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1/30/2015 12:00 AM

When I was in second grade and living in Racine, Wisconsin, there was a rabies outbreak in the greater Chicago area that received extensive media coverage. Parents kept children indoors because of a perceived risk of marauding mad dogs, and stories about the horrors of having to undergo the treatment shots were widely discussed. Even though I loved dogs, I was petrified of being bitten by a rabid animal. A recurring image from the front page of the newspaper (which I still vividly recall) of a wild-eyed dog foaming at the mouth and fiercely biting the bars of its quarantine cage made it difficult to fall asleep many nights that fall. I’ve wondered whether that childhood experience of fearing a deadly illness I didn’t understand influenced my decision to go into medicine. I am certain, however, that a widespread concern about a scary disease, whether it’s rabies or Ebola, can affect children and adolescents in lasting ways.

While we can’t shield our children from everything that is worrisome, risky, or unpleasant, how we as adults react can have a greater impact on a child’s psyche than the actual reality of the situation. Nowhere is that more evident than in our societal response to the Ebola epidemic. The facts facing Americans (in contrast to many in West African countries) as I write this in late fall of 2014 contrast sharply with the anxiety, verging on panic, seen in some quarters.

The facts are fairly straightforward: Ebola is a viral disease we have known about for decades but not attended to intensely because outbreaks have only occurred in isolated areas of west and central Africa. It is contagious only from direct contact with bodily fluids (blood, vomit, diarrhea, etc.) of those showing symptoms of the illness; the sicker the patient, the higher the viral load and the more contagious he or she is. About half of those who contact Ebola will die, and they are especially contagious in the days immediately before and after their death. There is no specific treatment for Ebola, and effective vaccines, now being developed, will not be widely available for at least a year. Americans at the highest risk for Ebola are health care workers exposed to the virus when caring for sick patients; they comprise all of the handful of cases in the United States.

To judge from the media response and the way Ebola in the United States is consuming our consciousness way out of proportion to the current danger, facts seem to have little bearing on the American anxiety level. Scared parents, extreme governmental quarantine measures, and a national sense of panic are likely to cause unnecessary suffering for children; adult anxiety is more contagious than Ebola.

Instead of communicating dread and danger through what is said and through nonverbal communication (facial expression, affect, preoccupation), adults should present to children a measured and rational approach about Ebola. Knowledge is power, and helping children bolster their cognitive mastery skills goes a long way to allaying undue anxiety. The first step in this process is to create an open and supportive environment where children can ask questions and feel comfortable sharing what they know. Then we have to listen carefully and calmly to what they say. Youngsters’ ability to understand illness varies hugely with age, from a five-year-old’s magical thinking to many adolescents’ ability to deal with abstract concepts. It is critical to meet children where they are developmentally and to use words and concepts they can understand. Whatever the level of communication, it is important that the information we provide be accurate and honest, yet light on the graphic details. The horrible picture of the rabid dog stuck with me from my childhood because as an eight-year-old, I couldn’t understand the verbal explanations provided by the adults. We need to allow for repeated discussions of Ebola, as children can rarely process affect-laden information in a single session. Additionally, repeated questioning may be a child’s way of asking for reassurance. 

As with any challenge, the Ebola crisis presents children with an opportunity for mastery and growth. Understanding the conditions in Africa — while differentiating them from the situation in the United States — can promote empathy for those less fortunate. Appreciating the heroism of medical workers on the front lines of the epidemic helps to define courage and self-sacrifice. If children can contribute some of their own money to a charitable organization fighting Ebola, it reinforces their developing social conscience and allows a sense of active mastery.

We know from other crises what helps and what hinders children’s efforts to cope with unsettling news. In our approach to Ebola, we should manage our anxiety, monitor our behavior, and make decisions based on equal parts of science and compassion. Our children will be the beneficiaries.

1/16/2015 12:00 AM

Do chores have developmental significance? In writing a White Paper to help understand what current published research says about chore participation and its benefits (Rende, 2015), it became clear that while chores have been influential in childhood and adolescence, the type of impact on daily family life has changed over the decades. Here I will sketch out three discernible trends I identified, and offer a viewpoint for the next staging in our professional thinking.

Three trends in research on chores

First, there was a consistent stream of influential papers published more than a decade ago proposing that regular participation in chores and household responsibilities carried multiple developmental benefits. There were review papers that cast chores as a healthy and proactive component of family routines and rituals that promote a sense of family cohesion and positive functioning in the home. Other studies, including more recent ones, reported benefits in terms of engagement in school and academic performance, reduced behavioral problems (both internalizing and externalizing), and protection from early drug use. Influential longitudinal studies, tracking from childhood through adulthood, positioned chores as a surprisingly influential factor that offered strong prediction of positive mental health in adulthood and professional success.

