Susan D. Swick, MD

Many advocating for more attention to psychosocial issues by primary care pediatricians focus on serious conditions and the value of early recognition. For example, early recognition of autism spectrum disorder could lead to earlier intensive treatment that might impact the long-term course. Early diagnosis and appropriate treatment of attention-deficit/hyperactivity disorder very likely will lessen symptoms and also maintain self-esteem under the withering ordeal – often punctuated by teacher comments – of trying to pay attention hour after hour in school

Are there seemingly less serious conditions very likely worthy of early diagnosis, even those on the edge of normal developmental hurdles? One of the essential tasks of childhood is mastering the anxiety that emerges as children face the new challenges of each developmental stage, so parents, teachers, and clinicians are (or need to be) used to bearing anxiety in the children with whom they work. Intense shyness and anxiety around separation from parents are routine and healthy in infants and toddlers from 6-18 months. Anxiety in new social situations, such as the first day of preschool, is the rule, not the exception. School-age children commonly experience a surge of anxiety around performance and independence, as they are managing and mastering new skills in these domains every day. This anxiety can cause distress, but it should get better every time a child faces it, as they become better at managing the situation. When a child has an anxious temperament, poor coping skills, or parents who struggle to manage their own anxiety, children may have a harder time mastering new, anxiety-provoking challenges across settings. But, with time, and even just one adult who patiently models good coping, they will face and manage challenges. Social anxiety disorder is present when specific social or performance situations provoke the same intense anxiety and avoidance over and over, and for more than 6 months.

Most infants and young children who are more timid and fearful seem to grow into a normal range of social behavior, although few become extroverts. Some of these shy children are cautious in new situations for a period of time measured in minutes, but once the situations are familiar, these children are indistinguishable from their peers. However, some of these temperamentally timid children emerge consistently more anxious with greater likelihood to have phobias and to have social anxiety that can seriously impact long term happiness, achievement, and increase risk taking behaviors. A pediatrician should watch and note the emerging pattern of a timid toddler to see if the shyness eases or impacts social functioning; by bending the course of social interactions, social anxiety disorder critically affects developing social skills, self-regulation, affect tolerance, emerging identity, and confidence. Recognition and effective treatment of social anxiety will keep a child on the optimal developmental trajectory.

Anxiety disorders are the most common psychiatric illnesses in the United States, and social anxiety disorder (previously labeled as social phobia) is the third most common psychiatric disorder in U.S. adults (after depression and alcohol dependence). Most persistent anxiety disorders begin in childhood, and social anxiety is no exception. The mean age of onset for social anxiety is 13 years old, and it rarely begins after the age of 25, with an annual prevalence around 7% in childhood and adolescence (Psychiatr. Clin. North Am. 2009;32;483-524).The DSM-5 criteria for social anxiety disorder include, “a marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others,” and exposure to those situations provokes intense anxiety, which in children can be marked by severe or prolonged crying, freezing, tantrums, shrinking from social situations, refusing to speak, or clinging to parents. In adolescents, it may trigger panic attacks. The avoidance and distress interfere with the child’s function in school, social activities, or relationships, and must have lasted for at least 6 months. To ensure that there is not another problem of social relatedness, the child should have shown some capacity to have normal peer relationships.

Will social anxiety disorder be vividly apparent to teachers, parents, and clinicians? No. The feeling of anxiety is an internal experience, not easily observed, and anxious children and teens are rarely eager or comfortable communicators about their own anxiety. Indeed, in a 2007 survey of patients in treatment for anxiety, 36% of people with social anxiety disorder reported experiencing symptoms for 10 or more years before seeking help. It’s true that the distress children experience when feeling intensely anxious will probably be observable, but all of those behaviors (clinging, crying, tantrums) are common and normal expressions of distress in childhood. Even in adolescence, while having a panic attack may prompt the teenager to seek care, she may not connect it with the anxiety she was feeling about being called on in class or talking to peers, especially if that is an anxiety she has experienced for a long time as a daily part of her lives and routines.

Social anxiety disorder is treatable. The first-line treatment in mild to moderate cases, particularly with younger children, is cognitive-behavioral therapy. This is a practical variant of psychotherapy in which children develop and practice skills at recognizing and labeling their own feelings of anxiety, identifying the situations that trigger them, and practicing relaxation strategies that help them to face and manage the anxiety-provoking situations rather than avoiding them.

When symptoms or the degree of impairment are more severe, medications can become an important part of treatment. SSRIs are the first-line medications used to treat social anxiety disorder, and the effective doses are often higher than effective antidepressant doses, although we often titrate toward those doses more slowly with anxious patients to avoid side effects that might increase or exacerbate their anxiety.

Even with effective medication treatment, though, psychotherapy will be an essential part of treatment. These young patients need to build the essential skills of anxiety management, although it is in the nature of anxiety that such patients often wish to dissolve their anxiety by simply using a pill.

Anxiety disorders are typically chronic and will persist without effective treatment. Failure to recognize and treat social anxiety disorder can distort or even derail healthy development and may result in major psychiatric complications. As a pediatrician, you are trying to stop or modify a chain of potential events. Imagine a socially anxious young woman who enters puberty in high school. Will she withdraw from social activities? Will she avoid new opportunities or interests? Will alcohol become a necessary social lubricant? Will she be at increased risk for sexual assault at a party or poor grades in school? Will social anxiety affect her choice of college, fearful of leaving home? The incidence of secondary depression and substance abuse disorders is substantially higher in adolescents with untreated anxiety disorders. Although a depressed, alcohol-dependent teenager is more likely to be recognized as needing treatment, once they have developed those complications, effective treatment of the underlying anxiety will be much more complicated and slow to treat. Prevention starting before puberty is a much more desirable approach.

Pediatricians truly do have the opportunity to improve outcomes for these patients, by learning to recognize this sometimes-invisible disorder. Children suffering from anxiety disorders are more likely to identify a physical concern than a psychological one. (They have a lot of headaches and tummy aches!) When you are seeing a “shy” school-age child who has persistent crying spells around attending school on test days or before each sporting event despite loving practice, it is useful to gather more history. Is there a family history of anxiety or depression? What are the circumstances of their crying jags or persistent tantrums? Ask teenagers about episodes of shortness of breath, tachycardia, dizziness or sweating that leave them feeling like they are going to die (panic attacks). See if they can rank their anxiety on a scale from 1-10, and find out of there are consistent situations where their anxiety seems disproportionate. Children or teens may recognize that their anxiety is not merited, or they may not. If their parent also suffers from anxiety, they are less likely to recognize that this intense, persistent “shyness” in their child represents a treatable symptom. When you simply have a high index of suspicion, it is worth a referral to a mental health expert to evaluate their anxiety.

Reassuring parents and children that this is a common, treatable problem in childhood will go a long way to diminishing the secrecy and shame that can accompany paralyzing anxiety, and help your patients toward a track that optimizes their psychosocial development.

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.

Many advocating for more attention to psychosocial issues by primary care pediatricians focus on serious conditions and the value of early recognition. For example, early recognition of autism spectrum disorder could lead to earlier intensive treatment that might impact the long-term course. Early diagnosis and appropriate treatment of attention-deficit/hyperactivity disorder very likely will lessen symptoms and also maintain self-esteem under the withering ordeal – often punctuated by teacher comments – of trying to pay attention hour after hour in school

Are there seemingly less serious conditions very likely worthy of early diagnosis, even those on the edge of normal developmental hurdles? One of the essential tasks of childhood is mastering the anxiety that emerges as children face the new challenges of each developmental stage, so parents, teachers, and clinicians are (or need to be) used to bearing anxiety in the children with whom they work. Intense shyness and anxiety around separation from parents are routine and healthy in infants and toddlers from 6-18 months. Anxiety in new social situations, such as the first day of preschool, is the rule, not the exception. School-age children commonly experience a surge of anxiety around performance and independence, as they are managing and mastering new skills in these domains every day. This anxiety can cause distress, but it should get better every time a child faces it, as they become better at managing the situation. When a child has an anxious temperament, poor coping skills, or parents who struggle to manage their own anxiety, children may have a harder time mastering new, anxiety-provoking challenges across settings. But, with time, and even just one adult who patiently models good coping, they will face and manage challenges. Social anxiety disorder is present when specific social or performance situations provoke the same intense anxiety and avoidance over and over, and for more than 6 months.

Most infants and young children who are more timid and fearful seem to grow into a normal range of social behavior, although few become extroverts. Some of these shy children are cautious in new situations for a period of time measured in minutes, but once the situations are familiar, these children are indistinguishable from their peers. However, some of these temperamentally timid children emerge consistently more anxious with greater likelihood to have phobias and to have social anxiety that can seriously impact long term happiness, achievement, and increase risk taking behaviors. A pediatrician should watch and note the emerging pattern of a timid toddler to see if the shyness eases or impacts social functioning; by bending the course of social interactions, social anxiety disorder critically affects developing social skills, self-regulation, affect tolerance, emerging identity, and confidence. Recognition and effective treatment of social anxiety will keep a child on the optimal developmental trajectory.

Anxiety disorders are the most common psychiatric illnesses in the United States, and social anxiety disorder (previously labeled as social phobia) is the third most common psychiatric disorder in U.S. adults (after depression and alcohol dependence). Most persistent anxiety disorders begin in childhood, and social anxiety is no exception. The mean age of onset for social anxiety is 13 years old, and it rarely begins after the age of 25, with an annual prevalence around 7% in childhood and adolescence (Psychiatr. Clin. North Am. 2009;32;483-524).The DSM-5 criteria for social anxiety disorder include, “a marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others,” and exposure to those situations provokes intense anxiety, which in children can be marked by severe or prolonged crying, freezing, tantrums, shrinking from social situations, refusing to speak, or clinging to parents. In adolescents, it may trigger panic attacks. The avoidance and distress interfere with the child’s function in school, social activities, or relationships, and must have lasted for at least 6 months. To ensure that there is not another problem of social relatedness, the child should have shown some capacity to have normal peer relationships.

Will social anxiety disorder be vividly apparent to teachers, parents, and clinicians? No. The feeling of anxiety is an internal experience, not easily observed, and anxious children and teens are rarely eager or comfortable communicators about their own anxiety. Indeed, in a 2007 survey of patients in treatment for anxiety, 36% of people with social anxiety disorder reported experiencing symptoms for 10 or more years before seeking help. It’s true that the distress children experience when feeling intensely anxious will probably be observable, but all of those behaviors (clinging, crying, tantrums) are common and normal expressions of distress in childhood. Even in adolescence, while having a panic attack may prompt the teenager to seek care, she may not connect it with the anxiety she was feeling about being called on in class or talking to peers, especially if that is an anxiety she has experienced for a long time as a daily part of her lives and routines.

Social anxiety disorder is treatable. The first-line treatment in mild to moderate cases, particularly with younger children, is cognitive-behavioral therapy. This is a practical variant of psychotherapy in which children develop and practice skills at recognizing and labeling their own feelings of anxiety, identifying the situations that trigger them, and practicing relaxation strategies that help them to face and manage the anxiety-provoking situations rather than avoiding them.

When symptoms or the degree of impairment are more severe, medications can become an important part of treatment. SSRIs are the first-line medications used to treat social anxiety disorder, and the effective doses are often higher than effective antidepressant doses, although we often titrate toward those doses more slowly with anxious patients to avoid side effects that might increase or exacerbate their anxiety.

Even with effective medication treatment, though, psychotherapy will be an essential part of treatment. These young patients need to build the essential skills of anxiety management, although it is in the nature of anxiety that such patients often wish to dissolve their anxiety by simply using a pill.

Anxiety disorders are typically chronic and will persist without effective treatment. Failure to recognize and treat social anxiety disorder can distort or even derail healthy development and may result in major psychiatric complications. As a pediatrician, you are trying to stop or modify a chain of potential events. Imagine a socially anxious young woman who enters puberty in high school. Will she withdraw from social activities? Will she avoid new opportunities or interests? Will alcohol become a necessary social lubricant? Will she be at increased risk for sexual assault at a party or poor grades in school? Will social anxiety affect her choice of college, fearful of leaving home? The incidence of secondary depression and substance abuse disorders is substantially higher in adolescents with untreated anxiety disorders. Although a depressed, alcohol-dependent teenager is more likely to be recognized as needing treatment, once they have developed those complications, effective treatment of the underlying anxiety will be much more complicated and slow to treat. Prevention starting before puberty is a much more desirable approach.

Pediatricians truly do have the opportunity to improve outcomes for these patients, by learning to recognize this sometimes-invisible disorder. Children suffering from anxiety disorders are more likely to identify a physical concern than a psychological one. (They have a lot of headaches and tummy aches!) When you are seeing a “shy” school-age child who has persistent crying spells around attending school on test days or before each sporting event despite loving practice, it is useful to gather more history. Is there a family history of anxiety or depression? What are the circumstances of their crying jags or persistent tantrums? Ask teenagers about episodes of shortness of breath, tachycardia, dizziness or sweating that leave them feeling like they are going to die (panic attacks). See if they can rank their anxiety on a scale from 1-10, and find out of there are consistent situations where their anxiety seems disproportionate. Children or teens may recognize that their anxiety is not merited, or they may not. If their parent also suffers from anxiety, they are less likely to recognize that this intense, persistent “shyness” in their child represents a treatable symptom. When you simply have a high index of suspicion, it is worth a referral to a mental health expert to evaluate their anxiety.

Reassuring parents and children that this is a common, treatable problem in childhood will go a long way to diminishing the secrecy and shame that can accompany paralyzing anxiety, and help your patients toward a track that optimizes their psychosocial development.

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.

Many advocating for more attention to psychosocial issues by primary care pediatricians focus on serious conditions and the value of early recognition. For example, early recognition of autism spectrum disorder could lead to earlier intensive treatment that might impact the long-term course. Early diagnosis and appropriate treatment of attention-deficit/hyperactivity disorder very likely will lessen symptoms and also maintain self-esteem under the withering ordeal – often punctuated by teacher comments – of trying to pay attention hour after hour in school

Are there seemingly less serious conditions very likely worthy of early diagnosis, even those on the edge of normal developmental hurdles? One of the essential tasks of childhood is mastering the anxiety that emerges as children face the new challenges of each developmental stage, so parents, teachers, and clinicians are (or need to be) used to bearing anxiety in the children with whom they work. Intense shyness and anxiety around separation from parents are routine and healthy in infants and toddlers from 6-18 months. Anxiety in new social situations, such as the first day of preschool, is the rule, not the exception. School-age children commonly experience a surge of anxiety around performance and independence, as they are managing and mastering new skills in these domains every day. This anxiety can cause distress, but it should get better every time a child faces it, as they become better at managing the situation. When a child has an anxious temperament, poor coping skills, or parents who struggle to manage their own anxiety, children may have a harder time mastering new, anxiety-provoking challenges across settings. But, with time, and even just one adult who patiently models good coping, they will face and manage challenges. Social anxiety disorder is present when specific social or performance situations provoke the same intense anxiety and avoidance over and over, and for more than 6 months.

Most infants and young children who are more timid and fearful seem to grow into a normal range of social behavior, although few become extroverts. Some of these shy children are cautious in new situations for a period of time measured in minutes, but once the situations are familiar, these children are indistinguishable from their peers. However, some of these temperamentally timid children emerge consistently more anxious with greater likelihood to have phobias and to have social anxiety that can seriously impact long term happiness, achievement, and increase risk taking behaviors. A pediatrician should watch and note the emerging pattern of a timid toddler to see if the shyness eases or impacts social functioning; by bending the course of social interactions, social anxiety disorder critically affects developing social skills, self-regulation, affect tolerance, emerging identity, and confidence. Recognition and effective treatment of social anxiety will keep a child on the optimal developmental trajectory.

Anxiety disorders are the most common psychiatric illnesses in the United States, and social anxiety disorder (previously labeled as social phobia) is the third most common psychiatric disorder in U.S. adults (after depression and alcohol dependence). Most persistent anxiety disorders begin in childhood, and social anxiety is no exception. The mean age of onset for social anxiety is 13 years old, and it rarely begins after the age of 25, with an annual prevalence around 7% in childhood and adolescence (Psychiatr. Clin. North Am. 2009;32;483-524).The DSM-5 criteria for social anxiety disorder include, “a marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others,” and exposure to those situations provokes intense anxiety, which in children can be marked by severe or prolonged crying, freezing, tantrums, shrinking from social situations, refusing to speak, or clinging to parents. In adolescents, it may trigger panic attacks. The avoidance and distress interfere with the child’s function in school, social activities, or relationships, and must have lasted for at least 6 months. To ensure that there is not another problem of social relatedness, the child should have shown some capacity to have normal peer relationships.

