Big Crowds Anxiety

Excitement and anxiety can sometimes look similar in children before a major event. A child with “excited jitters” may still eagerly talk about the game and respond well to reassurance, while a child experiencing genuine anxiety may become consumed by worry or even try to avoid attending altogether.

Physical symptoms can also appear in anxious children, including headaches, stomachaches and trouble sleeping leading up to the event.

“Excited jitters usually come and go, but anxiety tends to stick around and interfere with daily routines,” said Amanda Jordan, PsyD, psychologist with the Cook Children’s Psychology Department.

Preparing children ahead of time by showing them videos or photos of the stadium, discussing what they can expect and creating a clear game-day plan, can help prevent anxiety symptoms. Parents can also use “first-then” language to help children mentally organize the experience.

For example: “First we’ll find our seats, then we’ll get a snack.”

Families can also benefit from creating a safety plan before arriving at the venue, including identifying meeting spots and teaching children how to find stadium employees for help. Creating a funny family code word for moments when a child feels overwhelmed can also ease stress and remind children it’s okay to ask for a break.

Stadiums Sensory Impact

For many children, sport venues can overload the senses with bright lights, loud music, strong smells and tightly packed crowds. Dr. Jordan says sensory overload can trigger the body’s “fight, flight or freeze” response, making emotional regulation difficult. Children experiencing sensory overload may become irritable, restless or emotional. Others may withdraw, stop talking, cry or struggle to make decisions.

Several sport venues, especially the newest stadiums, now feature dedicated sensory rooms or quiet spaces designed to help guests decompress. Dr. Jordan encourages parents to research venues ahead of time to learn what accommodations are available and where they are located.

Even if a stadium does not offer a formal sensory room, quieter areas such as patios, hallways or less crowded sections may provide children with a chance to reset before returning to the event.

“These spaces can help lower anxiety and give children a place to regulate during stressful moments,” Dr. Jordan said.

Behavioral Challenges

Emotional outbursts during games can happen when children become overstimulated or overwhelmed. In those moments, Dr. Jordan says parents should focus less on discipline and more on helping children feel safe and calm. Getting down to the child’s eye level, speaking in calm tone and validating the child’s feelings can help them decompress and rebalance their emotions.

Parents can also use grounding techniques, such as deep breathing exercise or offering simple choices to help restore a sense of control.

For example: “Would you like to sit with me for a minute, or would you rather go walk around for a little bit?”

Dr. Jordan also encourages families to discuss coping strategies before the event so children know what support may look like if emotions escalate.

The emotional energy inside a stadium can also affect how children interpret social situations. Aggressive reactions from adults or fans may increase a child’s anxiety or sense of insecurity.

“Kids learn how to respond by watching the adults around them,” Dr. Jordan said.

Parents can help by calmly explaining emotional reactions happening around them, such as cheering after a goal or frustration following a penalty call.

Practical Advice

It is recommended to pack a few “mental health essentials” before attending a major sporting event with children.

Some of these items can include:

• Noise-canceling headphones, or earplugs
• Comfort items like a soft blanket or a plush toy
• Sensory or fidget toys
• Snacks

 These items can help children self-regulate and make the big game day more enjoyable.

Parents should also recognize when it might be time to leave early. If a child cannot recover emotionally after taking breaks or using calming strategies, it is time to prioritize the child’s wellbeing and step away from the event.

It’s also important to emphasize that sensory sensitivities are not limited to children with Autism spectrum disorder (ASD). Children with attention deficit hyperactivity disorder (ADHD), anxiety or trauma histories may also struggle in overstimulating environments.

“Sensory overload can affect many different children – and sometimes even parents too,” Dr. Jordan said.

Related Stories:

• Big Game, Big Safety: Preventing Hot Car Tragedies

• Big Game, Big Responsibility: Water Safety

• Cook Children’s Sports Medicine Physician Heals Young Athletes Through Pickleball Medicine Program

• Changes in routine
• Traveling
• Missing family members and loved one
• Pressures to create meaningful experiences
• Family dynamics
• Holiday shopping and gift giving

So what can parents do? How can we help our children process pressures to protect their mental health and emotional well-being?

Communicate Expectations
Planning ahead and explaining arrangements can help prepare kids for traveling, adjusting routines, meeting new people and more.

“Kids love to know what to expect,” Ashley Pagenkopf, MS, CCLS, child life specialist in Cook Children’s Emergency Department, said. “Establishing realistic expectations is the most practical tip I would offer to families. Kids thrive with boundaries and expectations.”

When visiting family and friends or even hosting a holiday reunion at home, communicating with kids about who they may meet is important.

“A huge help for kids is to have video chats with family members and friends they will see in advance,” Lisa Elliott, Ph.D., psychologist and manager of Cook Children’s Behavioral Health Clinic in Denton, suggests. “For littles, even reading books to them over video chat is a great way to engage them.”

Let your children know that feeling anxious around unfamiliar people is normal. Staying together as a family can help kids feel safe, and it’s important to remind them they can speak up if they feel uncomfortable or need a break from social gatherings.

Practice Self-Care
Managing family anxiety often begins with parents addressing their own stress.

“Kids are very good at reading adult emotions even if they are not verbally expressed, so if you are stressed out, it’s likely your child is anxious as well,” Cook Children’s psychiatrist Akemi Watkins, M.D., said. “It’s like the safety message on airplanes where you have to put the oxygen mask on yourself first before your child.”

Simple self-care practices can significantly enhance parents’ well-being. Prioritizing sleep, nutritious meals and regular exercise can make a big difference. For more information about self-care for parents, Cook Children’s has a guide of resources listed here.

Focus on Connection
One of the best ways to reduce holiday stress is to focus on connection. Finding ways to bring family and friends together can be fun and meaningful.

“I’ve had multiple kids share their favorite family traditions,” Dr. Elliot said. “Experiences like taking baked goods, lotions or other treats to a nursing home, helping in a soup kitchen serving holiday meals and even adopting a family and going shopping together for them.”

The holiday season presents an opportunity to teach children about generosity – a concept that studies show actually improves mental health. Doing things for others makes you feel good – emotionally and physically.

It also promotes empathy and resilience, which are important building blocks to emotional and mental strength and coping skills that help children deal with challenges.

Read examples of ways families can serve others together here.

September is National Suicide Prevention Month and it can make the difference in someone’s life to have emotional and mental health support with access to the resources they need. Being open to mental health education and counseling as well as finding the right medication or treatment is key. Often, parents can be hesitant to have their child on psychiatric medication. Cook Children’s psychiatrists are answering parents’ questions and raising awareness to help alleviate stigma and treatment for children.

What are mental health conditions?

Depression, ADHD, anxiety and behavior problems are the most common mental disorders found in children. According to the U.S. Centers for Disease Control and Prevention (CDC), “Mental disorders among children are described as serious changes in the way children typically learn, behave, or handle their emotions, causing distress and problems getting through the day.”

Kristen Pyrc, M.D., Medical Director of Psychiatry Outpatient Services and the Partial Hospitalization Program at Cook Children’s, said they diagnose mental health conditions when they are limiting a child or teen’s functioning.

“Worries, sadness, and anger are all normal emotions, but we become concerned when a kid’s sadness or anxiety keeps them from doing things that bring them joy, or things they need to do to take care of themselves like attending school, showering and interacting with friends,” she said.

How can mental health conditions be treated? 

Both counseling and medication can be used to treat a child with a mental health condition that affects their everyday life, but parents are often hesitant about having their child try medication.

“I’ve found medication and counseling to be equally effective for a child with anxiety and depression, but the combination of both gets kids better faster and safer,” Dr. Pyrc said.

Akemi Watkins, M.D., in Cook Children's Behavioral Health also recommends medication when needed. “If a child has moderate to severe depression or anxiety, we’ll recommend starting medication because current evidence suggests that a combination of medication and therapy is more effective than medication or therapy alone.”

Why are parents hesitant about their child taking medication?

Many parents are concerned with their child taking psychiatric medication because of potential side-effects, medication dependency, the stigma associated with it and even their own experience with mental health medications. The cost of prescription medications, especially name brand, can also be a major hurdle.

If a parent is questioning their child trying medication, Dr. Pyrc recommends, “Consider the risk of not treating anxiety, depression and ADHD, and whether that keeps them from reaching their full potential.”

Is it possible to get financial help to access medication?

The cost of medication often prevents parents from having their child try it. Name-brand prescriptions, especially when they are new to the market, are also out of most people’s price range.

Both Dr. Pyrc and Dr. Watkins help patients have access to their medication by finding similar, lower cost medications and recommending ways to find more affordable pricing.

“GoodRx can help you find the lowest cost pharmacy in your area,” they said. Dr. Pyrc also tells patients about CostPlus Drug Company which has many psychiatric medications at much lower costs that can be mailed.

How can we make taking medication a routine?

Helping a child get used to a new daily routine of taking medication can be challenging. Dr. Pyrc advises “habit-stacking” to make it easier.

“It means ‘stack on’ taking medication to something that you already do every day. Most people brush their teeth twice a day, so getting into the habit of taking medication after brushing your teeth is easier than trying to remember to take it at noon,” she said.

Setting phone notifications can also be helpful and Dr. Watkins advises the parent or guardian to be responsible for dispensing medication for safety reasons.

Medication Success Stories

Both Dr. Pyrc and Dr. Watkins have seen a lot of success stories when children and teens find the right medication.

“One of my favorite memories was a 1^st grader who had ADHD and got into trouble at school every day to the point that he did not want to go to school,” Dr. Pyrc shared. “After we started medication, he brought me his behavior log that had a smiley face for good behavior every day. I still remember the look on his face glowing with pride, and honestly, that is why I do my job.”

Dr. Watkins also experienced seeing her patients’ overall well-being and mental health improve.

“I had a teenage patient with depression and anxiety, and she was started on sertraline,” Dr. Watkins said. “After getting to a therapeutic dose, she was less socially isolated, less overwhelmed with anxiety and said that she was having fewer days where she felt depressed. She felt more motivated to attend school and her grades eventually improved as her depression and anxiety improved.”

Additional Support

When parents are still debating whether or not to have their child or teen try a psychiatric medication, Dr. Pyrc recommends they visit with their pediatrician who can help them understand what is “normal” or if something does need to be addressed. She also recommends researching the American Academy of Child and Adolescent Psychiatry (AACAP) to learn more about anxiety, depression, ADHD, sleep disorders and Autism in the AACAP Parents’ Medication Guides.

In this episode of Raising Joy, we discuss a new peer-to-peer support program that is underway in Cook Children's Pediatric Intensive Care Unit (PICU). Chaplain Amanda Payne Lindsay and Katelyn Terry, RN, join us to talk about the program's goals, how it works, and the impact it's having on PICU staff.

The PICU can be a traumatic environment for health care workers, and this program is aimed at limiting the impact of stress, depression, anxiety, and burnout. The program trains appointed PICU employees to serve as supportive peers to lean on in times of need.

Listen to learn how they started the peer-to-peer support program and why similar programs could benefit workplaces of all kinds.

Raising Joy is part of Cook Children’s Health Care System’s Joy Campaign, a communications initiative aimed at preventing youth suicides. For more information about the Joy Campaign, visit cookchildrens.org/joy.

New episodes of the Raising Joy podcast will be available each Tuesday. It is currently available on all major streaming platforms including Apple, Spotify and Google Podcasts.

Getting back into a routine after a long summer break can be tough for kids of all ages. In this episode of Raising Joy, we talk to Cook Children's psychologist, Whitney Appleby, Ph.D., about all things school. Dr. Appleby shares her expert advice on how to help kids get a good night's sleep, create a healthy routine, manage anxiety, and avoid burnout. As a mom of three, she knows the struggle is real, but she also knows that with a little planning and effort, we can set our kids up for a successful school year.

If you're looking for some helpful advice on how to get your kids back into a school routine, be sure to listen to this episode of Raising Joy!

Raising Joy is part of Cook Children’s Health Care System’s Joy Campaign, a communications initiative aimed at preventing youth suicides. For more information about the Joy Campaign, visit cookchildrens.org/joy. For information about resources, view the crisis resource sheets below (available in English and Spanish). A PDF version is also linked under “Downloads.” 

New episodes of the Raising Joy podcast will be available each Tuesday. It is currently available on all major streaming platforms including Apple, Spotify and Google Podcasts.

Back to school can be a difficult time for kids, especially if they suffer from anxiety.

On this episode of Raising Joy, we’re talking to Laura Anne Burgos, LCSW. She is a licensed clinical social worker and therapist in the Gastroenterology Department at Cook Children’s Medical Center. Laura Anne explains how the mind/body connection can trigger physical pain such as stomachaches and headaches. She also helps us understand when to seek help from teachers, therapists and doctors.

In addition to her clinical work, Laura Anne is also a canine handler for the Sit..Stay..PLAY! program at Cook Children’s. We talk to her about the value Cook Children’s facility dog program provides to patients, families and staff.

Raising Joy is part of Cook Children’s Health Care System’s Joy Campaign, a communications initiative aimed at preventing youth suicides. For more information about the Joy Campaign, visit cookchildrens.org/joy.

New episodes of the Raising Joy podcast will be available each Tuesday. It is currently available on all major streaming platforms including Apple, Spotify and Google Podcasts.

In June 2018, Payton Singh arrived via ambulance to Cook Children’s Emergency Department in a barrage of flashing lights and sirens. She was just 12 years old and decided to end her short life while her parents were away from home.

Payton and her family returned to Cook Children’s this week to reunite with her medical care team who saved her on her darkest day.

“I can’t even explain the emotion and the panic that sets in as a parent,” said Brandy Lumbert, Payton’s mother. “After getting the call, I remember running into the emergency room - they knew exactly who I was. And then she flat-lined right in front of me. As a parent, you want to jump in and tell the doctors and nurses to move faster, but you’re just standing there, helpless.”

Payton and the Lumberts also shared their story on the latest episode of our Raising Joy podcast.

Payton’s brother, Kegan, found her unconscious in her room and took action well beyond his years. Though he was just 8 years old, he had the wherewithal to call 911, put the family’s dogs outside and notify his parents that help was on the way.

 When officers arrived at the Lumbert’s home in Keller, Texas, they believed Payton had been without oxygen for 12 minutes.

 “Doctors told us, ‘She’s alive but she’s not showing any brain activity,” said Nick Lumbert, Payton’s stepfather.

 The medical team was able to stabilize Payton and moved her to the pediatric intensive care unit (PICU).

 “Every day in the ICU, we’d stare at the breathing machine to see how many breaths she was taking on her own,” said Nick. “It was very hard to go through that.”

Soon after being admitted to the hospital, Payton’s neurologist pulled the Lumberts aside to show them the scans of her brain. They revealed four small spots, an encouraging sign that the damage wasn’t as dire as it could have been. Still, it was unknown if she’d ever walk or talk again.  

On day five in the PICU, something unexpected happened.

“I remember walking through the doors and we hear all of the alarms going off and we take off running to her room,” said Brandy. “She had stood up next to the bed and was ripping everything off. She looked right at us and I was flabbergasted!”

And just like that, hope began to shine on the Lumbert family.

