Our Anxious Generation with child psychiatrist Elise Fallucco, MD

In this episode, Dr. Elise Fallucco, child psychiatrist, discusses childhood anxiety- how much is normal, when it is a problem and how to treat it.
Elise M. Fallucco, MD is a child and adolescent psychiatrist whose career has been focused on
empowering pediatric clinicians to provide high quality mental health care.  Dr. Fallucco is the creator
and host of the podcast, Child Mental Health for Pediatric Clinicians.  She is nationally recognized for
excellent in training clinicians to identify and treat children and teens with mental health problems.  Her
educational programs and research have been published by many esteemed medical journals including
The New England Journal of Medicine, The Journal of Adolescent Health, and Pediatrics.  

Cover art by Charlotte Feldman
Please note that while I am a pediatrician, I am not your child's pediatrician. This podcast is for informational purposes only and does not constitute medical advice. For any medical concerns or decisions, please reach out to your child’s health care professional.

Transcript

0:11

Welcome to Kids Matter. I'm Dr. Elisa Minkin. As a pediatrician, mom and grandma, I understand how challenging it can be to help our kids grow into their best selves. We are so much more powerful together. Here I will be sharing the knowledge and wisdom of a wide range of people who understand and care deeply about children. I'm hoping for your input as well because kids really do matter. They are our future.

Alisa Minkin 0:42

Hey, welcome back to the Kids Matter podcast. I'm really honored and really excited to have today Dr. Elise Fallucco. She is a child and adolescent psychiatrist whose career has been focused on empowering pediatric clinicians to provide high-quality mental health care. Dr. Fallucco is the creator and host of the podcast, Child's Mental Health for Pediatric Clinicians, and I will post the link to that in the show notes. She is nationally recognized for excellence in training clinicians to identify and treat children and teens with mental health problems. Her educational programs and research have been published by many esteemed medical journals, including The New England Journal of Medicine, the Journal of Adolescent Health, and Pediatrics. So I'm really excited to have you here today, Dr. Fallucco. I just came back to work with a focus on mental, developmental, and behavioral health. So I'm really excited to have you here, not just for parents, but also for clinicians or what we call them professional parents, right? Some of whom are parents, some of whom are not, but for all of them, because I think we have an angle for everybody here today. I think it's really important because we have a mental health crisis.

Elise Fallucco 1:55

Yes. Dr. Minkin, thank you so much for

Alisa Minkin 1:57

Excited to talk to your guests. I wanna talk about really specifically anxiety disorders. There's lots of things we could talk about, but I... Before we even get into anxiety disorders, I want you to tell us the basic definitions of not just anxiety disorders, but anxiety, because it's not the same thing. Anxiety isn't thrown around,

Elise Fallucco 2:20

the

Alisa Minkin 2:20

whether you're talking about disorder-level anxiety or anxiety disorder. And so I just wanna make a distinction. Anxiety is a normal human emotion that we all feel at different times. And in fact, it can be very healthy and adaptive, and it's our bodies and our brain's way of telling us that something is going on around there that we need to pay attention to.

Elise Fallucco 2:40

There that we need to pay attention

Alisa Minkin 2:42

if anxiety occurs and really short bursts, and we're paying attention to it, and we respond,

Elise Fallucco 2:47

and we're

Alisa Minkin 2:48

then

Elise Fallucco 2:48

attention

Alisa Minkin 2:49

feeling of anxiety goes away, and we're fine, and we can retur-return to normal function. the problem becomes when it gets to be what we would call like a disorder level or something that's clinically concerning. In which case,

Elise Fallucco 3:02

clinically

Alisa Minkin 3:02

what we see is that kids and teens will feel

Elise Fallucco 3:05

what

Alisa Minkin 3:05

anxiety that's

Elise Fallucco 3:06

and

Alisa Minkin 3:07

of proportion to the stressor that they're experiencing.

Elise Fallucco 3:09

proportion to the stressor that they're

Alisa Minkin 3:11

and it's something that is persistent, that goes on and

Elise Fallucco 3:14

and

Alisa Minkin 3:14

goes on to Affect their whole bodies, affect how their,

Elise Fallucco 3:17

to affect their,

Alisa Minkin 3:18

affect their day-to-day life, and affect their ability to just

Elise Fallucco 3:21

life and

Alisa Minkin 3:22

and function well, whether as a kid or as a teenager.

Elise Fallucco 3:26

as a kid or as a

Alisa Minkin 3:27

That-that's a really good answer. Succinct, I like it. I always think about it as frequency, intensity, duration, and how much is impacting function, right? Because it's a spectrum. It's not like there's anxiety on one side and anxiety disorder on the other side and nothing in between, right? And I think it's really important for pediatricians to be screening for anxiety, and I think many of us do. I think most of us do on some level. So what would you say the role of the pediatrician or a pediatric, professional, we have nurse practitioners and PAs and MDs and DOs, all of those. What would you say the role is in, in detecting and possibly treating Pediatric anxiety disorders?

Elise Fallucco 4:13

The very challenging thing about anxiety is

Alisa Minkin 4:16

that it's something that kids and teens experience on the inside of them,

Elise Fallucco 4:20

kids

Alisa Minkin 4:20

it's really hard for even them to recognize that something's going on and that they're not feeling well. And so it makes it critically

Elise Fallucco 4:26

feeling well.

Alisa Minkin 4:27

important to have a medical professional or even have your parents or somebody else

Elise Fallucco 4:31

or even

Alisa Minkin 4:32

screen and try to figure out is there anxiety present. 'Cause just by looking at a kid, you wouldn't know, "Are they experiencing anxiety?"

Elise Fallucco 4:39

you

Alisa Minkin 4:39

if you catch them on a good day or if things are going well and there's not a particular trigger,

Elise Fallucco 4:43

if things are

Alisa Minkin 4:44

they can look like everything's great. And so it's not just my recommendation to screen, but the US Preventative Services Task Force for years has been saying that in kids, I believe up to 11 and older, maybe it's eight and older- I think they said eight, but it's harder to screen for eight because I find that the younger they are, the harder it is to really assess that in a screen.

Elise Fallucco 5:07

Thank you. It is. Okay, they

Alisa Minkin 5:09

SCAR, S-C-A-R-E-D,

Elise Fallucco 5:20

A lengthy

Alisa Minkin 5:21

and

Elise Fallucco 5:22

Called the SCARED, the

Alisa Minkin 5:23

disorders.

Elise Fallucco 5:23

for

Alisa Minkin 5:23

It's 41 items.

Elise Fallucco 5:25

Disorders.

Alisa Minkin 5:26

lovely,

Elise Fallucco 5:26

forty-one

Alisa Minkin 5:27

long. And MARBI also have a shorter version called the SCARED. Oh. It's

Elise Fallucco 5:33

5

Alisa Minkin 5:33

S-C-A-R-E-D.org and that's one I really recommend for people to consider looking at. It's not gonna give you a full picture of anxiety, but it's like a quick and dirty way for a child to fill out a couple questions, a parent to fill out a couple questions,

Elise Fallucco 5:45

fill

Alisa Minkin 5:45

get a feel for

Elise Fallucco 5:46

a

Alisa Minkin 5:47

is there something

Elise Fallucco 5:47

questions, and

Alisa Minkin 5:48

going on here that we need to look into. And when you say quick and dirty, I used to do the SCARED, and the SCARED has many different subcategories of anxiety, and you're supposed to divide it out, and it would take me so long to do it, to get the subcategories, and it does give you some information, but it's the opposite of quick and dirty. Pediatricians are busy. Just... If you can do that screen, don't worry about it. Just look at the overall number as a screen. It is limited in the sense that a child may have a very specific subtype of anxiety, and the total may not reach the threshold, and yet they may really have a significant- Like phobia or separation anxiety or whatever, that's where the history comes in. I don't know that the SCARED is a good routine screener though. I think of the PSC, the pediatric... I think it's the Pediatric Symptom Checklist, and there's different numbers, 17, 25, I don't know. How do you look at that as a, as an anxiety screen for the general population of kids?

