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Solving stool refusal
When parents bring in their delightful, verbal 3-year-old for refusing to poop on the potty, it may seem laughable. But with impending preschool and costs of diapers, stool refusal can be a major aggravation for families! Fortunately,
Commonly a healthy, typically developing boy stands and urinates in the toilet just fine, but sneaks off behind the sofa to poop. Parent gyrations have gone from cajoling, to punishing, to offering trips to Disney! Flaring tempers can set the stage for stool refusal to be a power play.
There are a number of reasons stool refusal may give clues to child and family tendencies and relevant intervention. We always should be alert to rare medical problems such as Hirschsprung disease or traumas (from slammed toilet lids to sexual abuse). But while learning to use the toilet for urination and defecation generally occur around the same time, there are pitfalls making pooping in the potty different. An impending stool provides stronger sensations and more advance warning than urine and tends to come at regular times, making it logical to start toilet learning with sitting on the potty after meals.
But once seated on the potty, stools can require some waiting – not a typical toddler forte! While running to sit has novelty at first and may be reinforced by celebration, this quickly becomes routine and boring. Very active or very intense children especially hate having their play interrupted by a trip to the bathroom. Oppositional children just won’t perform if they think the parent cares! And unlike for urination, everyone can inhibit defecation long enough for the urge to pass. Repeated stool retention from ignoring the urge makes stools dessicated and harder, with resulting pain when finally passed. One painful stool makes many a young child decide “Never again!” and simply refuse the toilet. A rectal fissure can both start 
During unclogging and establishing a new stool pattern, the toddler should be matter-of-factly put back in diapers (not pull ups) saying “Oh well, you are just not ready for pants yet.” Dramatically placing the treasured Superhero underwear on the top shelf increases motivation (or promised if none have been acquired). Returning to diapers without shaming the child is key, and all caregivers need to buy in. They need to be good “actors,” conveying that they don’t really care about toileting to reduce the power struggle. If controlling poop is a battle, only the child can win!
When the soft stools are occurring several times per day, I suggest “M&M treatment”: 1 for sitting, 2 for peeing, and 3 for pooping = 6 potential M&Ms per episode. The “1 for sitting” (the easiest part), is not painful and restores the habit of complying. Remember, M&Ms are no match for a game on an iPad! By charting the times of stools, the parent can remove electronics ½ hour before the expected poop and restrict the child to one room of the house with a potty nearby. Parents can interact, but should avoid making this a rewarding playtime. When the child uses the potty rather than their pants, the room restriction is removed until the next window for pooping. If they poop outside the toilet, they remain restricted (and no electronics) until the next window (even the next day).
Some parents are especially sensitive to the smell and mess of stools and pass that attitude along to their child by saying “Ugh, you stink!” or “I can’t stand this mess!” or even handing the child to another caregiver in a gesture of rejection. These messages are not missed by the child, who may then not want to deal with the mess, either. I coach parents to stay at least neutral about stools, reminding them that, “Your child is going to have to poop her whole life!”
Demanding a diaper and then getting the special intimacy of bottom cleaning can be reinforcing. If there is a younger sibling, diaper changes may be a desired opportunity for the toddler to regress and retain some “baby privileges.” Other clues to this dynamic include thumb sucking, baby talk, clinginess, or being rough on the sibling. One part of addressing this issue is to prescribe “babying” the toddler by holding in arms, rocking, talking baby talk, offering a pacifier, and feeding him during daily parent-child one-on-one Special Time. This sounds crazy to parents aiming for grown up toileting, but I promise them the child will not go backwards! It addresses the child’s deep fear that the nurturing of infancy is no longer available.
You may have noticed that boys are much more likely to refuse stools than girls. Some of this difference may be that high activity, but learning to urinate standing up also is fun, a Big Boy feat, and a source of pride to fathers. If regular sitting to poop has not been well established before the fun of standing to pee is offered, the little guys are not so interested in sitting again to poop. Plus the wiping and hand washing after poops are further aggravations delaying return to the Legos. But more! By around age 3 years, both genders make the horrifying discovery that boys have a penis and girls don’t. At this age of confusion about potential transformations, the obvious conclusion is that the girl’s penis was lost! And that turd disappearing down the toilet looks a lot like a dismembered body part! Reassurance and education is in order. I address this with my “Penis Talk”: “Boys are made with a penis and girls are made with a vagina. (For boys:) When you get big like your Dad, your penis will be big, too. No one can ever take your penis away. (For girls, a less common concern.) You have always had a vagina. You did not lose a penis.” I recommend that you practice this in front of a mirror before first use!
Another cognitive milestone concerns what sorts of things can disappear dow
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at [email protected].
When parents bring in their delightful, verbal 3-year-old for refusing to poop on the potty, it may seem laughable. But with impending preschool and costs of diapers, stool refusal can be a major aggravation for families! Fortunately,
Commonly a healthy, typically developing boy stands and urinates in the toilet just fine, but sneaks off behind the sofa to poop. Parent gyrations have gone from cajoling, to punishing, to offering trips to Disney! Flaring tempers can set the stage for stool refusal to be a power play.
There are a number of reasons stool refusal may give clues to child and family tendencies and relevant intervention. We always should be alert to rare medical problems such as Hirschsprung disease or traumas (from slammed toilet lids to sexual abuse). But while learning to use the toilet for urination and defecation generally occur around the same time, there are pitfalls making pooping in the potty different. An impending stool provides stronger sensations and more advance warning than urine and tends to come at regular times, making it logical to start toilet learning with sitting on the potty after meals.
But once seated on the potty, stools can require some waiting – not a typical toddler forte! While running to sit has novelty at first and may be reinforced by celebration, this quickly becomes routine and boring. Very active or very intense children especially hate having their play interrupted by a trip to the bathroom. Oppositional children just won’t perform if they think the parent cares! And unlike for urination, everyone can inhibit defecation long enough for the urge to pass. Repeated stool retention from ignoring the urge makes stools dessicated and harder, with resulting pain when finally passed. One painful stool makes many a young child decide “Never again!” and simply refuse the toilet. A rectal fissure can both start
During unclogging and establishing a new stool pattern, the toddler should be matter-of-factly put back in diapers (not pull ups) saying “Oh well, you are just not ready for pants yet.” Dramatically placing the treasured Superhero underwear on the top shelf increases motivation (or promised if none have been acquired). Returning to diapers without shaming the child is key, and all caregivers need to buy in. They need to be good “actors,” conveying that they don’t really care about toileting to reduce the power struggle. If controlling poop is a battle, only the child can win!
When the soft stools are occurring several times per day, I suggest “M&M treatment”: 1 for sitting, 2 for peeing, and 3 for pooping = 6 potential M&Ms per episode. The “1 for sitting” (the easiest part), is not painful and restores the habit of complying. Remember, M&Ms are no match for a game on an iPad! By charting the times of stools, the parent can remove electronics ½ hour before the expected poop and restrict the child to one room of the house with a potty nearby. Parents can interact, but should avoid making this a rewarding playtime. When the child uses the potty rather than their pants, the room restriction is removed until the next window for pooping. If they poop outside the toilet, they remain restricted (and no electronics) until the next window (even the next day).
Some parents are especially sensitive to the smell and mess of stools and pass that attitude along to their child by saying “Ugh, you stink!” or “I can’t stand this mess!” or even handing the child to another caregiver in a gesture of rejection. These messages are not missed by the child, who may then not want to deal with the mess, either. I coach parents to stay at least neutral about stools, reminding them that, “Your child is going to have to poop her whole life!”
Demanding a diaper and then getting the special intimacy of bottom cleaning can be reinforcing. If there is a younger sibling, diaper changes may be a desired opportunity for the toddler to regress and retain some “baby privileges.” Other clues to this dynamic include thumb sucking, baby talk, clinginess, or being rough on the sibling. One part of addressing this issue is to prescribe “babying” the toddler by holding in arms, rocking, talking baby talk, offering a pacifier, and feeding him during daily parent-child one-on-one Special Time. This sounds crazy to parents aiming for grown up toileting, but I promise them the child will not go backwards! It addresses the child’s deep fear that the nurturing of infancy is no longer available.
You may have noticed that boys are much more likely to refuse stools than girls. Some of this difference may be that high activity, but learning to urinate standing up also is fun, a Big Boy feat, and a source of pride to fathers. If regular sitting to poop has not been well established before the fun of standing to pee is offered, the little guys are not so interested in sitting again to poop. Plus the wiping and hand washing after poops are further aggravations delaying return to the Legos. But more! By around age 3 years, both genders make the horrifying discovery that boys have a penis and girls don’t. At this age of confusion about potential transformations, the obvious conclusion is that the girl’s penis was lost! And that turd disappearing down the toilet looks a lot like a dismembered body part! Reassurance and education is in order. I address this with my “Penis Talk”: “Boys are made with a penis and girls are made with a vagina. (For boys:) When you get big like your Dad, your penis will be big, too. No one can ever take your penis away. (For girls, a less common concern.) You have always had a vagina. You did not lose a penis.” I recommend that you practice this in front of a mirror before first use!
Another cognitive milestone concerns what sorts of things can disappear dow
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at [email protected].
When parents bring in their delightful, verbal 3-year-old for refusing to poop on the potty, it may seem laughable. But with impending preschool and costs of diapers, stool refusal can be a major aggravation for families! Fortunately,
Commonly a healthy, typically developing boy stands and urinates in the toilet just fine, but sneaks off behind the sofa to poop. Parent gyrations have gone from cajoling, to punishing, to offering trips to Disney! Flaring tempers can set the stage for stool refusal to be a power play.
There are a number of reasons stool refusal may give clues to child and family tendencies and relevant intervention. We always should be alert to rare medical problems such as Hirschsprung disease or traumas (from slammed toilet lids to sexual abuse). But while learning to use the toilet for urination and defecation generally occur around the same time, there are pitfalls making pooping in the potty different. An impending stool provides stronger sensations and more advance warning than urine and tends to come at regular times, making it logical to start toilet learning with sitting on the potty after meals.
But once seated on the potty, stools can require some waiting – not a typical toddler forte! While running to sit has novelty at first and may be reinforced by celebration, this quickly becomes routine and boring. Very active or very intense children especially hate having their play interrupted by a trip to the bathroom. Oppositional children just won’t perform if they think the parent cares! And unlike for urination, everyone can inhibit defecation long enough for the urge to pass. Repeated stool retention from ignoring the urge makes stools dessicated and harder, with resulting pain when finally passed. One painful stool makes many a young child decide “Never again!” and simply refuse the toilet. A rectal fissure can both start
During unclogging and establishing a new stool pattern, the toddler should be matter-of-factly put back in diapers (not pull ups) saying “Oh well, you are just not ready for pants yet.” Dramatically placing the treasured Superhero underwear on the top shelf increases motivation (or promised if none have been acquired). Returning to diapers without shaming the child is key, and all caregivers need to buy in. They need to be good “actors,” conveying that they don’t really care about toileting to reduce the power struggle. If controlling poop is a battle, only the child can win!
When the soft stools are occurring several times per day, I suggest “M&M treatment”: 1 for sitting, 2 for peeing, and 3 for pooping = 6 potential M&Ms per episode. The “1 for sitting” (the easiest part), is not painful and restores the habit of complying. Remember, M&Ms are no match for a game on an iPad! By charting the times of stools, the parent can remove electronics ½ hour before the expected poop and restrict the child to one room of the house with a potty nearby. Parents can interact, but should avoid making this a rewarding playtime. When the child uses the potty rather than their pants, the room restriction is removed until the next window for pooping. If they poop outside the toilet, they remain restricted (and no electronics) until the next window (even the next day).
Some parents are especially sensitive to the smell and mess of stools and pass that attitude along to their child by saying “Ugh, you stink!” or “I can’t stand this mess!” or even handing the child to another caregiver in a gesture of rejection. These messages are not missed by the child, who may then not want to deal with the mess, either. I coach parents to stay at least neutral about stools, reminding them that, “Your child is going to have to poop her whole life!”
Demanding a diaper and then getting the special intimacy of bottom cleaning can be reinforcing. If there is a younger sibling, diaper changes may be a desired opportunity for the toddler to regress and retain some “baby privileges.” Other clues to this dynamic include thumb sucking, baby talk, clinginess, or being rough on the sibling. One part of addressing this issue is to prescribe “babying” the toddler by holding in arms, rocking, talking baby talk, offering a pacifier, and feeding him during daily parent-child one-on-one Special Time. This sounds crazy to parents aiming for grown up toileting, but I promise them the child will not go backwards! It addresses the child’s deep fear that the nurturing of infancy is no longer available.
You may have noticed that boys are much more likely to refuse stools than girls. Some of this difference may be that high activity, but learning to urinate standing up also is fun, a Big Boy feat, and a source of pride to fathers. If regular sitting to poop has not been well established before the fun of standing to pee is offered, the little guys are not so interested in sitting again to poop. Plus the wiping and hand washing after poops are further aggravations delaying return to the Legos. But more! By around age 3 years, both genders make the horrifying discovery that boys have a penis and girls don’t. At this age of confusion about potential transformations, the obvious conclusion is that the girl’s penis was lost! And that turd disappearing down the toilet looks a lot like a dismembered body part! Reassurance and education is in order. I address this with my “Penis Talk”: “Boys are made with a penis and girls are made with a vagina. (For boys:) When you get big like your Dad, your penis will be big, too. No one can ever take your penis away. (For girls, a less common concern.) You have always had a vagina. You did not lose a penis.” I recommend that you practice this in front of a mirror before first use!
Another cognitive milestone concerns what sorts of things can disappear dow
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at [email protected].
Adolescents and sleep, or the lack thereof
Every parent will attest that bright-eyed children grow into sleepy adolescents, and the science confirms their observations. There are multiple factors that prevent adolescents from getting the sleep they need, and inadequate sleep has serious consequences – from impaired learning to depressive symptoms, obesity to deadly accidents – all of which are potentially preventable with some practical strategies to promote adequate sleep.
Adolescence is a period of intense growth and development, so it is no surprise that adolescents require a lot of sleep, over 9 hours nightly. But surveys have shown that only 3% of American adolescents get 9 hours of sleep nightly, and the average amount of weeknight sleep is only 6 hours.1 Sleep deprivation is not a problem in childhood, so why can’t adolescents get enough sleep?
Over the last 15 years, a new factor – screen time – has worsened the adolescent sleep situation. Most teens have an electronic device in their bedroom and use it for homework, entertainment, and socializing well into the night. Multiple studies have confirmed that electronic exposure in the evening is associated with less sleep at night and more day time sleepiness,by competing with sleep and suppression of nocturnal melatonin release, which can delay the onset of sleep.2
It is ironic that many teens are staying up late for homework, when their lack of sleep can interfere with consolidation of learning. It also has powerful effects on working memory and reaction time, making both academic and athletic performance suffer. Chronically sleep-deprived teenagers often complain of difficulty with initiating and sustaining attention, which may lead to a mistaken diagnosis of ADHD, and stimulant treatment may further complicate sleep.
Good mental health is not the only casualty of inadequate sleep. A growing body of evidence links short sleep duration with an increased risk of obesity. This appears to be mediated by alterations in neurohormones associated with sleep, leading to higher carbohydrate and fat intake, more snacking and insulin resistance.
Anything that compromises attention and reaction time, including sleep deprivation, adds risk to driving, particularly for inexperienced and impulsive adolescent drivers. The National Highway Transportation Safety Administration estimates that drivers 25 and younger cause more than half of all “fall asleep” crashes.
Teenagers generally know that they are exhausted, but the strategies they might use to manage their fatigue can actually make things worse. Sleepy teenagers often consume large amounts of caffeine to get through their days and their homework at night. Caffeine, in turn, interferes with both the onset and quality of sleep, perpetuating the cycle. Even “catch-up” sleep on weekends is a strategy that can contribute to the problem, as it can lead to more disrupted sleep by pushing the onset of school night sleepiness even later.
While growing autonomy is part of why teenagers are sleep deprived, they will consider the caring and informed guidance of their pediatricians about their health. Ask your teenage patients how much sleep they usually get on a school night. It can be validating to show them how sleep deprived they are, and point out how strategies like caffeine and oversleeping might be making it worse. Explain that people (adults, too!) need to make time for sleep just as they might for exercise or friends. Tell them about “good sleep hygiene,” the practice of having consistent sleep times and routines that are conducive to restful sleep. This can include a hot shower before bed, reading for the last 30 minutes before lights out, and no screen time for at least 1 hour before bed. Indeed, it can be powerful to urge that everyone in the family takes screens out of their bedrooms.
Additionally, while they might sleep in on weekends, it shouldn’t be much more than an hour longer than on weekdays. And no naps after school! It is common for teens to feel overwhelmed by their commitments and that sleep must be the first thing to go. Use their growing sense of autonomy to remind them that they get to choose how to use their time, and balance will pay off much more than sacrificing sleep. A practical conversation about sleep can help them to make informed choices and thoughtfully take care of themselves before they head off to college.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
Resources
1. “Adolescent Sleep Needs and Patterns: Research Report and Resource Guide.” (Arlington, Va.: National Sleep Foundation, 2000.)
2. Pediatrics. 2014 Sep;134(3):e921-32.
3. Sleep. 2004 Nov 1;27(7):1351-8.
Every parent will attest that bright-eyed children grow into sleepy adolescents, and the science confirms their observations. There are multiple factors that prevent adolescents from getting the sleep they need, and inadequate sleep has serious consequences – from impaired learning to depressive symptoms, obesity to deadly accidents – all of which are potentially preventable with some practical strategies to promote adequate sleep.
