Michael S. Jellinek, MD

While autumn means the start of school, cooler nights, and the coming holiday season to most families, for seniors in high school it is crunch time: college application season. This is the last semester when grades "really matter" for their applications, they are preparing for a final set of SATs if needed, and they must write seemingly endless essays on some variation of "why I am special." Then they must organize their various application packages, with supporting materials and recommendations submitted on different schedules.

In addition to meeting with various advisers, everyone is probably asking them where they are applying and why they chose those particular schools – all of this while they are juggling the various extracurricular activities that they hope will help them stand out. In short, it is an exceptionally busy, stressful, and emotional time for any high school student who is hoping to gain admission to a competitive college.

These 17-year-olds have reason to be stressed. With admission rates for the most competitive schools dwindling to the low single digits (6.3% for Harvard and 7.9% for Yale in 2011) and even state schools becoming intensely competitive (University of California, Berkeley, admitted only 21% of applicants in 2011 and their median GPA was 4.19 on a 4.0 scale), students are understandably anxious, especially those students from families and communities that place great value on being accepted to an elite college. Add to that the anxiety about the increasingly burdensome cost of a college education. Then finish this with uncertainty about the job market they will face when they graduate.

For many, where they go to college is a "bottom line," a summary of all they have accomplished, their acknowledged potential, and who they "are." You get the picture.

Pediatricians are in a unique position to offer both seniors and their parents some healthy perspective about this process. While your patients are unlikely to ask you for college advice, you will get to hear about how stressed they are. A simple reminder that 1 year from now, they will be settling into a school that will provide them with an excellent education can sound fresh when coming from someone other than their parents. It also can help to remind them that rather than focusing on the very best school they can gain admission to, they should be looking for the school that will be the very best fit for them.

The application process may seem like a once-in-a-lifetime event, but it is also an opportunity to explore how to work hard in a way that is sustainable, that won’t leave them completely wiped out. Ask them about whether they are finding time for exercise and are eating reasonably well. Has their weight changed? Tell them about the data that suggest that those adolescents who sleep more than 7 hours nightly perform better on cognitive and physical tests. Their concentration will be better; they’ll do better in interviews, and are less likely to get sick. Remind them that finding small ways to relax in the midst of intense work also can be very effective in helping them feel better and perform better. Whether it\'s to exercise or play a little Angry Birds, taking regular breaks is usually well worth the time.

While offering this common sense advice, you also should be on the lookout for warning signs that your patient has moved from stress to distress. Do the patient and family have reasonable expectations? How much is "on the line" for everyone in the family? The more unreasonable their expectations, the more that is on the line, the greater the mental health risks. The pressures and insecurity that can accompany this process can trigger genuine depression or anxiety for vulnerable adolescents, and can exacerbate symptoms in those teenagers who were already managing psychiatric symptoms. These symptoms may have been overlooked by parents and teachers at a time when stress and exhaustion seem routine. Have they withdrawn from friends or previously beloved hobbies? Are they using drugs to try and improve their performance? Are they engaging in self-destructive behavior to manage their stress? Are they cutting? Restricting their food intake or compulsively exercising? Or have their grades started to drop? How have they responded to stress before? While one episode of getting drunk with friends to blow off steam is not alarming, be tuned in for the suggestion of a pattern. If you notice one, have a low threshold for a mental health referral. If they balk, saying that they do not have the time, you can remind them that when untreated, depression and anxiety could derail all their hard work. Making it discussable is the first step to getting them the extra support they may need.

You might hear from parents about their concerns about the stress of the college application process. For those parents who are speaking about "our application to Harvard," you might gently remind them that part of applying to college is about developing the organization and initiative to manage responsibilities independently. Next year, when their children are freshmen somewhere, they won’t have all of this help. This is an opportunity for them to manage an important task independently, asking for help if they need it. Indeed, parents demonstrate confidence in their adolescent’s abilities by stepping back.

It can be very helpful for parents to hear that while their senior might benefit from a (very) occasional reminder about deadlines, parents are exquisitely valuable to their senior in a different way. They are a uniquely qualified resource for an adolescent considering what he or she might want in a college education, with their unrivalled knowledge of the child’s unique interests, strengths, and needs. Parents are the keepers of great wisdom about their children’s gifts, and this perspective can be invaluable as seniors try to think through what they hope to get out of 4 years of hard work and great expense. And this expense matters, too. Parents also should be available to help their children consider what different school packages will cost, and honestly talk through what it will take to pay off these loans. These are difficult matters, but ones they are unlikely to consider deeply with peers or in leafing through the U.S. News college rankings. Yet how much debt they hold when they graduate will have enormous implications for their life’s path.

Some parents may be anxious that their son or daughter "just doesn’t care," and they are constantly nagging or simply doing all the preparation themselves, out of concern that otherwise it won’t happen. For these parents, you might gently suggest that when they hold so much anxiety, their child doesn’t have to hold any. While this might make the application process easy, it will leave their child at a disadvantage once they are at college and have to manage their own semester schedule (and laundry) all by themselves. Sometimes asking a school adviser to take a more active role is a better alternative than the parents getting more involved in a process that is designed to help high school seniors individuate and separate from home.

You are in a marvelous position to help your patients remember that this process is about their education and is not a horse race. Indeed, it is one of their last chances to work on a very adult undertaking with concerned adults (parents, teachers) nearby. If their parents can focus on helping their children to manage the stress, keep perspective, develop a nuanced appreciation of their own wishes and abilities, and cultivate both their discipline and flexibility, then the college crucible could instead be a passage that builds maturity and resiliency while parents and children are still enjoying eating dinner around the same table.

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 a 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.

While autumn means the start of school, cooler nights, and the coming holiday season to most families, for seniors in high school it is crunch time: college application season. This is the last semester when grades "really matter" for their applications, they are preparing for a final set of SATs if needed, and they must write seemingly endless essays on some variation of "why I am special." Then they must organize their various application packages, with supporting materials and recommendations submitted on different schedules.

In addition to meeting with various advisers, everyone is probably asking them where they are applying and why they chose those particular schools – all of this while they are juggling the various extracurricular activities that they hope will help them stand out. In short, it is an exceptionally busy, stressful, and emotional time for any high school student who is hoping to gain admission to a competitive college.

These 17-year-olds have reason to be stressed. With admission rates for the most competitive schools dwindling to the low single digits (6.3% for Harvard and 7.9% for Yale in 2011) and even state schools becoming intensely competitive (University of California, Berkeley, admitted only 21% of applicants in 2011 and their median GPA was 4.19 on a 4.0 scale), students are understandably anxious, especially those students from families and communities that place great value on being accepted to an elite college. Add to that the anxiety about the increasingly burdensome cost of a college education. Then finish this with uncertainty about the job market they will face when they graduate.

For many, where they go to college is a "bottom line," a summary of all they have accomplished, their acknowledged potential, and who they "are." You get the picture.

Pediatricians are in a unique position to offer both seniors and their parents some healthy perspective about this process. While your patients are unlikely to ask you for college advice, you will get to hear about how stressed they are. A simple reminder that 1 year from now, they will be settling into a school that will provide them with an excellent education can sound fresh when coming from someone other than their parents. It also can help to remind them that rather than focusing on the very best school they can gain admission to, they should be looking for the school that will be the very best fit for them.

The application process may seem like a once-in-a-lifetime event, but it is also an opportunity to explore how to work hard in a way that is sustainable, that won’t leave them completely wiped out. Ask them about whether they are finding time for exercise and are eating reasonably well. Has their weight changed? Tell them about the data that suggest that those adolescents who sleep more than 7 hours nightly perform better on cognitive and physical tests. Their concentration will be better; they’ll do better in interviews, and are less likely to get sick. Remind them that finding small ways to relax in the midst of intense work also can be very effective in helping them feel better and perform better. Whether it\'s to exercise or play a little Angry Birds, taking regular breaks is usually well worth the time.

While offering this common sense advice, you also should be on the lookout for warning signs that your patient has moved from stress to distress. Do the patient and family have reasonable expectations? How much is "on the line" for everyone in the family? The more unreasonable their expectations, the more that is on the line, the greater the mental health risks. The pressures and insecurity that can accompany this process can trigger genuine depression or anxiety for vulnerable adolescents, and can exacerbate symptoms in those teenagers who were already managing psychiatric symptoms. These symptoms may have been overlooked by parents and teachers at a time when stress and exhaustion seem routine. Have they withdrawn from friends or previously beloved hobbies? Are they using drugs to try and improve their performance? Are they engaging in self-destructive behavior to manage their stress? Are they cutting? Restricting their food intake or compulsively exercising? Or have their grades started to drop? How have they responded to stress before? While one episode of getting drunk with friends to blow off steam is not alarming, be tuned in for the suggestion of a pattern. If you notice one, have a low threshold for a mental health referral. If they balk, saying that they do not have the time, you can remind them that when untreated, depression and anxiety could derail all their hard work. Making it discussable is the first step to getting them the extra support they may need.

You might hear from parents about their concerns about the stress of the college application process. For those parents who are speaking about "our application to Harvard," you might gently remind them that part of applying to college is about developing the organization and initiative to manage responsibilities independently. Next year, when their children are freshmen somewhere, they won’t have all of this help. This is an opportunity for them to manage an important task independently, asking for help if they need it. Indeed, parents demonstrate confidence in their adolescent’s abilities by stepping back.

It can be very helpful for parents to hear that while their senior might benefit from a (very) occasional reminder about deadlines, parents are exquisitely valuable to their senior in a different way. They are a uniquely qualified resource for an adolescent considering what he or she might want in a college education, with their unrivalled knowledge of the child’s unique interests, strengths, and needs. Parents are the keepers of great wisdom about their children’s gifts, and this perspective can be invaluable as seniors try to think through what they hope to get out of 4 years of hard work and great expense. And this expense matters, too. Parents also should be available to help their children consider what different school packages will cost, and honestly talk through what it will take to pay off these loans. These are difficult matters, but ones they are unlikely to consider deeply with peers or in leafing through the U.S. News college rankings. Yet how much debt they hold when they graduate will have enormous implications for their life’s path.

Some parents may be anxious that their son or daughter "just doesn’t care," and they are constantly nagging or simply doing all the preparation themselves, out of concern that otherwise it won’t happen. For these parents, you might gently suggest that when they hold so much anxiety, their child doesn’t have to hold any. While this might make the application process easy, it will leave their child at a disadvantage once they are at college and have to manage their own semester schedule (and laundry) all by themselves. Sometimes asking a school adviser to take a more active role is a better alternative than the parents getting more involved in a process that is designed to help high school seniors individuate and separate from home.

You are in a marvelous position to help your patients remember that this process is about their education and is not a horse race. Indeed, it is one of their last chances to work on a very adult undertaking with concerned adults (parents, teachers) nearby. If their parents can focus on helping their children to manage the stress, keep perspective, develop a nuanced appreciation of their own wishes and abilities, and cultivate both their discipline and flexibility, then the college crucible could instead be a passage that builds maturity and resiliency while parents and children are still enjoying eating dinner around the same table.

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 a 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.

While autumn means the start of school, cooler nights, and the coming holiday season to most families, for seniors in high school it is crunch time: college application season. This is the last semester when grades "really matter" for their applications, they are preparing for a final set of SATs if needed, and they must write seemingly endless essays on some variation of "why I am special." Then they must organize their various application packages, with supporting materials and recommendations submitted on different schedules.

In addition to meeting with various advisers, everyone is probably asking them where they are applying and why they chose those particular schools – all of this while they are juggling the various extracurricular activities that they hope will help them stand out. In short, it is an exceptionally busy, stressful, and emotional time for any high school student who is hoping to gain admission to a competitive college.

These 17-year-olds have reason to be stressed. With admission rates for the most competitive schools dwindling to the low single digits (6.3% for Harvard and 7.9% for Yale in 2011) and even state schools becoming intensely competitive (University of California, Berkeley, admitted only 21% of applicants in 2011 and their median GPA was 4.19 on a 4.0 scale), students are understandably anxious, especially those students from families and communities that place great value on being accepted to an elite college. Add to that the anxiety about the increasingly burdensome cost of a college education. Then finish this with uncertainty about the job market they will face when they graduate.

For many, where they go to college is a "bottom line," a summary of all they have accomplished, their acknowledged potential, and who they "are." You get the picture.

Pediatricians are in a unique position to offer both seniors and their parents some healthy perspective about this process. While your patients are unlikely to ask you for college advice, you will get to hear about how stressed they are. A simple reminder that 1 year from now, they will be settling into a school that will provide them with an excellent education can sound fresh when coming from someone other than their parents. It also can help to remind them that rather than focusing on the very best school they can gain admission to, they should be looking for the school that will be the very best fit for them.