Soon after, Payton was transferred to Cook Children’s rehabilitation unit where she embarked on the long road to recovery. Over the next six months, she underwent treatment at three different hospitals across Texas.

Now, four years later, she is returning to Cook Children’s to say ‘thank you’ to the people who saved her life.

 On Thursday, September 1, 2022, Payton and her family were reunited with the doctors, nurses, and care team members who cared for her at Cook Children’s. This emotional reunion was requested by Payton, who is now a 17-year-old high school senior. She has a job, drives a car and is planning to pursue a career as a veterinarian.

The Lumberts recently shared their story on the Raising Joy podcast in hopes of encouraging other families who may find themselves in a similar situation.

 When asked what message she has for kids and teens who are struggling with their mental health, Payton said “Get help.”

 Their episode is now available on all major podcast platforms including Apple, Google and Spotify.

 September is Suicide Prevention Awareness Month.

 Here are some signs to be aware of – though not every suicide attempt will display signs. This is why it’s important to talk to children and teens about suicide, whether you suspect they are suicidal or not. 

1. Preoccupied with death (writing, drawings)
2. Talking about feelings of hopelessness
3. Talking about being a burden to others
4. Telling loved ones goodbye
5. Decline in performance
6. Giving prized possessions away
7. Isolating and withdrawing
8. Acting highly anxious or agitated
9. Acting reckless and taking risks
10. Rages
11. Changes in sleeping and/or eating
12. Use of alcohol/drugs
13. Dramatic changes in personality and/or appearance

If you feel your child needs help, please click here to find a Cook Children's Behavioral Health location near you. You can also address your concerns with your child’s pediatrician, psychologist or therapist.

The 988 Suicide & Crisis Lifeline (formerly known as the National Suicide Prevention Lifeline) offers 24/7 call, text and chat access to trained crisis counselors who can help people experiencing suicidal, substance use, and/or mental health crisis, or any other kind of emotional distress. People can also dial 988 if they are worried about a loved one who may need crisis support.

Raising Joy is part of Cook Children’s Health Care System’s Joy Campaign, a communications initiative aimed at preventing youth suicides. For more information about the Joy Campaign, visit cookchildrens.org/joy.

New episodes of the Raising Joy podcast will be available each Tuesday. It is currently available on all major streaming platforms including Apple, Spotify and Google Podcasts.

On the evening before the first day of school the multiple to do’s on a list have almost been checked off and completed: 

• Hair cuts 
• School supplies 
• School clothes and other necessities 
• Adjustment of bedtimes to make the early morning wake time doable 
• Meet the Teacher 

While I’m almost certain I’ve forgotten to add something to that list, a sense of angst, excitement, worry, uncertainty and joy all in one rush my mind. While it’s common for parents of kids that will begin school for the first time to feel these emotions intensely for the first time, it's not uncommon for parents of kids returning to school to feel these very same feelings once again.  

The world we are raising children in now seems very different from the not too distant past when we were school aged children ourselves. The last few years have proved to be anything but easy when it comes to parenting and raising children. While these complex situations have led to many difficulties and internal struggles; the resilience and innate perseverance of our own children is what reassures us that this will all be okay. 

While there are varied life circumstances and difficulties that parents may be facing, we must remember that a “first day” offers a new beginning and opportunity to help us through these complex situations in our lives. May we use this new beginning as an opportunity to form partnerships with teachers, school administrators and those who are a part of our child’s village to help them thrive. 

The emotions come rushing back after I’ve given myself a pep talk about the many worries that are usually put at ease when my children are on summer break. Will they be safe? A very loaded question because now they will leave my attentive side and learn to navigate their time away without me. Have I taught them enough about being kind? Will other children be kind to them?  

My worries ease some with knowing that although there are many factors beyond my control I have done my best to prepare them for these “first days” and beyond.

To all parents feeling all the feels on the evening before the “first day of school”  know that you are not alone. Continue to inspire kindness and connect with your village to help your children thrive. For they are our future and how we shape that future is dependent on us.

To all teachers and educators thank you for what you do every day for students and their families. Your willingness to remain in this profession has gone underappreciated for quite some time but we are so very thankful for what you do every day.

Lastly to ALL kids returning to school this year may this be a healthy, safe and successful school year for you!

 – Dr. Soria-Olmos

Anxiety and depression drive some teens to recreational marijuana as a way to self-medicate. But that coping strategy can backfire.

Health advocacy groups indicate a link between marijuana use and an increased chance for mental health problems. The National Institute on Drug Abuse and the American Academy of Child Adolescent Psychiatry, for instance, both list a correlation to schizophrenia, depression and anxiety. The Centers for Disease Control and Prevention cites those risks plus temporary psychosis – “not knowing what is real, hallucinations and paranoia” – on its list of mental health implications for dope users.

Lisa Elliott, Ph.D., psychologist/neuropsychologist and manager of the Behavioral Health Clinic at Cook Children’s in Denton, estimated that at least half of her adolescent patients report having tried or using marijuana. For those already struggling with their emotional well-being, is this something to avoid? “Yes. Put that in all capital letters: YES. We have too much evidence to show how harmful it is,” Dr. Elliott said. “There is a significant amount of research that supports the negative impact marijuana/THC use has, especially on the developing brain, so much so that it scares me for our kids’ future.”

Read more about the link between suicidality and young adults here.

Those harmful effects go beyond anxiety and depression to include impairment to intellectual functioning, memory, learning, attention, problem-solving skills and coordination, according to Dr. Elliott. Marijuana use also can cause coughing and wheezing, damage to the immune system and addiction for some people, she said. And when it comes to suicide, some studies show a relationship.    

“There’s been a significant increase in suicides as well as mental health disorders in states that have legalized marijuana,” Dr. Elliott said. “Can we say that marijuana causes suicides? We can’t really say that, but there’s a direct correlation. However, we also know that whenever you’re more depressed and also if you’re coming out of depression, you’re more likely to feel suicidal.”

Just breathe. Open up. You matter. That’s the truth behind the Joy Campaign, an ongoing rollout of articles, videos and other resources aimed to prevent youth suicide. Cook Children’s initiated the Joy Campaign in response to rising numbers of suicide attempts in our region and nationally. While raising awareness, the Joy Campaign delivers help and hope for children and teens who struggle with mental health. This article looks at the ways marijuana use complicates the picture.

How common is recreational marijuana among adolescents? The National Institute on Drug Abuse reports that 11.4% of eighth graders and 35.2% of 12th graders surveyed in 2020 said they had used marijuana in the past year. The Substance Abuse and Mental Health Services Administration calls marijuana the most common illegal drug in the United States, with particular risks for young users and pregnant women.

At Cook Children’s in 2019, there were 830 patients who acknowledged recent use of marijuana when they came to the Emergency Department (ED) for various complaints. That statistic increased to 986 patients in 2020 and 1,105 patients in 2021.  Patients as young as 10 years old were among that group who indicated “yes” to marijuana use on their ED intake paperwork.

In that three-year span at Cook Children’s, most of those who admitted using marijuana were discharged from the ED to home or self-care. Records show some of those patients left the ED against medical advice or were discharged to court or law enforcement. And there were 207 self-reporting marijuana users who were discharged from the Cook Children’s ED to psychiatric hospitals during 2019-2021.

 Dr. Elliott and others say marijuana products have become more potent in recent years. The cannabis plant’s main psychoactive ingredient, a molecule called tetrahydrocannabinol (THC), causes the “high” feeling. Marijuana can be smoked, vaped in an electronic cigarette, eaten in candy or baked edibles, or inhaled in dabs that contain especially high THC concentration.  

Recreational marijuana remains illegal in Texas. In states where it’s legal, consumers must be 21 or older to buy marijuana for non-medical use. Recreational use differs from approved medical use of cannabidiol oil (CBD). Doctors may prescribe CBD in children to help manage epileptic seizures and some other illnesses. But many young people mistakenly confuse THC with the medicinal value of CBD, Dr. Elliott said.  

To set the record straight in therapy sessions, she provides her patients with facts about the documented negative impacts of marijuana, including exacerbated problems with mental health, impaired driving, difficulty in school, diminished IQ scores, aggression, anger and legal consequences. Adolescents who admit to marijuana use tell Dr. Elliott that the drug is easy to come by, even at home or school. She asks them why they started and how it impacts them.

“They’ll say that they will smoke marijuana because it helps them deal with the stress and the trauma and as well as the conflict and unrest in our world. Some of them report that it helps them feel happier, relaxed. Several report that they use it to help them sleep. And several of them report that they used it because they were bored (during the pandemic lockdown) and couldn’t go do things.”

Depending on the reason they’re using the drug, Dr. Elliott works with her patients to treat any contributing factors such as anxiety or depression, peer pressure and low self-esteem. “I try to encourage them and lead them toward healthy coping tools,” she said. “There have been times when I have discharged patients and referred them to therapists who specialize in drugs and addiction because they’re unwilling to stop smoking. Therapy is not productive if they’re high.”  

The Child Mind Institute, a nonprofit organization promoting mental health, sponsored a virtual symposium in October 2021 that featured new research and a panel of experts on the topic “Marijuana and the Teenage Brain.” Among the symposium’s highlights: 

THC exposure in animal models has shown repeated association with increased risk for developing anxiety, depression, substance abuse disorders and psychosis. Exposure to THC changes the cells in the brain and restructures how the gene networks talk to each other.

Adolescence is a critical period for brain development. The adolescent brain is primed to take risks, satisfy immediate wants and be easily swayed by social influences.

Parents should have frequent conversations with their children about the facts that marijuana can be addictive, there’s no such thing as a safe amount, and there’s no way to predict how it will impact a person. Factors such as age, genetics and amount/concentration of the drug play a role. 

 Dr. Elliott cited the statistic that about 1 in 10 people who use marijuana will become addicted. For those who start using before age 18, the addiction risk rises to 1 in 6. Warning signs of Cannabis Use Disorder include cravings, unsuccessful efforts to quit, and increased tolerance to the drug.

“One of the most frightening concerns with marijuana use is the increase in psychotic episodes, especially in those who have a family history of mental illness,” she said. “We also know the recent research really shows that for kids and teens who smoke that higher potency of marijuana, it will increase their chances of developing psychosis nearly five times more than those who have never used.”

Parents should stay alert to behavior changes -- such as secrecy, a sudden decline in grades, less motivation – that might point to a cause for concern in teens. Dr. Elliott recommended that parents speak to their children early and often about the dangers of marijuana. Her encouragement to parents? Keep an ongoing dialogue, stay calm, and set clear expectations and boundaries. And if their teens do start using marijuana, find out why.  

“If they’re feeling stressed, let’s get them into therapy. If they need help sleeping, let’s go talk to our pediatrician and get the sleep addressed,” Dr. Elliott said. She pointed to the good news of hope for families who stay vigilant regarding drug use, social media and mental health in general.

“Parents need to increase their awareness and be hyper alert to this as being an issue. And to create that dialogue and open communication and to be willing to seek help, because if you’re willing to seek help, it teaches your child healthy coping tools.”

About Cook Children's Behavioral Health Program 

Growing up in today's world is hard, and many children or teens may go through life experiences that cause them to feel anxious, depressed or even suicidal. It can be hard for parents and caregivers to know when to ask for help. The Behavioral Health Center at Cook Children’s brings all services together in an expanded space to provide a dedicated team of physicians and professionals with the facilities, resources, tools and programs that deliver the high-quality treatment these vulnerable children need and deserve.

Cook Children's Behavioral Health (cookchildrens.org)

A young girl who was recently seen by Cook Children’s C.A.R.E. (Child Advocacy Resource and Evaluation) Team sat sobbing on the exam room floor, distraught after receiving a series of immunization shots.

Many of the children seen by the C.A.R.E. Team have experienced extreme trauma, says C.A.R.E. Team Medical Director Jamye Coffman, M.D., so even getting shots may cause intense anxiety. The team knew who to call for help.

Enter Kitty, a 7-year-old, silky-haired Golden Retriever and one of Cook Children’s six facility dogs, who quickly assessed the situation and knew exactly what to do. She went straight to the young girl who sat next to her sister and laid her head on the child’s lap.

“The little girl starts petting her,” Dr. Coffman says, “and her sister, who had been here before, says, ‘Just pet Kitty. It makes it not hurt as much—it’s Kitty magic.’ So, the little girl continues to pet Kitty, and the tears slow down, and she finally stops crying, and then she looks at her sister and says, ‘It did help. It is Kitty magic.’”

“Seeing is believing, right?” says Dr. Coffman, who also handles her canine helper. “Seeing how she helps bring kids down when they’re super anxious…and not only the kids, but the parents, too. They start petting the dog and the whole level in the room just comes down. It’s amazing to watch. She knows who to go to instinctively—I don’t know if it’s their smell, I don’t know what it is—but she tends to go to the most stressed person in the room. Sometimes it’s the parent, sometimes it’s the kid.”

But Kitty may not be the only one with magical powers.

Whether it’s highly trained therapy dogs, laid-back emotional support cats or pet pot-bellied pigs, animals appear to shoulder some of the emotional load as they interact with humans—and may even promote healthier mental health for their people, some researchers and animal handlers say.

So, what’s the secret behind “Kitty magic”? And could the human-animal bond make a difference for children and teens facing mental health issues, such as anxiety, depression, or suicidal inclinations—all on the rise since the pandemic began? The JOY Campaign asked experts who work with children and/or animals on a daily basis to discuss.

Kitty’s magic, as well as other animals’ abilities, may begin on the most basic level for humans, experts agree. The animals don’t judge. And that nonjudgmental approach may help those facing mental health issues.

“You can talk to your dog or your pet, and they love you no matter what,” Dr. Coffman says of the unique human-animal relationship.

“I think the biggest thing is the animal accepts you, however you are,” she adds. “They don’t see if you have disabilities. They don’t see if you have scars. They don’t see any of that. They just love you and accept you for you. And that’s it.”

For children and teens who are developmentally peer-driven during this part of their lives, that can be significant, says Dr. Janet Hoy-Gerlach, Ph.D., a professor of social work at The University of Toledo in Ohio. In June, she released the first peer-reviewed research study on the beneficial effects of emotional support animals (ESAs) for those with chronic mental illness.

“It’s a unique kind of support. It’s not an evaluative relationship in the way that humans have, especially with some of the challenges kids face with their peers during that excruciating adolescence, where it’s like hyper-judgment time,” says Dr. Hoy-Gerlach, who also co-authored a book titled The Human-Animal Interactions: A Social Work Guide. “The animal is safe. Animals aren’t making a value judgment on what they’re wearing or what they’re saying or what their hair looks like.”

With extensive work in counseling, crisis work and public mental health, she became interested in the human-animal bond and how it might help people with mental health issues after years of working as a crisis clinician in community mental health, where she conducted risk assessments of clients every day. Part of assessing people in crisis involved questioning them about what stopped them from following through on suicide to help identify their lifeline, she says, adding it’s important to figuring out “what’s keeping them alive.”

