Michael S. Jellinek, MD

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

Swick_Susan_D_CA_web.jpg

Bullying

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

Social Media

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

Substance Use and Abuse

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

Minimizing Risk and Cultivating Resilience

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

Jellinek_Michael_S 2019_web.jpg

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

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

References

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

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

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

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

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

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

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

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

Swick_Susan_D_CA_web.jpg

Bullying

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

Social Media

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

Substance Use and Abuse

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

Minimizing Risk and Cultivating Resilience

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

Jellinek_Michael_S 2019_web.jpg

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

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

References

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

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

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

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

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

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

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

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

Swick_Susan_D_CA_web.jpg

Bullying

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

Social Media

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

Substance Use and Abuse

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

Minimizing Risk and Cultivating Resilience

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

Jellinek_Michael_S 2019_web.jpg

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

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

References

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

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

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

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

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

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

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

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

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

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

Swick_Susan_D_CA_web.jpg

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

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

Introducing the Topic

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

Help Parents to Be Good Listeners

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

Identify Coping Strategies

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

Focus on the Basics

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

Set Up Speed Bumps

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

Jellinek_Michael_S 2019_web.jpg

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

Acknowledge the Strain

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

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

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

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

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

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

Swick_Susan_D_CA_web.jpg

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

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

Introducing the Topic

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

Help Parents to Be Good Listeners

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

Identify Coping Strategies

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

Focus on the Basics

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

Set Up Speed Bumps

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

Jellinek_Michael_S 2019_web.jpg

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

Acknowledge the Strain

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

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

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

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

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

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

Swick_Susan_D_CA_web.jpg

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

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

Introducing the Topic

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

Help Parents to Be Good Listeners

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

Identify Coping Strategies

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

Focus on the Basics

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

Set Up Speed Bumps

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

Jellinek_Michael_S 2019_web.jpg

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

Acknowledge the Strain

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

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

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

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

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

Suicide screening

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

Swick_Susan_D_CA_web.jpg

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.

Jellinek_Michael_S 2019_web.jpg

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.

Swick_Susan_D_CA_web.jpg

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.

Jellinek_Michael_S 2019_web.jpg

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.

Swick_Susan_D_CA_web.jpg

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.

Jellinek_Michael_S 2019_web.jpg

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

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

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

Next steps

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

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

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

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

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

Anxiety disorders in young children

Swick_Susan_D_CA_web.jpg

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

Jellinek_Michael_S 2019_web.jpg

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

Swick_Susan_D_CA_web.jpg

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

Jellinek_Michael_S 2019_web.jpg

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

Swick_Susan_D_CA_web.jpg

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

Jellinek_Michael_S 2019_web.jpg

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

Special cases: School refusal

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

Special cases: Adolescents with new anxiety symptoms

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

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

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

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

Anxiety disorders: Common and treatable

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

Swick_Susan_D_CA_web.jpg

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.

Jellinek_Michael_S 2019_web.jpg

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.

Swick_Susan_D_CA_web.jpg

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.

Jellinek_Michael_S 2019_web.jpg

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.

Swick_Susan_D_CA_web.jpg

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.

Jellinek_Michael_S 2019_web.jpg

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

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

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

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

Reference

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

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

First year of life: Parental mental health

Swick_Susan_D_CA_web.jpg

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.

Jellinek_Michael_S 2019_web.jpg

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

Swick_Susan_D_CA_web.jpg

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.

Jellinek_Michael_S 2019_web.jpg

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

Swick_Susan_D_CA_web.jpg

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.

Jellinek_Michael_S 2019_web.jpg

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

Early and later adolescence: Stress management skills

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

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

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

Infancy and up: Relational health

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

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

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

Swick_Susan_D_CALIF_web.jpg

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.

Jellinek_Michael_S 2019_web.jpg

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.

Swick_Susan_D_CALIF_web.jpg

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.

Jellinek_Michael_S 2019_web.jpg

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.

Swick_Susan_D_CALIF_web.jpg

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.

Attention-deficit/hyperactivity disorder (ADHD) is often a very challenging condition for parents to manage, both because of the “gleeful mayhem” children with ADHD manifest and because of the nature of effective treatments. Multiple randomized controlled studies and meta-analyses have demonstrated that stimulant medication with behavioral interventions is the optimal first-line treatment for children with both subtypes of ADHD, and that medications alone are superior to behavioral interventions alone. By improving attention and impulse control, the medications effectively decrease the many negative interactions with teachers, peers, and parents, aiding development and healthy self-esteem.

But many parents feel anxious about treating their young children with stimulants. Importantly, how children with ADHD will fare as adults is not predicted by their symptom level, but instead by the quality of their relationships with their parents, their ability to perform at school, and their social skills. Bring this framework to parents as you listen to their questions and help them decide on the best approach for their family. To assist you in these conversations, we will review the evidence for (or against) several of the most common alternatives to medication that parents are likely to ask about.
 

Diets and supplements

Dietary modifications are among the most popular “natural” approaches to managing ADHD in children. Diets that eliminate processed sugars or food additives (particularly artificial food coloring) are among the most common approaches discussed in the lay press. These diets are usually very time-consuming and disruptive for families to follow, and there is no evidence to support their general use in ADHD management. Those studies that rigorously examined them suggest that, for children with severe impairment who have failed to respond to medications for ADHD, a workup for food intolerance or nutritional deficits may reveal a different problem underlying their behavioral difficulties.¹

Swick_Susan_D_CALIF_web.jpg

Similarly, supplementation with high-dose omega-3 fatty acids is modestly helpful only in a subset of children with ADHD symptoms, and not nearly as effective as medications or behavioral interventions. Spending time on an exacting diet or buying expensive supplements is very unlikely to relieve the children’s symptoms and may only add to their stress at home. The “sugar high” parents note may be the rare joy of eating a candy bar and not sugar causing ADHD. Offer parents the guidance to focus on a healthy diet, high in fruits and vegetables, whole grains, and healthy protein, and on meals that emphasize family time instead of struggles around food.
 

Neurofeedback

Neurofeedback is an approach that grew out of the observation that many adults with ADHD had resting patterns of brain wave activity different from those of neurotypical adults. In neurofeedback, patients learn strategies that amplify the brain waves associated with focused mental activity, rather than listless or hyperactive states. Businesses market this service for all sorts of illnesses and challenges, ADHD chief among them. Despite the marketing, there are very few randomized controlled studies of this intervention for ADHD in youth, and those have shown only the possibility of a benefit.

While there is no evidence of serious side effects, these treatments are time-consuming and expensive and unlikely to be covered by any insurance. You might suggest to parents that they could achieve some of the same theoretical benefits by looking for hobbies that invite sustained focus in their children. That is, they should think about activities that interest the children, such as music lessons or karate, that they could practice in classes and at home. If the children find these activities even somewhat interesting (or just enjoy the reward of their parents’ or teachers’ attention), regular practice will be supporting their developing attention while building social skills and authentic self-confidence, rather than the activities feeling like a treatment for an illness or condition.

