Healthy children in body and mind

Image credit: © udra11 - stock.adobe.com.

Pediatric mental health concerns have been on the rise for more than a decade¹ and sharply increased during the COVID-19 pandemic.² Mental, emotional, and behavioral disorders have risen to include nearly 20% of our youth, with half of these disorders developing by aged 14 years.¹ Anxiety, depression, and attention-deficit/hyperactivity disorder (ADHD) are the leading mental health diagnoses.¹ However, only approximately 20% of children and adolescents needing mental health care ever receive treatment, leaving 80% without the psychological care they need.³

Mental health challenges present differently at each developmental stage. Children are concrete thinkers and lack the insight to understand their irrational fears, whereas adolescents can be egocentric, self-deprecating, and self-conscious, causing themselves more stress and anxiety. Children and adolescents with mental health concerns often avoid social situations such as school, sports activities, parties, and other activities that are essential for the proper development of social skills. This results in negative impacts on their development and increased risk of comorbid concerns such as poor school performance and attendance, increased fighting, social isolation, fear of new situations or people, substance abuse, and self-harm.⁴ Mental illness is often not recognized by caregivers as a serious concern until there are severe manifestations. In 2022, suicide was the second-leading cause of death for individuals aged 10 to 34 years.⁵

Many factors affect a child’s or adolescent’s mental health including stress and grief from the COVID-19 pandemic; the physical and emotional environment at home and school; violence; bullying; poverty; concerns about natural disasters, climate change, and political polarization; racial, ethnic, and gender discrimination; social media use; genetics; and lifestyle.^2,6 The US Preventive Services Task Force recommends screening children for anxiety starting at aged 8 years and for depression at aged 12 years.⁶However, access to mental health services can be difficult for many families, and barriers include social stigma, a shortage of mental health specialists, gaps in insurance coverage for mental health services, a lack of transportation and time off work, and other social determinants of health.³ But prompt access to affordable mental health management can have a life-altering impact on children and adolescents.¹

Lifestyle medicine in pediatrics

Lifestyle medicine is an evidence-based health care practice that utilizes therapeutic lifestyle interventions to treat chronic and acute medical concerns.⁷ It is a holistic approach to managing illness by balancing the whole person, focusing on the 6 pillars of lifestyle medicine, including nutrition, physical activity, sleep, social connections, stress management, and reducing risky behaviors.⁷ This approach results in better overall health outcomes, lower costs, improved patient satisfaction, enhanced health equity, and increased provider satisfaction.⁷ Chronic disease has been shown to decrease by as much as 80% when lifestyle measures are implemented in infancy.⁸

Challenges and setbacks occur when creating new behaviors, so support is essential for successfully implementing a healthier lifestyle. Parents can role model and teach healthy lifestyle choices to their children and adolescents. Pediatric primary care providers (PCPs) often have trusted, long-term relationships with families and are in a unique position to evaluate a patient’s physical and mental health during clinic visits and promote healthy lifestyle choices to improve physical and mental well-being.

Mental health in primary care

Pediatric PCPs are well-versed in helping caregivers navigate new challenges to their children’s growth and development. Communities are advancing in mental health awareness and normalizing mental health discussions. Pediatric PCPs can also help distraught caregivers distinguish between emotional phases and concerning behaviors that require further evaluation. Mental health care can be discussed by pediatric PCPs, patients, and caregivers during routine preventive health care visits.

There is an increased need for pediatric mental health care but a lack of specialized workforce to care for these children and adolescents.^1,3 Therefore, mental health care must be integrated into the pediatric primary care setting. Pediatric PCPs have a long-term rapport with families, making them ideal to initiate mental health care.⁶ All pediatric health care providers should discuss health promotion and mental health awareness with patients and caregivers at each clinic visit.

Childhood and adolescent screening tools for anxiety, depression, and risky behaviors can be completed during any clinic visit. The tools are often free and available in a paper or digital format and in several languages. Commonly used anxiety screening tools include the 7-Item Generalized Anxiety Disorder questionnaire, the Screen for Child Anxiety Related Emotional Disorders questionnaire, and the Spence Children’s Anxiety Scale.⁹ Depression screening tools include the Patient Health Questionnaire and the Kutcher Adolescent Depression Scale.⁹ Suicide risk can be assessed with the Ask Suicide-Screening Questions tool.⁹ The CRAFFT (car, relax, alone, forget, family or friends, trouble) questionnaire screens for risky behaviors.⁹ The Vanderbilt is often used to screen for ADHD.⁹ Psychosocial screening tools include the HEEADSSS (home, education/employment, eating, activities, drugs, sexuality, suicide/depression, and safety) tool, the Ages & Stages Questionnaire, the Strengths and Difficulties Questionnaires, and the Pediatric Symptom Checklist.⁹

Using these or other available tools in the primary care setting, along with a shared discussion on mental health management, can allow for timely diagnosis and prompt treatment of mental health or behavioral concerns.

