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Self-injury
Whether you have heard about “cutting” from breathless gossip reports about young starlets or anxious parents of adolescent girls, it seems to be a phenomenon that is on the rise.
As a pediatrician, you may be the first (or only) adult in a young person’s life who notices evidence of self-injury or who asks about it. Self-injurious behaviors may signal significant underlying psychiatric issues or something more benign and brief. Being alert to self-injury is not an easy task. The thought of teenagers cutting themselves on a regular basis and acknowledging their inner distress in your office requires a pediatrician’s self-awareness and emotional preparation. 
Self-injury, or nonsuicidal self-injury (NSSI) as it is known in the psychiatric literature, is indeed a relatively common phenomenon. In the United States, it affects approximately 10% of adolescents in a community sample, and as many as 35% of adolescents in treatment for any psychiatric illness. It begins most commonly between the ages of 13 and 15 years, and grows in prevalence through adolescence, dropping off in early adulthood. While adolescent girls are likely to start this behavior earlier than adolescent boys, the gender difference attenuates with age. Some studies have shown adolescent boys are more likely to engage in this behavior than girls by late adolescence.
NSSI typically takes the form of cutting oneself with a sharp object, but it also could involve scratching at the skin until it bleeds, hitting or burning oneself, or interfering with the healing of wounds. It classically was thought of as a symptom of borderline personality disorder, but is a behavior that also may occur with eating disorders, substance use disorders, and anxiety and depressive disorders in adolescents. Clinicians have conceptualized it as a maladaptive way to relieve intense emotional distress, signal distress to others, or inflict self-punishment. It usually starts as an impulsive behavior, and the combination of the intense emotions and high impulsivity of adolescence is why it is so common among this age group. For some adolescents, the impulse will be primarily one of curiosity, perhaps in the setting of some stress, and is more likely to occur if the behavior is common among a teenager’s peers. For those in intense emotional distress, it typically brings a fleeting sense of calm or numbing and an easing of tension. But this relief is usually followed by guilt and shame, and a return, sometimes compounded, of those uncomfortable emotions. Thus what starts as an impulse can become a repetitive, almost compulsive behavior.
If the self-injury happens regularly, it is very important that you show both concern and compassion. You might offer that whatever emotional pain they are experiencing, they deserve more support than a sharp object offers. You could ask about those illnesses that are frequently comorbid with self-injury: substance use, eating disorders, and anxiety and depressive disorders.
But it is essential that you ask about suicidal ideation and suicide attempts. If they are acutely suicidal or describe a history of previously hidden attempts, you will need to help them access care quickly, possibly recommending a visit to the emergency department unless they already have an outpatient treatment team. In these cases, you will need to share your concerns with their parents and help them find their way into the complex mental health system to get a comprehensive psychiatric evaluation and treatment.
Identifying and referring adolescents with NSSI is emotionally demanding work. Learn more from your patients, talk to those who evaluate them, and discuss the issues with colleagues – both to gain skills and to have support as you worry about these patients and help guide them through a complex system of care.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston.
Whether you have heard about “cutting” from breathless gossip reports about young starlets or anxious parents of adolescent girls, it seems to be a phenomenon that is on the rise.
As a pediatrician, you may be the first (or only) adult in a young person’s life who notices evidence of self-injury or who asks about it. Self-injurious behaviors may signal significant underlying psychiatric issues or something more benign and brief. Being alert to self-injury is not an easy task. The thought of teenagers cutting themselves on a regular basis and acknowledging their inner distress in your office requires a pediatrician’s self-awareness and emotional preparation.
Self-injury, or nonsuicidal self-injury (NSSI) as it is known in the psychiatric literature, is indeed a relatively common phenomenon. In the United States, it affects approximately 10% of adolescents in a community sample, and as many as 35% of adolescents in treatment for any psychiatric illness. It begins most commonly between the ages of 13 and 15 years, and grows in prevalence through adolescence, dropping off in early adulthood. While adolescent girls are likely to start this behavior earlier than adolescent boys, the gender difference attenuates with age. Some studies have shown adolescent boys are more likely to engage in this behavior than girls by late adolescence.
NSSI typically takes the form of cutting oneself with a sharp object, but it also could involve scratching at the skin until it bleeds, hitting or burning oneself, or interfering with the healing of wounds. It classically was thought of as a symptom of borderline personality disorder, but is a behavior that also may occur with eating disorders, substance use disorders, and anxiety and depressive disorders in adolescents. Clinicians have conceptualized it as a maladaptive way to relieve intense emotional distress, signal distress to others, or inflict self-punishment. It usually starts as an impulsive behavior, and the combination of the intense emotions and high impulsivity of adolescence is why it is so common among this age group. For some adolescents, the impulse will be primarily one of curiosity, perhaps in the setting of some stress, and is more likely to occur if the behavior is common among a teenager’s peers. For those in intense emotional distress, it typically brings a fleeting sense of calm or numbing and an easing of tension. But this relief is usually followed by guilt and shame, and a return, sometimes compounded, of those uncomfortable emotions. Thus what starts as an impulse can become a repetitive, almost compulsive behavior.
If the self-injury happens regularly, it is very important that you show both concern and compassion. You might offer that whatever emotional pain they are experiencing, they deserve more support than a sharp object offers. You could ask about those illnesses that are frequently comorbid with self-injury: substance use, eating disorders, and anxiety and depressive disorders.
But it is essential that you ask about suicidal ideation and suicide attempts. If they are acutely suicidal or describe a history of previously hidden attempts, you will need to help them access care quickly, possibly recommending a visit to the emergency department unless they already have an outpatient treatment team. In these cases, you will need to share your concerns with their parents and help them find their way into the complex mental health system to get a comprehensive psychiatric evaluation and treatment.
Identifying and referring adolescents with NSSI is emotionally demanding work. Learn more from your patients, talk to those who evaluate them, and discuss the issues with colleagues – both to gain skills and to have support as you worry about these patients and help guide them through a complex system of care.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston.
Whether you have heard about “cutting” from breathless gossip reports about young starlets or anxious parents of adolescent girls, it seems to be a phenomenon that is on the rise.
As a pediatrician, you may be the first (or only) adult in a young person’s life who notices evidence of self-injury or who asks about it. Self-injurious behaviors may signal significant underlying psychiatric issues or something more benign and brief. Being alert to self-injury is not an easy task. The thought of teenagers cutting themselves on a regular basis and acknowledging their inner distress in your office requires a pediatrician’s self-awareness and emotional preparation.
Self-injury, or nonsuicidal self-injury (NSSI) as it is known in the psychiatric literature, is indeed a relatively common phenomenon. In the United States, it affects approximately 10% of adolescents in a community sample, and as many as 35% of adolescents in treatment for any psychiatric illness. It begins most commonly between the ages of 13 and 15 years, and grows in prevalence through adolescence, dropping off in early adulthood. While adolescent girls are likely to start this behavior earlier than adolescent boys, the gender difference attenuates with age. Some studies have shown adolescent boys are more likely to engage in this behavior than girls by late adolescence.
NSSI typically takes the form of cutting oneself with a sharp object, but it also could involve scratching at the skin until it bleeds, hitting or burning oneself, or interfering with the healing of wounds. It classically was thought of as a symptom of borderline personality disorder, but is a behavior that also may occur with eating disorders, substance use disorders, and anxiety and depressive disorders in adolescents. Clinicians have conceptualized it as a maladaptive way to relieve intense emotional distress, signal distress to others, or inflict self-punishment. It usually starts as an impulsive behavior, and the combination of the intense emotions and high impulsivity of adolescence is why it is so common among this age group. For some adolescents, the impulse will be primarily one of curiosity, perhaps in the setting of some stress, and is more likely to occur if the behavior is common among a teenager’s peers. For those in intense emotional distress, it typically brings a fleeting sense of calm or numbing and an easing of tension. But this relief is usually followed by guilt and shame, and a return, sometimes compounded, of those uncomfortable emotions. Thus what starts as an impulse can become a repetitive, almost compulsive behavior.
If the self-injury happens regularly, it is very important that you show both concern and compassion. You might offer that whatever emotional pain they are experiencing, they deserve more support than a sharp object offers. You could ask about those illnesses that are frequently comorbid with self-injury: substance use, eating disorders, and anxiety and depressive disorders.
But it is essential that you ask about suicidal ideation and suicide attempts. If they are acutely suicidal or describe a history of previously hidden attempts, you will need to help them access care quickly, possibly recommending a visit to the emergency department unless they already have an outpatient treatment team. In these cases, you will need to share your concerns with their parents and help them find their way into the complex mental health system to get a comprehensive psychiatric evaluation and treatment.
Identifying and referring adolescents with NSSI is emotionally demanding work. Learn more from your patients, talk to those who evaluate them, and discuss the issues with colleagues – both to gain skills and to have support as you worry about these patients and help guide them through a complex system of care.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston.
50 years of child psychiatry, developmental-behavioral pediatrics
The 50th anniversary of Pediatric News prompts us to look back on the past 50 years in child psychiatry and developmental-behavioral pediatrics, and reflect on the evolution of the field. This includes the approach to diagnosis, the thinking about development and family, and the approach and access to treatment during this dynamic period.
While some historians identify the establishment of the first juvenile court in Chicago in 1899 and the work to help judges evaluate juvenile delinquency as the origin of child psychiatry in the United States, it was not until after World War II that the field really began to take root here, largely based on psychiatrists fleeing Europe and the seminal work of Anna Freud. Some of the earliest connections between pediatrics and child psychiatry were based on the work in England of Donald W. Winnicott, a practicing pediatrician and child psychiatrist, Albert J. Solnit, MD, at the Yale Child Study Center, and psychologically informed work of pediatrician Benjamin M. Spock, MD.
The first Diagnostic and Statistical Manual (DSM) was published in 1952, based on a codification of mental disorders established by the Navy during WWII. The American Academy of Child & Adolescent Psychiatry was established in 1953, the same year that the first “tranquilizer,” chlorpromazine (Thorazine) was introduced (in France), marking the start of a revolution in psychiatric care. In 1959, the first candidates sat for a licensing examination in child psychiatry. The Section on Developmental and Behavioral Pediatrics was established as part of the American Academy of Pediatrics in 1960 to support training in this area. The AACAP established a journal in 1961. Child guidance clinics started affiliating with hospitals and universities in the 1960’s, after the Community Mental Health Act of 1963. Then, in 1965, Julius B. Richmond, MD, (a pediatrician) and Uri Bronfenbrenner, PhD, (a developmental psychologist), recognizing the importance of ecological systems to child development, were involved in the creation of Head Start, and the first Joint Commission on Mental Health for Children was established by federal legislation in 1965. The field was truly coalescing into a distinct discipline of medicine, one that bridged pediatrics, psychiatry, and neurology with nonmedical disciplines such as justice and education.
The decade between 1967 and 1977 was a period of transition from the focus on psychoanalytic concepts typical of the first half of the century to a more systematic approach to diagnosis. Children in psychiatric treatment had commonly been seen for extended individual treatments, and those with more disruptive disorders often were hospitalized for long periods. Psychoanalysis focused on the unconscious (theoretical drives and conflicts) to guide treatment. Treatment often focused on the role (causal) of parents, and family treatment was common, even on inpatient units. The second edition of the DSM (DSM-II) was published in 1968, with its first distinct section for disorders of childhood and adolescence, and an overarching focus on psychodynamics. In 1974, the decision was made to publish a new edition of the DSM that would establish a multiaxial assessment system (separating “biological” mental health problems from personality disorders, medical illnesses, and psychosocial stressors) and research-oriented diagnostic criteria that would attempt to facilitate reliable diagnoses based on common clusters of symptoms. Field trials sponsored by the National Institute of Mental Health began in 1977 to establish the reliability of the new diagnoses.
The year 1977 saw the first Apple computer, the New York City blackout, the release of the first “Star Wars” movie, and also the start of a momentous decade in general and child psychiatry. The third edition of the DSM (DSM-III) was published in 1980, the beginning of a revolution in psychiatric diagnosis and treatments. It created reliable, reproducible diagnostic constructs to serve as the basis for studies on epidemiology and treatment. Implications of causality were replaced by description; for example, hyperkinetic reaction of childhood was redefined and labeled attention-deficit disorder. Recognizing the importance of research and training in this rapidly changing field, W.T. Grant Foundation funded 11 fellowship programs in 1977, and the Society for Developmental and Behavioral Pediatrics was founded in 1982 by the leaders of those programs.
In 1983, The AACAP published “Child Psychiatry: A Plan for the Coming Decades.” It was the result of 5 years’ work by 100 child psychiatrists, general psychiatrists, pediatricians, epidemiologists, nurses, leaders of the NIMH, and various child advocates. This report laid out a challenge for child psychiatry to develop research strategies that would allow evidence-based understanding and treatment of the mental illnesses of children. The established focus on individual experience and anecdotal data, particularly about social and psychodynamic influences, would shift towards a more scientific approach to diagnosis and treatment. This decade started an explosion in epidemiologic research, medication trials, and controlled studies of nonbiological treatments in child psychiatry. At the same time, the political landscape changed, and an ascendant conservatism began the process of closing publicly funded residential treatment centers that had offered care to the more chronically mentally ill and children with profound developmental disorders. This would accelerate the shift towards outpatient psychiatric care of children. Ironically, as research would accelerate in child psychiatry, access to effective treatments would become more difficult.
The decade from 1987 to 1997 was a period of dramatic growth in medication use in child psychiatry. Prozac was approved by the Food and Drug Administration for use in the United States in 1988 and soon followed by other selective serotonin reuptake inhibitors (Zoloft in 1991 and Paxil in 1992). The journal of the AACAP began to publish more randomized controlled trials of medication treatments in children with DSM-codified diagnoses, and clinicians became more comfortable using stimulants, antidepressants, and even antipsychotic medications in the outpatient setting. This trend was enhanced by the emergence of managed care and the denial of coverage for alleged “nonbiological” diagnoses and for many psychiatric treatments. Loss of reimbursement led to a significant decline in resources, particularly inpatient child psychiatry beds and specialized clinics. This, in turn, contributed to the growing emphasis on medication treatments for children’s mental health problems. For-profit managed care companies underbid each other to provide mental health coverage and incentivized medication visits. Of note, the medical budgets, not the mental health carve outs, were billed for the medication prescribed.
The Americans with Disabilities Act was passed in 1990, increasing the funding for school-based mental health resources for children, and in 1996, Congress passed the Mental Health Parity Act, the first of several legislative attempts to ensure parity between insurance coverage for medical and psychiatric illnesses – legislation that to this day has not achieved parity of access to care. As pediatricians took on more of mental health care, a multidisciplinary team created a primary care version of DSM IV, the DSM-IV-PC, in 1995, to assist with defining levels of symptoms less than disorder to facilitate earlier intervention. A formal subspecialty of developmental-behavioral pediatrics was established in 1999 to educate leaders. Pediatric residents have had required training in developmental-behavioral pediatrics since 2008.
The year 1997 saw the first nationwide survey of parents about attention-deficit/hyperactivity disorder, kicking off what could be called the decade of ADHD, in which prevalence rates steadily climbed, from 5.7% in 1997 to 9.5% in 2007. The prevalence of stimulant treatment in children skyrocketed in this period. According to the NIMH, stimulants were prescribed to 4.2% of 6- to 12-year-olds in 1996, and that number grew to 5.1% in 2008. For 13- to 18-year-olds, the rate more than doubled during this time, from 2.3% in 1996 to 4.9% in 2008. The prevalence of autism also grew dramatically during this time, from 1.9 per 1,000 in 1997-1999 to 7.4 per 1,000 in 2006-2008, probably based on an evolving understanding of the disorder and this diagnosis providing special access to resources in schools.
Research during this decade became increasingly focused on imaging studies of children (and adults), as leaders in the field were trying to move from symptom clusters to anatomic and physiologic correlates of psychiatric illness. The great increase in medication use in children hit a speed bump in October 2004, when the Food and Drug Administration issued a controversial public warning about an increased risk of suicidal thoughts or behaviors in youth being treated with SSRI antidepressants. As access to child psychiatric treatment had become more difficult over the preceding decades, pediatricians had assumed much of the medication treatment of common psychiatric problems. The FDA’s black box warning complicated pediatricians’ efforts to fill this void.
The last decade has been the decade of genetics and efforts to improve access to care. It started in 2007 with the FDA expanding its SSRI warning to acknowledge that depression itself increased the risk for suicide, in an effort to not discourage needed depression treatment in young people. But studies demonstrated that the rates of diagnosing and treating depression dropped dramatically in the years following the warning: Diagnoses of depression declined by as much as 42% in children, and the rate of antidepressant treatment in adolescents dropped by as much as 32% in the 2 years following the warning (N Engl J Med. 2014 Oct 30;371(18):1666-8). There was no compensatory increase in utilization of other kinds of treatments. While suicide rates in young people had been stubbornly steady from the mid-1970’s to the mid-1990’s, they began to decline in 1996, according to the Centers for Disease Control and Prevention. But that trend was broken in 2004, with a jump in attempted and completed suicides in young people. The rate stabilized later in the decade, but has never returned to the lows that were being achieved prior to the warning.
This decade was marked by the passage of the Affordable Care Act, including – again – an unfulfilled mandate for mental health parity for any insurance plans in the marketplace. Although diagnosis is still symptom based, the effort to define psychiatric disorders based on brain anatomy, neurotransmitters, and genomics continues to intensify. There is growing evidence that psychiatric disorders are not nature or nurture, but nature and nurture. Epigenetic findings show that environment impacts gene expression and brain functioning. These findings promise to deepen our understanding of the critical role of early experiences (consider Adverse Childhood Experiences [ACE] scores) and the promise of protective relationships, in schools and parenting.
And what will come next? We believe that silos – medical, psychiatric, parenting, school, environment – will be bridged to understand the many factors that impact behavior and treatment, but the need to advocate for policies that support funding for the education and mental health care of children and the training of professionals to provide that care is never ending. As our knowledge of the genome marches forward, we may discover effective strategies for preventing the emergence of mental illness in children or create individualized treatments. We may learn more about the role of nutrition and the microbiome in health and disease, about autoimmunity and mental illness. Our focus may return to parents, not as culprits, but as the mediators of health from the prenatal period on. Technology may enable us to improve access to effective treatments, with teens monitoring their sleep and mood, and accessing therapy on their smart phones. And our understanding of development and vulnerability may help us stem the rise in autism or collaborate with educators so that education could better put every child on their healthiest possible path. We look forward to experiencing it – and writing about it – with you!
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. They said they had no relevant financial disclosures. Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email them at pdnews@frontlinemedcom.com.
The 50th anniversary of Pediatric News prompts us to look back on the past 50 years in child psychiatry and developmental-behavioral pediatrics, and reflect on the evolution of the field. This includes the approach to diagnosis, the thinking about development and family, and the approach and access to treatment during this dynamic period.
While some historians identify the establishment of the first juvenile court in Chicago in 1899 and the work to help judges evaluate juvenile delinquency as the origin of child psychiatry in the United States, it was not until after World War II that the field really began to take root here, largely based on psychiatrists fleeing Europe and the seminal work of Anna Freud. Some of the earliest connections between pediatrics and child psychiatry were based on the work in England of Donald W. Winnicott, a practicing pediatrician and child psychiatrist, Albert J. Solnit, MD, at the Yale Child Study Center, and psychologically informed work of pediatrician Benjamin M. Spock, MD.
The first Diagnostic and Statistical Manual (DSM) was published in 1952, based on a codification of mental disorders established by the Navy during WWII. The American Academy of Child & Adolescent Psychiatry was established in 1953, the same year that the first “tranquilizer,” chlorpromazine (Thorazine) was introduced (in France), marking the start of a revolution in psychiatric care. In 1959, the first candidates sat for a licensing examination in child psychiatry. The Section on Developmental and Behavioral Pediatrics was established as part of the American Academy of Pediatrics in 1960 to support training in this area. The AACAP established a journal in 1961. Child guidance clinics started affiliating with hospitals and universities in the 1960’s, after the Community Mental Health Act of 1963. Then, in 1965, Julius B. Richmond, MD, (a pediatrician) and Uri Bronfenbrenner, PhD, (a developmental psychologist), recognizing the importance of ecological systems to child development, were involved in the creation of Head Start, and the first Joint Commission on Mental Health for Children was established by federal legislation in 1965. The field was truly coalescing into a distinct discipline of medicine, one that bridged pediatrics, psychiatry, and neurology with nonmedical disciplines such as justice and education.
The decade between 1967 and 1977 was a period of transition from the focus on psychoanalytic concepts typical of the first half of the century to a more systematic approach to diagnosis. Children in psychiatric treatment had commonly been seen for extended individual treatments, and those with more disruptive disorders often were hospitalized for long periods. Psychoanalysis focused on the unconscious (theoretical drives and conflicts) to guide treatment. Treatment often focused on the role (causal) of parents, and family treatment was common, even on inpatient units. The second edition of the DSM (DSM-II) was published in 1968, with its first distinct section for disorders of childhood and adolescence, and an overarching focus on psychodynamics. In 1974, the decision was made to publish a new edition of the DSM that would establish a multiaxial assessment system (separating “biological” mental health problems from personality disorders, medical illnesses, and psychosocial stressors) and research-oriented diagnostic criteria that would attempt to facilitate reliable diagnoses based on common clusters of symptoms. Field trials sponsored by the National Institute of Mental Health began in 1977 to establish the reliability of the new diagnoses.
The year 1977 saw the first Apple computer, the New York City blackout, the release of the first “Star Wars” movie, and also the start of a momentous decade in general and child psychiatry. The third edition of the DSM (DSM-III) was published in 1980, the beginning of a revolution in psychiatric diagnosis and treatments. It created reliable, reproducible diagnostic constructs to serve as the basis for studies on epidemiology and treatment. Implications of causality were replaced by description; for example, hyperkinetic reaction of childhood was redefined and labeled attention-deficit disorder. Recognizing the importance of research and training in this rapidly changing field, W.T. Grant Foundation funded 11 fellowship programs in 1977, and the Society for Developmental and Behavioral Pediatrics was founded in 1982 by the leaders of those programs.
In 1983, The AACAP published “Child Psychiatry: A Plan for the Coming Decades.” It was the result of 5 years’ work by 100 child psychiatrists, general psychiatrists, pediatricians, epidemiologists, nurses, leaders of the NIMH, and various child advocates. This report laid out a challenge for child psychiatry to develop research strategies that would allow evidence-based understanding and treatment of the mental illnesses of children. The established focus on individual experience and anecdotal data, particularly about social and psychodynamic influences, would shift towards a more scientific approach to diagnosis and treatment. This decade started an explosion in epidemiologic research, medication trials, and controlled studies of nonbiological treatments in child psychiatry. At the same time, the political landscape changed, and an ascendant conservatism began the process of closing publicly funded residential treatment centers that had offered care to the more chronically mentally ill and children with profound developmental disorders. This would accelerate the shift towards outpatient psychiatric care of children. Ironically, as research would accelerate in child psychiatry, access to effective treatments would become more difficult.
The decade from 1987 to 1997 was a period of dramatic growth in medication use in child psychiatry. Prozac was approved by the Food and Drug Administration for use in the United States in 1988 and soon followed by other selective serotonin reuptake inhibitors (Zoloft in 1991 and Paxil in 1992). The journal of the AACAP began to publish more randomized controlled trials of medication treatments in children with DSM-codified diagnoses, and clinicians became more comfortable using stimulants, antidepressants, and even antipsychotic medications in the outpatient setting. This trend was enhanced by the emergence of managed care and the denial of coverage for alleged “nonbiological” diagnoses and for many psychiatric treatments. Loss of reimbursement led to a significant decline in resources, particularly inpatient child psychiatry beds and specialized clinics. This, in turn, contributed to the growing emphasis on medication treatments for children’s mental health problems. For-profit managed care companies underbid each other to provide mental health coverage and incentivized medication visits. Of note, the medical budgets, not the mental health carve outs, were billed for the medication prescribed.