Adolescence is a period of intense growth and development, so it is no surprise that adolescents require a lot of sleep, over 9 hours nightly. But surveys have shown that only 3% of American adolescents get 9 hours of sleep nightly, and the average amount of weeknight sleep is only 6 hours.1 Sleep deprivation is not a problem in childhood, so why can’t adolescents get enough sleep?
Over the last 15 years, a new factor – screen time – has worsened the adolescent sleep situation. Most teens have an electronic device in their bedroom and use it for homework, entertainment, and socializing well into the night. Multiple studies have confirmed that electronic exposure in the evening is associated with less sleep at night and more day time sleepiness,by competing with sleep and suppression of nocturnal melatonin release, which can delay the onset of sleep.2
It is ironic that many teens are staying up late for homework, when their lack of sleep can interfere with consolidation of learning. It also has powerful effects on working memory and reaction time, making both academic and athletic performance suffer. Chronically sleep-deprived teenagers often complain of difficulty with initiating and sustaining attention, which may lead to a mistaken diagnosis of ADHD, and stimulant treatment may further complicate sleep.
Good mental health is not the only casualty of inadequate sleep. A growing body of evidence links short sleep duration with an increased risk of obesity. This appears to be mediated by alterations in neurohormones associated with sleep, leading to higher carbohydrate and fat intake, more snacking and insulin resistance.
Anything that compromises attention and reaction time, including sleep deprivation, adds risk to driving, particularly for inexperienced and impulsive adolescent drivers. The National Highway Transportation Safety Administration estimates that drivers 25 and younger cause more than half of all “fall asleep” crashes.
Teenagers generally know that they are exhausted, but the strategies they might use to manage their fatigue can actually make things worse. Sleepy teenagers often consume large amounts of caffeine to get through their days and their homework at night. Caffeine, in turn, interferes with both the onset and quality of sleep, perpetuating the cycle. Even “catch-up” sleep on weekends is a strategy that can contribute to the problem, as it can lead to more disrupted sleep by pushing the onset of school night sleepiness even later.
While growing autonomy is part of why teenagers are sleep deprived, they will consider the caring and informed guidance of their pediatricians about their health. Ask your teenage patients how much sleep they usually get on a school night. It can be validating to show them how sleep deprived they are, and point out how strategies like caffeine and oversleeping might be making it worse. Explain that people (adults, too!) need to make time for sleep just as they might for exercise or friends. Tell them about “good sleep hygiene,” the practice of having consistent sleep times and routines that are conducive to restful sleep. This can include a hot shower before bed, reading for the last 30 minutes before lights out, and no screen time for at least 1 hour before bed. Indeed, it can be powerful to urge that everyone in the family takes screens out of their bedrooms.
Additionally, while they might sleep in on weekends, it shouldn’t be much more than an hour longer than on weekdays. And no naps after school! It is common for teens to feel overwhelmed by their commitments and that sleep must be the first thing to go. Use their growing sense of autonomy to remind them that they get to choose how to use their time, and balance will pay off much more than sacrificing sleep. A practical conversation about sleep can help them to make informed choices and thoughtfully take care of themselves before they head off to college.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
Resources
1. “Adolescent Sleep Needs and Patterns: Research Report and Resource Guide.” (Arlington, Va.: National Sleep Foundation, 2000.)
2. Pediatrics. 2014 Sep;134(3):e921-32.
3. Sleep. 2004 Nov 1;27(7):1351-8.
Every parent will attest that bright-eyed children grow into sleepy adolescents, and the science confirms their observations. There are multiple factors that prevent adolescents from getting the sleep they need, and inadequate sleep has serious consequences – from impaired learning to depressive symptoms, obesity to deadly accidents – all of which are potentially preventable with some practical strategies to promote adequate sleep.
Adolescence is a period of intense growth and development, so it is no surprise that adolescents require a lot of sleep, over 9 hours nightly. But surveys have shown that only 3% of American adolescents get 9 hours of sleep nightly, and the average amount of weeknight sleep is only 6 hours.1 Sleep deprivation is not a problem in childhood, so why can’t adolescents get enough sleep?
Over the last 15 years, a new factor – screen time – has worsened the adolescent sleep situation. Most teens have an electronic device in their bedroom and use it for homework, entertainment, and socializing well into the night. Multiple studies have confirmed that electronic exposure in the evening is associated with less sleep at night and more day time sleepiness,by competing with sleep and suppression of nocturnal melatonin release, which can delay the onset of sleep.2
It is ironic that many teens are staying up late for homework, when their lack of sleep can interfere with consolidation of learning. It also has powerful effects on working memory and reaction time, making both academic and athletic performance suffer. Chronically sleep-deprived teenagers often complain of difficulty with initiating and sustaining attention, which may lead to a mistaken diagnosis of ADHD, and stimulant treatment may further complicate sleep.
Good mental health is not the only casualty of inadequate sleep. A growing body of evidence links short sleep duration with an increased risk of obesity. This appears to be mediated by alterations in neurohormones associated with sleep, leading to higher carbohydrate and fat intake, more snacking and insulin resistance.
Anything that compromises attention and reaction time, including sleep deprivation, adds risk to driving, particularly for inexperienced and impulsive adolescent drivers. The National Highway Transportation Safety Administration estimates that drivers 25 and younger cause more than half of all “fall asleep” crashes.
Teenagers generally know that they are exhausted, but the strategies they might use to manage their fatigue can actually make things worse. Sleepy teenagers often consume large amounts of caffeine to get through their days and their homework at night. Caffeine, in turn, interferes with both the onset and quality of sleep, perpetuating the cycle. Even “catch-up” sleep on weekends is a strategy that can contribute to the problem, as it can lead to more disrupted sleep by pushing the onset of school night sleepiness even later.
While growing autonomy is part of why teenagers are sleep deprived, they will consider the caring and informed guidance of their pediatricians about their health. Ask your teenage patients how much sleep they usually get on a school night. It can be validating to show them how sleep deprived they are, and point out how strategies like caffeine and oversleeping might be making it worse. Explain that people (adults, too!) need to make time for sleep just as they might for exercise or friends. Tell them about “good sleep hygiene,” the practice of having consistent sleep times and routines that are conducive to restful sleep. This can include a hot shower before bed, reading for the last 30 minutes before lights out, and no screen time for at least 1 hour before bed. Indeed, it can be powerful to urge that everyone in the family takes screens out of their bedrooms.
Additionally, while they might sleep in on weekends, it shouldn’t be much more than an hour longer than on weekdays. And no naps after school! It is common for teens to feel overwhelmed by their commitments and that sleep must be the first thing to go. Use their growing sense of autonomy to remind them that they get to choose how to use their time, and balance will pay off much more than sacrificing sleep. A practical conversation about sleep can help them to make informed choices and thoughtfully take care of themselves before they head off to college.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
Resources
1. “Adolescent Sleep Needs and Patterns: Research Report and Resource Guide.” (Arlington, Va.: National Sleep Foundation, 2000.)
2. Pediatrics. 2014 Sep;134(3):e921-32.
3. Sleep. 2004 Nov 1;27(7):1351-8.
What, you never filled the prescription?!
How many times do you come out of the exam room after seeing a patient in follow-up and heave a sigh because the parents did not give their child the medicine as you prescribed it?
Without adherence to the medication plan, a lot of suboptimal outcomes can and do occur. A urinary tract infection may come back partially treated, requiring a more extensive work-up. A strep infection may spread to family members. Inflammatory bowel disease may require bowel resection. Asthma may simmer with long-term inflammation and pulmonary compromise as well as concurrent activity limitations. Often children with asthma are given less than 50% of prescribed controller medicines. In one pediatric study, medication adherence was not even asked about in 66% of cases. In adults, 20%-30% of prescriptions are never filled.
As physicians, we are carefully schooled in making complex diagnoses, sorting out and prioritizing the laboratory work-up, and memorizing the latest and most effective treatment regimens. What is rarely taught, however, is how to conduct the conversation needed to optimize subsequent adherence to the medication plan.
Problem-solving counseling is an evidence-based method to improve medication adherence. This is a semistructured form of cognitive-behavioral intervention designed to engage the responsible person (parent or child) in shared decision making about whether and how to take medication, and which one to take. After all, for good or for bad, it is really their choice!
1. Problem definition. This step involves developing a clear and specific definition of the problem. Educating families about a medical condition has to start with asking what they already know. This often includes sagas of bad outcomes in relatives. Ask: Who do you know with asthma? How was it for them? The family needs to know symptoms, simple pathophysiology (such as inflammation you can’t see or feel), course, and prognosis. They also need to know where their child’s condition falls on the continuum. And they need to understand the essential prevention aspect of controllers in what appears to be an asymptomatic child. Failure to communicate this is a common reason for nonadherence in asthma.
2. Generation of alternatives. This involves brainstorming to identify multiple and creative solutions. This step will reveal past experiences as well as things the family learned on the Internet that may be true and relevant, or true but irrelevant, or false. Ask: What have you heard about treatments for asthma? What do you think would be best for your child? Generic handouts with a sampling of medicines, advantages and disadvantages, side effects, and costs of the main choices have been shown to be helpful guides that enhance adherence through empowering the family in their choice and reassuring family members that you have been thorough. It can be a balancing act to describe possible side effects without scaring the family into shutting down and being unable to make any choice at all. However, failure to discuss common effects they may notice – such as a racing heart from rescue medications – but that you think of as trivial, may also lead to nonadherence. A way to communicate about perceived side effects and manage them has to be part of an effective plan. Planning a phone or email check-in can make a big difference.
3. Decision making. This step involves evaluating all the solutions to identify the most effective and feasible option. Once the family understands the problem and the alternatives, it is crucial for you, as the physician, to not only ask their preference but be ready to suggest what you think would be best. While not wanting to be patronized, families want your opinion. I like to have family members close their eyes and visualize carrying out the selected routine. This is a good hypnotic technique for future remembering, but you also may discover important facts by this simple exercise, such as that the child gets up alone for school, making morning dosing unreliable. Shared decision making is not a way to abdicate your expert opinion, just to incorporate family preferences and factors.
4. Solution implementation. This step involves carrying out the plan. There is no substitute for a real life trial! There may be surprising issues: Autistic children may be afraid of a nebulizer machine. Sensitive children may refuse the flavor of some inhalers.
5. Solution verification. Evaluate the effectiveness of the solution and modify the plan as necessary. Follow-up contact is crucial, especially at the start of a new chronic medication plan. When families know that the plan can be changed if things do not go well or they change their minds, they will be less fearful of giving it a try and more honest about barriers they perceive or encounter rather than simply showing up at the next visit with the child’s condition out of control.
Although using problem-solving counseling may sound complicated, it is intended to be focused and brief, and has been shown to be feasibly done in the clinic by primary care providers, without lengthening the visit. CHADIS even has teleprompter text specific to parent-reported barriers to help you.
Even when family members understand and agrees to a medication plan during the visit, there are a variety of reasons they may not adhere to it. They may forget to give the medicine, be unable to afford it once prescribed, experience unpleasant side effects, encounter resistance from the child, or get unanticipated push back from family members. All of these issues can be addressed if you know that they happen. You just have to ask! Recommending smartphone reminders or reminder apps (such as Medisafe), using GoodRx to find cheaper sources, suggesting candy as a chaser, recommending behavior strategies for feisty kids, and providing written materials (or a phone call) for reluctant relatives are strategies you can prepare in advance to have in your quiver and are well worth your time.
If it weren’t enough to address adherence to optimize outcomes, asthma management and control will likely be a Clinical Quality Measure, determining how we will be paid starting this year. Now you have a tool to do it!
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
How many times do you come out of the exam room after seeing a patient in follow-up and heave a sigh because the parents did not give their child the medicine as you prescribed it?
Without adherence to the medication plan, a lot of suboptimal outcomes can and do occur. A urinary tract infection may come back partially treated, requiring a more extensive work-up. A strep infection may spread to family members. Inflammatory bowel disease may require bowel resection. Asthma may simmer with long-term inflammation and pulmonary compromise as well as concurrent activity limitations. Often children with asthma are given less than 50% of prescribed controller medicines. In one pediatric study, medication adherence was not even asked about in 66% of cases. In adults, 20%-30% of prescriptions are never filled.
As physicians, we are carefully schooled in making complex diagnoses, sorting out and prioritizing the laboratory work-up, and memorizing the latest and most effective treatment regimens. What is rarely taught, however, is how to conduct the conversation needed to optimize subsequent adherence to the medication plan.
Problem-solving counseling is an evidence-based method to improve medication adherence. This is a semistructured form of cognitive-behavioral intervention designed to engage the responsible person (parent or child) in shared decision making about whether and how to take medication, and which one to take. After all, for good or for bad, it is really their choice!
1. Problem definition. This step involves developing a clear and specific definition of the problem. Educating families about a medical condition has to start with asking what they already know. This often includes sagas of bad outcomes in relatives. Ask: Who do you know with asthma? How was it for them? The family needs to know symptoms, simple pathophysiology (such as inflammation you can’t see or feel), course, and prognosis. They also need to know where their child’s condition falls on the continuum. And they need to understand the essential prevention aspect of controllers in what appears to be an asymptomatic child. Failure to communicate this is a common reason for nonadherence in asthma.
2. Generation of alternatives. This involves brainstorming to identify multiple and creative solutions. This step will reveal past experiences as well as things the family learned on the Internet that may be true and relevant, or true but irrelevant, or false. Ask: What have you heard about treatments for asthma? What do you think would be best for your child? Generic handouts with a sampling of medicines, advantages and disadvantages, side effects, and costs of the main choices have been shown to be helpful guides that enhance adherence through empowering the family in their choice and reassuring family members that you have been thorough. It can be a balancing act to describe possible side effects without scaring the family into shutting down and being unable to make any choice at all. However, failure to discuss common effects they may notice – such as a racing heart from rescue medications – but that you think of as trivial, may also lead to nonadherence. A way to communicate about perceived side effects and manage them has to be part of an effective plan. Planning a phone or email check-in can make a big difference.
3. Decision making. This step involves evaluating all the solutions to identify the most effective and feasible option. Once the family understands the problem and the alternatives, it is crucial for you, as the physician, to not only ask their preference but be ready to suggest what you think would be best. While not wanting to be patronized, families want your opinion. I like to have family members close their eyes and visualize carrying out the selected routine. This is a good hypnotic technique for future remembering, but you also may discover important facts by this simple exercise, such as that the child gets up alone for school, making morning dosing unreliable. Shared decision making is not a way to abdicate your expert opinion, just to incorporate family preferences and factors.
4. Solution implementation. This step involves carrying out the plan. There is no substitute for a real life trial! There may be surprising issues: Autistic children may be afraid of a nebulizer machine. Sensitive children may refuse the flavor of some inhalers.
5. Solution verification. Evaluate the effectiveness of the solution and modify the plan as necessary. Follow-up contact is crucial, especially at the start of a new chronic medication plan. When families know that the plan can be changed if things do not go well or they change their minds, they will be less fearful of giving it a try and more honest about barriers they perceive or encounter rather than simply showing up at the next visit with the child’s condition out of control.
Although using problem-solving counseling may sound complicated, it is intended to be focused and brief, and has been shown to be feasibly done in the clinic by primary care providers, without lengthening the visit. CHADIS even has teleprompter text specific to parent-reported barriers to help you.
Even when family members understand and agrees to a medication plan during the visit, there are a variety of reasons they may not adhere to it. They may forget to give the medicine, be unable to afford it once prescribed, experience unpleasant side effects, encounter resistance from the child, or get unanticipated push back from family members. All of these issues can be addressed if you know that they happen. You just have to ask! Recommending smartphone reminders or reminder apps (such as Medisafe), using GoodRx to find cheaper sources, suggesting candy as a chaser, recommending behavior strategies for feisty kids, and providing written materials (or a phone call) for reluctant relatives are strategies you can prepare in advance to have in your quiver and are well worth your time.
If it weren’t enough to address adherence to optimize outcomes, asthma management and control will likely be a Clinical Quality Measure, determining how we will be paid starting this year. Now you have a tool to do it!
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
How many times do you come out of the exam room after seeing a patient in follow-up and heave a sigh because the parents did not give their child the medicine as you prescribed it?
Without adherence to the medication plan, a lot of suboptimal outcomes can and do occur. A urinary tract infection may come back partially treated, requiring a more extensive work-up. A strep infection may spread to family members. Inflammatory bowel disease may require bowel resection. Asthma may simmer with long-term inflammation and pulmonary compromise as well as concurrent activity limitations. Often children with asthma are given less than 50% of prescribed controller medicines. In one pediatric study, medication adherence was not even asked about in 66% of cases. In adults, 20%-30% of prescriptions are never filled.
As physicians, we are carefully schooled in making complex diagnoses, sorting out and prioritizing the laboratory work-up, and memorizing the latest and most effective treatment regimens. What is rarely taught, however, is how to conduct the conversation needed to optimize subsequent adherence to the medication plan.
Problem-solving counseling is an evidence-based method to improve medication adherence. This is a semistructured form of cognitive-behavioral intervention designed to engage the responsible person (parent or child) in shared decision making about whether and how to take medication, and which one to take. After all, for good or for bad, it is really their choice!