Nutrition

Food plays a large part in our lives as a nutritional and social component, from cooking the ingredients to savoring the meal. Meals should be enjoyed with friends and family whenever possible. Food not only fuels our physical bodies but also affects our mood and well-being and creates ties to our cultures.

Choosing healthy foods helps children grow and achieve and maintain a healthy weight. Good nutrition strengthens bones and muscles; keeps skin, teeth, and eyes healthy; supports cognitive and digestive abilities; and boosts immunity.¹⁰ Appropriately feeding our bodies and minds includes eating fruits and vegetables, lean proteins, and healthy carbohydrates; drinking plenty of water; reducing consumption of fatty, fried, and fast foods; and eating less processed foods and sugars.⁷

Skipping meals is like starving our brains, which can result in decreased cognitive abilities and moodiness. Research has shown that refusing breakfast is significantly related to depression, anxiety, stress, and psychological distress.¹¹

Pediatric PCPs can discuss healthy food choices during clinic visits using MyPlate resources such as coloring pages, educational handouts and tips, and recipes available in several languages.¹² In addition, parents can model healthy food choices and good table manners at family meals to encourage their children to adopt these habits.

Some families choose a plant-based diet based on preference, culture, or religion. Pediatric PCPs can guide these parents to ensure that children and adolescents are obtaining appropriate amounts of proteins, iron, zinc, iodized salt, and vitamin B₁₂.^7,8

Physical activity

Exercise is an important component of a child’s and adolescent’s life. Not only is it fun to move and play, but physical activity also promotes a lean body; increases muscle and bone strength; enhances brain growth and development; boosts sleep quality; and improves behavior, attention, and mood.¹³ Activities outside in nature, such as hiking, decrease stress and add a boost of joy, and the sunshine aids in vitamin D production.^7,8 Exercise also decreases fatigue and increases cognition, self-esteem, and the ability to deal with stress.⁷ For reasons such as these, schools include recess on playgrounds, physical exercise classes, and athletic competitions.

Children aged 6 to 17 years should have 60 minutes of moderate to vigorous physical activity scheduled each day.¹⁴ Some families may want to start with a low-impact activity and build motivation to keep up a regular activity routine.

A word of caution: Overuse of exercise could signal an underlying mental health concern or an unhealthy body image.¹⁵ Significant weight loss should be discussed to evaluate whether treatment is needed. Was the weight loss noticed by the patient or family? Was it purposeful? Was there a significant illness or event? What is the plan going forward?”

Restorative sleep

A good night’s sleep is important to recharge our bodies and minds, to help us fight infection, and to stabilize our mood.¹³ Consistent bedtimes and wake times help ensure that we get enough sleep. Nonstimulating bedtime routines, daily exercise, and avoiding caffeine late in the day make bedtime easier.¹⁶

Newborns sleep often and on a developing schedule around their feeding needs. Infants 4 to 12 months of age require approximately 12 to 16 hours of sleep per day. Toddlers (aged 1 to 3 years) need 11 to 14 hours of sleep daily. Preschoolers (aged 3 to 5 years) often still nap and need 10 to 13 hours of sleep each night. School-aged children (aged 6 to 12 years) need 9 to 12 hours of sleep, and adolescents (13 to 18 years) require 8 to 10 hours.⁷ Young adults should aim for 7 to 9 hours of sleep each day.

Children and adolescents sleep better when screens are kept out of the bedroom and electronics are off at least 1 hour before sleep.¹⁶ Research shows that as sleep improves, so do mental health concerns such as anxiety, depression, and ADHD.¹⁷ Homework, extracurricular activities after school, or time spent on hobbies, gaming, or social media can limit sleep and should be managed to find a proper balance. Parents can model good sleep practices to manage their own mental and physical health and to encourage appropriate sleep practices in their children and adolescents.

Cultural practices locally and around the world differ greatly in sleeping environments, sleeping arrangements, and sleep habits.¹⁸ There are drastically different sleeping expectations and attitudes toward the importance of sleep, which influence a family’s resting and recuperating practices. Pediatric providers can ask the family about sleeping habits and expectations before counseling them on improving their sleep management.