Will social anxiety disorder be vividly apparent to teachers, parents, and clinicians? No. The feeling of anxiety is an internal experience, not easily observed, and anxious children and teens are rarely eager or comfortable communicators about their own anxiety. Indeed, in a 2007 survey of patients in treatment for anxiety, 36% of people with social anxiety disorder reported experiencing symptoms for 10 or more years before seeking help. It’s true that the distress children experience when feeling intensely anxious will probably be observable, but all of those behaviors (clinging, crying, tantrums) are common and normal expressions of distress in childhood. Even in adolescence, while having a panic attack may prompt the teenager to seek care, she may not connect it with the anxiety she was feeling about being called on in class or talking to peers, especially if that is an anxiety she has experienced for a long time as a daily part of her lives and routines.

Social anxiety disorder is treatable. The first-line treatment in mild to moderate cases, particularly with younger children, is cognitive-behavioral therapy. This is a practical variant of psychotherapy in which children develop and practice skills at recognizing and labeling their own feelings of anxiety, identifying the situations that trigger them, and practicing relaxation strategies that help them to face and manage the anxiety-provoking situations rather than avoiding them.

When symptoms or the degree of impairment are more severe, medications can become an important part of treatment. SSRIs are the first-line medications used to treat social anxiety disorder, and the effective doses are often higher than effective antidepressant doses, although we often titrate toward those doses more slowly with anxious patients to avoid side effects that might increase or exacerbate their anxiety.

Even with effective medication treatment, though, psychotherapy will be an essential part of treatment. These young patients need to build the essential skills of anxiety management, although it is in the nature of anxiety that such patients often wish to dissolve their anxiety by simply using a pill.

Anxiety disorders are typically chronic and will persist without effective treatment. Failure to recognize and treat social anxiety disorder can distort or even derail healthy development and may result in major psychiatric complications. As a pediatrician, you are trying to stop or modify a chain of potential events. Imagine a socially anxious young woman who enters puberty in high school. Will she withdraw from social activities? Will she avoid new opportunities or interests? Will alcohol become a necessary social lubricant? Will she be at increased risk for sexual assault at a party or poor grades in school? Will social anxiety affect her choice of college, fearful of leaving home? The incidence of secondary depression and substance abuse disorders is substantially higher in adolescents with untreated anxiety disorders. Although a depressed, alcohol-dependent teenager is more likely to be recognized as needing treatment, once they have developed those complications, effective treatment of the underlying anxiety will be much more complicated and slow to treat. Prevention starting before puberty is a much more desirable approach.

Pediatricians truly do have the opportunity to improve outcomes for these patients, by learning to recognize this sometimes-invisible disorder. Children suffering from anxiety disorders are more likely to identify a physical concern than a psychological one. (They have a lot of headaches and tummy aches!) When you are seeing a “shy” school-age child who has persistent crying spells around attending school on test days or before each sporting event despite loving practice, it is useful to gather more history. Is there a family history of anxiety or depression? What are the circumstances of their crying jags or persistent tantrums? Ask teenagers about episodes of shortness of breath, tachycardia, dizziness or sweating that leave them feeling like they are going to die (panic attacks). See if they can rank their anxiety on a scale from 1-10, and find out of there are consistent situations where their anxiety seems disproportionate. Children or teens may recognize that their anxiety is not merited, or they may not. If their parent also suffers from anxiety, they are less likely to recognize that this intense, persistent “shyness” in their child represents a treatable symptom. When you simply have a high index of suspicion, it is worth a referral to a mental health expert to evaluate their anxiety.

Reassuring parents and children that this is a common, treatable problem in childhood will go a long way to diminishing the secrecy and shame that can accompany paralyzing anxiety, and help your patients toward a track that optimizes their psychosocial development.

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.

Perhaps the greatest transition in an adolescent’s life is the transition to college. The process of preparation, investigation, application, interviewing, waiting, choosing, and preparing to leave for college is one of the most exciting, exhausting, and challenging experiences in the life of an adolescent and his or her family. The final selection of a school can mark a shorthand summary of accomplishment and builds a major piece of a young adult’s identity.

Although there are certainly many steps to autonomy through childhood – walking, starting school, being home alone, driving a car – none compares to leaving the warmth and structure of home for the college experience. Once in the dorm, teens are probably more alone and independent than they have ever been before, likely without any long-standing friends, in an unfamiliar setting, and facing high expectations. College offers structure and support to help with this transition, and most adolescents are ready and even eager to start to manage their own lives pragmatically, academically, and socially. But there will be setbacks and failures, big and small, as they navigate new territory with virtually full independence. This transition would be a challenge to a mature adult and is daunting to someone who is doing this for the first time and with an identity that is still forming.

We know that most teenagers make this transition successfully. However, we also know that this new level of independence and responsibility and the loss of supervision and structure can place adolescents at risk for several problems. Some adolescents make poor or risky choices with serious consequences. Depression affects about 20% of all freshmen, with consequences that range from mild to severe, sometimes requiring a leave of absence. Many students who have managed mild problems with anxiety or body image may find that with more stress and less support, these problems grow into eating disorders and substance abuse disorders. It now appears that sexual assaults on campuses, often during “frat” parties and in the setting of substance use, are far more prevalent than previously acknowledged. Recently in the news was the tragic accident of a young woman under the influence of substances who was seriously injured when she fell out of a window. Finally, we know the most prevalent morbidity and mortality are from car accidents, many of which are related to risk taking and substance use.

Clearly there are critical developmental gains toward healthy adulthood when this transition goes well, and quite substantial risks when it does not. Pediatricians quite commonly follow their patients well into the college years, and at least treat patients during the time in which they are preparing to leave for college. Therefore the transition from high school to college can be considered a part of pediatric primary care. How can a pediatrician contribute to the adolescent’s preparations for this transition to essentially full, day-to-day autonomy? The pediatrician is in a position to offer meaningful guidance to these adolescent patients, and in some cases to their parents as well, particularly on the subjects of substance use, mental health, and sexuality. This process starts in early high school, with progressively more detailed and frank discussions into and through college.

Substance use

For purposes of this discussion, let’s focus on alcohol use. Talking about the risks of alcohol probably should start in late junior high and upon entry to high school. But if you have not yet had a discussion with your adolescent patient about drugs and alcohol, it is not too late to have one during the time before they start college. It would be helpful to learn about their personal and family history of alcohol and drug use. How has alcohol been discussed, and more importantly, used in the home by parents? What are your patients’ attitudes to drinking and related social pressure? Have they needed to be “rescued,” or have they needed to rescue friends? Have they been the designated driver? Have they passed out or seen someone pass out at a party? In these situations, how have they coped? What decisions have they made? Is there a pattern of self-monitoring or largely one of risk taking? What do they imagine college will be like with regard to drinking?

For your patients who have been decidedly sober through high school, it will be important to find out if they are curious about trying alcohol once they are on campus. Even if they voice shocked refusal, you might speak generally with them about the easy availability of alcohol at many parties on campus, particularly if they join a fraternity or sorority or even plan to be on a varsity sports team. Superior athletes are often surrounded by older students and often gain access to parties as freshmen or sophomores surrounded by far more experienced seniors. Speaking generally about how common it is to try alcohol in college, while offering details on how easy it can be for first-time drinkers to become drunk, can be very valuable. You might even offer them data and strategies on how to pace themselves: one drink per hour, no hard alcohol or “mysterious punch,” or two glasses of water for every beer are a few such strategies. You might note how quickly alcohol is absorbed and the risks of rapid ingestion of larger quantities. You should be clear that you are not endorsing underage drinking. Your goal is to ensure that they are equipped with knowledge about smart self-care, especially as intoxication can put them at risk for being victimized or exploited sexually, for serious accidents, for administrative problems, and even for medical consequences.

For your patients who have been risk takers, especially if they have had trouble with drugs or alcohol in high school, it will be important to speak with them about the likelihood that a risky pattern of substance use in high school will grow into a more serious problem in the less-supervised college setting. While this may sound to them like the exciting chance to have easier access and fewer restrictions or punishments, you have the opportunity to complicate their thinking about what this will actually mean. In all likelihood, their use will grow into a problem of abuse or dependence and could easily threaten their ability to succeed at college, landing them back in a far more restrictive setting. It may be valuable to talk with your patients about how they would know if their drug or alcohol use was becoming a problem. When would they say they have reached a limit they are concerned about? Would they be willing to see a therapist or psychiatrist about their substance use before leaving for college to make thoughtful plans for how to manage it? If they are willing, it may be protective to invite their parents into this conversation so that there is a better chance that they may discuss this with their parents outside of your office and once they are on campus.

Mental health

The prevalence of depressive and anxiety symptoms in the college years is very high, likely because of a combination of external stressors, loss of external supports, and continued rapid physical and neurologic development. For adolescents who have not experienced any mental health problems, it can be protective to have a conversation with them about the real risks of developing a mental health problem while they are at school and the value and efficacy of early treatment. You might tell them that while some anxiety and sadness are to be expected during a challenging transition, experiencing intense anxiety or sadness that is sustained (2 weeks or more) and that interferes with their functioning should prompt them to seek help from the student health services. They should be on the lookout for sustained disruptions in their sleep and loss of appetite and energy (the classic neurovegetative symptoms), and of course, any emerging hopelessness or suicidal preoccupation also should prompt them to turn to student health services for evaluation and support.

For your patients who have a history of psychiatric problems and treatment, it is critical – even if they are in remission – that you review with them when they should turn to the campus student health services for evaluation. What symptoms have indicated a worsening problem or relapse for them in the past? What might be the earliest signs of deterioration? If they are in active treatment, you should ensure that the treatment provider has built a transition plan for their treatment to continue on campus. Helping these patients to be smart about their self-care, just as you would if they were responsible for continuing treatment of their diabetes away from the supports of home, can be a powerful preventative intervention.

Sexuality

In all likelihood, you have already had a conversation about sex, even a brief one, with your adolescent patients by the time they are packing for college. But this is a key time to revisit the subject with them. You can begin an open-ended discussion about the fact that the years in college are commonly a time when adolescents start having sex (if they have not already done so). As such, it is important for them to learn about birth control and protection against sexually transmitted infections. This is normally a developmental stage in which sex becomes a more fully integrated part of their emerging identity and their healthy adult life. They may find that they develop a fuller awareness of whom they are attracted to and what they enjoy, and it is commonly a time of some experimentation or exploration. It is very meaningful for your young patients to hear about this nonjudgmentally from their pediatrician. This discussion should include some prevention, in the form of talk about the risks of sexual assault on campus. Help your patients, both male and female, to consider how new independence and access to alcohol can be a dangerous mix with the intense social scene on college campuses. Many situations in which they will be socializing with strangers will involve alcohol, even drugs. Would they have sex with someone if they or their partner were intoxicated? How would they know if the person they were connecting with was actually very intoxicated? How might they think about protecting a friend who seemed to be very intoxicated and at risk for sexual exploitation or assault? If they think they are witnessing a sexual assault or a risky situation, what could they do? If they are considering sex with someone, is it because they are attracted to and interested in that person, or are they feeling pressured, anxious, or bullied? Remind them that while exploration is healthy and should be fun, it also is wise to go slowly when something is new, and to be especially cautious when substance use is involved. They can protect themselves and their friends from the trauma of assault or of being accused of assaulting someone who could not meaningfully consent to sex with some thoughtful anticipation and planning. They took great care to arrange to get into college, and they can take equally great care with their own health and well-being.

Progressively relevant and honest discussions between a pediatrician and teenage patient can have a meaningful impact. Consider how teens could have access to you during their freshman year. Should they have your pager or your cell phone number if they feel they need your help? Should you schedule a psychosocial follow-up visit during a holiday break first semester and again as indicated? Doing what you can to anticipate and prevent harm during the transition to college is highly relevant to many if not all of your patients.

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.

Perhaps the greatest transition in an adolescent’s life is the transition to college. The process of preparation, investigation, application, interviewing, waiting, choosing, and preparing to leave for college is one of the most exciting, exhausting, and challenging experiences in the life of an adolescent and his or her family. The final selection of a school can mark a shorthand summary of accomplishment and builds a major piece of a young adult’s identity.

Although there are certainly many steps to autonomy through childhood – walking, starting school, being home alone, driving a car – none compares to leaving the warmth and structure of home for the college experience. Once in the dorm, teens are probably more alone and independent than they have ever been before, likely without any long-standing friends, in an unfamiliar setting, and facing high expectations. College offers structure and support to help with this transition, and most adolescents are ready and even eager to start to manage their own lives pragmatically, academically, and socially. But there will be setbacks and failures, big and small, as they navigate new territory with virtually full independence. This transition would be a challenge to a mature adult and is daunting to someone who is doing this for the first time and with an identity that is still forming.

We know that most teenagers make this transition successfully. However, we also know that this new level of independence and responsibility and the loss of supervision and structure can place adolescents at risk for several problems. Some adolescents make poor or risky choices with serious consequences. Depression affects about 20% of all freshmen, with consequences that range from mild to severe, sometimes requiring a leave of absence. Many students who have managed mild problems with anxiety or body image may find that with more stress and less support, these problems grow into eating disorders and substance abuse disorders. It now appears that sexual assaults on campuses, often during “frat” parties and in the setting of substance use, are far more prevalent than previously acknowledged. Recently in the news was the tragic accident of a young woman under the influence of substances who was seriously injured when she fell out of a window. Finally, we know the most prevalent morbidity and mortality are from car accidents, many of which are related to risk taking and substance use.

Clearly there are critical developmental gains toward healthy adulthood when this transition goes well, and quite substantial risks when it does not. Pediatricians quite commonly follow their patients well into the college years, and at least treat patients during the time in which they are preparing to leave for college. Therefore the transition from high school to college can be considered a part of pediatric primary care. How can a pediatrician contribute to the adolescent’s preparations for this transition to essentially full, day-to-day autonomy? The pediatrician is in a position to offer meaningful guidance to these adolescent patients, and in some cases to their parents as well, particularly on the subjects of substance use, mental health, and sexuality. This process starts in early high school, with progressively more detailed and frank discussions into and through college.

Substance use

For purposes of this discussion, let’s focus on alcohol use. Talking about the risks of alcohol probably should start in late junior high and upon entry to high school. But if you have not yet had a discussion with your adolescent patient about drugs and alcohol, it is not too late to have one during the time before they start college. It would be helpful to learn about their personal and family history of alcohol and drug use. How has alcohol been discussed, and more importantly, used in the home by parents? What are your patients’ attitudes to drinking and related social pressure? Have they needed to be “rescued,” or have they needed to rescue friends? Have they been the designated driver? Have they passed out or seen someone pass out at a party? In these situations, how have they coped? What decisions have they made? Is there a pattern of self-monitoring or largely one of risk taking? What do they imagine college will be like with regard to drinking?

For your patients who have been decidedly sober through high school, it will be important to find out if they are curious about trying alcohol once they are on campus. Even if they voice shocked refusal, you might speak generally with them about the easy availability of alcohol at many parties on campus, particularly if they join a fraternity or sorority or even plan to be on a varsity sports team. Superior athletes are often surrounded by older students and often gain access to parties as freshmen or sophomores surrounded by far more experienced seniors. Speaking generally about how common it is to try alcohol in college, while offering details on how easy it can be for first-time drinkers to become drunk, can be very valuable. You might even offer them data and strategies on how to pace themselves: one drink per hour, no hard alcohol or “mysterious punch,” or two glasses of water for every beer are a few such strategies. You might note how quickly alcohol is absorbed and the risks of rapid ingestion of larger quantities. You should be clear that you are not endorsing underage drinking. Your goal is to ensure that they are equipped with knowledge about smart self-care, especially as intoxication can put them at risk for being victimized or exploited sexually, for serious accidents, for administrative problems, and even for medical consequences.