1. Problem definition. This step involves developing a clear and specific definition of the problem. Educating families about a medical condition has to start with asking what they already know. This often includes sagas of bad outcomes in relatives. Ask: Who do you know with asthma? How was it for them? The family needs to know symptoms, simple pathophysiology (such as inflammation you can’t see or feel), course, and prognosis. They also need to know where their child’s condition falls on the continuum. And they need to understand the essential prevention aspect of controllers in what appears to be an asymptomatic child. Failure to communicate this is a common reason for nonadherence in asthma.
2. Generation of alternatives. This involves brainstorming to identify multiple and creative solutions. This step will reveal past experiences as well as things the family learned on the Internet that may be true and relevant, or true but irrelevant, or false. Ask: What have you heard about treatments for asthma? What do you think would be best for your child? Generic handouts with a sampling of medicines, advantages and disadvantages, side effects, and costs of the main choices have been shown to be helpful guides that enhance adherence through empowering the family in their choice and reassuring family members that you have been thorough. It can be a balancing act to describe possible side effects without scaring the family into shutting down and being unable to make any choice at all. However, failure to discuss common effects they may notice – such as a racing heart from rescue medications – but that you think of as trivial, may also lead to nonadherence. A way to communicate about perceived side effects and manage them has to be part of an effective plan. Planning a phone or email check-in can make a big difference.
3. Decision making. This step involves evaluating all the solutions to identify the most effective and feasible option. Once the family understands the problem and the alternatives, it is crucial for you, as the physician, to not only ask their preference but be ready to suggest what you think would be best. While not wanting to be patronized, families want your opinion. I like to have family members close their eyes and visualize carrying out the selected routine. This is a good hypnotic technique for future remembering, but you also may discover important facts by this simple exercise, such as that the child gets up alone for school, making morning dosing unreliable. Shared decision making is not a way to abdicate your expert opinion, just to incorporate family preferences and factors.
4. Solution implementation. This step involves carrying out the plan. There is no substitute for a real life trial! There may be surprising issues: Autistic children may be afraid of a nebulizer machine. Sensitive children may refuse the flavor of some inhalers.
5. Solution verification. Evaluate the effectiveness of the solution and modify the plan as necessary. Follow-up contact is crucial, especially at the start of a new chronic medication plan. When families know that the plan can be changed if things do not go well or they change their minds, they will be less fearful of giving it a try and more honest about barriers they perceive or encounter rather than simply showing up at the next visit with the child’s condition out of control.
Although using problem-solving counseling may sound complicated, it is intended to be focused and brief, and has been shown to be feasibly done in the clinic by primary care providers, without lengthening the visit. CHADIS even has teleprompter text specific to parent-reported barriers to help you.
Even when family members understand and agrees to a medication plan during the visit, there are a variety of reasons they may not adhere to it. They may forget to give the medicine, be unable to afford it once prescribed, experience unpleasant side effects, encounter resistance from the child, or get unanticipated push back from family members. All of these issues can be addressed if you know that they happen. You just have to ask! Recommending smartphone reminders or reminder apps (such as Medisafe), using GoodRx to find cheaper sources, suggesting candy as a chaser, recommending behavior strategies for feisty kids, and providing written materials (or a phone call) for reluctant relatives are strategies you can prepare in advance to have in your quiver and are well worth your time.
If it weren’t enough to address adherence to optimize outcomes, asthma management and control will likely be a Clinical Quality Measure, determining how we will be paid starting this year. Now you have a tool to do it!
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
Self-injury
Whether you have heard about “cutting” from breathless gossip reports about young starlets or anxious parents of adolescent girls, it seems to be a phenomenon that is on the rise.
As a pediatrician, you may be the first (or only) adult in a young person’s life who notices evidence of self-injury or who asks about it. Self-injurious behaviors may signal significant underlying psychiatric issues or something more benign and brief. Being alert to self-injury is not an easy task. The thought of teenagers cutting themselves on a regular basis and acknowledging their inner distress in your office requires a pediatrician’s self-awareness and emotional preparation.
Self-injury, or nonsuicidal self-injury (NSSI) as it is known in the psychiatric literature, is indeed a relatively common phenomenon. In the United States, it affects approximately 10% of adolescents in a community sample, and as many as 35% of adolescents in treatment for any psychiatric illness. It begins most commonly between the ages of 13 and 15 years, and grows in prevalence through adolescence, dropping off in early adulthood. While adolescent girls are likely to start this behavior earlier than adolescent boys, the gender difference attenuates with age. Some studies have shown adolescent boys are more likely to engage in this behavior than girls by late adolescence.
NSSI typically takes the form of cutting oneself with a sharp object, but it also could involve scratching at the skin until it bleeds, hitting or burning oneself, or interfering with the healing of wounds. It classically was thought of as a symptom of borderline personality disorder, but is a behavior that also may occur with eating disorders, substance use disorders, and anxiety and depressive disorders in adolescents. Clinicians have conceptualized it as a maladaptive way to relieve intense emotional distress, signal distress to others, or inflict self-punishment. It usually starts as an impulsive behavior, and the combination of the intense emotions and high impulsivity of adolescence is why it is so common among this age group. For some adolescents, the impulse will be primarily one of curiosity, perhaps in the setting of some stress, and is more likely to occur if the behavior is common among a teenager’s peers. For those in intense emotional distress, it typically brings a fleeting sense of calm or numbing and an easing of tension. But this relief is usually followed by guilt and shame, and a return, sometimes compounded, of those uncomfortable emotions. Thus what starts as an impulse can become a repetitive, almost compulsive behavior.
If the self-injury happens regularly, it is very important that you show both concern and compassion. You might offer that whatever emotional pain they are experiencing, they deserve more support than a sharp object offers. You could ask about those illnesses that are frequently comorbid with self-injury: substance use, eating disorders, and anxiety and depressive disorders.
But it is essential that you ask about suicidal ideation and suicide attempts. If they are acutely suicidal or describe a history of previously hidden attempts, you will need to help them access care quickly, possibly recommending a visit to the emergency department unless they already have an outpatient treatment team. In these cases, you will need to share your concerns with their parents and help them find their way into the complex mental health system to get a comprehensive psychiatric evaluation and treatment.
Identifying and referring adolescents with NSSI is emotionally demanding work. Learn more from your patients, talk to those who evaluate them, and discuss the issues with colleagues – both to gain skills and to have support as you worry about these patients and help guide them through a complex system of care.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston.
Whether you have heard about “cutting” from breathless gossip reports about young starlets or anxious parents of adolescent girls, it seems to be a phenomenon that is on the rise.
As a pediatrician, you may be the first (or only) adult in a young person’s life who notices evidence of self-injury or who asks about it. Self-injurious behaviors may signal significant underlying psychiatric issues or something more benign and brief. Being alert to self-injury is not an easy task. The thought of teenagers cutting themselves on a regular basis and acknowledging their inner distress in your office requires a pediatrician’s self-awareness and emotional preparation.
Self-injury, or nonsuicidal self-injury (NSSI) as it is known in the psychiatric literature, is indeed a relatively common phenomenon. In the United States, it affects approximately 10% of adolescents in a community sample, and as many as 35% of adolescents in treatment for any psychiatric illness. It begins most commonly between the ages of 13 and 15 years, and grows in prevalence through adolescence, dropping off in early adulthood. While adolescent girls are likely to start this behavior earlier than adolescent boys, the gender difference attenuates with age. Some studies have shown adolescent boys are more likely to engage in this behavior than girls by late adolescence.
NSSI typically takes the form of cutting oneself with a sharp object, but it also could involve scratching at the skin until it bleeds, hitting or burning oneself, or interfering with the healing of wounds. It classically was thought of as a symptom of borderline personality disorder, but is a behavior that also may occur with eating disorders, substance use disorders, and anxiety and depressive disorders in adolescents. Clinicians have conceptualized it as a maladaptive way to relieve intense emotional distress, signal distress to others, or inflict self-punishment. It usually starts as an impulsive behavior, and the combination of the intense emotions and high impulsivity of adolescence is why it is so common among this age group. For some adolescents, the impulse will be primarily one of curiosity, perhaps in the setting of some stress, and is more likely to occur if the behavior is common among a teenager’s peers. For those in intense emotional distress, it typically brings a fleeting sense of calm or numbing and an easing of tension. But this relief is usually followed by guilt and shame, and a return, sometimes compounded, of those uncomfortable emotions. Thus what starts as an impulse can become a repetitive, almost compulsive behavior.
If the self-injury happens regularly, it is very important that you show both concern and compassion. You might offer that whatever emotional pain they are experiencing, they deserve more support than a sharp object offers. You could ask about those illnesses that are frequently comorbid with self-injury: substance use, eating disorders, and anxiety and depressive disorders.
But it is essential that you ask about suicidal ideation and suicide attempts. If they are acutely suicidal or describe a history of previously hidden attempts, you will need to help them access care quickly, possibly recommending a visit to the emergency department unless they already have an outpatient treatment team. In these cases, you will need to share your concerns with their parents and help them find their way into the complex mental health system to get a comprehensive psychiatric evaluation and treatment.
Identifying and referring adolescents with NSSI is emotionally demanding work. Learn more from your patients, talk to those who evaluate them, and discuss the issues with colleagues – both to gain skills and to have support as you worry about these patients and help guide them through a complex system of care.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston.
Whether you have heard about “cutting” from breathless gossip reports about young starlets or anxious parents of adolescent girls, it seems to be a phenomenon that is on the rise.
As a pediatrician, you may be the first (or only) adult in a young person’s life who notices evidence of self-injury or who asks about it. Self-injurious behaviors may signal significant underlying psychiatric issues or something more benign and brief. Being alert to self-injury is not an easy task. The thought of teenagers cutting themselves on a regular basis and acknowledging their inner distress in your office requires a pediatrician’s self-awareness and emotional preparation.
Self-injury, or nonsuicidal self-injury (NSSI) as it is known in the psychiatric literature, is indeed a relatively common phenomenon. In the United States, it affects approximately 10% of adolescents in a community sample, and as many as 35% of adolescents in treatment for any psychiatric illness. It begins most commonly between the ages of 13 and 15 years, and grows in prevalence through adolescence, dropping off in early adulthood. While adolescent girls are likely to start this behavior earlier than adolescent boys, the gender difference attenuates with age. Some studies have shown adolescent boys are more likely to engage in this behavior than girls by late adolescence.
NSSI typically takes the form of cutting oneself with a sharp object, but it also could involve scratching at the skin until it bleeds, hitting or burning oneself, or interfering with the healing of wounds. It classically was thought of as a symptom of borderline personality disorder, but is a behavior that also may occur with eating disorders, substance use disorders, and anxiety and depressive disorders in adolescents. Clinicians have conceptualized it as a maladaptive way to relieve intense emotional distress, signal distress to others, or inflict self-punishment. It usually starts as an impulsive behavior, and the combination of the intense emotions and high impulsivity of adolescence is why it is so common among this age group. For some adolescents, the impulse will be primarily one of curiosity, perhaps in the setting of some stress, and is more likely to occur if the behavior is common among a teenager’s peers. For those in intense emotional distress, it typically brings a fleeting sense of calm or numbing and an easing of tension. But this relief is usually followed by guilt and shame, and a return, sometimes compounded, of those uncomfortable emotions. Thus what starts as an impulse can become a repetitive, almost compulsive behavior.
If the self-injury happens regularly, it is very important that you show both concern and compassion. You might offer that whatever emotional pain they are experiencing, they deserve more support than a sharp object offers. You could ask about those illnesses that are frequently comorbid with self-injury: substance use, eating disorders, and anxiety and depressive disorders.
But it is essential that you ask about suicidal ideation and suicide attempts. If they are acutely suicidal or describe a history of previously hidden attempts, you will need to help them access care quickly, possibly recommending a visit to the emergency department unless they already have an outpatient treatment team. In these cases, you will need to share your concerns with their parents and help them find their way into the complex mental health system to get a comprehensive psychiatric evaluation and treatment.
Identifying and referring adolescents with NSSI is emotionally demanding work. Learn more from your patients, talk to those who evaluate them, and discuss the issues with colleagues – both to gain skills and to have support as you worry about these patients and help guide them through a complex system of care.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston.
Not enough time? Time to rethink
Raising children is a lot like drinking out of a fire hose. Feeding, cleaning, dressing, transporting, teaching, entertaining, protecting, comforting, and managing one child is demanding, but is increased exponentially by multiple children, a spouse, and a job.
In our dataset of more than 74,900 parents of 0- to 3-year-olds completing a routine previsit questionnaire about the “best” and “hardest” parts of parenting their child, the most frequent spontaneous comment for the hardest part was “time-life balance.” The goal of asking these questions is to broaden the agenda for the pediatric visit to address stresses that are highly relevant to the child’s life in the family, and their current well-being and future outcome. The hardest part also rather succinctly captures the stress I hear every day from parents coming to me not only for health supervision, but especially for child behavior problems.
Setting limits on work to free up more time is not possible for everyone. Many people are grateful to have a job at all or need multiple jobs to make ends meet. They may not be in a position to negotiate for fewer tasks, hours, or roles. But others more fortunate may have fallen into a habit of taking on extra duties, taking work home, or simply not examining where they might set limits to preserve time for themselves and their family.
Working parents may need to prepare themselves for the onslaught when they get home. If the returning parent retreats into TV, the computer, or the bedroom, it makes the children feel angry and rejected. The parent who has been managing the household for the preceding hour(s) feels resentful, unappreciated, and often exhausted. I sometimes suggest that the returning parent pause 15 minutes to take a walk before picking children up at day care or go to the gym before coming home to be ready to engage, accept, and be present for whatever happens when they open the door.
Eliciting the “hardest part” can insert a pause for some much-needed problem-solving. Pointing out to parents the value to their child of working on their own time-life balance often gives them needed permission to make changes.
Balancing time for some parents may include setting some privacy for “alone time.” Individual desire to be alone varies, but trouble getting it is universal, especially with young children who don’t even respect a closed bathroom door! Given a young child’s need for contact about every 3-5 minutes, parents need to revise their expectations, wait until after bedtime, get some help, learn to do “token” relaxation, or all of these.
Parents often feel guilty for not attending more to their child, but then feel irritable about getting behind on other chores. It can be useful to cite the fact that mothers at home full time typically spend only 20 minutes of exclusive playtime with their child. I regularly prescribe 15 minutes of “special time” daily to break this irritability cycle for both the parent and child. Getting a babysitter does not mean that the parent has to leave the house and the undone laundry. I often suggest to resource-strapped families that they pay an 8-year-old neighbor to play with their kids for an hour several times per week. While not expecting to leave the child alone with such a “sitter,” one could relax in the tub, read a magazine, or make an uninterrupted phone call to a friend with such help.
The same parents feeling the pinch of too little time often are lacking in social support, a major buffer of stress. Sometimes, the solutions overlap. For example, trading play dates with another family by taking all their kids on a regular basis and vice versa requires no money exchange. Several kids playing together are often easier to care for than one’s own with their usual sibling struggles or boredom. And sharing of this kind can build lasting friendships and social support for the adults. Another often forgotten source of adult rest coupled with social support is religious services that offer “Sunday School.” The service has built-in cues to meditation, the kids make new friends protected by accepting teachers, and the social hour builds social support for the parents.
But we can’t really insert more hours in the day, right? Actually, one of the most valuable suggestions may be for parents to keep a diary of their activities for a few days. The average American in 2015 clocked 147 minutes watching TV, 103 minutes in front of a computer, 151 minutes on smart phones, and 43 minutes with a tablet. These time wasters may not only not feel satisfying or even relaxing, but even prompt anxiety or envy, and certainly take away from sleep, exercise, and intimacy. The American Academy of Pediatrics recently provided a Media Calculator and Family Media Plan intended to help families consider these choices for their child’s media life within all the other required activities of a day (including sleep), but adults could benefit from the same approach to making decisions about how they budget their time.
By mapping out actual time spent, parents can then reevaluate and choose differently. A useful question we might ask frazzled parents is “What fills your tank?” to help them come up with a list of activities that (used to be) regenerative to put on the new schedule. Most people blurt out “go on a cruise” (not practical) when “token” activities can suffice and be immediately possible. Coach them to be creative! Instead of a cruise, take a walk around the block; instead of going to a spa, request a back rub at bedtime; instead of a movie, watch a YouTube clip. When allowing oneself to be fully present to such “tokens,” they can have immense value. The practice of mindfulness (for which many training apps are available) can heighten awareness of each moment and expand the sense of time. Meditation and yoga training both are proven to provide benefits for relaxation and well-being that can be fit into anyone’s day.
While this column is intended to help with pediatric practice, I’ll bet you thought I was talking about you! With the pace of current health care practice and emphasis on “productivity,” many pediatricians are struggling with balancing time for themselves and their families as well. All the ideas just discussed also apply to you, but maybe, just maybe, you have the resources to insist on limits on work you haven’t seized. Cherishing the years when you have children in your life is for you, too, not just your patients. Remember, “The days are long, but the years are short.”
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 Frontline Medical News. Email her at [email protected].
Raising children is a lot like drinking out of a fire hose. Feeding, cleaning, dressing, transporting, teaching, entertaining, protecting, comforting, and managing one child is demanding, but is increased exponentially by multiple children, a spouse, and a job.
In our dataset of more than 74,900 parents of 0- to 3-year-olds completing a routine previsit questionnaire about the “best” and “hardest” parts of parenting their child, the most frequent spontaneous comment for the hardest part was “time-life balance.” The goal of asking these questions is to broaden the agenda for the pediatric visit to address stresses that are highly relevant to the child’s life in the family, and their current well-being and future outcome. The hardest part also rather succinctly captures the stress I hear every day from parents coming to me not only for health supervision, but especially for child behavior problems.
