Your child’s doctor can offer support when it comes to gender identity and sexual orientation.For pediatricians, taking good care of children as they navigate puberty and adolescence means listening — and talking — as kids figure out sexuality, identity and relationships. Even those lucky kids with supportive and open-minded parents often find they want to talk through these topics with an adult outside their immediate families, and the primary care visit should be a place to talk about every aspect of the child’s changing body and mind.The American Academy of Pediatrics is advising doctors to wear Pride stickers, display those rainbow symbols in our clinics, announce our own preferred pronouns and ask patients for theirs. We want to encourage kids to talk honestly about their own sexuality and gender questions, and we want to be sure they get those questions answered in a setting that supports them and protects their confidentiality.[Click here for the A.A.P. policy statement on good care for L.G.B.T. children and youth and here for the policy statement on good care for gender-diverse children.]How can parents find a pediatric practice that is welcoming, inclusive and ready to hold those important conversations? Here are some tips for making sure that a child has that expert adult to talk with — and for helping along those discussions at the pediatrician’s office. As a parent, you should feel that you also have access to help and advice, that you and the pediatrician are partnering to help your child.How to Find an L.G.B.T.Q.-Friendly PracticeWhen choosing a pediatric provider, keep those future conversations in mind. Charlotte J. Patterson, a professor of psychology at the University of Virginia, wrote in an email, “parents can ask questions about how practitioners handle issues relevant to sexual orientation and gender identity. This can help parents ensure that, whether gay or straight, cisgender or nonbinary, their children will receive safe, inclusive, and supportive medical care.” She also suggested that parents can consult with local groups — PFLAG or L.G.B.T.Q. resource centers — for recommendations about pediatric practices.Dr. Christopher Harris, the chairman of the American Academy of Pediatrics section on L.G.B.T. health and wellness, suggested that parents and patients could look for visual signs that indicate that a practice is friendly, like “posters on the wall, rainbows, rainbow flags, pronoun stickers on health care provider name tags, signs in the waiting room saying we care for all families.”And certainly adolescents pick up on all these signals and symbols. On medical Twitter recently, Dr. Anna Downs, a pediatric resident, tweeted about having an adolescent look at the rainbow badge she was wearing and ask excitedly, “So what kind of gay are you!?”Dr. Ilana Sherer, a pediatrician in Dublin, Calif., who is a member of the executive committee of the A.A.P. section on L.G.B.T. health and wellness, suggested that parents look on a practice’s website for language that indicates that the practice is friendly to everyone, which could include messages about serving different kinds of families, careful attention to pronouns, signals that the office is not making any assumptions.A practice that is trying to welcome these questions will have thought about what is communicated on the website, at the front desk, and on the forms to be filled in, as well as in the exam room. So parents should listen for the ways that questions are asked on intake forms and in initial interviews: “Are they asking questions in ways that allow somebody who is not straight and binary and cisgender to answer?” Dr. Sherer asked. “Do they understand that gay, straight, bisexual are not the only choices?” Look for doctors who ask open-ended questions, and who understand the diversity of child development, she said, and be wary of comments that “gender kids unnecessarily — are they giving a boy a He-Man sticker or letting him choose?”Dr. Sherer cares for many families with transgender and gender-diverse children, some who have been in her practice since early childhood, and others who find her because she speaks and writes about this population. “I hear being transgender being talked about like it’s a disorder,” she said. “My transgender kids are some of the kindest, bravest kids I have.” She tries to model for parents how to help and support their children, while also handling their own emotions, which can be complex, she said: “There’s obviously a loss to the parent but it’s not a loss of their child — it’s a loss of who they thought the child was.”For parents whose children are questioning their gender identity, “don’t be afraid to reach out to your pediatrician,” said Dr. Paria Hassouri, a pediatrician in Los Angeles who provides gender-affirming care, and who has written about her own experience as the parent of a transgender child. “Information is going to empower you to support your child and make decisions down the line.”The proportion of adolescents who report that they identify as other than heterosexual has been going up. Dr. Patterson was the corresponding author of a commentary published in late May in the journal JAMA Pediatrics, which discussed recent data — in one survey, 14.3 percent of adolescents in 2017 claimed an identity that was “lesbian, gay, bisexual, other, or questioning,” up from 7.3 percent in 2009. The article argued that while greater societal openness may have encouraged more honest answers, these adolescents are still vulnerable to stigma, bullying and abuse, and consequent mental health problems. So a strong and supportive relationship with a medical provider can be really important in helping an adolescent navigate these years.What to Expect From Your PediatricianParents should expect pediatricians to promise adolescents confidentiality. But there are some situations — especially if the child is at risk of self-harm — where a doctor can’t promise confidentiality; we lay those out clearly with kids.Parents should expect their children’s doctors to be trained in asking and answering questions about sexual behavior and sexual health, but also about issues of identification and identity.With adolescents, we’re also asking about identity, self-image, body changes, mental health, friendships, academic