There have not been published studies refuting these developmental benefits of chores. However, a second trend has been the recognition that the level of participation in chores and household responsibilities has been decreasing across generations. Studies have illuminated the declining percentage of time devoted to chores by children and adolescents across the decades. Intensive observations of middle-class families have painted a picture of youth who are disengaged from household responsibilities, particularly in comparison to other cultures and generations. Most recently, a survey conducted by Braun Research reported that while 82% of American adults reported doing chores as a child, only 28% are asking their children to do chores today.

This leads to the third notable trend. Current research has focused on the negative perceptions that surround chores in the family. Adults report that household responsibilities are a source of mental labor and stress. Physiological assessments reveal that adults are more stressed at home as compared to the workplace. Finding an appropriate balance between work and household responsibilities compounds the issue. Married partners struggle to find what is perceived to be an equitable division of labor. All this negativity experienced by adults certainly filters down to children. Disagreements about chores are a primary source of conflict between parents and adolescents. Parents and children disagree substantially on how many chores are getting done in the home, with children reporting doing much more than their parents say they are doing. Finally, typical approaches to try to increase youth’s participation — particularly providing an allowance — simply do not work.

Intrinsic motivation and chores

For developmental researchers and practitioners alike, the declines in chore involvement, and the notable negativity surrounding household responsibilities, are sources of concern. As more children grow up without the experience of doing chores at home, we wonder if all the definable developmental benefits will dissipate as well. For example, we have certainly seen much research devoted to the idea that youth are becoming more entitled across generations. We can speculate that work habits and social functioning in the school environment, and the broader societal context, may be affected. Furthermore, as parent-child conflict is a primary contributor to behavioral and emotional problems, we need to pay attention to the idea that the discord surrounding chores is a potentially influential factor in the clinical setting, particularly as a window into family dynamics and functioning.

Where do we turn next? Two directions in recent research offer substantial promise. First, current thinking in cognitive science has taken on the idea that it is possible for individuals to reframe their thinking to change “have-to” tasks (which become low-reward/low-motivation activities) into “want-to” behaviors (which maintain a reward level that sustains motivation). This framework, supported by laboratory data, provides one important clue on how to reprogram thinking on chores — it is essential that a sustainable source of intrinsic motivation be identified. For example, any potentially “low-reward” activity, like sticking with an exercise program in the face of fatigue after a long day of work, would be best reframed in terms of internal reward (e.g., this behavior will lead to positive health changes over time) rather than external motivators like pleasing a trainer. In terms of chores, the key element would be to identify what that influential source of intrinsic motivation would be.

This is where those earlier studies and scholarly thinking on chores become relevant again. What stands out in this work is the idea that household responsibilities can function as a critically important source of family cohesion if cast as a way of caretaking within the family. It’s notable that the studies demonstrating the developmental benefits of chores identified two key elements — the participation was regular, and a proximal process was nurturing a sense of empathy. Families that take on household responsibilities as a way of supporting each other’s needs and sharing in making home life better experience more positive interactions and cohesion, two powerful factors that predict social, emotional, and cognitive development. To this end, the suggestion is that we need to help caretakers and youth alike reframe their thinking about the role of chores. Chores could be rethought of as ways of providing care to everyone in the family, and not just a shared responsibility per se but rather an opportunity to express support for each other.

Changing family perceptions and conversations about chores

Given the image we have of youth perceptions in current studies, is this really attainable? The irony is that there is also an accumulating body of work on toddlers and young children that reveal an inherent drive to be a helper. There are many elegant studies that demonstrate how toddlers — even those not much more than one year old — are primed to help out an adult, particularly when not asked to do so. If an experimenter drops something, a toddler will pick it up for them. If an object is out of reach to the experimenter, a toddler will try to get it for them. Again, it is critical to realize that no reinforcement is necessary for this — in fact, any kind of material reward for helping behavior in the early years lessens the probability of helping out in the future. Just like allowances, material reward seems to undermine youth’s natural inclinations to be a helper.