Setting limits on work to free up more time is not possible for everyone. Many people are grateful to have a job at all or need multiple jobs to make ends meet. They may not be in a position to negotiate for fewer tasks, hours, or roles. But others more fortunate may have fallen into a habit of taking on extra duties, taking work home, or simply not examining where they might set limits to preserve time for themselves and their family.
Working parents may need to prepare themselves for the onslaught when they get home. If the returning parent retreats into TV, the computer, or the bedroom, it makes the children feel angry and rejected. The parent who has been managing the household for the preceding hour(s) feels resentful, unappreciated, and often exhausted. I sometimes suggest that the returning parent pause 15 minutes to take a walk before picking children up at day care or go to the gym before coming home to be ready to engage, accept, and be present for whatever happens when they open the door.
Eliciting the “hardest part” can insert a pause for some much-needed problem-solving. Pointing out to parents the value to their child of working on their own time-life balance often gives them needed permission to make changes.
Balancing time for some parents may include setting some privacy for “alone time.” Individual desire to be alone varies, but trouble getting it is universal, especially with young children who don’t even respect a closed bathroom door! Given a young child’s need for contact about every 3-5 minutes, parents need to revise their expectations, wait until after bedtime, get some help, learn to do “token” relaxation, or all of these.
Parents often feel guilty for not attending more to their child, but then feel irritable about getting behind on other chores. It can be useful to cite the fact that mothers at home full time typically spend only 20 minutes of exclusive playtime with their child. I regularly prescribe 15 minutes of “special time” daily to break this irritability cycle for both the parent and child. Getting a babysitter does not mean that the parent has to leave the house and the undone laundry. I often suggest to resource-strapped families that they pay an 8-year-old neighbor to play with their kids for an hour several times per week. While not expecting to leave the child alone with such a “sitter,” one could relax in the tub, read a magazine, or make an uninterrupted phone call to a friend with such help.
The same parents feeling the pinch of too little time often are lacking in social support, a major buffer of stress. Sometimes, the solutions overlap. For example, trading play dates with another family by taking all their kids on a regular basis and vice versa requires no money exchange. Several kids playing together are often easier to care for than one’s own with their usual sibling struggles or boredom. And sharing of this kind can build lasting friendships and social support for the adults. Another often forgotten source of adult rest coupled with social support is religious services that offer “Sunday School.” The service has built-in cues to meditation, the kids make new friends protected by accepting teachers, and the social hour builds social support for the parents.
But we can’t really insert more hours in the day, right? Actually, one of the most valuable suggestions may be for parents to keep a diary of their activities for a few days. The average American in 2015 clocked 147 minutes watching TV, 103 minutes in front of a computer, 151 minutes on smart phones, and 43 minutes with a tablet. These time wasters may not only not feel satisfying or even relaxing, but even prompt anxiety or envy, and certainly take away from sleep, exercise, and intimacy. The American Academy of Pediatrics recently provided a Media Calculator and Family Media Plan intended to help families consider these choices for their child’s media life within all the other required activities of a day (including sleep), but adults could benefit from the same approach to making decisions about how they budget their time.
By mapping out actual time spent, parents can then reevaluate and choose differently. A useful question we might ask frazzled parents is “What fills your tank?” to help them come up with a list of activities that (used to be) regenerative to put on the new schedule. Most people blurt out “go on a cruise” (not practical) when “token” activities can suffice and be immediately possible. Coach them to be creative! Instead of a cruise, take a walk around the block; instead of going to a spa, request a back rub at bedtime; instead of a movie, watch a YouTube clip. When allowing oneself to be fully present to such “tokens,” they can have immense value. The practice of mindfulness (for which many training apps are available) can heighten awareness of each moment and expand the sense of time. Meditation and yoga training both are proven to provide benefits for relaxation and well-being that can be fit into anyone’s day.
While this column is intended to help with pediatric practice, I’ll bet you thought I was talking about you! With the pace of current health care practice and emphasis on “productivity,” many pediatricians are struggling with balancing time for themselves and their families as well. All the ideas just discussed also apply to you, but maybe, just maybe, you have the resources to insist on limits on work you haven’t seized. Cherishing the years when you have children in your life is for you, too, not just your patients. Remember, “The days are long, but the years are short.”
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 Frontline Medical News. Email her at [email protected].
Raising children is a lot like drinking out of a fire hose. Feeding, cleaning, dressing, transporting, teaching, entertaining, protecting, comforting, and managing one child is demanding, but is increased exponentially by multiple children, a spouse, and a job.
In our dataset of more than 74,900 parents of 0- to 3-year-olds completing a routine previsit questionnaire about the “best” and “hardest” parts of parenting their child, the most frequent spontaneous comment for the hardest part was “time-life balance.” The goal of asking these questions is to broaden the agenda for the pediatric visit to address stresses that are highly relevant to the child’s life in the family, and their current well-being and future outcome. The hardest part also rather succinctly captures the stress I hear every day from parents coming to me not only for health supervision, but especially for child behavior problems.
Setting limits on work to free up more time is not possible for everyone. Many people are grateful to have a job at all or need multiple jobs to make ends meet. They may not be in a position to negotiate for fewer tasks, hours, or roles. But others more fortunate may have fallen into a habit of taking on extra duties, taking work home, or simply not examining where they might set limits to preserve time for themselves and their family.
Working parents may need to prepare themselves for the onslaught when they get home. If the returning parent retreats into TV, the computer, or the bedroom, it makes the children feel angry and rejected. The parent who has been managing the household for the preceding hour(s) feels resentful, unappreciated, and often exhausted. I sometimes suggest that the returning parent pause 15 minutes to take a walk before picking children up at day care or go to the gym before coming home to be ready to engage, accept, and be present for whatever happens when they open the door.
Eliciting the “hardest part” can insert a pause for some much-needed problem-solving. Pointing out to parents the value to their child of working on their own time-life balance often gives them needed permission to make changes.
Balancing time for some parents may include setting some privacy for “alone time.” Individual desire to be alone varies, but trouble getting it is universal, especially with young children who don’t even respect a closed bathroom door! Given a young child’s need for contact about every 3-5 minutes, parents need to revise their expectations, wait until after bedtime, get some help, learn to do “token” relaxation, or all of these.
Parents often feel guilty for not attending more to their child, but then feel irritable about getting behind on other chores. It can be useful to cite the fact that mothers at home full time typically spend only 20 minutes of exclusive playtime with their child. I regularly prescribe 15 minutes of “special time” daily to break this irritability cycle for both the parent and child. Getting a babysitter does not mean that the parent has to leave the house and the undone laundry. I often suggest to resource-strapped families that they pay an 8-year-old neighbor to play with their kids for an hour several times per week. While not expecting to leave the child alone with such a “sitter,” one could relax in the tub, read a magazine, or make an uninterrupted phone call to a friend with such help.
The same parents feeling the pinch of too little time often are lacking in social support, a major buffer of stress. Sometimes, the solutions overlap. For example, trading play dates with another family by taking all their kids on a regular basis and vice versa requires no money exchange. Several kids playing together are often easier to care for than one’s own with their usual sibling struggles or boredom. And sharing of this kind can build lasting friendships and social support for the adults. Another often forgotten source of adult rest coupled with social support is religious services that offer “Sunday School.” The service has built-in cues to meditation, the kids make new friends protected by accepting teachers, and the social hour builds social support for the parents.
But we can’t really insert more hours in the day, right? Actually, one of the most valuable suggestions may be for parents to keep a diary of their activities for a few days. The average American in 2015 clocked 147 minutes watching TV, 103 minutes in front of a computer, 151 minutes on smart phones, and 43 minutes with a tablet. These time wasters may not only not feel satisfying or even relaxing, but even prompt anxiety or envy, and certainly take away from sleep, exercise, and intimacy. The American Academy of Pediatrics recently provided a Media Calculator and Family Media Plan intended to help families consider these choices for their child’s media life within all the other required activities of a day (including sleep), but adults could benefit from the same approach to making decisions about how they budget their time.
By mapping out actual time spent, parents can then reevaluate and choose differently. A useful question we might ask frazzled parents is “What fills your tank?” to help them come up with a list of activities that (used to be) regenerative to put on the new schedule. Most people blurt out “go on a cruise” (not practical) when “token” activities can suffice and be immediately possible. Coach them to be creative! Instead of a cruise, take a walk around the block; instead of going to a spa, request a back rub at bedtime; instead of a movie, watch a YouTube clip. When allowing oneself to be fully present to such “tokens,” they can have immense value. The practice of mindfulness (for which many training apps are available) can heighten awareness of each moment and expand the sense of time. Meditation and yoga training both are proven to provide benefits for relaxation and well-being that can be fit into anyone’s day.
While this column is intended to help with pediatric practice, I’ll bet you thought I was talking about you! With the pace of current health care practice and emphasis on “productivity,” many pediatricians are struggling with balancing time for themselves and their families as well. All the ideas just discussed also apply to you, but maybe, just maybe, you have the resources to insist on limits on work you haven’t seized. Cherishing the years when you have children in your life is for you, too, not just your patients. Remember, “The days are long, but the years are short.”
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 Frontline Medical News. Email her at [email protected].
Stress management for ambitious students
Most parents hope that their children will be motivated and hard-working at school, but ambitious students usually face very high levels of stress. Ambitious young people typically push themselves very hard and may not spend enough time in play, relaxation, or exploring potential interests. Their time with peers might be more competitive than social or fun. They may become rigidly focused on a goal, paving the way for devastation if they fall short of their own expectations. They may internalize stress and not ask for help if it starts to take a toll on their mental health. But ambition is not incompatible with healthy development and well-being. Pediatricians usually know who the ambitious students in their practice are, and will hear about the stress they may be experiencing. You have the opportunity to offer them (or their parents) some strategies to manage their high stress levels, and build resilience.
Support ambition, but not perfectionism
It can be helpful to acknowledge to young people that they are ambitious, enabling them to acknowledge this fact about themselves. This kind of drive can be an admirable strength when it is part of an emerging identity, a wish to be successful as defined by the patient.
It is more likely to be problematic if it is a product of a parent’s need to have a child perform as they deem best. Second, it is critical to differentiate ambition from perfectionism. While ambition can keep someone focused and motivated in the face of difficulty, perfectionism is a bully that leaves a person feeling perpetually inadequate. Ambition without a specific interest or focus can lead to general perfectionism in a young person, and parents might unwittingly support this by applauding successes or becoming overinvested in this success reflecting onto them. When the pediatrician points out to a patient (and parents) that perfection is neither possible nor desirable, they may respond, “why wouldn’t I want to be perfect?” Remind them that perfectionism is actually the enemy of long-term accomplishment, discouraging risk-taking, reflection, and growth.
Celebrate failure!
The critical difference between an ambitious person who is persistent and determined (and thus equipped to succeed) and the brittle perfectionist is the ability to tolerate failure and setbacks. Point out to your patients that ambition means there will be a lot of setbacks, disappointments, and failures, as they attempt things that are challenging. Indeed, they should embrace each little failure, as that is how real learning and growth happen, especially if they are constantly stretching their goals.
As children or teenagers learn that failure is evidence that they are on track, working hard, and improving, they will develop tenacity and flexibility. Carol S. Dweck, PhD, a psychologist who has studied school performance in young people, has demonstrated that when young people are praised for their results they tend to give up when they fail, whereas if they are praised for their hard work and persistence, they redouble their effort when they fail. Parents, teachers, and pediatricians have the power to shift an ambitious child’s mindset (Dweck’s term) by helping the child change his or her thinking about what failure really means.
Cultivate self-awareness and perspective
It is one of the central tasks of growing up to learn what one’s interests, talents, and values are, and this self-knowledge is especially critical in ambitious young people. Without genuine interests or passions, ambition may feel like a hollow quest for approval. It is more likely to become general perfectionism. So children and teenagers need adults who are curious about their underlying interests, who patiently help them to cultivate these interests and dedicate their ambition to the pursuit of these passions. Younger children need adult time and support to explore a variety of interests, dabbling so they might figure out where their interests and talents converge. This can provide plenty of opportunity to celebrate effort over achievement. By adolescence, they should have a clearer sense of their personal interests and abilities, and will be deepening their efforts in fewer areas. Adolescence is also when they start to build a narrative of who they are and what values are truly their own. Parents can serve as models and facilitators for their teenagers’ emerging sets of values. Values such as honesty, compassion, or generosity (for example) organize one’s efforts, giving them deeper meaning and keeping difficulties in perspective. Values also will help ambitious young people set their own goals and create an individualized and meaningful definition of success, and keep bigger failures, losses, or disappointments in perspective.
Teach self-care
It seems obvious to state that learning how to care for one’s self is essential to well-being, but for ambitious young people (and adults), self-care is often the first thing to go (or the last thing they consider) in their busy days. Explain to your patients (and parents) that without adequate, consistent, restful sleep, all of their hard work will be inefficient or likely squandered. Explain that daily cardiovascular exercise is not frivolous, but rather essential to balance their cognitive efforts, and offers potent protection for their physical and mental health. There is even robust evidence that sleep and exercise are directly helpful to memory, learning, and creativity. When a parent models this kind of self-care, it is far more powerful than simply talking about it!
Relaxation is self-care!
While most teenagers do not need to be taught how to relax, those very ambitious ones are likely to need permission and even help in learning how to effectively and efficiently blow off steam. Help them to approach relaxation as they would approach a new subject, open-minded and trying different things to determine what works for them. Some may find exercise relaxing, while some may need a cognitive distraction (sometimes called “senseless fun,” an activity not dedicated to achievement) such as reading, family games, or television. Social time often is very effective relaxation for teenagers, and they should know that it is as important as sleep and studying for their performance. Some may find that a calming activity such as yoga or meditation recharges their batteries, whereas others may need noisy video games to feel renewed. Suggest that they should protect (just a little) time for relaxation even on their busiest days to help them develop good habits of self-care. Without consistent, reliable relaxation, ambitious young people are at risk for burnout or for impulsive and extreme behaviors such as binge-drinking.
Be on the lookout for red flags
In the same way that high performing athletes are at risk for stress fractures or other injuries of repetitive, intense physical activity, ambitious students are vulnerable to some of the problems that can follow sustained, intense cognitive effort. These risks go up if they are sleep deprived, stop exercising, or are socially isolated. Parents can be on the lookout for signs of depression or anxiety disorders, such as loss of energy, withdrawal from friends or beloved activities, persistent unhappiness or irritability (sustained over days to weeks), and of course morbid preoccupations.
Intense perfectionism is common among young people at risk for eating disorders, depression and self-injury, and anxiety disorders. Beyond recognizing signs, it is even more important for parents and pediatricians to equip ambitious young people to stay connected and ask for help if they experience a change in their emotional equilibrium. Suggest to your patients that they should never worry alone. They should ask for help if they are struggling to sleep, to sustain their motivation or effort, or notice feeling panicked, unusually tearful, or hopeless. Depression and anxiety are common and treatable problems in adolescents, but ambitious adolescents might be inclined to try to soldier through them. Caring adults should demystify and destigmatize mood and anxiety problems. You might point out that they would ask for help for a toothache or a painful knee joint, and that their mental health should be no different.
Many ambitious children have ambitious parents who might look back on their own adolescence and wonder if they were sufficiently balanced in their approach or whether they overreacted to failure. Sometimes honest sharing of successes, failures, and enduring dilemmas can build an empathic bridge from one generation to the next.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
Most parents hope that their children will be motivated and hard-working at school, but ambitious students usually face very high levels of stress. Ambitious young people typically push themselves very hard and may not spend enough time in play, relaxation, or exploring potential interests. Their time with peers might be more competitive than social or fun. They may become rigidly focused on a goal, paving the way for devastation if they fall short of their own expectations. They may internalize stress and not ask for help if it starts to take a toll on their mental health. But ambition is not incompatible with healthy development and well-being. Pediatricians usually know who the ambitious students in their practice are, and will hear about the stress they may be experiencing. You have the opportunity to offer them (or their parents) some strategies to manage their high stress levels, and build resilience.
Support ambition, but not perfectionism
It can be helpful to acknowledge to young people that they are ambitious, enabling them to acknowledge this fact about themselves. This kind of drive can be an admirable strength when it is part of an emerging identity, a wish to be successful as defined by the patient.
It is more likely to be problematic if it is a product of a parent’s need to have a child perform as they deem best. Second, it is critical to differentiate ambition from perfectionism. While ambition can keep someone focused and motivated in the face of difficulty, perfectionism is a bully that leaves a person feeling perpetually inadequate. Ambition without a specific interest or focus can lead to general perfectionism in a young person, and parents might unwittingly support this by applauding successes or becoming overinvested in this success reflecting onto them. When the pediatrician points out to a patient (and parents) that perfection is neither possible nor desirable, they may respond, “why wouldn’t I want to be perfect?” Remind them that perfectionism is actually the enemy of long-term accomplishment, discouraging risk-taking, reflection, and growth.
Celebrate failure!
The critical difference between an ambitious person who is persistent and determined (and thus equipped to succeed) and the brittle perfectionist is the ability to tolerate failure and setbacks. Point out to your patients that ambition means there will be a lot of setbacks, disappointments, and failures, as they attempt things that are challenging. Indeed, they should embrace each little failure, as that is how real learning and growth happen, especially if they are constantly stretching their goals.
