Behavioral Consult

We have all been using technology in our primary care practices for a long time but newer formats have been emerging so fast that our minds, much less our staff’s minds, may be spinning.

Our old friend the telephone, a time-soaking nemesis for scheduling, checking coverage, questions calls, prescribing, quick consults, and follow-up is being replaced by EHR portals and SMS for messaging (e.g. DoctorConnect, SimplePractice), drop-in televisits and patient education links on our websites (e.g. Schmitt Pediatric Care, Remedy Connect), and chatbots for scheduling (e.g. CHEC-UP). While time is saved, what is lost may be hearing the subtext of anxiety or misperceptions in parents’ voices that would change our advice and the empathetic human connection in conversations with our patients. A hybrid approach may be better.

The paper appointment book has been replaced by scheduling systems sometimes lacking in flexibility for double booking, sibling visits, and variable length or extremely valuable multi-professional visits. Allowing patients to book their own visits may place complex problems in inappropriate slots, so only allowing online requests for visits is safer. On the other hand, many of us can now squeeze in “same day” televisits (e.g. Blueberry Pediatrics), sometimes from outside our practice (e.g., zocdoc), to increase payments and even entice new patients to enroll.

Amazing advances in technology are being made in specialty care such as genetic modifications (CRISPR), immunotherapies (mRNA vaccines and AI drug design), robot-assisted surgery, and 3-D printing of body parts and prosthetics. Technology as treatment such as transcranial magnetic stimulation and vagal stimulation are finding value in psychiatry.

But beside being aware of and able to order such specialty technologies, innovations are now extending our senses in primary care such as amplified or visual stethoscopes, bedside ultrasound (e.g. Butterfly), remote visualization (oto-, endo-)scopes, photographic vision screens (e.g. iScreen) for skin lesion (VisualDx) and genetic syndrome facial recognition. We need to be sure that technologies are tested and calibrated for children and different racial groups and genders to provide safe and equitable care. Early adoption may not always be the best approach. Costs of technology, as usual, may limit access to these advanced care aids especially, as usual, in practices serving low income and rural communities.

Patients, especially younger parents and youth, now expect to participate and can directly benefit from technology as part of their health care. Validated parent or self-report screens (e.g. EHRs, Phreesia) can detect important issues early for more effective intervention. Such questionnaires typically provide a pass/fail result or score, but other delivery systems (e.g. CHADIS) include interpretation, assist patients/parents in setting visit priorities and health goals, and even chain results of one questionnaire to secondary screens to hone in on problems, sometimes obviating a time-consuming second visit. Patient-completed comprehensive questionnaires (e.g. Well Visit Planner, CHADIS) allow us time to use our skills to focus on concerns, education, and management rather than asking myriad routine questions. Some (e.g. CHADIS) even create visit documentation reducing our “pajama time” write ups (and burnout); automate repeated online measures to track progress; and use questionnaire results to trigger related patient-specific education and resources rather than the often-ignored generic EHR handouts.

Digital therapeutics such as apps for anxiety (e.g. Calm), depression (e.g. SparkRx, Cass), weight control (e.g. Noom, Lose it), fitness, or sleep tracking (e.g. Whoop) help educate and, in some cases, provide real-time feedback to personalize discovery of contributing factors in order to maintain motivation for positive health behavior change. Some video games improve ADHD symptoms (e.g. EndeavorRX). Virtual reality scenarios have been shown to desensitize those with PTSD and social anxiety or teach social skills to children with autism.

Systems that trigger resource listings (including apps) from screen results can help, but now with over 10,000 apps for mental health, knowing what to recommend for what conditions is a challenge for which ratings (e.g. MINDapps.org) can help. With few product reps visiting to tell us what’s new, we need to read critically about innovations, search the web, subscribe to the AAP SOAPM LISTSERV, visit exhibitors at professional meetings, and talk with peers.

All the digital data collected from health care technology, if assembled with privacy constraints and analyzed with advanced statistical methods, have the possibility, with or without inclusion of genomic data, to allow for more accurate diagnostic and treatment decision support. While AI can search widely for patterns, it needs to be “trained” on appropriate data to make correct conclusions. We are all aware that the history determines 85% of both diagnosis and treatment decisions, particularly in primary care where x-rays or lab tests are not often needed.

But history in EHR notes is often idiosyncratic, entered hours after the visit by the clinician, and does not include the information needed to define diagnostic or guideline criteria, even if the clinician knows and considered those criteria. EHR templates are presented blank and are onerous and time consuming for clinicians. In addition, individual patient barriers to care, preferences, and environmental or subjective concerns are infrequently documented even though they may make the biggest difference to adherence and/or outcomes.

Notes made from voice to text digital AI translation of the encounter (e.g. Nuance DAX) are even less likely to include diagnostic criteria as it would be inappropriate to speak these. To use EHR history data to train AI and to test efficacy of care using variations of guidelines, guideline-related data is needed from online patient entries in questionnaires that are transformed to fill in templates along with some structured choices for clinician entries forming visit notes (e.g. CHADIS). New apps to facilitate clinician documentation of guidelines (e.g. AvoMD) could streamline visits as well as help document guideline criteria. The resulting combination of guideline-relevant patient histories and objective data to test and iteratively refine guidelines will allow a process known as a “Learning Health System.”

Technology to collect this kind of data can allow for the aspirational American Academy of Pediatrics CHILD Registry to approach this goal. Population-level data can provide surveillance for illness, toxins, effects of climate change, social drivers of health, and even effects of technologies themselves such as social media and remote learning so that we can attempt to make the best choices for the future.

Clinicians, staff, and patients will need to develop trust in technology as it infiltrates all aspects of health care. Professionals need both evidence and experience to trust a technology, which takes time and effort. Disinformation in the media may reduce trust or evoke unwarranted trust, as we have all seen regarding vaccines. Clear and coherent public health messaging can help but is no longer a panacea for developing trust in health care. Our nonjudgmental listening and informed opinions are needed more than ever.

The biggest issues for new technology are likely to be the need for workflow adjustments, changing our habit patterns, training, and cost/benefit analyses. With today’s high staff churn, confusion and even chaos can ensue when adopting new technology.

Staff need to be part of the selection process, if at all possible, and discuss how roles and flow will need to change. Having one staff member be a champion and expert for new tech can move adoption to a shared process rather than imposing “one more thing.” It is crucial to discuss the benefits for patients and staff even if the change is required. Sometimes cost savings can include a bonus for staff or free group lunches. Providing a certificate of achievement or title promotion for mastering new tech may be appropriate. Giving some time off from other tasks to learn new workflows can reduce resistance rather than just adding it on to a regular workload. Office “huddles” going forward can include examples of benefits staff have observed or heard about from the adoption. There are quality improvement processes that engage the team — some that earn MOC-4 or CEU credits — that apply to making workflow changes and measuring them iteratively.

If technology takes over important aspects of the work of medical professionals, even if it is faster and/or more accurate, it may degrade clinical observational, interactional, and decision-making skills through lack of use. It may also remove the sense of self-efficacy that motivates professionals to endure onerous training and desire to enter the field. Using technology may reduce empathetic interactions that are basic to humanistic motivation, work satisfaction, and even community respect. Moral injury is already rampant in medicine from restrictions on freedom to do what we see as important for our patients. Technology has great potential and already is enhancing our ability to provide the best care for patients but the risks need to be watched for and ameliorated.

When technology automates comprehensive visit documentation that highlights priority and risk areas from patient input and individualizes decision support, it can facilitate the personalized care that we and our patients want to experience. We must not be so awed, intrigued, or wary of new technology to miss its benefits nor give up our good clinical judgment about the technology or about our patients.

Dr. Howard is assistant professor of pediatrics at The Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

We have all been using technology in our primary care practices for a long time but newer formats have been emerging so fast that our minds, much less our staff’s minds, may be spinning.

Our old friend the telephone, a time-soaking nemesis for scheduling, checking coverage, questions calls, prescribing, quick consults, and follow-up is being replaced by EHR portals and SMS for messaging (e.g. DoctorConnect, SimplePractice), drop-in televisits and patient education links on our websites (e.g. Schmitt Pediatric Care, Remedy Connect), and chatbots for scheduling (e.g. CHEC-UP). While time is saved, what is lost may be hearing the subtext of anxiety or misperceptions in parents’ voices that would change our advice and the empathetic human connection in conversations with our patients. A hybrid approach may be better.

The paper appointment book has been replaced by scheduling systems sometimes lacking in flexibility for double booking, sibling visits, and variable length or extremely valuable multi-professional visits. Allowing patients to book their own visits may place complex problems in inappropriate slots, so only allowing online requests for visits is safer. On the other hand, many of us can now squeeze in “same day” televisits (e.g. Blueberry Pediatrics), sometimes from outside our practice (e.g., zocdoc), to increase payments and even entice new patients to enroll.

Amazing advances in technology are being made in specialty care such as genetic modifications (CRISPR), immunotherapies (mRNA vaccines and AI drug design), robot-assisted surgery, and 3-D printing of body parts and prosthetics. Technology as treatment such as transcranial magnetic stimulation and vagal stimulation are finding value in psychiatry.

But beside being aware of and able to order such specialty technologies, innovations are now extending our senses in primary care such as amplified or visual stethoscopes, bedside ultrasound (e.g. Butterfly), remote visualization (oto-, endo-)scopes, photographic vision screens (e.g. iScreen) for skin lesion (VisualDx) and genetic syndrome facial recognition. We need to be sure that technologies are tested and calibrated for children and different racial groups and genders to provide safe and equitable care. Early adoption may not always be the best approach. Costs of technology, as usual, may limit access to these advanced care aids especially, as usual, in practices serving low income and rural communities.

Patients, especially younger parents and youth, now expect to participate and can directly benefit from technology as part of their health care. Validated parent or self-report screens (e.g. EHRs, Phreesia) can detect important issues early for more effective intervention. Such questionnaires typically provide a pass/fail result or score, but other delivery systems (e.g. CHADIS) include interpretation, assist patients/parents in setting visit priorities and health goals, and even chain results of one questionnaire to secondary screens to hone in on problems, sometimes obviating a time-consuming second visit. Patient-completed comprehensive questionnaires (e.g. Well Visit Planner, CHADIS) allow us time to use our skills to focus on concerns, education, and management rather than asking myriad routine questions. Some (e.g. CHADIS) even create visit documentation reducing our “pajama time” write ups (and burnout); automate repeated online measures to track progress; and use questionnaire results to trigger related patient-specific education and resources rather than the often-ignored generic EHR handouts.

Digital therapeutics such as apps for anxiety (e.g. Calm), depression (e.g. SparkRx, Cass), weight control (e.g. Noom, Lose it), fitness, or sleep tracking (e.g. Whoop) help educate and, in some cases, provide real-time feedback to personalize discovery of contributing factors in order to maintain motivation for positive health behavior change. Some video games improve ADHD symptoms (e.g. EndeavorRX). Virtual reality scenarios have been shown to desensitize those with PTSD and social anxiety or teach social skills to children with autism.

Systems that trigger resource listings (including apps) from screen results can help, but now with over 10,000 apps for mental health, knowing what to recommend for what conditions is a challenge for which ratings (e.g. MINDapps.org) can help. With few product reps visiting to tell us what’s new, we need to read critically about innovations, search the web, subscribe to the AAP SOAPM LISTSERV, visit exhibitors at professional meetings, and talk with peers.

All the digital data collected from health care technology, if assembled with privacy constraints and analyzed with advanced statistical methods, have the possibility, with or without inclusion of genomic data, to allow for more accurate diagnostic and treatment decision support. While AI can search widely for patterns, it needs to be “trained” on appropriate data to make correct conclusions. We are all aware that the history determines 85% of both diagnosis and treatment decisions, particularly in primary care where x-rays or lab tests are not often needed.

But history in EHR notes is often idiosyncratic, entered hours after the visit by the clinician, and does not include the information needed to define diagnostic or guideline criteria, even if the clinician knows and considered those criteria. EHR templates are presented blank and are onerous and time consuming for clinicians. In addition, individual patient barriers to care, preferences, and environmental or subjective concerns are infrequently documented even though they may make the biggest difference to adherence and/or outcomes.

Notes made from voice to text digital AI translation of the encounter (e.g. Nuance DAX) are even less likely to include diagnostic criteria as it would be inappropriate to speak these. To use EHR history data to train AI and to test efficacy of care using variations of guidelines, guideline-related data is needed from online patient entries in questionnaires that are transformed to fill in templates along with some structured choices for clinician entries forming visit notes (e.g. CHADIS). New apps to facilitate clinician documentation of guidelines (e.g. AvoMD) could streamline visits as well as help document guideline criteria. The resulting combination of guideline-relevant patient histories and objective data to test and iteratively refine guidelines will allow a process known as a “Learning Health System.”

Technology to collect this kind of data can allow for the aspirational American Academy of Pediatrics CHILD Registry to approach this goal. Population-level data can provide surveillance for illness, toxins, effects of climate change, social drivers of health, and even effects of technologies themselves such as social media and remote learning so that we can attempt to make the best choices for the future.