The application process may seem like a once-in-a-lifetime event, but it is also an opportunity to explore how to work hard in a way that is sustainable, that won’t leave them completely wiped out. Ask them about whether they are finding time for exercise and are eating reasonably well. Has their weight changed? Tell them about the data that suggest that those adolescents who sleep more than 7 hours nightly perform better on cognitive and physical tests. Their concentration will be better; they’ll do better in interviews, and are less likely to get sick. Remind them that finding small ways to relax in the midst of intense work also can be very effective in helping them feel better and perform better. Whether it\'s to exercise or play a little Angry Birds, taking regular breaks is usually well worth the time.

While offering this common sense advice, you also should be on the lookout for warning signs that your patient has moved from stress to distress. Do the patient and family have reasonable expectations? How much is "on the line" for everyone in the family? The more unreasonable their expectations, the more that is on the line, the greater the mental health risks. The pressures and insecurity that can accompany this process can trigger genuine depression or anxiety for vulnerable adolescents, and can exacerbate symptoms in those teenagers who were already managing psychiatric symptoms. These symptoms may have been overlooked by parents and teachers at a time when stress and exhaustion seem routine. Have they withdrawn from friends or previously beloved hobbies? Are they using drugs to try and improve their performance? Are they engaging in self-destructive behavior to manage their stress? Are they cutting? Restricting their food intake or compulsively exercising? Or have their grades started to drop? How have they responded to stress before? While one episode of getting drunk with friends to blow off steam is not alarming, be tuned in for the suggestion of a pattern. If you notice one, have a low threshold for a mental health referral. If they balk, saying that they do not have the time, you can remind them that when untreated, depression and anxiety could derail all their hard work. Making it discussable is the first step to getting them the extra support they may need.

You might hear from parents about their concerns about the stress of the college application process. For those parents who are speaking about "our application to Harvard," you might gently remind them that part of applying to college is about developing the organization and initiative to manage responsibilities independently. Next year, when their children are freshmen somewhere, they won’t have all of this help. This is an opportunity for them to manage an important task independently, asking for help if they need it. Indeed, parents demonstrate confidence in their adolescent’s abilities by stepping back.

It can be very helpful for parents to hear that while their senior might benefit from a (very) occasional reminder about deadlines, parents are exquisitely valuable to their senior in a different way. They are a uniquely qualified resource for an adolescent considering what he or she might want in a college education, with their unrivalled knowledge of the child’s unique interests, strengths, and needs. Parents are the keepers of great wisdom about their children’s gifts, and this perspective can be invaluable as seniors try to think through what they hope to get out of 4 years of hard work and great expense. And this expense matters, too. Parents also should be available to help their children consider what different school packages will cost, and honestly talk through what it will take to pay off these loans. These are difficult matters, but ones they are unlikely to consider deeply with peers or in leafing through the U.S. News college rankings. Yet how much debt they hold when they graduate will have enormous implications for their life’s path.

Some parents may be anxious that their son or daughter "just doesn’t care," and they are constantly nagging or simply doing all the preparation themselves, out of concern that otherwise it won’t happen. For these parents, you might gently suggest that when they hold so much anxiety, their child doesn’t have to hold any. While this might make the application process easy, it will leave their child at a disadvantage once they are at college and have to manage their own semester schedule (and laundry) all by themselves. Sometimes asking a school adviser to take a more active role is a better alternative than the parents getting more involved in a process that is designed to help high school seniors individuate and separate from home.

You are in a marvelous position to help your patients remember that this process is about their education and is not a horse race. Indeed, it is one of their last chances to work on a very adult undertaking with concerned adults (parents, teachers) nearby. If their parents can focus on helping their children to manage the stress, keep perspective, develop a nuanced appreciation of their own wishes and abilities, and cultivate both their discipline and flexibility, then the college crucible could instead be a passage that builds maturity and resiliency while parents and children are still enjoying eating dinner around the same table.

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 a 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.

How can I help parents reach out to an angry teenager?

First, determine the source of the anger. In many normal teenagers, some anger is expected, particularly if it stems from their intense drive for autonomy or a need to protect their vulnerable sense of self-esteem. Being angry is far better than being dependent or deeply embarrassed. In contrast, teens who engage in high-risk behaviors or who live with a psychiatric disorder can express anger beyond what you and a parent might be able to handle alone, and a mental health referral may be essential.

Watch for a pattern of almost daily anger, physical altercations, and/or persistent estrangement between adolescents and their families. This is a major concern, particularly when the parents feel that they’ve lost touch with their teenager, that no good connection remains between them, and that the teen is really functioning on his or her own, almost driven by anger toward the parents. An hour-long estrangement or a fight that lasts overnight can be normal. But if the estranged relationship persists day after day and week after week, the family needs additional help.

One might see such a pattern when an adolescent deals with a childhood divorce; if substances are involved; or if the teenager has an evolving problem that seems almost built in to their emerging identity and character.

It’s very, very hard for adolescents to separate from their parents and go off to a job or college when they feel estranged or bitter toward their parents. Negative feelings about their parents make their successes as young adults more challenging. These young people often do not reach – or they sabotage – their academic and interpersonal potential.

Advise parents to listen very closely to what is making the teen angry. Over several years, the parents’ job is to encourage autonomy and self-esteem in their child. The goal with 13-year-olds is to get them ready to be 18 years old, not to be 11. Parents don’t have to give in on every point, but they have to think, "How am I going to get my ninth grader to become a safe and independent college freshman?" Remind the parents that this is a process that can take about 5 years to accomplish; they don’t want to do it in 1 night, but they don’t want to take 10 years, either. Your advice for this family will evolve over time as well, because tools that are effective in helping an angry 13-year-old are unlikely to work when the adolescent turns 15 or 17. Lastly, this is a bumpy process with successes and failures. Celebrate the successes and give the failures a short life and a second chance.

Listen to parents’ descriptions of tensions with their angry teenager to figure out any real risks, such as true depression, early alcohol abuse, hyperactivity, and poor impulse control. High-risk teenagers will need more thought in terms of their developmental tendencies for autonomy and self-esteem.

On the other hand, you may encounter parents who grew up with very controlling parents themselves, or who express an abnormally high level of anxiety in your office. You need to help them to bridge the gap and arrive at some middle ground that does not completely alienate the teenager.

Balancing risk and autonomy may present a volatile challenge. You want to intervene before a young teenager’s anger drives her or him away completely. The goal is to avoid creating a situation in which a 16- or 17-year old is almost impossible to control and becomes alienated.

In terms of normal development and the angry teenager, autonomy and self-esteem are the most relevant dynamics.

Autonomy

Autonomy is probably the most central. Preteens gradually evolve from total dependence on their parents and a worldview that primarily encompasses only home and school to a much broader perspective. By their early teenage years, they start doing more things on their own, such as staying over at a friend’s house, and in general, they experience more of the world. They enter high school. They start to develop deeper relationships with same-sex peers and begin to hang out with the opposite sex, and maybe start to do more than hang out.

This can be a scary time for teenagers (and parents). At the same time, teenagers are trying to establish their identities by doing a lot of new things and competing in completely new ways. Plus, they are competing in the real world. The judgments they face are not like a second grade teacher’s saying, "You told a nice story at story time." Now they are competing for the varsity team with much of their self-esteem and identity on the line.

Anger may manifest as teenagers struggle to manage this urge to autonomy. They often become angry because someone limits their autonomy. Limits on where they can go, dictates on when they have to go to sleep, or restrictions on how late they can stay out with friends – these can all trigger an angry argument from a teenager. Some people believe that this kind of anger is necessary at times, because teenagers have to emerge a bit from the family in order to establish their own identities.

Help parents to recognize the expected anger and inevitable tension. Tension arises normally between a parent’s wish to protect the child and the teenager’s desire to have more autonomy, for example in negotiations about learning to drive. Tension also develops when a parent’s wish for the teenager not to be sexual directly conflicts with the teenager’s wish to have a boyfriend or girlfriend.

In establishing their autonomy, teenagers sometimes go past where they feel comfortable because of a strong desire to prove themselves. "I want to stay out until midnight. All my friends stay out until 1 o’clock in the morning." The teens might exaggerate, which reflects how intense their wishes are to move toward autonomy.

Self-Esteem

Protection of self-esteem is a second major reason for the expression of anger in normal teenagers. As they do all these new things, it’s quite easy for them to feel that they are not doing them well. They might think, for example, that they are not as good in sports as are their peers or older teenage friends; that they are not as attractive to the opposite sex; or that they are not as smart as other kids in middle or high school. Ongoing self-appraisal and feedback from peers are parts of the teenage experience for most, especially as they consider their futures and witness other people both succeeding and failing to achieve what they want.

Teenagers who are embarrassed about a particular failure might cloak the embarrassment with anger. For example, teens who thought they would be great film stars but who then don’t even get chosen for the school play might become angry and say, "I never really wanted to be in the play." Or they might blame their parents – or anyone else – for not adequately preparing them. They don’t want to own their own lack of success.

Sometimes they make up little lies so they don’t have to be embarrassed. "I didn’t break the pitcher and I don’t know who did," for example. They will even get into a fight to avoid taking responsibility, because doing so would be too damaging to their self-esteem or too embarrassing overall.

So how do you advise parents to reach out in these normal situations of anger? Educate them that if they go head-on with their teenager, the fight often escalates. If the teen’s anger is a solution to his inability to establish autonomy or stems from her embarrassment, and the parent argues back, then repeating the same embarrassing fact only "ups the ante" and increases the emotional intensity, which is going to make the anger worse.

The teenager really cannot back down. From his perspective, if he acquiesces to the parent, he is becoming more childlike at the same time he is trying to move beyond childhood. The teen would rather escalate the situation. That is why in some of these family situations, a minor issue such as a half-hour of curfew turns into a huge blowup.

Or, a teenager might not want to be embarrassed by her friends’ being able to stay out later, even though it’s only 30 minutes. There is a lot on the line for the teenager in terms of her self-esteem and her relationships with peers. So she will not back down.

And the parents feels that because they are the parents, they should set the rules, and even though it’s only 30 minutes, "the rule is what I say it is," so they escalate the conflict as well.

For these reasons, you may hear about very major arguments over very minor differences.

Instruct parents to try to be empathetic to the teenager, and to step back and assess the true risks. What does the teenager have at stake in this argument? How important is it to him, and why? If parents cannot answer those questions, they should really calm down and ask the teenager to explain her perspective. They will often find that an issue of autonomy, self-esteem, or embarrassment is at the core.

Also, advise parents to share their concerns with their teenager. They can tell their child exactly why they are anxious about a later curfew. Otherwise, the difference between a 10:30 and 11:00 p.m. curfew might seem capricious to the teen who is thinking that the parent just does not trust him. The parent, in contrast, might be worried that the teen is hanging out with new friends they don’t know very well. In this instance, they could ask their child, "Do you feel comfortable that even though some of these kids are strangers, you will be able to resist if they want to do something stupid?"

Or the parent could be anxious because the teenager could be planning to drive with another adolescent who just got her driver’s license and has no experience to prove she can drive safely. One potential solution is for the parent to permit a later curfew if the teen agrees to check in by cell phone at predetermined times. In other words, foster an adult-to–almost adult negotiation.

If teenagers understand what their parents are really worried about, it’s less likely they are going to screw up.

In most cases, parents who listen with empathy to the teenager can make a reasonable deal. These deals are not all going to be successful; not every teenager has the capacity to be 100% successful. (By the way, most adults don’t have this capacity, either.) The real trick is to make deals reasonable, so they have a reasonable chance of success.

Also, instruct the parent to not make a big deal out of it if the deal fails. They can make another deal; the goal is to find something that works, and not for a parent to win the argument and say, "See, I told you you’d get into trouble. You’re never staying out past 11 o’clock at night." That’s not going to work. It is better for parents to say, "We discussed the things I was concerned about, and you got into trouble. You made some noise and the neighbors called the police. Luckily, no one was hurt. You have to take these things into account. You’re getting older now."

You want them to face these difficult situations in safe settings a little at a time. This way, the teenager builds up a bank account of good judgment, trust, and second chances.

Another great recommendation is to encourage the teenager and parents to have some fun through shared activities when they are not arguing. With this strategy, anger is offset by positive experiences. Opportunities for good communication before and after one of these angry episodes will help the parents interact effectively with their teenagers.

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. He has no relevant disclosures.

How can I help parents reach out to an angry teenager?

First, determine the source of the anger. In many normal teenagers, some anger is expected, particularly if it stems from their intense drive for autonomy or a need to protect their vulnerable sense of self-esteem. Being angry is far better than being dependent or deeply embarrassed. In contrast, teens who engage in high-risk behaviors or who live with a psychiatric disorder can express anger beyond what you and a parent might be able to handle alone, and a mental health referral may be essential.

Watch for a pattern of almost daily anger, physical altercations, and/or persistent estrangement between adolescents and their families. This is a major concern, particularly when the parents feel that they’ve lost touch with their teenager, that no good connection remains between them, and that the teen is really functioning on his or her own, almost driven by anger toward the parents. An hour-long estrangement or a fight that lasts overnight can be normal. But if the estranged relationship persists day after day and week after week, the family needs additional help.

