Emotional problems

Winter Blues and Seasonal Affective Disorder

As winter approaches, some of us may experience the “winter blues” – feeling sad from shortening days, climbing into bed earlier and resenting waking up on dark mornings.

That’s different than Seasonal Affective Disorder (SAD), a term used to describe a type of depression that follows a seasonal pattern.

The most common form of SAD occurs in winter, although some people do experience symptoms during spring and summer. And while SAD is often talked about in terms of adults, children and adolescents are not necessarily immune.

Who is at risk for SAD?

SAD usually develops in a person’s early 20s but can occur in older children and teens. The risk for the disorder decreases as you get older. SAD is diagnosed most often in young women, but men who have SAD may suffer more severe symptoms. People with a family history of SAD or those who live in northern latitudes where daylight hours during winter are shorter are at a higher risk for developing SAD.

Symptoms of SAD

When experiencing SAD, a person may

  • withdraw socially and no longer enjoy things that used to be fun. It’s as if a person’s batteries have just run down.
  • crave comfort foods, including simple carbs such as pasta, breads, and sugar. With excess unhealthy calories and a lack of fresh fruits, vegetables, and whole grains, fatigue often sets in, leading to increased sleepiness and weight gain.
  • feel anxious, irritable, have trouble sleeping, or decreased appetite. These symptoms are more common with the spring/summer form of SAD.

​No Known Cause​

Researchers have not determined what causes SAD. There is some evidence pointing to a disruption of a person’s “circadian rhythm” — the body’s natural cycle of sleeping and waking. As the days shorten, the decreasing amount of light can throw off the body’s natural clock, triggering depression. Sunlight also plays a role in the brain’s production of melatonin and serotonin. During winter, your body produces more melatonin (which encourages sleep) and less serotonin (which fights depression). Researchers do not know why some people are more susceptible to SAD than others.

In general, SAD is a better-recognized disorder in adults because so many children’s mental health disorders emerge over time. Diagnosing SAD in a child is not easy, because determining the pattern of depression takes time. A doctor will typically attempt to determine whether a child is suffering from depression or anxiety first, then look at the pattern over time. The diagnosis of SAD is made only if a person meets criteria for a diagnosis of depression and if a seasonal pattern of symptoms has been present for at least 2 years.

In order to diagnose SAD, doctors need to perform a medical exam to rule out other possible causes of the symptoms. They may also administer questionnaires to determine mood and look for seasonal patterns.

Treating SADSeveral effective treatments can help ease the symptoms of SAD, including:Opening the window shades in your home. Simply bringing more sunlight into your life can treat mild cases.Spending time outdoors every day, even on cloudy days.Exercising regularly and eating a healthy diet, one low in carbohydrates and high in vegetables, fruit, and whole grains.Using a “dawn simulator,” which gradually turns on the bedroom light, tricking the body into thinking it’s an earlier sunrise.Planning a mid-winter family vacation to a sunny climate.Light therapy – sitting in front of a strong light box or wearing light visors, with UV rays filtered out. However, light therapy may have risks when used for children. Talk to your child’s doctor before considering this treatment option.If none of these treatments work, prescription antidepressants​ may help regulate the balance of serotonin and other neurotransmitters that affect mood. Antidepressants, however, come with a “black box” warning about the risk of suicidal thoughts and behavior. Parents with children on antidepressants need to be vigilant in watching for agitation, anxiety, or insomnia and make sure they continue to see their physician on a regular basis.

​Working through it together

Whether noticing symptoms of SAD in yourself or in your child, take it seriously. Treating this disorder early and diligently can turn the dark days of winter into a pleasant time of togetherness for your family. ​

Emotional problems

Understanding Childhood Fears and Anxieties

My child seems to be afraid of a lot of things. Should I be worried?

From time to time, every child experiences fear. As youngsters explore the world around them, having new experiences and confronting new challenges, anxieties are almost an unavoidable part of growing up.

Fears are Common:

According to one study, 43% of children between ages 6 and 12 had many fears and concerns. A fear of darkness, particularly being left alone in the dark, is one of the most common fears in this age group. So is a fear of animals, such as large barking dogs. Some children are afraid of fires, high places or thunderstorms. Others, conscious of news reports on TV and in the newspapers, are concerned about burglars, kidnappers or nuclear war. If there has been a recent serious illness or death in the family, they may become anxious about the health of those around them.

In middle childhood, fears wax and wane. Most are mild, but even when they intensify, they generally subside on their own after a while.

About Phobias:

Sometimes fears can become so extreme, persistent and focused that they develop into phobias. Phobias – which are strong and irrational fears – can become persistent and debilitating, significantly influencing and interfering with a child’s usual daily activities. For instance, a 6-year-old’s phobia about dogs might make him so panicky that he refuses to go outdoors at all because there could be a dog there. A 10-year-old child might become so terrified about news reports of a serial killer that he insists on sleeping with his parents at night.

Some children in this age group develop phobias about the people they meet in their everyday lives. This severe shyness can keep them from making friends at school and relating to most adults, especially strangers. They might consciously avoid social situations like birthday parties or Scout meetings, and they often find it difficult to converse comfortably with anyone except their immediate family.

Separation anxiety is also common in this age group. Sometimes this fear can intensify when the family moves to a new neighborhood or children are placed in a childcare setting where they feel uncomfortable. These youngsters might become afraid of going to summer camp or even attending school. Their phobias can cause physical symptoms like headaches or stomach pains and eventually lead the children to withdraw into their own world, becoming clinically depressed.

