Patient Presentation
A 2-year-old male came to clinic for a health supervision visit. His mother stated that her husband had taken another job in a distant state and they would be moving. She wanted to know how to help the 2-year-old and their 5-year-old with the transition.
The diagnosis of a family with a normative transition to a new location was made. The pediatrician asked if the children knew about the move (they didn’t yet), what type of home they would be living in (planning to move into a small home from their current apartment), childcare and school plans, and if the mother planned to work outside the home also (mother plans to stay at home currently but look for work later, older son will begin Kindergarten in the fall). The pediatrician noted that the children would experience the move differently because of their ages and that consistency and being physically available to the children was important. She discussed normal transitioning to Kindergarten expectations. She discussed safety issues inherent with traveling, the physical move and setting up a new household. She also discussed potential community services that could be accessed such as a local childcare resource and referral agency, school district, human resources office of the new company, chamber of commerce and the local realtor. The pediatrician helped the family to find another pediatrician and obtain a copy of their medical records electronically. She also reassured them that she and the practice would still be available to help them and they could call with any questions.
Discussion
Even normal life changing events can be stressful for individuals and families. Boyce categorizes transitions in this way:
- Normative or non-normative transition
- Normative transitions are events that occur to most children and families under usual circumstances, and may be planned or unplanned
- Entering kindergarten
- Moving to a new location (i.e. planned moved because of new job or unplanned move because of job loss)
- Beginning a new activity (e.g. sport, instrument)
- Beginning a new job
- Death of pet
- Non-normative transitions are unanticipated events that do not occur at the normal expected time
- Parental death
- Divorce
- Normative transitions are events that occur to most children and families under usual circumstances, and may be planned or unplanned
- Biological and psychosocial transitions
- Biological and psychosocial transitions often go hand-in-hand such as puberty
- Puberty
- Rites of passage (e.g. bar/bat mitzvah, learning to drive)
- Moving out of the family’s home (e.g. to own apartment)
- Biological and psychosocial transitions often go hand-in-hand such as puberty
- On-time and off-time transitions
- Transitions that are normal at one stage of life are very different if at another stage of life, i.e. the timing is off based on personal or societal expectations
- Childbearing (different if adolescent or 20-30 year old mother)
- Gifted student attending college at junior high or early high school age
- School redistricting and need to change schools not at the normal time (i.e. usually Kindergarten, middle school, high school)
- Transitions that are normal at one stage of life are very different if at another stage of life, i.e. the timing is off based on personal or societal expectations
Families of children with complex healthcare needs may have more difficulty with transitions. One paper found that the transitions were often too focused on the transition of services needed for the individual (e.g. movement from a children’s hospital providing care to an adult hospital). Normative transitions such as moving into one’s own apartment or group facility, was hampered by lack of transition planning and collaborative decision making. Another paper found for individuals with intellectual disabilities, life events were a risk factor for psychological problems.
Learning Point
Helping children and families cope with transitions including moving can be very rewarding but what each individual needs for a smooth transition varies.
Some concepts that may assist parents with transitions include:
- Recognize that different developmental ages will experience the move, differently – in the above example the 2-year-old will probably be most interested in the here and now and therefore be very interested in the novelty of the experience and show less awareness of the loss.
The 5-year-old will be much more aware of the loss and therefore may show sadness and grief at losing friends. - Novelty and consistency – while the novelty of the actual move, new home, school, etc. is fun, children and adult also want consistency in their lives and environments. Therefore it is important to continue old routines (e.g. having a family meal, going for a bike ride, going to bed at a specific time, etc.) if possible. Establishing new routines and expectations early also is important (e.g. different parent picks up child from daycare, time for homework, home chores, etc.)
Consistency in sleep, eating and activity patterns are important for children and families. - Parents being present physically and emotionally – Children need to have parents available to them to be able to be talk and be physically close. For a young child, physical closeness predominates as the child may not verbalize the bewilderment they are feeling, but older children while more verbal may still need the physical closeness (e.g. “I just want some quiet time with you around.”). Parenting alone can bring additional challenges but often parents can find a few minutes in the day, or other time such as the weekends to set aside time specifically for the children.
- Parental sharing – parents can often help their children by sharing that they are experiencing some stress too because of the move. While parents should not burden their children, the shared experience can help the child realize that they are not alone. The parent noting that it is a difficult time for the entire family, but that they expect some very good things to happen/have happened with the move and that together as a family they can get through this difficult time, can assist everyone in the family.
Sharing stories of other moves from parents, grandparents and friends lives also can help the child. Parents should be ready for the children to express both positive and negative emotions to the move. - Productive outlets – Children and adults need productive outlets for their stress. This can take many forms such as drawing and coloring, writing, sports and physical activity, listening to music, talking with a friends, etc.. Whatever was helpful before the move, most likely will be helpful after the move.
Involvement in the new community for both the children and parents can ease the transition. Some children may not have what seems to be “productive” outlets. For example, while role playing the child pretends with their dolls that they are moving and the dolls cry they don’t want go, and the child screams or even hits the dolls. This type of fantasy play has actually been shown to be advantageous for children to work out their feelings through play. - Decreasing the rate of transitions – in the example above, the mother initially was planning on staying at home with the children but later finding work outside the home. In this way, the children don’t have to also transition to a new childcare arrangement immediately. Fewer transitions all at once may help.
- Keeping in touch with friends and family – finding way to integrate into the new community is important but also maintaining previous ties is important especially for middle school and high school students. Appropriate use of electronic communications such as instant messaging, social networking andteleconferencing can help children with the natural process of transitioning relationships across space.
- Expectations – parents need to set appropriate expectations and meaningful responsibilities for children whether or not they are in transition. Age appropriate expectations help children to develop competence and mastery. During the actual move, older children can be given responsibilities such as cleaning the floor and unpacking their room. Later, different expectations for the new living environment need to be put into place. For example a high school student may now be expected to cut the grass but that was not an issue previously when the family lived in an apartment.
Some children may not adjust well and may need professional help. . Some signs to look for include anxiety, great sadness, poor socialization, significant problems with sleep or eating, falling grades, and apathy.
Questions for Further Discussion
1. When a family is moving, what advice and tips do you offer?
2. How does your advice change for children with special health care needs or special education needs?
3. When a family is new to the area, what local agencies and organizations do you suggest to them?
Related Cases
- Disease: Child Mental Health | Stress
- Symptom/Presentation: Health Maintenance and Disease Prevention
- Specialty: Psychiatry and Psychology | School | Social Services
- Age: Toddler | Preschooler
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Child Mental Health and Stress.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Boyer WT. Coping with Stressful Transitions, in Behavioral and Developmental Pediatrics, Parker and Zuckerman eds. Little Brown and Company, Boston, MA. 1995;52-55.
Kirk S. Transitions in the lives of young people with complex healthcare needs.
Child Care Health Dev. 2008 Sep;34(5):567-75.
Hulbert-Williams L, Hastings RP. Life events as a risk factor for psychological problems in individuals with intellectual disabilities: a critical review.
J Intellect Disabil Res. 2008 Nov;52(11):883-95.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
17. A therapeutic and ethically sound relationship with patients is created and sustained.
20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 
