A young teen patient, eyes averted, clutching a cell phone, sits in my office. It’s a scheduled annual exam, and the patient reports some ailments—fatigue, anxiety, and poor sleep. Across the room, the parent sits in apparent composure, but as my eyes meet the parent’s gaze and hover here for an instant, I register pain, frustration, and desperation. The patient’s symptoms are not new, and there may have been calls back and forth with my triage nurses. Perhaps the patient has been given a list of therapists, but a common refrain is that the calls go unreturned. Or there are no available appointments. Or the provider does not accept insurance.
Young people are contending with mental health issues while the system remains ill-equipped to meet their needs; this is not news. And this clinical scenario is not uncommon for me as a pediatrician. Annual visits, intended for anticipatory guidance, routine health maintenance conversations, and immunizations, are becoming increasingly eclipsed by attention necessary to mental health concerns.
Among these are anxiety, depression, disordered or restricted eating, ADHD, substance use, and self-injurious behaviors. Particularly common is the poor quality of sleep and general fatigue. The social isolation and uncertainty during the early pandemic years augmented the already escalating mental health crisis among our youth. As the prevalence of these afflictions has increased, I have spent an expanding amount of my time thinking about the forces at play with children and teens and how I can look the parents in the eye during my office visits with guidance that goes beyond an inadequate and rushed acknowledgment of how intolerable it is to see a child suffer and not be able to alleviate it.
Generally, those in my profession rely on committed and capable licensed mental health professionals, including psychiatrists, therapists, and school counselors, to investigate and direct therapeutic treatments. Yet, because these issues are pervasive and the reservoir of mental health professionals is inadequate to meet the demand, pediatricians are able to manage the conversations, prescribe medications, and bridge the gap. It’s not that I don’t delve into this area of medicine as I do the more traditional “bread and butter” topics of pediatric medicine—seasonal respiratory infections, evaluations for fever, growth, and developmental milestones, musculoskeletal injuries—rather, it simply feels impossible to do so meaningfully in the brief amount of time I have with the patient and their family and with the limited resources available. Whether it is due to a lack of self-efficacy or moral injury (according to Wendy Dean and Simon Talbot, the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control) or just the discomfort we physicians carry bearing witness to suffering, this impasse has led to collective exhaustion among pediatrician colleagues.
Recognizing the second impact of the youth mental health crisis on physicians, we desperately need to keep in practice, and facing my search to find something to offer families, I turned to recent research on the “psychology of happiness” and its foundations in neuroscience. Here, in the land of language about dopamine hits and automatic negative neural circuits, I have navigated through the science of how one’s well-being is influenced by our adverse childhood experiences (ACEs), our exposures to trauma, our inner chatter, and our genetics. In all my plodding and searching, one theme emerges loud and clear: treating ourselves with compassion and kindness improves our mental health. While patients and physicians may think of the inner drill sergeant as motivating and holding us accountable to our goals and ambitions, this universal default toward critical self-talk is associated with increased anxiety, depression, and isolation.
In the effort to address this struggle of our young patients, I’ve encapsulated my mid-career lessons into digestible sound bytes for parents, much akin to the more familiar guidance I’ve always offered, solicited or not, on safe sleep, car seats, screen-time limits, the use of sunscreen and the importance of immunizations.
Introducing the skills and practice of self-compassion has become a rote part of my visits as time allows. I hope that these skills, if learned and practiced early, may help inoculate against the onset of more severe symptoms of anxiety and depression. If given a “teachable moment,” I’m inclined to mention the science of kindness to ourselves as it relates to our productivity and overall well-being. Psychologist and author Rachel Turow, in her conversation with Yale professor of psychology Laurie Santos, summed it up nicely when she described negative inner dialogue as “the smoking of mental health.” She means that, like the effects of cigarette smoking, which may have an insidious onset, it quickly becomes an established, automatic habit with deleterious health effects that is hard to kick.
As with most issues relating to early childhood, children will learn skills through modeling their caregivers, so most of these suggestions are intended for caregivers. And not surprisingly, the advice given to patients/parents is also relevant to those treating the patient.
1. Awareness. Notice the language you use with yourself internally. Once you tune in to the sound waves of scolding, name-calling, or bullying yourself, you are more likely to recognize when a child does it. Children and adults alike may exclaim (outwardly or inwardly), “I’m so dumb” or, “Ugh,” in exasperation with oneself following a gaffe; or they may have thoughts of “I should have” and “Why didn’t I just …” If there is an opportunity for reflection, these are times to point out how a child may be treating him or herself (“It sounds like you are being hard on yourself,” for example).
2. Model desired behaviors. In a challenging moment, narrate your self-compassion for children to hear. In a moment of frustration or disappointment, instead of tensing up, cursing, reacting, etcetera, try taking a deep breath and acknowledging (even out loud), “This is a really hard moment for me, so I need to pause …” Psychologist Kristen Neff describes a self-compassion break as a pause to acknowledge the suffering and relate it to a world beyond the individual while being kind to oneself.
3. Breathing, kindly. A cornerstone of mindfulness, attention to our breath is a common starting place for teaching about this useful practice. With a self-compassion twist, we narrate an inhalation and exhalation by adding a tender name, comforting phrase or another similar moniker as we breathe. In her book The Self-Talk Workout, Rachel Turow suggests, “Inhale, friend, Exhale, friend.” Research by psychologist Ethan Kross and his colleagues supports the notion of emotional regulation when silently referring to oneself in the third person, however silly it may feel.
4. Practice, practice, practice. The skills of self-compassion are learned and acquired through repetition. The benefits come after repeated practice and thereby creating new pathways.
Eliza Humphreys is a pediatrician and certified life coach.
The author’s thoughts, views, and opinions in the text are their own and may not represent the opinions of their employer, organization, committee, or any other group or individual.