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.

The number of children showing up in emergency rooms for suicidal thoughts and attempts is on the rise, especially during the school year.

According to a new study published by the American Academy of Pediatrics, kids ages 5 to 17 were admitted to children’s hospitals for thinking about or trying to kill themselves twice as often in 2015 as 2008. Researchers at Monroe Carell Jr. Children’s Hospital at Vanderbilt embarked on the study after noticing more pediatric patients being kept in the hospital with mental health issues.

They found that girls are attempting suicide more often than boys. They also found that suicide attempts were highest during the school year and decreased during the summer months.

“On average, during the eight years included in the study, only 18.5 percent of total annual suicide ideation and suicide attempt encounters occurred during summer months,” the research team wrote in the publication.

Half of the encounters examined in the study involved teens aged 15 to 17.

Numbers High at Home

This disturbing trend is also evident at Cook Children’s.

In 2016 and 2017, more than 390 children were seen by the Psychiatry department at Cook Children’s for an attempted suicide. The team was consulted on more than 1,040 total cases for issues including depression, anxiety and/or attempted suicide. The majority of the children who attempted suicide were female (317 female, 76 boys) and the average age was about 14 years old.

Also like the study, the majority of suicide attempts seen at Cook Children’s occurred during the school year.

Kristen Pyrc, M.D., co-medical director of Psychiatry at Cook Children’s, realizes suicide in children and adolescents is a difficult topic for most parents. But she stresses it’s one that can’t be ignored.

“As a mental health professional, my worst fear is a child prematurely ending his or her own life,” Dr. Pyrc said. “As a mother, it is hard to comprehend the profound grief families must feel in the wake of a suicide.”

The American Academy of Pediatrics has updated their guidelines to recommend pediatricians routinely check for signs of depression in their young patients. The focus is to carefully screen patients ages 12 and over during annual checkups.

“I have found it is a good way to signal to kids and parents that we are open to talk about this and want them to ask us about it,” said Vanessa Charette, M.D., pediatrician at Cook Children’s Magnolia office in Fort Worth. “Even if nothing comes up, often a parent will return with the teen later wanting to talk about anxiety and depression.”

Suicide Attempts among Young Children

Another study published by the AAP found that younger children who die from suicide are more likely to do so impulsively while early adolescents tend to struggle with depression for some time then plan and carry out suicide. The researchers found that younger children were more likely to have experienced ADHD symptoms while early adolescents were more like to have experienced depression symptoms.

“What is important to realize is that in a young child, thoughts of suicide can occur without depression symptoms,” Dr. Pyrc said. “I have to wonder if some of the elementary-school-aged children meant to end their life, or if they act impulsively not fully appreciating the consequences. Unfortunately, the result is the same regardless of the child’s intent. A child’s life has ended prematurely, and family and friends are left with immense grief and a lifetime of regret.”

Dr. Pyrc said in childhood and adolescence, depression is more likely to present with irritability and angry outbursts than sadness. Young people are remarkably resilient and able to ‘compartmentalize,’ meaning they can feel deeply sad when alone but are able to socialize with their friends and appear happy on the surface.

Depression also manifests as changes in energy and sleep as well as social withdrawal, a drop in grades, or not engaging in activities they once enjoyed. If you see some of these signs and symptoms in your child, it may be time for an assessment. Starting with your pediatrician is a good first step because they can help assess for depression symptoms as well as rule out any medical problems that present similarly to depression.

Dr. Pyrc stresses it is vitally important to take children seriously when they say they want to die.

“I think it is easy to dismiss a statement like this from a child because it is hard to imagine that they fully understand what they are saying, but I would sure hate to be wrong,” she said. “I think it is important to believe our children and get help for them when they make suicidal statements. If you are concerned that a child may hurt him or herself or others, please seek professional help as quickly as possible. If you feel the threat is imminent, please take them to the Emergency Room for an assessment.”