Elise Fallucco 6:45

So that's-- like you said, it's a general screener. It's

Alisa Minkin 6:48

Trying to assess for a lot of things at once quickly, like attention problems, behavioral problems, anxiety, issues with your mood.

Elise Fallucco 6:58

issues

Alisa Minkin 6:58

so it can give you a general feel

Elise Fallucco 7:01

and

Alisa Minkin 7:01

for is there something here? But it's may- not specific for anxiety.

Elise Fallucco 7:06

specific

Alisa Minkin 7:07

other thing that I like to talk to families about is trying to think about is there a question or two that you could ask a child to assess whether they might have anxiety. And unfortunately, anxiety is one of these things where you can't just say, "Do you have anxiety?"

Elise Fallucco 7:23

can't just

Alisa Minkin 7:23

And

Elise Fallucco 7:24

"Do you

Alisa Minkin 7:24

even adults I think have a lot of misconceptions about what anxiety is. I think they think that having anxiety means

Elise Fallucco 7:32

I

Alisa Minkin 7:33

having discrete episodes of perhaps panic attacks where you become overwhelmed and experience a lot of physical symptoms, heart racing, shortness of breath,

Elise Fallucco 7:41

a lot of

Alisa Minkin 7:41

things like that.

Elise Fallucco 7:42

racing, shortness

Alisa Minkin 7:43

and while that occurs,

Elise Fallucco 7:44

that.

Alisa Minkin 7:45

In our population, that would be more something that you'd see in

Elise Fallucco 7:48

our

Alisa Minkin 7:48

older teenagers and adults. If we're really talking about kids and younger teenagers, their common manifestation of anxiety is, what we would call generalized anxiety disorder, something where they're worriers. And again, they may look like everything's fine, but in their mind,

Elise Fallucco 8:04

look like

Alisa Minkin 8:05

they're constantly fearing that there's potentially something catastrophic that could happen,

Elise Fallucco 8:09

potentially something catastrophic that could happen,

Alisa Minkin 8:12

at home or at school or to their parents or something else. But back to screening at eight versus say 11 or 12 we do in my practice screen all kids 12 and up with the GAD-7. The GAD-7 is free. It is seven questions, and the kid themself has to answer, 'cause one of the problems with the Pediatric Symptom Checklist is it's done by the parent, and it's an internalized sym- symptom. So I just wanna make that really clear. We're talking to clinicians right now. In terms of screening, the GAD-7 is approved for tested on what age and up? But I don't think it's eight. And I find that the kids between eight and 11 are often unable to read and comprehend and answer the questions well enough on, on the screens. Even the SCARED, by the way, even though the SCARED is approved for eight and up. So I think it's 11 or 12 for the GAD-7, and I think that's a reasonable... I think the task force is very lovely, but for all practicality, you can screen 11 or 12 and up with the GAD-7. And I really think you should because we are having an absolute explosion of both anxiety, depression, and both. And maybe you wanna talk for a few minutes of what other things are often associated with anxiety.

Elise Fallucco 9:21

Yeah. When I hear anxiety, you

Alisa Minkin 9:23

So I was thinking anything on your report together that's a lot of anxiety tend to run together. And in fact, there's a lot of overlap in the symptoms of anxiety and the symptoms of depression. So sometimes it's hard to tease out,

Elise Fallucco 9:40

the

Alisa Minkin 9:40

What are you dealing with?

Elise Fallucco 9:41

it's hard to tease

Alisa Minkin 9:42

the other common comorbidity or,

Elise Fallucco 9:45

the other

Alisa Minkin 9:45

commonly occurs, co-occurs with anxiety is ADHD.

Elise Fallucco 9:50

with anxiety

Alisa Minkin 9:51

huge overlap in ADHD and anxiety, and so typically what we'll see is kids will get diagnosed with ADHD maybe

Elise Fallucco 9:58

will get diagnosed with

Alisa Minkin 10:00

sometimes as young as four and five, but definitely during elementary school

Elise Fallucco 10:04

but

Alisa Minkin 10:04

or during the transition to middle school

Elise Fallucco 10:06

school

Alisa Minkin 10:06

high school.

Elise Fallucco 10:07

transition

Alisa Minkin 10:08

then it's around the preteen, tween times that we'll also pick up on, "Oh wait, I think we've also got some anxiety."

Elise Fallucco 10:14

on, "Oh, wait, I

Alisa Minkin 10:15

I think of it as bi-directional and also confusing in terms of what actually is going on, right? Because for example, you could have ADHD primarily inattentive, right? Because it's no longer ADD, it's either ADHD inattentive, hyperactive, or combined. So say you have ADHD inattentive, which by the way is more common in our females and is internalized and invisible, and then especially as they get older, they tend to be anxious because they can't pay attention. It's really what's coming first is the ADHD, which is often missed and untreated. But when you have a kid who people are saying is not paying attention and you don't know what's going inside them, it could really be they're not paying attention 'cause they're anxious as the primary problem.

Elise Fallucco 10:57

Exactly. And so the hard part the, that pediatric

Alisa Minkin 11:01

It's the

Elise Fallucco 11:02

out

Alisa Minkin 11:02

it's the issue that ADHD is primary and the anxiety is only related to

Elise Fallucco 11:07

and the

Alisa Minkin 11:07

issues,

Elise Fallucco 11:08

only

Alisa Minkin 11:08

to the underlying ADHD. So in other words, I... kids with ADHD

Elise Fallucco 11:12

other words, I...

Alisa Minkin 11:13

may have had problems at school or with tests or again, with

Elise Fallucco 11:17

at

Alisa Minkin 11:17

tuning in, so they're gonna be nervous in those situations appropriately.

Elise Fallucco 11:21

be

Alisa Minkin 11:22

But their anxiety is not in proportion to the stressor. The big stressor, it's hard for them, and so they would have appropriate levels of anxiety.

Elise Fallucco 11:27

the

Alisa Minkin 11:28

things happening

Elise Fallucco 11:34

But you would

Alisa Minkin 11:34

If the disorder was

Elise Fallucco 11:35

anxiety

Alisa Minkin 11:36

or social disorder, not an anxiety

Elise Fallucco 11:38

anxiety...