At about age 6 or 7, as children develop an understanding about death, another fear can arise. With the recognition that death will eventually affect everyone, and that it is permanent and irreversible, the normal worry about the possible death of family members – or even their own death – can intensify. In some cases, this preoccupation with death can become disabling.

Treating Fears & Phobias:

Fortunately, most phobias are quite treatable. In general, they are not a sign of serious mental illness requiring many months or years of therapy. However, if your child’s anxieties persist and interfere with her enjoyment of day-to-day life, she might benefit from some professional help from a psychiatrist or psychologist who specializes in treating phobias.

As part of the treatment plan for phobias, many therapists suggest exposing your child to the source of her anxiety in small, nonthreatening doses. Under a therapist’s guidance a child who is afraid of dogs might begin by talking about this fear and by looking at photographs or a videotape of dogs. Next, she might observe a live dog from behind the safety of a window. Then, with a parent or a therapist at her side, she might spend a few minutes in the same room with a friendly, gentle puppy. Eventually she will find himself able to pet the dog, then expose herself to situations with larger, unfamiliar dogs.

This gradual process is called desensitization, meaning that your child will become a little less sensitive to the source of her fear each time she confronts it. Ultimately, the child will no longer feel the need to avoid the situation that has been the basis of her phobia. While this process sounds like common sense and easy to carry out, it should be done only under the supervision of a professional.

Sometimes psychotherapy can also help children become more self-assured and less fearful. Breathing and relaxation exercises can assist youngsters in stressful circumstances too.

Occasionally, your doctor may recommend medications as a component of the treatment program, although never as the sole therapeutic tool. These drugs may include antidepressants, which are designed to ease the anxiety and panic that often underlie these problems.

What Parents Can Do:

Here are some suggestions that many parents find useful for their children with fears and phobias.

  • Talk with your child about his anxieties, and be sympathetic. Explain to him that many children have fears, but with your support he can learn to put them behind him.
  • Do not belittle or ridicule your child’s fears, particularly in front of his peers.
  • Do not try to coerce your youngster into being brave. It will take time for him to confront and gradually overcome his anxieties. You can, however, encourage (but not force) him to progressively come face-to-face with whatever he fears.

Since fears are a normal part of life and often are a response to a real or at least perceived threat in the child’s environment, parents should be reassuring and supportive. Talking with their children, parents should acknowledge, though not increase or reinforce, their children’s concerns. Point out what is already being done to protect the child, and involve the child in identifying additional steps that could be taken. Such simple, sensitive and straightforward parenting can resolve or at least manage most childhood fears. When realistic reassurances are not successful, the child’s fear may be a phobia.

Emotional problems

Treating Eating Disorders

​Eating disorders are real, treatable diseases. They frequently coexist with other illnesses such as depression, substance use, or anxiety disorders. Psychological and medicinal treatments are effective for many eating disorders. The earlier eating disorders are diagnosed and treated, the better the chances are for recovery.

How are eating disorders treated?

Typical treatment goals include restoring adequate nutrition, bringing weight to a healthy level, reducing excessive exercise, and stopping binging and purging behaviors. Treatment plans often are tailored to individual needs and may include one or more of the following:

  • Psychotherapy
  • Medical care and monitoring
  • Nutritional counseling
  • Medications

Some patients also may need to be hospitalized to treat problems caused by malnutrition or to ensure they eat enough if they are very underweight. Complete recovery is possible.

About psychotherapies:

Specific forms of psychotherapy, or talk therapy—including a family-based therapy and cognitive behavioral approaches—have been shown to be useful for treating specific eating disorders.

The Maudsley approach, for example, where parents of teens with anorexia nervosa assume responsibility for feeding their child, appears to be very effective in helping teens gain weight and improve eating habits and moods.

Others may undergo cognitive behavioral therapy (CBT) to reduce or eliminate binge-eating and purging behaviors. CBT helps a child learn how to identify distorted or unhelpful thinking patterns and recognize and change inaccurate beliefs.

About medications:

Medications such as antidepressants, antipsychotics, or mood stabilizers approved by the U.S. Food and Drug Administration (FDA) may also be helpful for treating eating disorders and other co-occurring illnesses such as anxiety or depression. Check the FDA website for the latest information on warnings, patient medication guides, or newly approved medications.

What is being done to better understand and treat eating disorders?

Researchers are finding that eating disorders are caused by a complex interaction of genetic, biological, psychological, and social factors. But many questions still need answers. Researchers are studying questions about genetics, brain function, and behavior to better understand and control eating disorders. Neuroimaging and genetic studies may also provide clues for how each person may respond to specific treatments.

  • Genetics: Mental health researchers are studying the various combinations of genes to determine if any DNA variations are associated with the risk of developing a mental disorder.
  • Neuroimaging: Magnetic resonance imaging (MRI), for example, may also lead to a better understanding of eating disorders. Neuroimaging already is used to identify abnormal brain activity in patients with schizophrenia, obsessive-compulsive disorder and depression. It may help researchers better understand how people with eating disorders process information, regardless of whether they have recovered or are still in the throes of their illness.
  • Behavioral or psychological research: Few studies of treatments for eating disorders have been conducted in the past due to the difficulty of this research. New studies currently underway, however, are aiming to remedy the lack of information available about treatment.
Emotional problems

Tourette Syndrome: A Not-So-Frightening Diagnosis

Tourette syndrome (TS) is a nervous system disorder. It causes people to have repetitive movements or sounds that they can’t control. These are known as tics, and they typically start in childhood. There are two types: motor tics and vocal tics.