Clinicians, staff, and patients will need to develop trust in technology as it infiltrates all aspects of health care. Professionals need both evidence and experience to trust a technology, which takes time and effort. Disinformation in the media may reduce trust or evoke unwarranted trust, as we have all seen regarding vaccines. Clear and coherent public health messaging can help but is no longer a panacea for developing trust in health care. Our nonjudgmental listening and informed opinions are needed more than ever.

The biggest issues for new technology are likely to be the need for workflow adjustments, changing our habit patterns, training, and cost/benefit analyses. With today’s high staff churn, confusion and even chaos can ensue when adopting new technology.

Staff need to be part of the selection process, if at all possible, and discuss how roles and flow will need to change. Having one staff member be a champion and expert for new tech can move adoption to a shared process rather than imposing “one more thing.” It is crucial to discuss the benefits for patients and staff even if the change is required. Sometimes cost savings can include a bonus for staff or free group lunches. Providing a certificate of achievement or title promotion for mastering new tech may be appropriate. Giving some time off from other tasks to learn new workflows can reduce resistance rather than just adding it on to a regular workload. Office “huddles” going forward can include examples of benefits staff have observed or heard about from the adoption. There are quality improvement processes that engage the team — some that earn MOC-4 or CEU credits — that apply to making workflow changes and measuring them iteratively.

If technology takes over important aspects of the work of medical professionals, even if it is faster and/or more accurate, it may degrade clinical observational, interactional, and decision-making skills through lack of use. It may also remove the sense of self-efficacy that motivates professionals to endure onerous training and desire to enter the field. Using technology may reduce empathetic interactions that are basic to humanistic motivation, work satisfaction, and even community respect. Moral injury is already rampant in medicine from restrictions on freedom to do what we see as important for our patients. Technology has great potential and already is enhancing our ability to provide the best care for patients but the risks need to be watched for and ameliorated.

When technology automates comprehensive visit documentation that highlights priority and risk areas from patient input and individualizes decision support, it can facilitate the personalized care that we and our patients want to experience. We must not be so awed, intrigued, or wary of new technology to miss its benefits nor give up our good clinical judgment about the technology or about our patients.

Dr. Howard is assistant professor of pediatrics at The Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

We have all been using technology in our primary care practices for a long time but newer formats have been emerging so fast that our minds, much less our staff’s minds, may be spinning.

Our old friend the telephone, a time-soaking nemesis for scheduling, checking coverage, questions calls, prescribing, quick consults, and follow-up is being replaced by EHR portals and SMS for messaging (e.g. DoctorConnect, SimplePractice), drop-in televisits and patient education links on our websites (e.g. Schmitt Pediatric Care, Remedy Connect), and chatbots for scheduling (e.g. CHEC-UP). While time is saved, what is lost may be hearing the subtext of anxiety or misperceptions in parents’ voices that would change our advice and the empathetic human connection in conversations with our patients. A hybrid approach may be better.

The paper appointment book has been replaced by scheduling systems sometimes lacking in flexibility for double booking, sibling visits, and variable length or extremely valuable multi-professional visits. Allowing patients to book their own visits may place complex problems in inappropriate slots, so only allowing online requests for visits is safer. On the other hand, many of us can now squeeze in “same day” televisits (e.g. Blueberry Pediatrics), sometimes from outside our practice (e.g., zocdoc), to increase payments and even entice new patients to enroll.

Amazing advances in technology are being made in specialty care such as genetic modifications (CRISPR), immunotherapies (mRNA vaccines and AI drug design), robot-assisted surgery, and 3-D printing of body parts and prosthetics. Technology as treatment such as transcranial magnetic stimulation and vagal stimulation are finding value in psychiatry.

But beside being aware of and able to order such specialty technologies, innovations are now extending our senses in primary care such as amplified or visual stethoscopes, bedside ultrasound (e.g. Butterfly), remote visualization (oto-, endo-)scopes, photographic vision screens (e.g. iScreen) for skin lesion (VisualDx) and genetic syndrome facial recognition. We need to be sure that technologies are tested and calibrated for children and different racial groups and genders to provide safe and equitable care. Early adoption may not always be the best approach. Costs of technology, as usual, may limit access to these advanced care aids especially, as usual, in practices serving low income and rural communities.

Patients, especially younger parents and youth, now expect to participate and can directly benefit from technology as part of their health care. Validated parent or self-report screens (e.g. EHRs, Phreesia) can detect important issues early for more effective intervention. Such questionnaires typically provide a pass/fail result or score, but other delivery systems (e.g. CHADIS) include interpretation, assist patients/parents in setting visit priorities and health goals, and even chain results of one questionnaire to secondary screens to hone in on problems, sometimes obviating a time-consuming second visit. Patient-completed comprehensive questionnaires (e.g. Well Visit Planner, CHADIS) allow us time to use our skills to focus on concerns, education, and management rather than asking myriad routine questions. Some (e.g. CHADIS) even create visit documentation reducing our “pajama time” write ups (and burnout); automate repeated online measures to track progress; and use questionnaire results to trigger related patient-specific education and resources rather than the often-ignored generic EHR handouts.

Digital therapeutics such as apps for anxiety (e.g. Calm), depression (e.g. SparkRx, Cass), weight control (e.g. Noom, Lose it), fitness, or sleep tracking (e.g. Whoop) help educate and, in some cases, provide real-time feedback to personalize discovery of contributing factors in order to maintain motivation for positive health behavior change. Some video games improve ADHD symptoms (e.g. EndeavorRX). Virtual reality scenarios have been shown to desensitize those with PTSD and social anxiety or teach social skills to children with autism.

Systems that trigger resource listings (including apps) from screen results can help, but now with over 10,000 apps for mental health, knowing what to recommend for what conditions is a challenge for which ratings (e.g. MINDapps.org) can help. With few product reps visiting to tell us what’s new, we need to read critically about innovations, search the web, subscribe to the AAP SOAPM LISTSERV, visit exhibitors at professional meetings, and talk with peers.

All the digital data collected from health care technology, if assembled with privacy constraints and analyzed with advanced statistical methods, have the possibility, with or without inclusion of genomic data, to allow for more accurate diagnostic and treatment decision support. While AI can search widely for patterns, it needs to be “trained” on appropriate data to make correct conclusions. We are all aware that the history determines 85% of both diagnosis and treatment decisions, particularly in primary care where x-rays or lab tests are not often needed.

But history in EHR notes is often idiosyncratic, entered hours after the visit by the clinician, and does not include the information needed to define diagnostic or guideline criteria, even if the clinician knows and considered those criteria. EHR templates are presented blank and are onerous and time consuming for clinicians. In addition, individual patient barriers to care, preferences, and environmental or subjective concerns are infrequently documented even though they may make the biggest difference to adherence and/or outcomes.

Notes made from voice to text digital AI translation of the encounter (e.g. Nuance DAX) are even less likely to include diagnostic criteria as it would be inappropriate to speak these. To use EHR history data to train AI and to test efficacy of care using variations of guidelines, guideline-related data is needed from online patient entries in questionnaires that are transformed to fill in templates along with some structured choices for clinician entries forming visit notes (e.g. CHADIS). New apps to facilitate clinician documentation of guidelines (e.g. AvoMD) could streamline visits as well as help document guideline criteria. The resulting combination of guideline-relevant patient histories and objective data to test and iteratively refine guidelines will allow a process known as a “Learning Health System.”

Technology to collect this kind of data can allow for the aspirational American Academy of Pediatrics CHILD Registry to approach this goal. Population-level data can provide surveillance for illness, toxins, effects of climate change, social drivers of health, and even effects of technologies themselves such as social media and remote learning so that we can attempt to make the best choices for the future.

Clinicians, staff, and patients will need to develop trust in technology as it infiltrates all aspects of health care. Professionals need both evidence and experience to trust a technology, which takes time and effort. Disinformation in the media may reduce trust or evoke unwarranted trust, as we have all seen regarding vaccines. Clear and coherent public health messaging can help but is no longer a panacea for developing trust in health care. Our nonjudgmental listening and informed opinions are needed more than ever.

The biggest issues for new technology are likely to be the need for workflow adjustments, changing our habit patterns, training, and cost/benefit analyses. With today’s high staff churn, confusion and even chaos can ensue when adopting new technology.

Staff need to be part of the selection process, if at all possible, and discuss how roles and flow will need to change. Having one staff member be a champion and expert for new tech can move adoption to a shared process rather than imposing “one more thing.” It is crucial to discuss the benefits for patients and staff even if the change is required. Sometimes cost savings can include a bonus for staff or free group lunches. Providing a certificate of achievement or title promotion for mastering new tech may be appropriate. Giving some time off from other tasks to learn new workflows can reduce resistance rather than just adding it on to a regular workload. Office “huddles” going forward can include examples of benefits staff have observed or heard about from the adoption. There are quality improvement processes that engage the team — some that earn MOC-4 or CEU credits — that apply to making workflow changes and measuring them iteratively.

If technology takes over important aspects of the work of medical professionals, even if it is faster and/or more accurate, it may degrade clinical observational, interactional, and decision-making skills through lack of use. It may also remove the sense of self-efficacy that motivates professionals to endure onerous training and desire to enter the field. Using technology may reduce empathetic interactions that are basic to humanistic motivation, work satisfaction, and even community respect. Moral injury is already rampant in medicine from restrictions on freedom to do what we see as important for our patients. Technology has great potential and already is enhancing our ability to provide the best care for patients but the risks need to be watched for and ameliorated.

When technology automates comprehensive visit documentation that highlights priority and risk areas from patient input and individualizes decision support, it can facilitate the personalized care that we and our patients want to experience. We must not be so awed, intrigued, or wary of new technology to miss its benefits nor give up our good clinical judgment about the technology or about our patients.

Dr. Howard is assistant professor of pediatrics at The Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

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

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

Suicide screening

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

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

Who is at greater risk?

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

Focus on the patient

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

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

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

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

Next steps

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

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

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

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

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

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

Suicide screening

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

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

Who is at greater risk?

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

Focus on the patient

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

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

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

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

Next steps

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

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

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

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

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

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

Suicide screening

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

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

Who is at greater risk?

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

Focus on the patient

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

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

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

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

Next steps

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

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

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

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

Checking on the well-being of mothers is one of the important acknowledged aspects of primary pediatric care. “How are you doing?” directed to the child’s mother has long been considered an appropriate question. The AAP recommends several checks in the Bright Futures Guidelines, including conducting several formal screens for depression and asking about “getting time alone with your partner” as well as other supports.

But I have recently become aware of new data that changes my ideas about what we pediatricians need to be doing as part of our care for children and their families, especially in the first year: Considering the risks to the mother of dying.

Maternal mortality increased by 26.6% from 2000 to 2014 across the United States such that it is higher now than it was for our own mothers. The U.S. now has the highest rates of maternal mortality among high-income nations, especially for Black, American Indian, or Alaska Native women, those of lower socioeconomic status, and those under 18 or over 35 years old.

You may be thinking, well, that is an issue for ob.gyns. Indeed, the most common reasons for maternal death are cardiovascular: hemorrhage, hypertensive disorders, deep vein thrombosis, and stroke, all usually occurring at or in the first week after birth. You may have heard about sudden unexpected heart failure from postpartum cardiomyopathy, although rare (1 in 1,000-4,000), presenting from 1 month pre birth to 5 months post delivery, which is when we may be the main clinicians seeing the mother, not the ob.gyns. This can be easily missed since it presents with shortness of breath and decreased exercise tolerance, fatigue, palpitations, and/or leg swelling. Serious eclampsia may have only symptoms of headache or abdominal pain. All of these may easily be mistaken for lingering pregnancy symptoms. But in higher income countries, such as the U.S., 38% of maternal deaths occur from 8 to 42 days after birth, the period for fatal infections as well as cardiac complications. Elevated risk for all of these causes of mortality include Black race, obesity, tobacco use, congenital heart disease, and being older than 40.

As pediatric providers, we may see mothers along with their infants as newborns in the hospital, at day 2, at 2 weeks, or even at 1-2 months after birth, potentially before their one recommended postnatal obstetric visit at 3-8 weeks. Asking the mother how she is feeling at those times should not just be a social nicety but rather an additional check for serious postnatal complications.
 

Additional concerns

But wait, it gets worse.

Did you know that the leading cause of maternal death from pregnancy up to 1 year after a birth is homicide?

