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A Teacher's Guide to OCD in the Classroom

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A Teacher's Guide to OCD in the Classroom

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Children who have obsessive-compulsive disorder (OCD) are plagued with unwanted thoughts, images or impulses that are difficult to suppress, causing them great stress and worry. These are called obsessions. To alleviate the anxiety caused by their obsessive thoughts, they perform repetitive, ritualized actions called compulsions. A child with OCD might need to line things up, touch things in a certain order when leaving the room or wash his hands repeatedly.

Obsessions Common in Kids With OCD

Contamination: Kids with this obsession are sometimes called "germaphobes." In schools, this plays out with kids worrying about other kids sneezing and coughing, touching things that might be dirty or getting sick in many different ways. This is the most common obsession seen in children.

Magical thinking: This is a kind of superstition, like "step on a crack, break your mother's back," taken to extremes. For example, kids might worry that their thoughts can cause someone to get hurt, or get sick. A child might think, "Unless my things are lined up in a certain way, mom will get in a car accident."

Catastrophizing: Some kids easily jump to the conclusion that something terrible has happened. For example, if her parents are five minutes late picking her up, a girl who is catastrophizing might tell herself that they've decided to abandon her.

Scrupulosity: This is when kids have obsessive worries about offending God or being blasphemous in some way.

What ifs: Kids may be plagued by a lot of different kinds of thoughts about bad things they could do. "What if I hurt someone? What if I stab someone? What if I kill someone?"

The "just right feeling": When OCD first develops, from about 6 to 9 years of age, kids may not know why they are doing something, but just that they need to do it until they get what we call the "just right feeling." So: "I'll line these things up until it just kind of feels right, and then I'll stop." And then over time - in the 9- to 12-year-old range - it evolves into magical thinking and becomes more superstitious in nature.

Behaviors You Might See in Students With OCD

Frequent requests to go to the bathroom: This could be to wash hands, if someone near the child was coughing or sneezing, or if she touched something that she perceives as contaminated. She could be washing items-pens, pencils, backpacks, books. It could also be an excuse to get out the classroom and just be away from everyone, and have some respite.

Constant reassurance-seeking: This takes the form of repetitive questions. "Are you sure that's the answer? Could you tell me again? Did you hear what I said?" Checking doors, windows, lockers, desks. Over and over and over again.

Getting stuck on tasks: Sometimes kids with OCD will need to finish something to completion, or understand it to completion, before they're able to move on. So if a child is working out what he did wrong on a math test, and the teacher says, "Now let's open the textbook and start a new chapter," he's not going to be able to shift gears.

Retracing: If a child leaves the classroom and worries that she left a pencil behind, she'll go back into the classroom and go to her desk and check. If she had a bad thought as she went through the doorway, she might have to "fix it" by going back through the doorway again saying a good word. If she had a bad thought when she went down a flight of stairs on the way to class, she might need to go back up that same stairway at the end of the period, even if it means being late to her next class.

Obsessive erasing: A child could be erasing a lot because the letters have to look perfect. Or he could have used a word that disturbs him. For example, if he has a fear of vomiting and he's written the word vomit, he might not be able to stand seeing that word, so he erases it. Kids start having erasers worn down to the metal. Teachers start to see holes in the paper. Words will be drawn over on the back of the page. A lot of different areas of writing become problematic.

Behaviors Often Confused With Another Disorder

Some behaviors associated with OCD are easy to confuse with ADHD, learning problems or being oppositional.

Distraction: If a child is busy thinking that if she doesn't turn the pen cap and count to four the right way then her mom is going to get sick, she's not going to be paying attention in class. And if her teacher calls on her to answer a question, her distraction might look like ADHD, but it isn't.

Slowness on exams, papers and tasks: Sometimes when kids take a long time, they're struggling with the perfectionism of needing to do things the right way. This could look like learning problems, or inattention, but it isn't.

Avoidance: Teachers might see a child who doesn't want to sit on the floor, or pick things up that touched the floor, or get his hands dirty in art class. He may avoid a lot of playground activities - kids with germ fears will view the playground the way some adults view the subway: it's gross. Why touch anything there?

Tapping and touching symmetrically: If a child sits down at her desk and she accidentally kicks the chair of the kid next to her with her right foot, she's going to have to then kick it with her left foot. That might look like somebody who's being oppositional, or somebody who's got too much energy, but actually it's OCD.

Complaints of anxiety and fatigue: There's one interesting theory that kids with OCD are smarter than other kids. And if you consider how much thinking they're doing, they're really using their brain more frequently than a lot of other kids are. But when that's coupled with a lot of anxiety, you can have a lot of fatigue. So it's common for kids with OCD to want to come home and take a nap after school.

How to Help Students With OCD

For children struggling with OCD, functioning in school can be complicated and very difficult. Here are some things you can do to help them, and the class as a whole, focus on learning:

Seating arrangement: If the school has noisy hallways, you might not want to have a child with OCD sit by the door. You might have her sit in the front, where she's less able to hear the noise and can stay more focused on her work. On the other hand, a child who has very observable symptoms, and doesn't want other kids to see her fidgeting with her hands, rocking or getting up a lot, might be better off closer to the door, toward the back of the room.

Extended time for tests and papers: If writing is a problem for a child who needs to find the perfect way to say something, he's going to need more time to finish those essay questions or papers.

Laptops for writing: If writing and rewriting/erasing is really problematic for a child, consider letting her use a laptop for taking notes, and having all assignments be typed instead of handwritten.

Private testing rooms: Research is quite clear that kids with OCD do better, are less overwhelmed and are more in control of their thoughts and their reactions if they're in a quiet place away from the other kids.

Skip reading out loud: Kids who feel they need to read perfectly may have to go back and reread sentences or whole paragraphs over and over to make sure they've got them right. So reading becomes a very laborious task, and reading in front of the class can become a nightmare. So if we know doing this is a problem for children, we can spare them.

Books on tape: If kids get so hung up reading that it takes forever, listening to the books can be a solution.

Break homework into chunks: If looking at a whole page of math makes kids feel overwhelmed and anxious - think of the potential for mistakes! - the problems can be broken up over four pages. It helps kids stay focused on doing the problems instead of worrying.

How to Minimize Behavioral Problems

Plan an escape route: Try working out a communication system so that if the student feels symptoms coming on, she can signal to you and leave the classroom, or go to a protected place in the classroom, without interrupting the class. It can prevent an embarrassing and disruptive blowup of symptoms in the classroom, and the other kids picking on or bullying her about it.

Be aware of triggering events: It's very important for teachers to know what kind of things might trigger the symptoms. Fatigue is a huge piece of OCD, and it can be exacerbated by medication. So it's important to know that if a child is drowsy in class, and maybe he's putting his head down, it's not because he's being oppositional or disrespectful, but because he's overwhelmed with fatigue.

Advance notice: Irritability and frustration are two of the longer-lasting things that kids with OCD are feeling on a daily basis. Changes in schedule can be very disruptive for a child with OCD, so it can be helpful for teachers to give advance notice of things. Kids who know what to expect are less likely to be thrown by the change.

Children with OCD are often teased and bullied because of their symptoms. Kids feel very uncomfortable about their rituals, knowing that they're being watched. It can be helpful to educate the whole class about what's going on, especially if a child is going to be in the same school for a number of years, and it can inspire a surprising amount of support from other children.

Peer understanding program: A peer understanding program includes a presentation in the classroom that explains (with the child participating) what OCD is. The child might say, "Listen, I have OCD. It's an anxiety disorder. It makes me think that my hands are dirty and I have to wash my hands a lot, so if you see me getting up and going to the sink to wash my hands, that's why." Psychologists can role-play with the teacher and child ahead of time, to anticipate questions his classmates might ask, and how to answer them.

A buddy system: A buddy is like a peer coach who sits next to the child and prompts him to keep up with note taking and staying on task. It can be great for the buddy, to foster a sense of confidence and pride and to be able to help someone in need, and great for fostering friendship.

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Lo sentimos, la página que usted busca no se ha podido encontrar. Puede intentar su búsqueda de nuevo o visitar la lista de temas populares. Children who have obsessive-compulsive disorder (OCD) are plagued with unwanted thoughts, images or impulses that are difficult to suppress, causing them great stress and worry.

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Here, you will find web-based professional development classes to help strengthen your knowledge of educating students with varying abilities.

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IRIS develops and disseminates free online open educational resources (OERs) about evidence-based instructional and behavioral practices. Intended for use in personnel preparation and professional development, these instructional resources are designed to help current and future educators improve the learning and behavioral outcomes of all students, especially struggling learners and those with disabilities.

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IRIS develops and disseminates free online open educational resources (OERs) about evidence-based instructional and behavioral practices. Intended for use in personnel preparation and professional development, these instructional resources are designed to help current and future educators improve the learning and behavioral outcomes of all students, especially struggling learners and those with disabilities.

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Watch the movie to learn how kids and teenagers faced the real problems of living with OCD.

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Most children and parents will have some distress or upset - so how do I know when a child or family needs additional help?

Ask your patients (and their parents) about reactions and coping.

Listen for ongoing or severe traumatic stress symptoms.

Consider a referral for a more thorough evaluation with a mental health professional if:

Traumatic stress reactions are severe or prolonged (more than a month).

Traumatic stress reactions interfere with recovery or with returning to normal activities.

Consider: Is the child participating in daily activities to the extent possible given their medical condition? Are stress reactions interfering with treatment adherence? Are new fears or worries troubling the child or parent?

Steps for making a referral Effective mental health treatment for traumatic stress Online resources - help in finding a mental health professional Distinguishing between types of mental health professionals
Therapist Resource Guide: There are many ongoing stressors that children and families endure after diagnosis of an illness or an injury. This guide focuses specifically on medical traumatic stress and responses that children and families may have.

Steps for making a referral

Mention concerns you have identified.
Say something like: "I'm concerned that (you are / your child is) having these upsetting thoughts and feelings. It might be useful to talk with a specialist who can help your family more."

Involve child and family in making a plan.
Ask for their ideas about what is needed now
Say something like: "What issues or difficulties are impacting you / your family the most right now? What would help make things better?"

Ask for permission to offer advice. Present advice as range of possibilities; be sure to incorporate patient/family ideas

Say something like: "I have some suggestions that have helped other patients in the past in situations similar to yours. May I share them with you?"

Range of possibilities might include: patient education materials / websites; speaking with social worker, local clergy, school counselor; seeking out support group, referral to therapist / community mental health center.

Ask about their readiness to act on this now or in the future.
Say something like: "Is this (suggested plan) something you would be willing to do when you leave today, or if you need it next week...month?"

Ask about barriers to potential plans / referrals, and strategies to overcome barriers.
Say something like: "What kinds of things would interfere with following-up on this plan we just discussed? How can we work through this so you end up getting the help you need.?"

Involve the child and parent in setting the agenda*:*Adapted from Wissow et al. (2008)

Keep the door open.

If your patient or their parents are not quite ready to act on a suggested referral now, arrange to follow up to see how your patient is doing.