For your patients who have been risk takers, especially if they have had trouble with drugs or alcohol in high school, it will be important to speak with them about the likelihood that a risky pattern of substance use in high school will grow into a more serious problem in the less-supervised college setting. While this may sound to them like the exciting chance to have easier access and fewer restrictions or punishments, you have the opportunity to complicate their thinking about what this will actually mean. In all likelihood, their use will grow into a problem of abuse or dependence and could easily threaten their ability to succeed at college, landing them back in a far more restrictive setting. It may be valuable to talk with your patients about how they would know if their drug or alcohol use was becoming a problem. When would they say they have reached a limit they are concerned about? Would they be willing to see a therapist or psychiatrist about their substance use before leaving for college to make thoughtful plans for how to manage it? If they are willing, it may be protective to invite their parents into this conversation so that there is a better chance that they may discuss this with their parents outside of your office and once they are on campus.

Mental health

The prevalence of depressive and anxiety symptoms in the college years is very high, likely because of a combination of external stressors, loss of external supports, and continued rapid physical and neurologic development. For adolescents who have not experienced any mental health problems, it can be protective to have a conversation with them about the real risks of developing a mental health problem while they are at school and the value and efficacy of early treatment. You might tell them that while some anxiety and sadness are to be expected during a challenging transition, experiencing intense anxiety or sadness that is sustained (2 weeks or more) and that interferes with their functioning should prompt them to seek help from the student health services. They should be on the lookout for sustained disruptions in their sleep and loss of appetite and energy (the classic neurovegetative symptoms), and of course, any emerging hopelessness or suicidal preoccupation also should prompt them to turn to student health services for evaluation and support.

For your patients who have a history of psychiatric problems and treatment, it is critical – even if they are in remission – that you review with them when they should turn to the campus student health services for evaluation. What symptoms have indicated a worsening problem or relapse for them in the past? What might be the earliest signs of deterioration? If they are in active treatment, you should ensure that the treatment provider has built a transition plan for their treatment to continue on campus. Helping these patients to be smart about their self-care, just as you would if they were responsible for continuing treatment of their diabetes away from the supports of home, can be a powerful preventative intervention.

Sexuality

In all likelihood, you have already had a conversation about sex, even a brief one, with your adolescent patients by the time they are packing for college. But this is a key time to revisit the subject with them. You can begin an open-ended discussion about the fact that the years in college are commonly a time when adolescents start having sex (if they have not already done so). As such, it is important for them to learn about birth control and protection against sexually transmitted infections. This is normally a developmental stage in which sex becomes a more fully integrated part of their emerging identity and their healthy adult life. They may find that they develop a fuller awareness of whom they are attracted to and what they enjoy, and it is commonly a time of some experimentation or exploration. It is very meaningful for your young patients to hear about this nonjudgmentally from their pediatrician. This discussion should include some prevention, in the form of talk about the risks of sexual assault on campus. Help your patients, both male and female, to consider how new independence and access to alcohol can be a dangerous mix with the intense social scene on college campuses. Many situations in which they will be socializing with strangers will involve alcohol, even drugs. Would they have sex with someone if they or their partner were intoxicated? How would they know if the person they were connecting with was actually very intoxicated? How might they think about protecting a friend who seemed to be very intoxicated and at risk for sexual exploitation or assault? If they think they are witnessing a sexual assault or a risky situation, what could they do? If they are considering sex with someone, is it because they are attracted to and interested in that person, or are they feeling pressured, anxious, or bullied? Remind them that while exploration is healthy and should be fun, it also is wise to go slowly when something is new, and to be especially cautious when substance use is involved. They can protect themselves and their friends from the trauma of assault or of being accused of assaulting someone who could not meaningfully consent to sex with some thoughtful anticipation and planning. They took great care to arrange to get into college, and they can take equally great care with their own health and well-being.

Progressively relevant and honest discussions between a pediatrician and teenage patient can have a meaningful impact. Consider how teens could have access to you during their freshman year. Should they have your pager or your cell phone number if they feel they need your help? Should you schedule a psychosocial follow-up visit during a holiday break first semester and again as indicated? Doing what you can to anticipate and prevent harm during the transition to college is highly relevant to many if not all of your patients.

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.

Perhaps the greatest transition in an adolescent’s life is the transition to college. The process of preparation, investigation, application, interviewing, waiting, choosing, and preparing to leave for college is one of the most exciting, exhausting, and challenging experiences in the life of an adolescent and his or her family. The final selection of a school can mark a shorthand summary of accomplishment and builds a major piece of a young adult’s identity.

Although there are certainly many steps to autonomy through childhood – walking, starting school, being home alone, driving a car – none compares to leaving the warmth and structure of home for the college experience. Once in the dorm, teens are probably more alone and independent than they have ever been before, likely without any long-standing friends, in an unfamiliar setting, and facing high expectations. College offers structure and support to help with this transition, and most adolescents are ready and even eager to start to manage their own lives pragmatically, academically, and socially. But there will be setbacks and failures, big and small, as they navigate new territory with virtually full independence. This transition would be a challenge to a mature adult and is daunting to someone who is doing this for the first time and with an identity that is still forming.

We know that most teenagers make this transition successfully. However, we also know that this new level of independence and responsibility and the loss of supervision and structure can place adolescents at risk for several problems. Some adolescents make poor or risky choices with serious consequences. Depression affects about 20% of all freshmen, with consequences that range from mild to severe, sometimes requiring a leave of absence. Many students who have managed mild problems with anxiety or body image may find that with more stress and less support, these problems grow into eating disorders and substance abuse disorders. It now appears that sexual assaults on campuses, often during “frat” parties and in the setting of substance use, are far more prevalent than previously acknowledged. Recently in the news was the tragic accident of a young woman under the influence of substances who was seriously injured when she fell out of a window. Finally, we know the most prevalent morbidity and mortality are from car accidents, many of which are related to risk taking and substance use.

Clearly there are critical developmental gains toward healthy adulthood when this transition goes well, and quite substantial risks when it does not. Pediatricians quite commonly follow their patients well into the college years, and at least treat patients during the time in which they are preparing to leave for college. Therefore the transition from high school to college can be considered a part of pediatric primary care. How can a pediatrician contribute to the adolescent’s preparations for this transition to essentially full, day-to-day autonomy? The pediatrician is in a position to offer meaningful guidance to these adolescent patients, and in some cases to their parents as well, particularly on the subjects of substance use, mental health, and sexuality. This process starts in early high school, with progressively more detailed and frank discussions into and through college.

Substance use

For purposes of this discussion, let’s focus on alcohol use. Talking about the risks of alcohol probably should start in late junior high and upon entry to high school. But if you have not yet had a discussion with your adolescent patient about drugs and alcohol, it is not too late to have one during the time before they start college. It would be helpful to learn about their personal and family history of alcohol and drug use. How has alcohol been discussed, and more importantly, used in the home by parents? What are your patients’ attitudes to drinking and related social pressure? Have they needed to be “rescued,” or have they needed to rescue friends? Have they been the designated driver? Have they passed out or seen someone pass out at a party? In these situations, how have they coped? What decisions have they made? Is there a pattern of self-monitoring or largely one of risk taking? What do they imagine college will be like with regard to drinking?

For your patients who have been decidedly sober through high school, it will be important to find out if they are curious about trying alcohol once they are on campus. Even if they voice shocked refusal, you might speak generally with them about the easy availability of alcohol at many parties on campus, particularly if they join a fraternity or sorority or even plan to be on a varsity sports team. Superior athletes are often surrounded by older students and often gain access to parties as freshmen or sophomores surrounded by far more experienced seniors. Speaking generally about how common it is to try alcohol in college, while offering details on how easy it can be for first-time drinkers to become drunk, can be very valuable. You might even offer them data and strategies on how to pace themselves: one drink per hour, no hard alcohol or “mysterious punch,” or two glasses of water for every beer are a few such strategies. You might note how quickly alcohol is absorbed and the risks of rapid ingestion of larger quantities. You should be clear that you are not endorsing underage drinking. Your goal is to ensure that they are equipped with knowledge about smart self-care, especially as intoxication can put them at risk for being victimized or exploited sexually, for serious accidents, for administrative problems, and even for medical consequences.

For your patients who have been risk takers, especially if they have had trouble with drugs or alcohol in high school, it will be important to speak with them about the likelihood that a risky pattern of substance use in high school will grow into a more serious problem in the less-supervised college setting. While this may sound to them like the exciting chance to have easier access and fewer restrictions or punishments, you have the opportunity to complicate their thinking about what this will actually mean. In all likelihood, their use will grow into a problem of abuse or dependence and could easily threaten their ability to succeed at college, landing them back in a far more restrictive setting. It may be valuable to talk with your patients about how they would know if their drug or alcohol use was becoming a problem. When would they say they have reached a limit they are concerned about? Would they be willing to see a therapist or psychiatrist about their substance use before leaving for college to make thoughtful plans for how to manage it? If they are willing, it may be protective to invite their parents into this conversation so that there is a better chance that they may discuss this with their parents outside of your office and once they are on campus.

Mental health

The prevalence of depressive and anxiety symptoms in the college years is very high, likely because of a combination of external stressors, loss of external supports, and continued rapid physical and neurologic development. For adolescents who have not experienced any mental health problems, it can be protective to have a conversation with them about the real risks of developing a mental health problem while they are at school and the value and efficacy of early treatment. You might tell them that while some anxiety and sadness are to be expected during a challenging transition, experiencing intense anxiety or sadness that is sustained (2 weeks or more) and that interferes with their functioning should prompt them to seek help from the student health services. They should be on the lookout for sustained disruptions in their sleep and loss of appetite and energy (the classic neurovegetative symptoms), and of course, any emerging hopelessness or suicidal preoccupation also should prompt them to turn to student health services for evaluation and support.

For your patients who have a history of psychiatric problems and treatment, it is critical – even if they are in remission – that you review with them when they should turn to the campus student health services for evaluation. What symptoms have indicated a worsening problem or relapse for them in the past? What might be the earliest signs of deterioration? If they are in active treatment, you should ensure that the treatment provider has built a transition plan for their treatment to continue on campus. Helping these patients to be smart about their self-care, just as you would if they were responsible for continuing treatment of their diabetes away from the supports of home, can be a powerful preventative intervention.

Sexuality

In all likelihood, you have already had a conversation about sex, even a brief one, with your adolescent patients by the time they are packing for college. But this is a key time to revisit the subject with them. You can begin an open-ended discussion about the fact that the years in college are commonly a time when adolescents start having sex (if they have not already done so). As such, it is important for them to learn about birth control and protection against sexually transmitted infections. This is normally a developmental stage in which sex becomes a more fully integrated part of their emerging identity and their healthy adult life. They may find that they develop a fuller awareness of whom they are attracted to and what they enjoy, and it is commonly a time of some experimentation or exploration. It is very meaningful for your young patients to hear about this nonjudgmentally from their pediatrician. This discussion should include some prevention, in the form of talk about the risks of sexual assault on campus. Help your patients, both male and female, to consider how new independence and access to alcohol can be a dangerous mix with the intense social scene on college campuses. Many situations in which they will be socializing with strangers will involve alcohol, even drugs. Would they have sex with someone if they or their partner were intoxicated? How would they know if the person they were connecting with was actually very intoxicated? How might they think about protecting a friend who seemed to be very intoxicated and at risk for sexual exploitation or assault? If they think they are witnessing a sexual assault or a risky situation, what could they do? If they are considering sex with someone, is it because they are attracted to and interested in that person, or are they feeling pressured, anxious, or bullied? Remind them that while exploration is healthy and should be fun, it also is wise to go slowly when something is new, and to be especially cautious when substance use is involved. They can protect themselves and their friends from the trauma of assault or of being accused of assaulting someone who could not meaningfully consent to sex with some thoughtful anticipation and planning. They took great care to arrange to get into college, and they can take equally great care with their own health and well-being.

Progressively relevant and honest discussions between a pediatrician and teenage patient can have a meaningful impact. Consider how teens could have access to you during their freshman year. Should they have your pager or your cell phone number if they feel they need your help? Should you schedule a psychosocial follow-up visit during a holiday break first semester and again as indicated? Doing what you can to anticipate and prevent harm during the transition to college is highly relevant to many if not all of your patients.

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.

Parents want to raise their children to be happy and successful in childhood and through adulthood. For many parents, this means giving their children as many opportunities to learn, practice, and master a wide variety of skills outside of school as they possibly can. These activities often include the study of a musical instrument, a sport, an activity in the arts, religious study, and even extra academic work such as math, computer science, or a second language. Each one of these activities can mean many classes or practices outside of the home each week and additional practice time at home.

When you combine these activities with school and homework, children can be busier than most professional adults. And their parents can feel like managing their child’s schedule is another full-time job. By asking parents how many afternoons and evenings are scheduled (or how many hours of down time their children have) each week, you begin a conversation that may help parents determine the right balance for each child and the family.

Without a doubt, there can be tremendous value in making time for extracurricular activities for children. School alone usually does not offer much exposure to music education and the arts, and a daily gym class is sadly a thing of the past for most children. There is a growing body of evidence that daily vigorous exercise in childhood not only promotes good physical health and restorative sleep, and fights obesity, but that it also promotes strong cognitive development and can prevent anxiety and mood symptoms. Sustained experience with a team sport cultivates discipline, frustration tolerance, and resilience alongside friendships and fun. Likewise, there is a growing body of evidence that learning to play a musical instrument contributes in broader ways to healthy cognitive development, cultivates discipline and frustration tolerance, and improves executive function and the attention and self-regulation skills that all school-age children need to develop. Exposure to the arts, to trade skills, or to rare languages may help children discover a unique interest or passion that will draw them through their adolescence. Discovering an area of passionate interest is one of the essential goals of childhood; it can help teens feel good about themselves, and is especially meaningful in children who may not be gaining a lot of self-esteem in other areas, such as schoolwork.

But the well-meant intentions of parents (or interests of children) sometimes can lead to so many extracurricular activities that children barely have time for homework, play, or relaxation. From kindergarten through middle school, children are at the perfect age to be exploring multiple activities as they learn about their own abilities, strengths, and interests. But it is a developmental period in which there also should be plenty of open, free creative play, often with a social component. This is where children not only learn about their own talents, but also try things they might fail at, developing their curiosity, social skills, self-awareness, and resilience. While it can be wonderful to have a weekly music lesson and a team sport at this age, it is critical that there also be protected free play or down time. During this developmental period, children may switch sports, instruments, or hobbies, and it is healthy that they have the time and space to do so. Parents will say that every hour of activity is "fun." But fun with a purpose is different from "senseless fun," which is just fun without an achievement goal. Adults may have "fun" working out, but also have senseless fun playing golf, having a drink with friends, or going to a movie.

Adolescents are more likely to be "pruning" their interests as they figure out where their passions lie. Teenagers may do fewer activities overall, but spend more time on each of them. Of course, many teens will be experiencing great pressure (internal, external or both) to build the strongest possible college applications with the "right" mix of extracurricular activities, which may not line up with their actual interests. They will face the pressure also to be performing at a very high level academically. Some may have jobs, as they seek to build independence. Then add to this the fact that many will be driving themselves to each activity and wanting to spend time with friends and romantic interests, and you have a recipe for adolescents whose every moment is accounted for, to the point that they may skimp on sleep and mealtimes and feel overwhelmed. In choosing how to manage their schedules, adolescents also should be learning about the value of self-care, protecting time to relax, exercise, and sleep adequately (with a good measure of senseless fun texting as they build their identity).

So how do you help your patients and their parents reestablish some balance? You can start by figuring out if they are overscheduled. Ask if their school-age children have as many free afternoons as scheduled ones? Do they have recurring play dates as well as Russian and math classes? Do they have time for senseless fun with friends, siblings, and parents? Ask teenagers how much sleep they are getting? How often is the family able to have dinner together? When is the last time they had time to read a book for pleasure or to explore a new interest? Some children and teenagers may be very busy, but will report feeling like their battery is charged by all of their activities. Although they are busy, their schedule may be a good balance for them. But when children or teens report feeling drained by the end (or middle) of their week, they are likely overscheduled.

If parents resist some easing, you should begin to wonder if the child is the one who chose the activity or it represents a parent’s interests instead? Some parents may have strong feelings about what activities made a difference in their lives, and may not be paying attention to how their child’s temperament is different from their own. Sometimes, parents who are working might feel guilty that they are not as available as they’d like to be. They may sign their child up for many activities, hoping to make up for what they worry they are failing to directly provide their child. Parents may need a gentle reminder that a happy, calm dinner with mom and dad often is more developmentally productive than a rushed drive between two practices and a violin lesson.

