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4/18/2015 12:00 AM

The brothers in the Boston Marathon bombing. Racketeer Whitey Bulger Jr. and his younger brother William, president of the Massachusetts Senate and then of the University of Massachusetts.

What do these two divergent tales of brothers teach us about sibling relationships? How is it that one pair of siblings bonds together to walk the same course while other siblings seek opposite pursuits?

On April 15, 2013, two homemade pressure-cooker bombs exploded near the finish line of the Boston Marathon. Three people, including an 8-year-old boy, were killed. Hundreds of others were seriously injured. The city of Boston was paralyzed by a gripping manhunt for two suspects — two brothers. Days later, 26-year-old Tamerlan Tsarnaev was killed during a shoot-out with police following the death of an MIT police officer and carjacking. Tamerlan’s younger brother, 19-year-old Dzhokhar Tsarnaev, was injured and subsequently captured. Dzhokhar was charged with using and conspiring to use a weapon of mass destruction resulting in death and malicious destruction of property resulting in death. Dzhokhar now awaits trial and is facing the death penalty in Massachusetts. At the time of the manhunt, the brothers allegedly were plotting together to detonate more explosives in Times Square in New York City.

Meanwhile in Boston, after decades on the FBI’s “Ten Most Wanted List,” James “Whitey” Bulger Jr. was about to stand trial on 32 counts of racketeering, money laundering, extortion, weapons, and murder charges. In the summer of 2013, Whitey was found guilty on 31 of the charges and was sentenced to two consecutive life terms. During Whitey’s trial, his younger brother, William Bulger, was in active retirement after 18 years as the president of the Massachusetts Senate as well as president of the University of Massachusetts, a position he resigned in the wake of controversy surrounding his refusal to testify about his brother. In contrast to Whitey, William was an army veteran and lawyer whose life was characterized by education and public service.

What do these two divergent tales of brothers teach us about sibling relationships? How is it that one pair of siblings bonds together to walk the same course while other siblings seek opposite pursuits?

Characteristics of sibling relationships

Children in the United States are more likely to grow up with their siblings than with their fathers. Over the course of their lifetimes, most children will spend more time with their siblings than they spend with anyone else, including their parents. Despite this reality, research and interventions for children focus on the parent-child relationship as the primary source of influence on child outcomes; the effects of siblings on child behavior and health are often underestimated. However, recent research reveals what brothers and sisters have recognized all along — that siblings play a key role in child development and behavior.

The differential power and roles between siblings are related to their broader cultural context. Cultures define who is considered a sibling, the meaning and importance of the relationship, and the obligations siblings have within the family and to one another. These cultural proscriptions are often dependent on immutable structural characteristics of the sibling relationship, such as birth order, gender, and age spacing. Prince William and Prince Henry (“Harry”) of Great Britain’s royal family provide a vivid public example of how the structural features of a sibling relationship can be institutionalized and shape expectations and life trajectories.

Sibling relationships are not elective; children pick their friends but not their brothers and sisters. Emotions between siblings are characteristically intense and can cycle rapidly between love and hostility. During early childhood, siblings are often primary companions as well as competitors. This is believed to provide a fertile training ground for the development of social skills and future relationships. The impact of a warm and supportive sibling relationship or a conflictual, unsupportive one is lifelong. Warmth in the sibling relationship is associated with significant social and emotional advantages in later life. For example, compared to only children, children who have at least one sibling at home display greater social competence and peer acceptance from kindergarten through their early school years. Adolescents who report positive sibling relationships have better peer relationships and fewer depressive symptoms later in life. Warmth and closeness in the sibling relationship are also associated with greater ease and intimacy in romantic relationships. Finally, during middle age and old age, mood, health, loneliness, and depression are related to how people feel about their sibling relationships. Having a close, positive relationship with one’s siblings is not only a source of life satisfaction, but can also provide a buffer from stressful events, such as parental absence, marital conflict, and illness. Younger siblings tend to imitate and “look up to” their older siblings. If the older sibling responds in an attentive and caring manner, the seeds of similarity are planted. If the older sibling is rejecting of the younger child, their paths are more likely to separate.