You might say: "I'd like to talk with you again in a few weeks to see how things are going."

Promote continuity of care.
If your care for this patient is ending, ask permission to communicate your concerns about traumatic stress reactions or risk factors to the child's primary care provider, or to other providers who will continue to take care of this patient.

Facilitating collaboration between pediatric health care and mental health providers: The American Academy of Pediatrics Task Force on Mental Health has developed tools to facilitate collaboration between pediatric health care providers and mental health professionals, including a Physician Referral and Feedback Form template

Effective mental health treatment for traumatic stress

There are very good and helpful treatments for children who continue to have traumatic stress symptoms.
What treatment approaches are effective?
Evidence-based treatments include cognitive-behavioral treatment approaches, and in particular Trauma-Focused Cognitive Behavior Therapy (TF-CBT).

Click here for a fact sheet about effective treatments for youth trauma from the National Child Traumatic Stress Network.

A recent article includes informative summaries of effective mental health treatments for child traumatic stress symptoms, and guidance for health care professionals:
Cohen, J, Kelleher, K, Mannarino, A.. Identifying, treating, and referring traumatized children: The role of pediatric providers. Archives of Pediatric and Adolescent Medicine 2008;162(5):447-452 How can I help parents find effective treatment for their child?
When helping parents find a counselor or therapist to help their child with traumatic stress symptoms, you might suggest that they ask prospective therapists questions such as:

Do you have experience working with children after trauma?

What is your approach to working with this type of problem?

What is your success rate?

How do you work with parents?

The National Child Traumatic Stress Network offers useful tips and information about finding a mental health professional to help children and their families after trauma.

Online resources - help in finding a mental health professional

The National Child Traumatic Stress Network (NCTSN) has trauma-trained, child mental health professionals and community-based treatment centers in 35 states in the US. For information about or referral to a NCTSN center near you, please go to the NCTSN Organizational Members site.
American Psychological Association - Psychologist Locator National Association of Social Workers - Find a Licensed Social Worker American Academy of Child and Adolescent Psychiatrists - Psychiatrist Finder Anxiety Disorders Association of America - Find a Therapist Sidran Institute Help Desk - Locate Trauma Resources ISTSS Clinician Directory - Find a Clinician, Counselor or Mental Health Professional
Distinguishing between types of mental health professionals

Psychologists are professionals who have earned a doctoral degree (Ph.D. or Psy.D.) after 4-6 years of graduate-level training in human behavior and development, psychological testing and evaluation, and psychotherapy. Psychologists are licensed by the state in which they practice.

Psychiatrists are physicians (M.D. or D.O.) who have completed medical school, plus additional advanced training in the evaluation and treatment of psychiatric disorders and emotional and behavioral problems. Psychiatrists are licensed by the state in which they practice. As medical doctors, psychiatrists can prescribe and monitor medications.

Clinical Social Workers are professionals who have earned a master's degree (M.S.W.) after 2-3 years of graduate training. Clinical Social Workers are licensed by the state in which they practice (LCSW or similar credential - varies by state).

Marriage and Family Therapists are professionals who have completed a master's degree (M.A. or M.S.) after 2-3 years of graduate training. Some Marriage and Family Therapists have completed a required amount of clinical hours and passed a state-administered examination to become licensed marriage and family therapist (LMFT).

Licensed Professional Counselors (LPC) & Licensed Mental Health Counselors (LMHC) are mental health professionals who have earned a master's degree (M.A. or M.S.) after 2-3 years of graduate training and have obtained a required amount of clinical experience and passed a state-administered licensing examination.

For more information on the training and credentialing of mental health professionals, see Mayo Clinic: Mental health providers.

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When and How to Refer for Mental Health Care

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Pediatric providers can follow specific steps to determine if and how to refer a child and familiy for further mental health services after a medically traumatic event. Providers can also become familiar with current evidence-based treatments and online resources for mental health services for traumatic stress.

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This website is a great resource for many different topics and is filled with articles, current events, research, information for parents, and resources for educators about behavior and learning issues.

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Child Mind Institute | Transforming Children’s Lives.

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The Child Mind Institute is an independent nonprofit dedicated to transforming the lives of children struggling with mental health and learning disorders.

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The Mayo Clinic website has information about the symptoms in teenagers, risk factors, and the complications of this serious mental disorder.

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This severe mental disorder can result in hallucinations, delusions, and extremely disordered thinking and behavior that interfere with daily living.

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Schizophrenia and Cognitive Behavioral Therapy

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Schizophrenia and Cognitive Behavioral Therapy

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This video series shows the leading therapy that is shown to be effective in treating schizophrenia, cognitive behavioral therapy or CBT.

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There are few psychological therapies that have been significantly researched and shown to be effective with schizophrenia, but the leading one is called Cognitive Behavioral Therapy for Psychosis / Schizophrenia. While medications can help minimize many of the "positive" symptoms - the voices, delusions, etc. that are common with schizophrenia, even with the medications many people are still not enjoying their lives, and may have residual, ongoing problems like occasional negative voices, lack of social interaction, low motivation, etc. Cognitive Behavioral Therapy for Schizophrenia is designed to help with these problems. One of the leaders in the field is a researcher / clinician by the name of David Kingdon in the UK. Here is a good series of videos by Dr. Kingdon that goes through the background science, and the implementation specifics of CBT for schizophrenia. We encourage you watch the entire series.

We've covered this approach in the past - and you can read more about this treatment and its history in the following stories: CBT for Schizophrenia Manual. CBT for schizophrenia is standard, first-line treatment (in addition to medications) in the UK and is recommended for everyone who has schizophrenia. In the USA - there are unfortunately few trained practitioners (we have a list here). More background reading on CBT for schizophrenia is here.
Video 1 - Introduction to CBT for Schizophrenia Video 2 - CBT for Schizophrenia - what does it Involve? Video 3 - CBT for Voices Video 4 - CBT for Delusions Video 5 - CBT for Schizophrenia WorkSheets Video 6 - CBT for Negative Symptoms (apathy, lack of social interaction, etc.)
Recent news: CBT beneficial for Medication-resistant Psychosis / Schizophrenia (Medscape)

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Cognitive Behavioral Therapy for Schizophrenia - Video Series

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There are few psychological therapies that have been significantly researched and shown to be effective with schizophrenia, but the leading one is called Cognitive Behavioral Therapy for Psychosis / Schizophrenia. While medications can help minimize many of the "positive" symptoms - the voices, delusions, etc.

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This article and video presentation explain the newest research on preventing schizophrenia.

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Increasingly clinical researchers are telling us that they believe that many, and perhaps most, cases of schizophrenia can be prevented through higher quality prenatal care (health of the mother prior to pregnancy, and during pregnancy) as through specific targeted nutritional, stress (including avoidance of getting the Flu during pregnancy - which is an important stressor that can increase risk of children getting schizophrenia later in life) and psychological approaches during childhood. We've covered this in depth in the past with our "Preventing Schizophrenia" page, but here we focus on two of the most interesting and compelling areas; Omega 3 fish oils, and prenatal choline supplementation.

Research done over the past 30 years on animals shows that high levels of the nutrient called choline (in the family of B Vitamins) results in "better" brains for the child - brains that are more resistant to stress, faster learning, and with better memories - in effect "supercharging" baby brains. A research study completed last year also showed that in higher doses during pregnancy (over 6 grams per day of phosphatidylcholine - as found in Lecithin, such as in this choline vitamin) reduced key rates of physiological schizophrenic risk factors in infants 33 days old. As the researchers say:

"Basic research indicates that choline supplementation during pregnancy facilitates cognitive functioning in offspring. Our finding that it ameliorates some of the pathophysiology associated with risk for schizophrenia now requires longer-term follow-up to assess whether it decreases risk for the later development of illness as well."

Read more about this research here: High Prenatal Choline May Prevent Schizophrenia / Mental Illness in Children

A good area to learn more about Choline during Pregnancy, and child brain development is at CholineBaby.com.

Another area of great interest and initial test validation are the high EPA version of omega-3 fatty acids taken during childhood. In Australia there is a group called " Orygen Health " that is researching this topic and has had very good initial results. Orygen's fish oil research, being led by Professor Patrick McGorry and Associate Professor Paul Amminger is testing whether omega-3 fatty acids (specifically those high in the EPA version of omega-3 fish oils) can help delay the onset of psychosis. Amminger believes the research could have breakthrough implications for prevention of schizophrenia.

'People often ask me if omega-3 fatty acids will be as good as anti-psychotics, but it seems they're even better.'

Professor William Carpenter from The University of Maryland says: 'If they can replicate that study, it may be the most important thing since Thorazine', referring to the discovery of the first antipsychotic drug in the 1950s.

There has recently been a good article that covers this area of research in the journal Nature.

See it here: Prevention: Before the Break

"These findings point to the importance of nutrition and avoiding infection during pregnancy, which are already prominent messages for having a healthy baby in the developed world. These guidelines may already be reducing schizophrenia incidence in developed nations, and extending them to developing countries may bring further decreases.

"Many of the big medical advances - say, in cardiovascular disease or cancer - have come through changes in our diet and behaviour," McGrath says. "There's no reason to think that mental illness would be any different."

The Orygen research group is so positive about this area of research that they've even submitted a patent on it - see this link: Orygen / McGorry Patent on Fish Oil for Prevention of Schizophrenia

Importantly - its not just any form of Omega-3 fish oils that help. Here is information from the patent application:

Preferably the composition includes about 700 mg of EPA and at least about 480 mg of DHA.

the ... dose of EPA administered to the subject per day is about 700 mg and the final dose of DHA administered to the subject per day is 480 mg. The composition may be administered in multiple dosages over the period of the day. For example, 4 capsules may be administered over the course of the day (two in the morning and two in the evening). However, other administration (such as once daily, or twice daily) are not excluded.

Whilst it is possible that EPA and DHA be administered alone, it is preferable that they are administered together in a single composition. When in a single composition, EPA and DHA are present in a ratio of between about 3:1 and 7:5, preferably between about 3:2 and 7:5. Accordingly, preferably the composition includes EPA and DHA (when combined) in a concentration of more than about 50%, preferably more than about 55%, more preferably about 60%.

Here at Schizophrenia.com the staff members who have kids (and a family history of schizophrenia) are giving them omega 3 fish oils with these specifications. The risks are minimal and the potential benefits huge. you can use google shopping search engine feature to find high EPA omega-3 fish oils - click on the link below and search through the list for the most cost effective products with higher EPA omega 3 oils:
Google Search for High EPA Omega 3
Some people use this product: iHerb Now Foods High EPA Fish Oil
Additional Reading and Resources: Fish Oil Could Prevent Schizophrenia in Young People A Video: Schizophrenia Prevention: An Idea Whose Time Has Come

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New Research on How to Prevent Schizophrenia

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Increasingly clinical researchers are telling us that they believe that many, and perhaps most, cases of schizophrenia can be prevented through higher quality prenatal care (health of the mother prior to pregnancy, and during pregnancy) as through specific targeted nutritional, stress (including avoidance of getting the Flu during pregnancy - which is an important stressor that can increase risk of children getting schizophrenia later in life) and psychological approaches during childhood.

