profession

Doctors need delicate touch when children are over-scheduled

How should physicians intervene when parents ask too much of their child?

The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to philip.perry@ama-assn.org, or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA. Posted Sept. 2, 2013.

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Scenario A physician suspects that a child's schedule is causing stress. How does that physician counsel the parents without insulting their parenting goals or abilities?

Reply Physicians comfortably advise patients about personal issues, telling them to lose weight, stop smoking or drink less. Yet when the advice involves parenting — particularly when it may be construed as critical — and even more so when it pertains to behavior parents believe is beneficial, doctors tread on tricky terrain. Near the top of the list of such sensitive topics are over-scheduled families.

A contemporary mantra is that to make your child successful, you must begin as early as possible with lessons, enrichment and a plan. What parents don't believe that their child has special talents? Who doesn't want a much-loved son or daughter to succeed? And who among us hasn't worried about whether our child can measure up in today's brutally competitive world?

Whether the dreams involve academics, athletics or the arts, parents with aspirations are convinced they must start focusing on skill development by the time the child reaches age 2. So infants attend music classes and, due to their busy calendars, toddler “play dates” must be scheduled weeks in advance.

Battle Hymn of the Tiger Mother was a controversial parenting book — not only because the author's relentlessness horrified some readers, but also because they wondered whether her methods actually might work. (After all, her daughter is at Harvard!)

We are doubters who think that an overscheduled child-rearing style is a serious health hazard, particularly considering the alarmingly high — and rising — rates of mental illness, anxiety and stress-related disorders, substance abuse and, sadly, suicide. Though this frenetic approach to children's free time has become the norm for middle- and upper-class families, it can create destructive stress that wreaks havoc with family life. It is a major public health concern; for families living this way, time together is fraught with anxiety and marital strife. Ironically, the lifestyle can deeply damage a child's health and well-being.

When our first book, Hyper-Parenting, was published in 2000, “over-scheduling” was a novel concept; now pediatricians, psychiatrists and school social workers report seeing it frequently. A parent schedules a pediatric appointment because a child has unexplained headaches, gastric distress, a tic or fatigue. The doctor asks what he or she does after school, and the frazzled but proud mom (not the child) answers: “Monday, soccer and math tutoring; Tuesday, soccer then piano; Wednesday, religious school; Thursday, long soccer practice, but Friday is free, which is good for play dates, since Madison plays in two soccer leagues with weekend games Saturday and Sunday.” It's exhausting for you to listen to — imagine how 9-year-old Madison, whose week looks like this, feels.

Enrichment activities can add enormously to children's lives. They teach teamwork, provide social connections, and help children find their passions. However, as with medications, more is not necessarily better. In the anxious race to give a child every iota of advantage, the balance between scheduled enrichment, down time and family time is often lost. Meanwhile, and also to the family's detriment, the individual child's preferences and temperament are overlooked.

As part of this trend, kids' sports have been professionalized. Competitive pressure even has insinuated itself into hockey and soccer leagues for 4-year-olds; America now has a ruthless national basketball Final Four tournament for second graders. The fallout is substantial. Orthopedic surgeons report between 2.2 million and 3.5 million recreation-linked bone fractures, dislocations and muscle injuries annually among 5- to 14-year-olds. At least 300,000 children suffer sports concussions each year.

In everyday life, self-esteem is intimately tied to what children sense their parents' opinion of them is. A child whose weeks are filled with ceaseless lessons, tutoring and practices gets the subliminal message that “if I need all this constant improvement, my parents must think I'm not very good at all.” This can create a self-fulfilling prophecy: Resenting the parents' lack of faith, a teenager gets even by living “down” to those supposed expectations.

The pressure to excel at everything leaves many children feeling depressed, despondent or rebellious, so they drink to relieve emotional distress or use illicit substances to escape into drug-induced daydreams. In fact, suburban teenage drug use is likely associated with the “overemphasis on achievement.” As one depressed, substance-abusing patient said, “In my family, it's Harvard, Yale or nothing … and I just can't measure up.”

To have enough energy and good humor to nurture children, parents need a life, too. Yet in our age of anxious hyperparenting, some parents wear sacrifices as merit badges. Every good parent sacrifices plenty, but competitive parenting helps no child we've known. The intense stress of a relentless family schedule — combined with work and economic pressures — leaves many parents with the same anxiety, depressive and stress-related disorders as their children. It's a phenomenon internists see regularly.

Use a gentle approach with parents

When asking about these touchy issues, physicians need to use a gentle hand — but ask they must, because parents trust their pediatricians on child rearing and their internists on matters relating to their health and well-being. So if you see a complaint you suspect is stress-related, it's good practice to ask about the family's scheduled activities and leisure time to get an idea of whether they have a sensible balance between them. If the family is tense and over-scheduled and doesn't recognize the need to slow down, you might keep a few principles in mind.

  • Many parents don't want their kids professionalized but worry that saying “no” to any possibility for enrichment would deprive their children. Their pediatrician's support can help them resist pressure from coaches, media and peers who insist that they must say “yes” to every activity, ceaselessly pushing their child to excel early. Remind them that childhood is a preparation, not an adult performance.
  • Enrichment activities are beneficial, but like a computer overloaded with software and games, too much of a good thing freezes the system. For an over-scheduled family, stopping entirely is neither practical nor advisable — but cutting back just a bit (5% to 10%) can help. Families may find that with just a little more down time, life becomes sane again.
  • Physicians can help parents realize that limiting children's activities models the role of responsible adults who must make hard, sensible choices about what promotes their family's health. Isn't that what we are asking our kids to do when we tell them to just say “no” to poisonous temptations?
  • No one-size-fits-all approach makes parenting good. Raising children is an ever-changing ballet, an idiosyncratic dance between parents, children, spouses, extended family, friends and the community at large. With each child, parents do novel steps that have never been done quite this way before — it will sometimes feel awkward. Reassure your patients that this is not pathology but “the human condition.”
  • Our children are with us for but a brief flicker of time before they become busy with friends, college, jobs and eventually their own families. Nothing is more valuable than family time. Encourage families to be unproductive sometimes — to spend time together with no goal other than sharing one another's company, perhaps taking walks or watching a movie. And with their doctor's kind encouragement, perhaps parents also will make time to talk and listen to their kids.

Physicians can reassure insecure parents, helping them appreciate that time with tough coaches is far less important than more time with Mom and Dad. Being with parents who enjoy their child bolsters a preteen's self-esteem more effectively than anything else. It's how kids develop the deep, inner conviction that they are worthwhile human beings who deserve unconditional love. As singer/songwriter Billy Joel put it, way back in the day, “I love you just the way you are.” Who among us is not enriched by that?

Alvin A Rosenfeld, MD, New York Presbyterian/Weill-Cornell Medical Center

Nicole Wise, writer/editor specializing in health, education and family life

The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to philip.perry@ama-assn.org, or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA.

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