Behavioral Consult

Seeking novelty is central to adolescence; experimentation is how they explore their identity, exert independence, and establish deep and connected relationships outside of the family. Research over the past 2 decades has demonstrated the neurobiological changes that underpin this increase in sensation seeking. Most adolescents are very good at assessing risk but are willing to tolerate higher levels of risk than adults in the pursuit of novelty.¹ If their knowledge base is limited or inaccurate, as is often the case with drugs and alcohol, accepting higher risk becomes more dangerous. Adolescents are more likely to trust their peers than their parents, but their pediatricians still have authority and credibility.

While there is ample credible information online (from the National Institute on Drug Abuse and the Substance Abuse and Mental Health Services Administration’s excellent websites, which can be recommended to teens), marijuana and hallucinogens (LSD and psilocybin) bear special discussion here because of changing legality and their potential medical utility. There is an emerging impression of safety with both; however, policy changes and for-profit marketing may not reflect the actual scientific evidence. You have the opportunity and authority to complicate your patient’s thinking by discussing the evidence supporting their medical utility, and the emerging evidence that both types of drugs may pose special risks for their developing brains.

By June 2021, marijuana was legal for recreational use in 19 states; Washington, D.C.; and Guam, and for “medical use” in 36 states and four territories. Entrepreneurs and activists have made spectacular claims that marijuana is effective for the treatment of everything from insomnia to PTSD, but the reality is less impressive. Of course, marijuana remains a schedule I drug under the federal Controlled Substances Act (1970), which has made it difficult for researchers to perform randomized controlled studies concerning treatment or risks.

However, there are a growing number of randomized controlled trials with synthetic cannabinoids (dronabinol and nabilone) and a (legal) drug derived from cannabis (cannabidiol or CBD, as distinct from the other active ingredient, tetrahydrocannabinol). There is Food and Drug Administration approval for CBD for the treatment of epilepsy in Lennox-Gastaut or Dravet syndrome in patients aged 2 years or younger, and for the synthetic agents for the treatment of chemotherapy-related nausea and vomiting in cancer patients and for the treatment of weight loss and muscle wasting related to HIV/AIDS. That’s it. There is some evidence that these agents may be effective for the treatment of muscle spasticity in multiple sclerosis, chronic pain of many etiologies, Tourette syndrome, insomnia related to multiple sclerosis and chronic pain, and possibly PTSD. But there have been multiple studies that have failed to demonstrate efficacy (or have demonstrated exacerbation) for a host of other medical and psychiatric problems.

While the evidence for marijuana’s medicinal uses is modest, there is substantial evidence that its use in adolescence carries risks. It is an addictive substance and regular use is associated with sustained modest cognitive impairment (a loss of up to eight IQ points in the clinically dependent) and higher rates of anxiety and depressive disorders. As with other substances, use before the age of 18 substantially raises the risk (as much as sevenfold) of developing addiction than the same rate of use in adulthood. The rate of schizophrenia in adolescents with heavy marijuana use is between six and seven times greater than in the general population, whereas similar adult use does not have this association.^2,3 Studies in rats have demonstrated that use during adolescence delays and permanently changes the maturation of the prefrontal cortex, an area of the brain that is essential for complex decision-making, sustaining attention, abstract reasoning, and impulse control.⁴ While we do not fully understand the exact nature of these changes, there is good reason to believe that regular marijuana use in adolescence leads to disruption of critical brain development and cognitive or even psychotic consequences. It is worth noting that the potency of many commercially available marijuana products is much higher than those that were studied, raising the risk and uncertainty further.

Hallucinogens, or “psychedelics” (from Greek for “mind manifesting”) are a class that includes LSD and psilocybin (a chemical found in over 200 species of mushrooms). They precipitate visual and auditory “hallucinations,” a loss of sense of self, and a sense of awe that may be transcendent or frightening. While psilocybin was used by many indigenous cultures in religious ceremonies, LSD was synthesized by a chemist at Sandoz in 1938 and made widely available for study until it was classified as a schedule I drug by the 1970 Controlled Substances Act. They are not addictive. Early research demonstrated promise in the treatment of alcohol dependence and several psychiatric conditions (including other addictions and treatment-resistant depression). Research resumed in 2018, demonstrating promise in the treatment of depression related to terminal illness. Research has also concerned the nature of consciousness and spiritual experiences. Hallucinogens have become popular in certain fields (high tech) as a means of optimizing creativity and performance (“microdosing”). There is modest evidence that use in people with a family history of psychotic illness may precipitate sustained psychotic symptoms. Regular use may further increase the risk of persistent psychosis and adolescent users of multiple substances are at high risk for regular hallucinogen use. Adolescents may think that ketamine, phencyclidine , and 3,4-methylenedioxymethamphetamine are also in this category, although they are different and considerably more risky drugs. Overall, these agents show therapeutic promise, but unless your young patients are facing depression related to a terminal illness and until we learn more from studies, the potential risk to their developing brains outweighs any potential benefits.

Aware of this information, you are ready to ask your adolescent patients about their drug and alcohol use and knowledge. Using phrases like “when did you first try ...” can increase the likelihood that your patients will be forthright with you. Or start by asking about what their friends are trying and talking about. Be curious about any drug and alcohol use at home. Find out what they are curious about, whom they trust, and where they get their information. Then you can offer your information about the dramatic changes happening in their brains (just like the rest of their bodies) and the special risks of drug use during this window of brain development. Acknowledge that the risks of marijuana use in adults may very well be lower than the risks of regular alcohol use but remind them about how their brains are different than those of adults. Delaying use until they are 18 (or ideally in their mid-20s when most brain development is complete), can dramatically lower these risks. For adolescents with a family history of addiction, psychosis, or mood and anxiety disorders, discuss the additional risks that drugs may present to them. And for those adolescents who acknowledge very early (before 13) or heavy use, be curious with them about whether they might be trying to “feel better” and not just “feel good.” Screen them for depression, suicidality, and anxiety disorders. Those underlying problems are treatable, but their course will only worsen with drug and alcohol use. You are in a unique position to help your adolescent patients make wise and well-informed choices and to get them assistance if they need it.

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

References

1. Romer D. Dev Psychobiol. 2010 Apr;52(3):263-76.

2. Szczepanski SM and Knight TR. Neuron. 2014;83:1002-18.

3. Renard J et al. Front Psychiatry. 2018;9:281.

4. Shen H. Proc Natl Acad Sci U S A. 2020 Jan 7;117(1):7-11.

Seeking novelty is central to adolescence; experimentation is how they explore their identity, exert independence, and establish deep and connected relationships outside of the family. Research over the past 2 decades has demonstrated the neurobiological changes that underpin this increase in sensation seeking. Most adolescents are very good at assessing risk but are willing to tolerate higher levels of risk than adults in the pursuit of novelty.¹ If their knowledge base is limited or inaccurate, as is often the case with drugs and alcohol, accepting higher risk becomes more dangerous. Adolescents are more likely to trust their peers than their parents, but their pediatricians still have authority and credibility.

While there is ample credible information online (from the National Institute on Drug Abuse and the Substance Abuse and Mental Health Services Administration’s excellent websites, which can be recommended to teens), marijuana and hallucinogens (LSD and psilocybin) bear special discussion here because of changing legality and their potential medical utility. There is an emerging impression of safety with both; however, policy changes and for-profit marketing may not reflect the actual scientific evidence. You have the opportunity and authority to complicate your patient’s thinking by discussing the evidence supporting their medical utility, and the emerging evidence that both types of drugs may pose special risks for their developing brains.

By June 2021, marijuana was legal for recreational use in 19 states; Washington, D.C.; and Guam, and for “medical use” in 36 states and four territories. Entrepreneurs and activists have made spectacular claims that marijuana is effective for the treatment of everything from insomnia to PTSD, but the reality is less impressive. Of course, marijuana remains a schedule I drug under the federal Controlled Substances Act (1970), which has made it difficult for researchers to perform randomized controlled studies concerning treatment or risks.

However, there are a growing number of randomized controlled trials with synthetic cannabinoids (dronabinol and nabilone) and a (legal) drug derived from cannabis (cannabidiol or CBD, as distinct from the other active ingredient, tetrahydrocannabinol). There is Food and Drug Administration approval for CBD for the treatment of epilepsy in Lennox-Gastaut or Dravet syndrome in patients aged 2 years or younger, and for the synthetic agents for the treatment of chemotherapy-related nausea and vomiting in cancer patients and for the treatment of weight loss and muscle wasting related to HIV/AIDS. That’s it. There is some evidence that these agents may be effective for the treatment of muscle spasticity in multiple sclerosis, chronic pain of many etiologies, Tourette syndrome, insomnia related to multiple sclerosis and chronic pain, and possibly PTSD. But there have been multiple studies that have failed to demonstrate efficacy (or have demonstrated exacerbation) for a host of other medical and psychiatric problems.

While the evidence for marijuana’s medicinal uses is modest, there is substantial evidence that its use in adolescence carries risks. It is an addictive substance and regular use is associated with sustained modest cognitive impairment (a loss of up to eight IQ points in the clinically dependent) and higher rates of anxiety and depressive disorders. As with other substances, use before the age of 18 substantially raises the risk (as much as sevenfold) of developing addiction than the same rate of use in adulthood. The rate of schizophrenia in adolescents with heavy marijuana use is between six and seven times greater than in the general population, whereas similar adult use does not have this association.^2,3 Studies in rats have demonstrated that use during adolescence delays and permanently changes the maturation of the prefrontal cortex, an area of the brain that is essential for complex decision-making, sustaining attention, abstract reasoning, and impulse control.⁴ While we do not fully understand the exact nature of these changes, there is good reason to believe that regular marijuana use in adolescence leads to disruption of critical brain development and cognitive or even psychotic consequences. It is worth noting that the potency of many commercially available marijuana products is much higher than those that were studied, raising the risk and uncertainty further.

Hallucinogens, or “psychedelics” (from Greek for “mind manifesting”) are a class that includes LSD and psilocybin (a chemical found in over 200 species of mushrooms). They precipitate visual and auditory “hallucinations,” a loss of sense of self, and a sense of awe that may be transcendent or frightening. While psilocybin was used by many indigenous cultures in religious ceremonies, LSD was synthesized by a chemist at Sandoz in 1938 and made widely available for study until it was classified as a schedule I drug by the 1970 Controlled Substances Act. They are not addictive. Early research demonstrated promise in the treatment of alcohol dependence and several psychiatric conditions (including other addictions and treatment-resistant depression). Research resumed in 2018, demonstrating promise in the treatment of depression related to terminal illness. Research has also concerned the nature of consciousness and spiritual experiences. Hallucinogens have become popular in certain fields (high tech) as a means of optimizing creativity and performance (“microdosing”). There is modest evidence that use in people with a family history of psychotic illness may precipitate sustained psychotic symptoms. Regular use may further increase the risk of persistent psychosis and adolescent users of multiple substances are at high risk for regular hallucinogen use. Adolescents may think that ketamine, phencyclidine , and 3,4-methylenedioxymethamphetamine are also in this category, although they are different and considerably more risky drugs. Overall, these agents show therapeutic promise, but unless your young patients are facing depression related to a terminal illness and until we learn more from studies, the potential risk to their developing brains outweighs any potential benefits.

Aware of this information, you are ready to ask your adolescent patients about their drug and alcohol use and knowledge. Using phrases like “when did you first try ...” can increase the likelihood that your patients will be forthright with you. Or start by asking about what their friends are trying and talking about. Be curious about any drug and alcohol use at home. Find out what they are curious about, whom they trust, and where they get their information. Then you can offer your information about the dramatic changes happening in their brains (just like the rest of their bodies) and the special risks of drug use during this window of brain development. Acknowledge that the risks of marijuana use in adults may very well be lower than the risks of regular alcohol use but remind them about how their brains are different than those of adults. Delaying use until they are 18 (or ideally in their mid-20s when most brain development is complete), can dramatically lower these risks. For adolescents with a family history of addiction, psychosis, or mood and anxiety disorders, discuss the additional risks that drugs may present to them. And for those adolescents who acknowledge very early (before 13) or heavy use, be curious with them about whether they might be trying to “feel better” and not just “feel good.” Screen them for depression, suicidality, and anxiety disorders. Those underlying problems are treatable, but their course will only worsen with drug and alcohol use. You are in a unique position to help your adolescent patients make wise and well-informed choices and to get them assistance if they need it.

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

References

1. Romer D. Dev Psychobiol. 2010 Apr;52(3):263-76.

2. Szczepanski SM and Knight TR. Neuron. 2014;83:1002-18.

3. Renard J et al. Front Psychiatry. 2018;9:281.

4. Shen H. Proc Natl Acad Sci U S A. 2020 Jan 7;117(1):7-11.

Seeking novelty is central to adolescence; experimentation is how they explore their identity, exert independence, and establish deep and connected relationships outside of the family. Research over the past 2 decades has demonstrated the neurobiological changes that underpin this increase in sensation seeking. Most adolescents are very good at assessing risk but are willing to tolerate higher levels of risk than adults in the pursuit of novelty.¹ If their knowledge base is limited or inaccurate, as is often the case with drugs and alcohol, accepting higher risk becomes more dangerous. Adolescents are more likely to trust their peers than their parents, but their pediatricians still have authority and credibility.

While there is ample credible information online (from the National Institute on Drug Abuse and the Substance Abuse and Mental Health Services Administration’s excellent websites, which can be recommended to teens), marijuana and hallucinogens (LSD and psilocybin) bear special discussion here because of changing legality and their potential medical utility. There is an emerging impression of safety with both; however, policy changes and for-profit marketing may not reflect the actual scientific evidence. You have the opportunity and authority to complicate your patient’s thinking by discussing the evidence supporting their medical utility, and the emerging evidence that both types of drugs may pose special risks for their developing brains.

By June 2021, marijuana was legal for recreational use in 19 states; Washington, D.C.; and Guam, and for “medical use” in 36 states and four territories. Entrepreneurs and activists have made spectacular claims that marijuana is effective for the treatment of everything from insomnia to PTSD, but the reality is less impressive. Of course, marijuana remains a schedule I drug under the federal Controlled Substances Act (1970), which has made it difficult for researchers to perform randomized controlled studies concerning treatment or risks.

However, there are a growing number of randomized controlled trials with synthetic cannabinoids (dronabinol and nabilone) and a (legal) drug derived from cannabis (cannabidiol or CBD, as distinct from the other active ingredient, tetrahydrocannabinol). There is Food and Drug Administration approval for CBD for the treatment of epilepsy in Lennox-Gastaut or Dravet syndrome in patients aged 2 years or younger, and for the synthetic agents for the treatment of chemotherapy-related nausea and vomiting in cancer patients and for the treatment of weight loss and muscle wasting related to HIV/AIDS. That’s it. There is some evidence that these agents may be effective for the treatment of muscle spasticity in multiple sclerosis, chronic pain of many etiologies, Tourette syndrome, insomnia related to multiple sclerosis and chronic pain, and possibly PTSD. But there have been multiple studies that have failed to demonstrate efficacy (or have demonstrated exacerbation) for a host of other medical and psychiatric problems.

While the evidence for marijuana’s medicinal uses is modest, there is substantial evidence that its use in adolescence carries risks. It is an addictive substance and regular use is associated with sustained modest cognitive impairment (a loss of up to eight IQ points in the clinically dependent) and higher rates of anxiety and depressive disorders. As with other substances, use before the age of 18 substantially raises the risk (as much as sevenfold) of developing addiction than the same rate of use in adulthood. The rate of schizophrenia in adolescents with heavy marijuana use is between six and seven times greater than in the general population, whereas similar adult use does not have this association.^2,3 Studies in rats have demonstrated that use during adolescence delays and permanently changes the maturation of the prefrontal cortex, an area of the brain that is essential for complex decision-making, sustaining attention, abstract reasoning, and impulse control.⁴ While we do not fully understand the exact nature of these changes, there is good reason to believe that regular marijuana use in adolescence leads to disruption of critical brain development and cognitive or even psychotic consequences. It is worth noting that the potency of many commercially available marijuana products is much higher than those that were studied, raising the risk and uncertainty further.

Hallucinogens, or “psychedelics” (from Greek for “mind manifesting”) are a class that includes LSD and psilocybin (a chemical found in over 200 species of mushrooms). They precipitate visual and auditory “hallucinations,” a loss of sense of self, and a sense of awe that may be transcendent or frightening. While psilocybin was used by many indigenous cultures in religious ceremonies, LSD was synthesized by a chemist at Sandoz in 1938 and made widely available for study until it was classified as a schedule I drug by the 1970 Controlled Substances Act. They are not addictive. Early research demonstrated promise in the treatment of alcohol dependence and several psychiatric conditions (including other addictions and treatment-resistant depression). Research resumed in 2018, demonstrating promise in the treatment of depression related to terminal illness. Research has also concerned the nature of consciousness and spiritual experiences. Hallucinogens have become popular in certain fields (high tech) as a means of optimizing creativity and performance (“microdosing”). There is modest evidence that use in people with a family history of psychotic illness may precipitate sustained psychotic symptoms. Regular use may further increase the risk of persistent psychosis and adolescent users of multiple substances are at high risk for regular hallucinogen use. Adolescents may think that ketamine, phencyclidine , and 3,4-methylenedioxymethamphetamine are also in this category, although they are different and considerably more risky drugs. Overall, these agents show therapeutic promise, but unless your young patients are facing depression related to a terminal illness and until we learn more from studies, the potential risk to their developing brains outweighs any potential benefits.

Aware of this information, you are ready to ask your adolescent patients about their drug and alcohol use and knowledge. Using phrases like “when did you first try ...” can increase the likelihood that your patients will be forthright with you. Or start by asking about what their friends are trying and talking about. Be curious about any drug and alcohol use at home. Find out what they are curious about, whom they trust, and where they get their information. Then you can offer your information about the dramatic changes happening in their brains (just like the rest of their bodies) and the special risks of drug use during this window of brain development. Acknowledge that the risks of marijuana use in adults may very well be lower than the risks of regular alcohol use but remind them about how their brains are different than those of adults. Delaying use until they are 18 (or ideally in their mid-20s when most brain development is complete), can dramatically lower these risks. For adolescents with a family history of addiction, psychosis, or mood and anxiety disorders, discuss the additional risks that drugs may present to them. And for those adolescents who acknowledge very early (before 13) or heavy use, be curious with them about whether they might be trying to “feel better” and not just “feel good.” Screen them for depression, suicidality, and anxiety disorders. Those underlying problems are treatable, but their course will only worsen with drug and alcohol use. You are in a unique position to help your adolescent patients make wise and well-informed choices and to get them assistance if they need it.

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

References

1. Romer D. Dev Psychobiol. 2010 Apr;52(3):263-76.

2. Szczepanski SM and Knight TR. Neuron. 2014;83:1002-18.

3. Renard J et al. Front Psychiatry. 2018;9:281.

4. Shen H. Proc Natl Acad Sci U S A. 2020 Jan 7;117(1):7-11.

Wishful thinking. “Repeated involuntary passage of stool in the underwear after the acquisition of toileting skills (typically > 4 years of age) in the absence of overt neuromuscular anorectal dysfunction,” formerly called encopresis, certainly still exists, renamed functional fecal incontinence (FFI). You have surely cared for many children with FFI over the years, mostly the 80% retentive (constipated) type but newer information may make your management more successful!

The first step in managing FFI is detecting it. This may seem easy as we get a whiff of its presence, even if the child and parents are unaware because of habituation to the odor. Children lose sensation from rectal dilation by the stool mass and become unaware of leakage. But they also are ashamed of and deny “accidents,” hide soiled underwear, and keep distance from parents and peers. Our physical exam may reveal an abdominal mass or perianal stool. While there, check the anal wink, anus placement, lower spine integrity, and ankle reflexes for rare neurological causes. A rectal exam is not required if the story fits but, if not, may show a dilated rectal vault and hard mass. Blood work, x-ray, ultrasound, barium enemas, or manometry are rarely indicated.

Instead of counting on expressed concern, we should routinely ask children about large, painful, or infrequent poops. There are even Rome IV criteria for constipation – at least two of the following without organic pathology and with duration of at least 1 month: less than 2 defecations/week, a history of hard or painful stools, retentive posturing or excessive stool retention, large stools blocking the toilet, large rectal fecal mass, or at least 1 episode of incontinence/week. Our history should request this but parents are often unaware of their child’s patterns except for that blocked toilet!

Other actionable history includes struggles over toilet training, early anal fissure or painful stools, a history of “straining”, crying, or crossing legs (attempts to withhold), short stature and/or diarrhea (possible celiac disease), abdominal pain, poor appetite, or a diet high in milk products or low in fiber. Family history may suggest rare organic causes such as hypothyroidism, Hirschsprung disease, multiple endocrine neoplasia type 2, or celiac disease, but also constipation (in 55%). After the newborn period (imperforate anus or meconium ileus), 95% of constipation is functional.

While constipation has a worldwide prevalence of 9.5%, low exercise and low-fiber diet are particularly American. Low total food intake as a cause is uncommon in the United States but another reason to screen for food insecurity.

Patterns of behavior can predispose to constipation and FFI. For the child, oppositionality, social anxiety, depression, or eating disorders may interfere with sufficient stool frequency and relaxation needed to fully evacuate at home, daycare, or school. Query every child with ADHD about stool patterns as inattention to urge plus impatience with completing defection (and ODD) are common disorders leading to FFI. Parents who are overly demanding, intrusive, rushing, irritable, anxious, or obsessive may also make routine toileting stressful. When caregivers are neglectful, fail to maintain routines for eating, or ignore dirty diapers, toilet training is more likely to fail and constipation ensue.