One might see such a pattern when an adolescent deals with a childhood divorce; if substances are involved; or if the teenager has an evolving problem that seems almost built in to their emerging identity and character.

It’s very, very hard for adolescents to separate from their parents and go off to a job or college when they feel estranged or bitter toward their parents. Negative feelings about their parents make their successes as young adults more challenging. These young people often do not reach – or they sabotage – their academic and interpersonal potential.

Advise parents to listen very closely to what is making the teen angry. Over several years, the parents’ job is to encourage autonomy and self-esteem in their child. The goal with 13-year-olds is to get them ready to be 18 years old, not to be 11. Parents don’t have to give in on every point, but they have to think, "How am I going to get my ninth grader to become a safe and independent college freshman?" Remind the parents that this is a process that can take about 5 years to accomplish; they don’t want to do it in 1 night, but they don’t want to take 10 years, either. Your advice for this family will evolve over time as well, because tools that are effective in helping an angry 13-year-old are unlikely to work when the adolescent turns 15 or 17. Lastly, this is a bumpy process with successes and failures. Celebrate the successes and give the failures a short life and a second chance.

Listen to parents’ descriptions of tensions with their angry teenager to figure out any real risks, such as true depression, early alcohol abuse, hyperactivity, and poor impulse control. High-risk teenagers will need more thought in terms of their developmental tendencies for autonomy and self-esteem.

On the other hand, you may encounter parents who grew up with very controlling parents themselves, or who express an abnormally high level of anxiety in your office. You need to help them to bridge the gap and arrive at some middle ground that does not completely alienate the teenager.

Balancing risk and autonomy may present a volatile challenge. You want to intervene before a young teenager’s anger drives her or him away completely. The goal is to avoid creating a situation in which a 16- or 17-year old is almost impossible to control and becomes alienated.

In terms of normal development and the angry teenager, autonomy and self-esteem are the most relevant dynamics.

Autonomy

Autonomy is probably the most central. Preteens gradually evolve from total dependence on their parents and a worldview that primarily encompasses only home and school to a much broader perspective. By their early teenage years, they start doing more things on their own, such as staying over at a friend’s house, and in general, they experience more of the world. They enter high school. They start to develop deeper relationships with same-sex peers and begin to hang out with the opposite sex, and maybe start to do more than hang out.

This can be a scary time for teenagers (and parents). At the same time, teenagers are trying to establish their identities by doing a lot of new things and competing in completely new ways. Plus, they are competing in the real world. The judgments they face are not like a second grade teacher’s saying, "You told a nice story at story time." Now they are competing for the varsity team with much of their self-esteem and identity on the line.

Anger may manifest as teenagers struggle to manage this urge to autonomy. They often become angry because someone limits their autonomy. Limits on where they can go, dictates on when they have to go to sleep, or restrictions on how late they can stay out with friends – these can all trigger an angry argument from a teenager. Some people believe that this kind of anger is necessary at times, because teenagers have to emerge a bit from the family in order to establish their own identities.

Help parents to recognize the expected anger and inevitable tension. Tension arises normally between a parent’s wish to protect the child and the teenager’s desire to have more autonomy, for example in negotiations about learning to drive. Tension also develops when a parent’s wish for the teenager not to be sexual directly conflicts with the teenager’s wish to have a boyfriend or girlfriend.

In establishing their autonomy, teenagers sometimes go past where they feel comfortable because of a strong desire to prove themselves. "I want to stay out until midnight. All my friends stay out until 1 o’clock in the morning." The teens might exaggerate, which reflects how intense their wishes are to move toward autonomy.

Self-Esteem

Protection of self-esteem is a second major reason for the expression of anger in normal teenagers. As they do all these new things, it’s quite easy for them to feel that they are not doing them well. They might think, for example, that they are not as good in sports as are their peers or older teenage friends; that they are not as attractive to the opposite sex; or that they are not as smart as other kids in middle or high school. Ongoing self-appraisal and feedback from peers are parts of the teenage experience for most, especially as they consider their futures and witness other people both succeeding and failing to achieve what they want.

Teenagers who are embarrassed about a particular failure might cloak the embarrassment with anger. For example, teens who thought they would be great film stars but who then don’t even get chosen for the school play might become angry and say, "I never really wanted to be in the play." Or they might blame their parents – or anyone else – for not adequately preparing them. They don’t want to own their own lack of success.

Sometimes they make up little lies so they don’t have to be embarrassed. "I didn’t break the pitcher and I don’t know who did," for example. They will even get into a fight to avoid taking responsibility, because doing so would be too damaging to their self-esteem or too embarrassing overall.

So how do you advise parents to reach out in these normal situations of anger? Educate them that if they go head-on with their teenager, the fight often escalates. If the teen’s anger is a solution to his inability to establish autonomy or stems from her embarrassment, and the parent argues back, then repeating the same embarrassing fact only "ups the ante" and increases the emotional intensity, which is going to make the anger worse.

The teenager really cannot back down. From his perspective, if he acquiesces to the parent, he is becoming more childlike at the same time he is trying to move beyond childhood. The teen would rather escalate the situation. That is why in some of these family situations, a minor issue such as a half-hour of curfew turns into a huge blowup.

Or, a teenager might not want to be embarrassed by her friends’ being able to stay out later, even though it’s only 30 minutes. There is a lot on the line for the teenager in terms of her self-esteem and her relationships with peers. So she will not back down.

And the parents feels that because they are the parents, they should set the rules, and even though it’s only 30 minutes, "the rule is what I say it is," so they escalate the conflict as well.

For these reasons, you may hear about very major arguments over very minor differences.

Instruct parents to try to be empathetic to the teenager, and to step back and assess the true risks. What does the teenager have at stake in this argument? How important is it to him, and why? If parents cannot answer those questions, they should really calm down and ask the teenager to explain her perspective. They will often find that an issue of autonomy, self-esteem, or embarrassment is at the core.

Also, advise parents to share their concerns with their teenager. They can tell their child exactly why they are anxious about a later curfew. Otherwise, the difference between a 10:30 and 11:00 p.m. curfew might seem capricious to the teen who is thinking that the parent just does not trust him. The parent, in contrast, might be worried that the teen is hanging out with new friends they don’t know very well. In this instance, they could ask their child, "Do you feel comfortable that even though some of these kids are strangers, you will be able to resist if they want to do something stupid?"

Or the parent could be anxious because the teenager could be planning to drive with another adolescent who just got her driver’s license and has no experience to prove she can drive safely. One potential solution is for the parent to permit a later curfew if the teen agrees to check in by cell phone at predetermined times. In other words, foster an adult-to–almost adult negotiation.

If teenagers understand what their parents are really worried about, it’s less likely they are going to screw up.

In most cases, parents who listen with empathy to the teenager can make a reasonable deal. These deals are not all going to be successful; not every teenager has the capacity to be 100% successful. (By the way, most adults don’t have this capacity, either.) The real trick is to make deals reasonable, so they have a reasonable chance of success.

Also, instruct the parent to not make a big deal out of it if the deal fails. They can make another deal; the goal is to find something that works, and not for a parent to win the argument and say, "See, I told you you’d get into trouble. You’re never staying out past 11 o’clock at night." That’s not going to work. It is better for parents to say, "We discussed the things I was concerned about, and you got into trouble. You made some noise and the neighbors called the police. Luckily, no one was hurt. You have to take these things into account. You’re getting older now."

You want them to face these difficult situations in safe settings a little at a time. This way, the teenager builds up a bank account of good judgment, trust, and second chances.

Another great recommendation is to encourage the teenager and parents to have some fun through shared activities when they are not arguing. With this strategy, anger is offset by positive experiences. Opportunities for good communication before and after one of these angry episodes will help the parents interact effectively with their teenagers.

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. He has no relevant disclosures.

How can I help parents reach out to an angry teenager?

First, determine the source of the anger. In many normal teenagers, some anger is expected, particularly if it stems from their intense drive for autonomy or a need to protect their vulnerable sense of self-esteem. Being angry is far better than being dependent or deeply embarrassed. In contrast, teens who engage in high-risk behaviors or who live with a psychiatric disorder can express anger beyond what you and a parent might be able to handle alone, and a mental health referral may be essential.

Watch for a pattern of almost daily anger, physical altercations, and/or persistent estrangement between adolescents and their families. This is a major concern, particularly when the parents feel that they’ve lost touch with their teenager, that no good connection remains between them, and that the teen is really functioning on his or her own, almost driven by anger toward the parents. An hour-long estrangement or a fight that lasts overnight can be normal. But if the estranged relationship persists day after day and week after week, the family needs additional help.

One might see such a pattern when an adolescent deals with a childhood divorce; if substances are involved; or if the teenager has an evolving problem that seems almost built in to their emerging identity and character.

It’s very, very hard for adolescents to separate from their parents and go off to a job or college when they feel estranged or bitter toward their parents. Negative feelings about their parents make their successes as young adults more challenging. These young people often do not reach – or they sabotage – their academic and interpersonal potential.

Advise parents to listen very closely to what is making the teen angry. Over several years, the parents’ job is to encourage autonomy and self-esteem in their child. The goal with 13-year-olds is to get them ready to be 18 years old, not to be 11. Parents don’t have to give in on every point, but they have to think, "How am I going to get my ninth grader to become a safe and independent college freshman?" Remind the parents that this is a process that can take about 5 years to accomplish; they don’t want to do it in 1 night, but they don’t want to take 10 years, either. Your advice for this family will evolve over time as well, because tools that are effective in helping an angry 13-year-old are unlikely to work when the adolescent turns 15 or 17. Lastly, this is a bumpy process with successes and failures. Celebrate the successes and give the failures a short life and a second chance.

Listen to parents’ descriptions of tensions with their angry teenager to figure out any real risks, such as true depression, early alcohol abuse, hyperactivity, and poor impulse control. High-risk teenagers will need more thought in terms of their developmental tendencies for autonomy and self-esteem.

On the other hand, you may encounter parents who grew up with very controlling parents themselves, or who express an abnormally high level of anxiety in your office. You need to help them to bridge the gap and arrive at some middle ground that does not completely alienate the teenager.

Balancing risk and autonomy may present a volatile challenge. You want to intervene before a young teenager’s anger drives her or him away completely. The goal is to avoid creating a situation in which a 16- or 17-year old is almost impossible to control and becomes alienated.

In terms of normal development and the angry teenager, autonomy and self-esteem are the most relevant dynamics.

Autonomy

Autonomy is probably the most central. Preteens gradually evolve from total dependence on their parents and a worldview that primarily encompasses only home and school to a much broader perspective. By their early teenage years, they start doing more things on their own, such as staying over at a friend’s house, and in general, they experience more of the world. They enter high school. They start to develop deeper relationships with same-sex peers and begin to hang out with the opposite sex, and maybe start to do more than hang out.

This can be a scary time for teenagers (and parents). At the same time, teenagers are trying to establish their identities by doing a lot of new things and competing in completely new ways. Plus, they are competing in the real world. The judgments they face are not like a second grade teacher’s saying, "You told a nice story at story time." Now they are competing for the varsity team with much of their self-esteem and identity on the line.

Anger may manifest as teenagers struggle to manage this urge to autonomy. They often become angry because someone limits their autonomy. Limits on where they can go, dictates on when they have to go to sleep, or restrictions on how late they can stay out with friends – these can all trigger an angry argument from a teenager. Some people believe that this kind of anger is necessary at times, because teenagers have to emerge a bit from the family in order to establish their own identities.

Help parents to recognize the expected anger and inevitable tension. Tension arises normally between a parent’s wish to protect the child and the teenager’s desire to have more autonomy, for example in negotiations about learning to drive. Tension also develops when a parent’s wish for the teenager not to be sexual directly conflicts with the teenager’s wish to have a boyfriend or girlfriend.

In establishing their autonomy, teenagers sometimes go past where they feel comfortable because of a strong desire to prove themselves. "I want to stay out until midnight. All my friends stay out until 1 o’clock in the morning." The teens might exaggerate, which reflects how intense their wishes are to move toward autonomy.

Self-Esteem

Protection of self-esteem is a second major reason for the expression of anger in normal teenagers. As they do all these new things, it’s quite easy for them to feel that they are not doing them well. They might think, for example, that they are not as good in sports as are their peers or older teenage friends; that they are not as attractive to the opposite sex; or that they are not as smart as other kids in middle or high school. Ongoing self-appraisal and feedback from peers are parts of the teenage experience for most, especially as they consider their futures and witness other people both succeeding and failing to achieve what they want.

Teenagers who are embarrassed about a particular failure might cloak the embarrassment with anger. For example, teens who thought they would be great film stars but who then don’t even get chosen for the school play might become angry and say, "I never really wanted to be in the play." Or they might blame their parents – or anyone else – for not adequately preparing them. They don’t want to own their own lack of success.

