Are Your Child's Behaviors or Emotional Reactions of Concern?

Are your child's behaviors or emotional reactions a serious problem?  Truly this is a question that comes up many times a day in my office.  Mostly I find that I can offer reassurance and guidance on what to do and what to expect next.  Many concerns simply represent normal and predictable parts of a child or adolescent's development.  Sometimes I must dig a little deeper.

Keep in mind that I am a general pediatrician and a mother, not a psychiatrist or psychologist.  I received the education a board-certified pediatrician is exposed to during her training and ongoing maintenance of certification.  My experience has developed over the years, as I have interacted and provided health care for many children.  I have a few validated assessment tools I can use when I need a more objective point of view.  However, to get an idea of what is going on, mostly I talk to parents and children and observe children in my office. 

Now, having properly oriented you, I want to let you in on some of the big things I consider when trying to help parents figure out if their child has a behavioral or emotional problem beyond the range of normal variation or development. 

1.  HAPPY?
I want children generally to be happy and able to participate in school and the activities they usually want to do.   Certainly a child will have ups and downs, good days and bad, temper tantrums, mood swings, and upsetting things that happen to them.  However, overall, a child will normally stay interested and have some enthusiasm for family, activities, friends, and at least some parts of the school day.

2.  PARTICIPATING IN LIFE?
I don't want a child's behaviors or emotional reactions over time to significantly limit their participation in family life, the school setting, friendships, and individual interests.  Again, this doesn't just mean having a bad day, or week.  The overall arc of a child's day-to-day life should allow them have the experiences they need to develop meaningful relationships, independence, confidence, and self-esteem.

3.  FITTING INTO THE FAMILY?
We have to get to know our children.  Different temperaments respond better to various forms of discipline and structure.  A frown and slight shake of the head may bring one three-year-old to the point of tears, while another won't respond until they have had several time-outs and a toy taken away!  Still, unless it is necessary because of a child's young age or special needs, a family should not have to adjust everything they do around a child's behavior or emotional reactions.  If, because of their child, parents find themselves usually quite limited in the places they can go, food they can eat, and people they can visit, this might be a concern.  Or, if a time-consuming amount of planning is necessary to get out the door, get a child to school, stay on a schedule, make sure the right snack and drink is available, etc. then this could be a red flag.

Can I generalize and say that if a child is usually happy, participates willingly in life, and fits into the family then there is nothing to worry about?  Probably it's not that easy!  However, if one or more of the above three questions starts to reveal a persistent problem, then I know I will have to look into it further.

Your personal pediatrician is a resource for you in helping to figure out what is normal for your child.  Other pieces of the puzzle may be filled in by talking to your child's teacher or daycare provider, other parents, relatives, or a school administrator or counselor. 

Answering the question of what to do about a particular behavior or emotional reaction will always involve trying to determine if it is a major or minor problem, if it is a part of normal and expected development, and if it is affecting multiple areas of a child's life.  I hope, as you struggle through the ups and downs of parenting, this gives you some ideas about how to think clearly about your child.

Fatigue, Teens, and Tweens

I see many tired teenagers in the office every day. They take naps after school, can hardly get out of bed in the morning, sometimes sleep half the day on weekends, and generally are low on energy. They always seem low on energy when it is time to get up to go to school, do homework, or do chores. They often revive in an amazing way when it is time for sports practice or competitions, or time to engage in some way with peers.

Their sleep habits are often poor--bedtime of 10:30 or later, then up at 6:30 on school days (teenagers should be getting about 10 hours of sleep at night, averaged over the week, without counting naps). Their phones, computers, TVs are in their rooms to distract them as they try to fall asleep. They often skip breakfast, or have a high sugar treat on the way out the door. Lunch is fast food, or the equivalent in high fat and low nutritional content. Or they don't eat lunch. Fluids can be minimal throughout the day. Some teens barely exercise. Most spend lots of time in front of a screen (TV, computer, games, phones).

Then there is the stress of being a teenager--six or seven teachers making demands, tests, homework, sports, clubs, applying to college (fatigue is VERY common for seniors in high school!), lack of spending money, or the added pressure of a job, relationships with family and friends, a boyfriend or girlfriend, fitting in socially...Actually listing this makes ME feel a little tired and stressed. Wouldn't YOU want a nap after school, too?

There are many causes of fatigue, both physical and emotional. Of course there are important medical causes of fatigue, and mental illness (such as depression) can lead to fatigue. However, fatigue is a common symptom, and MOST OF THE TIME it reflects common, ongoing, physical and emotional stress in a teen or tween's life.

My medical training leads me to think of the most likely things first. There is a kind of medical school joke about zebras and horses. You need the background information that in the United States of America you would be more likely to see horses than you would zebras. In fact, you would probably have to go to a zoo to see zebras, while you could just drive out to the country to see some horses.