The Americans with Disabilities Act was passed in 1990, increasing the funding for school-based mental health resources for children, and in 1996, Congress passed the Mental Health Parity Act, the first of several legislative attempts to ensure parity between insurance coverage for medical and psychiatric illnesses – legislation that to this day has not achieved parity of access to care. As pediatricians took on more of mental health care, a multidisciplinary team created a primary care version of DSM IV, the DSM-IV-PC, in 1995, to assist with defining levels of symptoms less than disorder to facilitate earlier intervention. A formal subspecialty of developmental-behavioral pediatrics was established in 1999 to educate leaders. Pediatric residents have had required training in developmental-behavioral pediatrics since 2008.
The year 1997 saw the first nationwide survey of parents about attention-deficit/hyperactivity disorder, kicking off what could be called the decade of ADHD, in which prevalence rates steadily climbed, from 5.7% in 1997 to 9.5% in 2007. The prevalence of stimulant treatment in children skyrocketed in this period. According to the NIMH, stimulants were prescribed to 4.2% of 6- to 12-year-olds in 1996, and that number grew to 5.1% in 2008. For 13- to 18-year-olds, the rate more than doubled during this time, from 2.3% in 1996 to 4.9% in 2008. The prevalence of autism also grew dramatically during this time, from 1.9 per 1,000 in 1997-1999 to 7.4 per 1,000 in 2006-2008, probably based on an evolving understanding of the disorder and this diagnosis providing special access to resources in schools.
Research during this decade became increasingly focused on imaging studies of children (and adults), as leaders in the field were trying to move from symptom clusters to anatomic and physiologic correlates of psychiatric illness. The great increase in medication use in children hit a speed bump in October 2004, when the Food and Drug Administration issued a controversial public warning about an increased risk of suicidal thoughts or behaviors in youth being treated with SSRI antidepressants. As access to child psychiatric treatment had become more difficult over the preceding decades, pediatricians had assumed much of the medication treatment of common psychiatric problems. The FDA’s black box warning complicated pediatricians’ efforts to fill this void.
The last decade has been the decade of genetics and efforts to improve access to care. It started in 2007 with the FDA expanding its SSRI warning to acknowledge that depression itself increased the risk for suicide, in an effort to not discourage needed depression treatment in young people. But studies demonstrated that the rates of diagnosing and treating depression dropped dramatically in the years following the warning: Diagnoses of depression declined by as much as 42% in children, and the rate of antidepressant treatment in adolescents dropped by as much as 32% in the 2 years following the warning (N Engl J Med. 2014 Oct 30;371(18):1666-8). There was no compensatory increase in utilization of other kinds of treatments. While suicide rates in young people had been stubbornly steady from the mid-1970’s to the mid-1990’s, they began to decline in 1996, according to the Centers for Disease Control and Prevention. But that trend was broken in 2004, with a jump in attempted and completed suicides in young people. The rate stabilized later in the decade, but has never returned to the lows that were being achieved prior to the warning.
This decade was marked by the passage of the Affordable Care Act, including – again – an unfulfilled mandate for mental health parity for any insurance plans in the marketplace. Although diagnosis is still symptom based, the effort to define psychiatric disorders based on brain anatomy, neurotransmitters, and genomics continues to intensify. There is growing evidence that psychiatric disorders are not nature or nurture, but nature and nurture. Epigenetic findings show that environment impacts gene expression and brain functioning. These findings promise to deepen our understanding of the critical role of early experiences (consider Adverse Childhood Experiences [ACE] scores) and the promise of protective relationships, in schools and parenting.
And what will come next? We believe that silos – medical, psychiatric, parenting, school, environment – will be bridged to understand the many factors that impact behavior and treatment, but the need to advocate for policies that support funding for the education and mental health care of children and the training of professionals to provide that care is never ending. As our knowledge of the genome marches forward, we may discover effective strategies for preventing the emergence of mental illness in children or create individualized treatments. We may learn more about the role of nutrition and the microbiome in health and disease, about autoimmunity and mental illness. Our focus may return to parents, not as culprits, but as the mediators of health from the prenatal period on. Technology may enable us to improve access to effective treatments, with teens monitoring their sleep and mood, and accessing therapy on their smart phones. And our understanding of development and vulnerability may help us stem the rise in autism or collaborate with educators so that education could better put every child on their healthiest possible path. We look forward to experiencing it – and writing about it – with you!
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. They said they had no relevant financial disclosures. Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email them at pdnews@frontlinemedcom.com.
The 50th anniversary of Pediatric News prompts us to look back on the past 50 years in child psychiatry and developmental-behavioral pediatrics, and reflect on the evolution of the field. This includes the approach to diagnosis, the thinking about development and family, and the approach and access to treatment during this dynamic period.
While some historians identify the establishment of the first juvenile court in Chicago in 1899 and the work to help judges evaluate juvenile delinquency as the origin of child psychiatry in the United States, it was not until after World War II that the field really began to take root here, largely based on psychiatrists fleeing Europe and the seminal work of Anna Freud. Some of the earliest connections between pediatrics and child psychiatry were based on the work in England of Donald W. Winnicott, a practicing pediatrician and child psychiatrist, Albert J. Solnit, MD, at the Yale Child Study Center, and psychologically informed work of pediatrician Benjamin M. Spock, MD.
The first Diagnostic and Statistical Manual (DSM) was published in 1952, based on a codification of mental disorders established by the Navy during WWII. The American Academy of Child & Adolescent Psychiatry was established in 1953, the same year that the first “tranquilizer,” chlorpromazine (Thorazine) was introduced (in France), marking the start of a revolution in psychiatric care. In 1959, the first candidates sat for a licensing examination in child psychiatry. The Section on Developmental and Behavioral Pediatrics was established as part of the American Academy of Pediatrics in 1960 to support training in this area. The AACAP established a journal in 1961. Child guidance clinics started affiliating with hospitals and universities in the 1960’s, after the Community Mental Health Act of 1963. Then, in 1965, Julius B. Richmond, MD, (a pediatrician) and Uri Bronfenbrenner, PhD, (a developmental psychologist), recognizing the importance of ecological systems to child development, were involved in the creation of Head Start, and the first Joint Commission on Mental Health for Children was established by federal legislation in 1965. The field was truly coalescing into a distinct discipline of medicine, one that bridged pediatrics, psychiatry, and neurology with nonmedical disciplines such as justice and education.
The decade between 1967 and 1977 was a period of transition from the focus on psychoanalytic concepts typical of the first half of the century to a more systematic approach to diagnosis. Children in psychiatric treatment had commonly been seen for extended individual treatments, and those with more disruptive disorders often were hospitalized for long periods. Psychoanalysis focused on the unconscious (theoretical drives and conflicts) to guide treatment. Treatment often focused on the role (causal) of parents, and family treatment was common, even on inpatient units. The second edition of the DSM (DSM-II) was published in 1968, with its first distinct section for disorders of childhood and adolescence, and an overarching focus on psychodynamics. In 1974, the decision was made to publish a new edition of the DSM that would establish a multiaxial assessment system (separating “biological” mental health problems from personality disorders, medical illnesses, and psychosocial stressors) and research-oriented diagnostic criteria that would attempt to facilitate reliable diagnoses based on common clusters of symptoms. Field trials sponsored by the National Institute of Mental Health began in 1977 to establish the reliability of the new diagnoses.
The year 1977 saw the first Apple computer, the New York City blackout, the release of the first “Star Wars” movie, and also the start of a momentous decade in general and child psychiatry. The third edition of the DSM (DSM-III) was published in 1980, the beginning of a revolution in psychiatric diagnosis and treatments. It created reliable, reproducible diagnostic constructs to serve as the basis for studies on epidemiology and treatment. Implications of causality were replaced by description; for example, hyperkinetic reaction of childhood was redefined and labeled attention-deficit disorder. Recognizing the importance of research and training in this rapidly changing field, W.T. Grant Foundation funded 11 fellowship programs in 1977, and the Society for Developmental and Behavioral Pediatrics was founded in 1982 by the leaders of those programs.
In 1983, The AACAP published “Child Psychiatry: A Plan for the Coming Decades.” It was the result of 5 years’ work by 100 child psychiatrists, general psychiatrists, pediatricians, epidemiologists, nurses, leaders of the NIMH, and various child advocates. This report laid out a challenge for child psychiatry to develop research strategies that would allow evidence-based understanding and treatment of the mental illnesses of children. The established focus on individual experience and anecdotal data, particularly about social and psychodynamic influences, would shift towards a more scientific approach to diagnosis and treatment. This decade started an explosion in epidemiologic research, medication trials, and controlled studies of nonbiological treatments in child psychiatry. At the same time, the political landscape changed, and an ascendant conservatism began the process of closing publicly funded residential treatment centers that had offered care to the more chronically mentally ill and children with profound developmental disorders. This would accelerate the shift towards outpatient psychiatric care of children. Ironically, as research would accelerate in child psychiatry, access to effective treatments would become more difficult.
The decade from 1987 to 1997 was a period of dramatic growth in medication use in child psychiatry. Prozac was approved by the Food and Drug Administration for use in the United States in 1988 and soon followed by other selective serotonin reuptake inhibitors (Zoloft in 1991 and Paxil in 1992). The journal of the AACAP began to publish more randomized controlled trials of medication treatments in children with DSM-codified diagnoses, and clinicians became more comfortable using stimulants, antidepressants, and even antipsychotic medications in the outpatient setting. This trend was enhanced by the emergence of managed care and the denial of coverage for alleged “nonbiological” diagnoses and for many psychiatric treatments. Loss of reimbursement led to a significant decline in resources, particularly inpatient child psychiatry beds and specialized clinics. This, in turn, contributed to the growing emphasis on medication treatments for children’s mental health problems. For-profit managed care companies underbid each other to provide mental health coverage and incentivized medication visits. Of note, the medical budgets, not the mental health carve outs, were billed for the medication prescribed.
The Americans with Disabilities Act was passed in 1990, increasing the funding for school-based mental health resources for children, and in 1996, Congress passed the Mental Health Parity Act, the first of several legislative attempts to ensure parity between insurance coverage for medical and psychiatric illnesses – legislation that to this day has not achieved parity of access to care. As pediatricians took on more of mental health care, a multidisciplinary team created a primary care version of DSM IV, the DSM-IV-PC, in 1995, to assist with defining levels of symptoms less than disorder to facilitate earlier intervention. A formal subspecialty of developmental-behavioral pediatrics was established in 1999 to educate leaders. Pediatric residents have had required training in developmental-behavioral pediatrics since 2008.
The year 1997 saw the first nationwide survey of parents about attention-deficit/hyperactivity disorder, kicking off what could be called the decade of ADHD, in which prevalence rates steadily climbed, from 5.7% in 1997 to 9.5% in 2007. The prevalence of stimulant treatment in children skyrocketed in this period. According to the NIMH, stimulants were prescribed to 4.2% of 6- to 12-year-olds in 1996, and that number grew to 5.1% in 2008. For 13- to 18-year-olds, the rate more than doubled during this time, from 2.3% in 1996 to 4.9% in 2008. The prevalence of autism also grew dramatically during this time, from 1.9 per 1,000 in 1997-1999 to 7.4 per 1,000 in 2006-2008, probably based on an evolving understanding of the disorder and this diagnosis providing special access to resources in schools.
Research during this decade became increasingly focused on imaging studies of children (and adults), as leaders in the field were trying to move from symptom clusters to anatomic and physiologic correlates of psychiatric illness. The great increase in medication use in children hit a speed bump in October 2004, when the Food and Drug Administration issued a controversial public warning about an increased risk of suicidal thoughts or behaviors in youth being treated with SSRI antidepressants. As access to child psychiatric treatment had become more difficult over the preceding decades, pediatricians had assumed much of the medication treatment of common psychiatric problems. The FDA’s black box warning complicated pediatricians’ efforts to fill this void.
The last decade has been the decade of genetics and efforts to improve access to care. It started in 2007 with the FDA expanding its SSRI warning to acknowledge that depression itself increased the risk for suicide, in an effort to not discourage needed depression treatment in young people. But studies demonstrated that the rates of diagnosing and treating depression dropped dramatically in the years following the warning: Diagnoses of depression declined by as much as 42% in children, and the rate of antidepressant treatment in adolescents dropped by as much as 32% in the 2 years following the warning (N Engl J Med. 2014 Oct 30;371(18):1666-8). There was no compensatory increase in utilization of other kinds of treatments. While suicide rates in young people had been stubbornly steady from the mid-1970’s to the mid-1990’s, they began to decline in 1996, according to the Centers for Disease Control and Prevention. But that trend was broken in 2004, with a jump in attempted and completed suicides in young people. The rate stabilized later in the decade, but has never returned to the lows that were being achieved prior to the warning.
This decade was marked by the passage of the Affordable Care Act, including – again – an unfulfilled mandate for mental health parity for any insurance plans in the marketplace. Although diagnosis is still symptom based, the effort to define psychiatric disorders based on brain anatomy, neurotransmitters, and genomics continues to intensify. There is growing evidence that psychiatric disorders are not nature or nurture, but nature and nurture. Epigenetic findings show that environment impacts gene expression and brain functioning. These findings promise to deepen our understanding of the critical role of early experiences (consider Adverse Childhood Experiences [ACE] scores) and the promise of protective relationships, in schools and parenting.
And what will come next? We believe that silos – medical, psychiatric, parenting, school, environment – will be bridged to understand the many factors that impact behavior and treatment, but the need to advocate for policies that support funding for the education and mental health care of children and the training of professionals to provide that care is never ending. As our knowledge of the genome marches forward, we may discover effective strategies for preventing the emergence of mental illness in children or create individualized treatments. We may learn more about the role of nutrition and the microbiome in health and disease, about autoimmunity and mental illness. Our focus may return to parents, not as culprits, but as the mediators of health from the prenatal period on. Technology may enable us to improve access to effective treatments, with teens monitoring their sleep and mood, and accessing therapy on their smart phones. And our understanding of development and vulnerability may help us stem the rise in autism or collaborate with educators so that education could better put every child on their healthiest possible path. We look forward to experiencing it – and writing about it – with you!
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. They said they had no relevant financial disclosures. Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email them at pdnews@frontlinemedcom.com.
Stress management for ambitious students
Most parents hope that their children will be motivated and hard-working at school, but ambitious students usually face very high levels of stress. Ambitious young people typically push themselves very hard and may not spend enough time in play, relaxation, or exploring potential interests. Their time with peers might be more competitive than social or fun. They may become rigidly focused on a goal, paving the way for devastation if they fall short of their own expectations. They may internalize stress and not ask for help if it starts to take a toll on their mental health. But ambition is not incompatible with healthy development and well-being. Pediatricians usually know who the ambitious students in their practice are, and will hear about the stress they may be experiencing. You have the opportunity to offer them (or their parents) some strategies to manage their high stress levels, and build resilience.
Support ambition, but not perfectionism
It can be helpful to acknowledge to young people that they are ambitious, enabling them to acknowledge this fact about themselves. This kind of drive can be an admirable strength when it is part of an emerging identity, a wish to be successful as defined by the patient.
It is more likely to be problematic if it is a product of a parent’s need to have a child perform as they deem best. Second, it is critical to differentiate ambition from perfectionism. While ambition can keep someone focused and motivated in the face of difficulty, perfectionism is a bully that leaves a person feeling perpetually inadequate. Ambition without a specific interest or focus can lead to general perfectionism in a young person, and parents might unwittingly support this by applauding successes or becoming overinvested in this success reflecting onto them. When the pediatrician points out to a patient (and parents) that perfection is neither possible nor desirable, they may respond, “why wouldn’t I want to be perfect?” Remind them that perfectionism is actually the enemy of long-term accomplishment, discouraging risk-taking, reflection, and growth.
Celebrate failure!
The critical difference between an ambitious person who is persistent and determined (and thus equipped to succeed) and the brittle perfectionist is the ability to tolerate failure and setbacks. Point out to your patients that ambition means there will be a lot of setbacks, disappointments, and failures, as they attempt things that are challenging. Indeed, they should embrace each little failure, as that is how real learning and growth happen, especially if they are constantly stretching their goals.
As children or teenagers learn that failure is evidence that they are on track, working hard, and improving, they will develop tenacity and flexibility. Carol S. Dweck, PhD, a psychologist who has studied school performance in young people, has demonstrated that when young people are praised for their results they tend to give up when they fail, whereas if they are praised for their hard work and persistence, they redouble their effort when they fail. Parents, teachers, and pediatricians have the power to shift an ambitious child’s mindset (Dweck’s term) by helping the child change his or her thinking about what failure really means.
Cultivate self-awareness and perspective
It is one of the central tasks of growing up to learn what one’s interests, talents, and values are, and this self-knowledge is especially critical in ambitious young people. Without genuine interests or passions, ambition may feel like a hollow quest for approval. It is more likely to become general perfectionism. So children and teenagers need adults who are curious about their underlying interests, who patiently help them to cultivate these interests and dedicate their ambition to the pursuit of these passions. Younger children need adult time and support to explore a variety of interests, dabbling so they might figure out where their interests and talents converge. This can provide plenty of opportunity to celebrate effort over achievement. By adolescence, they should have a clearer sense of their personal interests and abilities, and will be deepening their efforts in fewer areas. Adolescence is also when they start to build a narrative of who they are and what values are truly their own. Parents can serve as models and facilitators for their teenagers’ emerging sets of values. Values such as honesty, compassion, or generosity (for example) organize one’s efforts, giving them deeper meaning and keeping difficulties in perspective. Values also will help ambitious young people set their own goals and create an individualized and meaningful definition of success, and keep bigger failures, losses, or disappointments in perspective.
Teach self-care
It seems obvious to state that learning how to care for one’s self is essential to well-being, but for ambitious young people (and adults), self-care is often the first thing to go (or the last thing they consider) in their busy days. Explain to your patients (and parents) that without adequate, consistent, restful sleep, all of their hard work will be inefficient or likely squandered. Explain that daily cardiovascular exercise is not frivolous, but rather essential to balance their cognitive efforts, and offers potent protection for their physical and mental health. There is even robust evidence that sleep and exercise are directly helpful to memory, learning, and creativity. When a parent models this kind of self-care, it is far more powerful than simply talking about it!
Relaxation is self-care!
While most teenagers do not need to be taught how to relax, those very ambitious ones are likely to need permission and even help in learning how to effectively and efficiently blow off steam. Help them to approach relaxation as they would approach a new subject, open-minded and trying different things to determine what works for them. Some may find exercise relaxing, while some may need a cognitive distraction (sometimes called “senseless fun,” an activity not dedicated to achievement) such as reading, family games, or television. Social time often is very effective relaxation for teenagers, and they should know that it is as important as sleep and studying for their performance. Some may find that a calming activity such as yoga or meditation recharges their batteries, whereas others may need noisy video games to feel renewed. Suggest that they should protect (just a little) time for relaxation even on their busiest days to help them develop good habits of self-care. Without consistent, reliable relaxation, ambitious young people are at risk for burnout or for impulsive and extreme behaviors such as binge-drinking.
Be on the lookout for red flags
In the same way that high performing athletes are at risk for stress fractures or other injuries of repetitive, intense physical activity, ambitious students are vulnerable to some of the problems that can follow sustained, intense cognitive effort. These risks go up if they are sleep deprived, stop exercising, or are socially isolated. Parents can be on the lookout for signs of depression or anxiety disorders, such as loss of energy, withdrawal from friends or beloved activities, persistent unhappiness or irritability (sustained over days to weeks), and of course morbid preoccupations.
Intense perfectionism is common among young people at risk for eating disorders, depression and self-injury, and anxiety disorders. Beyond recognizing signs, it is even more important for parents and pediatricians to equip ambitious young people to stay connected and ask for help if they experience a change in their emotional equilibrium. Suggest to your patients that they should never worry alone. They should ask for help if they are struggling to sleep, to sustain their motivation or effort, or notice feeling panicked, unusually tearful, or hopeless. Depression and anxiety are common and treatable problems in adolescents, but ambitious adolescents might be inclined to try to soldier through them. Caring adults should demystify and destigmatize mood and anxiety problems. You might point out that they would ask for help for a toothache or a painful knee joint, and that their mental health should be no different.
Many ambitious children have ambitious parents who might look back on their own adolescence and wonder if they were sufficiently balanced in their approach or whether they overreacted to failure. Sometimes honest sharing of successes, failures, and enduring dilemmas can build an empathic bridge from one generation to the next.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.
Most parents hope that their children will be motivated and hard-working at school, but ambitious students usually face very high levels of stress. Ambitious young people typically push themselves very hard and may not spend enough time in play, relaxation, or exploring potential interests. Their time with peers might be more competitive than social or fun. They may become rigidly focused on a goal, paving the way for devastation if they fall short of their own expectations. They may internalize stress and not ask for help if it starts to take a toll on their mental health. But ambition is not incompatible with healthy development and well-being. Pediatricians usually know who the ambitious students in their practice are, and will hear about the stress they may be experiencing. You have the opportunity to offer them (or their parents) some strategies to manage their high stress levels, and build resilience.
Support ambition, but not perfectionism
It can be helpful to acknowledge to young people that they are ambitious, enabling them to acknowledge this fact about themselves. This kind of drive can be an admirable strength when it is part of an emerging identity, a wish to be successful as defined by the patient.
It is more likely to be problematic if it is a product of a parent’s need to have a child perform as they deem best. Second, it is critical to differentiate ambition from perfectionism. While ambition can keep someone focused and motivated in the face of difficulty, perfectionism is a bully that leaves a person feeling perpetually inadequate. Ambition without a specific interest or focus can lead to general perfectionism in a young person, and parents might unwittingly support this by applauding successes or becoming overinvested in this success reflecting onto them. When the pediatrician points out to a patient (and parents) that perfection is neither possible nor desirable, they may respond, “why wouldn’t I want to be perfect?” Remind them that perfectionism is actually the enemy of long-term accomplishment, discouraging risk-taking, reflection, and growth.
Celebrate failure!
The critical difference between an ambitious person who is persistent and determined (and thus equipped to succeed) and the brittle perfectionist is the ability to tolerate failure and setbacks. Point out to your patients that ambition means there will be a lot of setbacks, disappointments, and failures, as they attempt things that are challenging. Indeed, they should embrace each little failure, as that is how real learning and growth happen, especially if they are constantly stretching their goals.
As children or teenagers learn that failure is evidence that they are on track, working hard, and improving, they will develop tenacity and flexibility. Carol S. Dweck, PhD, a psychologist who has studied school performance in young people, has demonstrated that when young people are praised for their results they tend to give up when they fail, whereas if they are praised for their hard work and persistence, they redouble their effort when they fail. Parents, teachers, and pediatricians have the power to shift an ambitious child’s mindset (Dweck’s term) by helping the child change his or her thinking about what failure really means.
Cultivate self-awareness and perspective
It is one of the central tasks of growing up to learn what one’s interests, talents, and values are, and this self-knowledge is especially critical in ambitious young people. Without genuine interests or passions, ambition may feel like a hollow quest for approval. It is more likely to become general perfectionism. So children and teenagers need adults who are curious about their underlying interests, who patiently help them to cultivate these interests and dedicate their ambition to the pursuit of these passions. Younger children need adult time and support to explore a variety of interests, dabbling so they might figure out where their interests and talents converge. This can provide plenty of opportunity to celebrate effort over achievement. By adolescence, they should have a clearer sense of their personal interests and abilities, and will be deepening their efforts in fewer areas. Adolescence is also when they start to build a narrative of who they are and what values are truly their own. Parents can serve as models and facilitators for their teenagers’ emerging sets of values. Values such as honesty, compassion, or generosity (for example) organize one’s efforts, giving them deeper meaning and keeping difficulties in perspective. Values also will help ambitious young people set their own goals and create an individualized and meaningful definition of success, and keep bigger failures, losses, or disappointments in perspective.
