emergency since, without rapid attention, the behavior becomes more intractable. It is important to urge the parents to collaborate with the school to devise a plan for that child to attend, even in a very limited way, while they await a psychiatric evaluation.

School is a child’s primary occupation, but it is not the only domain in which function can be impaired by significant anxiety. Is the child dropping previously beloved activities or suddenly showing marked social isolation? Is sleep disrupted by nighttime fears or concerns about what will be faced the next day? Does the child seek reassurance about the same issue, even after it has been explicitly addressed by the parents, every day for an extended period of time? Has the child begun to demonstrate repetitive, compulsive behaviors – flicking light switches in response to anxiety about school performance – saying the behaviors are helpful although they do not appear logically connected to the child’s concern?

In each of these cases, the symptoms suggest that the anxiety the child is experiencing goes beyond what is normal and merits a psychiatric evaluation. A child who begins to seem very sad, sulky, or withdrawn from peers and interests in the setting of sustained anxiety may be developing depression (or may have anxiety as a component of depression) and also needs a psychiatric referral.

Anxiety that is not routine or adaptive can be the visible symptom of many different psychiatric problems, not only anxiety disorders. It is worth noting that children with undiagnosed attention deficit disorder (ADD), subtle developmental disorders, or learning disabilities often present with considerable anxiety about their function and performance in school, as they have faced sustained failure to keep up with their peers academically and sometimes socially.

Adolescents with emerging drug or alcohol problems may present with anxiety symptoms that do not seem connected to their actual stressors. Undiagnosed anxiety disorders can lead to substance abuse as teens attempt not just to feel good, but to feel better. Intense anxiety about weight or about changes in weight that are not discernible to others may signal an emerging eating disorder. Intense and sustained anxiety in the setting of social withdrawal and deteriorating function in adolescents may be the first sign of an emerging thought disorder.

Finally, when parents’ level of anxiety about their children makes it difficult or impossible for them to help their children tolerate and then learn to manage and master their normal or routine anxiety, a referral for a psychiatric evaluation for the child can be helpful. Although the youngster may not have an underlying anxiety disorder, starting therapy with a caring adult who can help the child tolerate this difficult affect will be essential to healthy development.

Most parents will bring their concerns about their children’s distress to their pediatricians, and you should reassure them that no one should worry alone. Most anxiety reflects emotional health and adaptability and is even a force driving healthy development, but sometimes it does signal a psychiatric problem. If the child’s function is impaired, if the anxiety is inappropriate to the stressor, or if the parents are unable to help a child develop healthy coping skills, you also should not worry alone and should make a referral for a psychiatric evaluation.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also chief clinical officer at Partners HealthCare, also in Boston. 

When is anxiety a normal, healthy part of a child’s development and when is it a psychiatric symptom that needs treatment? This question is likely to come up at many outpatient pediatric visits, as parents will be understandably concerned when faced with a child’s tears and fears.

It may help to discuss what we mean by anxiety. In child psychiatry, we consider anxiety to be a child’s normal subjective response to an internal or external event that causes concern, worry, or alarm. We also consider anxiety as an aspect of a child’s temperament, whether he or she has a highly anxious temperament, an easygoing one, or something in between. Anxiety can describe a patient’s ongoing, significant experience of concern, worry, or fear that may not be tied to any known cause and may lead to avoidance or dysfunction. Therefore, the extent and nature of a child’s anxiety requires the pediatrician’s understanding and differential assessment.

Anxiety also is a routine and, at times, motivating emotion experienced by children and adults, and the experience of anxiety serves a critical role in healthy development as it prepares or protects the body and mind. In younger children, anxiety protects against risky or dangerous forays without parents, whether toward unknown adults, new foods, or unfamiliar places. The experience of anxiety in a new setting confers a survival advantage on the smallest children, who are otherwise vulnerable without their parents to protect them. This anxiety also is an essential part of the earliest attachment between parents and their infants and toddlers, as parents are trained and rewarded to be present and vigilant about their young children’s location or needs.

From the ages of 7-12 years, anxiety often contributes to better or optimal cognitive, intellectual, social, and physical performance. As school-age children face new challenges, they worry about succeeding and work harder to master tasks. Ideally, the anxiety can be adaptive, supporting focus, attention, tenacity, and preparation. In this way, it supports learning and mastery, the central tasks of school-age children. Emotional maturity hinges on their experiencing, tolerating, and mastering anxiety.

Adolescents face many tasks, increasingly without direct parental presence or involvement. While teens should be developing their identity, intimacy in their relationships outside the home, independence, and better impulse control, they also need to be engaged in sustained hard work at school, activities, and athletics to prepare for the expectations and responsibilities they will face in college. Normal anxiety about whether they will be ready for a test, an independent project, or a college interview helps to fuel the focus and sustained effort they will need to prepare themselves (with little or no adult involvement). Appropriate anxiety about health, safety, or trouble with authority can counterbalance impulsivity, peer pressure, and even hormones as adolescents make choices of great consequence on their own and without experience or parents to guide them.

Although the parents of adolescents may be relieved to know that their teens are anxious about studying enough for a test or getting home safely from a cast party, most parents find it distressing to watch their children face and cope with anxiety. It is natural for parents to want to help their children with this distress, even protect them from it. And, of course, some parents may have more anxious temperaments or even anxiety disorders themselves. These parents may be highly sensitive to anxiety and, at the same time, have limited ability to help their children tolerate and learn to manage their own anxiety. For these families, reframing the value of anxiety may provide reassurance.