As children or teenagers learn that failure is evidence that they are on track, working hard, and improving, they will develop tenacity and flexibility. Carol S. Dweck, PhD, a psychologist who has studied school performance in young people, has demonstrated that when young people are praised for their results they tend to give up when they fail, whereas if they are praised for their hard work and persistence, they redouble their effort when they fail. Parents, teachers, and pediatricians have the power to shift an ambitious child’s mindset (Dweck’s term) by helping the child change his or her thinking about what failure really means.
Cultivate self-awareness and perspective
It is one of the central tasks of growing up to learn what one’s interests, talents, and values are, and this self-knowledge is especially critical in ambitious young people. Without genuine interests or passions, ambition may feel like a hollow quest for approval. It is more likely to become general perfectionism. So children and teenagers need adults who are curious about their underlying interests, who patiently help them to cultivate these interests and dedicate their ambition to the pursuit of these passions. Younger children need adult time and support to explore a variety of interests, dabbling so they might figure out where their interests and talents converge. This can provide plenty of opportunity to celebrate effort over achievement. By adolescence, they should have a clearer sense of their personal interests and abilities, and will be deepening their efforts in fewer areas. Adolescence is also when they start to build a narrative of who they are and what values are truly their own. Parents can serve as models and facilitators for their teenagers’ emerging sets of values. Values such as honesty, compassion, or generosity (for example) organize one’s efforts, giving them deeper meaning and keeping difficulties in perspective. Values also will help ambitious young people set their own goals and create an individualized and meaningful definition of success, and keep bigger failures, losses, or disappointments in perspective.
Teach self-care
It seems obvious to state that learning how to care for one’s self is essential to well-being, but for ambitious young people (and adults), self-care is often the first thing to go (or the last thing they consider) in their busy days. Explain to your patients (and parents) that without adequate, consistent, restful sleep, all of their hard work will be inefficient or likely squandered. Explain that daily cardiovascular exercise is not frivolous, but rather essential to balance their cognitive efforts, and offers potent protection for their physical and mental health. There is even robust evidence that sleep and exercise are directly helpful to memory, learning, and creativity. When a parent models this kind of self-care, it is far more powerful than simply talking about it!
Relaxation is self-care!
While most teenagers do not need to be taught how to relax, those very ambitious ones are likely to need permission and even help in learning how to effectively and efficiently blow off steam. Help them to approach relaxation as they would approach a new subject, open-minded and trying different things to determine what works for them. Some may find exercise relaxing, while some may need a cognitive distraction (sometimes called “senseless fun,” an activity not dedicated to achievement) such as reading, family games, or television. Social time often is very effective relaxation for teenagers, and they should know that it is as important as sleep and studying for their performance. Some may find that a calming activity such as yoga or meditation recharges their batteries, whereas others may need noisy video games to feel renewed. Suggest that they should protect (just a little) time for relaxation even on their busiest days to help them develop good habits of self-care. Without consistent, reliable relaxation, ambitious young people are at risk for burnout or for impulsive and extreme behaviors such as binge-drinking.
Be on the lookout for red flags
In the same way that high performing athletes are at risk for stress fractures or other injuries of repetitive, intense physical activity, ambitious students are vulnerable to some of the problems that can follow sustained, intense cognitive effort. These risks go up if they are sleep deprived, stop exercising, or are socially isolated. Parents can be on the lookout for signs of depression or anxiety disorders, such as loss of energy, withdrawal from friends or beloved activities, persistent unhappiness or irritability (sustained over days to weeks), and of course morbid preoccupations.
Intense perfectionism is common among young people at risk for eating disorders, depression and self-injury, and anxiety disorders. Beyond recognizing signs, it is even more important for parents and pediatricians to equip ambitious young people to stay connected and ask for help if they experience a change in their emotional equilibrium. Suggest to your patients that they should never worry alone. They should ask for help if they are struggling to sleep, to sustain their motivation or effort, or notice feeling panicked, unusually tearful, or hopeless. Depression and anxiety are common and treatable problems in adolescents, but ambitious adolescents might be inclined to try to soldier through them. Caring adults should demystify and destigmatize mood and anxiety problems. You might point out that they would ask for help for a toothache or a painful knee joint, and that their mental health should be no different.
Many ambitious children have ambitious parents who might look back on their own adolescence and wonder if they were sufficiently balanced in their approach or whether they overreacted to failure. Sometimes honest sharing of successes, failures, and enduring dilemmas can build an empathic bridge from one generation to the next.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
Most parents hope that their children will be motivated and hard-working at school, but ambitious students usually face very high levels of stress. Ambitious young people typically push themselves very hard and may not spend enough time in play, relaxation, or exploring potential interests. Their time with peers might be more competitive than social or fun. They may become rigidly focused on a goal, paving the way for devastation if they fall short of their own expectations. They may internalize stress and not ask for help if it starts to take a toll on their mental health. But ambition is not incompatible with healthy development and well-being. Pediatricians usually know who the ambitious students in their practice are, and will hear about the stress they may be experiencing. You have the opportunity to offer them (or their parents) some strategies to manage their high stress levels, and build resilience.
Support ambition, but not perfectionism
It can be helpful to acknowledge to young people that they are ambitious, enabling them to acknowledge this fact about themselves. This kind of drive can be an admirable strength when it is part of an emerging identity, a wish to be successful as defined by the patient.
It is more likely to be problematic if it is a product of a parent’s need to have a child perform as they deem best. Second, it is critical to differentiate ambition from perfectionism. While ambition can keep someone focused and motivated in the face of difficulty, perfectionism is a bully that leaves a person feeling perpetually inadequate. Ambition without a specific interest or focus can lead to general perfectionism in a young person, and parents might unwittingly support this by applauding successes or becoming overinvested in this success reflecting onto them. When the pediatrician points out to a patient (and parents) that perfection is neither possible nor desirable, they may respond, “why wouldn’t I want to be perfect?” Remind them that perfectionism is actually the enemy of long-term accomplishment, discouraging risk-taking, reflection, and growth.
Celebrate failure!
The critical difference between an ambitious person who is persistent and determined (and thus equipped to succeed) and the brittle perfectionist is the ability to tolerate failure and setbacks. Point out to your patients that ambition means there will be a lot of setbacks, disappointments, and failures, as they attempt things that are challenging. Indeed, they should embrace each little failure, as that is how real learning and growth happen, especially if they are constantly stretching their goals.
As children or teenagers learn that failure is evidence that they are on track, working hard, and improving, they will develop tenacity and flexibility. Carol S. Dweck, PhD, a psychologist who has studied school performance in young people, has demonstrated that when young people are praised for their results they tend to give up when they fail, whereas if they are praised for their hard work and persistence, they redouble their effort when they fail. Parents, teachers, and pediatricians have the power to shift an ambitious child’s mindset (Dweck’s term) by helping the child change his or her thinking about what failure really means.
Cultivate self-awareness and perspective
It is one of the central tasks of growing up to learn what one’s interests, talents, and values are, and this self-knowledge is especially critical in ambitious young people. Without genuine interests or passions, ambition may feel like a hollow quest for approval. It is more likely to become general perfectionism. So children and teenagers need adults who are curious about their underlying interests, who patiently help them to cultivate these interests and dedicate their ambition to the pursuit of these passions. Younger children need adult time and support to explore a variety of interests, dabbling so they might figure out where their interests and talents converge. This can provide plenty of opportunity to celebrate effort over achievement. By adolescence, they should have a clearer sense of their personal interests and abilities, and will be deepening their efforts in fewer areas. Adolescence is also when they start to build a narrative of who they are and what values are truly their own. Parents can serve as models and facilitators for their teenagers’ emerging sets of values. Values such as honesty, compassion, or generosity (for example) organize one’s efforts, giving them deeper meaning and keeping difficulties in perspective. Values also will help ambitious young people set their own goals and create an individualized and meaningful definition of success, and keep bigger failures, losses, or disappointments in perspective.
Teach self-care
It seems obvious to state that learning how to care for one’s self is essential to well-being, but for ambitious young people (and adults), self-care is often the first thing to go (or the last thing they consider) in their busy days. Explain to your patients (and parents) that without adequate, consistent, restful sleep, all of their hard work will be inefficient or likely squandered. Explain that daily cardiovascular exercise is not frivolous, but rather essential to balance their cognitive efforts, and offers potent protection for their physical and mental health. There is even robust evidence that sleep and exercise are directly helpful to memory, learning, and creativity. When a parent models this kind of self-care, it is far more powerful than simply talking about it!
Relaxation is self-care!
While most teenagers do not need to be taught how to relax, those very ambitious ones are likely to need permission and even help in learning how to effectively and efficiently blow off steam. Help them to approach relaxation as they would approach a new subject, open-minded and trying different things to determine what works for them. Some may find exercise relaxing, while some may need a cognitive distraction (sometimes called “senseless fun,” an activity not dedicated to achievement) such as reading, family games, or television. Social time often is very effective relaxation for teenagers, and they should know that it is as important as sleep and studying for their performance. Some may find that a calming activity such as yoga or meditation recharges their batteries, whereas others may need noisy video games to feel renewed. Suggest that they should protect (just a little) time for relaxation even on their busiest days to help them develop good habits of self-care. Without consistent, reliable relaxation, ambitious young people are at risk for burnout or for impulsive and extreme behaviors such as binge-drinking.
Be on the lookout for red flags
In the same way that high performing athletes are at risk for stress fractures or other injuries of repetitive, intense physical activity, ambitious students are vulnerable to some of the problems that can follow sustained, intense cognitive effort. These risks go up if they are sleep deprived, stop exercising, or are socially isolated. Parents can be on the lookout for signs of depression or anxiety disorders, such as loss of energy, withdrawal from friends or beloved activities, persistent unhappiness or irritability (sustained over days to weeks), and of course morbid preoccupations.
Intense perfectionism is common among young people at risk for eating disorders, depression and self-injury, and anxiety disorders. Beyond recognizing signs, it is even more important for parents and pediatricians to equip ambitious young people to stay connected and ask for help if they experience a change in their emotional equilibrium. Suggest to your patients that they should never worry alone. They should ask for help if they are struggling to sleep, to sustain their motivation or effort, or notice feeling panicked, unusually tearful, or hopeless. Depression and anxiety are common and treatable problems in adolescents, but ambitious adolescents might be inclined to try to soldier through them. Caring adults should demystify and destigmatize mood and anxiety problems. You might point out that they would ask for help for a toothache or a painful knee joint, and that their mental health should be no different.
Many ambitious children have ambitious parents who might look back on their own adolescence and wonder if they were sufficiently balanced in their approach or whether they overreacted to failure. Sometimes honest sharing of successes, failures, and enduring dilemmas can build an empathic bridge from one generation to the next.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
Threats in school: Is there a role for you?
Do you remember that kid in your class threatening to beat up a peer (or maybe you) after school? Mean children are not unique to current times. But actual threat to life while in school is a more recent problem, mainly due to the availability of firearms in American homes. Although rates of victimization have actually dropped 86% from 1992 to 2014, stories about school shootings are instantly broadcast across the country, making everyone feel that it could happen to them. Such public awareness also models threatening violence as a potent attention getter.
Often the threatening child lacks not only the skills to manage the frustrating situation, but also the language ability to choose less incendiary words. Saying, “I don’t think the way you handled that was fair to me,” might always be difficult, but is certainly impossible under the high emotions of the moment. Instead, “I’m going to kill you” pops out of their mouths. As for asking for help, school-aged children can only apologize or confess to being unsure a limited number of times before their need to save face takes precedence. This is especially true if they are confronted and humiliated in front of their peers.
Children who have oppositional or aggressive behavior diagnoses are by definition already in a pattern of reacting with hostility when demands are placed on them. In some cases, these negative reactions successfully get their parent(s) to back off the demand, resulting in what is called the “coercive cycle of interaction,” a prodrome to conduct disorder. Then, when a teacher issues a command, their reflexive response is more likely to be a defiant or aggressive one.
When threatening behavior is met by the supervising adults with confrontation, things may further accelerate, again especially in front of peers before whom the student does not want to look weak. Instead, a methodical approach to threat assessment in schools has been shown to be more effective. The main features of effective threat assessment involve identifying student threats, determining their seriousness, and developing intervention plans that both protect potential victims and address the underlying problem or conflict that sparked the threat.
A model program, Virginia Model for Student Threat Assessment by Dewey G. Cornell, PhD, of the University of Virginia, has been shown to help sort out transient (70%) from substantive (30%) threats and resulted in fewer long-term suspensions or expulsions and no cases in which the threats were carried out. (Send a copy to your local school superintendent.) While children receiving special education made three times more threats and more severe threats, they did not require more suspensions. With this threat assessment program, the number of disciplinary office referrals for these students declined by about 55% for the rest of that school year. Students in schools using this method reported less bullying, a greater willingness to seek help for bullying and threats, and more positive perceptions of the school climate as having fairer discipline and less aggression. Resulting plans to help the students involved in threats included modifications to special education plans, academic and behavioral support services, and referrals to mental health services. All these interventions are intended to address gaps in skills. In addition, ways to give even struggling students a meaningful connection to their school – for example, through sports, art, music, clubs, or volunteering – are essential components of both prevention and management.
There are several ways you, as a pediatrician, may be involved in the issue of threats at school. If one of your patients has been accused of threatening behavior, your knowledge of the child and family puts you in the best position to sort out the seriousness of the threat and appropriate next steps. Recently, one of my patients with mild autism was suspended for threatening to “kill the teacher.” He had never been aggressive at home or at school. This 8-year-old usually has a one-on-one aide, but the aide had been pulled to help other students. After an unannounced fire drill, the child called the teacher “evil” and was given his “third strike” for behavior, resulting in him making this threat.
Threat assessment in schools needs to follow the method of functional behavioral assessment, which should actually be standard for all school behavior problems. The method should consider the A (antecedent), B (behavior), C (consequence), and G (gaps) of the behavior. The antecedent here included the “setting” event of the fire drill. The behavior (sometimes also the belief) was the child’s negative reaction to the teacher (who had failed to protect him from being frightened). The consequence was a punishment (third strike) that the child felt was unfair. The gaps in skills included the facts that this is an anxious child who depends on support and routine because of his autism and who is also hypersensitive to loud noise such as a fire drill. In this case, I was able to explain these things to the school, but, in any case, you can, and should, request that the school perform a functional behavioral assessment when dealing with threats.
When you have a child with learning or emotional problems under your care, you need to include asking if they feel safe at school and if anything scary or bad has happened to them there. The parents may need to be directed to meet with school personnel about threats or fears the child reports. School violence prevention programs often include education of the children to be alert for and report threatening peers. This gives students an active role, but also may cause increased anxiety. Parents may need your support in requesting exemption from the school’s “violence prevention training” for anxious children. Anxious parents also may need extra coaching to avoid exposing their children to discussions about school threats.
In caring for all school-aged children (girls are as likely to be involved in school violence as boys), I ask about whether their teachers are nice or mean. I also ask if they have been bullied at school or have bullied others. I also sometimes ask struggling children, “If you had the choice, would you rather go to school or stay home?” The normal, almost universal preference is to go to school. School is the child’s job and social home, and, even when the work is hard, the need for mastery drives children to keep trying. Children preferring to be home are likely in pain and deserve careful assessment of their skills, their emotions, and the school and family environments.
While the percentage of students who reported being afraid of attack or harm at school decreased from 12% in 1995 to 3% in 2013, twice as many African American and Hispanic students feared being attacked than white students. It is clear that feeling anxious interferes with learning. Actual past experience with violence further lowers the threshold for feeling upset. The risk to learning of being fearful at school for children in stressed neighborhoods is multiplied by violence they may experience around them at home, causing even greater impact. Even when actual violence is rare, the media have put all kids and parents on edge about whether they are safe at school. This is a tragedy for everyone involved.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
Do you remember that kid in your class threatening to beat up a peer (or maybe you) after school? Mean children are not unique to current times. But actual threat to life while in school is a more recent problem, mainly due to the availability of firearms in American homes. Although rates of victimization have actually dropped 86% from 1992 to 2014, stories about school shootings are instantly broadcast across the country, making everyone feel that it could happen to them. Such public awareness also models threatening violence as a potent attention getter.
Often the threatening child lacks not only the skills to manage the frustrating situation, but also the language ability to choose less incendiary words. Saying, “I don’t think the way you handled that was fair to me,” might always be difficult, but is certainly impossible under the high emotions of the moment. Instead, “I’m going to kill you” pops out of their mouths. As for asking for help, school-aged children can only apologize or confess to being unsure a limited number of times before their need to save face takes precedence. This is especially true if they are confronted and humiliated in front of their peers.
Children who have oppositional or aggressive behavior diagnoses are by definition already in a pattern of reacting with hostility when demands are placed on them. In some cases, these negative reactions successfully get their parent(s) to back off the demand, resulting in what is called the “coercive cycle of interaction,” a prodrome to conduct disorder. Then, when a teacher issues a command, their reflexive response is more likely to be a defiant or aggressive one.
When threatening behavior is met by the supervising adults with confrontation, things may further accelerate, again especially in front of peers before whom the student does not want to look weak. Instead, a methodical approach to threat assessment in schools has been shown to be more effective. The main features of effective threat assessment involve identifying student threats, determining their seriousness, and developing intervention plans that both protect potential victims and address the underlying problem or conflict that sparked the threat.