Sometimes they make up little lies so they don’t have to be embarrassed. "I didn’t break the pitcher and I don’t know who did," for example. They will even get into a fight to avoid taking responsibility, because doing so would be too damaging to their self-esteem or too embarrassing overall.

So how do you advise parents to reach out in these normal situations of anger? Educate them that if they go head-on with their teenager, the fight often escalates. If the teen’s anger is a solution to his inability to establish autonomy or stems from her embarrassment, and the parent argues back, then repeating the same embarrassing fact only "ups the ante" and increases the emotional intensity, which is going to make the anger worse.

The teenager really cannot back down. From his perspective, if he acquiesces to the parent, he is becoming more childlike at the same time he is trying to move beyond childhood. The teen would rather escalate the situation. That is why in some of these family situations, a minor issue such as a half-hour of curfew turns into a huge blowup.

Or, a teenager might not want to be embarrassed by her friends’ being able to stay out later, even though it’s only 30 minutes. There is a lot on the line for the teenager in terms of her self-esteem and her relationships with peers. So she will not back down.

And the parents feels that because they are the parents, they should set the rules, and even though it’s only 30 minutes, "the rule is what I say it is," so they escalate the conflict as well.

For these reasons, you may hear about very major arguments over very minor differences.

Instruct parents to try to be empathetic to the teenager, and to step back and assess the true risks. What does the teenager have at stake in this argument? How important is it to him, and why? If parents cannot answer those questions, they should really calm down and ask the teenager to explain her perspective. They will often find that an issue of autonomy, self-esteem, or embarrassment is at the core.

Also, advise parents to share their concerns with their teenager. They can tell their child exactly why they are anxious about a later curfew. Otherwise, the difference between a 10:30 and 11:00 p.m. curfew might seem capricious to the teen who is thinking that the parent just does not trust him. The parent, in contrast, might be worried that the teen is hanging out with new friends they don’t know very well. In this instance, they could ask their child, "Do you feel comfortable that even though some of these kids are strangers, you will be able to resist if they want to do something stupid?"

Or the parent could be anxious because the teenager could be planning to drive with another adolescent who just got her driver’s license and has no experience to prove she can drive safely. One potential solution is for the parent to permit a later curfew if the teen agrees to check in by cell phone at predetermined times. In other words, foster an adult-to–almost adult negotiation.

If teenagers understand what their parents are really worried about, it’s less likely they are going to screw up.

In most cases, parents who listen with empathy to the teenager can make a reasonable deal. These deals are not all going to be successful; not every teenager has the capacity to be 100% successful. (By the way, most adults don’t have this capacity, either.) The real trick is to make deals reasonable, so they have a reasonable chance of success.

Also, instruct the parent to not make a big deal out of it if the deal fails. They can make another deal; the goal is to find something that works, and not for a parent to win the argument and say, "See, I told you you’d get into trouble. You’re never staying out past 11 o’clock at night." That’s not going to work. It is better for parents to say, "We discussed the things I was concerned about, and you got into trouble. You made some noise and the neighbors called the police. Luckily, no one was hurt. You have to take these things into account. You’re getting older now."

You want them to face these difficult situations in safe settings a little at a time. This way, the teenager builds up a bank account of good judgment, trust, and second chances.

Another great recommendation is to encourage the teenager and parents to have some fun through shared activities when they are not arguing. With this strategy, anger is offset by positive experiences. Opportunities for good communication before and after one of these angry episodes will help the parents interact effectively with their teenagers.

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. He has no relevant disclosures.

We all understand that bipolar disorder is a mood disorder, characterized by periods of depression and mania, that many of us have seen in adults.

That manic component can include euphoric mood, pressured speech, hypersexual behavior, grandiosity, excessive spending, delusions, and diminished need for sleep. The degree of mania can sometimes reach a psychotic level, meaning its scale is disconnected from reality. For example, a manic adult’s delusions might include his ability to solve the energy crisis or move the world toward peace.

The manic adult is driven in a very active and pressured way. In fact, it’s not uncommon for them to end up in an emergency department. They might, for example, get on a plane as part of some grandiose delusion. When they land, they are alone, in a different city, and acting psychotic. This bizarre behavior gets them transferred to the nearest hospital. We all understand that that happens.

But are there any kinds of behaviors in childhood and adolescence that mimic, parallel, or predict this kind of adult behavior? Pediatric patients certainly experience depression, but are there behaviors that cycle and look like something we call "mania"?

The differential diagnosis is really essential, but it’s not easy. The pediatricians’ job with these children is to recognize a potential mood disorder in terms of depressive symptoms, agitation, and irritability. Consider the symptoms, the age, and the context.

Assess your patient for behaviors that are intense and outside the range of what you typically see in the primary care setting. A mood disorder that has become a daily, dominant feature in the family is telling. Look for a persistent, chronic pattern of agitation and irritability – with frequent explosive and sometimes violent outbursts – to move your diagnosis more solidly in the direction of potential bipolar disorder. A very strong family history of bipolar disorder or mood disorders can support this direction in your diagnosis.

Even child and adolescent psychiatrists have not reached a consensus on whether these behaviors reflect a childhood form of bipolar disorder, or instead a distinct proposed disorder in the DSM-5 (5th edition of the Diagnostic and Statistical Manual of Mental Disorders) called disruptive mood dysregulation disorder (DMDD). This is an area of active controversy in our field (more on that later).

There is enough behavior in childhood and adolescence that reflects dysregulation in temper and agitation about different things, so proceed slowly before you label your patient with a mood disorder. Be careful not to overlap your diagnosis with behaviors that might be related to a child’s temperament or social circumstances (in which the behaviors could be understood as coming from environmental/family factors rather than from an internal mood state). For example, abuse from a parent or older sibling can lead to a miserable life, and a child’s irritable, angry, and moody tantrum behaviors might be completely unrelated to bipolar disorder or temper dysregulation.

That being said, when you meet one of these kids or talk to people who live with them, it’s very clear there is something wrong. Although the term "bipolar disorder" could be overextended among children and adolescents, it does not mean that there is not a group of kids who are very, very difficult to manage because of their chronic mood state.

In your differential diagnosis, distinguish these behaviors from those associated with substance use, oppositional defiant disorder, and/or attention-deficit/hyperactive disorder that is unresponsive to treatment.

Substance use is certainly associated with moodiness and dysregulated behavior. If I told you that an adolescent was using cocaine or was a young alcoholic, you would not be surprised to find out that she also was depressed, irritable, and agitated with a labile mood.

The pattern of behaviors can be a clue as well. You might see similar behaviors in a child with oppositional defiant disorder, but the parents will report that the behaviors emerge in specific situations. For example, a child might throw a tantrum when he objects to something, but not spontaneously or as a matter of essentially daily routine.

Once a diagnosis of severe mood disorder is suspected (and when bipolar or DMDD is considered likely), the management of one of these kids is probably beyond the scope of a typical primary care practice. Pediatricians have a great role to play in child and family mental health, but the severity of these behaviors indicates the need to refer to a child and adolescent psychiatrist.

Part of the reason for the controversy in this area is that we’re at an early point of differentiating kids with these behaviors. In the absence of genetic or biochemical markers, we’re trying to figure this out through observation, interviews, family histories, and follow-up. Maybe there are two, three, or more subtypes of these mood states, and we’re lumping them together without a valid basis. Maybe there are threads in childhood that we can follow to adult bipolar disorder, or threads we can follow to the proposed DMDD. We just don’t know yet.

Currently, there are camps debating this dilemma within child psychiatry. Some of the roots of this controversy began with the identification of a subset of children with ADHD who also had additional comorbidity related to their mood. Some were comorbid with depression and did not respond well to their ADHD medication. Clinicians began to wonder – especially as they looked more closely – whether these children really did have ADHD, or did they have a mood disorder that included depression and behaviors that included irritability and agitation? This generated more questions: Did the behaviors come and go? Were their hyperactive symptoms really part of a manic mood? Is this an early form of bipolar disorder in childhood or early adolescence, especially with a relevant positive family history?

Clearly, these children were miserable. They were very difficult to raise because of their mood swings. Some displayed quite agitated temper tantrums that did not seem to make sense; they got upset over something minor or even out of the blue without explanation (again, an internally generated irritability and agitation).

In an effort to help these patients and their families, some child psychiatrists tried medication that was not typical for ADHD. They wanted to determine, for example, if medication that was indicated for mood disorders and even bipolar disorders in adults could stabilize these childhood behaviors. The ultimate goal was to help these children function better at home and school, and to live more happily.

In fact, some of the children responded to medications that were not for their original diagnosis of hyperactivity. Some people began calling those children "bipolar."

As often happens in medicine, some may have expanded the use of that term beyond its initial precision. These children didn’t have the family history, their depression was not as severe, or maybe their irritability could be explained through a more thorough evaluation.

As the number of children who were being diagnosed as bipolar increased, their age range went younger and many of them received powerful medications.

Others clinicians felt that this adult diagnosis was being inappropriately stretched to apply to children. They agreed that there are children who seem to have irritability, agitation, and violent temper tantrums, and to be very disruptive and difficult to manage at home and school. But they didn’t want to use an adult term to describe this behavior, or to call these children ADHD because they didn’t fit that diagnosis. The clinicians began using the term DMDD: These children were "dysregulated" because their moods were not regulated in the developmentally expected manner, and because temper and irritability were among the manifestations.

Additional guidance may come from the working groups for the DSM-5. As they prepare for it, experts are debating that we shouldn’t call kids with these symptoms bipolar, but rather DMDD, and that we should try to study them within that framework. But that view is not unanimous and the answer is not yet final.

Dr. Michael Jellinek is a professor of psychiatry and pediatrics at Harvard Medical School, Boston. He is also president of Newton (Mass.)–Wellesley Hospital and chief of clinical affairs, Partners HealthCare. He said he has no relevant disclosures.

We all understand that bipolar disorder is a mood disorder, characterized by periods of depression and mania, that many of us have seen in adults.

That manic component can include euphoric mood, pressured speech, hypersexual behavior, grandiosity, excessive spending, delusions, and diminished need for sleep. The degree of mania can sometimes reach a psychotic level, meaning its scale is disconnected from reality. For example, a manic adult’s delusions might include his ability to solve the energy crisis or move the world toward peace.

The manic adult is driven in a very active and pressured way. In fact, it’s not uncommon for them to end up in an emergency department. They might, for example, get on a plane as part of some grandiose delusion. When they land, they are alone, in a different city, and acting psychotic. This bizarre behavior gets them transferred to the nearest hospital. We all understand that that happens.

But are there any kinds of behaviors in childhood and adolescence that mimic, parallel, or predict this kind of adult behavior? Pediatric patients certainly experience depression, but are there behaviors that cycle and look like something we call "mania"?

The differential diagnosis is really essential, but it’s not easy. The pediatricians’ job with these children is to recognize a potential mood disorder in terms of depressive symptoms, agitation, and irritability. Consider the symptoms, the age, and the context.

Assess your patient for behaviors that are intense and outside the range of what you typically see in the primary care setting. A mood disorder that has become a daily, dominant feature in the family is telling. Look for a persistent, chronic pattern of agitation and irritability – with frequent explosive and sometimes violent outbursts – to move your diagnosis more solidly in the direction of potential bipolar disorder. A very strong family history of bipolar disorder or mood disorders can support this direction in your diagnosis.

Even child and adolescent psychiatrists have not reached a consensus on whether these behaviors reflect a childhood form of bipolar disorder, or instead a distinct proposed disorder in the DSM-5 (5th edition of the Diagnostic and Statistical Manual of Mental Disorders) called disruptive mood dysregulation disorder (DMDD). This is an area of active controversy in our field (more on that later).

There is enough behavior in childhood and adolescence that reflects dysregulation in temper and agitation about different things, so proceed slowly before you label your patient with a mood disorder. Be careful not to overlap your diagnosis with behaviors that might be related to a child’s temperament or social circumstances (in which the behaviors could be understood as coming from environmental/family factors rather than from an internal mood state). For example, abuse from a parent or older sibling can lead to a miserable life, and a child’s irritable, angry, and moody tantrum behaviors might be completely unrelated to bipolar disorder or temper dysregulation.

That being said, when you meet one of these kids or talk to people who live with them, it’s very clear there is something wrong. Although the term "bipolar disorder" could be overextended among children and adolescents, it does not mean that there is not a group of kids who are very, very difficult to manage because of their chronic mood state.

In your differential diagnosis, distinguish these behaviors from those associated with substance use, oppositional defiant disorder, and/or attention-deficit/hyperactive disorder that is unresponsive to treatment.

Substance use is certainly associated with moodiness and dysregulated behavior. If I told you that an adolescent was using cocaine or was a young alcoholic, you would not be surprised to find out that she also was depressed, irritable, and agitated with a labile mood.

The pattern of behaviors can be a clue as well. You might see similar behaviors in a child with oppositional defiant disorder, but the parents will report that the behaviors emerge in specific situations. For example, a child might throw a tantrum when he objects to something, but not spontaneously or as a matter of essentially daily routine.