Conflict and aggression between siblings is very common. It has been suggested that one way siblings learn to manage competition and conflict is by differentiating themselves, carving out different identities or roles within the family. Thus, one child becomes known as the reckless, defiant one, while the other sibling becomes the easygoing, conservative one. Even when siblings pursue very distinct identities and life courses, their bond can be very enduring. Think of the case of the Bulger brothers. One brother led a life of crime and the other a life of public service. William was not able or willing to overcome the sibling bond to testify about his contact with his brother, thereby forfeiting his position as president of UMass. Physical aggression occurs among siblings in the majority of families (i.e., 70% of families). Sibling conflict has been measured up to eight times in a single hour and is the number-one reason for discord between parents and children. However, parents will also dismiss levels of violence between siblings that they would never conceive of tolerating if they occurred outside the context of a sibling relationship. Violence between siblings is the most common form of child abuse and is significantly related to later substance use and delinquency.

Sibling – strong effects within the family

Sibling relationships do not occur in a vacuum. Siblings share parents, relatives, and school and other social environments, as well as their genes. Siblings raised in a home with authoritarian, harsh parents are more likely to be at odds with one another. How parents handle sibling conflict has a significant impact on the sibling relationship. When parents intercede in sibling conflict to determine which child is most at fault or “who started it,” the sibling relationship sours. Siblings often compare themselves to one another and compare how they are treated by others, particularly parents. When children perceive favoritism or unfair differential parental treatment, the quality of the parent-child and sibling relationships suffers. For the less favored sibling, differential parental treatment is associated with lower self-esteem, more depressive symptoms, and more antisocial and delinquent behavior, as well as more substance use.

One area of particularly strong sibling influence, even stronger than the influence of parents, is in the development of antisocial attitudes and conduct, and health risk behavior. The process of “sibling deviancy training” refers to the situation in which (generally older) siblings model, encourage, and reinforce antisocial behavior in their younger siblings. Younger siblings who shadow and hang out with their older siblings are introduced to their antisocial peers and behavior and begin to display negative behaviors more than siblings who do not hang out with their antisocial siblings. Eventually, the sibling relationship transitions from deviancy training to partners in crime; older and younger siblings begin to conspire together in more antisocial behavior and substance use. Even after controlling for the effects of parent substance use, siblings are four times more likely to smoke if their older sibling smokes, and are twice as likely to drink alcohol if an older sibling does. Finally, younger sisters are five times more likely to become pregnant if they have an older sister who was pregnant. The power of the antisocial or behaviorally risky older sibling is magnified when parents are unstable or absent. Think back to the Tsarnaev brothers, whose parents, after years of struggling in the United States, returned to Russia, leaving the younger brother under the influence of his elder, radicalizing brother.

Conclusions and implications

Siblings hold the power to inspire as well as corrupt. Given the intensity and longevity of their bond, how can we engage this power for positive change? It is time to move beyond family interventions that are directed solely at parents (i.e., mothers). When working with children and adolescents, inquire about siblings — their relationships, strengths, and challenges. How much time do they spend together? How are they similar and where do their interests overlap? Be attentive and responsive to reports of sibling violence; do not dismiss these as “normal” and, therefore, acceptable. Consider how recommendations regarding one child might affect other children in the family. Is the heightened attention expected from parent-directed intervention likely to plant negative feelings of differential parental treatment among the other children? Actively help families understand that the investment made early in the sibling relationship has value that lasts a lifetime.

3/6/2015 12:00 AM

Parents are often concerned by certain behaviors they observe in their kids, such as crying, tantrums, difficulty following directions, shyness, difficulty separating, troubles with transitioning, and so on. But when do these behaviors warrant intervention?

Ally follows her mother wherever she goes. Lately, Ally’s been more tearful around leaving for school in the morning and keeps complaining that her stomach hurts. Ally always thinks she’s getting sick and worries every time she is around anyone who coughs or sneezes.

