76. 5 Things That Will CHANGE Your Practice

Dr. Elise Fallucco reviews five practice-changing lessons from the previous season of Child Mental Health for Pediatric Clinicians: 

• 1 - Ask better questions 
  • For example, use Dr. Waxmonsky’s ADHD assessment prompt, “When is the hardest time of day, and what is going on there?” to guide ADHD medication choice
• 2 - Look for the problem behind the problem 
  • Ask teens about energy drinks/caffeine and sleep timing, recognizing energy drink use may signal sleep deprivation; 
• 3 - Update how we talk to families about stimulants 
  • Emphasize that stimulants support wakefulness, alertness, and motivation rather than directly improving attention (based on Dr. Nico Dosenbach’s Cell study)
• 4 - Remember the brain prefers gradual change
  • Review Dr. Jeff Strawn’s SSRI cross-titration approach while monitoring serotonergic side effects; 
• 5 -  Prioritize clinician wellbeing!

00:00 Season Lessons Overview

00:19 Ask Better ADHD Questions

01:07 Energy Drinks and Sleep Clues

02:37 What Stimulants Really Do

03:54 Brain Prefers Gradual Med Changes

04:29 Cross Titration SSRI Switching

06:41 Clinician Wellbeing Matters

07:26 Thanks and Stay Connected

Links to Episodes Referenced:

69. How to Switch SSRIS with Dr. Jeffrey Strawn

71. ADHD stimulants do NOT impact the brain’s attention networks with Dr. Nico Dosenbach

74. Burnout in Healthcare: “The Pitt”, Stats, and Solutions!

75. Beyond the Buzz: Energy Drinks, Teen Health, and Safer Ways to Stay Energized with Roshni Patel

Check out our website PsychEd4Peds.com for more resources!
Follow us on Instagram @psyched4peds

Check out our NEW CME Audio-based, on-demand CME Course online at:

Pediatric Mental Health CME Toolkit - Cracking the ADHD Code: Essentials for Pediatric Clinicians. 

https://ce.nemours.org/content/podcast-series-cracking-adhd-code-essential-skills-pediatric-clinicians#group-tabs-node-course-default1