Teach self-care
It seems obvious to state that learning how to care for one’s self is essential to well-being, but for ambitious young people (and adults), self-care is often the first thing to go (or the last thing they consider) in their busy days. Explain to your patients (and parents) that without adequate, consistent, restful sleep, all of their hard work will be inefficient or likely squandered. Explain that daily cardiovascular exercise is not frivolous, but rather essential to balance their cognitive efforts, and offers potent protection for their physical and mental health. There is even robust evidence that sleep and exercise are directly helpful to memory, learning, and creativity. When a parent models this kind of self-care, it is far more powerful than simply talking about it!
Relaxation is self-care!
While most teenagers do not need to be taught how to relax, those very ambitious ones are likely to need permission and even help in learning how to effectively and efficiently blow off steam. Help them to approach relaxation as they would approach a new subject, open-minded and trying different things to determine what works for them. Some may find exercise relaxing, while some may need a cognitive distraction (sometimes called “senseless fun,” an activity not dedicated to achievement) such as reading, family games, or television. Social time often is very effective relaxation for teenagers, and they should know that it is as important as sleep and studying for their performance. Some may find that a calming activity such as yoga or meditation recharges their batteries, whereas others may need noisy video games to feel renewed. Suggest that they should protect (just a little) time for relaxation even on their busiest days to help them develop good habits of self-care. Without consistent, reliable relaxation, ambitious young people are at risk for burnout or for impulsive and extreme behaviors such as binge-drinking.
Be on the lookout for red flags
In the same way that high performing athletes are at risk for stress fractures or other injuries of repetitive, intense physical activity, ambitious students are vulnerable to some of the problems that can follow sustained, intense cognitive effort. These risks go up if they are sleep deprived, stop exercising, or are socially isolated. Parents can be on the lookout for signs of depression or anxiety disorders, such as loss of energy, withdrawal from friends or beloved activities, persistent unhappiness or irritability (sustained over days to weeks), and of course morbid preoccupations.
Intense perfectionism is common among young people at risk for eating disorders, depression and self-injury, and anxiety disorders. Beyond recognizing signs, it is even more important for parents and pediatricians to equip ambitious young people to stay connected and ask for help if they experience a change in their emotional equilibrium. Suggest to your patients that they should never worry alone. They should ask for help if they are struggling to sleep, to sustain their motivation or effort, or notice feeling panicked, unusually tearful, or hopeless. Depression and anxiety are common and treatable problems in adolescents, but ambitious adolescents might be inclined to try to soldier through them. Caring adults should demystify and destigmatize mood and anxiety problems. You might point out that they would ask for help for a toothache or a painful knee joint, and that their mental health should be no different.
Many ambitious children have ambitious parents who might look back on their own adolescence and wonder if they were sufficiently balanced in their approach or whether they overreacted to failure. Sometimes honest sharing of successes, failures, and enduring dilemmas can build an empathic bridge from one generation to the next.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.
Most parents hope that their children will be motivated and hard-working at school, but ambitious students usually face very high levels of stress. Ambitious young people typically push themselves very hard and may not spend enough time in play, relaxation, or exploring potential interests. Their time with peers might be more competitive than social or fun. They may become rigidly focused on a goal, paving the way for devastation if they fall short of their own expectations. They may internalize stress and not ask for help if it starts to take a toll on their mental health. But ambition is not incompatible with healthy development and well-being. Pediatricians usually know who the ambitious students in their practice are, and will hear about the stress they may be experiencing. You have the opportunity to offer them (or their parents) some strategies to manage their high stress levels, and build resilience.
Support ambition, but not perfectionism
It can be helpful to acknowledge to young people that they are ambitious, enabling them to acknowledge this fact about themselves. This kind of drive can be an admirable strength when it is part of an emerging identity, a wish to be successful as defined by the patient.
It is more likely to be problematic if it is a product of a parent’s need to have a child perform as they deem best. Second, it is critical to differentiate ambition from perfectionism. While ambition can keep someone focused and motivated in the face of difficulty, perfectionism is a bully that leaves a person feeling perpetually inadequate. Ambition without a specific interest or focus can lead to general perfectionism in a young person, and parents might unwittingly support this by applauding successes or becoming overinvested in this success reflecting onto them. When the pediatrician points out to a patient (and parents) that perfection is neither possible nor desirable, they may respond, “why wouldn’t I want to be perfect?” Remind them that perfectionism is actually the enemy of long-term accomplishment, discouraging risk-taking, reflection, and growth.
Celebrate failure!
The critical difference between an ambitious person who is persistent and determined (and thus equipped to succeed) and the brittle perfectionist is the ability to tolerate failure and setbacks. Point out to your patients that ambition means there will be a lot of setbacks, disappointments, and failures, as they attempt things that are challenging. Indeed, they should embrace each little failure, as that is how real learning and growth happen, especially if they are constantly stretching their goals.
As children or teenagers learn that failure is evidence that they are on track, working hard, and improving, they will develop tenacity and flexibility. Carol S. Dweck, PhD, a psychologist who has studied school performance in young people, has demonstrated that when young people are praised for their results they tend to give up when they fail, whereas if they are praised for their hard work and persistence, they redouble their effort when they fail. Parents, teachers, and pediatricians have the power to shift an ambitious child’s mindset (Dweck’s term) by helping the child change his or her thinking about what failure really means.
Cultivate self-awareness and perspective
It is one of the central tasks of growing up to learn what one’s interests, talents, and values are, and this self-knowledge is especially critical in ambitious young people. Without genuine interests or passions, ambition may feel like a hollow quest for approval. It is more likely to become general perfectionism. So children and teenagers need adults who are curious about their underlying interests, who patiently help them to cultivate these interests and dedicate their ambition to the pursuit of these passions. Younger children need adult time and support to explore a variety of interests, dabbling so they might figure out where their interests and talents converge. This can provide plenty of opportunity to celebrate effort over achievement. By adolescence, they should have a clearer sense of their personal interests and abilities, and will be deepening their efforts in fewer areas. Adolescence is also when they start to build a narrative of who they are and what values are truly their own. Parents can serve as models and facilitators for their teenagers’ emerging sets of values. Values such as honesty, compassion, or generosity (for example) organize one’s efforts, giving them deeper meaning and keeping difficulties in perspective. Values also will help ambitious young people set their own goals and create an individualized and meaningful definition of success, and keep bigger failures, losses, or disappointments in perspective.
Teach self-care
It seems obvious to state that learning how to care for one’s self is essential to well-being, but for ambitious young people (and adults), self-care is often the first thing to go (or the last thing they consider) in their busy days. Explain to your patients (and parents) that without adequate, consistent, restful sleep, all of their hard work will be inefficient or likely squandered. Explain that daily cardiovascular exercise is not frivolous, but rather essential to balance their cognitive efforts, and offers potent protection for their physical and mental health. There is even robust evidence that sleep and exercise are directly helpful to memory, learning, and creativity. When a parent models this kind of self-care, it is far more powerful than simply talking about it!
Relaxation is self-care!
While most teenagers do not need to be taught how to relax, those very ambitious ones are likely to need permission and even help in learning how to effectively and efficiently blow off steam. Help them to approach relaxation as they would approach a new subject, open-minded and trying different things to determine what works for them. Some may find exercise relaxing, while some may need a cognitive distraction (sometimes called “senseless fun,” an activity not dedicated to achievement) such as reading, family games, or television. Social time often is very effective relaxation for teenagers, and they should know that it is as important as sleep and studying for their performance. Some may find that a calming activity such as yoga or meditation recharges their batteries, whereas others may need noisy video games to feel renewed. Suggest that they should protect (just a little) time for relaxation even on their busiest days to help them develop good habits of self-care. Without consistent, reliable relaxation, ambitious young people are at risk for burnout or for impulsive and extreme behaviors such as binge-drinking.
Be on the lookout for red flags
In the same way that high performing athletes are at risk for stress fractures or other injuries of repetitive, intense physical activity, ambitious students are vulnerable to some of the problems that can follow sustained, intense cognitive effort. These risks go up if they are sleep deprived, stop exercising, or are socially isolated. Parents can be on the lookout for signs of depression or anxiety disorders, such as loss of energy, withdrawal from friends or beloved activities, persistent unhappiness or irritability (sustained over days to weeks), and of course morbid preoccupations.
Intense perfectionism is common among young people at risk for eating disorders, depression and self-injury, and anxiety disorders. Beyond recognizing signs, it is even more important for parents and pediatricians to equip ambitious young people to stay connected and ask for help if they experience a change in their emotional equilibrium. Suggest to your patients that they should never worry alone. They should ask for help if they are struggling to sleep, to sustain their motivation or effort, or notice feeling panicked, unusually tearful, or hopeless. Depression and anxiety are common and treatable problems in adolescents, but ambitious adolescents might be inclined to try to soldier through them. Caring adults should demystify and destigmatize mood and anxiety problems. You might point out that they would ask for help for a toothache or a painful knee joint, and that their mental health should be no different.
Many ambitious children have ambitious parents who might look back on their own adolescence and wonder if they were sufficiently balanced in their approach or whether they overreacted to failure. Sometimes honest sharing of successes, failures, and enduring dilemmas can build an empathic bridge from one generation to the next.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.
Discussing screen time with parents
The American Academy of Pediatrics released a new set of recommendations for the appropriate amount of screen time for children and adolescents in October 2016.
Among other changes, the AAP now recommends no screen time (except for video chatting) for infants and children up to 18 months old. For 18- to 24-month-olds, the AAP discourages screen time, recommending that parents introduce only selected “high-quality” programming and cowatch with their children. Likewise, for children up to 5 years old, the AAP urges parents to limit all screen time to 1 hour/day, half of its previous recommendation, and again recommends that parents cowatch with their children and use only reliable providers of quality content, such as the Public Broadcasting Service (PBS). For older children, the AAP does not set specific time limits, but recommends that parents collaborate with the children on a media plan that limits screen time so that it does not interfere with other important activities, including homework, social time, exercise, and sleep.
There also is evidence that teenagers who spend substantial time engaged passively in social media (seeing what others are doing or saying via Facebook or Instagram) report higher levels of depression and anxiety, whereas those who use social media as a platform to stay connected (via two-way communication) report lower levels of these symptoms. While many young people use social sites as a forum to find peer support, share concerns, or develop their own “voice,” some young people might be vulnerable to exploitation, cyberbullying, or even online solicitation. The key here may be for parents, who have a sense of their child’s strengths and vulnerabilities, to be aware of where their children are spending their virtual time and to check in about the kinds of connections they have there. Of course, screen time can be equally seductive for parents. And when a parent is spending time reading texts or checking for Facebook updates, they are missing opportunities to be engaged with their children, helping them with homework or simply noticing that they seem stressed, or catching an opportunity to talk with them.
The pediatrician has the opportunity to educate parents about the potential risks that unchecked screen time can pose to their children’s healthy development. But it is critical that you approach these conversations with specificity and compassion. Customize the conversation to the age and personality of the child and family. A computer in the bedroom may make sense for an academically oriented 9th grader in a demanding school who is generally well-balanced in activities and friendships. A bedroom computer may be a poor choice for an isolated 9th grader almost addicted to video games with few friends or activities.
Simply reciting recommendations may heighten a parent’s feelings of isolation and shame, and not lead to meaningful change. Instead, start by asking about the details: Where are the screens in the home? Bedrooms? Who has a computer, tablet, or smartphone? How are these screens used in the context of the child’s overall psychosocial functioning? Depending on the circumstance, a smaller change, such as “no phones while doing homework,” can make a big difference. Simple, clear rules can be easier to explain and enforce, and protect parents from the perils of daily negotiations of screen terms with their children or teenagers. Perhaps they can have a “phone zone” where phones get parked and charged once kids get home from school. Perhaps there are limits on TV or video games on school nights (for the student performing below potential, rather than the driven student who would benefit from down time). Perhaps for preteens, computer-based homework can be done only on the desktop computer that is kept in a family study, rather than a laptop in a bedroom where kids are more likely to become distracted and surf the net. Pediatricians can help families think through the right approach to screen time that may range from restriction to shared use exploring shared interests to jointly watching a favorite TV show or sporting event.
You can help parents consider how they will talk about all this, acknowledging what is fun and rewarding about TV shows, social media, and the Internet alongside the problems of excessive use. Ask parents if it is hard for them to put down their own phones or tablets. They can acknowledge this explicitly with their children when establishing new media use rules. It is powerful for children, especially teenagers, to hear their parents acknowledge that “phones, tablets, and computers are powerful tools, but we all need to improve our skills at being in control of our use of them.” You might suggest that parents try this exercise: list all of the activities they wish they had time for in every day, and how much time they would spend in them. Then they should guess how much time they spend in screen-based entertainment. If they wish to protect time for screen-based entertainment, they can actively choose to do so. If you are able to help parents better understand the risks of excessive screen time and facilitate desired and appropriate use of media, you will have added to the quality of the family’s life.
The AAP has resources to help pediatricians partner with parents to create a Family Media Use Plan (www.healthychildren.org/MediaUsePlan).
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.
The American Academy of Pediatrics released a new set of recommendations for the appropriate amount of screen time for children and adolescents in October 2016.
Among other changes, the AAP now recommends no screen time (except for video chatting) for infants and children up to 18 months old. For 18- to 24-month-olds, the AAP discourages screen time, recommending that parents introduce only selected “high-quality” programming and cowatch with their children. Likewise, for children up to 5 years old, the AAP urges parents to limit all screen time to 1 hour/day, half of its previous recommendation, and again recommends that parents cowatch with their children and use only reliable providers of quality content, such as the Public Broadcasting Service (PBS). For older children, the AAP does not set specific time limits, but recommends that parents collaborate with the children on a media plan that limits screen time so that it does not interfere with other important activities, including homework, social time, exercise, and sleep.
There also is evidence that teenagers who spend substantial time engaged passively in social media (seeing what others are doing or saying via Facebook or Instagram) report higher levels of depression and anxiety, whereas those who use social media as a platform to stay connected (via two-way communication) report lower levels of these symptoms. While many young people use social sites as a forum to find peer support, share concerns, or develop their own “voice,” some young people might be vulnerable to exploitation, cyberbullying, or even online solicitation. The key here may be for parents, who have a sense of their child’s strengths and vulnerabilities, to be aware of where their children are spending their virtual time and to check in about the kinds of connections they have there. Of course, screen time can be equally seductive for parents. And when a parent is spending time reading texts or checking for Facebook updates, they are missing opportunities to be engaged with their children, helping them with homework or simply noticing that they seem stressed, or catching an opportunity to talk with them.
The pediatrician has the opportunity to educate parents about the potential risks that unchecked screen time can pose to their children’s healthy development. But it is critical that you approach these conversations with specificity and compassion. Customize the conversation to the age and personality of the child and family. A computer in the bedroom may make sense for an academically oriented 9th grader in a demanding school who is generally well-balanced in activities and friendships. A bedroom computer may be a poor choice for an isolated 9th grader almost addicted to video games with few friends or activities.
Simply reciting recommendations may heighten a parent’s feelings of isolation and shame, and not lead to meaningful change. Instead, start by asking about the details: Where are the screens in the home? Bedrooms? Who has a computer, tablet, or smartphone? How are these screens used in the context of the child’s overall psychosocial functioning? Depending on the circumstance, a smaller change, such as “no phones while doing homework,” can make a big difference. Simple, clear rules can be easier to explain and enforce, and protect parents from the perils of daily negotiations of screen terms with their children or teenagers. Perhaps they can have a “phone zone” where phones get parked and charged once kids get home from school. Perhaps there are limits on TV or video games on school nights (for the student performing below potential, rather than the driven student who would benefit from down time). Perhaps for preteens, computer-based homework can be done only on the desktop computer that is kept in a family study, rather than a laptop in a bedroom where kids are more likely to become distracted and surf the net. Pediatricians can help families think through the right approach to screen time that may range from restriction to shared use exploring shared interests to jointly watching a favorite TV show or sporting event.
You can help parents consider how they will talk about all this, acknowledging what is fun and rewarding about TV shows, social media, and the Internet alongside the problems of excessive use. Ask parents if it is hard for them to put down their own phones or tablets. They can acknowledge this explicitly with their children when establishing new media use rules. It is powerful for children, especially teenagers, to hear their parents acknowledge that “phones, tablets, and computers are powerful tools, but we all need to improve our skills at being in control of our use of them.” You might suggest that parents try this exercise: list all of the activities they wish they had time for in every day, and how much time they would spend in them. Then they should guess how much time they spend in screen-based entertainment. If they wish to protect time for screen-based entertainment, they can actively choose to do so. If you are able to help parents better understand the risks of excessive screen time and facilitate desired and appropriate use of media, you will have added to the quality of the family’s life.
The AAP has resources to help pediatricians partner with parents to create a Family Media Use Plan (www.healthychildren.org/MediaUsePlan).
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.
The American Academy of Pediatrics released a new set of recommendations for the appropriate amount of screen time for children and adolescents in October 2016.
Among other changes, the AAP now recommends no screen time (except for video chatting) for infants and children up to 18 months old. For 18- to 24-month-olds, the AAP discourages screen time, recommending that parents introduce only selected “high-quality” programming and cowatch with their children. Likewise, for children up to 5 years old, the AAP urges parents to limit all screen time to 1 hour/day, half of its previous recommendation, and again recommends that parents cowatch with their children and use only reliable providers of quality content, such as the Public Broadcasting Service (PBS). For older children, the AAP does not set specific time limits, but recommends that parents collaborate with the children on a media plan that limits screen time so that it does not interfere with other important activities, including homework, social time, exercise, and sleep.
There also is evidence that teenagers who spend substantial time engaged passively in social media (seeing what others are doing or saying via Facebook or Instagram) report higher levels of depression and anxiety, whereas those who use social media as a platform to stay connected (via two-way communication) report lower levels of these symptoms. While many young people use social sites as a forum to find peer support, share concerns, or develop their own “voice,” some young people might be vulnerable to exploitation, cyberbullying, or even online solicitation. The key here may be for parents, who have a sense of their child’s strengths and vulnerabilities, to be aware of where their children are spending their virtual time and to check in about the kinds of connections they have there. Of course, screen time can be equally seductive for parents. And when a parent is spending time reading texts or checking for Facebook updates, they are missing opportunities to be engaged with their children, helping them with homework or simply noticing that they seem stressed, or catching an opportunity to talk with them.
The pediatrician has the opportunity to educate parents about the potential risks that unchecked screen time can pose to their children’s healthy development. But it is critical that you approach these conversations with specificity and compassion. Customize the conversation to the age and personality of the child and family. A computer in the bedroom may make sense for an academically oriented 9th grader in a demanding school who is generally well-balanced in activities and friendships. A bedroom computer may be a poor choice for an isolated 9th grader almost addicted to video games with few friends or activities.
Simply reciting recommendations may heighten a parent’s feelings of isolation and shame, and not lead to meaningful change. Instead, start by asking about the details: Where are the screens in the home? Bedrooms? Who has a computer, tablet, or smartphone? How are these screens used in the context of the child’s overall psychosocial functioning? Depending on the circumstance, a smaller change, such as “no phones while doing homework,” can make a big difference. Simple, clear rules can be easier to explain and enforce, and protect parents from the perils of daily negotiations of screen terms with their children or teenagers. Perhaps they can have a “phone zone” where phones get parked and charged once kids get home from school. Perhaps there are limits on TV or video games on school nights (for the student performing below potential, rather than the driven student who would benefit from down time). Perhaps for preteens, computer-based homework can be done only on the desktop computer that is kept in a family study, rather than a laptop in a bedroom where kids are more likely to become distracted and surf the net. Pediatricians can help families think through the right approach to screen time that may range from restriction to shared use exploring shared interests to jointly watching a favorite TV show or sporting event.
You can help parents consider how they will talk about all this, acknowledging what is fun and rewarding about TV shows, social media, and the Internet alongside the problems of excessive use. Ask parents if it is hard for them to put down their own phones or tablets. They can acknowledge this explicitly with their children when establishing new media use rules. It is powerful for children, especially teenagers, to hear their parents acknowledge that “phones, tablets, and computers are powerful tools, but we all need to improve our skills at being in control of our use of them.” You might suggest that parents try this exercise: list all of the activities they wish they had time for in every day, and how much time they would spend in them. Then they should guess how much time they spend in screen-based entertainment. If they wish to protect time for screen-based entertainment, they can actively choose to do so. If you are able to help parents better understand the risks of excessive screen time and facilitate desired and appropriate use of media, you will have added to the quality of the family’s life.
The AAP has resources to help pediatricians partner with parents to create a Family Media Use Plan (www.healthychildren.org/MediaUsePlan).
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.
School refusal
As summer winds down, it is routine for children and adolescents to feel a little melancholy or even worried about the approaching start of school. But for some students, anxiety about school is more than routine; it is insurmountable. School refusal is a serious behavioral problem: without assertive management, it can become a pattern which is very difficult to alter. Whether a child is complaining of vague somatic concerns or is explicitly refusing to go to school, the pediatrician’s office is often the first place a parent will turn to for help. If you can recognize the true nature of the problem, help to determine its cause, and facilitate the needed management, you will have effectively treated what can become a disabling problem for vulnerable young people.
School refusal is happening when a child has major difficulty attending school, associated with intense emotional distress. It can be a refusal to attend school or difficulty remaining in school for an entire day. It is distinct (but not mutually exclusive) from truancy, which is a failure to attend school associated with antisocial behavior or other conduct problems. In the pediatrician’s office, school refusal sounds like, “He was moaning about a stomachache yesterday, I kept him home, but he had no fever and ate okay. Then it all repeated again this morning.” Or you might hear, “She was whining about a headache, but when I said she had to go to school, she started crying and couldn’t stop. She was hysterical!” In teenagers, there may be somatic complaints or just a sleepy, sulky refusal to get out of bed. Children with truancy might fake illness (as compared with feeling sick), or simply leave school. Truant children often want to be out of school doing other things, and may keep their whereabouts a secret from their parents. While it might seem like just one tough morning that can be shrugged off, true school refusal will continue or escalate unless it is properly managed.
School refusal affects approximately 5% of all children annually, affecting girls and boys in equal numbers and with peaks in incidence at the ages of 5 to 6 years and again at 10 to 11 years. Approximately half of children and teenagers with school refusal have a treatable psychiatric illness. In the Great Smoky Mountain Study of 2003, where more than 1,400 children were observed, they categorized children as being anxious school refusers, truant, or “mixed school refusers,” with features of both truancy and anxiety. In children with truancy or anxious school refusal, 25% had a psychiatric illness. In the mixed school refusers, they found 88% had at least one psychiatric diagnosis and 42% had somatic complaints. While pure truancy will require different management strategies from school and parents, those young people who display features of both anxiety and truancy around school attendance are most likely to be suffering from a psychiatric illness. Those illnesses most commonly associated with difficulty attending school include anxiety disorders (separation anxiety, social phobia, generalized anxiety disorder) and depression.
While psychiatric illness is a common factor, there is also always a behavioral component to school refusal. This simply means that children are either avoiding unpleasant feelings associated with school, such as anxiety, or escaping uncomfortable situations, such as bullying or the stress of performance. On the positive side, children may be refusing school because they are pursuing the attention of important people (parents, peers) or pursuing pleasurable activities (playing video games, surfing the web or hanging out in town). Beyond an internal anxiety disorder, some children may be facing bullying or threats at school or may have to walk through a dangerous neighborhood to get to school. Some children may be missing school because of significant stress or transitions at home, such as financial difficulties or divorce. Other children may be staying home to take care of younger siblings because of a parent’s medical illness or substance abuse problem. Children who are being abused may be kept home to prevent suspicion about bruises. Lastly, some children feel they have to stay home to be with a lonely or depressed parent. Gently asking about these very real concerns will help determine the necessary course of action.
Pediatricians can play a central role in the management of school refusal. Often, the most important step is helping parents to understand that there is not an insidious medical problem driving the morning stomachaches and headaches. It is critical to clarify that (usually) their child is not feigning illness, but that there is significant distress around school that has led to this behavioral problem. Even children who have a genuine medical problem also can have school refusal. Once parents understand that without proper management, this behavior will continue or worsen, they usually are ready to collaborate on effective management. Their child may need a thorough psychiatric evaluation to rule out a treatable underlying psychiatric diagnosis, particularly if they have both anxious and truant behaviors. Most of the psychiatric problems associated with school refusal will require therapy and some may require medications for effective treatment.