You may feel anxious if your child is diagnosed with Tourette syndrome. That’s completely understandable. Educating yourself about this condition can go a long way in lessening your fears.

How did Tourette syndrome get its name?

Tourette is simply the last name of a French doctor who is credited with discovering the condition. In 1885, Gilles de la Tourette reported nine patients with the classic symptoms of this disorder. The condition was then named after him.

What are tics?

Tourette syndrome is a type of tic disorder. Tics can be short, fast, sudden or come in clusters. They can also vary in number, frequency, type, or severity. They can even disappear for weeks or months at a time.We often see Tourette syndrome portrayed in the media as people blurting out swear words. However, cursing and other outburts happen in less than 15% of patients.

Usually, tics start gradually. In fact, your child may have had them for a long time before you notice. Sometimes tics are so mild, they’re only found when a child is seen for other medical issues.

Examples of motor tics:

  • Eye blinking
  • Head jerking
  • Facial grimacing
  • Eye movements
  • Mouth opening
  • Shoulder shrugging
  • Knuckle cracking
  • Abdominal wall jerks
  • Little jumps while walking

Examples of verbal tics:

  • Sniffling
  • Sneezing
  • Throat clearing
  • Barking and other animal sounds
  • Squeaking
  • Snorting
  • Repeating words or phrases
  • Uncontrollable swearing

Examples of unusual tics:

  • Arching
  • Vomiting
  • Ear movements
  • Swallowing air
  • Movements of the soft palate (in the back of the throat)
  • Blocking tics such as freezing, fixed staring and certain postures that aren’t associated with another condition

Tics are categorized as either simple or complex:

  • Simple tics: These tics only involve certain muscle groups in the body. They can be motor or vocal tics. For instance, kids might shrug their shoulders (motor) or grunt (vocal).
  • Complex tics: These tics often involve several groups of muscles. Examples of complex tics are jumping or twisting (motor) and repeating words or phrases (vocal). Sometimes they’re a combination of motor and verbal tics.

Tics typically get worse when your child is anxious, stressed, excited, tired or angry. It’s not common, but tics can also happen while your child is sleeping. Keep in mind that tics are usually temporary and mild.

Some kids feel they can briefly control their tics. But the urge only grows until it finally explodes. The tic has to be released. When your child is focusing their attention on something else, their tics may improve.It might be tempting, but don’t ask your child to stop their tic behaviors. This just creates more tension for them and can actually make the tics worse.

It’s best not to point out or comment on your child’s tics either. This might make them more self-conscious, which could also make the tics worse. Instead, work at making your child’s environment a place where their tics are seen as natural and normal.

How is Tourette syndrome diagnosed?

There are no specific tests to diagnose TS. This includes laboratory tests such as blood tests, magnetic resonance imaging (MRI) or electroencephalogram (EEG). But sometimes these tests may be used to rule out other conditions that may be causing your child’s symptoms.

Healthcare professionals use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) to help diagnose TS.

Here are the symptoms a child must have for a diagnosis of Tourette syndrome:

  • Multiple motor tics and vocal tics, though they might not always happen at the same time
  • Tics that happen any times a day (usually in clusters), nearly every day, or off and on, for at least a year
  • Tics that began before age 18 years
  • Symptoms that aren’t from taking other drugs or having another medical condition such as seizures, Huntington’s disease, or post-viral encephalitis

Tourette syndrome is usually mild. Serious comorbidities (additional health conditions), complications and other related problems are rare.

What causes Tourette syndrome?

No one knows exactly what causes Tourette syndrome. Experts think it’s a combination of factors, including:

  • Genetics
  • Environment
  • An imbalance in brain chemicals called neurotransmitters

Tourette syndrome usually starts between the ages of 5 and 10 years. However, it can affect infants and adults too. It’s three to five times more common in boys than girls. Boys are also four times more likely to develop TS if their father has it.

Studies show TS affects 6% to 12% of people in all races and ethnic groups. It’s more common in people with autism spectrum disorder and Fragile X syndrome.

Many children with Tourette syndrome have other behavioral conditions too, including:

  • Attention-deficit/hyperactivity disorder (ADHD)
  • Obsessive-compulsive disorder (OCD)
  • Anxiety
  • Depression
  • Learning problems
  • Behavioral problems
  • Sleep disorders

Tourette syndrome treatment

There is no cure for Tourette syndrome. But many kids don’t need treatment at all. Your child’s symptoms only need to be treated if they’re interfering with life. If the tics affect their schoolwork, their social life or their behavior, for example, there are some treatment options that may help.

Cognitive behavioral intervention & talk therapy

The first line of treatment is a therapy called cognitive behavioral intervention for tics. This therapy is highly effective. But it isn’t always easy to get because there aren’t many psychologists trained in it.

Regular talk therapy can help your child learn to relax and cope with stress. If your child has other behavioral conditions, therapy can help with these as well.

Medication & other potential treatment options

Medications can’t completely get rid of Tourette syndrome symptoms.There are many different drugs used to treat tics. Your doctor will decide which is best for your child based on their other health conditions, such as depression or ADHD, and their age. Some of the medications that may be used to treat tics include:

AripiprazoleOlanzapineHaloperidolZiprasidoneQuetiapineSulpirideTiapridePergolideCannabisBotulinum toxin injections

Deep brain stimulation is an option for severe tics that don’t respond to other treatments. More research needs to be done on how effective and safe DBS is for children with Tourette syndrome.

