Susan D. Swick, MD

"What is the value of starting an allowance for our child? At what age? How much? Can it be a reward for doing chores?"

An allowance is one of many opportunities to help develop a child’s autonomy, self-esteem, and sense of responsibility, as well as to communicate a family’s values. An appreciation of the value of money and work is an essential part of growing up. How is money used in their domestic economy? To enforce chores? Reward school performance? In a relaxed or tense manner? Other than parental respect and affection, there are few tools as potent as money to help children and adolescents cultivate responsibility, patience, negotiation skills, and discipline.

The pediatrician can offer guidance rooted in knowledge of child development and behavioral principles on this issue. So, approach this opportunity enthusiastically if it comes up in an office visit or build it in to your approach to anticipatory guidance.

At what age should a child begin to get an allowance?

A child should be able to appreciate the value of money and be basically able to handle it in a simple transaction. Otherwise, a parent might as well be giving poker chips or stickers. Most children can retain the value of different coins and understand greater and lesser value by kindergarten or first grade. They should be able to consistently handle the essentials of addition and subtraction by second grade, so that they can figure out what their money would buy and add up change. Some children may be especially adroit at math, and thus interested in and able to handle an allowance earlier, and some may need a little extra time to be able to understand and manage an allowance.

When parents decide that the time is right for an allowance, they should have a conversation with their children to explain how much they will be receiving, when, and what it can be used for.

Should young children be able to spend their allowance?

There is little reason to give a child an allowance if it’s only for saving. (You might as well create a college fund that they can’t use, but could watch grow to illustrate compounding interest.) Being given some money tells the child that the parent is comfortable relinquishing this small bit of power and respects the child’s judgment. If 7-year-olds see a "two candy bars for a dollar" special in the supermarket, and they have a dollar of allowance, then it is up to them financially and nutritionally to make this choice.

Giving children some control does not mean that parents cannot be involved. An allowance provides the chance to let children learn about money, but children will learn more nuanced lessons if their parents are present to listen and reflect with them about the choices they face. Parents should be curious about what a child wants to buy, and talk with them about what they give up when they make any choice.

Beyond the piggy bank, parents might start a bank account in their child’s name. This way, they can delay or facilitate a purchase, as young children will need a parent to help them with a withdrawal. In a split system, where half of a child’s allowance goes into a bank account and half can be spending money, children can watch just how much they save, and compare it to what they may have to show for the money they have spent on themselves or for a holiday gift. In this way, money provides both the material and the reward for teaching children about the value of patience and self-control.

Once children are old enough to have unsupervised time outside of school and home, such as time at a mall or walking to town with friends, they will likely want (and possibly need) some money to spend. Depending on the location and child’s personality, this usually happens around sixth grade. It’s helpful if they have already had a small allowance and been introduced to the value of saving. But if not, this is a good time to begin an allowance rather than simply handing a child pocket money every time he or she goes somewhere with friends. Parents should consider with their children how to use this money (snacks, bus fare, etc.), but stepping back and allowing their children to then manage it on their own is a powerful way to support healthy independence. Times have changed and bus fare and a daily snack can be used to estimate a starting sum.

With older children and adolescents, having an allowance also can help build negotiation skills, whether they want a "raise" or want to purchase something large. Negotiating is a part of every relationship, provides a respectful nudge to autonomy, and contributes to the development of flexibility and listening skills. Negotiations may include added work like raking leaves, making the item a gift for a future holiday, or a reward for reasonable school performance. Parents don’t have to agree to an offer from their child, but can still admire their negotiation effort and model the same in good faith.

Should allowance be a reward for work or contingent on chores?

Children can understand the value of helping out and doing their share at home even before they can understand math, and it is often meaningful for chores to be established quite early, so that children grow up appreciating the value of what they do as well as who they are. Allowance is not a salary in this case; the reward for chores is that children feel they are contributing members of the family. But withholding allowance might still be a punishment, alongside losing dessert or time on the computer.

Some families have a two-level allowance. One for "breathing," a baseline for the child to have some discretion over money, and more for work done that is above and beyond their routine chores. This works especially well for teenagers who have routine expenses (school lunch, the bus), but can negotiate for more, perhaps saving the family the time or cost of mowing the lawn or shoveling snow. Teenagers can learn the value of a dollar earned, without having to work a half-time job (which has been shown to substantially imperil school performance). Responsibility and meaningful self-confidence come from being given control over money, having your judgment respected, saving for a future goal, negotiating reasonably, and earning larger sums for real work.

Some families may object: "Money for breathing! I had to work for every nickel, and my parents would have laughed in my face if I asked for that." Money is among the most sensitive topics in a family’s life and is a leading cause of discord and divorce. So the allowance discussion is an opportunity to assess the parents’ perspectives. Ask how money was handled in their families of origin. Were they poor growing up? Was money an instrument of control? Of tension between their parents? Do they often argue on how much to spend or what purchases are appropriate? Ask the parents to consider what values they want to keep from their past, and how they would like their own children to grow up learning about money, so that they can come to an agreement on an allowance plan. Values ("even if we have the money, spending that much on shoes is inconsistent with how we think money should be used") rather than control is the optimal approach.

How much is the right amount?

There is no single answer to this question. Consider the age of the child, the family’s finances, the values to be transmitted, and the child’s usual expenses. Also consider the developmental stage and personality of the individual child. Teenagers pose the biggest challenge. Consider a family of means with a teenage daughter who is very self-restrictive. Even with parental encouragement she would not buy herself a reasonably priced souvenir sweatshirt while at a concert. Here a higher allowance is a chance to say, "We believe this is a fair amount to spend on yourself, please do so, you deserve it." For a teenager who is more impulsive and irresponsible in spending, a more modest allowance would be appropriate. This would provide for lunch, snacks, and some autonomy on weekends, but real work would be needed to spend at higher levels. Parents should be open to adjustments as expenses go up with age, particularly as teenagers are learning to drive, and realistically decide what is "included" or the expectations for the allowance.

An allowance is one way to teach about money, to model the values of the family, to course correct some patterns from the past, to help the child learn how to plan, and to provide a key step to the independent functioning needed for college and early adulthood. Parents can demonstrate by their words and their own actions that money is a means to an end, not an end in itself, and that "the best things in life are free."

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.

"What is the value of starting an allowance for our child? At what age? How much? Can it be a reward for doing chores?"

An allowance is one of many opportunities to help develop a child’s autonomy, self-esteem, and sense of responsibility, as well as to communicate a family’s values. An appreciation of the value of money and work is an essential part of growing up. How is money used in their domestic economy? To enforce chores? Reward school performance? In a relaxed or tense manner? Other than parental respect and affection, there are few tools as potent as money to help children and adolescents cultivate responsibility, patience, negotiation skills, and discipline.

The pediatrician can offer guidance rooted in knowledge of child development and behavioral principles on this issue. So, approach this opportunity enthusiastically if it comes up in an office visit or build it in to your approach to anticipatory guidance.

At what age should a child begin to get an allowance?

A child should be able to appreciate the value of money and be basically able to handle it in a simple transaction. Otherwise, a parent might as well be giving poker chips or stickers. Most children can retain the value of different coins and understand greater and lesser value by kindergarten or first grade. They should be able to consistently handle the essentials of addition and subtraction by second grade, so that they can figure out what their money would buy and add up change. Some children may be especially adroit at math, and thus interested in and able to handle an allowance earlier, and some may need a little extra time to be able to understand and manage an allowance.

When parents decide that the time is right for an allowance, they should have a conversation with their children to explain how much they will be receiving, when, and what it can be used for.

Should young children be able to spend their allowance?

There is little reason to give a child an allowance if it’s only for saving. (You might as well create a college fund that they can’t use, but could watch grow to illustrate compounding interest.) Being given some money tells the child that the parent is comfortable relinquishing this small bit of power and respects the child’s judgment. If 7-year-olds see a "two candy bars for a dollar" special in the supermarket, and they have a dollar of allowance, then it is up to them financially and nutritionally to make this choice.

Giving children some control does not mean that parents cannot be involved. An allowance provides the chance to let children learn about money, but children will learn more nuanced lessons if their parents are present to listen and reflect with them about the choices they face. Parents should be curious about what a child wants to buy, and talk with them about what they give up when they make any choice.

Beyond the piggy bank, parents might start a bank account in their child’s name. This way, they can delay or facilitate a purchase, as young children will need a parent to help them with a withdrawal. In a split system, where half of a child’s allowance goes into a bank account and half can be spending money, children can watch just how much they save, and compare it to what they may have to show for the money they have spent on themselves or for a holiday gift. In this way, money provides both the material and the reward for teaching children about the value of patience and self-control.

Once children are old enough to have unsupervised time outside of school and home, such as time at a mall or walking to town with friends, they will likely want (and possibly need) some money to spend. Depending on the location and child’s personality, this usually happens around sixth grade. It’s helpful if they have already had a small allowance and been introduced to the value of saving. But if not, this is a good time to begin an allowance rather than simply handing a child pocket money every time he or she goes somewhere with friends. Parents should consider with their children how to use this money (snacks, bus fare, etc.), but stepping back and allowing their children to then manage it on their own is a powerful way to support healthy independence. Times have changed and bus fare and a daily snack can be used to estimate a starting sum.

With older children and adolescents, having an allowance also can help build negotiation skills, whether they want a "raise" or want to purchase something large. Negotiating is a part of every relationship, provides a respectful nudge to autonomy, and contributes to the development of flexibility and listening skills. Negotiations may include added work like raking leaves, making the item a gift for a future holiday, or a reward for reasonable school performance. Parents don’t have to agree to an offer from their child, but can still admire their negotiation effort and model the same in good faith.

Should allowance be a reward for work or contingent on chores?

Children can understand the value of helping out and doing their share at home even before they can understand math, and it is often meaningful for chores to be established quite early, so that children grow up appreciating the value of what they do as well as who they are. Allowance is not a salary in this case; the reward for chores is that children feel they are contributing members of the family. But withholding allowance might still be a punishment, alongside losing dessert or time on the computer.