Transcript

Dr. Elise Fallucco 0:00

Welcome back to Child Mental Health for Pediatric Clinicians I'm your host, Dr. Elise Fallucco, child psychiatrist and mom. When I was reflecting on the episodes this season, There were five major lessons that I learned That are changing the way that I think about approaching mental health problems in practice. Lesson number one, it's important to ask the right questions So in our Clinical Pearls episode with Dr. Waxmonsky He has some great questions that he likes to ask kids when assessing them for ADHD and determining treatment, and one of his questions is really great. It's asking the kid and the parent, "When is the hardest time of day, and what is going on there?" And then based on their answer, whether they're saying early morning, getting ready, doing the routine and getting out the door for school, or is it the afternoon when it's time for homework, or is it early evening? Basically, the family's response helps guide your decision as to which type of medicine you're gonna use to try to tackle the most important thing to the family so the first lesson's about asking better questions. The second lesson is look for the problem behind the problem. So for those of you who have listened to the Energy Drink podcast You remember that an astounding number of teens, not just in the US but across the world, are using energy drinks. In fact, after this episode aired, I had a conversation with my teenage son, and he casually mentioned that a bunch of his friends are regularly going to the local gas station And purchasing various energy drinks So hearing about how many teens are turning to energy drinks, it made me realize that There are likely so many people turning to these highly caffeinated products because they are not sleeping well. They are not getting enough sleep, and they are struggling to maintain alertness during the day So what that highlighted for me is Two main things. One, I need to do a much better job of specifically asking about energy drinks and caffeine use in teens And second I need to get back into the habit of asking, "What time do you go to bed and what time do you wake up typically?" To get a better quantitative feel for how they're sleeping So take home from lesson number two is Make sure to ask about energy drinks and sleeps. And remember that sometimes the energy drink isn't the problem, it's just a clue or a symptom of an underlying problem of sleep deprivation Okay, third lesson ADHD stimulants do not work the way that I thought they had. So perhaps the most surprising thing I learned all season was from Our episode with Dr. Nico Dosenbach, where we talked about his study published in the journal Cell about what ADHD stimulants do and what they don't And you have to go back and listen to the whole episode because it is so much fun and also really helpful. But bottom line, stimulants are not impacting your attention. All these years when we were telling kids and families that this is gonna help with your attention deficit hyperactivity disorder to take stimulants, really what we should have been saying and what we now know to say is that what stimulants really do is they help you stay awake and alert, and they help you feel more motivated to do things that previously you would've thought are not that interesting So the take home or clinical pearl From here was instead of telling families that stimulants help kids pay attention, We need to revise our spiel and make sure to tell families that stimulants help people stay engaged and stay motivated to do things like homework or writing or other assignments that they wouldn't typically find rewarding or fun The fourth lesson And this is our big psychopharm lesson, is that the brain likes gradual change So we had a bunch of episodes, many of which were with Dr. Jeff Strawn, where we talked about de-prescribing, in other words, taking people off of medicines. We also had an episode about switching SSRIs from one SSRI to another Ooh, and I forgot we even had a delightful mystery case at the beginning of the season And all of these episodes and discussions highlighted this one theme, which is our brain likes gradual changes And the two examples here would be the first one harkens to Dr. Strawn's strategy for switching from one SSRI to another. We talked about three different ways to approach this, but the way that he says he's increasingly accomplishing this is through cross-titration, which is a strategy very honestly I had rarely used. And cross titration I think of as kind of like the warm handoff. So you have your first SSRI that the patient is taking And instead of simply stopping that medicine and starting another medicine Or gradually tapering off the original medicine before starting a new medicine. Dr. Strawn talked about cross-titration, you keep your patient on their original SSRI while adding a second SSRI and give the brain and the body time to adjust to the new medication Knowing it can sometimes take four to six weeks, with the plan that eventually you'll taper down on SSRI number one once the patient has adjusted to the new medicine which is essentially keeping the patient on the original SSRI while starting the second SSRI as a low dose And this allows for a bridge and a more gradual transition between the two medications. Now side note, one of the reasons why I have not previously been a big fan of this strategy is because I don't like the idea of having somebody on two SSRIs at the same time, even briefly. when you do this, you wanna watch out for serotonergic side effects like nausea, vomiting, diarrhea, and flushing while you have these two SSRIs on board. But Dr. Strawn's point which is really well taken, is that when you start a new medicine, you're still starting from scratch, even if you have the old medicine on board, 'cause it's still gonna take the new medicine four to six weeks to work. So rather than having your patient restart and wait four to six weeks, at least keep them on the initial medication so they have some coverage while you're waiting for the new medicine to kick in. And again, of course, this is with the caveat that you wanna watch out for any potential serotonergic side effects while you have somebody on two SSRIs. And one of the final lessons that we've highlighted in this season is the importance of putting on our own oxygen mask And while the title of our podcast is Child Mental Health for Pediatric Clinicians, and we talk a lot about child mental health we can't forget the pediatric clinicians part! Clinician wellbeing is not separate from patient care. Our own wellbeing ultimately affects the way we show up every single day and the quality of care often that we're able to give our patients and their families. So if you haven't listened to that episode about burnout, it's worth checking out, and I'll include links in this podcast to some of the episodes I've shouted out So before we close I just wanna thank you for being a loyal listener and colleague of Child Mental Health this season and all of the seasons. And I wanna know what lesson have you learned that changed your practice this season? And what else are you curious about? What can we talk about to help support you in your ongoing practice of taking care of kids

7:48

with mental health problems

Dr. Elise Fallucco 7:49

for those of you who get our newsletter, please reply and let us know what are the lessons you're learning and what are the things you still want to learn about. And for those of you who are listening while bopping around, feel free to just click the link in the show notes to our website, psyched, the number four, peds.com, to sign up to become a friend and colleague and get a copy of our newsletter where you will get helpful resources, fun tips, and have the opportunity to write directly to us with any questions or thoughts you have. Take care, and look forward to talking to you next time