So where do we go from here? As adults we do have to be strong for our children. But in doing so, we have to take care of ourselves first. So, go into your room, close the door, cry if you need to, talk to your spouse, talk to your friends, and say that it’s not fair. Because it isn’t. But be there for your babies. Reassure them, hug them, love on them, and remind them that on a daily basis you and many others, do everything in your power to keep them safe. Safety, and school safety in particular, has improved in recent years, yet these incidents continue to happen.

I know as parents many of us want to grab our child and run as far away from this messy world as possible. But when horrible events take place, all of us have a choice to make. We can pull back and limit our activities and those of our kids, time outside, etc., or we can try to look at the situation and see what we can learn from it and how we can contribute and make a difference, so that hopefully similar events don’t continue to happen.

Yesterday was horrific and many lives were shattered. I have heard a number of rumblings about the suspect’s background and history, some of which may be true, some of which may not be. As adults, as parents, as humans, we have got to pay attention to our at-risk youth and reach out. We have got to take the time to try to make a difference in the life of “that kid.”

When you see a child or adolescent that might be isolating themselves or appear withdrawn, angry, or sitting at the table by themselves, make it a point to reach out, say hello, and ask them if they are doing OK, or need anything. Take the time to be a mentor in the schools, your community, etc., to work with youth and ask about noticeable changes in mood, appearance, or behavior. Share experiences, teach them skills, coach them and encourage them. I am talking about taking the time to show kids you care. If mentoring and intervention starts early it can make a tremendous difference in the lives of at risk youth, and potentially point them down a different road in the future. When you see a child that is troubled, you can also try to get them connected with resources and professionals both within the school system and the community. If just one person reaches out to an at risk child instead of pulling away, it can have tremendous positive implications for that child, and many others.

1. Health. Often, new teachers don’t know about your child’s health history. Many kiddos have severe nut allergies and teachers need to be aware of those food allergies, as well as if your child needs special medication or an EpiPen® injection. You should let your teacher know if your child has asthma, is diabetic or has any other serious health condition.

2. Educational Diagnoses. Teachers may not know your child has been diagnosed with a learning difference, dyslexia or an attention deficit problem. This is an opportunity to let teachers know about a 504 plan or IEP for your child. This is also a great time to let your teacher know what your child’s learning style is such as whether they are an auditory, visual or kinetic learner. Sharing your child’s areas of strengths and weaknesses is also helpful.

3. Emotional and family. Inform your teacher of any emotional factors that may impact your child such as divorce, death, illness or a parent being stationed overseas. It’s helpful for teachers to know the emotional factors that are impacting your child’s life which may help your teacher to understand and communicate better with your child.

4. Don’t settle for orientation. Teachers are bombarded with information at meet and greets during orientation. It’s hard to keep everyone and everything straight. My advice is to set up a conference with your child’s teacher as early as possible. One teacher told me she found it really helpful when parents provided a list of bullet points that included helpful information about their child, including the health and educational diagnoses, the strengths and weaknesses of the child, how the student learns the best, what the student responds to best when giving direction or correction and some points about the student’s social and personality style. Go in and set up an appointment one on one, especially if your child has special needs or considerations.

5. Be a team player. Every teacher I have spoken with has told me what they appreciate more than anything is for the parent to ask the teacher, ‘how can we help you? What information do you want to know?’ Most teachers prefer that team approach.

6. Be honest with yourself about your child. This is sometimes the most difficult tip for parents, but it’s so important. Know your child’s strengths and weakness. One of our biggest problems in today’s society is not teaching accountability. Set that example. Make sure your child knows his or her responsibility. Teachers have a difficult enough job without always blaming them, the school or another child. Please make sure you know how your child contributed to a situation and then take appropriate action from there.

Of course every child is different, and special, which makes communication between you and your teacher so important in having a great school year.

About the author

Lisa Elliott is a licensed psychologist and clinic manager of Cook Children’s Behavioral Health, located at 3201 Teasley Lane, Ste. 202, Denton, TX 76210. To make an appointment, call 940-484-4311. Cook Children’s Psychology provides care focused on children’s behavior, from ages 3 years through 17.