Positive social connections

Healthy relationships with family members, teachers, peers, friends, and people in the local community increase overall well-being for children, adolescents, and their families. Family, friends, and local religious/spiritual, academic, and cultural communities are integral parts of social connectedness. Social connections are important to adolescent mental and behavioral health, with research showing that they have lifelong benefits because they impart a sense of being cared for and welcomed. They also provide support and a sense of belonging and safety, which protects against choosing risky behaviors or experiencing emotional distress.¹⁹

Parents and pediatric PCPs can encourage positive social connections through employment opportunities, school extracurricular activities, sports, music, academic clubs, and community activities and events. These activities are skill-building opportunities for communication skills, social awareness, inclusivity, and conflict resolution.¹⁹

Screen time

Social connections accessed through digital connections have become a way of life for adolescents and children, creating positive effects and negative challenges—with the results depending on the online content they are exposed to, the amount of time spent on the activity, and the reactions from online audiences.¹⁹ The American Academy of Pediatrics recommends no screen time for children younger than 2 years and that parents set moderate limits on screen time as children develop based on the child’s needs, the content accessed, the child’s calming and coping mechanisms, whether it crowds out other activities, and the family’s communication and problem-solving mindset.²⁰

Developmentally appropriate digital connections such as online games and apps can entertain while also having positive effects on the well-being and education of young children.²¹ Teachers often use learning apps. In addition, friends and families can keep in touch through digital connections.

Bedrooms and meals can be media-free zones, and children should be cautioned not to provide personal details to online “friends.” Parental guidance on time limitations and observation of online activity are important to monitor the effects of digital connections on children and adolescents. Role modeling appropriate screen time use by parents is important to encourage children and adolescents to limit their own use.

Stress management

Children and adolescents experience stressors daily in the form of academic pressures, personal relationships with caregivers and friends, poverty and all its concerns, safety issues, bullying, and many more.²² Stress produces many somatic symptoms such as recurrent stomach aches, headaches, chest pain, nausea and vomiting, constipation or diarrhea, and leg and arm pains.²² Stress is a normal and unavoidable part of life, but we can learn to manage it and acquire skills to reduce its effects on our health.

Utilizing stress management techniques has been shown to reduce anxiety, depression, and stress itself and to improve social skills and academic achievements.²² Because many young children thrive on routines, a schedule can prevent meltdowns. Additionally, a calm, comfortable environment that is pleasant to all 5 senses helps us manage our stress levels.¹³ Parents can also encourage their children to identify and name their emotions and to control the resulting thoughts and behaviors.¹³ Mindfulness, breathing techniques, progressive muscle relaxation, guided imagery, and meditation are relaxation methods that can de-escalate a potentially stressful situation and decrease child and parental anxiety.²³ A good night’s sleep and daily exercise also help reduce stress.

Avoid risky substances

Alcohol, tobacco, cannabis, and prescribed and street drugs have deleterious effects on our bodies and our minds. Alcohol slows our thinking and our reaction time, tobacco increases our blood pressure and hardens our arteries, and cannabis impairs our judgment and senses. Recreational and prescribed drugs such as opioids can lead to severe health risks and often untimely deaths. Unfortunately, some adolescents use these risky substances to self-medicate or to avoid their mental health concerns instead of confronting them.²⁴ Warning signs that an adolescent may be abusing substances include sudden or extreme changes in habits, friends, appearance, or school or athletic performance; poor judgment and irresponsible behavior; withdrawal from family and friends; and the possession of drug paraphernalia.

Abstaining from these substances or seeking help and support to decrease or stop using them will greatly increase one’s quality of physical and mental health. The best first step in encouraging teenagers to refrain from drugs, tobacco, and alcohol is creating a safe, reliable, and open line of communication with caregivers. Lecturing teenagers should be avoided, but social media presentations of illicit substances and their effects on the body’s health, appearance, and functioning can be shown and discussed. Caregivers can tell of their own experiences with risky substances and give tips for responding to peer pressure. Caregivers also should be aware of the locations, activities, and friends of their adolescents; set clear behavioral boundaries and consequences; encourage honest communication; and watch for any warning signs of substance abuse.

Resilience

Difficulties in life are inevitable and bring emotional and physical distress. Parents can help children and adolescents build resilience, adapt well to difficult situations and environments, and thrive despite adversities. Healthy lifestyle choices such as encouraging family communication and time spent together, making good social connections, exercising daily, and taking time to rest and recuperate increase resiliency.²⁵ Providing a supportive and safe environment to grow, learn, master new skills, and face challenges helps strengthen the physical and mental health of our children.

Conclusion

Lifestyle choices such as healthy nutrition, daily exercise, good sleep, time with friends, stress management, and limited digital media time have a huge impact on the emotional, mental, and physical health of children and adolescents. Parents can encourage and role-model positive choices for their children and adolescents. Communities can advocate environments to practice healthy lifestyles. And pediatric PCPs can evaluate for mental health concerns along with physical concerns at each clinic visit and offer tips for lifestyle changes to promote positive health and holistic well-being.

About the author

Jennifer Lin Uzzell, DNP, APRN, CPNP-PC, PMHS, CLC, EBP-C, is a primary care pediatric nurse practitioner with interests in mental health, nutrition, breastfeeding, and integrating lifestyle medicine into clinical decision-making. She works in a pediatric clinic near Houston, Texas, precepts nurse practitioner students, and teaches at a local nursing school in the fall. Uzzell is a pediatric mental health specialist and a member of the American College of Lifestyle Medicine.

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