Alisa Minkin 11:39

it was just ADHD with ADHD related

Elise Fallucco 11:41

it was

Alisa Minkin 11:42

anxiety,

Elise Fallucco 11:42

with ADHD-related

Alisa Minkin 11:44

them to be fine in any other Situations and

Elise Fallucco 11:47

to

Alisa Minkin 11:47

not have anxiety except perhaps around social-

Elise Fallucco 11:49

have anxiety, except perhaps around social situations. Let's say there's, Again, I'm trying, I

Alisa Minkin 11:55

Again, I'm

Elise Fallucco 11:56

it as

Alisa Minkin 11:56

trying to think of examples. So academic would be one, and the second would be social situations. So let's say you're an ADHD type kid that tends to blurt out answers or

Elise Fallucco 12:05

kid that tends to

Alisa Minkin 12:06

interrupt people while they're talking,

Elise Fallucco 12:08

interrupt

Alisa Minkin 12:08

These sort of social groups that we're prone to,

Elise Fallucco 12:10

certain

Alisa Minkin 12:11

a professor

Elise Fallucco 12:12

there are gonna be

Alisa Minkin 12:12

might

Elise Fallucco 12:13

who

Alisa Minkin 12:13

"Oh, she's different," or, "He's different and I don't like that." And they don't know

Elise Fallucco 12:17

or, "He's

Alisa Minkin 12:17

that it's related to the ADHD. They just

Elise Fallucco 12:20

that it's

Alisa Minkin 12:20

are gonna

Elise Fallucco 12:21

ADHD.

Alisa Minkin 12:21

know, these other kids are gonna be sending non-verbal feedback like, "Hey..." Or even verbal feedback like, "Hey, why do you always butt in?" Or, "Hey, why did you say that?"

Elise Fallucco 12:30

do you always

Alisa Minkin 12:31

that's gonna make the child with ADHD feel like there's something wrong or they're not as successful socially as they would like to. And so then of course, appropriately,

Elise Fallucco 12:39

would like

Alisa Minkin 12:40

when they're in future social situations, they're gonna remember, "Hey, I've had problems in this before.

Elise Fallucco 12:44

gonna

Alisa Minkin 12:45

This doesn't make me feel comfortable. Maybe I want to avoid this

Elise Fallucco 12:48

make me feel comfortable. Maybe I want to avoid

Alisa Minkin 12:50

and so

Elise Fallucco 12:50

Or,

Alisa Minkin 12:51

to your point, I think it's a really astute clinician to think about is this appropriate anxiety in response to ADHD level

Elise Fallucco 13:00

response

Alisa Minkin 13:01

problems with functioning in social

Elise Fallucco 13:04

functioning And social

Alisa Minkin 13:05

Not only do we have an explosion in the amount of kids with these issues, but we don't have enough professionals at the same time, mental health professionals to deal with it. Okay. The bottom line is that we in the trenches, we pediatric clinicians in the trenches are being asked to take on a lot of the burden, both in detecting and sometimes even treating these issues with all the other pressures we have, with our time pressure, with poor reimbursement, whatever. We could go on about that forever. And pediatricians and pediatric professionals, I'm hugging you right now, giving you that hug because it's... I say this all the time, it's so hard to be a pediatrician nowadays for many reasons, and this is a big piece of it. Okay. I just wanna say though, screening does not take much time, especially if you don't do the SCAR. Unless you have extra time. You do the GAD-7 in the older kids, And there are ways you can do this. There are ways you can make time, but I think that's gonna be outside the scope of this. But in terms of screening, please, if you have a kid who you're thinking has ADHD, please consider anxiety as well, and the other way around at the same time, right? So think about both. You don't have to always look for ADHD, but if you're picking up ADHD for the first time, I believe you should always screen for anxiety.

Elise Fallucco 14:20

Yes. And then the other little pro tip or kind of clinical pearl that I wanted to share is that what you know,

Alisa Minkin 14:26

ADHD and anxiety run in families.

Elise Fallucco 14:29

and

Alisa Minkin 14:29

so if you have a parent or as a parent, if "Hey, I've got a lot of anxiety in my family tree,"

Elise Fallucco 14:35

I've got a lot of

Alisa Minkin 14:36

that means that your kids are gonna be higher risk for anxiety. And so as a benefit to your kids, you can look out for patterns that you can recognize and say, "Oh, wait.

Elise Fallucco 14:46

that

Alisa Minkin 14:46

Looks like we're,

Elise Fallucco 14:47

And

Alisa Minkin 14:48

looks like we're getting really riled up before certain events, and we're asking a lot of questions,

Elise Fallucco 14:53

events, and we're

Alisa Minkin 14:55

want to know what to expect. Th- this feels like a lot. This doesn't feel like developmentally typical. Maybe I should talk to the pediatrician about what's going on to see if

Elise Fallucco 15:04

to the

Alisa Minkin 15:04

maybe I've given my child a little bit of my anxiety." You're a neurospicy family. That's what we call them nowadays. And I think these are the best parents because if they know it in themselves, they can pick it up in their kids, and they become the best mama bears and papa bears sometimes. Usually mamas. So that's a really good point. So let's go right into what... We're gonna be back in the parent's seat right now. What should you do if you suspect your child has anxiety? What would be the next step you should take?

Elise Fallucco 15:38

So I would say if you suspect your child

Alisa Minkin 15:40

the pediatrician can be there and do the hard work of

Elise Fallucco 15:46

be

Alisa Minkin 15:47

using the SCARED 5 or the GAD-7, plus a good clinical assessment and asking the right questions to figure out, is this

Elise Fallucco 15:53

and

Alisa Minkin 15:53

appropriate level anxiety,

Elise Fallucco 15:55

this

Alisa Minkin 15:56

is this something that could be a disorder?

Elise Fallucco 15:58

or is this

Alisa Minkin 15:59

you know, something that's negatively impacting the child's life and their ability to have fun, engage with friends,

Elise Fallucco 16:05

their

Alisa Minkin 16:05

et cetera. And if

Elise Fallucco 16:06

friends,

Alisa Minkin 16:07

is concerned that it's a disorder level, at that point

Elise Fallucco 16:11

that it's a

Alisa Minkin 16:11

I would strongly Recommend getting therapy, particularly CBT or cognitive behavioral therapy to try to support the child. And then consider whether Is a particular clinical case where the child might benefit from medication.

Elise Fallucco 16:26

where the child

Alisa Minkin 16:26

a lot of stigma and a lot of talk about psychiatric medication, especially currently. And

Elise Fallucco 16:32

medication,

Alisa Minkin 16:33

myself, I know that

Elise Fallucco 16:34

And as a

Alisa Minkin 16:35

it is a hard, it's a hard pill to swallow to consider putting your child on a medication, and it certainly brings up

Elise Fallucco 16:42

your child on a

Alisa Minkin 16:43

more issues than when you're talking about a medication for, say, an ear infection

Elise Fallucco 16:47

a medication for,

Alisa Minkin 16:48

else.

Elise Fallucco 16:49

an ear infection

Alisa Minkin 16:50

so the

Elise Fallucco 16:51

And so the--

Alisa Minkin 16:53

that. I also want to say that

Elise Fallucco 16:54

just acknowledging

Alisa Minkin 16:55

be helpful, particularly for anxiety and after having treated so many kids,

Elise Fallucco 17:01

after having treated

Alisa Minkin 17:02

for anxiety, what they have taught me

Elise Fallucco 17:04

for anxiety,

Alisa Minkin 17:05

that, when you find

Elise Fallucco 17:07

is

Alisa Minkin 17:07

effective treatment or an effective medication, it really can be life-changing.

Elise Fallucco 17:11

an

Alisa Minkin 17:11

And I've even had,

Elise Fallucco 17:12

can be life-changing.