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Here, you can find webinars, research, ways to help students, how to cope in the workplace, and support groups for ADD and ADHD.

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Home - ADDA - Attention Deficit Disorder Association

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Empowering adults with adhd to live their best lives A Different Brain Requires a Different Approach Whether you're newly diagnosed, wondering if you have ADHD, or simply ready to take charge of your life - we're here to help. Have ...

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Claim your free ADHD Starter Kit here!  It includes a free subscription to ADDA Insider, advice, solutions, and recommendations for coping with ADHD.

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ADDA - Attention Deficit Disorder Association

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Introducing an easy, reliable and trusted way to gain the knowledge, strategies and solutions to overcome the challenges of Adult ADHD
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ADDA is here to guide you from wherever you are now to wherever you want to be. We'll help you live your best life as an adult with ADHD.

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Introducing an easy, reliable and trusted way to gain the knowledge, strategies and solutions to overcome the challenges of Adult ADHD Whether you're newly diagnosed with adult ADHD, or you've simply decided now's the time to take charge of your life and your ADHD, ADDA's Adult ADHD Starter Kit will start you off on the right foot.

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This fact sheet comes from the American Counseling Association and includes a description, assessment and intervention strategies, and medications that can be effective in treating conduct disorders.

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Stanford Children's Health addresses the signs, symptoms, causes, treatment, and ways to help a child with conduct disorder.

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What is conduct disorder in children?

Conduct disorder is a type of behavior disorder. It's when a child has antisocial behavior. He or she may disregard basic social standards and rules. He or she may also:

Be irresponsible

Skip school or run away (delinquent behavior)

Steal or do other things to violate the rights of others

Physically harm animals or other people, such as committing assault or rape

These behaviors sometimes happen together. But one or more may occur without the others.

What causes conduct disorder in a child?

Experts believe that many factors play a role in conduct disorder. These are:

Some children with conduct disorders seem to have a problem in the frontal lobe of the brain. This interferes with a child's ability to plan, stay away from harm, and learn from negative experiences.

Some experts believe that a series of traumatic experiences occurs for a child to develop a conduct disorder. These experiences then often lead to depressed mood, behavior problems, and involvement in a deviant peer group.

Which children are at risk for conduct disorder?

A conduct disorder is more common in boys than in girls. It is also more likely to develop in children or teens who come from homes that are:

Children with these mental health problems are also more likely to have conduct disorder:

Mood or anxiety disorders

Posttraumatic stress disorder (PTSD)

Substance abuse

Attention-deficit/hyperactivity disorder (ADHD)

Learning problems or learning disorders

Children or teens who are considered to have a difficult temperament are more likely to develop behavior problems.

What are the symptoms of conduct disorder in a child?

Most symptoms seen in children with conduct disorder also happen at times in children without this problem. But in children with the disorder, these symptoms occur more often. They also interfere with learning, school adjustment, and sometimes with the child's relationships.

Each child's symptoms may vary. But the 4 main groups of behaviors are described below.

Aggressive conduct

Destructive conduct

Deceitfulness

Violation of rules or age-appropriate norms

These symptoms may look like other mental health problems. Have your child see his or her healthcare provider for a diagnosis.

How is conduct disorder diagnosed in a child?

A child psychiatrist or qualified mental health expert can diagnose a conduct disorder. He or she will talk with parents and teachers about the child's behavior and may observe the child. In some cases, your child may need mental health testing.

If you notice symptoms of conduct disorder in your child or teen, you can help by seeking a diagnosis right away. Early treatment can often prevent future problems.

How is conduct disorder treated in a child?

Treatment will depend on your child's symptoms, age, and general health. It will also depend on how severe the condition is.

Treatment for conduct disorder may include:

Cognitive-behavioral therapy. A child learns how to better solve problems, communicate, and handle stress. He or she also learns how to control impulses and anger.

Family therapy. This therapy helps make changes in the family. It improves communication skills and family interactions.

Peer group therapy. A child develops better social and interpersonal skills.

Medicines. These are not often used to treat conduct disorder. But a child may need them for other symptoms or disorders such as ADHD. These other disorders often occurs along with symptoms of conduct disorder.

How can I help prevent conduct disorder in my child?

Experts don't know exactly why some children develop conduct disorder. Things such as a traumatic experience, social problems, and biological factors may be involved. To reduce the risk for this disorder, parents can learn positive parenting strategies. They can be good role models for their children.. This can help to create a closer parent-child relationship and give the child with examples of how to respectfully treat other people, animals, and property. It can also create a safe and stable home life for the child.

How can I help my child live with conduct disorder?

Early treatment for your child can often prevent future problems. Here are things you can do to help your child:

Keep all appointments with your child's healthcare provider.

Take part in family therapy as needed.

Talk to your child's healthcare provider about other providers who will be involved in your child's care. Your child may get care from a team that may include counselors, therapists, social workers, psychologists, and psychiatrists. Your child's care team will depend on his or her needs and how serious the disorder is.

Tell others about your child's conduct disorder. Work with your healthcare provider and schools to develop a treatment plan.

Reach out for support. Being in touch with other parents who have a child with conduct disorder may be helpful. If you feel overwhelmed or stressed out, talk with your healthcare provider about a support group for caregivers of children with conduct disorder.

When should I call my child's healthcare provider?

Call your healthcare provider right away if your child:

Feels extreme depression, fear, anxiety, or anger toward him or herself or others

Feels out of control

Hears voices that others don't hear

Sees things that others don't see

Can't sleep or eat for 3 days in a row

Shows behavior that concerns friends, family, or teachers, and others express concern about this behavior and ask you to seek help

Call 911 if your child has suicidal thoughts, a suicide plan, and the means to carry out the plan. Never leave them alone until the situation is assessed and treatment laid out. This may include a hospital stay.

Key points about conduct disorder in children

Conduct disorder is a type of behavior disorder. It's when a child has antisocial behavior.

Both genetic and environmental factors may play a role.

Children with other mental health problems are more likely to have this disorder.

Symptoms are divided into 4 main groups. They are aggression, destruction, deceitfulness, and violation of rules.

Therapy that helps the child interact better with others is the main treatment. Therapy may include both individual and family counseling. Medicines may be needed for other problems, such as ADHD.

Reach out for support. Being in touch with other parents who have a child with conduct disorder may be helpful.

Call 911 if your child has suicidal thoughts, a suicide plan, and the means to carry out the plan. Never leave the child alone.

Next steps

Tips to help you get the most from a visit to your child's healthcare provider:

Know the reason for the visit and what you want to happen.

Before your visit, write down questions you want answered.

At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you for your child.

Know why a new medicine or treatment is prescribed and how it will help your child. Also know what the side effects are.

Ask if your child's condition can be treated in other ways.

Know why a test or procedure is recommended and what the results could mean.

Know what to expect if your child does not take the medicine or have the test or procedure.

If your child has a follow-up appointment, write down the date, time, and purpose for that visit.

Know how you can contact your child's provider after office hours. This is important if your child becomes ill and you have questions or need advice.

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Conduct disorder is a type of behavior disorder. It's when a child has antisocial behavior. He or she may disregard basic social standards and rules. He or she may also: Be irresponsible Skip school or run away (delinquent behavior) Steal or do other things to violate the rights of others Physically harm animals or other people, such as committing assault or rape These behaviors sometimes happen together.

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Center for Parent Information and Resources

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Center for Parent Information and Resources

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A central hub of information, resources, and products for parents of children with disabilities.

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Finding the motivation to make positive lifestyle changes can be hard for anyone. For teenagers, it can be especially difficult when parents are the ones telling them to do it. But if they've fallen into unhealthy habits like vaping or alcohol abuse, change can be beneficial. Motivational interviewing is a form of therapy that creates a safe, non-judgmental environment for teens to establish their own goals and values and see how changing unhealthy behaviors can benefit them in the long run.

This series of articles comes from the Child Mind Institute, with most available in English and Spanish. Why might teens be resistant to therapy and how can parents and others to help them get the treatment they need? The articles explain how motivational interviewing can help teens gain the self-confidence to make important behavioral changes. To read more about motivational interviewing, and to connect with the articles in both English and Spanish, please visit CPIR's abstract.

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Center for Parent Information and Resources | Your Central Hub for Parent Centers Serving Families of Children With Disabilities

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Finding the motivation to make positive lifestyle changes can be hard for anyone. For teenagers, it can be especially difficult when parents are the ones telling them to do it. But if they've fallen into unhealthy habits like vaping or alcohol abuse, change can be beneficial.

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This fact sheet comes from the American Counseling Association and includes a description, assessment and intervention strategies, and medications that can be useful in treating bipolar disorders.

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Substance Abuse and Mental Health Services (SAMHSA)

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Substance Abuse and Mental Health Services (SAMHSA)

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This website provides free location services in order to find treatment for substance abuse and mental illness such as bipolar disorder and depression.

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Substance Abuse and Mental Health Services Administration

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Frequently Asked Questions - What is SAMHSA’s National Helpline?

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This website is great because it has resources for parents, but also has resources where kids and teens can learn about their thoughts, feelings, emotions and behaviors.

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It's normal for kids to feel sad, act grouchy, or be in a bad mood at times. But when a sad or bad mood lasts for weeks or longer, and when there are other changes in a child's behavior, it might be depression.

Therapy can help children who are going through sadness or depression. And there are things parents can do, too. Getting the right care can prevent things from getting worse and help a child feel better.

If sadness has lasted for weeks or longer, talk about it with your child's doctor.

How Can I Tell if My Child Is Depressed?

If a child is depressed, parents may notice some of these signs:

Sad or bad mood. A child may seem sad, lonely, unhappy, or grouchy. It can last weeks or months. A child may cry more easily. They may have more tantrums than before.

Being self-critical. Kids going through depression may complain a lot. They may say self-critical things like, "I can't do anything right." "I don't have any friends." "I can't do this." "It's too hard for me."

Lack of energy and effort. Depression can drain a child's energy. They might put less effort into school than before. Even doing little tasks can feel like too much effort. Kids may seem tired, give up easily, or not try.

Not enjoying things. Kids don't have as much fun with friends or enjoy playing like before. They may not feel like doing things they used to enjoy.

Sleep and eating changes. Kids may not sleep well or seem tired even if they get enough sleep. Some may not feel like eating. Others may overeat.

Aches and pains. Some children may have stomach aches or other pains. Some miss school days because of not feeling well, even though they aren't sick.

What Causes Child Depression?

Different things can lead to depression. There is no single cause. Some children have genes that make them more sensitive to depression. They may have other family members who have been depressed.

Some children go through stressful things. Some have faced loss, trauma, or hardships. Some go through serious health conditions. These things can lead to sadness or grief - and sometimes to depression.

Having extra support during and after hard times helps protect children from depression or lessen the effects. But even when they have good support, some children get depressed. Therapy can help them heal, feel better, and get back to enjoying things.

