Behavioral Consult

The development of language in children is like the canary in the coal mine – problems of genetics, medical conditions, and environment all can cause it to go awry. Whatever the cause, it is very important to make sure a child with a problem in this area gets prompt assistance, because how speech and language progress also affects many aspects of the child’s success in life and what it is like to parent them.

Some of the factors known to put a child at risk for delays or deviations in speech and language development include prematurity and low birth weight; genetic conditions such as Down syndrome; physical problems such as cerebral palsy or seizure disorders; hearing impairment; and, as usual, being a boy. The most common reason for delayed language is general delay or intellectual disability. A family history of speech and language disorders also adds to the risk, and one single gene defect has even been found for a few of these. Eight percent of young children have been estimated to have a delay in speech or language. The vast majority of them have no specific risk factors.

The “language environment” of the home is critical to language learning. Compared with high-income families, parents on welfare say one-third as many words to their children and working-class parents say one-half as many in the first 3 years. Because over 85% of a child’s words at age 3 years come from words heard from their parents, this is estimated to create a 30-million-word difference between children of high- versus low-income families by age 4 years! In addition, low-income parents provide two discouragements for each one encouragement, in contrast to one correction to six encouragements in high-income homes, with the additional psychological implications.

These sad facts contributed to the creation of the Reach Out and Read program, which I hope you have joined. A free book from the doctor at every checkup visit, some modeling of how to read to the child, and information about the importance of talking with the child are things you can do to emphasize the importance of language stimulation to development and academic success.

Most parents are very motivated by the promise of better school success from better language, but it can seem far away when the child is only 1 year old! A more immediate motivator is the threat of more temper tantrums and noncompliance in children with delayed language. Almost all children with language problems understand more than they can express. When the gap between understanding and speaking is greater, so is the child’s frustration. While a large percentage of children with expressive language problems will “outgrow” them, the pattern of angry reactivity and difficult parent child interactions may continue. This is a good reason to discuss promoting language but to also suggest Baby Signs (www.babysignstoo.com) starting in the first year, especially if communication frustration starts to emerge.

School is where the big impact from language impairments appears. And it is not just the significant association between early language disorders and persistent reading disability and even written language disability that you should worry about and monitor. Children with speech and language disorders, even simply dysarticulation, can be teased, bullied, and rejected socially. As a result, children with speech and language deficits experience lower self-esteem, greater discouragement, and sometimes reactive aggression. In addition to identifying these problems and getting treatment for the issues of language, learning, and socio-emotional adjustment, it is important to find nonverbal strengths in the child such as sports or music to give them a social group where they can find success.

Language problems in older children may be subtle and not noticed or complained about by their parents, who may have the same weakness. Even teachers may not connect the student’s poor academic performance to language difficulties because they seem to have “the basics.” If you notice a schoolaged child unable to understand or answer your questions with some sentence complexity, it is important to refer to a speech pathologist for assessment. Although there should be free evaluation and treatment services at the school, the speech pathologist may not be expert at assessing more complex language disorders. In addition, the child’s difficulties may not measure up as “impairing enough” to receive those services, and private services may be needed.

But if you do not feel like a child language expert, you are not alone! Not only were you lucky if you heard one lecture on language development during training, but the younger the child, the less language you are likely to hear from him or her during brief health supervision visits. The parent is probably dominating the conversation (if you are a good listener) trying to have their agenda addressed, and the child is either excited or terrified by your office environment.

The broadband developmental screening now recommended by the American Academy of Pediatrics for all children at 9, 18, and 30 months includes language milestones or parental concern, but these have not been shown to have adequate sensitivity or specificity and will miss many affected children.

Many young children with language disorders are now or will later be on the autism spectrum. The recommended autism-specific screens at 18 and 24-30 months will detect many, but not all, of these children. It is important to realize that the most common reason for a false positive autism screen is language delay, and it deserves follow-up and treatment even though not representing autism.

What should you do given these gaps between need, tools, and knowledge? Of course, collect the general and autism screens as recommended, but also use them when you or the parent have a concern. For children under 2 years, the parent’s report is generally accurate, as expected language is fairly simple. Infants should have different cries and reactions to caregivers in the first 3 months; babble and laugh by 6 months; and imitate sounds as well as recognize a few words by 1 year. While infants typically have 1-2 words by 12 months and two-word combinations by 18 months, as a cutoff they should show 1-2 words by 18 months and either 50 words or 2 words together by 24 months. Listening to a child’s spontaneous language is the best gauge of articulation. By age 2 years, we – a stranger to the child – can only expect to understand about 25% of what they say, but by 3 years it should be 66%, and by age 4 years almost 100%.

Gestures are an important aspect of communication. Use of gestures such as raising arms to be picked up or waving bye-bye by 1 year are typical. Between 1 and 2 years, children should follow your pointing and share their interests by pointing in addition to indicating named pictures and body parts. Deficits in use of gestures should spur a language evaluation and also are part of diagnosing autism, a much more serious and specific condition defined by communication deficits. Most autism screening tools include tapping gestures as well as spoken language.

After 2 years, language assessment has to include more elements than many parents can report easily or you can observe. There is now no formal additional language screening recommendation beyond surveillance, and the general developmental and autism screens. Every state has free child development services that can assess and provide intervention for children 0-3 years if you or the parent has concerns. But you may want to do more to either reassure or clarify the need for and type of referral by using a language-specific tool. The most accurate and practical tools applicable to children 8-35 months are the MacArthur-Bates Communicative Development Inventories (CDI) and the Language Development Survey (LDS), both parent completed. The LDS assesses based on a list of vocabulary words and examples of phrases, and the CDI has three different forms using vocabulary, gestures, and sentences.

After age 3 years, language is so complex that direct testing of the child is needed. A draft report from the U.S. Preventive Services Task Force in November 2014 presents a review of all available measures.

The good news is that a variety of approaches to therapy for speech and language disorders in young children are effective in reducing impairment. The most effective ones involve the parents in learning what communication skills to observe, stimulate, and reinforce, and have an adequate number of total hours of intervention spread over several months.

As for all children and youth with special health care needs, we have the responsibility to detect, monitor, refer, track, and support families of children with speech and language disorders to assure their best outcomes. Whatever the cause, improving the communication abilities of the child can make a big difference to many aspects of their lives.

Dr. Howard is an assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at [email protected].

The development of language in children is like the canary in the coal mine – problems of genetics, medical conditions, and environment all can cause it to go awry. Whatever the cause, it is very important to make sure a child with a problem in this area gets prompt assistance, because how speech and language progress also affects many aspects of the child’s success in life and what it is like to parent them.

Some of the factors known to put a child at risk for delays or deviations in speech and language development include prematurity and low birth weight; genetic conditions such as Down syndrome; physical problems such as cerebral palsy or seizure disorders; hearing impairment; and, as usual, being a boy. The most common reason for delayed language is general delay or intellectual disability. A family history of speech and language disorders also adds to the risk, and one single gene defect has even been found for a few of these. Eight percent of young children have been estimated to have a delay in speech or language. The vast majority of them have no specific risk factors.

The “language environment” of the home is critical to language learning. Compared with high-income families, parents on welfare say one-third as many words to their children and working-class parents say one-half as many in the first 3 years. Because over 85% of a child’s words at age 3 years come from words heard from their parents, this is estimated to create a 30-million-word difference between children of high- versus low-income families by age 4 years! In addition, low-income parents provide two discouragements for each one encouragement, in contrast to one correction to six encouragements in high-income homes, with the additional psychological implications.

These sad facts contributed to the creation of the Reach Out and Read program, which I hope you have joined. A free book from the doctor at every checkup visit, some modeling of how to read to the child, and information about the importance of talking with the child are things you can do to emphasize the importance of language stimulation to development and academic success.

Most parents are very motivated by the promise of better school success from better language, but it can seem far away when the child is only 1 year old! A more immediate motivator is the threat of more temper tantrums and noncompliance in children with delayed language. Almost all children with language problems understand more than they can express. When the gap between understanding and speaking is greater, so is the child’s frustration. While a large percentage of children with expressive language problems will “outgrow” them, the pattern of angry reactivity and difficult parent child interactions may continue. This is a good reason to discuss promoting language but to also suggest Baby Signs (www.babysignstoo.com) starting in the first year, especially if communication frustration starts to emerge.

School is where the big impact from language impairments appears. And it is not just the significant association between early language disorders and persistent reading disability and even written language disability that you should worry about and monitor. Children with speech and language disorders, even simply dysarticulation, can be teased, bullied, and rejected socially. As a result, children with speech and language deficits experience lower self-esteem, greater discouragement, and sometimes reactive aggression. In addition to identifying these problems and getting treatment for the issues of language, learning, and socio-emotional adjustment, it is important to find nonverbal strengths in the child such as sports or music to give them a social group where they can find success.

Language problems in older children may be subtle and not noticed or complained about by their parents, who may have the same weakness. Even teachers may not connect the student’s poor academic performance to language difficulties because they seem to have “the basics.” If you notice a schoolaged child unable to understand or answer your questions with some sentence complexity, it is important to refer to a speech pathologist for assessment. Although there should be free evaluation and treatment services at the school, the speech pathologist may not be expert at assessing more complex language disorders. In addition, the child’s difficulties may not measure up as “impairing enough” to receive those services, and private services may be needed.

But if you do not feel like a child language expert, you are not alone! Not only were you lucky if you heard one lecture on language development during training, but the younger the child, the less language you are likely to hear from him or her during brief health supervision visits. The parent is probably dominating the conversation (if you are a good listener) trying to have their agenda addressed, and the child is either excited or terrified by your office environment.

The broadband developmental screening now recommended by the American Academy of Pediatrics for all children at 9, 18, and 30 months includes language milestones or parental concern, but these have not been shown to have adequate sensitivity or specificity and will miss many affected children.

Many young children with language disorders are now or will later be on the autism spectrum. The recommended autism-specific screens at 18 and 24-30 months will detect many, but not all, of these children. It is important to realize that the most common reason for a false positive autism screen is language delay, and it deserves follow-up and treatment even though not representing autism.

What should you do given these gaps between need, tools, and knowledge? Of course, collect the general and autism screens as recommended, but also use them when you or the parent have a concern. For children under 2 years, the parent’s report is generally accurate, as expected language is fairly simple. Infants should have different cries and reactions to caregivers in the first 3 months; babble and laugh by 6 months; and imitate sounds as well as recognize a few words by 1 year. While infants typically have 1-2 words by 12 months and two-word combinations by 18 months, as a cutoff they should show 1-2 words by 18 months and either 50 words or 2 words together by 24 months. Listening to a child’s spontaneous language is the best gauge of articulation. By age 2 years, we – a stranger to the child – can only expect to understand about 25% of what they say, but by 3 years it should be 66%, and by age 4 years almost 100%.

Gestures are an important aspect of communication. Use of gestures such as raising arms to be picked up or waving bye-bye by 1 year are typical. Between 1 and 2 years, children should follow your pointing and share their interests by pointing in addition to indicating named pictures and body parts. Deficits in use of gestures should spur a language evaluation and also are part of diagnosing autism, a much more serious and specific condition defined by communication deficits. Most autism screening tools include tapping gestures as well as spoken language.

After 2 years, language assessment has to include more elements than many parents can report easily or you can observe. There is now no formal additional language screening recommendation beyond surveillance, and the general developmental and autism screens. Every state has free child development services that can assess and provide intervention for children 0-3 years if you or the parent has concerns. But you may want to do more to either reassure or clarify the need for and type of referral by using a language-specific tool. The most accurate and practical tools applicable to children 8-35 months are the MacArthur-Bates Communicative Development Inventories (CDI) and the Language Development Survey (LDS), both parent completed. The LDS assesses based on a list of vocabulary words and examples of phrases, and the CDI has three different forms using vocabulary, gestures, and sentences.

After age 3 years, language is so complex that direct testing of the child is needed. A draft report from the U.S. Preventive Services Task Force in November 2014 presents a review of all available measures.

The good news is that a variety of approaches to therapy for speech and language disorders in young children are effective in reducing impairment. The most effective ones involve the parents in learning what communication skills to observe, stimulate, and reinforce, and have an adequate number of total hours of intervention spread over several months.

As for all children and youth with special health care needs, we have the responsibility to detect, monitor, refer, track, and support families of children with speech and language disorders to assure their best outcomes. Whatever the cause, improving the communication abilities of the child can make a big difference to many aspects of their lives.

Dr. Howard is an assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at [email protected].

The development of language in children is like the canary in the coal mine – problems of genetics, medical conditions, and environment all can cause it to go awry. Whatever the cause, it is very important to make sure a child with a problem in this area gets prompt assistance, because how speech and language progress also affects many aspects of the child’s success in life and what it is like to parent them.

Some of the factors known to put a child at risk for delays or deviations in speech and language development include prematurity and low birth weight; genetic conditions such as Down syndrome; physical problems such as cerebral palsy or seizure disorders; hearing impairment; and, as usual, being a boy. The most common reason for delayed language is general delay or intellectual disability. A family history of speech and language disorders also adds to the risk, and one single gene defect has even been found for a few of these. Eight percent of young children have been estimated to have a delay in speech or language. The vast majority of them have no specific risk factors.

The “language environment” of the home is critical to language learning. Compared with high-income families, parents on welfare say one-third as many words to their children and working-class parents say one-half as many in the first 3 years. Because over 85% of a child’s words at age 3 years come from words heard from their parents, this is estimated to create a 30-million-word difference between children of high- versus low-income families by age 4 years! In addition, low-income parents provide two discouragements for each one encouragement, in contrast to one correction to six encouragements in high-income homes, with the additional psychological implications.

These sad facts contributed to the creation of the Reach Out and Read program, which I hope you have joined. A free book from the doctor at every checkup visit, some modeling of how to read to the child, and information about the importance of talking with the child are things you can do to emphasize the importance of language stimulation to development and academic success.

Most parents are very motivated by the promise of better school success from better language, but it can seem far away when the child is only 1 year old! A more immediate motivator is the threat of more temper tantrums and noncompliance in children with delayed language. Almost all children with language problems understand more than they can express. When the gap between understanding and speaking is greater, so is the child’s frustration. While a large percentage of children with expressive language problems will “outgrow” them, the pattern of angry reactivity and difficult parent child interactions may continue. This is a good reason to discuss promoting language but to also suggest Baby Signs (www.babysignstoo.com) starting in the first year, especially if communication frustration starts to emerge.

School is where the big impact from language impairments appears. And it is not just the significant association between early language disorders and persistent reading disability and even written language disability that you should worry about and monitor. Children with speech and language disorders, even simply dysarticulation, can be teased, bullied, and rejected socially. As a result, children with speech and language deficits experience lower self-esteem, greater discouragement, and sometimes reactive aggression. In addition to identifying these problems and getting treatment for the issues of language, learning, and socio-emotional adjustment, it is important to find nonverbal strengths in the child such as sports or music to give them a social group where they can find success.

Language problems in older children may be subtle and not noticed or complained about by their parents, who may have the same weakness. Even teachers may not connect the student’s poor academic performance to language difficulties because they seem to have “the basics.” If you notice a schoolaged child unable to understand or answer your questions with some sentence complexity, it is important to refer to a speech pathologist for assessment. Although there should be free evaluation and treatment services at the school, the speech pathologist may not be expert at assessing more complex language disorders. In addition, the child’s difficulties may not measure up as “impairing enough” to receive those services, and private services may be needed.

But if you do not feel like a child language expert, you are not alone! Not only were you lucky if you heard one lecture on language development during training, but the younger the child, the less language you are likely to hear from him or her during brief health supervision visits. The parent is probably dominating the conversation (if you are a good listener) trying to have their agenda addressed, and the child is either excited or terrified by your office environment.

The broadband developmental screening now recommended by the American Academy of Pediatrics for all children at 9, 18, and 30 months includes language milestones or parental concern, but these have not been shown to have adequate sensitivity or specificity and will miss many affected children.

Many young children with language disorders are now or will later be on the autism spectrum. The recommended autism-specific screens at 18 and 24-30 months will detect many, but not all, of these children. It is important to realize that the most common reason for a false positive autism screen is language delay, and it deserves follow-up and treatment even though not representing autism.

What should you do given these gaps between need, tools, and knowledge? Of course, collect the general and autism screens as recommended, but also use them when you or the parent have a concern. For children under 2 years, the parent’s report is generally accurate, as expected language is fairly simple. Infants should have different cries and reactions to caregivers in the first 3 months; babble and laugh by 6 months; and imitate sounds as well as recognize a few words by 1 year. While infants typically have 1-2 words by 12 months and two-word combinations by 18 months, as a cutoff they should show 1-2 words by 18 months and either 50 words or 2 words together by 24 months. Listening to a child’s spontaneous language is the best gauge of articulation. By age 2 years, we – a stranger to the child – can only expect to understand about 25% of what they say, but by 3 years it should be 66%, and by age 4 years almost 100%.

Gestures are an important aspect of communication. Use of gestures such as raising arms to be picked up or waving bye-bye by 1 year are typical. Between 1 and 2 years, children should follow your pointing and share their interests by pointing in addition to indicating named pictures and body parts. Deficits in use of gestures should spur a language evaluation and also are part of diagnosing autism, a much more serious and specific condition defined by communication deficits. Most autism screening tools include tapping gestures as well as spoken language.

After 2 years, language assessment has to include more elements than many parents can report easily or you can observe. There is now no formal additional language screening recommendation beyond surveillance, and the general developmental and autism screens. Every state has free child development services that can assess and provide intervention for children 0-3 years if you or the parent has concerns. But you may want to do more to either reassure or clarify the need for and type of referral by using a language-specific tool. The most accurate and practical tools applicable to children 8-35 months are the MacArthur-Bates Communicative Development Inventories (CDI) and the Language Development Survey (LDS), both parent completed. The LDS assesses based on a list of vocabulary words and examples of phrases, and the CDI has three different forms using vocabulary, gestures, and sentences.

After age 3 years, language is so complex that direct testing of the child is needed. A draft report from the U.S. Preventive Services Task Force in November 2014 presents a review of all available measures.

