Nicole Jederlinic, DO
Lindner Center of HOPE Staff Psychiatrist and Medical Director for the Cincinnati Children’s Hospital Acute Unit at Lindner Center of HOPE

As an inpatient and outpatient child / adolescent psychiatrist, I see children and teens, and, consequently, their families facing a wide range of mental health conditions. In the wake of the extensive remote learning related to the COVID-19 pandemic, these challenges have become increasingly common, and can range from social impairments to academic hardship to overt refusal to attend school.

According to the National Alliance on Mental Health, one in six children ages 6-17 experience a mental health disorder each year. Nearly half of all mental health conditions begin by age 14. While schools play a critical role in helping to identify concerns in children, schools are often tremendously (and increasingly) overwhelmed and can only do so much. As such, parents and guardians can play an active role in helping to identify their children’s struggles. Unfortunately, most kids won’t directly tell you they are struggling, so here are some signs to look out for:

-Talking about school becomes off limits, particularly about subjects in which your child may be struggling.

-Your child exhibits a major attitude change toward school. Children and teens may complain of being “bored”, which could also mean they do not understand the material.

-Your child exhibits changes in sleeping or eating patterns. Especially, look out for this on school nights.

-Your child spends too much time on homework. A rough estimate is that a child may have about ten minutes per grade level of homework per night. It’s important to be familiar with the teacher’s homework policy.

-Your child’s teacher explicitly expresses concerns. They see the behavior in school, BUT even they miss things, especially if your child tends to hold things in and is not disruptive.

-Your child begins to misbehave at school.

-Your child receives low grades and these are a drastic change from grades they previously earned.

-Your child spends much of the school day at the nurse with vague physical complaints, missing critical class time and socialization. At an extreme, your child may attempt to avoid going to school altogether.

Now that you’ve identified the problem, what can you do? Have an open conversation with your child – let them know what you’ve noticed and give them a chance to respond themselves. Try and stay open and really listen to their concerns without trying to assume your own interpretations like “they are lazy” or “they are overdramatic”. Remember, they may be guarded, so it’s important to gather additional information. Connect with your child’s teachers to get their thoughts. If difficulties are in one specific class, you could try tutoring or extra help from the teacher;  if they are more pervasive you may need to be more aggressive in how you address things. Try and determine the nature of the difficulty: is it more social/emotional or cognitive/academic? The school may be able to help distinguish this, and it’s okay to ask for additional help from a pediatrician, therapist or psychiatrist.

At public schools, you may formally request that the school evaluate your child’s needs by submitting a written request. Remember to sign and date the request, have the school sign and date when they receive the request and get a copy upon their acceptance of the letter. They have 30 days to respond and either agree to start an evaluation OR provide parents with a “Prior Written Notice” explaining why they do not think evaluation is warranted. This does not mean families cannot purse additional testing /evaluation on their own, but sometimes this can be costly.

Overt refusal to attend school is not a diagnosis in the psychiatric manual, but can point to a variety of psychological conditions like anxiety, trauma or depression. Approximately 2-5% of school children may experience school refusal. It’s important to remember this is NEVER normal. The failure to attend school has significant short and long-term effects on children’s social, emotional, and educational development. That said, it is a complicated problem and requires a collaborative approach to treat. Parents SHOULD NOT feel they are in this alone! Other members of the team may include a pediatrician, psychiatrist, or therapist. At some extremes, children may even require treatment in an inpatient psychiatric hospital or partial hospitalization program. It’s important to build relationships with the school and possibly others to help develop and plan for getting and keeping a child in school.

Typically, remote learning is not the answer to any school difficulties. Even prior to the pandemic, studies indicated that students who did remote learning were at a disadvantage. In 2015, a study of 158 virtual schools compared with traditional schools indicated virtual students obtained lower results in reading and math. In 2021, an analysis of virtual learning during the pandemic indicated a loss of five to nine months of learning with multiple psycho-social consequences including anxiety, depression, concentration difficulties, social isolation and lower levels of physical activity. In summary, there is little evidence of benefit with complete remote learning. More schools are offering hybrid learning models for students floundering in mainstream programs.

School is central to a child’s development. Parents now should have some tools and resources for identifying signs of struggle in their children. Early intervention is important to foster academic and social development and promote psychological well-being.


NAMI. Mental Health in Schools.

Linnell-Olsen, Lisa. (2020, May 20). 7 Warning Signs Your Child is Struggling in School. Very Well Family.