Successfully getting children back to school will require a behavior plan that is agreed upon by the parents and the school, and then used consistently. This plan will simply detail strategies to “demagnetize” the home and “remagnetize” the school. Such strategies might include ensuring that children are not allowed “screen time” when home from school, and that their homework expectations continue. It should support healthy routines, including a regular sleep schedule and exercise. It should facilitate their being able to gradually manage any anxiety associated with school (shorter days initially, the option to have time-outs in a favorite part of the school or with a favorite teacher). A behavior plan should detail strategies for the child to manage stress (relaxation strategies, connecting with supportive individuals, even singing a favorite song). This plan can detail reasonable accommodations for a medical or psychiatric condition and appropriate rewards for regular attendance, such as being able to go on a class trip.
Through all of this, the pediatrician is in a uniquely authoritative position to provide support and reassurance to parents of a school refusing child. The pediatrician has a unique ability to clarify for parents the seriousness of the behavioral problem, even if there is no medical problem. Compassionately acknowledging how much a child is suffering (and the parents, as well) is powerful. Remind parents that accommodating anxiety only shows a child you don’t think they can master it, and often keeps them from trying. Express confidence that this is a relatively common and treatable phenomenon. If a pediatrician’s and parents’ efforts do not work quickly, in a matter of a few days, urgent referral to a mental health consultant is indicated, as falling behind in school and any acceptance of staying home makes return to school more difficult every day.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston.
As summer winds down, it is routine for children and adolescents to feel a little melancholy or even worried about the approaching start of school. But for some students, anxiety about school is more than routine; it is insurmountable. School refusal is a serious behavioral problem: without assertive management, it can become a pattern which is very difficult to alter. Whether a child is complaining of vague somatic concerns or is explicitly refusing to go to school, the pediatrician’s office is often the first place a parent will turn to for help. If you can recognize the true nature of the problem, help to determine its cause, and facilitate the needed management, you will have effectively treated what can become a disabling problem for vulnerable young people.
School refusal is happening when a child has major difficulty attending school, associated with intense emotional distress. It can be a refusal to attend school or difficulty remaining in school for an entire day. It is distinct (but not mutually exclusive) from truancy, which is a failure to attend school associated with antisocial behavior or other conduct problems. In the pediatrician’s office, school refusal sounds like, “He was moaning about a stomachache yesterday, I kept him home, but he had no fever and ate okay. Then it all repeated again this morning.” Or you might hear, “She was whining about a headache, but when I said she had to go to school, she started crying and couldn’t stop. She was hysterical!” In teenagers, there may be somatic complaints or just a sleepy, sulky refusal to get out of bed. Children with truancy might fake illness (as compared with feeling sick), or simply leave school. Truant children often want to be out of school doing other things, and may keep their whereabouts a secret from their parents. While it might seem like just one tough morning that can be shrugged off, true school refusal will continue or escalate unless it is properly managed.
School refusal affects approximately 5% of all children annually, affecting girls and boys in equal numbers and with peaks in incidence at the ages of 5 to 6 years and again at 10 to 11 years. Approximately half of children and teenagers with school refusal have a treatable psychiatric illness. In the Great Smoky Mountain Study of 2003, where more than 1,400 children were observed, they categorized children as being anxious school refusers, truant, or “mixed school refusers,” with features of both truancy and anxiety. In children with truancy or anxious school refusal, 25% had a psychiatric illness. In the mixed school refusers, they found 88% had at least one psychiatric diagnosis and 42% had somatic complaints. While pure truancy will require different management strategies from school and parents, those young people who display features of both anxiety and truancy around school attendance are most likely to be suffering from a psychiatric illness. Those illnesses most commonly associated with difficulty attending school include anxiety disorders (separation anxiety, social phobia, generalized anxiety disorder) and depression.
While psychiatric illness is a common factor, there is also always a behavioral component to school refusal. This simply means that children are either avoiding unpleasant feelings associated with school, such as anxiety, or escaping uncomfortable situations, such as bullying or the stress of performance. On the positive side, children may be refusing school because they are pursuing the attention of important people (parents, peers) or pursuing pleasurable activities (playing video games, surfing the web or hanging out in town). Beyond an internal anxiety disorder, some children may be facing bullying or threats at school or may have to walk through a dangerous neighborhood to get to school. Some children may be missing school because of significant stress or transitions at home, such as financial difficulties or divorce. Other children may be staying home to take care of younger siblings because of a parent’s medical illness or substance abuse problem. Children who are being abused may be kept home to prevent suspicion about bruises. Lastly, some children feel they have to stay home to be with a lonely or depressed parent. Gently asking about these very real concerns will help determine the necessary course of action.
Pediatricians can play a central role in the management of school refusal. Often, the most important step is helping parents to understand that there is not an insidious medical problem driving the morning stomachaches and headaches. It is critical to clarify that (usually) their child is not feigning illness, but that there is significant distress around school that has led to this behavioral problem. Even children who have a genuine medical problem also can have school refusal. Once parents understand that without proper management, this behavior will continue or worsen, they usually are ready to collaborate on effective management. Their child may need a thorough psychiatric evaluation to rule out a treatable underlying psychiatric diagnosis, particularly if they have both anxious and truant behaviors. Most of the psychiatric problems associated with school refusal will require therapy and some may require medications for effective treatment.
Successfully getting children back to school will require a behavior plan that is agreed upon by the parents and the school, and then used consistently. This plan will simply detail strategies to “demagnetize” the home and “remagnetize” the school. Such strategies might include ensuring that children are not allowed “screen time” when home from school, and that their homework expectations continue. It should support healthy routines, including a regular sleep schedule and exercise. It should facilitate their being able to gradually manage any anxiety associated with school (shorter days initially, the option to have time-outs in a favorite part of the school or with a favorite teacher). A behavior plan should detail strategies for the child to manage stress (relaxation strategies, connecting with supportive individuals, even singing a favorite song). This plan can detail reasonable accommodations for a medical or psychiatric condition and appropriate rewards for regular attendance, such as being able to go on a class trip.
Through all of this, the pediatrician is in a uniquely authoritative position to provide support and reassurance to parents of a school refusing child. The pediatrician has a unique ability to clarify for parents the seriousness of the behavioral problem, even if there is no medical problem. Compassionately acknowledging how much a child is suffering (and the parents, as well) is powerful. Remind parents that accommodating anxiety only shows a child you don’t think they can master it, and often keeps them from trying. Express confidence that this is a relatively common and treatable phenomenon. If a pediatrician’s and parents’ efforts do not work quickly, in a matter of a few days, urgent referral to a mental health consultant is indicated, as falling behind in school and any acceptance of staying home makes return to school more difficult every day.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston.
As summer winds down, it is routine for children and adolescents to feel a little melancholy or even worried about the approaching start of school. But for some students, anxiety about school is more than routine; it is insurmountable. School refusal is a serious behavioral problem: without assertive management, it can become a pattern which is very difficult to alter. Whether a child is complaining of vague somatic concerns or is explicitly refusing to go to school, the pediatrician’s office is often the first place a parent will turn to for help. If you can recognize the true nature of the problem, help to determine its cause, and facilitate the needed management, you will have effectively treated what can become a disabling problem for vulnerable young people.
School refusal is happening when a child has major difficulty attending school, associated with intense emotional distress. It can be a refusal to attend school or difficulty remaining in school for an entire day. It is distinct (but not mutually exclusive) from truancy, which is a failure to attend school associated with antisocial behavior or other conduct problems. In the pediatrician’s office, school refusal sounds like, “He was moaning about a stomachache yesterday, I kept him home, but he had no fever and ate okay. Then it all repeated again this morning.” Or you might hear, “She was whining about a headache, but when I said she had to go to school, she started crying and couldn’t stop. She was hysterical!” In teenagers, there may be somatic complaints or just a sleepy, sulky refusal to get out of bed. Children with truancy might fake illness (as compared with feeling sick), or simply leave school. Truant children often want to be out of school doing other things, and may keep their whereabouts a secret from their parents. While it might seem like just one tough morning that can be shrugged off, true school refusal will continue or escalate unless it is properly managed.
School refusal affects approximately 5% of all children annually, affecting girls and boys in equal numbers and with peaks in incidence at the ages of 5 to 6 years and again at 10 to 11 years. Approximately half of children and teenagers with school refusal have a treatable psychiatric illness. In the Great Smoky Mountain Study of 2003, where more than 1,400 children were observed, they categorized children as being anxious school refusers, truant, or “mixed school refusers,” with features of both truancy and anxiety. In children with truancy or anxious school refusal, 25% had a psychiatric illness. In the mixed school refusers, they found 88% had at least one psychiatric diagnosis and 42% had somatic complaints. While pure truancy will require different management strategies from school and parents, those young people who display features of both anxiety and truancy around school attendance are most likely to be suffering from a psychiatric illness. Those illnesses most commonly associated with difficulty attending school include anxiety disorders (separation anxiety, social phobia, generalized anxiety disorder) and depression.
While psychiatric illness is a common factor, there is also always a behavioral component to school refusal. This simply means that children are either avoiding unpleasant feelings associated with school, such as anxiety, or escaping uncomfortable situations, such as bullying or the stress of performance. On the positive side, children may be refusing school because they are pursuing the attention of important people (parents, peers) or pursuing pleasurable activities (playing video games, surfing the web or hanging out in town). Beyond an internal anxiety disorder, some children may be facing bullying or threats at school or may have to walk through a dangerous neighborhood to get to school. Some children may be missing school because of significant stress or transitions at home, such as financial difficulties or divorce. Other children may be staying home to take care of younger siblings because of a parent’s medical illness or substance abuse problem. Children who are being abused may be kept home to prevent suspicion about bruises. Lastly, some children feel they have to stay home to be with a lonely or depressed parent. Gently asking about these very real concerns will help determine the necessary course of action.
Pediatricians can play a central role in the management of school refusal. Often, the most important step is helping parents to understand that there is not an insidious medical problem driving the morning stomachaches and headaches. It is critical to clarify that (usually) their child is not feigning illness, but that there is significant distress around school that has led to this behavioral problem. Even children who have a genuine medical problem also can have school refusal. Once parents understand that without proper management, this behavior will continue or worsen, they usually are ready to collaborate on effective management. Their child may need a thorough psychiatric evaluation to rule out a treatable underlying psychiatric diagnosis, particularly if they have both anxious and truant behaviors. Most of the psychiatric problems associated with school refusal will require therapy and some may require medications for effective treatment.
Successfully getting children back to school will require a behavior plan that is agreed upon by the parents and the school, and then used consistently. This plan will simply detail strategies to “demagnetize” the home and “remagnetize” the school. Such strategies might include ensuring that children are not allowed “screen time” when home from school, and that their homework expectations continue. It should support healthy routines, including a regular sleep schedule and exercise. It should facilitate their being able to gradually manage any anxiety associated with school (shorter days initially, the option to have time-outs in a favorite part of the school or with a favorite teacher). A behavior plan should detail strategies for the child to manage stress (relaxation strategies, connecting with supportive individuals, even singing a favorite song). This plan can detail reasonable accommodations for a medical or psychiatric condition and appropriate rewards for regular attendance, such as being able to go on a class trip.
Through all of this, the pediatrician is in a uniquely authoritative position to provide support and reassurance to parents of a school refusing child. The pediatrician has a unique ability to clarify for parents the seriousness of the behavioral problem, even if there is no medical problem. Compassionately acknowledging how much a child is suffering (and the parents, as well) is powerful. Remind parents that accommodating anxiety only shows a child you don’t think they can master it, and often keeps them from trying. Express confidence that this is a relatively common and treatable phenomenon. If a pediatrician’s and parents’ efforts do not work quickly, in a matter of a few days, urgent referral to a mental health consultant is indicated, as falling behind in school and any acceptance of staying home makes return to school more difficult every day.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston.
Psychotherapy
The term “psychotherapy” describes a variety of talk-based treatments for psychiatric illnesses. Its fundamental premise is that there are determinants of mood, anxiety, and behavior that are not fully in our conscious awareness. By becoming more aware or by developing skills in managing thoughts and feelings, patients can get relief from symptoms that often impair functioning. The focus on unconscious thoughts, feelings, and behaviors is the central principle of dynamic psychotherapy in which the therapist listens to the patients speak freely about important people and events in their day-to-day lives and takes note of themes that emerge. Eventually they offer “interpretations” to their patients about these patterns, and ways that current problems may connect to powerful experiences from their earlier lives.
Dynamic psychotherapy is often contrasted with supportive psychotherapy. This is not cheerleading, but instead refers to supporting the healthy ability to think about oneself, one’s thoughts and emotions, and one’s needs, and the tension that these can create with the expectations of society. In working with children and adolescents, therapists are almost always supporting the age-appropriate development of some of these skills, particularly if a child has gotten developmentally stuck because of depressive, anxious, or attentional symptoms. There are almost always supportive elements in psychotherapy with a school-age or teenage child.
For children with anxiety disorders or mild to moderate depression, cognitive-behavioral therapy (CBT) is an evidence-based first-line treatment. CBT is a structured psychotherapy that helps patients to identify specific thoughts that trigger or follow their mood or anxiety symptoms, and then sets about establishing new (less-distorted) thoughts or practicing avoided behaviors to help learn new responses. It appears to be especially effective for anxiety disorders (such as social phobia, panic disorder, and generalized anxiety disorder) and for obsessive-compulsive disorder. There are specialized types of CBT that can be offered to patients (including children) who have been exposed to trauma and even for teenagers experiencing psychotic symptoms. It should be noted that one of the reasons that CBT has a robust evidence base supporting its use is that it is one of the most structured types of psychotherapy. It is standardized, reproducible, and easier to study than most other varieties of psychotherapy. Practicing CBT requires specific training, so in looking for a CBT therapist, one needs to ask whether she is CBT trained, and even whether she is trained in the type of CBT specific for the disorder you are treating.
A relative of CBT is dialectical behavioral therapy or DBT, developed to treat borderline personality disorder, a maladaptive pattern of identity uncertainty, emotional instability, and impulsivity that often starts in adolescence, causing stormy relationships and poor self-regulation that can contribute to self-injury, substance abuse, and chronic suicidality. DBT focuses on cognitive patterns, and utilizes a patient’s strengths to build new skills at managing challenging thoughts and feelings. The “dialectic” relates to interpersonal relationships, as this is where these patients often have great difficulty. High-quality DBT is often done with both individual and group therapy sessions. There is substantial evidence supporting the efficacy of this therapy in patients with borderline personality disorder.
Play therapy generally refers to the use of play (with toys, dolls, art, or games) in therapy with the youngest children. Such young children are unlikely to speak in a fluid manner about their relationships or struggles, as they may lack some of the cognitive means to be self-reflective. So instead, a therapist will watch for themes in their play (aggression, cheating, repetitive stories with dolls or art) that may reflect important themes, that they will then work on in play or in speaking, as tolerated. Therapists of older children also may use play to help these children feel more comfortable as they proceed with CBT or another talk therapy.
While gathering data from parents is always part of therapy for children, family therapy brings the whole family into a room with the therapist, who focuses on the roles each person may play in the family and patterns of communication (verbal and otherwise) that may be contributing to a young person’s symptoms. Family therapy can be very important in treating anorexia nervosa, somatoform illnesses, and conduct disorder in children and adolescents. While it can be a complex type of therapy to study, there is significant evidence supporting its efficacy in these very challenging disorders of youth.
There is a growing body of evidence in adults demonstrating neuroimaging changes after effective psychotherapies. Several studies of patients with OCD who were successfully treated with CBT have demonstrated decreased metabolism in the right caudate nucleus, and those treated effectively for phobias showed decreased activity in the limbic and paralimbic areas. Interestingly, patients with OCD and phobias who were effectively treated with selective serotonin reuptake inhibitors demonstrated these same changes on functional neuroimaging (Mol Psychiatry. 2006 Jun;11[6]:528-38.). An Italian meta-analysis of patients treated for major depression with medications (usually selective serotonin reuptake inhibitors) or with psychotherapy (usually CBT) demonstrated different, and possibly complementary brain changes in the two treatment groups (Brain Imaging Behav. 2015 Jul 12. [Epub ahead of print]). With time, these studies may help us to better understand the nature of specific illnesses and more about neuroplasticity, and may even help us to understand when medications, therapy, or both are indicated.
Finally, it is worth noting that multiple studies indicate that one of the most consistent predictors of a positive outcome in psychotherapy is the presence of a strong treatment alliance between the therapist and the patient. Studies have demonstrated that a strong alliance was a better predictor of positive outcomes than type of psychotherapy, and seemed to be a strong predictor of positive outcomes even in cases where the treatment was pharmacologic. This makes it critical that when you are trying to help your patient find a “good therapist,” you consider whether the patient may need a specialized therapy (CBT, DBT, or family therapy). But you should also instruct your patient and their parents that it is very important that they like their therapist, that after several meetings they should feel comfortable meeting and talking honestly with him, and that they should feel that the therapist cares about them and is committed to their health and well-being.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.
The term “psychotherapy” describes a variety of talk-based treatments for psychiatric illnesses. Its fundamental premise is that there are determinants of mood, anxiety, and behavior that are not fully in our conscious awareness. By becoming more aware or by developing skills in managing thoughts and feelings, patients can get relief from symptoms that often impair functioning. The focus on unconscious thoughts, feelings, and behaviors is the central principle of dynamic psychotherapy in which the therapist listens to the patients speak freely about important people and events in their day-to-day lives and takes note of themes that emerge. Eventually they offer “interpretations” to their patients about these patterns, and ways that current problems may connect to powerful experiences from their earlier lives.
Dynamic psychotherapy is often contrasted with supportive psychotherapy. This is not cheerleading, but instead refers to supporting the healthy ability to think about oneself, one’s thoughts and emotions, and one’s needs, and the tension that these can create with the expectations of society. In working with children and adolescents, therapists are almost always supporting the age-appropriate development of some of these skills, particularly if a child has gotten developmentally stuck because of depressive, anxious, or attentional symptoms. There are almost always supportive elements in psychotherapy with a school-age or teenage child.
For children with anxiety disorders or mild to moderate depression, cognitive-behavioral therapy (CBT) is an evidence-based first-line treatment. CBT is a structured psychotherapy that helps patients to identify specific thoughts that trigger or follow their mood or anxiety symptoms, and then sets about establishing new (less-distorted) thoughts or practicing avoided behaviors to help learn new responses. It appears to be especially effective for anxiety disorders (such as social phobia, panic disorder, and generalized anxiety disorder) and for obsessive-compulsive disorder. There are specialized types of CBT that can be offered to patients (including children) who have been exposed to trauma and even for teenagers experiencing psychotic symptoms. It should be noted that one of the reasons that CBT has a robust evidence base supporting its use is that it is one of the most structured types of psychotherapy. It is standardized, reproducible, and easier to study than most other varieties of psychotherapy. Practicing CBT requires specific training, so in looking for a CBT therapist, one needs to ask whether she is CBT trained, and even whether she is trained in the type of CBT specific for the disorder you are treating.
A relative of CBT is dialectical behavioral therapy or DBT, developed to treat borderline personality disorder, a maladaptive pattern of identity uncertainty, emotional instability, and impulsivity that often starts in adolescence, causing stormy relationships and poor self-regulation that can contribute to self-injury, substance abuse, and chronic suicidality. DBT focuses on cognitive patterns, and utilizes a patient’s strengths to build new skills at managing challenging thoughts and feelings. The “dialectic” relates to interpersonal relationships, as this is where these patients often have great difficulty. High-quality DBT is often done with both individual and group therapy sessions. There is substantial evidence supporting the efficacy of this therapy in patients with borderline personality disorder.
Play therapy generally refers to the use of play (with toys, dolls, art, or games) in therapy with the youngest children. Such young children are unlikely to speak in a fluid manner about their relationships or struggles, as they may lack some of the cognitive means to be self-reflective. So instead, a therapist will watch for themes in their play (aggression, cheating, repetitive stories with dolls or art) that may reflect important themes, that they will then work on in play or in speaking, as tolerated. Therapists of older children also may use play to help these children feel more comfortable as they proceed with CBT or another talk therapy.
While gathering data from parents is always part of therapy for children, family therapy brings the whole family into a room with the therapist, who focuses on the roles each person may play in the family and patterns of communication (verbal and otherwise) that may be contributing to a young person’s symptoms. Family therapy can be very important in treating anorexia nervosa, somatoform illnesses, and conduct disorder in children and adolescents. While it can be a complex type of therapy to study, there is significant evidence supporting its efficacy in these very challenging disorders of youth.
There is a growing body of evidence in adults demonstrating neuroimaging changes after effective psychotherapies. Several studies of patients with OCD who were successfully treated with CBT have demonstrated decreased metabolism in the right caudate nucleus, and those treated effectively for phobias showed decreased activity in the limbic and paralimbic areas. Interestingly, patients with OCD and phobias who were effectively treated with selective serotonin reuptake inhibitors demonstrated these same changes on functional neuroimaging (Mol Psychiatry. 2006 Jun;11[6]:528-38.). An Italian meta-analysis of patients treated for major depression with medications (usually selective serotonin reuptake inhibitors) or with psychotherapy (usually CBT) demonstrated different, and possibly complementary brain changes in the two treatment groups (Brain Imaging Behav. 2015 Jul 12. [Epub ahead of print]). With time, these studies may help us to better understand the nature of specific illnesses and more about neuroplasticity, and may even help us to understand when medications, therapy, or both are indicated.
Finally, it is worth noting that multiple studies indicate that one of the most consistent predictors of a positive outcome in psychotherapy is the presence of a strong treatment alliance between the therapist and the patient. Studies have demonstrated that a strong alliance was a better predictor of positive outcomes than type of psychotherapy, and seemed to be a strong predictor of positive outcomes even in cases where the treatment was pharmacologic. This makes it critical that when you are trying to help your patient find a “good therapist,” you consider whether the patient may need a specialized therapy (CBT, DBT, or family therapy). But you should also instruct your patient and their parents that it is very important that they like their therapist, that after several meetings they should feel comfortable meeting and talking honestly with him, and that they should feel that the therapist cares about them and is committed to their health and well-being.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.
The term “psychotherapy” describes a variety of talk-based treatments for psychiatric illnesses. Its fundamental premise is that there are determinants of mood, anxiety, and behavior that are not fully in our conscious awareness. By becoming more aware or by developing skills in managing thoughts and feelings, patients can get relief from symptoms that often impair functioning. The focus on unconscious thoughts, feelings, and behaviors is the central principle of dynamic psychotherapy in which the therapist listens to the patients speak freely about important people and events in their day-to-day lives and takes note of themes that emerge. Eventually they offer “interpretations” to their patients about these patterns, and ways that current problems may connect to powerful experiences from their earlier lives.
Dynamic psychotherapy is often contrasted with supportive psychotherapy. This is not cheerleading, but instead refers to supporting the healthy ability to think about oneself, one’s thoughts and emotions, and one’s needs, and the tension that these can create with the expectations of society. In working with children and adolescents, therapists are almost always supporting the age-appropriate development of some of these skills, particularly if a child has gotten developmentally stuck because of depressive, anxious, or attentional symptoms. There are almost always supportive elements in psychotherapy with a school-age or teenage child.
For children with anxiety disorders or mild to moderate depression, cognitive-behavioral therapy (CBT) is an evidence-based first-line treatment. CBT is a structured psychotherapy that helps patients to identify specific thoughts that trigger or follow their mood or anxiety symptoms, and then sets about establishing new (less-distorted) thoughts or practicing avoided behaviors to help learn new responses. It appears to be especially effective for anxiety disorders (such as social phobia, panic disorder, and generalized anxiety disorder) and for obsessive-compulsive disorder. There are specialized types of CBT that can be offered to patients (including children) who have been exposed to trauma and even for teenagers experiencing psychotic symptoms. It should be noted that one of the reasons that CBT has a robust evidence base supporting its use is that it is one of the most structured types of psychotherapy. It is standardized, reproducible, and easier to study than most other varieties of psychotherapy. Practicing CBT requires specific training, so in looking for a CBT therapist, one needs to ask whether she is CBT trained, and even whether she is trained in the type of CBT specific for the disorder you are treating.