Common responses she heard were what she’d been taught to expect—usually protective factors, such as “I’m afraid about what will happen to my kids,” or “I don’t want to hurt my family,” or “I wouldn’t do that to my friends,” or “It’s against my faith, my spiritual beliefs, my religion.’ But another response she frequently heard during the assessments was one she hadn’t been exposed to in classes or training, which was “I can’t leave my pet.”

“I guess I had two reactions to that. One was on a personal level as somebody who has lived with animals my whole life and loved them tremendously. Like I totally got that response. It just made sense to me on a human-to-human level,” Dr. Hoy-Gerlach says. “As a clinician, it really hit me that this was something really overlooked. People were literally saying the reason they were alive was because of their animals.”

“And this was something that had never been talked about,” she says. “I was like, how are we missing this strength? This protective factor that many people have in their lives, and we don’t ask them about it. We don’t talk about it. And we certainly don’t support them, like help them keep the animal in their life if they’re facing a barrier or struggle.”

So began Dr. Hoy-Gerlach’s journey to merge a personal passion for animals and professional passion for mental health. Much of her work since has been focused on educating others, such as social workers, mental health workers and health care workers about the benefits of relationships with animals for human wellbeing, she says, adding she also supports a more intentional approach to using those benefits in how we help people stay healthy.

Dr. Hoy-Gerlach’s recently published study focused on 11 adults with stable, chronic mental illness—ranging from anxiety to depression to schizoaffective disorder—who were matched with a shelter cat or dog through the Hope and Recovery Pet Program, a community partnership between The University of Toledo, Toledo Humane Society and ProMedica. (Six adult cats and five dogs were involved in the study.)

Using saliva tests, researchers studied the participants’ biomarkers, such as cortisol, alpha amylase, both stress indicators, and oxytocin, known as the hormone that bonds mothers to babies. During home visits, the participants took saliva tests after focused interaction with their animal for 10 minutes at one month, three months, nine months and a year.

“What we saw, while not statistically significant in this study, was a visual pattern in oxytocin going up and cortisol going down,” she says. There was no significant rise or fall of alpha amylase.

Initially, several participants mentioned an adjustment phase where they experienced a bit of stress from their routines changing with a new animal. But after that, the participants “overwhelmingly talked about an improvement in their mental health, generally and with their symptoms,” Dr. Hoy-Gerlach says.

“They talked about their animal helping or distracting them from symptoms and being a source of comfort for them,” she says. “Those probably are the two things we heard most.”

While her study focused on adults, most of the results are still relevant to youth, she says, because we’re all humans and similarly hardwired for connection.

For example, in the case of ESAs or companion animals for children and teens, it’s looking at the benefits the animals can offer in everyday interaction based on whatever impairments need to be addressed, Dr. Hoy-Gerlach says. Unlike service or therapy animals, ESAs and pets aren’t trained to do special things.

“So, if a child has a lot of anxiety, physical contact with an animal who enjoys that could be a source of regulation that could help downregulate their stress responses,” she says. “It’s not that the animal is doing anything except typical friendly dog or cat behavior, like ‘I want to sit on you.’ But for somebody who has trauma, for instance, that can be grounding. I’ve talked with people who like the cat’s purr, the feel of the fur, the warmth of the body and pressure of their weight on them.”

“It’s multisensory, plus there’s comfort in the relationship. So, it’s thinking about the ways the animal can help, based on the evidence we have on how living with companion animals can benefits humans, then looking at the child’s specific symptoms and issues,” Dr. Hoy-Gerlach says.

Other groups are also following the human-animal bond and its advantages, especially during the pandemic, which has left many Americans of all ages feeling isolated, lonely and stressed.

As part of its “COVID-19 Pulse Study,” the American Pet Products Association (APPA) reported that 11.38 million households in the United States welcomed a new pet during the pandemic, according to an October 2020 article in Today’s Vetinary Business. And three out of four pet owners said spending time with a dog, cat or another animal species “helps reduce their stress and increase their sense of well-being during COVID-19,” the article stated.

In May 2020, the Human Animal Bond Research Institute (HABRI) along with Mental Health America (MHA) released a report stating pets not only “help alleviate stress, but they also improve owners’ moods and help fight depression.” In their survey, 74% of pet owners reported mental health improvements from having pets, and 75% said a friend’s or family member’s mental health improved. The report also mentioned 96% of pet owners agreed their pet has a positive impact on their life, based on a survey conducted by Nationwide and HABRI.

The scientific research showed the human-animal bond supports better mental health and “indicates pets can make a difference for those facing mental health concerns, including anxiety, depression, loneliness and stress,” according to HABRI’s report.

About three months ago, APPA launched a “Pet Feels” Campaign in conjunction with Mental Health Awareness Month that highlighted the advantages of pet ownership as part of its Pets Add Life (PAL) program. The campaign, posted with links on the APPA website, uses a series of videos that demonstrate the way pets help people cope with everyday stressors while also giving love and support during challenging times.

Despite promoting relationships with animals, Dr. Hoy-Gerlach cautions that they’re are not always for everyone. They shouldn’t be brought into a home if there’s a history of animal violence, extreme fear of animals, severe allergies or if a family member is unable to safely interact with an animal or vise-versa.

Laura Sonefeld, “Sit…Stay…PLAY” facility dog program coordinator and child life specialist at Cook Children’s Medical Center, often is approached by families who are considering getting a pet after watching their children interact with facility dogs at the hospital. The team of six dogs—Kitty, Steve, Neely, Chanel, Zuni and Brienne—are trained to work alongside a healthcare worker to provide comfort and socialization with patients and families in a hospital setting.

Sonefeld, who handles Steve, a 3-year-old Golden Doodle on the canine team, says she frequently is asked, “How do we get a dog like your dog?” She makes sure they understand the difference between service, therapy and support animals.

The first question she asks is “Are you wanting a dog to be able to bring to the hospital with you or one for emotional support and comfort at home?” That helps her determine the type of animal they’re looking for.

Most people want a pet, not a service or therapy animal.

“They say, ‘We’ve seen the benefits on our child when they’re here and interact with one of the facility dogs, and we want that at home, too,’” she says. “And I say absolutely. You get a pet. I feel like all animals have that potential to provide therapeutic support for families.”

Whether dogs, cats or other types, animals might help the entire family, not just an individual child.

“I highly recommend it, just for that everyday stress that all of us feel because we’re human,” Sonefeld says. “It doesn’t have to be someone that’s had a huge hospital experience. It could be someone simply dealing with everyday anxiety of school, of work, of making friends. I feel like the dogs help build that confidence and remind everybody that they are loved and special—that they deserve to feel that from people they interact with, too.”

Sometimes the entire family isn’t on board with getting a pet, Sonefeld says. It might be the mom or dad who is hesitant to take on more responsibility by having an animal.

But it seems the mysterious “Kitty magic” might work on that, too.

“Whoever the one is that’s not totally convinced usually ends up being the one who loves the dog the most,” Sonefeld says with a laugh. “Once they have had the experience, they’re like, ‘Oh, OK, I get it now.’”

The rising number of COVID-19 cases in North Texas is due to the delta variant, which is more contagious than other strains of COVID-19, and a significant number of unvaccinated people. With Texas doing away with virtual learning this school year and the COVID-19 vaccine not yet available for those under 12, many parents and children are understandably feeling anxious.

Amanda Jordan, Psy.D., a licensed psychologist at Cook Children’s Alliance, can relate. She has a child starting kindergarten in the fall and is experiencing similar feelings.

“I want parents to understand you can’t take care of others if you don’t take care of yourself first,” Dr. Jordan said. “You have to check in with yourself first to see how you’re feeling because you don’t want your children to pick up on your negative energy.”

As for parents, Dr. Jordan says it is important to engage with other parents, make sure to create and maintain their own schedule, talk with their partner/spouse and seek professional help when necessary.

Dr. Jordan says once parents have worked through their anxiety, it is good to start preparing children for their ‘new normal’ as early as possible. She says it’s important to pose open-ended questions such as, “I wonder what your first day will be like?” or “I wonder who your teacher will be this year?” These types of questions allow your child to open up about how they’re feeling and can lead to other questions or concerns they may have.

Dr. Jordan also stresses the importance of establishing a routine as school beings again because many children have been off of their schedule for more than a year. This routine includes bedtimes, meal times, changing eating habits, etc.

“There has been so much flexibility with virtual learning,” Dr. Jordan said. “Children have been going to bed and waking up later than normal, and could do their work at their own pace.”

She says starting a ‘school year’ routine before school officially starts can help ease some of the anxiety on the parents and children.

Another technique Dr. Jordan recommends to parents is called ‘Name it to tame it.’

“It is important to help children put a name on their feelings,” she said. “As parents, we want to fix things and say things like ‘don’t be scared’ or ‘you’re going to be fine,’ but you must validate their feelings.”

Dr. Jordan says to respond to children by validating their feelings and letting them know you understand how they feel and let them know they always have a safe space to express their feelings.

Along with the anxiety of returning to school, medical professionals at Cook Children’s are also getting questions about children wearing masks in the classrooms. Alice Phillips, M.D., a Cook Children’s pediatrician at Cook Children’s Cityview says she stands behind the recent recommendations from the American Association of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC), that all children K-12 should wear masks in classrooms this school year.

“I believe children need to be in school for their social skills, mental health, and other key personal connections,” Dr. Phillips said. “I recognize it’s a hot topic, but for students to stay in school without shutdowns or quarantines, we must do it safely.”

Dr. Phillips says the new delta variant is spreading rapidly in our unvaccinated population. At Cook Children’s we have seen a rise in the number of children testing positive for COVID as well as an increase in the number of children being hospitalized. For this reason, she believes it is even more important to make sure all children have masks on in the classroom, no matter their vaccination status.

“Parents have to begin modeling mask-wearing behavior at home, and support their children if they feel pressured to do otherwise by their peers,” Dr. Phillips said.

To prepare children to wear masks in the classroom, she says it’s important to explain to children the reality of doing ‘hard things,’  for our friends and communities. Equally important is providing encouragement to children when they're doing the right thing.

“I understand that it’s hard to be brave sometimes,” Dr. Phillips said. “The best we can do is encourage, support, and validate children’s feelings and let them know the ‘why’ behind masking and the importance of keeping themselves and others safe.”

Dr. Phillips says her advice to all adults is to get vaccinated and be an example. She advises all adults to wear a mask when they are in the grocery store and other public settings as recommended by the current CDC guidelines, 

“If parents are vaccinated and their children are not, I still advise the entire family to mask up to support the child and protect them,” she said.

If you have any questions about preparing for your children to head back to the classroom or need guidance for masking, contact your child’s pediatrician.

Read more about preparing for the upcoming school year here:

Cook Children's 10-Point Guide for Safely Reopening Schools

Should My Child Wear a Mask to School this Fall? 

Imagine living through a tornado. The wind howling over the sound of sirens. Lightning illuminates your home. Then, you hear it - the roar. You watch the ceiling start to give way. Fear turns to panic. Running on adrenaline, your body prepares for the worst.

This is what trauma can feel like. While a severe weather event can be traumatic, there are many reasons a person may experience trauma. It is defined as anything that overwhelms a person’s ability to cope. But trauma isn’t always easy to spot, even though its effects can last a lifetime.

“There are three different kinds of trauma. The first is acute, or a one-time event like a dog bite or car wreck,” said Denise Coover, LCSW, a trauma informed care specialist at Cook Children’s Medical Center. “Then there’s chronic trauma, where you may have several things happening at once, like domestic violence at home and bullying at school. Complex trauma happens when traumatic experiences occur within the context of a close relationship, such as sexual abuse committed by a family member, or someone who should keep you safe.”

During a traumatic event, the body releases two major stress hormones: norepinephrine and cortisol. Similar to adrenaline, norepinephrine boosts the heart rate and controls the fight-or-flight response. Cortisol is your body’s main stress hormone and slows non-essential functions, like digestion, when a threat is perceived.

“If your body experiences this stress response on a regular basis, it can cause long-term health problems,” said Kia Carter, M.D., co-medical director of Psychiatry at Cook Children’s. “A lot of people don’t realize that chronic exposure to stress hormones can cause high blood pressure, obesity, diabetes, issues with sleep and fatigue, as well as feelings of depression and hopelessness.” 

These hormones can also increase your memory of the event, leading to flashbacks, nightmares and PTSD. But when it comes to memory overall, people who’ve experienced significant trauma may find it hard to remember in general. This is due to the part of the brain that stores memory, the hippocampus, being overexerted.

The amygdala is another part of the brain affected by the stress response. This region controls emotions and can cause someone to react differently to something as simple as a door slamming. You can think of the amygdala as the brain’s ‘watchdog.’

“If someone has experienced something like domestic violence or a shooting, they may be sensitive to loud noises,” said Dr. Carter. “That’s because their amygdala is working overtime to keep them safe. We call this hypervigilance.”

For children, hypervigilance can make it hard for them to concentrate at school and follow directions. Instead of focusing on the classroom, their brain may be trying to anticipate what bad thing is going to happen next.

The prefrontal cortex is connected to the amygdala and is responsible for rational thinking. Chronic stress in childhood can damage the prefrontal cortex, which is still developing, and lead to a survival response being triggered even when there is no danger.

Understanding Trauma

According to the National Council for Behavioral Health, 70% of adults in the U.S. have experienced some type of traumatic event at least once in their lives. That's 223.4 million people. 

“Sometimes, when people experience trauma, they will compare themselves to others. For example, they may say, ‘I’m not a Syrian refugee so I haven’t experienced real trauma,’” said Coover. “But it doesn’t matter, if something overwhelmed your ability to cope, that makes it traumatic for you.”

At Cook Children’s, 94% of hospitalized psychiatry patients in 2020 reported experiencing at least one form of trauma. Untreated trauma in children can cause a number of problems including behavioral issues, mood swings, depression, anxiety, self-injury, hopelessness and thoughts of suicide. Kids may feel isolated because of how the traumatic event has affected them. Coover says it’s important for parents and teachers to be aware of the signs of trauma because they’re not always obvious.

“A child who’s falling asleep at school may seem like a problem student, but when you start digging into their history you may realize that they don’t feel safe at home and they’re in survival mode. But when they’re in the classroom, they feel safe so all of the sudden they can sleep,” she explained.

Another sign of trauma in both children and adults is physical pain without a known reason, called somatic symptoms. This is often seen in the form of migraines, stomach aches, and rouge pain the body that is not associated with injury. This phenomenon has been documented by experts such as psychiatrist Bessel van der Kolk in his book ‘The Body Keeps the Score.’ Kolk claims that stress and trauma becomes stored in the body if not addressed, and can eventually lead to illnesses such as autoimmune disorders and cancer.

“Whether you remember the trauma or not, your body always does,” said Coover. “I’ve had parents tell me this or that happened but their child was too young for it to affect them and I have to tell them, “No, that’s not the case.’”

Some examples of childhood trauma include:

• Physical, sexual and emotional abuse
• Neglect
• Domestic violence
• Homelessness
• Parents with untreated mental illness and/or substance abuse
• Divorce
• Bullying
• Losing a parent
• Incarceration of a parent

“Domestic violence is one that seems to surprise people, because they think if the child isn’t being hit it doesn’t affect them,” Coover said. “But it absolutely does, even if they just hear it. Sometimes what they’re imagining is even worse, or maybe it’s spot on. And kids tend to blame themselves for their parents fighting. They take on that guilt even though it’s not theirs to carry.”