Sleep and exercise

There are not many businesses or books selling worried and exhausted parents a quick nonmedication solution for their children’s ADHD in the form of healthy sleep and exercise habits. But these are safe and healthy ways to reduce symptoms and support development. Children with ADHD often enjoy and benefit from participating in a sport, and daily exercise can help with sleep and regulating their energy. They also often have difficulty with sleep initiation, and commonly do not get adequate or restful sleep. Inadequate sleep exacerbates inattention, distractibility, and irritability. Children with untreated ADHD also often spend a lot of time on screens, as it is difficult for them to shift away from rewarding activities, and parents can find screen time to be a welcome break from hyperactivity and negative interactions. But excessive screen time, especially close to bedtime, can worsen irritability and make sleep more difficult. Talk with parents about the value of establishing a routine around screen time, modest daily physical activity, and sleep that everyone can follow. If their family life is currently marked by late bedtimes and long hours in front of video games, this change will take effort. But within a few weeks, it could lead to significant improvements in energy, attention, and interactions at home.

Behavioral treatments

Effective behavioral treatments for ADHD do not change ADHD symptoms, but they do help children learn how to manage them. In “parent management training,” younger children and parents learn together how to avoid negative cycles of behavior (i.e., temper outbursts) by focusing on consistent routines and consequences that support children calmly learning to manage their impulses. The only other evidence-based treatment focuses on helping school age and older children develop executive functions – their planning, organization, and time management skills – with a range of age-appropriate tools. Both of these therapies may be more effective if the children are also receiving medication, but medication is not necessary for them to be helpful. It is important to note that play therapy and other evidence-based psychotherapies are not effective for management of ADHD, although they may treat comorbid problems.

Parent treatment

You may have diagnosed children with ADHD only to hear their parents respond by saying that they suspect (or know) that they (or their spouses) also have ADHD. This would not be surprising, as ADHD has one of the highest rates of heritability of psychiatric disorders, at 80%. Somewhere between 25% and 50% of parents of children with ADHD have ADHD themselves.² Screening for adults with ADHD, such as the Adult ADHD Self-Report Scale, is widely available and free. Speak with parents about the fact that behavioral treatments for their children’s ADHD are demanding. Such treatments require patience, calm, organization, and consistency.

If parents have ADHD, it may be very helpful for them to prioritize their own effective treatments, so that their attention and impulse control will support their parenting. They may be interested in learning about how treatment might also improve their performance at work and even the quality of their relationships. While there is some evidence that their children’s treatment outcome will hinge on the parents’ treatment,³ they deserve good care independent of the expectations of parenting.

Families benefit from a comprehensive “ADHD plan” for their children. This would start with an assessment of the severity of their children’s symptoms, specifying their impairment at home, school, and in social relationships. It would include their nonacademic performance, exploration of interests, and developing self-confidence. All of these considerations lead to setting reasonable expectations so the children can feel successful. Parents should think about how best to structure their children’s schedules to promote healthy sleep, exercise, and nutrition, and to expand opportunities for building their frustration tolerance, social skills, and executive function.

Parents will need to consider what kind of supports they themselves need to offer this structure. There are good resources available online for information and support, including Children and Adults with ADHD (chadd.org) and the ADHD Resource Center from the American Academy of Child and Adolescent Psychiatry (aacap.org). This approach may help parents to evaluate the potential risks and benefits of medications as a component of treatment. Most of the quick fixes for childhood ADHD on the market will take a family’s time and money without providing meaningful improvement. Parents should focus instead on the tried-and-true routines and supports that will help them to create the setting at home that will enable their children to flourish.
 

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

References

1. Millichap JG and Yee MM. Pediatrics. 2012 Feb;129(2):330-7.

2. Grimm O et al. Curr Psychiatry Rep. 2020 Feb 27;22(4):18.

3. Chronis-Tuscano A et al. J Abnorm Child Psychol. 2017 Apr;45(3):501-7.

Attention-deficit/hyperactivity disorder (ADHD) is often a very challenging condition for parents to manage, both because of the “gleeful mayhem” children with ADHD manifest and because of the nature of effective treatments. Multiple randomized controlled studies and meta-analyses have demonstrated that stimulant medication with behavioral interventions is the optimal first-line treatment for children with both subtypes of ADHD, and that medications alone are superior to behavioral interventions alone. By improving attention and impulse control, the medications effectively decrease the many negative interactions with teachers, peers, and parents, aiding development and healthy self-esteem.

But many parents feel anxious about treating their young children with stimulants. Importantly, how children with ADHD will fare as adults is not predicted by their symptom level, but instead by the quality of their relationships with their parents, their ability to perform at school, and their social skills. Bring this framework to parents as you listen to their questions and help them decide on the best approach for their family. To assist you in these conversations, we will review the evidence for (or against) several of the most common alternatives to medication that parents are likely to ask about.
 

Diets and supplements

Dietary modifications are among the most popular “natural” approaches to managing ADHD in children. Diets that eliminate processed sugars or food additives (particularly artificial food coloring) are among the most common approaches discussed in the lay press. These diets are usually very time-consuming and disruptive for families to follow, and there is no evidence to support their general use in ADHD management. Those studies that rigorously examined them suggest that, for children with severe impairment who have failed to respond to medications for ADHD, a workup for food intolerance or nutritional deficits may reveal a different problem underlying their behavioral difficulties.¹

Swick_Susan_D_CALIF_web.jpg

Similarly, supplementation with high-dose omega-3 fatty acids is modestly helpful only in a subset of children with ADHD symptoms, and not nearly as effective as medications or behavioral interventions. Spending time on an exacting diet or buying expensive supplements is very unlikely to relieve the children’s symptoms and may only add to their stress at home. The “sugar high” parents note may be the rare joy of eating a candy bar and not sugar causing ADHD. Offer parents the guidance to focus on a healthy diet, high in fruits and vegetables, whole grains, and healthy protein, and on meals that emphasize family time instead of struggles around food.
 

Neurofeedback

Neurofeedback is an approach that grew out of the observation that many adults with ADHD had resting patterns of brain wave activity different from those of neurotypical adults. In neurofeedback, patients learn strategies that amplify the brain waves associated with focused mental activity, rather than listless or hyperactive states. Businesses market this service for all sorts of illnesses and challenges, ADHD chief among them. Despite the marketing, there are very few randomized controlled studies of this intervention for ADHD in youth, and those have shown only the possibility of a benefit.

While there is no evidence of serious side effects, these treatments are time-consuming and expensive and unlikely to be covered by any insurance. You might suggest to parents that they could achieve some of the same theoretical benefits by looking for hobbies that invite sustained focus in their children. That is, they should think about activities that interest the children, such as music lessons or karate, that they could practice in classes and at home. If the children find these activities even somewhat interesting (or just enjoy the reward of their parents’ or teachers’ attention), regular practice will be supporting their developing attention while building social skills and authentic self-confidence, rather than the activities feeling like a treatment for an illness or condition.

Sleep and exercise

There are not many businesses or books selling worried and exhausted parents a quick nonmedication solution for their children’s ADHD in the form of healthy sleep and exercise habits. But these are safe and healthy ways to reduce symptoms and support development. Children with ADHD often enjoy and benefit from participating in a sport, and daily exercise can help with sleep and regulating their energy. They also often have difficulty with sleep initiation, and commonly do not get adequate or restful sleep. Inadequate sleep exacerbates inattention, distractibility, and irritability. Children with untreated ADHD also often spend a lot of time on screens, as it is difficult for them to shift away from rewarding activities, and parents can find screen time to be a welcome break from hyperactivity and negative interactions. But excessive screen time, especially close to bedtime, can worsen irritability and make sleep more difficult. Talk with parents about the value of establishing a routine around screen time, modest daily physical activity, and sleep that everyone can follow. If their family life is currently marked by late bedtimes and long hours in front of video games, this change will take effort. But within a few weeks, it could lead to significant improvements in energy, attention, and interactions at home.

