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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.


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;

Rhode Island Department of Health. Rhode Island data brief: Kids at risk. RI Youth Risk Behavior Survey. 2012;

8/1/2014 12:00 AM

Disruption of mastery of developmental skills specific to developmental periods

The mastery of developmental “skills” specifically associated with each developmental period can present unique challenges for a child or adolescent with intellectual disability (ID). A disruption in the mastery of specific developmental skills also can present unique challenges for the child or adolescent’s caregivers and family, in how they engage as well as respond to the child. In a previous article, the disruption of mastery of developmental skills specific to the periods of infancy, early childhood, and childhood was reviewed. In this article, the disruption of mastery of developmental skills specific to the periods of adolescence and adulthood is reviewed.


Adolescence is a challenging period for every teen as well as for those living and working with them. Physical changes, as well as the striving for greater independence and social acceptance, are even more difficult for teens presenting with cognitive and adaptive skill deficits.

Increasing sensitivity of the erogenous zones may lead to inappropriate touching in children unable to master social rules. Some females with more severe levels of ID may be unable to understand the physical sensation of menstruation. Physical discomfort may lead to increased irritability, self-injury, and aggression. Personal hygiene also may be a problem.

The commonly held prejudice that those with ID are likely perpetrators of sexual assaults belies the reality that they more likely may be victims of sexual mistreatment or abuse. Adolescence is a particularly risky period. Many children at this age are living in institutional settings, such as residential group homes, which may further increase the risk of abuse.

Deficits in social skills are particularly debilitating during this period. Complex social interactions, rapidly changing trends, and group cohesiveness are the norm. It is very challenging for adolescents with mild ID to keep up with their developmentally intact age-mates. Friendships with nondelayed peers, which may have flourished for years, are strained as these peers begin dating, working, and expressing their own independence. Children with ID may have the same dreams and expectations as their peers. Status symbols such as driving or a “cool” job may be out of reach. Medical or neurological conditions may contribute to physical abnormalities at an age when personal appearance has heightened significance. Depression and withdrawal are common as social failure accumulates. Suicidal ideation is not unusual. Relationships with adults are often more rewarding. Somatization or creative storytelling may increase as a means of soliciting professional help or to otherwise fill the void of loneliness.

Academic challenges often change during this period. Vocational skill development predominates. Those with more severe levels of ID will frequently be taught repetitive “prevocational” tasks that are often minimally rewarding. For adolescents with milder delays, attending vocational classes may be stigmatizing and a source of shame. Self-worth may diminish rapidly as teens with ID come to blame themselves for having a developmental disability.

Families face different stressors. Parents are aging and may feel increasingly overwhelmed by the demands of a teenager with ID. The normal developmental trajectory of increasing child independence may be disrupted, forcing families to face issues that have previously been avoided. For example, the opportunity for increased freedom for parents as their children leave the nest may prove illusory. In addition, issues of long-term care may arise when parents are no longer able to support more seriously delayed children. This is frequently a period when professional agencies become involved in the child’s life to plan vocational, social, and residential opportunities. However, many families find it stressful to relinquish some or all of the care of their children to others. Brothers and sisters may be overprotective or resentful of a sibling with special needs and find that the changes of adolescence have greater impact on family functioning.


As individuals with mild forms of ID reach adulthood, some might no longer be considered intellectually disabled. Relieved of the imposed structure of academics, some individuals with ID find appropriate jobs and housing arrangements that allow them to live independently. Unfortunately, stressors around child rearing, occupational or financial matters, and social relationships may lead to minor or major regression that requires additional family or professional support. Others with milder severity levels of ID receive support around occupational, residential, and social issues, as needed. Self-motivation and time management may be a challenge when rewards (i.e., a paycheck) are not immediate. In less supported worksites, relationships with coworkers can be challenging. Being criticized or taken advantage of is common.