Experts like Coover and Dr. Carter also warn that isolation triggered by the COVID-19 pandemic has led to even more traumatic experiences for many kids, especially those growing up in unhealthy environments. With so many students being forced into virtual school last year, their ability to escape and connect with people outside of their home was taken away.

“We are starting to see more kids talk about the effect the pandemic has had on them,” said Dr. Carter. “I had a patient tell me recently they’d been home alone for many months and hadn’t been able to see their friends or other people. They said they were tired of living that way, this patient became hopeless about life changing, which resulted in this patient attempting suicide.” 

The Power of Sharing

Dawn Hood-Patterson, Ph.D., thinks about trauma in the context of her own life. At 17, she was living in Colombia with her family when her trauma story began.

“I lived in Colombia during the time when Pablo Escobar had a grip on many regions in the country—there were car bombs, protests and the sound of gunshots. During that period of unrest, my dad was murdered outside our home,” she said. “So when I think about my trauma story, I think about what fostered my capacity for dealing with that.”

Dr. Hood-Patterson attributes her resilience in part to her parents who gave her a loving and supportive home. She also credits the school counselors who recognized that her frequent stomach aches were not just random pain, but the result of the stress that comes with living in a country experiencing civil unrest.

“It was all the adults who recognized the trauma was bearing impact on my life, and who said, ‘This trauma is real and we see Dawn in the midst of it,’” she said. “These same people gave me tools that helped me make meaning out of the chaos. And they said, ‘Here are some friends around you that have experienced similar things so you don’t feel so alone.’”

As program manager of Community Health and Adverse Childhood Experiences at the Center for Children’s Health, led by Cook Children’s, Dr. Hood-Patterson is using her experience to help people in North Texas. She’s part of the team behind The ACEs Task Force.

Adverse Childhood Experiences (ACEs) is a term based on a study conducted between 1995 and 1997 by Kaiser Permanente and the Centers for Disease Control and Prevention (CDC). The study, which involves 10 questions about what a person experienced before the age of 18, shows ACEs are associated with high-risk behaviors, chronic disease and reduced quality of life in adulthood. In 2019, The ACEs Task Force unveiled their “Blueprint for Safe, Healthy and School-Ready Children”. The plan includes 25 ways pregnant women, families, children and caregivers need to be supported in order to counteract adversity. Access to health care, healthy food, quality, affordable and safe housing are among the top concerns. Transportation, mental health services, substance use disorder treatment and high quality, affordable child care are also priorities for the task force.

Currently, Dr. Hood-Patterson and team are working on a project that would create support groups for parents and caregivers living with adversity. The so-called ‘Caregivers Alliance’ is part of the Build-a-Bridge program, led by Cook Children’s, and is in the early planning phases. It would focus on giving people a chance to share their stories of trauma and connect.

“This was born out of conversations that we had with community partners where we learned that a lot of people who are struggling with adversity often feel like they have a laundry list of things to do,” she said. “For families who receive things like housing assistance or SNAP benefits, every conversation they have is about updating paperwork and not missing deadlines. We envision this alliance to be a space where people can be seen and heard, and support one another.”

The Caregivers Alliance would also include access to education from the Center for Children’s Health for topics like car seat safety, water safety, safe sleep practices and more.

“I’m a believer that something powerful happens when we share out stories with each other,” said Dr. Hood-Patterson. “When we have the opportunity to share our stories, whether they’re of triumph or trauma, it hones our ability to make meaning out of the seemingly meaningless chaos of suffering.”

Bullying is an age-old issue. Generations old and new are familiar with the power plays of those that intentionally try to hurt another. It happens on the playground, in the classroom, by the locker, at the lunch table, on the bus, through social media networks and everywhere in between, and it can take a toll on a child or teen.

It’s important to understand the true definition of bullying. It is a conscious, intentional, hostile action towards another that is meant to hurt or create fear or terror, according to Lisa Elliott, Ph.D., psychologist and manager of the Behavioral Health Clinic at Cook Children’s in Denton. An act of bullying includes three elements—an imbalance of power, the intent to harm emotionally or physically and pleasure in witnessing the pain.

If you let them, bullies can plant seeds of rejection into your soul, some that can deceive you for a lifetime and create deep-rooted strongholds of confusion, fear, anger, bitterness, insecurity and thoughts of inadequacy, according to Cook Children’s mental health experts.

Research shows that adults who were bullied as a child have an increased risk of depression and anxiety; may suffer long-term negative consequences with jobs, income and relationships; and may experience poorer health. What’s worse, both those who bully and those who are bullied are more likely to exhibit suicide-related behavior.

“Being bullied can be a trauma for some kids because it overwhelms their ability to cope,” said Denise Coover, LCSW, a trauma informed care specialist at Cook Children’s Medical Center.

You Matter

As bullies target the insecurities of others, it can produce shame and guilt in the one being bullied. In the victim’s eyes, their perceived shortcoming or failure is validated by the bully. That’s when a wall goes up in many kids, and they retreat from those who can help them sift through the truth versus the lies.

“What someone says about you does not make it true,” Coover said. “And every negative thought that you have about yourself isn’t always true either. But when a bully hits on a particular insecurity, it’s hard for kids to put that into words so that someone can help them process it.”

On the flip side, those emotions are exactly what fuel bullies and their assaults. The pain bullies inflict on others is a direct result of emotions brewing within themselves, according to Coover. It’s a coping strategy, one that gives them a sense of control of their own perceived failures by elevating themselves over others.

“Kids will use behavior to say there is something wrong here,” Coover said. “And it’s up to a clinician, in-tune parents or a school system to figure out what the problem is because the behavior is telling us there’s something going on.”

It’s not that bullies bully because they are nothing but bullies. They bully because they don’t know who they are. Bullying gives them a sense of identity where they otherwise have no point of reference for purpose, belonging or intrinsic worth of themselves or others. Having a solid grasp on those things is like a coat of armor for kids against both becoming a bully and being negatively impacted by one. Establishing those values starts at home.

“We, as parents, can't be so unaware that we think that our child may not be the bully,” Dr. Elliott said. “It is absolutely critical that we not only talk about this with our children in order to protect them, but we also have to teach them how to be a good citizen.”

Dr. Elliott cautions that parents should not dismiss complaints about their child being a bully or bury their head in shame either. Address the issue. It’s a good opportunity to find out what may be behind the bully behavior, which you can then help your child overcome. Seize the moment to teach them about how to treat others with kindness and compassion. It could be an invaluable growth opportunity for your child and your relationship.

“What kids hear from you is what they will know about themselves,” Coover said about a parent’s role in building strong and resilient children.

Helping kids understand their intrinsic value as a created being can be like a shield from the flaming arrows of a bully. One way parents can plant and water the seeds of purpose and worth is by helping children identify what matters most about them and what is and isn’t true about themselves. They can also help frame their kid’s perspective by encouraging them in the journey of their endeavors, not just reveling in the outcome.

“When a kid brings home straight A’s, it’s a great thing to celebrate,” Coover explained. “But what’s more important for a parent to see and acknowledge is how hard the child worked, their dedication, how much they learned and the steps they took to achieve that. Kids need to hear that from parents, no matter the grade that resulted from their best effort and hard work.”

This helps reinforce competence, confidence and connection — as described in "Building Resilience in Children and Teens" by Kenneth R. Ginsburg, MD, MS Ed, FAAP. Resilience is the ability to bounce back from stress, trauma or hardship. It isn’t something we’re born with, but something learned. Oftentimes, through trial by fire, but also by watching others we love and respect bounce back from a difficult circumstance. Teaching kids to be resilient gives them a hopeful perspective.

The Rise of Cyberbullying

Bullies may use physical force, relentless verbal lashings or social exclusion to intimidate and control. But the rise of the internet and social media has added a new virtual venue where bullies seek to crush the spirit of their target. According to a 2018 Pew Research Study, 59% of teens have experienced some type of cyberbullying.

The pandemic made cyberbullying even easier as kids were forced out of classrooms and onto virtual platforms for learning and socializing. More time online translated to a 70% increase in hateful speech between kids and teens during online chats, according to a study conducted by L1GHT.

“This is a whole new world for parents and kids to navigate,” Dr. Elliott said. “Parents need to have controls. They need to have access to see what their kids are doing. It’s really important for parents to monitor what their kids are viewing, saying and sharing online.”

Cyberbullying can be extreme and pervasive, Dr. Elliott said. The internet is always open for business and provides harassers a direct line into the personal device of a victim. It’s fast, easy, far reaching, can be done anonymously and lives in infamy forever.

Cook Children’s experts shared these tips for protecting your child online:

• Continually educate yourself on the ins and outs of social media outlets. Do you know about TikTok, Instagram, YouTube and Snapchat, just to name a few? If not, you should. This is where your kids are hanging out. Educate yourself on how they work and how your kids are using them.

• Openly discuss bullying and cyberbullying with your kids on a consistent basis. These are conversations that need to be had more than once as your child matures. Ask your child if they have been bullied, how they handled the incident and how it made them feel. Talk to them about what they do when they see others being bullied. Are they being a good bystander? Teach them about empathy, and help them think through how to help others.

• To encourage kids to open up, have them write it, draw it or say it. If talking doesn’t come easy, kids who enjoy writing can journal their thoughts. Those with an artistic flair may prefer to illustrate them. Kids may be more receptive to talking if you strike up a conversation when engaging in an activity together, riding in the car or just having a casual discussion. Learn what communication tool works best for your child and embrace it.

When And How To Intervene

You may sense your child is being bullied if you see a change in their behavior. If they stop doing things they once loved, start spending lots of time alone in their room, are irritable and weepy or their grades plummet, you should take note that something may be wrong.

Sometimes parents need to intervene to stop a bully. Other times they simply need to problem-solve with—not for—their child. Coaching kids on how to respond appropriately on their own helps build confidence and resilience, and helps their brains develop problem-solving skills that benefit them for life.

“If we always do things for our kids, their brains don’t grow,” Coover said. So they become adults who can’t manage any kind of problem in life, because they’ve never had to do it. Someone has always stepped in to take care of it for them so their brain didn’t create those neural pathways to consider solutions.”

To know your role, Dr. Elliott says to start by determining what kind of bullying your child is experiencing. Are they being physically assaulted, verbally harassed or cyberbullied? How often is your child targeted?

If the bully is getting physical or threatening bodily harm, always report it to the proper authorities, be it school administration or law enforcement. In Texas, schools are required to adopt anti-bullying policies and establish procedures for reporting incidents. They must also notify parents and guardians of a reported incident and outline disciplinary actions for those who bully. To better understand the state’s bullying laws, check out tea.texas.gov and stopbullying.gov.

If the harassment is verbal in nature, it may benefit your child to take a different approach, one that equips them to respond to the bully themselves and helps them build life-long conflict management skills.

Don’t Feed The Rat

Knowing how to handle a bully can be the difference between a child suffering silently through relentless attacks versus a single incident that is stymied before it escalates to something more serious. It’s all about the balance of power, Dr. Elliott says, and ignoring a bully isn’t always the answer.

“Bullies thrive on a perception of power and control over another person’s emotions,” Dr. Elliott said. “Even when you ignore a bully, they still assume you are hurting inside. That perceived weakness keeps them coming back time and time again to satisfy their desire for power and control.”

Dr. Elliott has personally developed and tested a bullying response tool that she employs with her patients. Her method teaches kids to respond to bullies in a way that both quiets the harasser and builds resilience in the one being harassed. It essentially conveys a message to the bully that their opinion isn’t valued and, therefore, not offensive. She calls it The Rat Method. Click on the video below to hear Dr. Elliott explain her method in her own words.

There Is Hope

Your child can overcome either being a bully or being the victim of a bully. Together, you can create defenses against bullies, develop empathy for others and foster resilience to stop bullies and their bad intentions in their tracks. Your child’s short and long-term mental and emotional health will be better for it.

Over the past few weeks, we’ve published a series of articles about the mental health crisis shaking the foundation of our youngest generation. It’s been a difficult and heart-wrenching conversation as, together, we’ve opened our eyes to this issue. This week, we want to bring you some good news.

An innovative yet practical collaboration that embeds family therapists into Cook Children’s Neighborhood Clinics (NHCs) is expanding access to mental health services for children in some of Tarrant County’s most underserved communities. It’s a silver lining, if you will, amidst a rapidly growing crisis.

The Crisis

The critical issue of mental health struggles among children isn’t a new one. It’s been lurking under the surface for years. One Centers for Disease Control statistic states that the percentage of children ages 6 to 17 who have ever been diagnosed with either anxiety or depression increased from 5.4% in 2003 to 8% in 2007 and to 8.4% in 2011-2012. To put skin on that, approximately 4.4 million children in the U.S. ages 3 to 17 have diagnosed anxiety, and about 1.9 million have diagnosed depression. Couple that with an inadequate supply of mental health professionals across that country and you have an undeniable gap in mental health care for hurting kids. According to the American Academy of Child and Adolescent Psychiatry, there are only 8,300 practicing child and adolescent psychiatrists in the United States—a country with 74.2 million children.

Pile a pandemic on top of all of that and you have the makings of a nationwide mental health disaster. In many ways, COVID-19 opened Pandora's box. For millions of children, each measure taken to address the virus either triggered a new mental health struggle or exacerbated an existing one. The results are devastating, evidenced by the record number of children attempting or committing suicide. Some as young as 5 years old.

“I would say that, compared to last year, I have certainly experienced and seen a significant rise in the number of patients reporting anxiety, depression and even suicidal contemplation,” said Vida Amin, M.D., Neighborhood Clinics and Population Health Advisor.

The Silver Lining

Cook Children’s Health Care System took note of the adolescent mental health situation and the gap in services years before the start of the pandemic. Concern turned to action when the system began including mental health outreach as one of its yearly strategic initiatives. Over the course of several years, these initiatives have evolved from requiring universal depression screenings for all adolescents to improving access to mental health care for patients of Cook Children’s Neighborhood Clinics in fiscal year 2021. This latest initiative steered the concept of integrating family therapists into the primary care setting.

The program launched in December 2020—perfect timing given the pandemic’s toll. Three licensed family therapists rotate through Cook Children’s seven Neighborhood Clinics each week providing services that range from mental health evaluations to outpatient counseling to education for families and clinical professionals.

In its first month, NHC physicians and nurse practitioners referred a little more than 100 patients to the therapists for evaluation. By April 2021, that number had grown to more than 380 in a single month. So far, more than 111 patients have received outpatient counseling through the program.

Breaking Barriers

This care model helps alleviate three critical barriers for families seeking mental health services—access, cost and a reluctance to trust someone new with something so sensitive.

Right now in North Texas, it can take weeks, even months in some cases, to get an appointment with a therapist. There simply aren’t enough to go around. The same is true for many parts of the country.