The good news is that a variety of approaches to therapy for speech and language disorders in young children are effective in reducing impairment. The most effective ones involve the parents in learning what communication skills to observe, stimulate, and reinforce, and have an adequate number of total hours of intervention spread over several months.

As for all children and youth with special health care needs, we have the responsibility to detect, monitor, refer, track, and support families of children with speech and language disorders to assure their best outcomes. Whatever the cause, improving the communication abilities of the child can make a big difference to many aspects of their lives.

Dr. Howard is an assistant professor of pediatrics at the Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline. E-mail her at [email protected].

One of the greatest challenges you may face as a pediatrician is in helping your patients and families navigate the mental health system. Nearly 20% of children will experience a psychiatric illness before they turn 18, and a quarter of those will go on to experience a persistent or severe psychiatric illness. Whether a patient is experiencing symptoms that are mild or severe, their parents are likely to come to you first for an assessment and for help in finding a referral to the appropriate specialist.

Unlike the smooth process to refer to a neurologist or orthopedist, accessing treatment for mental health problems is often confusing and frustrating. Because of reimbursement that is below the cost of providing care, many community hospitals have closed their divisions of child and adolescent psychiatry, and academic medical centers often have a long wait for a provider. If you go through a patient’s insurance, usually the list of providers is woefully out-of-date, with most of them not accepting new referrals or insurance or both. If mental health services are “carved out” to cut costs, the primary insurer has no direct control of mental health services, and the carve out company is looking for providers willing to accept lower reimbursement and limit longer-term treatments. Faced with reimbursement and administrative demands by the carve out company, child psychiatrists, psychologists, and social workers that once staffed these services have chosen fee-for-service private offices that do not accept any insurance, leaving many communities without access to adequate resources. In private practice, these providers are busy, face no administrative demands to justify their work, and earn two or three times what insurers reimburse.

So families often turn to their schools and their pediatricians when faced with a mood, anxiety, or behavioral problem. While there is no straightforward solution to this problem of access, we have put together a “road map” to what services might be available and to help you in your approach to these patients.

It is first important to consider that mental health and developmental questions are now a major part of pediatric primary care. The majority of your visits will be well child care and psychosocial. So a part, maybe a third or half of mental health concerns might now be considered a routine part of primary care. Many practices are now doing psychosocial screening and more states are mandating reimbursement of this screening. Typically screening includes a CHATfor autism (Checklist for Autism in Toddlers), a developmental screen if indicated, a Pediatric Symptom Checklist for school-age children and adolescents, a Hamilton Rating Scale for Depression in adolescents, and a CRAFFTfor adolescent substance abuse. Some practices include a Hamilton or other depression screen for mothers of newborns and toddlers as maternal depression has a serious impact on the child and is responsive to treatment. If screening is reimbursed, some of that money could go to fund an on-site social worker, who can also bill for patient contact services, and thus provide the practice with an on-site mental health presence at break-even cost. This social worker may be expert in referring to local resources, may be trained in psychotherapy, or may even lead groups for parents of recent divorce, new mothers, facing attention-deficit/hyperactivity disorder (ADHD), etc.

The best place to start for a family with psychosocial concerns is to do a brief review of your patient’s day to day functioning – school, friends, family, activities, and mood. What is your best assessment of the problem, how much of the child and family’s life is affected, and how severe is the problem? There are many mental health problems for which the first-line treatment is a trial of medication according to an algorithm that you can use following American Academy of Pediatrics guidelines. For example, if considering stimulant treatment for a 7-year-old with possible attention difficulties, you can use broad screening instruments like the Pediatric Symptom Checklist or Childhood Behavior Checklist as well as the Vanderbilt Assessment Scales or Conners questionnaire that are specific for ADHD. Many pediatricians also are comfortable treating adolescent depression with medication and with comanagement from a social worker with a master’s degree or a doctorate level psychologist. Of course, treating depression requires a more careful interview, consideration of suicide risk, and more frequent follow-up visits.

As first-line treatment for depression and anxiety usually starts with psychotherapy, it is important to consider how you will access this component of mental health care. For those that don’t have a licensed clinical social worker on-site providing cognitive-behavioral therapy, many busy pediatric practices will establish a relationship with a therapist or group that has agreed to accept their referrals and accepts insurance reimbursement. If you are not fortunate enough to already have such a relationship, it can be fruitful to speak with colleagues in a busier practice about whom they use. It also can be fruitful to reach out to the graduate programs in psychology (PhD or PsyD programs) or social work in your community, to find out if they have a referral service or would like to connect recent graduates trying to establish themselves with referring pediatricians. Having a resource located in your office (employed by you or renting space) is ideal.

When a patient is presenting with a more complex set of symptoms or fails to respond to your initial treatments, then you will want to locate an appropriate referral to a child psychiatrist. If your group is affiliated with an academic medical center, find out what the procedure is for referring to their child psychiatrists or to the child psychiatry trainees. Often there is easy availability early in the academic year (summer), when children are less likely to present with problems and a new crop of trainees has arrived. Academic medical centers also will often be a hub for a lot of research activity, and research programs are usually eager to enroll patients without regard to their insurance. Good studies will provide patients with a formalized assessment that will clarify the diagnostic picture, ensuring that a child is on the path to the right treatment. Cultivating a connection with the research coordinator can ensure that your group knows about opportunities for free care that is easier to access than most.

Many states require schools to provide testing to clarify whether psychiatric symptoms, developmental issues, or learning disabilities are affecting a student’s ability to perform in school. Your office can educate parents that they should go to the school with their concerns and request a formal assessment. If testing indicates a condition, the school system is often required to provide appropriate educational services, such as tutoring for learning disabilities, occupational therapy, and social skills support for children on the autism spectrum, and even counseling for children with anxiety, mood, and behavioral issues. Often, the school psychologist or social worker will be a valuable resource in providing direct care to children or helping you and the parents identify excellent treaters in the community. For children with severe and persistent psychiatric illness, many states require that schools provide or pay for the services that are necessary to educate each child. This can mean anything from paying for an after school social skills group to paying for a therapeutic boarding school. In these cases, it is often helpful to have established a relationship with an educational consultant. These are usually social workers with expertise in mental health issues and the state’s educational system and regulations, and they will partner with parents for a modest fee to educate and empower parents so that they might get appropriate services from their schools. Again, it can be fruitful to speak with trusted colleagues and find one who has identified a local consultant that they trust.

Some states and counties have tried to address the problem of accessing psychiatric care for children, but often these are programs that have not been adequately marketed to pediatricians or families, so they may be under utilized. In Massachusetts and Connecticut, there is the state Child Psychiatry Access Project, which provides all pediatricians with free access to a consulting child psychiatrist by phone. It requires that pediatricians are willing to treat children themselves with the support and guidance of a consulting child psychiatrist, but it will also provide a face-to-face diagnostic evaluation of that child by a child psychiatrist so that they can in turn provide the best guidance to the pediatrician. And it provides a care coordinator who will help to identify appropriate treaters, such as a cognitive-behavioral therapist or a psychopharmacologist who accept the family’s insurance, when the pediatrician is unable to provide the recommended treatment. An online investigation through your state’s or county’s Office of Mental Health or your local Medical Society can help your office identify what resources may exist in your community.

Finally, your most critical task after a parent has come to you with concerns about their child’s mood, thinking, or behavior, may be in educating and supporting those parents. Prepare the parents by explaining to them how the mental health system is more fragmented and frustrating than most other medical specialties. Remind them that psychiatric symptoms and illnesses are eminently treatable, and it will be worth patiently navigating this complex system to eventually access the right care for their child. It can be helpful to suggest to them that if they can possibly afford to pay out-of-pocket for the appropriate care, it will make excellent treatment much easier to access in a timely way. It can be meaningful for parents to hear from you that it is worthwhile for them to call or write their insurance company and complain if that company has restricted access to child psychiatric care. They are, after all, the customers of their insurance company, and it is the silence, shame, and stigma surrounding psychiatric illness that has enabled insurance companies to restrict access to effective care. Finally, it can be very powerful to connect parents with support or advocacy organizations that will help them in navigating this system and in speaking up to their insurance companies, state health, or education agencies or in the press in ways that will diminish the stigma that still surrounds these problems. The National Alliance on Mental Illness (www.nami.org), The Bazelon Center for Mental Health Law (www.bazelon.org), and the American Academy of Child and Adolescent Psychiatry (www.aacap.org) all have excellent online resources that also help identify local organizations and resources for parents. If insurance companies refused to pay for potentially life-saving chemotherapy for a pediatric cancer, you can imagine that there would be many parents protesting to those insurers, to the news, and even to their local or state governments. Mental health care should be no different, as the problems can be as disabling and life-threatening and effective treatments and even cures exist.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].

One of the greatest challenges you may face as a pediatrician is in helping your patients and families navigate the mental health system. Nearly 20% of children will experience a psychiatric illness before they turn 18, and a quarter of those will go on to experience a persistent or severe psychiatric illness. Whether a patient is experiencing symptoms that are mild or severe, their parents are likely to come to you first for an assessment and for help in finding a referral to the appropriate specialist.

Unlike the smooth process to refer to a neurologist or orthopedist, accessing treatment for mental health problems is often confusing and frustrating. Because of reimbursement that is below the cost of providing care, many community hospitals have closed their divisions of child and adolescent psychiatry, and academic medical centers often have a long wait for a provider. If you go through a patient’s insurance, usually the list of providers is woefully out-of-date, with most of them not accepting new referrals or insurance or both. If mental health services are “carved out” to cut costs, the primary insurer has no direct control of mental health services, and the carve out company is looking for providers willing to accept lower reimbursement and limit longer-term treatments. Faced with reimbursement and administrative demands by the carve out company, child psychiatrists, psychologists, and social workers that once staffed these services have chosen fee-for-service private offices that do not accept any insurance, leaving many communities without access to adequate resources. In private practice, these providers are busy, face no administrative demands to justify their work, and earn two or three times what insurers reimburse.

So families often turn to their schools and their pediatricians when faced with a mood, anxiety, or behavioral problem. While there is no straightforward solution to this problem of access, we have put together a “road map” to what services might be available and to help you in your approach to these patients.

It is first important to consider that mental health and developmental questions are now a major part of pediatric primary care. The majority of your visits will be well child care and psychosocial. So a part, maybe a third or half of mental health concerns might now be considered a routine part of primary care. Many practices are now doing psychosocial screening and more states are mandating reimbursement of this screening. Typically screening includes a CHATfor autism (Checklist for Autism in Toddlers), a developmental screen if indicated, a Pediatric Symptom Checklist for school-age children and adolescents, a Hamilton Rating Scale for Depression in adolescents, and a CRAFFTfor adolescent substance abuse. Some practices include a Hamilton or other depression screen for mothers of newborns and toddlers as maternal depression has a serious impact on the child and is responsive to treatment. If screening is reimbursed, some of that money could go to fund an on-site social worker, who can also bill for patient contact services, and thus provide the practice with an on-site mental health presence at break-even cost. This social worker may be expert in referring to local resources, may be trained in psychotherapy, or may even lead groups for parents of recent divorce, new mothers, facing attention-deficit/hyperactivity disorder (ADHD), etc.

The best place to start for a family with psychosocial concerns is to do a brief review of your patient’s day to day functioning – school, friends, family, activities, and mood. What is your best assessment of the problem, how much of the child and family’s life is affected, and how severe is the problem? There are many mental health problems for which the first-line treatment is a trial of medication according to an algorithm that you can use following American Academy of Pediatrics guidelines. For example, if considering stimulant treatment for a 7-year-old with possible attention difficulties, you can use broad screening instruments like the Pediatric Symptom Checklist or Childhood Behavior Checklist as well as the Vanderbilt Assessment Scales or Conners questionnaire that are specific for ADHD. Many pediatricians also are comfortable treating adolescent depression with medication and with comanagement from a social worker with a master’s degree or a doctorate level psychologist. Of course, treating depression requires a more careful interview, consideration of suicide risk, and more frequent follow-up visits.

As first-line treatment for depression and anxiety usually starts with psychotherapy, it is important to consider how you will access this component of mental health care. For those that don’t have a licensed clinical social worker on-site providing cognitive-behavioral therapy, many busy pediatric practices will establish a relationship with a therapist or group that has agreed to accept their referrals and accepts insurance reimbursement. If you are not fortunate enough to already have such a relationship, it can be fruitful to speak with colleagues in a busier practice about whom they use. It also can be fruitful to reach out to the graduate programs in psychology (PhD or PsyD programs) or social work in your community, to find out if they have a referral service or would like to connect recent graduates trying to establish themselves with referring pediatricians. Having a resource located in your office (employed by you or renting space) is ideal.

When a patient is presenting with a more complex set of symptoms or fails to respond to your initial treatments, then you will want to locate an appropriate referral to a child psychiatrist. If your group is affiliated with an academic medical center, find out what the procedure is for referring to their child psychiatrists or to the child psychiatry trainees. Often there is easy availability early in the academic year (summer), when children are less likely to present with problems and a new crop of trainees has arrived. Academic medical centers also will often be a hub for a lot of research activity, and research programs are usually eager to enroll patients without regard to their insurance. Good studies will provide patients with a formalized assessment that will clarify the diagnostic picture, ensuring that a child is on the path to the right treatment. Cultivating a connection with the research coordinator can ensure that your group knows about opportunities for free care that is easier to access than most.

Many states require schools to provide testing to clarify whether psychiatric symptoms, developmental issues, or learning disabilities are affecting a student’s ability to perform in school. Your office can educate parents that they should go to the school with their concerns and request a formal assessment. If testing indicates a condition, the school system is often required to provide appropriate educational services, such as tutoring for learning disabilities, occupational therapy, and social skills support for children on the autism spectrum, and even counseling for children with anxiety, mood, and behavioral issues. Often, the school psychologist or social worker will be a valuable resource in providing direct care to children or helping you and the parents identify excellent treaters in the community. For children with severe and persistent psychiatric illness, many states require that schools provide or pay for the services that are necessary to educate each child. This can mean anything from paying for an after school social skills group to paying for a therapeutic boarding school. In these cases, it is often helpful to have established a relationship with an educational consultant. These are usually social workers with expertise in mental health issues and the state’s educational system and regulations, and they will partner with parents for a modest fee to educate and empower parents so that they might get appropriate services from their schools. Again, it can be fruitful to speak with trusted colleagues and find one who has identified a local consultant that they trust.

Some states and counties have tried to address the problem of accessing psychiatric care for children, but often these are programs that have not been adequately marketed to pediatricians or families, so they may be under utilized. In Massachusetts and Connecticut, there is the state Child Psychiatry Access Project, which provides all pediatricians with free access to a consulting child psychiatrist by phone. It requires that pediatricians are willing to treat children themselves with the support and guidance of a consulting child psychiatrist, but it will also provide a face-to-face diagnostic evaluation of that child by a child psychiatrist so that they can in turn provide the best guidance to the pediatrician. And it provides a care coordinator who will help to identify appropriate treaters, such as a cognitive-behavioral therapist or a psychopharmacologist who accept the family’s insurance, when the pediatrician is unable to provide the recommended treatment. An online investigation through your state’s or county’s Office of Mental Health or your local Medical Society can help your office identify what resources may exist in your community.

Finally, your most critical task after a parent has come to you with concerns about their child’s mood, thinking, or behavior, may be in educating and supporting those parents. Prepare the parents by explaining to them how the mental health system is more fragmented and frustrating than most other medical specialties. Remind them that psychiatric symptoms and illnesses are eminently treatable, and it will be worth patiently navigating this complex system to eventually access the right care for their child. It can be helpful to suggest to them that if they can possibly afford to pay out-of-pocket for the appropriate care, it will make excellent treatment much easier to access in a timely way. It can be meaningful for parents to hear from you that it is worthwhile for them to call or write their insurance company and complain if that company has restricted access to child psychiatric care. They are, after all, the customers of their insurance company, and it is the silence, shame, and stigma surrounding psychiatric illness that has enabled insurance companies to restrict access to effective care. Finally, it can be very powerful to connect parents with support or advocacy organizations that will help them in navigating this system and in speaking up to their insurance companies, state health, or education agencies or in the press in ways that will diminish the stigma that still surrounds these problems. The National Alliance on Mental Illness (www.nami.org), The Bazelon Center for Mental Health Law (www.bazelon.org), and the American Academy of Child and Adolescent Psychiatry (www.aacap.org) all have excellent online resources that also help identify local organizations and resources for parents. If insurance companies refused to pay for potentially life-saving chemotherapy for a pediatric cancer, you can imagine that there would be many parents protesting to those insurers, to the news, and even to their local or state governments. Mental health care should be no different, as the problems can be as disabling and life-threatening and effective treatments and even cures exist.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].

One of the greatest challenges you may face as a pediatrician is in helping your patients and families navigate the mental health system. Nearly 20% of children will experience a psychiatric illness before they turn 18, and a quarter of those will go on to experience a persistent or severe psychiatric illness. Whether a patient is experiencing symptoms that are mild or severe, their parents are likely to come to you first for an assessment and for help in finding a referral to the appropriate specialist.

Unlike the smooth process to refer to a neurologist or orthopedist, accessing treatment for mental health problems is often confusing and frustrating. Because of reimbursement that is below the cost of providing care, many community hospitals have closed their divisions of child and adolescent psychiatry, and academic medical centers often have a long wait for a provider. If you go through a patient’s insurance, usually the list of providers is woefully out-of-date, with most of them not accepting new referrals or insurance or both. If mental health services are “carved out” to cut costs, the primary insurer has no direct control of mental health services, and the carve out company is looking for providers willing to accept lower reimbursement and limit longer-term treatments. Faced with reimbursement and administrative demands by the carve out company, child psychiatrists, psychologists, and social workers that once staffed these services have chosen fee-for-service private offices that do not accept any insurance, leaving many communities without access to adequate resources. In private practice, these providers are busy, face no administrative demands to justify their work, and earn two or three times what insurers reimburse.

So families often turn to their schools and their pediatricians when faced with a mood, anxiety, or behavioral problem. While there is no straightforward solution to this problem of access, we have put together a “road map” to what services might be available and to help you in your approach to these patients.