Alisa Minkin 17:13

come back to me and say, "Man,

Elise Fallucco 17:15

some of my

Alisa Minkin 17:16

I wish we had done this a couple years ago," or, "I wish your family had even known to come and talk to you a couple years ago, because my experience in high school now or in middle school now is so different than what it was. I feel so much more like myself and so much more comfortable." That is really great. It's so hard because there is a strong anti-medication bias going through right now. And it's problematic because your child needs what they need. But back to the clinician and back to the parent, if you do suspect this, I'm going to say you may want to ask for a separate appointment to address that, because it often comes up at the well visit, and we really only have so much time at that well visit. And in order to properly address a mental health problem, you need time. So I really suggest, as a parent, advocating for a separate appointment with enough time, and as the clinician, advocating for coming back and seeing me. Maybe it'll be a telehealth, maybe it'll be in person, but to make that time, that adequate amount of time s- as a separate visit. And it might be multiple visits,

Elise Fallucco 18:17

Yeah.

Alisa Minkin 18:23

starting point. Going to your pediatrician, fine. Getting referrals. I want to give a great resource out there for both parents and clinicians, and that is the Project TEACH. I should really link it in the notes. Project TEACH has programs, ongoing educational programs, more intensive, on demand for clinicians who want to learn more about it, because m- most pediatricians are not adequately trained for the mental health that we're... i'm hoping down the road it will change because this is the thing that we still have to do. But so that is a great resource for clinicians, but it's also a great resource for parents. When you talk about screens, you yourself can go on the Project TEACH website. I tell parents to go there sometimes. And they have a separate set of rating scales, and you even as a parent can print out a rating scale of you think your child might have and complete them before you go to the doctor. 'Cause we're always trying to get those rating scales in before. So that can be helpful and for the clinician to, to order it. So what kinds of things can we do besides medication and besides therapy? Because there are at least one other thing I'm thinking of and that's things from the school. Sorry.

Elise Fallucco 19:33

what I would say is, the

Alisa Minkin 19:35

Okay

Elise Fallucco 19:36

w- thinking holistically about treating the whole child, yes,

Alisa Minkin 19:40

Quick plug in for therapy too.

Elise Fallucco 19:42

and I wanna put a quick

Alisa Minkin 19:43

one of my colleagues who's a pediatric psychologist

Elise Fallucco 19:46

one of my

Alisa Minkin 19:46

always talks about, when you recommend therapy to somebody,

Elise Fallucco 19:49

about,

Alisa Minkin 19:49

here's what you should say. You should say, "Look,

Elise Fallucco 19:52

here's

Alisa Minkin 19:52

by bringing your child to therapy, you're gonna be giving them a set of coping skills and tools in their toolbox that they can use now and for the rest of their life. It's an investment

Elise Fallucco 20:03

and for

Alisa Minkin 20:03

not only in now, but

Elise Fallucco 20:04

It's

Alisa Minkin 20:05

in, in their future." And so that's gonna be... anxiety's not gonna go away, and stressors are not gonna go away. And so the savvy family that

Elise Fallucco 20:12

go

Alisa Minkin 20:12

is able to get their kid connected to therapy

Elise Fallucco 20:15

able

Alisa Minkin 20:16

gonna be doing a lot of

Elise Fallucco 20:17

to

Alisa Minkin 20:17

good for them.

Elise Fallucco 20:18

is

Alisa Minkin 20:18

So we talked about therapy, we talked about medication.

Elise Fallucco 20:21

So We talked about

Alisa Minkin 20:22

obviously all of the things that pediatricians always tell you: have a good health

Elise Fallucco 20:25

the

Alisa Minkin 20:25

routine- get good sleep and try to exercise.

Elise Fallucco 20:28

try to

Alisa Minkin 20:28

those are gonna be really helpful. Check on your nutrition. And then

Elise Fallucco 20:31

helpful.

Alisa Minkin 20:32

role of the school is highly critical.

Elise Fallucco 20:34

The role of the

Alisa Minkin 20:35

What Would say, certainly each family has the opportunity to make a decision about how much information they wanna share with the school about their child. But I think

Elise Fallucco 20:44

share with the school

Alisa Minkin 20:45

letting the school know that you have identified that your child

Elise Fallucco 20:48

school

Alisa Minkin 20:48

right now is struggling with anxiety, is starting to get treatment, can be very helpful. And a lot of schools have different levels of supports that, everything from a 504 plan to an IEP

Elise Fallucco 21:00

plan

Alisa Minkin 21:00

formally help your child navigate the specific situations that

Elise Fallucco 21:05

Navigate the

Alisa Minkin 21:06

anxiety. That's great. And,

Elise Fallucco 21:07

that

Alisa Minkin 21:07

to clarify, a 504 plan is for accommodations and modifications for a child who doesn't meet the criteria of a student with a disability. So it could be a child with ADHD who's academically fine but needs to be refocused, redirected, or even a child... People don't know this, a child with anxiety may need extra time on tests or may need school-based counseling. And again, not everybody wants school-based counseling. Some people wanna keep their child's mental health challenges private. But to the degree that the mental health challenge affects the child in school, I do recommend u-utilizing school resources, right? Especially if a child has, say, ADHD and anxiety and they need counseling in school to deal with that, or sometimes group counseling. Wait, I wanna say one more thing before I forget. And that's that you talked about a toolbox, and I had a patient once who was about 10 years old at the time, who was getting excellent therapy and at one point needed more. Put the child on a medication for anxiety, and the child said to me the smartest thing. He said to me, "Now I have the key to open my toolbox that I got from therapy."

Elise Fallucco 22:15

Oh my

Alisa Minkin 22:16

parents, listen to what this bright child said and keep that in mind, right? We don't want to throw medication, and we don't want... If you're a parent and you're coming to the pediatrician and you feel like you just got a drug, like I always say, it's not like strep is to antibiotics as anxiety is to Prozac. It doesn't work like that, right?

Elise Fallucco 22:38

Yeah. It's more com- it's

Alisa Minkin 22:39

It should be more complicated, and unfortunately, there is time pressure that pediatric clinicians are facing. And that's true also for mental health clinicians who are taking insurance and are under the gun to, to do relatively quick visits, right? I don't have an easy answer for this other than as a parent, right? You're still the mama bear or papa bear and you're there to advocate for your child to get good healthcare, mental healthcare too.

Elise Fallucco 23:05

Yeah. And... and I do think part

Alisa Minkin 23:07

Yes,

Elise Fallucco 23:11

after

Alisa Minkin 23:12

Dr.

Elise Fallucco 23:12

to

Alisa Minkin 23:12

Minkin,

Elise Fallucco 23:13

your

Alisa Minkin 23:13

let them become aware, and then here are screening tools you can fill out or quizzes that you can take and share with the teacher, share with your child, share with your other child's parents or

Elise Fallucco 23:22

share

Alisa Minkin 23:22

kind of important adult in their life so that when you come to the pediatrician, you already come armed with here's what we've... here's the data we have so far. Here's what the school is saying. Here's what we're experiencing to make the most out of your time,

Elise Fallucco 23:36

to make the most

Alisa Minkin 23:37

with your pediatric

Elise Fallucco 23:37

your

Alisa Minkin 23:37

clinician. Absolutely. I wanna talk about anxiety in the parents. You talked before about things being genetic, and so we're not going to blame or shame parents, but we need to talk about this. Transmitted

Elise Fallucco 23:57

in

Alisa Minkin 23:57

potentially.