“The demand for behavioral health care far outweighs the number of treatment providers in the community,” said Christina Reed, LMSW, director of operations at Cook Children’s Neighborhood Clinics. “It’s just too much for nonprofits and other providers to keep up with. So for us to be able to offer this to our patients gives them that access that has been lacking in the community.”

Beyond adding much needed therapists to the landscape, bringing these services in house improves access by speeding up the referral and evaluation process. It also signals that mental health is just as important as physical health. As therapists share knowledge and integrate their care plans, physicians and nurse practitioners are increasingly looking through the lens of mental health when engaging with their patients.

“It helps to demonstrate that behavioral health care is a part of health care,” said Kelly Rand, LCSW, manager of patient and family support services at Cook Children’s Neighborhood Clinics. “You don't have to go to another office somewhere that you've never been before and that’s not familiar to get that support. It crosses that barrier to where it's not two separate services. It's all health care, and it's all here together.”

Access and cost go hand in hand. If one can be overcome, the other is often the next big hurdle. Many private practice therapists do not accept insurance, especially Medicaid, leaving families no choice but to pay out of pocket.

“We serve primarily Medicaid families,” Reed said. “If you are a child or a family on Medicaid trying to find mental health services, that is challenging and that's no secret. It’s always been challenging. Our families are left without many options because they can't pay cash for a private practice therapist.”

Counseling services at the NHCs are billed to the patient’s insurance provider, be it a private insurer or Medicaid. If a patient is not covered by insurance or Medicaid, therapists connect them to a counseling resource in the community that offers free or sliding scale fee services.  

Opening up about internal struggles can be hard. Knowing who to trust with such personal and sensitive information factors into a parent or child’s hesitancy to reach out. Embedding therapists within the primary care clinics where patients have established relationships and familiarity with providers helps build a bridge between reluctance and trust.

“There is something that our families value when it is a Cook Children’s name behind that referral or service,” Reed said. “When it's their pediatrician saying, ‘it's this person I work with right here that can help you,’ there's a lot of comfort and trust in that in a world that can be really scary. There's still a lot of stigma. There's still a lot of hurdles to jump through, even just internally, when seeking out that service.”

Comprehensive Care

For children who need emergency intervention or more intensive care than can be provided through outpatient therapy, NHC therapists work with Cook Children’s emergency department, behavioral health intake department, partial hospitalization program and inpatient psychiatry program to get patients the level of care they need.

“The NHCs are now performing 200-plus psychosocial assessments and plans of care each month,” said Robert Goodwill, senior vice president and chief operating officer of Cook Children’s Physician Network. “This is an integral part of identifying specific needs related to the level or type of care a child may need. These added resources have resulted in increased counseling sessions at the NHCs as well as the ability to connect patients and families to other services in our system and our community.”

Of the nearly 1,200 referrals NHC therapists have received since the start of the program, depression and anxiety rank as the top two issues.

“Depression and anxiety are by far the most common,” Rand said. “A third one would be ADHD or issues around attention concentration. From there, I would say, issues around some kind of trauma transition or loss. So a death loss, the loss or separation of parents, a traumatic family event, or some kind of big transition in the household. Of course, those things contribute to and cause depression, anxiety and attention difficulties in children.”

As the rising referral numbers demonstrate, this collaboration is bringing critical services to the doorsteps of underserved communities. It’s making the mental health care space easier to navigate and offering help and hope to hurting children.

In today’s society, social media is a major part of life for all age groups. While some use the platforms to keep up with family and friends, others use the sites for networking and job hunting. For those 18 and younger, social media has changed the way young people communicate with each other, often leading to inappropriate use, and bullying among other things.

As part of Cook Children’s Joy Campaign, which aims to reduce the number of children and teens attempting suicide, we’re looking at the role social media plays in the mental well-being of young people.

Kristen Pyrc, M.D., medical director of Psychiatry Outpatient Services and the Partial Hospitalization Program at Cook Children’s, says the number of her patients dealing with anxiety and depression has significantly increased over the past year. She’s concerned that social media is playing a role, especially during the pandemic when young people are online more than ever.

“I have seen an increase in depression symptoms in teenagers who had not had them before,” Dr.Pyrc said. “So maybe I regularly see them for something like ADHD, and now they are showing symptoms of depression on top of that.”

Dr. Pyrc said she often hears complaints from parents that their children are ‘tied’ to their phones. She believes a major problem with that is a lack of exposure to seeing friends in person, and the opportunity for kids to feel left out when they see peers online having fun without them.

“I think online culture can worsen students’ feelings of loneliness and rejection because they see their friends doing things together without them in real time,” she explained. “Also we tend to post things that highlight what’s going well in our lives, but may not tell the full story of the times that we feel sad or inadequate. When teens are feeling down, seeing everyone else having fun without them can make them feel worse.”

Katie Greer, an internet safety expert, has spent the past 15+ years educating students, parents, law enforcement, and large companies across the country about the importance of online safety.

“I have seen social media used to bring out the best in humanity, but I have also seen it rip families apart in a matter of minutes,” she said.

Greer, who began her work as the director of Internet Safety with the Massachusetts Attorney General’s Office, believes social media has evolved in ways no one was ready for. Not so long ago, bullying was something that happened mostly at school. Now, young people are bullied online, in front of countless people. Even worse, a bully’s comments can be liked and shared by others.

“Kids were already spending a lot of time on their phones and online, then came a global pandemic. Now, they’re attending school online and relying on things like gaming online and social media platforms to connect,” Greer said. “There’s a lot more opportunity for cyberbullying and while it can start with one person, it can be a matter of seconds for others to jump in with a like or a comment and gang up on the victim.”

Situations like this increase a child’s chances of dealing with anxiety, depression, and self-harm.

“We know that developmentally, children’s brains aren’t fully formed,” she said. “When we put something in front of them as complex as social media, it’s almost as if we are asking for trouble.”

Greer also warns parents about the newfound TikTok culture.

“TikTok is a platform that has created unrealistic expectations about everyday life,” she explained.

She said children and teens see their peers or influencers having “perfect” lives and begin to feel as if they’re inadequate, or aren’t enough or worth it.

“Children have a desire to fit in and they want to have as much or more than their friends,” Greer said. “When children see their friends flaunt material things, or lavish experiences, that can make them spiral.”

Another issue putting kids’ mental health in danger is ‘sexting’ or the exchange of nude photos and videos, which has become quite prevalent.

“I recently was made aware of an incident where a girl sent a guy nude photos and he leaked them. Once they were leaked, so many people saw them, the young girl was humiliated,” Greer recalled. “The family reported that this led to the young girl untimely killing herself out of embarrassment and humiliation that her photos were leaked.”

Greer said, in cases like these, it is vital to remember that not only does suicide hurt a family, it also tears apart the people who loved and supported the victim.

Cook Children’s launched the Joy Campaign, which this story is a part of, to bring awareness to the increase in suicides and suicide attempts being seen at the medical center. In 2020, seven Cook Children’s patients died of suicide, making suicide the leading cause of traumatic death for the first time ever. The hospital has also seen record numbers of patients being admitted for suicide attempts month after month, most recently in March when 43 children and teens were treated for injuries. While the increase in suicide attempts cannot directly be tied to the pandemic, Dr. Pyrc said children need certain things to properly function in day-to-day life.

“Kids need in-person interactions. They need sunshine and exercise and all things encompassing,” Dr. Pyrc said. “Whenever your world is mostly virtual, it can hurt both your physical health and mental health.”

What does Greer suggest parents do? Stay alert and ask questions.

“A simple, “How was your day?” or “How are your friends doing?” can go a long way in opening the lines of communication,” she said.

She emphasizes knowing what your child is looking at online and know who they are talking to. If you are concerned about your child’s safety, there are measures you can take.

“While I am typically against this and wouldn’t always recommend it, there are ways parents can use apps that will mirror their children’s phone,” Greer said. “I do believe this could hurt the trust between a parent and a child, and isn’t the best way to go about typical monitoring, and I only recommend phone mirroring for dire situations.”

Before leaving any session, Greer reminds everyone she speaks with about the importance of a trusted adult.

“I tell parents and all adults it is important that children have a trusted adult they know they can come to at all times. Parents have to be okay with the fact that the adult may be someone other than them, it is all about a child feeling safe and opening up,” she said. “I also remind every child that I come in contact with that having an adult you trust is one of the most important things you can do to protect yourself and even help a friend.”

Both Greer and Dr. Pyrc see the issue and know there is a lot of work to be done to ensure we are helping our children with their new reality. Both professionals share their tips to help parents and families better support their children.

1. Take your child’s phone before they go to sleep at night. Disrupted sleep has a negative impact on adolescents.
2. Have an open dialogue with your child without judgment and give them the ability to freely express themselves to you. Given the amount of time kids are online, these conversations should happen every day.
3. Ask about their social media. Talk to your child about what they’re seeing, how it impacts them/makes them feel, and know who they’re communicating with.
4. Ensure your child can identify a trusted adult and make sure they understand that an adult can be their go-to person at all times.
5. Talk to your child about good social media etiquette. Remind them if they see something, say something and describe how that can help save someone’s life.
6. If you believe your child is in danger, there are apps available that can monitor their phone so you can see everything they see and get them the help they need immediately.
7. Reach out for help. Do not wait until your child is in a dire situation to reach out for help and get them the resources that could save their life.

Monitor your child’s social media, and make sure you have their usernames/passwords in case of an emergency situation.

Important to note:

Instagram has an anonymous reporting tool that allows users to report when they believe something could be wrong with a friend. The site sends the person resources depending on what was reported on their behalf. These resources could be vital in saving someone’s life by simply reporting.

One year into COVID-19, it’s clear the pandemic is taking a toll on the mental wellbeing of children and teens.

In March, a record 43 patients were admitted to Cook Children’s Medical Center after attempting suicide. This staggering figure is nearly double the number of suicidal patients seen during the same time period of 2020. Even worse, kids are dying. Last year, Cook Children’s recorded seven suicide deaths, marking the first time suicide was the leading cause of trauma deaths at the hospital, surpassing child abuse and car wrecks.

“The mental health crisis was already happening, then it met a global pandemic and these are the consequences,” said Kristen Pyrc, M.D., co-medical director of Psychiatry at Cook Children’s.

“They’re less engaged and have less interaction with others, and instead are spending more time online and in virtual settings. And it’s hard for them to be hopeful about anything because so many things, like prom and graduation parties, are canceled.”

The issue is not unique to North Texas. Doctors and nurses from across the nation are reporting similar statistics. In February, NPR released an article titled “Child Psychiatrists Warn That The Pandemic May Be Driving Up Kids' Suicide Risk.” It found that children’s hospitals across the U.S. are seeing up a 250% increase in suicidal patients in emergency rooms since the pandemic began. While there are no nationwide numbers on child suicides in 2020 available yet, experts agree there is reason to be concerned.

The Impact

More children are suffering from stress, anxiety, depression, and suicidal thoughts than at any time in recent memory. Pediatricians like Kathleen Powderly, M.D. from Cook Children’s Pediatrics Magnolia say children as young as 7 are needing help.

“I’ve had a couple of elementary school students, which you don’t see very often, who are actively suicidal or have already had a suicide attempt. I’ve also managed more kids on antidepressants since the pandemic because it’s hard to get into doctors right now,” Dr. Powderly said. “COVID-19 is not as impactful in terms of volume of cases in pediatrics, but our volume of psychiatric patients has increased quite a bit.”

Previously, Dr. Powderly was the medical director of Cook Children’s Hospitalist Group, the attending physicians who care for children in the hospital. She says her team was seeing an increase in suicidal patients before she transitioned into the office setting five years ago and that the pandemic created a perfect storm. On top of the stressors kids were already dealing with, they’re now struggling with isolation, virtual school, and a loss of activities.

“We’re not going to be able to flip the switch and just go back to normal when this is over,” said Dr. Powderly. “This is going to take some time to come out of. I’ve even had patients tell me they’re struggling with being around people.”

Members of Cook Children’s Youth Advisory Council shared similar experiences in a recent meeting. The teens said they feel more anxious being around their friends in person because they’re so used to only seeing people online now. In addition to new stressors, there is a severe lack of mental health resources across the board.

A Growing Need

“There weren’t enough psychiatric beds to begin with, and then COVID happened and the capacity was reduced because you can’t have patients sharing rooms,” said Dr. Pyrc.

The need for more inpatient psychiatric beds for children and teens has been known for years. In 2017, Cook Children’s opened the Rees-Jones Behavioral Health Center to help address the issue. The unit has 15 inpatient beds available for children between the ages of 2 and 12. As we reported when the center opened, the kids who end up here are patients with complex trauma, medical and social needs. They are often suicidal or have tried to hurt someone else. Eight out of 10 have had something traumatic happen to them. They have either been abused physically or sexually, or they have experienced some sort of neglect.

Teenagers who need inpatient psychiatric care have to be treated elsewhere but often end up waiting on the medical floor of Cook Children’s until a bed opens up in the community, which can take days. With more kids needing these services, it’s not uncommon for Cook Children’s to have a dozen or more patients waiting in a regular hospital room for a transfer to a psychiatric facility that can care for them.

“There are just not enough resources in general,” said Dr. Pyrc. “It’s an awful place to be in. This is a national problem, but it affects us here locally. We need more funding and we need more mental health professionals to care for these patients.”

On the outpatient side, finding a licensed therapist to see a child can take months. The waitlist just to see a counselor at Cook Children’s can be as high as 250 days at any given time. Even with easier access to appointments with virtual visits, there are not enough mental health professionals to meet the need.

Kia Carter, M.D., co-medical director of Psychiatry at Cook Children’s, has been a vocal advocate for increased mental health funding. Testifying in front of the Texas Senate’s Committee on Health and Human Services recently, she said early identification, intervention and treatment is essential to preventing further complications from mental illness. But there are roadblocks.

“We get insurances denying a specific level of care saying that a child doesn’t need an inpatient level of care. We also get a lot of pushback about medication,” Dr. Carter said.

She also asked lawmakers for increased support and to consider giving mental health care providers more leverage with insurance companies.

Hoping for JOY

In the meantime, Cook Children’s aims to bring awareness to the mental health crisis affecting children and teens with the launch of a new suicide prevention campaign.

The Joy Campaign is an acronym that stands for:

Just breathe.

Open up.

You matter.

“If we can just get kids to slow down, realize that what they are experiencing is temporary and that they have a long life ahead of them, I think we can make an impact,” said Dr. Powderly.

For the next month, Cook Children’s will be releasing a series of articles on Checkup Newsroom weekly that address many of the issues at play, such as the pandemic, the role of over-the-counter medications, social media, as well as how minorities and LGBTQ+ young people are impacted. We’ll also be speaking with families who have lost a child to suicide to examine the effects on parents and siblings.

If you feel your child might be struggling, here are some of the warning signs to watch for:

• Anger
• Declining grades
• Lack of concern about appearance and hygiene
• Changes in eating and/or sleep
• Self-injury such as cutting
• Less motivation
• Alcohol/drug use
• Acting highly anxious or agitated
• Recklessness
• Giving away possessions 

If you’re concerned about your child’s mental health, seek help early. Schedule an appointment with a licensed counselor. If your child is actively suicidal, call 911 or take them to the nearest emergency room.

