“In some ways the holidays this year will be harder than last year for many people,” said Deborah Buccino, MD, pediatrician and REACH board member. “Earlier, we had pretty clear-cut rules about what you could and could not do safely. This year, we have a lot more gray areas.”
Navigating family gatherings is more complicated than ever. Families still want to protect elders and others for whom COVID-19 is most likely to be serious. Children under 5 still cannot be vaccinated, and many caregivers are hesitant about vaccines for children aged 5 to 11.
Suzanne Reiss, MD, a child, adolescent, and adult psychiatrist and REACH faculty member, pointed out that societal and media expectations about holidays being joyful clash with the realities of many people’s lives. That’s true every year. But this year piles on additional stresses: grief over lost loved ones, financial losses, continuing COVID anxiety, and many others.
How can pediatric primary care providers (PCPs) help?
Dr. Buccino and Dr. Reiss both emphasized the importance of listening. Simply feeling known and heard can be a help to both patients and caregivers. PCPs can ask open-ended questions like “How are you feeling about the holidays coming up?”
Since many teens in particular simply shrug and say “Okay,” Dr. Buccino often moves quickly to more specific questions, such as, “What are your plans for the holidays?”
Follow-up questions can be tailored to the teen’s response. For example, if he says, “We’re going to Nana’s for Thanksgiving, but then I guess I have to go to Dad’s for the first night of Hannukah,” the pediatrician can get into detail: “It sounds like you feel ambivalent about going to your dad’s. Were you involved in that decision? Have you told your mom or dad how you feel about it? Would it feel helpful to discuss this with your mom when she comes to join us?”
A key strategy both clinicians emphasized is involving families in coming up with their own solutions. “We want to have solutions, outline the bullet points,” said Dr. Reiss. “But that just doesn’t work!”
Dr. Buccino agreed. “When I was trained in pediatrics, it was primarily a top-down medical model. Doctors were expected to have and produce the answers. I learned in REACH training how to be present with families, listen, and help them find their own answers.”
Dr. Reiss stressed the importance of modified motivational interviewing, a technique taught in the REACH course Patient-Centered Mental Health in Pediatric Primary Care. The mnemonic for actions is LEAP:
“Instead of prescribing what to do, figure out where the family is,” said Dr. Reiss. For example, if a caregiver admits that she is stressed about the holidays, don’t launch into stress management techniques.
Instead, try something like, “What makes you the most anxious?” Then base any suggestions on what the caregiver says. For example, if she says, “There’s just so much to do!” you can ask, “Are all of those things equally important? Is there anything you could not do and your family would still enjoy the holiday?”
“When you get families to tell you what they can do, you get better compliance,” said Dr. Reiss.
Another way to come at a patient’s or caregiver’s struggles is to help them find their strengths. You can, for example, ask the teen what has helped him through other holidays at Dad’s house. “I also like to ask if there’s anything they’re looking forward to in the holiday season,” Dr. Buccino says. Holding on to something positive can make the less positive aspects more tolerable.
Young people who suffer from depression or anxiety may have trouble finding anything positive about either the holidays or themselves. In that case, Dr. Buccino said, she asks specific questions. “For example, I’ll say, ‘Is there something you like to do outside? Even taking a walk?’ And I might share with them how, during the pandemic, I have myself found a new sense of peace from being out in nature.”
Another tactic is to use cognitive behavioral therapy (CBT) techniques to help patients question their distorted thoughts. Many patients with depression and anxiety fall prey to all-or-nothing thinking, noted Dr. Reiss, or they blame themselves for everything.
CBT strategies can help. For example, you can ask the anxious teen, “What are you worried might happen when you go to Dad’s for Hanukkah?” Dig past global statements like “It’s all going to be terrible!” What specifically can happen? Maybe the teen says that his stepmom always is kinder to her own kids than to him. “OK,” you say, “that doesn’t feel good. What can you do to feel better?” The actual possibilities, once the teen identifies them, are almost always less dire than whatever vague terrors he imagines before he thinks rationally.
To combat the high expectations that stress many families, Dr. Reiss said she hoped more families would adopt new, small traditions, such as buying socks for people in a homeless shelter and wrapping them as a family. “It’s not the gifts children will remember,” she said. “It’s the traditions.”
“The opportunity to learn information to help me manage psychiatric conditions in my patients in this time where demand clearly outweighs supply of services, is going to be excellent for me as a PCP in my community.”