Find out if specific activities are born of interest or obligation. Demanding obligatory activities should have important meaning for the child, such as Hebrew lessons prior to a Bar Mitzvah. There should be only one demanding activity that is not fun for a child at a time, though. The balance may come from fun or less-structured activities. Asking a child in front of the parents what activities are (or would be) the most fun or interesting for them can help the family to think through how to prune activities when a child is overscheduled, and remind parents of the value of play.

It also can be helpful to consider a child’s temperament when talking with a family about finding greater balance. If a child is very shy, there can be greater developmental value in activities that promote social skills, even though that child might not naturally seek those activities out. Teens who are struggling to fulfill basic responsibilities may need to have their schedules streamlined, but it is important to preserve an activity that may aid in cultivating their discipline and organization (such as a sports team or a job they value). Highly driven, ambitious adolescents sleeping only 4 hours a night to fulfill their many responsibilities would benefit from making time for relaxation and sleep, and hearing this from a pediatrician may be the critical factor in making it happen.

Finally, ask parents how drained they feel by facilitating their child’s (or children’s) schedule. When parents are so busy with their children’s activities that family time is nonexistent, or one child is receiving a greatly disproportionate share of the parents’ time, it is worth examining. Reminding parents that time spent together around the dinner table and helping with homework or in a shared activity – time that may leave them feeling more charged than drained as parents – is critical for the well-being of the whole family.

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.

Parents want to raise their children to be happy and successful in childhood and through adulthood. For many parents, this means giving their children as many opportunities to learn, practice, and master a wide variety of skills outside of school as they possibly can. These activities often include the study of a musical instrument, a sport, an activity in the arts, religious study, and even extra academic work such as math, computer science, or a second language. Each one of these activities can mean many classes or practices outside of the home each week and additional practice time at home.

When you combine these activities with school and homework, children can be busier than most professional adults. And their parents can feel like managing their child’s schedule is another full-time job. By asking parents how many afternoons and evenings are scheduled (or how many hours of down time their children have) each week, you begin a conversation that may help parents determine the right balance for each child and the family.

Without a doubt, there can be tremendous value in making time for extracurricular activities for children. School alone usually does not offer much exposure to music education and the arts, and a daily gym class is sadly a thing of the past for most children. There is a growing body of evidence that daily vigorous exercise in childhood not only promotes good physical health and restorative sleep, and fights obesity, but that it also promotes strong cognitive development and can prevent anxiety and mood symptoms. Sustained experience with a team sport cultivates discipline, frustration tolerance, and resilience alongside friendships and fun. Likewise, there is a growing body of evidence that learning to play a musical instrument contributes in broader ways to healthy cognitive development, cultivates discipline and frustration tolerance, and improves executive function and the attention and self-regulation skills that all school-age children need to develop. Exposure to the arts, to trade skills, or to rare languages may help children discover a unique interest or passion that will draw them through their adolescence. Discovering an area of passionate interest is one of the essential goals of childhood; it can help teens feel good about themselves, and is especially meaningful in children who may not be gaining a lot of self-esteem in other areas, such as schoolwork.

But the well-meant intentions of parents (or interests of children) sometimes can lead to so many extracurricular activities that children barely have time for homework, play, or relaxation. From kindergarten through middle school, children are at the perfect age to be exploring multiple activities as they learn about their own abilities, strengths, and interests. But it is a developmental period in which there also should be plenty of open, free creative play, often with a social component. This is where children not only learn about their own talents, but also try things they might fail at, developing their curiosity, social skills, self-awareness, and resilience. While it can be wonderful to have a weekly music lesson and a team sport at this age, it is critical that there also be protected free play or down time. During this developmental period, children may switch sports, instruments, or hobbies, and it is healthy that they have the time and space to do so. Parents will say that every hour of activity is "fun." But fun with a purpose is different from "senseless fun," which is just fun without an achievement goal. Adults may have "fun" working out, but also have senseless fun playing golf, having a drink with friends, or going to a movie.

Adolescents are more likely to be "pruning" their interests as they figure out where their passions lie. Teenagers may do fewer activities overall, but spend more time on each of them. Of course, many teens will be experiencing great pressure (internal, external or both) to build the strongest possible college applications with the "right" mix of extracurricular activities, which may not line up with their actual interests. They will face the pressure also to be performing at a very high level academically. Some may have jobs, as they seek to build independence. Then add to this the fact that many will be driving themselves to each activity and wanting to spend time with friends and romantic interests, and you have a recipe for adolescents whose every moment is accounted for, to the point that they may skimp on sleep and mealtimes and feel overwhelmed. In choosing how to manage their schedules, adolescents also should be learning about the value of self-care, protecting time to relax, exercise, and sleep adequately (with a good measure of senseless fun texting as they build their identity).

So how do you help your patients and their parents reestablish some balance? You can start by figuring out if they are overscheduled. Ask if their school-age children have as many free afternoons as scheduled ones? Do they have recurring play dates as well as Russian and math classes? Do they have time for senseless fun with friends, siblings, and parents? Ask teenagers how much sleep they are getting? How often is the family able to have dinner together? When is the last time they had time to read a book for pleasure or to explore a new interest? Some children and teenagers may be very busy, but will report feeling like their battery is charged by all of their activities. Although they are busy, their schedule may be a good balance for them. But when children or teens report feeling drained by the end (or middle) of their week, they are likely overscheduled.

If parents resist some easing, you should begin to wonder if the child is the one who chose the activity or it represents a parent’s interests instead? Some parents may have strong feelings about what activities made a difference in their lives, and may not be paying attention to how their child’s temperament is different from their own. Sometimes, parents who are working might feel guilty that they are not as available as they’d like to be. They may sign their child up for many activities, hoping to make up for what they worry they are failing to directly provide their child. Parents may need a gentle reminder that a happy, calm dinner with mom and dad often is more developmentally productive than a rushed drive between two practices and a violin lesson.

Find out if specific activities are born of interest or obligation. Demanding obligatory activities should have important meaning for the child, such as Hebrew lessons prior to a Bar Mitzvah. There should be only one demanding activity that is not fun for a child at a time, though. The balance may come from fun or less-structured activities. Asking a child in front of the parents what activities are (or would be) the most fun or interesting for them can help the family to think through how to prune activities when a child is overscheduled, and remind parents of the value of play.

It also can be helpful to consider a child’s temperament when talking with a family about finding greater balance. If a child is very shy, there can be greater developmental value in activities that promote social skills, even though that child might not naturally seek those activities out. Teens who are struggling to fulfill basic responsibilities may need to have their schedules streamlined, but it is important to preserve an activity that may aid in cultivating their discipline and organization (such as a sports team or a job they value). Highly driven, ambitious adolescents sleeping only 4 hours a night to fulfill their many responsibilities would benefit from making time for relaxation and sleep, and hearing this from a pediatrician may be the critical factor in making it happen.

Finally, ask parents how drained they feel by facilitating their child’s (or children’s) schedule. When parents are so busy with their children’s activities that family time is nonexistent, or one child is receiving a greatly disproportionate share of the parents’ time, it is worth examining. Reminding parents that time spent together around the dinner table and helping with homework or in a shared activity – time that may leave them feeling more charged than drained as parents – is critical for the well-being of the whole family.

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.

Parents want to raise their children to be happy and successful in childhood and through adulthood. For many parents, this means giving their children as many opportunities to learn, practice, and master a wide variety of skills outside of school as they possibly can. These activities often include the study of a musical instrument, a sport, an activity in the arts, religious study, and even extra academic work such as math, computer science, or a second language. Each one of these activities can mean many classes or practices outside of the home each week and additional practice time at home.

When you combine these activities with school and homework, children can be busier than most professional adults. And their parents can feel like managing their child’s schedule is another full-time job. By asking parents how many afternoons and evenings are scheduled (or how many hours of down time their children have) each week, you begin a conversation that may help parents determine the right balance for each child and the family.

Without a doubt, there can be tremendous value in making time for extracurricular activities for children. School alone usually does not offer much exposure to music education and the arts, and a daily gym class is sadly a thing of the past for most children. There is a growing body of evidence that daily vigorous exercise in childhood not only promotes good physical health and restorative sleep, and fights obesity, but that it also promotes strong cognitive development and can prevent anxiety and mood symptoms. Sustained experience with a team sport cultivates discipline, frustration tolerance, and resilience alongside friendships and fun. Likewise, there is a growing body of evidence that learning to play a musical instrument contributes in broader ways to healthy cognitive development, cultivates discipline and frustration tolerance, and improves executive function and the attention and self-regulation skills that all school-age children need to develop. Exposure to the arts, to trade skills, or to rare languages may help children discover a unique interest or passion that will draw them through their adolescence. Discovering an area of passionate interest is one of the essential goals of childhood; it can help teens feel good about themselves, and is especially meaningful in children who may not be gaining a lot of self-esteem in other areas, such as schoolwork.

But the well-meant intentions of parents (or interests of children) sometimes can lead to so many extracurricular activities that children barely have time for homework, play, or relaxation. From kindergarten through middle school, children are at the perfect age to be exploring multiple activities as they learn about their own abilities, strengths, and interests. But it is a developmental period in which there also should be plenty of open, free creative play, often with a social component. This is where children not only learn about their own talents, but also try things they might fail at, developing their curiosity, social skills, self-awareness, and resilience. While it can be wonderful to have a weekly music lesson and a team sport at this age, it is critical that there also be protected free play or down time. During this developmental period, children may switch sports, instruments, or hobbies, and it is healthy that they have the time and space to do so. Parents will say that every hour of activity is "fun." But fun with a purpose is different from "senseless fun," which is just fun without an achievement goal. Adults may have "fun" working out, but also have senseless fun playing golf, having a drink with friends, or going to a movie.

Adolescents are more likely to be "pruning" their interests as they figure out where their passions lie. Teenagers may do fewer activities overall, but spend more time on each of them. Of course, many teens will be experiencing great pressure (internal, external or both) to build the strongest possible college applications with the "right" mix of extracurricular activities, which may not line up with their actual interests. They will face the pressure also to be performing at a very high level academically. Some may have jobs, as they seek to build independence. Then add to this the fact that many will be driving themselves to each activity and wanting to spend time with friends and romantic interests, and you have a recipe for adolescents whose every moment is accounted for, to the point that they may skimp on sleep and mealtimes and feel overwhelmed. In choosing how to manage their schedules, adolescents also should be learning about the value of self-care, protecting time to relax, exercise, and sleep adequately (with a good measure of senseless fun texting as they build their identity).

So how do you help your patients and their parents reestablish some balance? You can start by figuring out if they are overscheduled. Ask if their school-age children have as many free afternoons as scheduled ones? Do they have recurring play dates as well as Russian and math classes? Do they have time for senseless fun with friends, siblings, and parents? Ask teenagers how much sleep they are getting? How often is the family able to have dinner together? When is the last time they had time to read a book for pleasure or to explore a new interest? Some children and teenagers may be very busy, but will report feeling like their battery is charged by all of their activities. Although they are busy, their schedule may be a good balance for them. But when children or teens report feeling drained by the end (or middle) of their week, they are likely overscheduled.

If parents resist some easing, you should begin to wonder if the child is the one who chose the activity or it represents a parent’s interests instead? Some parents may have strong feelings about what activities made a difference in their lives, and may not be paying attention to how their child’s temperament is different from their own. Sometimes, parents who are working might feel guilty that they are not as available as they’d like to be. They may sign their child up for many activities, hoping to make up for what they worry they are failing to directly provide their child. Parents may need a gentle reminder that a happy, calm dinner with mom and dad often is more developmentally productive than a rushed drive between two practices and a violin lesson.

Find out if specific activities are born of interest or obligation. Demanding obligatory activities should have important meaning for the child, such as Hebrew lessons prior to a Bar Mitzvah. There should be only one demanding activity that is not fun for a child at a time, though. The balance may come from fun or less-structured activities. Asking a child in front of the parents what activities are (or would be) the most fun or interesting for them can help the family to think through how to prune activities when a child is overscheduled, and remind parents of the value of play.

It also can be helpful to consider a child’s temperament when talking with a family about finding greater balance. If a child is very shy, there can be greater developmental value in activities that promote social skills, even though that child might not naturally seek those activities out. Teens who are struggling to fulfill basic responsibilities may need to have their schedules streamlined, but it is important to preserve an activity that may aid in cultivating their discipline and organization (such as a sports team or a job they value). Highly driven, ambitious adolescents sleeping only 4 hours a night to fulfill their many responsibilities would benefit from making time for relaxation and sleep, and hearing this from a pediatrician may be the critical factor in making it happen.

Finally, ask parents how drained they feel by facilitating their child’s (or children’s) schedule. When parents are so busy with their children’s activities that family time is nonexistent, or one child is receiving a greatly disproportionate share of the parents’ time, it is worth examining. Reminding parents that time spent together around the dinner table and helping with homework or in a shared activity – time that may leave them feeling more charged than drained as parents – is critical for the well-being of the whole family.

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.

Questions about sleep – from newborns to teenagers – are among the most common in pediatric practice. A good night’s sleep is in everyone’s best interest for daily functioning and healthy development. Asking about sleep also provides a window into the family’s perspectives on discipline, parental cooperation, family stresses, and views on a child’s developing autonomy.

During their first year, infants may need as many as 18 hours of sleep daily, and the duration of sleep gradually declines thereafter to 8-10 hours nightly in adolescence. Sleep plays an essential role in consolidating memories, attention, and other cognitive functions; the immune system; and metabolism. Additionally, developing healthy sleep habits is one of the first and most profound ways that children learn to expect consistency from their parents, to soothe themselves, and to manage limits. As a child grows, her ability to plan, manage anxiety, and exercise discipline is cultivated through managing her sleep with increasing independence.

Preschoolers who are not getting adequate sleep may have behavioral problems, particularly in new settings (like school) or at transitional times (like bedtime). When a preschooler presents with hyperactivity, irritability, and tantrums, or failure to keep up with developmental expectations, asking about sleep patterns is a good early step. Although sleep disruption may be symptomatic of psychiatric disorders related to mood, anxiety, or attention, before you consider a disorder and treatment make sure that tensions at bedtime and poor sleeping habits are not a major factor.

How do you help tired, stressed parents encourage or enforce healthy sleep habits? Does the family have a routine after dinner that allows a child to settle down (such as taking a bath and then a quiet activity like reading a book with a parent)? Are the parents able to enforce this routine consistently, or does bedtime get dragged out for hours? And if so, why? In addition to ensuring that a child gets enough exercise during the day (but not in the hour before bed), parents will need to turn off the lights at a reasonably early hour so that a child may get adequate sleep before they will awaken with daylight.

Many parents will delay sleep until later as children push to stay awake and play. Sometimes, if both parents work and feel their only time with their children is after they return from work well into the evening, they may want more time with their children or feel guilty about having a strict, early bedtime routine. Reassure parents that even a short stretch of quality time with their children (reading to them, snuggling, asking about their day) is enough to nurture a profound connection.

"Screen time" merits special mention, especially in younger children. Letting children watch television or play on computers in order to "unwind" at the end of a long day is common, but in the time before bed, screen content can be very disruptive to restful sleep. Parents should assess if "screen time" is helping or hurting their child’s ability to fall asleep. Some families have found it helpful to have no screen time (any screen: television, computer, tablet, or cell phone) within 1 hour of lights going out: back-lit screens suppress endogenous melatonin release and can delay sleep. With school-age children, reading at bedtime is certainly preferable to an additional hour of computer time.

It is also worth asking where a child is sleeping. Do they have their own bed? Are they alone in their room? Is their room on the same level of the house as their parents’ room? Children who are anxious may sleep better if they share a room with a sibling or are close to their parents’ room. On the other hand, if they sleep with a sibling who is waking often during the night, they may have disrupted sleep.

It is worth finding out if a child is able to sleep through the night in their own bed. Many children have their own bed and room, but have a routine of sleeping in their parents’ bed. This usually results in inadequate sleep for both child and parents, and a child who does not learn how to appropriately soothe himself. Is it permissible for a child to climb into their parents’ bed in the middle of the night once in a while, if they have a bad dream, do not feel well, or have faced a stressful day? Yes. Is a child arguing to go to sleep in their parents’ bed, refusing to sleep in their own bed, with their parents "giving in"? Then it is a habit worth undoing.