What is the outlook for children with Tourette syndrome?

In general, there’s not much to fear when it comes to Tourette syndrome. Children with this disorder can live productive lives. They have a normal life expectancy.

About 30% of children with Tourette syndrome get better in adolescence or early adulthood. Another 30% carry their tics over into adulthood. Only a third get worse. But from those, just 2% to 5% need significant support in life.

Emotional problems

Teen Suicide Risk: What Parents Should Know

Which Kids Are At the Highest Risk for Suicide?

If you’re worried about your child’s risk for suicide, you are not alone.

In 2021, emergency departments across the U.S. noted a sharp rise in 12-to-17-year-olds needing treatment for suicidal thoughts or actions. And in a recent federal survey, more than 4 in 10 high school students reported feeling “persistently sad or hopeless,” while 1 in 5 said they’d thought about suicide.

Grief, isolation and fear caused by the COVID-19 pandemic are possible causes. But experts say the pressures that can lead young people to consider suicide have been rising for years.

Caring and informed family support can help kids cope when life feels overwhelming. You will feel better prepared to help your child when you know more about these suicide risk factors:

Previous suicide attempts

Young people who have already tried to take their lives face higher risks for suicide. Risks remain high for at least one year after a suicide attempt, so follow-up care is crucial. One study shows that the stigma and shame people feel after trying to end their lives may drive them to try again. After a suicide attempt, research also suggests that self-harm, such as cutting, places kids at higher risks for suicide in the following year.

Family experiences

There are many family issues that can affect youth suicide risks. For example, research shows that when one family member dies by suicide, others in the same family are more likely to take their own lives. Kids who live with abuse, violence, and other forms of trauma are also at greater risk of suicide. Separation from loved ones due to death, divorce, deployment, deportation, incarceration and other factors can cause mental health struggles that may contribute to suicide risks, as can the loss of stable housing. Studies also suggest that kids who are adopted and those who have spent time in foster care are more likely to be exposed to trauma and adversity; this can raise their risk for suicide.

Social pressures relating to sexual orientation or gender identity

Young people who identify as lesbian, gay, bisexual, transgender, queer or two-spirit (LGBTQ2S+) are 4 times more likely to attempt suicide than their straight (heterosexual or cisgender) peers. However, sexual orientation and gender identity themselves are not directly linked to suicide. Rather, youth who identify as LGBTQ2S+ may experience discrimination, hostility and rejection, which can lead to suicidal thoughts and actions. One study found that when kids experience negative family and social reactions to coming out, this can raise suicide risks.


Racism, discrimination and related systemic bias are extremely harmful to mental health. Also, a history of systemic racism limits children’s ability to access developmentally and culturally responsive mental health services in communities and schools. Racism and discrimination have led to significant differences in suicide risk and rates based on race and ethnicity. One study of Black and Latinx youth showed that even subtle discrimination is linked with suicidal thinking. As the American Psychological Association (APA) notes, race-related stress threatens the inner resources people need to cope with everyday life. The APA offers tools and insights for parents who, along with their kids, need strategies for overcoming the erosive effects of racism.


Adolescents who experience depression are more likely to attempt suicide. Parents may notice depression symptoms such as sadness, irritability, hopelessness, boredom, and the tendency to feel overwhelmed most or all the time. But some kids are good at hiding their feelings or don’t know how to share them. Since 1 in every 5 adolescents and teens will face depression at some point, the American Academy of Pediatrics (AAP) recommends that all kids aged 12 and over be screened for depression and suicide risks in yearly health checkups.

Other mental health conditions

Mood disorders, eating disorders and other psychiatric conditions can increase a child’s risk of suicide. For example, young people with schizophrenia may hear voices (auditory hallucinations) that seem to be telling them to take their own lives, even though they do not want to die.

Alcohol and substance use

Substance use is a factor in roughly 1 in 3 youth suicides. Young people may intentionally take large doses of drugs as a way of ending their lives. Alcohol and drug use can also cause a break from reality, or psychotic episode, that causes hallucinations or delusions that lead to suicide.

Behavior problems

Young people who experience extreme anger or have a history of aggressive, impulsive behavior face higher suicide risks. Strong feelings themselves aren’t the sole cause, since most children and teens experience intense emotions and moods. But youths who act out feelings in destructive ways may end their lives, especially if they are socially isolated, using drugs or alcohol, or consuming media in excessive, unhealthy ways.

Knowledge of other suicides, especially close to home

One study showed that when young people learn about the suicide of someone they know, they are more likely to consider or attempt suicide. Parents should pay close attention when suicides happen, especially when losses involve family members, friends, or school peers. Children and teens may need extra support, including professional counseling, to cope with strong feelings they are experiencing.

Easy access to guns

Firearms are the top cause of death for teens 15-19 years old who die by suicide. Even when guns are locked up, studies show that teens who live in homes with firearms are more likely to kill themselves than those in homes without guns. Teens, whose brains are still developing, tend to be more impulsive than adults. A momentary decision to attempt suicide with a gun often leaves no chance for rescue. The safest home for children and teens is one without guns. If guns are kept in the home, they should be stored safety: locked and unloaded, with ammunition stored separately in a locked location. Family members should make sure the child does not know the codes to the locks or the location of keys.