"Pressure's what you make out of it, all right? It's kind of like - pressure's kind of like your friend you had, your imaginary friend you had when you were 4 years old, right? If you think it's there, it's there. If you don't, you don't. That kind of the way we go about it."

Then he was asked if he had an imaginary friend. "I don't," he answered.

It's not surprising that a 61-year-old man doesn't have an imaginary friend, but it shouldn't be a concern if your child has a friend you can't see. 

Having a child with an imaginary friend can be worrisome, especially for new parents. "Is my child hallucinating?" "Is this an early sign of a social disorder?"

Despite how it looks, having an imaginary friend is normal for children. As many as 65 percent of children develop an imaginary friend, often while they are between the ages 2 and 6. Here are a few things you may not know about imaginary friends:

1. Imaginary friends are more common among first-born and only children.
2. Imaginary friends typically last less than 6 months.
3. Kids may use objects, such as blankets or stuff animals, to represent imaginary friends.
4. Exceptionally bright children often have imaginary friends.
5. There is no correlation between imaginary friends and psychological problems.

"Imaginary friends usually surface during transitional periods or times of emotional stress, such as a family illness," said Lena Zettler, MA, LPA, director of Psychology at Cook Children's. "An invisible friend can be a healthy outlet for kids to play out their emotions and cope with bad feelings.

Step 1: Groundwork

This phase is really a pre-step. Ideally, it should happen prior to the merger. Both parents need to take the time to learn and understand their own parenting styles and preferences. Whether you take a quiz online or read a 300 page book, it doesn’t matter as long as you understand your style well enough to be able to talk to your partner about your style of parenting. It may also be helpful to plan an "observation" date where you can watch your partner interacting and parenting his (or her) child. Afterward (not in front of the child) you can ask questions of your partner and discuss your differences and similarities. Be careful not to openly challenge your partner’s style. This is an opportunity to learn about each other, not to criticize.

Another very important part of the self-discovery phase is to check for emotional baggage. Most blended families are the product of divorce or the death of a parent which often involves intense personal emotions. Be sure your parenting style is not going to be affected by guilt, anger or defensiveness. Many parents feel so guilty subjecting their children to the turmoil of divorce that they parent out of guilt and become more permissive. It’s a myth that children need a break from discipline and structure following an event like this. They often need more structure and will find comfort in the predictability of your consistent parenting.

Step 2: Rebuilding

Bringing two families together creates an opportunity to craft something new. You and your partner get to construct a new household. Depending on the age of your children, this may be the perfect time to make new rules and establish new consequences. Having regular family meetings is particularly helpful and gives parents an opportunity to lay out details of the new plan while fielding the "But why…." and "How come…." questions. Even with proper explanation and clarification, details of the new plan are likely to be challenged and tested in the days, weeks, or months following the merge. This leads us to the final and most challenging step.

Step 3: Settling

You planned ahead, you laid it out, and now it’s time to let it settle. Some parts will work like a charm and other parts will seem like a complete failure. This is part of the parenting process and isn’t unique to blended families. However, blended families often come with circumstances that may make the settling process a little rough. There may be joint custody arrangements with your ex-spouse which make it necessary to think through rules and consequences you set in your home. You can’t ground your child from video games if he is going to be able to go over to his mother’s house and have unlimited play time. It’s better to set consequences you know you can enforce.

Another significant issue that might arise during your well-planned settling phase involves your child’s emotional and behavioral reaction to the divorce. If your child displays uncharacteristic behaviors such as sleep difficulty, appetite changes, poor school performance or social withdrawal it may indicate the development of an adjustment disorder, depression or anxiety. If this is the case, you and your child may need a mental health professional to steer you through the settling process. These issues can’t be addressed through consistent parenting alone.

Following these three steps does not ensure a perfectly blended family. It does, however, ensure that you will have established a foundation of open communication, compromise and flexibility that will enable your new family to weather any storm.