Is Your Child Depressed?

How can parents know what's typical moodiness and when there is a problem? Learn the signs of depression and ways to help your child feel better.

What Is the Therapy for Child Depression?

The therapy for child depression is cognitive behavioral therapy (CBT). Therapists help kids feel welcome and supported. They have kids talk about what they think and feel. They may use stories, play, lessons, or workbooks. These tools can help children feel at ease and get the most from CBT. When possible, a child's therapy includes their parent.

If a child has gone through a loss, trauma, or other difficult events, the therapy will include things that help a child heal from that, too. And if a parent is dealing with their own loss or depression, the child's therapist can help them get the care and support they need.

What Should I Do if I Think My Child Is Depressed?

If you think your child is depressed:

Talk with your child about sadness and depression. Kids might not know why they are so sad and why things seem so hard. Let them know you see that they're going through a hard time and that you're there to help. Listen, comfort, offer your support, and show love.

Set up a visit with your child's doctor. Let your child's doctor know if sad or bad moods seem to go on for a few weeks. By itself, this doesn't always mean a child is depressed. Tell your child's doctor if you have also noticed changes in your child's sleep, eating, energy, or effort. Tell them if your child is dealing with a loss, a big stress, or hardship.

The doctor will do a physical exam. A full exam lets the doctor check for health issues that could cause your child's symptoms. They can also check for depression. Your child's doctor may refer you to a child therapist. The doctor's office might have a child therapist on staff.

Set up a visit with a child therapist. A child therapist (mental health doctor) will spend time talking with you and your child. They will do an in-depth check for depression by asking questions and listening. The therapist can explain how therapy can help your child.

Take your child to therapy visits. The therapist may suggest a few visits, or more. Therapy can take time, but you will see progress along the way.

Be patient and kind. When your child acts moody or difficult, try to stay patient. Talk with your child's therapist about the best ways to respond when your child acts this way. Often, it helps to connect with your child in a calm way, then guide them to better behavior. Instead of feeling bad, this lets kids feel proud of doing better. It lets them see that you're proud of them, too.

Enjoy time together. Spend time with your child doing things you both can enjoy. Go for a walk, play a game, cook, read stories, make a craft, watch a funny movie. Spend time outdoors if you can. These things gently encourage positive moods. They help you and your child feel close.

Date reviewed: September 2021

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Childhood Depression: What Parents Need to Know (for Parents)

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When a sad or bad mood lasts for weeks or longer and there are other changes in a child's behavior, it might be depression. Learn the signs of depression and what parents can do to help their child.

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National Eading Disorders Association (NEDA)

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National Eading Disorders Association (NEDA)

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This helpline offers chat, calling, and texting to get help and support for eating disorders.  You can also find information about treatment, professional development, and research conducted.

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This website is tailored for teens who are wanting to know more about eating disorders, how they are diagnosed and treated, and what to do if you feel like you have an eating disorder.

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What Are Eating Disorders?

Eating disorders are problems that affect a person's eating behaviors as well as their attitudes and feelings about food - and about their body.

Eating disorders affect a person's mental health and can cause serious harm to a person's physical health.

There are several types of eating disorders.

What Are the Different Types of Eating Disorders?

Common types of eating disorders are anorexia, bulimia, binge eating, and avoidant/restrictive food intake disorder (ARFID).

Anorexia. People with anorexia:

eat very little on purpose, leading to a very low body weight

have an intense fear of weight gain and fear looking fat

have a distorted body image and see themselves as fat even when they are very thin

People with anorexia are very strict about what and how much they will eat. They may think about food or calories almost all the time.

To lose weight, some people with anorexia fast or exercise too much. Others may use laxatives, diuretics (water pills), or enemas.

Bulimia. People with bulimia:

overeat and feel out of control to stop, called binge eating

do things to make up for overeating, such as:

make themselves throw up on purpose after overeating, called purging

use laxatives, diuretics, weight loss pills, fast, or exercise a lot to prevent weight gain

judge themselves based on body shape and weight

People with bulimia eat much more (during a set period of time) than most people would. If a person regularly binges and purges, it may be a sign of bulimia. Unlike people with anorexia who are very low weight, people with bulimia may be thin, average weight, or overweight. People with bulimia often hide their eating and purging from others.

Binge eating. People with binge eating disorder:

overeat and feel out of control to stop

eat large amounts even when they are not hungry

may feel upset or guilty after binge eating

often gain weight and may become very overweight

Many people with binge eating disorder eat faster than normal. They may eat alone so others don't see how much they are eating. Unlike people with bulimia, those with binge eating disorder do not make themselves throw up, use laxatives, or exercise a lot to make up for binge eating. If a person binge eats at least once a week for 3 months, it may be a sign of binge eating disorder.

ARFID. People with avoidant/restrictive food intake disorder:

are not interested in food or avoid foods

lose weight, or don't gain expected amount of weight

are not afraid of gaining weight

don't have a poor body image

People with ARFID don't eat because they are turned off by the smell, taste, texture, or color of food. They may be afraid that they will choke or vomit. They don't have anorexia, bulimia, or another medical problem that would explain their eating behaviors.

How Do Eating Disorders Affect Health and Emotions?

Eating disorders can cause serious problems throughout the body.

Anorexia can lead to health problems caused by undernutrition and low body weight, such as:

low blood pressure

slow or irregular heartbeats

feeling tired, weak, dizzy, or faint

constipation and bloating

irregular periods

weak bones

delayed puberty and slow growth

People with anorexia may find it hard to focus and have trouble remembering things. Mood changes and emotional problems include:

feeling alone, sad, or depressed

anxiety and fears about gaining weight

thoughts of hurting themselves

Bulimia can lead to health problems caused by vomiting, laxatives, and diuretics, such as:

low blood pressure

irregular heartbeats

feeling tired, weak, dizzy, or faint

blood in vomit or stool (poop)

tooth erosion and cavities

swollen cheeks (salivary glands)

People with bulimia may have these emotional problems:

low self-esteem, anxiety, and depression

alcohol or drug problems

thoughts of hurting themselves

Binge eating can lead to weight-related health problems, such as:

diabetes

high blood pressure

high cholesterol and triglycerides

fatty liver

sleep apnea

People with binge eating disorder may:

have low self-esteem, anxiety, or depression

feel alone, out of control, angry, or helpless

have trouble coping with strong emotions or stressful events

ARFID may lead to health problems that stem from poor nutrition, similar to anorexia. People with ARFID may:

not get enough vitamins, minerals, and protein

need tube feeding and nutrition supplements

grow poorly

People with ARFID are more likely to have:

What Causes Eating Disorders?

There's no one cause for eating disorders. Genes, environment, and stressful events all play a role. Some things can increase a person's chance of having an eating disorder, such as:

poor body image

too much focus on weight or looks

dieting at a young age

playing sports that focus on weight (gymnastics, ballet, ice skating, and wrestling)

having a family member with an eating disorder

mental health problems such as anxiety, depression, or OCD

How Are Eating Disorders Diagnosed?

Health care providers and mental health professionals diagnose eating disorders based on history, symptoms, thought patterns, eating behaviors, and an exam.

The doctor will check weight and height and compare these to previous measurements on growth charts. The doctor may order tests to see if there is another reason for the eating problems and to check for problems caused by the eating disorder.

How Are Eating Disorders Treated?

Eating disorders are best treated by a team that includes a doctor, dietitian, and therapist. Treatment includes nutrition counseling, medical care, and talk therapy (individual, group, and family therapy). The doctor might prescribe medicine to treat binge eating, anxiety, depression, or other mental health concerns.

The details of the treatment depend on the type of eating disorder and how severe it is. Some people are hospitalized because of extreme weight loss and medical complications.

What if I Have an Eating Disorder?

If you think you may have an eating disorder:

Tell someone. Tell a parent, teacher, counselor, or an adult you trust. Let them know what you're going through. Ask them to help.

Get help early. When an eating disorder is caught early, a person has a better chance of recovery. Make an appointment with your doctor or an eating disorders specialist.

Go to all appointments. Treatment takes time and effort. Work hard to learn about yourself and your emotions. Ask questions any time you have them.

Be patient with yourself. There's so much to learn, and change happens a little at a time. Take care of yourself and be with people who support you.

Where Can I Learn More About Eating Disorders?

For more information on eating disorders, visit the National Eating Disorders Association (NEDA).

For more help and support, the National Association of Anorexia Nervosa and Associated Disorders (ANAD) offers these free resources:

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Eating disorders are problems that affect a person's eating behaviors as well as attitudes and feelings about food and their body. This article for teens describes how different eating disorders impact a person's health and emotions.

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Demi Lovato Talks About Eating Disorder (2013)

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This organization is dedicated to helping families cope with anxiety and depression, and includes a mental health checklist, strategies to support anxious children, and help finding support.

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Parenting and mental health - Beyond Blue

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Find parenting information and resources to support mental health and wellbeing for children, young people and families.

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How Kids are Coping with Pandemic Anxiety

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How Kids are Coping with Pandemic Anxiety

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This article provides a great deal of information about where anxiety comes from, how anxious parents plant the seed of anxiety, how the pandemic is creating anxiety in children, and the mistakes adults make in trying to handle anxiety in children.

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Too many kids show worrying signs of fragility from a very young age. Here's what we can do about it.

Despite more than a decade's evidence that helicopter parenting is counterproductive, kids today are perhaps Updated at 10:30 a.m. ET on April 17, 2020.
Imagine for a moment that the future is going to be even more stressful than the present. Maybe we don't need to imagine this. You probably believe it. According to a survey from the Pew Research Center last year, 60 percent of American adults think that three decades from now, the U.S. will be less powerful than it is today. Almost two-thirds say it will be even more divided politically. Fifty-nine percent think the environment will be degraded. Nearly three-quarters say that the gap between the haves and have-nots will be wider. A plurality expect the average family's standard of living to have declined. Most of us, presumably, have recently become acutely aware of the danger of global plagues.

To hear more feature stories, get the Audm iPhone app.

Suppose, too, that you are brave or crazy enough to have brought a child into this world, or rather this mess. If ever there were a moment for fortifying the psyche and girding the soul, surely this is it. But how do you prepare a child for life in an uncertain time-one far more psychologically taxing than the late-20th-century world into which you were born?

To protect children from physical harm, we buy car seats, we childproof, we teach them to swim, we hover. How, though, do you inoculate a child against future anguish? For that matter, what do you do if your child seems overwhelmed by life in the here and now?

You may already know that an increasing number of our kids are not all right. But to recap: After remaining more or less flat in the 1970s and '80s, rates of adolescent depression declined slightly from the early '90s through the mid-aughts. Shortly thereafter, though, they started climbing, and they haven't stopped. Many studies, drawing on multiple data sources, confirm this; one of the more recent analyses, by Pew, shows that from 2007 to 2017, the percentage of 12-to-17-year-olds who had experienced a major depressive episode in the previous year shot up from 8 percent to 13 percent -meaning that, in the span of a decade, the number of severely depressed teenagers went from 2 million to 3.2 million. Among girls, the rate was even higher; in 2017, one in five reported experiencing major depression.