Sam has a hard time following directions. His room is a mess, his homework is incomplete, and it’s a struggle to get him to do daily things like brushing his teeth. Sam frequently argues with his younger brother, and his mother feels like she has to yell in order to get anyone to do anything.

Parents are often concerned by certain behaviors they observe in their kids, such as crying, tantrums, difficulty following directions, shyness, difficulty separating, troubles with transitioning, and so on. But when do these behaviors warrant intervention? All of the above can be considered within the realm of normal childhood development. It is when these behaviors co-occur with other patterns of symptoms, have a negative impact on functioning, and cause distress in either the child or those around him/her that therapeutic intervention may be helpful and warranted. For example, with Ally, her parents may want to seek help if distress in the mornings continues to the point where it’s difficult getting to school or if she becomes so clingy to her mother that it’s hard for her mother to be able to work, run errands, or do things at home. With Sam, his parents may want to seek help if he starts doing poorly in school or if the level of conflict and overall stress at home remains high.

What’s the next step?

The first step to effectively addressing concerning behaviors in kids is to do a thorough evaluation of the symptoms, circumstances, and functions in order to fully understand the nature of behaviors. For example, in children specifically, it is common for acting-out behaviors, such as arguing, temper tantrums, or anger, to be in reality driven by anxiety. Once the nature of symptoms is more fully understood, appropriate intervention can take place.

Cognitive behavioral therapy (CBT) is one of the most commonly evaluated treatments for a range of psychological problems in children and adolescents. CBT is a therapy framework that emphasizes the role and link between thoughts, feelings, and behaviors in order to improve functioning. While some youngsters may not be able to fully take part in the entirety of a CBT model of treatment due to their cognitive/developmental levels, tailoring components of CBT for a specific child and treatment focus can be helpful.

Components of CBT treatment

There are different components of CBT depending on the specific treatment model, but for the purposes of describing a general overview, they are conceptualized here by three overarching components: psychoeducation, coping skills, and behavior practice/management.

  1. Psychoeducation. This consists of helping to better understand emotions and normalizing the fact that people experience a range of them, which are sometimes advantageous (e.g., having some anxiety before a test so that you are alert and concentrating) and sometimes impairing (e.g., having so much anxiety before a test that you can’t focus on the questions). Psychoeducation also involves understanding similarities/differences between emotions and helping children learn to identify the cues in their thinking and in their body in order to correctly label the emotional experience. It’s also important to be able to differentiate between varying levels of emotions. If a child thinks of everything that makes him nervous/scared and sees it all as the same intensity of that feeling, it would be very overwhelming. In CBT, children learn to view their emotions as a thermometer where they can tease apart situations/stimuli that would create a “10” on their meter versus a “5” or a “1” so that tackling these experiences starts to seem more manageable.
  2. Psychoeducation also focuses on learning to identify the thoughts, feelings, and actions that occur in a situation so that kids can start to see how modifying one part can affect another. For example, if Ally thinks that the person next to her is sick because he sneezed, she will start to feel anxious that she will get sick too. But if Ally is able to come up with other thoughts, this could alter how she feels. How anxious would she be if she thought that the person next to her sneezed not because he was sick but because something just tickled his nose? In exploring thoughts, children start to recognize when they fall into thinking traps by identifying cognitive distortions and labeling them as such. Cognitive distortions can include thinking the worst will happen (catastrophizing), thinking you know what others are thinking (mind-reading), and believing something without any proof (jumping to conclusions), among others. By learning to recognize thinking traps, youngsters can start to challenge them and become more flexible in their thinking, which may then alter how they feel and act.