Clean out and maintenance using medication are needed for FFI, but child and family behavior change are also critical; the combination has proven more successful. Both the child and parents need clear a explanation of how constipation develops from withholding, regardless of the reason (pain, anxiety, conflict, diet), leading to larger stools more difficult to pass as water is absorbed in the colon. The large mass stretches the bowel so that sensation and strength for motility is impaired and softer stool leaks by and out the rectum unbeknownst to the child. I find drawing “the rock of poop” in a dilated thin walled colon with nerves sparse and “liquid stool sneaking by” compared to a “muscular” colon with soft poop animates and objectifies this explanation. Making it clear that leaking is involuntary is key to having the parent and child directly forgive each other for prior anger, blaming, sneaking, or punishment. While the school-aged child needs to be in charge of toileting, resolving the conflict is essential.

The critical next step is cleaning out “the rocks,” which should only rarely be omitted. Polyethylene glycol (PEG, for example, Miralax) has the best evidence, tastes better (without electrolytes), and dosing 1-1.5 g/kg per day premixed in 10 mL/kg fluid of the child’s choice kept cold and swallowed within 30 minutes daily for 3-6 days until feces have no more chunks. This process disimpacts 95% of the time. Reassure parents of the long-term safety despite the warning on the label that it is intended for adult users. Lactulose or sorbitol (1 mL/kg, once or twice daily), magnesium hydroxide, bisacodyl, or senna are long second choices. Only if these fail should mineral oil 15-30 mL per year of age, up to 240 mL per day be used and then not in infants or if there is aspiration risk. While enemas (mineral oil, sodium phosphate, or saline) and p.o. PEG are equally effective, enemas are very intrusive and unnecessary. There is insufficient evidence for probiotics, prebiotics, or synbiotics.

It is crucial to be honest with the child and parents that clean out can be uncomfortable as cramping or leaking may occur. Thus, starting PEG after school on Friday and being prepared to stay home Monday (if rocks are still emerging) may be needed to avoid accidents.

After clean out, maintenance using daily PEG 0.4-0.8 g/kg per day (best) or lactulose needs to be continued for 2-6 or even 12 months to prevent relapse as the bowel recovers. Bowels need to produce 1-2 soft stools per day for 1 month before considering weaning off PEG. High-fiber (age of child plus 5-10 g/day) diet perpetually is more acceptable if we suggest Frosted Mini-Wheats, Fig Newtons, cookies or muffins baked with wheat bran, popcorn, or fruits with “p” in the name (for example, prunes, pears, apricots), Raisin Bran, or methylcellulose in juice or Popsicles, wafers (with jelly or frosting), or tablets. Infant diet can include brown sugar, or prune/apple/pear juice (Karo is no longer reliably osmotic). Diet needs to include 32-64 ounces of nonmilk fluids, although this will not serve as treatment alone. Limit cow milk to 16 oz. or consider eliminating it entirely if other treatments fail as cow milk is constipating.

Maintenance also requires coaching the child to commence “exercises” to “strengthen the bowel.” These consist of sitting with feet supported to elevate at the hip for 10 minutes by a timer after meals 2-3 times per day and pushing. Entertainment such as music, books, small toys, or a noncompetitive video game and/or rewards of cash, tokens, or treats may lighten the routine. These “exercises” need to be continued indefinitely and monitored with a stool diary. Monthly check-ins are essential to adherence and success, especially in the first 3-4 months, to address any relapses.

While constipation has consequences besides FFI: physical (abdominal pain, anal fissure, rectal prolapse, enuresis, UTI, vesicoureteral reflux, and upper urinary tract dilatation, poor appetite, or poor growth), emotional problems (lability, depression, anxiety, aggression, and low self-esteem), social problems (peer humiliation, teasing, rejection, parent upset, anger, shaming, and punishment), and school absence, we can be supportive and effective coaches for this chronic condition.

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

Wishful thinking. “Repeated involuntary passage of stool in the underwear after the acquisition of toileting skills (typically > 4 years of age) in the absence of overt neuromuscular anorectal dysfunction,” formerly called encopresis, certainly still exists, renamed functional fecal incontinence (FFI). You have surely cared for many children with FFI over the years, mostly the 80% retentive (constipated) type but newer information may make your management more successful!

The first step in managing FFI is detecting it. This may seem easy as we get a whiff of its presence, even if the child and parents are unaware because of habituation to the odor. Children lose sensation from rectal dilation by the stool mass and become unaware of leakage. But they also are ashamed of and deny “accidents,” hide soiled underwear, and keep distance from parents and peers. Our physical exam may reveal an abdominal mass or perianal stool. While there, check the anal wink, anus placement, lower spine integrity, and ankle reflexes for rare neurological causes. A rectal exam is not required if the story fits but, if not, may show a dilated rectal vault and hard mass. Blood work, x-ray, ultrasound, barium enemas, or manometry are rarely indicated.

Instead of counting on expressed concern, we should routinely ask children about large, painful, or infrequent poops. There are even Rome IV criteria for constipation – at least two of the following without organic pathology and with duration of at least 1 month: less than 2 defecations/week, a history of hard or painful stools, retentive posturing or excessive stool retention, large stools blocking the toilet, large rectal fecal mass, or at least 1 episode of incontinence/week. Our history should request this but parents are often unaware of their child’s patterns except for that blocked toilet!

Other actionable history includes struggles over toilet training, early anal fissure or painful stools, a history of “straining”, crying, or crossing legs (attempts to withhold), short stature and/or diarrhea (possible celiac disease), abdominal pain, poor appetite, or a diet high in milk products or low in fiber. Family history may suggest rare organic causes such as hypothyroidism, Hirschsprung disease, multiple endocrine neoplasia type 2, or celiac disease, but also constipation (in 55%). After the newborn period (imperforate anus or meconium ileus), 95% of constipation is functional.

While constipation has a worldwide prevalence of 9.5%, low exercise and low-fiber diet are particularly American. Low total food intake as a cause is uncommon in the United States but another reason to screen for food insecurity.

Patterns of behavior can predispose to constipation and FFI. For the child, oppositionality, social anxiety, depression, or eating disorders may interfere with sufficient stool frequency and relaxation needed to fully evacuate at home, daycare, or school. Query every child with ADHD about stool patterns as inattention to urge plus impatience with completing defection (and ODD) are common disorders leading to FFI. Parents who are overly demanding, intrusive, rushing, irritable, anxious, or obsessive may also make routine toileting stressful. When caregivers are neglectful, fail to maintain routines for eating, or ignore dirty diapers, toilet training is more likely to fail and constipation ensue.

Clean out and maintenance using medication are needed for FFI, but child and family behavior change are also critical; the combination has proven more successful. Both the child and parents need clear a explanation of how constipation develops from withholding, regardless of the reason (pain, anxiety, conflict, diet), leading to larger stools more difficult to pass as water is absorbed in the colon. The large mass stretches the bowel so that sensation and strength for motility is impaired and softer stool leaks by and out the rectum unbeknownst to the child. I find drawing “the rock of poop” in a dilated thin walled colon with nerves sparse and “liquid stool sneaking by” compared to a “muscular” colon with soft poop animates and objectifies this explanation. Making it clear that leaking is involuntary is key to having the parent and child directly forgive each other for prior anger, blaming, sneaking, or punishment. While the school-aged child needs to be in charge of toileting, resolving the conflict is essential.

The critical next step is cleaning out “the rocks,” which should only rarely be omitted. Polyethylene glycol (PEG, for example, Miralax) has the best evidence, tastes better (without electrolytes), and dosing 1-1.5 g/kg per day premixed in 10 mL/kg fluid of the child’s choice kept cold and swallowed within 30 minutes daily for 3-6 days until feces have no more chunks. This process disimpacts 95% of the time. Reassure parents of the long-term safety despite the warning on the label that it is intended for adult users. Lactulose or sorbitol (1 mL/kg, once or twice daily), magnesium hydroxide, bisacodyl, or senna are long second choices. Only if these fail should mineral oil 15-30 mL per year of age, up to 240 mL per day be used and then not in infants or if there is aspiration risk. While enemas (mineral oil, sodium phosphate, or saline) and p.o. PEG are equally effective, enemas are very intrusive and unnecessary. There is insufficient evidence for probiotics, prebiotics, or synbiotics.

It is crucial to be honest with the child and parents that clean out can be uncomfortable as cramping or leaking may occur. Thus, starting PEG after school on Friday and being prepared to stay home Monday (if rocks are still emerging) may be needed to avoid accidents.

After clean out, maintenance using daily PEG 0.4-0.8 g/kg per day (best) or lactulose needs to be continued for 2-6 or even 12 months to prevent relapse as the bowel recovers. Bowels need to produce 1-2 soft stools per day for 1 month before considering weaning off PEG. High-fiber (age of child plus 5-10 g/day) diet perpetually is more acceptable if we suggest Frosted Mini-Wheats, Fig Newtons, cookies or muffins baked with wheat bran, popcorn, or fruits with “p” in the name (for example, prunes, pears, apricots), Raisin Bran, or methylcellulose in juice or Popsicles, wafers (with jelly or frosting), or tablets. Infant diet can include brown sugar, or prune/apple/pear juice (Karo is no longer reliably osmotic). Diet needs to include 32-64 ounces of nonmilk fluids, although this will not serve as treatment alone. Limit cow milk to 16 oz. or consider eliminating it entirely if other treatments fail as cow milk is constipating.

Maintenance also requires coaching the child to commence “exercises” to “strengthen the bowel.” These consist of sitting with feet supported to elevate at the hip for 10 minutes by a timer after meals 2-3 times per day and pushing. Entertainment such as music, books, small toys, or a noncompetitive video game and/or rewards of cash, tokens, or treats may lighten the routine. These “exercises” need to be continued indefinitely and monitored with a stool diary. Monthly check-ins are essential to adherence and success, especially in the first 3-4 months, to address any relapses.

While constipation has consequences besides FFI: physical (abdominal pain, anal fissure, rectal prolapse, enuresis, UTI, vesicoureteral reflux, and upper urinary tract dilatation, poor appetite, or poor growth), emotional problems (lability, depression, anxiety, aggression, and low self-esteem), social problems (peer humiliation, teasing, rejection, parent upset, anger, shaming, and punishment), and school absence, we can be supportive and effective coaches for this chronic condition.

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

Wishful thinking. “Repeated involuntary passage of stool in the underwear after the acquisition of toileting skills (typically > 4 years of age) in the absence of overt neuromuscular anorectal dysfunction,” formerly called encopresis, certainly still exists, renamed functional fecal incontinence (FFI). You have surely cared for many children with FFI over the years, mostly the 80% retentive (constipated) type but newer information may make your management more successful!

The first step in managing FFI is detecting it. This may seem easy as we get a whiff of its presence, even if the child and parents are unaware because of habituation to the odor. Children lose sensation from rectal dilation by the stool mass and become unaware of leakage. But they also are ashamed of and deny “accidents,” hide soiled underwear, and keep distance from parents and peers. Our physical exam may reveal an abdominal mass or perianal stool. While there, check the anal wink, anus placement, lower spine integrity, and ankle reflexes for rare neurological causes. A rectal exam is not required if the story fits but, if not, may show a dilated rectal vault and hard mass. Blood work, x-ray, ultrasound, barium enemas, or manometry are rarely indicated.

Instead of counting on expressed concern, we should routinely ask children about large, painful, or infrequent poops. There are even Rome IV criteria for constipation – at least two of the following without organic pathology and with duration of at least 1 month: less than 2 defecations/week, a history of hard or painful stools, retentive posturing or excessive stool retention, large stools blocking the toilet, large rectal fecal mass, or at least 1 episode of incontinence/week. Our history should request this but parents are often unaware of their child’s patterns except for that blocked toilet!

Other actionable history includes struggles over toilet training, early anal fissure or painful stools, a history of “straining”, crying, or crossing legs (attempts to withhold), short stature and/or diarrhea (possible celiac disease), abdominal pain, poor appetite, or a diet high in milk products or low in fiber. Family history may suggest rare organic causes such as hypothyroidism, Hirschsprung disease, multiple endocrine neoplasia type 2, or celiac disease, but also constipation (in 55%). After the newborn period (imperforate anus or meconium ileus), 95% of constipation is functional.

While constipation has a worldwide prevalence of 9.5%, low exercise and low-fiber diet are particularly American. Low total food intake as a cause is uncommon in the United States but another reason to screen for food insecurity.

Patterns of behavior can predispose to constipation and FFI. For the child, oppositionality, social anxiety, depression, or eating disorders may interfere with sufficient stool frequency and relaxation needed to fully evacuate at home, daycare, or school. Query every child with ADHD about stool patterns as inattention to urge plus impatience with completing defection (and ODD) are common disorders leading to FFI. Parents who are overly demanding, intrusive, rushing, irritable, anxious, or obsessive may also make routine toileting stressful. When caregivers are neglectful, fail to maintain routines for eating, or ignore dirty diapers, toilet training is more likely to fail and constipation ensue.

Clean out and maintenance using medication are needed for FFI, but child and family behavior change are also critical; the combination has proven more successful. Both the child and parents need clear a explanation of how constipation develops from withholding, regardless of the reason (pain, anxiety, conflict, diet), leading to larger stools more difficult to pass as water is absorbed in the colon. The large mass stretches the bowel so that sensation and strength for motility is impaired and softer stool leaks by and out the rectum unbeknownst to the child. I find drawing “the rock of poop” in a dilated thin walled colon with nerves sparse and “liquid stool sneaking by” compared to a “muscular” colon with soft poop animates and objectifies this explanation. Making it clear that leaking is involuntary is key to having the parent and child directly forgive each other for prior anger, blaming, sneaking, or punishment. While the school-aged child needs to be in charge of toileting, resolving the conflict is essential.

The critical next step is cleaning out “the rocks,” which should only rarely be omitted. Polyethylene glycol (PEG, for example, Miralax) has the best evidence, tastes better (without electrolytes), and dosing 1-1.5 g/kg per day premixed in 10 mL/kg fluid of the child’s choice kept cold and swallowed within 30 minutes daily for 3-6 days until feces have no more chunks. This process disimpacts 95% of the time. Reassure parents of the long-term safety despite the warning on the label that it is intended for adult users. Lactulose or sorbitol (1 mL/kg, once or twice daily), magnesium hydroxide, bisacodyl, or senna are long second choices. Only if these fail should mineral oil 15-30 mL per year of age, up to 240 mL per day be used and then not in infants or if there is aspiration risk. While enemas (mineral oil, sodium phosphate, or saline) and p.o. PEG are equally effective, enemas are very intrusive and unnecessary. There is insufficient evidence for probiotics, prebiotics, or synbiotics.

It is crucial to be honest with the child and parents that clean out can be uncomfortable as cramping or leaking may occur. Thus, starting PEG after school on Friday and being prepared to stay home Monday (if rocks are still emerging) may be needed to avoid accidents.

After clean out, maintenance using daily PEG 0.4-0.8 g/kg per day (best) or lactulose needs to be continued for 2-6 or even 12 months to prevent relapse as the bowel recovers. Bowels need to produce 1-2 soft stools per day for 1 month before considering weaning off PEG. High-fiber (age of child plus 5-10 g/day) diet perpetually is more acceptable if we suggest Frosted Mini-Wheats, Fig Newtons, cookies or muffins baked with wheat bran, popcorn, or fruits with “p” in the name (for example, prunes, pears, apricots), Raisin Bran, or methylcellulose in juice or Popsicles, wafers (with jelly or frosting), or tablets. Infant diet can include brown sugar, or prune/apple/pear juice (Karo is no longer reliably osmotic). Diet needs to include 32-64 ounces of nonmilk fluids, although this will not serve as treatment alone. Limit cow milk to 16 oz. or consider eliminating it entirely if other treatments fail as cow milk is constipating.

Maintenance also requires coaching the child to commence “exercises” to “strengthen the bowel.” These consist of sitting with feet supported to elevate at the hip for 10 minutes by a timer after meals 2-3 times per day and pushing. Entertainment such as music, books, small toys, or a noncompetitive video game and/or rewards of cash, tokens, or treats may lighten the routine. These “exercises” need to be continued indefinitely and monitored with a stool diary. Monthly check-ins are essential to adherence and success, especially in the first 3-4 months, to address any relapses.

While constipation has consequences besides FFI: physical (abdominal pain, anal fissure, rectal prolapse, enuresis, UTI, vesicoureteral reflux, and upper urinary tract dilatation, poor appetite, or poor growth), emotional problems (lability, depression, anxiety, aggression, and low self-esteem), social problems (peer humiliation, teasing, rejection, parent upset, anger, shaming, and punishment), and school absence, we can be supportive and effective coaches for this chronic condition.

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

As your patients return to your offices for annual exams and sports physicals before the school year starts, everyone will still be processing the challenges, losses, and grief that have marked end of the COVID experience. There will be questions about the safety of vaccines for younger children, whether foreign travel is now a reasonable option, and about how best to help children – school age and teenagers, vulnerable and secure – get their footing socially and academically in the new school year. But dig a little, and you may hear about the silver linings of this past year: children who enjoyed having more time with their parents, parents who were with their families rather than in a car commuting for hours a day or traveling many days a month, grocery deliveries that eased the parent’s workload, adolescents who were able to pull back from overscheduled days, and opportunities for calm conversations that occurred quite naturally during nightly family dinners. Office visits present a dual opportunity to review – what were the psychological costs of COVID and what were positive personal and family adaptations to COVID they may want to continue as the pandemic ends?

Family dinner: Whether because sports practice was suspended, schooling was virtual, or working was at home, many families returned to eating dinner together during the pandemic year. Nightly dinners are a simple but powerful routine allowing all members of a family to reconnect and recharge together, and they are often the first things to disappear in the face of school, sports, and work demands. Research over the past several decades has demonstrated that regular family dinners are associated with better academic performance and higher self-esteem in children. They are also associated with lower rates of depression, substance abuse, eating disorders, and pregnancy in adolescents. Finally, they are associated with better cardiovascular health and lower rates of obesity in both youth and parents. The response is dose dependent, with more regular dinners leading to better outcomes. The food can be simple, what matters most is that the tone is warm, sharing, and curious, not rigid and controlling. Families can be an essential source of support as they help put events and feelings into context, giving them meaning or a framework based on the parents’ past, values, or perspective and on the family’s cultural history. Everyone benefits as family members cope with small and large setbacks, share values, and celebrate one another’s small and large successes. The return of the family dinner table, as often as is reasonable, is one “consequence” of COVID that families should try to preserve.

Consistent virtual family visits: Many families managed the cancellation of holiday visits or supported elderly relatives by connecting with family virtually. For some families, a weekly Zoom call came to function like a weekly family dinner with cousins and grandparents. Not only do these regular video calls protect elderly relatives from loneliness and isolation, but they also made it very easy for extended families to stay connected. Children cannot have too many caring adults around them, and regular calls mean that aunts, uncles, and grandparents can be an enthusiastic audience for their achievements and can offer perspective and guidance when needed. Staying connected without having to manage hours of travel makes it easy to build and maintain these family connections, creating bonds that will be deeper and stronger. Like family dinner, regular virtual gatherings with extended family are unequivocally beneficial for younger and older children and a valuable legacy of COVID.

Lowering the pressure: Many children struggled to stay engaged with virtual school and deeply missed time with friends or in activities like woodshop, soccer, or theater. But many other children had a chance to slow down from a relentless schedule of school, homework, sports, clubs, music lessons, tutoring, and on and on. For these children, many of whom are intensely ambitious and were not willing to voluntarily give up any activities, the forced slowdown of COVID has offered a new perspective on how they might manage their time. The COVID slowdown shone a light on the value of spending enough time in an activity to really learn it, and then choosing which activities to continue to explore and master, while opening time to explore new activities. There was also more time for “senseless fun,” activities that do not lead to achievement or recognition, but are simply fun, e.g., playing video games, splashing in a pool, or surfing the web. This process is critical to healthy development in early and later adolescence, and for many driven teenagers, it has been replaced by a tightly packed schedule of activities they felt they “should” be doing. If these young people hear from you that not only does the COVID pace feel better, but it can also contribute to better health and more meaningful learning and engagement, they may adopt a more thoughtful and intentional approach to managing their most precious asset – their time. Your discussion about prioritizing healthy exercise, virtual visits with friends, hobbies, or even senseless fun might reset the pressure gauge from high to moderate.

Homework help: Many children (and teenagers) found that their parents became an important source of academic support during the year of virtual school. While few parents welcomed the chance to master calculus, it is powerful for parents to know what their children are facing at school and for children to know that their parents are available to help them when they face a challenge. When parents can bear uncertainty, frustration, and even failure alongside their children, they help their children to cultivate tenacity and resilience, whether or not they can help them with a chemistry problem. Some parents will have special skills like knowing a language, being a good writer, or an academic expertise related to their work. But what matters more is working out how to help, not pressure or argue – how to share knowledge in a pleasurable manner. While it is important for children to have access to teachers and tutors with the knowledge and skills to help them learn specific subjects, the positive presence and involvement of their parents can make a valuable contribution to their psychological and educational development.

New ritual: Over the past 16 months, families found many creative ways to pass time together, from evening walks to reading aloud, listening to music, and even mastering new card games. The family evenings of a century earlier, when family members listened together to radio programs, practiced music, or played board games, seemed to have returned. While everyone could still escape to their own space to be on a screen activity alone, solitary computer time was leavened by collective time. Families may have rediscovered joy in shared recreation, exploration, or diversion. This kind of family time is a reward in itself, but it also deepens a child’s connections to everyone in their family. Such time provides lessons in how to turn boredom into something meaningful and even fun. COVID forced families inward and gave them more time. There were many costs including illness, deaths of friends and relatives, loss of time with peers, missed activities and milestones, and an impaired education. However, many of the coerced adaptations had a silver lining or unanticipated benefit. Keeping some of those benefits post COVID could enhance the lives of every member of the family.