A model program, Virginia Model for Student Threat Assessment by Dewey G. Cornell, PhD, of the University of Virginia, has been shown to help sort out transient (70%) from substantive (30%) threats and resulted in fewer long-term suspensions or expulsions and no cases in which the threats were carried out. (Send a copy to your local school superintendent.) While children receiving special education made three times more threats and more severe threats, they did not require more suspensions. With this threat assessment program, the number of disciplinary office referrals for these students declined by about 55% for the rest of that school year. Students in schools using this method reported less bullying, a greater willingness to seek help for bullying and threats, and more positive perceptions of the school climate as having fairer discipline and less aggression. Resulting plans to help the students involved in threats included modifications to special education plans, academic and behavioral support services, and referrals to mental health services. All these interventions are intended to address gaps in skills. In addition, ways to give even struggling students a meaningful connection to their school – for example, through sports, art, music, clubs, or volunteering – are essential components of both prevention and management.
There are several ways you, as a pediatrician, may be involved in the issue of threats at school. If one of your patients has been accused of threatening behavior, your knowledge of the child and family puts you in the best position to sort out the seriousness of the threat and appropriate next steps. Recently, one of my patients with mild autism was suspended for threatening to “kill the teacher.” He had never been aggressive at home or at school. This 8-year-old usually has a one-on-one aide, but the aide had been pulled to help other students. After an unannounced fire drill, the child called the teacher “evil” and was given his “third strike” for behavior, resulting in him making this threat.
Threat assessment in schools needs to follow the method of functional behavioral assessment, which should actually be standard for all school behavior problems. The method should consider the A (antecedent), B (behavior), C (consequence), and G (gaps) of the behavior. The antecedent here included the “setting” event of the fire drill. The behavior (sometimes also the belief) was the child’s negative reaction to the teacher (who had failed to protect him from being frightened). The consequence was a punishment (third strike) that the child felt was unfair. The gaps in skills included the facts that this is an anxious child who depends on support and routine because of his autism and who is also hypersensitive to loud noise such as a fire drill. In this case, I was able to explain these things to the school, but, in any case, you can, and should, request that the school perform a functional behavioral assessment when dealing with threats.
When you have a child with learning or emotional problems under your care, you need to include asking if they feel safe at school and if anything scary or bad has happened to them there. The parents may need to be directed to meet with school personnel about threats or fears the child reports. School violence prevention programs often include education of the children to be alert for and report threatening peers. This gives students an active role, but also may cause increased anxiety. Parents may need your support in requesting exemption from the school’s “violence prevention training” for anxious children. Anxious parents also may need extra coaching to avoid exposing their children to discussions about school threats.
In caring for all school-aged children (girls are as likely to be involved in school violence as boys), I ask about whether their teachers are nice or mean. I also ask if they have been bullied at school or have bullied others. I also sometimes ask struggling children, “If you had the choice, would you rather go to school or stay home?” The normal, almost universal preference is to go to school. School is the child’s job and social home, and, even when the work is hard, the need for mastery drives children to keep trying. Children preferring to be home are likely in pain and deserve careful assessment of their skills, their emotions, and the school and family environments.
While the percentage of students who reported being afraid of attack or harm at school decreased from 12% in 1995 to 3% in 2013, twice as many African American and Hispanic students feared being attacked than white students. It is clear that feeling anxious interferes with learning. Actual past experience with violence further lowers the threshold for feeling upset. The risk to learning of being fearful at school for children in stressed neighborhoods is multiplied by violence they may experience around them at home, causing even greater impact. Even when actual violence is rare, the media have put all kids and parents on edge about whether they are safe at school. This is a tragedy for everyone involved.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
Do you remember that kid in your class threatening to beat up a peer (or maybe you) after school? Mean children are not unique to current times. But actual threat to life while in school is a more recent problem, mainly due to the availability of firearms in American homes. Although rates of victimization have actually dropped 86% from 1992 to 2014, stories about school shootings are instantly broadcast across the country, making everyone feel that it could happen to them. Such public awareness also models threatening violence as a potent attention getter.
Often the threatening child lacks not only the skills to manage the frustrating situation, but also the language ability to choose less incendiary words. Saying, “I don’t think the way you handled that was fair to me,” might always be difficult, but is certainly impossible under the high emotions of the moment. Instead, “I’m going to kill you” pops out of their mouths. As for asking for help, school-aged children can only apologize or confess to being unsure a limited number of times before their need to save face takes precedence. This is especially true if they are confronted and humiliated in front of their peers.
Children who have oppositional or aggressive behavior diagnoses are by definition already in a pattern of reacting with hostility when demands are placed on them. In some cases, these negative reactions successfully get their parent(s) to back off the demand, resulting in what is called the “coercive cycle of interaction,” a prodrome to conduct disorder. Then, when a teacher issues a command, their reflexive response is more likely to be a defiant or aggressive one.
When threatening behavior is met by the supervising adults with confrontation, things may further accelerate, again especially in front of peers before whom the student does not want to look weak. Instead, a methodical approach to threat assessment in schools has been shown to be more effective. The main features of effective threat assessment involve identifying student threats, determining their seriousness, and developing intervention plans that both protect potential victims and address the underlying problem or conflict that sparked the threat.
A model program, Virginia Model for Student Threat Assessment by Dewey G. Cornell, PhD, of the University of Virginia, has been shown to help sort out transient (70%) from substantive (30%) threats and resulted in fewer long-term suspensions or expulsions and no cases in which the threats were carried out. (Send a copy to your local school superintendent.) While children receiving special education made three times more threats and more severe threats, they did not require more suspensions. With this threat assessment program, the number of disciplinary office referrals for these students declined by about 55% for the rest of that school year. Students in schools using this method reported less bullying, a greater willingness to seek help for bullying and threats, and more positive perceptions of the school climate as having fairer discipline and less aggression. Resulting plans to help the students involved in threats included modifications to special education plans, academic and behavioral support services, and referrals to mental health services. All these interventions are intended to address gaps in skills. In addition, ways to give even struggling students a meaningful connection to their school – for example, through sports, art, music, clubs, or volunteering – are essential components of both prevention and management.
There are several ways you, as a pediatrician, may be involved in the issue of threats at school. If one of your patients has been accused of threatening behavior, your knowledge of the child and family puts you in the best position to sort out the seriousness of the threat and appropriate next steps. Recently, one of my patients with mild autism was suspended for threatening to “kill the teacher.” He had never been aggressive at home or at school. This 8-year-old usually has a one-on-one aide, but the aide had been pulled to help other students. After an unannounced fire drill, the child called the teacher “evil” and was given his “third strike” for behavior, resulting in him making this threat.
Threat assessment in schools needs to follow the method of functional behavioral assessment, which should actually be standard for all school behavior problems. The method should consider the A (antecedent), B (behavior), C (consequence), and G (gaps) of the behavior. The antecedent here included the “setting” event of the fire drill. The behavior (sometimes also the belief) was the child’s negative reaction to the teacher (who had failed to protect him from being frightened). The consequence was a punishment (third strike) that the child felt was unfair. The gaps in skills included the facts that this is an anxious child who depends on support and routine because of his autism and who is also hypersensitive to loud noise such as a fire drill. In this case, I was able to explain these things to the school, but, in any case, you can, and should, request that the school perform a functional behavioral assessment when dealing with threats.
When you have a child with learning or emotional problems under your care, you need to include asking if they feel safe at school and if anything scary or bad has happened to them there. The parents may need to be directed to meet with school personnel about threats or fears the child reports. School violence prevention programs often include education of the children to be alert for and report threatening peers. This gives students an active role, but also may cause increased anxiety. Parents may need your support in requesting exemption from the school’s “violence prevention training” for anxious children. Anxious parents also may need extra coaching to avoid exposing their children to discussions about school threats.
In caring for all school-aged children (girls are as likely to be involved in school violence as boys), I ask about whether their teachers are nice or mean. I also ask if they have been bullied at school or have bullied others. I also sometimes ask struggling children, “If you had the choice, would you rather go to school or stay home?” The normal, almost universal preference is to go to school. School is the child’s job and social home, and, even when the work is hard, the need for mastery drives children to keep trying. Children preferring to be home are likely in pain and deserve careful assessment of their skills, their emotions, and the school and family environments.
While the percentage of students who reported being afraid of attack or harm at school decreased from 12% in 1995 to 3% in 2013, twice as many African American and Hispanic students feared being attacked than white students. It is clear that feeling anxious interferes with learning. Actual past experience with violence further lowers the threshold for feeling upset. The risk to learning of being fearful at school for children in stressed neighborhoods is multiplied by violence they may experience around them at home, causing even greater impact. Even when actual violence is rare, the media have put all kids and parents on edge about whether they are safe at school. This is a tragedy for everyone involved.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News.
Discussing screen time with parents
The American Academy of Pediatrics released a new set of recommendations for the appropriate amount of screen time for children and adolescents in October 2016.
Among other changes, the AAP now recommends no screen time (except for video chatting) for infants and children up to 18 months old. For 18- to 24-month-olds, the AAP discourages screen time, recommending that parents introduce only selected “high-quality” programming and cowatch with their children. Likewise, for children up to 5 years old, the AAP urges parents to limit all screen time to 1 hour/day, half of its previous recommendation, and again recommends that parents cowatch with their children and use only reliable providers of quality content, such as the Public Broadcasting Service (PBS). For older children, the AAP does not set specific time limits, but recommends that parents collaborate with the children on a media plan that limits screen time so that it does not interfere with other important activities, including homework, social time, exercise, and sleep.
There also is evidence that teenagers who spend substantial time engaged passively in social media (seeing what others are doing or saying via Facebook or Instagram) report higher levels of depression and anxiety, whereas those who use social media as a platform to stay connected (via two-way communication) report lower levels of these symptoms. While many young people use social sites as a forum to find peer support, share concerns, or develop their own “voice,” some young people might be vulnerable to exploitation, cyberbullying, or even online solicitation. The key here may be for parents, who have a sense of their child’s strengths and vulnerabilities, to be aware of where their children are spending their virtual time and to check in about the kinds of connections they have there. Of course, screen time can be equally seductive for parents. And when a parent is spending time reading texts or checking for Facebook updates, they are missing opportunities to be engaged with their children, helping them with homework or simply noticing that they seem stressed, or catching an opportunity to talk with them.
The pediatrician has the opportunity to educate parents about the potential risks that unchecked screen time can pose to their children’s healthy development. But it is critical that you approach these conversations with specificity and compassion. Customize the conversation to the age and personality of the child and family. A computer in the bedroom may make sense for an academically oriented 9th grader in a demanding school who is generally well-balanced in activities and friendships. A bedroom computer may be a poor choice for an isolated 9th grader almost addicted to video games with few friends or activities.
Simply reciting recommendations may heighten a parent’s feelings of isolation and shame, and not lead to meaningful change. Instead, start by asking about the details: Where are the screens in the home? Bedrooms? Who has a computer, tablet, or smartphone? How are these screens used in the context of the child’s overall psychosocial functioning? Depending on the circumstance, a smaller change, such as “no phones while doing homework,” can make a big difference. Simple, clear rules can be easier to explain and enforce, and protect parents from the perils of daily negotiations of screen terms with their children or teenagers. Perhaps they can have a “phone zone” where phones get parked and charged once kids get home from school. Perhaps there are limits on TV or video games on school nights (for the student performing below potential, rather than the driven student who would benefit from down time). Perhaps for preteens, computer-based homework can be done only on the desktop computer that is kept in a family study, rather than a laptop in a bedroom where kids are more likely to become distracted and surf the net. Pediatricians can help families think through the right approach to screen time that may range from restriction to shared use exploring shared interests to jointly watching a favorite TV show or sporting event.
You can help parents consider how they will talk about all this, acknowledging what is fun and rewarding about TV shows, social media, and the Internet alongside the problems of excessive use. Ask parents if it is hard for them to put down their own phones or tablets. They can acknowledge this explicitly with their children when establishing new media use rules. It is powerful for children, especially teenagers, to hear their parents acknowledge that “phones, tablets, and computers are powerful tools, but we all need to improve our skills at being in control of our use of them.” You might suggest that parents try this exercise: list all of the activities they wish they had time for in every day, and how much time they would spend in them. Then they should guess how much time they spend in screen-based entertainment. If they wish to protect time for screen-based entertainment, they can actively choose to do so. If you are able to help parents better understand the risks of excessive screen time and facilitate desired and appropriate use of media, you will have added to the quality of the family’s life.
The AAP has resources to help pediatricians partner with parents to create a Family Media Use Plan (www.healthychildren.org/MediaUsePlan).
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
The American Academy of Pediatrics released a new set of recommendations for the appropriate amount of screen time for children and adolescents in October 2016.
Among other changes, the AAP now recommends no screen time (except for video chatting) for infants and children up to 18 months old. For 18- to 24-month-olds, the AAP discourages screen time, recommending that parents introduce only selected “high-quality” programming and cowatch with their children. Likewise, for children up to 5 years old, the AAP urges parents to limit all screen time to 1 hour/day, half of its previous recommendation, and again recommends that parents cowatch with their children and use only reliable providers of quality content, such as the Public Broadcasting Service (PBS). For older children, the AAP does not set specific time limits, but recommends that parents collaborate with the children on a media plan that limits screen time so that it does not interfere with other important activities, including homework, social time, exercise, and sleep.
There also is evidence that teenagers who spend substantial time engaged passively in social media (seeing what others are doing or saying via Facebook or Instagram) report higher levels of depression and anxiety, whereas those who use social media as a platform to stay connected (via two-way communication) report lower levels of these symptoms. While many young people use social sites as a forum to find peer support, share concerns, or develop their own “voice,” some young people might be vulnerable to exploitation, cyberbullying, or even online solicitation. The key here may be for parents, who have a sense of their child’s strengths and vulnerabilities, to be aware of where their children are spending their virtual time and to check in about the kinds of connections they have there. Of course, screen time can be equally seductive for parents. And when a parent is spending time reading texts or checking for Facebook updates, they are missing opportunities to be engaged with their children, helping them with homework or simply noticing that they seem stressed, or catching an opportunity to talk with them.
The pediatrician has the opportunity to educate parents about the potential risks that unchecked screen time can pose to their children’s healthy development. But it is critical that you approach these conversations with specificity and compassion. Customize the conversation to the age and personality of the child and family. A computer in the bedroom may make sense for an academically oriented 9th grader in a demanding school who is generally well-balanced in activities and friendships. A bedroom computer may be a poor choice for an isolated 9th grader almost addicted to video games with few friends or activities.
Simply reciting recommendations may heighten a parent’s feelings of isolation and shame, and not lead to meaningful change. Instead, start by asking about the details: Where are the screens in the home? Bedrooms? Who has a computer, tablet, or smartphone? How are these screens used in the context of the child’s overall psychosocial functioning? Depending on the circumstance, a smaller change, such as “no phones while doing homework,” can make a big difference. Simple, clear rules can be easier to explain and enforce, and protect parents from the perils of daily negotiations of screen terms with their children or teenagers. Perhaps they can have a “phone zone” where phones get parked and charged once kids get home from school. Perhaps there are limits on TV or video games on school nights (for the student performing below potential, rather than the driven student who would benefit from down time). Perhaps for preteens, computer-based homework can be done only on the desktop computer that is kept in a family study, rather than a laptop in a bedroom where kids are more likely to become distracted and surf the net. Pediatricians can help families think through the right approach to screen time that may range from restriction to shared use exploring shared interests to jointly watching a favorite TV show or sporting event.
You can help parents consider how they will talk about all this, acknowledging what is fun and rewarding about TV shows, social media, and the Internet alongside the problems of excessive use. Ask parents if it is hard for them to put down their own phones or tablets. They can acknowledge this explicitly with their children when establishing new media use rules. It is powerful for children, especially teenagers, to hear their parents acknowledge that “phones, tablets, and computers are powerful tools, but we all need to improve our skills at being in control of our use of them.” You might suggest that parents try this exercise: list all of the activities they wish they had time for in every day, and how much time they would spend in them. Then they should guess how much time they spend in screen-based entertainment. If they wish to protect time for screen-based entertainment, they can actively choose to do so. If you are able to help parents better understand the risks of excessive screen time and facilitate desired and appropriate use of media, you will have added to the quality of the family’s life.
The AAP has resources to help pediatricians partner with parents to create a Family Media Use Plan (www.healthychildren.org/MediaUsePlan).
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
The American Academy of Pediatrics released a new set of recommendations for the appropriate amount of screen time for children and adolescents in October 2016.
Among other changes, the AAP now recommends no screen time (except for video chatting) for infants and children up to 18 months old. For 18- to 24-month-olds, the AAP discourages screen time, recommending that parents introduce only selected “high-quality” programming and cowatch with their children. Likewise, for children up to 5 years old, the AAP urges parents to limit all screen time to 1 hour/day, half of its previous recommendation, and again recommends that parents cowatch with their children and use only reliable providers of quality content, such as the Public Broadcasting Service (PBS). For older children, the AAP does not set specific time limits, but recommends that parents collaborate with the children on a media plan that limits screen time so that it does not interfere with other important activities, including homework, social time, exercise, and sleep.
There also is evidence that teenagers who spend substantial time engaged passively in social media (seeing what others are doing or saying via Facebook or Instagram) report higher levels of depression and anxiety, whereas those who use social media as a platform to stay connected (via two-way communication) report lower levels of these symptoms. While many young people use social sites as a forum to find peer support, share concerns, or develop their own “voice,” some young people might be vulnerable to exploitation, cyberbullying, or even online solicitation. The key here may be for parents, who have a sense of their child’s strengths and vulnerabilities, to be aware of where their children are spending their virtual time and to check in about the kinds of connections they have there. Of course, screen time can be equally seductive for parents. And when a parent is spending time reading texts or checking for Facebook updates, they are missing opportunities to be engaged with their children, helping them with homework or simply noticing that they seem stressed, or catching an opportunity to talk with them.