There are, however, some red flags that will indicate to the clinician that a referral and further evaluation, rather than reassurance, is critical. Even without understanding the subtleties of a child’s anxiety, any worry that causes a significant impairment in a child’s functioning should be referred for psychiatric evaluation. When a child refuses to attend school, even just for a few days, this is considered to be a psychiatric emergency since, without rapid attention, the behavior becomes more intractable. It is important to urge the parents to collaborate with the school to devise a plan for that child to attend, even in a very limited way, while they await a psychiatric evaluation.

School is a child’s primary occupation, but it is not the only domain in which function can be impaired by significant anxiety. Is the child dropping previously beloved activities or suddenly showing marked social isolation? Is sleep disrupted by nighttime fears or concerns about what will be faced the next day? Does the child seek reassurance about the same issue, even after it has been explicitly addressed by the parents, every day for an extended period of time? Has the child begun to demonstrate repetitive, compulsive behaviors – flicking light switches in response to anxiety about school performance – saying the behaviors are helpful although they do not appear logically connected to the child’s concern?

In each of these cases, the symptoms suggest that the anxiety the child is experiencing goes beyond what is normal and merits a psychiatric evaluation. A child who begins to seem very sad, sulky, or withdrawn from peers and interests in the setting of sustained anxiety may be developing depression (or may have anxiety as a component of depression) and also needs a psychiatric referral.

Anxiety that is not routine or adaptive can be the visible symptom of many different psychiatric problems, not only anxiety disorders. It is worth noting that children with undiagnosed attention deficit disorder (ADD), subtle developmental disorders, or learning disabilities often present with considerable anxiety about their function and performance in school, as they have faced sustained failure to keep up with their peers academically and sometimes socially.

Adolescents with emerging drug or alcohol problems may present with anxiety symptoms that do not seem connected to their actual stressors. Undiagnosed anxiety disorders can lead to substance abuse as teens attempt not just to feel good, but to feel better. Intense anxiety about weight or about changes in weight that are not discernible to others may signal an emerging eating disorder. Intense and sustained anxiety in the setting of social withdrawal and deteriorating function in adolescents may be the first sign of an emerging thought disorder.

Finally, when parents’ level of anxiety about their children makes it difficult or impossible for them to help their children tolerate and then learn to manage and master their normal or routine anxiety, a referral for a psychiatric evaluation for the child can be helpful. Although the youngster may not have an underlying anxiety disorder, starting therapy with a caring adult who can help the child tolerate this difficult affect will be essential to healthy development.

Most parents will bring their concerns about their children’s distress to their pediatricians, and you should reassure them that no one should worry alone. Most anxiety reflects emotional health and adaptability and is even a force driving healthy development, but sometimes it does signal a psychiatric problem. If the child’s function is impaired, if the anxiety is inappropriate to the stressor, or if the parents are unable to help a child develop healthy coping skills, you also should not worry alone and should make a referral for a psychiatric evaluation.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also chief clinical officer at Partners HealthCare, also in Boston. 

When is anxiety a normal, healthy part of a child’s development and when is it a psychiatric symptom that needs treatment? This question is likely to come up at many outpatient pediatric visits, as parents will be understandably concerned when faced with a child’s tears and fears.

It may help to discuss what we mean by anxiety. In child psychiatry, we consider anxiety to be a child’s normal subjective response to an internal or external event that causes concern, worry, or alarm. We also consider anxiety as an aspect of a child’s temperament, whether he or she has a highly anxious temperament, an easygoing one, or something in between. Anxiety can describe a patient’s ongoing, significant experience of concern, worry, or fear that may not be tied to any known cause and may lead to avoidance or dysfunction. Therefore, the extent and nature of a child’s anxiety requires the pediatrician’s understanding and differential assessment.

Anxiety also is a routine and, at times, motivating emotion experienced by children and adults, and the experience of anxiety serves a critical role in healthy development as it prepares or protects the body and mind. In younger children, anxiety protects against risky or dangerous forays without parents, whether toward unknown adults, new foods, or unfamiliar places. The experience of anxiety in a new setting confers a survival advantage on the smallest children, who are otherwise vulnerable without their parents to protect them. This anxiety also is an essential part of the earliest attachment between parents and their infants and toddlers, as parents are trained and rewarded to be present and vigilant about their young children’s location or needs.

From the ages of 7-12 years, anxiety often contributes to better or optimal cognitive, intellectual, social, and physical performance. As school-age children face new challenges, they worry about succeeding and work harder to master tasks. Ideally, the anxiety can be adaptive, supporting focus, attention, tenacity, and preparation. In this way, it supports learning and mastery, the central tasks of school-age children. Emotional maturity hinges on their experiencing, tolerating, and mastering anxiety.

Adolescents face many tasks, increasingly without direct parental presence or involvement. While teens should be developing their identity, intimacy in their relationships outside the home, independence, and better impulse control, they also need to be engaged in sustained hard work at school, activities, and athletics to prepare for the expectations and responsibilities they will face in college. Normal anxiety about whether they will be ready for a test, an independent project, or a college interview helps to fuel the focus and sustained effort they will need to prepare themselves (with little or no adult involvement). Appropriate anxiety about health, safety, or trouble with authority can counterbalance impulsivity, peer pressure, and even hormones as adolescents make choices of great consequence on their own and without experience or parents to guide them.