A relative of CBT is dialectical behavioral therapy or DBT, developed to treat borderline personality disorder, a maladaptive pattern of identity uncertainty, emotional instability, and impulsivity that often starts in adolescence, causing stormy relationships and poor self-regulation that can contribute to self-injury, substance abuse, and chronic suicidality. DBT focuses on cognitive patterns, and utilizes a patient’s strengths to build new skills at managing challenging thoughts and feelings. The “dialectic” relates to interpersonal relationships, as this is where these patients often have great difficulty. High-quality DBT is often done with both individual and group therapy sessions. There is substantial evidence supporting the efficacy of this therapy in patients with borderline personality disorder.
Play therapy generally refers to the use of play (with toys, dolls, art, or games) in therapy with the youngest children. Such young children are unlikely to speak in a fluid manner about their relationships or struggles, as they may lack some of the cognitive means to be self-reflective. So instead, a therapist will watch for themes in their play (aggression, cheating, repetitive stories with dolls or art) that may reflect important themes, that they will then work on in play or in speaking, as tolerated. Therapists of older children also may use play to help these children feel more comfortable as they proceed with CBT or another talk therapy.
While gathering data from parents is always part of therapy for children, family therapy brings the whole family into a room with the therapist, who focuses on the roles each person may play in the family and patterns of communication (verbal and otherwise) that may be contributing to a young person’s symptoms. Family therapy can be very important in treating anorexia nervosa, somatoform illnesses, and conduct disorder in children and adolescents. While it can be a complex type of therapy to study, there is significant evidence supporting its efficacy in these very challenging disorders of youth.
There is a growing body of evidence in adults demonstrating neuroimaging changes after effective psychotherapies. Several studies of patients with OCD who were successfully treated with CBT have demonstrated decreased metabolism in the right caudate nucleus, and those treated effectively for phobias showed decreased activity in the limbic and paralimbic areas. Interestingly, patients with OCD and phobias who were effectively treated with selective serotonin reuptake inhibitors demonstrated these same changes on functional neuroimaging (Mol Psychiatry. 2006 Jun;11[6]:528-38.). An Italian meta-analysis of patients treated for major depression with medications (usually selective serotonin reuptake inhibitors) or with psychotherapy (usually CBT) demonstrated different, and possibly complementary brain changes in the two treatment groups (Brain Imaging Behav. 2015 Jul 12. [Epub ahead of print]). With time, these studies may help us to better understand the nature of specific illnesses and more about neuroplasticity, and may even help us to understand when medications, therapy, or both are indicated.
Finally, it is worth noting that multiple studies indicate that one of the most consistent predictors of a positive outcome in psychotherapy is the presence of a strong treatment alliance between the therapist and the patient. Studies have demonstrated that a strong alliance was a better predictor of positive outcomes than type of psychotherapy, and seemed to be a strong predictor of positive outcomes even in cases where the treatment was pharmacologic. This makes it critical that when you are trying to help your patient find a “good therapist,” you consider whether the patient may need a specialized therapy (CBT, DBT, or family therapy). But you should also instruct your patient and their parents that it is very important that they like their therapist, that after several meetings they should feel comfortable meeting and talking honestly with him, and that they should feel that the therapist cares about them and is committed to their health and well-being.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.
Lead poisoning
Lead poisoning is a well-established cause of serious and permanent neurological, cognitive, and behavioral problems, particularly in exposed children.
Children can be exposed to lead from ingesting paint chips in their homes, when old paint is scrapped from the exterior of houses or bridges, and through the water they drink. The damage caused by lead poisoning was first recognized in the United States in the early 20th century, although lead was added to gasoline and paint until the 1970’s. Since then, regulations for lead in consumer products have become increasingly strict, and the Centers for Disease Control and Prevention’s definition of a toxic lead level has shifted from 60 micrograms/deciliter (mcg/dL) in 1970 to 5 mcg/dL in 2012. In many communities, removing lead paint up to the height of a young child is a requirement whenever an older home is sold.
Unfortunately, these regulations did not protect the families in Flint, Michigan from being exposed to high levels of lead when a change in water supply and inadequate water treatment allowed lead to enter the system from decaying water pipes. It is worth reviewing what is known about the short- and long-term consequences of lead exposure, and what lies ahead for the children of Flint.
Lead is a naturally occurring element that is not metabolized, but rather absorbed, distributed to tissues, and excreted. Lead can be inhaled (with 100% absorption) and introduced through the GI tract (with about 70% absorption in children and 20% absorption in adults). GI absorption is enhanced by calcium or iron deficiency, both conditions that are relatively common, especially in poor children and can lead to pica (or eating of non-nutritious materials), further increasing the chances of lead exposure. Absorbed lead is distributed to blood (for 28-36 days), soft tissue, including the nervous system (40 days), and to bone (where it lasts for over 25 years). Blood that is retained in growing bones can be mobilized during periods of physiologic stress (such as illness, injury, or pregnancy), meaning children exposed to lead during a period of rapid bone growth are at long-term risk for acute lead poisoning from their endogenous reservoir without a new exposure. What lead is not retained by tissues is excreted by the kidneys, with adults retaining about 1% of absorbed lead, while children younger than 2 years retain over 30% of absorbed lead. So children, especially toddlers, have a greater likelihood to absorb lead from the GI tract and to retain lead in their tissues, both due to active mineralization of bone and the permeability of the blood brain barrier, primarily in children under 3 years old. This is why we are addressing what will happen to the children of Flint and not to all the residents of Flint.
Lead competitively inhibits interactions between cations and sulfhydryl groups, which are present in most human biochemical reactions. This leads to irreversible cell damage and often cell death, especially within the central nervous system. Lead exposure is associated with particular dysfunction within dopaminergic pathways within the brain, and has been associated in a dose-dependent fashion with decreased prefrontal gray matter volume. Lead poisoning also has hematologic consequences (anemia), renal consequences (interstitial nephritis), gastrointestinal symptoms (vomiting, constipation), and endocrine consequences (reversible inhibition of Vitamin D metabolism and permanently short stature). But the CNS consequences of lead exposure are particularly devastating, as they appear to have no threshold and are permanent. Their incidence is the driving force for the CDC’s lowering of the official toxic lead level and the public health efforts to screen children and educate parents about the risk of lead exposure.
So what do these serious consequences look like? People with severe lead intoxication (blood lead levels greater than 70 mcg/dL) typically present with signs of acute encephalopathy (headache, vomiting, seizures, or coma) and require intensive medical management including chelation therapy. More typically, exposed children have low but accumulating levels of lead and present with nonspecific symptoms, including lost appetite, fatigue, irritability, and insomnia, which gradually worsen.
Behavior
High levels of impulsivity, aggression, and impaired attention are the prototypical sequelae of lead poisoning (following recovery from the acute intoxication). Multiple studies have demonstrated these high levels of aggressive and impulsive behaviors in preschoolers who were exposed to lead, and these behaviors appear to continue into adolescence and adulthood. Indeed, one study found that compared with children with the lowest measurable blood lead levels (0.2-0.7 mcg/dL), those children who were in the next two quartiles had seven and twelve times the odds of meeting diagnostic criteria for conduct disorder.1 There have even been studies which correlated atmospheric lead levels (when leaded gasoline was common) with crime rates 20 years later, which supported an association between childhood lead exposure and adult criminal activity.2-4.
Multiple studies have demonstrated higher rates of inattention, distractibility, and impulsivity in lead-exposed children than would be expected given the prevalence of attention-deficit/hyperactivity disorder (ADHD) in the general population. The incidence of these symptoms goes up in a dose-dependent fashion and appears to have no threshold (so they occur at even the lowest measurable blood lead levels). In a 2006 study of nearly 5,000 children between ages 4-15 years, those with blood lead levels greater than 2 mcg/dL (still below the level the CDC deems toxic) were four times more likely to be carrying a diagnosis of ADHD and be on stimulant medication than their peers with blood lead levels less than 0.8mcg/dL.
Cognition
Closely related to impulse control and attention, the cognitive domains of intelligence and executive function are clearly damaged by lead exposure. Poor performance on tasks requiring focus, cognitive flexibility, and inhibition of automatic responses was directly associated with higher blood lead levels in a group of preschoolers with levels between 0 and 13 mcg/dL.5
IQ has been found to be so consistently diminished by increasing blood lead levels that it is used as an overall index of neurodevelopmental morbidity of lead exposure, leading to the CDC’s adoption of a lower standard definition of toxic lead levels. Even very low blood lead levels are associated with decrements in IQ: children with blood lead levels less than 7.5 mcg/dL lost an average of 3 IQ points for every 1 mcg/dL increase in blood lead levels.6 In a study of 57,000 elementary school students in 2009, Miranda et al. found that those who had a blood lead level of 4 mcg/dL at 3 years old were significantly more likely to be diagnosed with a learning disability in elementary school. Another study of 48,000 children who had a blood lead level of 5 mcg/dL were 30% more likely to fail third grade reading and math tests than their peers without measurable lead levels.
Speech and language
More recent studies have demonstrated that children with higher bone lead concentrations had poorer performance on several language-processing measures, suggesting that childhood lead exposure damages language processing and function as the young people grow. These deficits in language processing can make social development and self-regulation much more challenging in adolescence, and make school and work settings much more challenging. These findings also have implications for the utility of psychotherapy, a language-based treatment, for the other behavioral problems of lead exposure.
Motor skills
Several recent studies have assessed both fine and gross motor skills in lead-exposed children. Findings have demonstrated that balance, coordination, gross motor and fine motor skills all appear to be compromised in a dose-dependent fashion by childhood lead exposure. These findings suggest that not only are children at greater risk for accident and injury through childhood and into adulthood, a risk already increased by their compromised attention and impulse control. But they also are likely to be physically clumsy, compromising an opportunity to cultivate strengths or experience mastery when cognitive tasks may prove frustrating for them.
With deficits in such fundamental cognitive, motor, and behavioral processes, exposed children are clearly vulnerable to more than ADHD, conduct disorder, and learning disabilities. These struggles may lead to secondary vulnerabilities to anxiety or mood symptoms or substance abuse as these children grow into teenagers who face frustration at every turn. In addition to treatment for their deficits in attention and executive function, these children will ideally receive specialized supports in school and at home, to be able to master cognitive tasks, manage new social circumstances and make friends, discover their interests and talents, and generally stay on their best developmental trajectories. Lastly, the specific consequences of lead exposure will vary for any individual child, so parents will have to deal with the uncertainty of their child’s behavior and development over many years. Clearly, the children of Flint face a long road that has been substantially impacted by their lead exposure. The only good that can come from the exposure in Flint is to heighten efforts to ensure that it never happens again.
1. Environ Health Perspect. 2008 Jul;116(7):956-62.
2. Environ Res. 2000 May;83(1):1-22.
3. Environ Res. 2007 Jul;104(3):315-36.
4. Arch Pediatr Adolesc Med. 2001 May;155(5):579-82.
5. Dev Neuropsychol. 2004;26(1):513-40.
6. Environ Health Perspect. 2005 Jul;113(7):894-9.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston.
Lead poisoning is a well-established cause of serious and permanent neurological, cognitive, and behavioral problems, particularly in exposed children.
Children can be exposed to lead from ingesting paint chips in their homes, when old paint is scrapped from the exterior of houses or bridges, and through the water they drink. The damage caused by lead poisoning was first recognized in the United States in the early 20th century, although lead was added to gasoline and paint until the 1970’s. Since then, regulations for lead in consumer products have become increasingly strict, and the Centers for Disease Control and Prevention’s definition of a toxic lead level has shifted from 60 micrograms/deciliter (mcg/dL) in 1970 to 5 mcg/dL in 2012. In many communities, removing lead paint up to the height of a young child is a requirement whenever an older home is sold.
Unfortunately, these regulations did not protect the families in Flint, Michigan from being exposed to high levels of lead when a change in water supply and inadequate water treatment allowed lead to enter the system from decaying water pipes. It is worth reviewing what is known about the short- and long-term consequences of lead exposure, and what lies ahead for the children of Flint.
Lead is a naturally occurring element that is not metabolized, but rather absorbed, distributed to tissues, and excreted. Lead can be inhaled (with 100% absorption) and introduced through the GI tract (with about 70% absorption in children and 20% absorption in adults). GI absorption is enhanced by calcium or iron deficiency, both conditions that are relatively common, especially in poor children and can lead to pica (or eating of non-nutritious materials), further increasing the chances of lead exposure. Absorbed lead is distributed to blood (for 28-36 days), soft tissue, including the nervous system (40 days), and to bone (where it lasts for over 25 years). Blood that is retained in growing bones can be mobilized during periods of physiologic stress (such as illness, injury, or pregnancy), meaning children exposed to lead during a period of rapid bone growth are at long-term risk for acute lead poisoning from their endogenous reservoir without a new exposure. What lead is not retained by tissues is excreted by the kidneys, with adults retaining about 1% of absorbed lead, while children younger than 2 years retain over 30% of absorbed lead. So children, especially toddlers, have a greater likelihood to absorb lead from the GI tract and to retain lead in their tissues, both due to active mineralization of bone and the permeability of the blood brain barrier, primarily in children under 3 years old. This is why we are addressing what will happen to the children of Flint and not to all the residents of Flint.
Lead competitively inhibits interactions between cations and sulfhydryl groups, which are present in most human biochemical reactions. This leads to irreversible cell damage and often cell death, especially within the central nervous system. Lead exposure is associated with particular dysfunction within dopaminergic pathways within the brain, and has been associated in a dose-dependent fashion with decreased prefrontal gray matter volume. Lead poisoning also has hematologic consequences (anemia), renal consequences (interstitial nephritis), gastrointestinal symptoms (vomiting, constipation), and endocrine consequences (reversible inhibition of Vitamin D metabolism and permanently short stature). But the CNS consequences of lead exposure are particularly devastating, as they appear to have no threshold and are permanent. Their incidence is the driving force for the CDC’s lowering of the official toxic lead level and the public health efforts to screen children and educate parents about the risk of lead exposure.
So what do these serious consequences look like? People with severe lead intoxication (blood lead levels greater than 70 mcg/dL) typically present with signs of acute encephalopathy (headache, vomiting, seizures, or coma) and require intensive medical management including chelation therapy. More typically, exposed children have low but accumulating levels of lead and present with nonspecific symptoms, including lost appetite, fatigue, irritability, and insomnia, which gradually worsen.
Behavior
High levels of impulsivity, aggression, and impaired attention are the prototypical sequelae of lead poisoning (following recovery from the acute intoxication). Multiple studies have demonstrated these high levels of aggressive and impulsive behaviors in preschoolers who were exposed to lead, and these behaviors appear to continue into adolescence and adulthood. Indeed, one study found that compared with children with the lowest measurable blood lead levels (0.2-0.7 mcg/dL), those children who were in the next two quartiles had seven and twelve times the odds of meeting diagnostic criteria for conduct disorder.1 There have even been studies which correlated atmospheric lead levels (when leaded gasoline was common) with crime rates 20 years later, which supported an association between childhood lead exposure and adult criminal activity.2-4.
Multiple studies have demonstrated higher rates of inattention, distractibility, and impulsivity in lead-exposed children than would be expected given the prevalence of attention-deficit/hyperactivity disorder (ADHD) in the general population. The incidence of these symptoms goes up in a dose-dependent fashion and appears to have no threshold (so they occur at even the lowest measurable blood lead levels). In a 2006 study of nearly 5,000 children between ages 4-15 years, those with blood lead levels greater than 2 mcg/dL (still below the level the CDC deems toxic) were four times more likely to be carrying a diagnosis of ADHD and be on stimulant medication than their peers with blood lead levels less than 0.8mcg/dL.
Cognition
Closely related to impulse control and attention, the cognitive domains of intelligence and executive function are clearly damaged by lead exposure. Poor performance on tasks requiring focus, cognitive flexibility, and inhibition of automatic responses was directly associated with higher blood lead levels in a group of preschoolers with levels between 0 and 13 mcg/dL.5
IQ has been found to be so consistently diminished by increasing blood lead levels that it is used as an overall index of neurodevelopmental morbidity of lead exposure, leading to the CDC’s adoption of a lower standard definition of toxic lead levels. Even very low blood lead levels are associated with decrements in IQ: children with blood lead levels less than 7.5 mcg/dL lost an average of 3 IQ points for every 1 mcg/dL increase in blood lead levels.6 In a study of 57,000 elementary school students in 2009, Miranda et al. found that those who had a blood lead level of 4 mcg/dL at 3 years old were significantly more likely to be diagnosed with a learning disability in elementary school. Another study of 48,000 children who had a blood lead level of 5 mcg/dL were 30% more likely to fail third grade reading and math tests than their peers without measurable lead levels.
Speech and language
More recent studies have demonstrated that children with higher bone lead concentrations had poorer performance on several language-processing measures, suggesting that childhood lead exposure damages language processing and function as the young people grow. These deficits in language processing can make social development and self-regulation much more challenging in adolescence, and make school and work settings much more challenging. These findings also have implications for the utility of psychotherapy, a language-based treatment, for the other behavioral problems of lead exposure.
Motor skills
Several recent studies have assessed both fine and gross motor skills in lead-exposed children. Findings have demonstrated that balance, coordination, gross motor and fine motor skills all appear to be compromised in a dose-dependent fashion by childhood lead exposure. These findings suggest that not only are children at greater risk for accident and injury through childhood and into adulthood, a risk already increased by their compromised attention and impulse control. But they also are likely to be physically clumsy, compromising an opportunity to cultivate strengths or experience mastery when cognitive tasks may prove frustrating for them.
With deficits in such fundamental cognitive, motor, and behavioral processes, exposed children are clearly vulnerable to more than ADHD, conduct disorder, and learning disabilities. These struggles may lead to secondary vulnerabilities to anxiety or mood symptoms or substance abuse as these children grow into teenagers who face frustration at every turn. In addition to treatment for their deficits in attention and executive function, these children will ideally receive specialized supports in school and at home, to be able to master cognitive tasks, manage new social circumstances and make friends, discover their interests and talents, and generally stay on their best developmental trajectories. Lastly, the specific consequences of lead exposure will vary for any individual child, so parents will have to deal with the uncertainty of their child’s behavior and development over many years. Clearly, the children of Flint face a long road that has been substantially impacted by their lead exposure. The only good that can come from the exposure in Flint is to heighten efforts to ensure that it never happens again.
1. Environ Health Perspect. 2008 Jul;116(7):956-62.
2. Environ Res. 2000 May;83(1):1-22.
3. Environ Res. 2007 Jul;104(3):315-36.
4. Arch Pediatr Adolesc Med. 2001 May;155(5):579-82.
5. Dev Neuropsychol. 2004;26(1):513-40.
6. Environ Health Perspect. 2005 Jul;113(7):894-9.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston.
Lead poisoning is a well-established cause of serious and permanent neurological, cognitive, and behavioral problems, particularly in exposed children.
Children can be exposed to lead from ingesting paint chips in their homes, when old paint is scrapped from the exterior of houses or bridges, and through the water they drink. The damage caused by lead poisoning was first recognized in the United States in the early 20th century, although lead was added to gasoline and paint until the 1970’s. Since then, regulations for lead in consumer products have become increasingly strict, and the Centers for Disease Control and Prevention’s definition of a toxic lead level has shifted from 60 micrograms/deciliter (mcg/dL) in 1970 to 5 mcg/dL in 2012. In many communities, removing lead paint up to the height of a young child is a requirement whenever an older home is sold.
Unfortunately, these regulations did not protect the families in Flint, Michigan from being exposed to high levels of lead when a change in water supply and inadequate water treatment allowed lead to enter the system from decaying water pipes. It is worth reviewing what is known about the short- and long-term consequences of lead exposure, and what lies ahead for the children of Flint.
Lead is a naturally occurring element that is not metabolized, but rather absorbed, distributed to tissues, and excreted. Lead can be inhaled (with 100% absorption) and introduced through the GI tract (with about 70% absorption in children and 20% absorption in adults). GI absorption is enhanced by calcium or iron deficiency, both conditions that are relatively common, especially in poor children and can lead to pica (or eating of non-nutritious materials), further increasing the chances of lead exposure. Absorbed lead is distributed to blood (for 28-36 days), soft tissue, including the nervous system (40 days), and to bone (where it lasts for over 25 years). Blood that is retained in growing bones can be mobilized during periods of physiologic stress (such as illness, injury, or pregnancy), meaning children exposed to lead during a period of rapid bone growth are at long-term risk for acute lead poisoning from their endogenous reservoir without a new exposure. What lead is not retained by tissues is excreted by the kidneys, with adults retaining about 1% of absorbed lead, while children younger than 2 years retain over 30% of absorbed lead. So children, especially toddlers, have a greater likelihood to absorb lead from the GI tract and to retain lead in their tissues, both due to active mineralization of bone and the permeability of the blood brain barrier, primarily in children under 3 years old. This is why we are addressing what will happen to the children of Flint and not to all the residents of Flint.
Lead competitively inhibits interactions between cations and sulfhydryl groups, which are present in most human biochemical reactions. This leads to irreversible cell damage and often cell death, especially within the central nervous system. Lead exposure is associated with particular dysfunction within dopaminergic pathways within the brain, and has been associated in a dose-dependent fashion with decreased prefrontal gray matter volume. Lead poisoning also has hematologic consequences (anemia), renal consequences (interstitial nephritis), gastrointestinal symptoms (vomiting, constipation), and endocrine consequences (reversible inhibition of Vitamin D metabolism and permanently short stature). But the CNS consequences of lead exposure are particularly devastating, as they appear to have no threshold and are permanent. Their incidence is the driving force for the CDC’s lowering of the official toxic lead level and the public health efforts to screen children and educate parents about the risk of lead exposure.
So what do these serious consequences look like? People with severe lead intoxication (blood lead levels greater than 70 mcg/dL) typically present with signs of acute encephalopathy (headache, vomiting, seizures, or coma) and require intensive medical management including chelation therapy. More typically, exposed children have low but accumulating levels of lead and present with nonspecific symptoms, including lost appetite, fatigue, irritability, and insomnia, which gradually worsen.
Behavior
High levels of impulsivity, aggression, and impaired attention are the prototypical sequelae of lead poisoning (following recovery from the acute intoxication). Multiple studies have demonstrated these high levels of aggressive and impulsive behaviors in preschoolers who were exposed to lead, and these behaviors appear to continue into adolescence and adulthood. Indeed, one study found that compared with children with the lowest measurable blood lead levels (0.2-0.7 mcg/dL), those children who were in the next two quartiles had seven and twelve times the odds of meeting diagnostic criteria for conduct disorder.1 There have even been studies which correlated atmospheric lead levels (when leaded gasoline was common) with crime rates 20 years later, which supported an association between childhood lead exposure and adult criminal activity.2-4.
Multiple studies have demonstrated higher rates of inattention, distractibility, and impulsivity in lead-exposed children than would be expected given the prevalence of attention-deficit/hyperactivity disorder (ADHD) in the general population. The incidence of these symptoms goes up in a dose-dependent fashion and appears to have no threshold (so they occur at even the lowest measurable blood lead levels). In a 2006 study of nearly 5,000 children between ages 4-15 years, those with blood lead levels greater than 2 mcg/dL (still below the level the CDC deems toxic) were four times more likely to be carrying a diagnosis of ADHD and be on stimulant medication than their peers with blood lead levels less than 0.8mcg/dL.