  3. Coping skills. After psychoeducation about thoughts/feelings/actions and the relationship between them, patients start to build a “toolbox” of skills to help them effectively manage emotional/physical distress. This component helps empower children to feel that they have the tools they need to conquer problems. Furthermore, in order to face stress-inducing situations, they may need to first learn to lessen their arousal level to the point where they can tolerate facing a stressful situation. The coping skills that are added to their toolbox may include things such as relaxation techniques (e.g., diaphragmatic breathing, progressive muscle relaxation, imagery) to help calm their bodies and minds enough to participate in treatment. Skills also include learning scripts to challenge cognitive distortions (e.g., “Do I know 100% that I will get sick?”, “Could there be other explanations why my brother threw the ball at me?”) so that ultimately children may become more flexible in their thinking instead of solely believing the automatic thought that comes to mind. Other distress-tolerance skills include proactive activities (e.g., taking a walk, listening to music, squeezing a stress ball) and positive thoughts to keep in mind in order to help manage distress.
  4. Behavior practice/management. The third component of CBT is where individuals get a chance to practice the skills that they have learned. It includes skill rehearsal, role-playing situations, and ultimately experiencing the situations. For some disorders, such as anxiety, the experiencing of a feared situation and habituating to it (i.e., anxiety lessening by remaining in the situation over time) is the key ingredient of treatment. However, some will need to use the psychoeducation and skills described above in order to even get to the point of being able to face a fear in any form. Another key aspect of this component of CBT is the idea of reinforcing a desired behavior, whether it’s facing a fear, complying with a direction, or reacting in a calm and appropriate way. Some children may respond to encouragement from adults and a feeling of self-efficacy, but most need external reinforcement in order to push through cognitive/emotional barriers to their goals. This typically involves parents setting up a reinforcement system in which kids can earn rewards for reaching certain goals. Rewards can be immediate or in the form of tokens that can be traded in for bigger rewards or privileges after earning a certain amount. It is essential that parents are always aware of what effect their response has on their child’s behavior so that they are not inadvertently increasing the likelihood of the problem behavior rather than the desired behavior. For example, if Sam argues around limits on videogame time, and his mother lets him keep playing so that he stops yelling, Sam has learned that the more he yells, the longer he gets to play. If Sam’s mother gives him a check mark for every time he turns off the game when prompted, Sam learns that by following directions, he earns tokens that he can then trade in for bigger rewards. Likewise, if Ally’s mother lets her stay home when she is crying, instead of fighting the anxiety, this will increase the likelihood that this pattern will continue. However, if Ally earns rewards for getting to school by a certain time, this may reinforce leaving home rather than staying home.

Summary

While childhood behaviors such as fears, tantrums, noncompliance, and the like may be part of normal development, patterns of behaviors may become distressing and start to impair functioning. When this happens, it’s important to seek help from a professional who can perform a thorough evaluation and determine appropriate intervention. CBT is an evidence-based treatment that can be applied to a variety of childhood problems. Developmental considerations, such as age and cognitive level, may determine whether treatment is more cognitive or behaviorally focused. CBT can be thought of as a skill set that children and parents both develop and improve over time with practice.

References

Christophersen ER, Mortweet SL. Treatments that work with children: Empirically-supported strategies for managing childhood problems. Washington, DC: American Psychological Association; 2001.

Creswell C, Waite P, Cooper P. Assessment and management of anxiety disorders in children and adolescents. Archives of Disease in Childhood 2014; 99(7):674–678.

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.

Parents’ Guide
6/15/2017 12:00 AM

When Netflix came out with its 13 Reasons Why series this spring, many parents didn’t even know about it until their children had already seen it. We turned on the radio or TV and heard about this show in which a girl commits suicide at the end, or got a concerned email from the school warning about the program. The young people had already seen it, however. The suicide appears to be revenge against the 13 people who the fictional girl blames for her suicide, in 13 separate tapes.

When Netflix came out with its 13 Reasons Why series this spring, many parents didn’t even know about it until their children had already seen it. We turned on the radio or TV and heard about this show in which a girl commits suicide at the end, or got a concerned email from the school warning about the program. The young people had already seen it, however. The suicide appears to be revenge against the 13 people the fictional girl blames for her suicide, detailed in 13 separate tapes.