It is first important to consider that mental health and developmental questions are now a major part of pediatric primary care. The majority of your visits will be well child care and psychosocial. So a part, maybe a third or half of mental health concerns might now be considered a routine part of primary care. Many practices are now doing psychosocial screening and more states are mandating reimbursement of this screening. Typically screening includes a CHATfor autism (Checklist for Autism in Toddlers), a developmental screen if indicated, a Pediatric Symptom Checklist for school-age children and adolescents, a Hamilton Rating Scale for Depression in adolescents, and a CRAFFTfor adolescent substance abuse. Some practices include a Hamilton or other depression screen for mothers of newborns and toddlers as maternal depression has a serious impact on the child and is responsive to treatment. If screening is reimbursed, some of that money could go to fund an on-site social worker, who can also bill for patient contact services, and thus provide the practice with an on-site mental health presence at break-even cost. This social worker may be expert in referring to local resources, may be trained in psychotherapy, or may even lead groups for parents of recent divorce, new mothers, facing attention-deficit/hyperactivity disorder (ADHD), etc.

The best place to start for a family with psychosocial concerns is to do a brief review of your patient’s day to day functioning – school, friends, family, activities, and mood. What is your best assessment of the problem, how much of the child and family’s life is affected, and how severe is the problem? There are many mental health problems for which the first-line treatment is a trial of medication according to an algorithm that you can use following American Academy of Pediatrics guidelines. For example, if considering stimulant treatment for a 7-year-old with possible attention difficulties, you can use broad screening instruments like the Pediatric Symptom Checklist or Childhood Behavior Checklist as well as the Vanderbilt Assessment Scales or Conners questionnaire that are specific for ADHD. Many pediatricians also are comfortable treating adolescent depression with medication and with comanagement from a social worker with a master’s degree or a doctorate level psychologist. Of course, treating depression requires a more careful interview, consideration of suicide risk, and more frequent follow-up visits.

As first-line treatment for depression and anxiety usually starts with psychotherapy, it is important to consider how you will access this component of mental health care. For those that don’t have a licensed clinical social worker on-site providing cognitive-behavioral therapy, many busy pediatric practices will establish a relationship with a therapist or group that has agreed to accept their referrals and accepts insurance reimbursement. If you are not fortunate enough to already have such a relationship, it can be fruitful to speak with colleagues in a busier practice about whom they use. It also can be fruitful to reach out to the graduate programs in psychology (PhD or PsyD programs) or social work in your community, to find out if they have a referral service or would like to connect recent graduates trying to establish themselves with referring pediatricians. Having a resource located in your office (employed by you or renting space) is ideal.

When a patient is presenting with a more complex set of symptoms or fails to respond to your initial treatments, then you will want to locate an appropriate referral to a child psychiatrist. If your group is affiliated with an academic medical center, find out what the procedure is for referring to their child psychiatrists or to the child psychiatry trainees. Often there is easy availability early in the academic year (summer), when children are less likely to present with problems and a new crop of trainees has arrived. Academic medical centers also will often be a hub for a lot of research activity, and research programs are usually eager to enroll patients without regard to their insurance. Good studies will provide patients with a formalized assessment that will clarify the diagnostic picture, ensuring that a child is on the path to the right treatment. Cultivating a connection with the research coordinator can ensure that your group knows about opportunities for free care that is easier to access than most.

Many states require schools to provide testing to clarify whether psychiatric symptoms, developmental issues, or learning disabilities are affecting a student’s ability to perform in school. Your office can educate parents that they should go to the school with their concerns and request a formal assessment. If testing indicates a condition, the school system is often required to provide appropriate educational services, such as tutoring for learning disabilities, occupational therapy, and social skills support for children on the autism spectrum, and even counseling for children with anxiety, mood, and behavioral issues. Often, the school psychologist or social worker will be a valuable resource in providing direct care to children or helping you and the parents identify excellent treaters in the community. For children with severe and persistent psychiatric illness, many states require that schools provide or pay for the services that are necessary to educate each child. This can mean anything from paying for an after school social skills group to paying for a therapeutic boarding school. In these cases, it is often helpful to have established a relationship with an educational consultant. These are usually social workers with expertise in mental health issues and the state’s educational system and regulations, and they will partner with parents for a modest fee to educate and empower parents so that they might get appropriate services from their schools. Again, it can be fruitful to speak with trusted colleagues and find one who has identified a local consultant that they trust.

Some states and counties have tried to address the problem of accessing psychiatric care for children, but often these are programs that have not been adequately marketed to pediatricians or families, so they may be under utilized. In Massachusetts and Connecticut, there is the state Child Psychiatry Access Project, which provides all pediatricians with free access to a consulting child psychiatrist by phone. It requires that pediatricians are willing to treat children themselves with the support and guidance of a consulting child psychiatrist, but it will also provide a face-to-face diagnostic evaluation of that child by a child psychiatrist so that they can in turn provide the best guidance to the pediatrician. And it provides a care coordinator who will help to identify appropriate treaters, such as a cognitive-behavioral therapist or a psychopharmacologist who accept the family’s insurance, when the pediatrician is unable to provide the recommended treatment. An online investigation through your state’s or county’s Office of Mental Health or your local Medical Society can help your office identify what resources may exist in your community.

Finally, your most critical task after a parent has come to you with concerns about their child’s mood, thinking, or behavior, may be in educating and supporting those parents. Prepare the parents by explaining to them how the mental health system is more fragmented and frustrating than most other medical specialties. Remind them that psychiatric symptoms and illnesses are eminently treatable, and it will be worth patiently navigating this complex system to eventually access the right care for their child. It can be helpful to suggest to them that if they can possibly afford to pay out-of-pocket for the appropriate care, it will make excellent treatment much easier to access in a timely way. It can be meaningful for parents to hear from you that it is worthwhile for them to call or write their insurance company and complain if that company has restricted access to child psychiatric care. They are, after all, the customers of their insurance company, and it is the silence, shame, and stigma surrounding psychiatric illness that has enabled insurance companies to restrict access to effective care. Finally, it can be very powerful to connect parents with support or advocacy organizations that will help them in navigating this system and in speaking up to their insurance companies, state health, or education agencies or in the press in ways that will diminish the stigma that still surrounds these problems. The National Alliance on Mental Illness (www.nami.org), The Bazelon Center for Mental Health Law (www.bazelon.org), and the American Academy of Child and Adolescent Psychiatry (www.aacap.org) all have excellent online resources that also help identify local organizations and resources for parents. If insurance companies refused to pay for potentially life-saving chemotherapy for a pediatric cancer, you can imagine that there would be many parents protesting to those insurers, to the news, and even to their local or state governments. Mental health care should be no different, as the problems can be as disabling and life-threatening and effective treatments and even cures exist.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at [email protected].

 Do you remember the discussion of the ethical dilemma of Huntington’s disease you probably participated in during medical school? The question was whether you would want to know that you were at risk for a chronic debilitating condition that would develop at some later age if there was nothing that could be done about it. In that discussion, you also may have heard about individuals who, after hearing about their risk status, become depressed or suicidal, depending on the story line.

Some pediatricians seem to have taken this example too far in arguing that there is no point in screening for issues of development, autism, maternal depression, or child mental health because “there are no services” available to treat them.

Despair is understandable. Physicians’ lack of knowledge about resources in the community is often a sore point among local agencies, parents, and even pediatricians themselves. In spite of United Way, state 3-1-1 programs ,and the occasionally available social worker, the resources with which we are familiar sometimes come from hard-working parents telling us about a program they found on their own. It also seems that, just when we hit upon a valuable resource, it runs out of funding, changes eligibility requirements, or loses key staff. Worse yet, we may rely on resources we know about because of our own children’s problems, activities, or friends. While the Internet is an increasingly valuable method of finding resources, there is no filter of the evidence-basis of the care provided, and the process of searching, vetting, and informing your patients is extremely time consuming, and often the patient is not eligible or has a long waiting period after all that.

There are important reasons not to succumb to throwing up one’s hands about service availability. And more important reasons to still screen even if you do not know where to refer.

Screening using validated tools is recommended by the American Academy of Pediatrics because parent concern and even clinical observation are not adequately sensitive to detect significant problems of development and mental health, even when done by experienced physicians who know families well. The process of screening sends an important message to the parents – that you care about the child’s progress and are using proven methods to ensure that it is going well and consider it part of complete medical care.

And families often already think that their child may have a problem, even when they don’t bring it up. Perhaps deep down they are afraid that somehow raising the question of autism will make it true. They may be in denial, are feeling guilty, or are under pressure from their spouse, relatives, or friends not to worry, that “he will grow out” of it, that better discipline will fix the problem, etc. They may even care so much about your positive regard that they do not want to seem overly anxious, obsessive, or be regarded as a failure for having a “defective” child. They, like you, also may be in despair about finding effective help.

But there can be serious consequences to not screening, even when you are not sure what you will do with the results. The family may push the child with delays or mental health problems beyond his abilities, and even become negative and punitive in trying to make him succeed, in the process promoting unnecessary behavior problems, discouragement, and even defiance in the child. Failure to detect also means failure to list the child on a registry for follow-up to determine progress or refer when resources become available. Some problems of development or mental health that are detected by screening may have medical causes that you can treat, even though counseling or therapy interventions are not available. Examples include hearing or vision deficits causing delays or anemia, sleep apnea, or hypothyroidism or maternal depression or attention-deficit/hyperactivity disorder (ADHD). For issues with a genetic basis, siblings may be born with same problem during the period of delay in making a diagnosis, a prime example being Fragile X. In untold cases, the family loses trust in you and in the medical system for not acknowledging a problem.

In many cases, your acknowledgment, explanation, sympathy, and advice can help enormously. Families can cope better, garner support from family or friends, deal with the child’s behavior better, and find steps to take to help their child in their own ways, even without formal services, once told that their child has a specific problem.

On a system level, it is important to realize that how services are established and maintained is far less rational than might be imagined. State programs, schools, hospitals, and insurers all have legal requirements to provide services within a certain time frame once referred. Even if the services are not there to help a your child or family right now, the referral itself adds to the data used to determine if services are adequate and to plan for additional service types or capacity. The Autism Waiver is one such example where waits are years long, but getting on the list is crucial to the future of the program.

Until you screen and give parents information – especially middle-class parents – we will never have the resources. As it was for lead paint, until we identified prevalence of elevated lead levels and the harm associated, we got no action on lead paint removal policies. Another example where complaints about access made a difference, is the relatively new Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 that requires health insurers and health plans to guarantee that financial requirements on benefits for mental health, such as copays, deductibles, and limitations on treatment benefits, are not more restrictive than those that are for medical benefits. This does not guarantee that services will be available or of high quality, but is a step toward accessibility.

You may be one of the many pediatricians who consider advocacy a basic component of your professional responsibilities. If you cannot advocate for services that you see your patients in need of, you can pass your concerns onto a group that does. Many American Academy of Pediatrics state chapters have so-called Pediatric Councils that receive ideas about system problems and put group pressure on leaders in the state to address them.

As in the historic painting of the physician leaning over the ill child whom he could not cure, after detection through screening our thoughtful evaluation, explanations, shared concern, and our patients’ advocacy have great value even when specific services are not yet available.

Dr. Howard is an assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.chadis.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. E-mail her at [email protected].

 Do you remember the discussion of the ethical dilemma of Huntington’s disease you probably participated in during medical school? The question was whether you would want to know that you were at risk for a chronic debilitating condition that would develop at some later age if there was nothing that could be done about it. In that discussion, you also may have heard about individuals who, after hearing about their risk status, become depressed or suicidal, depending on the story line.

Some pediatricians seem to have taken this example too far in arguing that there is no point in screening for issues of development, autism, maternal depression, or child mental health because “there are no services” available to treat them.

Despair is understandable. Physicians’ lack of knowledge about resources in the community is often a sore point among local agencies, parents, and even pediatricians themselves. In spite of United Way, state 3-1-1 programs ,and the occasionally available social worker, the resources with which we are familiar sometimes come from hard-working parents telling us about a program they found on their own. It also seems that, just when we hit upon a valuable resource, it runs out of funding, changes eligibility requirements, or loses key staff. Worse yet, we may rely on resources we know about because of our own children’s problems, activities, or friends. While the Internet is an increasingly valuable method of finding resources, there is no filter of the evidence-basis of the care provided, and the process of searching, vetting, and informing your patients is extremely time consuming, and often the patient is not eligible or has a long waiting period after all that.

There are important reasons not to succumb to throwing up one’s hands about service availability. And more important reasons to still screen even if you do not know where to refer.

Screening using validated tools is recommended by the American Academy of Pediatrics because parent concern and even clinical observation are not adequately sensitive to detect significant problems of development and mental health, even when done by experienced physicians who know families well. The process of screening sends an important message to the parents – that you care about the child’s progress and are using proven methods to ensure that it is going well and consider it part of complete medical care.

And families often already think that their child may have a problem, even when they don’t bring it up. Perhaps deep down they are afraid that somehow raising the question of autism will make it true. They may be in denial, are feeling guilty, or are under pressure from their spouse, relatives, or friends not to worry, that “he will grow out” of it, that better discipline will fix the problem, etc. They may even care so much about your positive regard that they do not want to seem overly anxious, obsessive, or be regarded as a failure for having a “defective” child. They, like you, also may be in despair about finding effective help.

But there can be serious consequences to not screening, even when you are not sure what you will do with the results. The family may push the child with delays or mental health problems beyond his abilities, and even become negative and punitive in trying to make him succeed, in the process promoting unnecessary behavior problems, discouragement, and even defiance in the child. Failure to detect also means failure to list the child on a registry for follow-up to determine progress or refer when resources become available. Some problems of development or mental health that are detected by screening may have medical causes that you can treat, even though counseling or therapy interventions are not available. Examples include hearing or vision deficits causing delays or anemia, sleep apnea, or hypothyroidism or maternal depression or attention-deficit/hyperactivity disorder (ADHD). For issues with a genetic basis, siblings may be born with same problem during the period of delay in making a diagnosis, a prime example being Fragile X. In untold cases, the family loses trust in you and in the medical system for not acknowledging a problem.

In many cases, your acknowledgment, explanation, sympathy, and advice can help enormously. Families can cope better, garner support from family or friends, deal with the child’s behavior better, and find steps to take to help their child in their own ways, even without formal services, once told that their child has a specific problem.

On a system level, it is important to realize that how services are established and maintained is far less rational than might be imagined. State programs, schools, hospitals, and insurers all have legal requirements to provide services within a certain time frame once referred. Even if the services are not there to help a your child or family right now, the referral itself adds to the data used to determine if services are adequate and to plan for additional service types or capacity. The Autism Waiver is one such example where waits are years long, but getting on the list is crucial to the future of the program.

Until you screen and give parents information – especially middle-class parents – we will never have the resources. As it was for lead paint, until we identified prevalence of elevated lead levels and the harm associated, we got no action on lead paint removal policies. Another example where complaints about access made a difference, is the relatively new Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 that requires health insurers and health plans to guarantee that financial requirements on benefits for mental health, such as copays, deductibles, and limitations on treatment benefits, are not more restrictive than those that are for medical benefits. This does not guarantee that services will be available or of high quality, but is a step toward accessibility.

You may be one of the many pediatricians who consider advocacy a basic component of your professional responsibilities. If you cannot advocate for services that you see your patients in need of, you can pass your concerns onto a group that does. Many American Academy of Pediatrics state chapters have so-called Pediatric Councils that receive ideas about system problems and put group pressure on leaders in the state to address them.

As in the historic painting of the physician leaning over the ill child whom he could not cure, after detection through screening our thoughtful evaluation, explanations, shared concern, and our patients’ advocacy have great value even when specific services are not yet available.

Dr. Howard is an assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.chadis.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. E-mail her at [email protected].

 Do you remember the discussion of the ethical dilemma of Huntington’s disease you probably participated in during medical school? The question was whether you would want to know that you were at risk for a chronic debilitating condition that would develop at some later age if there was nothing that could be done about it. In that discussion, you also may have heard about individuals who, after hearing about their risk status, become depressed or suicidal, depending on the story line.

Some pediatricians seem to have taken this example too far in arguing that there is no point in screening for issues of development, autism, maternal depression, or child mental health because “there are no services” available to treat them.

Despair is understandable. Physicians’ lack of knowledge about resources in the community is often a sore point among local agencies, parents, and even pediatricians themselves. In spite of United Way, state 3-1-1 programs ,and the occasionally available social worker, the resources with which we are familiar sometimes come from hard-working parents telling us about a program they found on their own. It also seems that, just when we hit upon a valuable resource, it runs out of funding, changes eligibility requirements, or loses key staff. Worse yet, we may rely on resources we know about because of our own children’s problems, activities, or friends. While the Internet is an increasingly valuable method of finding resources, there is no filter of the evidence-basis of the care provided, and the process of searching, vetting, and informing your patients is extremely time consuming, and often the patient is not eligible or has a long waiting period after all that.

There are important reasons not to succumb to throwing up one’s hands about service availability. And more important reasons to still screen even if you do not know where to refer.

Screening using validated tools is recommended by the American Academy of Pediatrics because parent concern and even clinical observation are not adequately sensitive to detect significant problems of development and mental health, even when done by experienced physicians who know families well. The process of screening sends an important message to the parents – that you care about the child’s progress and are using proven methods to ensure that it is going well and consider it part of complete medical care.

And families often already think that their child may have a problem, even when they don’t bring it up. Perhaps deep down they are afraid that somehow raising the question of autism will make it true. They may be in denial, are feeling guilty, or are under pressure from their spouse, relatives, or friends not to worry, that “he will grow out” of it, that better discipline will fix the problem, etc. They may even care so much about your positive regard that they do not want to seem overly anxious, obsessive, or be regarded as a failure for having a “defective” child. They, like you, also may be in despair about finding effective help.