Managing home finances, food shopping, laundry, and other life skills may be daunting tasks for individuals with milder severity levels of ID. Those individuals are more at risk for con artists and “scams.” Some engage in inappropriate or illegal activities without understanding the full import of their actions. Many have legal guardians. Sometimes, individuals and guardians disagree on issues, which may lead to tension and frustration. All of these factors may contribute to greater dependence on others than the individual desires.

Those with ID may have physical handicaps, limited mobility, or limited access to transportation. This enhances difficulties in keeping appointments and job expectations and creates further isolation. Individuals with more severe levels of ID in adulthood often work in a very structured and supportive environment. Behavioral issues such as aggression, self-injury, compulsions, and opposition are common and limit productivity. Ongoing assistance around self-care skills requires close supervision by family or agencies.

While a range of developmental challenges remain for individuals with ID and their families, advances in understanding and treating children with ID, while still evolving, have resulted in marked improvements in the quality of life.

7/18/2014 12:00 AM

When it comes to behavioral health care, the winds of change are blowing strong. While it may be an exaggeration to use the “perfect storm” metaphor, it is clear that the Affordable Care Act (a.k.a. Obamacare) and the potential for real mental health parity (i.e., the end to government-sanctioned discrimination by insurance companies against those with psychiatric disorders) are very likely to lead to new ways of providing mental health services. The Affordable Care Act seeks to expand health care coverage, improve quality, and control costs. One promising approach that is receiving considerable attention is integrated care, in which mental health services are provided together with medical care by a coordinated team of primary care and mental health professionals. Numerous clinical reports of pilot projects studying various models of integrated care have been encouraging, but less is known about the potential for cost savings.

To shed light on the economical impact of integrated care, the American Psychiatric Association commissioned the global consulting and actuarial firm Milliman, Inc. to study a large number of adults with chronic medical and behavioral comorbidities. Their report was released, to great fanfare, in April 2014 (, and it deserves our attention.

In essence, the report documents substantial levels of untreated mental health or substance abuse disorders among those with chronic medical conditions. Even though treatment of behavioral health problems accounts for about 30% of total health care spending for insured patients ($525 billion out of $1.7 trillion annually), they are far from fully addressed. Fragmented care results in general medical care costs for those with both chronic medical and mental conditions that are 200% to 300% more than general medical costs for those who have chronic mental conditions only. The report concludes that effective integrated care could save $26–$48 billion annually. Even though such a wide range underlines the fact that these figures are only estimates, the potential for savings of this magnitude (compared to steadily increasing costs) is turning the heads of health care planners. Should child mental health professionals jump on the bandwagon?

It turns out that, as is so often the case, one can’t simply extend the findings from a study based solely on adults to the world of children and adolescents. The pediatric population is, on the whole, mostly healthy. Beyond the neonatal period, serious (and expensive) chronic conditions are relatively rare in children and adolescents, in contrast to diabetes, heart disease, cancer, etc., which are common in every internal medicine primary care practice. Thus, the total and average per-patient health care costs are comparatively small for children and adolescents and the huge immediate savings, so tantalizingly described for adults in the Milliman Report, are not there to fund the pediatric shift to integrated care. Further, the medical health home for children and adolescents is more complicated than the corresponding integrated care site for adults. Due to children’s dependency on the important adults in their lives, pediatric care has to be family-centered, unlike the simpler patient-centered model that works for adults. Finally, the demographic changes that challenge our health care system — increasing minority percentages, growing income disparities, etc. — overall impact youngsters more than adults.

The danger I worry about is that because the immediate monetary savings associated with integrating behavioral and medical health care for adults are not readily seen for children’s services, children’s mental health and primary care will be left to languish in the fragmented, inadequate nonsystem that we are currently living with. I believe that would be short-sighted and tragic.