Cincinnati Children’s Hospital Inpatient Handouts. SPED Request for Families.

Kawsar, MD S., Yilanli, M and Marwaha, R. (2021, June 11). School Refusal. StatPearls (Internet).

Bissonnette, S and Boyer, C. (2021, July 27). The Effects of Remote Learning on the Progress of Students Before and during the Pandemic. Inciativa Educacao.

By Tracy Suzanne Cummings, MD 

Chief of Child and Adolescent Psychiatry 

If you have ever been a passenger on an airplane, you have heard the directive to don your own oxygen mask first before attempting to help someone else with theirs. Perhaps as February’s decorative hearts and cupids fill our visual fields, we can consider how this is true for our actual hearts and self-worth, particularly for the younger members of our population. After all, adolescence is a time of self-discovery and identification. Let us encourage teens to build and strengthen a relationship with themselves, thereby preparing them for the challenges of the complex tapestry that we call love. Building up the self-esteem and self-worth in our youth will bring about numerous long-lasting, positive changes that Cupid’s arrow could only dream of creating.

Self-esteem can be defined as the confidence in one’s own worth or  abilities. It often includes self-respect  and compassion. Once we are able to believe in our worth (which is vast and unique, and exists for everyone), we can better accept and give respect and compassion to those with whom  we have relationships, from friendships to romance. Without it, a person might sacrifice themselves to gain the approval of others, only to find later the disappointment in that superficial, unhealthy pattern. Unfortunately, most health classes will not cover relationships in their curriculum, and, naturally, teens will get their information from observing others and asking peers. They might seek social media likes and attention, rather than true connection, keeping face instead of keeping true to one’s essence. While they may long for roses, candy hearts, and chocolates, we need instead to attempt to instill the desire for an arrow pointing them to their own passions and skills. Recent data suggests that over 90% of thirteen to seventeen year-olds go online daily, with over 70% using more than one social media site (American Academy of Child and Adolescent Psychiatry). If only we could have confidence that those sites and online interactions would lead to affirmation!

So, here is where trusted adults can step in and make an impact, by modeling caring relationships and self-compassion. By doing so, we highlight their strengths and capabilities without social comparisons, teaching them to value their personal gifts now so they may be able to share them with a partner later. Helping a teen find their path to success might involve trial and error (it’s ok to not know right away what you want in life), adjusting expectations (self-imposed or otherwise), and creating the context in which wins can happen. While self-esteem and worth begin to be formed in childhood, improvements can be attained at all stages of life by working on the following:

* Insisting on equality and mutual respect in a relationships

* Setting appropriate boundaries

* Verbalizing needs

* Accepting feedback (perhaps even in the form of conflict)

* Acknowledging the possibility of failure, while trying to seek success

* Maintaining assertiveness

* Releasing the pressure of achieving the unattainable goal of perfection (in yourself and others)

If Cupid was really in the business of creating fulfilling and lasting relationships, we would see his arrows pointing towards boosting self-esteem. Besides, who needs a special day to have chocolate anyway?




Screen time recommendations vary by the child’s age. Presently, the American Academy of Pediatrics (AAP) recommends that for children younger than 18 months of age, the use of screen media other than video-chatting should mostly be discouraged. For children 2 to 5 years of age screens are acceptable for no more than one hour per day thus allowing them ample time to engage in other activities promoting growth. For older children, current guidelines encourage proactive development of an individualized Family Media Use Plan ( that takes in consideration the particular child’s maturation and needs. This article will focus on a few recent neurobiological findings addressing the effects of excessive screen time exposure on the growing brain in youth to help us be better informed as parents, educators and healthcare workers.

Preschoolers – if the content is educational, that’s all that matters, not how it is presented, right? Wrong! 

In a 2019 study by Cincinnati Children’s Hospital researchers documented associations between higher screen use and lower measures of brain structure and skills in preschool-aged children. The team examined the screen time habits and cognitive skills of 47 children, 3 to 5 years of age and conducted brain scans on each child.  Prior to the scans, the kids took a cognitive test and the parents filled out a questionnaire regarding their child’s screen time habits. The final score, called the ScreenQ score, was based on a number of criteria focusing on AAP recommendations, including whether the child was exposed to screens before 18 months of age, if they had a television in their room, and how much time they spend in front of screens. Scores ranged from zero to 26 and the higher scores represented less of an adherence to general screen time recommendations from the AAP. It was observed that higher ScreenQ scores were associated with lower brain white matter integrity, poorer expressive language and poorer cognitive skills suggesting that excessive time in front of a screen, even if the content is considered educational, might decrease cognitive skills in preschoolers. (1)

Elementary School Age and tweens -Reading is all good, right? Wrong!