performance, risky behaviors (smoking, drugs, alcohol) — the whole complex mix of adolescent activity and adjustment. When she’s talking to patients in the general pediatric clinic, Dr. Hassouri said, she starts by asking, “Do you feel comfortable in your body, how do you identify, what are the gender or genders of the people you are attracted to, rather than ‘Are you gay, straight or bisexual?’”Asking kids if they feel comfortable in their bodies as an opening question, she pointed out, could mean hearing about gender identity, but it might also open up other body-related concerns about weight or what they perceive as unattractiveness, or the pace of puberty. And as the conversation moves to other aspects of her patients’ lives, she tries to ask about interests and favorite activities in gender-neutral language.For some kids, she said, those questions of sexual orientation and gender identity can get confused — what begins with wanting to do “something not typical for the gender assigned to them” as young children may be “buried,” and then later on, around puberty, they may first begin to question their sexuality — “maybe I’m bisexual, maybe I’m gay.”Sometimes those feelings of not fitting in are really about the rigidity of gender expectations. Sometimes children are in fact becoming aware of their emerging sexual orientations — who they will be attracted to. And sometimes they will realize that those early feelings of wanting the “boy clothes” or the “girl toys” actually connect to their own gender identities — how they will identify and who they are.Support for ParentsParents should also expect to get support and guidance from their children’s doctor; part of helping children navigate these years is helping their parents be there for them. Dr. Hassouri said that when parents are talking to their own child, her advice is to “really listen to your child and believe what they’re telling you and support them, no matter what stage they are in their gender journey, in their sexuality journey.” And make sure the child is seeing a doctor who will also listen and support them at every stage.Dr. Sherer tells parents of young children that “there is a lot of fluidity in gender development.” With older children who may be questioning their gender identity, she finds herself modeling for parents how to show support, from discussing preferred pronouns onward. Parents sometimes jump right away to questions of medication and even eventual surgery, she said, when she, as the physician, never starts with those issues; the real question is immediate: “How can we help you feel affirmed in your identity; how can we help you feel good?” Thus, she advises parents to “not focus so much on the result, but on where their kid is in the moment.”Rather than trying to figure out, “is my kid going to be transgender, is my kid gay?” look at the child right there, right then, who is asking for love and support.“Parental support and acceptance are very powerful for reducing all sorts of negative outcomes” Dr. Sherer said. This kind of support is associated with better mental health as adolescents grow up and with reduced depression and suicidality. Supportive parents can also help kids who experience bullying or other school problems, and can make sure that their extended families treat them well.Pediatric practices can help adolescents and families locate resources like the Trevor Project, which offers a hotline for L.G.B.T.Q. youth, the It Gets Better Project or the Family Acceptance Project, which helps families that are ethnically, racially or religiously diverse support L.G.B.T.Q. children.

There can be a seven- or eight-week window around Covid vaccines when other shots can’t be given, so those who need them for camp, school or sports have to plan ahead.Greg Gold, a high school senior from Westchester County, N.Y., went to the doctor for a checkup last week. His pediatrician, Dr. Jane Guttenberg, had planned to give him his meningococcal B shot, which she wanted him to get before he goes to college this fall. But when Dr. Guttenberg heard that he had an appointment for his first Covid-19 vaccination the next day, she told him they would hold off on the meningococcal vaccine until after he was fully vaccinated against Covid-19.According to current recommendations from the Centers for Disease Control and Prevention, you aren’t supposed to get any other vaccine for two weeks before or after a Covid vaccine. That means that Mr. Gold, 17, will wait until mid-June to start the meningococcal B sequence — two shots, a month apart. He’ll still have time to get it done before he heads to Vanderbilt University in the fall, but the scheduling and juggling came as something of a surprise to him and his mother.Dr. Guttenberg, who practices in New York City and in Scarsdale, N.Y. (and at Bellevue Hospital where she is one of my colleagues), said, “I’m prioritizing the Covid vaccine for all these kids going to college.”Anyone with a teenager who is up against a deadline to be vaccinated for fall — or for camp this summer — should remember that vaccines have to be spaced, which can mean a seven- or eight-week window around Covid vaccines when other shots can’t be given.Dr. Lee Beers, a professor of pediatrics at Children’s National Hospital who is the president of the American Academy of Pediatrics, said, “We’re really trying to push the message, get in and see your pediatrician and get caught up on your routine vaccines now or you’re going to end up in this really tricky place and have to delay Covid vaccine or other vaccines.”With the news Monday that the Food and Drug Administration is preparing to authorize use of the Pfizer-BioNTech Covid-19 vaccine in children 12 to 15 years old by early next week, parents will need to plan with their pediatricians how to coordinate those along with catching up on their other shots. And younger children who have other shots due might want to consider catching up right now, so that they’re fully up-to-date for sports, camp or school. That way, as soon as they are eligible for Covid vaccines, there won’t be so much juggling to be done.And a lot of kids have catching up to do, said Dr. Bonnie Maldonado, a professor of global health and infectious diseases at Stanford who is the chair of the A.A.P. committee on infectious diseases. When it comes to immunization, she said, “We lost a lot of ground in the pandemic, and the biggest gaps are in the adolescent age group.”The regular vaccination schedule is determined primarily by burden of disease, said Dr. James Campbell, a professor of pediatric infectious diseases at the University of Maryland School of Medicine who is the chairman of the American Academy of Pediatrics subcommittee on vaccinations. You want peak protection at the age of peak risk, he said.Dr. Campbell pointed out that for all the stories about vaccine hesitancy, only 1 percent of the parents in the United States actually choose not to vaccinate their children at all — and that he believes the publicity drumbeat of the Covid vaccination campaign will ultimately leave parents more comfortable, not less.