Some families have a two-level allowance. One for "breathing," a baseline for the child to have some discretion over money, and more for work done that is above and beyond their routine chores. This works especially well for teenagers who have routine expenses (school lunch, the bus), but can negotiate for more, perhaps saving the family the time or cost of mowing the lawn or shoveling snow. Teenagers can learn the value of a dollar earned, without having to work a half-time job (which has been shown to substantially imperil school performance). Responsibility and meaningful self-confidence come from being given control over money, having your judgment respected, saving for a future goal, negotiating reasonably, and earning larger sums for real work.

Some families may object: "Money for breathing! I had to work for every nickel, and my parents would have laughed in my face if I asked for that." Money is among the most sensitive topics in a family’s life and is a leading cause of discord and divorce. So the allowance discussion is an opportunity to assess the parents’ perspectives. Ask how money was handled in their families of origin. Were they poor growing up? Was money an instrument of control? Of tension between their parents? Do they often argue on how much to spend or what purchases are appropriate? Ask the parents to consider what values they want to keep from their past, and how they would like their own children to grow up learning about money, so that they can come to an agreement on an allowance plan. Values ("even if we have the money, spending that much on shoes is inconsistent with how we think money should be used") rather than control is the optimal approach.

How much is the right amount?

There is no single answer to this question. Consider the age of the child, the family’s finances, the values to be transmitted, and the child’s usual expenses. Also consider the developmental stage and personality of the individual child. Teenagers pose the biggest challenge. Consider a family of means with a teenage daughter who is very self-restrictive. Even with parental encouragement she would not buy herself a reasonably priced souvenir sweatshirt while at a concert. Here a higher allowance is a chance to say, "We believe this is a fair amount to spend on yourself, please do so, you deserve it." For a teenager who is more impulsive and irresponsible in spending, a more modest allowance would be appropriate. This would provide for lunch, snacks, and some autonomy on weekends, but real work would be needed to spend at higher levels. Parents should be open to adjustments as expenses go up with age, particularly as teenagers are learning to drive, and realistically decide what is "included" or the expectations for the allowance.

An allowance is one way to teach about money, to model the values of the family, to course correct some patterns from the past, to help the child learn how to plan, and to provide a key step to the independent functioning needed for college and early adulthood. Parents can demonstrate by their words and their own actions that money is a means to an end, not an end in itself, and that "the best things in life are free."

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.

"What is the value of starting an allowance for our child? At what age? How much? Can it be a reward for doing chores?"

An allowance is one of many opportunities to help develop a child’s autonomy, self-esteem, and sense of responsibility, as well as to communicate a family’s values. An appreciation of the value of money and work is an essential part of growing up. How is money used in their domestic economy? To enforce chores? Reward school performance? In a relaxed or tense manner? Other than parental respect and affection, there are few tools as potent as money to help children and adolescents cultivate responsibility, patience, negotiation skills, and discipline.

The pediatrician can offer guidance rooted in knowledge of child development and behavioral principles on this issue. So, approach this opportunity enthusiastically if it comes up in an office visit or build it in to your approach to anticipatory guidance.

At what age should a child begin to get an allowance?

A child should be able to appreciate the value of money and be basically able to handle it in a simple transaction. Otherwise, a parent might as well be giving poker chips or stickers. Most children can retain the value of different coins and understand greater and lesser value by kindergarten or first grade. They should be able to consistently handle the essentials of addition and subtraction by second grade, so that they can figure out what their money would buy and add up change. Some children may be especially adroit at math, and thus interested in and able to handle an allowance earlier, and some may need a little extra time to be able to understand and manage an allowance.

When parents decide that the time is right for an allowance, they should have a conversation with their children to explain how much they will be receiving, when, and what it can be used for.

Should young children be able to spend their allowance?

There is little reason to give a child an allowance if it’s only for saving. (You might as well create a college fund that they can’t use, but could watch grow to illustrate compounding interest.) Being given some money tells the child that the parent is comfortable relinquishing this small bit of power and respects the child’s judgment. If 7-year-olds see a "two candy bars for a dollar" special in the supermarket, and they have a dollar of allowance, then it is up to them financially and nutritionally to make this choice.

Giving children some control does not mean that parents cannot be involved. An allowance provides the chance to let children learn about money, but children will learn more nuanced lessons if their parents are present to listen and reflect with them about the choices they face. Parents should be curious about what a child wants to buy, and talk with them about what they give up when they make any choice.

Beyond the piggy bank, parents might start a bank account in their child’s name. This way, they can delay or facilitate a purchase, as young children will need a parent to help them with a withdrawal. In a split system, where half of a child’s allowance goes into a bank account and half can be spending money, children can watch just how much they save, and compare it to what they may have to show for the money they have spent on themselves or for a holiday gift. In this way, money provides both the material and the reward for teaching children about the value of patience and self-control.

Once children are old enough to have unsupervised time outside of school and home, such as time at a mall or walking to town with friends, they will likely want (and possibly need) some money to spend. Depending on the location and child’s personality, this usually happens around sixth grade. It’s helpful if they have already had a small allowance and been introduced to the value of saving. But if not, this is a good time to begin an allowance rather than simply handing a child pocket money every time he or she goes somewhere with friends. Parents should consider with their children how to use this money (snacks, bus fare, etc.), but stepping back and allowing their children to then manage it on their own is a powerful way to support healthy independence. Times have changed and bus fare and a daily snack can be used to estimate a starting sum.

With older children and adolescents, having an allowance also can help build negotiation skills, whether they want a "raise" or want to purchase something large. Negotiating is a part of every relationship, provides a respectful nudge to autonomy, and contributes to the development of flexibility and listening skills. Negotiations may include added work like raking leaves, making the item a gift for a future holiday, or a reward for reasonable school performance. Parents don’t have to agree to an offer from their child, but can still admire their negotiation effort and model the same in good faith.

Should allowance be a reward for work or contingent on chores?

Children can understand the value of helping out and doing their share at home even before they can understand math, and it is often meaningful for chores to be established quite early, so that children grow up appreciating the value of what they do as well as who they are. Allowance is not a salary in this case; the reward for chores is that children feel they are contributing members of the family. But withholding allowance might still be a punishment, alongside losing dessert or time on the computer.

Some families have a two-level allowance. One for "breathing," a baseline for the child to have some discretion over money, and more for work done that is above and beyond their routine chores. This works especially well for teenagers who have routine expenses (school lunch, the bus), but can negotiate for more, perhaps saving the family the time or cost of mowing the lawn or shoveling snow. Teenagers can learn the value of a dollar earned, without having to work a half-time job (which has been shown to substantially imperil school performance). Responsibility and meaningful self-confidence come from being given control over money, having your judgment respected, saving for a future goal, negotiating reasonably, and earning larger sums for real work.

Some families may object: "Money for breathing! I had to work for every nickel, and my parents would have laughed in my face if I asked for that." Money is among the most sensitive topics in a family’s life and is a leading cause of discord and divorce. So the allowance discussion is an opportunity to assess the parents’ perspectives. Ask how money was handled in their families of origin. Were they poor growing up? Was money an instrument of control? Of tension between their parents? Do they often argue on how much to spend or what purchases are appropriate? Ask the parents to consider what values they want to keep from their past, and how they would like their own children to grow up learning about money, so that they can come to an agreement on an allowance plan. Values ("even if we have the money, spending that much on shoes is inconsistent with how we think money should be used") rather than control is the optimal approach.

How much is the right amount?

There is no single answer to this question. Consider the age of the child, the family’s finances, the values to be transmitted, and the child’s usual expenses. Also consider the developmental stage and personality of the individual child. Teenagers pose the biggest challenge. Consider a family of means with a teenage daughter who is very self-restrictive. Even with parental encouragement she would not buy herself a reasonably priced souvenir sweatshirt while at a concert. Here a higher allowance is a chance to say, "We believe this is a fair amount to spend on yourself, please do so, you deserve it." For a teenager who is more impulsive and irresponsible in spending, a more modest allowance would be appropriate. This would provide for lunch, snacks, and some autonomy on weekends, but real work would be needed to spend at higher levels. Parents should be open to adjustments as expenses go up with age, particularly as teenagers are learning to drive, and realistically decide what is "included" or the expectations for the allowance.

An allowance is one way to teach about money, to model the values of the family, to course correct some patterns from the past, to help the child learn how to plan, and to provide a key step to the independent functioning needed for college and early adulthood. Parents can demonstrate by their words and their own actions that money is a means to an end, not an end in itself, and that "the best things in life are free."

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.

Adolescence is characterized by milestone after milestone on a route that starts with early puberty and progresses to virtually complete autonomy by young adulthood. Obtaining a driver’s license is among the most meaningful steps along this path in terms of independence, responsibility, and risk. Learning to drive is a pragmatic, almost unique opportunity, as it often brings together a highly motivated teenager and concerned parents working together on a task over considerable time.

Teaching a teenager to drive encompasses teaching a skill, demonstrating an attitude, and communicating values concerning safety, peer relationships, paying for added expenses, and "adult" responsibility with rewards and consequences in the real world where not even parents can fix potential harms.

Driving is a major issue in pediatric primary care, as automobile accidents are the leading cause of morbidity and mortality in children under 18 years. Pediatricians can offer parents critical guidance about helping their children master this skill, appreciate the level of risk involved, add to their growing sense of the value of money, and balance new privileges with added expectations.

Pediatricians should be aware of their state’s laws regulating when adolescents may get a driver’s permit, what they have to do to get their driver’s license, and even additional regulations around when adolescents can drive unaccompanied or with friends. One guideline to optimize safety is for the "learner" to get as many miles of practice as possible under parental supervision. The first year or two of driving carries the highest risk of accident; extensive practice may mitigate that risk. Many adolescents take "drivers ed," but these limited hours may be more effective after many informal driving lessons with a parent or other trusted relative.

All parents have vivid memories of how they were taught to drive. Pediatricians might ask parents what learning to drive was like and what it meant to them. Do the parents want to repeat or modify their own experience when they have a "second" chance with their teenager? Parents bring unique knowledge of their child’s strengths and vulnerabilities as well as their own adolescent experiences to help guide any additional rules they may wish to put in place.