As Sansea L. Jacobson, M.D., writes in the commentary of this month’s issue (see p. 8), there are a lot of good reasons to be concerned about how the show will affect teens.

The problem, according to many, is not that the program existed, but that teens binge-watched it without any parental guidance. The series includes a lot of real problems: bullying, rape, drunk driving, and more. What could have been opportunities for guidance and assistance and open communication instead was a journey the teens took on their own.

Parents of young people who are already in treatment for psychiatric disorders should be particularly cautious. “We do not recommend that vulnerable youth, especially those who have any degree of suicidal ideation, watch this series,” the National Association of School Psychologists (NASP) said in a statement. “They may easily identify with the experiences portrayed and recognize both the intentional and unintentional effects on the central character.”

One of the individuals “blamed” by the girl was a school counselor who did not respond adequately to the girl’s plea for help. This in itself could make viewers think their counselors at school can’t help, according to NASP. Even the girl’s parents are seen as not helpful, because they know nothing about the events that led to her misery.

Many youth know that it’s fiction and not real life, and are capable of talking about the show. You should do that.

If your child is isolated, struggling, or “vulnerable to suggestive images and storylines,” it’s particularly important to help them process the series, according to NASP. “Research shows that exposure to another person’s suicide, or to graphic or sensationalized accounts of death, can be one of the many risk factors that youth struggling with mental health conditions cite as a reason they contemplate or attempt suicide,” NASP said.

Guidance for families

Below is guidance from NASP for parents.

  • Ask your child if they have heard or seen the series 13 Reasons Why. While we don’t recommend that they be encouraged to view the series, do tell them you want to watch it, with them or to catch up, and discuss their thoughts.
  • If they exhibit any of the warning signs above, don’t be afraid to ask if they have thought about suicide or if someone is hurting them. Raising the issue of suicide does not increase the risk or plant the idea. On the contrary, it creates the opportunity to offer help.
  • Ask your child if they think any of their friends or classmates exhibit warning signs. Talk with them about how to seek help for their friend or classmate. Guide them on how to respond when they see or hear any of the warning signs.
  • Listen to your children’s comments without judgment. Doing so requires that you fully concentrate, understand, respond, and then remember what is being said. Put your own agenda aside.
  • Get help from a school-employed or community-based mental health professional if you are concerned for your child’s safety or the safety of one of their peers.

Social networking

“The horse is out of the barn,” said Cora Collette Breuner, M.D., professor in the Department of Pediatrics at Seattle Children’s Hospital at the University of Washington, and chair of the committee on adolescence at the American Academy of Pediatrics.

“We can either ignore this and hope it goes away or take it on and be mindful of the dangers,” Breuner told me. She does not recommend that a youth who is actively depressed watch it. But she blames social media and the fact that teens have phones and watch whatever they want, without their parents’ knowledge.

“We give them these phones and all the data they want, and they can do whatever they want with it,” she said. It might be different if families were sitting together watching it on a screen. But be prepared to talk openly and to give guidance, interpreting some of the messages with a critical perspective. And don’t be afraid to make rules.

“Caring parents need to take on social networking,” she said. “We can demonize this show or we can be more aggressive about social media,” she said. “It’s as if we had no self-control, and the kids are autonomous and completely in charge.”

Breuner watched the entire series, and said that early on the show depicts one of the very real events that happens: a photo is rapidly shared on social media.

There are other problems with social media, even if it’s just showing off how happy you are, said Breuner. “Yes, it can be sad to watch someone who is really depressed hurt themselves,” she told us. But for some teens, it is just as sad to “look at how happy everybody else is and see what food they had for dinner.”

At this time of year, there are always more bouts of suicide and self-harm, said Breuner. The reason is usually that school is transitioning — some youth are anxious about summer, and others, even if they didn’t like school, are worried about losing the structure.