Although the parents of adolescents may be relieved to know that their teens are anxious about studying enough for a test or getting home safely from a cast party, most parents find it distressing to watch their children face and cope with anxiety. It is natural for parents to want to help their children with this distress, even protect them from it. And, of course, some parents may have more anxious temperaments or even anxiety disorders themselves. These parents may be highly sensitive to anxiety and, at the same time, have limited ability to help their children tolerate and learn to manage their own anxiety. For these families, reframing the value of anxiety may provide reassurance.

There are, however, some red flags that will indicate to the clinician that a referral and further evaluation, rather than reassurance, is critical. Even without understanding the subtleties of a child’s anxiety, any worry that causes a significant impairment in a child’s functioning should be referred for psychiatric evaluation. When a child refuses to attend school, even just for a few days, this is considered to be a psychiatric emergency since, without rapid attention, the behavior becomes more intractable. It is important to urge the parents to collaborate with the school to devise a plan for that child to attend, even in a very limited way, while they await a psychiatric evaluation.

School is a child’s primary occupation, but it is not the only domain in which function can be impaired by significant anxiety. Is the child dropping previously beloved activities or suddenly showing marked social isolation? Is sleep disrupted by nighttime fears or concerns about what will be faced the next day? Does the child seek reassurance about the same issue, even after it has been explicitly addressed by the parents, every day for an extended period of time? Has the child begun to demonstrate repetitive, compulsive behaviors – flicking light switches in response to anxiety about school performance – saying the behaviors are helpful although they do not appear logically connected to the child’s concern?

In each of these cases, the symptoms suggest that the anxiety the child is experiencing goes beyond what is normal and merits a psychiatric evaluation. A child who begins to seem very sad, sulky, or withdrawn from peers and interests in the setting of sustained anxiety may be developing depression (or may have anxiety as a component of depression) and also needs a psychiatric referral.

Anxiety that is not routine or adaptive can be the visible symptom of many different psychiatric problems, not only anxiety disorders. It is worth noting that children with undiagnosed attention deficit disorder (ADD), subtle developmental disorders, or learning disabilities often present with considerable anxiety about their function and performance in school, as they have faced sustained failure to keep up with their peers academically and sometimes socially.

Adolescents with emerging drug or alcohol problems may present with anxiety symptoms that do not seem connected to their actual stressors. Undiagnosed anxiety disorders can lead to substance abuse as teens attempt not just to feel good, but to feel better. Intense anxiety about weight or about changes in weight that are not discernible to others may signal an emerging eating disorder. Intense and sustained anxiety in the setting of social withdrawal and deteriorating function in adolescents may be the first sign of an emerging thought disorder.

Finally, when parents’ level of anxiety about their children makes it difficult or impossible for them to help their children tolerate and then learn to manage and master their normal or routine anxiety, a referral for a psychiatric evaluation for the child can be helpful. Although the youngster may not have an underlying anxiety disorder, starting therapy with a caring adult who can help the child tolerate this difficult affect will be essential to healthy development.

Most parents will bring their concerns about their children’s distress to their pediatricians, and you should reassure them that no one should worry alone. Most anxiety reflects emotional health and adaptability and is even a force driving healthy development, but sometimes it does signal a psychiatric problem. If the child’s function is impaired, if the anxiety is inappropriate to the stressor, or if the parents are unable to help a child develop healthy coping skills, you also should not worry alone and should make a referral for a psychiatric evaluation.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also chief clinical officer at Partners HealthCare, also in Boston. 

On the morning of Dec. 14, 2012, the authors submitted this piece on helping parents to discuss difficult events in the news with their children. It was written in the spirit of the many circumstances children hear or watch on the television news describing violent, scary, or sad events.

Within the hour, news broke that a gunman had entered an elementary school in Newtown, Conn., and shot many people, including children. Over the course of that terrible day, the full story took shape in a constant news flow that gripped all of us. Sandy Hook was unbearably tragic. Twenty first-grade students were murdered. Six teachers and staff members were murdered. The shooter had started by murdering his mother and finished by killing himself. Although there was some safety that he would not hurt anyone ever again, there was also the massive insecurity that we will never be able to feel safe again, even in an elementary school, and are unable to understand what could have made a person commit this crime.

Several of the points we make in this article are especially relevant to the events in Newtown. This event has received such intensive and unremitting coverage that even the youngest children probably have been exposed in some way to it. Parents will need to be attuned to any indications that their children have seen, heard, or read something about this, and they should check in with their children and find out what they know, what questions they have, and what they are worried about. Parents who are anxious that they will be introducing this horrifying story might ask, "Have you ever heard or seen something that was scary or upsetting, and hard to get out of your thoughts afterwards?" They should try to limit children’s exposure to these news reports, as children may be overwhelmed or confused by the constant repetition of the story and will have difficulty managing disturbing images.