A 2018 study from Cincinnati Children’s Hospital explored the time spent using screen-based media versus reading an actual book on the functional connectivity of the reading-related brain regions in children aged 8-12. Time spent on screens might be linked to impaired shifts in brain connectivity, while reading a book is linked to more beneficial neurobiological changes. The researchers had families rate how much time their children spent on various screens and how much time they spent reading actual books. The children’s brains were scanned, to assess how regions involved in language were connected, and it turned out that screen time was linked to poorer connectivity in areas that govern language and cognitive control. Reading a physical book, on the other hand, was linked to better connectivity in these regions. These findings underscore the importance of children reading real books to support healthy brain development and literacy and to consider limiting excessive screen time, even if some of the content presented through screens might be related to reading and considered educational. (2)

Tweens- screens are all bad, right? Wrong!

A 2019 study published in NeuroImage explored the effect of screen media activity on structural brain changes and how this might affect specific behaviors in 9-11 year olds. Structural scans of the brains of 4277 participants were correlated to screen activity like watching television, playing video games, or using social media. Some finding were expected, like individuals with significant exposure to activities engaging the visual system (watching TV or video) showing structural patterns suggestive of greater maturation in the visual system (i.e., thinner cortex). Some structural brain changes related to increased screen exposure were associated with more psychological issues and poorer performance on cognitive tests, while other latent variables did not show such relationship. The authors summarized that it remains difficult to conclude that brain structural characteristics related to screen media activity have uniformly negative consequences. Moreover, while some media activity associated brain structural changes were related to poorer cognitive performance, others were related to better cognitive performance suggesting that screen media activity can not be simplified as overarchingly “bad for the brain or for brain related functioning”.

Regardless of the age group discussed, one strategy to mitigate the potential risks associated with excessive exposure to screens is to ensure that the child has an overall well balanced and healthy lifestyle. This includes reinforcing proper eating and sleeping habits adequate for the age of the child, sufficient and diverse physical activity and providing plenty of opportunities for not screen related social interactions. Establishing a flexible family matrix of screen rated “rules” which dynamically adapts to the growing child would ensure that parents and educators factor in screen time exposure as one of the determinants when raising a healthy kid.

  1. John S. Hutton, Jonathan Dudley, Tzipi Horowitz-Kraus, Tom DeWitt, Scott K. Holland.
    Associations Between Screen-Based Media Use and Brain White Matter Integrity in
    Preschool-Aged Children. JAMA Pediatrics, 2019.
  2. Horowitz-Kraus T, Hutton JS. Brain connectivity in children is increased by the time they spend reading books and decreased by the length of exposure to screen-based media. Acta Paediatr. 2018;107(4):685-693.
  3. Paulus MP, Squeglia LM, Bagot K, et al. Screen media activity and brain structure in youth:
    Evidence for diverse structural correlation networks from the ABCD study. Neuroimage. 2019;

Anna Guerdjikova, PHD, LISW, CCRC
Director of Administrative Services, Harold C. Schott Foundation Eating Disorders Program, Lindner Center of HOPE, University of Cincinnati, Department of Psychiatry, Research Assistant Professor

by: Tracy S. Cummings, MD, Psychiatrist, Lindner Center of HOPE

Children and teens react, in part, on what they see from the adults around them. When parents and caregivers deal with the COVID-19 calmly and confidently, they can provide the best support for their children. Parents can be more reassuring to others around them, especially children, if they are better prepared.