Abundant evidence points to the lack of access to needed mental health services experienced by millions of children. Given that half of all lifetime mental illnesses begin by age 14 and three-quarters by age 24, the potential to prevent costly adult morbidity is where the savings lie with pediatric integrated care. The problem is that projections of savings are very difficult to calculate where the time frame is 20 years rather than 2 years. Improved access to children’s mental health services through integrated care models can be expected to eventually lead to fewer adults incarcerated in prisons, less productive time lost to substance abuse and depression, and fewer psychiatric hospitalizations and emergency room visits by adults. However, the long-term data on the timing and magnitude of these savings are lacking.

As I see it, child mental health professionals and our primary care colleagues need to plunge ahead into the exciting but uncharted waters of integrated services. Immediate cost savings cannot be the only marker of success. Improved functioning in school, fewer mental health crises, a reduction in the juvenile justice population, and normalized development are worthy outcomes to be demonstrated while the longitudinal benefits of prevention are accruing.

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.

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.

Be prepared

Before the school year starts, be sure your child is in good physical and mental health. Schedule doctor and dental checkups early. Discuss any concerns you have over your child’s emotional or psychological development with your pediatrician. Your doctor can help determine if your concerns are normal, age-appropriate issues or require further assessment. Your child will benefit if you can identify and begin addressing a potential issue before school starts. Schools appreciate the efforts of parents to remedy problems as soon as they are recognized.

Get organized

Make sure you have the essentials for the classroom and clothing, but don’t go overboard. Try to get the supplies as early as possible and fill the backpacks a week or two before school starts. Older children can help do this, but make sure they use a checklist that you can review. Some teachers require specific supplies, so save receipts for items that you may need to return later. Prepare a few easy dinners that freeze well before the school year starts so that you have them when necessary. This can help cut down on general household tension in the first weeks of school.

Re-establish routines

Plan to re-establish the bedtime and mealtime routines (especially breakfast) at least 1 week before school starts. Prepare your child for this change by talking with your child about the benefits of school routines in terms of not becoming overtired or overwhelmed by school work and activities. Include pre-bedtime reading and household chores if these were suspended during the summer. Pick a spot to keep backpacks and lunch boxes so that there are no desperate searches in the morning under time constraints. Get in the habit of making lunches the night before to make mornings run more smoothly.

What to do when anxiety arises

These recommendations can contribute to a positive and productive school experience for most children. Some children may exhibit more extreme opposition to or fear of school or may be coping with more specific learning or psychological difficulties.

If your child demonstrates problems that seem extreme in nature or go on for an extended period, you may want to contact the school to set up an appointment to meet with your child’s teachers and school psychologist. They may be able to offer direct or indirect support that will help identify and reduce the presenting problem. They may also suggest other resources within the school and the community to help you address the situation.

While children can display a variety of behaviors, it is generally wise not to over-interpret those behaviors. More often than not, time and a few intervention strategies will remedy the problem. Most children are wonderfully resilient and, with your support and encouragement, will thrive throughout their school experience.

  • Let your children know you care. If your child is anxious about school, send personal notes in the lunch box or book bag. Reinforce the ability to cope. Children absorb their parents’ anxiety, so model optimism and confidence for your child. Let your child know it is natural to be a little nervous anytime you start something new but that your child will be just fine once he or she becomes familiar with classmates, the teacher, and the school routine.
  • It is normal for every child to react to going back to school in his or her own way. This can make it tempting to apply your own experience to your child’s life. Although harkening back can provide insight, remember that your child is not you. Be calm and matter of fact. Listen and provide reassurance, but try not to heighten anxiety with old memories and good intentions.