Parents should be reassured that well-loved, valued children can cope with troubling news with the help of their parents’ explanations, reassurance, and guidance, and the resumption of normal activities. Most of the millions of children (and parents) indirectly exposed to the Sandy Hook murders will be resilient. Longer term, some children in your pediatric practice will not return to their usual functioning. Some children may have a vulnerability to anxiety or depression, and others may have had previous losses of loved ones through divorce or death. Some will be vulnerable secondary to poverty, abuse, or neglect. For these vulnerable children and parents, Sandy Hook will be a critical, longer-term event.

A parent who may have become too absorbed in the acute phase of the story did not limit access to the media. A child may develop anxiety about being safe in school, become clingy to parents, regress to a younger age, or have posttraumatic stress disorder symptoms of what they have seen on television (nightmares, flashback images, etc.). A parent may become very anxious about school safety and overly restrictive. These anxieties are a way of coping with past and current events – a solution to their anxiety. Pediatricians should be empathic, take a family history for anxiety and depression, and consider a mental health referral.

Even the best-adjusted parents in your practice should be reminded that their children’s feelings, questions, and worries will be different from their own. This particular tragedy will have a profound, painful resonance for all parents. It will be difficult to drop off their children at elementary school without worries about their safety and feelings of breathtaking sadness for those parents whose children did not come home on Dec. 14.

If parents don’t manage their own distress, their children will surely sense or pick up on parental anxiety and will be much harder to reassure. It is critical for parents (and teachers, librarians, classroom aides, principals, social workers, and physicians) to tend to themselves. They must manage their own sadness and distress by getting meaningful support and reassurance from friends, loved ones, spouses, religious leaders, community leaders, and counselors. They should turn off the news not only when their children are around, but also when it becomes too much for them to bear. They should make sure that their family’s routines, including their routine limits and rules, continue. This is organizing and reassuring for children and adults alike.

Of course, supporting the families who were directly affected by the murders in Newtown will be very different from supporting those affected by the news of those murders. There will need to be a thoughtful, community-wide mental health plan for all of these survivors; the parents, siblings, and spouses who suffered the death of a loved one; and the first responders so stressed by the intensity of what they had to do and see.

Just as surely, there will be questions about whether mental illness or developmental disorders are linked to these horrifying incidents of violence. The fact that the perpetrator in Newtown has already been described in the media as having been diagnosed with Asperger’s disorder ensures that many families, especially those raising children with developmental disabilities, will have questions about any association. We as physicians must be clear that only clinicians who personally evaluated or treated this young man can speak to any of his personal problems or diagnoses. More broadly, there is no predictable association between acts of mass murder and psychiatric illness or developmental disorder. Indeed, it would be a disservice and counterproductive to increase the stigma and social isolation that already make it so difficult for so many to seek psychiatric help.

On a final note, adults as well as children should be encouraged to consider appropriate, meaningful action they could take in response to this event. Whether they want to try to demonstrate compassion to the families of Newtown, work to improve safety in their schools and communities, be activists for gun regulation, or support improved mental health care, they should be encouraged to channel their emotional responses constructively. We can teach our children that there are inevitable small risks that are part of growing up, that we can only control so much of our future, and that we need to tolerate these risks – try to minimize them when it’s possible and to grieve and recover when we cannot.

It seems that not a week goes by without the occurrence of a heartbreaking or terrifying event that gets exhaustive coverage in the news. Although overwhelmed adults can choose to take a hiatus from media or emotionally distance themselves from events, parents quickly learn that children come to them routinely with questions about something they saw, heard, or read about in a newspaper, online, on the radio, on television, via social media, or just from talking with a friend at school. Without imposing restrictions that would severely limit the child’s appropriate growing autonomy, there is simply no way that parents can fully control that to which their school-aged children are exposed.

Talking about the news-based facts of life poses challenges for most parents. It is unlikely that any parent woke up on the morning of Sept. 11, 2001 ready for the questions their children would come home from school with that afternoon. School and mall shootings and deaths from child abuse can be especially frightening for children and parents alike. Even natural disasters or accidents can be terrifying in their randomness and heartbreaking in their consequences. Should parents offer blanket reassurances? Can they speak honestly about the bad things people do or the uncertainty and vulnerability that are (often unacknowledged) facts of life?

The first thing you might offer a worried parent is the reassurance that the good news is that their children are asking them these questions at all and that children cope with troubling news. The fact that they bring their feelings and questions to their parents is a great marker of their judgment and trust. Remind parents that if they simply welcome these questions, are curious about their children’s thoughts and feelings, and remind their children to never worry alone, they will have done a great job at handling these types of questions.

Beyond welcoming difficult questions, there are some strategies to share with parents to help them handle these types of questions well. If at all possible, the parent should "strike while the iron is hot" and find the time and privacy to have these conversations when they arise. But if they come up in a busy public setting, such as the check-out line at the grocery store, it is probably best to respond that this is a very important question that deserves their full attention. They can talk about it once they get back in the car or can sit down at home together.

The conversation should start by gathering more information. What got the child thinking about this topic? Did they see or hear or read something about it? What was their response to this? It is important that parents remember not to assume that they know what their child is actually asking or worried about. What might worry a parent about a plane crash or a mass shooting may be different from what worries a child. What may be on the mind of a first grader could be quite different than a sixth grader. Often, children will want to gather information also. They may have a lot of factual questions about an event that they have heard about. It is natural for parents to want to protect their young children from material that is scary or sad, but it would be harder for these children to overhear this material or have to navigate it alone. Therefore, acknowledging what is true about what the child has heard is appropriate.