Once a diagnosis of severe mood disorder is suspected (and when bipolar or DMDD is considered likely), the management of one of these kids is probably beyond the scope of a typical primary care practice. Pediatricians have a great role to play in child and family mental health, but the severity of these behaviors indicates the need to refer to a child and adolescent psychiatrist.

Part of the reason for the controversy in this area is that we’re at an early point of differentiating kids with these behaviors. In the absence of genetic or biochemical markers, we’re trying to figure this out through observation, interviews, family histories, and follow-up. Maybe there are two, three, or more subtypes of these mood states, and we’re lumping them together without a valid basis. Maybe there are threads in childhood that we can follow to adult bipolar disorder, or threads we can follow to the proposed DMDD. We just don’t know yet.

Currently, there are camps debating this dilemma within child psychiatry. Some of the roots of this controversy began with the identification of a subset of children with ADHD who also had additional comorbidity related to their mood. Some were comorbid with depression and did not respond well to their ADHD medication. Clinicians began to wonder – especially as they looked more closely – whether these children really did have ADHD, or did they have a mood disorder that included depression and behaviors that included irritability and agitation? This generated more questions: Did the behaviors come and go? Were their hyperactive symptoms really part of a manic mood? Is this an early form of bipolar disorder in childhood or early adolescence, especially with a relevant positive family history?

Clearly, these children were miserable. They were very difficult to raise because of their mood swings. Some displayed quite agitated temper tantrums that did not seem to make sense; they got upset over something minor or even out of the blue without explanation (again, an internally generated irritability and agitation).

In an effort to help these patients and their families, some child psychiatrists tried medication that was not typical for ADHD. They wanted to determine, for example, if medication that was indicated for mood disorders and even bipolar disorders in adults could stabilize these childhood behaviors. The ultimate goal was to help these children function better at home and school, and to live more happily.

In fact, some of the children responded to medications that were not for their original diagnosis of hyperactivity. Some people began calling those children "bipolar."

As often happens in medicine, some may have expanded the use of that term beyond its initial precision. These children didn’t have the family history, their depression was not as severe, or maybe their irritability could be explained through a more thorough evaluation.

As the number of children who were being diagnosed as bipolar increased, their age range went younger and many of them received powerful medications.

Others clinicians felt that this adult diagnosis was being inappropriately stretched to apply to children. They agreed that there are children who seem to have irritability, agitation, and violent temper tantrums, and to be very disruptive and difficult to manage at home and school. But they didn’t want to use an adult term to describe this behavior, or to call these children ADHD because they didn’t fit that diagnosis. The clinicians began using the term DMDD: These children were "dysregulated" because their moods were not regulated in the developmentally expected manner, and because temper and irritability were among the manifestations.

Additional guidance may come from the working groups for the DSM-5. As they prepare for it, experts are debating that we shouldn’t call kids with these symptoms bipolar, but rather DMDD, and that we should try to study them within that framework. But that view is not unanimous and the answer is not yet final.

Dr. Michael Jellinek is a professor of psychiatry and pediatrics at Harvard Medical School, Boston. He is also president of Newton (Mass.)–Wellesley Hospital and chief of clinical affairs, Partners HealthCare. He said he has no relevant disclosures.

We all understand that bipolar disorder is a mood disorder, characterized by periods of depression and mania, that many of us have seen in adults.

That manic component can include euphoric mood, pressured speech, hypersexual behavior, grandiosity, excessive spending, delusions, and diminished need for sleep. The degree of mania can sometimes reach a psychotic level, meaning its scale is disconnected from reality. For example, a manic adult’s delusions might include his ability to solve the energy crisis or move the world toward peace.

The manic adult is driven in a very active and pressured way. In fact, it’s not uncommon for them to end up in an emergency department. They might, for example, get on a plane as part of some grandiose delusion. When they land, they are alone, in a different city, and acting psychotic. This bizarre behavior gets them transferred to the nearest hospital. We all understand that that happens.

But are there any kinds of behaviors in childhood and adolescence that mimic, parallel, or predict this kind of adult behavior? Pediatric patients certainly experience depression, but are there behaviors that cycle and look like something we call "mania"?

The differential diagnosis is really essential, but it’s not easy. The pediatricians’ job with these children is to recognize a potential mood disorder in terms of depressive symptoms, agitation, and irritability. Consider the symptoms, the age, and the context.

Assess your patient for behaviors that are intense and outside the range of what you typically see in the primary care setting. A mood disorder that has become a daily, dominant feature in the family is telling. Look for a persistent, chronic pattern of agitation and irritability – with frequent explosive and sometimes violent outbursts – to move your diagnosis more solidly in the direction of potential bipolar disorder. A very strong family history of bipolar disorder or mood disorders can support this direction in your diagnosis.

Even child and adolescent psychiatrists have not reached a consensus on whether these behaviors reflect a childhood form of bipolar disorder, or instead a distinct proposed disorder in the DSM-5 (5th edition of the Diagnostic and Statistical Manual of Mental Disorders) called disruptive mood dysregulation disorder (DMDD). This is an area of active controversy in our field (more on that later).

There is enough behavior in childhood and adolescence that reflects dysregulation in temper and agitation about different things, so proceed slowly before you label your patient with a mood disorder. Be careful not to overlap your diagnosis with behaviors that might be related to a child’s temperament or social circumstances (in which the behaviors could be understood as coming from environmental/family factors rather than from an internal mood state). For example, abuse from a parent or older sibling can lead to a miserable life, and a child’s irritable, angry, and moody tantrum behaviors might be completely unrelated to bipolar disorder or temper dysregulation.

That being said, when you meet one of these kids or talk to people who live with them, it’s very clear there is something wrong. Although the term "bipolar disorder" could be overextended among children and adolescents, it does not mean that there is not a group of kids who are very, very difficult to manage because of their chronic mood state.

In your differential diagnosis, distinguish these behaviors from those associated with substance use, oppositional defiant disorder, and/or attention-deficit/hyperactive disorder that is unresponsive to treatment.

Substance use is certainly associated with moodiness and dysregulated behavior. If I told you that an adolescent was using cocaine or was a young alcoholic, you would not be surprised to find out that she also was depressed, irritable, and agitated with a labile mood.

The pattern of behaviors can be a clue as well. You might see similar behaviors in a child with oppositional defiant disorder, but the parents will report that the behaviors emerge in specific situations. For example, a child might throw a tantrum when he objects to something, but not spontaneously or as a matter of essentially daily routine.

Once a diagnosis of severe mood disorder is suspected (and when bipolar or DMDD is considered likely), the management of one of these kids is probably beyond the scope of a typical primary care practice. Pediatricians have a great role to play in child and family mental health, but the severity of these behaviors indicates the need to refer to a child and adolescent psychiatrist.

Part of the reason for the controversy in this area is that we’re at an early point of differentiating kids with these behaviors. In the absence of genetic or biochemical markers, we’re trying to figure this out through observation, interviews, family histories, and follow-up. Maybe there are two, three, or more subtypes of these mood states, and we’re lumping them together without a valid basis. Maybe there are threads in childhood that we can follow to adult bipolar disorder, or threads we can follow to the proposed DMDD. We just don’t know yet.

Currently, there are camps debating this dilemma within child psychiatry. Some of the roots of this controversy began with the identification of a subset of children with ADHD who also had additional comorbidity related to their mood. Some were comorbid with depression and did not respond well to their ADHD medication. Clinicians began to wonder – especially as they looked more closely – whether these children really did have ADHD, or did they have a mood disorder that included depression and behaviors that included irritability and agitation? This generated more questions: Did the behaviors come and go? Were their hyperactive symptoms really part of a manic mood? Is this an early form of bipolar disorder in childhood or early adolescence, especially with a relevant positive family history?

Clearly, these children were miserable. They were very difficult to raise because of their mood swings. Some displayed quite agitated temper tantrums that did not seem to make sense; they got upset over something minor or even out of the blue without explanation (again, an internally generated irritability and agitation).

In an effort to help these patients and their families, some child psychiatrists tried medication that was not typical for ADHD. They wanted to determine, for example, if medication that was indicated for mood disorders and even bipolar disorders in adults could stabilize these childhood behaviors. The ultimate goal was to help these children function better at home and school, and to live more happily.

In fact, some of the children responded to medications that were not for their original diagnosis of hyperactivity. Some people began calling those children "bipolar."

As often happens in medicine, some may have expanded the use of that term beyond its initial precision. These children didn’t have the family history, their depression was not as severe, or maybe their irritability could be explained through a more thorough evaluation.

As the number of children who were being diagnosed as bipolar increased, their age range went younger and many of them received powerful medications.

Others clinicians felt that this adult diagnosis was being inappropriately stretched to apply to children. They agreed that there are children who seem to have irritability, agitation, and violent temper tantrums, and to be very disruptive and difficult to manage at home and school. But they didn’t want to use an adult term to describe this behavior, or to call these children ADHD because they didn’t fit that diagnosis. The clinicians began using the term DMDD: These children were "dysregulated" because their moods were not regulated in the developmentally expected manner, and because temper and irritability were among the manifestations.

Additional guidance may come from the working groups for the DSM-5. As they prepare for it, experts are debating that we shouldn’t call kids with these symptoms bipolar, but rather DMDD, and that we should try to study them within that framework. But that view is not unanimous and the answer is not yet final.

Dr. Michael Jellinek is a professor of psychiatry and pediatrics at Harvard Medical School, Boston. He is also president of Newton (Mass.)–Wellesley Hospital and chief of clinical affairs, Partners HealthCare. He said he has no relevant disclosures.

Some parents of very young children – those 6 years old and younger – will come to you exhausted, feeling inadequate as parents, and even angry at their children.

Parents will report that their children with attention deficit/hyperactivity disorder are very difficult at home and in preschool. Probably when their children were around age 2, 3, or 4 years old, their parents began wondering if the youngsters were immature, were more impulsive, and had a shorter attention span, compared with peers.

Pediatricians will recognize this pattern as likely ADHD and, in addition to making an accurate diagnosis, know that much is at stake in guiding and supporting parents. A critical relationship is at risk as the child’s behavior evokes criticism and a negative tone from parents. Pediatricians should help parents set reasonable expectations and focus on behaviors and activities that build self-esteem. For some families, this work can be difficult and time consuming, requiring counseling and behavioral reward training – probably better delegated to a mental health specialist.

Attention span, impulsivity, and motoric hyperactivity are active concerns every waking hour of the child’s day. Certain demands in preschool, at a longer dinner, or in church may exacerbate the symptoms, whereas playing in the park or playing a fun-filled computer game may ease the symptoms. The pediatrician can sort through a typical day and recommend approaches that are consistent with developmentally reasonable expectations, and modified for the child’s ADHD symptoms.

Family history is another consideration. About 30% of children with ADHD come from fathers who had or have the disorder. Reminding a father of his difficulties growing up or any ongoing ADHD symptoms can be helpful in eliciting some empathy from him for his child’s suffering.

Beyond family life, ADHD will affect the choice of school and activities. Based on what works for the child, consider how many hours a child should spend in preschool and how much structure is helpful. How will the culture of the school fit the child’s style? Remember that the last thing a child with ADHD needs is an early school experience characterized by criticism and a sense of not being able to please teachers. A school with more recess and activity opportunities, as well as after-school programs, might be a good choice, and might offer some respite for parents.

As part of building self-esteem, ask parents if there is anything the child is really good at. For example, I treated a 6-year-old with ADHD who was gifted with computers. He was able to teach his peers and play games with friends, and he felt genuine pride working with a machine that was tolerant and nonjudgmental, and could be reset as needed. Might this not lead to a path of an after-school computer club or computer summer camp (that of course would include other activities)? Other young children may show strength in music, art, or a sport, and these activities are at least as important as remediating weaknesses.

Awareness of the different ADHD subtypes is important in general, but also can guide you in when to refer these children. Some kids with ADHD are more moody or depressed, some are more anxious, and others are more physically aggressive. Consider referral to a child and adolescent psychiatrist if one of these subtypes becomes more difficult to manage. A mental health consultation can help these higher-risk children.

Some children with ADHD also have learning disabilities, and diagnosis at a young age, before school failure, is invaluable. If you suspect this in a particular patient, you might want to recommend some early testing through the schools to avoid creation of unrealistic expectations in the classroom.

Parents may tell you their children are impulsive. While other kids are more predictable when playing in the sandbox, their children with ADHD may do something unpredictable. They might jump out of the sandbox or grab a toy from another child, for example. A mother of a 3-year-old with ADHD will stay closer to the sandbox because she doesn’t know what that child is going to do next.

Typically, the child also will have a shorter attention span. The parents cannot relax because they know the sandbox, or a particular project in the sandbox, won’t hold their child as long. Other children may be occupied for 15, 20, or even 30 minutes, but their young child with ADHD might last only 3 or 4 minutes and then need to move on.