Some adolescents, because of their anxiety, will be in no hurry to get their driver’s license. If your family lives where public transportation is good, there may be no need to push him faster than he can comfortably handle. But it can be helpful for parents to wonder with these adolescents what could be helpful about driving, such as whether it might be useful for building peer relationships, commuting to a summer job, or college. And the parent can be curious about what his teenager’s greatest anxiety about driving is. It may be easily addressed ("What if I run out of gas?"), or more profound. In either case, giving an anxious adolescent a chance to articulate what he is concerned about and to consider when the advantages of driving will outweigh the risks, can help him to feel he is actively choosing when to drive, not just passively waiting to feel less scared. This is an important distinction that can have resonance with later choices that may be intimidating, but necessary to normal development.

Then there are the parents in your practice who wish their adolescent were a bit more anxious. Their child is the eager, confident, leap-before-you-look type, which poses a different set of challenges with driving. This adolescent would benefit from a more methodical, structured approach to getting her driver’s license. Extensive driving practice should help to provide enough concerning moments to temper her bravado. Stricter rules (and consequences for breaking those rules) around practicing and driving will help the intrepid adolescent develop self-control as she expands her skills gradually.

Among the most worrisome teenagers are those who are very impulsive, including those with attention-deficit/hyperactivity disorder. It may be wise to require that this teen take his ADHD medication before driving, or have additional rules about friends and phones to minimize distractions; creating more structure and rules around this privilege can make a lifesaving difference for the impulsive teenager. During extensive practice sessions, there will be clear evidence of ADHD behaviors and how they impact driving, and these are teachable moments to build the adolescent’s self-awareness.

Driving safely is hard enough, and special efforts are necessary concerning the highest-risk behaviors. Parents are both regulators and role models on driving – with speed, courtesy, seat belts, cellphones, alcohol use, etc. It is hard to stay credible when parental behavior and teaching are not consistent.

Cell phones deserve a special discussion from parents, whether or not their children are highly distractible. Adolescents tend to be more frequently on the phone, texting, or updating their Facebook status. Having a phone available while alone in the car is a great safety plan, in case there is an accident or problem with the car. But parents need to have an explicit conversation about good car habits. It may be helpful for parents to ask that their children text once before driving and then when the car is off, or to keep the phone in the glove compartment in order to resist the urge to answer or return a call or text. There should be very strict consequences for texting while driving, in addition to any legal ones, ideally losing the privilege for a long enough time to be memorable. It is not overly dramatic for parents to have a conversation with their child about the likelihood of dying or killing someone as a result of something as simple as sending a text, and to use local reports of accidents to reinforce this standard.

The conversation about good driving habits also should focus on drugs and alcohol. Parents need to be able to tell their children about the serious dangers and legal consequences of driving drunk. But they also should be clear that any drug could impair their driving skills; marijuana is no safer to use before driving than alcohol. They should have a clear plan in place that will either rigidly follow the rule concerning the "designated driver" or facilitate their child calling them or a cab if they ever have used alcohol or drugs when out driving, without fear of significant repercussions. It is critical to establish that safety always comes first, and that it will always be helpful to be honest with parents when managing difficult situations.

Parents should consider whether driving privileges should require some financial contribution from their new driver to the car, gas, or insurance payments. This is a good time to step back and consider the parents’ values concerning money, the direction of the teenager’s attitudes, and how the costs of gas, insurance, or even an additional car fit into the values and priorities of the family. Contributing to the costs of a car can be very motivating to a teenager who might otherwise not be enthusiastic about working. For a busy and productive adolescent (and where the family can afford the costs), there may be less need to use car costs as leverage. Certainly, contributing money or service to the family is all part of new adult responsibilities that come with a license. Driving is an adult responsibility, and presents an ideal opportunity to teach adolescents about the balance between privileges and responsibilities, and about the family’s values about money.

Like other milestones in adolescence, driving can be an opportunity to add to the warmth and trust of an increasingly adult relationship between parent and teenager. Alternatively, driving can become a bitter struggle between parental control and the developmental push to autonomy. There will be errors and mistakes with both the technical and judgment aspects of this new territory.

Parents’ job is to protect teens from mistakes that are irreparable, while facilitating their expanding independence. In setting rules and expectations, parents can emphasize their confidence in their adolescent’s capacity to handle all the requirements of driving, while also impressing upon their teen the seriousness of this new privilege.

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

Adolescence is characterized by milestone after milestone on a route that starts with early puberty and progresses to virtually complete autonomy by young adulthood. Obtaining a driver’s license is among the most meaningful steps along this path in terms of independence, responsibility, and risk. Learning to drive is a pragmatic, almost unique opportunity, as it often brings together a highly motivated teenager and concerned parents working together on a task over considerable time.

Teaching a teenager to drive encompasses teaching a skill, demonstrating an attitude, and communicating values concerning safety, peer relationships, paying for added expenses, and "adult" responsibility with rewards and consequences in the real world where not even parents can fix potential harms.

Driving is a major issue in pediatric primary care, as automobile accidents are the leading cause of morbidity and mortality in children under 18 years. Pediatricians can offer parents critical guidance about helping their children master this skill, appreciate the level of risk involved, add to their growing sense of the value of money, and balance new privileges with added expectations.

Pediatricians should be aware of their state’s laws regulating when adolescents may get a driver’s permit, what they have to do to get their driver’s license, and even additional regulations around when adolescents can drive unaccompanied or with friends. One guideline to optimize safety is for the "learner" to get as many miles of practice as possible under parental supervision. The first year or two of driving carries the highest risk of accident; extensive practice may mitigate that risk. Many adolescents take "drivers ed," but these limited hours may be more effective after many informal driving lessons with a parent or other trusted relative.

All parents have vivid memories of how they were taught to drive. Pediatricians might ask parents what learning to drive was like and what it meant to them. Do the parents want to repeat or modify their own experience when they have a "second" chance with their teenager? Parents bring unique knowledge of their child’s strengths and vulnerabilities as well as their own adolescent experiences to help guide any additional rules they may wish to put in place.

Some adolescents, because of their anxiety, will be in no hurry to get their driver’s license. If your family lives where public transportation is good, there may be no need to push him faster than he can comfortably handle. But it can be helpful for parents to wonder with these adolescents what could be helpful about driving, such as whether it might be useful for building peer relationships, commuting to a summer job, or college. And the parent can be curious about what his teenager’s greatest anxiety about driving is. It may be easily addressed ("What if I run out of gas?"), or more profound. In either case, giving an anxious adolescent a chance to articulate what he is concerned about and to consider when the advantages of driving will outweigh the risks, can help him to feel he is actively choosing when to drive, not just passively waiting to feel less scared. This is an important distinction that can have resonance with later choices that may be intimidating, but necessary to normal development.

Then there are the parents in your practice who wish their adolescent were a bit more anxious. Their child is the eager, confident, leap-before-you-look type, which poses a different set of challenges with driving. This adolescent would benefit from a more methodical, structured approach to getting her driver’s license. Extensive driving practice should help to provide enough concerning moments to temper her bravado. Stricter rules (and consequences for breaking those rules) around practicing and driving will help the intrepid adolescent develop self-control as she expands her skills gradually.

Among the most worrisome teenagers are those who are very impulsive, including those with attention-deficit/hyperactivity disorder. It may be wise to require that this teen take his ADHD medication before driving, or have additional rules about friends and phones to minimize distractions; creating more structure and rules around this privilege can make a lifesaving difference for the impulsive teenager. During extensive practice sessions, there will be clear evidence of ADHD behaviors and how they impact driving, and these are teachable moments to build the adolescent’s self-awareness.

Driving safely is hard enough, and special efforts are necessary concerning the highest-risk behaviors. Parents are both regulators and role models on driving – with speed, courtesy, seat belts, cellphones, alcohol use, etc. It is hard to stay credible when parental behavior and teaching are not consistent.

Cell phones deserve a special discussion from parents, whether or not their children are highly distractible. Adolescents tend to be more frequently on the phone, texting, or updating their Facebook status. Having a phone available while alone in the car is a great safety plan, in case there is an accident or problem with the car. But parents need to have an explicit conversation about good car habits. It may be helpful for parents to ask that their children text once before driving and then when the car is off, or to keep the phone in the glove compartment in order to resist the urge to answer or return a call or text. There should be very strict consequences for texting while driving, in addition to any legal ones, ideally losing the privilege for a long enough time to be memorable. It is not overly dramatic for parents to have a conversation with their child about the likelihood of dying or killing someone as a result of something as simple as sending a text, and to use local reports of accidents to reinforce this standard.

The conversation about good driving habits also should focus on drugs and alcohol. Parents need to be able to tell their children about the serious dangers and legal consequences of driving drunk. But they also should be clear that any drug could impair their driving skills; marijuana is no safer to use before driving than alcohol. They should have a clear plan in place that will either rigidly follow the rule concerning the "designated driver" or facilitate their child calling them or a cab if they ever have used alcohol or drugs when out driving, without fear of significant repercussions. It is critical to establish that safety always comes first, and that it will always be helpful to be honest with parents when managing difficult situations.

Parents should consider whether driving privileges should require some financial contribution from their new driver to the car, gas, or insurance payments. This is a good time to step back and consider the parents’ values concerning money, the direction of the teenager’s attitudes, and how the costs of gas, insurance, or even an additional car fit into the values and priorities of the family. Contributing to the costs of a car can be very motivating to a teenager who might otherwise not be enthusiastic about working. For a busy and productive adolescent (and where the family can afford the costs), there may be less need to use car costs as leverage. Certainly, contributing money or service to the family is all part of new adult responsibilities that come with a license. Driving is an adult responsibility, and presents an ideal opportunity to teach adolescents about the balance between privileges and responsibilities, and about the family’s values about money.

Like other milestones in adolescence, driving can be an opportunity to add to the warmth and trust of an increasingly adult relationship between parent and teenager. Alternatively, driving can become a bitter struggle between parental control and the developmental push to autonomy. There will be errors and mistakes with both the technical and judgment aspects of this new territory.

Parents’ job is to protect teens from mistakes that are irreparable, while facilitating their expanding independence. In setting rules and expectations, parents can emphasize their confidence in their adolescent’s capacity to handle all the requirements of driving, while also impressing upon their teen the seriousness of this new privilege.

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

Adolescence is characterized by milestone after milestone on a route that starts with early puberty and progresses to virtually complete autonomy by young adulthood. Obtaining a driver’s license is among the most meaningful steps along this path in terms of independence, responsibility, and risk. Learning to drive is a pragmatic, almost unique opportunity, as it often brings together a highly motivated teenager and concerned parents working together on a task over considerable time.