Elise Fallucco 24:00

transmitted

Alisa Minkin 24:00

And then also I think as parents we model

Elise Fallucco 24:03

And then

Alisa Minkin 24:03

anxiety whether we realize it

Elise Fallucco 24:06

a little

Alisa Minkin 24:06

or not. So

Elise Fallucco 24:07

whether we

Alisa Minkin 24:08

for example,

Elise Fallucco 24:08

And like for example,

Alisa Minkin 24:10

if there's something... What is it? We do a lot of... Basically, as a parent, we're sort of,

Elise Fallucco 24:16

Basically,

Alisa Minkin 24:17

we can be a really positive model and we can help Of buffer stress for our children.

Elise Fallucco 24:21

help

Alisa Minkin 24:22

and,

Elise Fallucco 24:22

stress for

Alisa Minkin 24:23

so for example, like if a major... I live in Florida and we get a lot of hurricanes. So let's say a major hurricane is coming,

Elise Fallucco 24:30

So

Alisa Minkin 24:30

and

Elise Fallucco 24:31

let's say a

Alisa Minkin 24:31

if my response to it is, "Oh my gosh, hurricanes are so scary. We've got to run to Publix and get a bunch of water. We've got to do this," and it's, and I'm panicked, and how is this all gonna work? What I'm communicating to my kids is this is scary. Mom is scared,

Elise Fallucco 24:47

is this is,

Alisa Minkin 24:48

feel scared because this

Elise Fallucco 24:50

Then I'm gonna

Alisa Minkin 24:50

is something I don't know anything about it, but it seems like it's awful.

Elise Fallucco 24:53

appe-

Alisa Minkin 24:53

Whereas

Elise Fallucco 24:54

I

Alisa Minkin 24:54

on the other hand, if I can model like a sense of security and acknowledging that it's frightening, but that we've got it and that we'll be able to,

Elise Fallucco 25:02

but that we've got it,

Alisa Minkin 25:03

do okay as a family that communicates like a sense of calm to the children. And so I use the example of a hurricane to just say that,

Elise Fallucco 25:11

I

Alisa Minkin 25:11

In addition to maybe sharing our genes with our children, we're also demonstrating and modeling to them how to manage stress and what to do in case of situations,

Elise Fallucco 25:21

and what to

Alisa Minkin 25:22

stressful situations for the better or for the worse. And so for those of us who

Elise Fallucco 25:26

or for the

Alisa Minkin 25:26

are still struggling with a lot of anxiety, maybe what we don't realize is that we're, That there's a way that we're almost like transmitting that to our children. And so

Elise Fallucco 25:38

that we're

Alisa Minkin 25:38

I bring this up again not to blame or shame. This is just a part of who we are. It's, if you happen to have a lot of anxiety on your family tree like I do, that's,

Elise Fallucco 25:47

of anxiety

Alisa Minkin 25:47

is just the case. And so doing what you can to try to manage and find a great toolbox for your own anxiety is not only gonna help you, but it's gonna set a positive example for the kids and,

Elise Fallucco 26:00

gonna set a positive

Alisa Minkin 26:01

reduce their

Elise Fallucco 26:01

kids and,

Alisa Minkin 26:02

I love that, and I wanna add to that because think about the way the parent is thinking. Not only do I have an anxiety disorder, we're talking about the parent who has an ac-actual anxiety disorder that they're struggling with, but I also have to constantly co-regulate. They're talking so much about co-regulating, and you'll have to be calm for your child. But I'm not calm, I'm failing, and then you feel bad about yourself. No, it's the other way around. Think about a parent who I just said has ADHD, and they understand how to pick it up in their child and how they need to get help for their child. If you can address... First you have to know you have anxiety, then you'll have to address it. Your addressing your anxiety is modeling it for your children, not your being perfect. There is no perfect parent. We have to get rid of that. So I really wanna say that loud and clear, and I keep talking about this in my podcast over and over. In fact, I interviewed someone who goes by The Post-Traumatic Parent to talk about when you've had a traumatic childhood and how can you parent. It's all the same basic idea. By on your own addressing your issues, you will be modeling to your child. You don't have to be perfect. You don't have to always be regulated, but you do need to work on it. So some parents may need to access their own mental health for their own issues. But I also wanna talk about how we become anxious from our children's anxiety, and that's not the same thing, right? I'm pushing here.

Elise Fallucco 27:22

Oh

Alisa Minkin 27:22

Yes.

Elise Fallucco 27:22

So the bidirectional nature of anxiety between parents and kids. Yeah, of course, it's-- So a child and adolescent psychiatrist. I take care of kids with various

Alisa Minkin 27:32

Families who are navigating one of these struggles. And in that role, and then also in a role as a parent myself, what I know is

Elise Fallucco 27:39

in a role as a parent,

Alisa Minkin 27:41

as a parent, your child is the most important thing in the world. And so when your child is suffering and is struggling,

Elise Fallucco 27:47

your

Alisa Minkin 27:47

that is incredibly stressful as a parent, especially if you're not sure what's going on.

Elise Fallucco 27:52

especially

Alisa Minkin 27:52

and it's incredibly anxiety triggering because you keep thinking

Elise Fallucco 27:56

anxiety-triggering

Alisa Minkin 27:57

case scenario? Did I do this? Is,

Elise Fallucco 28:01

Did

Alisa Minkin 28:02

How is my child gonna get better? How is this affecting their life? Is this gonna

Elise Fallucco 28:06

how-- "Is this

Alisa Minkin 28:07

negatively impact things now and for the future? And

Elise Fallucco 28:10

things

Alisa Minkin 28:11

it's incredibly scary.

Elise Fallucco 28:12

and

Alisa Minkin 28:12

it really-- Yeah it really is. And I heard something just this past week that I really love. I think it's a reframing. Someone said, "It's good news that you might be playing a role in your child's anxiety." Instead of saying, "Oh it's not about your fault," but there's something that you're doing that could be making it worse because guess what you can do? You can stop doing that. You can make it better, and that's something that you have more control over than your child's internalized anxiety, right? Families

Elise Fallucco 28:48

tell families when I'm diagnosing a child with anxiety or evaluating a

Alisa Minkin 28:52

just like eye color or your hair color.

Elise Fallucco 28:54

families

Alisa Minkin 28:55

you know,

Elise Fallucco 28:55

your eye

Alisa Minkin 28:56

do you or does the other parent of the child

Elise Fallucco 28:58

do

Alisa Minkin 28:59

have anxiety, or do you suspect that they might? And usually one of the parents is "I think it's me. It's definitely me." Yeah. And so

Elise Fallucco 29:06

It's me."

Alisa Minkin 29:07

what I like to say is,

Elise Fallucco 29:08

so

Alisa Minkin 29:10

you know,

Elise Fallucco 29:10

like to

Alisa Minkin 29:10

this is actually a really positive thing because it gives you an appreciation, empathy, and understanding maybe what your child might be going through. And

Elise Fallucco 29:18

for what your

Alisa Minkin 29:18

as a

Elise Fallucco 29:19

be going

Alisa Minkin 29:19

psychiatrist, a very hard thing in practice is when you have a child who's struggling and the parents

Elise Fallucco 29:24

is

Alisa Minkin 29:25

don't understand it. And this happens often in anxiety

Elise Fallucco 29:28

and this

Alisa Minkin 29:28

maybe not with both parents, but at least with one parent who will say- "why can't she just shake out it out of school? Why she gets so stressed out before she has to speak in front of people?" Or,

Elise Fallucco 29:39

before she

Alisa Minkin 29:40

"Why is she still so worried?" Or, "Why is he still so worried about this?" "Come on, be tough. Get over it." And

Elise Fallucco 29:46

this?"