The pediatrician has the opportunity to educate parents about the potential risks that unchecked screen time can pose to their children’s healthy development. But it is critical that you approach these conversations with specificity and compassion. Customize the conversation to the age and personality of the child and family. A computer in the bedroom may make sense for an academically oriented 9th grader in a demanding school who is generally well-balanced in activities and friendships. A bedroom computer may be a poor choice for an isolated 9th grader almost addicted to video games with few friends or activities.
Simply reciting recommendations may heighten a parent’s feelings of isolation and shame, and not lead to meaningful change. Instead, start by asking about the details: Where are the screens in the home? Bedrooms? Who has a computer, tablet, or smartphone? How are these screens used in the context of the child’s overall psychosocial functioning? Depending on the circumstance, a smaller change, such as “no phones while doing homework,” can make a big difference. Simple, clear rules can be easier to explain and enforce, and protect parents from the perils of daily negotiations of screen terms with their children or teenagers. Perhaps they can have a “phone zone” where phones get parked and charged once kids get home from school. Perhaps there are limits on TV or video games on school nights (for the student performing below potential, rather than the driven student who would benefit from down time). Perhaps for preteens, computer-based homework can be done only on the desktop computer that is kept in a family study, rather than a laptop in a bedroom where kids are more likely to become distracted and surf the net. Pediatricians can help families think through the right approach to screen time that may range from restriction to shared use exploring shared interests to jointly watching a favorite TV show or sporting event.
You can help parents consider how they will talk about all this, acknowledging what is fun and rewarding about TV shows, social media, and the Internet alongside the problems of excessive use. Ask parents if it is hard for them to put down their own phones or tablets. They can acknowledge this explicitly with their children when establishing new media use rules. It is powerful for children, especially teenagers, to hear their parents acknowledge that “phones, tablets, and computers are powerful tools, but we all need to improve our skills at being in control of our use of them.” You might suggest that parents try this exercise: list all of the activities they wish they had time for in every day, and how much time they would spend in them. Then they should guess how much time they spend in screen-based entertainment. If they wish to protect time for screen-based entertainment, they can actively choose to do so. If you are able to help parents better understand the risks of excessive screen time and facilitate desired and appropriate use of media, you will have added to the quality of the family’s life.
The AAP has resources to help pediatricians partner with parents to create a Family Media Use Plan (www.healthychildren.org/MediaUsePlan).
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
Do as I say, not as I do! A futile plea
I am constantly amazed when parents come in complaining about their child’s nail biting or irritable attitude “no matter how many times I tell her” as they do these same things in front of me!
We have not evolved that far from our nonverbal ancestors to expect that words will speak louder than actions. Looking closely, you can see even very young infants gazing closely at their parents, then mirroring their facial expressions a few minutes later (because of slower processing). Mirroring is probably the correct word for this as the mirror neuron system of the brain has as its primary and crucial function allowing humans to copy what they see in others.
Children look to model, especially those who are slightly older and more adept than they are. Older siblings bask in this adoration at times and squeal in frustration at other times that their younger sister is “mocking” them by copying their speech and actions. When children are picking up serious negative behaviors from siblings or peers, particularly in adolescence, we need to coach parents to take action.
But watching parents is the most powerful or “salient” stimulus for learning. Some theorize that the long period of childhood evolved to allow children to learn the incredible amount of information necessary to live independently in our complex culture. This learning begins very early and requires close contact and careful observation of the minute details of how the parent survives every day.
Eating is a great primitive example of why children must model their parents. How do animals know which plants are poisonous? By watching others eat and spit, choke, or vomit. Entire families have nonpreferred foods passed on by modeling refusal as well as lack of exposure on the table. Conversely, picky eaters need to observe others, preferably admired peers and parents, eating those vegetables. (Tasting is also necessary, but that’s a topic for another day!) It is worth asking about family meals, without the distraction of a TV, as they are key moments to model nutritious eating for their lifetime.
In “underdeveloped” countries, infants are naturally carried everywhere and observing constantly. In our “developed” country, many infants spend hours each day at day care, modeling their caregivers or watching media examples of people interacting, which may not be the models parents would consciously choose. Parents often ask us about childcare, anxious about the extremely rare threat of abduction, when we should instead be advising them about what models they want for their children during this critical learning period.
Emotion cueing is a crucial component of modeling and an untaught constant of typical parent-child interaction. Crawling infants placed on a clear surface over a “visual cliff” that appeared to be a sudden precipice look to the parent’s affect to decide how to act. The mother was instructed to show fear or joy when her baby reached the apparent danger and looked up for a warning. When fear was shown, the infants backed off and cried. When joy was shown, the baby crawled gaily across the “cliff.” For parents who do not come by signaling confidence naturally but want to model this for their children, I advise they “fake it until you make it!”
Parents are instructing their progeny in how to feel and act in every situation, whether they know it or not. Confident parents model bravery; kind parents model compassion; flexible parents model resilience; patient parents model tolerance; anxious parents model caution; angry parents model aggression. Ignoring parents (think: on their cellphone, distracted, depressed, inebriated, or high) leave their children to feel confused and insecure. An adaptive child of an ignoring parent may demand information by crying, clinging, fighting with siblings, or hitting the parent. They are desperate for the parental attention to teach them and keep them safe. A more passive child may become increasingly inhibited in their exploration of the world. We need to consider possible modeling failures when such child reaction patterns are the complaint, and remember that the adverse model may not be in the room, requiring us to ask, “What other adult models does he see?”
Studies have shown that infants learn resilience when experiencing “mistakes” in parent-infant interaction; learning how to tolerate and repair an interaction that is not perfect. This is really good news for parents who feel that they must be perfect models for their children! For parents of anxious or obsessive children, I sometimes prescribe making mistakes and saying “Oh well,” as well as rewarding the child when they can say “Oh well” themselves. No child is too old to benefit from observing a parent apologize sincerely for a mistake.
Language is modeled, right down to accent. But when parents complain about their child cussing, raising their voice in anger, having an “attitude,” or “talking back,” it is worth asking (parent and child) “Where do you think they/you have heard talk like that?” It may be childcare providers, peers, TV, video games or online media (all of which may warrant a change), but it also may reflect interactions at home.
Children make stronger memories when emotions are high as these may signal danger, making recall more salient to survival. This salience helps explain the lasting detriments to learning and health of growing up with psychological abuse, marital discord, partner violence, mental illness, or criminal behavior (among the Adverse Childhood Experiences). Such experiences cause stress and a sense of the world as a dangerous place, but also become models for the child’s own later relationships as adults. While unavoidable, they can be buffered by parents’ explaining them and providing alternative positive modeling.
Watching the parent conduct their craft, a key component of apprenticeship and family businesses in the past, has been replaced by YouTube and avatars for learning physical skills. But “modeling the process” of pride in craftsmanship, persistence in a task, and recovering and starting over when things go awry are omitted from training videos. These are good reasons to assure that parents do chores, crafts, cooking, or camping with their children as some things will surely go wrong, giving parents the chance to model resilience and problem solving!
Although teens may protest conversations and activities, they are watching their parents for how to be a spouse, a neighbor, a friend, a leader, a citizen. Parents, who may be cutting their teens loose, need to continue to expect/require participation in family meals and outings. Those are opportunities to model adult-level interactions with each other and with the community as well as to talk about their activities at work, in volunteering, in charity, and in religious practice. The moral development of the adolescent is shaped by what they see to the degree that when parents state one moral code but violate it themselves (for example, cheating on taxes, running red lights), the teen is less likely to follow the principles long term that the parents have verbalized.
Parents often relate to us as though we were their own parents. While this “projection” can interfere with disclosure on touchy subjects, it is also an opportunity for us to model ways of relating and reacting from sympathizing with the 4-year-old screaming about vaccines to asking an 8-year-old why he thinks his parents are getting a divorce.
Parenting (and being a pediatrician) is an opportunity to enjoy reliving your youth or to get a “do over” of parts you would like to have different for your child. Playfulness and silliness model joy for the child that can last a lifetime.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at [email protected].
I am constantly amazed when parents come in complaining about their child’s nail biting or irritable attitude “no matter how many times I tell her” as they do these same things in front of me!
We have not evolved that far from our nonverbal ancestors to expect that words will speak louder than actions. Looking closely, you can see even very young infants gazing closely at their parents, then mirroring their facial expressions a few minutes later (because of slower processing). Mirroring is probably the correct word for this as the mirror neuron system of the brain has as its primary and crucial function allowing humans to copy what they see in others.
Children look to model, especially those who are slightly older and more adept than they are. Older siblings bask in this adoration at times and squeal in frustration at other times that their younger sister is “mocking” them by copying their speech and actions. When children are picking up serious negative behaviors from siblings or peers, particularly in adolescence, we need to coach parents to take action.
But watching parents is the most powerful or “salient” stimulus for learning. Some theorize that the long period of childhood evolved to allow children to learn the incredible amount of information necessary to live independently in our complex culture. This learning begins very early and requires close contact and careful observation of the minute details of how the parent survives every day.
Eating is a great primitive example of why children must model their parents. How do animals know which plants are poisonous? By watching others eat and spit, choke, or vomit. Entire families have nonpreferred foods passed on by modeling refusal as well as lack of exposure on the table. Conversely, picky eaters need to observe others, preferably admired peers and parents, eating those vegetables. (Tasting is also necessary, but that’s a topic for another day!) It is worth asking about family meals, without the distraction of a TV, as they are key moments to model nutritious eating for their lifetime.
In “underdeveloped” countries, infants are naturally carried everywhere and observing constantly. In our “developed” country, many infants spend hours each day at day care, modeling their caregivers or watching media examples of people interacting, which may not be the models parents would consciously choose. Parents often ask us about childcare, anxious about the extremely rare threat of abduction, when we should instead be advising them about what models they want for their children during this critical learning period.
Emotion cueing is a crucial component of modeling and an untaught constant of typical parent-child interaction. Crawling infants placed on a clear surface over a “visual cliff” that appeared to be a sudden precipice look to the parent’s affect to decide how to act. The mother was instructed to show fear or joy when her baby reached the apparent danger and looked up for a warning. When fear was shown, the infants backed off and cried. When joy was shown, the baby crawled gaily across the “cliff.” For parents who do not come by signaling confidence naturally but want to model this for their children, I advise they “fake it until you make it!”
Parents are instructing their progeny in how to feel and act in every situation, whether they know it or not. Confident parents model bravery; kind parents model compassion; flexible parents model resilience; patient parents model tolerance; anxious parents model caution; angry parents model aggression. Ignoring parents (think: on their cellphone, distracted, depressed, inebriated, or high) leave their children to feel confused and insecure. An adaptive child of an ignoring parent may demand information by crying, clinging, fighting with siblings, or hitting the parent. They are desperate for the parental attention to teach them and keep them safe. A more passive child may become increasingly inhibited in their exploration of the world. We need to consider possible modeling failures when such child reaction patterns are the complaint, and remember that the adverse model may not be in the room, requiring us to ask, “What other adult models does he see?”
Studies have shown that infants learn resilience when experiencing “mistakes” in parent-infant interaction; learning how to tolerate and repair an interaction that is not perfect. This is really good news for parents who feel that they must be perfect models for their children! For parents of anxious or obsessive children, I sometimes prescribe making mistakes and saying “Oh well,” as well as rewarding the child when they can say “Oh well” themselves. No child is too old to benefit from observing a parent apologize sincerely for a mistake.
Language is modeled, right down to accent. But when parents complain about their child cussing, raising their voice in anger, having an “attitude,” or “talking back,” it is worth asking (parent and child) “Where do you think they/you have heard talk like that?” It may be childcare providers, peers, TV, video games or online media (all of which may warrant a change), but it also may reflect interactions at home.
Children make stronger memories when emotions are high as these may signal danger, making recall more salient to survival. This salience helps explain the lasting detriments to learning and health of growing up with psychological abuse, marital discord, partner violence, mental illness, or criminal behavior (among the Adverse Childhood Experiences). Such experiences cause stress and a sense of the world as a dangerous place, but also become models for the child’s own later relationships as adults. While unavoidable, they can be buffered by parents’ explaining them and providing alternative positive modeling.
Watching the parent conduct their craft, a key component of apprenticeship and family businesses in the past, has been replaced by YouTube and avatars for learning physical skills. But “modeling the process” of pride in craftsmanship, persistence in a task, and recovering and starting over when things go awry are omitted from training videos. These are good reasons to assure that parents do chores, crafts, cooking, or camping with their children as some things will surely go wrong, giving parents the chance to model resilience and problem solving!
Although teens may protest conversations and activities, they are watching their parents for how to be a spouse, a neighbor, a friend, a leader, a citizen. Parents, who may be cutting their teens loose, need to continue to expect/require participation in family meals and outings. Those are opportunities to model adult-level interactions with each other and with the community as well as to talk about their activities at work, in volunteering, in charity, and in religious practice. The moral development of the adolescent is shaped by what they see to the degree that when parents state one moral code but violate it themselves (for example, cheating on taxes, running red lights), the teen is less likely to follow the principles long term that the parents have verbalized.
Parents often relate to us as though we were their own parents. While this “projection” can interfere with disclosure on touchy subjects, it is also an opportunity for us to model ways of relating and reacting from sympathizing with the 4-year-old screaming about vaccines to asking an 8-year-old why he thinks his parents are getting a divorce.
Parenting (and being a pediatrician) is an opportunity to enjoy reliving your youth or to get a “do over” of parts you would like to have different for your child. Playfulness and silliness model joy for the child that can last a lifetime.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at [email protected].
I am constantly amazed when parents come in complaining about their child’s nail biting or irritable attitude “no matter how many times I tell her” as they do these same things in front of me!
We have not evolved that far from our nonverbal ancestors to expect that words will speak louder than actions. Looking closely, you can see even very young infants gazing closely at their parents, then mirroring their facial expressions a few minutes later (because of slower processing). Mirroring is probably the correct word for this as the mirror neuron system of the brain has as its primary and crucial function allowing humans to copy what they see in others.
Children look to model, especially those who are slightly older and more adept than they are. Older siblings bask in this adoration at times and squeal in frustration at other times that their younger sister is “mocking” them by copying their speech and actions. When children are picking up serious negative behaviors from siblings or peers, particularly in adolescence, we need to coach parents to take action.
But watching parents is the most powerful or “salient” stimulus for learning. Some theorize that the long period of childhood evolved to allow children to learn the incredible amount of information necessary to live independently in our complex culture. This learning begins very early and requires close contact and careful observation of the minute details of how the parent survives every day.
Eating is a great primitive example of why children must model their parents. How do animals know which plants are poisonous? By watching others eat and spit, choke, or vomit. Entire families have nonpreferred foods passed on by modeling refusal as well as lack of exposure on the table. Conversely, picky eaters need to observe others, preferably admired peers and parents, eating those vegetables. (Tasting is also necessary, but that’s a topic for another day!) It is worth asking about family meals, without the distraction of a TV, as they are key moments to model nutritious eating for their lifetime.
In “underdeveloped” countries, infants are naturally carried everywhere and observing constantly. In our “developed” country, many infants spend hours each day at day care, modeling their caregivers or watching media examples of people interacting, which may not be the models parents would consciously choose. Parents often ask us about childcare, anxious about the extremely rare threat of abduction, when we should instead be advising them about what models they want for their children during this critical learning period.
Emotion cueing is a crucial component of modeling and an untaught constant of typical parent-child interaction. Crawling infants placed on a clear surface over a “visual cliff” that appeared to be a sudden precipice look to the parent’s affect to decide how to act. The mother was instructed to show fear or joy when her baby reached the apparent danger and looked up for a warning. When fear was shown, the infants backed off and cried. When joy was shown, the baby crawled gaily across the “cliff.” For parents who do not come by signaling confidence naturally but want to model this for their children, I advise they “fake it until you make it!”
Parents are instructing their progeny in how to feel and act in every situation, whether they know it or not. Confident parents model bravery; kind parents model compassion; flexible parents model resilience; patient parents model tolerance; anxious parents model caution; angry parents model aggression. Ignoring parents (think: on their cellphone, distracted, depressed, inebriated, or high) leave their children to feel confused and insecure. An adaptive child of an ignoring parent may demand information by crying, clinging, fighting with siblings, or hitting the parent. They are desperate for the parental attention to teach them and keep them safe. A more passive child may become increasingly inhibited in their exploration of the world. We need to consider possible modeling failures when such child reaction patterns are the complaint, and remember that the adverse model may not be in the room, requiring us to ask, “What other adult models does he see?”
Studies have shown that infants learn resilience when experiencing “mistakes” in parent-infant interaction; learning how to tolerate and repair an interaction that is not perfect. This is really good news for parents who feel that they must be perfect models for their children! For parents of anxious or obsessive children, I sometimes prescribe making mistakes and saying “Oh well,” as well as rewarding the child when they can say “Oh well” themselves. No child is too old to benefit from observing a parent apologize sincerely for a mistake.
Language is modeled, right down to accent. But when parents complain about their child cussing, raising their voice in anger, having an “attitude,” or “talking back,” it is worth asking (parent and child) “Where do you think they/you have heard talk like that?” It may be childcare providers, peers, TV, video games or online media (all of which may warrant a change), but it also may reflect interactions at home.