  • Do not overreact. If the first few days are a little rough, try not to overreact. Young children in particular may experience separation anxiety or shyness initially, but teachers are trained to help them adjust. If you drop them off, try not to linger. Reassure them that you love them, will think of them during the day, and will be back.
  • Remain calm and positive. Acknowledge anxiety over a bad experience the previous year. Children who had a difficult time academically or socially or were teased or bullied may be more fearful or reluctant to return to school. If you have not yet done so, share your child’s concern with the school and confirm that the problem has been addressed. Reassure your child that the problem will not occur again in the new school year, and that you and the school are working together to prevent further issues.
  • Reinforce your child’s ability to cope. Give your child a few strategies to manage a difficult situation on his or her own. But encourage your child to tell you or the teacher if the problem persists. Maintain open lines of communication with the school.
  • Arrange play dates. Try to arrange get-togethers with some of your child’s classmates before school starts and during the first weeks of school to help your child re-establish positive social relationships with peers.
  • Plan to volunteer in the classroom. If possible, plan to volunteer in the classroom at least periodically throughout the year. Doing so helps your child understand that school and family life are linked and that you care about the learning experience. Being in the classroom is also a good way to develop a relationship with your child’s teachers and classmates, and to get firsthand exposure to the classroom environment and routine. Most teachers welcome occasional parent help, even if you cannot volunteer regularly.

Getting help

Most back-to-school anxiety is anticipatory. If the level and type of anxiety seems a marked departure from your child’s usual behavior and lasts well past the beginning of the school year, consider seeking outside help. Start by talking with his teacher. Next, a school counselor or psychologist can provide valuable tips and resources. Anxiety disorders do affect children and are often overlooked because such children do not tend to act out.

In the end, the most important tool you can use is to know your own child. Observe the situation, but also try to keep it all in perspective. For most kids, back-to-school jitters will melt away as easily as summer slips into fall.


3/10/2014 12:00 AM

Social media is ever-present in the lives of children and adolescents and impacts the behavioral and mental health of children and adolescents, and as such it is important for parents and caregivers to be aware of the risks and benefits. Better understanding how and why adolescents interact with social media, as well as the associated risks and benefits, can help parents and caregivers engage in productive conversation and create strategies for responsible use.

Children and adolescents regularly use the Internet, cell phones, and video games to gather information and communicate with each other. This ability to interact with others is the unique feature of social media, which provides powerful new ways for teens to create and navigate their social environments. Teens’ use of social media occurs simultaneously with their developing identity, emerging sexuality, physical development, and moral consciousness. Social media is ever-present in the lives of children and adolescents and impacts the behavioral and mental health of children and adolescents, and as such it is important for parents and caregivers to be aware of the risks and benefits. Better understanding how and why adolescents interact with social media, as well as the associated risks and benefits, can help parents and caregivers engage in productive conversation and create strategies for responsible use.

Risks of Social Media

  • Risks to mental health. Many teens who are regular social media users report that they have many friends, get along well with their parents, and are happy at school. However, peer rejection and a lack of close friends are among the strongest predictors of depression and negative self-views. Teens who are the heaviest social media users report being less content and are more likely to report that they get into trouble a lot, are often sad or unhappy, and are often bored. Young women and girls tend to be at a higher risk for negative emotional and psychological consequences of social media interaction.
  • Cyberbullying. Use of social media also creates an opportunity for emotional distress from receiving threatening, harassing, or humiliating communication from another teen, or cyberbullying. Lesbian, gay, bisexual, and transgendered (LGBT) teens are the most likely to fall victim to this sort of bullying, followed by females. Individuals who are victims of cyberbullying are more likely to then perpetrate cyberbullying themselves. Cyberbullying is unfortunately quite common, can occur to any young person online, and can cause profound psychosocial outcomes, including depression, anxiety, severe isolation, and, tragically, suicide.
  • Text/picture messaging. While most teens use messaging responsibly, it is still an extremely powerful and private communication tool that can be used irresponsibly. With texting, teens cannot see the reaction of the person receiving the message, so their actions can be separated from the consequences. Any personal information, photos, or videos exchanged via text can quickly be provided to an audience other than the intended. It is important that teens know these messages can be even more lasting than a conversation or event in person. Sexting in particular is a concern for parents and teens, and 20% of teens have received or sent sexually explicit images or messages. Some teens who have engaged in sexting have been threatened or charged with felony child pornography charges, although some states have started characterizing such behaviors as juvenile-law misdemeanors.