Maternal perinatal mortality figures have not usually included “perinatal-associated” deaths, a maternal death attributable to a condition that is unaffected by the pregnancy and occurring within 1 year of delivery (that I will cite as perinatal henceforth). While half of maternal deaths occur during pregnancy, another half occur in the year following. There were 3.62 homicides per 100,000 live births among females who were pregnant or within 1 year postpartum, 16% more than for similarly aged nonpregnant and nonpostpartum women (3.12 deaths/100,000 population, P < .05). Homicides made up 8.4% of reported perinatal maternal deaths from all causes, with a rate of 1.7 per 100,000 live births, twice the rate of any one of the other leading causes noted above. Black women had seven times the risk of perinatal homicide as that of White women. Females under 20, many of them our own pediatric patients, had a greater than six times higher risk and those aged 20-24 had a 65% higher risk of pregnancy-associated homicide across race and ethnic groups. Homicide is most likely before 21 weeks of pregnancy, decreases in the third trimester, but increases again after birth. Two-thirds of pregnancy-associated homicide deaths occurred in the home, with the perpetrator a current or prior partner (> 59%, with 98% being male), 45%-50% were associated with reported intimate partner violence (IPV), and the most common method was a firearm (55%). Often the same women had histories of substance abuse, serious mental illness, and/or prior IPV, all risk factors for pregnancy-associated deaths, including from homicide.

Homicide? “Not the mothers in my practice,” you may say, but, if not homicide, drug-related deaths (3.68 per 100,000 person-years) and suicide (1.42 per 100,000 person-years) together comprise 18% of all maternal deaths. Non-Hispanic White women, Medicaid-insured women, and women residing in smaller cities were especially likely to die from drugs or suicide. More than half (54.3%) of perinatal suicides involve intimate partner conflict, which increases the risk ninefold. Perinatal mood disorders, affecting up to 15% of pregnant and postpartum U.S. women, is also a risk factor in substance abuse, opioid overdose death, and suicide.

And substance use has gotten more dangerous with the increase in fentanyl lacing. Pregnancy-associated deaths (4%-10% of deaths) involving opioids more than doubled between 2007 and 2016, and, although the rates are higher for Black women, the increase has been greater for non-Hispanic White women. Two-thirds of those deaths occur between 6 and 12 months postpartum, on our watch. Although many women decrease substance use during pregnancy, they may fall back into substance use (rates increase 4 times by 7-12 months after delivery) and not continue to receive treatment. Although pharmacotherapy (e.g., methadone, buprenorphine treatment) is the current standard of care for opioid use disorder (OUD) during pregnancy, nearly half receiving treatment in publicly funded centers are not receiving these medications and others may lose insurance or access to pregnancy-related treatment programs after delivery, increasing risk of relapse. Stigma, and punitive or discriminatory approaches to pregnant women with OUD (e.g., jail, removal of children) can dissuade them from participating in treatment, increasing overdose risk.

It is important to note that in more than half of the 41 deaths from violent trauma in one study (including 22 homicides), obstetrical providers knew of or suspected IPV. Also, the vast majority (74%) of those who died by drugs or suicide had made one or more emergency department or hospital visit between their delivery and death, and 39% had made three or more visits. Without knowing if anything was done in those cases, we also know that, in addition to thorough, compassionate providers, there is sometimes segmentation of responsibility, insensitivity, discrimination, racism, stigma, inequity, lack of resources, lack of access, lack of payment mechanisms, legal issues for immigrants, time constraints, and other systemic deficits that may hinder effective care for these and subsequent women.
 

Awareness and action

What should we, who are primary care pediatric providers, do about these threats to the mothers and pregnant young women we care for? Clearly, their children, our main patients, would be terribly and permanently hurt by harm coming to their mothers – the extreme adverse childhood experiences and social determinants of health to which we are already committed.

I hope this article will help alert pediatric providers to what is being published, mainly as women’s health and public health issues.

First, we need awareness of the physical symptoms that may come up in our interactions with pregnant and postpartum women so that we can educate them and expedite any indicated emergency care.

Next, we need to expand our routine screening of mothers and pregnant women from just the most impactful social determinants of health (including depression, substance use, and IPV) to include anxiety, past suicide attempts and current suicidal ideation, and the presence of firearms, early and repeatedly in the first year of the child’s life. Adults and teens are more likely to disclose risk for sensitive issues through questionnaires than through interviews, perhaps even more so when the identified patient is their child rather than themselves. Any screen can have false negatives, so asking directly when risk is suspected is important. The reason for screening could be framed as caring for the caregiver who is the most important person for the child. It could be accompanied by acknowledging that pregnancy and the first year of life can be difficult for mothers and their partners and that we want to support them and connect them to resources, if needed. When substance use disorder is acknowledged, we should prescribe and teach about Narcan for overdose. When there is IPV, we should discuss firearm removal/locking as well as counseling on a personal safety plan.

Working as part of an on-site or virtual team that includes professionals who know about community resources and can coordinate care is essential, in addition to educating about 211 for services and 988 for suicide risk.

Finally, we can advocate and vote for programs, people, and laws that support and safeguard women and families, address substance use, and reduce access to firearms.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

Checking on the well-being of mothers is one of the important acknowledged aspects of primary pediatric care. “How are you doing?” directed to the child’s mother has long been considered an appropriate question. The AAP recommends several checks in the Bright Futures Guidelines, including conducting several formal screens for depression and asking about “getting time alone with your partner” as well as other supports.

But I have recently become aware of new data that changes my ideas about what we pediatricians need to be doing as part of our care for children and their families, especially in the first year: Considering the risks to the mother of dying.

Maternal mortality increased by 26.6% from 2000 to 2014 across the United States such that it is higher now than it was for our own mothers. The U.S. now has the highest rates of maternal mortality among high-income nations, especially for Black, American Indian, or Alaska Native women, those of lower socioeconomic status, and those under 18 or over 35 years old.

You may be thinking, well, that is an issue for ob.gyns. Indeed, the most common reasons for maternal death are cardiovascular: hemorrhage, hypertensive disorders, deep vein thrombosis, and stroke, all usually occurring at or in the first week after birth. You may have heard about sudden unexpected heart failure from postpartum cardiomyopathy, although rare (1 in 1,000-4,000), presenting from 1 month pre birth to 5 months post delivery, which is when we may be the main clinicians seeing the mother, not the ob.gyns. This can be easily missed since it presents with shortness of breath and decreased exercise tolerance, fatigue, palpitations, and/or leg swelling. Serious eclampsia may have only symptoms of headache or abdominal pain. All of these may easily be mistaken for lingering pregnancy symptoms. But in higher income countries, such as the U.S., 38% of maternal deaths occur from 8 to 42 days after birth, the period for fatal infections as well as cardiac complications. Elevated risk for all of these causes of mortality include Black race, obesity, tobacco use, congenital heart disease, and being older than 40.

As pediatric providers, we may see mothers along with their infants as newborns in the hospital, at day 2, at 2 weeks, or even at 1-2 months after birth, potentially before their one recommended postnatal obstetric visit at 3-8 weeks. Asking the mother how she is feeling at those times should not just be a social nicety but rather an additional check for serious postnatal complications.
 

Additional concerns

But wait, it gets worse.

Did you know that the leading cause of maternal death from pregnancy up to 1 year after a birth is homicide?

Maternal perinatal mortality figures have not usually included “perinatal-associated” deaths, a maternal death attributable to a condition that is unaffected by the pregnancy and occurring within 1 year of delivery (that I will cite as perinatal henceforth). While half of maternal deaths occur during pregnancy, another half occur in the year following. There were 3.62 homicides per 100,000 live births among females who were pregnant or within 1 year postpartum, 16% more than for similarly aged nonpregnant and nonpostpartum women (3.12 deaths/100,000 population, P < .05). Homicides made up 8.4% of reported perinatal maternal deaths from all causes, with a rate of 1.7 per 100,000 live births, twice the rate of any one of the other leading causes noted above. Black women had seven times the risk of perinatal homicide as that of White women. Females under 20, many of them our own pediatric patients, had a greater than six times higher risk and those aged 20-24 had a 65% higher risk of pregnancy-associated homicide across race and ethnic groups. Homicide is most likely before 21 weeks of pregnancy, decreases in the third trimester, but increases again after birth. Two-thirds of pregnancy-associated homicide deaths occurred in the home, with the perpetrator a current or prior partner (> 59%, with 98% being male), 45%-50% were associated with reported intimate partner violence (IPV), and the most common method was a firearm (55%). Often the same women had histories of substance abuse, serious mental illness, and/or prior IPV, all risk factors for pregnancy-associated deaths, including from homicide.

Homicide? “Not the mothers in my practice,” you may say, but, if not homicide, drug-related deaths (3.68 per 100,000 person-years) and suicide (1.42 per 100,000 person-years) together comprise 18% of all maternal deaths. Non-Hispanic White women, Medicaid-insured women, and women residing in smaller cities were especially likely to die from drugs or suicide. More than half (54.3%) of perinatal suicides involve intimate partner conflict, which increases the risk ninefold. Perinatal mood disorders, affecting up to 15% of pregnant and postpartum U.S. women, is also a risk factor in substance abuse, opioid overdose death, and suicide.

And substance use has gotten more dangerous with the increase in fentanyl lacing. Pregnancy-associated deaths (4%-10% of deaths) involving opioids more than doubled between 2007 and 2016, and, although the rates are higher for Black women, the increase has been greater for non-Hispanic White women. Two-thirds of those deaths occur between 6 and 12 months postpartum, on our watch. Although many women decrease substance use during pregnancy, they may fall back into substance use (rates increase 4 times by 7-12 months after delivery) and not continue to receive treatment. Although pharmacotherapy (e.g., methadone, buprenorphine treatment) is the current standard of care for opioid use disorder (OUD) during pregnancy, nearly half receiving treatment in publicly funded centers are not receiving these medications and others may lose insurance or access to pregnancy-related treatment programs after delivery, increasing risk of relapse. Stigma, and punitive or discriminatory approaches to pregnant women with OUD (e.g., jail, removal of children) can dissuade them from participating in treatment, increasing overdose risk.

It is important to note that in more than half of the 41 deaths from violent trauma in one study (including 22 homicides), obstetrical providers knew of or suspected IPV. Also, the vast majority (74%) of those who died by drugs or suicide had made one or more emergency department or hospital visit between their delivery and death, and 39% had made three or more visits. Without knowing if anything was done in those cases, we also know that, in addition to thorough, compassionate providers, there is sometimes segmentation of responsibility, insensitivity, discrimination, racism, stigma, inequity, lack of resources, lack of access, lack of payment mechanisms, legal issues for immigrants, time constraints, and other systemic deficits that may hinder effective care for these and subsequent women.
 

Awareness and action

What should we, who are primary care pediatric providers, do about these threats to the mothers and pregnant young women we care for? Clearly, their children, our main patients, would be terribly and permanently hurt by harm coming to their mothers – the extreme adverse childhood experiences and social determinants of health to which we are already committed.

I hope this article will help alert pediatric providers to what is being published, mainly as women’s health and public health issues.

First, we need awareness of the physical symptoms that may come up in our interactions with pregnant and postpartum women so that we can educate them and expedite any indicated emergency care.

Next, we need to expand our routine screening of mothers and pregnant women from just the most impactful social determinants of health (including depression, substance use, and IPV) to include anxiety, past suicide attempts and current suicidal ideation, and the presence of firearms, early and repeatedly in the first year of the child’s life. Adults and teens are more likely to disclose risk for sensitive issues through questionnaires than through interviews, perhaps even more so when the identified patient is their child rather than themselves. Any screen can have false negatives, so asking directly when risk is suspected is important. The reason for screening could be framed as caring for the caregiver who is the most important person for the child. It could be accompanied by acknowledging that pregnancy and the first year of life can be difficult for mothers and their partners and that we want to support them and connect them to resources, if needed. When substance use disorder is acknowledged, we should prescribe and teach about Narcan for overdose. When there is IPV, we should discuss firearm removal/locking as well as counseling on a personal safety plan.

Working as part of an on-site or virtual team that includes professionals who know about community resources and can coordinate care is essential, in addition to educating about 211 for services and 988 for suicide risk.

Finally, we can advocate and vote for programs, people, and laws that support and safeguard women and families, address substance use, and reduce access to firearms.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

Checking on the well-being of mothers is one of the important acknowledged aspects of primary pediatric care. “How are you doing?” directed to the child’s mother has long been considered an appropriate question. The AAP recommends several checks in the Bright Futures Guidelines, including conducting several formal screens for depression and asking about “getting time alone with your partner” as well as other supports.

But I have recently become aware of new data that changes my ideas about what we pediatricians need to be doing as part of our care for children and their families, especially in the first year: Considering the risks to the mother of dying.

Maternal mortality increased by 26.6% from 2000 to 2014 across the United States such that it is higher now than it was for our own mothers. The U.S. now has the highest rates of maternal mortality among high-income nations, especially for Black, American Indian, or Alaska Native women, those of lower socioeconomic status, and those under 18 or over 35 years old.

You may be thinking, well, that is an issue for ob.gyns. Indeed, the most common reasons for maternal death are cardiovascular: hemorrhage, hypertensive disorders, deep vein thrombosis, and stroke, all usually occurring at or in the first week after birth. You may have heard about sudden unexpected heart failure from postpartum cardiomyopathy, although rare (1 in 1,000-4,000), presenting from 1 month pre birth to 5 months post delivery, which is when we may be the main clinicians seeing the mother, not the ob.gyns. This can be easily missed since it presents with shortness of breath and decreased exercise tolerance, fatigue, palpitations, and/or leg swelling. Serious eclampsia may have only symptoms of headache or abdominal pain. All of these may easily be mistaken for lingering pregnancy symptoms. But in higher income countries, such as the U.S., 38% of maternal deaths occur from 8 to 42 days after birth, the period for fatal infections as well as cardiac complications. Elevated risk for all of these causes of mortality include Black race, obesity, tobacco use, congenital heart disease, and being older than 40.