Teaching a teenager to drive encompasses teaching a skill, demonstrating an attitude, and communicating values concerning safety, peer relationships, paying for added expenses, and "adult" responsibility with rewards and consequences in the real world where not even parents can fix potential harms.

Driving is a major issue in pediatric primary care, as automobile accidents are the leading cause of morbidity and mortality in children under 18 years. Pediatricians can offer parents critical guidance about helping their children master this skill, appreciate the level of risk involved, add to their growing sense of the value of money, and balance new privileges with added expectations.

Pediatricians should be aware of their state’s laws regulating when adolescents may get a driver’s permit, what they have to do to get their driver’s license, and even additional regulations around when adolescents can drive unaccompanied or with friends. One guideline to optimize safety is for the "learner" to get as many miles of practice as possible under parental supervision. The first year or two of driving carries the highest risk of accident; extensive practice may mitigate that risk. Many adolescents take "drivers ed," but these limited hours may be more effective after many informal driving lessons with a parent or other trusted relative.

All parents have vivid memories of how they were taught to drive. Pediatricians might ask parents what learning to drive was like and what it meant to them. Do the parents want to repeat or modify their own experience when they have a "second" chance with their teenager? Parents bring unique knowledge of their child’s strengths and vulnerabilities as well as their own adolescent experiences to help guide any additional rules they may wish to put in place.

Some adolescents, because of their anxiety, will be in no hurry to get their driver’s license. If your family lives where public transportation is good, there may be no need to push him faster than he can comfortably handle. But it can be helpful for parents to wonder with these adolescents what could be helpful about driving, such as whether it might be useful for building peer relationships, commuting to a summer job, or college. And the parent can be curious about what his teenager’s greatest anxiety about driving is. It may be easily addressed ("What if I run out of gas?"), or more profound. In either case, giving an anxious adolescent a chance to articulate what he is concerned about and to consider when the advantages of driving will outweigh the risks, can help him to feel he is actively choosing when to drive, not just passively waiting to feel less scared. This is an important distinction that can have resonance with later choices that may be intimidating, but necessary to normal development.

Then there are the parents in your practice who wish their adolescent were a bit more anxious. Their child is the eager, confident, leap-before-you-look type, which poses a different set of challenges with driving. This adolescent would benefit from a more methodical, structured approach to getting her driver’s license. Extensive driving practice should help to provide enough concerning moments to temper her bravado. Stricter rules (and consequences for breaking those rules) around practicing and driving will help the intrepid adolescent develop self-control as she expands her skills gradually.

Among the most worrisome teenagers are those who are very impulsive, including those with attention-deficit/hyperactivity disorder. It may be wise to require that this teen take his ADHD medication before driving, or have additional rules about friends and phones to minimize distractions; creating more structure and rules around this privilege can make a lifesaving difference for the impulsive teenager. During extensive practice sessions, there will be clear evidence of ADHD behaviors and how they impact driving, and these are teachable moments to build the adolescent’s self-awareness.

Driving safely is hard enough, and special efforts are necessary concerning the highest-risk behaviors. Parents are both regulators and role models on driving – with speed, courtesy, seat belts, cellphones, alcohol use, etc. It is hard to stay credible when parental behavior and teaching are not consistent.

Cell phones deserve a special discussion from parents, whether or not their children are highly distractible. Adolescents tend to be more frequently on the phone, texting, or updating their Facebook status. Having a phone available while alone in the car is a great safety plan, in case there is an accident or problem with the car. But parents need to have an explicit conversation about good car habits. It may be helpful for parents to ask that their children text once before driving and then when the car is off, or to keep the phone in the glove compartment in order to resist the urge to answer or return a call or text. There should be very strict consequences for texting while driving, in addition to any legal ones, ideally losing the privilege for a long enough time to be memorable. It is not overly dramatic for parents to have a conversation with their child about the likelihood of dying or killing someone as a result of something as simple as sending a text, and to use local reports of accidents to reinforce this standard.

The conversation about good driving habits also should focus on drugs and alcohol. Parents need to be able to tell their children about the serious dangers and legal consequences of driving drunk. But they also should be clear that any drug could impair their driving skills; marijuana is no safer to use before driving than alcohol. They should have a clear plan in place that will either rigidly follow the rule concerning the "designated driver" or facilitate their child calling them or a cab if they ever have used alcohol or drugs when out driving, without fear of significant repercussions. It is critical to establish that safety always comes first, and that it will always be helpful to be honest with parents when managing difficult situations.

Parents should consider whether driving privileges should require some financial contribution from their new driver to the car, gas, or insurance payments. This is a good time to step back and consider the parents’ values concerning money, the direction of the teenager’s attitudes, and how the costs of gas, insurance, or even an additional car fit into the values and priorities of the family. Contributing to the costs of a car can be very motivating to a teenager who might otherwise not be enthusiastic about working. For a busy and productive adolescent (and where the family can afford the costs), there may be less need to use car costs as leverage. Certainly, contributing money or service to the family is all part of new adult responsibilities that come with a license. Driving is an adult responsibility, and presents an ideal opportunity to teach adolescents about the balance between privileges and responsibilities, and about the family’s values about money.

Like other milestones in adolescence, driving can be an opportunity to add to the warmth and trust of an increasingly adult relationship between parent and teenager. Alternatively, driving can become a bitter struggle between parental control and the developmental push to autonomy. There will be errors and mistakes with both the technical and judgment aspects of this new territory.

Parents’ job is to protect teens from mistakes that are irreparable, while facilitating their expanding independence. In setting rules and expectations, parents can emphasize their confidence in their adolescent’s capacity to handle all the requirements of driving, while also impressing upon their teen the seriousness of this new privilege.

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

A challenge unique to the practice of pediatrics is that it is not enough to know your patient well. To be an effective pediatrician, you must know the family well.

This may seem obvious, but it is so essential that it is worthy of some discussion. When your patient is young, all problems will be presented by the parents and will reflect the parents’ own values and anxieties as well as straightforward physical symptoms. Almost every intervention you offer will have to be accepted and managed by the parents. As your patients grow older, you may find that some families serve as a useful buffer to stress and others seem to amplify distress.

Every pediatrician knows that families differ in their self-awareness. Some know their biases and perspectives, some even know that how they were raised or their wishes might distort their view of a given situation. But there are other families that deny even the possibility of any distortion.

Over the years that you work with a family, you will come to know their personality, their unique areas of strength and strain, talent and vulnerability. But early in working with a family, you might pay attention to a few areas to help you learn quickly about a family’s style. With this understanding, you will better understand the context for certain complaints or concerns, and you will be better able to help parents help their children.

There need not be a major illness or serious problem for you to learn about a family’s style and perspective. The daily routines of most families offer rich and nuanced illustrations of their styles, and you might learn about them efficiently with only a few specific questions. One especially useful approach is to ask about a family’s mealtime routine.

Even with very young children, does the family eat together most nights? Do they cook or order in or eat out? Who cooks the food and do the children participate? Do they eat at a consistent time on most nights? Does the family sit down together and how long does the mealtime last? Is it chaotic or rushed? Is it generally pleasant and fun, or is there tension or conflict?

A portrait of mealtime will give you a sense of the parents’ abilities to plan and collaborate, and to stick with a plan even when it is challenging. It illustrates the value they may have placed on spending time consistently with their children as well as providing them with nourishing meals. It might also illustrate how much stress they are facing as a family, due to finances or busy schedules. You could ask if the current dinnertime routine is to their liking – is it what they want for the family? If this seems like a sensitive topic, you could go further and ask what dinnertime was like for them when they were growing up. You might be amazed at what you learn from this simple discussion.

Another daily ritual that can offer a vivid portrait of a family’s style is their children’s bedtime routine. Invite parents to tell you how bedtime goes in their home. Often, you won’t need to ask for any more than that, and you will get a lot of detail.

But if needed, ask about what time bedtime starts, and how consistent is the routine from night to night. Does the child get to bed by an appropriate time? Are parents able to enforce a bedtime or is there a lot of struggle over lights going out each night? Does the child stay in their bed or come into their parents’ room? Is there time for snuggling or talking before lights out?

Again, you will learn about parents’ ability to plan and collaborate with one another. You will learn a lot about parents’ ability to tolerate higher levels of stress, as bedtimes are typically charged by exhaustion (in both children and parents), excitement (as everyone is together), and even anxiety.

You also will learn a lot about how well attuned the parents are to their children’s moods, temperaments, and needs (as opposed to their wants). Bedtime is full of opportunities for parents to pick up on their children’s physical and emotional needs without their children’s help. How parents are managing this task, all while tolerating the roller coaster of their children’s and their own fatigue, tells you a great deal about their ability to bear a child’s distress. A capacity to bear and manage their child’s distress is an essential skill in parenting, often one that develops over time. When it is lacking, home can become a place of very intense and unremitting anxiety and distress, and children will have difficulty learning to soothe themselves. All of this can provide helpful context when that parent is calling you with a concern about that child.

When a family is facing a child’s illness or a challenging condition, such as a learning disability, it can be helpful to ask how they have managed other problems in the past. While the problem they are now facing may feel unprecedented or overwhelming, they have usually managed other challenges, such as moves, changes in employment or financial setbacks. Perhaps there has been a parent’s broken leg, Alzheimer’s disease in a grandparent, or even the loss of a beloved pet. Find out how the family has managed communication in these circumstances, have they been clear and honest, in age-appropriate ways with their children? Have they been attuned to their children’s questions and concerns, and available to really listen? Have they tried to focus on protecting essential family time (remember mealtimes?) and their children’s routines both in and out of school? Listening to these past situations and responses is caring, respectful, and in and of itself supportive. As their pediatrician, you needn’t teach them these skills, but merely remind them of those that they already have.

If you have asked about mealtime and bedtime, you will have a clinical sense of what life is like for your patient and this family. You will look for patterns that generally support development – thoughtful planning, patience, empathy, and connectedness – and you will intuitively know whether this family would benefit from some health promotion. What you learn may be directly helpful concerning mealtimes or bedtime. Asking the questions communicates a precedent that you are interested in the family and how it functions. With experience, you also will be able to make inferences about the relationship between the parents, how the family handles stress, and what are the family’s expectations. All of this information will build attunement and trust. It will enable you to ask the right questions and make more effective interventions throughout your work with your patient and their 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. He is also chief clinical officer at Partners HealthCare, also in Boston. E-mail Dr. Swick and Dr. Jellinek at pdnews@frontlinemedcom.com.