Behavioral treatments

Effective behavioral treatments for ADHD do not change ADHD symptoms, but they do help children learn how to manage them. In “parent management training,” younger children and parents learn together how to avoid negative cycles of behavior (i.e., temper outbursts) by focusing on consistent routines and consequences that support children calmly learning to manage their impulses. The only other evidence-based treatment focuses on helping school age and older children develop executive functions – their planning, organization, and time management skills – with a range of age-appropriate tools. Both of these therapies may be more effective if the children are also receiving medication, but medication is not necessary for them to be helpful. It is important to note that play therapy and other evidence-based psychotherapies are not effective for management of ADHD, although they may treat comorbid problems.

Parent treatment

You may have diagnosed children with ADHD only to hear their parents respond by saying that they suspect (or know) that they (or their spouses) also have ADHD. This would not be surprising, as ADHD has one of the highest rates of heritability of psychiatric disorders, at 80%. Somewhere between 25% and 50% of parents of children with ADHD have ADHD themselves.² Screening for adults with ADHD, such as the Adult ADHD Self-Report Scale, is widely available and free. Speak with parents about the fact that behavioral treatments for their children’s ADHD are demanding. Such treatments require patience, calm, organization, and consistency.

If parents have ADHD, it may be very helpful for them to prioritize their own effective treatments, so that their attention and impulse control will support their parenting. They may be interested in learning about how treatment might also improve their performance at work and even the quality of their relationships. While there is some evidence that their children’s treatment outcome will hinge on the parents’ treatment,³ they deserve good care independent of the expectations of parenting.

Families benefit from a comprehensive “ADHD plan” for their children. This would start with an assessment of the severity of their children’s symptoms, specifying their impairment at home, school, and in social relationships. It would include their nonacademic performance, exploration of interests, and developing self-confidence. All of these considerations lead to setting reasonable expectations so the children can feel successful. Parents should think about how best to structure their children’s schedules to promote healthy sleep, exercise, and nutrition, and to expand opportunities for building their frustration tolerance, social skills, and executive function.

Parents will need to consider what kind of supports they themselves need to offer this structure. There are good resources available online for information and support, including Children and Adults with ADHD (chadd.org) and the ADHD Resource Center from the American Academy of Child and Adolescent Psychiatry (aacap.org). This approach may help parents to evaluate the potential risks and benefits of medications as a component of treatment. Most of the quick fixes for childhood ADHD on the market will take a family’s time and money without providing meaningful improvement. Parents should focus instead on the tried-and-true routines and supports that will help them to create the setting at home that will enable their children to flourish.
 

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

References

1. Millichap JG and Yee MM. Pediatrics. 2012 Feb;129(2):330-7.

2. Grimm O et al. Curr Psychiatry Rep. 2020 Feb 27;22(4):18.

3. Chronis-Tuscano A et al. J Abnorm Child Psychol. 2017 Apr;45(3):501-7.

Attention-deficit/hyperactivity disorder (ADHD) is often a very challenging condition for parents to manage, both because of the “gleeful mayhem” children with ADHD manifest and because of the nature of effective treatments. Multiple randomized controlled studies and meta-analyses have demonstrated that stimulant medication with behavioral interventions is the optimal first-line treatment for children with both subtypes of ADHD, and that medications alone are superior to behavioral interventions alone. By improving attention and impulse control, the medications effectively decrease the many negative interactions with teachers, peers, and parents, aiding development and healthy self-esteem.

But many parents feel anxious about treating their young children with stimulants. Importantly, how children with ADHD will fare as adults is not predicted by their symptom level, but instead by the quality of their relationships with their parents, their ability to perform at school, and their social skills. Bring this framework to parents as you listen to their questions and help them decide on the best approach for their family. To assist you in these conversations, we will review the evidence for (or against) several of the most common alternatives to medication that parents are likely to ask about.
 

Diets and supplements

Dietary modifications are among the most popular “natural” approaches to managing ADHD in children. Diets that eliminate processed sugars or food additives (particularly artificial food coloring) are among the most common approaches discussed in the lay press. These diets are usually very time-consuming and disruptive for families to follow, and there is no evidence to support their general use in ADHD management. Those studies that rigorously examined them suggest that, for children with severe impairment who have failed to respond to medications for ADHD, a workup for food intolerance or nutritional deficits may reveal a different problem underlying their behavioral difficulties.¹

Swick_Susan_D_CALIF_web.jpg

Similarly, supplementation with high-dose omega-3 fatty acids is modestly helpful only in a subset of children with ADHD symptoms, and not nearly as effective as medications or behavioral interventions. Spending time on an exacting diet or buying expensive supplements is very unlikely to relieve the children’s symptoms and may only add to their stress at home. The “sugar high” parents note may be the rare joy of eating a candy bar and not sugar causing ADHD. Offer parents the guidance to focus on a healthy diet, high in fruits and vegetables, whole grains, and healthy protein, and on meals that emphasize family time instead of struggles around food.
 

Neurofeedback

Neurofeedback is an approach that grew out of the observation that many adults with ADHD had resting patterns of brain wave activity different from those of neurotypical adults. In neurofeedback, patients learn strategies that amplify the brain waves associated with focused mental activity, rather than listless or hyperactive states. Businesses market this service for all sorts of illnesses and challenges, ADHD chief among them. Despite the marketing, there are very few randomized controlled studies of this intervention for ADHD in youth, and those have shown only the possibility of a benefit.

While there is no evidence of serious side effects, these treatments are time-consuming and expensive and unlikely to be covered by any insurance. You might suggest to parents that they could achieve some of the same theoretical benefits by looking for hobbies that invite sustained focus in their children. That is, they should think about activities that interest the children, such as music lessons or karate, that they could practice in classes and at home. If the children find these activities even somewhat interesting (or just enjoy the reward of their parents’ or teachers’ attention), regular practice will be supporting their developing attention while building social skills and authentic self-confidence, rather than the activities feeling like a treatment for an illness or condition.

Sleep and exercise

There are not many businesses or books selling worried and exhausted parents a quick nonmedication solution for their children’s ADHD in the form of healthy sleep and exercise habits. But these are safe and healthy ways to reduce symptoms and support development. Children with ADHD often enjoy and benefit from participating in a sport, and daily exercise can help with sleep and regulating their energy. They also often have difficulty with sleep initiation, and commonly do not get adequate or restful sleep. Inadequate sleep exacerbates inattention, distractibility, and irritability. Children with untreated ADHD also often spend a lot of time on screens, as it is difficult for them to shift away from rewarding activities, and parents can find screen time to be a welcome break from hyperactivity and negative interactions. But excessive screen time, especially close to bedtime, can worsen irritability and make sleep more difficult. Talk with parents about the value of establishing a routine around screen time, modest daily physical activity, and sleep that everyone can follow. If their family life is currently marked by late bedtimes and long hours in front of video games, this change will take effort. But within a few weeks, it could lead to significant improvements in energy, attention, and interactions at home.

