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Consider adverse childhood experiences during the pandemic
We live in historic times. A worldwide pandemic is surging in the United States, with millions infected and the world’s highest death rate. Many of our hospitals are overwhelmed. Schools have been closed for months. Businesses are struggling, and unemployment is at record levels. The murder of George Floyd unleashed an outpouring of grief and rage over police brutality and structural racism.
It is ironic that this age of adversity emerged at the same time that efforts to assess and address childhood adversity are gaining momentum. The effects of adverse childhood experiences (ACEs) have been well known for decades, but only recently have efforts at universal screening been initiated in primary care offices around the country. The multiple crises we face have made this work more pressing than ever. And
While there has long been awareness, especially among pediatricians, of the social determinants of health, it was only 1995 when Robert F. Anda, MD, and Vincent J. Felitti, MD, set about studying over 13,000 adult patients at Kaiser Permanente to understand the relationship between childhood trauma and chronic health problems in adulthood. In 1998 they published the results of this landmark study, establishing that childhood trauma was common and that it predicted chronic diseases and psychosocial problems in adulthood1.
They detailed 10 specific ACEs, and a patient’s ACE score was determined by how many of these experiences they had before they turned 18 years: neglect (emotional or physical), abuse (emotional, physical or sexual), and household dysfunction (parental divorce, incarceration of a parent, domestic violence, parental mental illness, or parental substance abuse). They found that more than half of adults studied had a score of at least 1, and 6% had scores of 4 or more. Those adults with an ACE score of 4 or more are twice as likely to be obese, twice as likely to smoke, and seven times as likely to abuse alcohol as the rest of the population. They are 4 times as likely to have emphysema, 5 times as likely to have depression, and 12 times as likely to attempt suicide. They have higher rates of heart disease, autoimmune disorders, and cancer. Those with ACE scores of 6 or more have their life expectancy shortened by an average of 20 years.
The value of knowing about these risk factors would seem self-evident; it would inform a patient’s health care from screening for cancer or heart disease, referral for mild depressive symptoms, and counseling about alcohol consumption. But this research did not lead to the establishment of routine screening for childhood adversity in primary care practices. There are multiple reasons for this, including growing pressure on physician time and discomfort with starting conversations about potentially traumatic material. But perhaps the greatest obstacle has been uncertainty about what to offer patients who screened in. What is the treatment for a high ACE score?
Even without treatments, we have learned much about childhood adversity since Dr. Anda and Dr. Felitti published their landmark study. Other more chronic adverse childhood experiences also contribute to adult health risk, such as poverty, homelessness, discrimination, community violence, parental chronic illness, or disability or placement in foster care. Having a high ACE score does not only affect health in adulthood. Children with an ACE score of 4 are 2 times as likely to have asthma2,3 and allergies3, 2 times as likely to be obese4, 3 times as likely to have headaches3 and dental problems5,6, 4 times as likely to have depression7,8, 5 times as likely to have ADHD8,9, 7 times as likely to have high rates of school absenteeism3 and aggression10, and over 30 times as likely to have learning or behavioral problems at school4. There is a growing body of knowledge about how chronic, severe stress in childhood affects can lead to pathological alterations in neuroendocrine and immune function. But this has not led to any concrete treatments that may be preventive or reparative.
Movement toward expanding screening nonetheless has accelerated. In California, Nadine Burke-Harris, MD, a pediatrician who studied ACEs and children’s health was named the state’s first Surgeon General in 2019 and spearheaded an effort to make screening for ACEs easier. Starting in 2020, MediCal will pay for annual screenings, and the state is offering training and resources on how to screen and what to do with the information to help patients and families.
The coronavirus pandemic has only highlighted the risks of childhood adversity. The burden of infection and mortality has been borne disproportionately by people of color and those with multiple chronic medical conditions (obesity, cardiovascular disease, diabetes, etc.). While viruses do not discriminate, they are more likely to infect those with higher risk of exposure and to kill those who are physiologically vulnerable.
And the pandemic increases the risk for adversity for today’s children and families. When children cannot attend school, financially vulnerable parents may have to choose between supervising them or feeding them. Families who suddenly are all in a small apartment together without school or other outside supports may be at higher risk for domestic violence and child abuse. Unemployment and financial uncertainty will increase the rates of substance abuse and depression amongst parents. And the serious illness or death of a parent will be a more common event for children in the year ahead. One of these risk factors may increase the likelihood of others.
Beyond the obvious need for substantial policy changes focused on housing, education, and health care, And resilience can build on itself, as children face subsequent challenges with the support of caring connected adults.
The critical first step is asking. Then listen calmly and supportively, normalizing for parents and children how common these experiences are. Explain how they affect health and well-being. Explain that adversity and its consequences are not their fault. Then educate them about what is in their control: the skills they can practice to buffer against the consequences of adversity and build resilience. They sound simple, but still require effort and work. And the pandemic has created some difficulty (social distancing) and opportunity (more family time, fewer school demands).
Sleep
Help parents establish and protect consistent, restful sleep for their children. They can set a consistent bedtime and a calm routine, with screens all off at least 30 minutes before sleep and reading before sleep. Restful sleep is physiologically and psychologically protective to everyone in a family.
Movement
Beyond directly improving physical health, establishing habits of exercise – especially outside – every day can effectively manage ongoing stress, build skills of self-regulation, and help with sleep.
Find out what parents and their children like to do together (walking the dog, shooting hoops, even dancing) and help them devise ways to create family routines around exercise.
Nutrition
Food should be a source of pleasure, but stress can make food into a source of comfort or escape. Help parents to create realistic ways to consistently offer healthy family meals and discourage unhealthy habits.
Even small changes like water instead of soda can help, and there are nutritional and emotional benefits to eating a healthy breakfast or dinner together as a family.
Connections
Nourishing social connections are protective. Help parents think about protecting time to spend with their children for talking, playing games, or even singing.
They should support their children’s connections to other caring adults, through community organizations (church, community centers, or sports), and they should know who their children’s reliable friends are. Parents will benefit from these supports for themselves, which in turn will benefit the full family.
Self-awareness
Activities that cultivate mindfulness are protective. Parents can simply ask how their children are feeling, physically or emotionally, and be able to bear it when it is uncomfortable. Work towards nonjudgmental awareness of how they are feeling. Learning what is relaxing or recharging for them (exercise, music, a hot bath, a good book, time with a friend) will protect against defaulting into maladaptive coping such as escape, numbing, or avoidance.
Of course, if you learn about symptoms that suggest PTSD, depression, or addiction, you should help your patient connect with effective treatment. The difficulty of referring to a mental health provider does not mean you should not try and bring as many people onto the team and into the orbit of the child and family at risk. It may be easier to access some therapy given the new availability of telemedicine visits across many more systems of care. Although the heaviest burdens of adversity are not being borne equally, the fact that adversity is currently a shared experience makes this a moment of promise.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Dr. Swick and Dr. Jellinek had no relevant financial disclosures. Email them at pdnews@mdedge.com.