School-age children who are not getting adequate sleep also may appear more irritable, forgetful, and inattentive, and they may have problems with academic, athletic, and social performance. These are years in which children start to have more independence and responsibility for their bedtime routines. They may have greater access to screens in the evening, and may be in charge of setting an alarm or turning their light out. These are also years in which children are more likely to experience anxiety, as they face and manage a host of new challenges. Anxiety can be very disruptive of restful sleep, and will in turn cause more problems about which these children get anxious. Alongside their greater responsibility, school-age children still need basic and consistently enforced ground rules about sleep in order to build independence. Clearly at this age, reading before bedtime is a good option.

Parents should help their school-age children to start their homework early, and to enjoy screen time, but not within an hour of bedtime, and to follow a consistent (and more independent) routine before bed. Do they have a consistent bedtime? Do they take a shower or bath each night? (A hot shower or bath naturally cues the body that it is time for sleep as the body’s core temperature rises and then drops.) Do they read before lights out? Is the house quiet at their bedtime? Parents should also find out if their children have worries that are making it difficult to go to sleep. Are they worried about a test or big game? Or about bigger issues of safety? Parents can help a child to discuss their worries and address those that are addressable; usually, this is enough to help children learn to master their worries. When a school-age child’s anxiety does not improve with open discussion, then it may be helpful to have a more formal evaluation for anxiety with a mental health clinician.

Adolescence is a time in which sleep patterns naturally shift, while the need for sleep remains robust. Teenagers become tired later and need to sleep in until later in the morning, just at the same time that school demands impinge on sleep with an earlier start to the day and more extensive homework at night. Older adolescents may go out with friends on weekends and shift their bedtime routine by 4 or more hours for two nights out of every seven, which is as profoundly disruptive to restful sleep as traveling across four time zones and back every week. These are years in which more independence can again lead to more screen use in the evening, whether for writing a paper on a computer or texting a friend late into the night.

An adolescent who is sleep deprived may have low energy, be forgetful and distractible, and see their academic and athletic performance suffer. They may appear more withdrawn or moody. This is an age in which serious mood problems, such as depression, are more likely to emerge, and are associated with sleep problems. But these problems will not improve with simple sleep hygiene interventions; thus, the teens who do not get better after these interventions may need a psychiatric evaluation.

The strategies that might help adolescents are not much different from those for younger children. It is important with adolescents, however, to explain why they should exercise regularly, have a consistent bedtime routine, and not bring their cell phone to bed. While parents should still be able to set and enforce ground rules, they also need to be equipping their adolescents to understand and manage their sleep independently, which they will need to do soon enough. Encouraging self-regulation between ages 13 and 17 is essential as college or independence approaches, and efforts at control are hard to enforce and send the wrong message.

Inconsistent, inadequate sleep often reflects what has been a frustrating struggle for parents. Asking questions about sleep gives parents the supportive message that sleep is challenging and important, and may empower them to approach it with renewed firmness and clarity. When you help parents to set routines and limits that support consistent, adequate sleep, their children will be on a path to healthy development.

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.

Questions about sleep – from newborns to teenagers – are among the most common in pediatric practice. A good night’s sleep is in everyone’s best interest for daily functioning and healthy development. Asking about sleep also provides a window into the family’s perspectives on discipline, parental cooperation, family stresses, and views on a child’s developing autonomy.

During their first year, infants may need as many as 18 hours of sleep daily, and the duration of sleep gradually declines thereafter to 8-10 hours nightly in adolescence. Sleep plays an essential role in consolidating memories, attention, and other cognitive functions; the immune system; and metabolism. Additionally, developing healthy sleep habits is one of the first and most profound ways that children learn to expect consistency from their parents, to soothe themselves, and to manage limits. As a child grows, her ability to plan, manage anxiety, and exercise discipline is cultivated through managing her sleep with increasing independence.

Preschoolers who are not getting adequate sleep may have behavioral problems, particularly in new settings (like school) or at transitional times (like bedtime). When a preschooler presents with hyperactivity, irritability, and tantrums, or failure to keep up with developmental expectations, asking about sleep patterns is a good early step. Although sleep disruption may be symptomatic of psychiatric disorders related to mood, anxiety, or attention, before you consider a disorder and treatment make sure that tensions at bedtime and poor sleeping habits are not a major factor.

How do you help tired, stressed parents encourage or enforce healthy sleep habits? Does the family have a routine after dinner that allows a child to settle down (such as taking a bath and then a quiet activity like reading a book with a parent)? Are the parents able to enforce this routine consistently, or does bedtime get dragged out for hours? And if so, why? In addition to ensuring that a child gets enough exercise during the day (but not in the hour before bed), parents will need to turn off the lights at a reasonably early hour so that a child may get adequate sleep before they will awaken with daylight.

Many parents will delay sleep until later as children push to stay awake and play. Sometimes, if both parents work and feel their only time with their children is after they return from work well into the evening, they may want more time with their children or feel guilty about having a strict, early bedtime routine. Reassure parents that even a short stretch of quality time with their children (reading to them, snuggling, asking about their day) is enough to nurture a profound connection.

"Screen time" merits special mention, especially in younger children. Letting children watch television or play on computers in order to "unwind" at the end of a long day is common, but in the time before bed, screen content can be very disruptive to restful sleep. Parents should assess if "screen time" is helping or hurting their child’s ability to fall asleep. Some families have found it helpful to have no screen time (any screen: television, computer, tablet, or cell phone) within 1 hour of lights going out: back-lit screens suppress endogenous melatonin release and can delay sleep. With school-age children, reading at bedtime is certainly preferable to an additional hour of computer time.

It is also worth asking where a child is sleeping. Do they have their own bed? Are they alone in their room? Is their room on the same level of the house as their parents’ room? Children who are anxious may sleep better if they share a room with a sibling or are close to their parents’ room. On the other hand, if they sleep with a sibling who is waking often during the night, they may have disrupted sleep.

It is worth finding out if a child is able to sleep through the night in their own bed. Many children have their own bed and room, but have a routine of sleeping in their parents’ bed. This usually results in inadequate sleep for both child and parents, and a child who does not learn how to appropriately soothe himself. Is it permissible for a child to climb into their parents’ bed in the middle of the night once in a while, if they have a bad dream, do not feel well, or have faced a stressful day? Yes. Is a child arguing to go to sleep in their parents’ bed, refusing to sleep in their own bed, with their parents "giving in"? Then it is a habit worth undoing.

School-age children who are not getting adequate sleep also may appear more irritable, forgetful, and inattentive, and they may have problems with academic, athletic, and social performance. These are years in which children start to have more independence and responsibility for their bedtime routines. They may have greater access to screens in the evening, and may be in charge of setting an alarm or turning their light out. These are also years in which children are more likely to experience anxiety, as they face and manage a host of new challenges. Anxiety can be very disruptive of restful sleep, and will in turn cause more problems about which these children get anxious. Alongside their greater responsibility, school-age children still need basic and consistently enforced ground rules about sleep in order to build independence. Clearly at this age, reading before bedtime is a good option.

Parents should help their school-age children to start their homework early, and to enjoy screen time, but not within an hour of bedtime, and to follow a consistent (and more independent) routine before bed. Do they have a consistent bedtime? Do they take a shower or bath each night? (A hot shower or bath naturally cues the body that it is time for sleep as the body’s core temperature rises and then drops.) Do they read before lights out? Is the house quiet at their bedtime? Parents should also find out if their children have worries that are making it difficult to go to sleep. Are they worried about a test or big game? Or about bigger issues of safety? Parents can help a child to discuss their worries and address those that are addressable; usually, this is enough to help children learn to master their worries. When a school-age child’s anxiety does not improve with open discussion, then it may be helpful to have a more formal evaluation for anxiety with a mental health clinician.

Adolescence is a time in which sleep patterns naturally shift, while the need for sleep remains robust. Teenagers become tired later and need to sleep in until later in the morning, just at the same time that school demands impinge on sleep with an earlier start to the day and more extensive homework at night. Older adolescents may go out with friends on weekends and shift their bedtime routine by 4 or more hours for two nights out of every seven, which is as profoundly disruptive to restful sleep as traveling across four time zones and back every week. These are years in which more independence can again lead to more screen use in the evening, whether for writing a paper on a computer or texting a friend late into the night.

An adolescent who is sleep deprived may have low energy, be forgetful and distractible, and see their academic and athletic performance suffer. They may appear more withdrawn or moody. This is an age in which serious mood problems, such as depression, are more likely to emerge, and are associated with sleep problems. But these problems will not improve with simple sleep hygiene interventions; thus, the teens who do not get better after these interventions may need a psychiatric evaluation.

The strategies that might help adolescents are not much different from those for younger children. It is important with adolescents, however, to explain why they should exercise regularly, have a consistent bedtime routine, and not bring their cell phone to bed. While parents should still be able to set and enforce ground rules, they also need to be equipping their adolescents to understand and manage their sleep independently, which they will need to do soon enough. Encouraging self-regulation between ages 13 and 17 is essential as college or independence approaches, and efforts at control are hard to enforce and send the wrong message.

Inconsistent, inadequate sleep often reflects what has been a frustrating struggle for parents. Asking questions about sleep gives parents the supportive message that sleep is challenging and important, and may empower them to approach it with renewed firmness and clarity. When you help parents to set routines and limits that support consistent, adequate sleep, their children will be on a path to healthy development.

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.

Questions about sleep – from newborns to teenagers – are among the most common in pediatric practice. A good night’s sleep is in everyone’s best interest for daily functioning and healthy development. Asking about sleep also provides a window into the family’s perspectives on discipline, parental cooperation, family stresses, and views on a child’s developing autonomy.

During their first year, infants may need as many as 18 hours of sleep daily, and the duration of sleep gradually declines thereafter to 8-10 hours nightly in adolescence. Sleep plays an essential role in consolidating memories, attention, and other cognitive functions; the immune system; and metabolism. Additionally, developing healthy sleep habits is one of the first and most profound ways that children learn to expect consistency from their parents, to soothe themselves, and to manage limits. As a child grows, her ability to plan, manage anxiety, and exercise discipline is cultivated through managing her sleep with increasing independence.

Preschoolers who are not getting adequate sleep may have behavioral problems, particularly in new settings (like school) or at transitional times (like bedtime). When a preschooler presents with hyperactivity, irritability, and tantrums, or failure to keep up with developmental expectations, asking about sleep patterns is a good early step. Although sleep disruption may be symptomatic of psychiatric disorders related to mood, anxiety, or attention, before you consider a disorder and treatment make sure that tensions at bedtime and poor sleeping habits are not a major factor.

How do you help tired, stressed parents encourage or enforce healthy sleep habits? Does the family have a routine after dinner that allows a child to settle down (such as taking a bath and then a quiet activity like reading a book with a parent)? Are the parents able to enforce this routine consistently, or does bedtime get dragged out for hours? And if so, why? In addition to ensuring that a child gets enough exercise during the day (but not in the hour before bed), parents will need to turn off the lights at a reasonably early hour so that a child may get adequate sleep before they will awaken with daylight.

Many parents will delay sleep until later as children push to stay awake and play. Sometimes, if both parents work and feel their only time with their children is after they return from work well into the evening, they may want more time with their children or feel guilty about having a strict, early bedtime routine. Reassure parents that even a short stretch of quality time with their children (reading to them, snuggling, asking about their day) is enough to nurture a profound connection.

"Screen time" merits special mention, especially in younger children. Letting children watch television or play on computers in order to "unwind" at the end of a long day is common, but in the time before bed, screen content can be very disruptive to restful sleep. Parents should assess if "screen time" is helping or hurting their child’s ability to fall asleep. Some families have found it helpful to have no screen time (any screen: television, computer, tablet, or cell phone) within 1 hour of lights going out: back-lit screens suppress endogenous melatonin release and can delay sleep. With school-age children, reading at bedtime is certainly preferable to an additional hour of computer time.

It is also worth asking where a child is sleeping. Do they have their own bed? Are they alone in their room? Is their room on the same level of the house as their parents’ room? Children who are anxious may sleep better if they share a room with a sibling or are close to their parents’ room. On the other hand, if they sleep with a sibling who is waking often during the night, they may have disrupted sleep.

It is worth finding out if a child is able to sleep through the night in their own bed. Many children have their own bed and room, but have a routine of sleeping in their parents’ bed. This usually results in inadequate sleep for both child and parents, and a child who does not learn how to appropriately soothe himself. Is it permissible for a child to climb into their parents’ bed in the middle of the night once in a while, if they have a bad dream, do not feel well, or have faced a stressful day? Yes. Is a child arguing to go to sleep in their parents’ bed, refusing to sleep in their own bed, with their parents "giving in"? Then it is a habit worth undoing.

School-age children who are not getting adequate sleep also may appear more irritable, forgetful, and inattentive, and they may have problems with academic, athletic, and social performance. These are years in which children start to have more independence and responsibility for their bedtime routines. They may have greater access to screens in the evening, and may be in charge of setting an alarm or turning their light out. These are also years in which children are more likely to experience anxiety, as they face and manage a host of new challenges. Anxiety can be very disruptive of restful sleep, and will in turn cause more problems about which these children get anxious. Alongside their greater responsibility, school-age children still need basic and consistently enforced ground rules about sleep in order to build independence. Clearly at this age, reading before bedtime is a good option.

Parents should help their school-age children to start their homework early, and to enjoy screen time, but not within an hour of bedtime, and to follow a consistent (and more independent) routine before bed. Do they have a consistent bedtime? Do they take a shower or bath each night? (A hot shower or bath naturally cues the body that it is time for sleep as the body’s core temperature rises and then drops.) Do they read before lights out? Is the house quiet at their bedtime? Parents should also find out if their children have worries that are making it difficult to go to sleep. Are they worried about a test or big game? Or about bigger issues of safety? Parents can help a child to discuss their worries and address those that are addressable; usually, this is enough to help children learn to master their worries. When a school-age child’s anxiety does not improve with open discussion, then it may be helpful to have a more formal evaluation for anxiety with a mental health clinician.

Adolescence is a time in which sleep patterns naturally shift, while the need for sleep remains robust. Teenagers become tired later and need to sleep in until later in the morning, just at the same time that school demands impinge on sleep with an earlier start to the day and more extensive homework at night. Older adolescents may go out with friends on weekends and shift their bedtime routine by 4 or more hours for two nights out of every seven, which is as profoundly disruptive to restful sleep as traveling across four time zones and back every week. These are years in which more independence can again lead to more screen use in the evening, whether for writing a paper on a computer or texting a friend late into the night.

An adolescent who is sleep deprived may have low energy, be forgetful and distractible, and see their academic and athletic performance suffer. They may appear more withdrawn or moody. This is an age in which serious mood problems, such as depression, are more likely to emerge, and are associated with sleep problems. But these problems will not improve with simple sleep hygiene interventions; thus, the teens who do not get better after these interventions may need a psychiatric evaluation.

The strategies that might help adolescents are not much different from those for younger children. It is important with adolescents, however, to explain why they should exercise regularly, have a consistent bedtime routine, and not bring their cell phone to bed. While parents should still be able to set and enforce ground rules, they also need to be equipping their adolescents to understand and manage their sleep independently, which they will need to do soon enough. Encouraging self-regulation between ages 13 and 17 is essential as college or independence approaches, and efforts at control are hard to enforce and send the wrong message.

Inconsistent, inadequate sleep often reflects what has been a frustrating struggle for parents. Asking questions about sleep gives parents the supportive message that sleep is challenging and important, and may empower them to approach it with renewed firmness and clarity. When you help parents to set routines and limits that support consistent, adequate sleep, their children will be on a path to healthy development.

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.

If you ask the parents in your practice what their most important task is with their children, they will probably say something about keeping their child safe and developing their child’s character. They might speak about wanting to raise children who are ready to live independently, happily, and successfully. Beyond independence, they may also observe that they want to raise children of good character, with a deeply held value system that reflects their own core principles. The details of such a value system will vary from family to family, but often will include descriptive ideals such as being ethical, empathic, courageous, generous, ambitious, responsible, and having integrity. Because the everyday tasks of life with children can be so demanding, this larger task often does not get much direct attention from physicians and may not even be explicitly discussed between parents. A few questions from their physician can be profoundly helpful to parents as they reflect on practical strategies to cultivate the qualities of character that will prepare their children to live independent, happy, purposeful, and meaningful adult lives.