Benefits of Social Media

  • Socialization and communication. Most teens use online networks to extend the friendships they already have from other areas of their life. Social networking sites provide a way for teens to experience connectedness and opportunities to learn from each other. Online exchanges can help foster a child’s individual identity, and unique social skills create relationships between individuals of different social and cultural backgrounds.
  • Support. Social media can provide a supportive environment to explore romance, friendship, and social status. Social networking sites can allow teens to find support online that they may lack in traditional relationships, especially for teens who are often marginalized, such as LGBT teens, those who are living with an illness or disability, or those who may feel physically unattractive or socially reticent.
  • Accessing health information. Teens also use online searches to gain answers to many of their health concerns easily and anonymously. Adolescents use social media to gather information about health topics that are hard to discuss with others, such as drug use and sexual health. The mobile technologies that teens use daily — namely, cell phones, instant messaging, and text messaging — have already produced multiple improvements in their health care, such as increased medication adherence, better disease understanding, and fewer missed appointments.
  • Peace of mind. Because children and adolescents usually have a mobile device or cell phone with them at all times, parents and children alike can feel a greater sense of comfort in independence.

Social Media and Privacy

When Internet users visit various websites, they can leave behind evidence of which sites they have visited. This collective, ongoing record of one’s Web activity is called the digital footprint. Most studies show that teens do care about privacy and engage in privacy-protecting behaviors, such as adjusting their profiles to private from public access, refusing to provide identifying information, and avoiding certain websites. However, most youth do not read websites’ privacy policies or may be unaware that their information is at risk of disclosure to third parties like advertisers. Though concerned about talking to people they don’t know online, teens appear to be less worried about posting information about themselves.

Recommendations for Parents

Parents and caregivers need to educate themselves about social media and the ways their teens may use it, as well as the common risks, to help them understand and navigate the technologies. Parents should be aware that 13 years is the minimum age for most social media sites because the Children’s Online Privacy Protection Act (COPPA), enacted by Congress, prohibits websites from collecting information on children younger than 13 years without parental permission.

Family discussions about Internet presence and social media can result in less risky online behaviors — many teens who say their parents have talked to them often about social media reported greater concerns about online safety and sharing of personal information and photos and more limited sharing of information/pictures via the Internet, lower incidence of public online profiles, and lower incidence of talking or meeting people they only know from online. Conversations reinforcing the idea that “what goes online, stays online” are important between parents and children. For parents and caregivers, discussing media content with their teens can be an effective strategy to reduce the amount of personal information disclosed — more so than prohibiting access, as teens often perceive monitoring as a violation of their privacy. Teens are more receptive to user-empowered strategies where they become the agent of their own protection or even some form of industry protection than policing by parents or caregivers.

Additional Resources for Parents

Following are some resources for further research and information:

12/9/2013 12:00 AM

In the wake of Typhoon Haiyan, which recently devastated the Philippines, the importance of recognizing the traumatic impact of natural disasters on the mental health of children and adolescents is brought freshly to mind in addition to concerns for children’s physical health and safety. Survival quickly becomes the top priority and “survival means not only that we address children’s health, education and psychological well-being, but that we make sure their safety is given top priority,” according to Tomoo Hozumi, the United Nations Children’s Fund (UNICEF) representative in the Philippines. Hozumi further explains that recovery efforts in the Philippines are currently aimed at establishing a safe place “for children to begin the process of recovering from the loss of loved ones and the total upheaval in their lives,” but this is just the first step in the recovery process.

Natural disasters and trauma are of course not unique to any one corner of the world. Natural disasters and traumatic events can happen anywhere, and parents should be aware of the special psychological needs of children in relationship to such events. In order to deliver the most effective and necessary care as parents and guardians to children who have suffered such traumas, we will take a step back from the immediate crisis in the Philippines and examine the effects disaster and trauma have on children in a more universal sense. The following handout is designed to help parents recognize a disaster and the resulting trauma, and provide some strategies for mental health support.

What is a disaster?