Behavioral treatments

Effective behavioral treatments for ADHD do not change ADHD symptoms, but they do help children learn how to manage them. In “parent management training,” younger children and parents learn together how to avoid negative cycles of behavior (i.e., temper outbursts) by focusing on consistent routines and consequences that support children calmly learning to manage their impulses. The only other evidence-based treatment focuses on helping school age and older children develop executive functions – their planning, organization, and time management skills – with a range of age-appropriate tools. Both of these therapies may be more effective if the children are also receiving medication, but medication is not necessary for them to be helpful. It is important to note that play therapy and other evidence-based psychotherapies are not effective for management of ADHD, although they may treat comorbid problems.

Parent treatment

You may have diagnosed children with ADHD only to hear their parents respond by saying that they suspect (or know) that they (or their spouses) also have ADHD. This would not be surprising, as ADHD has one of the highest rates of heritability of psychiatric disorders, at 80%. Somewhere between 25% and 50% of parents of children with ADHD have ADHD themselves.² Screening for adults with ADHD, such as the Adult ADHD Self-Report Scale, is widely available and free. Speak with parents about the fact that behavioral treatments for their children’s ADHD are demanding. Such treatments require patience, calm, organization, and consistency.

If parents have ADHD, it may be very helpful for them to prioritize their own effective treatments, so that their attention and impulse control will support their parenting. They may be interested in learning about how treatment might also improve their performance at work and even the quality of their relationships. While there is some evidence that their children’s treatment outcome will hinge on the parents’ treatment,³ they deserve good care independent of the expectations of parenting.

Families benefit from a comprehensive “ADHD plan” for their children. This would start with an assessment of the severity of their children’s symptoms, specifying their impairment at home, school, and in social relationships. It would include their nonacademic performance, exploration of interests, and developing self-confidence. All of these considerations lead to setting reasonable expectations so the children can feel successful. Parents should think about how best to structure their children’s schedules to promote healthy sleep, exercise, and nutrition, and to expand opportunities for building their frustration tolerance, social skills, and executive function.

Parents will need to consider what kind of supports they themselves need to offer this structure. There are good resources available online for information and support, including Children and Adults with ADHD (chadd.org) and the ADHD Resource Center from the American Academy of Child and Adolescent Psychiatry (aacap.org). This approach may help parents to evaluate the potential risks and benefits of medications as a component of treatment. Most of the quick fixes for childhood ADHD on the market will take a family’s time and money without providing meaningful improvement. Parents should focus instead on the tried-and-true routines and supports that will help them to create the setting at home that will enable their children to flourish.
 

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

References

1. Millichap JG and Yee MM. Pediatrics. 2012 Feb;129(2):330-7.

2. Grimm O et al. Curr Psychiatry Rep. 2020 Feb 27;22(4):18.

3. Chronis-Tuscano A et al. J Abnorm Child Psychol. 2017 Apr;45(3):501-7.

Meditation has become a popular practice in the United States over the last decade. It is not limited to adults, but can be learned and practiced by children and teenagers also. Variants are being used in many schools as parts of a social and emotional learning curriculum, and different kinds of mindfulness practices are common parts of psychological treatments. In this month’s column, we will review the evidence that supports the efficacy of a meditation practice to treat the mental health problems that are common in children and adolescents, and review how it might be a useful adjunct to the screening, education, and treatments that you offer your young patients.

Swick_Susan_D_CALIF_web.jpg

There are many different types of meditation practices, but the unifying feature is known as mindfulness. Most broadly, mindfulness refers to a state of nonjudgmental awareness of one’s thoughts, feelings, or sensations. A mindfulness meditation practice involves physical stillness and focused attention, typically on the physical sensations of one’s breath. When thoughts, feelings, or physical sensations intrude on the stillness, one learns to cultivate a nonjudgmental awareness of those experiences without disrupting the state of quiet concentration. It could be said that meditation is easy to learn and difficult to master, and that is why it should be practiced regularly. Part of its growing popularity has undoubtedly been served by the ease with which people can access a variety of guided meditations (through apps, YouTube, and beyond) that make it relatively easy to access a variety of methods to learn how to practice mindfulness meditation.

The benefits of meditation in adults are well-established, including lower blood pressure, lower rates of heart disease, lower markers of inflammation, better sleep, and self-described levels of well-being. Meditation appears to be especially effective at mitigating the cardiovascular, metabolic, autoimmune, and inflammatory consequences of high-stress or unhealthy lifestyles in adults. Children and adolescents typically do not suffer from these diseases, but there is growing evidence that mindfulness practices can improve self-reported stress management skills, well-being, and sleep in young people; skills that can protect their physical and mental health. In addition, there is some evidence that mindfulness can be effective as a treatment for the common psychiatric illnesses of youth.
 

Anxiety

There is robust evidence for the efficacy of mindfulness-based interventions (including a regular mindfulness meditation practice) in the treatment of anxiety disorders in youth. Multiple studies and meta-analyses have demonstrated significant and sustained improvement in anxiety symptoms in these young patients. This makes sense when one considers that most psychotherapy treatments for anxiety include the cultivation of self-awareness and the ability to recognize the feelings of anxiety. This is critical as youth with anxiety disorders often mistake these feelings for facts. The treatment then shifts toward practice tolerating these feelings to help children develop an appreciation that they can face and manage anxiety and that it does not need to be avoided. Part of tolerating these feelings includes building skills to facilitate calm and physical relaxation in the face of these anxious feelings.

This is the core of exposure-based psychotherapies. Mindfulness practices echo the cultivation of self-awareness with focus and physical calm. Studies have shown that mindfulness-based interventions have significant and lasting effects on the symptoms of anxiety disorders in youth, including those youth with comorbid ADHD and learning disabilities. It is important to be aware that, for youth who have experienced trauma, mindfulness meditation can trigger a flood of re-experiencing phenomena, and it is important that those youth also are receiving treatment for PTSD.
 

Depression

There is evidence that some of the symptoms that occur as part of depression in adolescents improve with mindfulness-based interventions. In particular, symptoms of anger, irritability, disruptive behaviors, suicidality, and even impulsive self-injury improve with mindfulness-based interventions. Dialectical behavioral therapy (DBT) and acceptance and commitment therapy (ACT) have the nonjudgmental self-awareness of mindfulness built in as a component of the therapy. But mindfulness practices without explicit cognitive and behavioral components of psychotherapy for depression are not effective as stand-alone treatment of major depressive disorder in youth.

Multiple meta-analyses have demonstrated that stimulant treatment is more effective than behavioral or environmental interventions in the treatment of ADHD in children and adolescents, and combined treatments have not shown substantial additional improvement over medications alone in randomized controlled studies. But there is a lot of interest in finding effective treatments beyond medications that will help children with ADHD build important cognitive and behavioral skills that may lag developmentally.

Now there is an emerging body of evidence indicating that mindfulness skills in children with ADHD are quite effective for improving their sustained attention, social skills, behavioral control, and even hyperactivity. Additionally, methods to teach mindfulness skills to children who struggle with stillness and focused attention have been developed for these studies (“mindful martial arts”). Again, this intervention has not yet shown the same level of efficacy as medication treatments for ADHD symptoms, but it has demonstrated promise in early trials. Interestingly, it has also shown promise as a component of parenting interventions for youth with ADHD.