Read this story in Spanish here.

The past nine months have been marked by upheaval, uncertainty, isolation and change with the youngest among us feeling the weight of it all, and doctors at Cook Children’s Medical Center are sounding the alarm.

“I’ve been employed as a psychologist at Cook Children’s going on 26 plus years and never in my time have I seen such an intense number of patients with severe anxiety and depression,” said Lisa Elliott, PhD, manager of the behavioral health clinic at Cook Children’s. “It’s not uncommon for us to have high acuity patients periodically, but that’s become the norm for weeks and weeks where 70 to 80 percent of our total number of visits for anxiety and depression are severe.”

Dr. Elliott attributes the uptick, in large part, to fallout from COVID-19. 

A June 2020 survey of parents published in the medical journal “Pediatrics” revealed that, since the start of the pandemic, more than 1 in 4 parents reported a decline in their own mental health, and 1 in 7 reported worsening behavioral health in their children. Both a decline in parental mental health and child behavioral health were reported by 1 in 10 families, according to the study “Well-being of Parents and Children During the COVID-19 Pandemic: A National Survey.”

Cook Children’s mental health experts say screen time, social media, academic performance pressures and lack of sleep all stress a child’s mental and behavioral health. All of those stressors have been exacerbated this year by pandemic-induced factors such as school closings, virtual learning, social distancing and isolation, according to Kathleen Powderly, M.D., a pediatrician on the medical staff at Cook Children’s. If ignored, these pressures can be a breeding ground for anxiety and depression.

And mental health experts are bracing for what is yet to come during the holidays as it’s not uncommon to see an uptick in depression and anxiety in children this time of year, particularly when there has been a significant family change, like in the case of divorce or loss of a loved one, according to Dr. Elliott.

So what is a parent to do? How do we help our children process these pressures to protect their mental and emotional well-being?

“We have to instill hope and stay calm and reasonable about it and, at the same time, not show fear.” Dr. Elliott said. “This is critical because we are going to set the tempo for our children. We will be what they follow. So it’s critical that we are calm and follow the safety guidelines, but tell our children this is not the way it’s going to be forever.”

And what better time than the holidays to model, teach and inspire hope?

Generosity Breeds Health and Hope

As stressful as the holiday season in tandem with a pandemic can be, it also presents a unique opportunity to teach children a concept that studies show actually improves mental health. It’s long been known that generosity and giving incite the same increase in one’s happy hormones as exercising. Giving makes you feel good—emotionally and mentally.

“Research shows that in addition to eating healthy and getting quality sleep, there are three things we can do to help keep depression at bay,” Dr. Elliott said. “One of them is exercising and another is socializing because they both increase endorphins. But the one that has the most long-lasting impact is philanthropy work. Doing things for others.”

A 2018 study published in the journal “Psychosomatic Medicine: Journal of Biobehavioral Medicine” showed a correlation between giving and increased activity in parts of the brain associated with altruism, reward and parental care and behavior. It further demonstrated that acts of generosity toward a targeted, or known, individual in need resulted in reduced activity in the amygdala—a positive given the amygdala is an emotion processing brain structure that signals the fight-or-flight mode when under stress. Increased activity in the amygdala is often seen in individuals with anxiety.

In addition to the chemical reactions philanthropy produces in the brain, doing good for others can help reframe one’s focus. Seeing the pain, suffering and circumstances of others gives perspective on one’s own struggles.

“Volunteer work helps create compassion because it draws concern away from ourselves,” Dr. Elliott said. “That’s why doing for others is so valuable for children. It teaches them compassion and optimism, and helps them develop gratitude.”

It also promotes the concepts of empathy and resilience, which are important building blocks for emotional and mental strength and valuable coping skills that help children deal with other challenges that come their way, according to Dr. Elliott.

This year, the need for generosity and service to others is especially great, given the economic impact of the pandemic. COVID-19 safety guidelines may require outside-of-the-box thinking to safely, yet personally, meet a need, but don’t let that stop you. It’s a great opportunity to get creative with your child.

With the help of Cook Children’s certified child life specialist Lauren Lasrich, MS, CCLS, we’ve compiled a list of ideas to help you and your family get started.

• Pack a grocery bag full of items and ingredients needed for Thanksgiving dinner for a neighbor in need. Let your child help create the menu and shop for the items together, either online or in the store. Deliver the groceries to their doorstep with a homemade card created by your family/child.
• Gather the family to rake leaves and clean up the lawn of an elderly or disabled individual. You’ll help a friend and get some sunshine and exercise for yourself and your family at the same time. Sunshine and physical activity are mood boosters!
• Adopt a family in need for the holidays. Check with your child’s school to see if they collect Christmas gifts for students in need and offer to purchase something on the student’s/family’s wish list. Get your child involved in the shopping process, be it online or in store.
• Together with your child, research a local organization or charity that promotes a cause you connect with and find out how you can help them meet the needs of those they serve. Create a family donation jar and save change to donate to the charity.
• Organize a neighborhood food drive and collect non-perishable food items from your neighborhood to donate to a local food pantry. Let your child decorate a donation box and put it on your porch so that your neighbors can safely deliver their donations.
• The end of the year is a great time to reduce and reuse! Go through your house and collect gently used household and clothing items you no longer need/use to donate to a local charity.
• Write letters/draw pictures to deployed military members or health care workers. For information on how to do this, or other ideas for supporting our troops, check out How Can I Support the Troops? 5 Ways You Can Help Deployed Soldiers at uso.org.
• Do a drive-thru Christmas caroling tour in your neighborhood. Let your neighbors know ahead of time when you plan to be out caroling so they can step outside and enjoy the show. Decorate your car ahead of time as a festive and fun family activity.
• Make toiletry kits and donate them to a local homeless shelter.

Not only will these activities help others, but they’ll give your child a project to look forward to.

“I tell people, especially during the pandemic, you have to have one thing to look forward to,” Dr. Powderly said. “It may not be the same thing that you enjoy previously, but you have to have something to look forward to because it gives you hope, and that’s what we all kind of need a little bit more of right now is hope.”

What to Watch For

Knowing the signs and symptoms of anxiety and depression can help you help your child before things get severe. For children, look for three or more of these symptoms, according to Dr. Elliott:

• Excessive worry for more time than typical. The difference between normal worry and anxiety disorder is the severity.
• Difficulty controlling worry.
• Easily fatigued.
• Restlessness and difficulty concentrating.
• Irritability.
• Muscle tension.
• Sleep disturbances.
• Sudden change in grades and school performance.
• Disinterest in a previously loved activity.

If your child is experiencing any of these symptoms and you are concerned about their mental or behavioral health, Cook Children’s is here to help. To access any of the hospital’s behavioral health services, call 682-885-3917. For emergencies, call 911.

“September of 2020 has been the highest month ever that we've seen suicidal patients admitted to our medical center,” said Kia Carter, M.D., medical director of Psychiatry at Cook Children’s. “We've seen this number rising year after year, so it's not surprising that it's this high. Suicide has become the second leading cause of death for kids and adolescents in the last year, versus two years ago when it was the third leading cause of death.”

This news comes after a near-record month in August when 29 patients were admitted for intentional suicide attempts. The patients admitted to Cook Children’s in September were between the ages of 6 and 18 years old. Dr. Carter says she feels the pandemic has played a moderate role in the increase, but that we typically see higher numbers in the fall months when kids return to school. In September of 2019, for example, Cook Children’s admitted 32 patients for suicide attempts.

“We've definitely seen this number rising in the last five years, but I do think that the amount of stress that we as a society have experienced in the last six months has caused some of our kids and adults to struggle more,” said Dr. Carter.

Virtual school may also be playing a role in mental health of kids. The Rees-Jones Behavioral Health Center at Cook Children’s has become a resource for children and teens who report feeling hopeless and not knowing how to cope with the isolation the pandemic has caused.

“I think everything in proportion is good, but when something is to this extent where some kids have had to do 100% virtual since March, it’s been very difficult,” Dr. Carter explained. “When kids have school, they have an outlet. They have other people to talk to. They have friends and social activities. Now, it’s just them, their parents and siblings.”

She says it’s important to know that some kids do very well with virtual learning, but it’s up to parents to know what works best for their child. Also, some families may have to choose virtual learning if the child or another family member falls into the high-risk category for COVID-19. In that case, parents should remember to ask for help when they need it. School counselors, nurses, teachers and their pediatrician are all great resources.

Warning Signs

Dr. Carter says the biggest thing to look for is a change in your child’s behavior, which she acknowledges can be difficult during the pandemic. She says little things like sleeping more than usual or not wanting to engage or interact in activities they used to enjoy can be signs of depression.

“Start engaging a little more and check in, like ‘Hey, are you feeling okay? I noticed you were getting a little angry at us for no reason,'” she said.

While it’s easy to write off irritation as a side effect of being a teenager, it is one of the primary symptoms of depression in children and adolescents.

Other signs to watch for include:

• Declining grades
• Lack of concern about appearance and hygiene
• Changes in eating and/or sleep
• Self-injury such as cutting
• Less motivation
• Alcohol/drug use
• Acting highly anxious or agitated
• Recklessness

Dr. Carter says girls are more likely to be hospitalized for attempting suicide, but boys tend to make more lethal attempts. As for age, Cook Children’s data shows 14 to 15 years old is the average for suicide attempt admissions, but more recently, the majority of patients have been around 12 to 13 years of age.

With many kids at home alone due to COVID-19, increased access to things like medication, firearms and the internet may also be contributing to the increase in patients. Dr. Carter says her team has also seen more patients participating in social media challenges where kids are hurting themselves.

“We have seen a rise in cutting behaviors, which are a form of self-injury. This is not always considered a suicide attempt but more of a maladaptive behavioral response to stress.”

She says these are things often picked up on social media, reinforcing the importance of knowing what your child is looking at and who they are talking to on the internet.

What Can Parents Do?

Get help.

If you’re concerned for the immediate safety of your child, take them to an emergency room. Trained professionals will evaluate your child to see what next steps need to be taken.

If you’re concerned about your child’s mental health (but not that they will harm themselves), you can contact your pediatrician, school nurse or counselor for a list of outpatient resources in your area.

If you feel your child may need a higher level of care (but it’s not an emergency), you can call Cook Children’s Behavioral Health Intake Department at 682-885-3917. Our team will help arrange referral for outpatient therapy and medication management, partial hospitalization day treatment options or inpatient treatment if needed.

Partial hospitalization allows children to receive treatment including medication management, family and group therapy at the Rees-Jones Behavioral Health Center during the day, while allowing them to go home at night. Children who are deemed an immediate danger to themselves may be admitted to the inpatient unit for 24/7 monitoring and treatment. The Rees-Jones Behavioral Health Center, is one of the few places in North Texas that offers inpatient psychiatric care for children between the ages of 2 and 12.

“Our biggest hope is that we can help families find the support and resources they need, and that we can educate our school systems about warning signs and screenings because they are hopefully going to come in contact with those kids before we do,” said Dr. Carter. “We don't want the numbers to continue to rise and we continue to lose our children. Remember that suicide is preventable.”

“We've definitely seen a high number of adolescent suicide attempts over the past couple of months, especially during COVID-19,” said Kia Carter, M.D., medical director of psychiatry at Cook Children’s Medical Center. “We've also seen younger kids endorse suicidal ideation.”

At Cook Children’s, the vast majority of patients treated for self-harming are girls, typically between the ages of 13 and 15. But Dr. Carter says she’s had patients in her unit as young as 4 years old talking about wanting to die.

“We've seen a huge increase with younger kids knowing what death is because of video games,” said Dr. Carter. “We have to assess their cognitive level and find out if they know what death means or do they think it’s like the video game where they die, but get a backup player.”

So far in 2020, 192 kids have been admitted to Cook Children’s for attempting suicide. Compare that to the same time period in 2015 when the hospital saw 88 patients - less than half of the current statistics.

Unfortunately, the data from Cook Children’s Behavioral Health Center is in line with a new study from the Centers for Disease Control and Prevention (CDC). The article, released Sept. 11, shows suicide rates among 10 to 24 year olds have increased 57.4% from 2007 to 2018.

"It's a real trend that has been demanding, for a while, a serious public health and research effort to understand what is happening and why," said Anna Mueller, an associate professor of sociology at Indiana University Bloomington. In an interview with USA Today, Mueller said she doesn’t buy that it’s just social media, though we do know many children express anxiety and depression linked to social media.

“Social media plays a big role in the mental health of children and teens,” said Dr. Carter. “They experience bullying online, they may not feel self-worth because they’re comparing themselves to what they see on Instagram. They’re also getting ideas on the internet about how to harm themselves.”

Dr. Carter says social media and sites like YouTube have made self-harm almost acceptable. She says children are looking to those avenues to find out how many pills to take or other ways they can attempt suicide.

“A lot of kids will research how much medication to take to not wake up,” said Dr. Carter. “I would say 99% of the overdoses we see have some over-the-counter component.”

Since January, 31 children have been admitted to Cook Children’s for ingesting too much Benadryl. At least three of the Benadryl overdoses are linked to a TikTok challenge, but the majority of cases were among patients intending to harm themselves. Other drugs commonly found in medicine cabinets such as Tylenol, aspirin and ibuprofen are also frequently used.

So why do children and teens take these drastic measures?

“When people feel like they're not going to get better and there's no way out, they tend to go to these levels,” Dr. Carter explained. “I think the biggest thing is hopelessness. When kids feel like they don't have anyone to talk to, they don’t feel like they can communicate with their parents or they’re getting bullied and they don’t have a social circle. Some kids also are struggling with gender and sexual identity.”

About 30% of the children assessed by Cook Children’s Behavioral Health Center report issues with gender or sexual orientation. Among those are patients diagnosed with gender dysphoria, a feeling of discomfort or distress that can occur when someone feels their gender identity differs from their sex.

“There are some kids who physically don't feel comfortable in the body they're in and they don't feel that they relate to the other girls or the other boys. We see this occur a lot around age 10,” said Dr. Carter. “A lot of times parents feel like it's a phase, and that might be true, but I would encourage parents to not minimize it because kids can begin to feel hopeless.”

She suggests parents keep an open mind, listen to their children and get them in to see a licensed professional counselor. And she says it’s ok to not agree with their feelings, but to share those thoughts with your spouse or a friend instead of the child.

“If you're resistant to it, your child's going to shut down and that can cause a whole realm of depression, hopelessness and not wanting to be alive anymore,” she said.

With COVID-19 and social distancing, spotting signs of depression and hopelessness can be challenging. Things that may have seemed out of the norm in the past, like avoiding social activities, may not be so odd now. But Dr. Carter says watching for changes in behavior is still key.

“Most kids still want to play video games and have their cell phones, so if they don’t want a new video game and all they want to do is sleep, you’re going to want to assess where that change is coming from,” she said.

Other signs of depression to look out for include:

• Declining grades
• Lack of concern about appearance and hygiene
• Changes in eating and/or sleep
• Self-injury such as cutting
• Less motivation
• Alcohol/drug use
• Acting highly anxious or agitated
• Recklessness

If you feel your child needs help, please talk to your pediatrician or call 682-885-3917 for a referral to Cook Children's Behavioral Health Center.