A disaster is a significant calamitous event that generally involves injury or loss of life and destruction of property. A disaster can affect both small and large populations and is typically outside the scope of normal human experience. It is widely accepted that the psychosocial effects in children after disaster are influenced greatly by the nature of disaster itself, the level of exposure to the disaster, the extent to which the children and those around them are personally affected by the disaster, and the individual characteristics of children, including their age and stage of development. In addition, children are uniquely affected by disasters because they are afflicted not only by the trauma of the event but also by their parents’ fear and distress. Parents are often suffering from the psychological effects of the disaster or traumatic event themselves, but it is important to understand that a parent or guardian’s reaction to a traumatic event has a significant bearing on the experience of the child.

What should parents look for?

Traumatic reactions in children can vary in degree and intensity based on the developmental stage and age of the child, but here are some general indicators of the traumatic impact that can result from a disaster event:

  • Avoidance: Children may try to avoid reminders, activities, thoughts, and feelings related to a traumatic event. Children may withdraw from social events and interactions, block out or forget details of the traumatic event, or appear numb or unable to express a wide range of emotional responses.
  • Re-experiencing: Children may show evidence of reliving aspects of the event or of having recurring images and thoughts of the traumatic event. Children may engage in role-playing or acting out of the trauma-related event, have nightmares of the disaster or trauma, or display a distressed reaction to reminders of the trauma.
  • Heightened agitation: Children may show agitation and elevated responsiveness to reminders of the event. Symptoms of elevated responsiveness include sleep problems, nervousness, irritability, crying, anxiety, appetite changes, and inability to concentrate.

What should parents do to help prevent trauma from disasters?

Preparedness is a key in offsetting some of the short- and long-term effects of experiencing a traumatic event. Natural disasters in particular can be unpredictable, so having a general emergency plan in place with a family evacuation plan, designated meeting place, and communication strategy can be a great way to mediate a child’s anxiety before the disaster takes place. Identify evacuation routes and prepare an emergency kit so that children know there is a definite plan in place for a disaster. Practice and review your evacuation plan — predictability goes a long way in creating a sense of stability and familiarity in the emergency situation in the wake of a disaster. All of these preparations will also benefit the emotional and psychological state of the adults involved in disaster situations, too. As previously mentioned, the traumatic impact of a disaster on a child is directly related to the impact of the disaster on the parents or guardians, so any advance measures are an opportunity to make sure that you as a parent are prepared to handle a disaster situation to the best of your ability, in turn creating a better experience for your child.

In the event of a natural disaster, be sure to maintain your routines and normal activities, providing your child with as much of a safe and predictable environment as possible. Ask your child to help — giving children the opportunity to help out will build their sense of usefulness and control during stressful times. This could be volunteering in the disaster-stricken community or household, but be mindful of any negative reactions to disaster-related stimuli or situations. Be patient and calm with your child. Provide clear and factual (and age-appropriate) information regarding the traumatic situation while limiting media coverage of the event, both prior to and post. Sensationalized and graphic content may elicit feelings of fear, anxiety, and uncertainty in children prior to disaster, and children may re-experience these same negative feelings when confronted with media coverage after the event.

How can parents help children cope?

Parents can play a significant role in helping children cope with the trauma of a natural disaster. Encouraging a child to take up a new hobby or continue a commitment to an existing hobby will serve as a distraction from the events of a natural disaster. Writing in a journal or maintaining contact via mail, email, or phone with close friends to share feelings and experiences while continuing a normal sense of connectedness can assist in positive adjustment and coping. Social events are a good opportunity to facilitate this communication, too. Volunteering money, time, or resources can help children create a sense of accomplishment and purpose that assists with personal recovery.

Of course, seek professional help if your child is having difficulty coping. Parents and school professionals should pay close attention to children’s feelings and behaviors. The process may be a gradual one, but children should be able to slowly resume family and social activities. If you see your child struggling with this readjustment, do not hesitate to seek professional help and consultation.

Sources: UNICEF, American Academy of Pediatrics, NYU Child Study Center,


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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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