One way to get a sense of how parents are preparing their children for independence is to ask how they are they teaching their children about the value of money. Do they give their children a predictable allowance? Is it contingent on chores or responsibilities? Do their children have a bank account or a piggy bank? Do they spend time talking with their children about how they manage their money or plan for large purchases? Money is often a charged subject for families. Asking about it explicitly can help support open, thoughtful communication within the family. Parents will be very interested to learn that such discussions and efforts can powerfully support the development of independence, self-confidence, patience, good judgment, and responsibility in their children. You might inform parents that they can consider their child’s natural temperament when having these discussions. An anxious child, who may be prone to worries about poverty and perfection, might benefit from hearing that money is something that everyone needs to learn how to manage, and it is a tool that can make life easier, but it is not a measure of a person’s worth. On the other hand, a very easygoing child may benefit from having an allowance that is contingent on chores or an adolescent could be urged to get a job rather than depend on allowance. This is how they will learn the real value of work and will cultivate discipline, planning, and the meaningful confidence that they know how to work hard. Whether a family is struggling or can afford more than they choose to spend, the values inherent in financial decisions will be very meaningful for the preadolescent or teenager.

While all parents would likely agree that they hope to raise children who are disciplined, responsible, and independent, the other values that they hope their children appreciate and integrate will cover a wider territory. If you understand what the parents in your practice consider to be their most important values, it also will enhance your understanding of that family’s priorities and how they will manage challenges. You might ask them, "What three values, such as caring about others, honesty, or bravery, would you most like to cultivate in your children?" For those parents that have not actively reflected on their values and behavior or where there are differences between parents concerning values, this may be the start of an important conversation at home.

With ethical qualities that are interpersonal, such as empathy or generosity, there is a growing body of evidence in the psychological literature that suggests that children are much more likely to emulate their parents’ behavior than to follow their suggestions. In a classic experiment published in 1975, the psychologist J. Philippe Rushton observed how school-age children’s generous behaviors correspond with the generous (or selfish) behaviors or suggestions of parents and teachers. Rushton found that there was a very robust relationship between what the adults did and what the children did, one that could powerfully counteract what the adults said (when they disagreed). It seems actions truly do speak louder than words.

Clearly, parents should actively pay attention to how they are living their values, demonstrating them to their children in choices they make, both large and small. Then they can consider what experiences might encourage these values for their children. If they value empathy, what sorts of experiences will give their children the chance to experience and develop empathy for others? They might think about school-based activities or hobbies that can foster empathy. Is there an activity dedicated to helping children in need or to partnering with children with physical disabilities? Perhaps there is a group of children that work toward a chosen public service. If there is not such a group at their children’s school, they should consider starting one. By living these values, by doing it in a way that teaches these values to other children, and by being involved in their children’s school experience, parents can very powerfully nourish the development of these values and behaviors in their children.

Parents also might keep these important values in mind as they are helping their older children choose extracurricular activities or apply for summer jobs. While their children are considering what is most interesting to them, what will "look good" on a college application, or how to make the most money, parents might keep in mind how important values, such as empathy, generosity, bravery, discipline, or patience might be nurtured by the various experiences. Ultimately, these will be their teenager’s choices to make, but parents can still have a powerful influence by showing an interest and highlighting the importance of principles beyond dollars or college ambitions.

Emphasizing the potency of modeling treasured values does not mean that parents shouldn’t also talk about these values and even mixed feelings as they approach difficult, value-laden decisions in their own lives. What matters is how such values are discussed. Praise is powerful, and it appears that when parents praise a child’s character, it is even more powerful than when they praise a behavior. This is especially true for younger children (6- to 12-year-olds), when children lightly try on many different behaviors but are considering the kinds of people they wish to be. Likewise, when children fail to live up to their parents’ values, it is effective for parents to share their disappointment, but they should take care not to shame their children, which leave children feeling discouraged and powerless to change.

Beyond praise and reproach, when parents talk openly and with curiosity about these complex, nuanced topics, and genuinely listen to their children’s questions, thoughts, and opinions about them, they are communicating that their child’s thinking, feelings, and character are valued. Parents should look for opportunities to discuss values one step removed from their children. They could discuss characters’ choices in a movie or book, issues faced by their or their children’s friends, challenges managed by a celebrated athlete or celebrity or even events in a reality television show they have watched together. With these conversations, they are helping their children nurture their own ideas about values and demonstrating genuine confidence that their children can develop their own opinions about such complex matters. They also contribute to a climate in which their children appreciate that values should be carefully considered and may evolve over time. These conversations will be most helpful as their teenagers become more autonomous and face choices on their own in late high school, college, and young adulthood. They will build a strong foundation on which their children will gradually construct their own considered, individual value system, one they can reflect upon and modify over their lifetime.

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.

If you ask the parents in your practice what their most important task is with their children, they will probably say something about keeping their child safe and developing their child’s character. They might speak about wanting to raise children who are ready to live independently, happily, and successfully. Beyond independence, they may also observe that they want to raise children of good character, with a deeply held value system that reflects their own core principles. The details of such a value system will vary from family to family, but often will include descriptive ideals such as being ethical, empathic, courageous, generous, ambitious, responsible, and having integrity. Because the everyday tasks of life with children can be so demanding, this larger task often does not get much direct attention from physicians and may not even be explicitly discussed between parents. A few questions from their physician can be profoundly helpful to parents as they reflect on practical strategies to cultivate the qualities of character that will prepare their children to live independent, happy, purposeful, and meaningful adult lives.

One way to get a sense of how parents are preparing their children for independence is to ask how they are they teaching their children about the value of money. Do they give their children a predictable allowance? Is it contingent on chores or responsibilities? Do their children have a bank account or a piggy bank? Do they spend time talking with their children about how they manage their money or plan for large purchases? Money is often a charged subject for families. Asking about it explicitly can help support open, thoughtful communication within the family. Parents will be very interested to learn that such discussions and efforts can powerfully support the development of independence, self-confidence, patience, good judgment, and responsibility in their children. You might inform parents that they can consider their child’s natural temperament when having these discussions. An anxious child, who may be prone to worries about poverty and perfection, might benefit from hearing that money is something that everyone needs to learn how to manage, and it is a tool that can make life easier, but it is not a measure of a person’s worth. On the other hand, a very easygoing child may benefit from having an allowance that is contingent on chores or an adolescent could be urged to get a job rather than depend on allowance. This is how they will learn the real value of work and will cultivate discipline, planning, and the meaningful confidence that they know how to work hard. Whether a family is struggling or can afford more than they choose to spend, the values inherent in financial decisions will be very meaningful for the preadolescent or teenager.

While all parents would likely agree that they hope to raise children who are disciplined, responsible, and independent, the other values that they hope their children appreciate and integrate will cover a wider territory. If you understand what the parents in your practice consider to be their most important values, it also will enhance your understanding of that family’s priorities and how they will manage challenges. You might ask them, "What three values, such as caring about others, honesty, or bravery, would you most like to cultivate in your children?" For those parents that have not actively reflected on their values and behavior or where there are differences between parents concerning values, this may be the start of an important conversation at home.

With ethical qualities that are interpersonal, such as empathy or generosity, there is a growing body of evidence in the psychological literature that suggests that children are much more likely to emulate their parents’ behavior than to follow their suggestions. In a classic experiment published in 1975, the psychologist J. Philippe Rushton observed how school-age children’s generous behaviors correspond with the generous (or selfish) behaviors or suggestions of parents and teachers. Rushton found that there was a very robust relationship between what the adults did and what the children did, one that could powerfully counteract what the adults said (when they disagreed). It seems actions truly do speak louder than words.

Clearly, parents should actively pay attention to how they are living their values, demonstrating them to their children in choices they make, both large and small. Then they can consider what experiences might encourage these values for their children. If they value empathy, what sorts of experiences will give their children the chance to experience and develop empathy for others? They might think about school-based activities or hobbies that can foster empathy. Is there an activity dedicated to helping children in need or to partnering with children with physical disabilities? Perhaps there is a group of children that work toward a chosen public service. If there is not such a group at their children’s school, they should consider starting one. By living these values, by doing it in a way that teaches these values to other children, and by being involved in their children’s school experience, parents can very powerfully nourish the development of these values and behaviors in their children.

Parents also might keep these important values in mind as they are helping their older children choose extracurricular activities or apply for summer jobs. While their children are considering what is most interesting to them, what will "look good" on a college application, or how to make the most money, parents might keep in mind how important values, such as empathy, generosity, bravery, discipline, or patience might be nurtured by the various experiences. Ultimately, these will be their teenager’s choices to make, but parents can still have a powerful influence by showing an interest and highlighting the importance of principles beyond dollars or college ambitions.

Emphasizing the potency of modeling treasured values does not mean that parents shouldn’t also talk about these values and even mixed feelings as they approach difficult, value-laden decisions in their own lives. What matters is how such values are discussed. Praise is powerful, and it appears that when parents praise a child’s character, it is even more powerful than when they praise a behavior. This is especially true for younger children (6- to 12-year-olds), when children lightly try on many different behaviors but are considering the kinds of people they wish to be. Likewise, when children fail to live up to their parents’ values, it is effective for parents to share their disappointment, but they should take care not to shame their children, which leave children feeling discouraged and powerless to change.

Beyond praise and reproach, when parents talk openly and with curiosity about these complex, nuanced topics, and genuinely listen to their children’s questions, thoughts, and opinions about them, they are communicating that their child’s thinking, feelings, and character are valued. Parents should look for opportunities to discuss values one step removed from their children. They could discuss characters’ choices in a movie or book, issues faced by their or their children’s friends, challenges managed by a celebrated athlete or celebrity or even events in a reality television show they have watched together. With these conversations, they are helping their children nurture their own ideas about values and demonstrating genuine confidence that their children can develop their own opinions about such complex matters. They also contribute to a climate in which their children appreciate that values should be carefully considered and may evolve over time. These conversations will be most helpful as their teenagers become more autonomous and face choices on their own in late high school, college, and young adulthood. They will build a strong foundation on which their children will gradually construct their own considered, individual value system, one they can reflect upon and modify over their lifetime.

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.

If you ask the parents in your practice what their most important task is with their children, they will probably say something about keeping their child safe and developing their child’s character. They might speak about wanting to raise children who are ready to live independently, happily, and successfully. Beyond independence, they may also observe that they want to raise children of good character, with a deeply held value system that reflects their own core principles. The details of such a value system will vary from family to family, but often will include descriptive ideals such as being ethical, empathic, courageous, generous, ambitious, responsible, and having integrity. Because the everyday tasks of life with children can be so demanding, this larger task often does not get much direct attention from physicians and may not even be explicitly discussed between parents. A few questions from their physician can be profoundly helpful to parents as they reflect on practical strategies to cultivate the qualities of character that will prepare their children to live independent, happy, purposeful, and meaningful adult lives.

One way to get a sense of how parents are preparing their children for independence is to ask how they are they teaching their children about the value of money. Do they give their children a predictable allowance? Is it contingent on chores or responsibilities? Do their children have a bank account or a piggy bank? Do they spend time talking with their children about how they manage their money or plan for large purchases? Money is often a charged subject for families. Asking about it explicitly can help support open, thoughtful communication within the family. Parents will be very interested to learn that such discussions and efforts can powerfully support the development of independence, self-confidence, patience, good judgment, and responsibility in their children. You might inform parents that they can consider their child’s natural temperament when having these discussions. An anxious child, who may be prone to worries about poverty and perfection, might benefit from hearing that money is something that everyone needs to learn how to manage, and it is a tool that can make life easier, but it is not a measure of a person’s worth. On the other hand, a very easygoing child may benefit from having an allowance that is contingent on chores or an adolescent could be urged to get a job rather than depend on allowance. This is how they will learn the real value of work and will cultivate discipline, planning, and the meaningful confidence that they know how to work hard. Whether a family is struggling or can afford more than they choose to spend, the values inherent in financial decisions will be very meaningful for the preadolescent or teenager.

While all parents would likely agree that they hope to raise children who are disciplined, responsible, and independent, the other values that they hope their children appreciate and integrate will cover a wider territory. If you understand what the parents in your practice consider to be their most important values, it also will enhance your understanding of that family’s priorities and how they will manage challenges. You might ask them, "What three values, such as caring about others, honesty, or bravery, would you most like to cultivate in your children?" For those parents that have not actively reflected on their values and behavior or where there are differences between parents concerning values, this may be the start of an important conversation at home.

With ethical qualities that are interpersonal, such as empathy or generosity, there is a growing body of evidence in the psychological literature that suggests that children are much more likely to emulate their parents’ behavior than to follow their suggestions. In a classic experiment published in 1975, the psychologist J. Philippe Rushton observed how school-age children’s generous behaviors correspond with the generous (or selfish) behaviors or suggestions of parents and teachers. Rushton found that there was a very robust relationship between what the adults did and what the children did, one that could powerfully counteract what the adults said (when they disagreed). It seems actions truly do speak louder than words.

Clearly, parents should actively pay attention to how they are living their values, demonstrating them to their children in choices they make, both large and small. Then they can consider what experiences might encourage these values for their children. If they value empathy, what sorts of experiences will give their children the chance to experience and develop empathy for others? They might think about school-based activities or hobbies that can foster empathy. Is there an activity dedicated to helping children in need or to partnering with children with physical disabilities? Perhaps there is a group of children that work toward a chosen public service. If there is not such a group at their children’s school, they should consider starting one. By living these values, by doing it in a way that teaches these values to other children, and by being involved in their children’s school experience, parents can very powerfully nourish the development of these values and behaviors in their children.

Parents also might keep these important values in mind as they are helping their older children choose extracurricular activities or apply for summer jobs. While their children are considering what is most interesting to them, what will "look good" on a college application, or how to make the most money, parents might keep in mind how important values, such as empathy, generosity, bravery, discipline, or patience might be nurtured by the various experiences. Ultimately, these will be their teenager’s choices to make, but parents can still have a powerful influence by showing an interest and highlighting the importance of principles beyond dollars or college ambitions.

Emphasizing the potency of modeling treasured values does not mean that parents shouldn’t also talk about these values and even mixed feelings as they approach difficult, value-laden decisions in their own lives. What matters is how such values are discussed. Praise is powerful, and it appears that when parents praise a child’s character, it is even more powerful than when they praise a behavior. This is especially true for younger children (6- to 12-year-olds), when children lightly try on many different behaviors but are considering the kinds of people they wish to be. Likewise, when children fail to live up to their parents’ values, it is effective for parents to share their disappointment, but they should take care not to shame their children, which leave children feeling discouraged and powerless to change.

Beyond praise and reproach, when parents talk openly and with curiosity about these complex, nuanced topics, and genuinely listen to their children’s questions, thoughts, and opinions about them, they are communicating that their child’s thinking, feelings, and character are valued. Parents should look for opportunities to discuss values one step removed from their children. They could discuss characters’ choices in a movie or book, issues faced by their or their children’s friends, challenges managed by a celebrated athlete or celebrity or even events in a reality television show they have watched together. With these conversations, they are helping their children nurture their own ideas about values and demonstrating genuine confidence that their children can develop their own opinions about such complex matters. They also contribute to a climate in which their children appreciate that values should be carefully considered and may evolve over time. These conversations will be most helpful as their teenagers become more autonomous and face choices on their own in late high school, college, and young adulthood. They will build a strong foundation on which their children will gradually construct their own considered, individual value system, one they can reflect upon and modify over their lifetime.

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.

Technology and social media now occupy a central place in the lives of our children and adolescents. According to data from the Pew Research Center in 2012, 75% of U.S. adolescents text. Texting has far outpaced phone calls and e-mail among adolescents as the primary means of (electronic) communication with family and friends. The number of texts they send has grown dramatically over the last few years, with a median of 100 texts sent daily among older adolescent girls in 2012. And it is increasingly challenging to distinguish texting from communication via other social media platforms: Flickr, Tumblr, Snapchat, Instagram, and Twitter. The new technology has augmented the local park or hangout as an essential aspect of adolescents developing their identity through intense interaction with peers.

We physicians who orbit the lives of adolescents may have difficulty keeping up with these developments, but we have a responsibility to be curious with our patients and their parents about the use of social media. We appreciate the developmental forces in adolescence that lead to new independence, heightened impulsivity, the intense importance of friendships, and sexual curiosity. When these developmental forces play out online rather than in high school hallways, there are new risks of unexpected consequences, serious psychological and even legal complications. In the same way that we speak with our patients and their parents about other risky behaviors, we should be curious about patients’ online behaviors and be prepared to offer them guidance as to how to lower risk and offer their parents guidance in establishing and enforcing reasonable rules and boundaries.