If a child has heard that people died in a school bus accident, then it is appropriate for a parent to acknowledge what is true without euphemism. Difficult facts should then be followed with an acknowledgment of the difficult feelings that can come with them. "How does this make you feel?" or "It makes me so sad that some children died in that accident" are examples of labeling and bearing these strong feelings. Again, parents should be sure to be curious about their child’s feelings as well as modeling how they handle such feelings.

After having a chance to discuss some of the factual details of the news and the emotions that follow, it will be critical for parents to offer appropriate reassurance and even a potential course of action. School-age children have the cognitive capacity to learn about complex issues that may be reflected in news events, such as global warming or mental illness, but they usually lack the emotional maturity to comfortably hold the anxiety and uncertainty that can follow. Therefore, parents should offer clear reassurance to their school-age children.

Although they cannot promise total immunity from illness, risks, or accidents, they can remind their children about how they are safe. For example, after discussing that there is fighting in Syria in which some children have been injured or killed, they should remind their children that their family lives in a safe community where there is no war or fighting. There may be an opportunity to teach their children about how to protect themselves in specific situations if the difficult topic lends itself to this. They could, for example, review what children should do in case of a fire or if they witness a physical fight or are offered a ride by a stranger.

Finally, school-age children can feel very distressed by the unfairness that is often a component of newsworthy events. At this stage in development, children are working hard to master and follow the rules in all sorts of settings, from soccer to social situations to algebra. They can become very upset when the rules don’t seem to apply, and, of course, life is often unfair in ways that parents cannot make right. Offering their children some perspectives, values, and actions they might take in response to a specific tragedy or injustice is helpful for their children’s coping and their development.

Parents may talk with their children about ways to raise money to help victims of an earthquake or to collect food for people displaced by a flood. Or they might want to think about working with friends and teachers at their school to create a bike safety curriculum. There are many schools and communities that have been profoundly affected in positive ways by efforts that grew from such conversations between concerned school-age children and their parents.

Pediatricians are uniquely qualified to help parents manage these difficult topics when they arise. Some parents may ask about this directly, but it may be helpful to create a handout to keep in the waiting room about this issue. Or you could create a page on your practice’s website. You also should remain attuned to when parents mention troubling news events in passing and take those opportunities to find out how they have handled them with their children. Although parents naturally feel that there are stories they would prefer to shield their children from, with your guidance they can see that even these difficult topics present opportunities to support their children’s preparation for adolescence and adulthood.

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

On the morning of Dec. 14, 2012, the authors submitted this piece on helping parents to discuss difficult events in the news with their children. It was written in the spirit of the many circumstances children hear or watch on the television news describing violent, scary, or sad events.

Within the hour, news broke that a gunman had entered an elementary school in Newtown, Conn., and shot many people, including children. Over the course of that terrible day, the full story took shape in a constant news flow that gripped all of us. Sandy Hook was unbearably tragic. Twenty first-grade students were murdered. Six teachers and staff members were murdered. The shooter had started by murdering his mother and finished by killing himself. Although there was some safety that he would not hurt anyone ever again, there was also the massive insecurity that we will never be able to feel safe again, even in an elementary school, and are unable to understand what could have made a person commit this crime.

Several of the points we make in this article are especially relevant to the events in Newtown. This event has received such intensive and unremitting coverage that even the youngest children probably have been exposed in some way to it. Parents will need to be attuned to any indications that their children have seen, heard, or read something about this, and they should check in with their children and find out what they know, what questions they have, and what they are worried about. Parents who are anxious that they will be introducing this horrifying story might ask, "Have you ever heard or seen something that was scary or upsetting, and hard to get out of your thoughts afterwards?" They should try to limit children’s exposure to these news reports, as children may be overwhelmed or confused by the constant repetition of the story and will have difficulty managing disturbing images.

Parents should be reassured that well-loved, valued children can cope with troubling news with the help of their parents’ explanations, reassurance, and guidance, and the resumption of normal activities. Most of the millions of children (and parents) indirectly exposed to the Sandy Hook murders will be resilient. Longer term, some children in your pediatric practice will not return to their usual functioning. Some children may have a vulnerability to anxiety or depression, and others may have had previous losses of loved ones through divorce or death. Some will be vulnerable secondary to poverty, abuse, or neglect. For these vulnerable children and parents, Sandy Hook will be a critical, longer-term event.

A parent who may have become too absorbed in the acute phase of the story did not limit access to the media. A child may develop anxiety about being safe in school, become clingy to parents, regress to a younger age, or have posttraumatic stress disorder symptoms of what they have seen on television (nightmares, flashback images, etc.). A parent may become very anxious about school safety and overly restrictive. These anxieties are a way of coping with past and current events – a solution to their anxiety. Pediatricians should be empathic, take a family history for anxiety and depression, and consider a mental health referral.

Even the best-adjusted parents in your practice should be reminded that their children’s feelings, questions, and worries will be different from their own. This particular tragedy will have a profound, painful resonance for all parents. It will be difficult to drop off their children at elementary school without worries about their safety and feelings of breathtaking sadness for those parents whose children did not come home on Dec. 14.