“In the end, this will be very good for vaccines that so much emphasis has been put on the process and the safety and the review,” Dr. Campbell said.“In the past, I think people didn’t realize just how much scrutiny there is,” of serious reactions to any vaccine, Dr. Campbell said, or how much attention is paid to schedule, dose, and immune response when a new vaccine is tested.When it comes to the Covid vaccines, Dr. Maldonado said, “We’re not overly specifically concerned about anything with this vaccine, we’re just following the normal processes.”Still, it’s possible that younger children, who typically have more robust immune systems than adults, may react more strongly to the Covid vaccines. That is why vaccine studies in children look carefully at dosage and immunologic reactivity, Dr. Beers said: “They often start with a smaller group, give a lower dose of vaccine, test the response, work their way up to the dose needed for adequate immunity.”Dr. Campbell and his colleagues at Maryland are just starting their first study of Covid vaccine in children under 12. And no one, he said, should be trying to convince parents that the vaccines are safe and effective in this age group until the data are available: “I have no reason to believe they won’t be safe and effective, but the proof is in the pudding — I want to see the pudding.”Getting children caught up on their regular vaccines makes sense because it will keep them well protected if other diseases flare up now that the pandemic has driven down the rates of the usual childhood immunizations. Doctors are worried about a whole list of vaccine-preventable diseases, including measles, whooping cough, meningitis, HPV and flu.Will Covid vaccines eventually fit into the schedule of routine childhood immunizations, and if so, at what age? Because the new vaccines are still in an emergency use authorization phase, “Nobody has answers; we’ll have to see over time,” Dr. Maldonado said.For some diseases, it’s possible to vaccinate children for lifelong protection. Sometimes you wait to vaccinate until you reach the age when risk is higher. For example, we give HPV vaccine to children sometime between 9 and 12, so they will be immune before they become sexually active. We time the meningococcal vaccine for that age because the disease is more common in teenagers and young adults than in elementary school children.Other diseases are most dangerous to infants or young children, so you need to vaccinate in infancy — such as rotavirus, which can cause severe dehydrating diarrhea in infants and small children, or whooping cough. Covid-19 is a disease that tends to be less severe in children, but which has still caused a great deal of serious illness. “We appreciate the fact that children are less at risk, but take seriously that they can get quite ill, that they can have long-haul symptoms or MIS-C,” Dr. Beers said, referring to the rare but serious Covid-related inflammatory condition in children.And in addition to protecting children, immunizing them against Covid-19 may protect the adults around them; Dr. Campbell said that having pneumococcal vaccine in the infant schedule had meant not only a major reduction in disease for children, but also a drop disease in older adults who have contact with kids who are immunized.Many families are waiting eagerly for vaccines to be available for their under-16 children. And many 16- to 18-year-olds are as eager to be vaccinated as their pediatricians are to see them get their shots. Mr. Gold, who, along with his whole family, had Covid-19 in March, was happy to be able to keep his vaccine appointment, and to come back in June for his first meningococcal B shot, and happy that there was time to get it all done before the fall.

Young people experiencing the body changes of puberty without being in school are facing a unique set of challenges. Here’s how parents can support them.A pediatrician friend saw a 10-year-old girl recently, for her yearly checkup. Like so many children (and so many adults) among us, she had gained a little extra weight over the past year, but she was fundamentally healthy. “The mom says to me, ‘You know, she’s very self-conscious, she’s developed over this last year, and none of her friends have, and it makes her so uncomfortable and it makes her sad,’” said the pediatrician, Dr. Terri McFadden, a professor of pediatrics at Emory University School of Medicine.The child had been attending virtual classes, and she was worried about going back into the classroom looking different; her mother had tried to explain to her that different people develop at different rates, Dr. McFadden said, but “she just felt she wasn’t normal, she wasn’t like her friends.”Most of the children in Dr. McFadden’s practice have been out of school for a full year, she said, and while many are eager to return to their friends, some are anxious about going back. Many have gained a significant amount of weight, which alone can make them worried about how they may be received by their peers. “School can be cruel,” Dr. McFadden said.While some schools have already gone back to in-person classes, circumstances vary across the country. Many children in the public school system in Atlanta, where Dr. McFadden practices, have been at home for more than a year. Some may be returning to school in bodies that have morphed over months at home, and while classmates may have noticed certain developments like a cracking voice, acne or facial hair on Zoom screens, other changes will be much more evident in person.