Texting is an increasingly commonplace means of communication. Many families will provide a new sixth grader with a cell phone to help the child manage a new bus route or a solo walk home, and texting can be an efficient way to stay connected.

But texting can pose a particular problem when it includes sexual material, or "sexting." Definitions vary, but sexting is most consistently defined as the taking of an explicit photograph of oneself and sending it to another via text or e-mail. There have been few controlled studies, but smaller surveys have suggested that between 20% and 30% of older adolescents have sent a sext, and a higher percentage have received them. Most of those sending these explicit photos are girls, and more than half of them report having been pressured to do so by a boy. While the likelihood of sending and receiving sexts is greatest among older adolescents, it can be a red flag for low self-esteem or social insecurity if a school-age or young teen is sending sexts.

More trouble can arise if these explicit photographs are shared with a wider audience, as can sometimes happen. This can lead to intense shame and psychological distress, bullying, and isolation; the subsequent stress can cause depression, anxiety, or even suicidality. Even without the shame of wide distribution, several studies have found a correlation between sexting and impulsivity and substance use in adolescents. Then there are child pornography statutes that can find 18-year-olds charged with a felony for sharing a photo of someone under 18. Beyond sexting, the circulating of other personal photos or posts (about drinking at a party, for example) can seem a harmless impulse, but these are often permanent and might haunt adolescents as they apply to college or for jobs. The consequences of an impulsive photo shared online can be unexpected, enduring, and occasionally devastating, and, like other teenage behavior, long-term consequences are rarely a top priority.

Although the value of staying connected so easily and frequently is enormous, these platforms also bring the possibility of predators who are looking to make more than a virtual connection with children and teens. The potential anonymity of these platforms also can make for group exchanges that can become mean spirited or abusive, and quickly deteriorate into cyberbullying. It can be difficult to find actual adults to supervise or manage these situations, and the risks for depression, anxiety, school avoidance, and suicidality among bullied adolescents (and among the bulliers) is well established.

Among other risks associated with extensive amounts of time spent virtually connected is the difficulty some adolescents have in shutting off or even silencing their phone; what precious little sleep they are getting is further squeezed by texts throughout the night. For those adolescents who have difficulty getting off of their phone or the computer, they can fall behind in school work or spend less time in the wide range of physical, intellectual, and creative activities that should be a part of a healthy adolescence. When too many relationships are managed virtually, teens can struggle with the nuances of communication and emotional understanding that happen in live exchanges. The abilities to be patient, to tolerate frustration or uncertainty, and to defer gratification are essential life skills, and are not cultivated in time spent tending virtual connections. These subtler risks of online activity may be especially pronounced for young people with problems with attention, impulsivity, mood, or developmental issues.

So how much time do your patients spend online every day? Does it interfere with getting their homework done? Have they withdrawn from prior hobbies? Would they rather text their friends or hang out with them? Do they have their own phone? Have they ever seen a sext? Have they felt pressure to send one? Do they turn their phone off at night? Have they ever been involved in texts that felt cruel?

These questions are similar to ones that arose when day to day life was face to face; they flow from expected adolescent development, but are now worth considering for both the real and the virtual world. And if, as a pediatrician, you can ask these questions of your patients directly and warmly, you will likely get honest answers. Most young people, although nimble with these technologies, are happy to have your interest in this area and even your advice about their use of these technologies.

It can be equally powerful to speak with parents about this to find out what their concerns are, whether they understand the role of this technology as part of adolescent development, and whether they know the answers to questions about their child’s use of technology. It can help to ask whether they find themselves on their smartphones when they are with their children and are supposed to be watching them play soccer or are eating dinner together.

Parents need to be mindful of what they are modeling if they hope to help their children better control their use of technology. It can be powerful for parents to hear that it is reasonable for them to set firm, clear rules around technology use, and enforce those rules. Parents can explain warmly and clearly that phones and computers go off at a certain time or are taken away, that they don’t belong at the dinner table, and that their children should imagine that every text they send or photo they post could be seen by their parents, teachers, or college admissions committee before they hit send.

As technology changes and the teenager matures, sharing some of the dilemmas or challenges of current technology and negotiating expectations and enforcing rules, in the context of ongoing, honest communication, is likely the best path. When the teenager’s use of the technology reflects poor judgment, rigid overuse, or serious risk taking, mental health referral is indicated.

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.

Technology and social media now occupy a central place in the lives of our children and adolescents. According to data from the Pew Research Center in 2012, 75% of U.S. adolescents text. Texting has far outpaced phone calls and e-mail among adolescents as the primary means of (electronic) communication with family and friends. The number of texts they send has grown dramatically over the last few years, with a median of 100 texts sent daily among older adolescent girls in 2012. And it is increasingly challenging to distinguish texting from communication via other social media platforms: Flickr, Tumblr, Snapchat, Instagram, and Twitter. The new technology has augmented the local park or hangout as an essential aspect of adolescents developing their identity through intense interaction with peers.

We physicians who orbit the lives of adolescents may have difficulty keeping up with these developments, but we have a responsibility to be curious with our patients and their parents about the use of social media. We appreciate the developmental forces in adolescence that lead to new independence, heightened impulsivity, the intense importance of friendships, and sexual curiosity. When these developmental forces play out online rather than in high school hallways, there are new risks of unexpected consequences, serious psychological and even legal complications. In the same way that we speak with our patients and their parents about other risky behaviors, we should be curious about patients’ online behaviors and be prepared to offer them guidance as to how to lower risk and offer their parents guidance in establishing and enforcing reasonable rules and boundaries.

Texting is an increasingly commonplace means of communication. Many families will provide a new sixth grader with a cell phone to help the child manage a new bus route or a solo walk home, and texting can be an efficient way to stay connected.

But texting can pose a particular problem when it includes sexual material, or "sexting." Definitions vary, but sexting is most consistently defined as the taking of an explicit photograph of oneself and sending it to another via text or e-mail. There have been few controlled studies, but smaller surveys have suggested that between 20% and 30% of older adolescents have sent a sext, and a higher percentage have received them. Most of those sending these explicit photos are girls, and more than half of them report having been pressured to do so by a boy. While the likelihood of sending and receiving sexts is greatest among older adolescents, it can be a red flag for low self-esteem or social insecurity if a school-age or young teen is sending sexts.

More trouble can arise if these explicit photographs are shared with a wider audience, as can sometimes happen. This can lead to intense shame and psychological distress, bullying, and isolation; the subsequent stress can cause depression, anxiety, or even suicidality. Even without the shame of wide distribution, several studies have found a correlation between sexting and impulsivity and substance use in adolescents. Then there are child pornography statutes that can find 18-year-olds charged with a felony for sharing a photo of someone under 18. Beyond sexting, the circulating of other personal photos or posts (about drinking at a party, for example) can seem a harmless impulse, but these are often permanent and might haunt adolescents as they apply to college or for jobs. The consequences of an impulsive photo shared online can be unexpected, enduring, and occasionally devastating, and, like other teenage behavior, long-term consequences are rarely a top priority.

Although the value of staying connected so easily and frequently is enormous, these platforms also bring the possibility of predators who are looking to make more than a virtual connection with children and teens. The potential anonymity of these platforms also can make for group exchanges that can become mean spirited or abusive, and quickly deteriorate into cyberbullying. It can be difficult to find actual adults to supervise or manage these situations, and the risks for depression, anxiety, school avoidance, and suicidality among bullied adolescents (and among the bulliers) is well established.

Among other risks associated with extensive amounts of time spent virtually connected is the difficulty some adolescents have in shutting off or even silencing their phone; what precious little sleep they are getting is further squeezed by texts throughout the night. For those adolescents who have difficulty getting off of their phone or the computer, they can fall behind in school work or spend less time in the wide range of physical, intellectual, and creative activities that should be a part of a healthy adolescence. When too many relationships are managed virtually, teens can struggle with the nuances of communication and emotional understanding that happen in live exchanges. The abilities to be patient, to tolerate frustration or uncertainty, and to defer gratification are essential life skills, and are not cultivated in time spent tending virtual connections. These subtler risks of online activity may be especially pronounced for young people with problems with attention, impulsivity, mood, or developmental issues.

So how much time do your patients spend online every day? Does it interfere with getting their homework done? Have they withdrawn from prior hobbies? Would they rather text their friends or hang out with them? Do they have their own phone? Have they ever seen a sext? Have they felt pressure to send one? Do they turn their phone off at night? Have they ever been involved in texts that felt cruel?

These questions are similar to ones that arose when day to day life was face to face; they flow from expected adolescent development, but are now worth considering for both the real and the virtual world. And if, as a pediatrician, you can ask these questions of your patients directly and warmly, you will likely get honest answers. Most young people, although nimble with these technologies, are happy to have your interest in this area and even your advice about their use of these technologies.

It can be equally powerful to speak with parents about this to find out what their concerns are, whether they understand the role of this technology as part of adolescent development, and whether they know the answers to questions about their child’s use of technology. It can help to ask whether they find themselves on their smartphones when they are with their children and are supposed to be watching them play soccer or are eating dinner together.

Parents need to be mindful of what they are modeling if they hope to help their children better control their use of technology. It can be powerful for parents to hear that it is reasonable for them to set firm, clear rules around technology use, and enforce those rules. Parents can explain warmly and clearly that phones and computers go off at a certain time or are taken away, that they don’t belong at the dinner table, and that their children should imagine that every text they send or photo they post could be seen by their parents, teachers, or college admissions committee before they hit send.

As technology changes and the teenager matures, sharing some of the dilemmas or challenges of current technology and negotiating expectations and enforcing rules, in the context of ongoing, honest communication, is likely the best path. When the teenager’s use of the technology reflects poor judgment, rigid overuse, or serious risk taking, mental health referral is indicated.

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.

Technology and social media now occupy a central place in the lives of our children and adolescents. According to data from the Pew Research Center in 2012, 75% of U.S. adolescents text. Texting has far outpaced phone calls and e-mail among adolescents as the primary means of (electronic) communication with family and friends. The number of texts they send has grown dramatically over the last few years, with a median of 100 texts sent daily among older adolescent girls in 2012. And it is increasingly challenging to distinguish texting from communication via other social media platforms: Flickr, Tumblr, Snapchat, Instagram, and Twitter. The new technology has augmented the local park or hangout as an essential aspect of adolescents developing their identity through intense interaction with peers.

We physicians who orbit the lives of adolescents may have difficulty keeping up with these developments, but we have a responsibility to be curious with our patients and their parents about the use of social media. We appreciate the developmental forces in adolescence that lead to new independence, heightened impulsivity, the intense importance of friendships, and sexual curiosity. When these developmental forces play out online rather than in high school hallways, there are new risks of unexpected consequences, serious psychological and even legal complications. In the same way that we speak with our patients and their parents about other risky behaviors, we should be curious about patients’ online behaviors and be prepared to offer them guidance as to how to lower risk and offer their parents guidance in establishing and enforcing reasonable rules and boundaries.

Texting is an increasingly commonplace means of communication. Many families will provide a new sixth grader with a cell phone to help the child manage a new bus route or a solo walk home, and texting can be an efficient way to stay connected.

But texting can pose a particular problem when it includes sexual material, or "sexting." Definitions vary, but sexting is most consistently defined as the taking of an explicit photograph of oneself and sending it to another via text or e-mail. There have been few controlled studies, but smaller surveys have suggested that between 20% and 30% of older adolescents have sent a sext, and a higher percentage have received them. Most of those sending these explicit photos are girls, and more than half of them report having been pressured to do so by a boy. While the likelihood of sending and receiving sexts is greatest among older adolescents, it can be a red flag for low self-esteem or social insecurity if a school-age or young teen is sending sexts.

More trouble can arise if these explicit photographs are shared with a wider audience, as can sometimes happen. This can lead to intense shame and psychological distress, bullying, and isolation; the subsequent stress can cause depression, anxiety, or even suicidality. Even without the shame of wide distribution, several studies have found a correlation between sexting and impulsivity and substance use in adolescents. Then there are child pornography statutes that can find 18-year-olds charged with a felony for sharing a photo of someone under 18. Beyond sexting, the circulating of other personal photos or posts (about drinking at a party, for example) can seem a harmless impulse, but these are often permanent and might haunt adolescents as they apply to college or for jobs. The consequences of an impulsive photo shared online can be unexpected, enduring, and occasionally devastating, and, like other teenage behavior, long-term consequences are rarely a top priority.

Although the value of staying connected so easily and frequently is enormous, these platforms also bring the possibility of predators who are looking to make more than a virtual connection with children and teens. The potential anonymity of these platforms also can make for group exchanges that can become mean spirited or abusive, and quickly deteriorate into cyberbullying. It can be difficult to find actual adults to supervise or manage these situations, and the risks for depression, anxiety, school avoidance, and suicidality among bullied adolescents (and among the bulliers) is well established.

Among other risks associated with extensive amounts of time spent virtually connected is the difficulty some adolescents have in shutting off or even silencing their phone; what precious little sleep they are getting is further squeezed by texts throughout the night. For those adolescents who have difficulty getting off of their phone or the computer, they can fall behind in school work or spend less time in the wide range of physical, intellectual, and creative activities that should be a part of a healthy adolescence. When too many relationships are managed virtually, teens can struggle with the nuances of communication and emotional understanding that happen in live exchanges. The abilities to be patient, to tolerate frustration or uncertainty, and to defer gratification are essential life skills, and are not cultivated in time spent tending virtual connections. These subtler risks of online activity may be especially pronounced for young people with problems with attention, impulsivity, mood, or developmental issues.

So how much time do your patients spend online every day? Does it interfere with getting their homework done? Have they withdrawn from prior hobbies? Would they rather text their friends or hang out with them? Do they have their own phone? Have they ever seen a sext? Have they felt pressure to send one? Do they turn their phone off at night? Have they ever been involved in texts that felt cruel?

These questions are similar to ones that arose when day to day life was face to face; they flow from expected adolescent development, but are now worth considering for both the real and the virtual world. And if, as a pediatrician, you can ask these questions of your patients directly and warmly, you will likely get honest answers. Most young people, although nimble with these technologies, are happy to have your interest in this area and even your advice about their use of these technologies.

It can be equally powerful to speak with parents about this to find out what their concerns are, whether they understand the role of this technology as part of adolescent development, and whether they know the answers to questions about their child’s use of technology. It can help to ask whether they find themselves on their smartphones when they are with their children and are supposed to be watching them play soccer or are eating dinner together.

Parents need to be mindful of what they are modeling if they hope to help their children better control their use of technology. It can be powerful for parents to hear that it is reasonable for them to set firm, clear rules around technology use, and enforce those rules. Parents can explain warmly and clearly that phones and computers go off at a certain time or are taken away, that they don’t belong at the dinner table, and that their children should imagine that every text they send or photo they post could be seen by their parents, teachers, or college admissions committee before they hit send.

As technology changes and the teenager matures, sharing some of the dilemmas or challenges of current technology and negotiating expectations and enforcing rules, in the context of ongoing, honest communication, is likely the best path. When the teenager’s use of the technology reflects poor judgment, rigid overuse, or serious risk taking, mental health referral is indicated.

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.

Currently in the United States, less than 0.5% of the population serves in the uniformed armed services. This small sliver of the population has borne a large burden over the past dozen years, as the United States engaged in wars in both Iraq and Afghanistan. While those in the armed services have traditionally been quite young themselves, Operation Iraqi Freedom and Operation Enduring Freedom saw many more Army Reservists and National Guardsmen deployed.

Many of those deployed are parents, coming from civilian communities and jobs rather than from military bases. While combat operations in Iraq and Afghanistan have officially ceased, there are many families still living with the effects of a military deployment, whether deployment is ongoing or the deployed parent recently returned; the effects of deployment include post-traumatic stress disorder (PTSD) or traumatic brain injury (TBI) in a returning parent, or even the death of a parent.

As many as 2 million children in the United States have lived through a parent’s deployment, with more than 800,000 living through two or more deployments. Pediatricians are in a unique position to provide useful information and support to the parents of these children, especially for those not on military bases, which have all of the built-in supports such a location may provide.

Supporting resilience in the families of our military service members can begin with a simple question, "Is someone in your family serving in the military?" Simply asking this question suggests you understand the range of risks, level of stress, and potential isolation of these "single" parents. Children with a deployed parent are at greater risk for anxiety and depression than their civilian peers are, and the risk goes up with longer or multiple deployments.