Not all children and teens respond to stress in the same way. Some common changes to watch for include

  • Excessive crying or irritation in younger children
  • Returning to behaviors they have outgrown (for example, toileting accidents or bedwetting)
  • Excessive worry or sadness
  • Unhealthy eating or sleeping habits
  • Irritability and “acting out” behaviors in teens
  • Poor school performance or avoiding school
  • Difficulty with attention and concentration
  • Avoidance of activities enjoyed in the past
  • Unexplained headaches or body pain
  • Use of alcohol, tobacco, or other drugs

There are many things you can do to support your child

  • Take time to talk with your child or teen about the COVID-19 outbreak. Answer questions and share facts about COVID-19 in a way that your child or teen can understand.
  • Reassure your child or teen that they are safe. Let them know it is ok if they feel upset. Share with them how you deal with your own stress so that they can learn how to cope from you.
  • Limit your family’s exposure to news coverage of the event, including social media. Children may misinterpret what they hear and can be frightened about something they do not understand.
  • Try to keep up with regular routines. If schools are closed, create a schedule for learning activities and relaxing or fun activities.
  • Be a role model.  Take breaks, get plenty of sleep, exercise, and eat well. Connect with your friends and family members.

The emotional impact of an emergency on a child depends on a child’s characteristics and experiences, the social and economic circumstances of the family and community, and the availability of local resources. Not all children respond in the same ways. Some might have more severe, longer-lasting reactions. The following specific factors may affect a child’s emotional response:

  • Direct involvement with the emergency
  • Previous traumatic or stressful event
  • Belief that the child or a loved one may die
  • Loss of a family member, close friend, or pet
  • Separation from caregivers
  • Physical injury
  • How parents and caregivers respond
  • Family resources
  • Relationships and communication among family members
  • Repeated exposure to mass media coverage of the emergency and aftermath
  • Ongoing stress due to the change in familiar routines and living conditions
  • Cultural differences
  • Community resilience
For 7 to 10 year olds

Older children may feel sad, mad, or afraid that the event will happen again. Peers may share false information; however, parents or caregivers can correct the misinformation. Older children may focus on details of the event and want to talk about it all the time or not want to talk about it at all. They may have trouble concentrating.

For preteens and teenagers

Some preteens and teenagers respond to trauma by acting out. This could include reckless driving, and alcohol or drug use. Others may become afraid to leave the home. They may cut back on how much time they spend with their friends. They can feel overwhelmed by their intense emotions and feel unable to talk about them. Their emotions may lead to increased arguing and even fighting with siblings, parents/caregivers or other adults.

More on taking care of your family

Disasters and other crisis events have the potential to cause short- and long-term effects on the psychological functioning, emotional adjustment, health, and developmental trajectory of children. It’s important that pediatricians, and all adults in a position to support children, are prepared to help children understand what has happened and to promote effective coping strategies. This will help to reduce the impact of the disaster as well as any associated bereavement and secondary stressors.

Stress is intrinsic to many major life events that children and families face, including the experience of significant illness and its treatment. The information provided about how to help children cope after disaster and crisis is therefore relevant for many encounters that pediatricians will have with children, even outside the context of a disaster.

Talk about the event with your child. To not talk about it makes the event even more threatening in your child’s mind. Silence suggests that what has occurred is too horrible to even speak of. Silence may also imply to your child that you don’t think their reactions are important or appropriate.

  • Start by asking what your child has already heard about the events and what understanding he or she has reached. As your child explains, listen for misinformation, misconceptions, and underlying fears or concerns, and then address these.
  • Explain – as simply and directly as possible – the events that occurred. The amount of information that will be helpful to a child depends on his or her age. For example, older children generally want and will benefit from more detailed information than younger children. Because every child is different, take cues from your own child as to how much information to provide.
  • Encourage your child to ask questions, and answer those questions directly. Like adults, children are better able to cope with a crisis if they feel they understand it. Question-and-answer exchanges help to ensure ongoing support as your child begins to understand the crisis and the response to it.
  • Limit television viewing of disasters and other crisis events, especially for younger children. Consider coverage on all media, including the internet and social media. When older children watch television, try to watch with them and use the opportunity to discuss what is being seen and how it makes you and your child feel.

Healthy Children. Org provides additional insights

  • Recognize that your child may appear disinterested. In the aftermath of a crisis, younger children may not know or understand what has happened or its implications. Older children and adolescents, who are used to turning to their peers for advice, may initially resist invitations from parents and other caregivers to discuss events and their personal reactions. Or, they may simply not feel ready to discuss their concerns.
  • Reassure children of the steps that are being taken to keep them safe. Terrorist attacks and other disasters remind us that we are never completely safe from harm. Now more than ever it is important to reassure children that, in reality, they should feel safe in their schools, homes, and communities.
  • Consider sharing your feelings about the event or crisis with your child. This is an opportunity for you to role model how to cope and how to plan for the future. Before you reach out, however, be sure that you are able to express a positive or hopeful plan.
  • Help your child to identify concrete actions he or she can take to help those affected by recent events. Rather than focus on what could have been done to prevent a terrorist attack or other disaster, concentrate on what can be done now to help those affected by the event.