But there can be serious consequences to not screening, even when you are not sure what you will do with the results. The family may push the child with delays or mental health problems beyond his abilities, and even become negative and punitive in trying to make him succeed, in the process promoting unnecessary behavior problems, discouragement, and even defiance in the child. Failure to detect also means failure to list the child on a registry for follow-up to determine progress or refer when resources become available. Some problems of development or mental health that are detected by screening may have medical causes that you can treat, even though counseling or therapy interventions are not available. Examples include hearing or vision deficits causing delays or anemia, sleep apnea, or hypothyroidism or maternal depression or attention-deficit/hyperactivity disorder (ADHD). For issues with a genetic basis, siblings may be born with same problem during the period of delay in making a diagnosis, a prime example being Fragile X. In untold cases, the family loses trust in you and in the medical system for not acknowledging a problem.

In many cases, your acknowledgment, explanation, sympathy, and advice can help enormously. Families can cope better, garner support from family or friends, deal with the child’s behavior better, and find steps to take to help their child in their own ways, even without formal services, once told that their child has a specific problem.

On a system level, it is important to realize that how services are established and maintained is far less rational than might be imagined. State programs, schools, hospitals, and insurers all have legal requirements to provide services within a certain time frame once referred. Even if the services are not there to help a your child or family right now, the referral itself adds to the data used to determine if services are adequate and to plan for additional service types or capacity. The Autism Waiver is one such example where waits are years long, but getting on the list is crucial to the future of the program.

Until you screen and give parents information – especially middle-class parents – we will never have the resources. As it was for lead paint, until we identified prevalence of elevated lead levels and the harm associated, we got no action on lead paint removal policies. Another example where complaints about access made a difference, is the relatively new Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 that requires health insurers and health plans to guarantee that financial requirements on benefits for mental health, such as copays, deductibles, and limitations on treatment benefits, are not more restrictive than those that are for medical benefits. This does not guarantee that services will be available or of high quality, but is a step toward accessibility.

You may be one of the many pediatricians who consider advocacy a basic component of your professional responsibilities. If you cannot advocate for services that you see your patients in need of, you can pass your concerns onto a group that does. Many American Academy of Pediatrics state chapters have so-called Pediatric Councils that receive ideas about system problems and put group pressure on leaders in the state to address them.

As in the historic painting of the physician leaning over the ill child whom he could not cure, after detection through screening our thoughtful evaluation, explanations, shared concern, and our patients’ advocacy have great value even when specific services are not yet available.

Dr. Howard is an assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.chadis.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. E-mail her at [email protected].

The recently coined term “helicopter parents” refers to parents who hover close to their children with the impression that this will keep them safe or ensure their success. We more formally call these parents “overprotective,” “overintrusive,” or “facilitators” for their kids. The new term may make this behavior seem more normal or even more amusing than it really is.

When you see helicopter parents in your practice, it's hard to know exactly what your role should be. How intrusive should you be to try to change their ways? Is helicopter parenting just a trendy societal or cultural phenomenon? Or do you really have enough information that it is a problem to justify your offering advice?

Even though answers to those questions may still be “up in the air,” overall such overprotection can have significant side effects and should be “on our radar”!

There are some pretty obvious reasons for the increase in helicopter parenting. One is cell phones. Everybody has cell phones, even some 6-year-old children. All the calling and texting back and forth makes it too easy to know every move the child makes. These days, if the children are not out of the house with their cell phones, they likely are at home playing video games or in a sport to which they were driven by the parent.

And these activity choices are part of a vicious cycle being selected – if not to promote entry to Harvard then to keep kids busy. Once one family puts their kids in planned activities, there are fewer peers available to play with after school, so other parents do the same. Smaller family sizes also can encourage helicopter parenting. If parents have five children, there is no time for hovering! Families with fewer children also may have more psychologically invested in each child.

I think that it is no accident that helicopter parenting has emerged at the same time most women are in the workplace full time. When home, working mothers, full of guilt, “up their efforts” to make sure they are being good parents.

Other reasons for a heightened level of hovering is parents' perception that they need to keep their kids safe in what feels like a threatening world. Families also are responding to increased competitiveness for college entry and jobs by doing all they can to position their children to achieve these goals. Of course, parents also want to show their love and concern. In some cases, high levels of protectiveness are appropriate: The child may attend a school where kids are carrying knives, or Dad is coming home drunk and the child needs to be protected. Such circumstances are the exception, though. More common pathology is that a parent is overanxious in general or even has an anxiety disorder.

While overprotectiveness may be understandable, it has significant developmental consequences. When parents dictate most of the children's activities, this can preclude the children from discovering, pursuing, and “owning” their interests. Overall, it can lessen the children's self-esteem because they have fewer opportunities to achieve things they consider to be all their own. Also, when a parent participates in the child's activities, they, as adults, will likely be more competent than the child. That can make a child feel less competent, whereas a kid doing things with peers has a decent chance of being the best. Helicopter parents also typically are aiming to avoid all kinds of risk for their precious child. The protected child may be physically safe, but can become risk aversive and miss the chance to learn how to appropriately assess real dangers. If parents “helicopter” because they are always afraid something bad is going to happen – like a pedophile is going to jump out of the bushes or the child is going to be abducted – they also transmit these fears to the child.

Children who are too restricted may even have health effects from sitting at home, eating too much, and not getting enough exercise.

But what can you do when you think problems may be developing from a helicopter parent? Parents may not perceive any problem at all. In this case, motivational interviewing can help. This technique can be used to move many different types of behavior and can fit into a primary care visit.

A motivational interview is a dialogue between the clinician and patient with specific steps. First, find out if the parent or child perceives any problem at all. You might say, “Wow, you certainly have your kid in all kinds of activities and are working hard to provide all these opportunities. Is your level of involvement a problem for you or your child in any way?” Watching the child's face when you ask this can be very revealing, and can also be used as a point of reflection for the interview.

You might also say: “Have you considered whether you really need to or want to do all of these things?” or “Have you considered backing off?” If the response is, “No, I've never thought about this before,” the parent may ask you in return: “Do you think it's a problem?” Then you have the opportunity to go over the potential pros and cons I've already outlined.

You might ask: “What are the good things about being this involved with your child?” And when you ask this, push them to include not only the effects (he's learned to play the violin or is now state ranked in tennis) but the way they feel about it as well. Parents might say things that reveal their reasons such as: “It makes me feel that I'm a good parent because I've done all these things for her” or “I feel more comfortable when I'm at work because I know he is safe at his karate class.”

Then you might ask them: “Is there any downside to being so involved in all of your child's activities?” You might get this response: “I'm beginning to resent it. I signed him up for all these activities, and now I don't have any free time any more.”

The next step in motivational interviewing is to ask about their readiness for change in a gentle way. “Do you think you might consider backing off?” If they say yes, you can ask, “What would be one of the things you could back off on now?” Make sure it is specific and also includes a time frame: “When would you be able to make this change?” In one family I was helping, the child had been talking to his parents on the phone 20 times a day. For him, a goal-setting question was, “What would it take to cut that down to 15 times?” Don't set an unrealistic goal such as stopping altogether.

Some parents initially will not be amenable to changing their behavior. For example, if they say, “I don't know. I never thought about this before,” you may need to be more circumspect. You might say, “Is there something else about this way of relating to your child that is making you want to continue?” Or use other parents as an example: “Some parents find when they back off the child becomes more relaxed, gets right on his homework by himself, and is happier.”

Garnering support for a change in behavior is an important component. You might ask: “Who could help you back off?” Finding other parents to have as friends who are not so intense, who don't feel the need to have a perfect child, or who are willing to let their kids be more autonomous may be key. Some websites and social networks developing to help parents back off from helicoptering promote “slow parenting,” “free-range parenting,” or “simplicity parenting.”

One important goal of the motivational interview is to come away with a time-based action plan. For a parent who says: “I don't want to change anything” or “This is the most important thing I'm doing for my kid,” you can keep change on the agenda by saying something like: “OK, perhaps we can talk about it when you bring her back for her vaccine in 2 months” and then make a note in the chart so you remember.

Inability to follow an agreed-upon plan can reveal where the parents or child is getting stuck, so this can be subsequently addressed. On a follow-up contact ask how it went and praise them, especially if they exceeded the goal. Or the parent may say, “When I tried to do that, he had a panic attack” or “I got depressed. I felt worthless, like I was not protecting my child.” That will help you understand the barriers for these parents and help you arrange appropriate treatment.

Even though helicopter parenting sounds like something new, addressing it employs your same old clinical skills.

---Barbara J. Howard, M.D.

The recently coined term “helicopter parents” refers to parents who hover close to their children with the impression that this will keep them safe or ensure their success. We more formally call these parents “overprotective,” “overintrusive,” or “facilitators” for their kids. The new term may make this behavior seem more normal or even more amusing than it really is.

When you see helicopter parents in your practice, it's hard to know exactly what your role should be. How intrusive should you be to try to change their ways? Is helicopter parenting just a trendy societal or cultural phenomenon? Or do you really have enough information that it is a problem to justify your offering advice?

Even though answers to those questions may still be “up in the air,” overall such overprotection can have significant side effects and should be “on our radar”!

There are some pretty obvious reasons for the increase in helicopter parenting. One is cell phones. Everybody has cell phones, even some 6-year-old children. All the calling and texting back and forth makes it too easy to know every move the child makes. These days, if the children are not out of the house with their cell phones, they likely are at home playing video games or in a sport to which they were driven by the parent.

And these activity choices are part of a vicious cycle being selected – if not to promote entry to Harvard then to keep kids busy. Once one family puts their kids in planned activities, there are fewer peers available to play with after school, so other parents do the same. Smaller family sizes also can encourage helicopter parenting. If parents have five children, there is no time for hovering! Families with fewer children also may have more psychologically invested in each child.

I think that it is no accident that helicopter parenting has emerged at the same time most women are in the workplace full time. When home, working mothers, full of guilt, “up their efforts” to make sure they are being good parents.

Other reasons for a heightened level of hovering is parents' perception that they need to keep their kids safe in what feels like a threatening world. Families also are responding to increased competitiveness for college entry and jobs by doing all they can to position their children to achieve these goals. Of course, parents also want to show their love and concern. In some cases, high levels of protectiveness are appropriate: The child may attend a school where kids are carrying knives, or Dad is coming home drunk and the child needs to be protected. Such circumstances are the exception, though. More common pathology is that a parent is overanxious in general or even has an anxiety disorder.

While overprotectiveness may be understandable, it has significant developmental consequences. When parents dictate most of the children's activities, this can preclude the children from discovering, pursuing, and “owning” their interests. Overall, it can lessen the children's self-esteem because they have fewer opportunities to achieve things they consider to be all their own. Also, when a parent participates in the child's activities, they, as adults, will likely be more competent than the child. That can make a child feel less competent, whereas a kid doing things with peers has a decent chance of being the best. Helicopter parents also typically are aiming to avoid all kinds of risk for their precious child. The protected child may be physically safe, but can become risk aversive and miss the chance to learn how to appropriately assess real dangers. If parents “helicopter” because they are always afraid something bad is going to happen – like a pedophile is going to jump out of the bushes or the child is going to be abducted – they also transmit these fears to the child.

Children who are too restricted may even have health effects from sitting at home, eating too much, and not getting enough exercise.

But what can you do when you think problems may be developing from a helicopter parent? Parents may not perceive any problem at all. In this case, motivational interviewing can help. This technique can be used to move many different types of behavior and can fit into a primary care visit.

A motivational interview is a dialogue between the clinician and patient with specific steps. First, find out if the parent or child perceives any problem at all. You might say, “Wow, you certainly have your kid in all kinds of activities and are working hard to provide all these opportunities. Is your level of involvement a problem for you or your child in any way?” Watching the child's face when you ask this can be very revealing, and can also be used as a point of reflection for the interview.

You might also say: “Have you considered whether you really need to or want to do all of these things?” or “Have you considered backing off?” If the response is, “No, I've never thought about this before,” the parent may ask you in return: “Do you think it's a problem?” Then you have the opportunity to go over the potential pros and cons I've already outlined.

You might ask: “What are the good things about being this involved with your child?” And when you ask this, push them to include not only the effects (he's learned to play the violin or is now state ranked in tennis) but the way they feel about it as well. Parents might say things that reveal their reasons such as: “It makes me feel that I'm a good parent because I've done all these things for her” or “I feel more comfortable when I'm at work because I know he is safe at his karate class.”

Then you might ask them: “Is there any downside to being so involved in all of your child's activities?” You might get this response: “I'm beginning to resent it. I signed him up for all these activities, and now I don't have any free time any more.”

The next step in motivational interviewing is to ask about their readiness for change in a gentle way. “Do you think you might consider backing off?” If they say yes, you can ask, “What would be one of the things you could back off on now?” Make sure it is specific and also includes a time frame: “When would you be able to make this change?” In one family I was helping, the child had been talking to his parents on the phone 20 times a day. For him, a goal-setting question was, “What would it take to cut that down to 15 times?” Don't set an unrealistic goal such as stopping altogether.

Some parents initially will not be amenable to changing their behavior. For example, if they say, “I don't know. I never thought about this before,” you may need to be more circumspect. You might say, “Is there something else about this way of relating to your child that is making you want to continue?” Or use other parents as an example: “Some parents find when they back off the child becomes more relaxed, gets right on his homework by himself, and is happier.”

Garnering support for a change in behavior is an important component. You might ask: “Who could help you back off?” Finding other parents to have as friends who are not so intense, who don't feel the need to have a perfect child, or who are willing to let their kids be more autonomous may be key. Some websites and social networks developing to help parents back off from helicoptering promote “slow parenting,” “free-range parenting,” or “simplicity parenting.”

One important goal of the motivational interview is to come away with a time-based action plan. For a parent who says: “I don't want to change anything” or “This is the most important thing I'm doing for my kid,” you can keep change on the agenda by saying something like: “OK, perhaps we can talk about it when you bring her back for her vaccine in 2 months” and then make a note in the chart so you remember.

Inability to follow an agreed-upon plan can reveal where the parents or child is getting stuck, so this can be subsequently addressed. On a follow-up contact ask how it went and praise them, especially if they exceeded the goal. Or the parent may say, “When I tried to do that, he had a panic attack” or “I got depressed. I felt worthless, like I was not protecting my child.” That will help you understand the barriers for these parents and help you arrange appropriate treatment.

Even though helicopter parenting sounds like something new, addressing it employs your same old clinical skills.

---Barbara J. Howard, M.D.

The recently coined term “helicopter parents” refers to parents who hover close to their children with the impression that this will keep them safe or ensure their success. We more formally call these parents “overprotective,” “overintrusive,” or “facilitators” for their kids. The new term may make this behavior seem more normal or even more amusing than it really is.

When you see helicopter parents in your practice, it's hard to know exactly what your role should be. How intrusive should you be to try to change their ways? Is helicopter parenting just a trendy societal or cultural phenomenon? Or do you really have enough information that it is a problem to justify your offering advice?

Even though answers to those questions may still be “up in the air,” overall such overprotection can have significant side effects and should be “on our radar”!

There are some pretty obvious reasons for the increase in helicopter parenting. One is cell phones. Everybody has cell phones, even some 6-year-old children. All the calling and texting back and forth makes it too easy to know every move the child makes. These days, if the children are not out of the house with their cell phones, they likely are at home playing video games or in a sport to which they were driven by the parent.

And these activity choices are part of a vicious cycle being selected – if not to promote entry to Harvard then to keep kids busy. Once one family puts their kids in planned activities, there are fewer peers available to play with after school, so other parents do the same. Smaller family sizes also can encourage helicopter parenting. If parents have five children, there is no time for hovering! Families with fewer children also may have more psychologically invested in each child.

I think that it is no accident that helicopter parenting has emerged at the same time most women are in the workplace full time. When home, working mothers, full of guilt, “up their efforts” to make sure they are being good parents.

Other reasons for a heightened level of hovering is parents' perception that they need to keep their kids safe in what feels like a threatening world. Families also are responding to increased competitiveness for college entry and jobs by doing all they can to position their children to achieve these goals. Of course, parents also want to show their love and concern. In some cases, high levels of protectiveness are appropriate: The child may attend a school where kids are carrying knives, or Dad is coming home drunk and the child needs to be protected. Such circumstances are the exception, though. More common pathology is that a parent is overanxious in general or even has an anxiety disorder.

While overprotectiveness may be understandable, it has significant developmental consequences. When parents dictate most of the children's activities, this can preclude the children from discovering, pursuing, and “owning” their interests. Overall, it can lessen the children's self-esteem because they have fewer opportunities to achieve things they consider to be all their own. Also, when a parent participates in the child's activities, they, as adults, will likely be more competent than the child. That can make a child feel less competent, whereas a kid doing things with peers has a decent chance of being the best. Helicopter parents also typically are aiming to avoid all kinds of risk for their precious child. The protected child may be physically safe, but can become risk aversive and miss the chance to learn how to appropriately assess real dangers. If parents “helicopter” because they are always afraid something bad is going to happen – like a pedophile is going to jump out of the bushes or the child is going to be abducted – they also transmit these fears to the child.

Children who are too restricted may even have health effects from sitting at home, eating too much, and not getting enough exercise.

But what can you do when you think problems may be developing from a helicopter parent? Parents may not perceive any problem at all. In this case, motivational interviewing can help. This technique can be used to move many different types of behavior and can fit into a primary care visit.

A motivational interview is a dialogue between the clinician and patient with specific steps. First, find out if the parent or child perceives any problem at all. You might say, “Wow, you certainly have your kid in all kinds of activities and are working hard to provide all these opportunities. Is your level of involvement a problem for you or your child in any way?” Watching the child's face when you ask this can be very revealing, and can also be used as a point of reflection for the interview.

You might also say: “Have you considered whether you really need to or want to do all of these things?” or “Have you considered backing off?” If the response is, “No, I've never thought about this before,” the parent may ask you in return: “Do you think it's a problem?” Then you have the opportunity to go over the potential pros and cons I've already outlined.

You might ask: “What are the good things about being this involved with your child?” And when you ask this, push them to include not only the effects (he's learned to play the violin or is now state ranked in tennis) but the way they feel about it as well. Parents might say things that reveal their reasons such as: “It makes me feel that I'm a good parent because I've done all these things for her” or “I feel more comfortable when I'm at work because I know he is safe at his karate class.”