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

As your patients return to your offices for annual exams and sports physicals before the school year starts, everyone will still be processing the challenges, losses, and grief that have marked end of the COVID experience. There will be questions about the safety of vaccines for younger children, whether foreign travel is now a reasonable option, and about how best to help children – school age and teenagers, vulnerable and secure – get their footing socially and academically in the new school year. But dig a little, and you may hear about the silver linings of this past year: children who enjoyed having more time with their parents, parents who were with their families rather than in a car commuting for hours a day or traveling many days a month, grocery deliveries that eased the parent’s workload, adolescents who were able to pull back from overscheduled days, and opportunities for calm conversations that occurred quite naturally during nightly family dinners. Office visits present a dual opportunity to review – what were the psychological costs of COVID and what were positive personal and family adaptations to COVID they may want to continue as the pandemic ends?

Family dinner: Whether because sports practice was suspended, schooling was virtual, or working was at home, many families returned to eating dinner together during the pandemic year. Nightly dinners are a simple but powerful routine allowing all members of a family to reconnect and recharge together, and they are often the first things to disappear in the face of school, sports, and work demands. Research over the past several decades has demonstrated that regular family dinners are associated with better academic performance and higher self-esteem in children. They are also associated with lower rates of depression, substance abuse, eating disorders, and pregnancy in adolescents. Finally, they are associated with better cardiovascular health and lower rates of obesity in both youth and parents. The response is dose dependent, with more regular dinners leading to better outcomes. The food can be simple, what matters most is that the tone is warm, sharing, and curious, not rigid and controlling. Families can be an essential source of support as they help put events and feelings into context, giving them meaning or a framework based on the parents’ past, values, or perspective and on the family’s cultural history. Everyone benefits as family members cope with small and large setbacks, share values, and celebrate one another’s small and large successes. The return of the family dinner table, as often as is reasonable, is one “consequence” of COVID that families should try to preserve.

Consistent virtual family visits: Many families managed the cancellation of holiday visits or supported elderly relatives by connecting with family virtually. For some families, a weekly Zoom call came to function like a weekly family dinner with cousins and grandparents. Not only do these regular video calls protect elderly relatives from loneliness and isolation, but they also made it very easy for extended families to stay connected. Children cannot have too many caring adults around them, and regular calls mean that aunts, uncles, and grandparents can be an enthusiastic audience for their achievements and can offer perspective and guidance when needed. Staying connected without having to manage hours of travel makes it easy to build and maintain these family connections, creating bonds that will be deeper and stronger. Like family dinner, regular virtual gatherings with extended family are unequivocally beneficial for younger and older children and a valuable legacy of COVID.

Lowering the pressure: Many children struggled to stay engaged with virtual school and deeply missed time with friends or in activities like woodshop, soccer, or theater. But many other children had a chance to slow down from a relentless schedule of school, homework, sports, clubs, music lessons, tutoring, and on and on. For these children, many of whom are intensely ambitious and were not willing to voluntarily give up any activities, the forced slowdown of COVID has offered a new perspective on how they might manage their time. The COVID slowdown shone a light on the value of spending enough time in an activity to really learn it, and then choosing which activities to continue to explore and master, while opening time to explore new activities. There was also more time for “senseless fun,” activities that do not lead to achievement or recognition, but are simply fun, e.g., playing video games, splashing in a pool, or surfing the web. This process is critical to healthy development in early and later adolescence, and for many driven teenagers, it has been replaced by a tightly packed schedule of activities they felt they “should” be doing. If these young people hear from you that not only does the COVID pace feel better, but it can also contribute to better health and more meaningful learning and engagement, they may adopt a more thoughtful and intentional approach to managing their most precious asset – their time. Your discussion about prioritizing healthy exercise, virtual visits with friends, hobbies, or even senseless fun might reset the pressure gauge from high to moderate.

Homework help: Many children (and teenagers) found that their parents became an important source of academic support during the year of virtual school. While few parents welcomed the chance to master calculus, it is powerful for parents to know what their children are facing at school and for children to know that their parents are available to help them when they face a challenge. When parents can bear uncertainty, frustration, and even failure alongside their children, they help their children to cultivate tenacity and resilience, whether or not they can help them with a chemistry problem. Some parents will have special skills like knowing a language, being a good writer, or an academic expertise related to their work. But what matters more is working out how to help, not pressure or argue – how to share knowledge in a pleasurable manner. While it is important for children to have access to teachers and tutors with the knowledge and skills to help them learn specific subjects, the positive presence and involvement of their parents can make a valuable contribution to their psychological and educational development.

New ritual: Over the past 16 months, families found many creative ways to pass time together, from evening walks to reading aloud, listening to music, and even mastering new card games. The family evenings of a century earlier, when family members listened together to radio programs, practiced music, or played board games, seemed to have returned. While everyone could still escape to their own space to be on a screen activity alone, solitary computer time was leavened by collective time. Families may have rediscovered joy in shared recreation, exploration, or diversion. This kind of family time is a reward in itself, but it also deepens a child’s connections to everyone in their family. Such time provides lessons in how to turn boredom into something meaningful and even fun. COVID forced families inward and gave them more time. There were many costs including illness, deaths of friends and relatives, loss of time with peers, missed activities and milestones, and an impaired education. However, many of the coerced adaptations had a silver lining or unanticipated benefit. Keeping some of those benefits post COVID could enhance the lives of every member of the family.

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

As your patients return to your offices for annual exams and sports physicals before the school year starts, everyone will still be processing the challenges, losses, and grief that have marked end of the COVID experience. There will be questions about the safety of vaccines for younger children, whether foreign travel is now a reasonable option, and about how best to help children – school age and teenagers, vulnerable and secure – get their footing socially and academically in the new school year. But dig a little, and you may hear about the silver linings of this past year: children who enjoyed having more time with their parents, parents who were with their families rather than in a car commuting for hours a day or traveling many days a month, grocery deliveries that eased the parent’s workload, adolescents who were able to pull back from overscheduled days, and opportunities for calm conversations that occurred quite naturally during nightly family dinners. Office visits present a dual opportunity to review – what were the psychological costs of COVID and what were positive personal and family adaptations to COVID they may want to continue as the pandemic ends?

Family dinner: Whether because sports practice was suspended, schooling was virtual, or working was at home, many families returned to eating dinner together during the pandemic year. Nightly dinners are a simple but powerful routine allowing all members of a family to reconnect and recharge together, and they are often the first things to disappear in the face of school, sports, and work demands. Research over the past several decades has demonstrated that regular family dinners are associated with better academic performance and higher self-esteem in children. They are also associated with lower rates of depression, substance abuse, eating disorders, and pregnancy in adolescents. Finally, they are associated with better cardiovascular health and lower rates of obesity in both youth and parents. The response is dose dependent, with more regular dinners leading to better outcomes. The food can be simple, what matters most is that the tone is warm, sharing, and curious, not rigid and controlling. Families can be an essential source of support as they help put events and feelings into context, giving them meaning or a framework based on the parents’ past, values, or perspective and on the family’s cultural history. Everyone benefits as family members cope with small and large setbacks, share values, and celebrate one another’s small and large successes. The return of the family dinner table, as often as is reasonable, is one “consequence” of COVID that families should try to preserve.

Consistent virtual family visits: Many families managed the cancellation of holiday visits or supported elderly relatives by connecting with family virtually. For some families, a weekly Zoom call came to function like a weekly family dinner with cousins and grandparents. Not only do these regular video calls protect elderly relatives from loneliness and isolation, but they also made it very easy for extended families to stay connected. Children cannot have too many caring adults around them, and regular calls mean that aunts, uncles, and grandparents can be an enthusiastic audience for their achievements and can offer perspective and guidance when needed. Staying connected without having to manage hours of travel makes it easy to build and maintain these family connections, creating bonds that will be deeper and stronger. Like family dinner, regular virtual gatherings with extended family are unequivocally beneficial for younger and older children and a valuable legacy of COVID.

Lowering the pressure: Many children struggled to stay engaged with virtual school and deeply missed time with friends or in activities like woodshop, soccer, or theater. But many other children had a chance to slow down from a relentless schedule of school, homework, sports, clubs, music lessons, tutoring, and on and on. For these children, many of whom are intensely ambitious and were not willing to voluntarily give up any activities, the forced slowdown of COVID has offered a new perspective on how they might manage their time. The COVID slowdown shone a light on the value of spending enough time in an activity to really learn it, and then choosing which activities to continue to explore and master, while opening time to explore new activities. There was also more time for “senseless fun,” activities that do not lead to achievement or recognition, but are simply fun, e.g., playing video games, splashing in a pool, or surfing the web. This process is critical to healthy development in early and later adolescence, and for many driven teenagers, it has been replaced by a tightly packed schedule of activities they felt they “should” be doing. If these young people hear from you that not only does the COVID pace feel better, but it can also contribute to better health and more meaningful learning and engagement, they may adopt a more thoughtful and intentional approach to managing their most precious asset – their time. Your discussion about prioritizing healthy exercise, virtual visits with friends, hobbies, or even senseless fun might reset the pressure gauge from high to moderate.

Homework help: Many children (and teenagers) found that their parents became an important source of academic support during the year of virtual school. While few parents welcomed the chance to master calculus, it is powerful for parents to know what their children are facing at school and for children to know that their parents are available to help them when they face a challenge. When parents can bear uncertainty, frustration, and even failure alongside their children, they help their children to cultivate tenacity and resilience, whether or not they can help them with a chemistry problem. Some parents will have special skills like knowing a language, being a good writer, or an academic expertise related to their work. But what matters more is working out how to help, not pressure or argue – how to share knowledge in a pleasurable manner. While it is important for children to have access to teachers and tutors with the knowledge and skills to help them learn specific subjects, the positive presence and involvement of their parents can make a valuable contribution to their psychological and educational development.

New ritual: Over the past 16 months, families found many creative ways to pass time together, from evening walks to reading aloud, listening to music, and even mastering new card games. The family evenings of a century earlier, when family members listened together to radio programs, practiced music, or played board games, seemed to have returned. While everyone could still escape to their own space to be on a screen activity alone, solitary computer time was leavened by collective time. Families may have rediscovered joy in shared recreation, exploration, or diversion. This kind of family time is a reward in itself, but it also deepens a child’s connections to everyone in their family. Such time provides lessons in how to turn boredom into something meaningful and even fun. COVID forced families inward and gave them more time. There were many costs including illness, deaths of friends and relatives, loss of time with peers, missed activities and milestones, and an impaired education. However, many of the coerced adaptations had a silver lining or unanticipated benefit. Keeping some of those benefits post COVID could enhance the lives of every member of the family.

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

The news is portraying our modern time as an existential crisis as though our very existence is threatened. An existential crisis is a profound feeling of lack of meaning, choice, or freedom in one’s life that makes even existing seem worthless. It can emerge as early as 5 years old, especially in introspective, gifted children, when they realize that death is permanent and universal, after a real loss or a story of a loss or failure, or from a sense of guilt.

The past 18 months of COVID-19 have been a perfect storm for developing an existential crisis. One of the main sources of life meaning for children is friendships. COVID-19 has reduced or blocked access to old and new friends. Younger children, when asked what makes a friend, will say “we like to do the same things.” Virtual play dates help but don’t replace shared experiences.

School provides meaning for children not only from socializing but also from accomplishing academic tasks – fulfilling Erickson’s stages of “mastery” and “productivity.” Teachers were better able to carry out hands-on activities, group assignments, and field trips in person so that all children and learning styles were engaged and successful. Not having in-person school has also meant loss of extracurricular activities, sports, and clubs as sources of mastery.

Loss of the structure of daily life, common during COVID-19, for waking, dressing, meals, chores, homework time, bathing, or bedtime can be profoundly disorienting.

For adolescents, opportunities to contribute to society and become productive by volunteering or being employed have been stunted by quarantine and social distancing. Some teens have had to care for relatives at home so that parents can earn a living, which, while meaningful, blocks age-essential socializing.

Meaning can also be created at any age by community structures and agreed upon beliefs such as religion. While religious membership is low in the United States, members have been largely unable to attend services. Following sports teams, an alternate “religion” and source of identity, was on hold for many months.

Existential despair can also come from major life losses. COVID-19 has taken a terrible toll of lives, homes, and jobs for millions. As short-term thinkers, when children see so many of their plans and dreams for making the team, having a girlfriend, going to prom, attending summer camp, or graduating, it feels like the end of the world they had imagined. Even the most important source of meaning – connection to family – has been disrupted by lockdown, illness, or loss.

The loss of choice and freedom goes beyond being stuck indoors. Advanced classes and exams, as well as resume-building jobs or volunteering, which teens saw as essential to college, disappeared; sometimes also the money needed was exhausted by COVID-19 unemployment. Work-at-home parents supervising virtual school see their children’s malaise or panic and pressure them to work harder, which is impossible for despairing children. Observing a parent losing his or her job makes a teen’s own career aspirations uncertain. Teen depression and suicidal ideation/acts have shot up from hopelessness, with loss of meaning at the core.

A profound sense of powerlessness has taken over. COVID-19, an invisible threat, has taken down lives. Even with amazingly effective vaccines available, fear and helplessness have burned into our brains. Helplessness to stop structural racism and the arbitrary killings of our own Black citizens by police has finally registered. And climate change is now reported as an impending disaster that may not be stoppable.

So this must be the worst time in history, right? Actually, no. The past 60 years have been a period of historically remarkable stability of government, economy, and natural forces. Perhaps knowing no other world has made these problems appear unsolvable to the parents of our patients. Their own sense of meaning has been challenged in a way similar to that of their children. Perhaps from lack of privacy or peers, parents have been sharing their own sense of powerlessness with their children directly or indirectly, making it harder to reassure them.

With COVID-19 waning in the United States, many of the sources of meaning just discussed can be reinstated by way of in-person play dates, school, sports, socializing, practicing religion, volunteering, and getting jobs. Although there is “existential therapy,” what our children need most is adult leadership showing confidence in life’s meaning, even if we have to hide our own worries. Parents can point out that, even if it takes years, people have made it through difficult times in the past, and there are many positive alternatives for education and employment.

Children need to repeatedly hear about ways they are valued that are not dependent on accomplishments. Thanking them for and telling others about their effort, ideas, curiosity, integrity, love, and kindness point out meaning for their existence independent of world events. Parents need to establish routines and rules for children to demonstrate that life goes on as usual. Chores helpful to the family are a practical contribution. Family activities that are challenging and unpredictable set up for discussing, modeling, and building resilience; for example, visiting new places, camping, hiking, trying a new sport, or adopting a pet give opportunities to say: “Oh, well, we’ll find another way.”

Parents can share stories or books about people who made it through tougher times, such as Abraham Lincoln, or better, personal, or family experiences overcoming challenges. Recalling and nicknaming instances of the child’s own resilience is valuable. Books such as “The Little Engine That Could,” “Chicken Little,” and fairy tales of overcoming doubts when facing challenges can be helpful. “Stay calm and carry on,” a saying from the British when they were being bombed during World War II, has become a meme.

As clinicians we need to sort out significant complicated grief, anxiety, obsessive compulsive disorder, depression, or suicidal ideation, and provide assessment and treatment. But when children get stuck in existential futility, in addition to engaging them in meaningful activities, we can advise parents to coach them to distract themselves, “put the thoughts in a box in your head” to consider later, and/or write down or photograph things that make them grateful. Good lessons for us all to reinvent meaning in our lives.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at [email protected].

The news is portraying our modern time as an existential crisis as though our very existence is threatened. An existential crisis is a profound feeling of lack of meaning, choice, or freedom in one’s life that makes even existing seem worthless. It can emerge as early as 5 years old, especially in introspective, gifted children, when they realize that death is permanent and universal, after a real loss or a story of a loss or failure, or from a sense of guilt.

The past 18 months of COVID-19 have been a perfect storm for developing an existential crisis. One of the main sources of life meaning for children is friendships. COVID-19 has reduced or blocked access to old and new friends. Younger children, when asked what makes a friend, will say “we like to do the same things.” Virtual play dates help but don’t replace shared experiences.

School provides meaning for children not only from socializing but also from accomplishing academic tasks – fulfilling Erickson’s stages of “mastery” and “productivity.” Teachers were better able to carry out hands-on activities, group assignments, and field trips in person so that all children and learning styles were engaged and successful. Not having in-person school has also meant loss of extracurricular activities, sports, and clubs as sources of mastery.

Loss of the structure of daily life, common during COVID-19, for waking, dressing, meals, chores, homework time, bathing, or bedtime can be profoundly disorienting.

For adolescents, opportunities to contribute to society and become productive by volunteering or being employed have been stunted by quarantine and social distancing. Some teens have had to care for relatives at home so that parents can earn a living, which, while meaningful, blocks age-essential socializing.

Meaning can also be created at any age by community structures and agreed upon beliefs such as religion. While religious membership is low in the United States, members have been largely unable to attend services. Following sports teams, an alternate “religion” and source of identity, was on hold for many months.

Existential despair can also come from major life losses. COVID-19 has taken a terrible toll of lives, homes, and jobs for millions. As short-term thinkers, when children see so many of their plans and dreams for making the team, having a girlfriend, going to prom, attending summer camp, or graduating, it feels like the end of the world they had imagined. Even the most important source of meaning – connection to family – has been disrupted by lockdown, illness, or loss.

The loss of choice and freedom goes beyond being stuck indoors. Advanced classes and exams, as well as resume-building jobs or volunteering, which teens saw as essential to college, disappeared; sometimes also the money needed was exhausted by COVID-19 unemployment. Work-at-home parents supervising virtual school see their children’s malaise or panic and pressure them to work harder, which is impossible for despairing children. Observing a parent losing his or her job makes a teen’s own career aspirations uncertain. Teen depression and suicidal ideation/acts have shot up from hopelessness, with loss of meaning at the core.

A profound sense of powerlessness has taken over. COVID-19, an invisible threat, has taken down lives. Even with amazingly effective vaccines available, fear and helplessness have burned into our brains. Helplessness to stop structural racism and the arbitrary killings of our own Black citizens by police has finally registered. And climate change is now reported as an impending disaster that may not be stoppable.

So this must be the worst time in history, right? Actually, no. The past 60 years have been a period of historically remarkable stability of government, economy, and natural forces. Perhaps knowing no other world has made these problems appear unsolvable to the parents of our patients. Their own sense of meaning has been challenged in a way similar to that of their children. Perhaps from lack of privacy or peers, parents have been sharing their own sense of powerlessness with their children directly or indirectly, making it harder to reassure them.

With COVID-19 waning in the United States, many of the sources of meaning just discussed can be reinstated by way of in-person play dates, school, sports, socializing, practicing religion, volunteering, and getting jobs. Although there is “existential therapy,” what our children need most is adult leadership showing confidence in life’s meaning, even if we have to hide our own worries. Parents can point out that, even if it takes years, people have made it through difficult times in the past, and there are many positive alternatives for education and employment.

Children need to repeatedly hear about ways they are valued that are not dependent on accomplishments. Thanking them for and telling others about their effort, ideas, curiosity, integrity, love, and kindness point out meaning for their existence independent of world events. Parents need to establish routines and rules for children to demonstrate that life goes on as usual. Chores helpful to the family are a practical contribution. Family activities that are challenging and unpredictable set up for discussing, modeling, and building resilience; for example, visiting new places, camping, hiking, trying a new sport, or adopting a pet give opportunities to say: “Oh, well, we’ll find another way.”

Parents can share stories or books about people who made it through tougher times, such as Abraham Lincoln, or better, personal, or family experiences overcoming challenges. Recalling and nicknaming instances of the child’s own resilience is valuable. Books such as “The Little Engine That Could,” “Chicken Little,” and fairy tales of overcoming doubts when facing challenges can be helpful. “Stay calm and carry on,” a saying from the British when they were being bombed during World War II, has become a meme.

As clinicians we need to sort out significant complicated grief, anxiety, obsessive compulsive disorder, depression, or suicidal ideation, and provide assessment and treatment. But when children get stuck in existential futility, in addition to engaging them in meaningful activities, we can advise parents to coach them to distract themselves, “put the thoughts in a box in your head” to consider later, and/or write down or photograph things that make them grateful. Good lessons for us all to reinvent meaning in our lives.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at [email protected].

The news is portraying our modern time as an existential crisis as though our very existence is threatened. An existential crisis is a profound feeling of lack of meaning, choice, or freedom in one’s life that makes even existing seem worthless. It can emerge as early as 5 years old, especially in introspective, gifted children, when they realize that death is permanent and universal, after a real loss or a story of a loss or failure, or from a sense of guilt.

The past 18 months of COVID-19 have been a perfect storm for developing an existential crisis. One of the main sources of life meaning for children is friendships. COVID-19 has reduced or blocked access to old and new friends. Younger children, when asked what makes a friend, will say “we like to do the same things.” Virtual play dates help but don’t replace shared experiences.

School provides meaning for children not only from socializing but also from accomplishing academic tasks – fulfilling Erickson’s stages of “mastery” and “productivity.” Teachers were better able to carry out hands-on activities, group assignments, and field trips in person so that all children and learning styles were engaged and successful. Not having in-person school has also meant loss of extracurricular activities, sports, and clubs as sources of mastery.

Loss of the structure of daily life, common during COVID-19, for waking, dressing, meals, chores, homework time, bathing, or bedtime can be profoundly disorienting.

For adolescents, opportunities to contribute to society and become productive by volunteering or being employed have been stunted by quarantine and social distancing. Some teens have had to care for relatives at home so that parents can earn a living, which, while meaningful, blocks age-essential socializing.