If parents don’t manage their own distress, their children will surely sense or pick up on parental anxiety and will be much harder to reassure. It is critical for parents (and teachers, librarians, classroom aides, principals, social workers, and physicians) to tend to themselves. They must manage their own sadness and distress by getting meaningful support and reassurance from friends, loved ones, spouses, religious leaders, community leaders, and counselors. They should turn off the news not only when their children are around, but also when it becomes too much for them to bear. They should make sure that their family’s routines, including their routine limits and rules, continue. This is organizing and reassuring for children and adults alike.

Of course, supporting the families who were directly affected by the murders in Newtown will be very different from supporting those affected by the news of those murders. There will need to be a thoughtful, community-wide mental health plan for all of these survivors; the parents, siblings, and spouses who suffered the death of a loved one; and the first responders so stressed by the intensity of what they had to do and see.

Just as surely, there will be questions about whether mental illness or developmental disorders are linked to these horrifying incidents of violence. The fact that the perpetrator in Newtown has already been described in the media as having been diagnosed with Asperger’s disorder ensures that many families, especially those raising children with developmental disabilities, will have questions about any association. We as physicians must be clear that only clinicians who personally evaluated or treated this young man can speak to any of his personal problems or diagnoses. More broadly, there is no predictable association between acts of mass murder and psychiatric illness or developmental disorder. Indeed, it would be a disservice and counterproductive to increase the stigma and social isolation that already make it so difficult for so many to seek psychiatric help.

On a final note, adults as well as children should be encouraged to consider appropriate, meaningful action they could take in response to this event. Whether they want to try to demonstrate compassion to the families of Newtown, work to improve safety in their schools and communities, be activists for gun regulation, or support improved mental health care, they should be encouraged to channel their emotional responses constructively. We can teach our children that there are inevitable small risks that are part of growing up, that we can only control so much of our future, and that we need to tolerate these risks – try to minimize them when it’s possible and to grieve and recover when we cannot.

It seems that not a week goes by without the occurrence of a heartbreaking or terrifying event that gets exhaustive coverage in the news. Although overwhelmed adults can choose to take a hiatus from media or emotionally distance themselves from events, parents quickly learn that children come to them routinely with questions about something they saw, heard, or read about in a newspaper, online, on the radio, on television, via social media, or just from talking with a friend at school. Without imposing restrictions that would severely limit the child’s appropriate growing autonomy, there is simply no way that parents can fully control that to which their school-aged children are exposed.

Talking about the news-based facts of life poses challenges for most parents. It is unlikely that any parent woke up on the morning of Sept. 11, 2001 ready for the questions their children would come home from school with that afternoon. School and mall shootings and deaths from child abuse can be especially frightening for children and parents alike. Even natural disasters or accidents can be terrifying in their randomness and heartbreaking in their consequences. Should parents offer blanket reassurances? Can they speak honestly about the bad things people do or the uncertainty and vulnerability that are (often unacknowledged) facts of life?

The first thing you might offer a worried parent is the reassurance that the good news is that their children are asking them these questions at all and that children cope with troubling news. The fact that they bring their feelings and questions to their parents is a great marker of their judgment and trust. Remind parents that if they simply welcome these questions, are curious about their children’s thoughts and feelings, and remind their children to never worry alone, they will have done a great job at handling these types of questions.

Beyond welcoming difficult questions, there are some strategies to share with parents to help them handle these types of questions well. If at all possible, the parent should "strike while the iron is hot" and find the time and privacy to have these conversations when they arise. But if they come up in a busy public setting, such as the check-out line at the grocery store, it is probably best to respond that this is a very important question that deserves their full attention. They can talk about it once they get back in the car or can sit down at home together.

The conversation should start by gathering more information. What got the child thinking about this topic? Did they see or hear or read something about it? What was their response to this? It is important that parents remember not to assume that they know what their child is actually asking or worried about. What might worry a parent about a plane crash or a mass shooting may be different from what worries a child. What may be on the mind of a first grader could be quite different than a sixth grader. Often, children will want to gather information also. They may have a lot of factual questions about an event that they have heard about. It is natural for parents to want to protect their young children from material that is scary or sad, but it would be harder for these children to overhear this material or have to navigate it alone. Therefore, acknowledging what is true about what the child has heard is appropriate.

If a child has heard that people died in a school bus accident, then it is appropriate for a parent to acknowledge what is true without euphemism. Difficult facts should then be followed with an acknowledgment of the difficult feelings that can come with them. "How does this make you feel?" or "It makes me so sad that some children died in that accident" are examples of labeling and bearing these strong feelings. Again, parents should be sure to be curious about their child’s feelings as well as modeling how they handle such feelings.

After having a chance to discuss some of the factual details of the news and the emotions that follow, it will be critical for parents to offer appropriate reassurance and even a potential course of action. School-age children have the cognitive capacity to learn about complex issues that may be reflected in news events, such as global warming or mental illness, but they usually lack the emotional maturity to comfortably hold the anxiety and uncertainty that can follow. Therefore, parents should offer clear reassurance to their school-age children.

Although they cannot promise total immunity from illness, risks, or accidents, they can remind their children about how they are safe. For example, after discussing that there is fighting in Syria in which some children have been injured or killed, they should remind their children that their family lives in a safe community where there is no war or fighting. There may be an opportunity to teach their children about how to protect themselves in specific situations if the difficult topic lends itself to this. They could, for example, review what children should do in case of a fire or if they witness a physical fight or are offered a ride by a stranger.