AACAP Recommendations for talking to children about COVID-19 :

Talking to Children About Coronavirus (COVID19)

  • Remember that children tend to personalize situations. For example, they may worryabout their own safety and the safety of immediate family members. They may alsoworry about friends or relatives who travel or who live far away.
  • Be reassuring, but don’t make unrealistic promises. It’s fine to let children know that they are safe in their house or in their school. But you can’t promise that there will be no cases of coronavirus in your state or community.
  • Let children know that there are lots of people helping the people affected by the coronavirus outbreak. It’s a good opportunity to show children that when something scary or bad happens, there are people to help.
  • Children learn from watching their parents and teachers. They will be very interested in how you respond to news about the coronavirus outbreak. They also learn from listening to your conversations with other adults.
  • Don’t let children watch too much television with frightening images. The repetition of such scenes can be disturbing and confusing.
  • Children who have experienced serious illness or losses in th
  • Although parents and teachers may follow the news and the daily updates with interest and attention, most children just want to be children. They may not want to think about what’s happening across the country or elsewhere in the world. They’d rather play ball, go sledding, climb trees or ride bikes.


Several suicides among local high school students has the Cincinnati community mourning these losses and searching for answers. WCPO’s Tanya O’Rourke spoke with Lindner Center of HOPE Medical Director of Inpatient and Partial Hospital Program Services Dr. Tracy Cummings about what families need to know about suicide prevention for themselves and their children.

According to Dr. Cummings, suicide has become more prevalent in recent years. “It’s striking actually – up to almost 30% increase since 1999.” This may be a conservative estimate due to stigma discouraging people from self-reporting suicide attempts.

Cummings cites risk factors that correlate with suicide attempts, including a family history of suicide, previous attempts, or a recent loss among close relatives or friends. Dr. Cummings also refers to a “contagion effect,” where one suicide within a community may trigger additional attempts by people who are suffering.

Social media use can also affect teens. Suggestions are offered on how parents can approach their kids on the topic of self-harm. Parents should not worry about “implanting” thoughts into their children’s minds by asking them directly about suicide. Rather, it is imperative that parents start a direct conversation with their children.




Watch both parts of Dr. Cummings’ two-segment interview on WCPO’s YouTube Page

Part 1


Part 2

A New Way to Balance Digital Usage

It’s a concern for parents across the country.

Teenagers are consumed by countless digital distractions. Smart phones, gaming consoles, or any number of devices connected to the Internet compete for their attention.

Concerns over growing and habitual media use are nothing new, but the broad availability of portable devices seem to have “leveled up” the problem. Now, more children are becoming addicted to online content and gaming.

Popular video games like Fortnite are played by more than 200 million people. Some teens spend as much as 12 hours or more[i] a day playing online, while others spend the same amount of time engaged in social networks. This obsession can affect health as well as school and work performance.

A 2012 study estimated In 2018, The World Health Organization even classified video game addiction[iii] as a mental health disorder.

But how do you know when a habit has crossed over into an addiction? And what do you do when it is clear your son or daughter is addicted?

For children who show signs of internet addiction, a recent study[iv] suggests each child needs to be evaluated in context of their own unique situation. Personality traits, type of game(s) played, life situations and cultural expectations can all explain excessive gaming. For example, if the habit is used to replace real-life social interactions or escape from life traumas and stress, an Internet or gaming addiction may be in play.

“Today’s society is dependent upon technology, mobile devices, social media, and the Internet,” says Dr. Chris J. Tuell, clinical director of addiction services at Lindner Center of HOPE. “However, when dependence crosses over to an addiction, it’s time to take steps to regain control.”

Several habitual behaviors can indicate Internet and gaming addiction. “The three C’s of addiction also apply to Internet addiction,” says Dr. Tuell. “If someone exhibits a loss of control, a compulsion/obsession to be online, irritability when offline, or continues to use technology despite negative consequences, they may be suffering from Internet addiction.”

The Reboot Program

To combat Internet and gaming addiction, and provide a resource for families who need help, Lindner Center of HOPE has introduced a new program called “Reboot.” The first two weeks of the Reboot program involve a comprehensive assessment of the teenager to draft a course of treatment. The second two weeks focus on developing better habits with technology.