Cognition
Closely related to impulse control and attention, the cognitive domains of intelligence and executive function are clearly damaged by lead exposure. Poor performance on tasks requiring focus, cognitive flexibility, and inhibition of automatic responses was directly associated with higher blood lead levels in a group of preschoolers with levels between 0 and 13 mcg/dL.5
IQ has been found to be so consistently diminished by increasing blood lead levels that it is used as an overall index of neurodevelopmental morbidity of lead exposure, leading to the CDC’s adoption of a lower standard definition of toxic lead levels. Even very low blood lead levels are associated with decrements in IQ: children with blood lead levels less than 7.5 mcg/dL lost an average of 3 IQ points for every 1 mcg/dL increase in blood lead levels.6 In a study of 57,000 elementary school students in 2009, Miranda et al. found that those who had a blood lead level of 4 mcg/dL at 3 years old were significantly more likely to be diagnosed with a learning disability in elementary school. Another study of 48,000 children who had a blood lead level of 5 mcg/dL were 30% more likely to fail third grade reading and math tests than their peers without measurable lead levels.
Speech and language
More recent studies have demonstrated that children with higher bone lead concentrations had poorer performance on several language-processing measures, suggesting that childhood lead exposure damages language processing and function as the young people grow. These deficits in language processing can make social development and self-regulation much more challenging in adolescence, and make school and work settings much more challenging. These findings also have implications for the utility of psychotherapy, a language-based treatment, for the other behavioral problems of lead exposure.
Motor skills
Several recent studies have assessed both fine and gross motor skills in lead-exposed children. Findings have demonstrated that balance, coordination, gross motor and fine motor skills all appear to be compromised in a dose-dependent fashion by childhood lead exposure. These findings suggest that not only are children at greater risk for accident and injury through childhood and into adulthood, a risk already increased by their compromised attention and impulse control. But they also are likely to be physically clumsy, compromising an opportunity to cultivate strengths or experience mastery when cognitive tasks may prove frustrating for them.
With deficits in such fundamental cognitive, motor, and behavioral processes, exposed children are clearly vulnerable to more than ADHD, conduct disorder, and learning disabilities. These struggles may lead to secondary vulnerabilities to anxiety or mood symptoms or substance abuse as these children grow into teenagers who face frustration at every turn. In addition to treatment for their deficits in attention and executive function, these children will ideally receive specialized supports in school and at home, to be able to master cognitive tasks, manage new social circumstances and make friends, discover their interests and talents, and generally stay on their best developmental trajectories. Lastly, the specific consequences of lead exposure will vary for any individual child, so parents will have to deal with the uncertainty of their child’s behavior and development over many years. Clearly, the children of Flint face a long road that has been substantially impacted by their lead exposure. The only good that can come from the exposure in Flint is to heighten efforts to ensure that it never happens again.
1. Environ Health Perspect. 2008 Jul;116(7):956-62.
2. Environ Res. 2000 May;83(1):1-22.
3. Environ Res. 2007 Jul;104(3):315-36.
4. Arch Pediatr Adolesc Med. 2001 May;155(5):579-82.
5. Dev Neuropsychol. 2004;26(1):513-40.
6. Environ Health Perspect. 2005 Jul;113(7):894-9.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston.
Debunking marijuana myths for teens
The annual checkup has long provided an opportunity for early adolescents to learn about the risks of alcohol and drug use from a trusted source who may be less biased than parents, teachers, or police. Parents also turn to their child’s pediatrician for guidance on how to broach this important topic with their children, or they may come with concerns about their children’s use of drugs or alcohol.
Marijuana has become an increasingly complex topic, as its legal status has rapidly changed: It’s legal to purchase marijuana in four states (Alaska, Colorado, Oregon, and Washington, as well as the District of Columbia); it is decriminalized in 20 states and the District of Columbia for certain marijuana possession offenses; and it is legal to use medical marijuana in 23 states. As its legal status changes, attitudes about its use also have shifted, and its availability, form, and potency all have changed dramatically in just the past decade. Further, we ourselves may have mixed feelings about marijuana use based on our own experience as adolescents and sampling bias. We may have seen its low-level use and minimal effects in young or mature adults, or we may have seen substantial use of marijuana have a major deleterious impact on a friend or become a gateway drug for addiction to dangerous substances.
Before addressing marijuana use with adolescent patients and dealing with their potential skepticism concerning any harm, it is worth spending a little time looking in the mirror to consider your perspective on marijuana use and your response to disbelief.
According to the National Institute on Drug Abuse’s Monitoring the Future (MTF) survey, almost 12% of 8th graders, 27% of 10th graders, and 35% of 12th graders in the United States reported having used marijuana in the past year. Among the 12th graders in that 2014 survey, almost 20% were current users of marijuana and 6% were daily users. Many surveys, including the MTF, have demonstrated that attitudes of teenagers have shifted about marijuana’s dangerousness, with a steep and steady decline in the number of teenagers believing that regular marijuana use poses a risk to their health and well-being. In 2014, less than 40% of 12th graders in the MTF survey agreed that regular use of marijuana would pose a risk to their well-being, compared with a peak of almost 80% of 12th graders in the early 1990’s.
Pediatricians have an opportunity to change their patient’s thinking about marijuana. At the checkup when you routinely ask about alcohol and drug use, ask about marijuana use in particular. You might start by asking if they have heard their friends talking about marijuana? What have they heard? Are other kids using it? Have they ever seen anyone use it? Have their friends invited them to try? You should find out if they think it is safe or dangerous, and how it compares with cigarettes, alcohol, and other drugs on this score. Then you may be able to debunk some myths you hear from them.
Myth No. 1: Marijuana is medicine
Although 23 states allow the legal sale of marijuana for “medicinal purposes,” it is important to note that there are currently no Food and Drug Administration–approved indications for medical marijuana. There is modest evidence that the active compounds in marijuana (delta-9-tetra-hydrocannabinol [THC] and other cannabinoids) can be effective in the management of the muscle spasticity associated with multiple sclerosis, the treatment of nausea associated with chemotherapy, and increasing the appetite of patients with wasting due to AIDS, and there are FDA-approved synthetic cannabinoids that can be prescribed for these symptoms. It is also important to note that there is no evidence that THC or other cannabinoids are useful in the treatment of mood or anxiety symptoms, even though these are often used as reasons for seeking medicinal marijuana. Indeed, marijuana may cause or worsen several psychiatric problems.
Myth No. 2: Marijuana is safe
Although there is consensus that moderate marijuana use in adulthood poses only limited health risks (including the known risks of smoking), there is robust evidence that marijuana use during youth (through the early 20s) causes several serious and permanent effects on the developing brain. One 2012 study showed that for youth who are dependent on marijuana before they are 18 years, there is an 8-point drop in IQ in adulthood (Proc Natl Acad Sci USA. 2012 Oct 2;109[40]:E2657-64). This IQ drop persists even if they quit smoking, and does not occur for those who first become dependent on marijuana in adulthood. A 2015 study demonstrated that even for adolescents who are light smokers (one to two times weekly) with no evidence of marijuana dependence, there are significant abnormalities in the size and shape of their amygdala and nucleus accumbens, with associated changes in their motivation, decision making, attention, functional memory, and processing of emotions(J Neurosci. 2014 Apr 16;34[16]:5529-38). These abnormalities increase with increased frequency of use, and are not seen in those who begin smoking in adulthood (mid-20s and later).
Beyond these findings of cognitive deficits, evidence is growing that adolescent marijuana use is associated with several psychiatric illnesses, including depression and anxiety. There is especially strong evidence for a causal link between marijuana use and psychotic illnesses in (genetically) vulnerable young people. Any marijuana user can experience a brief psychotic reaction if the amount ingested or smoked is great enough, but for those young people who carry a specific variant of the gene for catechol-o-methyltransferase (COMT, an enzyme that degrades neurotransmitters), smoking marijuana in adolescence nearly triples their risk of developing schizophrenia in adulthood. For youth with a variant of the AKT gene (another enzyme affecting dopamine signaling in the brain), daily use of marijuana raises their risk of developing schizophrenia sevenfold. Clearly, marijuana can be the critical environmental trigger for schizophrenia in genetically vulnerable youth. Until we have a comprehensive knowledge of the relevant genes, and routinely check every patient’s complete genetic profile, it is reasonable to assume that any young person using marijuana is significantly increasing the risk of developing schizophrenia, a chronic and disabling condition.
Myth No. 3: Marijuana has no effect on driving
Marijuana intoxication significantly affects motor coordination, reaction time, and judgment, and multiple studies have demonstrated a direct relationship between blood THC concentration and impaired driving ability. A recent meta-analysis demonstrated that the risk of being in a car accident doubled after marijuana use (Drug Alcohol Depend. 2004 Feb 7;73[2]:109-19). These studies usually involved adults, and it is reasonable to assume that the risks may be more pronounced in adolescents, particularly ones who are new to driving or have other problems that could affect their attention or reaction time (such as attention-deficit/hyperactivity disorder). Beyond letting patients know about the increased risks of accidents, it may be worth reminding them that driving while intoxicated – even with legal use marijuana – is a criminal offense.
Myth No. 4: Marijuana has no effect on schoolwork
Aside from the risks of causing long-term cognitive changes and psychiatric problems that can affect school performance, the direct effects of marijuana intoxication can linger and affect school performance well after its use. The “high” from marijuana typically lasts from 1 to 3 hours, but the drug’s effects on higher-level cognitive processes (mediated by the neocortex and hippocampus) can last for days. So a teenager who smokes on Saturday night may have lingering impairment of motivation, the ability to shift attention, the ability to learn complex tasks, and working memory. These are all critical cognitive abilities for learning, and can make studying on Sunday and performing well on a test on Monday much more difficult.
Myth No. 5: Marijuana is not addictive
Marijuana is addictive, with studies suggesting that nearly 9% of marijuana users will become addicted. Again, the risks are far greater for young people. Among people who begin using marijuana during adolescence, the rate of addiction climbs to 17%, and can be as high as 50% in daily users. Remember that addiction describes a pattern of continued use despite that use causing significant legal, social, or school and work problems. Users also may develop physical dependence, with a withdrawal syndrome that includes irritability, restlessness, insomnia, and appetite changes; these can last as long as 2 weeks.
Currently available forms of marijuana are much more potent than those that were studied and used in prior decades. On average, the potency of smoked marijuana has tripled, and there are concentrates (in oil form, for example) and hybrids with much higher potency still. More potent marijuana increases the high from even a small dose, and increases the likelihood of addiction and of other immediate and lingering complications of its use. So, parents who think they know what marijuana does to adolescents based on their own youthful experiences are significantly underestimating the risks.
When asking your patients explicitly about marijuana use, be curious and nonjudgmental, but also be frank and forthright about what is known about the risks associated with its use. Although the current legal and political changes around marijuana use may have given them the impression that marijuana use is safe, you want them to have the facts they need to make informed decisions. Even if you only discuss one of these myths with your patients, you will have equipped them with powerful information that they may use and share with their friends.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.
The annual checkup has long provided an opportunity for early adolescents to learn about the risks of alcohol and drug use from a trusted source who may be less biased than parents, teachers, or police. Parents also turn to their child’s pediatrician for guidance on how to broach this important topic with their children, or they may come with concerns about their children’s use of drugs or alcohol.
Marijuana has become an increasingly complex topic, as its legal status has rapidly changed: It’s legal to purchase marijuana in four states (Alaska, Colorado, Oregon, and Washington, as well as the District of Columbia); it is decriminalized in 20 states and the District of Columbia for certain marijuana possession offenses; and it is legal to use medical marijuana in 23 states. As its legal status changes, attitudes about its use also have shifted, and its availability, form, and potency all have changed dramatically in just the past decade. Further, we ourselves may have mixed feelings about marijuana use based on our own experience as adolescents and sampling bias. We may have seen its low-level use and minimal effects in young or mature adults, or we may have seen substantial use of marijuana have a major deleterious impact on a friend or become a gateway drug for addiction to dangerous substances.
Before addressing marijuana use with adolescent patients and dealing with their potential skepticism concerning any harm, it is worth spending a little time looking in the mirror to consider your perspective on marijuana use and your response to disbelief.
According to the National Institute on Drug Abuse’s Monitoring the Future (MTF) survey, almost 12% of 8th graders, 27% of 10th graders, and 35% of 12th graders in the United States reported having used marijuana in the past year. Among the 12th graders in that 2014 survey, almost 20% were current users of marijuana and 6% were daily users. Many surveys, including the MTF, have demonstrated that attitudes of teenagers have shifted about marijuana’s dangerousness, with a steep and steady decline in the number of teenagers believing that regular marijuana use poses a risk to their health and well-being. In 2014, less than 40% of 12th graders in the MTF survey agreed that regular use of marijuana would pose a risk to their well-being, compared with a peak of almost 80% of 12th graders in the early 1990’s.
Pediatricians have an opportunity to change their patient’s thinking about marijuana. At the checkup when you routinely ask about alcohol and drug use, ask about marijuana use in particular. You might start by asking if they have heard their friends talking about marijuana? What have they heard? Are other kids using it? Have they ever seen anyone use it? Have their friends invited them to try? You should find out if they think it is safe or dangerous, and how it compares with cigarettes, alcohol, and other drugs on this score. Then you may be able to debunk some myths you hear from them.
Myth No. 1: Marijuana is medicine
Although 23 states allow the legal sale of marijuana for “medicinal purposes,” it is important to note that there are currently no Food and Drug Administration–approved indications for medical marijuana. There is modest evidence that the active compounds in marijuana (delta-9-tetra-hydrocannabinol [THC] and other cannabinoids) can be effective in the management of the muscle spasticity associated with multiple sclerosis, the treatment of nausea associated with chemotherapy, and increasing the appetite of patients with wasting due to AIDS, and there are FDA-approved synthetic cannabinoids that can be prescribed for these symptoms. It is also important to note that there is no evidence that THC or other cannabinoids are useful in the treatment of mood or anxiety symptoms, even though these are often used as reasons for seeking medicinal marijuana. Indeed, marijuana may cause or worsen several psychiatric problems.
Myth No. 2: Marijuana is safe
Although there is consensus that moderate marijuana use in adulthood poses only limited health risks (including the known risks of smoking), there is robust evidence that marijuana use during youth (through the early 20s) causes several serious and permanent effects on the developing brain. One 2012 study showed that for youth who are dependent on marijuana before they are 18 years, there is an 8-point drop in IQ in adulthood (Proc Natl Acad Sci USA. 2012 Oct 2;109[40]:E2657-64). This IQ drop persists even if they quit smoking, and does not occur for those who first become dependent on marijuana in adulthood. A 2015 study demonstrated that even for adolescents who are light smokers (one to two times weekly) with no evidence of marijuana dependence, there are significant abnormalities in the size and shape of their amygdala and nucleus accumbens, with associated changes in their motivation, decision making, attention, functional memory, and processing of emotions(J Neurosci. 2014 Apr 16;34[16]:5529-38). These abnormalities increase with increased frequency of use, and are not seen in those who begin smoking in adulthood (mid-20s and later).
Beyond these findings of cognitive deficits, evidence is growing that adolescent marijuana use is associated with several psychiatric illnesses, including depression and anxiety. There is especially strong evidence for a causal link between marijuana use and psychotic illnesses in (genetically) vulnerable young people. Any marijuana user can experience a brief psychotic reaction if the amount ingested or smoked is great enough, but for those young people who carry a specific variant of the gene for catechol-o-methyltransferase (COMT, an enzyme that degrades neurotransmitters), smoking marijuana in adolescence nearly triples their risk of developing schizophrenia in adulthood. For youth with a variant of the AKT gene (another enzyme affecting dopamine signaling in the brain), daily use of marijuana raises their risk of developing schizophrenia sevenfold. Clearly, marijuana can be the critical environmental trigger for schizophrenia in genetically vulnerable youth. Until we have a comprehensive knowledge of the relevant genes, and routinely check every patient’s complete genetic profile, it is reasonable to assume that any young person using marijuana is significantly increasing the risk of developing schizophrenia, a chronic and disabling condition.
Myth No. 3: Marijuana has no effect on driving
Marijuana intoxication significantly affects motor coordination, reaction time, and judgment, and multiple studies have demonstrated a direct relationship between blood THC concentration and impaired driving ability. A recent meta-analysis demonstrated that the risk of being in a car accident doubled after marijuana use (Drug Alcohol Depend. 2004 Feb 7;73[2]:109-19). These studies usually involved adults, and it is reasonable to assume that the risks may be more pronounced in adolescents, particularly ones who are new to driving or have other problems that could affect their attention or reaction time (such as attention-deficit/hyperactivity disorder). Beyond letting patients know about the increased risks of accidents, it may be worth reminding them that driving while intoxicated – even with legal use marijuana – is a criminal offense.
Myth No. 4: Marijuana has no effect on schoolwork
Aside from the risks of causing long-term cognitive changes and psychiatric problems that can affect school performance, the direct effects of marijuana intoxication can linger and affect school performance well after its use. The “high” from marijuana typically lasts from 1 to 3 hours, but the drug’s effects on higher-level cognitive processes (mediated by the neocortex and hippocampus) can last for days. So a teenager who smokes on Saturday night may have lingering impairment of motivation, the ability to shift attention, the ability to learn complex tasks, and working memory. These are all critical cognitive abilities for learning, and can make studying on Sunday and performing well on a test on Monday much more difficult.
Myth No. 5: Marijuana is not addictive
Marijuana is addictive, with studies suggesting that nearly 9% of marijuana users will become addicted. Again, the risks are far greater for young people. Among people who begin using marijuana during adolescence, the rate of addiction climbs to 17%, and can be as high as 50% in daily users. Remember that addiction describes a pattern of continued use despite that use causing significant legal, social, or school and work problems. Users also may develop physical dependence, with a withdrawal syndrome that includes irritability, restlessness, insomnia, and appetite changes; these can last as long as 2 weeks.
Currently available forms of marijuana are much more potent than those that were studied and used in prior decades. On average, the potency of smoked marijuana has tripled, and there are concentrates (in oil form, for example) and hybrids with much higher potency still. More potent marijuana increases the high from even a small dose, and increases the likelihood of addiction and of other immediate and lingering complications of its use. So, parents who think they know what marijuana does to adolescents based on their own youthful experiences are significantly underestimating the risks.
When asking your patients explicitly about marijuana use, be curious and nonjudgmental, but also be frank and forthright about what is known about the risks associated with its use. Although the current legal and political changes around marijuana use may have given them the impression that marijuana use is safe, you want them to have the facts they need to make informed decisions. Even if you only discuss one of these myths with your patients, you will have equipped them with powerful information that they may use and share with their friends.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.
The annual checkup has long provided an opportunity for early adolescents to learn about the risks of alcohol and drug use from a trusted source who may be less biased than parents, teachers, or police. Parents also turn to their child’s pediatrician for guidance on how to broach this important topic with their children, or they may come with concerns about their children’s use of drugs or alcohol.
Marijuana has become an increasingly complex topic, as its legal status has rapidly changed: It’s legal to purchase marijuana in four states (Alaska, Colorado, Oregon, and Washington, as well as the District of Columbia); it is decriminalized in 20 states and the District of Columbia for certain marijuana possession offenses; and it is legal to use medical marijuana in 23 states. As its legal status changes, attitudes about its use also have shifted, and its availability, form, and potency all have changed dramatically in just the past decade. Further, we ourselves may have mixed feelings about marijuana use based on our own experience as adolescents and sampling bias. We may have seen its low-level use and minimal effects in young or mature adults, or we may have seen substantial use of marijuana have a major deleterious impact on a friend or become a gateway drug for addiction to dangerous substances.
Before addressing marijuana use with adolescent patients and dealing with their potential skepticism concerning any harm, it is worth spending a little time looking in the mirror to consider your perspective on marijuana use and your response to disbelief.
According to the National Institute on Drug Abuse’s Monitoring the Future (MTF) survey, almost 12% of 8th graders, 27% of 10th graders, and 35% of 12th graders in the United States reported having used marijuana in the past year. Among the 12th graders in that 2014 survey, almost 20% were current users of marijuana and 6% were daily users. Many surveys, including the MTF, have demonstrated that attitudes of teenagers have shifted about marijuana’s dangerousness, with a steep and steady decline in the number of teenagers believing that regular marijuana use poses a risk to their health and well-being. In 2014, less than 40% of 12th graders in the MTF survey agreed that regular use of marijuana would pose a risk to their well-being, compared with a peak of almost 80% of 12th graders in the early 1990’s.
Pediatricians have an opportunity to change their patient’s thinking about marijuana. At the checkup when you routinely ask about alcohol and drug use, ask about marijuana use in particular. You might start by asking if they have heard their friends talking about marijuana? What have they heard? Are other kids using it? Have they ever seen anyone use it? Have their friends invited them to try? You should find out if they think it is safe or dangerous, and how it compares with cigarettes, alcohol, and other drugs on this score. Then you may be able to debunk some myths you hear from them.
Myth No. 1: Marijuana is medicine
Although 23 states allow the legal sale of marijuana for “medicinal purposes,” it is important to note that there are currently no Food and Drug Administration–approved indications for medical marijuana. There is modest evidence that the active compounds in marijuana (delta-9-tetra-hydrocannabinol [THC] and other cannabinoids) can be effective in the management of the muscle spasticity associated with multiple sclerosis, the treatment of nausea associated with chemotherapy, and increasing the appetite of patients with wasting due to AIDS, and there are FDA-approved synthetic cannabinoids that can be prescribed for these symptoms. It is also important to note that there is no evidence that THC or other cannabinoids are useful in the treatment of mood or anxiety symptoms, even though these are often used as reasons for seeking medicinal marijuana. Indeed, marijuana may cause or worsen several psychiatric problems.
Myth No. 2: Marijuana is safe
Although there is consensus that moderate marijuana use in adulthood poses only limited health risks (including the known risks of smoking), there is robust evidence that marijuana use during youth (through the early 20s) causes several serious and permanent effects on the developing brain. One 2012 study showed that for youth who are dependent on marijuana before they are 18 years, there is an 8-point drop in IQ in adulthood (Proc Natl Acad Sci USA. 2012 Oct 2;109[40]:E2657-64). This IQ drop persists even if they quit smoking, and does not occur for those who first become dependent on marijuana in adulthood. A 2015 study demonstrated that even for adolescents who are light smokers (one to two times weekly) with no evidence of marijuana dependence, there are significant abnormalities in the size and shape of their amygdala and nucleus accumbens, with associated changes in their motivation, decision making, attention, functional memory, and processing of emotions(J Neurosci. 2014 Apr 16;34[16]:5529-38). These abnormalities increase with increased frequency of use, and are not seen in those who begin smoking in adulthood (mid-20s and later).
Beyond these findings of cognitive deficits, evidence is growing that adolescent marijuana use is associated with several psychiatric illnesses, including depression and anxiety. There is especially strong evidence for a causal link between marijuana use and psychotic illnesses in (genetically) vulnerable young people. Any marijuana user can experience a brief psychotic reaction if the amount ingested or smoked is great enough, but for those young people who carry a specific variant of the gene for catechol-o-methyltransferase (COMT, an enzyme that degrades neurotransmitters), smoking marijuana in adolescence nearly triples their risk of developing schizophrenia in adulthood. For youth with a variant of the AKT gene (another enzyme affecting dopamine signaling in the brain), daily use of marijuana raises their risk of developing schizophrenia sevenfold. Clearly, marijuana can be the critical environmental trigger for schizophrenia in genetically vulnerable youth. Until we have a comprehensive knowledge of the relevant genes, and routinely check every patient’s complete genetic profile, it is reasonable to assume that any young person using marijuana is significantly increasing the risk of developing schizophrenia, a chronic and disabling condition.
Myth No. 3: Marijuana has no effect on driving
Marijuana intoxication significantly affects motor coordination, reaction time, and judgment, and multiple studies have demonstrated a direct relationship between blood THC concentration and impaired driving ability. A recent meta-analysis demonstrated that the risk of being in a car accident doubled after marijuana use (Drug Alcohol Depend. 2004 Feb 7;73[2]:109-19). These studies usually involved adults, and it is reasonable to assume that the risks may be more pronounced in adolescents, particularly ones who are new to driving or have other problems that could affect their attention or reaction time (such as attention-deficit/hyperactivity disorder). Beyond letting patients know about the increased risks of accidents, it may be worth reminding them that driving while intoxicated – even with legal use marijuana – is a criminal offense.