“I definitely have seen a lot of people with a lot of weight gain and worry about going back,” said Dr. Holly Gooding, the head of adolescent medicine at Emory University School of Medicine. She always asks teenagers how school is going, she said, and nowadays, many of them say they’ll be going back in the fall. That presents an opportunity to ask more specifically about re-entry, she said, and open up the subject of body image.Dr. Chanelle Coble, an adolescent medicine specialist at N.Y.U. Grossman School of Medicine, said that young people are experiencing the body changes of puberty without the supports they would usually get from their peer group, and that is part of the general stress of the pandemic year. In her New York City practice, Dr. Coble said that she has seen higher than usual rates of severe anxiety and depression, as well as disordered eating, including among 11-, 12- and 13-year-olds.Some of these were children who gained weight early in the pandemic, and then, perhaps in reaction, started restricting their eating. In some, the weight loss has been so severe that they have stopped growing, or stopped menstruating.“Puberty is a general time of angst for people,” said Dr. Jennifer Miller, a pediatric endocrinologist at the Ann & Robert H. Lurie Children’s Hospital of Chicago, and an assistant professor of pediatrics at the Northwestern University Feinberg School of Medicine. It’s a stage when adolescents tend to be sensitive about changes in their bodies and how others perceive those changes, and the anxieties of returning to school — or more generally to life after lockdown — make that more pronounced.Dr. Jami Josefson, a pediatric endocrinologist at Lurie Children’s Hospital and an associate professor at Northwestern, said that going back to school after being out may be like seeing a relative you haven’t seen in a long time — there will always be comments about how the child has grown and changed.Some children will be taller, some will be more developed, some boys will have changing voices while others won’t. “This is all a normal part of going through adolescence, but it might seem a little more sudden,” Dr. Josefson said.Families should talk with children about how these changes are normal, about how everyone’s body changes, but not in unison. Dr. Coble suggested, “start with the basics, how are you eating, how are you sleeping?”If your children have been truly isolated, think about helping them ease back in — perhaps by encouraging them to spend socially distanced time outside with one good friend. Pandemic or no pandemic, children and families need reliable information about puberty. Dr. Adiaha Spinks-Franklin, a developmental behavioral pediatrician at Texas Children’s Hospital and an associate professor at Baylor College of Medicine, sends families to Amaze.org, which has videos aimed at kids, and to the Healthy Bodies Toolkit site developed by Vanderbilt University.Even in nonpandemic times, life is often harder for early developers, who remain emotionally and intellectually the same age as their peers, but who may look significantly older. Dr. Carol Ford, a professor of pediatrics and division chief of adolescent medicine at the Children’s Hospital of Philadelphia, said that the children who develop early always need more support, and that may be particularly true now, when the changes may be starker after an interval away. Parents need to be ready to have concrete and detailed conversations about issues like personal hygiene (yes, your sweat starts to smell different) and the developments still to come (menstruation, wet dreams).Some adolescent specialists have raised questions about whether the emotional intensity of lockdown and the pandemic year may actually have contributed to early puberty; Dr. Spinks-Franklin said, “I’ve had quite a few of my girls start their periods during the pandemic.” She has wondered whether stress has had something to do with that, or whether it is just regular development.One preliminary analysis out of Italy that was published in March suggested that referrals for early puberty in girls were significantly increased during the first six months of the pandemic, compared to the same six-month period of 2019. From March to September of 2020, 246 children, almost all girls, were referred to Bambino Gesù Children’s Hospital in Rome to be evaluated for suspected precocious puberty, compared to 118 during the same months of 2019. The authors raised questions about the possible links to stress, higher caloric intake and increased screen use, to be addressed with further research.If you think your child might be developing too early, schedule an appointment for an in-person checkup, and ask their pediatrician to discuss issues of puberty and body image. After the 10-year-old’s mother brought up the subject, Dr. McFadden talked with her patient, reinforcing the message that the body changes of puberty are normal and healthy. She talked with the mother about speaking with the child’s teachers, “so there will be a cadre of folks looking out for her as she re-emerges into in-person school.” And she and the mother discussed the risks that can attend early development in girls, who may be taken for older than they are, or preyed upon.Make sure that your child has clothes that fit her changing body and doesn’t seem to be popping out of too-short pants or too-tight shirts, which will draw attention to the changes. Talk about whether a child developing breasts wants to wear a camisole or bra. Talk through the logistics of getting your period at school, and make sure she knows where to go if she needs help or supplies.Though Dr. Miller sees patients for puberty-related questions and problems, her own sense of puberty during the pandemic also reflects her experience as a parent. “We have an 11-year-old daughter who is emotionally a roller coaster,” she said. Her daughter’s school recently had the “puberty talk,” in person, and her daughter reported, “The best part was being in one room with all the girls.”Her daughter then asked her pediatric endocrinologist mother why anyone needed to be a doctor focusing on puberty, Dr. Miller said, “Since all I do is talk about how it’s a completely normal thing for your body to go through.”