References
1. Am J Prev Med. 1998 May;14(4):245-58.
2. Ann Allergy Asthma Immunol. 2015;114: 379-84.
3. BMC Public Health. 2018. doi: 10.1186/s12889-018-5699-8.
4. Child Abuse Negl. 2011 Jun;35(6):408-13.
5. Community Dent Oral Epidemiol. 2015;43:193-9.
6. Community Dent Oral Epidemiol. 2018 Oct;46(5): 442-8.
7. Pediatrics 2016 Apr. doi: 10.1542/peds.2015-4016.
8. Matern Child Health J. 2016 Apr. doi: 10.1007/s10995-015-1915-7.
9. Acad Pediatr. 2017 May-Jun. doi: 10.1016/j.acap.2016.08.013.
10. Pediatrics. 2010 Apr. doi: 10.1542/peds.2009-0597.
This article was updated 7/27/2020.
We live in historic times. A worldwide pandemic is surging in the United States, with millions infected and the world’s highest death rate. Many of our hospitals are overwhelmed. Schools have been closed for months. Businesses are struggling, and unemployment is at record levels. The murder of George Floyd unleashed an outpouring of grief and rage over police brutality and structural racism.
It is ironic that this age of adversity emerged at the same time that efforts to assess and address childhood adversity are gaining momentum. The effects of adverse childhood experiences (ACEs) have been well known for decades, but only recently have efforts at universal screening been initiated in primary care offices around the country. The multiple crises we face have made this work more pressing than ever. And
While there has long been awareness, especially among pediatricians, of the social determinants of health, it was only 1995 when Robert F. Anda, MD, and Vincent J. Felitti, MD, set about studying over 13,000 adult patients at Kaiser Permanente to understand the relationship between childhood trauma and chronic health problems in adulthood. In 1998 they published the results of this landmark study, establishing that childhood trauma was common and that it predicted chronic diseases and psychosocial problems in adulthood1.
They detailed 10 specific ACEs, and a patient’s ACE score was determined by how many of these experiences they had before they turned 18 years: neglect (emotional or physical), abuse (emotional, physical or sexual), and household dysfunction (parental divorce, incarceration of a parent, domestic violence, parental mental illness, or parental substance abuse). They found that more than half of adults studied had a score of at least 1, and 6% had scores of 4 or more. Those adults with an ACE score of 4 or more are twice as likely to be obese, twice as likely to smoke, and seven times as likely to abuse alcohol as the rest of the population. They are 4 times as likely to have emphysema, 5 times as likely to have depression, and 12 times as likely to attempt suicide. They have higher rates of heart disease, autoimmune disorders, and cancer. Those with ACE scores of 6 or more have their life expectancy shortened by an average of 20 years.
The value of knowing about these risk factors would seem self-evident; it would inform a patient’s health care from screening for cancer or heart disease, referral for mild depressive symptoms, and counseling about alcohol consumption. But this research did not lead to the establishment of routine screening for childhood adversity in primary care practices. There are multiple reasons for this, including growing pressure on physician time and discomfort with starting conversations about potentially traumatic material. But perhaps the greatest obstacle has been uncertainty about what to offer patients who screened in. What is the treatment for a high ACE score?
Even without treatments, we have learned much about childhood adversity since Dr. Anda and Dr. Felitti published their landmark study. Other more chronic adverse childhood experiences also contribute to adult health risk, such as poverty, homelessness, discrimination, community violence, parental chronic illness, or disability or placement in foster care. Having a high ACE score does not only affect health in adulthood. Children with an ACE score of 4 are 2 times as likely to have asthma2,3 and allergies3, 2 times as likely to be obese4, 3 times as likely to have headaches3 and dental problems5,6, 4 times as likely to have depression7,8, 5 times as likely to have ADHD8,9, 7 times as likely to have high rates of school absenteeism3 and aggression10, and over 30 times as likely to have learning or behavioral problems at school4. There is a growing body of knowledge about how chronic, severe stress in childhood affects can lead to pathological alterations in neuroendocrine and immune function. But this has not led to any concrete treatments that may be preventive or reparative.
Movement toward expanding screening nonetheless has accelerated. In California, Nadine Burke-Harris, MD, a pediatrician who studied ACEs and children’s health was named the state’s first Surgeon General in 2019 and spearheaded an effort to make screening for ACEs easier. Starting in 2020, MediCal will pay for annual screenings, and the state is offering training and resources on how to screen and what to do with the information to help patients and families.
The coronavirus pandemic has only highlighted the risks of childhood adversity. The burden of infection and mortality has been borne disproportionately by people of color and those with multiple chronic medical conditions (obesity, cardiovascular disease, diabetes, etc.). While viruses do not discriminate, they are more likely to infect those with higher risk of exposure and to kill those who are physiologically vulnerable.
And the pandemic increases the risk for adversity for today’s children and families. When children cannot attend school, financially vulnerable parents may have to choose between supervising them or feeding them. Families who suddenly are all in a small apartment together without school or other outside supports may be at higher risk for domestic violence and child abuse. Unemployment and financial uncertainty will increase the rates of substance abuse and depression amongst parents. And the serious illness or death of a parent will be a more common event for children in the year ahead. One of these risk factors may increase the likelihood of others.
Beyond the obvious need for substantial policy changes focused on housing, education, and health care, And resilience can build on itself, as children face subsequent challenges with the support of caring connected adults.
The critical first step is asking. Then listen calmly and supportively, normalizing for parents and children how common these experiences are. Explain how they affect health and well-being. Explain that adversity and its consequences are not their fault. Then educate them about what is in their control: the skills they can practice to buffer against the consequences of adversity and build resilience. They sound simple, but still require effort and work. And the pandemic has created some difficulty (social distancing) and opportunity (more family time, fewer school demands).
Sleep
Help parents establish and protect consistent, restful sleep for their children. They can set a consistent bedtime and a calm routine, with screens all off at least 30 minutes before sleep and reading before sleep. Restful sleep is physiologically and psychologically protective to everyone in a family.
Movement
Beyond directly improving physical health, establishing habits of exercise – especially outside – every day can effectively manage ongoing stress, build skills of self-regulation, and help with sleep.
Find out what parents and their children like to do together (walking the dog, shooting hoops, even dancing) and help them devise ways to create family routines around exercise.
Nutrition
Food should be a source of pleasure, but stress can make food into a source of comfort or escape. Help parents to create realistic ways to consistently offer healthy family meals and discourage unhealthy habits.
Even small changes like water instead of soda can help, and there are nutritional and emotional benefits to eating a healthy breakfast or dinner together as a family.
Connections
Nourishing social connections are protective. Help parents think about protecting time to spend with their children for talking, playing games, or even singing.
They should support their children’s connections to other caring adults, through community organizations (church, community centers, or sports), and they should know who their children’s reliable friends are. Parents will benefit from these supports for themselves, which in turn will benefit the full family.
Self-awareness
Activities that cultivate mindfulness are protective. Parents can simply ask how their children are feeling, physically or emotionally, and be able to bear it when it is uncomfortable. Work towards nonjudgmental awareness of how they are feeling. Learning what is relaxing or recharging for them (exercise, music, a hot bath, a good book, time with a friend) will protect against defaulting into maladaptive coping such as escape, numbing, or avoidance.
Of course, if you learn about symptoms that suggest PTSD, depression, or addiction, you should help your patient connect with effective treatment. The difficulty of referring to a mental health provider does not mean you should not try and bring as many people onto the team and into the orbit of the child and family at risk. It may be easier to access some therapy given the new availability of telemedicine visits across many more systems of care. Although the heaviest burdens of adversity are not being borne equally, the fact that adversity is currently a shared experience makes this a moment of promise.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Dr. Swick and Dr. Jellinek had no relevant financial disclosures. Email them at pdnews@mdedge.com.