This column, "Behavioral Consult," appears regularly in Pediatric News, a publication of IMNG Medical Media.

A challenge unique to the practice of pediatrics is that it is not enough to know your patient well. To be an effective pediatrician, you must know the family well.

This may seem obvious, but it is so essential that it is worthy of some discussion. When your patient is young, all problems will be presented by the parents and will reflect the parents’ own values and anxieties as well as straightforward physical symptoms. Almost every intervention you offer will have to be accepted and managed by the parents. As your patients grow older, you may find that some families serve as a useful buffer to stress and others seem to amplify distress.

Every pediatrician knows that families differ in their self-awareness. Some know their biases and perspectives, some even know that how they were raised or their wishes might distort their view of a given situation. But there are other families that deny even the possibility of any distortion.

Over the years that you work with a family, you will come to know their personality, their unique areas of strength and strain, talent and vulnerability. But early in working with a family, you might pay attention to a few areas to help you learn quickly about a family’s style. With this understanding, you will better understand the context for certain complaints or concerns, and you will be better able to help parents help their children.

There need not be a major illness or serious problem for you to learn about a family’s style and perspective. The daily routines of most families offer rich and nuanced illustrations of their styles, and you might learn about them efficiently with only a few specific questions. One especially useful approach is to ask about a family’s mealtime routine.

Even with very young children, does the family eat together most nights? Do they cook or order in or eat out? Who cooks the food and do the children participate? Do they eat at a consistent time on most nights? Does the family sit down together and how long does the mealtime last? Is it chaotic or rushed? Is it generally pleasant and fun, or is there tension or conflict?

A portrait of mealtime will give you a sense of the parents’ abilities to plan and collaborate, and to stick with a plan even when it is challenging. It illustrates the value they may have placed on spending time consistently with their children as well as providing them with nourishing meals. It might also illustrate how much stress they are facing as a family, due to finances or busy schedules. You could ask if the current dinnertime routine is to their liking – is it what they want for the family? If this seems like a sensitive topic, you could go further and ask what dinnertime was like for them when they were growing up. You might be amazed at what you learn from this simple discussion.

Another daily ritual that can offer a vivid portrait of a family’s style is their children’s bedtime routine. Invite parents to tell you how bedtime goes in their home. Often, you won’t need to ask for any more than that, and you will get a lot of detail.

But if needed, ask about what time bedtime starts, and how consistent is the routine from night to night. Does the child get to bed by an appropriate time? Are parents able to enforce a bedtime or is there a lot of struggle over lights going out each night? Does the child stay in their bed or come into their parents’ room? Is there time for snuggling or talking before lights out?

Again, you will learn about parents’ ability to plan and collaborate with one another. You will learn a lot about parents’ ability to tolerate higher levels of stress, as bedtimes are typically charged by exhaustion (in both children and parents), excitement (as everyone is together), and even anxiety.

You also will learn a lot about how well attuned the parents are to their children’s moods, temperaments, and needs (as opposed to their wants). Bedtime is full of opportunities for parents to pick up on their children’s physical and emotional needs without their children’s help. How parents are managing this task, all while tolerating the roller coaster of their children’s and their own fatigue, tells you a great deal about their ability to bear a child’s distress. A capacity to bear and manage their child’s distress is an essential skill in parenting, often one that develops over time. When it is lacking, home can become a place of very intense and unremitting anxiety and distress, and children will have difficulty learning to soothe themselves. All of this can provide helpful context when that parent is calling you with a concern about that child.

When a family is facing a child’s illness or a challenging condition, such as a learning disability, it can be helpful to ask how they have managed other problems in the past. While the problem they are now facing may feel unprecedented or overwhelming, they have usually managed other challenges, such as moves, changes in employment or financial setbacks. Perhaps there has been a parent’s broken leg, Alzheimer’s disease in a grandparent, or even the loss of a beloved pet. Find out how the family has managed communication in these circumstances, have they been clear and honest, in age-appropriate ways with their children? Have they been attuned to their children’s questions and concerns, and available to really listen? Have they tried to focus on protecting essential family time (remember mealtimes?) and their children’s routines both in and out of school? Listening to these past situations and responses is caring, respectful, and in and of itself supportive. As their pediatrician, you needn’t teach them these skills, but merely remind them of those that they already have.

If you have asked about mealtime and bedtime, you will have a clinical sense of what life is like for your patient and this family. You will look for patterns that generally support development – thoughtful planning, patience, empathy, and connectedness – and you will intuitively know whether this family would benefit from some health promotion. What you learn may be directly helpful concerning mealtimes or bedtime. Asking the questions communicates a precedent that you are interested in the family and how it functions. With experience, you also will be able to make inferences about the relationship between the parents, how the family handles stress, and what are the family’s expectations. All of this information will build attunement and trust. It will enable you to ask the right questions and make more effective interventions throughout your work with your patient and their 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. He is also chief clinical officer at Partners HealthCare, also in Boston. E-mail Dr. Swick and Dr. Jellinek at pdnews@frontlinemedcom.com.

This column, "Behavioral Consult," appears regularly in Pediatric News, a publication of IMNG Medical Media.

A challenge unique to the practice of pediatrics is that it is not enough to know your patient well. To be an effective pediatrician, you must know the family well.

This may seem obvious, but it is so essential that it is worthy of some discussion. When your patient is young, all problems will be presented by the parents and will reflect the parents’ own values and anxieties as well as straightforward physical symptoms. Almost every intervention you offer will have to be accepted and managed by the parents. As your patients grow older, you may find that some families serve as a useful buffer to stress and others seem to amplify distress.

Every pediatrician knows that families differ in their self-awareness. Some know their biases and perspectives, some even know that how they were raised or their wishes might distort their view of a given situation. But there are other families that deny even the possibility of any distortion.

Over the years that you work with a family, you will come to know their personality, their unique areas of strength and strain, talent and vulnerability. But early in working with a family, you might pay attention to a few areas to help you learn quickly about a family’s style. With this understanding, you will better understand the context for certain complaints or concerns, and you will be better able to help parents help their children.

There need not be a major illness or serious problem for you to learn about a family’s style and perspective. The daily routines of most families offer rich and nuanced illustrations of their styles, and you might learn about them efficiently with only a few specific questions. One especially useful approach is to ask about a family’s mealtime routine.

Even with very young children, does the family eat together most nights? Do they cook or order in or eat out? Who cooks the food and do the children participate? Do they eat at a consistent time on most nights? Does the family sit down together and how long does the mealtime last? Is it chaotic or rushed? Is it generally pleasant and fun, or is there tension or conflict?

A portrait of mealtime will give you a sense of the parents’ abilities to plan and collaborate, and to stick with a plan even when it is challenging. It illustrates the value they may have placed on spending time consistently with their children as well as providing them with nourishing meals. It might also illustrate how much stress they are facing as a family, due to finances or busy schedules. You could ask if the current dinnertime routine is to their liking – is it what they want for the family? If this seems like a sensitive topic, you could go further and ask what dinnertime was like for them when they were growing up. You might be amazed at what you learn from this simple discussion.

Another daily ritual that can offer a vivid portrait of a family’s style is their children’s bedtime routine. Invite parents to tell you how bedtime goes in their home. Often, you won’t need to ask for any more than that, and you will get a lot of detail.

But if needed, ask about what time bedtime starts, and how consistent is the routine from night to night. Does the child get to bed by an appropriate time? Are parents able to enforce a bedtime or is there a lot of struggle over lights going out each night? Does the child stay in their bed or come into their parents’ room? Is there time for snuggling or talking before lights out?

Again, you will learn about parents’ ability to plan and collaborate with one another. You will learn a lot about parents’ ability to tolerate higher levels of stress, as bedtimes are typically charged by exhaustion (in both children and parents), excitement (as everyone is together), and even anxiety.

You also will learn a lot about how well attuned the parents are to their children’s moods, temperaments, and needs (as opposed to their wants). Bedtime is full of opportunities for parents to pick up on their children’s physical and emotional needs without their children’s help. How parents are managing this task, all while tolerating the roller coaster of their children’s and their own fatigue, tells you a great deal about their ability to bear a child’s distress. A capacity to bear and manage their child’s distress is an essential skill in parenting, often one that develops over time. When it is lacking, home can become a place of very intense and unremitting anxiety and distress, and children will have difficulty learning to soothe themselves. All of this can provide helpful context when that parent is calling you with a concern about that child.

When a family is facing a child’s illness or a challenging condition, such as a learning disability, it can be helpful to ask how they have managed other problems in the past. While the problem they are now facing may feel unprecedented or overwhelming, they have usually managed other challenges, such as moves, changes in employment or financial setbacks. Perhaps there has been a parent’s broken leg, Alzheimer’s disease in a grandparent, or even the loss of a beloved pet. Find out how the family has managed communication in these circumstances, have they been clear and honest, in age-appropriate ways with their children? Have they been attuned to their children’s questions and concerns, and available to really listen? Have they tried to focus on protecting essential family time (remember mealtimes?) and their children’s routines both in and out of school? Listening to these past situations and responses is caring, respectful, and in and of itself supportive. As their pediatrician, you needn’t teach them these skills, but merely remind them of those that they already have.

If you have asked about mealtime and bedtime, you will have a clinical sense of what life is like for your patient and this family. You will look for patterns that generally support development – thoughtful planning, patience, empathy, and connectedness – and you will intuitively know whether this family would benefit from some health promotion. What you learn may be directly helpful concerning mealtimes or bedtime. Asking the questions communicates a precedent that you are interested in the family and how it functions. With experience, you also will be able to make inferences about the relationship between the parents, how the family handles stress, and what are the family’s expectations. All of this information will build attunement and trust. It will enable you to ask the right questions and make more effective interventions throughout your work with your patient and their 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. He is also chief clinical officer at Partners HealthCare, also in Boston. E-mail Dr. Swick and Dr. Jellinek at pdnews@frontlinemedcom.com.