An even more wrenching manifestation of this trend can be seen in the suicide numbers. From 2007 to 2017, suicides among 10-to-24-year-olds rose 56 percent, overtaking homicide as the second leading cause of death in this age group (after accidents). The increase among preadolescents and younger teens is particularly startling. Suicides by children ages 5 to 11 have almost doubled in recent years. Children's emergency-room visits for suicide attempts or suicidal ideation rose from 580,000 in 2007 to 1.1 million in 2015; 43 percent of those visits were by children younger than 11. Trying to understand why the sort of emotional distress that once started in adolescence now seems to be leaching into younger age groups, I called Laura Prager, a child psychiatrist at Massachusetts General Hospital and a co-author of Suicide by Security Blanket, and Other Stories From the Child Psychiatry Emergency Service. Could she explain what was going on? "There are many theories, but I don't understand it fully," she replied. "I don't know that anyone does."
From December 2015: Hanna Rosin on the Silicon Valley suicides
One possible contributing factor is that, in 2004, the FDA put a warning on antidepressants, noting a possible association between antidepressant use and suicidal thinking in some young people. Prescriptions of antidepressants to children fell off sharply-leading experts to debate whether the warning resulted in more deaths than it prevented. The opioid epidemic also appears to be playing a role: One study suggests that a sixth of the increase in teen suicides can be linked to parental opioid addiction. Some experts have suggested that rising distress among preteen and adolescent girls might be linked to the fact that girls are getting their period earlier and earlier (a trend that has itself been linked to various factors, including obesity and chemical exposure).

Even taken together, though, these explanations don't totally account for what's going on. Nor can they account for the fragility that now seems to accompany so many kids out of adolescence and into their young-adult years. The closest thing to a unified theory of the case- one put forth in The Atlantic three years ago by the psychologist Jean M. Twenge and in many other places by many other people-is that smartphones and social media are to blame. But that can't explain the distress we see in kids too young to have phones. And the more the relationship between phones and mental health is studied, the less straightforward it seems. For one thing, kids the world over have smartphones, but most other countries aren't experiencing similar rises in suicides. For another, meta-analyses of recent research have found that the overall associations between screen time and adolescent well-being range from relatively small to nonexistent. (Some studies have even found positive effects: When adolescents text more in a given day, for example, they report feeling less depressed and anxious, probably because they feel greater social connection and support.)

A stronger case can be made that social media is potentially hazardous for people who are already at risk of anxiety and depression. "What we are seeing now," writes Candice Odgers, a professor at UC Irvine who has reviewed the literature closely, "might be the emergence of a new kind of digital divide, in which differences in online experiences are amplifying risks among [the] already-vulnerable." For instance, kids who are anxious are more likely than other kids to be bullied-and kids who are cyberbullied are much more likely to consider suicide. And for young people who are already struggling, online distractions can make retreating from offline life all too tempting, which can lead to deepening isolation and depression.

This more or less brings us back to where we started: Some of the kids aren't all right, and certain aspects of contemporary American life are making them less all right, at younger and younger ages. But none of this suggests much in the way of solutions. Taking phones away from miserable kids seems like a bad idea; as long as that's where much of teenagers' social lives are transacted, you'll only isolate them. Do we campaign to take away the happy kids' phones too? Wage a war on early puberty? What?

Video: Kids Feel Pandemic Anxiety Too

I have been thinking about these questions a lot lately, for journalistic reasons as well as personal ones. I am the mother of two children, 6 and 10, whose lineage includes more than its share of mental illness. Having lost one family member to suicide and watched another ravaged by addiction and psychiatric disability, I have no deeper wish for my kids than that they not be similarly afflicted. And yet, given the apparent direction of our country and our world, not to mention the ordeal that is late-stage meritocracy, I haven't been feeling optimistic about the conditions for future sanity-theirs, mine, or anyone's.
From September 2019: Daniel Markovits on how meritocracy harms everyone
To my surprise, as I began interviewing experts in children's mental health-clinicians, neuroscientists doing cutting-edge research, parents who'd achieved this unofficial status as a result of their kids' difficulties-an unusually unified chorus emerged. For all the brain's mysteries, for everything we still don't know about genetics and epigenetics, the people I spoke with emphasized what we do know about when emotional disorders start and how we might head more of them off at the pass. The when: childhood-very often early childhood. The how: treatment of anxiety, which was repeatedly described as a gateway to other mental disorders, or, in one mother's vivid phrasing, "the road to hell."

Actually, the focus on anxiety wasn't so surprising. Of course anxiety. Anxiety is, in 2020, ubiquitous, inescapable, an ambient condition. Over the course of this century, the percentage of outpatient doctors' visits in America involving a prescription for an anti-anxiety medication such as Xanax or Valium has doubled.* As for the kids: A study published in 2018, the most recent effort at such a tabulation, found that in just five years, anxiety-disorder diagnoses among young people had increased 17 percent. Anxiety is the topic of pop music (Ariana Grande's "Breathin," Julia Michaels and Selena Gomez's "Anxiety"), the country's best-selling graphic novel (Raina Telgemeier's Guts), and a whole cohort's sense of humor (see Generation Z's seemingly bottomless appetite for anxiety memes). The New York Times has even published a roundup of anxiety-themed books for little ones. "Anxiety is on the rise in all age groups," it explained, "and toddlers are not immune."
How do you inoculate a child against future anguish? What do you do if your child already seems overwhelmed in the here and now?
The good news is that new forms of treatment for children's anxiety disorders are emerging-and, as we'll see, that treatment can forestall a host of later problems. Even so, there is a problem with much of the anxiety about children's anxiety, and it brings us closer to the heart of the matter. Anxiety disorders are well worth preventing, but anxietyitself is not something to be warded off. It is a universal and necessary response to stress and uncertainty. I heard repeatedly from therapists and researchers while reporting this piece that anxiety is uncomfortable but, as with most discomfort, we can learn to tolerate it.

Yet we are doing the opposite: Far too often, we insulate our children from distress and discomfort entirely. And children who don't learn to cope with distress face a rough path to adulthood. A growing number of middle- and high-school students appear to be avoiding school due to anxiety or depression; some have stopped attending entirely. As a symptom of deteriorating mental health, experts say, "school refusal" is the equivalent of a four-alarm fire, both because it signals profound distress and because it can lead to so-called failure to launch-seen in the rising share of young adults who don't work or attend school and who are dependent on their parents.

Lynn Lyons, a therapist and co-author of Anxious Kids, Anxious Parents, told me that the childhood mental-health crisis risks becoming self-perpetuating: "The worse that the numbers get about our kids' mental health-the more anxiety, depression, and suicide increase-the more fearful parents become. The more fearful parents become, the more they continue to do the things that are inadvertently contributing to these problems."
Read: What the coronavirus will do to kids
This is the essence of our moment. The problem with kids today is also a crisis of parenting today, which is itself growing worse as parental stress rises, for a variety of reasons. And so we have a vicious cycle in which adult stress leads to child stress, which leads to more adult stress, which leads to an epidemic of anxiety at all ages.

I. The Seeds of Anxiety

Over the past two or three decades, epidemiologists have conducted large, nationally representative studies screening children for psychiatric disorders, then following those children into adulthood. As a result, we now know that anxiety disorders are by far the most common psychiatric condition in children, and are far more common than we thought 20 or 30 years ago. We know they affect nearly a third of adolescents ages 13 to 18, and that their median age of onset is 11, although some anxiety disorders start much earlier (the median age for a phobia to start is 7).

Many cases of childhood anxiety go away on their own-and if you don't have an anxiety disorder in childhood, you're unlikely to develop one as an adult. Less happily, the cases that don't resolve tend to get more severe and to lead to further problems- first additional anxiety disorders, then mood and substance-abuse disorders. "Age 4 might be specific phobia. Age 7 is going to be separation anxiety plus the specific phobia," says Anne Marie Albano, the director of the Columbia University Clinic for Anxiety and Related Disorders. "Age 12 is going to be separation anxiety, social anxiety, and the specific phobia. Anxiety picks its own friends up first before it branches into the other disorders." And the earlier it starts, the more likely depression is to follow.

All of which means we can no longer assume that childhood distress is a phase to be grown out of. "The group of kids whose problems don't go away account for most adults who have problems," says the National Institute of Mental Health's Daniel Pine, a leading authority on how anxiety develops in children. "People go on to develop a whole host of other problems that aren't anxiety." Ronald C. Kessler, a professor of health-care policy at Harvard, once made this point especially vividly: "Fear of dogs at age 5 or 10 is important not because fear of dogs impairs the quality of your life," he said. "Fear of dogs is important because it makes you four times more likely to end up a 25-year-old, depressed, high-school-dropout single mother who is drug-dependent."

Compounding this, the young kids with mental-health problems today may have worse long-term prospects than did similar kids in decades past. That is the conclusion drawn by Ruth Sellers, a University of Sussex research psychologist who examined three longitudinal studies of British youth. Sellers found that youth with mental-health problems at age 7 are more likely to be socially isolated and victimized by peers later in childhood, and to have mental-health and academic difficulties at age 16. Concerningly, despite decreased stigma and increases in mental-health-care spending, these associations have been growing stronger over time.

Big societal shifts such as the ones we've undergone in recent years can hit people with particular traits particularly hard. A recent example comes from China, where shy, quiet children used to be well liked and tended to thrive. Following rapid social and economic change in urban areas, values have changed, and these children now tend to be rejected by their peers-and, surely no coincidence, are more prone to depressive symptoms. I thought of this when I met recently with the leaders of a support group for parents of struggling young adults in the Washington, D.C., area, most of whom still live at home. Some of these grown children have psychiatric diagnoses; all have had difficulty with the hurdles and humiliations of life in a deeply competitive culture, one with a narrowing definition of success and a rising cost of living.

The hope of early treatment is that by getting to a child when she's 7, we may be able to stop or at least slow the distressing trajectory charted by Sellers and other researchers. And cognitive behavioral therapy, the most empirically supported therapy for anxiety, is often sufficient to do just that. In the case of anxiety, CBT typically involves a combination of what's known as "cognitive restructuring"-learning to spot maladaptive beliefs and challenge them-and exposure to the very things that cause you anxiety. The goal of exposure is to desensitize you to these things and also to give you practice riding out your anxious feelings, rather than avoiding them.

Most of the time, according to the largest and most authoritative study to date, CBT works: After a 12-week course, 60 percent of children with anxiety disorders were "very much improved" or "much improved." But it isn't a permanent cure-its results tend to fade over time, and people whose anxiety resurges may need follow-up courses.

A bigger problem is that cognitive behavioral therapy can only work if the patient is motivated, and many anxious children have approximately zero interest in battling their fears. And CBT focuses on the child's role in his or her anxiety disorder, while neglecting the parents' responses to that anxiety. (Even when a parent participates in the therapy, the emphasis typically remains on what the child, not the parent, is doing.)