References
1. Am J Prev Med. 1998 May;14(4):245-58.
2. Ann Allergy Asthma Immunol. 2015;114: 379-84.
3. BMC Public Health. 2018. doi: 10.1186/s12889-018-5699-8.
4. Child Abuse Negl. 2011 Jun;35(6):408-13.
5. Community Dent Oral Epidemiol. 2015;43:193-9.
6. Community Dent Oral Epidemiol. 2018 Oct;46(5): 442-8.
7. Pediatrics 2016 Apr. doi: 10.1542/peds.2015-4016.
8. Matern Child Health J. 2016 Apr. doi: 10.1007/s10995-015-1915-7.
9. Acad Pediatr. 2017 May-Jun. doi: 10.1016/j.acap.2016.08.013.
10. Pediatrics. 2010 Apr. doi: 10.1542/peds.2009-0597.
This article was updated 7/27/2020.
We live in historic times. A worldwide pandemic is surging in the United States, with millions infected and the world’s highest death rate. Many of our hospitals are overwhelmed. Schools have been closed for months. Businesses are struggling, and unemployment is at record levels. The murder of George Floyd unleashed an outpouring of grief and rage over police brutality and structural racism.
It is ironic that this age of adversity emerged at the same time that efforts to assess and address childhood adversity are gaining momentum. The effects of adverse childhood experiences (ACEs) have been well known for decades, but only recently have efforts at universal screening been initiated in primary care offices around the country. The multiple crises we face have made this work more pressing than ever. And
While there has long been awareness, especially among pediatricians, of the social determinants of health, it was only 1995 when Robert F. Anda, MD, and Vincent J. Felitti, MD, set about studying over 13,000 adult patients at Kaiser Permanente to understand the relationship between childhood trauma and chronic health problems in adulthood. In 1998 they published the results of this landmark study, establishing that childhood trauma was common and that it predicted chronic diseases and psychosocial problems in adulthood1.
They detailed 10 specific ACEs, and a patient’s ACE score was determined by how many of these experiences they had before they turned 18 years: neglect (emotional or physical), abuse (emotional, physical or sexual), and household dysfunction (parental divorce, incarceration of a parent, domestic violence, parental mental illness, or parental substance abuse). They found that more than half of adults studied had a score of at least 1, and 6% had scores of 4 or more. Those adults with an ACE score of 4 or more are twice as likely to be obese, twice as likely to smoke, and seven times as likely to abuse alcohol as the rest of the population. They are 4 times as likely to have emphysema, 5 times as likely to have depression, and 12 times as likely to attempt suicide. They have higher rates of heart disease, autoimmune disorders, and cancer. Those with ACE scores of 6 or more have their life expectancy shortened by an average of 20 years.
The value of knowing about these risk factors would seem self-evident; it would inform a patient’s health care from screening for cancer or heart disease, referral for mild depressive symptoms, and counseling about alcohol consumption. But this research did not lead to the establishment of routine screening for childhood adversity in primary care practices. There are multiple reasons for this, including growing pressure on physician time and discomfort with starting conversations about potentially traumatic material. But perhaps the greatest obstacle has been uncertainty about what to offer patients who screened in. What is the treatment for a high ACE score?
Even without treatments, we have learned much about childhood adversity since Dr. Anda and Dr. Felitti published their landmark study. Other more chronic adverse childhood experiences also contribute to adult health risk, such as poverty, homelessness, discrimination, community violence, parental chronic illness, or disability or placement in foster care. Having a high ACE score does not only affect health in adulthood. Children with an ACE score of 4 are 2 times as likely to have asthma2,3 and allergies3, 2 times as likely to be obese4, 3 times as likely to have headaches3 and dental problems5,6, 4 times as likely to have depression7,8, 5 times as likely to have ADHD8,9, 7 times as likely to have high rates of school absenteeism3 and aggression10, and over 30 times as likely to have learning or behavioral problems at school4. There is a growing body of knowledge about how chronic, severe stress in childhood affects can lead to pathological alterations in neuroendocrine and immune function. But this has not led to any concrete treatments that may be preventive or reparative.
Movement toward expanding screening nonetheless has accelerated. In California, Nadine Burke-Harris, MD, a pediatrician who studied ACEs and children’s health was named the state’s first Surgeon General in 2019 and spearheaded an effort to make screening for ACEs easier. Starting in 2020, MediCal will pay for annual screenings, and the state is offering training and resources on how to screen and what to do with the information to help patients and families.
The coronavirus pandemic has only highlighted the risks of childhood adversity. The burden of infection and mortality has been borne disproportionately by people of color and those with multiple chronic medical conditions (obesity, cardiovascular disease, diabetes, etc.). While viruses do not discriminate, they are more likely to infect those with higher risk of exposure and to kill those who are physiologically vulnerable.
And the pandemic increases the risk for adversity for today’s children and families. When children cannot attend school, financially vulnerable parents may have to choose between supervising them or feeding them. Families who suddenly are all in a small apartment together without school or other outside supports may be at higher risk for domestic violence and child abuse. Unemployment and financial uncertainty will increase the rates of substance abuse and depression amongst parents. And the serious illness or death of a parent will be a more common event for children in the year ahead. One of these risk factors may increase the likelihood of others.
Beyond the obvious need for substantial policy changes focused on housing, education, and health care, And resilience can build on itself, as children face subsequent challenges with the support of caring connected adults.
The critical first step is asking. Then listen calmly and supportively, normalizing for parents and children how common these experiences are. Explain how they affect health and well-being. Explain that adversity and its consequences are not their fault. Then educate them about what is in their control: the skills they can practice to buffer against the consequences of adversity and build resilience. They sound simple, but still require effort and work. And the pandemic has created some difficulty (social distancing) and opportunity (more family time, fewer school demands).
Sleep
Help parents establish and protect consistent, restful sleep for their children. They can set a consistent bedtime and a calm routine, with screens all off at least 30 minutes before sleep and reading before sleep. Restful sleep is physiologically and psychologically protective to everyone in a family.
Movement
Beyond directly improving physical health, establishing habits of exercise – especially outside – every day can effectively manage ongoing stress, build skills of self-regulation, and help with sleep.
Find out what parents and their children like to do together (walking the dog, shooting hoops, even dancing) and help them devise ways to create family routines around exercise.
Nutrition
Food should be a source of pleasure, but stress can make food into a source of comfort or escape. Help parents to create realistic ways to consistently offer healthy family meals and discourage unhealthy habits.
Even small changes like water instead of soda can help, and there are nutritional and emotional benefits to eating a healthy breakfast or dinner together as a family.
Connections
Nourishing social connections are protective. Help parents think about protecting time to spend with their children for talking, playing games, or even singing.
They should support their children’s connections to other caring adults, through community organizations (church, community centers, or sports), and they should know who their children’s reliable friends are. Parents will benefit from these supports for themselves, which in turn will benefit the full family.