As pediatric providers, we may see mothers along with their infants as newborns in the hospital, at day 2, at 2 weeks, or even at 1-2 months after birth, potentially before their one recommended postnatal obstetric visit at 3-8 weeks. Asking the mother how she is feeling at those times should not just be a social nicety but rather an additional check for serious postnatal complications.
 

Additional concerns

But wait, it gets worse.

Did you know that the leading cause of maternal death from pregnancy up to 1 year after a birth is homicide?

Maternal perinatal mortality figures have not usually included “perinatal-associated” deaths, a maternal death attributable to a condition that is unaffected by the pregnancy and occurring within 1 year of delivery (that I will cite as perinatal henceforth). While half of maternal deaths occur during pregnancy, another half occur in the year following. There were 3.62 homicides per 100,000 live births among females who were pregnant or within 1 year postpartum, 16% more than for similarly aged nonpregnant and nonpostpartum women (3.12 deaths/100,000 population, P < .05). Homicides made up 8.4% of reported perinatal maternal deaths from all causes, with a rate of 1.7 per 100,000 live births, twice the rate of any one of the other leading causes noted above. Black women had seven times the risk of perinatal homicide as that of White women. Females under 20, many of them our own pediatric patients, had a greater than six times higher risk and those aged 20-24 had a 65% higher risk of pregnancy-associated homicide across race and ethnic groups. Homicide is most likely before 21 weeks of pregnancy, decreases in the third trimester, but increases again after birth. Two-thirds of pregnancy-associated homicide deaths occurred in the home, with the perpetrator a current or prior partner (> 59%, with 98% being male), 45%-50% were associated with reported intimate partner violence (IPV), and the most common method was a firearm (55%). Often the same women had histories of substance abuse, serious mental illness, and/or prior IPV, all risk factors for pregnancy-associated deaths, including from homicide.

Homicide? “Not the mothers in my practice,” you may say, but, if not homicide, drug-related deaths (3.68 per 100,000 person-years) and suicide (1.42 per 100,000 person-years) together comprise 18% of all maternal deaths. Non-Hispanic White women, Medicaid-insured women, and women residing in smaller cities were especially likely to die from drugs or suicide. More than half (54.3%) of perinatal suicides involve intimate partner conflict, which increases the risk ninefold. Perinatal mood disorders, affecting up to 15% of pregnant and postpartum U.S. women, is also a risk factor in substance abuse, opioid overdose death, and suicide.

And substance use has gotten more dangerous with the increase in fentanyl lacing. Pregnancy-associated deaths (4%-10% of deaths) involving opioids more than doubled between 2007 and 2016, and, although the rates are higher for Black women, the increase has been greater for non-Hispanic White women. Two-thirds of those deaths occur between 6 and 12 months postpartum, on our watch. Although many women decrease substance use during pregnancy, they may fall back into substance use (rates increase 4 times by 7-12 months after delivery) and not continue to receive treatment. Although pharmacotherapy (e.g., methadone, buprenorphine treatment) is the current standard of care for opioid use disorder (OUD) during pregnancy, nearly half receiving treatment in publicly funded centers are not receiving these medications and others may lose insurance or access to pregnancy-related treatment programs after delivery, increasing risk of relapse. Stigma, and punitive or discriminatory approaches to pregnant women with OUD (e.g., jail, removal of children) can dissuade them from participating in treatment, increasing overdose risk.

It is important to note that in more than half of the 41 deaths from violent trauma in one study (including 22 homicides), obstetrical providers knew of or suspected IPV. Also, the vast majority (74%) of those who died by drugs or suicide had made one or more emergency department or hospital visit between their delivery and death, and 39% had made three or more visits. Without knowing if anything was done in those cases, we also know that, in addition to thorough, compassionate providers, there is sometimes segmentation of responsibility, insensitivity, discrimination, racism, stigma, inequity, lack of resources, lack of access, lack of payment mechanisms, legal issues for immigrants, time constraints, and other systemic deficits that may hinder effective care for these and subsequent women.
 

Awareness and action

What should we, who are primary care pediatric providers, do about these threats to the mothers and pregnant young women we care for? Clearly, their children, our main patients, would be terribly and permanently hurt by harm coming to their mothers – the extreme adverse childhood experiences and social determinants of health to which we are already committed.

I hope this article will help alert pediatric providers to what is being published, mainly as women’s health and public health issues.

First, we need awareness of the physical symptoms that may come up in our interactions with pregnant and postpartum women so that we can educate them and expedite any indicated emergency care.

Next, we need to expand our routine screening of mothers and pregnant women from just the most impactful social determinants of health (including depression, substance use, and IPV) to include anxiety, past suicide attempts and current suicidal ideation, and the presence of firearms, early and repeatedly in the first year of the child’s life. Adults and teens are more likely to disclose risk for sensitive issues through questionnaires than through interviews, perhaps even more so when the identified patient is their child rather than themselves. Any screen can have false negatives, so asking directly when risk is suspected is important. The reason for screening could be framed as caring for the caregiver who is the most important person for the child. It could be accompanied by acknowledging that pregnancy and the first year of life can be difficult for mothers and their partners and that we want to support them and connect them to resources, if needed. When substance use disorder is acknowledged, we should prescribe and teach about Narcan for overdose. When there is IPV, we should discuss firearm removal/locking as well as counseling on a personal safety plan.

Working as part of an on-site or virtual team that includes professionals who know about community resources and can coordinate care is essential, in addition to educating about 211 for services and 988 for suicide risk.

Finally, we can advocate and vote for programs, people, and laws that support and safeguard women and families, address substance use, and reduce access to firearms.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

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

Anxiety disorders in young children

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

Obsessive-compulsive disorder

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

PTSD

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

Special cases: School refusal

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

Special cases: Adolescents with new anxiety symptoms

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

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

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

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

Anxiety disorders in young children

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

Obsessive-compulsive disorder

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

PTSD

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

Special cases: School refusal

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

Special cases: Adolescents with new anxiety symptoms

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

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

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

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

Anxiety disorders in young children

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

Obsessive-compulsive disorder

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

PTSD

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

Special cases: School refusal

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

Special cases: Adolescents with new anxiety symptoms

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

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

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

The best plan for oppositional behavior in a school-aged child is prevention at younger ages! But here is the family coming to see us, struggling to get cooperation, and often increasingly embarrassed and angry.

Sometimes the dynamics leading to this behavior seem obvious: the parent tells their child to put away the toys they have pulled out in your waiting room, is ignored, and cleans them up themselves without a word. The child smugly fiddles with their cell phone, reinforced by removal of the task. Even without a defined reward, this still constitutes positive reinforcement as it increases the likelihood of the same future behavior of ignoring a parental directive.

Preventing this “mild” oppositionality at a younger age may come from the parent jollying the child through the clean up, participating with them in a game-like way counting the toys or making it a race, or even using only one request before grasping the child’s hand and “assisting” them in picking up a toy while praising cooperation but these tactics become less appropriate with age.

Other factors that may have led to school-aged child refusal include yelling at them, shaming, comparing them with a more compliant sibling, threatening a punishment that is never carried out, or deferring a consequence to the other caregiver. Of course, no child would want to please a caregiver with this kind of interaction by obeying them. By school age, children have a greater need to exert autonomy and avoid humiliation and may do this by getting angry, talking back, insulting the parent, or leaving the scene. This is especially likely if peers or siblings are present and the child wants to show that they can’t be bossed around.
 

Practical advice

So what can we advise when habits of refusal have already been established? Keeping in mind the major school-age psychosocial tasks of developing autonomy and self-esteem, the parent may need to overdo opportunities for this child to have choices and experience respect. When the child has a generalized oppositional stance, the parent may feel that it is difficult to identify opportunities to do this. The key in that case is to set up for cooperation and focus on small positive or neutral bits of behavior to reinforce. For example, requesting that the child do something they want to do anyways, such as come for a snack or turn on the TV, can be met with a brief but sincere “thanks” or “thanks for hopping on that.”

Sarcasm is counterproductive at all times, as it is insulting. Asking the child’s opinion regularly then listening and reflecting, rephrasing what they said, and even checking to see if the parent “got it right” do not require that the parent agrees. Any disagreement that the parent feels is needed can be withheld for a few minutes to indicate respect for the child’s opinion. For a child to learn to make “good choices” of behavior comes also from noticing how “not so good choices” worked out, a reflection the parent can try to elicit nonjudgmentally. Rebuilding the relationship can be done over time with respectful communication and assuring daily times of showing interest in the child, fooling around together, or playing a game.

While giving more choices respects autonomy, the options must really be acceptable to the parent. They may allow the child to choose some aspects of family activities – a skate park, or a certain eatery, or parts of the outing could be optional. Sometimes the order of upcoming events can provide a choice even if attendance is required. Sometimes the dress code can be flexible (flip flops, okay sure!), or a friend (preferably a well-behaved one!) could be invited along.
 

Pitfalls to avoid

Avoiding humiliation may be obvious, such as not complementing a singing performance or insistence on the child self-reporting bad behavior. For some families the parents may need to avoid their own embarrassing habits of “bad jokes” or outlandish clothes as a reasonable accommodation. Other kinds of humiliation to avoid may be specific to the child’s weaknesses, such as insisting that a clumsy child play on a team or a shy child speak to strangers. While it may be valuable for the child to work on those weaknesses, this should be done in private, if possible, or even with a coach who is not the parent if the relationship is strained.

Sensitive or anxious children are more prone to embarrassment and may then react with oppositional responses. They often do better with notice or coaching for upcoming events that may be in a category that has upset them in the past; for example, a visit from an overly affectionate aunt. Children may gain respect for their parents by being given a task that serves as an early escape route for these situations (Oh, would you please run out to the car and get my sweater?) although progressively tolerating undesirable situations is also important practice. A kindly debrief later with praise for progress also builds skills.
 

Reinforcing behaviors and revisiting consequences

Gaining more privileges as the reward for cooperation and responsibility is the natural sequence with development but oppositional children may need a chart, ideally negotiated as a family, to be clear about this cause-effect plan and what is expected for them to earn more freedom. Another benefit of a chart is that it is an objective translator of rules that can literally be pointed to rather than a parent-child conversation that could become an argument. Parents need to make expectations clear and follow through on promised increased privileges or consequences to be seen as fair. Having regular routines for chores, not just for activities, reduces refusal as well. Such concrete steps are especially important for children with ADHD who are often easily distracted from parental requests even if they meant to follow them and have a weak sense of timing. I have seen some wise parents give their distracted or impulsive child “a minute to decide if that is their final choice” before levying a consequence.

“When-then” statements can be useful both for coaching appropriate behavior in advance, debriefs, and alerting to consequences when needed. For example: “When you ask your aunt a question right away when you meet her then her hugs will be shorter” is coaching. “When you come home an hour late then you will have an hour earlier curfew the next week” is a graded consequence.
 

The cell phone issue

I can’t omit mentioning the specific situation of a child on a cell phone or tablet ignoring or refusing requests. While having possession of such a device may be seen as a safety measure (How can he reach me?) and social coinage (All my friends have one!), they are distracting and addicting and now the most common reason I see for oppositional interactions. This has been discussed elsewhere, so let me just say that a device is a privilege and should not “belong” to a child. Delaying the age of “lending” the device, establishing rules for use to certain situations and durations, and removing it for defined periods if it is interfering with cooperation are basic principles, even though enforcing them may result in upsets. Parents may need to change their own device use to be able to address oppositional behavior in their child.

Strategies for building better behavior

How important is it for the parent to verbalize what they are doing to instruct or accommodate their school-aged child? In the presence of others, the fewer words highlighting that an intervention is underway the better. Sometimes having a secret signal to prompt or praise, even a wink, can be helpful without being humiliating. These should be decided on together in private and practiced at first in nonstressful situations. Comments of appreciation or praise are appropriate then and are often reinforcing but should be very specific; for example, “I’m glad you got ready right away when it was time to leave” rather than general or backwards praise “Ready on time today, huh?” For some, especially younger or special-needs children, marks, points, tickets, tokens, or little prizes may be beneficial reinforcers, especially when trying to establish new patterns of interaction. Praise should fairly quickly replace more concrete rewards, though, by weaning, first by intermittent delivery or spacing further apart.

When counseling about oppositional behavior in school-aged children eliciting specific examples is key to determining whether parents are overly rigid or lax, have realistic expectations for their individual child’s temperament, skills, and past experiences (for example, traumas). As Ross Greene, PhD, points out,¹ assisting families in understanding the gaps in skills that bring out opposition and categorizing behaviors into the rare “must-do’s,” and the many “just drop it’s,” in order to focus on understanding and building strategies and cooperation for situations that are important but not critical (Plan B) may require regular counseling by a mental health professional to help a child develop adaptive behavior and facilitate family harmony.