We tend to think of childhood as a time of innocence and joy, but as many as 2 to 3 percent of children from ages 6 to 12 can have serious depression.When parents bring their children in for medical care these days, there is no such thing as a casual, “Hey, how’s it going?” We doctors walk into every exam room prepared to hear a story of sadness and stress, or at the very least, of coping and keeping it together in this very hard year, full of isolation, loss, tragedy and hardship, with routines disrupted and comfort hard to come by.Parents have carried heavy burdens of stress and responsibility, worrying about themselves but also watching their children struggle, and there is worldwide concern about depression and suicidality among young people. But it isn’t only the adults and the young adults and teenagers who are suffering and sad; young children can also experience depression, but it can look very different, which makes it challenging for parents — or doctors — to recognize it and provide help.Rachel Busman, a clinical psychologist at the Child Mind Institute in New York City, said that it can be hard to think about depression in younger children because we picture childhood as a time of innocence and joy. But as many as 2 to 3 percent of children ages 6 to 12 can have serious depression, she said. And children with anxiety disorders, which are present in more than 7 percent of children aged 3 to 17, are also at risk for depression.Dr. Helen Egger, until recently the chair of child and adolescent psychiatry at N.Y.U. Langone Health, said that according to her epidemiologic research, between 1 and 2 percent of young children — as young as 3 — are depressedDepression was originally conceived of as an adult problem. Maria Kovacs, professor of psychiatry at the University of Pittsburgh School of Medicine, said that in the 1950s and ’60s, there were child psychiatrists who believed that children did not have sufficient ego development to feel depression, but that research that she and other colleagues did in the ’70s showed that “school age children can suffer from diagnosable depression.”Before adolescence, depression is equally common in girls and boys, though among adolescents, it is twice as common in girls, and that predominance then lasts across most of adult life, until old age, when it again appears to equalize.What does depression look like in younger children?When young children are depressed, Dr. Kovacs said, it’s not unusual for “the primary mood to be irritability, not sadness — it comes across as being very cranky.” And children are much less likely to understand that what they’re feeling is depression, or identify it that way. “It almost never happens that they say, ‘something’s wrong because I’m sad,’” Dr. Kovacs said. It’s up to adults to look for signs that something is not right, she said.The best way for parents to recognize depression in young children is not so much by what a child says as by what the child does — or stops doing. Look for “significant changes in functioning,” Dr. Kovacs said, “if a child stops playing with favorite things, stops responding to what he used to respond to.”This might mean a child loses interest in the toys or games or jokes or rituals that used to be reliably fun or entertaining, or doesn’t seem interested in the usual back and forth of family life.“You’ve had a kid who was one way and then you see that they’re more irritable and sad,” said Dr. Egger, who is now the chief medical and scientific officer at Little Otter, a new online mental health care company for children. Children may seem flattened, have less energy or tire easily. And they may start complaining about physical symptoms, especially stomach aches and headaches. They may sleep more — or less — or lose their appetites.A preschool-aged child might be depressed if she is having daily tantrums, with behaviors that risk hurting herself or other people. Depression “may look like a behavior problem but is really being driven by what the kid is feeling inside,” Dr. Egger said.“It’s like walking through the world with dark-colored glasses,” Dr. Busman said. “It’s about myself, about the other person, and the world — I suck, this sucks, everything sucks.”Should I ask about suicidal thoughts?The irritability and the anger — or the flatness and the shutting down — can be signs of profound sadness. And while suicide attempts by elementary school-aged children are rare, they do happen and have increased in recent years. Suicide was the second leading cause of death in children 10 to 14 in 2018, and a 2019 JAMA study showed increasing emergency room visits by children for suicidal thoughts or actions from 2007 to 2015 — 41 percent in children under 11 years old. The presence of suicidal thoughts should be seen as a call for help.The most problematic myth about suicide is the fear “that if you ask about suicide you’re putting the idea in their heads,” said Dr. Kovacs, who developed the Children’s Depression Inventory which is used all over the world.“If you’re dealing with a child for whom this is not an issue, they’re just going to stare at you like you’re out of your head,” Dr. Kovacs said. “You cannot harm somebody by asking them.”But what if children say they have thought of suicide? As with adults, this suggests the child is living with pain and perhaps thinking about a way out. Dr. Kovacs said, children may imagine death as “a release, a surcease, a relief.”Dr. Busman said that she works with children who may say, “I don’t want to kill myself but I feel so bad I don’t know what else to do and say.”If a child talks about wanting to die, ask what that child means, and get help from a therapist if you’re concerned. A statement like this can be a real signal that a child is in distress, so don’t dismiss it or write it off as something the child is just saying for attention, she said.How can treatment help?“Parents should take child symptoms very seriously,” said Jonathan Comer, professor of psychology and psychiatry at Florida International University. “In serious forms it snowballs with time, and earlier onset is associated with worse outcomes across the life span.”In a 2016 longitudinal study, Dr. Kovacs and her colleagues traced the course of depression starting in childhood, and found recurrent episodes in later life.So if you see changes like withdrawal from activities, irritability or sadness, fatigue, or sleep disturbances that persist for two weeks, consider having the child evaluated by someone who is familiar with mental health issues in children of that age. Start with your pediatrician, who will know about resources available in your area.Parents should insist on a comprehensive mental health evaluation, Dr. Busman said, including gathering history from the parent, spending time with the child and talking to the school. An evaluation should include questions about symptoms of depression as well as looking for other problems, like attention deficit hyperactivity disorder or anxiety, which may be at the root of the child’s distress.Early treatment is effective, Dr. Comer said, “There’s terrific evidence for family-focused treatment for child depression — it focuses on family interactions and their impact on mood.” With children from 3 to 7, he said, versions of parent-child interaction therapy, known as PCIT, are often used — essentially coaching parents, and helping them emphasize and praise what is positive about their children’s behavior.As much as possible, parents should try to keep children going outside, taking walks, even playing outdoor games, even if they are less enthusiastic about their usual activities. As with adults, physical exercise has both mental and biological benefits — as do fresh air and sunshine.Depression does not necessarily lend itself to simple cause-and-effect explanations, but Dr. Kovacs emphasized that with a first episode in a child, there is almost always a particular stressor that has set off the problem. It could be a change in the family constellation — a parental divorce, a death — or it could be something more subtle, like an anxiety that has spiraled out of control. If a child does begin therapy, part of the treatment will be to identify — and talk about — that stressor.How can I find help for my child?If you’re concerned that your child might be depressed, start with your pediatrician or other primary care provider. Some clinics and health centers will have in-house mental health services, and you may be able to have your child seen there. Some doctors will have links to local therapists with experience with young children. Mental health specialists can be in short supply (and there’s a lot of need right now), so be open to the possibility of care being delivered remotely, through telehealth. Dr. Kovacs also suggested that parents who are looking for treatment consider clinical psychology department clinics at a local university, where students in psychology and counseling are supervised by licensed psychologists; she said such clinics often have good availability.[The Society of Clinical Child and Adolescent Psychology has advice on how to know if treatment is evidence-based.]“Parents should see children’s struggles as opportunities to intervene,” Dr. Comer said. “The majority of early child mood problems will go away with time, sensitive parenting and supportive environments.”