Self-awareness
Activities that cultivate mindfulness are protective. Parents can simply ask how their children are feeling, physically or emotionally, and be able to bear it when it is uncomfortable. Work towards nonjudgmental awareness of how they are feeling. Learning what is relaxing or recharging for them (exercise, music, a hot bath, a good book, time with a friend) will protect against defaulting into maladaptive coping such as escape, numbing, or avoidance.
Of course, if you learn about symptoms that suggest PTSD, depression, or addiction, you should help your patient connect with effective treatment. The difficulty of referring to a mental health provider does not mean you should not try and bring as many people onto the team and into the orbit of the child and family at risk. It may be easier to access some therapy given the new availability of telemedicine visits across many more systems of care. Although the heaviest burdens of adversity are not being borne equally, the fact that adversity is currently a shared experience makes this a moment of promise.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Dr. Swick and Dr. Jellinek had no relevant financial disclosures. Email them at pdnews@mdedge.com.
References
1. Am J Prev Med. 1998 May;14(4):245-58.
2. Ann Allergy Asthma Immunol. 2015;114: 379-84.
3. BMC Public Health. 2018. doi: 10.1186/s12889-018-5699-8.
4. Child Abuse Negl. 2011 Jun;35(6):408-13.
5. Community Dent Oral Epidemiol. 2015;43:193-9.
6. Community Dent Oral Epidemiol. 2018 Oct;46(5): 442-8.
7. Pediatrics 2016 Apr. doi: 10.1542/peds.2015-4016.
8. Matern Child Health J. 2016 Apr. doi: 10.1007/s10995-015-1915-7.
9. Acad Pediatr. 2017 May-Jun. doi: 10.1016/j.acap.2016.08.013.
10. Pediatrics. 2010 Apr. doi: 10.1542/peds.2009-0597.
This article was updated 7/27/2020.
Help parents manage screen time thoughtfully
It has been 2 years since we last wrote about the potential risks to children and adolescents of spending too much time on screens. While there have been studies in the interval that offer us more information about the effects of heavy screen use and the developing brain, there is little certainty about what is optimal for children and adolescents, and less still on how parents might effectively equip their children to make good use of screens without suffering ill effects.
You might recall that back in October of 2016, the American Academy of Pediatrics published screen time guidelines: recommending no screen time for infants and children up to 18 months old, limiting all screen time to 1 hour per day for children up to 5 years old, and 2 hours daily for older children (up to 11 years old), so that it would not interfere with homework, social time, exercise, and sleep. At the time, data suggested that children from 2 to 11 years old were spending an average of 4.5 hours per day on screens (TV, computer, tablets, or smartphones, not counting homework).
The Adolescent Brain Cognitive Development Study began in September 2016 to evaluate the effects of Canadian recommendations for 8- to 11-year-olds (9-11 hours sleep nightly, 1 hour of exercise daily, and 2 hours or less of screen time daily; the study subjects are in the United States). This fall they published their initial results, demonstrating that only 51% get the recommended amount of sleep, only 37% kept their daily screen time to under 2 hours, and only 18% were getting the recommended amount of exercise. Only 5% of children consistently met all three recommendations while 29% of children didn’t meet any of the recommendations.
The researchers assessed the children’s cognitive development and found that after 1 year, those children who met the screen time recommendations, both screen time and sleep, or all three recommendations demonstrated “superior global cognition.” Children were spending an average of 3.7 hours daily on screens, and those children who were spending 2 hours or less on screens performed 4% better on tests of cognitive function than did children spending the average amount of time. Sleep and exercise differences alone did not contribute to significant differences in cognitive function. This study will continue for another 10 years.1
In a much smaller study out of Cincinnati Children’s Hospital, researchers asked parents to describe the amount of time a child spent on reading and in screen-based media activities, then completed MRI scans of the children’s brains.2 They found a strong association between reading time and higher functional connectivity between the parts of the brain responsible for visual word formation and those responsible for language and cognitive control, with a negative correlation between functional connectivity and time spent in screen-based media activities.
While these studies are important pieces of data as we build a deeper understanding about the effects of screen-based media use on children’s cognitive and behavioral development, they do not offer certainty about causality. These studies do not yet clarify whether certain children are especially vulnerable to the untoward effects of heavy screen-based media use. Perhaps the research will someday offer guidelines with certainty, but families need guidance now. Without doubt, digital devices are here to stay, are important to homework, and can facilitate independence, long-distance connections, important technical work-skills, and even senseless fun and relaxation. So we will focus on offering some principles to help you guide young people (or their parents) in approaching screen time thoughtfully.
While recommending no more than 2 hours of daily screen time seems reasonable, it may be more useful to focus on what young people are doing with the rest of their time. Are they getting adequate, restful sleep? Are they able to exercise most days? Do they have enough time for homework? Do they have time for friends (time actually together, not just texting)? What about time for hobbies? When parents focus on the precious resource of time and all of the activities their children both need and want to do, it sets the frame for them to say that their children are allowed to have time to relax with screen-based media as long as it does not take away from these other priorities. Ensuring that the child has at least 8 hours of sleep, after homework and sports, also will set natural limits on screen time.
Parents also can use the frame of development to guide their rules about screen time. If use of an electronic device serves a developmental task, then it is reasonable. If it interferes with a developmental task, then it should be limited. Adolescents (ages 12-20) should be exploring their own identities, establishing independence, deepening social relationships, and learning to manage their impulses. Some interests can be most easily explored with the aid of a computer (such as with programming, art history, or astronomy). Use of cellphones can facilitate teenagers’ being more independent with plans or transportation. Social connections can be supported by texting or FaceTime. Some close friends may be in a different sport or live far away, and it is possible to stay connected only virtually. However, when use of electronic devices keeps the child from engaging with new friends and new interests or from getting into the world to establish real independence (i.e., a job), then there should be limits. In all of these cases, it is critical that adults explain to teenagers what is guiding their thinking about limits on screen time. Open discussions about the great utility and fun that screens can provide, as well as the challenge of keeping those activities in balance with other important activities, helps adolescents set the frame for that rapidly approaching time when they will be making those choices without adult supervision.
Younger children (ages 8-11) should be sampling a wide array of activities and interests and experiencing challenges and eventual mastery across domains. Video games can be very compelling for this age group because they appeal to exactly this drive to master a challenge. Parents want to ensure that their children can have senseless fun, and still have enough time to explore actual activities: social, athletic, creative, and academic. They can be ready to explain the why of rules, but consistent rules, enforced for everyone at home, are most helpful for this age group.
You also can help parents to consider the child’s temperament when thinking about which rules will be appropriate. Anxious children and teenagers may be especially prone to immersive virtual activities that allow them to avoid the stress of real undertakings or interactions. But anxious children may be able to prepare for something anxiety provoking by exploring it virtually first. Youth with ADHD are going to struggle with shifting away from video games or other electronic activities they enjoy that don’t have a natural ending, and will need strict rules and patient support around balanced screen time use. Screen time may play to a child’s strengths, enabling creative children to take in a wide range of art or music and even create their own when other resources are limited.
Finally, all parents should consider what their own screen use is teaching their children. Adolescents are unlikely to listen to their parents’ recommendations if the parents spend hours online after work. Younger children need their parents’ engaged attention: being coaches and cheerleaders for all of their efforts at mastery. You can help parents to imagine rules that the whole family can follow. They can consider how screen time helps them connect with their children, such as watching a favorite program or sport together. They can explore shared interests online together. They can even relax with ridiculous cat videos together! Screen time together is valuable if it supports parents’ connections with their children, while their rules ensure adequate time for sleep, physical activity, and developmental priorities.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Lancet Child Adolesc Health. 2018 Nov 1;2(11):783-91.