Then you might ask them: “Is there any downside to being so involved in all of your child's activities?” You might get this response: “I'm beginning to resent it. I signed him up for all these activities, and now I don't have any free time any more.”

The next step in motivational interviewing is to ask about their readiness for change in a gentle way. “Do you think you might consider backing off?” If they say yes, you can ask, “What would be one of the things you could back off on now?” Make sure it is specific and also includes a time frame: “When would you be able to make this change?” In one family I was helping, the child had been talking to his parents on the phone 20 times a day. For him, a goal-setting question was, “What would it take to cut that down to 15 times?” Don't set an unrealistic goal such as stopping altogether.

Some parents initially will not be amenable to changing their behavior. For example, if they say, “I don't know. I never thought about this before,” you may need to be more circumspect. You might say, “Is there something else about this way of relating to your child that is making you want to continue?” Or use other parents as an example: “Some parents find when they back off the child becomes more relaxed, gets right on his homework by himself, and is happier.”

Garnering support for a change in behavior is an important component. You might ask: “Who could help you back off?” Finding other parents to have as friends who are not so intense, who don't feel the need to have a perfect child, or who are willing to let their kids be more autonomous may be key. Some websites and social networks developing to help parents back off from helicoptering promote “slow parenting,” “free-range parenting,” or “simplicity parenting.”

One important goal of the motivational interview is to come away with a time-based action plan. For a parent who says: “I don't want to change anything” or “This is the most important thing I'm doing for my kid,” you can keep change on the agenda by saying something like: “OK, perhaps we can talk about it when you bring her back for her vaccine in 2 months” and then make a note in the chart so you remember.

Inability to follow an agreed-upon plan can reveal where the parents or child is getting stuck, so this can be subsequently addressed. On a follow-up contact ask how it went and praise them, especially if they exceeded the goal. Or the parent may say, “When I tried to do that, he had a panic attack” or “I got depressed. I felt worthless, like I was not protecting my child.” That will help you understand the barriers for these parents and help you arrange appropriate treatment.

Even though helicopter parenting sounds like something new, addressing it employs your same old clinical skills.

---Barbara J. Howard, M.D.

[email protected]

Some parents of very young children – those 6 years old and younger – will come to you exhausted, feeling inadequate as parents, and even angry at their children.

Parents will report that their children with attention-deficit/hyperactivity disorder are very difficult at home and in preschool. Probably when their children were around age 2, 3, or 4 years old, their parents began wondering if the youngsters were immature, were more impulsive, and had a shorter attention span, compared with peers.

Pediatricians will recognize this pattern as likely ADHD and, in addition to making an accurate diagnosis, know that much is at stake in guiding and supporting parents. A critical relationship is at risk as the child's behavior evokes criticism and a negative tone from parents. Pediatricians should help parents set reasonable expectations and focus on behaviors and activities that build self-esteem. For some families, this work can be difficult and time consuming, requiring counseling and behavioral reward training – probably better delegated to a mental health specialist.

Attention span, impulsivity, and motoric hyperactivity are active concerns every waking hour of the child's day. Certain demands in preschool, at a longer dinner, or in church may exacerbate the symptoms, whereas playing in the park or playing a fun-filled computer game may ease the symptoms. The pediatrician can sort through a typical day and recommend approaches that are consistent with developmentally reasonable expectations, and modified for the child's ADHD symptoms.

Family history is another consideration. About 30% of children with ADHD come from fathers who had or have the disorder. Reminding a father of his difficulties growing up or any ongoing ADHD symptoms can be helpful in eliciting some empathy from him for his child's suffering.

Beyond family life, ADHD will affect the choice of school and activities. Based on what works for the child, consider how many hours a child should spend in preschool and how much structure is helpful. How will the culture of the school fit the child's style? Remember that the last thing a child with ADHD needs is an early school experience characterized by criticism and a sense of not being able to please teachers. A school with more recess and activity opportunities, as well as after-school programs, might be a good choice, and might offer some respite for parents.

As part of building self-esteem, ask parents if there is anything the child is really good at. For example, I treated a 6-year-old with ADHD who was gifted with computers. He was able to teach his peers and play games with friends, and he felt genuine pride working with a machine that was tolerant and nonjudgmental, and could be reset as needed. Might this not lead to a path of an after-school computer club or computer summer camp (that of course would include other activities)? Other young children may show strength in music, art, or a sport, and these activities are at least as important as remediating weaknesses.

Awareness of the different ADHD subtypes is important in general, but also can guide you in when to refer these children. Some kids with ADHD are more moody or depressed, some are more anxious, and others are more physically aggressive. Consider referral to a child and adolescent psychiatrist if one of these subtypes becomes more difficult to manage. A mental health consultation can help these higher-risk children.

Some children with ADHD also have learning disabilities, and diagnosis at a young age, before school failure, is invaluable. If you suspect this in a particular patient, you might want to recommend some early testing through the schools to avoid creation of unrealistic expectations in the classroom.

Parents may tell you their children are impulsive. While other kids are more predictable when playing in the sandbox, their children with ADHD may do something unpredictable. They might jump out of the sandbox or grab a toy from another child, for example. A mother of a 3-year-old with ADHD will stay closer to the sandbox because she doesn't know what that child is going to do next.

Typically, the child also will have a shorter attention span. The parents cannot relax because they know the sandbox, or a particular project in the sandbox, won't hold their child as long. Other children may be occupied for 15, 20, or even 30 minutes, but their young child with ADHD might last only 3 or 4 minutes and then need to move on. That, as you can imagine, is going to make the parenting demands much higher. Remember this doesn't happen for just 1 or 2 hours per day; children with true ADHD are going to be like this from the time they get up until the time they go to sleep.

All these behaviors associated with ADHD set these children up for a fair amount of criticism. The parents are tempted, especially if they don't understand the disorder, to say: “Don't do that!”; “Put that down!”; “I just bought you this – why don't you want to play with it?”; “Why can't you play like your friend Johnny does?”; “Why can't you sit still for a minute while Mommy fixes dinner?”

These children are subject to a lot of negative feedback from their environment. The world is not very tolerant of a young child, or even an older child, with ADHD. My guess is if these children are in preschool, the teacher is having the same issues with their behaviors. They may get criticized during circle time or while doing a certain project. Except for recess and lunch, they are going to be under a lot of scrutiny and most of the feedback is going to be negative.

We can see how children with ADHD, in a typical day, can hear 10, if not 25, negative comments. That is about two to three per hour. That degree of criticism begins to become part of how they see themselves, and they become fairly self-critical.

One of the key risks from ADHD at this young age is that it's hard for these children to differentiate if what they are doing is bad or if they are bad. Their self-esteem is very vulnerable. One principle that guides a lot of my management of these youngsters with ADHD is figuring out how to protect or enhance their self-esteem. Therefore, one of the initial things I ask parents to do is to think about how much negative criticism their child is hearing. Next, I ask them to think about what are reasonable expectations for that particular child.

Any opportunity to build self-esteem and build a sense of success based on reasonable expectations is worthwhile. A lot of parents will start sports for their children when they are 4 or 5. Kids with ADHD don't do very well in the outfield of T-ball because they are distracted. They don't stand out there waiting for the hit, and then they get yelled at for missing the ball. Help parents choose a sport that fits their children. I've seen some ADHD kids be goalies because they have to pay attention for a few seconds when the ball is coming, and then when the ball is somewhere else they can daydream with impunity. A lot of children with ADHD do well with swimming, for example, because there are fewer rules and they have a little more freedom. Others thrive with the structure and sense of accomplishment that comes from the “belt” system of karate.

Clearly one of the most effective treatments for the symptoms of ADHD is medication. Medication will increase attention span in school, church, or at dinner. Of course, every parent has concerns about how young to start children on medication, or whether to use medication at all. For those families, the first set of efforts may be directed to setting reasonable expectations and reviewing daily activities.

This focus will help, but will not be enough, and medication will be a critical part of treatment. Medication adds some risk, but the benefits to the child's functioning and self-esteem often outweigh these risks.

One of the things that medication probably does best is reduce the amount of negative feedback because the child will not be as impulsive and will appear to have a longer attention span. Again, you can ask too much of a child, but you will see higher expectations if the child is taking medication that is working correctly. Once ADHD is diagnosed in a young child, the pediatrician has a key role in trying to protect and enhance the child's self-esteem, advising on the child's day-to-day functioning, and supporting the overall care with appropriate use of medications.

[email protected]

Some parents of very young children – those 6 years old and younger – will come to you exhausted, feeling inadequate as parents, and even angry at their children.

Parents will report that their children with attention-deficit/hyperactivity disorder are very difficult at home and in preschool. Probably when their children were around age 2, 3, or 4 years old, their parents began wondering if the youngsters were immature, were more impulsive, and had a shorter attention span, compared with peers.

Pediatricians will recognize this pattern as likely ADHD and, in addition to making an accurate diagnosis, know that much is at stake in guiding and supporting parents. A critical relationship is at risk as the child's behavior evokes criticism and a negative tone from parents. Pediatricians should help parents set reasonable expectations and focus on behaviors and activities that build self-esteem. For some families, this work can be difficult and time consuming, requiring counseling and behavioral reward training – probably better delegated to a mental health specialist.

Attention span, impulsivity, and motoric hyperactivity are active concerns every waking hour of the child's day. Certain demands in preschool, at a longer dinner, or in church may exacerbate the symptoms, whereas playing in the park or playing a fun-filled computer game may ease the symptoms. The pediatrician can sort through a typical day and recommend approaches that are consistent with developmentally reasonable expectations, and modified for the child's ADHD symptoms.

Family history is another consideration. About 30% of children with ADHD come from fathers who had or have the disorder. Reminding a father of his difficulties growing up or any ongoing ADHD symptoms can be helpful in eliciting some empathy from him for his child's suffering.

Beyond family life, ADHD will affect the choice of school and activities. Based on what works for the child, consider how many hours a child should spend in preschool and how much structure is helpful. How will the culture of the school fit the child's style? Remember that the last thing a child with ADHD needs is an early school experience characterized by criticism and a sense of not being able to please teachers. A school with more recess and activity opportunities, as well as after-school programs, might be a good choice, and might offer some respite for parents.

As part of building self-esteem, ask parents if there is anything the child is really good at. For example, I treated a 6-year-old with ADHD who was gifted with computers. He was able to teach his peers and play games with friends, and he felt genuine pride working with a machine that was tolerant and nonjudgmental, and could be reset as needed. Might this not lead to a path of an after-school computer club or computer summer camp (that of course would include other activities)? Other young children may show strength in music, art, or a sport, and these activities are at least as important as remediating weaknesses.

Awareness of the different ADHD subtypes is important in general, but also can guide you in when to refer these children. Some kids with ADHD are more moody or depressed, some are more anxious, and others are more physically aggressive. Consider referral to a child and adolescent psychiatrist if one of these subtypes becomes more difficult to manage. A mental health consultation can help these higher-risk children.

Some children with ADHD also have learning disabilities, and diagnosis at a young age, before school failure, is invaluable. If you suspect this in a particular patient, you might want to recommend some early testing through the schools to avoid creation of unrealistic expectations in the classroom.

Parents may tell you their children are impulsive. While other kids are more predictable when playing in the sandbox, their children with ADHD may do something unpredictable. They might jump out of the sandbox or grab a toy from another child, for example. A mother of a 3-year-old with ADHD will stay closer to the sandbox because she doesn't know what that child is going to do next.

Typically, the child also will have a shorter attention span. The parents cannot relax because they know the sandbox, or a particular project in the sandbox, won't hold their child as long. Other children may be occupied for 15, 20, or even 30 minutes, but their young child with ADHD might last only 3 or 4 minutes and then need to move on. That, as you can imagine, is going to make the parenting demands much higher. Remember this doesn't happen for just 1 or 2 hours per day; children with true ADHD are going to be like this from the time they get up until the time they go to sleep.

All these behaviors associated with ADHD set these children up for a fair amount of criticism. The parents are tempted, especially if they don't understand the disorder, to say: “Don't do that!”; “Put that down!”; “I just bought you this – why don't you want to play with it?”; “Why can't you play like your friend Johnny does?”; “Why can't you sit still for a minute while Mommy fixes dinner?”

These children are subject to a lot of negative feedback from their environment. The world is not very tolerant of a young child, or even an older child, with ADHD. My guess is if these children are in preschool, the teacher is having the same issues with their behaviors. They may get criticized during circle time or while doing a certain project. Except for recess and lunch, they are going to be under a lot of scrutiny and most of the feedback is going to be negative.

We can see how children with ADHD, in a typical day, can hear 10, if not 25, negative comments. That is about two to three per hour. That degree of criticism begins to become part of how they see themselves, and they become fairly self-critical.

One of the key risks from ADHD at this young age is that it's hard for these children to differentiate if what they are doing is bad or if they are bad. Their self-esteem is very vulnerable. One principle that guides a lot of my management of these youngsters with ADHD is figuring out how to protect or enhance their self-esteem. Therefore, one of the initial things I ask parents to do is to think about how much negative criticism their child is hearing. Next, I ask them to think about what are reasonable expectations for that particular child.

Any opportunity to build self-esteem and build a sense of success based on reasonable expectations is worthwhile. A lot of parents will start sports for their children when they are 4 or 5. Kids with ADHD don't do very well in the outfield of T-ball because they are distracted. They don't stand out there waiting for the hit, and then they get yelled at for missing the ball. Help parents choose a sport that fits their children. I've seen some ADHD kids be goalies because they have to pay attention for a few seconds when the ball is coming, and then when the ball is somewhere else they can daydream with impunity. A lot of children with ADHD do well with swimming, for example, because there are fewer rules and they have a little more freedom. Others thrive with the structure and sense of accomplishment that comes from the “belt” system of karate.

Clearly one of the most effective treatments for the symptoms of ADHD is medication. Medication will increase attention span in school, church, or at dinner. Of course, every parent has concerns about how young to start children on medication, or whether to use medication at all. For those families, the first set of efforts may be directed to setting reasonable expectations and reviewing daily activities.

This focus will help, but will not be enough, and medication will be a critical part of treatment. Medication adds some risk, but the benefits to the child's functioning and self-esteem often outweigh these risks.

One of the things that medication probably does best is reduce the amount of negative feedback because the child will not be as impulsive and will appear to have a longer attention span. Again, you can ask too much of a child, but you will see higher expectations if the child is taking medication that is working correctly. Once ADHD is diagnosed in a young child, the pediatrician has a key role in trying to protect and enhance the child's self-esteem, advising on the child's day-to-day functioning, and supporting the overall care with appropriate use of medications.

[email protected]

Some parents of very young children – those 6 years old and younger – will come to you exhausted, feeling inadequate as parents, and even angry at their children.

Parents will report that their children with attention-deficit/hyperactivity disorder are very difficult at home and in preschool. Probably when their children were around age 2, 3, or 4 years old, their parents began wondering if the youngsters were immature, were more impulsive, and had a shorter attention span, compared with peers.

Pediatricians will recognize this pattern as likely ADHD and, in addition to making an accurate diagnosis, know that much is at stake in guiding and supporting parents. A critical relationship is at risk as the child's behavior evokes criticism and a negative tone from parents. Pediatricians should help parents set reasonable expectations and focus on behaviors and activities that build self-esteem. For some families, this work can be difficult and time consuming, requiring counseling and behavioral reward training – probably better delegated to a mental health specialist.

Attention span, impulsivity, and motoric hyperactivity are active concerns every waking hour of the child's day. Certain demands in preschool, at a longer dinner, or in church may exacerbate the symptoms, whereas playing in the park or playing a fun-filled computer game may ease the symptoms. The pediatrician can sort through a typical day and recommend approaches that are consistent with developmentally reasonable expectations, and modified for the child's ADHD symptoms.

Family history is another consideration. About 30% of children with ADHD come from fathers who had or have the disorder. Reminding a father of his difficulties growing up or any ongoing ADHD symptoms can be helpful in eliciting some empathy from him for his child's suffering.

Beyond family life, ADHD will affect the choice of school and activities. Based on what works for the child, consider how many hours a child should spend in preschool and how much structure is helpful. How will the culture of the school fit the child's style? Remember that the last thing a child with ADHD needs is an early school experience characterized by criticism and a sense of not being able to please teachers. A school with more recess and activity opportunities, as well as after-school programs, might be a good choice, and might offer some respite for parents.

As part of building self-esteem, ask parents if there is anything the child is really good at. For example, I treated a 6-year-old with ADHD who was gifted with computers. He was able to teach his peers and play games with friends, and he felt genuine pride working with a machine that was tolerant and nonjudgmental, and could be reset as needed. Might this not lead to a path of an after-school computer club or computer summer camp (that of course would include other activities)? Other young children may show strength in music, art, or a sport, and these activities are at least as important as remediating weaknesses.

Awareness of the different ADHD subtypes is important in general, but also can guide you in when to refer these children. Some kids with ADHD are more moody or depressed, some are more anxious, and others are more physically aggressive. Consider referral to a child and adolescent psychiatrist if one of these subtypes becomes more difficult to manage. A mental health consultation can help these higher-risk children.

Some children with ADHD also have learning disabilities, and diagnosis at a young age, before school failure, is invaluable. If you suspect this in a particular patient, you might want to recommend some early testing through the schools to avoid creation of unrealistic expectations in the classroom.

Parents may tell you their children are impulsive. While other kids are more predictable when playing in the sandbox, their children with ADHD may do something unpredictable. They might jump out of the sandbox or grab a toy from another child, for example. A mother of a 3-year-old with ADHD will stay closer to the sandbox because she doesn't know what that child is going to do next.

Typically, the child also will have a shorter attention span. The parents cannot relax because they know the sandbox, or a particular project in the sandbox, won't hold their child as long. Other children may be occupied for 15, 20, or even 30 minutes, but their young child with ADHD might last only 3 or 4 minutes and then need to move on. That, as you can imagine, is going to make the parenting demands much higher. Remember this doesn't happen for just 1 or 2 hours per day; children with true ADHD are going to be like this from the time they get up until the time they go to sleep.