Somewhat counterintuitively, the risk can be higher for adolescents than for younger children. Adolescents have more complex needs to adjust and test their emerging identities with both parents, and they are faced with greater real-world risks given their many hours of unsupervised time, access to alcohol, and, if they are old enough, the ability to drive. It can be useful to find out if the child is functioning well at school, at home, and with peers, or if there have been any changes in function since the parent was deployed. This may be an ideal time to consider using a mental health screening instrument, such as the Pediatric Symptom Checklist (PSC) to check for functional impairment that may indicate a need for a mental health referral.

It is also important to ask the remaining parent how they are managing the deployment. The combined effect of their anxiety about their partner’s safety; sudden, single parenthood; and the financial strains that deployment can bring is often profound. Families with a deployed reservist are likely to experience some social isolation as they manage these challenges outside of the structure and organization of the military community. It can be meaningful for these parents to receive support from a pediatrician, and the suggestion that they make good use of all of their available supports, whether through the military, a faith organization, family, or community-service agencies.

On a practical level, it can be very helpful to consider how the family is managing communication around the deployment. How much should their children know about the details of the parent’s deployment? How is the child or adolescent dealing with the information? How anxious are they? What questions are they asking? Do the children feel they have enough information or would they prefer to know more? Are there certain things they don’t want to know? Do they know to ask a trusted adult if they have a specific worry or hear something worrisome at school, on television, or even at home? How is the parent himself or herself adjusting? Is she able to cope with the stress? Is he depressed or overwhelmed?

Similarly, it can be powerful for a parent to hear from their pediatrician that it is protective to preserve a child’s routines, rules, and responsibilities during a parent’s deployment. Even an adolescent will find it reassuring and organizing to have consistency in her schedule. School, extracurricular activities, homework, sports, and play dates should continue whenever possible, and parents may need to use their support network to help with this. They might focus on special rituals, such as holidays or birthdays, and document them so that they can be shared with the deployed parent, either in a care package or when they return.

While a parent’s return will be eagerly anticipated, it will also be a time of some unexpected changes and challenges. During deployment, usually 8 to 12 months, their children will have grown and changed, and the at-home parent will have adjusted to a different pace and routines. Simple questions can help the other parent anticipate and prepare for the challenge of reintegration into the home and community. What have they told their children about the return? Have they talked about what might be difficult? What has been surprising or easier during the parent’s deployment? What will be easier after that parent returns? How have they changed since their parent was deployed? What are they most curious about? What are they most worried about? Reintegration takes time, but as long as there are open lines of communication during the transition and supports to turn to in case of significant difficulties, it will be successful.

If a parent has recently returned, it is reasonable to ask if there have been any unexpected problems. While some injuries are visible, many returning soldiers will experience the "invisible wounds" of TBI or PTSD. There is ample evidence that many veterans will not seek care for PTSD, and those who do may experience significant barriers to accessing treatment. These conditions will affect a whole family, so asking a parent (and your patient) about concerning behaviors, such as anxiety, anger, avoidance, withdrawal, or substance abuse in a returned parent can be the first step to helping a family. Reminding parents that there are resources available to them, whether through the Department of Veterans Affairs, community service agencies, or even online (see below), can empower them to help the returning parent get the needed treatment and support.

Finally, the death of a parent during deployment is a subject worthy of its own column. Express your condolences while acknowledging that grief is a gradual process that is different for each individual and is especially different for children and spouses. Ask if they are taking good care of themselves and have enough personal support. You might remind a parent that some regressive behaviors, moodiness, or even seeming normalcy are all typical expressions of grief in children and require patience. Increased risk-taking behaviors in an adolescent or significant dysfunction (refusing to go to school or total withdrawal from friends and extracurricular activities) are concerning, though, and should be referred for additional evaluation and support. Assess the parent’s capacity during this difficult time, and see if the surviving parent and children have access to sufficient support or whether a referral for mental health services is needed. For a child to know that she can speak to another family member, teacher, or coach can be protective and allay guilt, as she can voice her grief or worries to an adult who is not grieving as intensely as her surviving parent. Finally, you might work with parents to locate the community resources that are available to them and their children as they manage this painful adjustment while also supporting their children’s healthiest development.

Some examples of online resources for the families of deployed or returned veterans:

• The Department of Veterans Affairs Mental Health page.

• The Veteran Parenting Toolkit.

• The Home Base Program.

Most of us are isolated from the difficulties that military families routinely face, and it is easy to forget the impact and the risks to children when parents are deployed. We should not forget their service and their needs.

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. He is chief clinical officer at Partners HealthCare, also in Boston. E-mail Dr. Swick and Dr. Jellinek at pdnews@frontlinemedcom.com.

Currently in the United States, less than 0.5% of the population serves in the uniformed armed services. This small sliver of the population has borne a large burden over the past dozen years, as the United States engaged in wars in both Iraq and Afghanistan. While those in the armed services have traditionally been quite young themselves, Operation Iraqi Freedom and Operation Enduring Freedom saw many more Army Reservists and National Guardsmen deployed.

Many of those deployed are parents, coming from civilian communities and jobs rather than from military bases. While combat operations in Iraq and Afghanistan have officially ceased, there are many families still living with the effects of a military deployment, whether deployment is ongoing or the deployed parent recently returned; the effects of deployment include post-traumatic stress disorder (PTSD) or traumatic brain injury (TBI) in a returning parent, or even the death of a parent.

As many as 2 million children in the United States have lived through a parent’s deployment, with more than 800,000 living through two or more deployments. Pediatricians are in a unique position to provide useful information and support to the parents of these children, especially for those not on military bases, which have all of the built-in supports such a location may provide.

Supporting resilience in the families of our military service members can begin with a simple question, "Is someone in your family serving in the military?" Simply asking this question suggests you understand the range of risks, level of stress, and potential isolation of these "single" parents. Children with a deployed parent are at greater risk for anxiety and depression than their civilian peers are, and the risk goes up with longer or multiple deployments.

Somewhat counterintuitively, the risk can be higher for adolescents than for younger children. Adolescents have more complex needs to adjust and test their emerging identities with both parents, and they are faced with greater real-world risks given their many hours of unsupervised time, access to alcohol, and, if they are old enough, the ability to drive. It can be useful to find out if the child is functioning well at school, at home, and with peers, or if there have been any changes in function since the parent was deployed. This may be an ideal time to consider using a mental health screening instrument, such as the Pediatric Symptom Checklist (PSC) to check for functional impairment that may indicate a need for a mental health referral.

It is also important to ask the remaining parent how they are managing the deployment. The combined effect of their anxiety about their partner’s safety; sudden, single parenthood; and the financial strains that deployment can bring is often profound. Families with a deployed reservist are likely to experience some social isolation as they manage these challenges outside of the structure and organization of the military community. It can be meaningful for these parents to receive support from a pediatrician, and the suggestion that they make good use of all of their available supports, whether through the military, a faith organization, family, or community-service agencies.

On a practical level, it can be very helpful to consider how the family is managing communication around the deployment. How much should their children know about the details of the parent’s deployment? How is the child or adolescent dealing with the information? How anxious are they? What questions are they asking? Do the children feel they have enough information or would they prefer to know more? Are there certain things they don’t want to know? Do they know to ask a trusted adult if they have a specific worry or hear something worrisome at school, on television, or even at home? How is the parent himself or herself adjusting? Is she able to cope with the stress? Is he depressed or overwhelmed?

Similarly, it can be powerful for a parent to hear from their pediatrician that it is protective to preserve a child’s routines, rules, and responsibilities during a parent’s deployment. Even an adolescent will find it reassuring and organizing to have consistency in her schedule. School, extracurricular activities, homework, sports, and play dates should continue whenever possible, and parents may need to use their support network to help with this. They might focus on special rituals, such as holidays or birthdays, and document them so that they can be shared with the deployed parent, either in a care package or when they return.

While a parent’s return will be eagerly anticipated, it will also be a time of some unexpected changes and challenges. During deployment, usually 8 to 12 months, their children will have grown and changed, and the at-home parent will have adjusted to a different pace and routines. Simple questions can help the other parent anticipate and prepare for the challenge of reintegration into the home and community. What have they told their children about the return? Have they talked about what might be difficult? What has been surprising or easier during the parent’s deployment? What will be easier after that parent returns? How have they changed since their parent was deployed? What are they most curious about? What are they most worried about? Reintegration takes time, but as long as there are open lines of communication during the transition and supports to turn to in case of significant difficulties, it will be successful.

If a parent has recently returned, it is reasonable to ask if there have been any unexpected problems. While some injuries are visible, many returning soldiers will experience the "invisible wounds" of TBI or PTSD. There is ample evidence that many veterans will not seek care for PTSD, and those who do may experience significant barriers to accessing treatment. These conditions will affect a whole family, so asking a parent (and your patient) about concerning behaviors, such as anxiety, anger, avoidance, withdrawal, or substance abuse in a returned parent can be the first step to helping a family. Reminding parents that there are resources available to them, whether through the Department of Veterans Affairs, community service agencies, or even online (see below), can empower them to help the returning parent get the needed treatment and support.

Finally, the death of a parent during deployment is a subject worthy of its own column. Express your condolences while acknowledging that grief is a gradual process that is different for each individual and is especially different for children and spouses. Ask if they are taking good care of themselves and have enough personal support. You might remind a parent that some regressive behaviors, moodiness, or even seeming normalcy are all typical expressions of grief in children and require patience. Increased risk-taking behaviors in an adolescent or significant dysfunction (refusing to go to school or total withdrawal from friends and extracurricular activities) are concerning, though, and should be referred for additional evaluation and support. Assess the parent’s capacity during this difficult time, and see if the surviving parent and children have access to sufficient support or whether a referral for mental health services is needed. For a child to know that she can speak to another family member, teacher, or coach can be protective and allay guilt, as she can voice her grief or worries to an adult who is not grieving as intensely as her surviving parent. Finally, you might work with parents to locate the community resources that are available to them and their children as they manage this painful adjustment while also supporting their children’s healthiest development.

Some examples of online resources for the families of deployed or returned veterans:

• The Department of Veterans Affairs Mental Health page.

• The Veteran Parenting Toolkit.

• The Home Base Program.

Most of us are isolated from the difficulties that military families routinely face, and it is easy to forget the impact and the risks to children when parents are deployed. We should not forget their service and their needs.

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. He is chief clinical officer at Partners HealthCare, also in Boston. E-mail Dr. Swick and Dr. Jellinek at pdnews@frontlinemedcom.com.

Currently in the United States, less than 0.5% of the population serves in the uniformed armed services. This small sliver of the population has borne a large burden over the past dozen years, as the United States engaged in wars in both Iraq and Afghanistan. While those in the armed services have traditionally been quite young themselves, Operation Iraqi Freedom and Operation Enduring Freedom saw many more Army Reservists and National Guardsmen deployed.

Many of those deployed are parents, coming from civilian communities and jobs rather than from military bases. While combat operations in Iraq and Afghanistan have officially ceased, there are many families still living with the effects of a military deployment, whether deployment is ongoing or the deployed parent recently returned; the effects of deployment include post-traumatic stress disorder (PTSD) or traumatic brain injury (TBI) in a returning parent, or even the death of a parent.

As many as 2 million children in the United States have lived through a parent’s deployment, with more than 800,000 living through two or more deployments. Pediatricians are in a unique position to provide useful information and support to the parents of these children, especially for those not on military bases, which have all of the built-in supports such a location may provide.

Supporting resilience in the families of our military service members can begin with a simple question, "Is someone in your family serving in the military?" Simply asking this question suggests you understand the range of risks, level of stress, and potential isolation of these "single" parents. Children with a deployed parent are at greater risk for anxiety and depression than their civilian peers are, and the risk goes up with longer or multiple deployments.

Somewhat counterintuitively, the risk can be higher for adolescents than for younger children. Adolescents have more complex needs to adjust and test their emerging identities with both parents, and they are faced with greater real-world risks given their many hours of unsupervised time, access to alcohol, and, if they are old enough, the ability to drive. It can be useful to find out if the child is functioning well at school, at home, and with peers, or if there have been any changes in function since the parent was deployed. This may be an ideal time to consider using a mental health screening instrument, such as the Pediatric Symptom Checklist (PSC) to check for functional impairment that may indicate a need for a mental health referral.

It is also important to ask the remaining parent how they are managing the deployment. The combined effect of their anxiety about their partner’s safety; sudden, single parenthood; and the financial strains that deployment can bring is often profound. Families with a deployed reservist are likely to experience some social isolation as they manage these challenges outside of the structure and organization of the military community. It can be meaningful for these parents to receive support from a pediatrician, and the suggestion that they make good use of all of their available supports, whether through the military, a faith organization, family, or community-service agencies.

On a practical level, it can be very helpful to consider how the family is managing communication around the deployment. How much should their children know about the details of the parent’s deployment? How is the child or adolescent dealing with the information? How anxious are they? What questions are they asking? Do the children feel they have enough information or would they prefer to know more? Are there certain things they don’t want to know? Do they know to ask a trusted adult if they have a specific worry or hear something worrisome at school, on television, or even at home? How is the parent himself or herself adjusting? Is she able to cope with the stress? Is he depressed or overwhelmed?

Similarly, it can be powerful for a parent to hear from their pediatrician that it is protective to preserve a child’s routines, rules, and responsibilities during a parent’s deployment. Even an adolescent will find it reassuring and organizing to have consistency in her schedule. School, extracurricular activities, homework, sports, and play dates should continue whenever possible, and parents may need to use their support network to help with this. They might focus on special rituals, such as holidays or birthdays, and document them so that they can be shared with the deployed parent, either in a care package or when they return.

While a parent’s return will be eagerly anticipated, it will also be a time of some unexpected changes and challenges. During deployment, usually 8 to 12 months, their children will have grown and changed, and the at-home parent will have adjusted to a different pace and routines. Simple questions can help the other parent anticipate and prepare for the challenge of reintegration into the home and community. What have they told their children about the return? Have they talked about what might be difficult? What has been surprising or easier during the parent’s deployment? What will be easier after that parent returns? How have they changed since their parent was deployed? What are they most curious about? What are they most worried about? Reintegration takes time, but as long as there are open lines of communication during the transition and supports to turn to in case of significant difficulties, it will be successful.

If a parent has recently returned, it is reasonable to ask if there have been any unexpected problems. While some injuries are visible, many returning soldiers will experience the "invisible wounds" of TBI or PTSD. There is ample evidence that many veterans will not seek care for PTSD, and those who do may experience significant barriers to accessing treatment. These conditions will affect a whole family, so asking a parent (and your patient) about concerning behaviors, such as anxiety, anger, avoidance, withdrawal, or substance abuse in a returned parent can be the first step to helping a family. Reminding parents that there are resources available to them, whether through the Department of Veterans Affairs, community service agencies, or even online (see below), can empower them to help the returning parent get the needed treatment and support.

Finally, the death of a parent during deployment is a subject worthy of its own column. Express your condolences while acknowledging that grief is a gradual process that is different for each individual and is especially different for children and spouses. Ask if they are taking good care of themselves and have enough personal support. You might remind a parent that some regressive behaviors, moodiness, or even seeming normalcy are all typical expressions of grief in children and require patience. Increased risk-taking behaviors in an adolescent or significant dysfunction (refusing to go to school or total withdrawal from friends and extracurricular activities) are concerning, though, and should be referred for additional evaluation and support. Assess the parent’s capacity during this difficult time, and see if the surviving parent and children have access to sufficient support or whether a referral for mental health services is needed. For a child to know that she can speak to another family member, teacher, or coach can be protective and allay guilt, as she can voice her grief or worries to an adult who is not grieving as intensely as her surviving parent. Finally, you might work with parents to locate the community resources that are available to them and their children as they manage this painful adjustment while also supporting their children’s healthiest development.

Some examples of online resources for the families of deployed or returned veterans:

• The Department of Veterans Affairs Mental Health page.

• The Veteran Parenting Toolkit.

• The Home Base Program.

Most of us are isolated from the difficulties that military families routinely face, and it is easy to forget the impact and the risks to children when parents are deployed. We should not forget their service and their needs.

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. He is chief clinical officer at Partners HealthCare, also in Boston. E-mail Dr. Swick and Dr. Jellinek at pdnews@frontlinemedcom.com.