2. Acta Paediatra. 2018 Apr;107(4):685-93
It has been 2 years since we last wrote about the potential risks to children and adolescents of spending too much time on screens. While there have been studies in the interval that offer us more information about the effects of heavy screen use and the developing brain, there is little certainty about what is optimal for children and adolescents, and less still on how parents might effectively equip their children to make good use of screens without suffering ill effects.
You might recall that back in October of 2016, the American Academy of Pediatrics published screen time guidelines: recommending no screen time for infants and children up to 18 months old, limiting all screen time to 1 hour per day for children up to 5 years old, and 2 hours daily for older children (up to 11 years old), so that it would not interfere with homework, social time, exercise, and sleep. At the time, data suggested that children from 2 to 11 years old were spending an average of 4.5 hours per day on screens (TV, computer, tablets, or smartphones, not counting homework).
The Adolescent Brain Cognitive Development Study began in September 2016 to evaluate the effects of Canadian recommendations for 8- to 11-year-olds (9-11 hours sleep nightly, 1 hour of exercise daily, and 2 hours or less of screen time daily; the study subjects are in the United States). This fall they published their initial results, demonstrating that only 51% get the recommended amount of sleep, only 37% kept their daily screen time to under 2 hours, and only 18% were getting the recommended amount of exercise. Only 5% of children consistently met all three recommendations while 29% of children didn’t meet any of the recommendations.
The researchers assessed the children’s cognitive development and found that after 1 year, those children who met the screen time recommendations, both screen time and sleep, or all three recommendations demonstrated “superior global cognition.” Children were spending an average of 3.7 hours daily on screens, and those children who were spending 2 hours or less on screens performed 4% better on tests of cognitive function than did children spending the average amount of time. Sleep and exercise differences alone did not contribute to significant differences in cognitive function. This study will continue for another 10 years.1
In a much smaller study out of Cincinnati Children’s Hospital, researchers asked parents to describe the amount of time a child spent on reading and in screen-based media activities, then completed MRI scans of the children’s brains.2 They found a strong association between reading time and higher functional connectivity between the parts of the brain responsible for visual word formation and those responsible for language and cognitive control, with a negative correlation between functional connectivity and time spent in screen-based media activities.
While these studies are important pieces of data as we build a deeper understanding about the effects of screen-based media use on children’s cognitive and behavioral development, they do not offer certainty about causality. These studies do not yet clarify whether certain children are especially vulnerable to the untoward effects of heavy screen-based media use. Perhaps the research will someday offer guidelines with certainty, but families need guidance now. Without doubt, digital devices are here to stay, are important to homework, and can facilitate independence, long-distance connections, important technical work-skills, and even senseless fun and relaxation. So we will focus on offering some principles to help you guide young people (or their parents) in approaching screen time thoughtfully.
While recommending no more than 2 hours of daily screen time seems reasonable, it may be more useful to focus on what young people are doing with the rest of their time. Are they getting adequate, restful sleep? Are they able to exercise most days? Do they have enough time for homework? Do they have time for friends (time actually together, not just texting)? What about time for hobbies? When parents focus on the precious resource of time and all of the activities their children both need and want to do, it sets the frame for them to say that their children are allowed to have time to relax with screen-based media as long as it does not take away from these other priorities. Ensuring that the child has at least 8 hours of sleep, after homework and sports, also will set natural limits on screen time.
Parents also can use the frame of development to guide their rules about screen time. If use of an electronic device serves a developmental task, then it is reasonable. If it interferes with a developmental task, then it should be limited. Adolescents (ages 12-20) should be exploring their own identities, establishing independence, deepening social relationships, and learning to manage their impulses. Some interests can be most easily explored with the aid of a computer (such as with programming, art history, or astronomy). Use of cellphones can facilitate teenagers’ being more independent with plans or transportation. Social connections can be supported by texting or FaceTime. Some close friends may be in a different sport or live far away, and it is possible to stay connected only virtually. However, when use of electronic devices keeps the child from engaging with new friends and new interests or from getting into the world to establish real independence (i.e., a job), then there should be limits. In all of these cases, it is critical that adults explain to teenagers what is guiding their thinking about limits on screen time. Open discussions about the great utility and fun that screens can provide, as well as the challenge of keeping those activities in balance with other important activities, helps adolescents set the frame for that rapidly approaching time when they will be making those choices without adult supervision.
Younger children (ages 8-11) should be sampling a wide array of activities and interests and experiencing challenges and eventual mastery across domains. Video games can be very compelling for this age group because they appeal to exactly this drive to master a challenge. Parents want to ensure that their children can have senseless fun, and still have enough time to explore actual activities: social, athletic, creative, and academic. They can be ready to explain the why of rules, but consistent rules, enforced for everyone at home, are most helpful for this age group.
You also can help parents to consider the child’s temperament when thinking about which rules will be appropriate. Anxious children and teenagers may be especially prone to immersive virtual activities that allow them to avoid the stress of real undertakings or interactions. But anxious children may be able to prepare for something anxiety provoking by exploring it virtually first. Youth with ADHD are going to struggle with shifting away from video games or other electronic activities they enjoy that don’t have a natural ending, and will need strict rules and patient support around balanced screen time use. Screen time may play to a child’s strengths, enabling creative children to take in a wide range of art or music and even create their own when other resources are limited.
Finally, all parents should consider what their own screen use is teaching their children. Adolescents are unlikely to listen to their parents’ recommendations if the parents spend hours online after work. Younger children need their parents’ engaged attention: being coaches and cheerleaders for all of their efforts at mastery. You can help parents to imagine rules that the whole family can follow. They can consider how screen time helps them connect with their children, such as watching a favorite program or sport together. They can explore shared interests online together. They can even relax with ridiculous cat videos together! Screen time together is valuable if it supports parents’ connections with their children, while their rules ensure adequate time for sleep, physical activity, and developmental priorities.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Lancet Child Adolesc Health. 2018 Nov 1;2(11):783-91.
2. Acta Paediatra. 2018 Apr;107(4):685-93
It has been 2 years since we last wrote about the potential risks to children and adolescents of spending too much time on screens. While there have been studies in the interval that offer us more information about the effects of heavy screen use and the developing brain, there is little certainty about what is optimal for children and adolescents, and less still on how parents might effectively equip their children to make good use of screens without suffering ill effects.
You might recall that back in October of 2016, the American Academy of Pediatrics published screen time guidelines: recommending no screen time for infants and children up to 18 months old, limiting all screen time to 1 hour per day for children up to 5 years old, and 2 hours daily for older children (up to 11 years old), so that it would not interfere with homework, social time, exercise, and sleep. At the time, data suggested that children from 2 to 11 years old were spending an average of 4.5 hours per day on screens (TV, computer, tablets, or smartphones, not counting homework).
The Adolescent Brain Cognitive Development Study began in September 2016 to evaluate the effects of Canadian recommendations for 8- to 11-year-olds (9-11 hours sleep nightly, 1 hour of exercise daily, and 2 hours or less of screen time daily; the study subjects are in the United States). This fall they published their initial results, demonstrating that only 51% get the recommended amount of sleep, only 37% kept their daily screen time to under 2 hours, and only 18% were getting the recommended amount of exercise. Only 5% of children consistently met all three recommendations while 29% of children didn’t meet any of the recommendations.