Bullying and cyberbullying

Kids who are bullied―and those who bully others―face higher risks of suicidal thoughts and actions. This is true whether bullying happens face-to-face or online (cyberbullying). A 2021 study found that adolescents who were bullied online were roughly 12 times more likely to have suicidal thoughts than peers who were not.

How to provide the support young people need

Suicide is the second leading cause of death among young people 10 to 24 years old, so families should know the warning signs and be ready to help their children.

Know that it’s OK to ask about suicide. If you are concerned about your child, ask them directly if they are thinking about suicide. Studies have shown that asking about suicide will not “put the idea into their head.” In fact, it could open the door to an honest conversation about their mental health.

Make sure kids know it’s OK to talk about suicide. Raise the topic in a calm, non-judgmental way to help them feel safe sharing their thoughts and feelings. Here are tips for opening the conversation.

Don’t wait to seek professional help. If you see signs that your child might be considering suicide, get in touch with your family pediatrician right away to find mental health resources and support. If you need immediate support, call the National Suicide Prevention Lifeline at 1(800) 273-TALK or contact the Crisis Text Line by texting “TALK” to 741741 in the United States or Canada.

Consider telehealth. Your child may find it easier to talk with health professionals from the comfort of home. For teens especially, online health appointments should take place in a private space, which may help them speak more freely. Telehealth visits are also a convenient way to make sure young people get the timely, ongoing support they need.

If you are unsure about what to do or need immediate support, call the National Suicide Prevention Lifeline at 1-800-273-TALK (273-8255). This lifeline is open 24 hours a day, 7 days a week, from anywhere in the United States.

Emotional problems

Soiling (Encopresis)

My child is way past toilet training, but he still soils his underwear. What should I do?

Encopresis is one of the more frustrating disorders of middle childhood. It is the passing of stools into the underwear or pajamas, far past the time of normal toilet training. Encopresis affects about 1.5 percent of young school children and can create tremendous anxiety and embarrassment for children and their families.

Encopresis is not a disease but rather a symptom of a complex relationship between the body and psychological/environmental stresses. Boys with encopresis outnumber girls by a ratio of six to one, although the reasons for this greater prevalence among males is not known. The condition is not related to social class, family size, the child’s position in the family or the age of the parents.

Two types

Doctors divide cases of encopresis into two categories: primary and secondary. Children with the primary disorder have had continuous soiling throughout their lives, without any period in which they were successfully toilet trained. By contrast, children with the secondary form may develop this condition after they have been toilet trained, such as upon entering school or encountering other experiences that might be stressful.

A frustrating condition

Children, parents, grandparents, teachers and friends alike are often baffled by this problem. Adults sometimes assume that the child is soiling himself on purpose. While this may not be the case, children can play an active role in managing the processes involved in this disorder.

The physical aspects of encopresis

When encopresis occurs, it begins with stool retention in the colon. Many of these youngsters simply may not respond to the urge to defecate and thus withhold their stools. As the intestinal walls and the nerves within them stretch, nerve sensations in the area diminish. Also, the intestines progressively lose their ability to contract and squeeze the stools out of the body. Therefore, these children find it increasingly difficult to have a normal bowel movement. Most of these children are chronically constipated.

With time, these retained stools become harder, larger and much more difficult to pass. Bowel movements then can be painful, which further discourages these children from passing the stools.

Eventually, the sphincters (the muscular valves that normally keep stools inside the rectum) are no longer able to hold back all the stool. Large, hard feces may be retained in the colon (large intestine) and rectum, but liquid stool can begin to seep around this impacted mass, passing through the anus and staining the underwear. At other times, semiformed or partial bowel movements may pass into the underwear, and because of the decreased sensation, the child may not be aware of it.

Possible causes

Some youngsters are predisposed from birth to early colonic inertia – that is, a tendency toward constipation because their intestinal tracts lack full mobility. Early in life these children might have experienced constipation that required dietary and medical management.

Some children develop constipation and encopresis because of unsuccessful toilet training as toddlers. They may have fought the toilet training process, been pushed too fast, or were punished for having accidents. Struggling with their parents for control, they may have voluntarily withheld their stools, straining to hold them as long as they could. Some children may actually have had a fear of the toilet, even thinking that they themselves might be flushed away.

A number of other factors can also contribute to the eventual development of encopresis. Sometimes children may have pain when they have a bowel movement due to an infection or a tear near their rectum. Emotional causes can include limited access to a toilet or shyness over its use (at school, for example), or stressful life events (marital discord between parents, moves to a new neighborhood, family physical or mental illnesses or new siblings). While most children with encopresis are also constipated, some are not. These children may refuse to use the toilet and simply have normal bowel movements in their underwear or other inappropriate places. In general, these children are demonstrating their attempts to control some difficult aspects of their lives. Professional help is advisable for these children and their families.

Many parents are astonished that their child with encopresis may not even be conscious of the odor emanating from the stool in his pants. When this odor is constant, the smelling centers of the brain may become accustomed to it, and thus the child actually is no longer aware of it. As a result, these youngsters often are surprised when a parent or someone else tells them that they have an odor. While the youngster himself may not be bothered by the smell, the people around him may not be sympathetic to his problem.

Psychological effects

Exasperated parents often place great pressure on their child to change this behavior – something the youngster may be incapable of without help from a pediatrician. While family members may have ideas on how to solve the problem, their efforts generally will fail when they do not understand the physiological mechanisms at work.