All these behaviors associated with ADHD set these children up for a fair amount of criticism. The parents are tempted, especially if they don't understand the disorder, to say: “Don't do that!”; “Put that down!”; “I just bought you this – why don't you want to play with it?”; “Why can't you play like your friend Johnny does?”; “Why can't you sit still for a minute while Mommy fixes dinner?”

These children are subject to a lot of negative feedback from their environment. The world is not very tolerant of a young child, or even an older child, with ADHD. My guess is if these children are in preschool, the teacher is having the same issues with their behaviors. They may get criticized during circle time or while doing a certain project. Except for recess and lunch, they are going to be under a lot of scrutiny and most of the feedback is going to be negative.

We can see how children with ADHD, in a typical day, can hear 10, if not 25, negative comments. That is about two to three per hour. That degree of criticism begins to become part of how they see themselves, and they become fairly self-critical.

One of the key risks from ADHD at this young age is that it's hard for these children to differentiate if what they are doing is bad or if they are bad. Their self-esteem is very vulnerable. One principle that guides a lot of my management of these youngsters with ADHD is figuring out how to protect or enhance their self-esteem. Therefore, one of the initial things I ask parents to do is to think about how much negative criticism their child is hearing. Next, I ask them to think about what are reasonable expectations for that particular child.

Any opportunity to build self-esteem and build a sense of success based on reasonable expectations is worthwhile. A lot of parents will start sports for their children when they are 4 or 5. Kids with ADHD don't do very well in the outfield of T-ball because they are distracted. They don't stand out there waiting for the hit, and then they get yelled at for missing the ball. Help parents choose a sport that fits their children. I've seen some ADHD kids be goalies because they have to pay attention for a few seconds when the ball is coming, and then when the ball is somewhere else they can daydream with impunity. A lot of children with ADHD do well with swimming, for example, because there are fewer rules and they have a little more freedom. Others thrive with the structure and sense of accomplishment that comes from the “belt” system of karate.

Clearly one of the most effective treatments for the symptoms of ADHD is medication. Medication will increase attention span in school, church, or at dinner. Of course, every parent has concerns about how young to start children on medication, or whether to use medication at all. For those families, the first set of efforts may be directed to setting reasonable expectations and reviewing daily activities.

This focus will help, but will not be enough, and medication will be a critical part of treatment. Medication adds some risk, but the benefits to the child's functioning and self-esteem often outweigh these risks.

One of the things that medication probably does best is reduce the amount of negative feedback because the child will not be as impulsive and will appear to have a longer attention span. Again, you can ask too much of a child, but you will see higher expectations if the child is taking medication that is working correctly. Once ADHD is diagnosed in a young child, the pediatrician has a key role in trying to protect and enhance the child's self-esteem, advising on the child's day-to-day functioning, and supporting the overall care with appropriate use of medications.

[email protected]

Different forms of trauma can cause posttraumatic stress disorder in children, whether from an objective event like a car crash or sports injury to trauma involving loved ones, such as domestic violence, abuse, or neglect.

Pediatricians can help by routinely screening for dysfunction and by asking questions at annual well-child visits. Overt symptoms include fear related to the trauma such as avoiding the traumatic setting or activity. Less specific symptoms include anxiety, avoidance, social isolation, depression, and low self-esteem.

If a standard screen such as the Pediatric Symptom Checklist or another instrument reveals psychosocial dysfunction, you have to determine the cause of dysfunction, and PTSD should certainly be considered.

Is there family discord leading to violence in the home? If you suspect PTSD, ask a child what happened and why he or she thinks it happened. Determine if the child is blaming himself or herself in any way. Is the child grieving following a permanent injury and/or loss of a loved one? How have the parents discussed any traumatic event with the child? Do the parents feel traumatized by the child's experience?

If PTSD is a possibility, ask if the child is experiencing flashbacks, intrusive thoughts, and/or any related anxiety.

Some symptoms are expected after a traumatic event or following cancer or critical care treatment experienced as traumatic. Most children and adolescents overcome the fear of riding in a car or playing the sport that resulted in the trauma.

However, symptoms that persist for a month or more, with avoidance and associated anxiety, are core to the diagnosis of PTSD. The anxiety can build and be self-reinforcing so as to interfere with daily functioning. At this point, consider referral to a mental health specialist, preferably one with some experience in PTSD treatment. A specialist can help the patient overcome his or her anxiety and return to functioning through cognitive and behavioral techniques such as reframing the events, dealing with any guilt, and staged exposure to the anxiety.

If one of your patients experienced a car crash or other major trauma, you will likely know about it, already be treating the child, and should be planning to monitor them for signs of PTSD. In contrast, detection of subtle PTSD is more challenging, particularly if the trauma is unknown or occurred years ago. Trauma related to domestic violence or sexual abuse first requires consideration of this possibility and then gentle, empathic, and persistent questioning.

Triggers for reliving/reexperiencing the trauma also can be straightforward. For example, a child who gets into a car with a similar interior design years after a crash can immediately experience and emotionally return to the trauma. Other triggers are less obvious, such as a teenage girl who was held down and forced to have sex against her will, who later feels constrained by tight clothing and immediately relives the fear and anguish.

Like many presentations in pediatrics, management of PTSD depends on the developmental stage of the child, including his or her cognitive abilities and emotional state. For example, infants or toddlers might not be able to make much sense of what is happening when they witness domestic violence. Terror, fear, and confusion are their most likely reactions.

School-age children aged 5–8 years would not fully understand either, but they will try to make some sense of the domestic violence. Assuming no one reassures them otherwise, they also may feel that something they did sparked or contributed to the violence. For example, if they overhear arguments around issues in the family and hear their name mentioned, they may quickly assume that they are the cause of the domestic violence. This can lead to feelings of guilt, self-criticism, and unworthiness.

Adolescents will experience some of the same reactions as younger children. They will still experience shock, even if they are better equipped to conceptualize the domestic violence. Some will feel powerless because they cannot end the strife, particularly at a time when they are supposed to have more control over the real world. Teens might feel they have not lived up to expectations and perceive some blame. Others may choose to flee, find support through friends, and/or may deal with their feelings using substances.

Act when you encounter a patient who feels very guilty about parental fighting or who justifies abuse because he feels worthless or was told repeatedly he was a bad child. Help him realize he was not responsible for the conflict and that no one deserves abuse. Discuss other, more realistic possibilities for the family paradigm.

These are not easy conversations. Some pediatricians will feel comfortable working at this depth, others will prefer to refer.

Healing from PTSD related to family violence, sexual abuse, or criminal activity is a several-step process. As one's sense of guilt diminishes, other emotions such as anger at not being better protected or valued need to be addressed. Finally, there needs to be some grieving for what was lacking and some acceptance of what was possible. This is not a simple process; however, it is worthwhile because if their PTSD remains untreated, there is a greater likelihood they will continue to relive traumatic memories as adults.

There is some controversy as to whether talking through the traumatic event over and over truly helps. Some clinicians feel that a certain amount of supportive discussion in a calm way makes sense, especially early. But solely repeating the details of the event may re-traumatize the child and intensify negative feelings, especially if the memories are very vivid.

Cognitive and behavioral approaches can help the child reframe their trauma. An example is exposure therapy, where the child is carefully reexposed to the trauma in stages while they learn to reframe and diminish the intensity of the experience. Often, ideas about the trauma come out that can be examined objectively to try to lessen some of those traumatic feelings.

Exposure therapy also can incorporate gradual steps to help the child overcome their fear. If a person survived a plane crash, the first step might be to take him or her to the airport, then to board an airplane without taking off, and so forth. This approach reintroduces the trauma without eliciting a full response. You don't want the brain to go on “red alert” again. In a state of hyperarousal, reliving the trauma may do more harm than good.

The terrified moments that children experience during a traumatic sequence tend to get burned into their memories much more strongly than everyday events. A school-age child might remember nothing about an uneventful trip in the car, but if a traumatic accident happens, often she remembers almost every detail. She recalls descriptive elements of what happened as well as the emotional fright or anguish very vividly.

Sometimes vivid, traumatic memories will enter your patient's mind spontaneously without him knowing why. In other cases, there are triggers. Sometimes these flashbacks arise shortly following trauma and sometimes they take years.

Pediatricians can do their patients and families a service if they are aware of PTSD either after an overt event like a car accident or by considering trauma in an anxious or dysfunctional child.

[email protected]

Different forms of trauma can cause posttraumatic stress disorder in children, whether from an objective event like a car crash or sports injury to trauma involving loved ones, such as domestic violence, abuse, or neglect.

Pediatricians can help by routinely screening for dysfunction and by asking questions at annual well-child visits. Overt symptoms include fear related to the trauma such as avoiding the traumatic setting or activity. Less specific symptoms include anxiety, avoidance, social isolation, depression, and low self-esteem.

If a standard screen such as the Pediatric Symptom Checklist or another instrument reveals psychosocial dysfunction, you have to determine the cause of dysfunction, and PTSD should certainly be considered.

Is there family discord leading to violence in the home? If you suspect PTSD, ask a child what happened and why he or she thinks it happened. Determine if the child is blaming himself or herself in any way. Is the child grieving following a permanent injury and/or loss of a loved one? How have the parents discussed any traumatic event with the child? Do the parents feel traumatized by the child's experience?

If PTSD is a possibility, ask if the child is experiencing flashbacks, intrusive thoughts, and/or any related anxiety.

Some symptoms are expected after a traumatic event or following cancer or critical care treatment experienced as traumatic. Most children and adolescents overcome the fear of riding in a car or playing the sport that resulted in the trauma.

However, symptoms that persist for a month or more, with avoidance and associated anxiety, are core to the diagnosis of PTSD. The anxiety can build and be self-reinforcing so as to interfere with daily functioning. At this point, consider referral to a mental health specialist, preferably one with some experience in PTSD treatment. A specialist can help the patient overcome his or her anxiety and return to functioning through cognitive and behavioral techniques such as reframing the events, dealing with any guilt, and staged exposure to the anxiety.

If one of your patients experienced a car crash or other major trauma, you will likely know about it, already be treating the child, and should be planning to monitor them for signs of PTSD. In contrast, detection of subtle PTSD is more challenging, particularly if the trauma is unknown or occurred years ago. Trauma related to domestic violence or sexual abuse first requires consideration of this possibility and then gentle, empathic, and persistent questioning.

Triggers for reliving/reexperiencing the trauma also can be straightforward. For example, a child who gets into a car with a similar interior design years after a crash can immediately experience and emotionally return to the trauma. Other triggers are less obvious, such as a teenage girl who was held down and forced to have sex against her will, who later feels constrained by tight clothing and immediately relives the fear and anguish.

Like many presentations in pediatrics, management of PTSD depends on the developmental stage of the child, including his or her cognitive abilities and emotional state. For example, infants or toddlers might not be able to make much sense of what is happening when they witness domestic violence. Terror, fear, and confusion are their most likely reactions.

School-age children aged 5–8 years would not fully understand either, but they will try to make some sense of the domestic violence. Assuming no one reassures them otherwise, they also may feel that something they did sparked or contributed to the violence. For example, if they overhear arguments around issues in the family and hear their name mentioned, they may quickly assume that they are the cause of the domestic violence. This can lead to feelings of guilt, self-criticism, and unworthiness.

Adolescents will experience some of the same reactions as younger children. They will still experience shock, even if they are better equipped to conceptualize the domestic violence. Some will feel powerless because they cannot end the strife, particularly at a time when they are supposed to have more control over the real world. Teens might feel they have not lived up to expectations and perceive some blame. Others may choose to flee, find support through friends, and/or may deal with their feelings using substances.

Act when you encounter a patient who feels very guilty about parental fighting or who justifies abuse because he feels worthless or was told repeatedly he was a bad child. Help him realize he was not responsible for the conflict and that no one deserves abuse. Discuss other, more realistic possibilities for the family paradigm.

These are not easy conversations. Some pediatricians will feel comfortable working at this depth, others will prefer to refer.

Healing from PTSD related to family violence, sexual abuse, or criminal activity is a several-step process. As one's sense of guilt diminishes, other emotions such as anger at not being better protected or valued need to be addressed. Finally, there needs to be some grieving for what was lacking and some acceptance of what was possible. This is not a simple process; however, it is worthwhile because if their PTSD remains untreated, there is a greater likelihood they will continue to relive traumatic memories as adults.

There is some controversy as to whether talking through the traumatic event over and over truly helps. Some clinicians feel that a certain amount of supportive discussion in a calm way makes sense, especially early. But solely repeating the details of the event may re-traumatize the child and intensify negative feelings, especially if the memories are very vivid.

Cognitive and behavioral approaches can help the child reframe their trauma. An example is exposure therapy, where the child is carefully reexposed to the trauma in stages while they learn to reframe and diminish the intensity of the experience. Often, ideas about the trauma come out that can be examined objectively to try to lessen some of those traumatic feelings.

Exposure therapy also can incorporate gradual steps to help the child overcome their fear. If a person survived a plane crash, the first step might be to take him or her to the airport, then to board an airplane without taking off, and so forth. This approach reintroduces the trauma without eliciting a full response. You don't want the brain to go on “red alert” again. In a state of hyperarousal, reliving the trauma may do more harm than good.

The terrified moments that children experience during a traumatic sequence tend to get burned into their memories much more strongly than everyday events. A school-age child might remember nothing about an uneventful trip in the car, but if a traumatic accident happens, often she remembers almost every detail. She recalls descriptive elements of what happened as well as the emotional fright or anguish very vividly.

Sometimes vivid, traumatic memories will enter your patient's mind spontaneously without him knowing why. In other cases, there are triggers. Sometimes these flashbacks arise shortly following trauma and sometimes they take years.

Pediatricians can do their patients and families a service if they are aware of PTSD either after an overt event like a car accident or by considering trauma in an anxious or dysfunctional child.

[email protected]

Different forms of trauma can cause posttraumatic stress disorder in children, whether from an objective event like a car crash or sports injury to trauma involving loved ones, such as domestic violence, abuse, or neglect.

Pediatricians can help by routinely screening for dysfunction and by asking questions at annual well-child visits. Overt symptoms include fear related to the trauma such as avoiding the traumatic setting or activity. Less specific symptoms include anxiety, avoidance, social isolation, depression, and low self-esteem.

If a standard screen such as the Pediatric Symptom Checklist or another instrument reveals psychosocial dysfunction, you have to determine the cause of dysfunction, and PTSD should certainly be considered.

Is there family discord leading to violence in the home? If you suspect PTSD, ask a child what happened and why he or she thinks it happened. Determine if the child is blaming himself or herself in any way. Is the child grieving following a permanent injury and/or loss of a loved one? How have the parents discussed any traumatic event with the child? Do the parents feel traumatized by the child's experience?

If PTSD is a possibility, ask if the child is experiencing flashbacks, intrusive thoughts, and/or any related anxiety.

Some symptoms are expected after a traumatic event or following cancer or critical care treatment experienced as traumatic. Most children and adolescents overcome the fear of riding in a car or playing the sport that resulted in the trauma.

However, symptoms that persist for a month or more, with avoidance and associated anxiety, are core to the diagnosis of PTSD. The anxiety can build and be self-reinforcing so as to interfere with daily functioning. At this point, consider referral to a mental health specialist, preferably one with some experience in PTSD treatment. A specialist can help the patient overcome his or her anxiety and return to functioning through cognitive and behavioral techniques such as reframing the events, dealing with any guilt, and staged exposure to the anxiety.

If one of your patients experienced a car crash or other major trauma, you will likely know about it, already be treating the child, and should be planning to monitor them for signs of PTSD. In contrast, detection of subtle PTSD is more challenging, particularly if the trauma is unknown or occurred years ago. Trauma related to domestic violence or sexual abuse first requires consideration of this possibility and then gentle, empathic, and persistent questioning.

Triggers for reliving/reexperiencing the trauma also can be straightforward. For example, a child who gets into a car with a similar interior design years after a crash can immediately experience and emotionally return to the trauma. Other triggers are less obvious, such as a teenage girl who was held down and forced to have sex against her will, who later feels constrained by tight clothing and immediately relives the fear and anguish.

Like many presentations in pediatrics, management of PTSD depends on the developmental stage of the child, including his or her cognitive abilities and emotional state. For example, infants or toddlers might not be able to make much sense of what is happening when they witness domestic violence. Terror, fear, and confusion are their most likely reactions.

School-age children aged 5–8 years would not fully understand either, but they will try to make some sense of the domestic violence. Assuming no one reassures them otherwise, they also may feel that something they did sparked or contributed to the violence. For example, if they overhear arguments around issues in the family and hear their name mentioned, they may quickly assume that they are the cause of the domestic violence. This can lead to feelings of guilt, self-criticism, and unworthiness.

Adolescents will experience some of the same reactions as younger children. They will still experience shock, even if they are better equipped to conceptualize the domestic violence. Some will feel powerless because they cannot end the strife, particularly at a time when they are supposed to have more control over the real world. Teens might feel they have not lived up to expectations and perceive some blame. Others may choose to flee, find support through friends, and/or may deal with their feelings using substances.

Act when you encounter a patient who feels very guilty about parental fighting or who justifies abuse because he feels worthless or was told repeatedly he was a bad child. Help him realize he was not responsible for the conflict and that no one deserves abuse. Discuss other, more realistic possibilities for the family paradigm.

These are not easy conversations. Some pediatricians will feel comfortable working at this depth, others will prefer to refer.

Healing from PTSD related to family violence, sexual abuse, or criminal activity is a several-step process. As one's sense of guilt diminishes, other emotions such as anger at not being better protected or valued need to be addressed. Finally, there needs to be some grieving for what was lacking and some acceptance of what was possible. This is not a simple process; however, it is worthwhile because if their PTSD remains untreated, there is a greater likelihood they will continue to relive traumatic memories as adults.

There is some controversy as to whether talking through the traumatic event over and over truly helps. Some clinicians feel that a certain amount of supportive discussion in a calm way makes sense, especially early. But solely repeating the details of the event may re-traumatize the child and intensify negative feelings, especially if the memories are very vivid.