The researchers assessed the children’s cognitive development and found that after 1 year, those children who met the screen time recommendations, both screen time and sleep, or all three recommendations demonstrated “superior global cognition.” Children were spending an average of 3.7 hours daily on screens, and those children who were spending 2 hours or less on screens performed 4% better on tests of cognitive function than did children spending the average amount of time. Sleep and exercise differences alone did not contribute to significant differences in cognitive function. This study will continue for another 10 years.1
In a much smaller study out of Cincinnati Children’s Hospital, researchers asked parents to describe the amount of time a child spent on reading and in screen-based media activities, then completed MRI scans of the children’s brains.2 They found a strong association between reading time and higher functional connectivity between the parts of the brain responsible for visual word formation and those responsible for language and cognitive control, with a negative correlation between functional connectivity and time spent in screen-based media activities.
While these studies are important pieces of data as we build a deeper understanding about the effects of screen-based media use on children’s cognitive and behavioral development, they do not offer certainty about causality. These studies do not yet clarify whether certain children are especially vulnerable to the untoward effects of heavy screen-based media use. Perhaps the research will someday offer guidelines with certainty, but families need guidance now. Without doubt, digital devices are here to stay, are important to homework, and can facilitate independence, long-distance connections, important technical work-skills, and even senseless fun and relaxation. So we will focus on offering some principles to help you guide young people (or their parents) in approaching screen time thoughtfully.
While recommending no more than 2 hours of daily screen time seems reasonable, it may be more useful to focus on what young people are doing with the rest of their time. Are they getting adequate, restful sleep? Are they able to exercise most days? Do they have enough time for homework? Do they have time for friends (time actually together, not just texting)? What about time for hobbies? When parents focus on the precious resource of time and all of the activities their children both need and want to do, it sets the frame for them to say that their children are allowed to have time to relax with screen-based media as long as it does not take away from these other priorities. Ensuring that the child has at least 8 hours of sleep, after homework and sports, also will set natural limits on screen time.
Parents also can use the frame of development to guide their rules about screen time. If use of an electronic device serves a developmental task, then it is reasonable. If it interferes with a developmental task, then it should be limited. Adolescents (ages 12-20) should be exploring their own identities, establishing independence, deepening social relationships, and learning to manage their impulses. Some interests can be most easily explored with the aid of a computer (such as with programming, art history, or astronomy). Use of cellphones can facilitate teenagers’ being more independent with plans or transportation. Social connections can be supported by texting or FaceTime. Some close friends may be in a different sport or live far away, and it is possible to stay connected only virtually. However, when use of electronic devices keeps the child from engaging with new friends and new interests or from getting into the world to establish real independence (i.e., a job), then there should be limits. In all of these cases, it is critical that adults explain to teenagers what is guiding their thinking about limits on screen time. Open discussions about the great utility and fun that screens can provide, as well as the challenge of keeping those activities in balance with other important activities, helps adolescents set the frame for that rapidly approaching time when they will be making those choices without adult supervision.
Younger children (ages 8-11) should be sampling a wide array of activities and interests and experiencing challenges and eventual mastery across domains. Video games can be very compelling for this age group because they appeal to exactly this drive to master a challenge. Parents want to ensure that their children can have senseless fun, and still have enough time to explore actual activities: social, athletic, creative, and academic. They can be ready to explain the why of rules, but consistent rules, enforced for everyone at home, are most helpful for this age group.
You also can help parents to consider the child’s temperament when thinking about which rules will be appropriate. Anxious children and teenagers may be especially prone to immersive virtual activities that allow them to avoid the stress of real undertakings or interactions. But anxious children may be able to prepare for something anxiety provoking by exploring it virtually first. Youth with ADHD are going to struggle with shifting away from video games or other electronic activities they enjoy that don’t have a natural ending, and will need strict rules and patient support around balanced screen time use. Screen time may play to a child’s strengths, enabling creative children to take in a wide range of art or music and even create their own when other resources are limited.
Finally, all parents should consider what their own screen use is teaching their children. Adolescents are unlikely to listen to their parents’ recommendations if the parents spend hours online after work. Younger children need their parents’ engaged attention: being coaches and cheerleaders for all of their efforts at mastery. You can help parents to imagine rules that the whole family can follow. They can consider how screen time helps them connect with their children, such as watching a favorite program or sport together. They can explore shared interests online together. They can even relax with ridiculous cat videos together! Screen time together is valuable if it supports parents’ connections with their children, while their rules ensure adequate time for sleep, physical activity, and developmental priorities.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Lancet Child Adolesc Health. 2018 Nov 1;2(11):783-91.
2. Acta Paediatra. 2018 Apr;107(4):685-93
Kids and accidents
Summer is upon us, a season of delight for children and teens. School is out, the days are long, warm, and full of activities they get to choose. But we know that summer is also the season of accidents. While adventurous activities can lead to scratches, sprains, and broken bones, many accidents are far more serious. The Centers for Disease Control and Prevention reported that in 2014 (the most recent data available), accidental injuries were the leading cause of death for children from the age of 1 year through young adulthood (age 24 years). Car accidents, drowning, burns, suffocation, poisoning, and being struck while on a bike or other vehicle are the most prominent causes of injury or death in youth.
When something is an “accident,” we understand it to be an unfortunate event that happened by chance, without deliberate cause, and not easily foreseeable or preventable. But many accidents that befall children, while not deliberate, might be more foreseeable and preventable than they first appear. With younger children, parents directly oversee their children, ensuring they wear bike helmets, are placed in appropriate car restraints, cannot play with lighters, are always in sight when learning to swim (with a family pool well fenced and locked), and have no access to guns (and the guns are not loaded and have trigger locks!).
As their children grow older, parents must manage the challenging task of teaching their children to manage risk as they cultivate independence: learning to always put on their bike helmet before riding home from school, avoiding diving into shallow water, and not riding in a car with an impaired driver. Both the direct supervision of younger children and the teaching of older children and teenagers are very demanding of time and energy for parents. Terrible accidents can occur during truly unpredictable moments of distraction, but for too many parents, these moments of distraction are in fact predictable. If parents are strained by financial troubles, a disintegrating marriage, a serious illness in a spouse or elderly parent, or their own mental illness, their ability to be fully present and patient to supervise their children will be predictably impaired. During the summer months, when children may be home all day and looking for adventure, parental stress and distraction result in a high-risk environment that makes serious accidents more likely.
You as a child care provider are wonderful at providing supportive reminders to parents about the basics of child safety and supervision. Every checkup includes questions about whether anyone smokes at home and whether there is a working smoke detector. You ask about bike helmets and booster seats, and whether there are firearms in the home and if so, whether they are properly stored and locked. While there are often no formal questions about the level of family stress at a checkup, it would be simple to add: “Would you say the stress level at home is low, moderate, or high?” Such an open-ended question could lead to discussion of those factors that might be causing stress and give you a quick sense of how equipped the parent (or parents) are to handle it. Without a doubt, physicians’ practices are themselves stressed for time, and asking parents about their own stress may seem like opening Pandora’s box. But by being curious, bringing the important matter of domestic stress into the conversation about a child’s health and well being can by itself be therapeutic. The parents found the time to bring their child to this appointment, despite their stress. By simply bringing their awareness to the impact their stress could have on the safety of their children, you may have made a critical difference.