Scrolling may work for social media, but experts say that for school assignments, kids learn better if they slow down their reading.In this pandemic year, parents have been watching — often anxiously — their children’s increasing reliance on screens for every aspect of their education. It can feel as if there’s no turning back to the time when learning involved hitting the actual books.But the format children read in can make a difference in terms of how they absorb information.Naomi Baron, who is professor emerita of linguistics at American University and author of a new book, “How We Read Now: Strategic Choices for Print, Screen and Audio,” said, “there are two components, the physical medium and the mind-set we bring to reading on that medium — and everything else sort of follows from that.”Because we use screens for social purposes and for amusement, we all — adults and children — get used to absorbing online material, much of which was designed to be read quickly and casually, without much effort. And then we tend to use that same approach to on-screen reading with harder material that we need to learn from, to slow down with, to absorb more carefully. A result can be that we don’t give that material the right kind of attention.For early readersWith younger children, Professor Baron said, it makes sense to stick with print to the extent that it is possible. (Full disclosure: As the national medical director of the program Reach Out and Read, I believe fervently in the value of reading print books to young children.) Print, she said, makes it easier for parents and children to interact with language, questions and answers, what is called “dialogic reading.” Further, many apps and e-books have too many distractions.Dr. Jenny Radesky, a developmental behavioral pediatrician who is an assistant professor of pediatrics at Michigan Medicine C.S. Mott Children’s Hospital in Ann Arbor, said that apps designed to teach reading in the early years of school rely on “gamification meant to keep children engaged.” And though they do successfully teach core skills, she said, “what has been missing in remote schooling is the classroom context, the teacher as meaning maker, to tie it all together, helping it be more meaningful to you, not just a bunch of curricular components you’ve mastered.”Any time that parents are able to engage with family reading time is good, using whatever medium works best for them, said Dr. Tiffany Munzer, also a developmental behavioral pediatrician at Mott Children’s Hospital, who has studied how young children use e-books. However, Dr. Munzer was the lead author on a 2019 study that found that parents and toddlers spoke less overall, and also spoke less about the story when they were looking at electronic books compared with print books, and another study that showed less social back-and-forth — the toddlers were more likely to be using the screens by themselves.“There are some electronic books that are designed really well,” Dr. Munzer said, pointing to a study of one book (designed by PBS) that included a character who guided parents in engaging their children around the story. “On the other hand, there’s research that suggests that a lot of what you find in the most popular apps have all these visually salient features which distracts from the core content and makes it harder for kids to glean the content, harder for parents to have really rich dialogue.”Still, she said, it’s not fair to expect parents to navigate this technology — it should be the job of the software developers to design electronic books that encourage language and interactions, tailored to a child’s developmental level.With preschoolers as opposed to toddlers, Professor Baron said, “there are now beginning to be some smarter designs where the components of the book or the app help further the story line or encourage dialogic reading — that’s now part of the discussion.”Dr. Radesky, who was involved in the research projects with Dr. Munzer, talked about the importance of helping children master reading that goes beyond specific remembered details — words or characters or events — so a child is “able to integrate knowledge gained from the story with life experience.” And again, she said, that isn’t what is stressed in digital design. “Stuff that makes you think, makes you slow down and process things deeply, doesn’t sell, doesn’t get the most clicks,” she said.Parents can help with this when their children are young, Dr. Radesky said, by discussing the story and asking the questions that help children draw those connections.For school-age kids“When kids enter digital spaces, they have access to an infinite number of platforms and websites in addition to those e-books you’re supposed to be reading,” Dr. Radesky said. “We’ve all been on the ground helping our kids through remote learning and watching them not be able to resist opening up that tab that’s less demanding.”“All through the fall I was constantly helping families manage getting their child off YouTube,” Dr. Radesky said. “They’re bored, it’s easy to open up a browser window,” as adults know all too well. “I’m concerned that during remote learning, kids have learned to orient toward devices with this very skimmy partial attention.”Professor Baron said that in an ideal world, children would learn “how to read contiguous text for enjoyment, how to stop, how to reflect.”In elementary school, she said, there’s an opportunity to start a conversation about the advantages of the different media: “It goes for print, goes for a digital screen, goes for audio, goes for video, they all have their uses — we need to make kids aware that not all media are best suited to all purposes.” Children can experiment with reading digitally and in print, and can be encouraged to talk about what they perceived and what they enjoyed.Dr. Radesky talked about helping children develop what she called “metacognition,” in which they ask themselves questions like, “how does my brain feel, what does this do to my attention span?” Starting around the age of 