One way we can support families to adopt a new mindset about chores, one focused on caretaking and helping rather than arguments about taking on low-motivation tasks, is to encourage family conversation. We’ve known, for decades, that the simple act of spending devoted time together as a family — as in the case of shared family dinners — pulls for more cohesive conversation, sharing of perspectives, open avenues of communication, and perceived positive support. Within these contexts of family conversation, it is suggested that parental talk about chores emphasizes “we” rather than the “you” and “me” and the nurturing aspects for caretakers and youth alike. Turning household responsibilities into shared activities provides social support and reduces mental labor and stress. Furthermore, there is accumulating evidence that a powerful form of reinforcement in childhood is to foster children’s growing sense of themselves as a “helper” (as opposed to reinforcing the actual helping behavior). Praising the child using “helper” as a noun (rather than “helping” as a verb) has been shown to cultivate a sense of self as a caretaker motivated to help others. The family offers perhaps the most influential context to nurture this process, and reframing chores as a tangible way to help in the family — and a shared goal of family members — is a forward-looking way of reversing the troubling trends we have seen over decades.

Reference

Rende R. The misperception of chores: What’s really at stake? 2015. Paper prepared for the Whirlpool Corporation.

9/1/2014 12:00 AM

Around the country, there is a growing need for pediatric mental health problems to be treated in primary care settings (DeMaso et al., 2010). Ask any pediatrician or family doctor nationwide — there simply aren’t enough mental health providers. In Rhode Island alone, according to 2011 Department of Health data, about 25% of teens report feeling depressed, and about 9% have attempted suicide (Rhode Island Department of Health, 2012). Despite the need in Rhode Island and nationwide, mental and physical health have historically not only been treated separately, but also insured and reimbursed separately, creating barriers that keep mental health from integrating into the rest of medicine (DeMaso et al., 2010). However, this landscape is slowly changing, as psychiatric and pediatric medical providers attempt to fill this gap by practicing in a more collaborative and integrated fashion.

This article summarizes a modest pilot project in integrated care at the primary care clinic of Hasbro Children’s Hospital this past year. The goal was to see if a mental health provider (myself) could successfully integrate and work collaboratively with pediatrics providers according to the guidelines suggested by the American Academy of Child and Adolescent Psychiatry in A Guide to Building Collaborative Mental Health Care Partnerships in Pediatric Primary Care (DeMaso et al., 2010). These guidelines state that in order to successfully integrate psychiatric services in a primary care setting, there must be (1) timely access to consultation, (2) direct psychiatric services, (3) care coordination, and (4) primary care provider education. What follows are some details and reflections regarding the year’s work.

Initial discussions with personnel in the primary care clinic suggested the need for some kind of referral clinic where primary care physicians (PCPs) could easily send patients. However, no such referral clinic was available, and I had some reservations about creating one, as I was concerned it would fill up quickly, making it hard to accept new referrals. In addition, the referral clinic model seemed to reinforce the idea that what mental health professionals do is not only unknowable but separate from primary care. Massachusetts originally started out with telephone-only consultation to PCPs. This model avoided the issue of full clinics but did not involve one-on-one time with patients. Not seeing patients directly also seemed like it would make it hard to give accurate recommendations and may leave PCPs to implement the majority of the plan, with which they may or may not feel comfortable.

In the end, the attempt was to create a consult service that was both co-located and collaborative, meaning that the emphasis was on teaching primary care providers to start to provide mental health services themselves while giving me the option to step in and see patients directly if the situation called for it. I would be located directly in the working area of the clinic, making timely access to consultation, as well as direct psychiatric evaluations, easy. However, I anticipated that referring patients to places where they could receive further treatment would be a large portion of what I would be doing. It was a goal to make sure time was devoted to emphasizing aspects of the mental status and neurological examinations that are often glossed over for the sake of time. I also planned to do some teaching didactically (via morning reports on depression, anxiety, psychosis, and ADHD) that would also double as advertisement to the pediatricians of the availability of my services.

The pilot project was in operation between August 2013 and June 2014. The majority of the patients seen were school-age children and adolescents who had managed Medicaid insurance. Typically, PCPs had questions about where to send patients for mental health services. Concerns about ADHD, depression, anxiety, and dysregulated behavior (e.g., anger, aggression, tantrums, and oppositionality) were also very common. In about two-thirds of the cases, we were able to resolve the issue without my becoming directly involved. In the remaining third of the cases, I went in the room to see the patient, at times accompanied by the PCP.