When parents report a high level of stress, you might follow up with more specific questions about their supports. Who provides them with practical help or a supportive ear? Do they have a strong community of friends, nearby family, or a supportive faith community? Are there practical ways to outsource some of the demands they may be juggling? You should be prepared to offer resources if a parent reports domestic violence. Some pediatric practices will employ social workers who can facilitate connecting stressed families with appropriate resources. But if your practice does not, a little time online can build a database of virtual and community resources that a family can start with.
You are also in a unique position to appreciate that certain children are themselves at higher risk for accidents. Children and adolescents with attention-deficit/hyperactivity disorder may be more distractible and impulsive than their peers. And summer is often a season when families decide to suspend stimulant treatment to promote weight gain or growth. These children and teens are at elevated risk to “leap before they look,” and parents should be reminded of their higher level of risk and need for supervision, at least when having a conversation about whether to suspend stimulant treatment. Children with a history of oppositional behaviors also can prove more challenging to supervise than their peers. Beyond the risk of self-injury or suicide, youth with depressive disorders can have impaired concentration and attention, and may not assess the risk of certain activities very well. These children can be challenging to parent at all times, so their parents likely manage a higher general level of parenting stress, and can benefit from your inquiry and additional resources.
A parent’s task of supervising is different with adolescents than with younger children. It is as much about effective communication and modeling how to assess risk and make judgments as it is about time spent watching the children. But these tasks take time and patience, perhaps even more than the supervision of younger kids. And while a teenager may have good judgment, who her friends are matters as much as her own judgment. Teenagers take more chances when they are with friends, and particularly with thrill-seeking friends. If parents are too distracted or busy to know who their teenager is spending time with, that itself raises the teenager’s chances of risky behaviors and accidental injury.
Of course, when teenagers are experimenting with alcohol or drugs, the risk of serious accidents increases significantly. The Centers for Disease Control and Prevention estimates that approximately half of the nonmedical deaths of 15- to 24-year-olds involve drug or alcohol use. Stressed parents are less likely to be spending time with their teenagers to ask about drugs and alcohol: Who is using them? When and where? What else are they hearing about drugs and alcohol? It also takes time and a calm, clear, and open presence to talk with teenagers about expectations and ground rules around drug or alcohol experimentation (which has been shown to diminish the rate of regular use of drugs or alcohol in teens by as much as half). It takes time for parents to explain to their teenager that they should ALWAYS call home if they are anywhere they do not feel safe, even if it involves drugs or alcohol. It is complex to set rules and expectations while also being clear that their safety always comes first. You can encourage parents to know their teen’s friends, and to have a conversation about the rules around drug and alcohol use and to set a safety plan. Parents who are too stressed to even know where to start will benefit from a longer conversation, and can be referred to some good websites or for a mental health consultation.
Summer should be a time of skill building, adventure, growing independence, and some rest and relaxation. Helping parents to pay attention to their own stress level and access needed supports may be the critical factor in preventing accidents and promoting the health and well being of their children during this wonderful, but risky season.
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 (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston.
Summer is upon us, a season of delight for children and teens. School is out, the days are long, warm, and full of activities they get to choose. But we know that summer is also the season of accidents. While adventurous activities can lead to scratches, sprains, and broken bones, many accidents are far more serious. The Centers for Disease Control and Prevention reported that in 2014 (the most recent data available), accidental injuries were the leading cause of death for children from the age of 1 year through young adulthood (age 24 years). Car accidents, drowning, burns, suffocation, poisoning, and being struck while on a bike or other vehicle are the most prominent causes of injury or death in youth.
When something is an “accident,” we understand it to be an unfortunate event that happened by chance, without deliberate cause, and not easily foreseeable or preventable. But many accidents that befall children, while not deliberate, might be more foreseeable and preventable than they first appear. With younger children, parents directly oversee their children, ensuring they wear bike helmets, are placed in appropriate car restraints, cannot play with lighters, are always in sight when learning to swim (with a family pool well fenced and locked), and have no access to guns (and the guns are not loaded and have trigger locks!).
As their children grow older, parents must manage the challenging task of teaching their children to manage risk as they cultivate independence: learning to always put on their bike helmet before riding home from school, avoiding diving into shallow water, and not riding in a car with an impaired driver. Both the direct supervision of younger children and the teaching of older children and teenagers are very demanding of time and energy for parents. Terrible accidents can occur during truly unpredictable moments of distraction, but for too many parents, these moments of distraction are in fact predictable. If parents are strained by financial troubles, a disintegrating marriage, a serious illness in a spouse or elderly parent, or their own mental illness, their ability to be fully present and patient to supervise their children will be predictably impaired. During the summer months, when children may be home all day and looking for adventure, parental stress and distraction result in a high-risk environment that makes serious accidents more likely.
You as a child care provider are wonderful at providing supportive reminders to parents about the basics of child safety and supervision. Every checkup includes questions about whether anyone smokes at home and whether there is a working smoke detector. You ask about bike helmets and booster seats, and whether there are firearms in the home and if so, whether they are properly stored and locked. While there are often no formal questions about the level of family stress at a checkup, it would be simple to add: “Would you say the stress level at home is low, moderate, or high?” Such an open-ended question could lead to discussion of those factors that might be causing stress and give you a quick sense of how equipped the parent (or parents) are to handle it. Without a doubt, physicians’ practices are themselves stressed for time, and asking parents about their own stress may seem like opening Pandora’s box. But by being curious, bringing the important matter of domestic stress into the conversation about a child’s health and well being can by itself be therapeutic. The parents found the time to bring their child to this appointment, despite their stress. By simply bringing their awareness to the impact their stress could have on the safety of their children, you may have made a critical difference.
When parents report a high level of stress, you might follow up with more specific questions about their supports. Who provides them with practical help or a supportive ear? Do they have a strong community of friends, nearby family, or a supportive faith community? Are there practical ways to outsource some of the demands they may be juggling? You should be prepared to offer resources if a parent reports domestic violence. Some pediatric practices will employ social workers who can facilitate connecting stressed families with appropriate resources. But if your practice does not, a little time online can build a database of virtual and community resources that a family can start with.
You are also in a unique position to appreciate that certain children are themselves at higher risk for accidents. Children and adolescents with attention-deficit/hyperactivity disorder may be more distractible and impulsive than their peers. And summer is often a season when families decide to suspend stimulant treatment to promote weight gain or growth. These children and teens are at elevated risk to “leap before they look,” and parents should be reminded of their higher level of risk and need for supervision, at least when having a conversation about whether to suspend stimulant treatment. Children with a history of oppositional behaviors also can prove more challenging to supervise than their peers. Beyond the risk of self-injury or suicide, youth with depressive disorders can have impaired concentration and attention, and may not assess the risk of certain activities very well. These children can be challenging to parent at all times, so their parents likely manage a higher general level of parenting stress, and can benefit from your inquiry and additional resources.