Children make stronger memories when emotions are high as these may signal danger, making recall more salient to survival. This salience helps explain the lasting detriments to learning and health of growing up with psychological abuse, marital discord, partner violence, mental illness, or criminal behavior (among the Adverse Childhood Experiences). Such experiences cause stress and a sense of the world as a dangerous place, but also become models for the child’s own later relationships as adults. While unavoidable, they can be buffered by parents’ explaining them and providing alternative positive modeling.
Watching the parent conduct their craft, a key component of apprenticeship and family businesses in the past, has been replaced by YouTube and avatars for learning physical skills. But “modeling the process” of pride in craftsmanship, persistence in a task, and recovering and starting over when things go awry are omitted from training videos. These are good reasons to assure that parents do chores, crafts, cooking, or camping with their children as some things will surely go wrong, giving parents the chance to model resilience and problem solving!
Although teens may protest conversations and activities, they are watching their parents for how to be a spouse, a neighbor, a friend, a leader, a citizen. Parents, who may be cutting their teens loose, need to continue to expect/require participation in family meals and outings. Those are opportunities to model adult-level interactions with each other and with the community as well as to talk about their activities at work, in volunteering, in charity, and in religious practice. The moral development of the adolescent is shaped by what they see to the degree that when parents state one moral code but violate it themselves (for example, cheating on taxes, running red lights), the teen is less likely to follow the principles long term that the parents have verbalized.
Parents often relate to us as though we were their own parents. While this “projection” can interfere with disclosure on touchy subjects, it is also an opportunity for us to model ways of relating and reacting from sympathizing with the 4-year-old screaming about vaccines to asking an 8-year-old why he thinks his parents are getting a divorce.
Parenting (and being a pediatrician) is an opportunity to enjoy reliving your youth or to get a “do over” of parts you would like to have different for your child. Playfulness and silliness model joy for the child that can last a lifetime.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS (www.CHADIS.com). She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at [email protected].
School refusal
As summer winds down, it is routine for children and adolescents to feel a little melancholy or even worried about the approaching start of school. But for some students, anxiety about school is more than routine; it is insurmountable. School refusal is a serious behavioral problem: without assertive management, it can become a pattern which is very difficult to alter. Whether a child is complaining of vague somatic concerns or is explicitly refusing to go to school, the pediatrician’s office is often the first place a parent will turn to for help. If you can recognize the true nature of the problem, help to determine its cause, and facilitate the needed management, you will have effectively treated what can become a disabling problem for vulnerable young people.
School refusal is happening when a child has major difficulty attending school, associated with intense emotional distress. It can be a refusal to attend school or difficulty remaining in school for an entire day. It is distinct (but not mutually exclusive) from truancy, which is a failure to attend school associated with antisocial behavior or other conduct problems. In the pediatrician’s office, school refusal sounds like, “He was moaning about a stomachache yesterday, I kept him home, but he had no fever and ate okay. Then it all repeated again this morning.” Or you might hear, “She was whining about a headache, but when I said she had to go to school, she started crying and couldn’t stop. She was hysterical!” In teenagers, there may be somatic complaints or just a sleepy, sulky refusal to get out of bed. Children with truancy might fake illness (as compared with feeling sick), or simply leave school. Truant children often want to be out of school doing other things, and may keep their whereabouts a secret from their parents. While it might seem like just one tough morning that can be shrugged off, true school refusal will continue or escalate unless it is properly managed.
School refusal affects approximately 5% of all children annually, affecting girls and boys in equal numbers and with peaks in incidence at the ages of 5 to 6 years and again at 10 to 11 years. Approximately half of children and teenagers with school refusal have a treatable psychiatric illness. In the Great Smoky Mountain Study of 2003, where more than 1,400 children were observed, they categorized children as being anxious school refusers, truant, or “mixed school refusers,” with features of both truancy and anxiety. In children with truancy or anxious school refusal, 25% had a psychiatric illness. In the mixed school refusers, they found 88% had at least one psychiatric diagnosis and 42% had somatic complaints. While pure truancy will require different management strategies from school and parents, those young people who display features of both anxiety and truancy around school attendance are most likely to be suffering from a psychiatric illness. Those illnesses most commonly associated with difficulty attending school include anxiety disorders (separation anxiety, social phobia, generalized anxiety disorder) and depression.
While psychiatric illness is a common factor, there is also always a behavioral component to school refusal. This simply means that children are either avoiding unpleasant feelings associated with school, such as anxiety, or escaping uncomfortable situations, such as bullying or the stress of performance. On the positive side, children may be refusing school because they are pursuing the attention of important people (parents, peers) or pursuing pleasurable activities (playing video games, surfing the web or hanging out in town). Beyond an internal anxiety disorder, some children may be facing bullying or threats at school or may have to walk through a dangerous neighborhood to get to school. Some children may be missing school because of significant stress or transitions at home, such as financial difficulties or divorce. Other children may be staying home to take care of younger siblings because of a parent’s medical illness or substance abuse problem. Children who are being abused may be kept home to prevent suspicion about bruises. Lastly, some children feel they have to stay home to be with a lonely or depressed parent. Gently asking about these very real concerns will help determine the necessary course of action.
Pediatricians can play a central role in the management of school refusal. Often, the most important step is helping parents to understand that there is not an insidious medical problem driving the morning stomachaches and headaches. It is critical to clarify that (usually) their child is not feigning illness, but that there is significant distress around school that has led to this behavioral problem. Even children who have a genuine medical problem also can have school refusal. Once parents understand that without proper management, this behavior will continue or worsen, they usually are ready to collaborate on effective management. Their child may need a thorough psychiatric evaluation to rule out a treatable underlying psychiatric diagnosis, particularly if they have both anxious and truant behaviors. Most of the psychiatric problems associated with school refusal will require therapy and some may require medications for effective treatment.
Successfully getting children back to school will require a behavior plan that is agreed upon by the parents and the school, and then used consistently. This plan will simply detail strategies to “demagnetize” the home and “remagnetize” the school. Such strategies might include ensuring that children are not allowed “screen time” when home from school, and that their homework expectations continue. It should support healthy routines, including a regular sleep schedule and exercise. It should facilitate their being able to gradually manage any anxiety associated with school (shorter days initially, the option to have time-outs in a favorite part of the school or with a favorite teacher). A behavior plan should detail strategies for the child to manage stress (relaxation strategies, connecting with supportive individuals, even singing a favorite song). This plan can detail reasonable accommodations for a medical or psychiatric condition and appropriate rewards for regular attendance, such as being able to go on a class trip.
Through all of this, the pediatrician is in a uniquely authoritative position to provide support and reassurance to parents of a school refusing child. The pediatrician has a unique ability to clarify for parents the seriousness of the behavioral problem, even if there is no medical problem. Compassionately acknowledging how much a child is suffering (and the parents, as well) is powerful. Remind parents that accommodating anxiety only shows a child you don’t think they can master it, and often keeps them from trying. Express confidence that this is a relatively common and treatable phenomenon. If a pediatrician’s and parents’ efforts do not work quickly, in a matter of a few days, urgent referral to a mental health consultant is indicated, as falling behind in school and any acceptance of staying home makes return to school more difficult every day.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston.
As summer winds down, it is routine for children and adolescents to feel a little melancholy or even worried about the approaching start of school. But for some students, anxiety about school is more than routine; it is insurmountable. School refusal is a serious behavioral problem: without assertive management, it can become a pattern which is very difficult to alter. Whether a child is complaining of vague somatic concerns or is explicitly refusing to go to school, the pediatrician’s office is often the first place a parent will turn to for help. If you can recognize the true nature of the problem, help to determine its cause, and facilitate the needed management, you will have effectively treated what can become a disabling problem for vulnerable young people.
School refusal is happening when a child has major difficulty attending school, associated with intense emotional distress. It can be a refusal to attend school or difficulty remaining in school for an entire day. It is distinct (but not mutually exclusive) from truancy, which is a failure to attend school associated with antisocial behavior or other conduct problems. In the pediatrician’s office, school refusal sounds like, “He was moaning about a stomachache yesterday, I kept him home, but he had no fever and ate okay. Then it all repeated again this morning.” Or you might hear, “She was whining about a headache, but when I said she had to go to school, she started crying and couldn’t stop. She was hysterical!” In teenagers, there may be somatic complaints or just a sleepy, sulky refusal to get out of bed. Children with truancy might fake illness (as compared with feeling sick), or simply leave school. Truant children often want to be out of school doing other things, and may keep their whereabouts a secret from their parents. While it might seem like just one tough morning that can be shrugged off, true school refusal will continue or escalate unless it is properly managed.
School refusal affects approximately 5% of all children annually, affecting girls and boys in equal numbers and with peaks in incidence at the ages of 5 to 6 years and again at 10 to 11 years. Approximately half of children and teenagers with school refusal have a treatable psychiatric illness. In the Great Smoky Mountain Study of 2003, where more than 1,400 children were observed, they categorized children as being anxious school refusers, truant, or “mixed school refusers,” with features of both truancy and anxiety. In children with truancy or anxious school refusal, 25% had a psychiatric illness. In the mixed school refusers, they found 88% had at least one psychiatric diagnosis and 42% had somatic complaints. While pure truancy will require different management strategies from school and parents, those young people who display features of both anxiety and truancy around school attendance are most likely to be suffering from a psychiatric illness. Those illnesses most commonly associated with difficulty attending school include anxiety disorders (separation anxiety, social phobia, generalized anxiety disorder) and depression.
While psychiatric illness is a common factor, there is also always a behavioral component to school refusal. This simply means that children are either avoiding unpleasant feelings associated with school, such as anxiety, or escaping uncomfortable situations, such as bullying or the stress of performance. On the positive side, children may be refusing school because they are pursuing the attention of important people (parents, peers) or pursuing pleasurable activities (playing video games, surfing the web or hanging out in town). Beyond an internal anxiety disorder, some children may be facing bullying or threats at school or may have to walk through a dangerous neighborhood to get to school. Some children may be missing school because of significant stress or transitions at home, such as financial difficulties or divorce. Other children may be staying home to take care of younger siblings because of a parent’s medical illness or substance abuse problem. Children who are being abused may be kept home to prevent suspicion about bruises. Lastly, some children feel they have to stay home to be with a lonely or depressed parent. Gently asking about these very real concerns will help determine the necessary course of action.
Pediatricians can play a central role in the management of school refusal. Often, the most important step is helping parents to understand that there is not an insidious medical problem driving the morning stomachaches and headaches. It is critical to clarify that (usually) their child is not feigning illness, but that there is significant distress around school that has led to this behavioral problem. Even children who have a genuine medical problem also can have school refusal. Once parents understand that without proper management, this behavior will continue or worsen, they usually are ready to collaborate on effective management. Their child may need a thorough psychiatric evaluation to rule out a treatable underlying psychiatric diagnosis, particularly if they have both anxious and truant behaviors. Most of the psychiatric problems associated with school refusal will require therapy and some may require medications for effective treatment.
Successfully getting children back to school will require a behavior plan that is agreed upon by the parents and the school, and then used consistently. This plan will simply detail strategies to “demagnetize” the home and “remagnetize” the school. Such strategies might include ensuring that children are not allowed “screen time” when home from school, and that their homework expectations continue. It should support healthy routines, including a regular sleep schedule and exercise. It should facilitate their being able to gradually manage any anxiety associated with school (shorter days initially, the option to have time-outs in a favorite part of the school or with a favorite teacher). A behavior plan should detail strategies for the child to manage stress (relaxation strategies, connecting with supportive individuals, even singing a favorite song). This plan can detail reasonable accommodations for a medical or psychiatric condition and appropriate rewards for regular attendance, such as being able to go on a class trip.
Through all of this, the pediatrician is in a uniquely authoritative position to provide support and reassurance to parents of a school refusing child. The pediatrician has a unique ability to clarify for parents the seriousness of the behavioral problem, even if there is no medical problem. Compassionately acknowledging how much a child is suffering (and the parents, as well) is powerful. Remind parents that accommodating anxiety only shows a child you don’t think they can master it, and often keeps them from trying. Express confidence that this is a relatively common and treatable phenomenon. If a pediatrician’s and parents’ efforts do not work quickly, in a matter of a few days, urgent referral to a mental health consultant is indicated, as falling behind in school and any acceptance of staying home makes return to school more difficult every day.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston.
As summer winds down, it is routine for children and adolescents to feel a little melancholy or even worried about the approaching start of school. But for some students, anxiety about school is more than routine; it is insurmountable. School refusal is a serious behavioral problem: without assertive management, it can become a pattern which is very difficult to alter. Whether a child is complaining of vague somatic concerns or is explicitly refusing to go to school, the pediatrician’s office is often the first place a parent will turn to for help. If you can recognize the true nature of the problem, help to determine its cause, and facilitate the needed management, you will have effectively treated what can become a disabling problem for vulnerable young people.
School refusal is happening when a child has major difficulty attending school, associated with intense emotional distress. It can be a refusal to attend school or difficulty remaining in school for an entire day. It is distinct (but not mutually exclusive) from truancy, which is a failure to attend school associated with antisocial behavior or other conduct problems. In the pediatrician’s office, school refusal sounds like, “He was moaning about a stomachache yesterday, I kept him home, but he had no fever and ate okay. Then it all repeated again this morning.” Or you might hear, “She was whining about a headache, but when I said she had to go to school, she started crying and couldn’t stop. She was hysterical!” In teenagers, there may be somatic complaints or just a sleepy, sulky refusal to get out of bed. Children with truancy might fake illness (as compared with feeling sick), or simply leave school. Truant children often want to be out of school doing other things, and may keep their whereabouts a secret from their parents. While it might seem like just one tough morning that can be shrugged off, true school refusal will continue or escalate unless it is properly managed.
School refusal affects approximately 5% of all children annually, affecting girls and boys in equal numbers and with peaks in incidence at the ages of 5 to 6 years and again at 10 to 11 years. Approximately half of children and teenagers with school refusal have a treatable psychiatric illness. In the Great Smoky Mountain Study of 2003, where more than 1,400 children were observed, they categorized children as being anxious school refusers, truant, or “mixed school refusers,” with features of both truancy and anxiety. In children with truancy or anxious school refusal, 25% had a psychiatric illness. In the mixed school refusers, they found 88% had at least one psychiatric diagnosis and 42% had somatic complaints. While pure truancy will require different management strategies from school and parents, those young people who display features of both anxiety and truancy around school attendance are most likely to be suffering from a psychiatric illness. Those illnesses most commonly associated with difficulty attending school include anxiety disorders (separation anxiety, social phobia, generalized anxiety disorder) and depression.
While psychiatric illness is a common factor, there is also always a behavioral component to school refusal. This simply means that children are either avoiding unpleasant feelings associated with school, such as anxiety, or escaping uncomfortable situations, such as bullying or the stress of performance. On the positive side, children may be refusing school because they are pursuing the attention of important people (parents, peers) or pursuing pleasurable activities (playing video games, surfing the web or hanging out in town). Beyond an internal anxiety disorder, some children may be facing bullying or threats at school or may have to walk through a dangerous neighborhood to get to school. Some children may be missing school because of significant stress or transitions at home, such as financial difficulties or divorce. Other children may be staying home to take care of younger siblings because of a parent’s medical illness or substance abuse problem. Children who are being abused may be kept home to prevent suspicion about bruises. Lastly, some children feel they have to stay home to be with a lonely or depressed parent. Gently asking about these very real concerns will help determine the necessary course of action.
Pediatricians can play a central role in the management of school refusal. Often, the most important step is helping parents to understand that there is not an insidious medical problem driving the morning stomachaches and headaches. It is critical to clarify that (usually) their child is not feigning illness, but that there is significant distress around school that has led to this behavioral problem. Even children who have a genuine medical problem also can have school refusal. Once parents understand that without proper management, this behavior will continue or worsen, they usually are ready to collaborate on effective management. Their child may need a thorough psychiatric evaluation to rule out a treatable underlying psychiatric diagnosis, particularly if they have both anxious and truant behaviors. Most of the psychiatric problems associated with school refusal will require therapy and some may require medications for effective treatment.
Successfully getting children back to school will require a behavior plan that is agreed upon by the parents and the school, and then used consistently. This plan will simply detail strategies to “demagnetize” the home and “remagnetize” the school. Such strategies might include ensuring that children are not allowed “screen time” when home from school, and that their homework expectations continue. It should support healthy routines, including a regular sleep schedule and exercise. It should facilitate their being able to gradually manage any anxiety associated with school (shorter days initially, the option to have time-outs in a favorite part of the school or with a favorite teacher). A behavior plan should detail strategies for the child to manage stress (relaxation strategies, connecting with supportive individuals, even singing a favorite song). This plan can detail reasonable accommodations for a medical or psychiatric condition and appropriate rewards for regular attendance, such as being able to go on a class trip.
Through all of this, the pediatrician is in a uniquely authoritative position to provide support and reassurance to parents of a school refusing child. The pediatrician has a unique ability to clarify for parents the seriousness of the behavioral problem, even if there is no medical problem. Compassionately acknowledging how much a child is suffering (and the parents, as well) is powerful. Remind parents that accommodating anxiety only shows a child you don’t think they can master it, and often keeps them from trying. Express confidence that this is a relatively common and treatable phenomenon. If a pediatrician’s and parents’ efforts do not work quickly, in a matter of a few days, urgent referral to a mental health consultant is indicated, as falling behind in school and any acceptance of staying home makes return to school more difficult every day.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston.