That, as you can imagine, is going to make the parenting demands much higher. Remember this doesn’t happen for just 1 or 2 hours per day; children with true ADHD are going to be like this from the time they get up until the time they go to sleep.

All these behaviors associated with ADHD set these children up for a fair amount of criticism. The parents are tempted, especially if they don’t understand the disorder, to say:

"Don’t do that!"

"Put that down!"

"Come back here!"

"I just bought you this – why don’t you want to play with it?"

"Why can’t you play like your friend Johnny does?"

"Why can’t you sit still for a minute while Mommy fixes dinner?"

These children are subject to a lot of negative feedback from their environment. The world is not very tolerant of a young child, or even an older child, with ADHD.

My guess is if these children are in preschool, the teacher is having the same issues with their behaviors. They may get criticized during circle time or while doing a certain project. Except for recess and lunch, they are going to be under a lot of scrutiny, and most of the feedback is going to be negative.

We can see how children with ADHD, in a typical day, can hear 10, if not 25, negative comments. That is about two to three per hour. That degree of criticism begins to become part of how they see themselves, and they become fairly self-critical.

One of the key risks from ADHD at this young age is that it’s hard for these children to differentiate if what they are doing is bad or if they are bad. Their self-esteem is very vulnerable. One principle that guides a lot of my management of these youngsters with ADHD is figuring out how to protect or enhance their self esteem.

Therefore, one of the initial things I ask parents to do is to think about how much negative criticism their child is hearing. Next, I ask them to think about what are reasonable expectations for that particular child.

If these children do sit down to work, and you know they only have 10 minutes in them, you may want to help them succeed within those 10 minutes, rather than having them flounder and then criticize them at 12 or 14 minutes for not getting the task done.

We don’t have the same expectations for every 4-year-old or 6-year-old. We tailor expectations to who they are. One child might be able to stay on task for 20 minutes, but another for only 3 minutes. Is it fair to expect them both to do something for 20 minutes?

One example might be going to church, where children with ADHD will find it very hard to sit through a sermon they don’t understand. It may be a religious family, but is it reasonable to expect these children to last through church? Also, is it reasonable to criticize them six times during a sermon because they can’t sit still?

So try to turn whatever they’ve got into a success rather than have expectations they can’t meet.

Think about what style of behavior you want to reinforce and what you may not want to encourage. Explain to parents that they may want to reward behavior that is in the right direction.

You can recommend that when the child is impulsive and interrupts, the parent may want to ignore this behavior. Or suggest that if a child grabs the mother’s shirt to ask for something, the parent should say, "That is not going to work." On the other hand, if they say "Mom, can I have a glass of milk?" get them that milk in a very responsive way.

Any opportunity to build self-esteem and build a sense of success based on reasonable expectations is worthwhile. A lot of parents will start sports for their children when they are 4 or 5. Kids with ADHD don’t do very well in the outfield of T-ball because they are distracted. They don’t stand out there waiting for the hit, and then they get yelled at for missing the ball. Help parents choose a sport that fits their children. I’ve seen some ADHD kids be goalies because they have to pay attention for a few seconds when the ball is coming, and then when the ball is somewhere else they can daydream with impunity. A lot of children with ADHD do well with swimming, for example, because there are fewer rules and they have a little more freedom. Others thrive with the structure and sense of accomplishment that comes from the "belt" system of karate.

Clearly one of the most effective treatments for the symptoms of ADHD is medication. Medication will increase attention span in school, church, or at dinner. Of course, every parent has concerns about how young to start children on medication, or whether to use medication at all. For those families, the first set of efforts may be directed to setting reasonable expectations and reviewing daily activities.

This focus will help, but will not be enough, and medication will be a critical part of treatment. Medication adds some risk, but the benefits to the child’s functioning and self-esteem often outweigh these risks.

Pediatricians will see and diagnose, and will be the primary treaters for, many young children with ADHD. One of the things that medication probably does best is reduce the amount of negative feedback because the child will not be as impulsive and will appear to have a longer attention span. Again, you can ask too much of a child, but you will see higher expectations if the child is taking medication that is working correctly.

Once ADHD is diagnosed in a young child, the pediatrician has a key role in trying to protect and enhance the child’s self-esteem, advising on the child’s day-to-day functioning, and supporting the overall care with appropriate use of medications.

Some parents of very young children – those 6 years old and younger – will come to you exhausted, feeling inadequate as parents, and even angry at their children.

Parents will report that their children with attention deficit/hyperactivity disorder are very difficult at home and in preschool. Probably when their children were around age 2, 3, or 4 years old, their parents began wondering if the youngsters were immature, were more impulsive, and had a shorter attention span, compared with peers.

Pediatricians will recognize this pattern as likely ADHD and, in addition to making an accurate diagnosis, know that much is at stake in guiding and supporting parents. A critical relationship is at risk as the child’s behavior evokes criticism and a negative tone from parents. Pediatricians should help parents set reasonable expectations and focus on behaviors and activities that build self-esteem. For some families, this work can be difficult and time consuming, requiring counseling and behavioral reward training – probably better delegated to a mental health specialist.

Attention span, impulsivity, and motoric hyperactivity are active concerns every waking hour of the child’s day. Certain demands in preschool, at a longer dinner, or in church may exacerbate the symptoms, whereas playing in the park or playing a fun-filled computer game may ease the symptoms. The pediatrician can sort through a typical day and recommend approaches that are consistent with developmentally reasonable expectations, and modified for the child’s ADHD symptoms.

Family history is another consideration. About 30% of children with ADHD come from fathers who had or have the disorder. Reminding a father of his difficulties growing up or any ongoing ADHD symptoms can be helpful in eliciting some empathy from him for his child’s suffering.

Beyond family life, ADHD will affect the choice of school and activities. Based on what works for the child, consider how many hours a child should spend in preschool and how much structure is helpful. How will the culture of the school fit the child’s style? Remember that the last thing a child with ADHD needs is an early school experience characterized by criticism and a sense of not being able to please teachers. A school with more recess and activity opportunities, as well as after-school programs, might be a good choice, and might offer some respite for parents.

As part of building self-esteem, ask parents if there is anything the child is really good at. For example, I treated a 6-year-old with ADHD who was gifted with computers. He was able to teach his peers and play games with friends, and he felt genuine pride working with a machine that was tolerant and nonjudgmental, and could be reset as needed. Might this not lead to a path of an after-school computer club or computer summer camp (that of course would include other activities)? Other young children may show strength in music, art, or a sport, and these activities are at least as important as remediating weaknesses.

Awareness of the different ADHD subtypes is important in general, but also can guide you in when to refer these children. Some kids with ADHD are more moody or depressed, some are more anxious, and others are more physically aggressive. Consider referral to a child and adolescent psychiatrist if one of these subtypes becomes more difficult to manage. A mental health consultation can help these higher-risk children.

Some children with ADHD also have learning disabilities, and diagnosis at a young age, before school failure, is invaluable. If you suspect this in a particular patient, you might want to recommend some early testing through the schools to avoid creation of unrealistic expectations in the classroom.

Parents may tell you their children are impulsive. While other kids are more predictable when playing in the sandbox, their children with ADHD may do something unpredictable. They might jump out of the sandbox or grab a toy from another child, for example. A mother of a 3-year-old with ADHD will stay closer to the sandbox because she doesn’t know what that child is going to do next.

Typically, the child also will have a shorter attention span. The parents cannot relax because they know the sandbox, or a particular project in the sandbox, won’t hold their child as long. Other children may be occupied for 15, 20, or even 30 minutes, but their young child with ADHD might last only 3 or 4 minutes and then need to move on.

That, as you can imagine, is going to make the parenting demands much higher. Remember this doesn’t happen for just 1 or 2 hours per day; children with true ADHD are going to be like this from the time they get up until the time they go to sleep.

All these behaviors associated with ADHD set these children up for a fair amount of criticism. The parents are tempted, especially if they don’t understand the disorder, to say:

"Don’t do that!"

"Put that down!"

"Come back here!"

"I just bought you this – why don’t you want to play with it?"

"Why can’t you play like your friend Johnny does?"

"Why can’t you sit still for a minute while Mommy fixes dinner?"

These children are subject to a lot of negative feedback from their environment. The world is not very tolerant of a young child, or even an older child, with ADHD.

My guess is if these children are in preschool, the teacher is having the same issues with their behaviors. They may get criticized during circle time or while doing a certain project. Except for recess and lunch, they are going to be under a lot of scrutiny, and most of the feedback is going to be negative.

We can see how children with ADHD, in a typical day, can hear 10, if not 25, negative comments. That is about two to three per hour. That degree of criticism begins to become part of how they see themselves, and they become fairly self-critical.

One of the key risks from ADHD at this young age is that it’s hard for these children to differentiate if what they are doing is bad or if they are bad. Their self-esteem is very vulnerable. One principle that guides a lot of my management of these youngsters with ADHD is figuring out how to protect or enhance their self esteem.

Therefore, one of the initial things I ask parents to do is to think about how much negative criticism their child is hearing. Next, I ask them to think about what are reasonable expectations for that particular child.

If these children do sit down to work, and you know they only have 10 minutes in them, you may want to help them succeed within those 10 minutes, rather than having them flounder and then criticize them at 12 or 14 minutes for not getting the task done.

We don’t have the same expectations for every 4-year-old or 6-year-old. We tailor expectations to who they are. One child might be able to stay on task for 20 minutes, but another for only 3 minutes. Is it fair to expect them both to do something for 20 minutes?

One example might be going to church, where children with ADHD will find it very hard to sit through a sermon they don’t understand. It may be a religious family, but is it reasonable to expect these children to last through church? Also, is it reasonable to criticize them six times during a sermon because they can’t sit still?

So try to turn whatever they’ve got into a success rather than have expectations they can’t meet.

Think about what style of behavior you want to reinforce and what you may not want to encourage. Explain to parents that they may want to reward behavior that is in the right direction.

You can recommend that when the child is impulsive and interrupts, the parent may want to ignore this behavior. Or suggest that if a child grabs the mother’s shirt to ask for something, the parent should say, "That is not going to work." On the other hand, if they say "Mom, can I have a glass of milk?" get them that milk in a very responsive way.

Any opportunity to build self-esteem and build a sense of success based on reasonable expectations is worthwhile. A lot of parents will start sports for their children when they are 4 or 5. Kids with ADHD don’t do very well in the outfield of T-ball because they are distracted. They don’t stand out there waiting for the hit, and then they get yelled at for missing the ball. Help parents choose a sport that fits their children. I’ve seen some ADHD kids be goalies because they have to pay attention for a few seconds when the ball is coming, and then when the ball is somewhere else they can daydream with impunity. A lot of children with ADHD do well with swimming, for example, because there are fewer rules and they have a little more freedom. Others thrive with the structure and sense of accomplishment that comes from the "belt" system of karate.

Clearly one of the most effective treatments for the symptoms of ADHD is medication. Medication will increase attention span in school, church, or at dinner. Of course, every parent has concerns about how young to start children on medication, or whether to use medication at all. For those families, the first set of efforts may be directed to setting reasonable expectations and reviewing daily activities.

This focus will help, but will not be enough, and medication will be a critical part of treatment. Medication adds some risk, but the benefits to the child’s functioning and self-esteem often outweigh these risks.

Pediatricians will see and diagnose, and will be the primary treaters for, many young children with ADHD. One of the things that medication probably does best is reduce the amount of negative feedback because the child will not be as impulsive and will appear to have a longer attention span. Again, you can ask too much of a child, but you will see higher expectations if the child is taking medication that is working correctly.

Once ADHD is diagnosed in a young child, the pediatrician has a key role in trying to protect and enhance the child’s self-esteem, advising on the child’s day-to-day functioning, and supporting the overall care with appropriate use of medications.

Some parents of very young children – those 6 years old and younger – will come to you exhausted, feeling inadequate as parents, and even angry at their children.

Parents will report that their children with attention deficit/hyperactivity disorder are very difficult at home and in preschool. Probably when their children were around age 2, 3, or 4 years old, their parents began wondering if the youngsters were immature, were more impulsive, and had a shorter attention span, compared with peers.

Pediatricians will recognize this pattern as likely ADHD and, in addition to making an accurate diagnosis, know that much is at stake in guiding and supporting parents. A critical relationship is at risk as the child’s behavior evokes criticism and a negative tone from parents. Pediatricians should help parents set reasonable expectations and focus on behaviors and activities that build self-esteem. For some families, this work can be difficult and time consuming, requiring counseling and behavioral reward training – probably better delegated to a mental health specialist.

Attention span, impulsivity, and motoric hyperactivity are active concerns every waking hour of the child’s day. Certain demands in preschool, at a longer dinner, or in church may exacerbate the symptoms, whereas playing in the park or playing a fun-filled computer game may ease the symptoms. The pediatrician can sort through a typical day and recommend approaches that are consistent with developmentally reasonable expectations, and modified for the child’s ADHD symptoms.