Meaning can also be created at any age by community structures and agreed upon beliefs such as religion. While religious membership is low in the United States, members have been largely unable to attend services. Following sports teams, an alternate “religion” and source of identity, was on hold for many months.

Existential despair can also come from major life losses. COVID-19 has taken a terrible toll of lives, homes, and jobs for millions. As short-term thinkers, when children see so many of their plans and dreams for making the team, having a girlfriend, going to prom, attending summer camp, or graduating, it feels like the end of the world they had imagined. Even the most important source of meaning – connection to family – has been disrupted by lockdown, illness, or loss.

The loss of choice and freedom goes beyond being stuck indoors. Advanced classes and exams, as well as resume-building jobs or volunteering, which teens saw as essential to college, disappeared; sometimes also the money needed was exhausted by COVID-19 unemployment. Work-at-home parents supervising virtual school see their children’s malaise or panic and pressure them to work harder, which is impossible for despairing children. Observing a parent losing his or her job makes a teen’s own career aspirations uncertain. Teen depression and suicidal ideation/acts have shot up from hopelessness, with loss of meaning at the core.

A profound sense of powerlessness has taken over. COVID-19, an invisible threat, has taken down lives. Even with amazingly effective vaccines available, fear and helplessness have burned into our brains. Helplessness to stop structural racism and the arbitrary killings of our own Black citizens by police has finally registered. And climate change is now reported as an impending disaster that may not be stoppable.

So this must be the worst time in history, right? Actually, no. The past 60 years have been a period of historically remarkable stability of government, economy, and natural forces. Perhaps knowing no other world has made these problems appear unsolvable to the parents of our patients. Their own sense of meaning has been challenged in a way similar to that of their children. Perhaps from lack of privacy or peers, parents have been sharing their own sense of powerlessness with their children directly or indirectly, making it harder to reassure them.

With COVID-19 waning in the United States, many of the sources of meaning just discussed can be reinstated by way of in-person play dates, school, sports, socializing, practicing religion, volunteering, and getting jobs. Although there is “existential therapy,” what our children need most is adult leadership showing confidence in life’s meaning, even if we have to hide our own worries. Parents can point out that, even if it takes years, people have made it through difficult times in the past, and there are many positive alternatives for education and employment.

Children need to repeatedly hear about ways they are valued that are not dependent on accomplishments. Thanking them for and telling others about their effort, ideas, curiosity, integrity, love, and kindness point out meaning for their existence independent of world events. Parents need to establish routines and rules for children to demonstrate that life goes on as usual. Chores helpful to the family are a practical contribution. Family activities that are challenging and unpredictable set up for discussing, modeling, and building resilience; for example, visiting new places, camping, hiking, trying a new sport, or adopting a pet give opportunities to say: “Oh, well, we’ll find another way.”

Parents can share stories or books about people who made it through tougher times, such as Abraham Lincoln, or better, personal, or family experiences overcoming challenges. Recalling and nicknaming instances of the child’s own resilience is valuable. Books such as “The Little Engine That Could,” “Chicken Little,” and fairy tales of overcoming doubts when facing challenges can be helpful. “Stay calm and carry on,” a saying from the British when they were being bombed during World War II, has become a meme.

As clinicians we need to sort out significant complicated grief, anxiety, obsessive compulsive disorder, depression, or suicidal ideation, and provide assessment and treatment. But when children get stuck in existential futility, in addition to engaging them in meaningful activities, we can advise parents to coach them to distract themselves, “put the thoughts in a box in your head” to consider later, and/or write down or photograph things that make them grateful. Good lessons for us all to reinvent meaning in our lives.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. Email her at [email protected].

Postpartum depression (PPD) is a common and treatable problem affecting over 10% of all pregnant women. Without routine use of a screening questionnaire, many women go undiagnosed and without treatment. The risks of untreated PPD in a new mother are the risks of depression tripled: to her health and to the health of her new infant and their whole family. Although pediatricians treat children, they take care of the whole family. They appreciate their role in offering support and guidance to new parents, and in the case of PPD, they are in a unique position. The American Academy of Pediatrics recognized this when they issued their policy statement, “Incorporating Recognition and Management of Perinatal Depression into Pediatric Practice,” in January 2019. By screening, tracking, and connecting affected mothers to care and services, you can truly provide “two-generational care” for your youngest patients.

PPD affects an estimated one in seven women (13%) globally. In one large retrospective study that looked at the 39 weeks before and after delivery, 15.4% of mothers received a diagnosis of PPD and a second study indicated that 22% of new mothers had depressive symptoms that were persistent for 6 months.¹ The pathways to PPD include prior personal or family history of depression, stressors in the family (connected to social determinants of health), previous miscarriage or serious complications in a previous pregnancy, and sensitivity to hormonal changes. Indeed, PPD is the most common complication of childbirth.² Although as many as half of all women eventually diagnosed with PPD had symptoms during their pregnancy, the misperception that PPD is only post partum leads to it being mistaken for the normal process of adjustment to parenthood. PPD is particularly insidious as new mothers are likely to be silent if they feel shame for not enjoying what they have been told will be a special and happy time, and those around them may mistake symptoms for the normal “baby blues” that will resolve quickly and with routine supports.

Untreated PPD, creates risks for mother, infant, and family as she manages needless suffering during a critical period for her new baby. While depression may remit over months without treatment, suicide is a real risk, and accounts for 20% of postpartum deaths.³ Infants face serious developmental consequences when their mothers are withdrawn and disconnected from them during the first months of life, including impaired social development, physical growth, and cognitive development. This impairment persists. Exposure to maternal depression during infancy is associated with lower IQ, attentional problems, and special educational needs by elementary school,⁴ and is a risk factor for psychiatric illnesses in childhood and adolescence.^5,6 PPD has a broad range of severity, including psychosis that may include paranoia with the rare risk of infanticide. And maternal depression can add to the strains in a vulnerable caregiver relationship that can raise the risk for neglect or abuse of the mother, children, or both.

It is important to note that anxiety is often the presenting problem in perinatal mood disorders, with mothers experiencing intense morbid worries about their infant’s safety and health, and fear of inadequacy, criticism, and even infant removal. These fears may reinforce silence and isolation. But pediatricians are one group that these mothers are most likely to share their anxieties with as they look for reassurance. It can be challenging to distinguish PPD from obsessive-compulsive disorder or PTSD. The critical work of the pediatrician is not specific diagnosis and treatment. Instead, your task is to provide screening and support, to create a safe place to overcome silence and shame.

There are many reliable and valid screening instruments available for depression, but the Edinburgh Postnatal Depression Scale (EDPS) has been specially developed for and tested in this population. It is a 10-item scale that is easy to complete and to score. Scores range from 0 to 30 and a score of 10 is considered a cutoff for depression. It can be used to track symptoms and is free and widely available online and in multiple languages. Ideally, this scale can be administered as part of a previsit, automatically entered into an electronic medical record and given at regular intervals during the infant’s first year of primary care. Some new mothers, especially if they are suffering from depression, may feel anxious about filling this out. It is important that your staff tell them that you screen all new mothers in your practice, and that PPD is common and treatable and the pediatrician’s office is committed to the health of the whole family.

If a new mother screens positive, you might consider yourself to have three tasks: Reassure her that she is a wonderful mother and this is a treatable illness, not a cause for guilt, shame, or alarm; expand her support and decrease her isolation by helping her to communicate with her family; and identify treatment resources for her. Start by being curious about some of her specific worries or feelings, her energy level, feelings of isolation or trouble with sleep. Offer compassion and validation around the pain of these experiences in the midst of so much transition. Only after hearing a little detail about her experience, then you may offer that such feelings are common, but when they are persistent or severe, they often indicate PPD, and that her screening test suggests they do for her. Offer that this form of depression is very treatable, with both pharmacologic and psychotherapy interventions. And if she is resistant, gently offer that treatment will be very protective of her new infant’s physical, social, and cognitive growth and development. Hearing this from a pediatrician is powerful for a new mother, even if depressed. Finally, ask if you might help her bring other important adults in her family into an understanding of this. Could she tell her spouse? Her sister? Her best friend? Perhaps she could bring one of them to the next weekly visit, so you can all speak together. This intervention greatly improves the likelihood of her engaging in treatment, and strong interpersonal connections are therapeutic in and of themselves.

For treatment, the easier your office can make it, the more likely she is to follow up. Identify local resources, perhaps through connected community organizations such as Jewish Family and Children’s Services or through a public program like California’s First Five. Connect with the local obstetric practice, which may already have a referral process in place. If you can connect with her primary care provider, they may take on the referral process or may even have integrated capacity for treatment. Identify strategies that may support her restful sleep, including realistic daily exercise, sharing infant care, and being cautious with caffeine and screen time. Identify ways for her to meet other new mothers or reconnect with friends. Reassure her that easy attachment activities, such as reading a book or singing to her baby can be good for both of them without requiring much energy. This may sound like a daunting task, but the conversation will only take a few minutes. Helping an isolated new parent recognize that their feelings of fear, inadequacy, and guilt are not facts, offering some simple immediate strategies and facilitating a referral can be lifesaving.

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

References

1. Dietz PM et al. Am J Psychiatry. 2007;164(10):1515-20.

2. Hanusa BH et al. J Women’s Health (Larchmt) 2008;17(4):585-96.

3. Lindahl V et al. Arch Womens Ment Health. 2005;8(2):77-87.

4. Hay DF et al. J Child Psychol Psychiatry. 2001;42(7):871-89.

5. Tully EC et al. Am J Psychiatry. 2008:165(9):1148-54.

6. Maternal depression and child development. Paediatr. Child Health 2004;9(8):575-98.

Postpartum depression (PPD) is a common and treatable problem affecting over 10% of all pregnant women. Without routine use of a screening questionnaire, many women go undiagnosed and without treatment. The risks of untreated PPD in a new mother are the risks of depression tripled: to her health and to the health of her new infant and their whole family. Although pediatricians treat children, they take care of the whole family. They appreciate their role in offering support and guidance to new parents, and in the case of PPD, they are in a unique position. The American Academy of Pediatrics recognized this when they issued their policy statement, “Incorporating Recognition and Management of Perinatal Depression into Pediatric Practice,” in January 2019. By screening, tracking, and connecting affected mothers to care and services, you can truly provide “two-generational care” for your youngest patients.

PPD affects an estimated one in seven women (13%) globally. In one large retrospective study that looked at the 39 weeks before and after delivery, 15.4% of mothers received a diagnosis of PPD and a second study indicated that 22% of new mothers had depressive symptoms that were persistent for 6 months.¹ The pathways to PPD include prior personal or family history of depression, stressors in the family (connected to social determinants of health), previous miscarriage or serious complications in a previous pregnancy, and sensitivity to hormonal changes. Indeed, PPD is the most common complication of childbirth.² Although as many as half of all women eventually diagnosed with PPD had symptoms during their pregnancy, the misperception that PPD is only post partum leads to it being mistaken for the normal process of adjustment to parenthood. PPD is particularly insidious as new mothers are likely to be silent if they feel shame for not enjoying what they have been told will be a special and happy time, and those around them may mistake symptoms for the normal “baby blues” that will resolve quickly and with routine supports.

Untreated PPD, creates risks for mother, infant, and family as she manages needless suffering during a critical period for her new baby. While depression may remit over months without treatment, suicide is a real risk, and accounts for 20% of postpartum deaths.³ Infants face serious developmental consequences when their mothers are withdrawn and disconnected from them during the first months of life, including impaired social development, physical growth, and cognitive development. This impairment persists. Exposure to maternal depression during infancy is associated with lower IQ, attentional problems, and special educational needs by elementary school,⁴ and is a risk factor for psychiatric illnesses in childhood and adolescence.^5,6 PPD has a broad range of severity, including psychosis that may include paranoia with the rare risk of infanticide. And maternal depression can add to the strains in a vulnerable caregiver relationship that can raise the risk for neglect or abuse of the mother, children, or both.

It is important to note that anxiety is often the presenting problem in perinatal mood disorders, with mothers experiencing intense morbid worries about their infant’s safety and health, and fear of inadequacy, criticism, and even infant removal. These fears may reinforce silence and isolation. But pediatricians are one group that these mothers are most likely to share their anxieties with as they look for reassurance. It can be challenging to distinguish PPD from obsessive-compulsive disorder or PTSD. The critical work of the pediatrician is not specific diagnosis and treatment. Instead, your task is to provide screening and support, to create a safe place to overcome silence and shame.

There are many reliable and valid screening instruments available for depression, but the Edinburgh Postnatal Depression Scale (EDPS) has been specially developed for and tested in this population. It is a 10-item scale that is easy to complete and to score. Scores range from 0 to 30 and a score of 10 is considered a cutoff for depression. It can be used to track symptoms and is free and widely available online and in multiple languages. Ideally, this scale can be administered as part of a previsit, automatically entered into an electronic medical record and given at regular intervals during the infant’s first year of primary care. Some new mothers, especially if they are suffering from depression, may feel anxious about filling this out. It is important that your staff tell them that you screen all new mothers in your practice, and that PPD is common and treatable and the pediatrician’s office is committed to the health of the whole family.

If a new mother screens positive, you might consider yourself to have three tasks: Reassure her that she is a wonderful mother and this is a treatable illness, not a cause for guilt, shame, or alarm; expand her support and decrease her isolation by helping her to communicate with her family; and identify treatment resources for her. Start by being curious about some of her specific worries or feelings, her energy level, feelings of isolation or trouble with sleep. Offer compassion and validation around the pain of these experiences in the midst of so much transition. Only after hearing a little detail about her experience, then you may offer that such feelings are common, but when they are persistent or severe, they often indicate PPD, and that her screening test suggests they do for her. Offer that this form of depression is very treatable, with both pharmacologic and psychotherapy interventions. And if she is resistant, gently offer that treatment will be very protective of her new infant’s physical, social, and cognitive growth and development. Hearing this from a pediatrician is powerful for a new mother, even if depressed. Finally, ask if you might help her bring other important adults in her family into an understanding of this. Could she tell her spouse? Her sister? Her best friend? Perhaps she could bring one of them to the next weekly visit, so you can all speak together. This intervention greatly improves the likelihood of her engaging in treatment, and strong interpersonal connections are therapeutic in and of themselves.

For treatment, the easier your office can make it, the more likely she is to follow up. Identify local resources, perhaps through connected community organizations such as Jewish Family and Children’s Services or through a public program like California’s First Five. Connect with the local obstetric practice, which may already have a referral process in place. If you can connect with her primary care provider, they may take on the referral process or may even have integrated capacity for treatment. Identify strategies that may support her restful sleep, including realistic daily exercise, sharing infant care, and being cautious with caffeine and screen time. Identify ways for her to meet other new mothers or reconnect with friends. Reassure her that easy attachment activities, such as reading a book or singing to her baby can be good for both of them without requiring much energy. This may sound like a daunting task, but the conversation will only take a few minutes. Helping an isolated new parent recognize that their feelings of fear, inadequacy, and guilt are not facts, offering some simple immediate strategies and facilitating a referral can be lifesaving.

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

References

1. Dietz PM et al. Am J Psychiatry. 2007;164(10):1515-20.

2. Hanusa BH et al. J Women’s Health (Larchmt) 2008;17(4):585-96.

3. Lindahl V et al. Arch Womens Ment Health. 2005;8(2):77-87.

4. Hay DF et al. J Child Psychol Psychiatry. 2001;42(7):871-89.

5. Tully EC et al. Am J Psychiatry. 2008:165(9):1148-54.

6. Maternal depression and child development. Paediatr. Child Health 2004;9(8):575-98.

Postpartum depression (PPD) is a common and treatable problem affecting over 10% of all pregnant women. Without routine use of a screening questionnaire, many women go undiagnosed and without treatment. The risks of untreated PPD in a new mother are the risks of depression tripled: to her health and to the health of her new infant and their whole family. Although pediatricians treat children, they take care of the whole family. They appreciate their role in offering support and guidance to new parents, and in the case of PPD, they are in a unique position. The American Academy of Pediatrics recognized this when they issued their policy statement, “Incorporating Recognition and Management of Perinatal Depression into Pediatric Practice,” in January 2019. By screening, tracking, and connecting affected mothers to care and services, you can truly provide “two-generational care” for your youngest patients.

PPD affects an estimated one in seven women (13%) globally. In one large retrospective study that looked at the 39 weeks before and after delivery, 15.4% of mothers received a diagnosis of PPD and a second study indicated that 22% of new mothers had depressive symptoms that were persistent for 6 months.¹ The pathways to PPD include prior personal or family history of depression, stressors in the family (connected to social determinants of health), previous miscarriage or serious complications in a previous pregnancy, and sensitivity to hormonal changes. Indeed, PPD is the most common complication of childbirth.² Although as many as half of all women eventually diagnosed with PPD had symptoms during their pregnancy, the misperception that PPD is only post partum leads to it being mistaken for the normal process of adjustment to parenthood. PPD is particularly insidious as new mothers are likely to be silent if they feel shame for not enjoying what they have been told will be a special and happy time, and those around them may mistake symptoms for the normal “baby blues” that will resolve quickly and with routine supports.

Untreated PPD, creates risks for mother, infant, and family as she manages needless suffering during a critical period for her new baby. While depression may remit over months without treatment, suicide is a real risk, and accounts for 20% of postpartum deaths.³ Infants face serious developmental consequences when their mothers are withdrawn and disconnected from them during the first months of life, including impaired social development, physical growth, and cognitive development. This impairment persists. Exposure to maternal depression during infancy is associated with lower IQ, attentional problems, and special educational needs by elementary school,⁴ and is a risk factor for psychiatric illnesses in childhood and adolescence.^5,6 PPD has a broad range of severity, including psychosis that may include paranoia with the rare risk of infanticide. And maternal depression can add to the strains in a vulnerable caregiver relationship that can raise the risk for neglect or abuse of the mother, children, or both.

It is important to note that anxiety is often the presenting problem in perinatal mood disorders, with mothers experiencing intense morbid worries about their infant’s safety and health, and fear of inadequacy, criticism, and even infant removal. These fears may reinforce silence and isolation. But pediatricians are one group that these mothers are most likely to share their anxieties with as they look for reassurance. It can be challenging to distinguish PPD from obsessive-compulsive disorder or PTSD. The critical work of the pediatrician is not specific diagnosis and treatment. Instead, your task is to provide screening and support, to create a safe place to overcome silence and shame.

There are many reliable and valid screening instruments available for depression, but the Edinburgh Postnatal Depression Scale (EDPS) has been specially developed for and tested in this population. It is a 10-item scale that is easy to complete and to score. Scores range from 0 to 30 and a score of 10 is considered a cutoff for depression. It can be used to track symptoms and is free and widely available online and in multiple languages. Ideally, this scale can be administered as part of a previsit, automatically entered into an electronic medical record and given at regular intervals during the infant’s first year of primary care. Some new mothers, especially if they are suffering from depression, may feel anxious about filling this out. It is important that your staff tell them that you screen all new mothers in your practice, and that PPD is common and treatable and the pediatrician’s office is committed to the health of the whole family.

If a new mother screens positive, you might consider yourself to have three tasks: Reassure her that she is a wonderful mother and this is a treatable illness, not a cause for guilt, shame, or alarm; expand her support and decrease her isolation by helping her to communicate with her family; and identify treatment resources for her. Start by being curious about some of her specific worries or feelings, her energy level, feelings of isolation or trouble with sleep. Offer compassion and validation around the pain of these experiences in the midst of so much transition. Only after hearing a little detail about her experience, then you may offer that such feelings are common, but when they are persistent or severe, they often indicate PPD, and that her screening test suggests they do for her. Offer that this form of depression is very treatable, with both pharmacologic and psychotherapy interventions. And if she is resistant, gently offer that treatment will be very protective of her new infant’s physical, social, and cognitive growth and development. Hearing this from a pediatrician is powerful for a new mother, even if depressed. Finally, ask if you might help her bring other important adults in her family into an understanding of this. Could she tell her spouse? Her sister? Her best friend? Perhaps she could bring one of them to the next weekly visit, so you can all speak together. This intervention greatly improves the likelihood of her engaging in treatment, and strong interpersonal connections are therapeutic in and of themselves.

For treatment, the easier your office can make it, the more likely she is to follow up. Identify local resources, perhaps through connected community organizations such as Jewish Family and Children’s Services or through a public program like California’s First Five. Connect with the local obstetric practice, which may already have a referral process in place. If you can connect with her primary care provider, they may take on the referral process or may even have integrated capacity for treatment. Identify strategies that may support her restful sleep, including realistic daily exercise, sharing infant care, and being cautious with caffeine and screen time. Identify ways for her to meet other new mothers or reconnect with friends. Reassure her that easy attachment activities, such as reading a book or singing to her baby can be good for both of them without requiring much energy. This may sound like a daunting task, but the conversation will only take a few minutes. Helping an isolated new parent recognize that their feelings of fear, inadequacy, and guilt are not facts, offering some simple immediate strategies and facilitating a referral can be lifesaving.

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

References

1. Dietz PM et al. Am J Psychiatry. 2007;164(10):1515-20.

2. Hanusa BH et al. J Women’s Health (Larchmt) 2008;17(4):585-96.

3. Lindahl V et al. Arch Womens Ment Health. 2005;8(2):77-87.

4. Hay DF et al. J Child Psychol Psychiatry. 2001;42(7):871-89.

5. Tully EC et al. Am J Psychiatry. 2008:165(9):1148-54.

6. Maternal depression and child development. Paediatr. Child Health 2004;9(8):575-98.

You read “thoughts of being better off dead” on your next patient’s PHQ-9 screen results and break into a sweat. After eliciting the teen’s realistic suicide plan and intent you send him to the ED with his parent for crisis mental health evaluation. When you call the family that evening to follow-up you hear that he was discharged with a “mental health counseling” appointment next week.