This column, "Behavioral Consult," appears regularly in Pediatric News, a publication of IMNG Medical Media.

With the summer approaching, you are likely getting bombarded with health forms to fill out for summer camps, and fielding questions from parents like, "What age is best for sleepaway camp?"

In addition to simply filling out forms, consider taking the opportunity to help parents in the summer-planning process. Summer planning should be used as an opportunity to do much more for children than just fill their days or augment their college applications. You can help parents bring a developmental perspective to their planning by encouraging them to use the summer experience to help build their child’s self-esteem and autonomy.

© diego_cervo/iStockphoto.com

Encourage parents to step back and assess their child’s strengths and weaknesses and consider what experience might make a difference in their child’s life. For instance, the summer can be used to help a shy child feel more comfortable with peers, to encourage a fair athlete to become a better athlete or help a passionate athlete compete at a higher level, to encourage a child with a budding interest in theater to give it a try, to help an obese child lose weight or a weak child gain strength, or to help an adolescent with learning problems and low self-esteem gain confidence by succeeding in a summer job.

Taking it a step further, you can encourage parents to consider the quality of the child’s friendships during summer planning. Consider asking parents the following questions: Does your child have a group of more superficial friends but struggle with the competitiveness and compromises of a one-on-one friendship? Does your child have only one close friend and no others? Could the appropriate friend facilitate or enrich the summer experience? For a child with a math disability, what is the relative gain of a summer spent with a math tutor instead of friends? The answer: It will probably feel like punishment. Instead, encourage parents to focus on cultivating skills such as initiative, discipline, patience, and frustration tolerance through enhancing an academic strength (like computers or theater), instead of focusing on a weakness.

While some of these options seem obvious, setting reasonable expectations, fitting the experience into the child’s personality, and finding the right setting take good judgment and effort, and taking a developmental perspective is key.

• Young school-age children. At this age, the central task is mastery of relatively new cognitive abilities. Giving these kids an opportunity to stretch their skills across several domains – in a sports camp that has a strong social component or a day camp with mixed activities – can be just right.

• Older school-age children (aged 9-12). These children can benefit from a camp experience that provides an opportunity for self-direction and independence, as they prepare for middle school. Sleepaway camps can help some children develop lifelong skills, such as camping, woodworking, or canoeing, and help foster friendships. Sleepaway camps also give children a chance to get away from a discordant home situation or from school cliques that have been rejecting.

• Young adolescents (aged 13-15). At this age, adolescents benefit from an opportunity to focus on a single area of interest, as they are in the process of deepening their sense of identity. A summer experience that allows them to engage in one enterprise can make a great difference in their growing ability to discern between their abilities and their interests.

• Older adolescents (aged 16-19). Older adolescents will continue to cultivate their individual identities, while managing greater independence, developing better impulse control, and learning to cultivate relationships with other adults. These teenagers may benefit from summer plans that promote these skills in ways that are genuine and instructive, but relatively low risk. They may want to consider a structured experience living with a family in another country and studying the language, or a residential work experience, such as on a cooperative farm.

• College. Once teenagers have gone to college, they may want to rest during the summer. A vacation is valuable, but 3 uninterrupted months is a precious resource to spend solely on relaxation. Internships can help with the career decision-making process, and could help them land a job after college. But it is hard to overstate the value of young adults having a paid job in the summer. A genuine work experience during the summer can be a laboratory for them to develop responsibility, become aware of their strengths and weaknesses, develop independence and patience, and help them decide what career they may eventually pursue.

Enjoyment is the fuel that drives the developmental engine, and may be what distinguishes it from children’s experiences at school. Imagine a 10-year-old child who has struggled (or maybe just straggled) socially due to shyness, but who has an encyclopedic knowledge (and love) of computer programming. If there was a day camp that grouped children into teams that would then design a new computer programming language over the course of a week, that could be a great fit for this child. The child’s interest in and self-confidence about computer programming would engage him or her in the project, while allowing the child to work on social skills. The fact that the other children have a shared interest further tips the scales in favor of social success. Social success reinforces healthy skill development, which will make it easier for the child to face a social situation in less-favorable circumstances, perhaps at school. The great thing about development is that mastery often begets mastery.

We appreciate that economic limitations can limit summer planning. Sleepaway camps can be expensive, and a teenager taking on a job may be essential for the family budget. However, even within these constraints, there may be creative options through local organizations like the Boys and Girls Clubs of America and through extended family. And for most, summers well spent (a dozen or so opportunities, each 2-3 months long) are terrific ways to enhance self-esteem and broaden experiences.

 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 also chief clinical officer at Partners HealthCare, also in Boston. 

With the summer approaching, you are likely getting bombarded with health forms to fill out for summer camps, and fielding questions from parents like, "What age is best for sleepaway camp?"

In addition to simply filling out forms, consider taking the opportunity to help parents in the summer-planning process. Summer planning should be used as an opportunity to do much more for children than just fill their days or augment their college applications. You can help parents bring a developmental perspective to their planning by encouraging them to use the summer experience to help build their child’s self-esteem and autonomy.

© diego_cervo/iStockphoto.com

Encourage parents to step back and assess their child’s strengths and weaknesses and consider what experience might make a difference in their child’s life. For instance, the summer can be used to help a shy child feel more comfortable with peers, to encourage a fair athlete to become a better athlete or help a passionate athlete compete at a higher level, to encourage a child with a budding interest in theater to give it a try, to help an obese child lose weight or a weak child gain strength, or to help an adolescent with learning problems and low self-esteem gain confidence by succeeding in a summer job.

Taking it a step further, you can encourage parents to consider the quality of the child’s friendships during summer planning. Consider asking parents the following questions: Does your child have a group of more superficial friends but struggle with the competitiveness and compromises of a one-on-one friendship? Does your child have only one close friend and no others? Could the appropriate friend facilitate or enrich the summer experience? For a child with a math disability, what is the relative gain of a summer spent with a math tutor instead of friends? The answer: It will probably feel like punishment. Instead, encourage parents to focus on cultivating skills such as initiative, discipline, patience, and frustration tolerance through enhancing an academic strength (like computers or theater), instead of focusing on a weakness.

While some of these options seem obvious, setting reasonable expectations, fitting the experience into the child’s personality, and finding the right setting take good judgment and effort, and taking a developmental perspective is key.

• Young school-age children. At this age, the central task is mastery of relatively new cognitive abilities. Giving these kids an opportunity to stretch their skills across several domains – in a sports camp that has a strong social component or a day camp with mixed activities – can be just right.

• Older school-age children (aged 9-12). These children can benefit from a camp experience that provides an opportunity for self-direction and independence, as they prepare for middle school. Sleepaway camps can help some children develop lifelong skills, such as camping, woodworking, or canoeing, and help foster friendships. Sleepaway camps also give children a chance to get away from a discordant home situation or from school cliques that have been rejecting.

• Young adolescents (aged 13-15). At this age, adolescents benefit from an opportunity to focus on a single area of interest, as they are in the process of deepening their sense of identity. A summer experience that allows them to engage in one enterprise can make a great difference in their growing ability to discern between their abilities and their interests.

• Older adolescents (aged 16-19). Older adolescents will continue to cultivate their individual identities, while managing greater independence, developing better impulse control, and learning to cultivate relationships with other adults. These teenagers may benefit from summer plans that promote these skills in ways that are genuine and instructive, but relatively low risk. They may want to consider a structured experience living with a family in another country and studying the language, or a residential work experience, such as on a cooperative farm.

• College. Once teenagers have gone to college, they may want to rest during the summer. A vacation is valuable, but 3 uninterrupted months is a precious resource to spend solely on relaxation. Internships can help with the career decision-making process, and could help them land a job after college. But it is hard to overstate the value of young adults having a paid job in the summer. A genuine work experience during the summer can be a laboratory for them to develop responsibility, become aware of their strengths and weaknesses, develop independence and patience, and help them decide what career they may eventually pursue.

Enjoyment is the fuel that drives the developmental engine, and may be what distinguishes it from children’s experiences at school. Imagine a 10-year-old child who has struggled (or maybe just straggled) socially due to shyness, but who has an encyclopedic knowledge (and love) of computer programming. If there was a day camp that grouped children into teams that would then design a new computer programming language over the course of a week, that could be a great fit for this child. The child’s interest in and self-confidence about computer programming would engage him or her in the project, while allowing the child to work on social skills. The fact that the other children have a shared interest further tips the scales in favor of social success. Social success reinforces healthy skill development, which will make it easier for the child to face a social situation in less-favorable circumstances, perhaps at school. The great thing about development is that mastery often begets mastery.

We appreciate that economic limitations can limit summer planning. Sleepaway camps can be expensive, and a teenager taking on a job may be essential for the family budget. However, even within these constraints, there may be creative options through local organizations like the Boys and Girls Clubs of America and through extended family. And for most, summers well spent (a dozen or so opportunities, each 2-3 months long) are terrific ways to enhance self-esteem and broaden experiences.

 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 also chief clinical officer at Partners HealthCare, also in Boston. 

With the summer approaching, you are likely getting bombarded with health forms to fill out for summer camps, and fielding questions from parents like, "What age is best for sleepaway camp?"

In addition to simply filling out forms, consider taking the opportunity to help parents in the summer-planning process. Summer planning should be used as an opportunity to do much more for children than just fill their days or augment their college applications. You can help parents bring a developmental perspective to their planning by encouraging them to use the summer experience to help build their child’s self-esteem and autonomy.

© diego_cervo/iStockphoto.com

Encourage parents to step back and assess their child’s strengths and weaknesses and consider what experience might make a difference in their child’s life. For instance, the summer can be used to help a shy child feel more comfortable with peers, to encourage a fair athlete to become a better athlete or help a passionate athlete compete at a higher level, to encourage a child with a budding interest in theater to give it a try, to help an obese child lose weight or a weak child gain strength, or to help an adolescent with learning problems and low self-esteem gain confidence by succeeding in a summer job.