Alisa Minkin 29:46

Those words are often

Elise Fallucco 29:47

Get

Alisa Minkin 29:47

spoken by an adult who has not struggled with an anxiety- Right. They don't

Elise Fallucco 29:53

with

Alisa Minkin 29:53

get it

Elise Fallucco 29:55

and can be-- Yeah, and it can be

Alisa Minkin 29:56

parent who's "Yes here's

Elise Fallucco 29:57

And

Alisa Minkin 29:58

why

Elise Fallucco 29:58

on the

Alisa Minkin 29:58

you feel this

Elise Fallucco 29:59

a

Alisa Minkin 29:59

way. In fact,

Elise Fallucco 30:00

"I

Alisa Minkin 30:00

I have felt very similarly.

Elise Fallucco 30:01

understand why you feel this way. In fact, I have

Alisa Minkin 30:03

Here's

Elise Fallucco 30:04

similarly.

Alisa Minkin 30:05

what we're gonna do." But there's also the flip side of the parent who understands it all too well, and their child's pain is greater than their pain, and they can't tolerate the child's pain, and therefore they're not helping the child move forward, right? Because I want you to talk just a minute about the cycle of avoidance and anxiety and how a parent could play into that or not. So obviously,

Elise Fallucco 30:25

Ugh.

Alisa Minkin 30:25

so see

Elise Fallucco 30:26

It--

Alisa Minkin 30:27

so common

Elise Fallucco 30:27

avoidance, and I have

Alisa Minkin 30:28

in

Elise Fallucco 30:28

negative visceral reaction because this cycle of

Alisa Minkin 30:32

with

Elise Fallucco 30:32

something we

Alisa Minkin 30:32

very well-intentioned

Elise Fallucco 30:33

common in families of, from very

Alisa Minkin 30:35

let me give an example.

Elise Fallucco 30:36

Let me give

Alisa Minkin 30:37

so first of all, let me define it. So avoidance is this idea of,

Elise Fallucco 30:39

so first of all, let me define it. So avoidance is this idea

Alisa Minkin 30:42

occurs when your child is very stressed out about something. Let's say,

Elise Fallucco 30:47

out about something. Let's say,

Alisa Minkin 30:49

I'm in Florida again, so I'm gonna give you a lot of water-based analogies.

Elise Fallucco 30:52

so I'm gonna give you a lot of

Alisa Minkin 30:54

In addition to the hurricane we have a lot of end of school field trips to places that involve water. So let's say

Elise Fallucco 31:01

places that

Alisa Minkin 31:02

are going to swim with the manatees, for example.

Elise Fallucco 31:04

these kids are going to

Alisa Minkin 31:05

and one of the kids is very scared about getting in the water, which is a very common phobia.

Elise Fallucco 31:09

about getting in the water,

Alisa Minkin 31:10

because they don't know how to swim or not because of any,

Elise Fallucco 31:13

not because they don't know,

Alisa Minkin 31:14

particularly health condition or, anything that we would expect to cause that. And so what's gonna happen is the child is gonna say, "I don't wanna get in the water. That's really scary." And the parent is gonna see how upset this child gets, like how physically activated. "I'm getting a headache. I'm getting a tummy ache. It's, I'm afraid that this is gonna happen, and I'm gonna embarrass myself."

Elise Fallucco 31:34

gonna happen, and I'm gonna

Alisa Minkin 31:36

the parent wants-- When you see a child in distress, all you want is to stop it. You want to fix it. You want to make it go away. And so what parents accidentally do

Elise Fallucco 31:44

so

Alisa Minkin 31:45

help their child avoid stress instead of overcome it. And so

Elise Fallucco 31:48

avoid

Alisa Minkin 31:49

it's really easy to be like, "Oh, baby, you don't have to get in the water.

Elise Fallucco 31:53

"Oh,

Alisa Minkin 31:53

I don't want you to feel that way." So you wanna take it away from them. But what we don't realize is that we're inadvertently making the anxiety and distress worse. We are robbing kids of the opportunity to be able to

Elise Fallucco 32:05

kids of the

Alisa Minkin 32:06

practice their coping skills to master overcoming

Elise Fallucco 32:09

coping

Alisa Minkin 32:10

stressful situations by allowing them to avoid them.

Elise Fallucco 32:14

by

Alisa Minkin 32:15

And inadvertently what we're communicating is "Yes, you're right.

Elise Fallucco 32:18

we're

Alisa Minkin 32:18

This situation is too much for you to handle,

Elise Fallucco 32:22

is

Alisa Minkin 32:22

and so you should just not do it."

Elise Fallucco 32:25

and so you

Alisa Minkin 32:25

and that's the opposite of empowering. It's disempowering. And not just that, but not just that. I'm sorry, but not just that, but what avoidance does is right at that moment, the child feels better and the parent feels better. But what happens in the long run? Every time you don't face your fear, it grows. You're not even maintaining. You're exacerbating the problem,

Elise Fallucco 32:47

yeah,

Alisa Minkin 32:47

right? And this is not to blame. And then the question is what is a parent to do who typically has their own anxiety and is anxious from their kid's anxiety? And you can send them to all the therapists in the world, but it's your interaction at the moment that's gonna make the difference. How do we help those parents help their kids? So

Elise Fallucco 33:07

and I think

Alisa Minkin 33:08

first,

Elise Fallucco 33:11

talking about it is really the first step because, again, it's one of these s- frustrating, counterintuitive things about parenting, where we are well-meaning. We are really trying to help. We're trying to do the right thing, and we're trying to help our children. And so it seems in the moment that this is the right thing and, just letting families know

Alisa Minkin 33:32

of those choices and how,

Elise Fallucco 33:34

consequences

Alisa Minkin 33:35

empowering them with strategies to help their child through it instead of just saying, "Nope, rip off the Band-Aid, you've gotta do it." This is where the role of therapy comes in and working with the parent and the child to come up with what is a plan. What are,

Elise Fallucco 33:49

up

Alisa Minkin 33:49

when we get to the field trip

Elise Fallucco 33:51

you

Alisa Minkin 33:51

and I'm near the water,

Elise Fallucco 33:52

get

Alisa Minkin 33:53

what are things that I can do to help re-regulate, help calm myself down?

Elise Fallucco 33:56

to

Alisa Minkin 33:57

Or what are things that we can do between now and the field trip to help me desensitize or become more comfortable in water or address whatever the situations are leading up to that? And then the parent can become the coach saying, "Okay, here are the things we worked about in therapy. Here's what we're gonna do

Elise Fallucco 34:12

the things we worked about

Alisa Minkin 34:13

to help you overcome this and, help you be very brave."

Elise Fallucco 34:17

this and,

Alisa Minkin 34:17

But you also need the just right challenge. I'm thinking that there may be a child that says I cannot go on that trip. I can't. I can't do it." And that is not necessarily avoidance, but don't do nothing, right? We're talking about the kind of exposure and prevention therapy for a phobia means you gradually work your way up the ladder of how scary thing is rather than stay in the bottom of that ladder. So I think that's really important. And I wanna mention SPACE.. It was created by Dr. Eli Lebowitz who was I believe a psychologist, and I think it's called Supportive Parenting for Anxiety in Childhood something. I got four of the five letters, I think. And I'm gonna link, I'm gonna link to that, I believe, in the show notes. I'm gonna link in the show notes to SPACE because this is a very specific way of working with parents. Because if you're... I believe that when children have anxiety it's best to work with the parents as well. Some don't, but a lot of parents are like, "Okay, my kid's going to therapy for their anxiety," and then there's nothing given to the parents, and yet they're with the kid the rest of the, 23 hours of the day or whatever, or seven days a week except for that one hour a week, right? So SPACE is very specifically to work with the parents to work with their kids. So I don't know how accessible it is, but it's a really good model. I think there are therapists who are trained in it, like potentially everywhere. I don't know if you can look up on a website or something. So in terms of the kind of therapy, you're a psychiatrist, you don't do therapy, you really do more medication, correct? I think

Elise Fallucco 35:42

It varies.