Encopresis can lead to a struggle within the family. As parents and siblings become increasingly frustrated and angry, family activities may be curtailed or the child with encopresis may be ostracized from them. By this stage, the problem often has become a family preoccupation.

As the child and family fruitlessly battle over the child’s bowel control, the conflict may extend to other areas of the child’s life. His schoolwork may suffer; his responsibilities and chores around the home may be ignored. He may also become angry, withdrawn, anxious, and depressed, often as a result of being teased and feeling humiliated.

Management of encopresis

Encopresis is a chronic, complex – but solvable – problem. However, the longer it exists, the more difficult it is to treat. The child should be taught how the bowel works, and that he can strengthen the muscles and nerves that control bowel function. Parents should not blame the child and make him feel guilty, since that contributes to lower self-esteem and makes him feel less competent to solve the problem.

Parents often use a behavior modification or reward system that encourages the child’s proper toilet habits. He might receive a star or sticker on a chart for each day he goes without soiling and a special small toy, for example, after a week. This approach works best for a child who truly wishes to solve the problem and is fully cooperative in that effort.

Some youngsters have significant behavioral and emotional difficulties that interfere with the treatment program. Psychological counseling for these children helps them deal with issues like peer conflicts, academic difficulties, and low self-esteem, all of which can contribute to encopresis.

Throughout this treatment process, parents should remind the child that there are other youngsters who have the same problem. In fact, children with the same difficulty probably attend his own school.

Children with encopresis may have occasional relapses and failures during and after treatment; these are actually quite normal, particularly in the early phases. Ultimate success may take months or even years.

One of the most important tasks of parents is to seek early treatment for this problem. Many mothers and fathers feel ashamed and unsupported when their child has encopresis. But parents should not just wait for it to go away. They should consult their doctor and make a persistent effort to solve the problem. If the symptoms are allowed to linger, the child’s self-esteem and social confidence may be damaged even more.


When encopresis is occurring in a school-age child, a physician experienced in encopresis treatment and interested in working with the child and the family should be involved.

The treatment goals will probably be four fold:

  • To establish regular bowel habits in the child
  • To reduce stool retention
  • To restore normal physiological control over bowel function
  • To defuse conflicts and reduce concerns within the family brought on by the child’s symptoms

To accomplish these goals, attention will be focused not only on the physical basis of encopresis but also on its behavioral and psychological components and consequences.

In the initial phase of medical care, the intestinal tract often has to be cleansed with medications. For the first week or two the child may need enemas, strong laxatives or suppositories to empty the intestinal tract so it can shrink to a more normal size.

The maintenance phase of management involves scheduling regular times to use the toilet in conjunction with daily laxatives like mineral oil or milk of magnesia. Proper diet is important, too, with sufficient fluids and high-fiber foods. These steps will keep the stool soft and prevent constipation. When improperly supervised, these interventions have potential dangers for the health of the child and so should be done only under the supervision of the child’s physician. The maintenance phase will usually last two to three months or longer.

Emotional problems

School Avoidance: Tips for Concerned Parents

​School avoidance – sometimes called school refusal or school phobia – is not uncommon and occurs in as many as 5% of children. These children may outright refuse to attend school or create reasons why they should not go. 

They may miss a lot of school, complaining of not feeling well, with vague, unexplainable symptoms. Many of these children have anxiety-related symptoms over which they have no conscious control. Perhaps they have headaches, stomachaches, hyperventilation, nausea or dizziness. In general, more clear-cut symptoms like vomiting, diarrhea, fever or weight loss, which are likely to have a physical basis, are uncommon. 

School refusal symptoms occur most often on school days, and are usually absent on weekends. When these children are examined by a doctor, no true illnesses are detected or diagnosed. However, since the type of symptoms these children complain of can be caused by a physical illness, a medical examination should usually be part of their evaluation.

School-Related Anxiety:

Most often, school-avoiding children do not know precisely why they feel ill, and they may have difficulty communicating what is causing their discomfort or upset. 

When school-related anxiety is causing school avoidance, the symptoms may be ways to communicate emotional ​struggle with issues like:

  • Fear of failure
  • Problems with other children (for instance, teasing because they are “fat” or “short”)
  • Anxieties over toileting in a public bathroom
  • A perceived “meanness” of the teacher
  • Threats of physical harm (as from a school bully)
  • Actual physical harm

Tips for Concerned Parents:

As a first step, the management of school avoidance involves an examination by a doctor who can rule out physical illness and assist the parents in designing a plan of treatment. Once physical illness has been eliminated as a cause of the child’s symptoms, the parents’ efforts should be directed not only at understanding the pressures the child is experiencing but also at getting him or her back in school.