Taking it a step further, you can encourage parents to consider the quality of the child’s friendships during summer planning. Consider asking parents the following questions: Does your child have a group of more superficial friends but struggle with the competitiveness and compromises of a one-on-one friendship? Does your child have only one close friend and no others? Could the appropriate friend facilitate or enrich the summer experience? For a child with a math disability, what is the relative gain of a summer spent with a math tutor instead of friends? The answer: It will probably feel like punishment. Instead, encourage parents to focus on cultivating skills such as initiative, discipline, patience, and frustration tolerance through enhancing an academic strength (like computers or theater), instead of focusing on a weakness.

While some of these options seem obvious, setting reasonable expectations, fitting the experience into the child’s personality, and finding the right setting take good judgment and effort, and taking a developmental perspective is key.

• Young school-age children. At this age, the central task is mastery of relatively new cognitive abilities. Giving these kids an opportunity to stretch their skills across several domains – in a sports camp that has a strong social component or a day camp with mixed activities – can be just right.

• Older school-age children (aged 9-12). These children can benefit from a camp experience that provides an opportunity for self-direction and independence, as they prepare for middle school. Sleepaway camps can help some children develop lifelong skills, such as camping, woodworking, or canoeing, and help foster friendships. Sleepaway camps also give children a chance to get away from a discordant home situation or from school cliques that have been rejecting.

• Young adolescents (aged 13-15). At this age, adolescents benefit from an opportunity to focus on a single area of interest, as they are in the process of deepening their sense of identity. A summer experience that allows them to engage in one enterprise can make a great difference in their growing ability to discern between their abilities and their interests.

• Older adolescents (aged 16-19). Older adolescents will continue to cultivate their individual identities, while managing greater independence, developing better impulse control, and learning to cultivate relationships with other adults. These teenagers may benefit from summer plans that promote these skills in ways that are genuine and instructive, but relatively low risk. They may want to consider a structured experience living with a family in another country and studying the language, or a residential work experience, such as on a cooperative farm.

• College. Once teenagers have gone to college, they may want to rest during the summer. A vacation is valuable, but 3 uninterrupted months is a precious resource to spend solely on relaxation. Internships can help with the career decision-making process, and could help them land a job after college. But it is hard to overstate the value of young adults having a paid job in the summer. A genuine work experience during the summer can be a laboratory for them to develop responsibility, become aware of their strengths and weaknesses, develop independence and patience, and help them decide what career they may eventually pursue.

Enjoyment is the fuel that drives the developmental engine, and may be what distinguishes it from children’s experiences at school. Imagine a 10-year-old child who has struggled (or maybe just straggled) socially due to shyness, but who has an encyclopedic knowledge (and love) of computer programming. If there was a day camp that grouped children into teams that would then design a new computer programming language over the course of a week, that could be a great fit for this child. The child’s interest in and self-confidence about computer programming would engage him or her in the project, while allowing the child to work on social skills. The fact that the other children have a shared interest further tips the scales in favor of social success. Social success reinforces healthy skill development, which will make it easier for the child to face a social situation in less-favorable circumstances, perhaps at school. The great thing about development is that mastery often begets mastery.

We appreciate that economic limitations can limit summer planning. Sleepaway camps can be expensive, and a teenager taking on a job may be essential for the family budget. However, even within these constraints, there may be creative options through local organizations like the Boys and Girls Clubs of America and through extended family. And for most, summers well spent (a dozen or so opportunities, each 2-3 months long) are terrific ways to enhance self-esteem and broaden experiences.

 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 also chief clinical officer at Partners HealthCare, also in Boston. 

When is anxiety a normal, healthy part of a child’s development and when is it a psychiatric symptom that needs treatment? This question is likely to come up at many outpatient pediatric visits, as parents will be understandably concerned when faced with a child’s tears and fears.

It may help to discuss what we mean by anxiety. In child psychiatry, we consider anxiety to be a child’s normal subjective response to an internal or external event that causes concern, worry, or alarm. We also consider anxiety as an aspect of a child’s temperament, whether he or she has a highly anxious temperament, an easygoing one, or something in between. Anxiety can describe a patient’s ongoing, significant experience of concern, worry, or fear that may not be tied to any known cause and may lead to avoidance or dysfunction. Therefore, the extent and nature of a child’s anxiety requires the pediatrician’s understanding and differential assessment.

Anxiety also is a routine and, at times, motivating emotion experienced by children and adults, and the experience of anxiety serves a critical role in healthy development as it prepares or protects the body and mind. In younger children, anxiety protects against risky or dangerous forays without parents, whether toward unknown adults, new foods, or unfamiliar places. The experience of anxiety in a new setting confers a survival advantage on the smallest children, who are otherwise vulnerable without their parents to protect them. This anxiety also is an essential part of the earliest attachment between parents and their infants and toddlers, as parents are trained and rewarded to be present and vigilant about their young children’s location or needs.

From the ages of 7-12 years, anxiety often contributes to better or optimal cognitive, intellectual, social, and physical performance. As school-age children face new challenges, they worry about succeeding and work harder to master tasks. Ideally, the anxiety can be adaptive, supporting focus, attention, tenacity, and preparation. In this way, it supports learning and mastery, the central tasks of school-age children. Emotional maturity hinges on their experiencing, tolerating, and mastering anxiety.

Adolescents face many tasks, increasingly without direct parental presence or involvement. While teens should be developing their identity, intimacy in their relationships outside the home, independence, and better impulse control, they also need to be engaged in sustained hard work at school, activities, and athletics to prepare for the expectations and responsibilities they will face in college. Normal anxiety about whether they will be ready for a test, an independent project, or a college interview helps to fuel the focus and sustained effort they will need to prepare themselves (with little or no adult involvement). Appropriate anxiety about health, safety, or trouble with authority can counterbalance impulsivity, peer pressure, and even hormones as adolescents make choices of great consequence on their own and without experience or parents to guide them.

Although the parents of adolescents may be relieved to know that their teens are anxious about studying enough for a test or getting home safely from a cast party, most parents find it distressing to watch their children face and cope with anxiety. It is natural for parents to want to help their children with this distress, even protect them from it. And, of course, some parents may have more anxious temperaments or even anxiety disorders themselves. These parents may be highly sensitive to anxiety and, at the same time, have limited ability to help their children tolerate and learn to manage their own anxiety. For these families, reframing the value of anxiety may provide reassurance.

There are, however, some red flags that will indicate to the clinician that a referral and further evaluation, rather than reassurance, is critical. Even without understanding the subtleties of a child’s anxiety, any worry that causes a significant impairment in a child’s functioning should be referred for psychiatric evaluation. When a child refuses to attend school, even just for a few days, this is considered to be a psychiatric emergency since, without rapid attention, the behavior becomes more intractable. It is important to urge the parents to collaborate with the school to devise a plan for that child to attend, even in a very limited way, while they await a psychiatric evaluation.

School is a child’s primary occupation, but it is not the only domain in which function can be impaired by significant anxiety. Is the child dropping previously beloved activities or suddenly showing marked social isolation? Is sleep disrupted by nighttime fears or concerns about what will be faced the next day? Does the child seek reassurance about the same issue, even after it has been explicitly addressed by the parents, every day for an extended period of time? Has the child begun to demonstrate repetitive, compulsive behaviors – flicking light switches in response to anxiety about school performance – saying the behaviors are helpful although they do not appear logically connected to the child’s concern?

In each of these cases, the symptoms suggest that the anxiety the child is experiencing goes beyond what is normal and merits a psychiatric evaluation. A child who begins to seem very sad, sulky, or withdrawn from peers and interests in the setting of sustained anxiety may be developing depression (or may have anxiety as a component of depression) and also needs a psychiatric referral.

Anxiety that is not routine or adaptive can be the visible symptom of many different psychiatric problems, not only anxiety disorders. It is worth noting that children with undiagnosed attention deficit disorder (ADD), subtle developmental disorders, or learning disabilities often present with considerable anxiety about their function and performance in school, as they have faced sustained failure to keep up with their peers academically and sometimes socially.

Adolescents with emerging drug or alcohol problems may present with anxiety symptoms that do not seem connected to their actual stressors. Undiagnosed anxiety disorders can lead to substance abuse as teens attempt not just to feel good, but to feel better. Intense anxiety about weight or about changes in weight that are not discernible to others may signal an emerging eating disorder. Intense and sustained anxiety in the setting of social withdrawal and deteriorating function in adolescents may be the first sign of an emerging thought disorder.

Finally, when parents’ level of anxiety about their children makes it difficult or impossible for them to help their children tolerate and then learn to manage and master their normal or routine anxiety, a referral for a psychiatric evaluation for the child can be helpful. Although the youngster may not have an underlying anxiety disorder, starting therapy with a caring adult who can help the child tolerate this difficult affect will be essential to healthy development.

Most parents will bring their concerns about their children’s distress to their pediatricians, and you should reassure them that no one should worry alone. Most anxiety reflects emotional health and adaptability and is even a force driving healthy development, but sometimes it does signal a psychiatric problem. If the child’s function is impaired, if the anxiety is inappropriate to the stressor, or if the parents are unable to help a child develop healthy coping skills, you also should not worry alone and should make a referral for a psychiatric evaluation.

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 also chief clinical officer at Partners HealthCare, also in Boston. 

When is anxiety a normal, healthy part of a child’s development and when is it a psychiatric symptom that needs treatment? This question is likely to come up at many outpatient pediatric visits, as parents will be understandably concerned when faced with a child’s tears and fears.

It may help to discuss what we mean by anxiety. In child psychiatry, we consider anxiety to be a child’s normal subjective response to an internal or external event that causes concern, worry, or alarm. We also consider anxiety as an aspect of a child’s temperament, whether he or she has a highly anxious temperament, an easygoing one, or something in between. Anxiety can describe a patient’s ongoing, significant experience of concern, worry, or fear that may not be tied to any known cause and may lead to avoidance or dysfunction. Therefore, the extent and nature of a child’s anxiety requires the pediatrician’s understanding and differential assessment.

Anxiety also is a routine and, at times, motivating emotion experienced by children and adults, and the experience of anxiety serves a critical role in healthy development as it prepares or protects the body and mind. In younger children, anxiety protects against risky or dangerous forays without parents, whether toward unknown adults, new foods, or unfamiliar places. The experience of anxiety in a new setting confers a survival advantage on the smallest children, who are otherwise vulnerable without their parents to protect them. This anxiety also is an essential part of the earliest attachment between parents and their infants and toddlers, as parents are trained and rewarded to be present and vigilant about their young children’s location or needs.