“For those struggling with self-control, this program helps them re-center their lives and avoid additional complications,” said Dr. Tuell.

According to Mental Health America[v], the nation’s leading non-profit mental health advocacy organization,  children with Internet addiction often struggle with other mental health problems like alcohol and substance use, depression, and/or aggression.

Addiction experts at Lindner Center of HOPE assess if patients are suffering from one or more co-occurring disorders, like depression. Identifying underlying mental health conditions helps to personalize treatment plans for each “Reboot” patient – increasing their odds of winning the battle with internet and gaming addiction.

Addictions Expertise

In addition to internet and gaming addictions, Lindner Center of HOPE treats most substance and behavioral addictions, including heroin, morphine, hydrocodone, oxycodone, amphetamine, methamphetamine, LSD, alcohol, cocaine, marijuana and tobacco, gambling and pornography. Plans may include medication-assisted treatment, therapy or support groups, and screenings for underlying issues like depression and anxiety.

About Lindner Center of HOPE

Lindner Center of HOPE, located in Mason, OH, is a comprehensive mental health center providing patient-centered, scientifically advanced care for individuals suffering with mental illness. Learn more at

# #  #

[i] Feely, J. & Palmeri, C. (2018, Nov. 27). Fortnite Addiction Is Forcing Kids Into Video-Game Rehab.

[ii] Cash, H., Rae, C. D., Steel, A. H., & Winkler, A. (2012). Internet Addiction: A Brief Summary of Research and Practice. Current psychiatry reviews8(4), 292-298.

[iii] Price, L. & Snider, M. (2018, June 19). Video game addiction is a mental health disorder, WHO says, but some health experts don’t agree.

[iv] Kuss D. J. (2013). Internet gaming addiction: current perspectives. Psychology research and behavior management6, 125-37. doi:10.2147/PRBM.S39476

[v] Mental Health America. Risky Business: Internet Addiction.



Reuters featured the success story of a teenager who found help with Internet and gaming addiction through a new treatment program at the Lindner Center of HOPE. The story explains why more medical professionals are taking Internet addiction seriously and how the Lindner Center has pioneered a program to meet this modern condition.

A 2012 study estimates that between 1.5 percent and 8.2 percent of people in the U.S. and Europe experience “problematic computer use.” In 2018, The World Health Organization even classified video game addiction as a mental health disorder.

To combat Internet and gaming addiction, and provide a resource for families who need help, Lindner Center of HOPE has introduced a new program, called “Reboot.”

“This program helps those struggling with a loss of control to re-center their lives to avoid additional complications,” said Dr. Chris J. Tuell, Lindner Center of HOPE Clinical Director of Addiction Services.

Your donation will help more people like Danny recover from mental illness and return to feeling more like themselves. Donate here:



Read more:


Jennifer L. Shoenfelt, MD
Board Certified Child, Adolescent, and Adult Psychiatrist, Lindner Center of HOPE
Assistant Professor, University of Cincinnati, College of Medicine, Department of Psychiatry and Behavioral Neuroscience Assistant Professor, Wright State University, Boonshoft School of Medicine, Department of Psychiatry

Depression is on the rise in American teens and young adults. Adolescent girls, in particular, seem to be the most vulnerable youth, according to recent research published online in the Journal of Pediatrics.  Data collected between 2005 and 2014, analyzed by the Johns Hopkins University School of Public Health, concluded that “the 12 month prevalence of major depressive episodes in adolescents increased from 8.7% in 2005 to 11.3% by 2014”.  This number rose from 4.5% to 5.7% in boys and 13.1% to 17.3% in girls. The reasons for this increase remain under discussion. However, cyber bullying has been hypothesized as one trigger, particularly for girls.

How does a parent know when and where to seek help? How can parents support their child or adolescent suffering from depression? Here are some general guidelines for getting started.