A highly promising new treatment out of Yale University's Child Study Center called SPACE (Supportive Parenting for Anxious Childhood Emotions) takes a different approach. SPACE treats kids without directlytreating kids, and by instead treating their parents. It is as effective as CBT, according to a widely noted study published in the Journal of the American Academy of C hild & Adolescent Psychiatry earlier this year, and reaches even those kids who refuse help. Not surprisingly, it has provoked a tremendous amount of excitement in the children's-mental-health world-so much so that when I began reporting this piece, I quickly lost track of the number of people who asked whether I'd read about it yet, or talked with Eli Lebowitz, the psychology professor who created it.

In working directly with parents, Lebowitz's approach aims to provide not a temporary solution, but a foundation for a lifetime of successful coping. SPACE is also, I have come to believe, much more than a way of treating childhood anxiety-it is an important keyhole to the broken way American adults now approach parenting.

When Lebowitz teaches other clinicians how to do SPACE, he starts by telling them, several times, that he's not blaming parents for their kids' pathologies.

"Because we represent a field with a very rich history of blaming parents for pretty much everything-autism, schizophrenia, eating disorders-this is a really important point," he said one Sunday morning in January, as he and his collaborator Yaara Shimshoni kicked off a two-day training for therapists. A few dozen were in attendance, having traveled to Yale from across the country so that they might learn to help parents reduce what Lebowitz calls "accommodating" behaviors and what the rest of us may call "behaviors typical of a 21st-century parent."

"There really isn't evidence to demonstrate that parents cause children's anxiety disorders in the vast majority of cases," Lebowitz said. But-and this is a big but-there is research establishing a correlation between children's anxiety and parents' behavior. SPACE, he continued, is predicated on the simple idea that you can combat a kid's anxiety disorder by reducing parental accommodation-basically, those things a parent does to alleviate a child's anxious feelings. If a child is afraid of dogs, an accommodation might be walking her across the street so as to avoid one. If a child is scared of the dark, it might be letting him sleep in your bed.

Lebowitz borrowed the concept about a decade ago from the literature on how obsessive-compulsive disorder affects a patient's family members and vice versa. (As he put it to me, family members end up living as though they, too, have OCD: " Everybody's washing their hands. Everybody's changing their clothes. Nobody's saying this word or that word.") In the years since, accommodation has become a focus of anxiety research. We now know that about 95 percent of parents of anxious children engage in accommodation. We also know that higher degrees of accommodation are associated with more severe anxiety symptoms, more severe impairment, and worse treatment outcomes. These findings have potential implications even for children who are not (yet) clinically anxious: The everyday efforts we make to prevent kids' distress-minimizing things that worry them or scare them, assisting with difficult tasks rather than letting them struggle-may not help them manage it in the long term. When my daughter is in tears because she hasn't finished a school project that's due the next morning, I sometimes stop her crying by coaching her through the rest of it. But when I do, she doesn't learn to handle deadline jitters. When she asks me whether anyone in our family will die of COVID-19, an unequivocal "No, don't worry" may reassure her now, but a longer, harder conversation about life's uncertainties might do more to help her in the future.
more overprotected, more leery of adulthood, more in need of therapy.
Parents know they aren't helping their kids by accommodating their fears; they tell Lebowitz as much. But they also say they don't know how to stop. They fear that day-to-day life will become unmanageable.

Here are some things that, over the course of the SPACE training, I heard of parents doing to avoid setting off their anxious children:

Going upstairs to get a child's backpack before school because the child is scared to be alone in any area of the house and the parent doesn't have time to argue about it. Driving a child to school because the child is frightened of the bus, with the result that the mother is late to work every single day.

Tying and retying a child's shoes until they feel just right.

Spending 30 minutes a day, on average, checking and rechecking a child's homework.

Announcing one's presence as one moves around the house, so that a child will at all times know where to find a parent ("I'm going to the kitchen, Oliver"). Accompanying a 9-year-old child to the toilet because he is afraid to be alone. Allowing a 9-year-old to accompany a parent to the toilet because he is afraid to be alone. Peeing in a bucket-a mother, not a child-because the basement playroom has no bathroom, and the child is afraid to be alone.

Allowing a child to sleep in the parents' bed. Sitting or lying with a child while he falls asleep.

Always carrying a plastic bag because a child is afraid she'll vomit.

Cutting a 13-year-old's food because she's afraid of knives.

Ceasing to have visitors because a child is intensely shy. Speaking for a child in restaurants. Asking a child's teacher not to call on her in class.

Installing the Find My Friends app on a child's phone so that the child can track the parents' whereabouts.

Preparing different foods for a child because she won't eat what everyone else eats.

Buying a new burglar alarm. Buying a new car. Seriously contemplating buying a new house.

The list went on and on. The most disorienting thing about it was not its length, but the way it merged stories that seemed to me bizarre but turned out to be commonplace with stories that sounded familiar but upon further consideration seemed unhealthy. Many of us think nothing of preparing different meals for different family members. Bedtime has become such a protracted affair that parents may now do the work a stuffed animal once did.

I barely suppressed a laugh at the idea of a kid tracking his parents, rather than vice versa, but murmurs of recognition sounded around the room. "That's common," one therapist said. The idea of buying a new house must have made my eyebrows go up, because another woman leaned over and whispered: "I have a family that moved to a split-level because the daughter didn't like to be out of earshot."

Over the course of 12 sessions, SPACE helps parents figure out how to start reducing their accommodations, while also expressing empathy for their child's suffering and confidence in her capabilities. If it works, and usually it does, it sets in motion a virtuous cycle: As parent behavior changes, kids will start coping for themselves. As they cope, they'll come to feel more capable, and they will be treated as such by their parents, who will further reduce accommodation. In turn, the entire family's well-being will improve.

AtlanticLIVE: Children in an Anxious Age

II. The Anxious Parent

Most critiques of this century's child-rearing practices have treated parents as rational actors, however extreme some of our actions might be. If we hover above our children (or lawn-mower or bulldoze or snowplow a path for them), we are said to do so in reaction to the surrounding conditions-media coverage of kidnappings, for example, or plummeting college-admission rates. In other words, modern parents, or at least the upper-middle-class ones who populate most articles about parenting trends, are widely perceived not as flailing but as the opposite: too hyper, too competent, too vigilant. And yet, despite more than a decade's evidence that helicopter parenting is counterproductive-see, among other widely read takedowns, the Atlantic articles " How to Land Your Kid in Therapy," by Lori Gottlieb, and " The Overprotected Kid," by Hanna Rosin, and such books as Julie Lythcott-Haims's How to Raise an Adult- kids today are perhaps more overprotected, more leery of adulthood, more in need of therapy.

Which raises a question: If modern parents are so unrelentingly on top of things, why have we not corrected course? Could it be that we are not at all on top of things? Might our children's faltering mental health be related less to our hard-driving style than to our exhaustion and guilt and failure to put our foot down? We complain about kids being thin-skinned and susceptible to peer pressure, but maybe we're the ones who are hypersensitive, to the judgment of our peers and, especially, of our children. And the harder we try to do the right thing-the more we nurture them, the more quickly we respond to their needs-the more we tie ourselves in knots.

Recently, several longtime commentators on the parenting scene have begun to sound similar notes. Take the evolution of Madeline Levine, the Bay Area psychologist whose 2006 best seller, The Price of Privilege, (reasonably) chastised parents for imposing their own ambitions on their children. Her new book, Ready or Not, offers a darker if also more sympathetic take on what it's like to rear children in a world that appears to be unraveling, noting "the damage [that] unchecked anxiety does to parents' decision-making."

Consider, too, the 2018 book The Self-Driven Child, by William Stixrud, a clinical neuropsychologist, and Ned Johnson, who runs a successful Washington, D.C., tutoring business (as close as one gets to a ringside seat at the meritocratic circus). They argue that today's parents deprive children of meaningful control over their own lives, putting them at heightened risk of anxiety and depression. And they devote a whole chapter to how parents ' mental health is harming that of their children. "Children don't need perfect parents, but they do benefit greatly from parents who can serve as a non-anxious presence," they write.

The book has struck such a chord among parents that, two years after its publication, Stixrud and Johnson are still on the national speaking circuit. In their hundreds of appearances and thousands of conversations with parents, they have come to believe that parents' anxiety about their kids is even greater than they had realized, and more concerning. Watching them do a Q&A with private-school parents in December, I could see why. The audience was vibrating with self-doubt, asking fumbling questions about everything from academic pressure to sleep.

When I had coffee with Johnson the next day and later emailed with him, he told me that, since writing the book, he has concluded that parents' overprotection of kids includes an under-recognized element of self-protection. When we shelter kids from difficulty or challenge, he says, we are not merely shielding them from distress; we are warding off the distress that their distress causes us. Moreover, when school and family systems both have a baseline level of stress-when adults are always on high alert-kids don't get a chance to rebound, and so they resist taking on the sorts of natural and healthy risks that will help them grow. " Et voilà," he said, "a generation of anxious kids, looking fearfully at the world around them, who become anxious adults.

"What happened to us adults that made us the helicopter parents we too often are?"

Anxiety travels in families. It travels in families partly because it has a hereditary component: Studies of twins suggest that about 30 to 40 percent of a person's risk for an anxiety disorder is genetic (versus 60 percent or more for bipolar disorder, autism, and schizophrenia). To an even greater extent, anxiety travels in families because it is contagious-from spouse to spouse, from child to parent, and especially from parent to child. More than half of children who live with an anxious parent end up meeting the criteria for an anxiety disorder themselves.

Recognizing the relationship between parental and child anxiety suggests an important means of prevention and intervention: Because anxiety is only partially genetic, a change in parenting style may well help spare a child's mental health.

In one famous study of how changes to parental health affect a child's health, Myrna Weissman, a professor at Columbia University, established that treating a depressed mother with antidepressants quickly reduced depressive symptoms in her child; other researchers have since found that treating a mother with psychotherapy (such as CBT) has the same indirect benefit for her kids. In 2015, Golda S. Ginsburg of the University of Connecticut published the results of the first American study specifically focused on preventing anxiety disorders in children of anxious parents. The intervention, which involved giving anxious parents and their children eight weekly sessions with a therapist who taught them about anxiety, had dramatic effects: Within a year, only 5 percent of the children whose families had received the intervention met the criteria for an anxiety disorder, compared with 31 percent of children in a control group.

Another hint as to how parenting can affect childhood anxiety comes from the research on what's known as behavioral inhibition-a shy, sensitive temperament that's found in about 15 percent of 3-year-olds and that constitutes one of the strongest known risk factors for the development of anxiety disorders. Nathan Fox of the University of Maryland has spent the past few decades conducting longitudinal studies that explore how this temperament predicts experiences later in life. About 20 years ago, as Fox and his colleague Kenneth Rubin combed through the data from the first of these studies, trying to figure out what differentiated the kids who overcame their inhibition from the ones who didn't, they came across an unexpected clue: Those who went to day care for their first two years were far more likely to be spared anxiety down the line than those who stayed home.