Family history is another consideration. About 30% of children with ADHD come from fathers who had or have the disorder. Reminding a father of his difficulties growing up or any ongoing ADHD symptoms can be helpful in eliciting some empathy from him for his child’s suffering.

Beyond family life, ADHD will affect the choice of school and activities. Based on what works for the child, consider how many hours a child should spend in preschool and how much structure is helpful. How will the culture of the school fit the child’s style? Remember that the last thing a child with ADHD needs is an early school experience characterized by criticism and a sense of not being able to please teachers. A school with more recess and activity opportunities, as well as after-school programs, might be a good choice, and might offer some respite for parents.

As part of building self-esteem, ask parents if there is anything the child is really good at. For example, I treated a 6-year-old with ADHD who was gifted with computers. He was able to teach his peers and play games with friends, and he felt genuine pride working with a machine that was tolerant and nonjudgmental, and could be reset as needed. Might this not lead to a path of an after-school computer club or computer summer camp (that of course would include other activities)? Other young children may show strength in music, art, or a sport, and these activities are at least as important as remediating weaknesses.

Awareness of the different ADHD subtypes is important in general, but also can guide you in when to refer these children. Some kids with ADHD are more moody or depressed, some are more anxious, and others are more physically aggressive. Consider referral to a child and adolescent psychiatrist if one of these subtypes becomes more difficult to manage. A mental health consultation can help these higher-risk children.

Some children with ADHD also have learning disabilities, and diagnosis at a young age, before school failure, is invaluable. If you suspect this in a particular patient, you might want to recommend some early testing through the schools to avoid creation of unrealistic expectations in the classroom.

Parents may tell you their children are impulsive. While other kids are more predictable when playing in the sandbox, their children with ADHD may do something unpredictable. They might jump out of the sandbox or grab a toy from another child, for example. A mother of a 3-year-old with ADHD will stay closer to the sandbox because she doesn’t know what that child is going to do next.

Typically, the child also will have a shorter attention span. The parents cannot relax because they know the sandbox, or a particular project in the sandbox, won’t hold their child as long. Other children may be occupied for 15, 20, or even 30 minutes, but their young child with ADHD might last only 3 or 4 minutes and then need to move on.

That, as you can imagine, is going to make the parenting demands much higher. Remember this doesn’t happen for just 1 or 2 hours per day; children with true ADHD are going to be like this from the time they get up until the time they go to sleep.

All these behaviors associated with ADHD set these children up for a fair amount of criticism. The parents are tempted, especially if they don’t understand the disorder, to say:

"Don’t do that!"

"Put that down!"

"Come back here!"

"I just bought you this – why don’t you want to play with it?"

"Why can’t you play like your friend Johnny does?"

"Why can’t you sit still for a minute while Mommy fixes dinner?"

These children are subject to a lot of negative feedback from their environment. The world is not very tolerant of a young child, or even an older child, with ADHD.

My guess is if these children are in preschool, the teacher is having the same issues with their behaviors. They may get criticized during circle time or while doing a certain project. Except for recess and lunch, they are going to be under a lot of scrutiny, and most of the feedback is going to be negative.

We can see how children with ADHD, in a typical day, can hear 10, if not 25, negative comments. That is about two to three per hour. That degree of criticism begins to become part of how they see themselves, and they become fairly self-critical.

One of the key risks from ADHD at this young age is that it’s hard for these children to differentiate if what they are doing is bad or if they are bad. Their self-esteem is very vulnerable. One principle that guides a lot of my management of these youngsters with ADHD is figuring out how to protect or enhance their self esteem.

Therefore, one of the initial things I ask parents to do is to think about how much negative criticism their child is hearing. Next, I ask them to think about what are reasonable expectations for that particular child.

If these children do sit down to work, and you know they only have 10 minutes in them, you may want to help them succeed within those 10 minutes, rather than having them flounder and then criticize them at 12 or 14 minutes for not getting the task done.

We don’t have the same expectations for every 4-year-old or 6-year-old. We tailor expectations to who they are. One child might be able to stay on task for 20 minutes, but another for only 3 minutes. Is it fair to expect them both to do something for 20 minutes?

One example might be going to church, where children with ADHD will find it very hard to sit through a sermon they don’t understand. It may be a religious family, but is it reasonable to expect these children to last through church? Also, is it reasonable to criticize them six times during a sermon because they can’t sit still?

So try to turn whatever they’ve got into a success rather than have expectations they can’t meet.

Think about what style of behavior you want to reinforce and what you may not want to encourage. Explain to parents that they may want to reward behavior that is in the right direction.

You can recommend that when the child is impulsive and interrupts, the parent may want to ignore this behavior. Or suggest that if a child grabs the mother’s shirt to ask for something, the parent should say, "That is not going to work." On the other hand, if they say "Mom, can I have a glass of milk?" get them that milk in a very responsive way.

Any opportunity to build self-esteem and build a sense of success based on reasonable expectations is worthwhile. A lot of parents will start sports for their children when they are 4 or 5. Kids with ADHD don’t do very well in the outfield of T-ball because they are distracted. They don’t stand out there waiting for the hit, and then they get yelled at for missing the ball. Help parents choose a sport that fits their children. I’ve seen some ADHD kids be goalies because they have to pay attention for a few seconds when the ball is coming, and then when the ball is somewhere else they can daydream with impunity. A lot of children with ADHD do well with swimming, for example, because there are fewer rules and they have a little more freedom. Others thrive with the structure and sense of accomplishment that comes from the "belt" system of karate.

Clearly one of the most effective treatments for the symptoms of ADHD is medication. Medication will increase attention span in school, church, or at dinner. Of course, every parent has concerns about how young to start children on medication, or whether to use medication at all. For those families, the first set of efforts may be directed to setting reasonable expectations and reviewing daily activities.

This focus will help, but will not be enough, and medication will be a critical part of treatment. Medication adds some risk, but the benefits to the child’s functioning and self-esteem often outweigh these risks.

Pediatricians will see and diagnose, and will be the primary treaters for, many young children with ADHD. One of the things that medication probably does best is reduce the amount of negative feedback because the child will not be as impulsive and will appear to have a longer attention span. Again, you can ask too much of a child, but you will see higher expectations if the child is taking medication that is working correctly.

Once ADHD is diagnosed in a young child, the pediatrician has a key role in trying to protect and enhance the child’s self-esteem, advising on the child’s day-to-day functioning, and supporting the overall care with appropriate use of medications.

Different forms of trauma can cause posttraumatic stress disorder in children, whether from an objective event like a car crash or sports injury to trauma involving loved ones, such as domestic violence, abuse, or neglect.

Pediatricians can help by routinely screening for dysfunction and by asking questions at annual well-child visits. Overt symptoms include fear related to the trauma such as avoiding the traumatic setting or activity. Less specific symptoms include anxiety, avoidance, social isolation, depression, and low self-esteem.

If a standard screen such as the Pediatric Symptom Checklist or another instrument reveals psychosocial dysfunction, you have to determine the cause of dysfunction, and PTSD should certainly be considered.

Is there family discord leading to violence in the home? If you suspect PTSD, ask a child what happened and why he or she thinks it happened. Determine if the child is blaming himself or herself in any way. Is the child grieving following a permanent injury and/or loss of a loved one? How have the parents discussed any traumatic event with the child? Do the parents feel traumatized by the child’s experience?

If PTSD is a possibility, ask if the child is experiencing flashbacks, intrusive thoughts, and/or any related anxiety.

Some symptoms are expected after a traumatic event or following cancer or critical care treatment experienced as traumatic. Most children and adolescents overcome the fear of riding in a car or playing the sport that resulted in the trauma.

However, symptoms that persist for a month or more, with avoidance and associated anxiety, are core to the diagnosis of PTSD. The anxiety can build and be self-reinforcing so as to interfere with daily functioning. At this point, consider referral to a mental health specialist, preferably one with some experience in PTSD treatment. A specialist can help the patient overcome his or her anxiety and return to functioning through cognitive and behavioral techniques such as reframing the events, dealing with any guilt, and staged exposure to the anxiety.

If one of your patients experienced a car crash or other major trauma, you will likely know about it, already be treating the child, and should be planning to monitor him for signs of PTSD. In contrast, detection of subtle PTSD is more challenging, particularly if the trauma is unknown or occurred years ago. Trauma related to domestic violence or sexual abuse first requires consideration of this possibility and then gentle, empathic, and persistent questioning.

Triggers for reliving/reexperiencing the trauma also can be straightforward. For example, a child who gets into a car with a similar interior design years after a crash can immediately experience and emotionally return to the trauma. Other triggers are less obvious, such as a teenage girl who was held down and forced to have sex against her will, who later feels constrained by tight clothing and immediately relives the fear and anguish.

Like many presentations in pediatrics, management of PTSD depends on the developmental stage of the child, including his or her cognitive abilities and emotional state. For example, infants or toddlers might not be able to make much sense of what is happening when they witness domestic violence. Terror, fear, and confusion are their most likely reactions.

School-age children aged 5-8 years would not fully understand either, but they will try to make some sense of the domestic violence. Assuming no one reassures them otherwise, they also may feel that something they did sparked or contributed to the violence. For example, if they overhear arguments around issues in the family and hear their name mentioned, they may quickly assume that they are the cause of the domestic violence. This can lead to feelings of guilt, self-criticism, and unworthiness.

Adolescents will experience some of the same reactions as younger children. They will still experience shock, even if they are better equipped to conceptualize the domestic violence. Some will feel powerless because they cannot end the strife, particularly at a time when they are supposed to have more control over the real world. Again, teenagers might feel they have not lived up to expectations and perceive some blame. Others may choose to flee, find support through friends, and/or may deal with their feelings using substances.

Act when you encounter a patient who feels very guilty about parental fighting or who justifies abuse because he feels worthless or was told repeatedly he was a bad child. Help him realize he was not responsible for the conflict and that no one deserves abuse. Discuss other, more realistic possibilities for the family paradigm.

These are not easy conversations. Some pediatricians will feel comfortable working at this depth, others will prefer to refer.

Healing from PTSD related to family violence, sexual abuse, or criminal activity is a several-step process. As one’s sense of guilt diminishes, other emotions such as anger at not being better protected or valued need to be addressed. Finally, there needs to be some grieving for what was lacking and some acceptance of what was possible.

This is not a simple process; however, it is worthwhile because if their PTSD remains untreated, there is a greater likelihood they will continue to relive traumatic memories as young adults and beyond.

There is some controversy as to whether talking through the traumatic event over and over truly helps. Some clinicians feel that a certain amount of supportive discussion in a calm way makes sense, especially early. But solely repeating the details of the event may re-traumatize the child and intensify negative feelings, especially if the memories are very vivid.

Cognitive and behavioral approaches can help the child reframe their trauma. An example is exposure therapy, where the child is carefully reexposed to the trauma in stages while they learn to reframe and diminish the intensity of the experience. Often, ideas about the trauma come out that can be examined objectively to try to lessen some of those traumatic feelings.

Exposure therapy also can incorporate gradual steps to help the child overcome their fear. For example, if a person survived a plane crash, the first step might be to take him or her to the airport, then to board an airplane without taking off, and so forth. This approach reintroduces the trauma without eliciting a full response. You don’t want the brain to go on "red alert" again. In a state of hyperarousal, reliving the trauma may do more harm than good.

The terrified moments that children experience during a traumatic sequence tend to get burned into their memories much more strongly than everyday events. A school-age child might remember nothing about an uneventful trip in the car, but if a traumatic accident happens, often she remembers almost every detail. She recalls descriptive elements of what happened as well as the emotional fright or anguish very vividly.

Sometimes vivid, traumatic memories will enter your patient’s mind spontaneously without him knowing why. In other cases, there are triggers. The classic example is the combat veteran who hears a sudden, loud noise and immediately feels in danger. Similarly, someone shouting or crying can trigger a strong flashback for the child exposed to domestic violence.

Sometimes these flashbacks arise shortly following trauma and sometimes they take years. I know of an adult patient for whom painful memories of physical abuse and trauma arose when she became pregnant. When she considered what it would be like to raise her child, it rekindled a lot of memories of her own childhood.

In other cases, consequences are less direct. For example, a woman who was traumatized as a child by witnessing fighting in her home may overreact and try to never fight with her partner. Others might relive the experience by causing a lot of arguments.

We still have much to learn about PTSD. What is the nature of the neurobiology? Why are some children more vulnerable than others? How can medications such as selective serotonin reuptake inhibitors best be used in children and adolescents with persistent PTSD?

Pediatricians can do their patients and families a service if they are aware of PTSD either after an overt event like a car accident or by considering trauma in an anxious or dysfunctional child.

This column, "Behavioral Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Jellinek is chief of child psychiatry at Massachusetts General Hospital and professor of psychiatry and of pediatrics at Harvard Medical School, Boston. To comment, e-mail him at pdnews@elsevier.com.

Different forms of trauma can cause posttraumatic stress disorder in children, whether from an objective event like a car crash or sports injury to trauma involving loved ones, such as domestic violence, abuse, or neglect.