Reference

1. Greene RW. The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children, Sixth Edition, (New York: Harper Paperbacks, 2021).

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at pdnews@mdedge.com.

The best plan for oppositional behavior in a school-aged child is prevention at younger ages! But here is the family coming to see us, struggling to get cooperation, and often increasingly embarrassed and angry.

Sometimes the dynamics leading to this behavior seem obvious: the parent tells their child to put away the toys they have pulled out in your waiting room, is ignored, and cleans them up themselves without a word. The child smugly fiddles with their cell phone, reinforced by removal of the task. Even without a defined reward, this still constitutes positive reinforcement as it increases the likelihood of the same future behavior of ignoring a parental directive.

Preventing this “mild” oppositionality at a younger age may come from the parent jollying the child through the clean up, participating with them in a game-like way counting the toys or making it a race, or even using only one request before grasping the child’s hand and “assisting” them in picking up a toy while praising cooperation but these tactics become less appropriate with age.

Other factors that may have led to school-aged child refusal include yelling at them, shaming, comparing them with a more compliant sibling, threatening a punishment that is never carried out, or deferring a consequence to the other caregiver. Of course, no child would want to please a caregiver with this kind of interaction by obeying them. By school age, children have a greater need to exert autonomy and avoid humiliation and may do this by getting angry, talking back, insulting the parent, or leaving the scene. This is especially likely if peers or siblings are present and the child wants to show that they can’t be bossed around.
 

Practical advice

So what can we advise when habits of refusal have already been established? Keeping in mind the major school-age psychosocial tasks of developing autonomy and self-esteem, the parent may need to overdo opportunities for this child to have choices and experience respect. When the child has a generalized oppositional stance, the parent may feel that it is difficult to identify opportunities to do this. The key in that case is to set up for cooperation and focus on small positive or neutral bits of behavior to reinforce. For example, requesting that the child do something they want to do anyways, such as come for a snack or turn on the TV, can be met with a brief but sincere “thanks” or “thanks for hopping on that.”

Sarcasm is counterproductive at all times, as it is insulting. Asking the child’s opinion regularly then listening and reflecting, rephrasing what they said, and even checking to see if the parent “got it right” do not require that the parent agrees. Any disagreement that the parent feels is needed can be withheld for a few minutes to indicate respect for the child’s opinion. For a child to learn to make “good choices” of behavior comes also from noticing how “not so good choices” worked out, a reflection the parent can try to elicit nonjudgmentally. Rebuilding the relationship can be done over time with respectful communication and assuring daily times of showing interest in the child, fooling around together, or playing a game.

While giving more choices respects autonomy, the options must really be acceptable to the parent. They may allow the child to choose some aspects of family activities – a skate park, or a certain eatery, or parts of the outing could be optional. Sometimes the order of upcoming events can provide a choice even if attendance is required. Sometimes the dress code can be flexible (flip flops, okay sure!), or a friend (preferably a well-behaved one!) could be invited along.
 

Pitfalls to avoid

Avoiding humiliation may be obvious, such as not complementing a singing performance or insistence on the child self-reporting bad behavior. For some families the parents may need to avoid their own embarrassing habits of “bad jokes” or outlandish clothes as a reasonable accommodation. Other kinds of humiliation to avoid may be specific to the child’s weaknesses, such as insisting that a clumsy child play on a team or a shy child speak to strangers. While it may be valuable for the child to work on those weaknesses, this should be done in private, if possible, or even with a coach who is not the parent if the relationship is strained.

Sensitive or anxious children are more prone to embarrassment and may then react with oppositional responses. They often do better with notice or coaching for upcoming events that may be in a category that has upset them in the past; for example, a visit from an overly affectionate aunt. Children may gain respect for their parents by being given a task that serves as an early escape route for these situations (Oh, would you please run out to the car and get my sweater?) although progressively tolerating undesirable situations is also important practice. A kindly debrief later with praise for progress also builds skills.
 

Reinforcing behaviors and revisiting consequences

Gaining more privileges as the reward for cooperation and responsibility is the natural sequence with development but oppositional children may need a chart, ideally negotiated as a family, to be clear about this cause-effect plan and what is expected for them to earn more freedom. Another benefit of a chart is that it is an objective translator of rules that can literally be pointed to rather than a parent-child conversation that could become an argument. Parents need to make expectations clear and follow through on promised increased privileges or consequences to be seen as fair. Having regular routines for chores, not just for activities, reduces refusal as well. Such concrete steps are especially important for children with ADHD who are often easily distracted from parental requests even if they meant to follow them and have a weak sense of timing. I have seen some wise parents give their distracted or impulsive child “a minute to decide if that is their final choice” before levying a consequence.

“When-then” statements can be useful both for coaching appropriate behavior in advance, debriefs, and alerting to consequences when needed. For example: “When you ask your aunt a question right away when you meet her then her hugs will be shorter” is coaching. “When you come home an hour late then you will have an hour earlier curfew the next week” is a graded consequence.
 

The cell phone issue

I can’t omit mentioning the specific situation of a child on a cell phone or tablet ignoring or refusing requests. While having possession of such a device may be seen as a safety measure (How can he reach me?) and social coinage (All my friends have one!), they are distracting and addicting and now the most common reason I see for oppositional interactions. This has been discussed elsewhere, so let me just say that a device is a privilege and should not “belong” to a child. Delaying the age of “lending” the device, establishing rules for use to certain situations and durations, and removing it for defined periods if it is interfering with cooperation are basic principles, even though enforcing them may result in upsets. Parents may need to change their own device use to be able to address oppositional behavior in their child.

Strategies for building better behavior

How important is it for the parent to verbalize what they are doing to instruct or accommodate their school-aged child? In the presence of others, the fewer words highlighting that an intervention is underway the better. Sometimes having a secret signal to prompt or praise, even a wink, can be helpful without being humiliating. These should be decided on together in private and practiced at first in nonstressful situations. Comments of appreciation or praise are appropriate then and are often reinforcing but should be very specific; for example, “I’m glad you got ready right away when it was time to leave” rather than general or backwards praise “Ready on time today, huh?” For some, especially younger or special-needs children, marks, points, tickets, tokens, or little prizes may be beneficial reinforcers, especially when trying to establish new patterns of interaction. Praise should fairly quickly replace more concrete rewards, though, by weaning, first by intermittent delivery or spacing further apart.

When counseling about oppositional behavior in school-aged children eliciting specific examples is key to determining whether parents are overly rigid or lax, have realistic expectations for their individual child’s temperament, skills, and past experiences (for example, traumas). As Ross Greene, PhD, points out,¹ assisting families in understanding the gaps in skills that bring out opposition and categorizing behaviors into the rare “must-do’s,” and the many “just drop it’s,” in order to focus on understanding and building strategies and cooperation for situations that are important but not critical (Plan B) may require regular counseling by a mental health professional to help a child develop adaptive behavior and facilitate family harmony.

Reference

1. Greene RW. The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children, Sixth Edition, (New York: Harper Paperbacks, 2021).

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at pdnews@mdedge.com.

The best plan for oppositional behavior in a school-aged child is prevention at younger ages! But here is the family coming to see us, struggling to get cooperation, and often increasingly embarrassed and angry.

Sometimes the dynamics leading to this behavior seem obvious: the parent tells their child to put away the toys they have pulled out in your waiting room, is ignored, and cleans them up themselves without a word. The child smugly fiddles with their cell phone, reinforced by removal of the task. Even without a defined reward, this still constitutes positive reinforcement as it increases the likelihood of the same future behavior of ignoring a parental directive.

Preventing this “mild” oppositionality at a younger age may come from the parent jollying the child through the clean up, participating with them in a game-like way counting the toys or making it a race, or even using only one request before grasping the child’s hand and “assisting” them in picking up a toy while praising cooperation but these tactics become less appropriate with age.

Other factors that may have led to school-aged child refusal include yelling at them, shaming, comparing them with a more compliant sibling, threatening a punishment that is never carried out, or deferring a consequence to the other caregiver. Of course, no child would want to please a caregiver with this kind of interaction by obeying them. By school age, children have a greater need to exert autonomy and avoid humiliation and may do this by getting angry, talking back, insulting the parent, or leaving the scene. This is especially likely if peers or siblings are present and the child wants to show that they can’t be bossed around.
 

Practical advice

So what can we advise when habits of refusal have already been established? Keeping in mind the major school-age psychosocial tasks of developing autonomy and self-esteem, the parent may need to overdo opportunities for this child to have choices and experience respect. When the child has a generalized oppositional stance, the parent may feel that it is difficult to identify opportunities to do this. The key in that case is to set up for cooperation and focus on small positive or neutral bits of behavior to reinforce. For example, requesting that the child do something they want to do anyways, such as come for a snack or turn on the TV, can be met with a brief but sincere “thanks” or “thanks for hopping on that.”

Sarcasm is counterproductive at all times, as it is insulting. Asking the child’s opinion regularly then listening and reflecting, rephrasing what they said, and even checking to see if the parent “got it right” do not require that the parent agrees. Any disagreement that the parent feels is needed can be withheld for a few minutes to indicate respect for the child’s opinion. For a child to learn to make “good choices” of behavior comes also from noticing how “not so good choices” worked out, a reflection the parent can try to elicit nonjudgmentally. Rebuilding the relationship can be done over time with respectful communication and assuring daily times of showing interest in the child, fooling around together, or playing a game.

While giving more choices respects autonomy, the options must really be acceptable to the parent. They may allow the child to choose some aspects of family activities – a skate park, or a certain eatery, or parts of the outing could be optional. Sometimes the order of upcoming events can provide a choice even if attendance is required. Sometimes the dress code can be flexible (flip flops, okay sure!), or a friend (preferably a well-behaved one!) could be invited along.
 

Pitfalls to avoid

Avoiding humiliation may be obvious, such as not complementing a singing performance or insistence on the child self-reporting bad behavior. For some families the parents may need to avoid their own embarrassing habits of “bad jokes” or outlandish clothes as a reasonable accommodation. Other kinds of humiliation to avoid may be specific to the child’s weaknesses, such as insisting that a clumsy child play on a team or a shy child speak to strangers. While it may be valuable for the child to work on those weaknesses, this should be done in private, if possible, or even with a coach who is not the parent if the relationship is strained.

Sensitive or anxious children are more prone to embarrassment and may then react with oppositional responses. They often do better with notice or coaching for upcoming events that may be in a category that has upset them in the past; for example, a visit from an overly affectionate aunt. Children may gain respect for their parents by being given a task that serves as an early escape route for these situations (Oh, would you please run out to the car and get my sweater?) although progressively tolerating undesirable situations is also important practice. A kindly debrief later with praise for progress also builds skills.
 

Reinforcing behaviors and revisiting consequences

Gaining more privileges as the reward for cooperation and responsibility is the natural sequence with development but oppositional children may need a chart, ideally negotiated as a family, to be clear about this cause-effect plan and what is expected for them to earn more freedom. Another benefit of a chart is that it is an objective translator of rules that can literally be pointed to rather than a parent-child conversation that could become an argument. Parents need to make expectations clear and follow through on promised increased privileges or consequences to be seen as fair. Having regular routines for chores, not just for activities, reduces refusal as well. Such concrete steps are especially important for children with ADHD who are often easily distracted from parental requests even if they meant to follow them and have a weak sense of timing. I have seen some wise parents give their distracted or impulsive child “a minute to decide if that is their final choice” before levying a consequence.

“When-then” statements can be useful both for coaching appropriate behavior in advance, debriefs, and alerting to consequences when needed. For example: “When you ask your aunt a question right away when you meet her then her hugs will be shorter” is coaching. “When you come home an hour late then you will have an hour earlier curfew the next week” is a graded consequence.
 

The cell phone issue

I can’t omit mentioning the specific situation of a child on a cell phone or tablet ignoring or refusing requests. While having possession of such a device may be seen as a safety measure (How can he reach me?) and social coinage (All my friends have one!), they are distracting and addicting and now the most common reason I see for oppositional interactions. This has been discussed elsewhere, so let me just say that a device is a privilege and should not “belong” to a child. Delaying the age of “lending” the device, establishing rules for use to certain situations and durations, and removing it for defined periods if it is interfering with cooperation are basic principles, even though enforcing them may result in upsets. Parents may need to change their own device use to be able to address oppositional behavior in their child.

Strategies for building better behavior

How important is it for the parent to verbalize what they are doing to instruct or accommodate their school-aged child? In the presence of others, the fewer words highlighting that an intervention is underway the better. Sometimes having a secret signal to prompt or praise, even a wink, can be helpful without being humiliating. These should be decided on together in private and practiced at first in nonstressful situations. Comments of appreciation or praise are appropriate then and are often reinforcing but should be very specific; for example, “I’m glad you got ready right away when it was time to leave” rather than general or backwards praise “Ready on time today, huh?” For some, especially younger or special-needs children, marks, points, tickets, tokens, or little prizes may be beneficial reinforcers, especially when trying to establish new patterns of interaction. Praise should fairly quickly replace more concrete rewards, though, by weaning, first by intermittent delivery or spacing further apart.