The show is definitely not appropriate for anyone who is depressed, or for anyone under 15, said Breuner. Finally, if you as a parent can’t sit through the series with your children, you should recommend that your children not watch it. “Are kids going to sneak around and watch it without their parents? Yes. Times are going so fast. We’re trying to keep up. Parents also need to practice some self-forgiveness.”

For more information:

Parents’ Guide
3/13/2017 12:00 PM

The American Academy of Pediatrics (AAP) has taken the lead on protecting immigrant children, as the Trump administration issued a series of executive orders shortly after taking office in January that included raids by Immigration and Customs Enforcement (ICE) police from the federal Department of Homeland Security. There were also children denied entry who were refugees, vetted with their families for years and already cleared to enter.

“The mission of the American Academy of Pediatrics is to protect the health and well-being of all children — no matter where they or their parents were born,” wrote Fernando Stein, M.D., AAP president, in a Jan. 25 position statement. “Immigrant families are our neighbors, they are part of every community, and they are our patients. The Executive Orders signed today are harmful to immigrant children and families throughout our country. Many of the children who will be most affected are the victims of unspeakable violence and have been exposed to trauma. Children do not immigrate, they flee. They are coming to the U.S. seeking safe haven in our country and they need our compassion and assistance. Broad scale expansion of family detention only exacerbates their suffering.

“Far too many children in this country already live in constant fear that their parents will be taken into custody or deported, and the message these children received today from the highest levels of our federal government exacerbates that fear and anxiety. No child should ever live in fear. When children are scared, it can impact their health and development. Indeed, fear and stress, particularly prolonged exposure to serious stress — known as toxic stress — can harm the developing brain and negatively impact short- and long-term health.

“The American Academy of Pediatrics is non-partisan and pro-children. We urge President Trump and his Administration to ensure that children and families who are fleeing violence and adversity can continue to seek refuge in our country. Immigrant children and families are an integral part of our communities and our nation, and they deserve to be cared for, treated with compassion, and celebrated. Most of all, they deserve to be healthy and safe. Pediatricians stand with the immigrant families we care for and will continue to advocate that their needs are met and prioritized.”

Advice to pediatricians

Medscape interviewed Julie M. Linton, M.D., co-chairperson of the AAP Immigrant Health Special Interest Group and a pediatrician in Winston-Salem, North Carolina, about immigration. Linton cares for many immigrant children. The interview was published Feb. 8 under the title “The Black Cloud of Deportation and Stress in Immigrant Children.”

Medscape: How can primary care providers who have immigrant kids in their practice recognize and assess these children? These families may be afraid to disclose their immigration status to anyone, even the pediatrician. What questions can or cannot be asked, and how can clinicians be respectful of the family’s need for privacy?

Dr Linton: This is a very real phenomenon and something with which we commonly struggle in clinical practice. Providing culturally effective care from the start is critical for families who prefer languages other than English. Having skilled interpreters to help us to communicate directly with families is essential, unless you are an official bilingual provider in the child or family’s preferred language and are able to successfully communicate with them. Very clear interpretation for communication is critical when you are talking about any issue related to health, and particularly when you’re talking about sensitive issues. If we are going to ask families about stress as it relates to immigration, it’s very important that we make it clear to the family that the reason we are asking these questions is because these are all things that can affect their child’s health. I often say something along the lines of ‘I’m going to ask some personal questions to understand your family’s journey. Many of the children and families I care for face chronic stress that can impact health. I want to understand how stress may be affecting your child’s health and how we may be able to help you.’

Medscape: What about documenting the care of these children? Is it safe to document a child’s citizenship status within the health record?

Dr Linton: If an immigration officer or team contacts a pediatrician for patient information, the pediatrician should be aware that all medical information, including documentation, is multifaceted and protected by the Health Insurance Affordability and Accountability 1996 (HIPAA) Act of 1996. It can be helpful to seek assistance from the legal department at the healthcare facility, or from the solo practitioner’s own legal counsel.