  1. Observe your child’s behavior for idiosyncrasies or changes. Children with depression may demonstrate low mood, irritability, anger, fear or anxiety, mood swings, disruptive or risk-taking behavior, disobedience/defiance/ illegal behavior, isolation, lack of self-care/hygiene, decreased interest in previously enjoyable activities, decreased energy, increased or decreased sleep, increased or decreased appetite, and changes in friendships or family relationships. Some children turn to drugs or alcohol. Others turn to the internet for support or socialization. School performance may deteriorate, or attendance may decrease due to physical complaints or blatant truancy. Some children engage in self-harming behaviors or talk of death and dying.
  2. Engage your child in daily conversation or other one- on -one activity to open lines of communication.  Gently ask questions about your child’s change in mood, daily life and issues or how he or she is getting along with others. Find novel ways, if necessary, for your child to communicate his or her feelings. This may include sharing a journal that you pass back and forth or quantifying your child’s mood with a “mood scale” (0= severe depression and suicidal thinking versus 5 = happy mood/doing well) or even sharing “emojis” reflecting how the child is feeling that day. If your child expresses suicidal thoughts, such as not wanting to live or wishing he or she were dead, talks about ending his or her life, or engages in writing suicide notes – please take them directly to the local emergency room for further psychiatric evaluation.
  3. Talk to your pediatrician or family doctor about your child’s mood or changes in behavior. Consult with your child’s teachers or school counselor. Talk to your minister, priest, or rabbi. Arrange timely assistance for your child, perhaps through your Employee Assistance Program or through your health insurance. These professionals can assist you in finding a qualified mental health professional to provide evaluation and counseling.
  4. Monitor and limit phone, computer and electronics time. Know with whom your child is communicating. Watch internet history, cellphone texting, and social media communications. Kids looking for support often look in the wrong places and meet the wrong people while there.
  5. Encourage a healthy and consistent sleep schedule.  Children and teens need about 8-10 hours of sleep per night. A regular pre-sleep routine that does not include electronics and enhances relaxation along with a scheduled bedtime and wake-up time are all tenets of a healthy sleep habit.
  6. Encourage healthy eating habits. Limit sodas, caffeine, sugar- laden foods and snacks. If your child is not eating regular meals or portions, encourage smaller, more frequent meals of healthy foods throughout the day. Observe aberrant behaviors at meals, such as restricting caloric intake, leaving the table immediately after eating to go to the restroom and diverting food by hiding it or throwing it away. Observe striking weight loss, excessive exercising, or obsessive concerns with body image that may indicate concern for an eating disorder.
  7. Be consistent and firm with limit setting. Some parents feel badly for their child with depression and feel they should relax limits or house rules to decrease perceived stress on the child with depression. They fear being too strict or harsh. Maintain the same or even slightly more stringent rules with your child to maintain structure and avoid singling out the child with depression. Treat all children in the family equally. Be aware of your child’s whereabouts and safety at all times.
  8. Safety- proof your home. Lock up all medications, even over- the -counter medications, and seemingly harmless remedies. Secure anything in the home that could be used as a weapon, particularly firearms. Remove firearms from the home entirely. Secure alcohol or remove it from the home entirely.
  9. Ensure that you are taking care of your own well-being and mental health. Depression can run in families. If you, as the parent, are struggling with your own mental health, it will be difficult to remain objective and supportive toward your child, who is also struggling. It may also make identifying your child’s depression more difficult or impossible. Resist the urge to tell your child that you know how they must feel or that you were once depressed or are currently depressed. Avoid trying to give advice or sharing how you have battled your own depression.

Practice listening attentively and reassuring your child that you will get them whatever help is needed for them to feel better and return to a healthy, happy life. Be sure to get help for yourself, such as therapy or medication or both. This will assist you in being the best possible support for your child and family.

Identifying child and adolescent depression and dealing with it can be overwhelming. The key is to reach out for assistance and allow others to provide their support and expertise, so that a team approach can be utilized to its fullest. Organizations such as the American Academy of Child and Adolescent Psychiatry, National Alliance on Mental Illness (NAMI) and the American Psychiatric Association are all excellent sources of information and support.

Mojtabai R, Olfson M, Han B. National trends in the prevalence and treatment of depression in adolescents and young girls. Pediatrics. 2016; doi: 10. 1542/peds.2016-1878.
Glowinski AL, D’Amelio G. Depression is a deadly growing threat to our youth: time to rally. Pediatrics. 2016; doi:10.1542/peds.2016-2869.
American Academy of Child and Adolescent Psychiatry. Your Adolescent. 1999. 301-304.