So, in south west Michigan, if an animal looked and smelled like a horse, was the same general size as a horse, walked and sounded like a horse--but you just couldn't see its hide to tell if it was striped or plain--would it be more likely a horse or a zebra? The right answer here, of course, is that a HORSE would be more likely than a zebra. It would not be impossible to see a zebra (I guess a farmer could have one as a pet, or one could have escaped from a zoo), but out in the country in south west Michigan you are probably looking at horses.

That means, that when I am assessing someone for the cause of their fatigue, I keep the possibility of zebras (or less common illnesses) in mind, but I do NOT usually end up seeing stripes. I am going to ask general questions about the patient's life, and these answers will factor in an important way into what I think is causing my patient's fatigue. I might ask any or all of the following questions, or even think of other questions that are centered around lifestyle, home, and school:

1. How is school going? Grades, attendance, completing assignments, behavioral concerns at school...new challenges, perfectionism, getting behind in school?
2. How are you getting along with your family? Who do you get along with best? worst?
3. How are things at home?
4. Anything changed at home? Divorce, separation, illness, pets, job loss, troubled sibling...
5. How are things with friends?
6. Dating? How is that going? How long? Physically involved with this person?
7. Are you in trouble with anyone? Suspended? Grounded? Have a probation officer?
8. Substance use/abuse? Tobacco, alcohol, illegal drugs, prescription drugs...
9. What is your daily schedule like?
10. When do you have free time? What do you do with it?
11. What are your eating patterns like? Do you eat three meals? Drink enough water? Take a vitamin?
12. Are you happy with your weight? Dieting? Losing or gaining weight?
13. When and how much do you exercise?
14. Are most teenagers happier than you?
15. Are most teenagers having more fun than you?
16. Do most teenagers have more friends than you?
17. Are most teenagers more popular than you?
18. Are most teenagers thinner than you?

I think this list could be endless. Hopefully you see my point, that any number of these factors could be important considerations in figuring out why your child is tired all the time.

Of course there are the so-called "red flags" when it comes to fatigue. Here I am thinking about signs of depression, deliberate self-harm ("cutting"), thoughts of suicide, a suicide plan. I am also looking for excessive, paralyzing anxiety or panic.

And finally, last on my list, still important but much less likely, the reason most parents bring their fatigued teen or tween to see me, PHYSICAL ILLNESS as a cause of fatigue. Here is where I see parents worry. They believe their teenager has hypoglycemia, or diabetes, or a thyroid condition, or anemia. Now I am asking about weight loss, blood in stools, diarrhea, urinary frequency, excessive thirst, excessively heavy periods, palpitations, dry skin, constipation, night sweats, absent or fewer periods, joint swelling or pain, and other physical symptoms. I always ask about headaches and stomachaches as well, but many people have these symptoms so it doesn't usually help me narrow things down.

Follow all of the above by a physical exam, and sometimes blood work (often just general screening for anemia, hypothyroidism, and a general metabolic panel that includes a blood sugar level), and I am usually left with a physically normal appearing teenager who has normal blood tests. Parents are relieved. BUT THE TEENAGER IS STILL TIRED!

In my respectful, and humble opinion, the blood tests have contributed very little to the evaluation of the fatigued teen/tween. The physical/medical disorders that could have led to abnormal blood tests just aren't that common in comparison to the psychological, lifestyle, and mental health issues that can lead to fatigue. And while it may relieve YOU, as the parent, to know the blood tests are normal, it didn't help your teen overcome his fatigue!

I am not advocating skipping the medical work up for a fatigued teenager. What I want is for parents and teens to take a close look at their lifestyle, diet, sleep habits, stress, and mental health, and to consider these issues as a possible important cause of fatigue. MOST OF THE TIME these issues will be THE cause of the fatigue, so I don't think we can ignore them.

I don't want to miss an important physical cause of fatigue any more than you do, but I do want to help your child feel better. That will probably take us looking at the whole picture, not just ordering a blood draw. And it may involve a solution that is not as easy as taking a pill. It could include changes in lifestyle, diet, nutrition, sleep habits, exercise. Or a recommendation may be made for counseling or family therapy.

You might also be able to tell from this blog that an evaluation for fatigue deserves its own appointment in my office. This is not a work up I can easily add on to the end of a visit for a cough, strep throat, or wart, or piggy-back on to a sibling's appointment. We need to give this symptom the time and attention it demands. After reviewing the information above, however, you may have more insight into the problem and have some ideas for helping your teen. It's usually ok to try some things before making the appointment.

As I always say, this blog is intended to provide general information for situations that are not specific to any patient or family. My blog is not meant to be medically comprehensive and cannot take every situation or symptom into consideration. Every one deserves to have their concerns personally addressed by their own doctor, and the information in my blog is not a substitute for that kind of attention.