From the ages of 7-12 years, anxiety often contributes to better or optimal cognitive, intellectual, social, and physical performance. As school-age children face new challenges, they worry about succeeding and work harder to master tasks. Ideally, the anxiety can be adaptive, supporting focus, attention, tenacity, and preparation. In this way, it supports learning and mastery, the central tasks of school-age children. Emotional maturity hinges on their experiencing, tolerating, and mastering anxiety.

Adolescents face many tasks, increasingly without direct parental presence or involvement. While teens should be developing their identity, intimacy in their relationships outside the home, independence, and better impulse control, they also need to be engaged in sustained hard work at school, activities, and athletics to prepare for the expectations and responsibilities they will face in college. Normal anxiety about whether they will be ready for a test, an independent project, or a college interview helps to fuel the focus and sustained effort they will need to prepare themselves (with little or no adult involvement). Appropriate anxiety about health, safety, or trouble with authority can counterbalance impulsivity, peer pressure, and even hormones as adolescents make choices of great consequence on their own and without experience or parents to guide them.

Although the parents of adolescents may be relieved to know that their teens are anxious about studying enough for a test or getting home safely from a cast party, most parents find it distressing to watch their children face and cope with anxiety. It is natural for parents to want to help their children with this distress, even protect them from it. And, of course, some parents may have more anxious temperaments or even anxiety disorders themselves. These parents may be highly sensitive to anxiety and, at the same time, have limited ability to help their children tolerate and learn to manage their own anxiety. For these families, reframing the value of anxiety may provide reassurance.

There are, however, some red flags that will indicate to the clinician that a referral and further evaluation, rather than reassurance, is critical. Even without understanding the subtleties of a child’s anxiety, any worry that causes a significant impairment in a child’s functioning should be referred for psychiatric evaluation. When a child refuses to attend school, even just for a few days, this is considered to be a psychiatric emergency since, without rapid attention, the behavior becomes more intractable. It is important to urge the parents to collaborate with the school to devise a plan for that child to attend, even in a very limited way, while they await a psychiatric evaluation.

School is a child’s primary occupation, but it is not the only domain in which function can be impaired by significant anxiety. Is the child dropping previously beloved activities or suddenly showing marked social isolation? Is sleep disrupted by nighttime fears or concerns about what will be faced the next day? Does the child seek reassurance about the same issue, even after it has been explicitly addressed by the parents, every day for an extended period of time? Has the child begun to demonstrate repetitive, compulsive behaviors – flicking light switches in response to anxiety about school performance – saying the behaviors are helpful although they do not appear logically connected to the child’s concern?

In each of these cases, the symptoms suggest that the anxiety the child is experiencing goes beyond what is normal and merits a psychiatric evaluation. A child who begins to seem very sad, sulky, or withdrawn from peers and interests in the setting of sustained anxiety may be developing depression (or may have anxiety as a component of depression) and also needs a psychiatric referral.

Anxiety that is not routine or adaptive can be the visible symptom of many different psychiatric problems, not only anxiety disorders. It is worth noting that children with undiagnosed attention deficit disorder (ADD), subtle developmental disorders, or learning disabilities often present with considerable anxiety about their function and performance in school, as they have faced sustained failure to keep up with their peers academically and sometimes socially.

Adolescents with emerging drug or alcohol problems may present with anxiety symptoms that do not seem connected to their actual stressors. Undiagnosed anxiety disorders can lead to substance abuse as teens attempt not just to feel good, but to feel better. Intense anxiety about weight or about changes in weight that are not discernible to others may signal an emerging eating disorder. Intense and sustained anxiety in the setting of social withdrawal and deteriorating function in adolescents may be the first sign of an emerging thought disorder.

Finally, when parents’ level of anxiety about their children makes it difficult or impossible for them to help their children tolerate and then learn to manage and master their normal or routine anxiety, a referral for a psychiatric evaluation for the child can be helpful. Although the youngster may not have an underlying anxiety disorder, starting therapy with a caring adult who can help the child tolerate this difficult affect will be essential to healthy development.

Most parents will bring their concerns about their children’s distress to their pediatricians, and you should reassure them that no one should worry alone. Most anxiety reflects emotional health and adaptability and is even a force driving healthy development, but sometimes it does signal a psychiatric problem. If the child’s function is impaired, if the anxiety is inappropriate to the stressor, or if the parents are unable to help a child develop healthy coping skills, you also should not worry alone and should make a referral for a psychiatric evaluation.

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 also chief clinical officer at Partners HealthCare, also in Boston. 

When is anxiety a normal, healthy part of a child’s development and when is it a psychiatric symptom that needs treatment? This question is likely to come up at many outpatient pediatric visits, as parents will be understandably concerned when faced with a child’s tears and fears.

It may help to discuss what we mean by anxiety. In child psychiatry, we consider anxiety to be a child’s normal subjective response to an internal or external event that causes concern, worry, or alarm. We also consider anxiety as an aspect of a child’s temperament, whether he or she has a highly anxious temperament, an easygoing one, or something in between. Anxiety can describe a patient’s ongoing, significant experience of concern, worry, or fear that may not be tied to any known cause and may lead to avoidance or dysfunction. Therefore, the extent and nature of a child’s anxiety requires the pediatrician’s understanding and differential assessment.

Anxiety also is a routine and, at times, motivating emotion experienced by children and adults, and the experience of anxiety serves a critical role in healthy development as it prepares or protects the body and mind. In younger children, anxiety protects against risky or dangerous forays without parents, whether toward unknown adults, new foods, or unfamiliar places. The experience of anxiety in a new setting confers a survival advantage on the smallest children, who are otherwise vulnerable without their parents to protect them. This anxiety also is an essential part of the earliest attachment between parents and their infants and toddlers, as parents are trained and rewarded to be present and vigilant about their young children’s location or needs.

From the ages of 7-12 years, anxiety often contributes to better or optimal cognitive, intellectual, social, and physical performance. As school-age children face new challenges, they worry about succeeding and work harder to master tasks. Ideally, the anxiety can be adaptive, supporting focus, attention, tenacity, and preparation. In this way, it supports learning and mastery, the central tasks of school-age children. Emotional maturity hinges on their experiencing, tolerating, and mastering anxiety.

Adolescents face many tasks, increasingly without direct parental presence or involvement. While teens should be developing their identity, intimacy in their relationships outside the home, independence, and better impulse control, they also need to be engaged in sustained hard work at school, activities, and athletics to prepare for the expectations and responsibilities they will face in college. Normal anxiety about whether they will be ready for a test, an independent project, or a college interview helps to fuel the focus and sustained effort they will need to prepare themselves (with little or no adult involvement). Appropriate anxiety about health, safety, or trouble with authority can counterbalance impulsivity, peer pressure, and even hormones as adolescents make choices of great consequence on their own and without experience or parents to guide them.

Although the parents of adolescents may be relieved to know that their teens are anxious about studying enough for a test or getting home safely from a cast party, most parents find it distressing to watch their children face and cope with anxiety. It is natural for parents to want to help their children with this distress, even protect them from it. And, of course, some parents may have more anxious temperaments or even anxiety disorders themselves. These parents may be highly sensitive to anxiety and, at the same time, have limited ability to help their children tolerate and learn to manage their own anxiety. For these families, reframing the value of anxiety may provide reassurance.

There are, however, some red flags that will indicate to the clinician that a referral and further evaluation, rather than reassurance, is critical. Even without understanding the subtleties of a child’s anxiety, any worry that causes a significant impairment in a child’s functioning should be referred for psychiatric evaluation. When a child refuses to attend school, even just for a few days, this is considered to be a psychiatric emergency since, without rapid attention, the behavior becomes more intractable. It is important to urge the parents to collaborate with the school to devise a plan for that child to attend, even in a very limited way, while they await a psychiatric evaluation.

School is a child’s primary occupation, but it is not the only domain in which function can be impaired by significant anxiety. Is the child dropping previously beloved activities or suddenly showing marked social isolation? Is sleep disrupted by nighttime fears or concerns about what will be faced the next day? Does the child seek reassurance about the same issue, even after it has been explicitly addressed by the parents, every day for an extended period of time? Has the child begun to demonstrate repetitive, compulsive behaviors – flicking light switches in response to anxiety about school performance – saying the behaviors are helpful although they do not appear logically connected to the child’s concern?

In each of these cases, the symptoms suggest that the anxiety the child is experiencing goes beyond what is normal and merits a psychiatric evaluation. A child who begins to seem very sad, sulky, or withdrawn from peers and interests in the setting of sustained anxiety may be developing depression (or may have anxiety as a component of depression) and also needs a psychiatric referral.

Anxiety that is not routine or adaptive can be the visible symptom of many different psychiatric problems, not only anxiety disorders. It is worth noting that children with undiagnosed attention deficit disorder (ADD), subtle developmental disorders, or learning disabilities often present with considerable anxiety about their function and performance in school, as they have faced sustained failure to keep up with their peers academically and sometimes socially.

Adolescents with emerging drug or alcohol problems may present with anxiety symptoms that do not seem connected to their actual stressors. Undiagnosed anxiety disorders can lead to substance abuse as teens attempt not just to feel good, but to feel better. Intense anxiety about weight or about changes in weight that are not discernible to others may signal an emerging eating disorder. Intense and sustained anxiety in the setting of social withdrawal and deteriorating function in adolescents may be the first sign of an emerging thought disorder.

Finally, when parents’ level of anxiety about their children makes it difficult or impossible for them to help their children tolerate and then learn to manage and master their normal or routine anxiety, a referral for a psychiatric evaluation for the child can be helpful. Although the youngster may not have an underlying anxiety disorder, starting therapy with a caring adult who can help the child tolerate this difficult affect will be essential to healthy development.

Most parents will bring their concerns about their children’s distress to their pediatricians, and you should reassure them that no one should worry alone. Most anxiety reflects emotional health and adaptability and is even a force driving healthy development, but sometimes it does signal a psychiatric problem. If the child’s function is impaired, if the anxiety is inappropriate to the stressor, or if the parents are unable to help a child develop healthy coping skills, you also should not worry alone and should make a referral for a psychiatric evaluation.

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 also chief clinical officer at Partners HealthCare, also in Boston.