The majority of interventions involved education provided to the PCP, generally case discussion — such as exploring other diagnoses, discussing how to ask about psychiatric symptoms, and providing handouts or journal articles related to the patient’s condition. The next most frequent interventions involved referring patients to community mental health providers and suggesting that pediatricians use a standardized way of tracking patient symptoms given that patients do not always get seen by the same provider in the clinic and sometimes may answer differently on paper as opposed to when interviewed. Scales widely available on the Internet were generally used, such as the PHQ-9 for depression, the SCARED for anxiety, and Vanderbilt parent and teacher forms for ADHD. In a sizable number of cases, there were questions about psychiatric medications, and in some cases, we initiated medications at the end of the visit. Less frequently, additional neurological examination, cognitive testing, or brief individual therapy was done with patients (e.g., motivational interviewing and relaxation training).

This was a relatively small sample of data comprising about a year’s worth of time in the Hasbro primary care clinic. These results suggesting an emphasis on case management and education are not surprising. As mentioned in the introduction, care coordination and primary care provider education were two out of the four components AACAP identified in order to create successful psychiatric-primary care collaboration (DeMaso et al., 2010). The first two components, timely access to consultation and direct psychiatric services, however, are necessary in order to create full integration.

This model attempted to fulfill all four components. There were, of course, a number of limitations. I was only available ½ to 1 day a week. Ideally, there could have been a consistent psychiatry presence in the clinic 4–5 days a week. Also, the high number of referrals out to community mental health centers was necessary because there was no clinic to which I could directly and expediently refer patients. There is definitely a need for a referral clinic where primary care patients can be seen for short courses of treatment. Ideally, it should be located within the primary clinic itself, as that is where patients are used to going.

Having a mental health referral clinic outside the confines of a primary care clinic with support staff familiar with psychiatric coding, billing, and prior authorization is a model used by many places around the nation, and not much different from how specialty care has always been provided. If my experiences over the last year can serve as evidence, however, the lack of co-location may result in a failure of integration. Many times, pediatricians did not come to me with a fully formed question, so this required a short but more extensive discussion to flesh out. In addition, communication was easy since we could talk in person. Trying to get a busy pediatrician going in and out of rooms on the phone would have resulted in hours of frustrating phone tag. In theory, information could have been exchanged through the medical record, but given that it was sensitive information that often needed to be discussed, not all of it belonged in the chart.

I would add a fifth component to AACAP’s criteria for successful integration — in order for integration to be sustainable, it must be financially feasible. This is the main challenge that integrative care has at this point, as no one is sure how exactly to do that. The traditional way health care is reimbursed (payment in exchange for services) does not work for integrative care, as much of it involves education and case management, which are important for both patients and providers but haven’t (traditionally) generated revenue.

However, I remain optimistic. As more health care systems start moving to capitated models, where a lump sum of health care dollars is provided to manage patients, there will be more incentives to help patients be as healthy as possible (rather than as sick as possible). In addition, within the next few years, we will hopefully see the results of mental health parity, and hopefully the time that patients and providers now spend obtaining prior authorization for psychiatric services will be a thing of the past. Until we get there, mental health professionals should continue to push for change in the medical arena. If we as mental health providers wish to be on equal footing with our medical colleagues, they need to see us doing our work. They also need to understand what it is we do and how to find us, and that there is nothing inherently magical about mental health evaluation and treatment — that with some training, they, too, can start to do some of it. However, if this is to happen, we need to take responsibility for our image and advocate for ourselves not only within the hospital system, but also in the field of medicine as a whole.

References

DeMaso, D, et al. A guide to building collaborative mental health care partnerships in pediatric primary care. AACAP Committee on Collaboration with Medical Professionals. 2010; http://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/guide_to_building_collaborative_mental_health_care_partnerships.pdf.

Rhode Island Department of Health. Rhode Island data brief: Kids at risk. RI Youth Risk Behavior Survey. 2012;  http://www.health.ri.gov/publications/databriefs/2011RIHighSchoolHealthRisks.pdf.

2/1/2015 12:00 AM
2/1/2015 12:00 AM

Watching this film may help children see how difficult parenting can be — and that parents are people too, with their own foibles. It will also help parents see how they look to their children. And it may help parents connect with their own boyhoods or girlhoods.

Parents Guide
9/1/2014 12:00 AM
Going from long, lazy summer days back to the rigors of a classroom can be a bumpy road for your child. It’s normal for him or her to experience a range of emotions about returning to school. Though each child responds to going back to school differently, you can take steps to address jitters and make the transition time smoother. Following are some common causes of and strategies to overcome back-to-school anxiety.
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    Gregory K. Fritz, M.D.
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    Dr Fritz is a professor of psychiatry and director of child and adolescent psychiatry at the Brown University School of Medicine, where he conducts research and teaches.
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