You do not need to wait for decisive evidence from randomized controlled trials to recommend mindfulness training for your patients with anxiety, ADHD, or even depression. Indeed, this practice alone may be adequate as a treatment for mild to moderate anxiety disorders. But you can also recommend it as an empowering and effective adjunctive treatment for almost every psychiatric illness and subclinical syndrome, and one that is affordable and easy for families to access. It would be valuable for you to recommend that your patients and their parents both try a mindfulness practice alongside your recommendations about healthy sleep, exercise, and nutrition. There are free apps such as Smiling Mind, Sound Mind, and Thrive Global that families can try together. Some children may need to move physically to be able to practice mindfulness, so yoga or walking meditations can be a better practice for them. When parents can try mindfulness practice alongside their children, it will facilitate their child’s efforts to develop these skills, and the improved sleep, focus, and stress management skills in parents can make a significant difference in the health and well-being of the whole family.

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.

Meditation has become a popular practice in the United States over the last decade. It is not limited to adults, but can be learned and practiced by children and teenagers also. Variants are being used in many schools as parts of a social and emotional learning curriculum, and different kinds of mindfulness practices are common parts of psychological treatments. In this month’s column, we will review the evidence that supports the efficacy of a meditation practice to treat the mental health problems that are common in children and adolescents, and review how it might be a useful adjunct to the screening, education, and treatments that you offer your young patients.

Swick_Susan_D_CALIF_web.jpg

There are many different types of meditation practices, but the unifying feature is known as mindfulness. Most broadly, mindfulness refers to a state of nonjudgmental awareness of one’s thoughts, feelings, or sensations. A mindfulness meditation practice involves physical stillness and focused attention, typically on the physical sensations of one’s breath. When thoughts, feelings, or physical sensations intrude on the stillness, one learns to cultivate a nonjudgmental awareness of those experiences without disrupting the state of quiet concentration. It could be said that meditation is easy to learn and difficult to master, and that is why it should be practiced regularly. Part of its growing popularity has undoubtedly been served by the ease with which people can access a variety of guided meditations (through apps, YouTube, and beyond) that make it relatively easy to access a variety of methods to learn how to practice mindfulness meditation.

The benefits of meditation in adults are well-established, including lower blood pressure, lower rates of heart disease, lower markers of inflammation, better sleep, and self-described levels of well-being. Meditation appears to be especially effective at mitigating the cardiovascular, metabolic, autoimmune, and inflammatory consequences of high-stress or unhealthy lifestyles in adults. Children and adolescents typically do not suffer from these diseases, but there is growing evidence that mindfulness practices can improve self-reported stress management skills, well-being, and sleep in young people; skills that can protect their physical and mental health. In addition, there is some evidence that mindfulness can be effective as a treatment for the common psychiatric illnesses of youth.
 

Anxiety

There is robust evidence for the efficacy of mindfulness-based interventions (including a regular mindfulness meditation practice) in the treatment of anxiety disorders in youth. Multiple studies and meta-analyses have demonstrated significant and sustained improvement in anxiety symptoms in these young patients. This makes sense when one considers that most psychotherapy treatments for anxiety include the cultivation of self-awareness and the ability to recognize the feelings of anxiety. This is critical as youth with anxiety disorders often mistake these feelings for facts. The treatment then shifts toward practice tolerating these feelings to help children develop an appreciation that they can face and manage anxiety and that it does not need to be avoided. Part of tolerating these feelings includes building skills to facilitate calm and physical relaxation in the face of these anxious feelings.

This is the core of exposure-based psychotherapies. Mindfulness practices echo the cultivation of self-awareness with focus and physical calm. Studies have shown that mindfulness-based interventions have significant and lasting effects on the symptoms of anxiety disorders in youth, including those youth with comorbid ADHD and learning disabilities. It is important to be aware that, for youth who have experienced trauma, mindfulness meditation can trigger a flood of re-experiencing phenomena, and it is important that those youth also are receiving treatment for PTSD.
 

Depression

There is evidence that some of the symptoms that occur as part of depression in adolescents improve with mindfulness-based interventions. In particular, symptoms of anger, irritability, disruptive behaviors, suicidality, and even impulsive self-injury improve with mindfulness-based interventions. Dialectical behavioral therapy (DBT) and acceptance and commitment therapy (ACT) have the nonjudgmental self-awareness of mindfulness built in as a component of the therapy. But mindfulness practices without explicit cognitive and behavioral components of psychotherapy for depression are not effective as stand-alone treatment of major depressive disorder in youth.

Multiple meta-analyses have demonstrated that stimulant treatment is more effective than behavioral or environmental interventions in the treatment of ADHD in children and adolescents, and combined treatments have not shown substantial additional improvement over medications alone in randomized controlled studies. But there is a lot of interest in finding effective treatments beyond medications that will help children with ADHD build important cognitive and behavioral skills that may lag developmentally.

Now there is an emerging body of evidence indicating that mindfulness skills in children with ADHD are quite effective for improving their sustained attention, social skills, behavioral control, and even hyperactivity. Additionally, methods to teach mindfulness skills to children who struggle with stillness and focused attention have been developed for these studies (“mindful martial arts”). Again, this intervention has not yet shown the same level of efficacy as medication treatments for ADHD symptoms, but it has demonstrated promise in early trials. Interestingly, it has also shown promise as a component of parenting interventions for youth with ADHD.

You do not need to wait for decisive evidence from randomized controlled trials to recommend mindfulness training for your patients with anxiety, ADHD, or even depression. Indeed, this practice alone may be adequate as a treatment for mild to moderate anxiety disorders. But you can also recommend it as an empowering and effective adjunctive treatment for almost every psychiatric illness and subclinical syndrome, and one that is affordable and easy for families to access. It would be valuable for you to recommend that your patients and their parents both try a mindfulness practice alongside your recommendations about healthy sleep, exercise, and nutrition. There are free apps such as Smiling Mind, Sound Mind, and Thrive Global that families can try together. Some children may need to move physically to be able to practice mindfulness, so yoga or walking meditations can be a better practice for them. When parents can try mindfulness practice alongside their children, it will facilitate their child’s efforts to develop these skills, and the improved sleep, focus, and stress management skills in parents can make a significant difference in the health and well-being of the whole family.

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.

Meditation has become a popular practice in the United States over the last decade. It is not limited to adults, but can be learned and practiced by children and teenagers also. Variants are being used in many schools as parts of a social and emotional learning curriculum, and different kinds of mindfulness practices are common parts of psychological treatments. In this month’s column, we will review the evidence that supports the efficacy of a meditation practice to treat the mental health problems that are common in children and adolescents, and review how it might be a useful adjunct to the screening, education, and treatments that you offer your young patients.

Swick_Susan_D_CALIF_web.jpg

There are many different types of meditation practices, but the unifying feature is known as mindfulness. Most broadly, mindfulness refers to a state of nonjudgmental awareness of one’s thoughts, feelings, or sensations. A mindfulness meditation practice involves physical stillness and focused attention, typically on the physical sensations of one’s breath. When thoughts, feelings, or physical sensations intrude on the stillness, one learns to cultivate a nonjudgmental awareness of those experiences without disrupting the state of quiet concentration. It could be said that meditation is easy to learn and difficult to master, and that is why it should be practiced regularly. Part of its growing popularity has undoubtedly been served by the ease with which people can access a variety of guided meditations (through apps, YouTube, and beyond) that make it relatively easy to access a variety of methods to learn how to practice mindfulness meditation.