Finally, school-age children can feel very distressed by the unfairness that is often a component of newsworthy events. At this stage in development, children are working hard to master and follow the rules in all sorts of settings, from soccer to social situations to algebra. They can become very upset when the rules don’t seem to apply, and, of course, life is often unfair in ways that parents cannot make right. Offering their children some perspectives, values, and actions they might take in response to a specific tragedy or injustice is helpful for their children’s coping and their development.

Parents may talk with their children about ways to raise money to help victims of an earthquake or to collect food for people displaced by a flood. Or they might want to think about working with friends and teachers at their school to create a bike safety curriculum. There are many schools and communities that have been profoundly affected in positive ways by efforts that grew from such conversations between concerned school-age children and their parents.

Pediatricians are uniquely qualified to help parents manage these difficult topics when they arise. Some parents may ask about this directly, but it may be helpful to create a handout to keep in the waiting room about this issue. Or you could create a page on your practice’s website. You also should remain attuned to when parents mention troubling news events in passing and take those opportunities to find out how they have handled them with their children. Although parents naturally feel that there are stories they would prefer to shield their children from, with your guidance they can see that even these difficult topics present opportunities to support their children’s preparation for adolescence and adulthood.

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

On the morning of Dec. 14, 2012, the authors submitted this piece on helping parents to discuss difficult events in the news with their children. It was written in the spirit of the many circumstances children hear or watch on the television news describing violent, scary, or sad events.

Within the hour, news broke that a gunman had entered an elementary school in Newtown, Conn., and shot many people, including children. Over the course of that terrible day, the full story took shape in a constant news flow that gripped all of us. Sandy Hook was unbearably tragic. Twenty first-grade students were murdered. Six teachers and staff members were murdered. The shooter had started by murdering his mother and finished by killing himself. Although there was some safety that he would not hurt anyone ever again, there was also the massive insecurity that we will never be able to feel safe again, even in an elementary school, and are unable to understand what could have made a person commit this crime.

Several of the points we make in this article are especially relevant to the events in Newtown. This event has received such intensive and unremitting coverage that even the youngest children probably have been exposed in some way to it. Parents will need to be attuned to any indications that their children have seen, heard, or read something about this, and they should check in with their children and find out what they know, what questions they have, and what they are worried about. Parents who are anxious that they will be introducing this horrifying story might ask, "Have you ever heard or seen something that was scary or upsetting, and hard to get out of your thoughts afterwards?" They should try to limit children’s exposure to these news reports, as children may be overwhelmed or confused by the constant repetition of the story and will have difficulty managing disturbing images.

Parents should be reassured that well-loved, valued children can cope with troubling news with the help of their parents’ explanations, reassurance, and guidance, and the resumption of normal activities. Most of the millions of children (and parents) indirectly exposed to the Sandy Hook murders will be resilient. Longer term, some children in your pediatric practice will not return to their usual functioning. Some children may have a vulnerability to anxiety or depression, and others may have had previous losses of loved ones through divorce or death. Some will be vulnerable secondary to poverty, abuse, or neglect. For these vulnerable children and parents, Sandy Hook will be a critical, longer-term event.

A parent who may have become too absorbed in the acute phase of the story did not limit access to the media. A child may develop anxiety about being safe in school, become clingy to parents, regress to a younger age, or have posttraumatic stress disorder symptoms of what they have seen on television (nightmares, flashback images, etc.). A parent may become very anxious about school safety and overly restrictive. These anxieties are a way of coping with past and current events – a solution to their anxiety. Pediatricians should be empathic, take a family history for anxiety and depression, and consider a mental health referral.

Even the best-adjusted parents in your practice should be reminded that their children’s feelings, questions, and worries will be different from their own. This particular tragedy will have a profound, painful resonance for all parents. It will be difficult to drop off their children at elementary school without worries about their safety and feelings of breathtaking sadness for those parents whose children did not come home on Dec. 14.

If parents don’t manage their own distress, their children will surely sense or pick up on parental anxiety and will be much harder to reassure. It is critical for parents (and teachers, librarians, classroom aides, principals, social workers, and physicians) to tend to themselves. They must manage their own sadness and distress by getting meaningful support and reassurance from friends, loved ones, spouses, religious leaders, community leaders, and counselors. They should turn off the news not only when their children are around, but also when it becomes too much for them to bear. They should make sure that their family’s routines, including their routine limits and rules, continue. This is organizing and reassuring for children and adults alike.

Of course, supporting the families who were directly affected by the murders in Newtown will be very different from supporting those affected by the news of those murders. There will need to be a thoughtful, community-wide mental health plan for all of these survivors; the parents, siblings, and spouses who suffered the death of a loved one; and the first responders so stressed by the intensity of what they had to do and see.

Just as surely, there will be questions about whether mental illness or developmental disorders are linked to these horrifying incidents of violence. The fact that the perpetrator in Newtown has already been described in the media as having been diagnosed with Asperger’s disorder ensures that many families, especially those raising children with developmental disabilities, will have questions about any association. We as physicians must be clear that only clinicians who personally evaluated or treated this young man can speak to any of his personal problems or diagnoses. More broadly, there is no predictable association between acts of mass murder and psychiatric illness or developmental disorder. Indeed, it would be a disservice and counterproductive to increase the stigma and social isolation that already make it so difficult for so many to seek psychiatric help.