8 to 10, she said, children are developing the skills to understand how they stay on task and how they get distracted. “Kids recognize when the classroom gets too busy; we want them to recognize when you go into a really busy digital space,” she said.For older readersIn experiments with middle school and university students asked to read a passage and then be tested on it, Professor Baron said, there is a mismatch between how they feel they learn and how they actually perform.Students who think they read better — or more efficiently — on the screen will still do better on the test if they have read the passage on the page. And college students who print out articles, she said, tend to have higher grades and better test scores. There is also research to suggest that university students who used authentic books, magazines or newspapers to write an essay wrote more sophisticated essays than those just given printouts.With complex text in any format, slowing down helps. Professor Baron said that parents can model this at home, sitting and relaxing over a book, reading without rushing and perhaps generally de-emphasizing speed when it comes to learning. Teachers can be trained to help students develop “deep reading, mindful, focusing on the text,” she said.For example, students can be trained in digital annotation, highlighting but also making marginal notes, so that they have to slow down and add their own words. “We’ve known that for years, we’ve done it with print, we have to realize that if you want to learn something from a digital document, annotate,” she said.There are also studies that suggest that reading comprehension is better onscreen when readers page down — that is, when they see a page (or a screen) of text at a time, and then move to the next, rather than continuously scrolling through text.Seeing information on the page may help a student see a book as something with a structure, rather than just text from which you grab some quick information.No one is going to take screens out of children’s lives, or out of their learning. But the more we exploit the rich possibilities of digital reading, the more important it may be to encourage children to try out reading things in different ways, and to discuss what it feels like, and perhaps to have adults reflect on their own reading habits. Reading on digital devices can motivate recalcitrant readers, Professor Baron said, and there are many good reasons to do some of your reading on a screen.But, of course, it’s a different experience.“There’s a physicality,” Professor Baron said. “So many young people talk about the smell of books, talk about reading print as being ‘real’ reading.”

#masthead-section-label, #masthead-bar-one { display: none }At HomeWatch: ‘WandaVision’Travel: More SustainablyFreeze: Homemade TreatsCheck Out: Podcasters’ Favorite PodcastsAdvertisementContinue reading the main storySupported byContinue reading the main storyThe CheckupDiagnosing Autism in the PandemicAutism spectrum disorder is often suspected when young children stand out as being different from their peers. That can be much harder in this isolated time.Credit…Yifan WuMarch 1, 2021We talk often in pediatrics about the importance of early identification and early treatment of autism spectrum disorder, with its hallmark issues of social communication problems and restricted repetitive behavior patterns. “Early” means paying particularly close attention to the behavior and development of children between ages 1 and 3, and checking in with their parents about any concerns.But what does that mean for young children who have now spent half their lives — or more — in the special circumstances of the pandemic?Dr. Heidi Feldman, a professor of developmental and behavioral pediatrics at Stanford University School of Medicine, said, “We don’t know what the impact of one year of very restricted social interaction is going to be on children.” Some of the behavior patterns that children are showing now may be the result of these strange living conditions, or they may reflect stress, trauma and the social isolation that many families have experienced, she said.Dr. Feldman said that first-time parents who have been operating in the increased isolation of the pandemic may have very limited context for appreciating where their child’s behavior falls. They’re missing the input they might usually get from teachers and child care providers.Dr. Eileen Costello, a clinical professor of pediatrics at Boston University School of Medicine and chief of ambulatory pediatrics at Boston Medical Center, said, “Especially for the really little ones, the only eyes that are on them are their parents’. They’re not seeing uncles and aunts and cousins, not in preschool.”Dr. Costello and I are co-authors of the book “Quirky Kids: Understanding and Supporting Your Child With Developmental Differences.” We use the word “quirky” to encompass children whose development does not follow standard patterns, whether or not they fit the criteria for a specific diagnosis. Some of these children will accumulate several different diagnoses as they grow and change — and as different demands are made on them in terms of academic performance and social life — and others will never fit the criteria for any specific formal diagnosis.Dr. Adiaha Spinks-Franklin, a developmental behavioral pediatrician at Texas Children’s Hospital and an associate professor at Baylor College of Medicine, said that because parents right now are at home more, sometimes they are more likely to notice unusual or concerning patterns — repetitive behaviors, or communications problems like echolalia, in which a child repeats words. This can be completely normal, and is in fact part of how children learn to talk, but it can be concerning if it’s the major part of a child’s language as the child grows. By the age of 2, children should be saying lots of their own words.When parents — or teachers or doctors — do have concerns, getting a developmental assessment done has its own complexity in the pandemic.Catherine