Have you done enough to prevent this child from dying at his own hand? I imagine that this haunts you as it does me. It is terrifying to know that, of youth with suicidal ideation, over one-third attempt suicide, most within 1-2 years, and 20%-40% do so without having had a plan.

We now know that certain kinds of psychotherapy have evidence for preventing subsequent suicide in teens at high risk due to suicidal ideation and past attempts. Cognitive behavioral therapy (CBT) has the best evidence including its subtypes for youth with relevant histories: for both suicide and substance use (integrated, or I-CBT), trauma focused (TF-CBT), traumatic grief (CTG-CBT), and CBT-I, for the potent risk factor of insomnia. The other treatment shown to reduce risk is dialectical behavioral therapy–adolescent (DBT-A) focused on strengthening skills in interpersonal effectiveness, mindfulness, distress tolerance, and emotion regulation adapted to youth by adding family therapy and multifamily skills training. Interpersonal psychotherapy (IPT) adapted for suicidal and self-harming adolescents (IPT-SA) also has evidence.

Some school programs have shown moderate efficacy, for example (IPT-A-IN) addresses the social and interpersonal context, and Youth Aware of Mental Health, a school curriculum to increase knowledge, help-seeking, and ways of coping with depression and suicidal behavior, that cut suicide attempts by half.

You may be able to recommend, refer to, or check to see if a youth can be provided one of the above therapies with best evidence but getting any counseling at all can be hard and some, especially minority families may decline formal interventions. Any therapy – CBT, DBT, or IPT – acceptable to the youth and family can be helpful. You can often determine if the key components are being provided by asking the teen what they are working on in therapy.

It is clear that checking in regularly with teens who have been through a suicide crisis is crucial to ensure that they continue in therapy long and consistently enough, that the family is involved in treatment, and that they are taught emotion regulation, distress tolerance, and safety planning. Warm, consistent parenting, good parent-child communication, and monitoring are protective factors but also skills that can be boosted to reduce future risk of suicide. When there is family dysfunction, conflict, or weak relationships, getting help for family relationships such as through attachment-based family therapy (ABFT) or family cognitive behavioral therapy is a priority. When bereavement or parental depression is contributing to youth suicidal thoughts, addressing these specifically can reduce suicide risk.

Sometimes family members, even with counseling, are not the best supporters for a teen in pain. When youths nominated their own support team to be informed about risk factors, diagnosis, and treatment plans and to stay in contact weekly there was a 6.6-fold lower risk of death than for nonsupported youth.

But how much of this evidence-based intervention can you ensure from your position in primary care? Refer if you can but regular supportive contacts alone reduce risk so you, trusted staff, school counselors, or even the now more available teletherapists may help. You can work with your patient to fill out a written commitment-to-safety plan (e.g. U. Colorado, CHADIS) of strategies they can use when having suicidal thoughts such as self-distractions, problem-solving, listing things they are looking forward to, things to do to get their mind off suicidal thoughts, and selecting support people to understand their situation with whom to be in regular contact. Any plan needs to take into account how understanding, supportive, and available the family is, factors you are most likely to be able to judge from your ongoing relationship, but that immediate risk may change. Contact within 48 hours, check-in within 1-2 weeks, and provision of crisis hotline information are essential actions.

Recommending home safety is part of routine anticipatory guidance but reduction of lethal means is essential in these cases. Guns are the most lethal method of suicide but discussing safe gun storage has been shown to be more effective than arguing in vain for gun removal. Medication overdose, a common means, can be reduced by not prescribing tricyclics (ineffective and more lethal), and advising parents to lock up all household medications.

You can ask about and coach teens on how to avoid the hazards of participating in online discussion groups, bullying, and cyberbullying (with risk for both perpetrator and victim), all risk factors for suicide. Managing insomnia can improve depression and is within your skills. While pediatricians can’t treat the suicide risk factors of family poverty, unemployment, or loss of culture/identity, we can refer affected families to community resources.

Repeated suicide screens can help but are imperfect, so listen to the child or parent for risk signs such as the youth having self-reported worthlessness, low self-esteem, speaking negatively about self, anhedonia, or poor emotion regulation. Children with impulsive aggression, often familial, are at special risk of suicide. This trait, while more common in ADHD, is not confined to that condition. You can help by optimizing medical management of impulsivity, when appropriate.

Most youth who attempt suicide have one or more mental health diagnoses, particularly major depressive disorder (MDD), eating disorder, ADHD, conduct, or intermittent explosive disorder. When MDD is comorbid with anxiety, suicides increase 9.5-fold. Children on the autism spectrum are more likely to have been bullied and eight times more likely to commit suicide. LGBTQ youth are five times more often bullied and are at high risk for suicide. The more common issues of school failure or substance use also confer risk. While we do our best caring for children with these conditions we may not be thinking about, screening, or monitoring for their suicide risk. It may be important for us to explain that, despite black-box warnings, rates of SSRI prescribing for depression are inversely related to suicides.

Child maltreatment is the highest risk factor for suicide (population attributed risk, or PAR, 9.6%-14.5%), particularly sexual misuse. All together, adverse childhood experiences have a PAR for suicide of 80%. Continuity allows you to monitor for developmental times when distress from past experiences often reemerges, e.g., puberty, dating onset, or divorce. Getting consent and sharing these highly sensitive but potentially triggering factors as well as prior diagnoses with a newly assigned therapist can be helpful to prioritize treatments to prevent a suicide attempt, because they may be difficult to elicit and timeliness is essential.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].

References

Brent DA. J Am Acad Child Adolesc Psychiatry. 2019;58(1):25-35.

Cha CB et al. J Child Psychol Psychiatry. 2018;59(4):460-82.

You read “thoughts of being better off dead” on your next patient’s PHQ-9 screen results and break into a sweat. After eliciting the teen’s realistic suicide plan and intent you send him to the ED with his parent for crisis mental health evaluation. When you call the family that evening to follow-up you hear that he was discharged with a “mental health counseling” appointment next week.

Have you done enough to prevent this child from dying at his own hand? I imagine that this haunts you as it does me. It is terrifying to know that, of youth with suicidal ideation, over one-third attempt suicide, most within 1-2 years, and 20%-40% do so without having had a plan.

We now know that certain kinds of psychotherapy have evidence for preventing subsequent suicide in teens at high risk due to suicidal ideation and past attempts. Cognitive behavioral therapy (CBT) has the best evidence including its subtypes for youth with relevant histories: for both suicide and substance use (integrated, or I-CBT), trauma focused (TF-CBT), traumatic grief (CTG-CBT), and CBT-I, for the potent risk factor of insomnia. The other treatment shown to reduce risk is dialectical behavioral therapy–adolescent (DBT-A) focused on strengthening skills in interpersonal effectiveness, mindfulness, distress tolerance, and emotion regulation adapted to youth by adding family therapy and multifamily skills training. Interpersonal psychotherapy (IPT) adapted for suicidal and self-harming adolescents (IPT-SA) also has evidence.

Some school programs have shown moderate efficacy, for example (IPT-A-IN) addresses the social and interpersonal context, and Youth Aware of Mental Health, a school curriculum to increase knowledge, help-seeking, and ways of coping with depression and suicidal behavior, that cut suicide attempts by half.

You may be able to recommend, refer to, or check to see if a youth can be provided one of the above therapies with best evidence but getting any counseling at all can be hard and some, especially minority families may decline formal interventions. Any therapy – CBT, DBT, or IPT – acceptable to the youth and family can be helpful. You can often determine if the key components are being provided by asking the teen what they are working on in therapy.

It is clear that checking in regularly with teens who have been through a suicide crisis is crucial to ensure that they continue in therapy long and consistently enough, that the family is involved in treatment, and that they are taught emotion regulation, distress tolerance, and safety planning. Warm, consistent parenting, good parent-child communication, and monitoring are protective factors but also skills that can be boosted to reduce future risk of suicide. When there is family dysfunction, conflict, or weak relationships, getting help for family relationships such as through attachment-based family therapy (ABFT) or family cognitive behavioral therapy is a priority. When bereavement or parental depression is contributing to youth suicidal thoughts, addressing these specifically can reduce suicide risk.

Sometimes family members, even with counseling, are not the best supporters for a teen in pain. When youths nominated their own support team to be informed about risk factors, diagnosis, and treatment plans and to stay in contact weekly there was a 6.6-fold lower risk of death than for nonsupported youth.

But how much of this evidence-based intervention can you ensure from your position in primary care? Refer if you can but regular supportive contacts alone reduce risk so you, trusted staff, school counselors, or even the now more available teletherapists may help. You can work with your patient to fill out a written commitment-to-safety plan (e.g. U. Colorado, CHADIS) of strategies they can use when having suicidal thoughts such as self-distractions, problem-solving, listing things they are looking forward to, things to do to get their mind off suicidal thoughts, and selecting support people to understand their situation with whom to be in regular contact. Any plan needs to take into account how understanding, supportive, and available the family is, factors you are most likely to be able to judge from your ongoing relationship, but that immediate risk may change. Contact within 48 hours, check-in within 1-2 weeks, and provision of crisis hotline information are essential actions.

Recommending home safety is part of routine anticipatory guidance but reduction of lethal means is essential in these cases. Guns are the most lethal method of suicide but discussing safe gun storage has been shown to be more effective than arguing in vain for gun removal. Medication overdose, a common means, can be reduced by not prescribing tricyclics (ineffective and more lethal), and advising parents to lock up all household medications.

You can ask about and coach teens on how to avoid the hazards of participating in online discussion groups, bullying, and cyberbullying (with risk for both perpetrator and victim), all risk factors for suicide. Managing insomnia can improve depression and is within your skills. While pediatricians can’t treat the suicide risk factors of family poverty, unemployment, or loss of culture/identity, we can refer affected families to community resources.

Repeated suicide screens can help but are imperfect, so listen to the child or parent for risk signs such as the youth having self-reported worthlessness, low self-esteem, speaking negatively about self, anhedonia, or poor emotion regulation. Children with impulsive aggression, often familial, are at special risk of suicide. This trait, while more common in ADHD, is not confined to that condition. You can help by optimizing medical management of impulsivity, when appropriate.

Most youth who attempt suicide have one or more mental health diagnoses, particularly major depressive disorder (MDD), eating disorder, ADHD, conduct, or intermittent explosive disorder. When MDD is comorbid with anxiety, suicides increase 9.5-fold. Children on the autism spectrum are more likely to have been bullied and eight times more likely to commit suicide. LGBTQ youth are five times more often bullied and are at high risk for suicide. The more common issues of school failure or substance use also confer risk. While we do our best caring for children with these conditions we may not be thinking about, screening, or monitoring for their suicide risk. It may be important for us to explain that, despite black-box warnings, rates of SSRI prescribing for depression are inversely related to suicides.

Child maltreatment is the highest risk factor for suicide (population attributed risk, or PAR, 9.6%-14.5%), particularly sexual misuse. All together, adverse childhood experiences have a PAR for suicide of 80%. Continuity allows you to monitor for developmental times when distress from past experiences often reemerges, e.g., puberty, dating onset, or divorce. Getting consent and sharing these highly sensitive but potentially triggering factors as well as prior diagnoses with a newly assigned therapist can be helpful to prioritize treatments to prevent a suicide attempt, because they may be difficult to elicit and timeliness is essential.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].

References

Brent DA. J Am Acad Child Adolesc Psychiatry. 2019;58(1):25-35.

Cha CB et al. J Child Psychol Psychiatry. 2018;59(4):460-82.

You read “thoughts of being better off dead” on your next patient’s PHQ-9 screen results and break into a sweat. After eliciting the teen’s realistic suicide plan and intent you send him to the ED with his parent for crisis mental health evaluation. When you call the family that evening to follow-up you hear that he was discharged with a “mental health counseling” appointment next week.

Have you done enough to prevent this child from dying at his own hand? I imagine that this haunts you as it does me. It is terrifying to know that, of youth with suicidal ideation, over one-third attempt suicide, most within 1-2 years, and 20%-40% do so without having had a plan.

We now know that certain kinds of psychotherapy have evidence for preventing subsequent suicide in teens at high risk due to suicidal ideation and past attempts. Cognitive behavioral therapy (CBT) has the best evidence including its subtypes for youth with relevant histories: for both suicide and substance use (integrated, or I-CBT), trauma focused (TF-CBT), traumatic grief (CTG-CBT), and CBT-I, for the potent risk factor of insomnia. The other treatment shown to reduce risk is dialectical behavioral therapy–adolescent (DBT-A) focused on strengthening skills in interpersonal effectiveness, mindfulness, distress tolerance, and emotion regulation adapted to youth by adding family therapy and multifamily skills training. Interpersonal psychotherapy (IPT) adapted for suicidal and self-harming adolescents (IPT-SA) also has evidence.

Some school programs have shown moderate efficacy, for example (IPT-A-IN) addresses the social and interpersonal context, and Youth Aware of Mental Health, a school curriculum to increase knowledge, help-seeking, and ways of coping with depression and suicidal behavior, that cut suicide attempts by half.

You may be able to recommend, refer to, or check to see if a youth can be provided one of the above therapies with best evidence but getting any counseling at all can be hard and some, especially minority families may decline formal interventions. Any therapy – CBT, DBT, or IPT – acceptable to the youth and family can be helpful. You can often determine if the key components are being provided by asking the teen what they are working on in therapy.

It is clear that checking in regularly with teens who have been through a suicide crisis is crucial to ensure that they continue in therapy long and consistently enough, that the family is involved in treatment, and that they are taught emotion regulation, distress tolerance, and safety planning. Warm, consistent parenting, good parent-child communication, and monitoring are protective factors but also skills that can be boosted to reduce future risk of suicide. When there is family dysfunction, conflict, or weak relationships, getting help for family relationships such as through attachment-based family therapy (ABFT) or family cognitive behavioral therapy is a priority. When bereavement or parental depression is contributing to youth suicidal thoughts, addressing these specifically can reduce suicide risk.

Sometimes family members, even with counseling, are not the best supporters for a teen in pain. When youths nominated their own support team to be informed about risk factors, diagnosis, and treatment plans and to stay in contact weekly there was a 6.6-fold lower risk of death than for nonsupported youth.

But how much of this evidence-based intervention can you ensure from your position in primary care? Refer if you can but regular supportive contacts alone reduce risk so you, trusted staff, school counselors, or even the now more available teletherapists may help. You can work with your patient to fill out a written commitment-to-safety plan (e.g. U. Colorado, CHADIS) of strategies they can use when having suicidal thoughts such as self-distractions, problem-solving, listing things they are looking forward to, things to do to get their mind off suicidal thoughts, and selecting support people to understand their situation with whom to be in regular contact. Any plan needs to take into account how understanding, supportive, and available the family is, factors you are most likely to be able to judge from your ongoing relationship, but that immediate risk may change. Contact within 48 hours, check-in within 1-2 weeks, and provision of crisis hotline information are essential actions.

Recommending home safety is part of routine anticipatory guidance but reduction of lethal means is essential in these cases. Guns are the most lethal method of suicide but discussing safe gun storage has been shown to be more effective than arguing in vain for gun removal. Medication overdose, a common means, can be reduced by not prescribing tricyclics (ineffective and more lethal), and advising parents to lock up all household medications.

You can ask about and coach teens on how to avoid the hazards of participating in online discussion groups, bullying, and cyberbullying (with risk for both perpetrator and victim), all risk factors for suicide. Managing insomnia can improve depression and is within your skills. While pediatricians can’t treat the suicide risk factors of family poverty, unemployment, or loss of culture/identity, we can refer affected families to community resources.

Repeated suicide screens can help but are imperfect, so listen to the child or parent for risk signs such as the youth having self-reported worthlessness, low self-esteem, speaking negatively about self, anhedonia, or poor emotion regulation. Children with impulsive aggression, often familial, are at special risk of suicide. This trait, while more common in ADHD, is not confined to that condition. You can help by optimizing medical management of impulsivity, when appropriate.

Most youth who attempt suicide have one or more mental health diagnoses, particularly major depressive disorder (MDD), eating disorder, ADHD, conduct, or intermittent explosive disorder. When MDD is comorbid with anxiety, suicides increase 9.5-fold. Children on the autism spectrum are more likely to have been bullied and eight times more likely to commit suicide. LGBTQ youth are five times more often bullied and are at high risk for suicide. The more common issues of school failure or substance use also confer risk. While we do our best caring for children with these conditions we may not be thinking about, screening, or monitoring for their suicide risk. It may be important for us to explain that, despite black-box warnings, rates of SSRI prescribing for depression are inversely related to suicides.

Child maltreatment is the highest risk factor for suicide (population attributed risk, or PAR, 9.6%-14.5%), particularly sexual misuse. All together, adverse childhood experiences have a PAR for suicide of 80%. Continuity allows you to monitor for developmental times when distress from past experiences often reemerges, e.g., puberty, dating onset, or divorce. Getting consent and sharing these highly sensitive but potentially triggering factors as well as prior diagnoses with a newly assigned therapist can be helpful to prioritize treatments to prevent a suicide attempt, because they may be difficult to elicit and timeliness is essential.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at [email protected].

References

Brent DA. J Am Acad Child Adolesc Psychiatry. 2019;58(1):25-35.

Cha CB et al. J Child Psychol Psychiatry. 2018;59(4):460-82.

This spring may bring an unusual transition for families: a return to in-person school after nearly a year in a virtual classroom. This will undoubtedly come as a welcome relief to many parents worried about their children’s education and development and struggling with running school from home. But it is important for parents to remember that transitions, even happy ones, are difficult. You can help parents to anticipate what may be challenging about this transition for their children so that they are all prepared and can diminish struggles and support their children’s mastery.

Be curious about their children’s thoughts and feelings

Parents should adopt a truly curious and open-minded approach with their children. Remind parents that, while they are experts on their own children, they should not assume they know what their children are thinking or feeling about the return to school. Some children, especially ones struggling with learning problems or difficulty with peers, will have grown very comfortable being at home with parents or siblings. Some children, especially pre- and early teens, may have changed substantially in the year and might feel uncertain about returning to a prior team or group of friends. Some children may feel concerned about leaving a pet at home alone. Some children may be going to a new school and be anxious about facing such a big transition without the usual planning and supports. Those on a college track may be worried they are “behind” academically or in college preparation.

Parents can show up when and where their children are most likely to talk, perhaps bath time or bedtime for younger children or in the car together with their adolescents. They can ask: “Have you been thinking about what it might be like to go back to school? Have your friends been chatting about it?” They might be curious together about what might have changed in a year. What might be really great about being back in a classroom? What might they miss about home school? And what might be new? Are you worried about the work, any of your friends, or not being home? If children can begin to anticipate both the good and the difficult, they will be better equipped to face and manage the challenges and appreciate the delights.

Children in elementary school are built to master new situations but are also prone to anxiety about new expectations and demands. Parents can be calmly curious about what their thoughts, feelings, and questions are and look for answers together. Often all they need is to see parents being calm in the face of uncertainty, bearing the strong feelings that may come, and preserving curiosity and compassion. Adolescents may be grieving the things they have missed, or they may have concerns about relationships and practical matters such as the implications for applying to college. Parents can offer compassion and validation and help them to devise their own strategies to face the practical challenges they are concerned about.
 

Be mindful of their children’s vulnerabilities

While most children will find the transition back to school easier than they may anticipate, there will be some for whom the transition will be very challenging. Children who have been bullied at school may have found themselves able to concentrate and learn free of the fear and stress of a classmate’s taunts or stares. Children with learning disabilities or ADHD have probably struggled with online school, but they have also likely established strategies and supports during the year that have enabled them to get enough individualized help to get their work done. These children are vulnerable to falling behind and getting discouraged when these supports are lost, and possibly not replaced with new ones in the chaos of transition. Parents should reassure their children that they will work with the school to make sure that they can succeed in the classroom as they did at home.

Children with an inhibited or shy temperament might have found that it was easier to focus and listen in the comfortable setting of home than in a busy, stimulating classroom. Children who suffer from anxiety disorders that may make separating from parents or managing the performance and social demands of school extra difficult will find the return to school especially challenging. Some younger children may have experienced the emergence of an anxiety disorder during the past year, and the return to school may mark the challenge that brings heretofore quiet symptoms into full relief.

These children have all enjoyed being able to avoid the discomfort of certain anxiety-provoking situations, and they may be particularly stressed by anticipating a return to school. Younger children may begin to have stomach aches and other physical complaints as the return to school gets close, older children may seem more withdrawn or irritable or begin discussing ways to continue school from home. Parents should help their children try to identify and describe their worries. For anxious children, having a chance to practice may be very helpful. Visiting their school, especially if it is a new school, or having a planned hangout with a friend (with appropriate precautions) is the kind of exposure that can lessen anticipatory anxiety. If this is not enough, parents should not hesitate to bring in other caring, supportive adults, such as school counselors or therapists that may be essential to helping their children face and manage what may be intense anxiety.
 

Consider routines to support their transition

Just as parents begin to return their children to an earlier bedtime toward the end of summer, it will be helpful to consider how changing certain routines will support their children now. If children will need to get up earlier to be ready for a bus or a team practice, they should start moving bedtime and wake-up time earlier gradually. Uniforms or backpacks that have not been seen for a year should be dug out. Children who are planning a return to a sport may benefit from gradually increasing their exercise or starting training now. This will have the added benefit of improving sleep and energy and fortifying children for the challenges of change. Parents might consider reaching out to other parents in the same class as their children and having a virtual conversation to share their thoughts.