On a final note, adults as well as children should be encouraged to consider appropriate, meaningful action they could take in response to this event. Whether they want to try to demonstrate compassion to the families of Newtown, work to improve safety in their schools and communities, be activists for gun regulation, or support improved mental health care, they should be encouraged to channel their emotional responses constructively. We can teach our children that there are inevitable small risks that are part of growing up, that we can only control so much of our future, and that we need to tolerate these risks – try to minimize them when it’s possible and to grieve and recover when we cannot.

It seems that not a week goes by without the occurrence of a heartbreaking or terrifying event that gets exhaustive coverage in the news. Although overwhelmed adults can choose to take a hiatus from media or emotionally distance themselves from events, parents quickly learn that children come to them routinely with questions about something they saw, heard, or read about in a newspaper, online, on the radio, on television, via social media, or just from talking with a friend at school. Without imposing restrictions that would severely limit the child’s appropriate growing autonomy, there is simply no way that parents can fully control that to which their school-aged children are exposed.

Talking about the news-based facts of life poses challenges for most parents. It is unlikely that any parent woke up on the morning of Sept. 11, 2001 ready for the questions their children would come home from school with that afternoon. School and mall shootings and deaths from child abuse can be especially frightening for children and parents alike. Even natural disasters or accidents can be terrifying in their randomness and heartbreaking in their consequences. Should parents offer blanket reassurances? Can they speak honestly about the bad things people do or the uncertainty and vulnerability that are (often unacknowledged) facts of life?

The first thing you might offer a worried parent is the reassurance that the good news is that their children are asking them these questions at all and that children cope with troubling news. The fact that they bring their feelings and questions to their parents is a great marker of their judgment and trust. Remind parents that if they simply welcome these questions, are curious about their children’s thoughts and feelings, and remind their children to never worry alone, they will have done a great job at handling these types of questions.

Beyond welcoming difficult questions, there are some strategies to share with parents to help them handle these types of questions well. If at all possible, the parent should "strike while the iron is hot" and find the time and privacy to have these conversations when they arise. But if they come up in a busy public setting, such as the check-out line at the grocery store, it is probably best to respond that this is a very important question that deserves their full attention. They can talk about it once they get back in the car or can sit down at home together.

The conversation should start by gathering more information. What got the child thinking about this topic? Did they see or hear or read something about it? What was their response to this? It is important that parents remember not to assume that they know what their child is actually asking or worried about. What might worry a parent about a plane crash or a mass shooting may be different from what worries a child. What may be on the mind of a first grader could be quite different than a sixth grader. Often, children will want to gather information also. They may have a lot of factual questions about an event that they have heard about. It is natural for parents to want to protect their young children from material that is scary or sad, but it would be harder for these children to overhear this material or have to navigate it alone. Therefore, acknowledging what is true about what the child has heard is appropriate.

If a child has heard that people died in a school bus accident, then it is appropriate for a parent to acknowledge what is true without euphemism. Difficult facts should then be followed with an acknowledgment of the difficult feelings that can come with them. "How does this make you feel?" or "It makes me so sad that some children died in that accident" are examples of labeling and bearing these strong feelings. Again, parents should be sure to be curious about their child’s feelings as well as modeling how they handle such feelings.

After having a chance to discuss some of the factual details of the news and the emotions that follow, it will be critical for parents to offer appropriate reassurance and even a potential course of action. School-age children have the cognitive capacity to learn about complex issues that may be reflected in news events, such as global warming or mental illness, but they usually lack the emotional maturity to comfortably hold the anxiety and uncertainty that can follow. Therefore, parents should offer clear reassurance to their school-age children.

Although they cannot promise total immunity from illness, risks, or accidents, they can remind their children about how they are safe. For example, after discussing that there is fighting in Syria in which some children have been injured or killed, they should remind their children that their family lives in a safe community where there is no war or fighting. There may be an opportunity to teach their children about how to protect themselves in specific situations if the difficult topic lends itself to this. They could, for example, review what children should do in case of a fire or if they witness a physical fight or are offered a ride by a stranger.

Finally, school-age children can feel very distressed by the unfairness that is often a component of newsworthy events. At this stage in development, children are working hard to master and follow the rules in all sorts of settings, from soccer to social situations to algebra. They can become very upset when the rules don’t seem to apply, and, of course, life is often unfair in ways that parents cannot make right. Offering their children some perspectives, values, and actions they might take in response to a specific tragedy or injustice is helpful for their children’s coping and their development.

Parents may talk with their children about ways to raise money to help victims of an earthquake or to collect food for people displaced by a flood. Or they might want to think about working with friends and teachers at their school to create a bike safety curriculum. There are many schools and communities that have been profoundly affected in positive ways by efforts that grew from such conversations between concerned school-age children and their parents.

Pediatricians are uniquely qualified to help parents manage these difficult topics when they arise. Some parents may ask about this directly, but it may be helpful to create a handout to keep in the waiting room about this issue. Or you could create a page on your practice’s website. You also should remain attuned to when parents mention troubling news events in passing and take those opportunities to find out how they have handled them with their children. Although parents naturally feel that there are stories they would prefer to shield their children from, with your guidance they can see that even these difficult topics present opportunities to support their children’s preparation for adolescence and adulthood.

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