Myth No. 4: Marijuana has no effect on schoolwork
Aside from the risks of causing long-term cognitive changes and psychiatric problems that can affect school performance, the direct effects of marijuana intoxication can linger and affect school performance well after its use. The “high” from marijuana typically lasts from 1 to 3 hours, but the drug’s effects on higher-level cognitive processes (mediated by the neocortex and hippocampus) can last for days. So a teenager who smokes on Saturday night may have lingering impairment of motivation, the ability to shift attention, the ability to learn complex tasks, and working memory. These are all critical cognitive abilities for learning, and can make studying on Sunday and performing well on a test on Monday much more difficult.
Myth No. 5: Marijuana is not addictive
Marijuana is addictive, with studies suggesting that nearly 9% of marijuana users will become addicted. Again, the risks are far greater for young people. Among people who begin using marijuana during adolescence, the rate of addiction climbs to 17%, and can be as high as 50% in daily users. Remember that addiction describes a pattern of continued use despite that use causing significant legal, social, or school and work problems. Users also may develop physical dependence, with a withdrawal syndrome that includes irritability, restlessness, insomnia, and appetite changes; these can last as long as 2 weeks.
Currently available forms of marijuana are much more potent than those that were studied and used in prior decades. On average, the potency of smoked marijuana has tripled, and there are concentrates (in oil form, for example) and hybrids with much higher potency still. More potent marijuana increases the high from even a small dose, and increases the likelihood of addiction and of other immediate and lingering complications of its use. So, parents who think they know what marijuana does to adolescents based on their own youthful experiences are significantly underestimating the risks.
When asking your patients explicitly about marijuana use, be curious and nonjudgmental, but also be frank and forthright about what is known about the risks associated with its use. Although the current legal and political changes around marijuana use may have given them the impression that marijuana use is safe, you want them to have the facts they need to make informed decisions. Even if you only discuss one of these myths with your patients, you will have equipped them with powerful information that they may use and share with their friends.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. Email them at pdnews@frontlinemedcom.com.
Discussions about sexual orientation
The biological transition to puberty has always marked a critical point in a primary care pediatrician’s relationship to a patient. Adolescents’ capacity for abstract reasoning, their movement to autonomy, their nuanced sense of identity, their need for privacy, and their emerging sexuality together give the pediatrician an opportunity and a responsibility to create a safe place to talk. Your office can be an oasis from parents, peers, and a society that seems saturated with sexuality. You can be trusted more than the Internet and offer discussions that are leavened by your long-standing relationship with the patient.
The growing public awareness, acceptance, and legal standing given to gay, lesbian, bisexual, and transgender individuals represents welcome societal progress, and we sense that amidst this richer public conversation, a growing number of children and adolescents are presenting with questions or worries about their own emerging sexual orientation or gender identity. We would like to start with our key takeaway: Discussions about sexual orientation and gender identity do not require that you give answers or predict the future. Focus instead on being a curious, compassionate, and nonjudgmental listener, and you will be effective at helping your patient to better manage new, uncertain, and possibly stressful feelings.
Our focus today is how to create a safe setting and specifically how to ask about and discuss sexual orientation. Most teenagers will wonder at some point about their orientation. Studies suggest that among adults, 5%-10% are attracted to the same sex and 3% describe themselves as gay or bisexual. Such surveys are very challenging, though, and in our experience, these percentages are higher. Sexual orientation is believed to exist on a continuum rather than in a simple binary state – some people identify as purely homosexual or heterosexual, and the rest exist somewhere in the middle. Sharing this fact alone can offer a very helpful perspective to young people who are feeling pressure to “figure out” if they are gay or straight.
While sexual orientation describes whom a person is attracted to, gender identity is a person’s internal sense of his or her own gender. It emerges in childhood and becomes more rich and nuanced in adolescence and adulthood, and, like sexual orientation, it is also believed to exist on a continuum rather than in a simple binary state. Less than 0.1% of youth will experience gender dysphoria, or the pressing feeling that their gender identity is not the same as their phenotypic sex. While questions about gender identity should be approached with the same curious, compassionate, and nonjudgmental style, we will not discuss the management of patients with gender dysphoria here. It is a very complex (and controversial) topic. And, as a practical matter, sexual orientation will likely be a more common issue with your patients, whereas questions about gender identity will come up much less frequently.
It is worth knowing that there is a range of mental health issues that are associated with the stress of feeling comfortable with one’s sexual identity. There is some evidence that young people who identify as gay or bisexual have elevated risk for mood disorders (depression), anxiety disorders, conduct disorder, and substance use disorders, but this finding has not been consistent (Am J Public Health. 2010:100[12]; 2426-32). However, there is unequivocal evidence that there is an elevated risk for suicide attempts in lesbian, gay, or bisexual (LGB) youth above their heterosexual peers. One survey found that 9th-12th grade students who identified as LGB were up to seven times as likely to have a suicide attempt as were their peers who identify as heterosexual. This risk is especially pronounced in male adolescents and continues into adulthood, when there is an elevated risk for suicide completion among adult males who identify as homosexual, although not in adult females (J Homosex. 2011 Jan;58[1]:10-51). Importantly, the risk for suicide attempt in LGB adolescents remains elevated even in those adolescents without any diagnosable mental illness, likely attributable to the stresses of isolation, family conflict, stigmatization, or bullying that LGB adolescents are likely to experience.
Asking your early-adolescent patients in a calm and comfortable manner about sexual feelings builds an environment in which thoughts, feelings, and questions about sex and sexuality are more easily shared. It is important to find language that feels like yours, which you can use with ease. Perhaps starting with, “At about your age, I ask every patient of mine whether they are beginning to have sexual feelings. This is when you really want to be around someone, in a way that’s more powerful and different from even your favorite friend. Some people call it getting butterflies in your stomach.” If your patient recognizes what you are talking about, you might continue, “Do you feel attracted to boys or girls or both? Do you have those feelings about kids in your class or people you know, like a teacher? Perhaps about a celebrity in a TV show or a band?” You should absolutely reassure them, “You don’t have to talk about anything you do not want to, but you should know that this is a normal part of becoming a teenager. I talk about this a lot with patients who are younger and older than you are. I keep what we talk about very private, and sometimes this is the only place a teenager feels safe to ask questions.” If you start this process early enough – by the start of middle school – the patient will probably be a bit embarrassed or giggle and not talk much. But, by the next annual physical or the one after that, the issue will be more familiar and less charged. A meaningful discussion may start.
With patients who do describe feeling attracted to people of the same sex, more specific questions may be appropriate. You should expect these feelings to exist on a continuum: You may encounter a school-age child with great clarity about exactly whom she is attracted to and what that means, or an older teenager who is far less certain, responding to a less intense interest or having been told by a peer that he is probably gay. It can be powerfully reassuring to remind your patient that adolescence is when we start to figure out to whom we are attracted. They don’t have to decide, but just be aware of these feelings as they emerge, essentially getting to know themselves without any feelings of urgency or pressure. You might ask, “Have you wondered if you were gay or bisexual? Have you spoken to any friends about your feelings or have you experimented with a boy or girl to try and figure this out?” It’s very helpful if you ask if they are worried or stressed by these feelings. Some young people will suffer from internalized homophobia, which may be helped by your accepting stance or may require a referral for more ongoing support. It can be valuable to find out if they are dating people of the same sex, or if their “relationships” have all been online. While this “virtual” dating may seem safer, it may not help them better understand themselves and may expose them to exploitation or predatory behavior. If your patient is sexually active, you should be comfortable talking with them about the risks of unprotected sex and same-sex safe-sex practices.
It is particularly important to ask your adolescent LGB patient about whom they have told, and what responses have they gotten. The presence of good friends and loving family members is critical to all adolescents’ emotional well-being. If they have talked about their sexual orientation with their peers, have their friends been supportive, or has it left them more isolated at school? You should find out if they have been teased or bullied, and ask specifically about online teasing or harassment. If they are being bullied, how have they handled that? Find out also if they feel free to ask or talk about this subject with their parents. If not, try to understand if they are simply embarrassed and unsure how to bring it up, or if there is a strong sense that they will be shamed or even rejected by their parents. If the parents are truly shaming or rejecting, it will be critical to consider what kind of support may be necessary. Teens who are facing isolation or bullying at school may benefit from resources such as a gay-straight student alliance or a community organization dedicated to issues facing LGB youth. For patients who are facing hostile or rejecting parents, it can be protective to connect them with a therapist as well, as you are mindful of their marked isolation and subsequently heightened risk for mood problems and even suicide attempts.
Along a similar vein, it is very important that you are aware of your own comfort level with these issues. While discussing sexual orientation may feel awkward if it is new for you, it is important to be realistic if you cannot be supportive of your patients who are gay. If for religious or other reasons you are not comfortable talking about sexual orientation in an accepting, nonjudgmental manner, you should seek guidance on how to thoughtfully care for your LGB patients or appropriately refer them to someone who can provide a more-supportive treatment setting.
When you create an office that makes sexuality a safe topic for discussion, you should expect that you will hear questions or concerns about which you yourself may not know the answers. Do not panic, just maintain your posture of being a curious, compassionate, and nonjudgmental listener, and then look for the answers. We are delighted this news organization has devoted a column to the optimal care of LGBT youth (LGBT Youth Consult) and encourage the primary care pediatrician to “never to worry alone,” and instead get some advice and expert teammates when dealing with these complex and important issues.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, in Newton, Mass. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston.
The biological transition to puberty has always marked a critical point in a primary care pediatrician’s relationship to a patient. Adolescents’ capacity for abstract reasoning, their movement to autonomy, their nuanced sense of identity, their need for privacy, and their emerging sexuality together give the pediatrician an opportunity and a responsibility to create a safe place to talk. Your office can be an oasis from parents, peers, and a society that seems saturated with sexuality. You can be trusted more than the Internet and offer discussions that are leavened by your long-standing relationship with the patient.
The growing public awareness, acceptance, and legal standing given to gay, lesbian, bisexual, and transgender individuals represents welcome societal progress, and we sense that amidst this richer public conversation, a growing number of children and adolescents are presenting with questions or worries about their own emerging sexual orientation or gender identity. We would like to start with our key takeaway: Discussions about sexual orientation and gender identity do not require that you give answers or predict the future. Focus instead on being a curious, compassionate, and nonjudgmental listener, and you will be effective at helping your patient to better manage new, uncertain, and possibly stressful feelings.
Our focus today is how to create a safe setting and specifically how to ask about and discuss sexual orientation. Most teenagers will wonder at some point about their orientation. Studies suggest that among adults, 5%-10% are attracted to the same sex and 3% describe themselves as gay or bisexual. Such surveys are very challenging, though, and in our experience, these percentages are higher. Sexual orientation is believed to exist on a continuum rather than in a simple binary state – some people identify as purely homosexual or heterosexual, and the rest exist somewhere in the middle. Sharing this fact alone can offer a very helpful perspective to young people who are feeling pressure to “figure out” if they are gay or straight.
While sexual orientation describes whom a person is attracted to, gender identity is a person’s internal sense of his or her own gender. It emerges in childhood and becomes more rich and nuanced in adolescence and adulthood, and, like sexual orientation, it is also believed to exist on a continuum rather than in a simple binary state. Less than 0.1% of youth will experience gender dysphoria, or the pressing feeling that their gender identity is not the same as their phenotypic sex. While questions about gender identity should be approached with the same curious, compassionate, and nonjudgmental style, we will not discuss the management of patients with gender dysphoria here. It is a very complex (and controversial) topic. And, as a practical matter, sexual orientation will likely be a more common issue with your patients, whereas questions about gender identity will come up much less frequently.
It is worth knowing that there is a range of mental health issues that are associated with the stress of feeling comfortable with one’s sexual identity. There is some evidence that young people who identify as gay or bisexual have elevated risk for mood disorders (depression), anxiety disorders, conduct disorder, and substance use disorders, but this finding has not been consistent (Am J Public Health. 2010:100[12]; 2426-32). However, there is unequivocal evidence that there is an elevated risk for suicide attempts in lesbian, gay, or bisexual (LGB) youth above their heterosexual peers. One survey found that 9th-12th grade students who identified as LGB were up to seven times as likely to have a suicide attempt as were their peers who identify as heterosexual. This risk is especially pronounced in male adolescents and continues into adulthood, when there is an elevated risk for suicide completion among adult males who identify as homosexual, although not in adult females (J Homosex. 2011 Jan;58[1]:10-51). Importantly, the risk for suicide attempt in LGB adolescents remains elevated even in those adolescents without any diagnosable mental illness, likely attributable to the stresses of isolation, family conflict, stigmatization, or bullying that LGB adolescents are likely to experience.
Asking your early-adolescent patients in a calm and comfortable manner about sexual feelings builds an environment in which thoughts, feelings, and questions about sex and sexuality are more easily shared. It is important to find language that feels like yours, which you can use with ease. Perhaps starting with, “At about your age, I ask every patient of mine whether they are beginning to have sexual feelings. This is when you really want to be around someone, in a way that’s more powerful and different from even your favorite friend. Some people call it getting butterflies in your stomach.” If your patient recognizes what you are talking about, you might continue, “Do you feel attracted to boys or girls or both? Do you have those feelings about kids in your class or people you know, like a teacher? Perhaps about a celebrity in a TV show or a band?” You should absolutely reassure them, “You don’t have to talk about anything you do not want to, but you should know that this is a normal part of becoming a teenager. I talk about this a lot with patients who are younger and older than you are. I keep what we talk about very private, and sometimes this is the only place a teenager feels safe to ask questions.” If you start this process early enough – by the start of middle school – the patient will probably be a bit embarrassed or giggle and not talk much. But, by the next annual physical or the one after that, the issue will be more familiar and less charged. A meaningful discussion may start.
With patients who do describe feeling attracted to people of the same sex, more specific questions may be appropriate. You should expect these feelings to exist on a continuum: You may encounter a school-age child with great clarity about exactly whom she is attracted to and what that means, or an older teenager who is far less certain, responding to a less intense interest or having been told by a peer that he is probably gay. It can be powerfully reassuring to remind your patient that adolescence is when we start to figure out to whom we are attracted. They don’t have to decide, but just be aware of these feelings as they emerge, essentially getting to know themselves without any feelings of urgency or pressure. You might ask, “Have you wondered if you were gay or bisexual? Have you spoken to any friends about your feelings or have you experimented with a boy or girl to try and figure this out?” It’s very helpful if you ask if they are worried or stressed by these feelings. Some young people will suffer from internalized homophobia, which may be helped by your accepting stance or may require a referral for more ongoing support. It can be valuable to find out if they are dating people of the same sex, or if their “relationships” have all been online. While this “virtual” dating may seem safer, it may not help them better understand themselves and may expose them to exploitation or predatory behavior. If your patient is sexually active, you should be comfortable talking with them about the risks of unprotected sex and same-sex safe-sex practices.
It is particularly important to ask your adolescent LGB patient about whom they have told, and what responses have they gotten. The presence of good friends and loving family members is critical to all adolescents’ emotional well-being. If they have talked about their sexual orientation with their peers, have their friends been supportive, or has it left them more isolated at school? You should find out if they have been teased or bullied, and ask specifically about online teasing or harassment. If they are being bullied, how have they handled that? Find out also if they feel free to ask or talk about this subject with their parents. If not, try to understand if they are simply embarrassed and unsure how to bring it up, or if there is a strong sense that they will be shamed or even rejected by their parents. If the parents are truly shaming or rejecting, it will be critical to consider what kind of support may be necessary. Teens who are facing isolation or bullying at school may benefit from resources such as a gay-straight student alliance or a community organization dedicated to issues facing LGB youth. For patients who are facing hostile or rejecting parents, it can be protective to connect them with a therapist as well, as you are mindful of their marked isolation and subsequently heightened risk for mood problems and even suicide attempts.
Along a similar vein, it is very important that you are aware of your own comfort level with these issues. While discussing sexual orientation may feel awkward if it is new for you, it is important to be realistic if you cannot be supportive of your patients who are gay. If for religious or other reasons you are not comfortable talking about sexual orientation in an accepting, nonjudgmental manner, you should seek guidance on how to thoughtfully care for your LGB patients or appropriately refer them to someone who can provide a more-supportive treatment setting.
When you create an office that makes sexuality a safe topic for discussion, you should expect that you will hear questions or concerns about which you yourself may not know the answers. Do not panic, just maintain your posture of being a curious, compassionate, and nonjudgmental listener, and then look for the answers. We are delighted this news organization has devoted a column to the optimal care of LGBT youth (LGBT Youth Consult) and encourage the primary care pediatrician to “never to worry alone,” and instead get some advice and expert teammates when dealing with these complex and important issues.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, in Newton, Mass. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston.
The biological transition to puberty has always marked a critical point in a primary care pediatrician’s relationship to a patient. Adolescents’ capacity for abstract reasoning, their movement to autonomy, their nuanced sense of identity, their need for privacy, and their emerging sexuality together give the pediatrician an opportunity and a responsibility to create a safe place to talk. Your office can be an oasis from parents, peers, and a society that seems saturated with sexuality. You can be trusted more than the Internet and offer discussions that are leavened by your long-standing relationship with the patient.
The growing public awareness, acceptance, and legal standing given to gay, lesbian, bisexual, and transgender individuals represents welcome societal progress, and we sense that amidst this richer public conversation, a growing number of children and adolescents are presenting with questions or worries about their own emerging sexual orientation or gender identity. We would like to start with our key takeaway: Discussions about sexual orientation and gender identity do not require that you give answers or predict the future. Focus instead on being a curious, compassionate, and nonjudgmental listener, and you will be effective at helping your patient to better manage new, uncertain, and possibly stressful feelings.
Our focus today is how to create a safe setting and specifically how to ask about and discuss sexual orientation. Most teenagers will wonder at some point about their orientation. Studies suggest that among adults, 5%-10% are attracted to the same sex and 3% describe themselves as gay or bisexual. Such surveys are very challenging, though, and in our experience, these percentages are higher. Sexual orientation is believed to exist on a continuum rather than in a simple binary state – some people identify as purely homosexual or heterosexual, and the rest exist somewhere in the middle. Sharing this fact alone can offer a very helpful perspective to young people who are feeling pressure to “figure out” if they are gay or straight.
While sexual orientation describes whom a person is attracted to, gender identity is a person’s internal sense of his or her own gender. It emerges in childhood and becomes more rich and nuanced in adolescence and adulthood, and, like sexual orientation, it is also believed to exist on a continuum rather than in a simple binary state. Less than 0.1% of youth will experience gender dysphoria, or the pressing feeling that their gender identity is not the same as their phenotypic sex. While questions about gender identity should be approached with the same curious, compassionate, and nonjudgmental style, we will not discuss the management of patients with gender dysphoria here. It is a very complex (and controversial) topic. And, as a practical matter, sexual orientation will likely be a more common issue with your patients, whereas questions about gender identity will come up much less frequently.
It is worth knowing that there is a range of mental health issues that are associated with the stress of feeling comfortable with one’s sexual identity. There is some evidence that young people who identify as gay or bisexual have elevated risk for mood disorders (depression), anxiety disorders, conduct disorder, and substance use disorders, but this finding has not been consistent (Am J Public Health. 2010:100[12]; 2426-32). However, there is unequivocal evidence that there is an elevated risk for suicide attempts in lesbian, gay, or bisexual (LGB) youth above their heterosexual peers. One survey found that 9th-12th grade students who identified as LGB were up to seven times as likely to have a suicide attempt as were their peers who identify as heterosexual. This risk is especially pronounced in male adolescents and continues into adulthood, when there is an elevated risk for suicide completion among adult males who identify as homosexual, although not in adult females (J Homosex. 2011 Jan;58[1]:10-51). Importantly, the risk for suicide attempt in LGB adolescents remains elevated even in those adolescents without any diagnosable mental illness, likely attributable to the stresses of isolation, family conflict, stigmatization, or bullying that LGB adolescents are likely to experience.
Asking your early-adolescent patients in a calm and comfortable manner about sexual feelings builds an environment in which thoughts, feelings, and questions about sex and sexuality are more easily shared. It is important to find language that feels like yours, which you can use with ease. Perhaps starting with, “At about your age, I ask every patient of mine whether they are beginning to have sexual feelings. This is when you really want to be around someone, in a way that’s more powerful and different from even your favorite friend. Some people call it getting butterflies in your stomach.” If your patient recognizes what you are talking about, you might continue, “Do you feel attracted to boys or girls or both? Do you have those feelings about kids in your class or people you know, like a teacher? Perhaps about a celebrity in a TV show or a band?” You should absolutely reassure them, “You don’t have to talk about anything you do not want to, but you should know that this is a normal part of becoming a teenager. I talk about this a lot with patients who are younger and older than you are. I keep what we talk about very private, and sometimes this is the only place a teenager feels safe to ask questions.” If you start this process early enough – by the start of middle school – the patient will probably be a bit embarrassed or giggle and not talk much. But, by the next annual physical or the one after that, the issue will be more familiar and less charged. A meaningful discussion may start.
With patients who do describe feeling attracted to people of the same sex, more specific questions may be appropriate. You should expect these feelings to exist on a continuum: You may encounter a school-age child with great clarity about exactly whom she is attracted to and what that means, or an older teenager who is far less certain, responding to a less intense interest or having been told by a peer that he is probably gay. It can be powerfully reassuring to remind your patient that adolescence is when we start to figure out to whom we are attracted. They don’t have to decide, but just be aware of these feelings as they emerge, essentially getting to know themselves without any feelings of urgency or pressure. You might ask, “Have you wondered if you were gay or bisexual? Have you spoken to any friends about your feelings or have you experimented with a boy or girl to try and figure this out?” It’s very helpful if you ask if they are worried or stressed by these feelings. Some young people will suffer from internalized homophobia, which may be helped by your accepting stance or may require a referral for more ongoing support. It can be valuable to find out if they are dating people of the same sex, or if their “relationships” have all been online. While this “virtual” dating may seem safer, it may not help them better understand themselves and may expose them to exploitation or predatory behavior. If your patient is sexually active, you should be comfortable talking with them about the risks of unprotected sex and same-sex safe-sex practices.
It is particularly important to ask your adolescent LGB patient about whom they have told, and what responses have they gotten. The presence of good friends and loving family members is critical to all adolescents’ emotional well-being. If they have talked about their sexual orientation with their peers, have their friends been supportive, or has it left them more isolated at school? You should find out if they have been teased or bullied, and ask specifically about online teasing or harassment. If they are being bullied, how have they handled that? Find out also if they feel free to ask or talk about this subject with their parents. If not, try to understand if they are simply embarrassed and unsure how to bring it up, or if there is a strong sense that they will be shamed or even rejected by their parents. If the parents are truly shaming or rejecting, it will be critical to consider what kind of support may be necessary. Teens who are facing isolation or bullying at school may benefit from resources such as a gay-straight student alliance or a community organization dedicated to issues facing LGB youth. For patients who are facing hostile or rejecting parents, it can be protective to connect them with a therapist as well, as you are mindful of their marked isolation and subsequently heightened risk for mood problems and even suicide attempts.
Along a similar vein, it is very important that you are aware of your own comfort level with these issues. While discussing sexual orientation may feel awkward if it is new for you, it is important to be realistic if you cannot be supportive of your patients who are gay. If for religious or other reasons you are not comfortable talking about sexual orientation in an accepting, nonjudgmental manner, you should seek guidance on how to thoughtfully care for your LGB patients or appropriately refer them to someone who can provide a more-supportive treatment setting.
When you create an office that makes sexuality a safe topic for discussion, you should expect that you will hear questions or concerns about which you yourself may not know the answers. Do not panic, just maintain your posture of being a curious, compassionate, and nonjudgmental listener, and then look for the answers. We are delighted this news organization has devoted a column to the optimal care of LGBT youth (LGBT Youth Consult) and encourage the primary care pediatrician to “never to worry alone,” and instead get some advice and expert teammates when dealing with these complex and important issues.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, in Newton, Mass. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston.