If their family has developed some new “COVID routines” that they have come to enjoy, they should find a way to preserve them. Perhaps they are having dinner together more often or have established a family game night or Netflix night. Help parents consider how to avoid falling back into overscheduling their children and themselves. If they created a time to Zoom with distant or vulnerable loved ones, they might decide to continue this. School may determine some of their routines, but they should also prioritize their family connections and well-being in deciding how to schedule their days.
 

Find opportunity for mastery and meaning

As parents are listening, validating, and planning with their children, they might use this time to reflect on valuable lessons. They might point out the value of patience: Adjusting to change takes time and happens in fits and starts. It has been 12 months since many of the pandemic changes started and it will take more than a few days to adjust as schools reopen. They might point out how proud they are of what their children have been able to learn, build, or do during this year, what they admire about them. It may be a time to consider what their family may have lost and gained during the past year, what they are eager to leave behind, and what they might like to keep. And it is also a chance for parents to observe that change is an inevitable part of life (especially when growing up). It is always challenging, and often brings loss and sadness. But if we pay attention, there are also the green shoots of what is new and possible.

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

This spring may bring an unusual transition for families: a return to in-person school after nearly a year in a virtual classroom. This will undoubtedly come as a welcome relief to many parents worried about their children’s education and development and struggling with running school from home. But it is important for parents to remember that transitions, even happy ones, are difficult. You can help parents to anticipate what may be challenging about this transition for their children so that they are all prepared and can diminish struggles and support their children’s mastery.

Be curious about their children’s thoughts and feelings

Parents should adopt a truly curious and open-minded approach with their children. Remind parents that, while they are experts on their own children, they should not assume they know what their children are thinking or feeling about the return to school. Some children, especially ones struggling with learning problems or difficulty with peers, will have grown very comfortable being at home with parents or siblings. Some children, especially pre- and early teens, may have changed substantially in the year and might feel uncertain about returning to a prior team or group of friends. Some children may feel concerned about leaving a pet at home alone. Some children may be going to a new school and be anxious about facing such a big transition without the usual planning and supports. Those on a college track may be worried they are “behind” academically or in college preparation.

Parents can show up when and where their children are most likely to talk, perhaps bath time or bedtime for younger children or in the car together with their adolescents. They can ask: “Have you been thinking about what it might be like to go back to school? Have your friends been chatting about it?” They might be curious together about what might have changed in a year. What might be really great about being back in a classroom? What might they miss about home school? And what might be new? Are you worried about the work, any of your friends, or not being home? If children can begin to anticipate both the good and the difficult, they will be better equipped to face and manage the challenges and appreciate the delights.

Children in elementary school are built to master new situations but are also prone to anxiety about new expectations and demands. Parents can be calmly curious about what their thoughts, feelings, and questions are and look for answers together. Often all they need is to see parents being calm in the face of uncertainty, bearing the strong feelings that may come, and preserving curiosity and compassion. Adolescents may be grieving the things they have missed, or they may have concerns about relationships and practical matters such as the implications for applying to college. Parents can offer compassion and validation and help them to devise their own strategies to face the practical challenges they are concerned about.
 

Be mindful of their children’s vulnerabilities

While most children will find the transition back to school easier than they may anticipate, there will be some for whom the transition will be very challenging. Children who have been bullied at school may have found themselves able to concentrate and learn free of the fear and stress of a classmate’s taunts or stares. Children with learning disabilities or ADHD have probably struggled with online school, but they have also likely established strategies and supports during the year that have enabled them to get enough individualized help to get their work done. These children are vulnerable to falling behind and getting discouraged when these supports are lost, and possibly not replaced with new ones in the chaos of transition. Parents should reassure their children that they will work with the school to make sure that they can succeed in the classroom as they did at home.

Children with an inhibited or shy temperament might have found that it was easier to focus and listen in the comfortable setting of home than in a busy, stimulating classroom. Children who suffer from anxiety disorders that may make separating from parents or managing the performance and social demands of school extra difficult will find the return to school especially challenging. Some younger children may have experienced the emergence of an anxiety disorder during the past year, and the return to school may mark the challenge that brings heretofore quiet symptoms into full relief.

These children have all enjoyed being able to avoid the discomfort of certain anxiety-provoking situations, and they may be particularly stressed by anticipating a return to school. Younger children may begin to have stomach aches and other physical complaints as the return to school gets close, older children may seem more withdrawn or irritable or begin discussing ways to continue school from home. Parents should help their children try to identify and describe their worries. For anxious children, having a chance to practice may be very helpful. Visiting their school, especially if it is a new school, or having a planned hangout with a friend (with appropriate precautions) is the kind of exposure that can lessen anticipatory anxiety. If this is not enough, parents should not hesitate to bring in other caring, supportive adults, such as school counselors or therapists that may be essential to helping their children face and manage what may be intense anxiety.
 

Consider routines to support their transition

Just as parents begin to return their children to an earlier bedtime toward the end of summer, it will be helpful to consider how changing certain routines will support their children now. If children will need to get up earlier to be ready for a bus or a team practice, they should start moving bedtime and wake-up time earlier gradually. Uniforms or backpacks that have not been seen for a year should be dug out. Children who are planning a return to a sport may benefit from gradually increasing their exercise or starting training now. This will have the added benefit of improving sleep and energy and fortifying children for the challenges of change. Parents might consider reaching out to other parents in the same class as their children and having a virtual conversation to share their thoughts.

If their family has developed some new “COVID routines” that they have come to enjoy, they should find a way to preserve them. Perhaps they are having dinner together more often or have established a family game night or Netflix night. Help parents consider how to avoid falling back into overscheduling their children and themselves. If they created a time to Zoom with distant or vulnerable loved ones, they might decide to continue this. School may determine some of their routines, but they should also prioritize their family connections and well-being in deciding how to schedule their days.
 

Find opportunity for mastery and meaning

As parents are listening, validating, and planning with their children, they might use this time to reflect on valuable lessons. They might point out the value of patience: Adjusting to change takes time and happens in fits and starts. It has been 12 months since many of the pandemic changes started and it will take more than a few days to adjust as schools reopen. They might point out how proud they are of what their children have been able to learn, build, or do during this year, what they admire about them. It may be a time to consider what their family may have lost and gained during the past year, what they are eager to leave behind, and what they might like to keep. And it is also a chance for parents to observe that change is an inevitable part of life (especially when growing up). It is always challenging, and often brings loss and sadness. But if we pay attention, there are also the green shoots of what is new and possible.

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

This spring may bring an unusual transition for families: a return to in-person school after nearly a year in a virtual classroom. This will undoubtedly come as a welcome relief to many parents worried about their children’s education and development and struggling with running school from home. But it is important for parents to remember that transitions, even happy ones, are difficult. You can help parents to anticipate what may be challenging about this transition for their children so that they are all prepared and can diminish struggles and support their children’s mastery.

Be curious about their children’s thoughts and feelings

Parents should adopt a truly curious and open-minded approach with their children. Remind parents that, while they are experts on their own children, they should not assume they know what their children are thinking or feeling about the return to school. Some children, especially ones struggling with learning problems or difficulty with peers, will have grown very comfortable being at home with parents or siblings. Some children, especially pre- and early teens, may have changed substantially in the year and might feel uncertain about returning to a prior team or group of friends. Some children may feel concerned about leaving a pet at home alone. Some children may be going to a new school and be anxious about facing such a big transition without the usual planning and supports. Those on a college track may be worried they are “behind” academically or in college preparation.

Parents can show up when and where their children are most likely to talk, perhaps bath time or bedtime for younger children or in the car together with their adolescents. They can ask: “Have you been thinking about what it might be like to go back to school? Have your friends been chatting about it?” They might be curious together about what might have changed in a year. What might be really great about being back in a classroom? What might they miss about home school? And what might be new? Are you worried about the work, any of your friends, or not being home? If children can begin to anticipate both the good and the difficult, they will be better equipped to face and manage the challenges and appreciate the delights.

Children in elementary school are built to master new situations but are also prone to anxiety about new expectations and demands. Parents can be calmly curious about what their thoughts, feelings, and questions are and look for answers together. Often all they need is to see parents being calm in the face of uncertainty, bearing the strong feelings that may come, and preserving curiosity and compassion. Adolescents may be grieving the things they have missed, or they may have concerns about relationships and practical matters such as the implications for applying to college. Parents can offer compassion and validation and help them to devise their own strategies to face the practical challenges they are concerned about.
 

Be mindful of their children’s vulnerabilities

While most children will find the transition back to school easier than they may anticipate, there will be some for whom the transition will be very challenging. Children who have been bullied at school may have found themselves able to concentrate and learn free of the fear and stress of a classmate’s taunts or stares. Children with learning disabilities or ADHD have probably struggled with online school, but they have also likely established strategies and supports during the year that have enabled them to get enough individualized help to get their work done. These children are vulnerable to falling behind and getting discouraged when these supports are lost, and possibly not replaced with new ones in the chaos of transition. Parents should reassure their children that they will work with the school to make sure that they can succeed in the classroom as they did at home.

Children with an inhibited or shy temperament might have found that it was easier to focus and listen in the comfortable setting of home than in a busy, stimulating classroom. Children who suffer from anxiety disorders that may make separating from parents or managing the performance and social demands of school extra difficult will find the return to school especially challenging. Some younger children may have experienced the emergence of an anxiety disorder during the past year, and the return to school may mark the challenge that brings heretofore quiet symptoms into full relief.

These children have all enjoyed being able to avoid the discomfort of certain anxiety-provoking situations, and they may be particularly stressed by anticipating a return to school. Younger children may begin to have stomach aches and other physical complaints as the return to school gets close, older children may seem more withdrawn or irritable or begin discussing ways to continue school from home. Parents should help their children try to identify and describe their worries. For anxious children, having a chance to practice may be very helpful. Visiting their school, especially if it is a new school, or having a planned hangout with a friend (with appropriate precautions) is the kind of exposure that can lessen anticipatory anxiety. If this is not enough, parents should not hesitate to bring in other caring, supportive adults, such as school counselors or therapists that may be essential to helping their children face and manage what may be intense anxiety.
 

Consider routines to support their transition

Just as parents begin to return their children to an earlier bedtime toward the end of summer, it will be helpful to consider how changing certain routines will support their children now. If children will need to get up earlier to be ready for a bus or a team practice, they should start moving bedtime and wake-up time earlier gradually. Uniforms or backpacks that have not been seen for a year should be dug out. Children who are planning a return to a sport may benefit from gradually increasing their exercise or starting training now. This will have the added benefit of improving sleep and energy and fortifying children for the challenges of change. Parents might consider reaching out to other parents in the same class as their children and having a virtual conversation to share their thoughts.

If their family has developed some new “COVID routines” that they have come to enjoy, they should find a way to preserve them. Perhaps they are having dinner together more often or have established a family game night or Netflix night. Help parents consider how to avoid falling back into overscheduling their children and themselves. If they created a time to Zoom with distant or vulnerable loved ones, they might decide to continue this. School may determine some of their routines, but they should also prioritize their family connections and well-being in deciding how to schedule their days.
 

Find opportunity for mastery and meaning

As parents are listening, validating, and planning with their children, they might use this time to reflect on valuable lessons. They might point out the value of patience: Adjusting to change takes time and happens in fits and starts. It has been 12 months since many of the pandemic changes started and it will take more than a few days to adjust as schools reopen. They might point out how proud they are of what their children have been able to learn, build, or do during this year, what they admire about them. It may be a time to consider what their family may have lost and gained during the past year, what they are eager to leave behind, and what they might like to keep. And it is also a chance for parents to observe that change is an inevitable part of life (especially when growing up). It is always challenging, and often brings loss and sadness. But if we pay attention, there are also the green shoots of what is new and possible.

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

“What kind of parent are you? Why don’t you straighten him out!” rants the woman being jostled in the grocery store by your patient. “Easy for you to say,” thinks your patient’s frazzled and now insulted parent.

Blaming the parent for an out-of-control child has historically been a common refrain of neighbors, relatives, and even strangers. But considering child behavior as resulting from both parent and child factors is central to the current transactional model of child development. In this model, mismatch of the parent’s and child’s response patterns is seen as setting them up for chronically rough interactions around parent requests/demands. A parent escalating quickly from a briefly stated request to a tirade may create more tension paired with an anxious child who takes time to act, for example. Once a parent (and ultimately the child) recognize patterns in what leads to conflict, they can become more proactive in predicting and negotiating these situations. Ross Greene, PhD, explains this in his book “The Explosive Child,” calling the method Collaborative Problem Solving (now Collaborative & Proactive Solutions or CPS).

While there are general principles parents can use to modify what they consider “mis”behaviors, these methods often do not account for the “missing” skills of the individual child (and parent) predisposing to those “mis”takes. Thinking of misbehaviors as being because of a kind of “learning disability” in the child rather than willful defiance can help cool off interactions by instead focusing on solving the underlying problem.

What kinds of “gaps in skills” set a child up for defiant or explosive reactions? If you think about what features of children, and parent-child relationships are associated with harmonious interactions this becomes evident. Children over 3 who are patient, easygoing, flexible or adaptable, and good at transitions and problem-solving can delay gratification and tolerate frustration, regulate their emotions, explain their desires, and multitask. They are better at reading the parent’s needs and intent and tend to interpret requests as positive or at least neutral and are more likely to comply with parent requests without a fuss.

What? No kid you know is great at all of these? These skills, at best variable, develop with maturation. Some are part of temperament, considered normal variation in personality. For example, so-called difficult temperament includes low adaptability, high-intensity reactions, low regularity, tendency to withdraw, and negative mood. But in the extreme, weaknesses in these skills are core to or comorbid with diagnosable mental health disorders. Defiance and irritable responses are criteria for oppositional defiant disorder (ODD), and less severe categories called aggressive/oppositional problem or variation. ODD is often found in children diagnosed with ADHD (65%), Tourette’s (15%-65%), depression (70% if severe), bipolar disorder (85%), OCD, anxiety (45%), autism, and language-processing disorders (55%), or trauma. These conditions variably include lower emotion regulation, poorer executive functioning including poor task shifting and impulsivity, obsessiveness, lower expressive and receptive communication skills, and less social awareness that facilitates harmonious problem solving.

The basic components of the CPS approach to addressing parent-child conflict sound intuitive but defining them clearly is important when families are stuck. There are three levels of plans. If the problem is an emergency or nonnegotiable, e.g., child hurting the cat, it may call for Plan A – parent-imposed solutions, sometimes with consequences or rewards. As children mature, Plan A should be used less frequently. If solving the problem is not a top life priority, Plan C – postponing action, may be appropriate. Plan C highlights that behavior change is a long-term project and “picking your fights” is important.

The biggest value of CPS for resolving behavior problems comes from intermediate Plan B. In Plan B the first step of problem solving for parents facing child defiance or upset is to empathically and nonjudgmentally figure out the child’s concern. Questions such as “I’ve noticed that when I remind you that it is trash night you start shouting. What’s up with that?” then patiently asking about the who, what, where, and when of their concern and checking to ensure understanding. Specificity is important as well as noting times when the reaction occurs or not.

Once the child’s concern is clear, e.g., feeling that the demand to take out the trash now interrupts his games during the only time his friends are online, the parents should echo the child’s concern then express their own concern about how the behavior is affecting them and others, potentially including the child; e.g., mother is so upset by the shouting that she can’t sleep, and worry that the child is not learning responsibility, and then checking for child understanding.

Finally, the parent invites brainstorming for a solution that addresses both of their concerns, first asking the child for suggestions, aiming for a strategy that is realistic and specific. Children reluctant to make suggestions may need more time and the parent may be wondering “if there is a way for both of our concerns to be addressed.” Solutions chosen are then tried for several weeks, success tracked, and needed changes negotiated.

For parents, using a collaborative approach to dealing with their child’s behavior takes skills they may not have at the moment, or ever. Especially under the stresses of COVID-19 lockdown, taking a step back from an encounter to consider lack of a skill to turn off the video game promptly when a Zoom meeting starts is challenging. Parents may also genetically share the child’s predisposing ADHD, anxiety, depression, OCD, or weakness in communication or social sensitivity.

Sometimes part of the solution for a conflict is for the parent to reduce expectations. This requires understanding and accepting the child’s cognitive or emotional limitations. Reducing expectations is ideally done before a request rather than by giving in after it, which reinforces protests. For authoritarian adults rigid in their belief that parents are boss, changing expectations can be tough and can feel like losing control or failing as a leader. One benefit of working with a CPS coach (see livesinthebalance.org or ThinkKids.org) is to help parents identify their own limitations.

Predicting the types of demands that tend to create conflict, such as to act immediately or be flexible about options, allows parents to prioritize those requests for calmer moments or when there is more time for discussion. Reviewing a checklist of common gaps in skills and creating a list of expectations and triggers that are difficult for the child helps the family be more proactive in developing solutions. Authors of CPS have validated a checklist of skill deficits, “Thinking Skills Inventory,” to facilitate detection of gaps that is educational plus useful for planning specific solutions.

CPS has been shown in randomized trials with both parent groups and in home counseling to be as effective as Parent Training in reducing oppositional behavior and reducing maternal stress, with effects lasting even longer.

CPS Plan B notably has no reward or punishment components as it assumes the child wants to behave acceptably but can’t; has the “will but not the skill.” When skill deficits are worked around the child is satisfied with complying and pleasing the parents. The idea of a “function” of the misbehavior for the child of gaining attention or reward or avoiding consequences is reinterpreted as serving to communicate the problem the child is having trouble in meeting the parent’s demand. When the parent understands and helps the child solve the problem his/her misbehavior is no longer needed. A benefit of the communication and mutual problem solving used in CPS is on not only improving behavior but empowering parents and children, building parental empathy, and improving child skills.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication is as a paid expert to MDedge News. Email her at [email protected].

Reference

Greene RW et al. A transactional model of oppositional behavior: Underpinnings of the Collaborative Problem Solving approach. J Psychosom Res. 2003;55(1):67-75.

“What kind of parent are you? Why don’t you straighten him out!” rants the woman being jostled in the grocery store by your patient. “Easy for you to say,” thinks your patient’s frazzled and now insulted parent.

Blaming the parent for an out-of-control child has historically been a common refrain of neighbors, relatives, and even strangers. But considering child behavior as resulting from both parent and child factors is central to the current transactional model of child development. In this model, mismatch of the parent’s and child’s response patterns is seen as setting them up for chronically rough interactions around parent requests/demands. A parent escalating quickly from a briefly stated request to a tirade may create more tension paired with an anxious child who takes time to act, for example. Once a parent (and ultimately the child) recognize patterns in what leads to conflict, they can become more proactive in predicting and negotiating these situations. Ross Greene, PhD, explains this in his book “The Explosive Child,” calling the method Collaborative Problem Solving (now Collaborative & Proactive Solutions or CPS).

While there are general principles parents can use to modify what they consider “mis”behaviors, these methods often do not account for the “missing” skills of the individual child (and parent) predisposing to those “mis”takes. Thinking of misbehaviors as being because of a kind of “learning disability” in the child rather than willful defiance can help cool off interactions by instead focusing on solving the underlying problem.

What kinds of “gaps in skills” set a child up for defiant or explosive reactions? If you think about what features of children, and parent-child relationships are associated with harmonious interactions this becomes evident. Children over 3 who are patient, easygoing, flexible or adaptable, and good at transitions and problem-solving can delay gratification and tolerate frustration, regulate their emotions, explain their desires, and multitask. They are better at reading the parent’s needs and intent and tend to interpret requests as positive or at least neutral and are more likely to comply with parent requests without a fuss.

What? No kid you know is great at all of these? These skills, at best variable, develop with maturation. Some are part of temperament, considered normal variation in personality. For example, so-called difficult temperament includes low adaptability, high-intensity reactions, low regularity, tendency to withdraw, and negative mood. But in the extreme, weaknesses in these skills are core to or comorbid with diagnosable mental health disorders. Defiance and irritable responses are criteria for oppositional defiant disorder (ODD), and less severe categories called aggressive/oppositional problem or variation. ODD is often found in children diagnosed with ADHD (65%), Tourette’s (15%-65%), depression (70% if severe), bipolar disorder (85%), OCD, anxiety (45%), autism, and language-processing disorders (55%), or trauma. These conditions variably include lower emotion regulation, poorer executive functioning including poor task shifting and impulsivity, obsessiveness, lower expressive and receptive communication skills, and less social awareness that facilitates harmonious problem solving.

The basic components of the CPS approach to addressing parent-child conflict sound intuitive but defining them clearly is important when families are stuck. There are three levels of plans. If the problem is an emergency or nonnegotiable, e.g., child hurting the cat, it may call for Plan A – parent-imposed solutions, sometimes with consequences or rewards. As children mature, Plan A should be used less frequently. If solving the problem is not a top life priority, Plan C – postponing action, may be appropriate. Plan C highlights that behavior change is a long-term project and “picking your fights” is important.

The biggest value of CPS for resolving behavior problems comes from intermediate Plan B. In Plan B the first step of problem solving for parents facing child defiance or upset is to empathically and nonjudgmentally figure out the child’s concern. Questions such as “I’ve noticed that when I remind you that it is trash night you start shouting. What’s up with that?” then patiently asking about the who, what, where, and when of their concern and checking to ensure understanding. Specificity is important as well as noting times when the reaction occurs or not.

Once the child’s concern is clear, e.g., feeling that the demand to take out the trash now interrupts his games during the only time his friends are online, the parents should echo the child’s concern then express their own concern about how the behavior is affecting them and others, potentially including the child; e.g., mother is so upset by the shouting that she can’t sleep, and worry that the child is not learning responsibility, and then checking for child understanding.