The benefits of meditation in adults are well-established, including lower blood pressure, lower rates of heart disease, lower markers of inflammation, better sleep, and self-described levels of well-being. Meditation appears to be especially effective at mitigating the cardiovascular, metabolic, autoimmune, and inflammatory consequences of high-stress or unhealthy lifestyles in adults. Children and adolescents typically do not suffer from these diseases, but there is growing evidence that mindfulness practices can improve self-reported stress management skills, well-being, and sleep in young people; skills that can protect their physical and mental health. In addition, there is some evidence that mindfulness can be effective as a treatment for the common psychiatric illnesses of youth.
 

Anxiety

There is robust evidence for the efficacy of mindfulness-based interventions (including a regular mindfulness meditation practice) in the treatment of anxiety disorders in youth. Multiple studies and meta-analyses have demonstrated significant and sustained improvement in anxiety symptoms in these young patients. This makes sense when one considers that most psychotherapy treatments for anxiety include the cultivation of self-awareness and the ability to recognize the feelings of anxiety. This is critical as youth with anxiety disorders often mistake these feelings for facts. The treatment then shifts toward practice tolerating these feelings to help children develop an appreciation that they can face and manage anxiety and that it does not need to be avoided. Part of tolerating these feelings includes building skills to facilitate calm and physical relaxation in the face of these anxious feelings.

This is the core of exposure-based psychotherapies. Mindfulness practices echo the cultivation of self-awareness with focus and physical calm. Studies have shown that mindfulness-based interventions have significant and lasting effects on the symptoms of anxiety disorders in youth, including those youth with comorbid ADHD and learning disabilities. It is important to be aware that, for youth who have experienced trauma, mindfulness meditation can trigger a flood of re-experiencing phenomena, and it is important that those youth also are receiving treatment for PTSD.
 

Depression

There is evidence that some of the symptoms that occur as part of depression in adolescents improve with mindfulness-based interventions. In particular, symptoms of anger, irritability, disruptive behaviors, suicidality, and even impulsive self-injury improve with mindfulness-based interventions. Dialectical behavioral therapy (DBT) and acceptance and commitment therapy (ACT) have the nonjudgmental self-awareness of mindfulness built in as a component of the therapy. But mindfulness practices without explicit cognitive and behavioral components of psychotherapy for depression are not effective as stand-alone treatment of major depressive disorder in youth.

Multiple meta-analyses have demonstrated that stimulant treatment is more effective than behavioral or environmental interventions in the treatment of ADHD in children and adolescents, and combined treatments have not shown substantial additional improvement over medications alone in randomized controlled studies. But there is a lot of interest in finding effective treatments beyond medications that will help children with ADHD build important cognitive and behavioral skills that may lag developmentally.

Now there is an emerging body of evidence indicating that mindfulness skills in children with ADHD are quite effective for improving their sustained attention, social skills, behavioral control, and even hyperactivity. Additionally, methods to teach mindfulness skills to children who struggle with stillness and focused attention have been developed for these studies (“mindful martial arts”). Again, this intervention has not yet shown the same level of efficacy as medication treatments for ADHD symptoms, but it has demonstrated promise in early trials. Interestingly, it has also shown promise as a component of parenting interventions for youth with ADHD.

You do not need to wait for decisive evidence from randomized controlled trials to recommend mindfulness training for your patients with anxiety, ADHD, or even depression. Indeed, this practice alone may be adequate as a treatment for mild to moderate anxiety disorders. But you can also recommend it as an empowering and effective adjunctive treatment for almost every psychiatric illness and subclinical syndrome, and one that is affordable and easy for families to access. It would be valuable for you to recommend that your patients and their parents both try a mindfulness practice alongside your recommendations about healthy sleep, exercise, and nutrition. There are free apps such as Smiling Mind, Sound Mind, and Thrive Global that families can try together. Some children may need to move physically to be able to practice mindfulness, so yoga or walking meditations can be a better practice for them. When parents can try mindfulness practice alongside their children, it will facilitate their child’s efforts to develop these skills, and the improved sleep, focus, and stress management skills in parents can make a significant difference in the health and well-being of the whole family.

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.

Managing psychiatric illnesses is rapidly becoming routine practice for primary care pediatricians, whether screening for symptoms of anxiety and depression, starting medication, or providing psychoeducation to youth and parents. Pediatricians can provide strategies to address the impairments of sleep, energy, motivation and appetite that can accompany these illnesses. Psychotherapy, a relationship based on understanding and providing support, should be a core element of treatment for emotional disorders, but there is a great deal of uncertainty around what therapies are supported by evidence. This month, we offer a primer on the evidence-based psychotherapies for youth and we also recognize that research defining the effectiveness of psychotherapy is limited and complex.

Cognitive-behavioral psychotherapy (CBT)

Mention psychotherapy and most people think of a patient reclining on a couch free-associating about their childhood while a therapist sits behind them taking notes. This potent image stems from psychoanalytic psychotherapy, developed in the 19th century by Sigmund Freud, and was based on his theory that unconscious conflicts drove most of the puzzling behaviors and emotional distress associated with “neurosis.” Psychoanalysis became popular in 20th century America, even for use with children. Evidence is hard to develop since psychoanalytic therapy often lasts years, there are a limited number of patients, and the method is hard to standardize.

Swick_Susan_D_CALIF_web.jpg

A focus on how to shape behaviors directly also emerged in the early 20th century (in the work of John Watson and Ivan Pavlov). Aaron Beck, MD, the father of CBT, observed in his psychoanalytic treatments that many patients appeared to be experiencing emotional distress around thoughts that were not unconscious. Instead, his patients were experiencing “automatic thoughts,” or rapid, often-distorted thoughts that have the force of truth in the thinker. These thoughts create emotional distress and behaviors that may reinforce the thoughts and emotional distress. For example, a depressed patient who is uncomfortable in social situations may think “nobody ever likes me.” This may cause them to appear uncomfortable or unfriendly in a new social situation and prevent them from making connections, perpetuating a cycle of isolation, insecurity, and loneliness. Identifying these automatic thoughts, and their connection to painful feelings and perpetuating behaviors is at the core of CBT.

In CBT the therapist is much more active than in psychoanalysis. They engage patients in identifying thought distortions together, challenging them on the truth of these thoughts and recognizing the connection to emotional distress. They also identify maladaptive behaviors and focus on strategies to build new more effective behavioral responses to thoughts, feelings, and situations. This is often done with gradual “exposures” to new behaviors, which are naturally reinforced by better outcomes or lowered distress. When performed with high fidelity, CBT is a very structured treatment that is closer to an emotionally supportive form of coaching and skill building. CBT is at the core of most evidence-based psychotherapies that have emerged in the past 60 years.

CBT is the first-line treatment for anxiety disorders in children, adolescents, and adults. A variant called “exposure and response prevention” is the first-line treatment for obsessive-compulsive disorder, and is predominantly behavioral. It is focused on preventing patients with anxiety disorders from engaging in the maladaptive behaviors that lower their anxiety in the short term but cause worsened anxiety and impairment over time (such as avoiding social situations when they are worried that others won’t like them).

CBT is also a first-line treatment for major depressive episodes in teenagers and adults, although those for whom the symptoms are severe often need medication to be able to fully participate in therapy. There are variants of CBT that have demonstrated efficacy in the treatment of posttraumatic stress disorder, bulimia, and even psychosis. It makes developmental sense that therapies with a problem-focused coaching approach might be more effective in children and adolescents than open-ended exploratory psychotherapies.