It’s natural for parents to want to protect their children when they are distressed. But when it comes to anxiety, taking kids out of anxiety-provoking situations may not always be the right answer.

In fact, we should make a distinction between positive stress and clinical anxiety. Understand that an episode of anxiety/fearfulness/avoidance isn’t limited to a full blown clinical anxiety disorder.

Positive stress (like fears of taking a test, or going down a slide, etc.) is actually vital to normal child development and for teaching a child coping skills and the resiliency in learning to fail and then try again.

If a child’s anxious responses are expanding or not improving, however, they need to seek the help of a psychologist or therapist who can help assess the scope of the problem and craft a unique treatment plan that may include Cognitive Behavioral Therapy (CBT).

The psychologists we spoke to for this article found the parent often have an underlying anxiety disorder that may be untreated. While CBT is one very helpful treatment option (and one that is very applicable for straightforward anxiety in older teens and adults), kids are very different and there may be other factors mitigating the anxious response.

By attempting to protect your children from these situations, you may actually be enabling them to avoid and escape the situation. Then kids never learn to work through the root cause of their anxiety.

Here are 5 quick facts to remember:

Fact 1: Your child may not be happy or comfortable all of the time, and this is OK.

Fact 2: It’s difficult to see your child frustrated or disappointed, and this is also Ok.

Fact 3: Your child WILL get angry with you, and this is OK

Fact 4: Your child WILL say mean things to you, and this is also OK

Fact 5: You do not need to rush to fix it/ make it better.

Fact 6: Your child’s anxious behavior is NOT a reflection on you as a parent.

Anxiety affects 25% of children ages 13 to 18. Let untreated, anxiety can lead to depression, academic underachievement, poor social skills and substance abuse.

Sometimes, it’s difficult for parents to recognized anxiety. Kids can become easily frustrated with changes, have meltdowns, over-react, be difficult to soothe, be very reactive, struggle with transitions, be easily embarrassed, not be able to tolerate feedback/criticism, etc.

Parents (or others), may see these emotions as an anger, mood or ADHD issue, when there can be more to it, and testing can be helpful to decipher it.

One of the best treatments for anxiety is Cognitive Behavioral Therapy (CBT) from a licensed behavioral health specialist, and has proven to provide better symptom reduction than medication for most children. While licensed psychologists play an important role in behavioral health, in terms of providing psychological testing, as well as therapy, our licensed professional counselors at Cook Children’s are vital as well in providing and teaching very creative and useful coping skills every day.

When choosing a CBT therapist, make sure they use “exposure” technique. The goal of CBT is to teach people how to help themselves through anxiety-provoking situations, not to escape or avoid them.

Cognitive Behavioral Therapy will help the parent too, as a child with anxiety affects the entire family unit. There is no “cure” for anxiety, but there are resources to learn to manage it differently. Don’t take away the opportunity to experience bad things, or your child will become emotionally fragile and never be able to handle anything.

Tips:

• Teach by example and be aware of your own feelings/ actions
• Praise the effort
• Don’t reward the wrong behavior
• Plan 15-30 minutes a day of one-on-one time
• Allow 30 minutes of decompression time after school with activity the child needs: either physical activity or calm activity
• After a tantrum, talk about it, learn to problem solve
• Find something to be grateful for in a bad situation/ outcome

Much like a peanut allergy is the body’s over-sensitivity to peanuts, anxiety is an over-sensitivity to worry. Anxiety can include:

• Overestimating danger
• Expecting the worst

Physical symptoms such as palpitations, difficulty breathing, stomach upset, trouble sleeping and attempting to avoid any perceived anxiety-inducing situation.

To learn more about Cook Children's Behavioral Health services, click here.

In her more than 25 years at Cook Children's, nothing prepared Lisa Elliott, Ph.D., a licensed psychologist for the past few months. She calls them "the most challenging time I've had in all my years at Cook Children's concerning patient needs."

Since the end of school, many pediatricians, psychologists, psychiatrists, and other health care providers are seeing an uptick in teenagers with signs and symptoms of anxiety, depression, and other severe health and mental issues.

During three weeks in May, Elliott met with children she says were contemplating suicide and another she believes attempted suicide. She also made three calls to Child Protective Services, and she phoned the FBI and Exploited Children for the same case: a sexual predator attempting to get sexual pictures.

Joy Crabtree, Psy.D., and a licensed psychologist at Cook Children's, echoes many of the same sentiments as Elliott.

Crabtree's seen an increase in anxiety and depression in her adolescent patients, as well as more anxiety in younger children. Crabtree believes social isolation, being away from school (or "typical school"), and out of a routine are all things that have contributed to children's mental state right now. 

Amani Terrell, M.D., a Cook Children's pediatrician in Keller, agrees that the coronavirus has brought a tremendous degree of turmoil. 

"The sheer uncertainty of the pandemic can create fear and anxiety in anyone, especially in the face of ever-changing recommendations and expectations," Dr. Terrell said. "This microscopic, invisible monster has created a global threat to health care and the economy and has forced unprecedented interventions, including lockdowns, school closures, and pleas for social distancing. As a consequence, many of us are starting to see an uptick in teenagers with signs and symptoms of anxiety and depression.”

"The cancellation of important school events like prom and graduation can be devastating to an adolescent. Kids can feel disconnected from friends and classmates," Dr. Terrell said. "Some teens may be internalizing the stress and anxiety of parents and caregivers, who may be struggling emotionally and financially. Many youths who have already struggled with mental health issues may have exacerbations of their symptoms as a result of social isolation. They may not have easy access to counseling or other therapies."

Dr. Terrell urges parents to recognize the signs and symptoms of mental health problems (which sometimes can be confused with typical teen behavior). If they notice these problems, she advises parents to seek professional help from their child's pediatrician. Unchecked, teens with depression may be unable to cope emotionally, which can lead to dangerous behaviors, such as alcohol/drug abuse and sex. It increases the risk of suicide or self-harm. 

Our experts encourage parents to watch for any change in a child's mood. Parents may notice sadness, depression, hopelessness, irritability, anger, and hostility. You may see more tearfulness and changes in activity levels. Watch for more withdrawal from friends and family, change in friends, and loss of interest in activities once enjoyed. 

Other signs include sleep disturbance, change in appetite, restlessness, agitation, fatigue, lack of energy/motivation, feelings of worthlessness, and guilt. Depressed kids may have difficulty concentrating, making decisions, and may even see a drop in grades. 

Always be aware of signs of depression and keep a close eye on your child. Never ignore symptoms. If you see signs of depression, contact your physician and obtain referrals for a psychologist or therapist trained in pediatric and adolescent care. 

If a child is talking about suicide, get help immediately. It is critical not to ignore this cry for help regardless of their reasons. 

Know that if your child is struggling with a chronic illness, including depression, it will impact the entire family. Families will require a lot of support: emotional, financial, and physical. Most importantly, the support needs to be ongoing. It's important to allow family members to vent frustration and grieve. Therapy is beneficial. If your teen is struggling with this problem, the entire family will need help to get through it. 

If you feel your child needs help, please talk to your pediatrician or call 682-885-3917 for a referral into Cook Children's Psychology department.

Referenced from AAP- How to Recognize Signs of Depression

Believe it or not, summer’s almost over and the new school year will begin before you know it.

Are you ready? Or are you like a certain dad I know who usually waits until the last minute? Last year, this dad forgot:

• To book his child's physicals so he had to scramble to get checkups before flu shots.
• His daughter has some pretty significant fears about going into school the first day and he didn’t take the time to properly prepare her.
• To get his son's asthma inhalers refilled and the forms on file so that he could have it at school (until April when he was having a flare).

Don't be like me…here are 10 steps you can take to make sure you and your child are ready for back to school.

1. Vaccines - Make sure that your child is up to date on vaccines. As your kids get older, your school might prevent them from enrolling in classes or other benefits, which might make it difficult to get their classes scheduled, etc. Vaccines are routinely scheduled at 4 years old (measles, whooping cough and polio among others), 11-12 (whooping cough and meningitis) and 16 (meningitis). At Cook Children's, we also recommend the HPV vaccination starting at age 11.
2. Physicals - If your child plans to participate in a sport or marching band they may need a sports physical form to be completed by your child's doctor. This requirement is required by the UIL before junior high, ninth and eleventh grade but many schools ask for it each year. The marching band requirement is new so not as many parents are aware. I expect we'll be doing a lot of those in the first few weeks of August. Students who are attending private schools or participating in sports that aren’t governed by the UIL may have other physical exam requirements. Many of these kids are already out in the heat working hard preparing for their upcoming season, so I recommend getting these as soon as possible.
3. Forms - Don't be that parent who realized in April that their child doesn't have his inhaler or the form required to take it at school (ahem ... me). Here are some common medications your child might take which might need to be administered at school: inhalers/nebulizers for asthma, insulin, ADHD medications and pain reducers.
4. Sleep - Transitioning back to a sleep schedule that works for school might be the most difficult transition in prepping for back to school. The older your child, the more likely they are to be going to bed too late and sleeping in. Start making subtle changes in their bedtime over the next few weeks. Rolling bedtime back 30 minutes at a time can make the transition to early morning easier.
5. Screen time - Just like sleep, screen time can get away from us a bit over the summer (Fortnite! I’m looking at you). An immediate drop off in daily screen time can be a struggle so starting to make changes now can help your screen junkies detox a bit before they go back to school.
6. Your child’s back to school fear or anxiety - Many children deal with some fears about going back to school. These fears can be mild or they can be more severe, almost debilitating. Helping your child prepare for the transition by talking them through their day, setting up a play date with classmates ahead of time or taking a tour of the school can orient (or re-orient them) back to school in a way that can be helpful. If the anxiety is more severe, consider talking with your pediatrician or a play therapist in advance to help them and you prepare.
7. Your back to school fear or anxiety - Getting yourself prepared for back to school is almost as important as preparing your child. Some parents will kick their kids out the door and drive off to their gym class without a second thought. For others, the transition can be just as hard on the parent as the child. Begin now to prepare yourself for what it will feel like those first few days at drop off. Showing emotions with your child is certainly OK, but a prolonged, tearful drop off can make things harder on your child.
8. Supplies - Get your child ready for back to school by buying their school supplies in advance whenever possible. Whether you buy the prepared packet from school or enjoy the process of shopping for individual supplies doesn't matter, just make sure your child is well prepared with what they need to start the year off right. Buy some extra tissues or hand sanitizer to help the teacher out.
9. Set goals - My favorite part of a new school year is the fresh start that kids can get. Whether last year was amazing or a huge struggle, it's a great opportunity to help our kids realize that they can always work on something to make themselves better. Using last year as a guide, help them set some goals that focus both on their strengths and challenges.
10. Attend meet the teacher night - Sometimes these events occur before school and sometimes they occur a little after school starts. Use meet the teacher night strategically to help frame your child in a positive light. This can go a long way to helping your child accomplish their goals for the year.

Whether you're counting the hours until you can send the kids back or dreading the return of early mornings, hopefully, these tips will help you think through some of the things you need to consider. I know it did for me.

What topics did we miss?

Related To This Topic:

• Vaccines and Immunizations
• Immunization Schedule
• Common Questions About Immunizations
• Knowing Your Child's Medical History
• Sleep Center
• Your Kids Are Ready For School. But Are You?
• 5 Questions Every Parent Should Ask Their Child's Teacher
• 6 Ways You Can Help The Teacher Understand Your Child

L. Frank Baum, The Wonderful Wizard of Oz

Anxiety in children is a normal part of life, just like it is in adulthood. When a child is frightened, for example by a scary movie, they may have trouble getting to sleep. However, when anxiety cannot be comforted and is out of proportion with the given situation that can be a sign of an anxiety disorder in children.

Childhood anxiety occurs in about one-in-four children at sometime between the ages of 13 and 18. However, the lifetime prevalence of a severe anxiety disorder in children 13-18 is about 6 percent. Left untreated, anxiety in children can cause problems in school, at home and continue into adulthood.

Especially during this time of year, you may notice your child feeling anxious in preparation for standardized testing. 

As we approach STAAR tests in our area, we hear a lot about kids becoming anxious.

Sometimes it’s easy to spot: the outward nervousness, nail-biting, jitteriness, moodiness, irritability and outright refusal to participate in a specific activity, like school or when it's test time. Other times anxiety is not as easy to see, but can still be just as debilitating and lead to further behavioral, as well as physical, problems.

Some of the less distinct signs of anxiety can include frequent stomach aches, headaches, trouble sleeping and difficulty concentrating. It can be difficult to discern whether these symptoms are due to some kind of illness, something your child ate or an emotional stressor of some kind. There are things parents can do to better understand anxiety, including learning what is normal and what needs their attention.

“Normal” Anxiety:

Separation anxiety usually begins around 6 to 8 months of age, and we accept it as pretty much a normal stage of development. A child that had previously been happy while getting passed around to anyone and everyone, making funny noises and faces, may suddenly become a little weary of the aunt she doesn’t see regularly. This fear of a parent leaving may not subside until she is 2 to 3 years old. By then, a child will usually cry for a short period and, with some hesitance, calm down and connect with the new person. In order for children to overcome this stage of separation anxiety, they must feel safe in their home environment, trust people other than their parents, and trust that their parents will return. Parents will play a significant role in preparing their children to deal effectively with daily stresses.

Anxiety and Fear

It’s important to remember that fear is a normal human emotion. Fear is an unpleasant feeling of apprehension caused by the presence or anticipation of danger, according to New Source Counseling. But not all fear is bad. A healthy level of fear can protect our children and us from danger.

Anxiety is slightly more broad and pervasive than fear, but can still be useful when within normal levels. Anxiety is feelings of worry, nervousness or agitation, or an uneasiness of mind and body. It’s often about something that is going to happen rather than current threats. Fear is an element of anxiety, and when these emotions get out of hand they can cause serious disturbances in our children’s lives.

Remember the following four “S’s” to assess the extent to which your children’s anxiety or fear is affecting them.

1. Surplus: Is your child’s anxiety exaggerated from what is “developmentally normal”? Is the fear or anxiety there even when the source of danger isn’t? Is it virtually impossible for them to stop the worry?
2. Storm: Does the fear match the level of danger? Are they easily upset and out-of-control and inconsolable? Do they react negatively when you try to help?
3. Spoiler: Is the anxiety or fear significantly interfering with everyday activities? Does it negatively impact sleep, eating, relationships, and/or activities your child used to enjoy?
4. Stuck: Does your child’s fear or anxiety last longer than is expected? Is the fear or worry present all day, or for weeks or months? Are they having feelings like worry, panic, or agitation that will not go away?

If the answer to these questions is “yes,” it may be time to seek some help in treating your child’s anxiety or fear.

Preventive:

I often tell parents they are their child’s most effective preventative therapist. Every child has fear and anxiety from time to time, but a parent can comfort and give kids the skills they need to effectively deal with their worries. At the youngest ages (newborn to 2) it's important to provide a safe, positive and responsive environment. As kids grow up, separation anxiety is normal; but it's still important to prepare kids for changes and for separations from their caregiver, get them used to new people, and reassure them that they are safe and loved. When specific fears arise (fear of spiders, the dark, clowns, etc.) parents can help their children with age-appropriate discussion, educating the child about the object of their fear, precautions they can take, and possible solutions. It is important for parents to validate children’s feelings but still comfort them.