Finally, the parent invites brainstorming for a solution that addresses both of their concerns, first asking the child for suggestions, aiming for a strategy that is realistic and specific. Children reluctant to make suggestions may need more time and the parent may be wondering “if there is a way for both of our concerns to be addressed.” Solutions chosen are then tried for several weeks, success tracked, and needed changes negotiated.

For parents, using a collaborative approach to dealing with their child’s behavior takes skills they may not have at the moment, or ever. Especially under the stresses of COVID-19 lockdown, taking a step back from an encounter to consider lack of a skill to turn off the video game promptly when a Zoom meeting starts is challenging. Parents may also genetically share the child’s predisposing ADHD, anxiety, depression, OCD, or weakness in communication or social sensitivity.

Sometimes part of the solution for a conflict is for the parent to reduce expectations. This requires understanding and accepting the child’s cognitive or emotional limitations. Reducing expectations is ideally done before a request rather than by giving in after it, which reinforces protests. For authoritarian adults rigid in their belief that parents are boss, changing expectations can be tough and can feel like losing control or failing as a leader. One benefit of working with a CPS coach (see livesinthebalance.org or ThinkKids.org) is to help parents identify their own limitations.

Predicting the types of demands that tend to create conflict, such as to act immediately or be flexible about options, allows parents to prioritize those requests for calmer moments or when there is more time for discussion. Reviewing a checklist of common gaps in skills and creating a list of expectations and triggers that are difficult for the child helps the family be more proactive in developing solutions. Authors of CPS have validated a checklist of skill deficits, “Thinking Skills Inventory,” to facilitate detection of gaps that is educational plus useful for planning specific solutions.

CPS has been shown in randomized trials with both parent groups and in home counseling to be as effective as Parent Training in reducing oppositional behavior and reducing maternal stress, with effects lasting even longer.

CPS Plan B notably has no reward or punishment components as it assumes the child wants to behave acceptably but can’t; has the “will but not the skill.” When skill deficits are worked around the child is satisfied with complying and pleasing the parents. The idea of a “function” of the misbehavior for the child of gaining attention or reward or avoiding consequences is reinterpreted as serving to communicate the problem the child is having trouble in meeting the parent’s demand. When the parent understands and helps the child solve the problem his/her misbehavior is no longer needed. A benefit of the communication and mutual problem solving used in CPS is on not only improving behavior but empowering parents and children, building parental empathy, and improving child skills.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication is as a paid expert to MDedge News. Email her at [email protected].

Reference

Greene RW et al. A transactional model of oppositional behavior: Underpinnings of the Collaborative Problem Solving approach. J Psychosom Res. 2003;55(1):67-75.

“What kind of parent are you? Why don’t you straighten him out!” rants the woman being jostled in the grocery store by your patient. “Easy for you to say,” thinks your patient’s frazzled and now insulted parent.

Blaming the parent for an out-of-control child has historically been a common refrain of neighbors, relatives, and even strangers. But considering child behavior as resulting from both parent and child factors is central to the current transactional model of child development. In this model, mismatch of the parent’s and child’s response patterns is seen as setting them up for chronically rough interactions around parent requests/demands. A parent escalating quickly from a briefly stated request to a tirade may create more tension paired with an anxious child who takes time to act, for example. Once a parent (and ultimately the child) recognize patterns in what leads to conflict, they can become more proactive in predicting and negotiating these situations. Ross Greene, PhD, explains this in his book “The Explosive Child,” calling the method Collaborative Problem Solving (now Collaborative & Proactive Solutions or CPS).

While there are general principles parents can use to modify what they consider “mis”behaviors, these methods often do not account for the “missing” skills of the individual child (and parent) predisposing to those “mis”takes. Thinking of misbehaviors as being because of a kind of “learning disability” in the child rather than willful defiance can help cool off interactions by instead focusing on solving the underlying problem.

What kinds of “gaps in skills” set a child up for defiant or explosive reactions? If you think about what features of children, and parent-child relationships are associated with harmonious interactions this becomes evident. Children over 3 who are patient, easygoing, flexible or adaptable, and good at transitions and problem-solving can delay gratification and tolerate frustration, regulate their emotions, explain their desires, and multitask. They are better at reading the parent’s needs and intent and tend to interpret requests as positive or at least neutral and are more likely to comply with parent requests without a fuss.

What? No kid you know is great at all of these? These skills, at best variable, develop with maturation. Some are part of temperament, considered normal variation in personality. For example, so-called difficult temperament includes low adaptability, high-intensity reactions, low regularity, tendency to withdraw, and negative mood. But in the extreme, weaknesses in these skills are core to or comorbid with diagnosable mental health disorders. Defiance and irritable responses are criteria for oppositional defiant disorder (ODD), and less severe categories called aggressive/oppositional problem or variation. ODD is often found in children diagnosed with ADHD (65%), Tourette’s (15%-65%), depression (70% if severe), bipolar disorder (85%), OCD, anxiety (45%), autism, and language-processing disorders (55%), or trauma. These conditions variably include lower emotion regulation, poorer executive functioning including poor task shifting and impulsivity, obsessiveness, lower expressive and receptive communication skills, and less social awareness that facilitates harmonious problem solving.

The basic components of the CPS approach to addressing parent-child conflict sound intuitive but defining them clearly is important when families are stuck. There are three levels of plans. If the problem is an emergency or nonnegotiable, e.g., child hurting the cat, it may call for Plan A – parent-imposed solutions, sometimes with consequences or rewards. As children mature, Plan A should be used less frequently. If solving the problem is not a top life priority, Plan C – postponing action, may be appropriate. Plan C highlights that behavior change is a long-term project and “picking your fights” is important.

The biggest value of CPS for resolving behavior problems comes from intermediate Plan B. In Plan B the first step of problem solving for parents facing child defiance or upset is to empathically and nonjudgmentally figure out the child’s concern. Questions such as “I’ve noticed that when I remind you that it is trash night you start shouting. What’s up with that?” then patiently asking about the who, what, where, and when of their concern and checking to ensure understanding. Specificity is important as well as noting times when the reaction occurs or not.

Once the child’s concern is clear, e.g., feeling that the demand to take out the trash now interrupts his games during the only time his friends are online, the parents should echo the child’s concern then express their own concern about how the behavior is affecting them and others, potentially including the child; e.g., mother is so upset by the shouting that she can’t sleep, and worry that the child is not learning responsibility, and then checking for child understanding.

Finally, the parent invites brainstorming for a solution that addresses both of their concerns, first asking the child for suggestions, aiming for a strategy that is realistic and specific. Children reluctant to make suggestions may need more time and the parent may be wondering “if there is a way for both of our concerns to be addressed.” Solutions chosen are then tried for several weeks, success tracked, and needed changes negotiated.

For parents, using a collaborative approach to dealing with their child’s behavior takes skills they may not have at the moment, or ever. Especially under the stresses of COVID-19 lockdown, taking a step back from an encounter to consider lack of a skill to turn off the video game promptly when a Zoom meeting starts is challenging. Parents may also genetically share the child’s predisposing ADHD, anxiety, depression, OCD, or weakness in communication or social sensitivity.

Sometimes part of the solution for a conflict is for the parent to reduce expectations. This requires understanding and accepting the child’s cognitive or emotional limitations. Reducing expectations is ideally done before a request rather than by giving in after it, which reinforces protests. For authoritarian adults rigid in their belief that parents are boss, changing expectations can be tough and can feel like losing control or failing as a leader. One benefit of working with a CPS coach (see livesinthebalance.org or ThinkKids.org) is to help parents identify their own limitations.

Predicting the types of demands that tend to create conflict, such as to act immediately or be flexible about options, allows parents to prioritize those requests for calmer moments or when there is more time for discussion. Reviewing a checklist of common gaps in skills and creating a list of expectations and triggers that are difficult for the child helps the family be more proactive in developing solutions. Authors of CPS have validated a checklist of skill deficits, “Thinking Skills Inventory,” to facilitate detection of gaps that is educational plus useful for planning specific solutions.

CPS has been shown in randomized trials with both parent groups and in home counseling to be as effective as Parent Training in reducing oppositional behavior and reducing maternal stress, with effects lasting even longer.

CPS Plan B notably has no reward or punishment components as it assumes the child wants to behave acceptably but can’t; has the “will but not the skill.” When skill deficits are worked around the child is satisfied with complying and pleasing the parents. The idea of a “function” of the misbehavior for the child of gaining attention or reward or avoiding consequences is reinterpreted as serving to communicate the problem the child is having trouble in meeting the parent’s demand. When the parent understands and helps the child solve the problem his/her misbehavior is no longer needed. A benefit of the communication and mutual problem solving used in CPS is on not only improving behavior but empowering parents and children, building parental empathy, and improving child skills.
 

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication is as a paid expert to MDedge News. Email her at [email protected].

Reference

Greene RW et al. A transactional model of oppositional behavior: Underpinnings of the Collaborative Problem Solving approach. J Psychosom Res. 2003;55(1):67-75.

The first weeks of 2021 have us considering how best to face compound challenges and we expect parents will be looking to their pediatricians for guidance. There are daily stories of the COVID-19 death toll, an abstraction made real by tragic stories of shattered families. Most families are approaching the first anniversary of their children being in virtual school, with growing concerns about the quality of virtual education, loss of socialization and group activities, and additional risks facing poor and vulnerable children. There are real concerns about the future impact of children spending so much time every day on their screens for school, extracurricular activities, social time, and relaxation. While the COVID-19 vaccines promise a return to “normal” sometime in 2021, in-person school may not return until late in the spring or next fall.

After the events of Jan. 6, families face an additional challenge: Discussing the violent invasion of the U.S. Capitol by the president’s supporters. This event was shocking, frightening, and confusing for most, and continues to be heavily covered in the news and online. There is a light in all this darkness. We have the opportunity to talk with our children – and to share explanations, perspectives, values, and even the discomfort of the unknowns – about COVID-19, use of the Internet, and the violence of Jan 6. We will consider how parents can approach this challenge for three age groups. With each group, parents will need to be calm and curious and will need time to give their children their full attention. We are all living through history. When parents can be fully present with their children, even for short periods at meals or at bedtime, it will help all to get their balance back and start to make sense of the extraordinary events we have been facing.

The youngest children (aged 3-6 years), those who were in preschool or kindergarten before the pandemic, need the most from their parents during this time. If they are attending school virtually, their online school days are likely short and challenging. Children at this age are mastering behavior rather than cognitive tasks. They are learning how to manage their bodies in space (stay in their seats!), how to be patient and kind (take turns!), and how to manage frustration (math is hard, try again!). Without the physical presence of their teacher and classmates, these lessons are tougher to internalize. Given their age-appropriate short attention spans, they often walk away from a screen, even if it’s class time. They are more likely to be paying attention to their parents, responding to the emotional climate at home. Even if they are not watching news websites themselves, they are likely to have overheard or noticed the news about recent events. Parents of young children should take care to turn off the television or their own computer, as repeated frightening videos of the insurrection can cause their children to worry that these events continue to unfold. These children need their parents’ undivided attention, even just for a little while. Play a board game with them (good chance to stay in their seats, take turns, and manage losing). Or get them outside for some physical play. While playing, parents can ask what they have seen, heard, or understand about what happened in the Capitol. Then they can correct misperceptions that might be frightening and offer reasonable reassurances in language these young children can understand. They might tell their children that sometimes people get angry when they have lost, and even adults can behave badly and make mistakes. They can focus on who the helpers are, and what they could do to help also. They could write letters of appreciation to their elected officials or to the Capitol police who were so brave in protecting others. If their children are curious, parents can find books or videos that are age appropriate about the Constitution and how elections work in a democracy. Parents don’t need to be able to answer every question, watching “Schoolhouse Rock” videos on YouTube together is a wonderful way to complement their online school and support their healthy development.

School-aged children (7-12 years) are developmentally focused on mastery experiences, whether they are social, academic, or athletic. They may be better equipped to pay attention and do homework than their younger siblings, but they will miss building friendships and having a real audience for their efforts as they build emotional maturity. They are prone to worry and distress about the big events that they can understand, at least in concrete terms, but have never faced before. These children usually have been able to use social media and online games to stay connected to friends, but they are less likely than their older siblings to independently exercise or explore new interests without a parent or teacher to guide and support them. These children are likely to be spending a lot of their time online on websites their parents don’t know about, and most likely to be curious about the events of Jan. 6. Parents should close their own device and invite their school-age children to show them what they are working on in school. Be curious about all of it, even how they are doing gym or music class. Then ask about what they have seen or heard about the election and its aftermath at school, from friends, or on their own. Let them be the teachers about what happened and how they learned about it. Parents can correct misinformation or offer reliable sources of information they can investigate together. What they will need is validation of the difficult feelings that events like these can cause; that is, acknowledgment, acceptance, and understanding of big feelings, without trying to just make those feelings go away. Parents might help them to be curious about what can make people get angry, break laws, and even hurt others, and how we protest injustices in a democracy. These children may be ready to take a deeper dive into history, via a good film or documentary, with their parents’ company for discussion afterward. Be their audience and model curiosity and patience, all the while validating the feelings that might arise.

Teenagers are developmentally focused on building their own identities, cultivating independence, and deeper relationships beyond their family. While they may be well equipped to manage online learning and to stay connected to their friends and teachers through electronic means, they are also facing considerable challenge, as their ability to explore new interests, build new relationships, and be meaningfully independent has been profoundly restrained over the past year. And they are facing other losses, as milestones like proms, performances, and competitions have been altered or missed. Parents still know when their teenager is most likely to talk, and they should check in with them during those times. They can ask them about what classes are working online and which ones aren’t, and what extracurriculars are still possible. They should not be discouraged if their teenager only offers cursory responses, it matters that they are showing up and showing interest. The election and its aftermath provide a meaningful matter to discuss; parents can find out if it is being discussed by any teachers or friends. What do they think triggered the events of Jan. 6? Who should be held responsible? How to reasonably protest injustice? What does a society do when citizens can’t agree on facts? More than offering reassurance, parents should be curious about their adolescent’s developing identity and their values, how they are thinking about complex issues around free speech and justice. It is a wonderful opportunity for parents to learn about their adolescent’s emerging identity, to be tolerant of their autonomy, and an opportunity to offer their perspective and values.

At every age, parents need to be present by listening and drawing their children out without distraction. Now is a time to build relationships and to use the difficult events of the day to shed light on deeper issues and values. This is hard, but far better than having children deal with these issues in darkness or alone.

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

The first weeks of 2021 have us considering how best to face compound challenges and we expect parents will be looking to their pediatricians for guidance. There are daily stories of the COVID-19 death toll, an abstraction made real by tragic stories of shattered families. Most families are approaching the first anniversary of their children being in virtual school, with growing concerns about the quality of virtual education, loss of socialization and group activities, and additional risks facing poor and vulnerable children. There are real concerns about the future impact of children spending so much time every day on their screens for school, extracurricular activities, social time, and relaxation. While the COVID-19 vaccines promise a return to “normal” sometime in 2021, in-person school may not return until late in the spring or next fall.

After the events of Jan. 6, families face an additional challenge: Discussing the violent invasion of the U.S. Capitol by the president’s supporters. This event was shocking, frightening, and confusing for most, and continues to be heavily covered in the news and online. There is a light in all this darkness. We have the opportunity to talk with our children – and to share explanations, perspectives, values, and even the discomfort of the unknowns – about COVID-19, use of the Internet, and the violence of Jan 6. We will consider how parents can approach this challenge for three age groups. With each group, parents will need to be calm and curious and will need time to give their children their full attention. We are all living through history. When parents can be fully present with their children, even for short periods at meals or at bedtime, it will help all to get their balance back and start to make sense of the extraordinary events we have been facing.

The youngest children (aged 3-6 years), those who were in preschool or kindergarten before the pandemic, need the most from their parents during this time. If they are attending school virtually, their online school days are likely short and challenging. Children at this age are mastering behavior rather than cognitive tasks. They are learning how to manage their bodies in space (stay in their seats!), how to be patient and kind (take turns!), and how to manage frustration (math is hard, try again!). Without the physical presence of their teacher and classmates, these lessons are tougher to internalize. Given their age-appropriate short attention spans, they often walk away from a screen, even if it’s class time. They are more likely to be paying attention to their parents, responding to the emotional climate at home. Even if they are not watching news websites themselves, they are likely to have overheard or noticed the news about recent events. Parents of young children should take care to turn off the television or their own computer, as repeated frightening videos of the insurrection can cause their children to worry that these events continue to unfold. These children need their parents’ undivided attention, even just for a little while. Play a board game with them (good chance to stay in their seats, take turns, and manage losing). Or get them outside for some physical play. While playing, parents can ask what they have seen, heard, or understand about what happened in the Capitol. Then they can correct misperceptions that might be frightening and offer reasonable reassurances in language these young children can understand. They might tell their children that sometimes people get angry when they have lost, and even adults can behave badly and make mistakes. They can focus on who the helpers are, and what they could do to help also. They could write letters of appreciation to their elected officials or to the Capitol police who were so brave in protecting others. If their children are curious, parents can find books or videos that are age appropriate about the Constitution and how elections work in a democracy. Parents don’t need to be able to answer every question, watching “Schoolhouse Rock” videos on YouTube together is a wonderful way to complement their online school and support their healthy development.

School-aged children (7-12 years) are developmentally focused on mastery experiences, whether they are social, academic, or athletic. They may be better equipped to pay attention and do homework than their younger siblings, but they will miss building friendships and having a real audience for their efforts as they build emotional maturity. They are prone to worry and distress about the big events that they can understand, at least in concrete terms, but have never faced before. These children usually have been able to use social media and online games to stay connected to friends, but they are less likely than their older siblings to independently exercise or explore new interests without a parent or teacher to guide and support them. These children are likely to be spending a lot of their time online on websites their parents don’t know about, and most likely to be curious about the events of Jan. 6. Parents should close their own device and invite their school-age children to show them what they are working on in school. Be curious about all of it, even how they are doing gym or music class. Then ask about what they have seen or heard about the election and its aftermath at school, from friends, or on their own. Let them be the teachers about what happened and how they learned about it. Parents can correct misinformation or offer reliable sources of information they can investigate together. What they will need is validation of the difficult feelings that events like these can cause; that is, acknowledgment, acceptance, and understanding of big feelings, without trying to just make those feelings go away. Parents might help them to be curious about what can make people get angry, break laws, and even hurt others, and how we protest injustices in a democracy. These children may be ready to take a deeper dive into history, via a good film or documentary, with their parents’ company for discussion afterward. Be their audience and model curiosity and patience, all the while validating the feelings that might arise.

Teenagers are developmentally focused on building their own identities, cultivating independence, and deeper relationships beyond their family. While they may be well equipped to manage online learning and to stay connected to their friends and teachers through electronic means, they are also facing considerable challenge, as their ability to explore new interests, build new relationships, and be meaningfully independent has been profoundly restrained over the past year. And they are facing other losses, as milestones like proms, performances, and competitions have been altered or missed. Parents still know when their teenager is most likely to talk, and they should check in with them during those times. They can ask them about what classes are working online and which ones aren’t, and what extracurriculars are still possible. They should not be discouraged if their teenager only offers cursory responses, it matters that they are showing up and showing interest. The election and its aftermath provide a meaningful matter to discuss; parents can find out if it is being discussed by any teachers or friends. What do they think triggered the events of Jan. 6? Who should be held responsible? How to reasonably protest injustice? What does a society do when citizens can’t agree on facts? More than offering reassurance, parents should be curious about their adolescent’s developing identity and their values, how they are thinking about complex issues around free speech and justice. It is a wonderful opportunity for parents to learn about their adolescent’s emerging identity, to be tolerant of their autonomy, and an opportunity to offer their perspective and values.

At every age, parents need to be present by listening and drawing their children out without distraction. Now is a time to build relationships and to use the difficult events of the day to shed light on deeper issues and values. This is hard, but far better than having children deal with these issues in darkness or alone.

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

The first weeks of 2021 have us considering how best to face compound challenges and we expect parents will be looking to their pediatricians for guidance. There are daily stories of the COVID-19 death toll, an abstraction made real by tragic stories of shattered families. Most families are approaching the first anniversary of their children being in virtual school, with growing concerns about the quality of virtual education, loss of socialization and group activities, and additional risks facing poor and vulnerable children. There are real concerns about the future impact of children spending so much time every day on their screens for school, extracurricular activities, social time, and relaxation. While the COVID-19 vaccines promise a return to “normal” sometime in 2021, in-person school may not return until late in the spring or next fall.

After the events of Jan. 6, families face an additional challenge: Discussing the violent invasion of the U.S. Capitol by the president’s supporters. This event was shocking, frightening, and confusing for most, and continues to be heavily covered in the news and online. There is a light in all this darkness. We have the opportunity to talk with our children – and to share explanations, perspectives, values, and even the discomfort of the unknowns – about COVID-19, use of the Internet, and the violence of Jan 6. We will consider how parents can approach this challenge for three age groups. With each group, parents will need to be calm and curious and will need time to give their children their full attention. We are all living through history. When parents can be fully present with their children, even for short periods at meals or at bedtime, it will help all to get their balance back and start to make sense of the extraordinary events we have been facing.