“Citizenship is relevant to health, and clinicians want to document these conversations in the confidential medical record. The AAP firmly believes that medical records should not be used in any immigration enforcement action; that’s part of our immigrant child health policy statement that was published in 2013. The question about how to best document these conversations in the medical record should be deferred to legal colleagues, but I can share some insight into how I approach this issue. For more information, the AAP’s Immigrant Health Toolkit has answers to some of these legal questions. For even more up-to-date information about legal issues that affect immigrant families, the National Immigration Law Center (NILC) is an outstanding resource for providers and families. It tends to be directed toward legal providers but has information that can be extrapolated to healthcare as well. I often use that as my resource because the NILC keeps its information up to date more than any other group and is very sensitive to advocacy issues that pertain to these populations.

Medscape: Here is the most important question: If you have an immigrant child in your practice who is experiencing the negative health effects of stress, what can you do? What are some best practices?

Dr Linton: First and foremost in the setting of fear and stress, children need buffering support from loving parents or caregivers. We know that enduring, supportive relationships with caregivers help children to overcome stress and build healthy brains. For many of the immigrant children whom I see in clinic, supportive family relationships create a buffer for ongoing stress. As pediatricians, we have a crucial role in supporting families as they support their children. Some of the things that we can celebrate in that process include enhancing the ‘serve and return’ — interactions with children that are supportive and encourage brain development. These include reading, talking, and singing with children; spending quiet time; and engaging in conversations that answer a child’s questions at the right level.

Medscape: What about the ‘bystander’ child and family in diverse communities who fear for their friends and neighbors?

Dr Linton: This is a very real issue. Children worry about bad things happening to their friends. We are all connected to one another, and the more that we can support all children in coping with uncertainty and fear, the more likely it is that we can support positive brain development and achieve collective prosperity for the future of our country. I wish that I didn’t have to use the precious little time I have with families to discuss the potentially harmful effects of stress on their child’s developing brains. As a pediatrician, my role is to help children grow, develop, and reach their full potential to contribute to our collective America. I hope that we can continue to work together to support children in reaching their full potential to contribute to our economy, to our community, and to our country.”

Editor’s note: This article touches also on the plight of refugee children, denied entry from seven countries by a Trump executive order. Their fate, as well as that of others from those countries, is in the hands of the courts.

Parents’ Guide
1/13/2017 12:00 AM

“It’s hard to be a parent tonight for a lot of us,” said Van Jones, a CNN political commentator, as the election returns were coming in in the early morning hours of Nov. 9, showing that Donald Trump was winning. “You tell your kids, ‘Don’t be a bully.’ You tell your kids, ‘Don’t be a bigot.’ You tell your kids, ‘Do your homework and be prepared,’” said Jones, who is black. “Then you have this outcome, and you have people putting children to bed tonight and they’re afraid of breakfast.”

Weeks afterward, there was still confusion, despair even, among many of the people who were deeply afraid of what a Trump presidency might mean. Trump’s supporters boasted about winning, which was to be expected. But hate speech — anti-immigrant, racist, bigoted rants — was reported as well. This followed Trump’s campaign, which included many anti-immigrant statements, a well-documented mockery of a reporter with a physical disability, and statements urging crowd members to rough up protesters.

As difficult as it was for some people to absorb the results — even Trump’s supporters hadn’t expected he would win — it was even more difficult for children. On Nov. 11, the American Academy of Pediatrics (AAP) gave some advice for how to talk to children about the election. The statement, from Karen Remley, M.D., M.B.A., M.P.H., F.A.A.P., CEO/executive vice president of the AAP, came in response to requests from pediatricians across the country. “They’ve requested advice on how to speak to children and families about the results, how to help each other cope with disturbing rhetoric, and how to explain news reports of protests,” she wrote. “They have sought reassurance that our mission remains steadfast to advance policies that protect all children.”

The AAP is known for being one of the few organizations that exists to further the interests of patients — children and adolescents — above all. “Even as we do everything we can as a national organization to represent children’s needs to our newly elected leaders, it is so important that all children feel safe and protected in their day-to-day lives,” write Remley. “As pediatricians and pediatric medical and surgical subspecialists, parents and grandparents, we can serve as a source of comfort and safety, reassuring children and supporting families.”