Here are some guidelines for helping your child overcome this problem:

  • Talk with your child about the reasons why he or she does not want to go to school. Consider all the possibilities and state them. Be sympathetic, supportive, and understanding of why he or she is upset. Try to resolve any stressful situations the two of you identify as causing his worries or symptoms.
  • Acknowledge that you understand your child’s concerns, but insist on his or her immediate return to school. The longer your child stays home, the more difficult his or her eventual return will be. Explain that he or she is in good health and his or her physical symptoms are probably due to concerns other things – perhaps about grades, homework, relationships with teachers, anxieties over social pressure or legitimate fears of violence at school. Let your child know that school attendance is required by law. He or she will continue to exert some pressure upon you to stay home, but you must remain determined to get your child back in school.
  • Discuss your child’s school avoidance with the school staff, including his or her teacher, the principal, and the school nurse. Share with them your plans for your child’s return to school and enlist their support and assistance.
  • Make a commitment to be extra firm on school mornings, when children complain most about their symptoms. Keep discussions about physical symptoms or anxieties to a minimum. For example, do not ask your child how he or she feels. If he ior she is well enough to be up and around the house, then he or she is well enough to attend school. 
  • If your child’s anxieties are severe, he or she might benefit from a step-wise return to school. For example: On day one, he or she might get up in the morning and get dressed, and then you might drive him or her by the school so he or she can get some feel for it before you finally return home together. On day two, your child might go to school for just half a day, or for only a favorite class or two. On day three, your child can finally return for a full day of school.
  • Your pediatrician might help ease your child’s transition back to school by writing a note verifying that he or she had some symptoms keeping him or her from attending school, but though the symptoms might persist, he or she is now able to return to class. This can keep your child from feeling embarrassed or humiliated.
  • Request help from the school staff for assistance with your child while he or she is at school. A school nurse or secretary can care for your child should he or she become symptomatic, and encourage his or her return to the classroom.
  • If a problem like a school bully or an unreasonable teacher is the cause of your child’s anxiety, become an advocate for your child and discuss these problems with the school staff. The teacher or principal may need to make some adjustments to relieve the pressure on your child in the classroom or on the playground.
  • If your child stays home, be sure he or she is safe and comfortable, but do not give him or her any special treatment. Your child’s symptoms should be treated with consideration and understanding. If your child’s complaints warrant it, he or she should stay in bed. However, your child’s day should not be a holiday. There should be no special snacks and no visitors, and he or she should be supervised.
  • Your child may need to see a doctor when he or she stays home because of a physical illness. Reasons to remain home might include not just complaints of discomfort but recognizable symptoms: a temperature greater than 101 degrees, vomiting, diarrhea, a rash, a hacking cough, an earache or a toothache. 
  • Help your child develop independence by encouraging activities with other children outside the home. These can include clubs, sports activities, and overnights with friends.

When to Seek Help:

While you might try to manage school refusal on your own, if your child’s school avoidance lasts more than one week, you and your child may need professional assistance to deal with it. 

First, your child should be examined by your pediatrician. If his or her school refusal persists, or if he or she has chronic or intermittent signs of separation difficulties when going to school – in combination with physical symptoms that are interfering with her functioning – your doctor may recommend a consultation with a child psychiatrist or psychologist.

Even if your child denies having negative experiences at school or with other children, his or her unexplainable physical symptoms should motivate you to schedule a medical evaluation.​

Emotional problems

Schizophrenia in Children, Teens and Young Adults

Schizophrenia is a chronic mental health disorder that affects how a person feels, thinks, and behaves. The condition causes people to shift back and forth between reality and their distorted perceptions of reality. Early treatment is crucial to help kids and teens with schizophrenia do their best in school or work and in their relationships with others.

At what age does schizophrenia usually develop?

Schizophrenia is usually diagnosed anywhere between the late teen years and the early 30s. When teens are diagnosed before they’re 18, it’s called early-onset schizophrenia. Kids younger than 13 can develop schizophrenia too, known as childhood-onset schizophrenia, but this is extremely rare.

Schizophrenia tends to show up earlier in males than females. For males, it’s typically between ages 18 and 25 and for females, between ages 25 and 35.

Signs and symptoms of schizophrenia

Early Signs

When schizophrenia first starts, you may notice issues such as:


  • Confused thoughts and speech
  • Difficulty concentrating
  • Strange ideas, thoughts, or statements
  • Not being able to tell the difference between reality and television or dreams


  • Excessive moodiness
  • Severe depression or irritability
  • Suicidal thoughts
  • Lack of emotion
  • Paralyzing anxiety and fear
  • Extreme suspicion of others


  • Having new problems at school
  • Withdrawing from family and friends
  • Increased isolation
  • Immature behavior
  • Noticeable changes in personality or behavior
  • Problems with friends or peers
  • Not keeping up with personal hygiene

Later Signs

As kids and teens with schizophrenia get older, their signs and symptoms become more like the ones adults experience. These may include:

Psychotic Symptoms

When schizophrenia cases a shift to altered reality, this is called psychosis. Periods of psychosis are also known as psychotic episodes. During a psychotic episode, a person may not be able to tell what’s real and what’s not. They may hear or see things that aren’t real (hallucinations). They might have beliefs or fears that aren’t true (delusions). Their thoughts may be disorganized, their speech may not make sense, and they may behave oddly. Kids and teens are more likely to have visual hallucinations and less likely to have delusions than adults.

Negative symptoms

  • Negative symptoms mean your child isn’t functioning normally. Examples include:
  • Lack of motivation
  • An obvious decline in personal hygiene
  • Avoiding people and activities
  • Loss of enjoyment
  • No eye contact, no change in facial expressions, or talking in a flat tone

Behavior changes

  • You may notice differences in your child’s behavior, such as:
  • Unpredictable behavior
  • Difficulty completing tasks or meeting goals
  • Unresponsive to others
  • Moving around too much
  • Unusual posture

Cognitive symptoms

Some people experience serious cognitive (thinking) symptoms, while others don’t notice them as much. These symptoms can include:

  • Problems with concentration
  • Attention and memory problems
  • Difficulty processing and using information

What causes schizophrenia?