BY: Elizabeth Wassenaar, MS, MD, Lindner Center of HOPE, Staff Psychiatrist and Medical Director of Williams House


Life can be overwhelming and we all would like to take a day off every once in a while. Likely, as helping professionals, we don’t take mental health days as often as we could actually benefit from them.  This is one of the reasons why, when a child or adolescent refuses to go to school, we may be initially sympathetic.  Maybe a day or two off will help, we may think.  In too many cases, however, we see that a day or two off turns into something much more problematic as parents and professionals struggle to get a school avoider back to school.  Homework piles up, grades start to fall, and friends wonder what has happened to their classmate.  Parents try many different tactics to try to get their child back to school; bribing, negotiating, punishing, or even carrying a child through the school door.

Children want to not go to school for many reasonable causes: kids can be cruel; learning can be difficult; anxiety about performance can be overwhelming; health concerns can require special privileges that feel too identifying; and getting up early in the morning is harder for some more than others. Furthermore, mental illness can make school attendance difficult for many additional reasons.  There are good reasons to keep children home from school – physical illnesses can be contagious, some stages of mental illness are better treated with mental rest, and in some cases of bullying the safest way to deal with an unsafe situation is to remove the child.

Nevertheless, school refusal is avoidance, and anxiety loves avoidance. Nothing is more reinforcing that one cannot handle something than not doing it.  So, after one has checked on physical health and for other explanations, how can professionals support parents to keep their children in school or break the cycle of school avoidance and school refusal?

  1. Help parents identify the behaviors of avoidance and link that to anxiety.

Avoidance is a coping mechanism for dealing with anxiety, which can become maladaptive when avoidance becomes the only options. Avoidance can look a lot of different ways –tantrums, tearfulness, vague physical symptoms, negotiation (more on that later), chaos, and so on.  Parents may not be able to recognize all of the forms avoidance can take. Helping them objectify avoidance will help them strategize on how to deal with it.

  1. We have to truly believe that avoiding school will not make it better.

It can be tempting to collude with anxiety that the precipitant needs to be avoided for all the reasons laid out in this article and we need to be internally convinced that anxiety is not correctly assessing the situation. As difficult as school can be, school occupies a unique place in a child’s life.  It is the place of work, play, and love.  Learning and playing are the main jobs of childhood.  Playing looks both like playing at recess and like experimenting in relationships with both friendship and love. Identity is formed and reformed through our work, play, and love.  When a child is not in school for an extended length of time, they are abrupting their opportunity for this developmental process to proceed.

  1. Negotiation is another way of avoiding and is a dangerous game.

Many of my patients have used a variety of negotiating tactics with their parent: “Let me go in later and then I’ll go, I promise” or “Let me catch up on my work today and I’ll go in tomorrow”. Small avoidances add up to large avoidance and are not moving towards your goal.  Reverse the negotiation and set up conditions that will allow an out as long one starts the day at school.  Often, once anxiety has lost its argument that one cannot handle going to school, staying in school through the day is easier to manage.

  1. Encourage parents to work with the school

Parents and school are on the same side of this concern – both parties want the child to be successful in school. For parents, this may be the first time dealing with school refusal, but it is most certainly not the first time the school has dealt with school refusal.  Most schools have a variety of plans to help keep a child in school.  Have parents reach out to the school and let them know what is going on.

  1. Set small goals that lead to the victory

The ultimate goal of full school participation is an overwhelming prospect. Depending on how severe the school refusal is, reintroducing school can be an extended process of gradually introducing larger and larger challenges.  Perhaps, on the first day, one can only walk through the school doors.  Maybe a student will be able to be in the school building, but not in classes.  Parents can engage trusted friends to provide motivation and encouragement through social interaction and distraction while at school.

  1. School has many different forms

Many families choose alternative school arrangements including home schooling, virtual schooling, and others, for a variety of reasons and this article is not meant to convict choices that do not have a child in a classroom every day. There are many viable options for school that provide an environment that promote healthy development.  When a family is making a decision to change the way school is delivered, help them examine what factors are involved in their decision.  If they are making the decision from a place of believing that the anxiety that drives school avoidance cannot be defeated then, help them with all the ways described above.

School is a venerable and sometimes dreaded rite of passage. A great deal rides on academic and social success in school which increases anxiety and can lead to school refusal.  As a team, parents, professionals, and schools can help keep children and adolescents in school and accomplishing their goals.

On October 28, 2015, Dr. Elizabeth Wassenaar, Lindner Center of HOPE Psychiatrist and Williams House Medical Director, joined Lon Woodbury on the Woodbury Report radio show.  Their discussion focused on outlining the benefits of a residential assessment for mental health concerns in adolescents.

Click here to listen.