Grandparents and the new baby
A couple having a baby brings together two family traditions that themselves blended the previous generations’ experiences and perspectives. Each of the new parents has been raised by two parents with their own histories, values, successes, and crises all available and potentially playing a part in the new baby’s future. A baby’s arrival can call forth memories of past successes, failures, hopes, and dreams – some fulfilled and some not.
As the pediatrician, you serve as an authority and a resource for the new parents. You will hear questions that have roots that may go back one, two, or more generations. Some may involve discipline, approaches to food, religious issues, or more subtle concerns relating to control and autonomy. And you may find that they will bring you the challenge of managing the beliefs, values, and expectations of the new grandparents. You may even find these new grandparents in your office! You have a unique opportunity to help new parents set a course with their own parents or in-laws that can promote family cohesion and honor family traditions or values, while empowering parents to trust themselves and truly be in charge of raising their own children.
Imagine this scenario: A young couple has just had their first baby, a son. The paternal grandfather, who played soccer in high school and college, presents his first grandchild with his own college soccer ball, proclaiming with great emotion that soccer will certainly be a part of his grandson’s future.
While this simple act may seem touching, it might also be perceived by the new parents as intrusive or controlling. How does the new father (who was maybe more bookish than athletic) feel the burden of this expectation? Perhaps the mother may wish her son to be more of a scholar than an athlete, or may want no expectation set, but may feel uncomfortable speaking honestly with her father-in-law. And this scenario is just about the gift of a soccer ball!
Grandparents (like parents) come with expectations, with beliefs about what practices worked and what failed over a wide range of areas from child rearing to managing finances to career to marriage. The arrival of a new grandchild will likely prompt them to share these beliefs, and do so in the way they usually communicate with their own children, be it blunt, emotional, indirect, or mute. These views might be forcefully presented, if a grandparent feels guilty or unfulfilled because a meaningful hope for their own child did not materialize: The new grandchild is their “last chance.” While their love and interest, their experience and wisdom can be invaluable, they might also arouse insecurity in a new parent or be disruptive. If they share opinions in a way that is stressful, devaluing, or confusing for new parents, that can translate into anxious, uncertain interactions with their new baby or a climate at home that is full of conflict instead of calm.
Parents are already blending their two styles and values, challenging enough before also trying to blend the elements of four grandparents.
The first weeks after the arrival of the new baby is a crucial time in the baby’s development, as well as in the development of the new parents, as all are rapidly acquiring new skills, adjusting to a new schedule, and learning how to understand and respond to each other. During these hard early days, grandparents often will be present, staying in the home or nearby to offer support to their children. Very commonly, they will share their opinions about such basics as nutrition and sleep. These are areas that are fundamentally important for a baby’s healthy development, but can be mysterious and challenging for new parents. They may seek out guidance from friends, books, websites, and pediatricians, as well as the new grandparents.
While their accumulated wisdom may be as helpful as their helping with laundry or meal preparation (think, “sleep when the baby sleeps”), it also might not. Perhaps the opinions are misguided (think, “sleeping on the tummy was always fine in my day”). And grandparents who are inadvertently undermining (“I don’t understand the difficulty, nursing was so easy for me”), or highly anxious might add to the new parents’ stress and uncertainty rather than alleviate it.
Grandparents also may come with strong cultural beliefs about child rearing. In families that are only one or two generations removed from immigration to this country, there may be powerfully held ideas about newborns, ones that might be inextricably linked for the grandparents with their drive to preserve their own cultural background. These may include ideas about when a child can eat solid food or what he or she should start eating. They may include beliefs that a child should never be put down or should be left to cry for long periods, lest they be “spoiled.” They might include ideas about when a baby can swim or how best to bathe them, what sorts of toys are appropriate or when their hair can be cut. While many of these beliefs have cultural value and no medical implications (like the timing of the first haircut), some may fly in the face of current scientific evidence (such as eating solids before they are able). And even when they are “safe,” new parents may experience these beliefs as fraught directives: ones that they may not believe in, but which will make them guilty of some cultural betrayal if they do not follow them.
Along a similar vein, grandparents may enter the home of their new grandchild with passionately held religious beliefs. While few of these may have direct medical implications for the new baby (such as circumcision), they can still have profound implications for life in the family’s home. When parents and grandparents all share the same religious beliefs, there is less possibility of conflict. But when new parents come from different religious traditions or no longer share their parents’ faith, there is high potential for emotionally charged differences. And if the new parents have not anticipated these conversations (say, whether or not to circumcise a baby boy when one parent is Jewish and the other is Protestant), trying to sort out these matters while also learning to change diapers or nurse a colicky baby can make a challenging situation into an overwhelming one.
Lastly, about 1% of all households have same-sex partners or marriages and about one in four are raising children. While same-sex parenthood has rapidly gained cultural acceptance over the past decade, it is possible that some grandparents will not have fully accepted the reality of their own child’s sexual orientation and committed relationship. If the parents speak to you about such a fraught situation, listen supportively. When it sounds like there is ambivalence in the grandparents, the new parents can try to nurture the love that is there and be patient when their own parents still struggle. They should nurture the connections with those in their families that offer unconditional support and who can model love and acceptance for the new grandparents. In situations in which there is deeper alienation and little or no contact, offer that they might want to find a way to share photos and stories through one who remains close to their parents and periodically offer opportunities to rebuild relationships. A new grandchild can be a loving moment to take a fresh look at unresolved anger and loss, and as clinicians we have seen families resolve differences as they look to a new baby’s future.
Pediatricians are in a unique position of both neutrality and authority with their new patient’s parents and grandparents. When parents come to a newborn check or well-baby check, it can be invaluable to determine “who else is helping you?” After finding out about nursing or feeding the baby and about sleep, inquire about where they are getting any guidance or support. Friends or siblings with children? Books or websites? Grandparents? What has been helpful and what has not? When you hear about grandparents and see an eye-roll or hear a deep sigh, be curious about what has been helpful and what has been challenging. It is vitally helpful to first-time parents to be validated in their feeling that their own parents are a valuable resource, but not without their challenges.
While it may be important to offer a “medical” opinion about certain matters (back-sleeping, cosleeping, and introducing solids, for example), on most matters, the pediatrician’s role will be to help parents set a framework that will help them to cultivate what is precious and helpful from grandparents while minimizing conflict or unnecessary stress. For new parents, this may be as simple as reminding them that while this is an vital time for the baby’s development, it is also a big transition for them into parenthood and a significant transition for their parents or in-laws into grandparenthood. Help the new parents to understand that there is sometimes no one “right” way to handle certain decisions or challenges, and they will have to try a variety of strategies before finding the one that fits them as parents to this particular child. Remind them that parenting is a learning curve and it is common to feel stressed in new territory with high stakes. But they will find the right rhythm with being attuned to their new baby and eventually managing routines and limits. They are allowed to embrace the support that they find helpful and limit that which they experience as deeply undermining, dismissive, or judgmental.
When you notice that parents sound very angry at or alienated from grandparents, particularly when it is causing some marital conflict, it can be powerful for you to suggest that they should sort out their wishes and beliefs as parents first and then find a clear and loving way to communicate these to the grandparents. Remind them that they are becoming the experts on their children and that they will best be able to set appropriate routines and expectations. But remind them also that grandparents are potentially a treasure to their grandchildren, beyond the help with laundry and meal preparation at the very start of a child’s life.
There can never be enough loving, interested adults in a child’s orbit or a big enough cheering section. And grandparents can be uniquely passionate, patient, curious, and supportive to their growing grandchildren. They bring perspective on a family’s history, wonderful as a growing child builds a story about who they are and where they come from. And their interest and love will help a growing child build a sense of what characteristics make them a treasure to others. Few people can do this as well as grandparents, and letting them begin this involvement at the start of their grandchild’s life only supports this role.
While the arrival of a new baby will be a joyful event for a family, it will also be emotionally complex. Providing your patient’s parents with support and even some language that may help them cultivate the grandparents’ interest and love, while building healthy boundaries around their own parenting, may help set the stage for the healthiest development of your very young patient.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at pdnews@frontlinemedcom.com.
A couple having a baby brings together two family traditions that themselves blended the previous generations’ experiences and perspectives. Each of the new parents has been raised by two parents with their own histories, values, successes, and crises all available and potentially playing a part in the new baby’s future. A baby’s arrival can call forth memories of past successes, failures, hopes, and dreams – some fulfilled and some not.
As the pediatrician, you serve as an authority and a resource for the new parents. You will hear questions that have roots that may go back one, two, or more generations. Some may involve discipline, approaches to food, religious issues, or more subtle concerns relating to control and autonomy. And you may find that they will bring you the challenge of managing the beliefs, values, and expectations of the new grandparents. You may even find these new grandparents in your office! You have a unique opportunity to help new parents set a course with their own parents or in-laws that can promote family cohesion and honor family traditions or values, while empowering parents to trust themselves and truly be in charge of raising their own children.
Imagine this scenario: A young couple has just had their first baby, a son. The paternal grandfather, who played soccer in high school and college, presents his first grandchild with his own college soccer ball, proclaiming with great emotion that soccer will certainly be a part of his grandson’s future.
While this simple act may seem touching, it might also be perceived by the new parents as intrusive or controlling. How does the new father (who was maybe more bookish than athletic) feel the burden of this expectation? Perhaps the mother may wish her son to be more of a scholar than an athlete, or may want no expectation set, but may feel uncomfortable speaking honestly with her father-in-law. And this scenario is just about the gift of a soccer ball!
Grandparents (like parents) come with expectations, with beliefs about what practices worked and what failed over a wide range of areas from child rearing to managing finances to career to marriage. The arrival of a new grandchild will likely prompt them to share these beliefs, and do so in the way they usually communicate with their own children, be it blunt, emotional, indirect, or mute. These views might be forcefully presented, if a grandparent feels guilty or unfulfilled because a meaningful hope for their own child did not materialize: The new grandchild is their “last chance.” While their love and interest, their experience and wisdom can be invaluable, they might also arouse insecurity in a new parent or be disruptive. If they share opinions in a way that is stressful, devaluing, or confusing for new parents, that can translate into anxious, uncertain interactions with their new baby or a climate at home that is full of conflict instead of calm.
Parents are already blending their two styles and values, challenging enough before also trying to blend the elements of four grandparents.
The first weeks after the arrival of the new baby is a crucial time in the baby’s development, as well as in the development of the new parents, as all are rapidly acquiring new skills, adjusting to a new schedule, and learning how to understand and respond to each other. During these hard early days, grandparents often will be present, staying in the home or nearby to offer support to their children. Very commonly, they will share their opinions about such basics as nutrition and sleep. These are areas that are fundamentally important for a baby’s healthy development, but can be mysterious and challenging for new parents. They may seek out guidance from friends, books, websites, and pediatricians, as well as the new grandparents.
While their accumulated wisdom may be as helpful as their helping with laundry or meal preparation (think, “sleep when the baby sleeps”), it also might not. Perhaps the opinions are misguided (think, “sleeping on the tummy was always fine in my day”). And grandparents who are inadvertently undermining (“I don’t understand the difficulty, nursing was so easy for me”), or highly anxious might add to the new parents’ stress and uncertainty rather than alleviate it.
Grandparents also may come with strong cultural beliefs about child rearing. In families that are only one or two generations removed from immigration to this country, there may be powerfully held ideas about newborns, ones that might be inextricably linked for the grandparents with their drive to preserve their own cultural background. These may include ideas about when a child can eat solid food or what he or she should start eating. They may include beliefs that a child should never be put down or should be left to cry for long periods, lest they be “spoiled.” They might include ideas about when a baby can swim or how best to bathe them, what sorts of toys are appropriate or when their hair can be cut. While many of these beliefs have cultural value and no medical implications (like the timing of the first haircut), some may fly in the face of current scientific evidence (such as eating solids before they are able). And even when they are “safe,” new parents may experience these beliefs as fraught directives: ones that they may not believe in, but which will make them guilty of some cultural betrayal if they do not follow them.
Along a similar vein, grandparents may enter the home of their new grandchild with passionately held religious beliefs. While few of these may have direct medical implications for the new baby (such as circumcision), they can still have profound implications for life in the family’s home. When parents and grandparents all share the same religious beliefs, there is less possibility of conflict. But when new parents come from different religious traditions or no longer share their parents’ faith, there is high potential for emotionally charged differences. And if the new parents have not anticipated these conversations (say, whether or not to circumcise a baby boy when one parent is Jewish and the other is Protestant), trying to sort out these matters while also learning to change diapers or nurse a colicky baby can make a challenging situation into an overwhelming one.
Lastly, about 1% of all households have same-sex partners or marriages and about one in four are raising children. While same-sex parenthood has rapidly gained cultural acceptance over the past decade, it is possible that some grandparents will not have fully accepted the reality of their own child’s sexual orientation and committed relationship. If the parents speak to you about such a fraught situation, listen supportively. When it sounds like there is ambivalence in the grandparents, the new parents can try to nurture the love that is there and be patient when their own parents still struggle. They should nurture the connections with those in their families that offer unconditional support and who can model love and acceptance for the new grandparents. In situations in which there is deeper alienation and little or no contact, offer that they might want to find a way to share photos and stories through one who remains close to their parents and periodically offer opportunities to rebuild relationships. A new grandchild can be a loving moment to take a fresh look at unresolved anger and loss, and as clinicians we have seen families resolve differences as they look to a new baby’s future.
Pediatricians are in a unique position of both neutrality and authority with their new patient’s parents and grandparents. When parents come to a newborn check or well-baby check, it can be invaluable to determine “who else is helping you?” After finding out about nursing or feeding the baby and about sleep, inquire about where they are getting any guidance or support. Friends or siblings with children? Books or websites? Grandparents? What has been helpful and what has not? When you hear about grandparents and see an eye-roll or hear a deep sigh, be curious about what has been helpful and what has been challenging. It is vitally helpful to first-time parents to be validated in their feeling that their own parents are a valuable resource, but not without their challenges.
While it may be important to offer a “medical” opinion about certain matters (back-sleeping, cosleeping, and introducing solids, for example), on most matters, the pediatrician’s role will be to help parents set a framework that will help them to cultivate what is precious and helpful from grandparents while minimizing conflict or unnecessary stress. For new parents, this may be as simple as reminding them that while this is an vital time for the baby’s development, it is also a big transition for them into parenthood and a significant transition for their parents or in-laws into grandparenthood. Help the new parents to understand that there is sometimes no one “right” way to handle certain decisions or challenges, and they will have to try a variety of strategies before finding the one that fits them as parents to this particular child. Remind them that parenting is a learning curve and it is common to feel stressed in new territory with high stakes. But they will find the right rhythm with being attuned to their new baby and eventually managing routines and limits. They are allowed to embrace the support that they find helpful and limit that which they experience as deeply undermining, dismissive, or judgmental.
When you notice that parents sound very angry at or alienated from grandparents, particularly when it is causing some marital conflict, it can be powerful for you to suggest that they should sort out their wishes and beliefs as parents first and then find a clear and loving way to communicate these to the grandparents. Remind them that they are becoming the experts on their children and that they will best be able to set appropriate routines and expectations. But remind them also that grandparents are potentially a treasure to their grandchildren, beyond the help with laundry and meal preparation at the very start of a child’s life.
There can never be enough loving, interested adults in a child’s orbit or a big enough cheering section. And grandparents can be uniquely passionate, patient, curious, and supportive to their growing grandchildren. They bring perspective on a family’s history, wonderful as a growing child builds a story about who they are and where they come from. And their interest and love will help a growing child build a sense of what characteristics make them a treasure to others. Few people can do this as well as grandparents, and letting them begin this involvement at the start of their grandchild’s life only supports this role.
While the arrival of a new baby will be a joyful event for a family, it will also be emotionally complex. Providing your patient’s parents with support and even some language that may help them cultivate the grandparents’ interest and love, while building healthy boundaries around their own parenting, may help set the stage for the healthiest development of your very young patient.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at pdnews@frontlinemedcom.com.
A couple having a baby brings together two family traditions that themselves blended the previous generations’ experiences and perspectives. Each of the new parents has been raised by two parents with their own histories, values, successes, and crises all available and potentially playing a part in the new baby’s future. A baby’s arrival can call forth memories of past successes, failures, hopes, and dreams – some fulfilled and some not.
As the pediatrician, you serve as an authority and a resource for the new parents. You will hear questions that have roots that may go back one, two, or more generations. Some may involve discipline, approaches to food, religious issues, or more subtle concerns relating to control and autonomy. And you may find that they will bring you the challenge of managing the beliefs, values, and expectations of the new grandparents. You may even find these new grandparents in your office! You have a unique opportunity to help new parents set a course with their own parents or in-laws that can promote family cohesion and honor family traditions or values, while empowering parents to trust themselves and truly be in charge of raising their own children.
Imagine this scenario: A young couple has just had their first baby, a son. The paternal grandfather, who played soccer in high school and college, presents his first grandchild with his own college soccer ball, proclaiming with great emotion that soccer will certainly be a part of his grandson’s future.
While this simple act may seem touching, it might also be perceived by the new parents as intrusive or controlling. How does the new father (who was maybe more bookish than athletic) feel the burden of this expectation? Perhaps the mother may wish her son to be more of a scholar than an athlete, or may want no expectation set, but may feel uncomfortable speaking honestly with her father-in-law. And this scenario is just about the gift of a soccer ball!
Grandparents (like parents) come with expectations, with beliefs about what practices worked and what failed over a wide range of areas from child rearing to managing finances to career to marriage. The arrival of a new grandchild will likely prompt them to share these beliefs, and do so in the way they usually communicate with their own children, be it blunt, emotional, indirect, or mute. These views might be forcefully presented, if a grandparent feels guilty or unfulfilled because a meaningful hope for their own child did not materialize: The new grandchild is their “last chance.” While their love and interest, their experience and wisdom can be invaluable, they might also arouse insecurity in a new parent or be disruptive. If they share opinions in a way that is stressful, devaluing, or confusing for new parents, that can translate into anxious, uncertain interactions with their new baby or a climate at home that is full of conflict instead of calm.
Parents are already blending their two styles and values, challenging enough before also trying to blend the elements of four grandparents.
The first weeks after the arrival of the new baby is a crucial time in the baby’s development, as well as in the development of the new parents, as all are rapidly acquiring new skills, adjusting to a new schedule, and learning how to understand and respond to each other. During these hard early days, grandparents often will be present, staying in the home or nearby to offer support to their children. Very commonly, they will share their opinions about such basics as nutrition and sleep. These are areas that are fundamentally important for a baby’s healthy development, but can be mysterious and challenging for new parents. They may seek out guidance from friends, books, websites, and pediatricians, as well as the new grandparents.
While their accumulated wisdom may be as helpful as their helping with laundry or meal preparation (think, “sleep when the baby sleeps”), it also might not. Perhaps the opinions are misguided (think, “sleeping on the tummy was always fine in my day”). And grandparents who are inadvertently undermining (“I don’t understand the difficulty, nursing was so easy for me”), or highly anxious might add to the new parents’ stress and uncertainty rather than alleviate it.
Grandparents also may come with strong cultural beliefs about child rearing. In families that are only one or two generations removed from immigration to this country, there may be powerfully held ideas about newborns, ones that might be inextricably linked for the grandparents with their drive to preserve their own cultural background. These may include ideas about when a child can eat solid food or what he or she should start eating. They may include beliefs that a child should never be put down or should be left to cry for long periods, lest they be “spoiled.” They might include ideas about when a baby can swim or how best to bathe them, what sorts of toys are appropriate or when their hair can be cut. While many of these beliefs have cultural value and no medical implications (like the timing of the first haircut), some may fly in the face of current scientific evidence (such as eating solids before they are able). And even when they are “safe,” new parents may experience these beliefs as fraught directives: ones that they may not believe in, but which will make them guilty of some cultural betrayal if they do not follow them.
Along a similar vein, grandparents may enter the home of their new grandchild with passionately held religious beliefs. While few of these may have direct medical implications for the new baby (such as circumcision), they can still have profound implications for life in the family’s home. When parents and grandparents all share the same religious beliefs, there is less possibility of conflict. But when new parents come from different religious traditions or no longer share their parents’ faith, there is high potential for emotionally charged differences. And if the new parents have not anticipated these conversations (say, whether or not to circumcise a baby boy when one parent is Jewish and the other is Protestant), trying to sort out these matters while also learning to change diapers or nurse a colicky baby can make a challenging situation into an overwhelming one.
Lastly, about 1% of all households have same-sex partners or marriages and about one in four are raising children. While same-sex parenthood has rapidly gained cultural acceptance over the past decade, it is possible that some grandparents will not have fully accepted the reality of their own child’s sexual orientation and committed relationship. If the parents speak to you about such a fraught situation, listen supportively. When it sounds like there is ambivalence in the grandparents, the new parents can try to nurture the love that is there and be patient when their own parents still struggle. They should nurture the connections with those in their families that offer unconditional support and who can model love and acceptance for the new grandparents. In situations in which there is deeper alienation and little or no contact, offer that they might want to find a way to share photos and stories through one who remains close to their parents and periodically offer opportunities to rebuild relationships. A new grandchild can be a loving moment to take a fresh look at unresolved anger and loss, and as clinicians we have seen families resolve differences as they look to a new baby’s future.
Pediatricians are in a unique position of both neutrality and authority with their new patient’s parents and grandparents. When parents come to a newborn check or well-baby check, it can be invaluable to determine “who else is helping you?” After finding out about nursing or feeding the baby and about sleep, inquire about where they are getting any guidance or support. Friends or siblings with children? Books or websites? Grandparents? What has been helpful and what has not? When you hear about grandparents and see an eye-roll or hear a deep sigh, be curious about what has been helpful and what has been challenging. It is vitally helpful to first-time parents to be validated in their feeling that their own parents are a valuable resource, but not without their challenges.
While it may be important to offer a “medical” opinion about certain matters (back-sleeping, cosleeping, and introducing solids, for example), on most matters, the pediatrician’s role will be to help parents set a framework that will help them to cultivate what is precious and helpful from grandparents while minimizing conflict or unnecessary stress. For new parents, this may be as simple as reminding them that while this is an vital time for the baby’s development, it is also a big transition for them into parenthood and a significant transition for their parents or in-laws into grandparenthood. Help the new parents to understand that there is sometimes no one “right” way to handle certain decisions or challenges, and they will have to try a variety of strategies before finding the one that fits them as parents to this particular child. Remind them that parenting is a learning curve and it is common to feel stressed in new territory with high stakes. But they will find the right rhythm with being attuned to their new baby and eventually managing routines and limits. They are allowed to embrace the support that they find helpful and limit that which they experience as deeply undermining, dismissive, or judgmental.
When you notice that parents sound very angry at or alienated from grandparents, particularly when it is causing some marital conflict, it can be powerful for you to suggest that they should sort out their wishes and beliefs as parents first and then find a clear and loving way to communicate these to the grandparents. Remind them that they are becoming the experts on their children and that they will best be able to set appropriate routines and expectations. But remind them also that grandparents are potentially a treasure to their grandchildren, beyond the help with laundry and meal preparation at the very start of a child’s life.
There can never be enough loving, interested adults in a child’s orbit or a big enough cheering section. And grandparents can be uniquely passionate, patient, curious, and supportive to their growing grandchildren. They bring perspective on a family’s history, wonderful as a growing child builds a story about who they are and where they come from. And their interest and love will help a growing child build a sense of what characteristics make them a treasure to others. Few people can do this as well as grandparents, and letting them begin this involvement at the start of their grandchild’s life only supports this role.
While the arrival of a new baby will be a joyful event for a family, it will also be emotionally complex. Providing your patient’s parents with support and even some language that may help them cultivate the grandparents’ interest and love, while building healthy boundaries around their own parenting, may help set the stage for the healthiest development of your very young patient.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at pdnews@frontlinemedcom.com.