"On one level, it's intuitive," Fox says. "You put them into an environment with other kids; they're desensitized to novelty or unfamiliarity; they get to interact at a very early age with other kids." Fox and Rubin suspected that day care was also giving some behaviorally inhibited kids a much-needed break from their parents, who were likely to have an anxious parenting style-again, anxiety runs in families. Day care wasn't the key factor; parenting was. Fox and Rubin found, and other researchers have since confirmed, that parenting style at age 2 predicts continuing behavioral inhibition at age 4-and, in turn, later risk of psychological problems. As Rubin put it to me: "The kids who maintain reticent behavior are the kids whose parents bubble-wrap them."

III. Short-Term Gain, Long-Term Pain

We all have dreams, and Angela and Seth's was to stop making turkey loaf.

By the time they sought help from the SPACE program's Yaara Shimshoni last year, they had served it to their then-6-year-old son, Owen, some 3,000 times. (I have changed parents' and children's names.) Put another way, virtually every day for four years-two-thirds of his life-Owen had eaten turkey loaf for both lunch and dinner. For breakfast, he favored dry Cheerios.

Calling Owen a picky eater wouldn't have captured the extent of the problem. He was terrified of most foods. On those rare occasions when he tasted something new, he would gag. Going out together as a family was a minor ordeal: Either they packed turkey loaf to take with them, or they hurried home before the next meal. Mostly, the family just stayed in. "If we ran out of it, Owen would have an absolute fit," Seth said when he and Angela spoke with me in February. Once, after a supermarket strike disrupted the local turkey supply, he spent the night driving from store to store, searching for enough meat to get through the week.

Trying to understand how two down-to-earth-sounding people had found themselves in this predicament, I asked Angela and Seth whether they had been fans of turkey loaf to begin with. Was the recipe an old family favorite? "Oh God, no," Seth said, horrified, explaining that they'd found it on a kids'-food blog when Owen was a toddler. "Disgusting," Angela said with conviction. "It looks like prison food," Seth added. They were very clear about another thing, too: They hadn't simply found themselves in this predicament; over the course of their 12-week program with Shimshoni, they'd concluded that they'd helped create it. "Owen started off with eating issues"-he had been born prematurely and stayed in the NICU for a month because he refused to feed-"and we started getting our own anxieties" is how Seth put it. "I thought that I was doing the right thing by just keeping him happy and making him comfortable," Angela said.

As ready as Owen's parents were to take responsibility for his issues, I couldn't help but notice the role played by something else: time, and the juggling acts parents develop to compensate for the lack of it. Owen wouldn't have been fed turkey loaf 3,000 times had he and his parents been sharing meals; they wouldn't have stood for it. But, like many parents, they staggered their work schedules. Seth picked Owen up at day care and fed him dinner. He and Angela ate later, after Owen was asleep. One of the first changes Shimshoni recommended was that they begin having dinner as a family. Owen didn't have to eat everything his parents ate, but he could choose only from among the foods on the table-no substitutions. After dinner, the kitchen closed for the night. Shimshoni says her goal is not to turn a picky eater into an omnivore, but to get a kid like Owen to the point where he can find something to eat in most situations. When I spoke with Angela and Seth, Owen was several months into his post-SPACE life. He isn't an adventurous eater, but he now gets by without bringing turkey loaf everywhere.

If the instinct to protect a child leads many of us into the trap of overparenting, I've come to believe that time pressures keep us there. In conversation after conversation with parents who were struggling to reduce a child's dependency and fearfulness, rushed weekday mornings and evenings emerged as the crucible in which bad habits had formed. Eli Lebowitz makes much the same point. "One of the reasons parents accommodate is a child in distress, but another big reason is I want to get my child to school. That is a powerful driver too," he said: " I have to get to work after I drop you at school. "

Ruthie Arbit, a therapist who specializes in maternal and pediatric mental health, observes that for mothers, especially, time pressure can be compounded by guilt. "When there's all the guilt that, as a working parent, I missed X, Y, Z," she told me, "it's a lot harder to follow through with an unpleasant behavioral intervention." And if you have only an hour with your child at night, you'd like it to be a pleasant one. A parent's own underlying anxiety may also come to the fore. More than once in my interviews with SPACE parents and clinicians, I found myself thinking of the program as a form of exposure therapy not just for kids but for parents: If we learn to tolerate our children's discomfort, we can stop getting in the way of their efforts to cope with it.

Therapists who treat anxiety like to talk about how short-term pain leads to long-term gain-how enduring discomfort now can make you more resilient later. In recent decades, however, the opposite principle has guided many American parents, and not only when it comes to the parenting of anxious children: On everything from toilet training to eating and sleeping habits, many of our parenting strategies trade short-term gain (a few minutes saved here, a conflict averted there) for long-term pain.

That we would cut corners in this way is maybe inevitable in a country that lacks adequate parental leave or quality, affordable child care; one in which school and employment schedules are misaligned, and in which our work culture expects employees to always be on. Add to the mix a permissive streak in American child-rearing, one that has simultaneously indulged children and encouraged their independence, and you have an extremely labor-intensive recipe for parental misery. "The accusation that American mothers coddle their children is not new," writes the historian Paula S. Fass in her 2016 book, The End of American Childhood-but its recent combination with maternal employment has made for especially overburdened lives. By way of illustrating the point, she relates the contrast that Sara Harkness and Charles Super, two ethnographers, have drawn between American and Dutch parents:

American parents much more frequently emphasize individual attention, active interaction, and the developmental needs of the child ... Dutch parents put their faith in regularity of habits (rest, quiet, and cleanliness) and family time together, especially around meals ... One result of these different goals in households equally devoted to children's welfare was that American parents were often tired and appeared frazzled. They tended to complain about their children's sleeping habits and gave in to their demands because they were too exhausted to fight in the middle of the night.

The problem isn't that American parents aren't trying; if anything we're trying too hard, but in ways that backfire, leaving us less time for the things that matter most. At a lab I visited at the University of Maryland, I learned about the Turtle Program, an intervention that, among other things, directs parents to set aside five minutes of "special time" each day with their behaviorally inhibited preschoolers, to be spent doing whatever the child chooses, with no directions or corrections given by parents. Parents told me how thirstily their children had drunk up this modest amount of time, so I tried it on my (non-anxious) 6-year-old. He was at first incredulous and then overjoyed. I realized, in dismay, just how divided my attention is most of the time, and how many of our interactions are dominated by my telling him to do this or not to do that, especially when I am rushing.
From July/August 2018: Erika Christakis on the dangers of distracted parenting
Changes in the way we've approached toilet training are a particularly dramatic example of how something that seems child-friendly can turn out to be parent-unfriendly and therefore everyone-unfriendly. As the early-childhood expert Erika Christakis notes in The Importance of Being Little, the age at which children are toilet trained has crept up over time. Several decades ago, 60 percent of 18-month-olds were fully trained. Studies earlier this century show only about half of American children being toilet trained by age 3, and today it's not uncommon to see 4-year-olds wearing Pull-Ups. Some people have attributed this to a move away from harsh, old-school training methods, but I wonder whether an equal problem isn't parents' lack of time. Around my daughter's second birthday, I saw a copy of Potty Training for Dummies by the register at Buy Buy Baby and impulsively bought it. I might not have, had I realized that it prescribed a festive three-day boot camp mortifyingly called "Potty Mambo Weekend." In any case, the approach worked-but in conversations, I noticed how overwhelmed some friends seemed by the idea. Who had three days to spare? And yet, as Christakis notes, "time spent changing diapers is surely worth something, too." (Delayed potty training makes for a strange contrast with the fact that many preschools have recently become more academic. The split screen between the two things-learning to read and write, still in diapers-foreshadows the situation later on, when high-school kids shoulder intense academic pressure even as many are behind in developing life skills.)

Or consider sleep. Whichever side one takes in the wars over infant sleep-training and bed-sharing, as children grow older, it can be easy to fall into the trap of privileging one night's sleep over long-term sleep skills. Among parents I surveyed, certain refrains emerged. "I often let my 9 year old fall asleep w/us b/c she has anxiety at night," one mother wrote me. "The sleeping in our bed is just us wanting to go to sleep as well." Others mentioned how different their approach was from that of their parents. "As a kid, I was terrified of the dark. I had a night-light, and that was it," another mother observed. "I don't think it even occurred to me to ask my parents to stay with me while I fell asleep, nor can I imagine they would have entertained it if asked."

Of course, the more we parent this way day to day, the more time parenting consumes over the years. Understanding this cycle sheds light on a widely remarked-upon and baffling statistic: Time-use studies tell us that parents today spend significantly more hours caring for children than parents did 50 years ago, despite the fact that we work more hours outside the home. One explanation for this strange fact, as has been widely noted, is that kids today spend less time on their own. But a second, as we've just seen, is that parents really are doing more for their kids-and many kids are doing less for themselves.

IV. Failure to Launch

For one hint of just how much parenting style may influence a child's anxiety level, consider the diverging paths of boys and girls.

"There is no greater risk factor for anxiety disorders than being born female," Andrea Petersen writes in On Edge, her exploration of anxiety. "Women are about twice as likely as men to develop one, and women's illnesses generally last longer, have more severe symptoms, and are more disabling." Weirdly enough, females start off the less anxious sex; male newborns are the fussy, irritable ones. Various theories have been advanced as to why women end up more fearful and inhibited than men, but to my mind the most convincing is that, when we were kids, adults responded disparately to our fears. "When girls are anxious, adults are more likely to be protective and allow them to avoid scary situations. Boys are told to suck it up ... It is as if boys are engaged in continual exposure therapy," Petersen writes, going on to detail a damning body of research showing how parents have, through the decades, encouraged bravery and independence in boys while discouraging those traits in girls.

Maybe the way to think about recent parenting is this: All kids today are being overprotected the way only girls used to be. Except the changes in childhood are far broader than that. Even girls, after all, used to get themselves around the neighborhood and have summer jobs and chores. Today, only 10 percent of kids walk or bicycle to school, a steep decline from decades past. Forty years ago, 58 percent of teenagers got summer jobs; today, 35 percent do, and the after-school job is an even rarer species. When Braun Research surveyed more than 1,000 American adults, 82 percent said that as children they'd had regular chores-but only 28 percent said their own children did.

The problem with these declines is not that the activities in question are inherently virtuous, but that they provide children with two very important things, the first of which is experience tolerating discomfort. When I began interviewing clinicians, I was struck by how many of them talked about the importance of learning to endure emotional upset as well as physical distress and even pain. (Elisa Nebolsine, a child therapist who specializes in CBT, told me that when she meets parents, one of her first questions is: "How does your kid do being uncomfortable, being tired, being hot, being hungry?") This message was so consistent, in fact, that some of the therapists started to sound like members of a cult with a sadistic bent. But I came to understand their concern. The more I thought about it, the more I saw myself shielding my kids from even the mild discomforts of my own childhood. Unless I had a high fever as a child, I was never given an analgesic. Why was I so ready to dole out liquid Tylenol, and in a choice of flavors? Speaking of flavors, why was I buying Crest Kid's Sparkle Fun Toothpaste at a 50 percent markup over regular, I mean "spicy," toothpaste (the only kind I knew as a child)? And why was I vetting my kids' movie selections on Common Sense Media, a website that exhaustively catalogs frightening or otherwise objectionable content in children's entertainment?