If your child worries persistently or excessively about a specific issue, like a test, teach him or her how to problem solve and take appropriate action to eliminate worries that can be controlled. It is also effective for parents to teach basic relaxation breathing and progressive relaxation or alternating between tensing and relaxing the muscles, at a young age and practice it with your children. This is a great activity to practice at bedtime. Another popular and effective coping skill which can be practiced during times of calm is known as

 “5-4-3-2-1” Coping Technique :

Breathe in for 5 seconds, hold the breath for 5 seconds, and breathe out for 5 seconds. Continue this pattern until you find your thoughts slowing down or until necessary. While focusing on breathing, focus on the following external thoughts:

5: FIVE things you see.

4: FOUR things you can touch

3: THREE things you hear

2:  TWO things you can smell

1: ONE thing you can taste

Of course, sometimes even parents and children need a little help. If these techniques still don’t seem to alleviate the anxiety – get help early!

Be sure to ask your pediatrician if a counselor or a play therapist, or even a psychiatrist or/and medication may be needed, especially if the symptoms are interfering with experiencing a childhood full of life and laughter! Research has shown that the earlier that childhood anxiety is treated, the more successful it is treated!

Assure your kids that everything will be fine and they will do great on their tests. 

Good luck!

Should we plan on making baseball practice?

Are we prepared if the storm hits our home or while we are driving?

What can I do to ease the fears of my child who is afraid of storms?

First, your outdoor plans may need to be put on hold. According to the National Weather Service, you should start paying attention to the weather around 4 p.m. today. Storms will increase in coverage during the evening and overnight hours.

Next, have a plan for your family’s safety. Kaysey Pollan, Environmental Safety and Emergency Management officer at Cook Children’s, says everyone should know where they are going to go during severe weather.

“If you don’t have access to underground shelter, move to the interior room or hallway on the lowest floor and get under a sturdy piece of furniture,” Pollan says. “If you live in a mobile home, get out and find secure shelter.”

In addition to knowing where to seek shelter, families should have a designated meeting place away from home (a neighbor’s house or a street corner in the neighborhood) where you would gather if you were separated during an emergency. Make sure everyone in your family knows where the meeting place is located.

If you are driving during a storm, stay in your car and try to find shelter (but not under an overpass). The only exception is if there’s a tornado coming toward you. If you can’t find shelter, get out of the car and find the most low-lying area (ditch, ravine, etc.). Lay flat on your stomach and cover your head with your hands. If it’s hailing, stop driving and find a place to park like inside a garage, under a carwash or a service station awning. If you have small children with you, put them under you and cover their eyes.

Whether or not your child is afraid of storms, it’s important for parents to stay calm during severe weather. Children are quick to pick up on their parents’ fears and anxieties and during an emergency and they will look to you for safety and reassurance.

“Parents should do their best to manage their own anxiety. If parents are calm it will help calm their children,” said Kristi Mannon, Ph.D., psychologist at Cook Children’s Medical Center. “Parents should do their best to avoid watching news coverage in front of their children. Parents can check on weather updates on their phone or a device away from their children in order to stay informed.”

Dr. Mannon also advises parents not to dismiss their child’s feelings or to scold them.

“If a parent needs to complete a task such as preparing dinner and their child is expressing fear, they can take a break for a few seconds, make eye-contact with their child, acknowledge their fear, and tell them they will talk about it as soon as dinner is ready,” she said.

“You can help your child stay calm not only by managing your own fears, but by having a supply kit ready to go,” said Justin Smith, M.D., pediatrician at Cook Children’s Pediatrics Trophy Club. “Make sure you have snacks and something for your child to drink in case you have to remain under shelter for an extended period of time.”

Also, don’t let darkness become an added fear. Dr. Smith advises parents to have flashlights in a place that is easily accessible, and not just the one on your smartphone.

“You don’t want to run the risk of your phone dying and losing your flashlight too. It’s always a good idea to have a real flashlight handy,” he said.

Another tip – distraction can go a long way with children.

“Have a box of items that don’t rely on electricity such as coloring books, board games, a deck of cards or a favorite stuffed animal,” he said. “This can help during the storm and if you have to leave your house during a disaster.”

It is also important to be honest with children about what’s going on. However, make sure the amount of information and detail you share is appropriate for their age level.

It’s also a good idea to know the difference between a Watch and a Warning.

A Watch means conditions are favorable for severe weather to occur over the next several hours. The National Weather Service advises you to continue activities as normal, but monitor the weather and be ready to act if a Warning is issued.

A Warning means head for cover! This is an indication that severe weather is imminent or already occurring at your location. Seek shelter on the lowest floor of a sturdy building and stay away from windows.

One easy way to prepare for severe weather is to download the tornado app created by The American Red Cross. It provides alerts, watches, warnings, and plan-ahead lists right to your phone.

The American Academy of Pediatrics also has compiled a thorough list if wants to prepare for a disaster. You can find it here. 

Stress, the negative influences upon our daily lives, and anxiety, the worry and mental energy directed toward stress, are part of every human life from infancy through adulthood.

One particular stress or worry can be addressed, but it will inevitably be replaced by another. Teaching our children how to deal with the stress and anxiety of life is one of the more important things we can do as parents.

Given a person’s age, developmental level, personality, etc. anxiety can manifest in many ways. Classically, stranger and separation anxiety emerge around 6+ months of age. This represents a normal developmental milestone of learning how some people and situations are part of the “family universe” and some are not; and how a child learns a sense of “self.” As children grow, anxiety can begin to show itself in ways less obvious than just crying, such as elevated heart rate, nervous tics, tantrums, inattention or difficulty focusing, complaints of pain (tummy aches, headaches), etc.

Studies have shown that anxiety is highly inheritable. If a child is very anxious, not uncommonly, there will be a parent who has struggled with anxiety. Furthermore, recent evidence shows that not only is anxiety genetic, it actually may be even more of a learned predisposition. Children mirror their anxious parents. This actually is encouraging news, however. It means there can be a significant impact from teaching our children how they can effectively deal with stress and anxiety.

STRATEGIES FOR CHILDREN:

DISTRACTION: It is the most effective strategy for infants and very young toddlers but it can also be very useful for older children. For instance, instead of discussing immunizations/shots extensively, talk more about what prizes are to be had afterward or other positive things about the day. If you look for the good, you will find it. Help your child find it.

JUST BREATHE: As we become anxious, our “fight-or-flight” system, our sympathetic nervous system, kicks in increasing our heart rate, respiration rate, etc. As our minds subconsciously recognize this, it increases our anxiety further. Luckily, we can mindfully break this feedback loop by concentrating on our breathing. For kids, a timer is especially useful. You instruct a child to slowly breathe in through the nose for 4-5 seconds, then slowly out through the nose for 4-5 seconds. Watching the timer the entire time, trying to make the in and out of one breath to be about 10 seconds, and repeating continuously for just a few minutes can be remarkably calming. Doing it with them can also calm us. Breathing techniques can be adapted for the age of the child - such as “blowing out candles slowly” (use fingers for pretend) for younger kids and guided imagery - imagining a calm, peaceful place while breathing slowly - for older children.

BUILDING SAFE AWARENESS AND SUPPORT: The personal recognition of when and how anxiety hits is fundamental to dealing with it and a hallmark of Cognitive Behavioral Therapy (CBT), the most well studied treatment of anxiety. Once a child can learn to identify the onset of anxious thoughts, they can also start using their personal breathing/calming techniques, refer to personal, home-made cards with positive self-talk on them (“when I feel nervous, I remember that Mommy loves me no matter what”, etc).

EXPLORE WITH ART: It can be very helpful for younger children to draw their fears. This can help the parents understand particulars, help them discuss it, and actually serves to lessen the child’s fears. Older kids can benefit from journaling their anxiety. Interspersed with their written worries, written affirmations and strategies can help.

PROFESSIONAL HELP

A simplistic, but nonetheless helpful, dictum used in the primary care field as it pertains to mental health conditions is that when a particular problem - anxiety, inattention, sadness, etc. - becomes significant to interfere with “normal” life, professional help should be sought. For younger children and for those with mild problems, the information in this packet and resources listed herein may be sufficient. Play or talk therapy may be an adjunct. For older children with more severe problems, Cognitive Behavioral Therapy holds the most promise.

Medication can sometimes be indicated for severe anxiety. However, it should not be seen as a cure. Patients who just take medication don’t fare as well with anxiety disorders as those who take medication and teach the mind to deal with inevitable stress and anxiety of life.

Parents can help by making sure that children plan accordingly for testing days at school. Find out from your children and the school how they’re doing and the likelihood of not performing well on tests. This will help alleviate fears by pacing preparation for the tests, creating a plan to help kids succeed and encouraging them to problem-solve their worries.

Here are steps you can take to help your child during this stressful time:

1. Ask for help. If your child is especially anxious about test taking, set up a meeting with the teacher and school counselor to come up with a plan to ease fears on test day.
2. Go online and get sample items of practice tests from previous years and, if needed, practice with your children at home.
3. Practice deep breathing exercises at home. Then on test day, they will be able to put these practices into action.
4. Make sure your child gets plenty of rest. Studies have found that people who get eight hours of sleep before taking a math test are nearly three times more likely to figure out the problem than people who stay awake all night.
5. Control your children’s anxiety by making sure they are prepared. Focus on good study habits and the importance of not waiting until the last minute to cram before the test. There’s still time. Also, make sure your child has everything he or she needs going into the test. Even if it’s a new sharpened pencil. Make a check list the night before to avoid stress.
6. Stay away from entertainment as test time approaches. It’s not easy, but your child needs to study and not spend all night watching TV, looking at Facebook^® or being on the computer. You can wait on that until after the test.
7. Help your child keep mistakes in perspective. Everyone makes them and nobody is perfect. As you move closer to tests and studying, use wrong answers as a learning opportunity.
8. Eat right. Make sure your child has had enough sleep, exercise and healthy food. Avoid heavy food or desserts that may upset the stomach. Avoid  high sugar foods that may keep your child up all night and  make sure your child has a healthy breakfast (low-sugar cereal or oatmeal) the morning of the test.
9. Expect distractions. Let your child know someone in the class will have sniffles. Some kid will be banging his pencil on the desk. Someone may be humming. Those kids have their own stress. Just warn your child this is going to happen, but don’t let it be a bother.
10. After testing is completed, create ways to celebrate with your child. What you want to focus on in this celebration is the success of managing their stress, and not whether they passed or failed, which they won’t know for weeks.

About 3 percent of kids suffer from severe selective eating, to the extent that they can't eat out at a restaurant, said lead researcher Nancy Zucker, an eating disorders specialist at Duke University Medical Center in Durham, N.C.

Severely selective eaters are more than twice as likely to be diagnosed with depression or social anxiety, when compared with kids who'll eat anything, according to findings published online Aug. 3 in the journal Pediatrics.

Alaina Everett, a Cook Children’s licensed psychologist in Denton, says severe picky eating can be treated from a psychological/behavioral perspective as well as through oral-motor and sensory therapies and trying new foods for children who have severe selective eating can be terrifying.

“The fear is only intensified when parents make threats or express anger and frustration,” Everett said. “In our psychology department we emphasize the belief that kids do well if they can. Likewise they will eat well if they can. But there are obstacles that get in the way. Whether the original issue is a sensory processing disorder, oral-motor weakness or a gastrointestinal problem, all these kids have one thing in common, anxiety.”

From a psychological standpoint, these kids have had unpleasant experiences with food and the lingering trauma may be real. This is especially true for well-meaning moms who hide veggies in their kids’ favorite foods. If you have a seriously picky eater, Everett says this strategy will back-fire big time.

So how much anxiety can meal time actually cause?

“It is not uncommon in my practice to see children cry, scream, hide under the table, and quite literally shake at the sight of a novel food or when asked to join me at the table,” said Amanda Fyfe, a speech-language pathologist at Cook Children's in Arlington and Mansfield. “The anxiety severe picky eaters cope with is real and it can be intense. These kiddos often have months or years of negative food experiences fueling this fear, and unraveling it takes real work on everyone’s part. “

Fyfe says severely picky eaters:

• Have a significantly limited food repertoires (think 10 foods). These foods are probably similar in some way, although figuring out the rhyme or reason to what your little guy will or won’t eat can be mind boggling. It may be that his safe foods are the same color or have the same texture.
• Frustrate us with behavior that makes mealtime at home a catastrophe and eating out unheard of. He may refuse to eat with your family or cry and scream at the sight of the casserole you’ve so lovingly prepared.
• Refuse foods based on ALL sensory properties, including appearance, smell, texture, and taste. A picky eater may not even tolerate an offensive food on his plate. The sight of a non-preferred food may cause gagging, retching, and vomiting. Eating is more than simply chewing and swallowing. Interacting with, smelling, touching, and tasting are ALL important steps in the eating process. And disruption can occur at any step.
• May struggle to meet nutritional demands

“A child will not eat the broccoli and pork chops if you wait him out. He just won’t,” Fyfe said. “In fact, he may grow more and more rigid in his food selection because he IS hungry and grumpy. If a food or experience causes a child stress, discomfort, or pain, he will avoid it, plain and simple.”

Fyfe says these children are hypersensitive to foods in ways most of us might not even consider when planning our meals. Foods have to pass many tests before deemed acceptable for consumption, believe it or not, and severely picky eaters really put their meals to the test.

The first and possibly the most important test his dinner must pass? What it looks like. Children are acutely aware of the color of the food and may question why the color, shape, or size changes from bite to bite or from meal to meal. In addition, they might become overwhelmed by the smell of a particularly pungent food (think roasted broccoli, guys) and lose all ability to even consider tasting it. The texture of yogurt or pudding may cause a gag with incredible force. All of these reactions to food can lead to increased behavior disruption and meal time chaos.

“They can taste everything,” Everett said. “Zucchini pasta does not fool anyone and they are likely to stop eating pasta altogether. Presenting motivators like extra video game time can help, but it doesn’t solve the underlying anxiety. The scenario will just repeat itself when the next new food is presented.”

If your child shows signs of extreme picky eating, you will need some help. Talk to your child’s pediatrician about scheduling a feeding evaluation with a speech-language pathologist to determine the origin of the feeding woes and develop strategies to improve the eating experience for the entire family. A child psychologist may also be used if necessary.

http://www.npr.org/sections/health-shots/2015/08/03/428016725/could-your-childs-picky-eating-be-a-sign-of-depression

https://childhealthanddevelopment.files.wordpress.com/2012/03/kaytoomey.pdf

About the author

Amanda Fyfe is a speech-language pathologist at Cook Children's in Arlington and Mansfield. Speech/language pathologists focus on oral motor, speech, language and communication skills to enhance development, restore function and to prevent disability from pediatric conditions, illness or injury. Click here to find the closest Cook Children's Rehabilition Services near you.