Lord, a professor of psychiatry and education at the University of California, Los Angeles, said, “I’m doing diagnoses right now in my back yard, which is insane.” But with the protective gear that would have to be worn at the hospital, she said, “we look like we’re from outer space,” and could be too intimidating to small children.Dr. Lord said. “We do remote interviews with parents, we try to see videos of the kid, then have them come — we have a big back yard.” And they continue to use the Zoom technology, even across the yard.The standardized assessment for autism spectrum disorder can’t be done masked, because it depends on interpreting the child’s expressions and observing reactions to the examiner’s facial expressions. Dr. Lord said there is a shorter version that children can do with their parents — everyone unmasked — while the clinicians watch without being in the room. This may not be as accurate — researchers are still analyzing the data — but they are hopeful that it will be helpful in many cases.“When we see kids in clinic, we have to be masked, and if they’re over 2, they have to be masked,” Dr. Feldman said. Earlier in the pandemic, a family that was convinced that their child had autism came to the clinic. “This kid had not seen anybody other than his parents and had not been anyplace other than his home — he was so terrified — the in-person visit was very, very hard.” They used a room with a one-way mirror, so the parents could be alone with the child, and could take their masks off, but “even with that, he had such a hard time settling down.”Dr. Lord was the lead author on a review paper on autism spectrum disorder published in Nature Reviews in 2020. She emphasized the importance of early diagnosis so that children can get early help with communication: “Kids who are going to become fluent speakers, their language starts to change between 2 and 3, and 3 and 4, and 4 and 5,” Dr. Lord said. “We want to be sure we optimize what happens in those years and that’s very hard to do if people are stuck at home.”She recommended that parents request the free assessments that can be done through early intervention, in many cases now being done remotely.Developmental assessments can include remote visits. “We have gotten quite good at doing telehealth evaluations,” Dr. Feldman said. “We get the kids in their own environments and their own toys, we get to see what they do at home.”“Sometimes making the diagnosis of autism over telehealth in a very young child is incredibly challenging,” Dr. Spinks-Franklin said. “Families that don’t have access to consistent reliable high-speed internet are also impacted — a video visit may not be possible or may be interrupted.”Even before the pandemic, many families faced long waits to get those developmental assessments. “Those who are vulnerable already are always going to be more severely affected — families who already had more limited access to primary care providers or are underinsured or uninsured already had a harder time,” Dr. Spinks-Franklin said.Now, she said, the pandemic is placing those families even more at risk, because of the likelihood of economic hardship from jobs loss, underemployment or lost health care benefits. The disparities are exacerbated, and the chance of getting to the right clinic and the right health care professional go down.Right now, because families are isolated or may not have good access to medical care, neurodevelopmental problems may be being missed in these critical early years, when getting diagnosed would help children get therapy. On the other hand, some children who don’t have these underlying problems and are just reacting to the strange and often anxiety-provoking circumstances of pandemic life may mistakenly be thought to be showing signs of autism.Parents and even doctors may worry about autism spectrum disorder in children who have attention deficit hyperactivity disorder or anxiety, and who are being seen in unusual situations — in a parking lot, for example. “I’ve been undoing diagnoses,” Dr. Lord said. “It’s not surprising that a kid is looking a bit less relaxed.”Dr. Spinks-Franklin said that the pressures of the pandemic may act on children as other stresses do, and show up as more extreme behavior, such as more frequent tantrums or increased irritability.“All that bounces is not A.D.H.D.; all that flaps is not autism,” Dr. Spinks-Franklin said.What Parents Can DoTo understand whether a child’s extreme behavior represents chronic stress and increased frustration related to the hardships that families are living through, or is a sign of a neurodevelopmental disorder, it’s important to figure out whether these behaviors were present before the pandemic, Dr. Spinks-Franklin said.If parents have concerns about a child’s development or behavior, a good place to start is to talk the question through with the child’s primary care provider, who can also review the record with the parents and talk about the child’s early developmental course.If parents still have concerns, it’s reasonable to request a referral for a full developmental assessment. Early intervention, a federally mandated program, offers help and therapy if a child seems to be significantly delayed in any developmental domain, but does not make diagnoses.Some developmental markers reflect a child’s early progress with speech and language, and with social interactions. The following are adapted from “Quirky Kids.”A baby babbles by 6 months, and the babble increases in complexityBy 9 months, a baby responds to his or her nameBy 15 to 18 months, a child can say some words and follow simple directionsBy 18 months, a child can put two words togetherBy 2 ½ to 3, a child can speak in simple sentences with some fluency and inflection — a question sounds like a questionBy 4 months, babies make eye contact and respond with social smilesBy 1 year, they can point to show interest, and wave goodbyeFrom about 2, they respond to other children and can interact in games with some back-and-forthAdvertisementContinue reading the main story