When counseling about oppositional behavior in school-aged children eliciting specific examples is key to determining whether parents are overly rigid or lax, have realistic expectations for their individual child’s temperament, skills, and past experiences (for example, traumas). As Ross Greene, PhD, points out,¹ assisting families in understanding the gaps in skills that bring out opposition and categorizing behaviors into the rare “must-do’s,” and the many “just drop it’s,” in order to focus on understanding and building strategies and cooperation for situations that are important but not critical (Plan B) may require regular counseling by a mental health professional to help a child develop adaptive behavior and facilitate family harmony.

Reference

1. Greene RW. The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children, Sixth Edition, (New York: Harper Paperbacks, 2021).

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at pdnews@mdedge.com.

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

Anxiety disorders: Common and treatable

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

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

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

Anxiety screening and treatment

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

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

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

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

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

Reference

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

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

Anxiety disorders: Common and treatable

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

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

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

Anxiety screening and treatment

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

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

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

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

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

Reference

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

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

Anxiety disorders: Common and treatable

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

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

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

Anxiety screening and treatment

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

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

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

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

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

Reference

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

When I speak with parents and colleagues about the well-being of today’s youth, the nearly unanimous cry is the negative effects of social media. But then, after a few moments of silence they say, “I don’t know how we can stop it. The genie is out of the bottle.”

The helplessness we as responsible adults and professionals feel about our inability to change this cultural shift to youth fixation on social media and its increasingly clear impact on depression, anxiety, self-esteem, and even suicide is profound. In China the country has “simply” regulated access to the Internet for children to 2 hours per day and blocked many websites. But such universal restriction is not likely in the United States. We need some other solutions.
 

A solution for all ages

Reach Out and Read, an international program promoting early relational health and literacy by encouraging and modeling reading and handing out books to families with children aged 0-5 years, has significant evidence for improving child development and parent-child interaction.

But why stop promoting reading and the associated parent-child bonding at 5 years old? Academic progress, child mental health and well-being, and family relationships are all currently in trouble and could all benefit from more reading. As pediatric providers for all ages of children and youth we can effectively promote reading as part of preventive care, not just for the youngest.

Reading fluency is a key factor in academic success. A study from 2019, before the pandemic, found that by the end of high school, students were reading 19% slower than were students of a similar age 50 years ago. The possible reasons, among many, include poverty with its effect on vocabulary, modeling and access to books, hours on social media, and less unstructured time to read for pleasure. With less reading comes less practice. Reading then doesn’t feel as comfortable and is avoided.

The pandemic made measures of academic level even worse, with reading fluency in second and third grade now about 30% behind what would be expected. Reading fluency and comprehension become more critical for future academic progress beginning in third grade when “learning to read” shifts to “reading to learn.” Educators are doing their best to catch children up but with limited support resources, and families need strategies to help their children.

Early strategies to promote reading by discussing the benefits with parents of bedtime stories and sharing books seems easy in comparison to encouraging school-aged children and older youth to read. But there are good reasons and strategies to persist.

Reading can help a child’s mental health as well as development. After a day at school, picking up another book may seem to the parent like more homework. But “reading for pleasure” is different. Reading has been shown to lower heart rate and muscle tension and reduce stress by as much as 68% in minutes, even lowering cortisol and activating pleasure centers of the brain. An immersive story can distract one from worries and be a real escape; the opposite of looking at social media online where peer comparisons and a constant stream of nasty comments 24/7 are culprits producing anxiety, depression, eating disorders, and suicide. Books that have characters going through similar struggles as those of the youth provide a sense of not being alone with these stresses and generally include models of problem solving and resolution that can inspire hopefulness. Joining (or starting) a kids’ or parent-child book club offers a chance to socialize with a nonjudgmental shared focus. There are books with content about all sorts of topics that may be areas the child or youth have as life and career goals that may help them gain new ideas and confidence as well as knowledge and skills. Having clear ideas about future roles is a one way to reduce the chance of developing depression and even suicide.

Reading a book, ideally illuminated by a warm colored light, assists in falling asleep, a huge issue for many youth. This is valuable in itself as inadequate sleep is a large contributor to worsening of many mental conditions. In contrast, the blue light from computer screens makes it harder to fall asleep. When reading a book is a bedtime habit, just as for babies and toddlers and whether read to by a parent (no age is too old!) or reading alone, the routine itself helps prepare the brain to transition into sleep.
 

Encouraging good habits

But how can parents get their children away from scanning the Internet to reading books? The American Academy of Pediatrics suggests setting time blocks for the day designated for school, exercise, homework, media, and sleep with a goal of a healthy balance. Reading could be added to the family’s plan. Making reading in the same room with parents as a regular habit both models reading (as parents have to get offline, too!) and sets up an opportunity to ask questions and converse about the reading materials, thereby building family relationships. Children are notorious for being recalcitrant about talking “about their day” when coming home from school. Having a less personal and intrusive subject to talk about creates a favorable setting for precious parent-child discussions. Some families read aloud to each other. This comes up naturally when reading a clip from a newspaper or magazine. It is especially valuable and inclusive for younger children who may not yet be able to read that level of material.

Getting creative

Some other strategies to promote reading include bringing books, magazines, or even comics with subjects that interest the child or youth into the house and leaving them around without comment. Getting started on a book series (Nancy Drew, Harry Potter, etc.) that is captivating provides extra incentive. Parents can talk about their favorites from their childhood, some of which are timeless! Families may need to be creative and find literature about the online characters from video games or movies that already interest their child, even if those are not seen as ideal learning material. Not commenting on the presence of the reading material takes the pressure off and makes it clear that it is their choice whether to read them or not.

Books need to be seen as a gift rather than a “penalty” for being online. Visiting a bookstore together or giving a gift certificate for books are other ways a parent can support reading while indicating that the youth has choice. There are now more than 150,000 Little Free Library locations worldwide (visible on the app) where books can be obtained 24/7 at no cost. Bringing books to donate or even joining the cause and becoming a steward of one of these pop-up libraries models high valuation of reading but is also a volunteer activity of which the child can be proud. We brought our children’s old books to our pediatric practice and encouraged patients to “bring one and take one.” Of course, the public library is often an option and is free. Another advantage of the library is that librarians and other children there may make suggestions of books that are popular with children their age. There are lots of specific suggestions online as well.

We need to be aware that children who resist reading books may have reading weaknesses. We can assess reading fluency with standard Gray Oral Reading paragraphs or the Wide Range Achievement test in the office or recommend a reading assessment by the school. Parents who already know that their child has a reading problem may be getting advice from teachers or tutors on how to help. But to promote reading that is not onerous for a child with a reading disability, parents can do more reading aloud at home, offer audiobooks or podcasts at home or play them while driving, and aim for books with a lower reading level. Teachers or librarians can make suggestions. It is important for family members to not be judgmental about a child’s choice of reading materials.

We do not need to feel helpless in the face of the Internet – we can recommend more reading!
 

Dr. Howard is assistant professor of pediatrics at The Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

When I speak with parents and colleagues about the well-being of today’s youth, the nearly unanimous cry is the negative effects of social media. But then, after a few moments of silence they say, “I don’t know how we can stop it. The genie is out of the bottle.”

The helplessness we as responsible adults and professionals feel about our inability to change this cultural shift to youth fixation on social media and its increasingly clear impact on depression, anxiety, self-esteem, and even suicide is profound. In China the country has “simply” regulated access to the Internet for children to 2 hours per day and blocked many websites. But such universal restriction is not likely in the United States. We need some other solutions.
 

A solution for all ages

Reach Out and Read, an international program promoting early relational health and literacy by encouraging and modeling reading and handing out books to families with children aged 0-5 years, has significant evidence for improving child development and parent-child interaction.

But why stop promoting reading and the associated parent-child bonding at 5 years old? Academic progress, child mental health and well-being, and family relationships are all currently in trouble and could all benefit from more reading. As pediatric providers for all ages of children and youth we can effectively promote reading as part of preventive care, not just for the youngest.

Reading fluency is a key factor in academic success. A study from 2019, before the pandemic, found that by the end of high school, students were reading 19% slower than were students of a similar age 50 years ago. The possible reasons, among many, include poverty with its effect on vocabulary, modeling and access to books, hours on social media, and less unstructured time to read for pleasure. With less reading comes less practice. Reading then doesn’t feel as comfortable and is avoided.

The pandemic made measures of academic level even worse, with reading fluency in second and third grade now about 30% behind what would be expected. Reading fluency and comprehension become more critical for future academic progress beginning in third grade when “learning to read” shifts to “reading to learn.” Educators are doing their best to catch children up but with limited support resources, and families need strategies to help their children.

Early strategies to promote reading by discussing the benefits with parents of bedtime stories and sharing books seems easy in comparison to encouraging school-aged children and older youth to read. But there are good reasons and strategies to persist.

Reading can help a child’s mental health as well as development. After a day at school, picking up another book may seem to the parent like more homework. But “reading for pleasure” is different. Reading has been shown to lower heart rate and muscle tension and reduce stress by as much as 68% in minutes, even lowering cortisol and activating pleasure centers of the brain. An immersive story can distract one from worries and be a real escape; the opposite of looking at social media online where peer comparisons and a constant stream of nasty comments 24/7 are culprits producing anxiety, depression, eating disorders, and suicide. Books that have characters going through similar struggles as those of the youth provide a sense of not being alone with these stresses and generally include models of problem solving and resolution that can inspire hopefulness. Joining (or starting) a kids’ or parent-child book club offers a chance to socialize with a nonjudgmental shared focus. There are books with content about all sorts of topics that may be areas the child or youth have as life and career goals that may help them gain new ideas and confidence as well as knowledge and skills. Having clear ideas about future roles is a one way to reduce the chance of developing depression and even suicide.

Reading a book, ideally illuminated by a warm colored light, assists in falling asleep, a huge issue for many youth. This is valuable in itself as inadequate sleep is a large contributor to worsening of many mental conditions. In contrast, the blue light from computer screens makes it harder to fall asleep. When reading a book is a bedtime habit, just as for babies and toddlers and whether read to by a parent (no age is too old!) or reading alone, the routine itself helps prepare the brain to transition into sleep.
 

Encouraging good habits

But how can parents get their children away from scanning the Internet to reading books? The American Academy of Pediatrics suggests setting time blocks for the day designated for school, exercise, homework, media, and sleep with a goal of a healthy balance. Reading could be added to the family’s plan. Making reading in the same room with parents as a regular habit both models reading (as parents have to get offline, too!) and sets up an opportunity to ask questions and converse about the reading materials, thereby building family relationships. Children are notorious for being recalcitrant about talking “about their day” when coming home from school. Having a less personal and intrusive subject to talk about creates a favorable setting for precious parent-child discussions. Some families read aloud to each other. This comes up naturally when reading a clip from a newspaper or magazine. It is especially valuable and inclusive for younger children who may not yet be able to read that level of material.

Getting creative

Some other strategies to promote reading include bringing books, magazines, or even comics with subjects that interest the child or youth into the house and leaving them around without comment. Getting started on a book series (Nancy Drew, Harry Potter, etc.) that is captivating provides extra incentive. Parents can talk about their favorites from their childhood, some of which are timeless! Families may need to be creative and find literature about the online characters from video games or movies that already interest their child, even if those are not seen as ideal learning material. Not commenting on the presence of the reading material takes the pressure off and makes it clear that it is their choice whether to read them or not.

Books need to be seen as a gift rather than a “penalty” for being online. Visiting a bookstore together or giving a gift certificate for books are other ways a parent can support reading while indicating that the youth has choice. There are now more than 150,000 Little Free Library locations worldwide (visible on the app) where books can be obtained 24/7 at no cost. Bringing books to donate or even joining the cause and becoming a steward of one of these pop-up libraries models high valuation of reading but is also a volunteer activity of which the child can be proud. We brought our children’s old books to our pediatric practice and encouraged patients to “bring one and take one.” Of course, the public library is often an option and is free. Another advantage of the library is that librarians and other children there may make suggestions of books that are popular with children their age. There are lots of specific suggestions online as well.

We need to be aware that children who resist reading books may have reading weaknesses. We can assess reading fluency with standard Gray Oral Reading paragraphs or the Wide Range Achievement test in the office or recommend a reading assessment by the school. Parents who already know that their child has a reading problem may be getting advice from teachers or tutors on how to help. But to promote reading that is not onerous for a child with a reading disability, parents can do more reading aloud at home, offer audiobooks or podcasts at home or play them while driving, and aim for books with a lower reading level. Teachers or librarians can make suggestions. It is important for family members to not be judgmental about a child’s choice of reading materials.

We do not need to feel helpless in the face of the Internet – we can recommend more reading!
 

Dr. Howard is assistant professor of pediatrics at The Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

When I speak with parents and colleagues about the well-being of today’s youth, the nearly unanimous cry is the negative effects of social media. But then, after a few moments of silence they say, “I don’t know how we can stop it. The genie is out of the bottle.”