Alisa Minkin 35:42

it's

Elise Fallucco 35:43

say

Alisa Minkin 35:43

different. It means typically MDs and our job is evaluating a kid holistically, trying to figure out what is, making a diagnosis and

Elise Fallucco 35:51

is

Alisa Minkin 35:51

trying to figure out what is going on and developing a treatment plan that can include therapy, can include medication. I think given the national shortage of child psychiatrists,

Elise Fallucco 36:01

the national shortage of

Alisa Minkin 36:03

in an effort to have To be able to see as many patients as we possibly can, a lot of us have focused more on the medication management side of treatment as opposed to med management plus therapy. But it, it depends where you practice. A lot of psychiatrists are also doing a lot of therapy as well

Elise Fallucco 36:18

of psychiatrists are

Alisa Minkin 36:18

I'm hoping to interview someone who's trained in space because I think it's a really important approach I want people to be more aware of. Let's talk a little bit more about medication,

Elise Fallucco 36:39

so I-- first, what I would say

Alisa Minkin 36:41

right? Say we've made the decision to do it. What would

Elise Fallucco 36:42

gold

Alisa Minkin 36:43

that look like? Medication

Elise Fallucco 36:43

medication

Alisa Minkin 36:44

for anxiety tends to use what

Elise Fallucco 36:45

is to use,

Alisa Minkin 36:46

call

Elise Fallucco 36:46

what we

Alisa Minkin 36:47

SSRIs. They're sometimes called antidepressants, but we're not using them for depression in this case. We're using for anxiety. And so these are medications that can take

Elise Fallucco 36:53

for

Alisa Minkin 36:54

really up to four to six weeks to work. You take them

Elise Fallucco 36:57

really up

Alisa Minkin 36:57

on a daily basis,

Elise Fallucco 36:58

to You take

Alisa Minkin 36:59

and what we believe is happening is that it's,

Elise Fallucco 37:02

and what we

Alisa Minkin 37:02

basically helping our brains adjust to our anxiety.

Elise Fallucco 37:06

our brains adjust to our

Alisa Minkin 37:08

and medication can be incredibly effective. It's very well-tolerated. These medications have been studied for decades and decades,

Elise Fallucco 37:14

These medications

Alisa Minkin 37:15

children

Elise Fallucco 37:16

for decades and

Alisa Minkin 37:17

and

Elise Fallucco 37:17

In children and adolescents.

Alisa Minkin 37:19

So these would be medications like fluoxetine or Prozac,

Elise Fallucco 37:22

would be

Alisa Minkin 37:23

Sertraline, which is Zoloft, Citalopram, which is Celexa, or Escitalopram, which is Lexapro. And sometimes what happens is a lot of the parents are on medication themselves

Elise Fallucco 37:35

is a

Alisa Minkin 37:35

anxiety, or one of these SSRI-type medications for anxiety. And what I would say is

Elise Fallucco 37:41

medications

Alisa Minkin 37:42

questions I ask families when we're talking about medication is,

Elise Fallucco 37:45

I ask

Alisa Minkin 37:45

"Okay

Elise Fallucco 37:45

when we're

Alisa Minkin 37:46

So if one of the parents has "He has anxiety. Have you tried medications? And if so, which ones worked well for you and which ones didn't work?" Because that can help direct us to know more quickly what would work with your child.

Elise Fallucco 37:58

know, more quickly what would work

Alisa Minkin 38:00

about, what about... I'm sorry, but what about the genetic testing? I'm hearing more and more people are using the genetic testing. What are your thoughts on that? Which

Elise Fallucco 38:10

So you're talking

Alisa Minkin 38:11

is a different way to get an idea. It's a little saliva

Elise Fallucco 38:17

this

Alisa Minkin 38:17

and we'll be able To know which medicine is gonna work for you for anxiety or depression. We've done some really excellent studies in the field on this, and essentially what we've found is unfortunately the technology is not quite there.

Elise Fallucco 38:32

the technology

Alisa Minkin 38:32

line is it's

Elise Fallucco 38:33

there.

Alisa Minkin 38:34

very rarely gonna be able to tell you which medication will

Elise Fallucco 38:37

rarely gonna

Alisa Minkin 38:38

in your brain. It can give you information about

Elise Fallucco 38:41

It

Alisa Minkin 38:42

quickly or how slowly your body metabolizes certain medications, which, can a guide

Elise Fallucco 38:47

medications,

Alisa Minkin 38:48

dosing adjustment, can help you know if you're gonna need a really low dose

Elise Fallucco 38:52

help you know

Alisa Minkin 38:53

if you're a rapid meta- metabolizer and your body eats up meds really quickly, maybe you're gonna need to push to a higher dose. So it provides information to that end, but I would say it's certainly not a necessary first step in considering medication treatments.

Elise Fallucco 39:07

first step in considering medication

Alisa Minkin 39:09

currently it's not lived up to the hype of being able to find the right medicine for you.

Elise Fallucco 39:14

hype of

Alisa Minkin 39:14

you know, just like scientists and clinicians treating any other illness or,

Elise Fallucco 39:20

treating

Alisa Minkin 39:20

disorder, we, we rely on the evidence, and so we have a lot of evidence

Elise Fallucco 39:25

on the evidence. And

Alisa Minkin 39:26

suggest that these SSRIs are very effective in children and teens with anxiety and can

Elise Fallucco 39:32

teens with

Alisa Minkin 39:33

with few side effects.

Elise Fallucco 39:35

be well-tolerated

Alisa Minkin 39:36

And in terms of what to expect when your child is first started, and what I'm thinking about is it should be started at a low dose, meaning that's not gonna be the correct dose, and how long would it take to take effect? A low dose to make sure and help the child

Elise Fallucco 39:54

with a very low dose

Alisa Minkin 39:55

adjust to the medication.

Elise Fallucco 39:56

To help the

Alisa Minkin 39:57

Sometimes it is the first couple of weeks as your body's adjusting to the medication. Ultimately, at least it's like you may have a tiny

Elise Fallucco 40:03

what

Alisa Minkin 40:03

little bit of stomach upset or you may have like extra energy or be a little tired,

Elise Fallucco 40:07

like you

Alisa Minkin 40:08

typically your body will adjust over a couple days and that should go away. You should really have

Elise Fallucco 40:12

over a

Alisa Minkin 40:13

minimal, if any side effects.

Elise Fallucco 40:15

have

Alisa Minkin 40:15

but it take... It's almost like a vitamin in the sense that it takes time to build up into your system. It can take four to six weeks to see a maximum effect on the first dose.

Elise Fallucco 40:24

weeks to see a

Alisa Minkin 40:25

for some kids, starting low dose is actually gonna be

Elise Fallucco 40:28

the starting

Alisa Minkin 40:29

where we end

Elise Fallucco 40:30

actually

Alisa Minkin 40:30

a lot of kids, we're gonna end up escalating after four to six weeks and to try to get to

Elise Fallucco 40:35

four

Alisa Minkin 40:36

target dose that's best for their body and brain.