Traditional CBT was not very effective for patients with a variant of depression that is marked by stormy relationships, irritability, chronic suicidality, and impulsive attempts to regulate discomfort (including bingeing, purging, sexual acting-out, drug use, and self-injury or cutting), a symptom pattern called “borderline personality disorder.” These patients often ended up on multiple medications with only modest improvements in their function and well-being.

But in the 1990s, a research psychologist named Marsha Linnehan developed a modified version of CBT to use with these patients called dialectical-behavioral therapy (DBT). The “dialectic” emphasizes the role of two things being true at once, in this case the need for acceptance and change. DBT helps patients develop distress tolerance and emotional regulation skills alongside adaptive social and communication skills. DBT has demonstrated efficacy in the treatment of these patients as well as in the treatment of other disorders marked by poor distress tolerance and self-regulation (such as substance use disorders, binge-eating disorder, and PTSD).

DBT was adapted for use in adolescents given the prevalence of these problems in this age group, and it is the first-line treatment for adolescents with these specific mood and behavioral symptoms. High-fidelity DBT has an individual, group, and family component that are all essential for the treatment to be effective.

Instruction about the principles of CBT and DBT is a part of graduate school in psychology, but not every postgraduate training program includes thorough training in their practice. Completion of this specialized training leads to certification. It is very important that families understand that anyone may call themselves a psychotherapist. Those therapists who have master’s degrees (MSW, MFT, PCC, and others) may not have had exposure to these evidence-based treatments in their shorter graduate programs. Even doctoral-level training programs often do not include complete training in the high-fidelity delivery of these therapies.

It is critical that you help families be educated consumers and ask therapists if they have training and certification in the recommended therapy. The Psychology Today website has a therapist referral resource that includes this information. Training programs can provide access to therapists who are learning these therapies; with skilled supervision, they can provide excellent treatment.

We should note that there are several other evidence-based therapies, including family-based treatment for anorexia nervosa, motivational interviewing for substance use disorders, and interpersonal psychotherapy for depression associated with high family conflict in adolescents.

There is good evidence that the quality of the alliance between therapist and patient is a critical predictor of whether a therapy will be effective. It is appropriate for your patient to look for a therapist that they can trust and talk to and that their therapist be trained in the recommended psychotherapy. Otherwise, your patient is spending valuable time and money on an enterprise that may not be effective. This can leave them and their parents feeling discouraged or even hopeless about the prospects for recovery and promote an overreliance on medications. In addition to providing your patients with effective screening, initiating medication treatment, and psychoeducation, you can enhance their ability to find an optimal therapist to relieve their suffering.

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.

Managing psychiatric illnesses is rapidly becoming routine practice for primary care pediatricians, whether screening for symptoms of anxiety and depression, starting medication, or providing psychoeducation to youth and parents. Pediatricians can provide strategies to address the impairments of sleep, energy, motivation and appetite that can accompany these illnesses. Psychotherapy, a relationship based on understanding and providing support, should be a core element of treatment for emotional disorders, but there is a great deal of uncertainty around what therapies are supported by evidence. This month, we offer a primer on the evidence-based psychotherapies for youth and we also recognize that research defining the effectiveness of psychotherapy is limited and complex.

Cognitive-behavioral psychotherapy (CBT)

Mention psychotherapy and most people think of a patient reclining on a couch free-associating about their childhood while a therapist sits behind them taking notes. This potent image stems from psychoanalytic psychotherapy, developed in the 19th century by Sigmund Freud, and was based on his theory that unconscious conflicts drove most of the puzzling behaviors and emotional distress associated with “neurosis.” Psychoanalysis became popular in 20th century America, even for use with children. Evidence is hard to develop since psychoanalytic therapy often lasts years, there are a limited number of patients, and the method is hard to standardize.

Swick_Susan_D_CALIF_web.jpg

A focus on how to shape behaviors directly also emerged in the early 20th century (in the work of John Watson and Ivan Pavlov). Aaron Beck, MD, the father of CBT, observed in his psychoanalytic treatments that many patients appeared to be experiencing emotional distress around thoughts that were not unconscious. Instead, his patients were experiencing “automatic thoughts,” or rapid, often-distorted thoughts that have the force of truth in the thinker. These thoughts create emotional distress and behaviors that may reinforce the thoughts and emotional distress. For example, a depressed patient who is uncomfortable in social situations may think “nobody ever likes me.” This may cause them to appear uncomfortable or unfriendly in a new social situation and prevent them from making connections, perpetuating a cycle of isolation, insecurity, and loneliness. Identifying these automatic thoughts, and their connection to painful feelings and perpetuating behaviors is at the core of CBT.

In CBT the therapist is much more active than in psychoanalysis. They engage patients in identifying thought distortions together, challenging them on the truth of these thoughts and recognizing the connection to emotional distress. They also identify maladaptive behaviors and focus on strategies to build new more effective behavioral responses to thoughts, feelings, and situations. This is often done with gradual “exposures” to new behaviors, which are naturally reinforced by better outcomes or lowered distress. When performed with high fidelity, CBT is a very structured treatment that is closer to an emotionally supportive form of coaching and skill building. CBT is at the core of most evidence-based psychotherapies that have emerged in the past 60 years.

CBT is the first-line treatment for anxiety disorders in children, adolescents, and adults. A variant called “exposure and response prevention” is the first-line treatment for obsessive-compulsive disorder, and is predominantly behavioral. It is focused on preventing patients with anxiety disorders from engaging in the maladaptive behaviors that lower their anxiety in the short term but cause worsened anxiety and impairment over time (such as avoiding social situations when they are worried that others won’t like them).

CBT is also a first-line treatment for major depressive episodes in teenagers and adults, although those for whom the symptoms are severe often need medication to be able to fully participate in therapy. There are variants of CBT that have demonstrated efficacy in the treatment of posttraumatic stress disorder, bulimia, and even psychosis. It makes developmental sense that therapies with a problem-focused coaching approach might be more effective in children and adolescents than open-ended exploratory psychotherapies.

Traditional CBT was not very effective for patients with a variant of depression that is marked by stormy relationships, irritability, chronic suicidality, and impulsive attempts to regulate discomfort (including bingeing, purging, sexual acting-out, drug use, and self-injury or cutting), a symptom pattern called “borderline personality disorder.” These patients often ended up on multiple medications with only modest improvements in their function and well-being.

But in the 1990s, a research psychologist named Marsha Linnehan developed a modified version of CBT to use with these patients called dialectical-behavioral therapy (DBT). The “dialectic” emphasizes the role of two things being true at once, in this case the need for acceptance and change. DBT helps patients develop distress tolerance and emotional regulation skills alongside adaptive social and communication skills. DBT has demonstrated efficacy in the treatment of these patients as well as in the treatment of other disorders marked by poor distress tolerance and self-regulation (such as substance use disorders, binge-eating disorder, and PTSD).

DBT was adapted for use in adolescents given the prevalence of these problems in this age group, and it is the first-line treatment for adolescents with these specific mood and behavioral symptoms. High-fidelity DBT has an individual, group, and family component that are all essential for the treatment to be effective.