The helplessness we as responsible adults and professionals feel about our inability to change this cultural shift to youth fixation on social media and its increasingly clear impact on depression, anxiety, self-esteem, and even suicide is profound. In China the country has “simply” regulated access to the Internet for children to 2 hours per day and blocked many websites. But such universal restriction is not likely in the United States. We need some other solutions.
 

A solution for all ages

Reach Out and Read, an international program promoting early relational health and literacy by encouraging and modeling reading and handing out books to families with children aged 0-5 years, has significant evidence for improving child development and parent-child interaction.

But why stop promoting reading and the associated parent-child bonding at 5 years old? Academic progress, child mental health and well-being, and family relationships are all currently in trouble and could all benefit from more reading. As pediatric providers for all ages of children and youth we can effectively promote reading as part of preventive care, not just for the youngest.

Reading fluency is a key factor in academic success. A study from 2019, before the pandemic, found that by the end of high school, students were reading 19% slower than were students of a similar age 50 years ago. The possible reasons, among many, include poverty with its effect on vocabulary, modeling and access to books, hours on social media, and less unstructured time to read for pleasure. With less reading comes less practice. Reading then doesn’t feel as comfortable and is avoided.

The pandemic made measures of academic level even worse, with reading fluency in second and third grade now about 30% behind what would be expected. Reading fluency and comprehension become more critical for future academic progress beginning in third grade when “learning to read” shifts to “reading to learn.” Educators are doing their best to catch children up but with limited support resources, and families need strategies to help their children.

Early strategies to promote reading by discussing the benefits with parents of bedtime stories and sharing books seems easy in comparison to encouraging school-aged children and older youth to read. But there are good reasons and strategies to persist.

Reading can help a child’s mental health as well as development. After a day at school, picking up another book may seem to the parent like more homework. But “reading for pleasure” is different. Reading has been shown to lower heart rate and muscle tension and reduce stress by as much as 68% in minutes, even lowering cortisol and activating pleasure centers of the brain. An immersive story can distract one from worries and be a real escape; the opposite of looking at social media online where peer comparisons and a constant stream of nasty comments 24/7 are culprits producing anxiety, depression, eating disorders, and suicide. Books that have characters going through similar struggles as those of the youth provide a sense of not being alone with these stresses and generally include models of problem solving and resolution that can inspire hopefulness. Joining (or starting) a kids’ or parent-child book club offers a chance to socialize with a nonjudgmental shared focus. There are books with content about all sorts of topics that may be areas the child or youth have as life and career goals that may help them gain new ideas and confidence as well as knowledge and skills. Having clear ideas about future roles is a one way to reduce the chance of developing depression and even suicide.

Reading a book, ideally illuminated by a warm colored light, assists in falling asleep, a huge issue for many youth. This is valuable in itself as inadequate sleep is a large contributor to worsening of many mental conditions. In contrast, the blue light from computer screens makes it harder to fall asleep. When reading a book is a bedtime habit, just as for babies and toddlers and whether read to by a parent (no age is too old!) or reading alone, the routine itself helps prepare the brain to transition into sleep.
 

Encouraging good habits

But how can parents get their children away from scanning the Internet to reading books? The American Academy of Pediatrics suggests setting time blocks for the day designated for school, exercise, homework, media, and sleep with a goal of a healthy balance. Reading could be added to the family’s plan. Making reading in the same room with parents as a regular habit both models reading (as parents have to get offline, too!) and sets up an opportunity to ask questions and converse about the reading materials, thereby building family relationships. Children are notorious for being recalcitrant about talking “about their day” when coming home from school. Having a less personal and intrusive subject to talk about creates a favorable setting for precious parent-child discussions. Some families read aloud to each other. This comes up naturally when reading a clip from a newspaper or magazine. It is especially valuable and inclusive for younger children who may not yet be able to read that level of material.

Getting creative

Some other strategies to promote reading include bringing books, magazines, or even comics with subjects that interest the child or youth into the house and leaving them around without comment. Getting started on a book series (Nancy Drew, Harry Potter, etc.) that is captivating provides extra incentive. Parents can talk about their favorites from their childhood, some of which are timeless! Families may need to be creative and find literature about the online characters from video games or movies that already interest their child, even if those are not seen as ideal learning material. Not commenting on the presence of the reading material takes the pressure off and makes it clear that it is their choice whether to read them or not.

Books need to be seen as a gift rather than a “penalty” for being online. Visiting a bookstore together or giving a gift certificate for books are other ways a parent can support reading while indicating that the youth has choice. There are now more than 150,000 Little Free Library locations worldwide (visible on the app) where books can be obtained 24/7 at no cost. Bringing books to donate or even joining the cause and becoming a steward of one of these pop-up libraries models high valuation of reading but is also a volunteer activity of which the child can be proud. We brought our children’s old books to our pediatric practice and encouraged patients to “bring one and take one.” Of course, the public library is often an option and is free. Another advantage of the library is that librarians and other children there may make suggestions of books that are popular with children their age. There are lots of specific suggestions online as well.

We need to be aware that children who resist reading books may have reading weaknesses. We can assess reading fluency with standard Gray Oral Reading paragraphs or the Wide Range Achievement test in the office or recommend a reading assessment by the school. Parents who already know that their child has a reading problem may be getting advice from teachers or tutors on how to help. But to promote reading that is not onerous for a child with a reading disability, parents can do more reading aloud at home, offer audiobooks or podcasts at home or play them while driving, and aim for books with a lower reading level. Teachers or librarians can make suggestions. It is important for family members to not be judgmental about a child’s choice of reading materials.

We do not need to feel helpless in the face of the Internet – we can recommend more reading!
 

Dr. Howard is assistant professor of pediatrics at The Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

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

First year of life: Parental mental health

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

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

Toddlers and up: Emotional literacy

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

School-age children: Adding mindfulness

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

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

Early and later adolescence: Stress management skills

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

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

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

Infancy and up: Relational health

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

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

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

First year of life: Parental mental health

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

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

Toddlers and up: Emotional literacy

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

School-age children: Adding mindfulness

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

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

Early and later adolescence: Stress management skills

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

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

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

Infancy and up: Relational health

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

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

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

First year of life: Parental mental health

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

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

Toddlers and up: Emotional literacy

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

School-age children: Adding mindfulness

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

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

Early and later adolescence: Stress management skills

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

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

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

Infancy and up: Relational health

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

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

Although I have worked with depressed patients for many years, I have come to realize that it is now unfortunately an essential primary care skill to have nuanced conversations about reducing access to and use of deadly weapons (lethal means) for all families.

Firearms are now the leading cause of death for U.S. children and youth aged 1-24 years, an increase of 29.5% from 2019 to 2020. Among all youth firearm deaths, homicides (58%), suicides (37%), unintentional shootings (2%), and legal intervention (1%) were causes. These horrific numbers do not even include almost 400,000 child ED visits from 2010 to 2019 for nonfatal firearm injuries that were unintentional (39.4%), assault-related (37.7%), or self-harm (1.7%).

Accidental injury from firearms is greater when the weapon is a handgun or pistol as these are small enough to be fired by a 2-year-old, more likely to be stored loaded with ammunition as “self-protection,” and less likely to be in a gun storage case.

While an overall decline in gun ownership has occurred in homes with children ages 1-5, the proportion of weapons that are handguns has actually increased, posing higher danger to the family itself. We can’t assume hiding a weapon is ever enough as children often know the location of guns and their keys or lock codes.

Many Americans fear for their safety, have doubts about policing as protective, and strongly assert the need to protect themselves. While asking about guns in the home is universally recommended, these beliefs need to be taken into account in the discussion. It is also important to speak with the firearm owner, most often the father. We might ask, “Do you feel that you need a firearm in your home to feel safe?” as a way to nonjudgmentally acknowledge their beliefs. Because women are more likely to be killed by their spouses than by all other types of assailants combined, we can ask, “What dangers worry you the most?” and “Do you feel safe in your current and any past relationships?” If their answer is worrisome, the discussion must first turn to dealing with the family situation. If the perceived threat is outside the family, we can inform families that having a gun in evidence in the home greatly increases the risk of being hurt by an assailant as well as risk for child injury and death. We might ask, “Can you think of any other ways to protect your home (for example, alarm system, outdoor lighting, dog, or pepper spray)?”

If parents insist on keeping a gun, we can strongly and directly recommend that all firearms be stored locked, unloaded, and with ammunition locked and stored separately. We can provide information on such locking and storage options. Programs in which information on devices to disable the gun were provided – such as cables to pass through the chamber or trigger locks – have shown big increases in safe gun storage. It may be worth saying/posting information on the Child Access Prevention (CAP) laws, enacted by many states, making adults owning firearms that are not stored safely unloaded legally responsible for any resulting injuries or deaths. Such laws have reduced injuries of both children and adults by 30%-40%, unintentional gun deaths by 23%, and gun suicides by 11% (for 14- to 17-year-olds).

If the reason for owning a gun is for hunting, the owner is more likely to have had firearm safety training and use a long gun. Long guns are more difficult for a child. Discussing safe hunting gun storage is still worth recommending, as is removing any handguns they may own as these are most dangerous.

Removing or securing firearms is important for everyone’s safety but it is an essential and perhaps more difficult topic of discussion when a child is at risk for suicide or harming others. We need to consider some crucial facts about completed suicide, now the leading cause of death in children and adolescents and largely from guns. Most suicide attempts occur within 10 minutes of having a wave of suicidal thoughts. These waves of thoughts may be acted upon immediately when lethal means are available, with guns by far the most likely to result in death. It is therefore critical to assess access and counsel about lethal means in every family with a child reporting thoughts of killing themselves or others, or a history of violence or substance use. Even without imminent risk of self-harm, we can start a discussion about securing lethal means by saying, “It’s like wearing a seatbelt; you don’t expect a car crash, but if one happens, wearing a safety belt can greatly reduce injury. Guns are the most frequent cause of dying, so let’s make a plan to reduce access to those.”

Creating a written plan to deal with waves of suicidal thoughts is the basis of a Safety Plan. We can accurately remind families and youth that “When someone is struggling like this, sometimes suicidal feelings can show up and get worse fast. There are steps I routinely recommend to make things safer at home.”

It is important to assess the presence of guns in the primary home and other places the child spends time even if we have asked in the past, as things change. If firearms are present, even if locked up appropriately, when a child is having suicidal thoughts we can say, “What some gun owners in your situation do is store weapons elsewhere temporarily with someone they trust, at a self-storage unit, gun or pawn shop, or police department. I’d like to talk over storage options like that with you.” If the child themself owns the firearm, they need to agree with a removal or lock up plan for giving up their access.

If the gun owner is unwilling to remove firearms, even temporarily, we can ask them to lock them up separately from ammunition, a move that alone reduces danger a lot, and ensure the child has no access to the keys or combination. Better yet, we can ask, “Would you be willing to ask someone who doesn’t live in your home to hold the keys or to change the combination temporarily or at least store the ammunition?” They could also remove from the home a critical component of the gun so that it can’t fire, such as the slide or firing pin. If even those steps are not accepted, we can ask, “What other options would you be willing to consider to increase your child’s safety, at least until s/he is doing better?”

Whatever plan we negotiate with the family, as for any health behavior change strategy, it is more likely to be implemented if we summarize the specifics, write them down, and set a time-frame for carrying it out. We might say, “Let’s review who’s doing what and when: Dad will take the guns to his uncle’s house tomorrow and meanwhile, he will put them in the gun safe.” A follow-up call or contact soon, a key part of management of suicidal ideation, also signals how strongly we care about these safety measures and has been shown to increase implementation. We might call to say, “I wanted to check in and see how [you/your child] is doing and also ask how the plan is going that we talked about for gun storage.”

Discussions about firearms can spark strong emotions, especially if the family suspects political motivations. The Florida law prohibiting health care providers from discussing guns with patients was overturned but the thinking remains and may give us pause before having these important conversations. First of all, we need to stay calm and be prepared with key facts. The “sandwich” method is a useful approach to reduce resistance: start with something you can agree on (such as “What we hear on the news can make us all scared about safety”); then add the facts we want to convey (such as “You are actually less likely to get hurt in a break-in if you do not have a gun”); then conclude with a positive (such as “I can see that you are giving a lot of thought to how to keep your family safe”). Families generally trust our intentions and knowledge and appreciate rather than resent safety counseling when it is given in a nonjudgmental manner. Because we are protectors of child health, firearm safety must be an essential part of our anticipatory guidance.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

*Wording suggestions adapted from https://www.hsph.harvard.edu/means-matter/recommendations/clinicians.

Although I have worked with depressed patients for many years, I have come to realize that it is now unfortunately an essential primary care skill to have nuanced conversations about reducing access to and use of deadly weapons (lethal means) for all families.