The youngest children (aged 3-6 years), those who were in preschool or kindergarten before the pandemic, need the most from their parents during this time. If they are attending school virtually, their online school days are likely short and challenging. Children at this age are mastering behavior rather than cognitive tasks. They are learning how to manage their bodies in space (stay in their seats!), how to be patient and kind (take turns!), and how to manage frustration (math is hard, try again!). Without the physical presence of their teacher and classmates, these lessons are tougher to internalize. Given their age-appropriate short attention spans, they often walk away from a screen, even if it’s class time. They are more likely to be paying attention to their parents, responding to the emotional climate at home. Even if they are not watching news websites themselves, they are likely to have overheard or noticed the news about recent events. Parents of young children should take care to turn off the television or their own computer, as repeated frightening videos of the insurrection can cause their children to worry that these events continue to unfold. These children need their parents’ undivided attention, even just for a little while. Play a board game with them (good chance to stay in their seats, take turns, and manage losing). Or get them outside for some physical play. While playing, parents can ask what they have seen, heard, or understand about what happened in the Capitol. Then they can correct misperceptions that might be frightening and offer reasonable reassurances in language these young children can understand. They might tell their children that sometimes people get angry when they have lost, and even adults can behave badly and make mistakes. They can focus on who the helpers are, and what they could do to help also. They could write letters of appreciation to their elected officials or to the Capitol police who were so brave in protecting others. If their children are curious, parents can find books or videos that are age appropriate about the Constitution and how elections work in a democracy. Parents don’t need to be able to answer every question, watching “Schoolhouse Rock” videos on YouTube together is a wonderful way to complement their online school and support their healthy development.

School-aged children (7-12 years) are developmentally focused on mastery experiences, whether they are social, academic, or athletic. They may be better equipped to pay attention and do homework than their younger siblings, but they will miss building friendships and having a real audience for their efforts as they build emotional maturity. They are prone to worry and distress about the big events that they can understand, at least in concrete terms, but have never faced before. These children usually have been able to use social media and online games to stay connected to friends, but they are less likely than their older siblings to independently exercise or explore new interests without a parent or teacher to guide and support them. These children are likely to be spending a lot of their time online on websites their parents don’t know about, and most likely to be curious about the events of Jan. 6. Parents should close their own device and invite their school-age children to show them what they are working on in school. Be curious about all of it, even how they are doing gym or music class. Then ask about what they have seen or heard about the election and its aftermath at school, from friends, or on their own. Let them be the teachers about what happened and how they learned about it. Parents can correct misinformation or offer reliable sources of information they can investigate together. What they will need is validation of the difficult feelings that events like these can cause; that is, acknowledgment, acceptance, and understanding of big feelings, without trying to just make those feelings go away. Parents might help them to be curious about what can make people get angry, break laws, and even hurt others, and how we protest injustices in a democracy. These children may be ready to take a deeper dive into history, via a good film or documentary, with their parents’ company for discussion afterward. Be their audience and model curiosity and patience, all the while validating the feelings that might arise.

Teenagers are developmentally focused on building their own identities, cultivating independence, and deeper relationships beyond their family. While they may be well equipped to manage online learning and to stay connected to their friends and teachers through electronic means, they are also facing considerable challenge, as their ability to explore new interests, build new relationships, and be meaningfully independent has been profoundly restrained over the past year. And they are facing other losses, as milestones like proms, performances, and competitions have been altered or missed. Parents still know when their teenager is most likely to talk, and they should check in with them during those times. They can ask them about what classes are working online and which ones aren’t, and what extracurriculars are still possible. They should not be discouraged if their teenager only offers cursory responses, it matters that they are showing up and showing interest. The election and its aftermath provide a meaningful matter to discuss; parents can find out if it is being discussed by any teachers or friends. What do they think triggered the events of Jan. 6? Who should be held responsible? How to reasonably protest injustice? What does a society do when citizens can’t agree on facts? More than offering reassurance, parents should be curious about their adolescent’s developing identity and their values, how they are thinking about complex issues around free speech and justice. It is a wonderful opportunity for parents to learn about their adolescent’s emerging identity, to be tolerant of their autonomy, and an opportunity to offer their perspective and values.

At every age, parents need to be present by listening and drawing their children out without distraction. Now is a time to build relationships and to use the difficult events of the day to shed light on deeper issues and values. This is hard, but far better than having children deal with these issues in darkness or alone.

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

All pediatricians are relieved that the rates of children smoking cigarettes has dropped steadily since 2011. This decline seems to be associated with education on the dangers of cigarettes and fewer parents smoking. Perhaps less modeling of cigarette use in movies (although it increased again from 2010 to 2019) and lawsuits against advertisements targeting children also has helped.

licsiren/iStock/Getty Images

Vaping increases the risk of severe COVID-19 disease

While EVALI deaths dropped in months after being explained, the COVID-19 epidemic is now a much greater threat to vapers. Vaping, smoking, and even second-hand smoke are associated with a greater likelihood of infection with COVID-19. Vaping increases risk of severe COVID-19 disease because of its immediate paralysis of lung cilia. Sharing vape devices and touching one’s lips while using also increase the risk of virus transmission. Vaping and smoking increase the number of ACE2 receptors to which the SARS-CoV-2 virus attaches causing the characteristic cell damage, and suppresses macrophages and neutrophils, resulting in more smokers testing positive, being twice as likely to develop a severe illness and get hospitalized because of pneumonia from COVID-19, and being less likely to recover. Unfortunately, addressing this new threat to the immediate and long-term health of our patients appears to be more complicated than for addressing smoking tobacco. First of all, vaping is much more difficult to detect than smelly cigarettes sending smoke signals from behind the garage or in the school bathrooms. Many, if not most, adults do not recognize the vaping devices when they see them, as many are tiny and some look like computer thumb drives. The aerosol emitted when in use, while containing dangerous toxins, has less odor than tobacco smoke. Vaping equipment and ads have been designed to attract youth, including linking them to sports and music events. Vaping has been advertised as a way to wean off nicotine addiction, a claim that has some scientific evidence in adults, but at a lower dose of nicotine. Warning children about the dangers of marijuana vaping has been made less credible by the rapid expansion of legalization of marijuana around the United States, eliciting “I told you it was fine” reactions from youth. And the person vaping does not know what or how much of the psychoactive components are being delivered into their bodies. One Juul pod, for example, has the equivalent in nicotine of an entire pack of 20 cigarettes. They are highly addictive, especially to the developing brain, such that youth who vape are more likely to become addicted and to smoke cigarettes in the future.

Help from federal regulation has been weak

While all 50 states ban sales to youth, adults can still buy. Food and Drug Administration limitations on kid-friendly ads, and use of sweet, fruity, and mint flavorings that are most preferred by children, apply only to new producers. The FDA does not yet regulate content of vaping solutions.

So we pediatricians are on the front line for this new threat to prevent vaping or convince youth to cut down or quit. The first step in addressing vaping is being knowledgeable about its many known and emerging health risks. It may seem obvious that the dangers of vaping microscopic particles depends on the contents. Water vapor alone is not dangerous; in fact, we prescribe it in nebulizers. Unfortunately, the contents of different vaping products vary and are not well defined in different vape products. The process of using an electric current to vaporize a substance can make it more toxic than the precursor, and teens have little idea about the substances they are inhaling. The psychoactive components vary from nicotine to tetrahydrocannabinol in varying amounts. These have the well known effects of stimulation or a high, but also the potential adverse effects of poor concentration, agitation, and even psychosis. Most e-cigarettes contain nicotine, which is highly addictive and can harm adolescent brain development, which continues into the early- to mid-20s. About two-thirds of Juul users aged 15-24 years did not know that it always contains nicotine, as do 99% of all vape solutions (Centers for Disease Control and Prevention, 2020). Earlier use of nicotine is more highly associated with later addiction to tobacco products that cause lung damage, acid reflux, insulin resistance, harm to the testes, harm to fetuses, cancer, and heart disease.

E-cigarette aerosols also contain dozens of other harmful substances besides nicotine ranging from acetone, propylene glycol, and metals to formaldehyde and ethyl benzene. These same chemicals are part of familiar toxic substances such as antifreeze, paint thinner, and pesticides. These cause ear, eye and throat irritation, and impairments in the cardiovascular system reducing athletic ability – at the least. Some flavorings in vape fluids also are toxic. Even the residual left on furniture and floors is harmful to those coming in contact, including pets.
 

How to encourage teens not to vaping

Trying to scare youth about health hazards is not generally effective in stopping risk behaviors since adolescence is a time of perceived singularity (it does not apply to me) and even a sense of immortality. Teens also see peers who vape as being unaffected and decide on using based on this small personal sample instead of valid statistics.

But teens do pay some attention to peer models or influencers saying why they do not use. One source of such testimony you can refer to is videos of inspiring athletes, musicians, and other “cool” young adults found on the naturalhigh.org website. You may know other examples of community teens desisting you can reference.

Parent rules, and less so advice, against smoking have been shown to be effective in deterring youth cigarette smoking. Because parents are less aware of vaping and its dangers, another step we can take is educating parents in our practices about vaping, its variable forms, its effects, and dangers, supplying authoritative materials, and advising them to talk with their children. Other steps the American Academy of Pediatrics recommends regarding smoking is for parents to be a role model of not using or try to quit, designate the house and car as smoking free, avoid children viewing smoking in media, tell their children about the side effects, and encourage their children who use to quit. Parents also can encourage schools to teach and have rules about smoking and vaping (e.g., med.stanford.edu/tobaccopreventiontoolkit.html).

Another approach we have been using is to not only screen for all substance use, but also to gather information about the teen’s strengths, activities, and life goals both to enhance rapport and to reference during motivational interviewing as reasons to avoid, reduce, or quit vaping. Motivational interviewing has been shown to help patients make healthier lifestyle choices by nonjudgmentally exploring their pros and cons in a conversation that takes into account readiness to change. This fits well with the stage of developing autonomy when teens want above all to make their own decisions. The cons of using can be discussed as including the effects and side effects of vaping interfering with their favored activities and moving towards their identified goals. Praising abstinence and asking them to show you how they could decline offers to vape are valuable reinforcement you can provide.

Finally, we all know that teens hate being manipulated. Vaping education we provide can make it clear that youth are being tricked by companies – most being large cigarette producers who know the dangers of vaping – into getting addicted so these companies can get rich on their money.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication is as a paid expert to MDedge News. Email her at [email protected].

All pediatricians are relieved that the rates of children smoking cigarettes has dropped steadily since 2011. This decline seems to be associated with education on the dangers of cigarettes and fewer parents smoking. Perhaps less modeling of cigarette use in movies (although it increased again from 2010 to 2019) and lawsuits against advertisements targeting children also has helped.

licsiren/iStock/Getty Images

Vaping increases the risk of severe COVID-19 disease

While EVALI deaths dropped in months after being explained, the COVID-19 epidemic is now a much greater threat to vapers. Vaping, smoking, and even second-hand smoke are associated with a greater likelihood of infection with COVID-19. Vaping increases risk of severe COVID-19 disease because of its immediate paralysis of lung cilia. Sharing vape devices and touching one’s lips while using also increase the risk of virus transmission. Vaping and smoking increase the number of ACE2 receptors to which the SARS-CoV-2 virus attaches causing the characteristic cell damage, and suppresses macrophages and neutrophils, resulting in more smokers testing positive, being twice as likely to develop a severe illness and get hospitalized because of pneumonia from COVID-19, and being less likely to recover. Unfortunately, addressing this new threat to the immediate and long-term health of our patients appears to be more complicated than for addressing smoking tobacco. First of all, vaping is much more difficult to detect than smelly cigarettes sending smoke signals from behind the garage or in the school bathrooms. Many, if not most, adults do not recognize the vaping devices when they see them, as many are tiny and some look like computer thumb drives. The aerosol emitted when in use, while containing dangerous toxins, has less odor than tobacco smoke. Vaping equipment and ads have been designed to attract youth, including linking them to sports and music events. Vaping has been advertised as a way to wean off nicotine addiction, a claim that has some scientific evidence in adults, but at a lower dose of nicotine. Warning children about the dangers of marijuana vaping has been made less credible by the rapid expansion of legalization of marijuana around the United States, eliciting “I told you it was fine” reactions from youth. And the person vaping does not know what or how much of the psychoactive components are being delivered into their bodies. One Juul pod, for example, has the equivalent in nicotine of an entire pack of 20 cigarettes. They are highly addictive, especially to the developing brain, such that youth who vape are more likely to become addicted and to smoke cigarettes in the future.

Help from federal regulation has been weak

While all 50 states ban sales to youth, adults can still buy. Food and Drug Administration limitations on kid-friendly ads, and use of sweet, fruity, and mint flavorings that are most preferred by children, apply only to new producers. The FDA does not yet regulate content of vaping solutions.

So we pediatricians are on the front line for this new threat to prevent vaping or convince youth to cut down or quit. The first step in addressing vaping is being knowledgeable about its many known and emerging health risks. It may seem obvious that the dangers of vaping microscopic particles depends on the contents. Water vapor alone is not dangerous; in fact, we prescribe it in nebulizers. Unfortunately, the contents of different vaping products vary and are not well defined in different vape products. The process of using an electric current to vaporize a substance can make it more toxic than the precursor, and teens have little idea about the substances they are inhaling. The psychoactive components vary from nicotine to tetrahydrocannabinol in varying amounts. These have the well known effects of stimulation or a high, but also the potential adverse effects of poor concentration, agitation, and even psychosis. Most e-cigarettes contain nicotine, which is highly addictive and can harm adolescent brain development, which continues into the early- to mid-20s. About two-thirds of Juul users aged 15-24 years did not know that it always contains nicotine, as do 99% of all vape solutions (Centers for Disease Control and Prevention, 2020). Earlier use of nicotine is more highly associated with later addiction to tobacco products that cause lung damage, acid reflux, insulin resistance, harm to the testes, harm to fetuses, cancer, and heart disease.

E-cigarette aerosols also contain dozens of other harmful substances besides nicotine ranging from acetone, propylene glycol, and metals to formaldehyde and ethyl benzene. These same chemicals are part of familiar toxic substances such as antifreeze, paint thinner, and pesticides. These cause ear, eye and throat irritation, and impairments in the cardiovascular system reducing athletic ability – at the least. Some flavorings in vape fluids also are toxic. Even the residual left on furniture and floors is harmful to those coming in contact, including pets.
 

How to encourage teens not to vaping

Trying to scare youth about health hazards is not generally effective in stopping risk behaviors since adolescence is a time of perceived singularity (it does not apply to me) and even a sense of immortality. Teens also see peers who vape as being unaffected and decide on using based on this small personal sample instead of valid statistics.

But teens do pay some attention to peer models or influencers saying why they do not use. One source of such testimony you can refer to is videos of inspiring athletes, musicians, and other “cool” young adults found on the naturalhigh.org website. You may know other examples of community teens desisting you can reference.

Parent rules, and less so advice, against smoking have been shown to be effective in deterring youth cigarette smoking. Because parents are less aware of vaping and its dangers, another step we can take is educating parents in our practices about vaping, its variable forms, its effects, and dangers, supplying authoritative materials, and advising them to talk with their children. Other steps the American Academy of Pediatrics recommends regarding smoking is for parents to be a role model of not using or try to quit, designate the house and car as smoking free, avoid children viewing smoking in media, tell their children about the side effects, and encourage their children who use to quit. Parents also can encourage schools to teach and have rules about smoking and vaping (e.g., med.stanford.edu/tobaccopreventiontoolkit.html).

Another approach we have been using is to not only screen for all substance use, but also to gather information about the teen’s strengths, activities, and life goals both to enhance rapport and to reference during motivational interviewing as reasons to avoid, reduce, or quit vaping. Motivational interviewing has been shown to help patients make healthier lifestyle choices by nonjudgmentally exploring their pros and cons in a conversation that takes into account readiness to change. This fits well with the stage of developing autonomy when teens want above all to make their own decisions. The cons of using can be discussed as including the effects and side effects of vaping interfering with their favored activities and moving towards their identified goals. Praising abstinence and asking them to show you how they could decline offers to vape are valuable reinforcement you can provide.

Finally, we all know that teens hate being manipulated. Vaping education we provide can make it clear that youth are being tricked by companies – most being large cigarette producers who know the dangers of vaping – into getting addicted so these companies can get rich on their money.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication is as a paid expert to MDedge News. Email her at [email protected].

All pediatricians are relieved that the rates of children smoking cigarettes has dropped steadily since 2011. This decline seems to be associated with education on the dangers of cigarettes and fewer parents smoking. Perhaps less modeling of cigarette use in movies (although it increased again from 2010 to 2019) and lawsuits against advertisements targeting children also has helped.

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Vaping increases the risk of severe COVID-19 disease

While EVALI deaths dropped in months after being explained, the COVID-19 epidemic is now a much greater threat to vapers. Vaping, smoking, and even second-hand smoke are associated with a greater likelihood of infection with COVID-19. Vaping increases risk of severe COVID-19 disease because of its immediate paralysis of lung cilia. Sharing vape devices and touching one’s lips while using also increase the risk of virus transmission. Vaping and smoking increase the number of ACE2 receptors to which the SARS-CoV-2 virus attaches causing the characteristic cell damage, and suppresses macrophages and neutrophils, resulting in more smokers testing positive, being twice as likely to develop a severe illness and get hospitalized because of pneumonia from COVID-19, and being less likely to recover. Unfortunately, addressing this new threat to the immediate and long-term health of our patients appears to be more complicated than for addressing smoking tobacco. First of all, vaping is much more difficult to detect than smelly cigarettes sending smoke signals from behind the garage or in the school bathrooms. Many, if not most, adults do not recognize the vaping devices when they see them, as many are tiny and some look like computer thumb drives. The aerosol emitted when in use, while containing dangerous toxins, has less odor than tobacco smoke. Vaping equipment and ads have been designed to attract youth, including linking them to sports and music events. Vaping has been advertised as a way to wean off nicotine addiction, a claim that has some scientific evidence in adults, but at a lower dose of nicotine. Warning children about the dangers of marijuana vaping has been made less credible by the rapid expansion of legalization of marijuana around the United States, eliciting “I told you it was fine” reactions from youth. And the person vaping does not know what or how much of the psychoactive components are being delivered into their bodies. One Juul pod, for example, has the equivalent in nicotine of an entire pack of 20 cigarettes. They are highly addictive, especially to the developing brain, such that youth who vape are more likely to become addicted and to smoke cigarettes in the future.

Help from federal regulation has been weak

While all 50 states ban sales to youth, adults can still buy. Food and Drug Administration limitations on kid-friendly ads, and use of sweet, fruity, and mint flavorings that are most preferred by children, apply only to new producers. The FDA does not yet regulate content of vaping solutions.

So we pediatricians are on the front line for this new threat to prevent vaping or convince youth to cut down or quit. The first step in addressing vaping is being knowledgeable about its many known and emerging health risks. It may seem obvious that the dangers of vaping microscopic particles depends on the contents. Water vapor alone is not dangerous; in fact, we prescribe it in nebulizers. Unfortunately, the contents of different vaping products vary and are not well defined in different vape products. The process of using an electric current to vaporize a substance can make it more toxic than the precursor, and teens have little idea about the substances they are inhaling. The psychoactive components vary from nicotine to tetrahydrocannabinol in varying amounts. These have the well known effects of stimulation or a high, but also the potential adverse effects of poor concentration, agitation, and even psychosis. Most e-cigarettes contain nicotine, which is highly addictive and can harm adolescent brain development, which continues into the early- to mid-20s. About two-thirds of Juul users aged 15-24 years did not know that it always contains nicotine, as do 99% of all vape solutions (Centers for Disease Control and Prevention, 2020). Earlier use of nicotine is more highly associated with later addiction to tobacco products that cause lung damage, acid reflux, insulin resistance, harm to the testes, harm to fetuses, cancer, and heart disease.

E-cigarette aerosols also contain dozens of other harmful substances besides nicotine ranging from acetone, propylene glycol, and metals to formaldehyde and ethyl benzene. These same chemicals are part of familiar toxic substances such as antifreeze, paint thinner, and pesticides. These cause ear, eye and throat irritation, and impairments in the cardiovascular system reducing athletic ability – at the least. Some flavorings in vape fluids also are toxic. Even the residual left on furniture and floors is harmful to those coming in contact, including pets.
 

How to encourage teens not to vaping

Trying to scare youth about health hazards is not generally effective in stopping risk behaviors since adolescence is a time of perceived singularity (it does not apply to me) and even a sense of immortality. Teens also see peers who vape as being unaffected and decide on using based on this small personal sample instead of valid statistics.

But teens do pay some attention to peer models or influencers saying why they do not use. One source of such testimony you can refer to is videos of inspiring athletes, musicians, and other “cool” young adults found on the naturalhigh.org website. You may know other examples of community teens desisting you can reference.

Parent rules, and less so advice, against smoking have been shown to be effective in deterring youth cigarette smoking. Because parents are less aware of vaping and its dangers, another step we can take is educating parents in our practices about vaping, its variable forms, its effects, and dangers, supplying authoritative materials, and advising them to talk with their children. Other steps the American Academy of Pediatrics recommends regarding smoking is for parents to be a role model of not using or try to quit, designate the house and car as smoking free, avoid children viewing smoking in media, tell their children about the side effects, and encourage their children who use to quit. Parents also can encourage schools to teach and have rules about smoking and vaping (e.g., med.stanford.edu/tobaccopreventiontoolkit.html).

Another approach we have been using is to not only screen for all substance use, but also to gather information about the teen’s strengths, activities, and life goals both to enhance rapport and to reference during motivational interviewing as reasons to avoid, reduce, or quit vaping. Motivational interviewing has been shown to help patients make healthier lifestyle choices by nonjudgmentally exploring their pros and cons in a conversation that takes into account readiness to change. This fits well with the stage of developing autonomy when teens want above all to make their own decisions. The cons of using can be discussed as including the effects and side effects of vaping interfering with their favored activities and moving towards their identified goals. Praising abstinence and asking them to show you how they could decline offers to vape are valuable reinforcement you can provide.

Finally, we all know that teens hate being manipulated. Vaping education we provide can make it clear that youth are being tricked by companies – most being large cigarette producers who know the dangers of vaping – into getting addicted so these companies can get rich on their money.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication is as a paid expert to MDedge News. Email her at [email protected].