Doing chores and getting oneself where one needs to go also provide another, more obvious benefit: a sense of personal competence. This may be why doing chores from age 3 or 4 onward has been found to be a very strong predictor of academic, professional, and relational success in young adulthood. Obviously many people do just fine in life without ever having a summer job or walking themselves to school. But these developments combine with the recent changes in child-rearing and technology to create a particularly toxic combination: teenagers with a deficit of life skills, a lack of practice weathering the frustrations to which that deficit may lead, and the means to retreat and distract themselves from those frustrations.
From November 2018: Alexis Madrigal on the dangers of YouTube for young children
Over the past five years, the age at which most kids get a smartphone has continued to tick downward. In 2015, according to a study by Common Sense Media, 32 percent of 11-year-olds had one; last year, 53 percent did. Several factors appear to be driving this and related trends. For kids of all ages, screens are cheap and reliable babysitters (see: time famine). Some parents embrace phones because they enable tracking of kids (see: parental anxiety). Others surrender to demands for technology because they can't tolerate either their own kids' anger or peer pressure from other kids' parents. Finally, many parents have difficulty limiting their own device use, which may weaken their feeling of authority on the matter.

Again, technology is not necessarily bad for mental health, especially as kids get older; for many teens, it can be a conduit for social support. But if you have an anxiety disorder and want to avoid things-other people, say, or the outside world-various aspects of digital life are ideally (meaning disastrously) suited to that goal. This appears to be especially true for two groups in particular. The first is young adults experiencing failure to launch-not working or attending school, and dependent on their parents. The second is those teenagers practicing "school refusal." Lebowitz's approach to both groups is multifaceted, as it must be-by the time young people get to this point, their problems tend to be pretty complicated. One key tactic is to strategically limit internet access when it seems to be making avoidance of something too comfortable-much the way he tries to limit parental accommodation. In school-refusal cases, for example, he counsels that if a kid is home during the school day, she shouldn't have access to things she wouldn't have if she were at school: TVs, phones, tablets, video games, parental attention, even recreational reading. "Books are highly entertaining, and boredom is our ally in this particular struggle," Lebowitz explained during the SPACE training I attended.

This was the only moment in the two-day workshop when I heard participants express skepticism-our lives were too enmeshed with tech, they suggested, and kids were too tech savvy; removing internet access, even for a school day, was a lost cause. Lebowitz held firm. If you want to, you can. TV connected to the wall? Take the cord and the remote to work. Too many devices to keep track of? Get Circle, an access controller that attaches to your router. He is hair-on-fire about this point: For vulnerable kids, on-demand internet access makes hiding out much too comfortable. "It's almost like the internet is devised to enable these problems, because you're not naturally bored," he said. "You can have social stimulation without the social stress of actual people."

Lebowitz published a small study in 2012 on his work with parents of failure-to-launch young adults and has since treated a few dozen more families, with promising results. He says one of the most gratifying parts of his work is when, years later, he gets letters from parents with updates on a son or daughter who has finally gone to college or gotten married or otherwise picked up a life that was on hold. In February, I talked with the parents of one such young adult, Andy, who is in his early 20s. When Clive and Nora started working with Lebowitz, early last year, Andy hadn't attended school regularly in several years, due to a stew of learning issues, depression, and anxiety. He was enrolled in a private high school, though he essentially never went. They had tried, with mixed success, different therapies, but eventually he refused help. Most of the time, he stayed in his room.
The more overwhelming the world gets, the more adults try to blindfold children.
Lebowitz encouraged Clive and Nora to pick a single goal-Andy finishing high school-and to focus on how their accommodations (housing Andy, feeding him, giving him a car and a phone and Wi-Fi) were helping him avoid it. Jumping back into school overnight was unrealistic, so Lebowitz advised breaking the goal into achievable steps. The first, which lasted for a few weeks, was for Andy to get himself to school every day. He didn't have to go to class, but he did need to send his parents a selfie proving that he'd been there; if he didn't, they would withhold internet access for 24 hours.

When Clive and Nora announced this plan, Andy said it was really stupid. But within a day or two, he was complying, and he took more small steps in the months that followed. He started dating, and even had a girlfriend for several months; today, he's almost finished with high school. Clive and Nora's own thinking and behavior have also shifted radically. Nora says that if she had known sooner what she knows now, she would have reacted far less to Andy's anxiety from the beginning. "Even when he was 4 or 5, he would ask me to stay home from school, and I often accommodated that," she said. Clive now realizes that the more he helped Andy solve problems over the years, the worse Andy's own problem-solving skills got.

This isn't to say that the past year has been entirely smooth; along the way Nora and Clive have repeatedly been tempted to swoop in and help. One example of this has stuck with me. When Andy skipped school for a few days, they turned off the internet, so he began using his phone's data and soon ran out. He wanted to go see his girlfriend, but he didn't know how to get to her house without Waze, so he started sending his parents panicked texts, asking what they expected him to do. In turn they had a crisis of confidence. They wanted him out of the house and seeing people. Should they buy him more data? They called Lebowitz. "It's not your problem," he told them. "Just say, 'We trust that you will find your way.' "

And he did.

V. "Draw the Earthquake"

Parenting style is not the only thing that can fortify our kids. Sleep, exercise, and friendship all confer tremendous psychological benefits, and are within our powers to promote, both individually and societally. A morally more urgent task is to reduce poverty, instability, and deep trauma (as opposed to ordinary stress) in children's lives; research on these adverse childhood experiences demonstrates the overwhelming risk they pose to psychological functioning. The lack of children's mental-health care is another pressing problem: Most children who need it don't get it, and what they do get tends not to be evidence-based care (such as CBT). Finally, if we want to create the conditions for children's mental health, we must first create the conditions for adult sanity, in the form of more support for families. It's been said that a society that cares about children must also care about parents. That's undoubtedly true. It's also been said that a parent is only as happy as her unhappiest child. That's true too, though, again, the relationship runs both ways. The more our unhappy children worry, the more we worry about them, and the more we worry about them, the more we do the very things that lead their worries to flourish.
From March 2019: Erika Christakis on how active shooter drills are tragically misguided
Of the many cutting portrayals of modern motherhood offered up by HBO's Big Little Lies, the most evocative may be the episode in which Amabella, the second-grade daughter of Renata (played by Laura Dern), has a panic attack at school and passes out. A child therapist is dispatched, and reports that young Amabella is worried about the planet. "Her class is evidently talking about climate change," the therapist explains. "She's gotten the message that we're doomed." Renata is livid at the school for spilling the beans, as are other parents; a meeting is convened with the principal, who limply declares anxiety "an epidemic in our schools." Because it is Big Little Lies, the particulars are over the top (Renata promises, or threatens, to "buy a fucking polar bear" for each kid), but the angst is recognizable.

When I spoke with Kathryn L. Humphreys, a psychology professor at Vanderbilt University who specializes in the effects of caregiving in early life, she observed a widespread hesitancy to talk about depressing concepts with kids. Parents seem to feel that doing so is "developmentally inappropriate," she mused, though this strikes her as exactly backwards given what we know about the benefits of graduated exposure to things that frighten us. Humphreys listens to the news after work, and her 4-year-old daughter will often ask tough questions. She told me she understands why people are concerned about having difficult conversations with kids, and yet, she asked, "At what age is it that you think kids are capable of that?" Scary things are happening all the time, and avoiding them-"We're just gonna turn off the news!" as she put it-won't change that. "Sometimes it's the avoidance that makes it harder for kids who are anxious," she added.

In my experience, this cloistering extends to everything from the Holocaust to sex. I'm surprised by how many of my friends think their fourth and fifth graders don't know how babies are made. Meanwhile, the efforts parents make to promote belief in, for example, Santa Claus seem more fervent than ever, via tools like Elf on the Shelf and apps that supposedly show Santa's visit to your home. One of the more revealing mommy-board threads I've encountered began with an irate warning titled "Super Fudge book outs Santa as fake." More than 100 people jumped into the outraged fray that followed, all over a revelation in a classic Judy Blume novel that's aimed at third-to-sixth graders and that came out four decades ago. So we find ourselves with a bizarre mishmash: Some adults think their fourth graders believe in Santa Claus and don't know how babies are made while other adults-or maybe some of the same adults-think fourth graders should have smartphones. In another era, the desire to keep kids in the dark might not be a problem, but it's a strange combination with the easy access many of them now have to Pornhub and viral videos of real-life violence.

As I contemplate the likelihood that my kids' lives will be more stressful than mine, my mind keeps wandering to two children's drawings reproduced in the pediatrician W. Thomas Boyce's book The Orchid and the Dandelion: Why Some Children Struggle and How All Can Thrive. Both depict California's 1989 Loma Prieta earthquake, which killed dozens of people-and also, as chance would have it, occurred midway through a study Boyce was conducting of whether stress increased local children's susceptibility to illness. Naturally, he and his team expanded the study to incorporate their reactions to the disaster, and they asked each child to "draw the earthquake." The kids' responses varied dramatically. Some produced cheerful pictures-"homes with minor damage, happy families, and smiling yellow suns"-while others generated scenes of destruction and injury, fear and sadness. To Boyce's fascination, children who drew darker scenes tended to stay healthy in the weeks that followed, while those who drew sunny pictures were more likely to come down with infections and illnesses.

Boyce now believes it was protective for children to create "honest, even brutal depictions of a no-doubt-about-it disaster." We talk about things that scare us, he ventures, "because it makes them gradually less scary; about sadness, because it makes the sadness diminish a little each time we do." I am drawn to this story in part because in 1989 I was 11 years old, I lived in the Bay Area, and I was deeply, morbidly fascinated by the earthquake and its human toll. But I am also attracted to it because its moral is at odds with the way adults so often try to shield children from difficult topics. In fact, it sometimes seems that the more overwhelming the world gets, the more adults try to blindfold children.

In the end, one lesson we might derive from everything scientists and clinicians have learned about anxiety is this: If we want to prepare our kids for difficult times, we should let them fail at things now, and allow them to encounter obstacles and to talk candidly about worrisome topics. To be very clear, this is not a cure-all for mental illness. What we need to recognize, though, is that our current approach to childhood doesn't reduce basic human vulnerabilities. It exacerbates them.
This article appears in the May 2020 print edition with the headline "Childhood in an Anxious Age."
* This article originally stated that more than a quarter of doctor visits end with a prescription for an anti-anxiety medication. In fact, 7.4 percent do.

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emergence of a new kind of digital divide

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Too many kids show worrying signs of fragility from a very young age. Here's what we can do about it.