Firearms are now the leading cause of death for U.S. children and youth aged 1-24 years, an increase of 29.5% from 2019 to 2020. Among all youth firearm deaths, homicides (58%), suicides (37%), unintentional shootings (2%), and legal intervention (1%) were causes. These horrific numbers do not even include almost 400,000 child ED visits from 2010 to 2019 for nonfatal firearm injuries that were unintentional (39.4%), assault-related (37.7%), or self-harm (1.7%).

Accidental injury from firearms is greater when the weapon is a handgun or pistol as these are small enough to be fired by a 2-year-old, more likely to be stored loaded with ammunition as “self-protection,” and less likely to be in a gun storage case.

While an overall decline in gun ownership has occurred in homes with children ages 1-5, the proportion of weapons that are handguns has actually increased, posing higher danger to the family itself. We can’t assume hiding a weapon is ever enough as children often know the location of guns and their keys or lock codes.

Many Americans fear for their safety, have doubts about policing as protective, and strongly assert the need to protect themselves. While asking about guns in the home is universally recommended, these beliefs need to be taken into account in the discussion. It is also important to speak with the firearm owner, most often the father. We might ask, “Do you feel that you need a firearm in your home to feel safe?” as a way to nonjudgmentally acknowledge their beliefs. Because women are more likely to be killed by their spouses than by all other types of assailants combined, we can ask, “What dangers worry you the most?” and “Do you feel safe in your current and any past relationships?” If their answer is worrisome, the discussion must first turn to dealing with the family situation. If the perceived threat is outside the family, we can inform families that having a gun in evidence in the home greatly increases the risk of being hurt by an assailant as well as risk for child injury and death. We might ask, “Can you think of any other ways to protect your home (for example, alarm system, outdoor lighting, dog, or pepper spray)?”

If parents insist on keeping a gun, we can strongly and directly recommend that all firearms be stored locked, unloaded, and with ammunition locked and stored separately. We can provide information on such locking and storage options. Programs in which information on devices to disable the gun were provided – such as cables to pass through the chamber or trigger locks – have shown big increases in safe gun storage. It may be worth saying/posting information on the Child Access Prevention (CAP) laws, enacted by many states, making adults owning firearms that are not stored safely unloaded legally responsible for any resulting injuries or deaths. Such laws have reduced injuries of both children and adults by 30%-40%, unintentional gun deaths by 23%, and gun suicides by 11% (for 14- to 17-year-olds).

If the reason for owning a gun is for hunting, the owner is more likely to have had firearm safety training and use a long gun. Long guns are more difficult for a child. Discussing safe hunting gun storage is still worth recommending, as is removing any handguns they may own as these are most dangerous.

Removing or securing firearms is important for everyone’s safety but it is an essential and perhaps more difficult topic of discussion when a child is at risk for suicide or harming others. We need to consider some crucial facts about completed suicide, now the leading cause of death in children and adolescents and largely from guns. Most suicide attempts occur within 10 minutes of having a wave of suicidal thoughts. These waves of thoughts may be acted upon immediately when lethal means are available, with guns by far the most likely to result in death. It is therefore critical to assess access and counsel about lethal means in every family with a child reporting thoughts of killing themselves or others, or a history of violence or substance use. Even without imminent risk of self-harm, we can start a discussion about securing lethal means by saying, “It’s like wearing a seatbelt; you don’t expect a car crash, but if one happens, wearing a safety belt can greatly reduce injury. Guns are the most frequent cause of dying, so let’s make a plan to reduce access to those.”

Creating a written plan to deal with waves of suicidal thoughts is the basis of a Safety Plan. We can accurately remind families and youth that “When someone is struggling like this, sometimes suicidal feelings can show up and get worse fast. There are steps I routinely recommend to make things safer at home.”

It is important to assess the presence of guns in the primary home and other places the child spends time even if we have asked in the past, as things change. If firearms are present, even if locked up appropriately, when a child is having suicidal thoughts we can say, “What some gun owners in your situation do is store weapons elsewhere temporarily with someone they trust, at a self-storage unit, gun or pawn shop, or police department. I’d like to talk over storage options like that with you.” If the child themself owns the firearm, they need to agree with a removal or lock up plan for giving up their access.

If the gun owner is unwilling to remove firearms, even temporarily, we can ask them to lock them up separately from ammunition, a move that alone reduces danger a lot, and ensure the child has no access to the keys or combination. Better yet, we can ask, “Would you be willing to ask someone who doesn’t live in your home to hold the keys or to change the combination temporarily or at least store the ammunition?” They could also remove from the home a critical component of the gun so that it can’t fire, such as the slide or firing pin. If even those steps are not accepted, we can ask, “What other options would you be willing to consider to increase your child’s safety, at least until s/he is doing better?”

Whatever plan we negotiate with the family, as for any health behavior change strategy, it is more likely to be implemented if we summarize the specifics, write them down, and set a time-frame for carrying it out. We might say, “Let’s review who’s doing what and when: Dad will take the guns to his uncle’s house tomorrow and meanwhile, he will put them in the gun safe.” A follow-up call or contact soon, a key part of management of suicidal ideation, also signals how strongly we care about these safety measures and has been shown to increase implementation. We might call to say, “I wanted to check in and see how [you/your child] is doing and also ask how the plan is going that we talked about for gun storage.”

Discussions about firearms can spark strong emotions, especially if the family suspects political motivations. The Florida law prohibiting health care providers from discussing guns with patients was overturned but the thinking remains and may give us pause before having these important conversations. First of all, we need to stay calm and be prepared with key facts. The “sandwich” method is a useful approach to reduce resistance: start with something you can agree on (such as “What we hear on the news can make us all scared about safety”); then add the facts we want to convey (such as “You are actually less likely to get hurt in a break-in if you do not have a gun”); then conclude with a positive (such as “I can see that you are giving a lot of thought to how to keep your family safe”). Families generally trust our intentions and knowledge and appreciate rather than resent safety counseling when it is given in a nonjudgmental manner. Because we are protectors of child health, firearm safety must be an essential part of our anticipatory guidance.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

*Wording suggestions adapted from https://www.hsph.harvard.edu/means-matter/recommendations/clinicians.

Although I have worked with depressed patients for many years, I have come to realize that it is now unfortunately an essential primary care skill to have nuanced conversations about reducing access to and use of deadly weapons (lethal means) for all families.

Firearms are now the leading cause of death for U.S. children and youth aged 1-24 years, an increase of 29.5% from 2019 to 2020. Among all youth firearm deaths, homicides (58%), suicides (37%), unintentional shootings (2%), and legal intervention (1%) were causes. These horrific numbers do not even include almost 400,000 child ED visits from 2010 to 2019 for nonfatal firearm injuries that were unintentional (39.4%), assault-related (37.7%), or self-harm (1.7%).

Accidental injury from firearms is greater when the weapon is a handgun or pistol as these are small enough to be fired by a 2-year-old, more likely to be stored loaded with ammunition as “self-protection,” and less likely to be in a gun storage case.

While an overall decline in gun ownership has occurred in homes with children ages 1-5, the proportion of weapons that are handguns has actually increased, posing higher danger to the family itself. We can’t assume hiding a weapon is ever enough as children often know the location of guns and their keys or lock codes.

Many Americans fear for their safety, have doubts about policing as protective, and strongly assert the need to protect themselves. While asking about guns in the home is universally recommended, these beliefs need to be taken into account in the discussion. It is also important to speak with the firearm owner, most often the father. We might ask, “Do you feel that you need a firearm in your home to feel safe?” as a way to nonjudgmentally acknowledge their beliefs. Because women are more likely to be killed by their spouses than by all other types of assailants combined, we can ask, “What dangers worry you the most?” and “Do you feel safe in your current and any past relationships?” If their answer is worrisome, the discussion must first turn to dealing with the family situation. If the perceived threat is outside the family, we can inform families that having a gun in evidence in the home greatly increases the risk of being hurt by an assailant as well as risk for child injury and death. We might ask, “Can you think of any other ways to protect your home (for example, alarm system, outdoor lighting, dog, or pepper spray)?”

If parents insist on keeping a gun, we can strongly and directly recommend that all firearms be stored locked, unloaded, and with ammunition locked and stored separately. We can provide information on such locking and storage options. Programs in which information on devices to disable the gun were provided – such as cables to pass through the chamber or trigger locks – have shown big increases in safe gun storage. It may be worth saying/posting information on the Child Access Prevention (CAP) laws, enacted by many states, making adults owning firearms that are not stored safely unloaded legally responsible for any resulting injuries or deaths. Such laws have reduced injuries of both children and adults by 30%-40%, unintentional gun deaths by 23%, and gun suicides by 11% (for 14- to 17-year-olds).

If the reason for owning a gun is for hunting, the owner is more likely to have had firearm safety training and use a long gun. Long guns are more difficult for a child. Discussing safe hunting gun storage is still worth recommending, as is removing any handguns they may own as these are most dangerous.

Removing or securing firearms is important for everyone’s safety but it is an essential and perhaps more difficult topic of discussion when a child is at risk for suicide or harming others. We need to consider some crucial facts about completed suicide, now the leading cause of death in children and adolescents and largely from guns. Most suicide attempts occur within 10 minutes of having a wave of suicidal thoughts. These waves of thoughts may be acted upon immediately when lethal means are available, with guns by far the most likely to result in death. It is therefore critical to assess access and counsel about lethal means in every family with a child reporting thoughts of killing themselves or others, or a history of violence or substance use. Even without imminent risk of self-harm, we can start a discussion about securing lethal means by saying, “It’s like wearing a seatbelt; you don’t expect a car crash, but if one happens, wearing a safety belt can greatly reduce injury. Guns are the most frequent cause of dying, so let’s make a plan to reduce access to those.”

Creating a written plan to deal with waves of suicidal thoughts is the basis of a Safety Plan. We can accurately remind families and youth that “When someone is struggling like this, sometimes suicidal feelings can show up and get worse fast. There are steps I routinely recommend to make things safer at home.”

It is important to assess the presence of guns in the primary home and other places the child spends time even if we have asked in the past, as things change. If firearms are present, even if locked up appropriately, when a child is having suicidal thoughts we can say, “What some gun owners in your situation do is store weapons elsewhere temporarily with someone they trust, at a self-storage unit, gun or pawn shop, or police department. I’d like to talk over storage options like that with you.” If the child themself owns the firearm, they need to agree with a removal or lock up plan for giving up their access.

If the gun owner is unwilling to remove firearms, even temporarily, we can ask them to lock them up separately from ammunition, a move that alone reduces danger a lot, and ensure the child has no access to the keys or combination. Better yet, we can ask, “Would you be willing to ask someone who doesn’t live in your home to hold the keys or to change the combination temporarily or at least store the ammunition?” They could also remove from the home a critical component of the gun so that it can’t fire, such as the slide or firing pin. If even those steps are not accepted, we can ask, “What other options would you be willing to consider to increase your child’s safety, at least until s/he is doing better?”

Whatever plan we negotiate with the family, as for any health behavior change strategy, it is more likely to be implemented if we summarize the specifics, write them down, and set a time-frame for carrying it out. We might say, “Let’s review who’s doing what and when: Dad will take the guns to his uncle’s house tomorrow and meanwhile, he will put them in the gun safe.” A follow-up call or contact soon, a key part of management of suicidal ideation, also signals how strongly we care about these safety measures and has been shown to increase implementation. We might call to say, “I wanted to check in and see how [you/your child] is doing and also ask how the plan is going that we talked about for gun storage.”

Discussions about firearms can spark strong emotions, especially if the family suspects political motivations. The Florida law prohibiting health care providers from discussing guns with patients was overturned but the thinking remains and may give us pause before having these important conversations. First of all, we need to stay calm and be prepared with key facts. The “sandwich” method is a useful approach to reduce resistance: start with something you can agree on (such as “What we hear on the news can make us all scared about safety”); then add the facts we want to convey (such as “You are actually less likely to get hurt in a break-in if you do not have a gun”); then conclude with a positive (such as “I can see that you are giving a lot of thought to how to keep your family safe”). Families generally trust our intentions and knowledge and appreciate rather than resent safety counseling when it is given in a nonjudgmental manner. Because we are protectors of child health, firearm safety must be an essential part of our anticipatory guidance.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.

*Wording suggestions adapted from https://www.hsph.harvard.edu/means-matter/recommendations/clinicians.

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

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

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

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

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

First: Know your child

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

Second: Use adolescent development as your guide

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

Independence

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

Social relationships

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

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

Investigating and experimenting with interests (identity)

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

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

Managing anxiety or distress

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

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

Self-care

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

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

Third: Be mindful of what you model

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

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

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

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

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

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

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

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

First: Know your child

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

Second: Use adolescent development as your guide

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

Independence

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

Social relationships

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

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

Investigating and experimenting with interests (identity)

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

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

Managing anxiety or distress

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

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

Self-care

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

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

Third: Be mindful of what you model

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

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

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

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

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

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

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

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

First: Know your child

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

Second: Use adolescent development as your guide

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

Independence

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

Social relationships

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

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

Investigating and experimenting with interests (identity)

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

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

Managing anxiety or distress

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

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

Self-care

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

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

Third: Be mindful of what you model

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

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

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