No one knows what causes schizophrenia. Experts believe that it develops from a combination of factors, including genetics, environment, and brain chemistry.

How is schizophrenia diagnosed?

Your pediatrician may be the first healthcare provider you see if you’re concerned that your child has schizophrenia. They can rule out other causes of your child’s symptoms like another mental illness, a medical condition, or drug or alcohol use.

Be aware that diagnosing schizophrenia can be a long process, especially with kids and teens. It’s important that your doctor makes absolutely sure there isn’t something else going on before making a diagnosis of schizophrenia.

How is schizophrenia treated?

If your child is diagnosed with schizophrenia, they’ll need treatment for the rest of their life. A child psychiatrist with experience in treating kids with schizophrenia will likely be in charge of your child’s care. There will probably be other team members too, such as nurses and therapists.

Treatments for schizophrenia include:


Antipsychotic medications are the foundation of treatment for kids and teens with schizophrenia. These medicines are the same kinds that are used for adults with schizophrenia. They help with psychotic symptoms like hallucinations and delusions.

Like all medications, the goal is to keep your child’s symptoms to a minimum using the lowest possible dose of medicine. It can take some time for your doctor to figure out which medication (or combination of medications) works best and at what dose. Your child may need other medicines as well, such as anti-anxiety medication or antidepressants.

Antipsychotics have potential side effects and health risks. The side effects in children and teens can be different and more serious than they are in adults. Your doctor will monitor for side effects with certain medications. Keep track of any side effects you notice and let your doctor know if they are serious or don’t go away.

Cognitive behavioral therapy (CBT)

Psychotherapy, also known as talk therapy, is another instrumental part of your child’s treatment. One type that’s good for treating schizophrenia is cognitive behavioral therapy (CBT). It can help your child cope with hallucinations and delusions, as well as work on behaviors. It also helps them learn to manage the challenges and stress that schizophrenia can create.

Other psychosocial treatments

There are other treatments that can improve your child’s life too. For instance, family therapy can boost your family’s communication and help you learn more about what your child is dealing with.

Social skills training can help your child build relationship skills and improve their memory and attention problems.

Your child may also benefit from special education services at school. This can be in the form of a 504 or an individualized education program (IEP). A federal program called Supported Employment can help your child get and keep a job.


There may be times when your child needs to be hospitalized to prevent danger to themselves or others. This can happen when their symptoms are severe and they need extra care and a safe place. Once your child’s symptoms are under better control, they can go home. You can also look into partial hospitalization or residential treatment programs.


Early intervention can greatly improve symptoms for a child or teen with schizophrenia. Left untreated, schizophrenia can cause serious behavioral, emotional, and health problems. If you think your child has signs or symptoms of schizophrenia, be sure to talk to your pediatrician.​

Emotional problems

Post-Traumatic Stress Disorder (PTSD)

Description: recurrent disturbing memories of a traumatic experience.

Post-traumatic stress disorder (PTSD) forces people to relive ordeals such as murder, rape, war, accidents and natural disasters. The recollections come in the form of persistent memories and nightmares, as well as flashbacks—memories so vivid that the person feels transported back to the horrific event for a matter of seconds or hours. Some patients become so immersed in the scene that they lose touch with reality; the imaginary sights, sounds, smells and emotions seem real to them. Afterward, they usually display phobic reactions to whatever situations or activities triggered the awful memories.

Not every victim or witness to a crime, accident or other form of disaster develops PTSD. In those that do, the symptoms typically appear within three months and linger for a period of several months. Researchers at Children’s Hospital of Philadelphia studied approximately one hundred children and teenagers who’d been injured in car crashes. One in four met the diagnostic criteria for post-traumatic stress disorder, including youngsters with only minor injuries.

Signs of Post-Traumatic Stress  Disorder

Two or more of the following symptoms when reminded of the traumatic experience:

  • insomnia
  • irritability or angry outbursts
  • poor concentration
  • memory impairment
  • startles easily
  • feeling of detachment, numbness
  • always seems to be watching out for danger
Emotional problems


Description: persistent, irrational fears about certain objects or situations.

Teenagers suffering from a phobia are usually mature enough to recognize that their intense fear defies logic, but they are unable to control it. The phobias seen most frequently during adolescence are agoraphobia, fear of leaving a familiar setting, such as one’s home, social phobia, a painful fear of humiliating oneself in public; and specific phobia, a chronic fear of a single thing or event. Among the more common phobias to prey upon teens are fears of snakes, heights, needle injections, flying in airplanes and getting low grades.

As long as the object of the phobia can generally be avoided and not disrupt a child’s day-to-day life, treatment may not be necessary. Social phobia, though, almost always gets in the way of normal functioning. Young people with social phobia may be too intimidated to speak up in the classroom or present a speech. (Fear of speaking in public is the most common manifestation of social phobia.)

This is not the same thing as shyness. Plenty of people with social phobia are outgoing and completely at ease around others much of the time. But the thought of attending a party, walking into class late or any number of situations can send them into a panic. With some teens, social phobia takes the form of school avoidance. They wake up in the morning complaining of various physical ailments, which not-so-mysteriously vanish once they’re pardoned from having to attend school.

Signs of a Phobia

One or more of the following symptoms when exposed to or thinking about the source of the phobia:

  • palpitations
  • sweating
  • trembling and shaking
  • nausea
  • diarrhea
  • flushed face
  • disturbing thoughts and images