Pediatricians can help by routinely screening for dysfunction and by asking questions at annual well-child visits. Overt symptoms include fear related to the trauma such as avoiding the traumatic setting or activity. Less specific symptoms include anxiety, avoidance, social isolation, depression, and low self-esteem.

If a standard screen such as the Pediatric Symptom Checklist or another instrument reveals psychosocial dysfunction, you have to determine the cause of dysfunction, and PTSD should certainly be considered.

Is there family discord leading to violence in the home? If you suspect PTSD, ask a child what happened and why he or she thinks it happened. Determine if the child is blaming himself or herself in any way. Is the child grieving following a permanent injury and/or loss of a loved one? How have the parents discussed any traumatic event with the child? Do the parents feel traumatized by the child’s experience?

If PTSD is a possibility, ask if the child is experiencing flashbacks, intrusive thoughts, and/or any related anxiety.

Some symptoms are expected after a traumatic event or following cancer or critical care treatment experienced as traumatic. Most children and adolescents overcome the fear of riding in a car or playing the sport that resulted in the trauma.

However, symptoms that persist for a month or more, with avoidance and associated anxiety, are core to the diagnosis of PTSD. The anxiety can build and be self-reinforcing so as to interfere with daily functioning. At this point, consider referral to a mental health specialist, preferably one with some experience in PTSD treatment. A specialist can help the patient overcome his or her anxiety and return to functioning through cognitive and behavioral techniques such as reframing the events, dealing with any guilt, and staged exposure to the anxiety.

If one of your patients experienced a car crash or other major trauma, you will likely know about it, already be treating the child, and should be planning to monitor him for signs of PTSD. In contrast, detection of subtle PTSD is more challenging, particularly if the trauma is unknown or occurred years ago. Trauma related to domestic violence or sexual abuse first requires consideration of this possibility and then gentle, empathic, and persistent questioning.

Triggers for reliving/reexperiencing the trauma also can be straightforward. For example, a child who gets into a car with a similar interior design years after a crash can immediately experience and emotionally return to the trauma. Other triggers are less obvious, such as a teenage girl who was held down and forced to have sex against her will, who later feels constrained by tight clothing and immediately relives the fear and anguish.

Like many presentations in pediatrics, management of PTSD depends on the developmental stage of the child, including his or her cognitive abilities and emotional state. For example, infants or toddlers might not be able to make much sense of what is happening when they witness domestic violence. Terror, fear, and confusion are their most likely reactions.

School-age children aged 5-8 years would not fully understand either, but they will try to make some sense of the domestic violence. Assuming no one reassures them otherwise, they also may feel that something they did sparked or contributed to the violence. For example, if they overhear arguments around issues in the family and hear their name mentioned, they may quickly assume that they are the cause of the domestic violence. This can lead to feelings of guilt, self-criticism, and unworthiness.

Adolescents will experience some of the same reactions as younger children. They will still experience shock, even if they are better equipped to conceptualize the domestic violence. Some will feel powerless because they cannot end the strife, particularly at a time when they are supposed to have more control over the real world. Again, teenagers might feel they have not lived up to expectations and perceive some blame. Others may choose to flee, find support through friends, and/or may deal with their feelings using substances.

Act when you encounter a patient who feels very guilty about parental fighting or who justifies abuse because he feels worthless or was told repeatedly he was a bad child. Help him realize he was not responsible for the conflict and that no one deserves abuse. Discuss other, more realistic possibilities for the family paradigm.

These are not easy conversations. Some pediatricians will feel comfortable working at this depth, others will prefer to refer.

Healing from PTSD related to family violence, sexual abuse, or criminal activity is a several-step process. As one’s sense of guilt diminishes, other emotions such as anger at not being better protected or valued need to be addressed. Finally, there needs to be some grieving for what was lacking and some acceptance of what was possible.

This is not a simple process; however, it is worthwhile because if their PTSD remains untreated, there is a greater likelihood they will continue to relive traumatic memories as young adults and beyond.

There is some controversy as to whether talking through the traumatic event over and over truly helps. Some clinicians feel that a certain amount of supportive discussion in a calm way makes sense, especially early. But solely repeating the details of the event may re-traumatize the child and intensify negative feelings, especially if the memories are very vivid.

Cognitive and behavioral approaches can help the child reframe their trauma. An example is exposure therapy, where the child is carefully reexposed to the trauma in stages while they learn to reframe and diminish the intensity of the experience. Often, ideas about the trauma come out that can be examined objectively to try to lessen some of those traumatic feelings.

Exposure therapy also can incorporate gradual steps to help the child overcome their fear. For example, if a person survived a plane crash, the first step might be to take him or her to the airport, then to board an airplane without taking off, and so forth. This approach reintroduces the trauma without eliciting a full response. You don’t want the brain to go on "red alert" again. In a state of hyperarousal, reliving the trauma may do more harm than good.

The terrified moments that children experience during a traumatic sequence tend to get burned into their memories much more strongly than everyday events. A school-age child might remember nothing about an uneventful trip in the car, but if a traumatic accident happens, often she remembers almost every detail. She recalls descriptive elements of what happened as well as the emotional fright or anguish very vividly.

Sometimes vivid, traumatic memories will enter your patient’s mind spontaneously without him knowing why. In other cases, there are triggers. The classic example is the combat veteran who hears a sudden, loud noise and immediately feels in danger. Similarly, someone shouting or crying can trigger a strong flashback for the child exposed to domestic violence.

Sometimes these flashbacks arise shortly following trauma and sometimes they take years. I know of an adult patient for whom painful memories of physical abuse and trauma arose when she became pregnant. When she considered what it would be like to raise her child, it rekindled a lot of memories of her own childhood.

In other cases, consequences are less direct. For example, a woman who was traumatized as a child by witnessing fighting in her home may overreact and try to never fight with her partner. Others might relive the experience by causing a lot of arguments.

We still have much to learn about PTSD. What is the nature of the neurobiology? Why are some children more vulnerable than others? How can medications such as selective serotonin reuptake inhibitors best be used in children and adolescents with persistent PTSD?

Pediatricians can do their patients and families a service if they are aware of PTSD either after an overt event like a car accident or by considering trauma in an anxious or dysfunctional child.

This column, "Behavioral Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Jellinek is chief of child psychiatry at Massachusetts General Hospital and professor of psychiatry and of pediatrics at Harvard Medical School, Boston. To comment, e-mail him at pdnews@elsevier.com.

Different forms of trauma can cause posttraumatic stress disorder in children, whether from an objective event like a car crash or sports injury to trauma involving loved ones, such as domestic violence, abuse, or neglect.

Pediatricians can help by routinely screening for dysfunction and by asking questions at annual well-child visits. Overt symptoms include fear related to the trauma such as avoiding the traumatic setting or activity. Less specific symptoms include anxiety, avoidance, social isolation, depression, and low self-esteem.

If a standard screen such as the Pediatric Symptom Checklist or another instrument reveals psychosocial dysfunction, you have to determine the cause of dysfunction, and PTSD should certainly be considered.

Is there family discord leading to violence in the home? If you suspect PTSD, ask a child what happened and why he or she thinks it happened. Determine if the child is blaming himself or herself in any way. Is the child grieving following a permanent injury and/or loss of a loved one? How have the parents discussed any traumatic event with the child? Do the parents feel traumatized by the child’s experience?

If PTSD is a possibility, ask if the child is experiencing flashbacks, intrusive thoughts, and/or any related anxiety.

Some symptoms are expected after a traumatic event or following cancer or critical care treatment experienced as traumatic. Most children and adolescents overcome the fear of riding in a car or playing the sport that resulted in the trauma.

However, symptoms that persist for a month or more, with avoidance and associated anxiety, are core to the diagnosis of PTSD. The anxiety can build and be self-reinforcing so as to interfere with daily functioning. At this point, consider referral to a mental health specialist, preferably one with some experience in PTSD treatment. A specialist can help the patient overcome his or her anxiety and return to functioning through cognitive and behavioral techniques such as reframing the events, dealing with any guilt, and staged exposure to the anxiety.

If one of your patients experienced a car crash or other major trauma, you will likely know about it, already be treating the child, and should be planning to monitor him for signs of PTSD. In contrast, detection of subtle PTSD is more challenging, particularly if the trauma is unknown or occurred years ago. Trauma related to domestic violence or sexual abuse first requires consideration of this possibility and then gentle, empathic, and persistent questioning.

Triggers for reliving/reexperiencing the trauma also can be straightforward. For example, a child who gets into a car with a similar interior design years after a crash can immediately experience and emotionally return to the trauma. Other triggers are less obvious, such as a teenage girl who was held down and forced to have sex against her will, who later feels constrained by tight clothing and immediately relives the fear and anguish.

Like many presentations in pediatrics, management of PTSD depends on the developmental stage of the child, including his or her cognitive abilities and emotional state. For example, infants or toddlers might not be able to make much sense of what is happening when they witness domestic violence. Terror, fear, and confusion are their most likely reactions.

School-age children aged 5-8 years would not fully understand either, but they will try to make some sense of the domestic violence. Assuming no one reassures them otherwise, they also may feel that something they did sparked or contributed to the violence. For example, if they overhear arguments around issues in the family and hear their name mentioned, they may quickly assume that they are the cause of the domestic violence. This can lead to feelings of guilt, self-criticism, and unworthiness.

Adolescents will experience some of the same reactions as younger children. They will still experience shock, even if they are better equipped to conceptualize the domestic violence. Some will feel powerless because they cannot end the strife, particularly at a time when they are supposed to have more control over the real world. Again, teenagers might feel they have not lived up to expectations and perceive some blame. Others may choose to flee, find support through friends, and/or may deal with their feelings using substances.

Act when you encounter a patient who feels very guilty about parental fighting or who justifies abuse because he feels worthless or was told repeatedly he was a bad child. Help him realize he was not responsible for the conflict and that no one deserves abuse. Discuss other, more realistic possibilities for the family paradigm.

These are not easy conversations. Some pediatricians will feel comfortable working at this depth, others will prefer to refer.

Healing from PTSD related to family violence, sexual abuse, or criminal activity is a several-step process. As one’s sense of guilt diminishes, other emotions such as anger at not being better protected or valued need to be addressed. Finally, there needs to be some grieving for what was lacking and some acceptance of what was possible.

This is not a simple process; however, it is worthwhile because if their PTSD remains untreated, there is a greater likelihood they will continue to relive traumatic memories as young adults and beyond.

There is some controversy as to whether talking through the traumatic event over and over truly helps. Some clinicians feel that a certain amount of supportive discussion in a calm way makes sense, especially early. But solely repeating the details of the event may re-traumatize the child and intensify negative feelings, especially if the memories are very vivid.

Cognitive and behavioral approaches can help the child reframe their trauma. An example is exposure therapy, where the child is carefully reexposed to the trauma in stages while they learn to reframe and diminish the intensity of the experience. Often, ideas about the trauma come out that can be examined objectively to try to lessen some of those traumatic feelings.

Exposure therapy also can incorporate gradual steps to help the child overcome their fear. For example, if a person survived a plane crash, the first step might be to take him or her to the airport, then to board an airplane without taking off, and so forth. This approach reintroduces the trauma without eliciting a full response. You don’t want the brain to go on "red alert" again. In a state of hyperarousal, reliving the trauma may do more harm than good.

The terrified moments that children experience during a traumatic sequence tend to get burned into their memories much more strongly than everyday events. A school-age child might remember nothing about an uneventful trip in the car, but if a traumatic accident happens, often she remembers almost every detail. She recalls descriptive elements of what happened as well as the emotional fright or anguish very vividly.

Sometimes vivid, traumatic memories will enter your patient’s mind spontaneously without him knowing why. In other cases, there are triggers. The classic example is the combat veteran who hears a sudden, loud noise and immediately feels in danger. Similarly, someone shouting or crying can trigger a strong flashback for the child exposed to domestic violence.

Sometimes these flashbacks arise shortly following trauma and sometimes they take years. I know of an adult patient for whom painful memories of physical abuse and trauma arose when she became pregnant. When she considered what it would be like to raise her child, it rekindled a lot of memories of her own childhood.

In other cases, consequences are less direct. For example, a woman who was traumatized as a child by witnessing fighting in her home may overreact and try to never fight with her partner. Others might relive the experience by causing a lot of arguments.

We still have much to learn about PTSD. What is the nature of the neurobiology? Why are some children more vulnerable than others? How can medications such as selective serotonin reuptake inhibitors best be used in children and adolescents with persistent PTSD?

Pediatricians can do their patients and families a service if they are aware of PTSD either after an overt event like a car accident or by considering trauma in an anxious or dysfunctional child.

This column, "Behavioral Consult," regularly appears in Pediatric News, an Elsevier publication. Dr. Jellinek is chief of child psychiatry at Massachusetts General Hospital and professor of psychiatry and of pediatrics at Harvard Medical School, Boston. To comment, e-mail him at pdnews@elsevier.com.