Instruction about the principles of CBT and DBT is a part of graduate school in psychology, but not every postgraduate training program includes thorough training in their practice. Completion of this specialized training leads to certification. It is very important that families understand that anyone may call themselves a psychotherapist. Those therapists who have master’s degrees (MSW, MFT, PCC, and others) may not have had exposure to these evidence-based treatments in their shorter graduate programs. Even doctoral-level training programs often do not include complete training in the high-fidelity delivery of these therapies.

It is critical that you help families be educated consumers and ask therapists if they have training and certification in the recommended therapy. The Psychology Today website has a therapist referral resource that includes this information. Training programs can provide access to therapists who are learning these therapies; with skilled supervision, they can provide excellent treatment.

We should note that there are several other evidence-based therapies, including family-based treatment for anorexia nervosa, motivational interviewing for substance use disorders, and interpersonal psychotherapy for depression associated with high family conflict in adolescents.

There is good evidence that the quality of the alliance between therapist and patient is a critical predictor of whether a therapy will be effective. It is appropriate for your patient to look for a therapist that they can trust and talk to and that their therapist be trained in the recommended psychotherapy. Otherwise, your patient is spending valuable time and money on an enterprise that may not be effective. This can leave them and their parents feeling discouraged or even hopeless about the prospects for recovery and promote an overreliance on medications. In addition to providing your patients with effective screening, initiating medication treatment, and psychoeducation, you can enhance their ability to find an optimal therapist to relieve their suffering.

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.

Managing psychiatric illnesses is rapidly becoming routine practice for primary care pediatricians, whether screening for symptoms of anxiety and depression, starting medication, or providing psychoeducation to youth and parents. Pediatricians can provide strategies to address the impairments of sleep, energy, motivation and appetite that can accompany these illnesses. Psychotherapy, a relationship based on understanding and providing support, should be a core element of treatment for emotional disorders, but there is a great deal of uncertainty around what therapies are supported by evidence. This month, we offer a primer on the evidence-based psychotherapies for youth and we also recognize that research defining the effectiveness of psychotherapy is limited and complex.

Cognitive-behavioral psychotherapy (CBT)

Mention psychotherapy and most people think of a patient reclining on a couch free-associating about their childhood while a therapist sits behind them taking notes. This potent image stems from psychoanalytic psychotherapy, developed in the 19th century by Sigmund Freud, and was based on his theory that unconscious conflicts drove most of the puzzling behaviors and emotional distress associated with “neurosis.” Psychoanalysis became popular in 20th century America, even for use with children. Evidence is hard to develop since psychoanalytic therapy often lasts years, there are a limited number of patients, and the method is hard to standardize.

Swick_Susan_D_CALIF_web.jpg

A focus on how to shape behaviors directly also emerged in the early 20th century (in the work of John Watson and Ivan Pavlov). Aaron Beck, MD, the father of CBT, observed in his psychoanalytic treatments that many patients appeared to be experiencing emotional distress around thoughts that were not unconscious. Instead, his patients were experiencing “automatic thoughts,” or rapid, often-distorted thoughts that have the force of truth in the thinker. These thoughts create emotional distress and behaviors that may reinforce the thoughts and emotional distress. For example, a depressed patient who is uncomfortable in social situations may think “nobody ever likes me.” This may cause them to appear uncomfortable or unfriendly in a new social situation and prevent them from making connections, perpetuating a cycle of isolation, insecurity, and loneliness. Identifying these automatic thoughts, and their connection to painful feelings and perpetuating behaviors is at the core of CBT.

In CBT the therapist is much more active than in psychoanalysis. They engage patients in identifying thought distortions together, challenging them on the truth of these thoughts and recognizing the connection to emotional distress. They also identify maladaptive behaviors and focus on strategies to build new more effective behavioral responses to thoughts, feelings, and situations. This is often done with gradual “exposures” to new behaviors, which are naturally reinforced by better outcomes or lowered distress. When performed with high fidelity, CBT is a very structured treatment that is closer to an emotionally supportive form of coaching and skill building. CBT is at the core of most evidence-based psychotherapies that have emerged in the past 60 years.

CBT is the first-line treatment for anxiety disorders in children, adolescents, and adults. A variant called “exposure and response prevention” is the first-line treatment for obsessive-compulsive disorder, and is predominantly behavioral. It is focused on preventing patients with anxiety disorders from engaging in the maladaptive behaviors that lower their anxiety in the short term but cause worsened anxiety and impairment over time (such as avoiding social situations when they are worried that others won’t like them).

CBT is also a first-line treatment for major depressive episodes in teenagers and adults, although those for whom the symptoms are severe often need medication to be able to fully participate in therapy. There are variants of CBT that have demonstrated efficacy in the treatment of posttraumatic stress disorder, bulimia, and even psychosis. It makes developmental sense that therapies with a problem-focused coaching approach might be more effective in children and adolescents than open-ended exploratory psychotherapies.

Traditional CBT was not very effective for patients with a variant of depression that is marked by stormy relationships, irritability, chronic suicidality, and impulsive attempts to regulate discomfort (including bingeing, purging, sexual acting-out, drug use, and self-injury or cutting), a symptom pattern called “borderline personality disorder.” These patients often ended up on multiple medications with only modest improvements in their function and well-being.

But in the 1990s, a research psychologist named Marsha Linnehan developed a modified version of CBT to use with these patients called dialectical-behavioral therapy (DBT). The “dialectic” emphasizes the role of two things being true at once, in this case the need for acceptance and change. DBT helps patients develop distress tolerance and emotional regulation skills alongside adaptive social and communication skills. DBT has demonstrated efficacy in the treatment of these patients as well as in the treatment of other disorders marked by poor distress tolerance and self-regulation (such as substance use disorders, binge-eating disorder, and PTSD).

DBT was adapted for use in adolescents given the prevalence of these problems in this age group, and it is the first-line treatment for adolescents with these specific mood and behavioral symptoms. High-fidelity DBT has an individual, group, and family component that are all essential for the treatment to be effective.

Instruction about the principles of CBT and DBT is a part of graduate school in psychology, but not every postgraduate training program includes thorough training in their practice. Completion of this specialized training leads to certification. It is very important that families understand that anyone may call themselves a psychotherapist. Those therapists who have master’s degrees (MSW, MFT, PCC, and others) may not have had exposure to these evidence-based treatments in their shorter graduate programs. Even doctoral-level training programs often do not include complete training in the high-fidelity delivery of these therapies.

It is critical that you help families be educated consumers and ask therapists if they have training and certification in the recommended therapy. The Psychology Today website has a therapist referral resource that includes this information. Training programs can provide access to therapists who are learning these therapies; with skilled supervision, they can provide excellent treatment.

We should note that there are several other evidence-based therapies, including family-based treatment for anorexia nervosa, motivational interviewing for substance use disorders, and interpersonal psychotherapy for depression associated with high family conflict in adolescents.

There is good evidence that the quality of the alliance between therapist and patient is a critical predictor of whether a therapy will be effective. It is appropriate for your patient to look for a therapist that they can trust and talk to and that their therapist be trained in the recommended psychotherapy. Otherwise, your patient is spending valuable time and money on an enterprise that may not be effective. This can leave them and their parents feeling discouraged or even hopeless about the prospects for recovery and promote an overreliance on medications. In addition to providing your patients with effective screening, initiating medication treatment, and psychoeducation, you can enhance their ability to find an optimal therapist to relieve their suffering.

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.