Here are some of the AAP’s recommendations for parents:

  • Take care of yourself first. Children depend on the adults around them to be and feel safe and secure. If you are anxious or angry, children are likely to be more affected by your emotional state than by your words. Find someone you trust to help with your personal concerns.
  • ​Explain — as simply and directly as possible — the results of the election and what they mean for who is in charge of the country. Start by asking what your child has already heard and what understanding he or she has reached. As your child explains, listen for misinformation, misconceptions, and underlying fears or concerns. The amount of information that will be helpful to a child depends on his or her age. For example, older children generally want and will benefit from more detailed information than younger children. Because every child is different, take cues from your own child as to how much information to provide.
  • Pay attention to what your children are viewing on television, the internet and social media, especially younger children. When children watch news on television, try to watch with them and use the opportunity to discuss what is being seen and how it makes you and your child feel.
  • Consider sharing your feelings about the election with your child. This is an opportunity for you to model how to react to the news, especially if you talked openly about the potential results as a family in the weeks leading up to the election. Be sure that you are able to express a positive or hopeful approach about the future and be reassuring.
  • Share with your child your own values and beliefs, including how you as a family treat others who are different or who may disagree with you. Kindness is important. Teach your child that if you disagree with someone, you can talk with them kindly about the way you feel.
  • Encourage your child to ask questions, and answer them directly. Question-and-answer exchanges help to ensure ongoing support as your child begins to understand the response to current events. Don’t force the issue with your child. Instead, extend multiple invitations for discussion and then provide an increased physical and emotional presence as you wait for him or her to be ready to accept those invitations.
  • If your child has seen or experienced discrimination based on race, religion, ethnicity, gender, or sexual orientation, either from other children or adults, encourage your child to discuss what he or she has experienced. Observing someone we care about being discriminated against, or experiencing discrimination ourselves, is scary, and reminds us that now more than ever it is important to reassure children that they deserve to feel and be safe in their schools, homes, and communities.
  • Allow your child to express what he or she is feeling, including fear, anxiety, or anger. Listen as your child talks about it, again and again if necessary. Reassure your child of the steps that are being taken to keep him or her safe. Children should be encouraged to tell a trusted adult, such as a parent or a teacher, if they are bullied or feel threatened.
  • Engage in activities with your children that demonstrate your values. Volunteer together at an organization whose mission is dedicated to a cause you care about, give your child ideas about individual actions he or she can take every day to help fight prejudice, and take care to discuss issues of shared concern as a family.

“As we turn to our newly elected leaders, the Academy will continue to advocate for and promote healthy children, support secure families, build strong communities and ensure that the United States is a leading nation for children,” concluded Remley. “We will remain constant in our pursuit of health and well-being for all children. We will be steadfast in our approach of using evidence, policy and our passion for children in our dialogue and discussion.”

Obviously your concerns will be more intense if your child has faced hate speech in school. Teachers have reported that such incidents spiked after the election. As always, advocate for your child. Be sure that the school knows and responds appropriately. Your child is counting on you, now more than ever.

Finally, keep your home life normal. Young children in particular need security, and need their parents to be in control. Do not react or overreact to what you hear on the radio or TV, or see on the internet. It might be a good time to buy an actual newspaper and read it with your child. Older children can learn on their own and keep track of what’s going on in politics. After all, they will be voting soon. Teach them to think for themselves, to not to succumb to peer pressure: there is a sense in middle and high school that bullies carry the day. Not so. Votes are private.

Van Jones’ children one day will see the clip of him almost in tears the night of the election, asking how he could explain the results. Perhaps they already have. They will have had time to adjust to the new reality, and they will not have to harbor secret fears about an unknown threat.

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  • Meet the Editor

    Gregory K. Fritz, M.D.
    Editor

    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.
    Alison Knopf
    Managing editor

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