A parent’s task of supervising is different with adolescents than with younger children. It is as much about effective communication and modeling how to assess risk and make judgments as it is about time spent watching the children. But these tasks take time and patience, perhaps even more than the supervision of younger kids. And while a teenager may have good judgment, who her friends are matters as much as her own judgment. Teenagers take more chances when they are with friends, and particularly with thrill-seeking friends. If parents are too distracted or busy to know who their teenager is spending time with, that itself raises the teenager’s chances of risky behaviors and accidental injury.
Of course, when teenagers are experimenting with alcohol or drugs, the risk of serious accidents increases significantly. The Centers for Disease Control and Prevention estimates that approximately half of the nonmedical deaths of 15- to 24-year-olds involve drug or alcohol use. Stressed parents are less likely to be spending time with their teenagers to ask about drugs and alcohol: Who is using them? When and where? What else are they hearing about drugs and alcohol? It also takes time and a calm, clear, and open presence to talk with teenagers about expectations and ground rules around drug or alcohol experimentation (which has been shown to diminish the rate of regular use of drugs or alcohol in teens by as much as half). It takes time for parents to explain to their teenager that they should ALWAYS call home if they are anywhere they do not feel safe, even if it involves drugs or alcohol. It is complex to set rules and expectations while also being clear that their safety always comes first. You can encourage parents to know their teen’s friends, and to have a conversation about the rules around drug and alcohol use and to set a safety plan. Parents who are too stressed to even know where to start will benefit from a longer conversation, and can be referred to some good websites or for a mental health consultation.
Summer should be a time of skill building, adventure, growing independence, and some rest and relaxation. Helping parents to pay attention to their own stress level and access needed supports may be the critical factor in preventing accidents and promoting the health and well being of their children during this wonderful, but risky season.
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 (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston.
Summer is upon us, a season of delight for children and teens. School is out, the days are long, warm, and full of activities they get to choose. But we know that summer is also the season of accidents. While adventurous activities can lead to scratches, sprains, and broken bones, many accidents are far more serious. The Centers for Disease Control and Prevention reported that in 2014 (the most recent data available), accidental injuries were the leading cause of death for children from the age of 1 year through young adulthood (age 24 years). Car accidents, drowning, burns, suffocation, poisoning, and being struck while on a bike or other vehicle are the most prominent causes of injury or death in youth.
When something is an “accident,” we understand it to be an unfortunate event that happened by chance, without deliberate cause, and not easily foreseeable or preventable. But many accidents that befall children, while not deliberate, might be more foreseeable and preventable than they first appear. With younger children, parents directly oversee their children, ensuring they wear bike helmets, are placed in appropriate car restraints, cannot play with lighters, are always in sight when learning to swim (with a family pool well fenced and locked), and have no access to guns (and the guns are not loaded and have trigger locks!).
As their children grow older, parents must manage the challenging task of teaching their children to manage risk as they cultivate independence: learning to always put on their bike helmet before riding home from school, avoiding diving into shallow water, and not riding in a car with an impaired driver. Both the direct supervision of younger children and the teaching of older children and teenagers are very demanding of time and energy for parents. Terrible accidents can occur during truly unpredictable moments of distraction, but for too many parents, these moments of distraction are in fact predictable. If parents are strained by financial troubles, a disintegrating marriage, a serious illness in a spouse or elderly parent, or their own mental illness, their ability to be fully present and patient to supervise their children will be predictably impaired. During the summer months, when children may be home all day and looking for adventure, parental stress and distraction result in a high-risk environment that makes serious accidents more likely.
You as a child care provider are wonderful at providing supportive reminders to parents about the basics of child safety and supervision. Every checkup includes questions about whether anyone smokes at home and whether there is a working smoke detector. You ask about bike helmets and booster seats, and whether there are firearms in the home and if so, whether they are properly stored and locked. While there are often no formal questions about the level of family stress at a checkup, it would be simple to add: “Would you say the stress level at home is low, moderate, or high?” Such an open-ended question could lead to discussion of those factors that might be causing stress and give you a quick sense of how equipped the parent (or parents) are to handle it. Without a doubt, physicians’ practices are themselves stressed for time, and asking parents about their own stress may seem like opening Pandora’s box. But by being curious, bringing the important matter of domestic stress into the conversation about a child’s health and well being can by itself be therapeutic. The parents found the time to bring their child to this appointment, despite their stress. By simply bringing their awareness to the impact their stress could have on the safety of their children, you may have made a critical difference.
When parents report a high level of stress, you might follow up with more specific questions about their supports. Who provides them with practical help or a supportive ear? Do they have a strong community of friends, nearby family, or a supportive faith community? Are there practical ways to outsource some of the demands they may be juggling? You should be prepared to offer resources if a parent reports domestic violence. Some pediatric practices will employ social workers who can facilitate connecting stressed families with appropriate resources. But if your practice does not, a little time online can build a database of virtual and community resources that a family can start with.
You are also in a unique position to appreciate that certain children are themselves at higher risk for accidents. Children and adolescents with attention-deficit/hyperactivity disorder may be more distractible and impulsive than their peers. And summer is often a season when families decide to suspend stimulant treatment to promote weight gain or growth. These children and teens are at elevated risk to “leap before they look,” and parents should be reminded of their higher level of risk and need for supervision, at least when having a conversation about whether to suspend stimulant treatment. Children with a history of oppositional behaviors also can prove more challenging to supervise than their peers. Beyond the risk of self-injury or suicide, youth with depressive disorders can have impaired concentration and attention, and may not assess the risk of certain activities very well. These children can be challenging to parent at all times, so their parents likely manage a higher general level of parenting stress, and can benefit from your inquiry and additional resources.
A parent’s task of supervising is different with adolescents than with younger children. It is as much about effective communication and modeling how to assess risk and make judgments as it is about time spent watching the children. But these tasks take time and patience, perhaps even more than the supervision of younger kids. And while a teenager may have good judgment, who her friends are matters as much as her own judgment. Teenagers take more chances when they are with friends, and particularly with thrill-seeking friends. If parents are too distracted or busy to know who their teenager is spending time with, that itself raises the teenager’s chances of risky behaviors and accidental injury.
Of course, when teenagers are experimenting with alcohol or drugs, the risk of serious accidents increases significantly. The Centers for Disease Control and Prevention estimates that approximately half of the nonmedical deaths of 15- to 24-year-olds involve drug or alcohol use. Stressed parents are less likely to be spending time with their teenagers to ask about drugs and alcohol: Who is using them? When and where? What else are they hearing about drugs and alcohol? It also takes time and a calm, clear, and open presence to talk with teenagers about expectations and ground rules around drug or alcohol experimentation (which has been shown to diminish the rate of regular use of drugs or alcohol in teens by as much as half). It takes time for parents to explain to their teenager that they should ALWAYS call home if they are anywhere they do not feel safe, even if it involves drugs or alcohol. It is complex to set rules and expectations while also being clear that their safety always comes first. You can encourage parents to know their teen’s friends, and to have a conversation about the rules around drug and alcohol use and to set a safety plan. Parents who are too stressed to even know where to start will benefit from a longer conversation, and can be referred to some good websites or for a mental health consultation.
Summer should be a time of skill building, adventure, growing independence, and some rest and relaxation. Helping parents to pay attention to their own stress level and access needed supports may be the critical factor in preventing accidents and promoting the health and well being of their children during this wonderful, but risky season.
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 (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston.