Cognitive and behavioral approaches can help the child reframe their trauma. An example is exposure therapy, where the child is carefully reexposed to the trauma in stages while they learn to reframe and diminish the intensity of the experience. Often, ideas about the trauma come out that can be examined objectively to try to lessen some of those traumatic feelings.

Exposure therapy also can incorporate gradual steps to help the child overcome their fear. If a person survived a plane crash, the first step might be to take him or her to the airport, then to board an airplane without taking off, and so forth. This approach reintroduces the trauma without eliciting a full response. You don't want the brain to go on “red alert” again. In a state of hyperarousal, reliving the trauma may do more harm than good.

The terrified moments that children experience during a traumatic sequence tend to get burned into their memories much more strongly than everyday events. A school-age child might remember nothing about an uneventful trip in the car, but if a traumatic accident happens, often she remembers almost every detail. She recalls descriptive elements of what happened as well as the emotional fright or anguish very vividly.

Sometimes vivid, traumatic memories will enter your patient's mind spontaneously without him knowing why. In other cases, there are triggers. Sometimes these flashbacks arise shortly following trauma and sometimes they take years.

Pediatricians can do their patients and families a service if they are aware of PTSD either after an overt event like a car accident or by considering trauma in an anxious or dysfunctional child.

[email protected]

Adolescent substance use is a big, difficult issue. Alcohol, cigarettes, and marijuana – and to a lesser extent, cocaine – are endemic to most high schools.

It's not at all unusual for high school juniors and seniors to drink or even to binge drink. In addition, about 15%-20% of them smoke cigarettes, depending on the community, and probably more than that try or intermittently smoke marijuana.

One approach is to educate parents about which children may be at higher risk for substance use.

For example, most teenagers are at some risk and need to be watched for any high-risk activities, especially drinking and driving or riding in a car with a friend who has been drinking. If parents begin to see a serious problem – such as binge drinking every weekend, obvious use of marijuana on a regular basis, or obvious use of cocaine – take it very seriously. Talk with patients and parents, and provide a referral for services as indicated.

Other kids might be at slightly higher risk in high school, based on their achievements. A good athlete who joins the varsity team in 9th or 10th grade, or the talented 9th-grader who lands the lead in the high school play, tend to spend more time with juniors and seniors. They get invited to parties and events outside their peer groups. Without the judgment of an older child and while trying to “keep up,” they might be more vulnerable to problematic substance use. The difference between a 14-year-old and a 17-year-old is enormous, and the peer pressure of being with seniors is considerable.

Recognize that some kids start high school already predisposed and at quite high risk for substance use problems: A patient with biologic or genetic risk factors; a patient with untreated depression or anxiety; and/or an adolescent with attention-deficit/hyperactivity disorder (ADHD) are examples.

Left unaddressed, these kids are predisposed to earlier and more serious substance use. Some children with genetic and/or biological risk factors begin drinking heavily before their 14th birthday. In contrast, the typical age of onset for alcohol use includes some experimentation at 15 or 16 years that becomes binge drinking for some a year or two later.

Biology predisposes some adolescents to nicotine addiction or heavy use of marijuana or alcohol. While adolescent brains are in development and experience the expected stress of puberty and building an identity, some teenagers' brains may be more susceptible to addiction than others. In addition, genetics and environment can play a role, evidenced by the higher risks for children whose parents have a personal or family history of substance use problems. If there is a strong history of alcoholism in the family or if a parent is a recovering alcoholic, discuss with parents how their past might influence how they treat their teenager. Advise them what information should be shared to alert the teenager to the potential risks. It might help a child at age 12 or 13 to know that he or she may be especially vulnerable to the dangers of substance use, and this may well open up an avenue of communication and trust that could be helpful later.

Anxiety and depression also have genetic roots in some patients. Asking parents about their family history of substance abuse, depression, or serious mental health disorder should be a routine part of pediatric practice.

In addition, implementing screening tests makes sense in adolescence. Such screening tests are publicly available and reviewed by the American Academy of Pediatrics Bright Futures: Mental Health effort (http://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.htmlwww.aap.org/pcorss/demos/mht.html

Children with ADHD make up another high-risk group. They also seem to be more vulnerable to cigarettes, alcohol, and marijuana. These teenagers can be driven to find relief in these substances because of brain biology and/or secondary to the stress of living with their ADHD symptoms.

On the plus side, ADHD kids treated appropriately with stimulants and support services have lower levels of substance use and probably higher self-esteem. Ensure they have the best treatment possible for their ADHD to minimize their substance use risk as much as possible.

As they become young teenagers, they should have a full review of all their ADHD treatment and how their typical day plays out at school and at home. Consider some additional preventative counseling to help these children face their substance use challenges throughout adolescence.

Offer such guidance to all children and parents, but especially to those in one of these high-risk groups. Suggest strategies that support and reinforce their resiliency. A warm, positive relationship with an adult is a protective factor. Also, kids who feel connected to a school, church, or sports team tend to be a little more resilient to some of these influences.

Facilitate open, honest communication between the parent and adolescent. Many parents might not realize that this is more effective than are attempts to control their teen's behavior 24/7. Over-control is impossible given the lifestyle of most 15-, 16- or 17-year-olds. Between cell phones, cars, and the amount of time they are out of the house, parents cannot control them to a level of stopping all substance use.

Even if more control is possible, the effort works against the adolescent's developmental trajectory toward increasing autonomy. The real goal of adolescence in our culture is to learn how to live in the real world and to prepare for autonomy as young adults. High school is a preparation for college life and adulthood where good judgment, safety, and socialization are important learned behaviors. Teaching adolescents how to navigate all this is an essential role for physicians and parents.

Part of growing autonomy is privacy. While it is tempting to invade that privacy to learn about substance use or to clarify other concerns, it is not clear that such efforts support the long-term goals of raising a teenager. Such efforts at control and investigation, including blood or urine testing, are best reserved when the benefits outweigh the risks, when there is a substance abuse problem that needs to be addressed.

[email protected]

Adolescent substance use is a big, difficult issue. Alcohol, cigarettes, and marijuana – and to a lesser extent, cocaine – are endemic to most high schools.

It's not at all unusual for high school juniors and seniors to drink or even to binge drink. In addition, about 15%-20% of them smoke cigarettes, depending on the community, and probably more than that try or intermittently smoke marijuana.

One approach is to educate parents about which children may be at higher risk for substance use.

For example, most teenagers are at some risk and need to be watched for any high-risk activities, especially drinking and driving or riding in a car with a friend who has been drinking. If parents begin to see a serious problem – such as binge drinking every weekend, obvious use of marijuana on a regular basis, or obvious use of cocaine – take it very seriously. Talk with patients and parents, and provide a referral for services as indicated.

Other kids might be at slightly higher risk in high school, based on their achievements. A good athlete who joins the varsity team in 9th or 10th grade, or the talented 9th-grader who lands the lead in the high school play, tend to spend more time with juniors and seniors. They get invited to parties and events outside their peer groups. Without the judgment of an older child and while trying to “keep up,” they might be more vulnerable to problematic substance use. The difference between a 14-year-old and a 17-year-old is enormous, and the peer pressure of being with seniors is considerable.

Recognize that some kids start high school already predisposed and at quite high risk for substance use problems: A patient with biologic or genetic risk factors; a patient with untreated depression or anxiety; and/or an adolescent with attention-deficit/hyperactivity disorder (ADHD) are examples.

Left unaddressed, these kids are predisposed to earlier and more serious substance use. Some children with genetic and/or biological risk factors begin drinking heavily before their 14th birthday. In contrast, the typical age of onset for alcohol use includes some experimentation at 15 or 16 years that becomes binge drinking for some a year or two later.

Biology predisposes some adolescents to nicotine addiction or heavy use of marijuana or alcohol. While adolescent brains are in development and experience the expected stress of puberty and building an identity, some teenagers' brains may be more susceptible to addiction than others. In addition, genetics and environment can play a role, evidenced by the higher risks for children whose parents have a personal or family history of substance use problems. If there is a strong history of alcoholism in the family or if a parent is a recovering alcoholic, discuss with parents how their past might influence how they treat their teenager. Advise them what information should be shared to alert the teenager to the potential risks. It might help a child at age 12 or 13 to know that he or she may be especially vulnerable to the dangers of substance use, and this may well open up an avenue of communication and trust that could be helpful later.

Anxiety and depression also have genetic roots in some patients. Asking parents about their family history of substance abuse, depression, or serious mental health disorder should be a routine part of pediatric practice.

In addition, implementing screening tests makes sense in adolescence. Such screening tests are publicly available and reviewed by the American Academy of Pediatrics Bright Futures: Mental Health effort (http://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.htmlwww.aap.org/pcorss/demos/mht.html

Children with ADHD make up another high-risk group. They also seem to be more vulnerable to cigarettes, alcohol, and marijuana. These teenagers can be driven to find relief in these substances because of brain biology and/or secondary to the stress of living with their ADHD symptoms.

On the plus side, ADHD kids treated appropriately with stimulants and support services have lower levels of substance use and probably higher self-esteem. Ensure they have the best treatment possible for their ADHD to minimize their substance use risk as much as possible.

As they become young teenagers, they should have a full review of all their ADHD treatment and how their typical day plays out at school and at home. Consider some additional preventative counseling to help these children face their substance use challenges throughout adolescence.

Offer such guidance to all children and parents, but especially to those in one of these high-risk groups. Suggest strategies that support and reinforce their resiliency. A warm, positive relationship with an adult is a protective factor. Also, kids who feel connected to a school, church, or sports team tend to be a little more resilient to some of these influences.

Facilitate open, honest communication between the parent and adolescent. Many parents might not realize that this is more effective than are attempts to control their teen's behavior 24/7. Over-control is impossible given the lifestyle of most 15-, 16- or 17-year-olds. Between cell phones, cars, and the amount of time they are out of the house, parents cannot control them to a level of stopping all substance use.

Even if more control is possible, the effort works against the adolescent's developmental trajectory toward increasing autonomy. The real goal of adolescence in our culture is to learn how to live in the real world and to prepare for autonomy as young adults. High school is a preparation for college life and adulthood where good judgment, safety, and socialization are important learned behaviors. Teaching adolescents how to navigate all this is an essential role for physicians and parents.

Part of growing autonomy is privacy. While it is tempting to invade that privacy to learn about substance use or to clarify other concerns, it is not clear that such efforts support the long-term goals of raising a teenager. Such efforts at control and investigation, including blood or urine testing, are best reserved when the benefits outweigh the risks, when there is a substance abuse problem that needs to be addressed.

[email protected]

Adolescent substance use is a big, difficult issue. Alcohol, cigarettes, and marijuana – and to a lesser extent, cocaine – are endemic to most high schools.

It's not at all unusual for high school juniors and seniors to drink or even to binge drink. In addition, about 15%-20% of them smoke cigarettes, depending on the community, and probably more than that try or intermittently smoke marijuana.

One approach is to educate parents about which children may be at higher risk for substance use.

For example, most teenagers are at some risk and need to be watched for any high-risk activities, especially drinking and driving or riding in a car with a friend who has been drinking. If parents begin to see a serious problem – such as binge drinking every weekend, obvious use of marijuana on a regular basis, or obvious use of cocaine – take it very seriously. Talk with patients and parents, and provide a referral for services as indicated.

Other kids might be at slightly higher risk in high school, based on their achievements. A good athlete who joins the varsity team in 9th or 10th grade, or the talented 9th-grader who lands the lead in the high school play, tend to spend more time with juniors and seniors. They get invited to parties and events outside their peer groups. Without the judgment of an older child and while trying to “keep up,” they might be more vulnerable to problematic substance use. The difference between a 14-year-old and a 17-year-old is enormous, and the peer pressure of being with seniors is considerable.

Recognize that some kids start high school already predisposed and at quite high risk for substance use problems: A patient with biologic or genetic risk factors; a patient with untreated depression or anxiety; and/or an adolescent with attention-deficit/hyperactivity disorder (ADHD) are examples.

Left unaddressed, these kids are predisposed to earlier and more serious substance use. Some children with genetic and/or biological risk factors begin drinking heavily before their 14th birthday. In contrast, the typical age of onset for alcohol use includes some experimentation at 15 or 16 years that becomes binge drinking for some a year or two later.

Biology predisposes some adolescents to nicotine addiction or heavy use of marijuana or alcohol. While adolescent brains are in development and experience the expected stress of puberty and building an identity, some teenagers' brains may be more susceptible to addiction than others. In addition, genetics and environment can play a role, evidenced by the higher risks for children whose parents have a personal or family history of substance use problems. If there is a strong history of alcoholism in the family or if a parent is a recovering alcoholic, discuss with parents how their past might influence how they treat their teenager. Advise them what information should be shared to alert the teenager to the potential risks. It might help a child at age 12 or 13 to know that he or she may be especially vulnerable to the dangers of substance use, and this may well open up an avenue of communication and trust that could be helpful later.

Anxiety and depression also have genetic roots in some patients. Asking parents about their family history of substance abuse, depression, or serious mental health disorder should be a routine part of pediatric practice.

In addition, implementing screening tests makes sense in adolescence. Such screening tests are publicly available and reviewed by the American Academy of Pediatrics Bright Futures: Mental Health effort (http://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.htmlwww.aap.org/pcorss/demos/mht.html

Children with ADHD make up another high-risk group. They also seem to be more vulnerable to cigarettes, alcohol, and marijuana. These teenagers can be driven to find relief in these substances because of brain biology and/or secondary to the stress of living with their ADHD symptoms.

On the plus side, ADHD kids treated appropriately with stimulants and support services have lower levels of substance use and probably higher self-esteem. Ensure they have the best treatment possible for their ADHD to minimize their substance use risk as much as possible.

As they become young teenagers, they should have a full review of all their ADHD treatment and how their typical day plays out at school and at home. Consider some additional preventative counseling to help these children face their substance use challenges throughout adolescence.

Offer such guidance to all children and parents, but especially to those in one of these high-risk groups. Suggest strategies that support and reinforce their resiliency. A warm, positive relationship with an adult is a protective factor. Also, kids who feel connected to a school, church, or sports team tend to be a little more resilient to some of these influences.

Facilitate open, honest communication between the parent and adolescent. Many parents might not realize that this is more effective than are attempts to control their teen's behavior 24/7. Over-control is impossible given the lifestyle of most 15-, 16- or 17-year-olds. Between cell phones, cars, and the amount of time they are out of the house, parents cannot control them to a level of stopping all substance use.

Even if more control is possible, the effort works against the adolescent's developmental trajectory toward increasing autonomy. The real goal of adolescence in our culture is to learn how to live in the real world and to prepare for autonomy as young adults. High school is a preparation for college life and adulthood where good judgment, safety, and socialization are important learned behaviors. Teaching adolescents how to navigate all this is an essential role for physicians and parents.

Part of growing autonomy is privacy. While it is tempting to invade that privacy to learn about substance use or to clarify other concerns, it is not clear that such efforts support the long-term goals of raising a teenager. Such efforts at control and investigation, including blood or urine testing, are best reserved when the benefits outweigh the risks, when there is a substance abuse problem that needs to be addressed.

www.CHADIS.com[email protected]

“The preschool just called for the second time about Jason's behavior! What can I do?” This plea to you the pediatrician makes your stomach turn upside down. “What am I supposed to do about that?” you ask yourself. You're not there to see what is happening, and the parent isn't either.

This scenario is made even more difficult because the parents can be desperate for advice and quick solutions. It is incredibly inconvenient when a child is thrown out of child care or preschool for bad behavior, especially for parents who both work. Parents may even get hysterical because they immediately envision their darling failing to get into Harvard based on an inability to interact properly in preschool.

The differential diagnosis of this complaint takes some good sleuthing, but can make a big difference in the life of a young child.

Young children deal with social interaction issues that also confront grown-ups, but without the skills to navigate and manage them.

Learning social skills is a major benefit of preschool and kindergarten, particularly for children with few siblings or siblings of much different ages. The poem “All I Need to Know I Learned in Kindergarten” describes many of these social benefits, including learning to share, take turns, act kindly, and use manners. The poem does not mention some of the other less poetic skills developed at this age, however: learning how to tease successfully, pull your punches, stand tall when there is a bully, bounce back when people insult you or after you wet your pants, tell if someone is a real friend, and deal with a critical teacher who is screaming all the time.

Young children normally practice a social interaction known as “inclusion/exclusion,” where one day they say, “Oh, you're my best friend. Let's go have our secret club.” But the next day they say, “You're not my friend anymore. I've got a new best friend. You can't play with me.” In general, the best short- and long-term outcomes occur when children work out minor interaction problems on their own, with a little teacher support, but serious problems are handled privately by the adults.

Ask for specific information about one of the incidents from both the child and the parent. If a child comes home from school and says, “This kid called me names,” parents can ask, “What kind of names?” to distinguish normal teasing from a toxic environment that needs to be changed. Abnormal teasing is more vicious and adultlike, for example, a peer calling the child a “whore” or using a racial epithet.

Don't forget to suggest ways to pump up resilience such as getting sufficient sleep and proper nutrition.

Next, assess the child with problematic peer behavior for skill deficits. A child with a gap may act up to distract others from noticing, out of frustration or as result of discrimination the child experiences. Often children this age who are aggressive have shortcomings in language. They may speak a different language at home or still communicate only in two- or three-word phrases, and therefore are unable to keep up with others and feel – or actually are – left out. They don't have the repartee to negotiate social situations and can become the victim of taunting and teasing, a specialty of girls.

Children with gross motor skill deficits, particularly boys, also may experience difficulty keeping up with their peers. In some cases, they are rejected by the group for being unable to kick a soccer ball or to climb a jungle gym as well as others can, and they are angry as a result.

Check fine motor skills as well. A child with poor coordination may be slow to finish work and/or be ashamed of what they do produce. Children can be very self-critical at this age and even tear up their papers. If the teacher asks everyone to draw a truck, and another student pointedly says, 'That doesn't look like a truck,” the child might punch in return. The child is acting up in frustration.

While children at this age are just on the edge of acquiring “perspective taking” (considering another's point of view), in the most severe form, difficulty in doing this can be a sign of autism spectrum disorder. Peers quickly pick up on this and may tease them, call them names, and/or reject their awkward attempts to engage. Try telling them a joke or asking them to tell one, and you may see why.

You can help by addressing any detected skill deficits with language therapy or physical therapy. Importantly, suggest ways to build their skills while allowing them to bypass social humiliation. Let children who are not athletic skip recess, assigning them the task of getting out the snacks to avoid further humiliation. Then work on their motor skills through after-school karate instead.

Anxiety can spark aggression, too. If you are afraid, it seems better to strike first. If anxiety seems key, the parents and school will need to soften their handling of the child and help him or her put feelings into words to assist the child in not acting out.

Since some children will misbehave to get a teacher's attention, recommend that the parents drop in unannounced. Often the way a classroom appears (or is staffed) at 8 a.m. drop-off time is not the same way it operates at 10:30 a.m. Suggest a parent watch the part of the day their child complains about the most, which is frequently recess.

Even though there are bad situations and bad schools, most schools have great teachers and other professionals from whom parents can gain valuable information and advice.

Generally teachers can explain the timing of a child's troubles, for example, during circle time he cannot sit still or during craft time because his fine motor skills are not well developed. Having parents seek out these examples is the most efficient way to identify deficits in need of help.

Suggest parents speak to their child empathically instead of giving instructions. In this culture, boys especially are told to “keep a stiff upper lip” or “be a big soldier.” A better approach is to say, “Yes, it's tough when kids talk to you like that” or “I understand this really makes you sad and you feel like crying.”

It also helps when parents share a similar experience from their own childhood. For example, parents can say, “You know, when I was your age, I had an experience like this – I had a kid who was always on my case.”

Parents can promote social development as well. For example, role playing can clearly help a child develop appropriate socioemotional skills. Parents can use this strategy either before an incident – for example, to rehearse how a child might react to a bully in class – or afterward, to help the child determine what he or she might have said or done differently and prepare for the next time. Use of social stories can foster these skills (see www.socialstories.com

Parents who experienced a bad peer interaction as a preschooler or kindergartener may project their concerns on their child who may be doing just fine. The parents might be supersensitive to teasing, for example, and bring an otherwise minor incident to your attention and/or become overintrusive at school. Asking, “How was it for you when you were little? Did you ever run into anything like this?” may bring out past experiences as an important factor predisposing to overreaction. If they wet their pants in kindergarten and never got over it, realizing this connection makes it possible for them to back off and let the school and child handle the current problem.

Watch for red flags or warning signs that problematic behaviors are not within the range of normal stress. The child initially doing well at school who suddenly does not want to return is one example.

Sadly, you need to always consider whether there is abuse going on at school, including sexual abuse. Sudden adjustment problems at home, such as trouble sleeping, nightmares, or bed-wetting, also should raise your level of concern.

Also ask parents if their preschooler suddenly became more difficult to manage at home. Some children who experience negative peer interactions will cling to parents, but oppositional or defiant behavior is more common. Of course, 4-year-old children are notoriously brassy, so you cannot consider back talk a warning sign unless it is part of a sudden change in the normal flow of the child's behavior.

A child this stressed over school may need to be cared for at home or moved to a family day care situation

Unfortunately, the modern practice of grouping of kids of the same age together in a classroom increases the likelihood of interactions going badly. Ten 2-year-old children are not necessarily capable of peacefully spending hours together at a time. When a serious behavioral problem arises in this kind of setting, I frequently recommend family-based day care instead of center-based day care because children will be with others of different ages and different skill levels, and hopefully some of them will be more mature.

Support parents in deciding to pull the child out of a school if the situation is bad. If, for example, the school administration is unresponsive to or dismissive of a parent, removal of the child may be the best option. A new parent recently came to the parent group at our clinic. She reported that a teacher responded to her child's behavior problem by putting him in a closet, which would have been egregious enough, but the teacher also said that there were spiders and bugs in the closet that were going to get him before closing the door. I was flabbergasted. The school tried to defend the teacher for doing this, and my final advice was to “pull the kid.” Any school that ignorant of normal child development cannot be fixed.

www.CHADIS.com[email protected]

“The preschool just called for the second time about Jason's behavior! What can I do?” This plea to you the pediatrician makes your stomach turn upside down. “What am I supposed to do about that?” you ask yourself. You're not there to see what is happening, and the parent isn't either.

This scenario is made even more difficult because the parents can be desperate for advice and quick solutions. It is incredibly inconvenient when a child is thrown out of child care or preschool for bad behavior, especially for parents who both work. Parents may even get hysterical because they immediately envision their darling failing to get into Harvard based on an inability to interact properly in preschool.

The differential diagnosis of this complaint takes some good sleuthing, but can make a big difference in the life of a young child.

Young children deal with social interaction issues that also confront grown-ups, but without the skills to navigate and manage them.

Learning social skills is a major benefit of preschool and kindergarten, particularly for children with few siblings or siblings of much different ages. The poem “All I Need to Know I Learned in Kindergarten” describes many of these social benefits, including learning to share, take turns, act kindly, and use manners. The poem does not mention some of the other less poetic skills developed at this age, however: learning how to tease successfully, pull your punches, stand tall when there is a bully, bounce back when people insult you or after you wet your pants, tell if someone is a real friend, and deal with a critical teacher who is screaming all the time.

Young children normally practice a social interaction known as “inclusion/exclusion,” where one day they say, “Oh, you're my best friend. Let's go have our secret club.” But the next day they say, “You're not my friend anymore. I've got a new best friend. You can't play with me.” In general, the best short- and long-term outcomes occur when children work out minor interaction problems on their own, with a little teacher support, but serious problems are handled privately by the adults.

Ask for specific information about one of the incidents from both the child and the parent. If a child comes home from school and says, “This kid called me names,” parents can ask, “What kind of names?” to distinguish normal teasing from a toxic environment that needs to be changed. Abnormal teasing is more vicious and adultlike, for example, a peer calling the child a “whore” or using a racial epithet.

Don't forget to suggest ways to pump up resilience such as getting sufficient sleep and proper nutrition.

Next, assess the child with problematic peer behavior for skill deficits. A child with a gap may act up to distract others from noticing, out of frustration or as result of discrimination the child experiences. Often children this age who are aggressive have shortcomings in language. They may speak a different language at home or still communicate only in two- or three-word phrases, and therefore are unable to keep up with others and feel – or actually are – left out. They don't have the repartee to negotiate social situations and can become the victim of taunting and teasing, a specialty of girls.

Children with gross motor skill deficits, particularly boys, also may experience difficulty keeping up with their peers. In some cases, they are rejected by the group for being unable to kick a soccer ball or to climb a jungle gym as well as others can, and they are angry as a result.

Check fine motor skills as well. A child with poor coordination may be slow to finish work and/or be ashamed of what they do produce. Children can be very self-critical at this age and even tear up their papers. If the teacher asks everyone to draw a truck, and another student pointedly says, 'That doesn't look like a truck,” the child might punch in return. The child is acting up in frustration.

While children at this age are just on the edge of acquiring “perspective taking” (considering another's point of view), in the most severe form, difficulty in doing this can be a sign of autism spectrum disorder. Peers quickly pick up on this and may tease them, call them names, and/or reject their awkward attempts to engage. Try telling them a joke or asking them to tell one, and you may see why.

You can help by addressing any detected skill deficits with language therapy or physical therapy. Importantly, suggest ways to build their skills while allowing them to bypass social humiliation. Let children who are not athletic skip recess, assigning them the task of getting out the snacks to avoid further humiliation. Then work on their motor skills through after-school karate instead.

Anxiety can spark aggression, too. If you are afraid, it seems better to strike first. If anxiety seems key, the parents and school will need to soften their handling of the child and help him or her put feelings into words to assist the child in not acting out.

Since some children will misbehave to get a teacher's attention, recommend that the parents drop in unannounced. Often the way a classroom appears (or is staffed) at 8 a.m. drop-off time is not the same way it operates at 10:30 a.m. Suggest a parent watch the part of the day their child complains about the most, which is frequently recess.

Even though there are bad situations and bad schools, most schools have great teachers and other professionals from whom parents can gain valuable information and advice.

Generally teachers can explain the timing of a child's troubles, for example, during circle time he cannot sit still or during craft time because his fine motor skills are not well developed. Having parents seek out these examples is the most efficient way to identify deficits in need of help.

Suggest parents speak to their child empathically instead of giving instructions. In this culture, boys especially are told to “keep a stiff upper lip” or “be a big soldier.” A better approach is to say, “Yes, it's tough when kids talk to you like that” or “I understand this really makes you sad and you feel like crying.”

It also helps when parents share a similar experience from their own childhood. For example, parents can say, “You know, when I was your age, I had an experience like this – I had a kid who was always on my case.”

Parents can promote social development as well. For example, role playing can clearly help a child develop appropriate socioemotional skills. Parents can use this strategy either before an incident – for example, to rehearse how a child might react to a bully in class – or afterward, to help the child determine what he or she might have said or done differently and prepare for the next time. Use of social stories can foster these skills (see www.socialstories.com

Parents who experienced a bad peer interaction as a preschooler or kindergartener may project their concerns on their child who may be doing just fine. The parents might be supersensitive to teasing, for example, and bring an otherwise minor incident to your attention and/or become overintrusive at school. Asking, “How was it for you when you were little? Did you ever run into anything like this?” may bring out past experiences as an important factor predisposing to overreaction. If they wet their pants in kindergarten and never got over it, realizing this connection makes it possible for them to back off and let the school and child handle the current problem.

Watch for red flags or warning signs that problematic behaviors are not within the range of normal stress. The child initially doing well at school who suddenly does not want to return is one example.

Sadly, you need to always consider whether there is abuse going on at school, including sexual abuse. Sudden adjustment problems at home, such as trouble sleeping, nightmares, or bed-wetting, also should raise your level of concern.

Also ask parents if their preschooler suddenly became more difficult to manage at home. Some children who experience negative peer interactions will cling to parents, but oppositional or defiant behavior is more common. Of course, 4-year-old children are notoriously brassy, so you cannot consider back talk a warning sign unless it is part of a sudden change in the normal flow of the child's behavior.

A child this stressed over school may need to be cared for at home or moved to a family day care situation

Unfortunately, the modern practice of grouping of kids of the same age together in a classroom increases the likelihood of interactions going badly. Ten 2-year-old children are not necessarily capable of peacefully spending hours together at a time. When a serious behavioral problem arises in this kind of setting, I frequently recommend family-based day care instead of center-based day care because children will be with others of different ages and different skill levels, and hopefully some of them will be more mature.

Support parents in deciding to pull the child out of a school if the situation is bad. If, for example, the school administration is unresponsive to or dismissive of a parent, removal of the child may be the best option. A new parent recently came to the parent group at our clinic. She reported that a teacher responded to her child's behavior problem by putting him in a closet, which would have been egregious enough, but the teacher also said that there were spiders and bugs in the closet that were going to get him before closing the door. I was flabbergasted. The school tried to defend the teacher for doing this, and my final advice was to “pull the kid.” Any school that ignorant of normal child development cannot be fixed.

www.CHADIS.com[email protected]

“The preschool just called for the second time about Jason's behavior! What can I do?” This plea to you the pediatrician makes your stomach turn upside down. “What am I supposed to do about that?” you ask yourself. You're not there to see what is happening, and the parent isn't either.

This scenario is made even more difficult because the parents can be desperate for advice and quick solutions. It is incredibly inconvenient when a child is thrown out of child care or preschool for bad behavior, especially for parents who both work. Parents may even get hysterical because they immediately envision their darling failing to get into Harvard based on an inability to interact properly in preschool.

The differential diagnosis of this complaint takes some good sleuthing, but can make a big difference in the life of a young child.

Young children deal with social interaction issues that also confront grown-ups, but without the skills to navigate and manage them.

Learning social skills is a major benefit of preschool and kindergarten, particularly for children with few siblings or siblings of much different ages. The poem “All I Need to Know I Learned in Kindergarten” describes many of these social benefits, including learning to share, take turns, act kindly, and use manners. The poem does not mention some of the other less poetic skills developed at this age, however: learning how to tease successfully, pull your punches, stand tall when there is a bully, bounce back when people insult you or after you wet your pants, tell if someone is a real friend, and deal with a critical teacher who is screaming all the time.

Young children normally practice a social interaction known as “inclusion/exclusion,” where one day they say, “Oh, you're my best friend. Let's go have our secret club.” But the next day they say, “You're not my friend anymore. I've got a new best friend. You can't play with me.” In general, the best short- and long-term outcomes occur when children work out minor interaction problems on their own, with a little teacher support, but serious problems are handled privately by the adults.

Ask for specific information about one of the incidents from both the child and the parent. If a child comes home from school and says, “This kid called me names,” parents can ask, “What kind of names?” to distinguish normal teasing from a toxic environment that needs to be changed. Abnormal teasing is more vicious and adultlike, for example, a peer calling the child a “whore” or using a racial epithet.

Don't forget to suggest ways to pump up resilience such as getting sufficient sleep and proper nutrition.

Next, assess the child with problematic peer behavior for skill deficits. A child with a gap may act up to distract others from noticing, out of frustration or as result of discrimination the child experiences. Often children this age who are aggressive have shortcomings in language. They may speak a different language at home or still communicate only in two- or three-word phrases, and therefore are unable to keep up with others and feel – or actually are – left out. They don't have the repartee to negotiate social situations and can become the victim of taunting and teasing, a specialty of girls.

Children with gross motor skill deficits, particularly boys, also may experience difficulty keeping up with their peers. In some cases, they are rejected by the group for being unable to kick a soccer ball or to climb a jungle gym as well as others can, and they are angry as a result.

Check fine motor skills as well. A child with poor coordination may be slow to finish work and/or be ashamed of what they do produce. Children can be very self-critical at this age and even tear up their papers. If the teacher asks everyone to draw a truck, and another student pointedly says, 'That doesn't look like a truck,” the child might punch in return. The child is acting up in frustration.

While children at this age are just on the edge of acquiring “perspective taking” (considering another's point of view), in the most severe form, difficulty in doing this can be a sign of autism spectrum disorder. Peers quickly pick up on this and may tease them, call them names, and/or reject their awkward attempts to engage. Try telling them a joke or asking them to tell one, and you may see why.

You can help by addressing any detected skill deficits with language therapy or physical therapy. Importantly, suggest ways to build their skills while allowing them to bypass social humiliation. Let children who are not athletic skip recess, assigning them the task of getting out the snacks to avoid further humiliation. Then work on their motor skills through after-school karate instead.

Anxiety can spark aggression, too. If you are afraid, it seems better to strike first. If anxiety seems key, the parents and school will need to soften their handling of the child and help him or her put feelings into words to assist the child in not acting out.

Since some children will misbehave to get a teacher's attention, recommend that the parents drop in unannounced. Often the way a classroom appears (or is staffed) at 8 a.m. drop-off time is not the same way it operates at 10:30 a.m. Suggest a parent watch the part of the day their child complains about the most, which is frequently recess.

Even though there are bad situations and bad schools, most schools have great teachers and other professionals from whom parents can gain valuable information and advice.

Generally teachers can explain the timing of a child's troubles, for example, during circle time he cannot sit still or during craft time because his fine motor skills are not well developed. Having parents seek out these examples is the most efficient way to identify deficits in need of help.

Suggest parents speak to their child empathically instead of giving instructions. In this culture, boys especially are told to “keep a stiff upper lip” or “be a big soldier.” A better approach is to say, “Yes, it's tough when kids talk to you like that” or “I understand this really makes you sad and you feel like crying.”

It also helps when parents share a similar experience from their own childhood. For example, parents can say, “You know, when I was your age, I had an experience like this – I had a kid who was always on my case.”

Parents can promote social development as well. For example, role playing can clearly help a child develop appropriate socioemotional skills. Parents can use this strategy either before an incident – for example, to rehearse how a child might react to a bully in class – or afterward, to help the child determine what he or she might have said or done differently and prepare for the next time. Use of social stories can foster these skills (see www.socialstories.com

Parents who experienced a bad peer interaction as a preschooler or kindergartener may project their concerns on their child who may be doing just fine. The parents might be supersensitive to teasing, for example, and bring an otherwise minor incident to your attention and/or become overintrusive at school. Asking, “How was it for you when you were little? Did you ever run into anything like this?” may bring out past experiences as an important factor predisposing to overreaction. If they wet their pants in kindergarten and never got over it, realizing this connection makes it possible for them to back off and let the school and child handle the current problem.

Watch for red flags or warning signs that problematic behaviors are not within the range of normal stress. The child initially doing well at school who suddenly does not want to return is one example.

Sadly, you need to always consider whether there is abuse going on at school, including sexual abuse. Sudden adjustment problems at home, such as trouble sleeping, nightmares, or bed-wetting, also should raise your level of concern.

Also ask parents if their preschooler suddenly became more difficult to manage at home. Some children who experience negative peer interactions will cling to parents, but oppositional or defiant behavior is more common. Of course, 4-year-old children are notoriously brassy, so you cannot consider back talk a warning sign unless it is part of a sudden change in the normal flow of the child's behavior.

A child this stressed over school may need to be cared for at home or moved to a family day care situation

Unfortunately, the modern practice of grouping of kids of the same age together in a classroom increases the likelihood of interactions going badly. Ten 2-year-old children are not necessarily capable of peacefully spending hours together at a time. When a serious behavioral problem arises in this kind of setting, I frequently recommend family-based day care instead of center-based day care because children will be with others of different ages and different skill levels, and hopefully some of them will be more mature.

Support parents in deciding to pull the child out of a school if the situation is bad. If, for example, the school administration is unresponsive to or dismissive of a parent, removal of the child may be the best option. A new parent recently came to the parent group at our clinic. She reported that a teacher responded to her child's behavior problem by putting him in a closet, which would have been egregious enough, but the teacher also said that there were spiders and bugs in the closet that were going to get him before closing the door. I was flabbergasted. The school tried to defend the teacher for doing this, and my final advice was to “pull the kid.” Any school that ignorant of normal child development cannot be fixed.