Elise Fallucco 40:38

a target dose that's

Alisa Minkin 40:39

That's a really good explanation So what would you say about knowing when a medication is not working? How long would that take to even know?

Elise Fallucco 40:54

It depends. Sometimes in the first

Alisa Minkin 40:56

I see.

Elise Fallucco 40:57

you will not be able to tolerate the medicine or

Alisa Minkin 41:00

Sometimes

Elise Fallucco 41:02

I hate

Alisa Minkin 41:02

if we start on too high of a dose for a child, then they'll feel extra. They can develop what's called activation. So they can feel like way too much energy and feel extra antsy and irritable, and it's usually very obvious. And you stop the medicine and you know that was not a good one for you, and then you can try another one. Usually, typically starting at a low dose like we recommend, try to avoid that,

Elise Fallucco 41:25

dose

Alisa Minkin 41:25

of side effect.

Elise Fallucco 41:26

to

Alisa Minkin 41:26

But we have,

Elise Fallucco 41:28

type of side

Alisa Minkin 41:28

dosing guides and dosing ranges that help us understand like what are a typ-- what are typically effective doses for these meds for children and adolescents so that when you get to that dose, you can evaluate, have,

Elise Fallucco 41:40

to that You

Alisa Minkin 41:40

are we there? Are we feeling much better? Or has there been a trend towards, as we go up from one dose to the next, we tend to start feeling much better, but we're not

Elise Fallucco 41:49

we

Alisa Minkin 41:49

there, so you need to increase it further.

Elise Fallucco 41:52

there," so

Alisa Minkin 41:52

all signs that this is potentially a helpful medication. If you get to a target dose and you have not seen really anything, at that point I think it's time to consider switching to an alternate medication,

Elise Fallucco 42:02

to consider

Alisa Minkin 42:03

haven't had any signs that it's helpful or effective and with increasing effectiveness at higher doses. Could there be any other reason for the medications not working? Say you've tried several. The patient saying, "This

Elise Fallucco 42:17

Anytime

Alisa Minkin 42:18

medication is not working for me."

Elise Fallucco 42:19

where you're

Alisa Minkin 42:20

It's always a

Elise Fallucco 42:21

is not

Alisa Minkin 42:21

good time to go check. Maybe you want to step back and say, "Okay, am I treating the right thing?

Elise Fallucco 42:25

back and

Alisa Minkin 42:26

something that we're missing?"

Elise Fallucco 42:27

the right thing?

Alisa Minkin 42:28

you know, we're--

Elise Fallucco 42:29

that

Alisa Minkin 42:29

we're talking about anxiety here, we've thought that this is anxiety, but have I really checked all of the bases or checked all the boxes rather? I may stick my head up for it and say,

Elise Fallucco 42:39

rather.

Alisa Minkin 42:39

there something else that could be going on that I'm not sure of?

Elise Fallucco 42:43

else that could be

Alisa Minkin 42:43

I would say,

Elise Fallucco 42:44

that I'm not sure of? and

Alisa Minkin 42:45

you know, we have a whole approach that we like to use clinically and that we teach for pediatric clinicians about approaching anxiety, and one of the things that's important to rule out is trauma.

Elise Fallucco 42:54

Rule out

Alisa Minkin 42:55

an event that could be resulting in like a post-traumatic stress symptom, which

Elise Fallucco 43:00

in a

Alisa Minkin 43:01

is not gonna respond really easily

Elise Fallucco 43:02

which

Alisa Minkin 43:03

to SSRI medication. It needs a different level, different type of therapy and a different,

Elise Fallucco 43:08

level,

Alisa Minkin 43:08

level of treatment. So

Elise Fallucco 43:10

and a

Alisa Minkin 43:10

I would say you go back to the drawing board a little bit and when things aren't working and you make,

Elise Fallucco 43:15

and

Alisa Minkin 43:16

make sure that you've looked at and considered other diagnostic possibilities and that you're not missing a case of post-traumatic stress. That's really important to know, and I think that also underscores the importance of having counseling at the same time. I do believe that almost across the board, anybody who's on medication should also be in counseling. What do you think about that?

Elise Fallucco 43:38

I-- Oh my gosh.

Alisa Minkin 43:40

Those who are not able to access anybody for medical problems but still have access to therapy.

Elise Fallucco 43:48

mental health problems,

Alisa Minkin 43:49

I think the reality

Elise Fallucco 43:50

to therapy.

Alisa Minkin 43:51

is that it is complicated in that therapy Not a one-and-done type thing. It requires an investment, it requires a lot of time and sometimes expense because of issues with lack of mental health parity from insurance. It's not,

Elise Fallucco 44:07

from insurance.

Alisa Minkin 44:07

You're not paying a very minimal co-pay to see a therapist if they're taking your insurance at all. It can be expensive, and it requires Involvement of the parent and the child in,

Elise Fallucco 44:18

the

Alisa Minkin 44:18

let's say, six to eight one-hour visits over the course of however many months at least. And so all of that is time away from work, time away from other children.

Elise Fallucco 44:27

away from work,

Alisa Minkin 44:28

and so

Elise Fallucco 44:29

from other children.

Alisa Minkin 44:30

I, again, as a parent, I recognize the real cost of all of this, that it is very hard to invest in therapy, and it's-- I wish it were as simple and as accessible as

Elise Fallucco 44:40

were as simple and

Alisa Minkin 44:41

Just hop on a Zoom call with your therapist.

Elise Fallucco 44:43

Just hop

Alisa Minkin 44:44

I do wanna say a couple things. I have several things. Number one is that sometimes it's nice to start counseling first for especially the milder cases and see if that's enough, and only then start the medication if it's not enough. But for some kids, their anxiety is so strong they can't engage in any therapy, and you need to do the medication first. I do have a subset of kids, those who have more of a social anxiety, who absolutely do not want therapy. And they sometimes do very well on medication alone. And then the third thing I wanna say is not all therapists and therapy is created equally. It may not be a good match, the specific therapist or the subtype of therapy, especially when it comes to trauma. Okay? Because sometimes they're doing CBT, and it's not ev-- Maybe it's trauma-informed or maybe it's not, but it's not trauma-focused and it's not the same thing, and they're getting worse or are not getting better, and you're upping the medication because you're not appropriately addressing. They're in therapy, but they're not in the right therapy or with the right therapist or both.

Elise Fallucco 45:50

And I think that's sometimes hard hard for clinicians even to figure out, if we've referred somebody to therapy, how is it going?

Alisa Minkin 45:56

parents try to understand what, what's going on because especially if the parents don't have

Elise Fallucco 46:02

going

Alisa Minkin 46:02

as much of a role in the therapy. I'm with you, Dr. Hinken, I want the parents to be involved in therapy more than

Elise Fallucco 46:09

to be

Alisa Minkin 46:10

beyond just a quick check-in, like two thumbs up, school is great. The parents need to be given support and strategies for how they can be the child's coach at home

Elise Fallucco 46:19

for

Alisa Minkin 46:20

how they could be supporting them throughout the week to implement these strategies. And even if you've got a very savvy, let's say, 17-year-old teen,

Elise Fallucco 46:29

let's

Alisa Minkin 46:29

that teen still is living in the same house as the parent. And so

Elise Fallucco 46:32

is living

Alisa Minkin 46:33

it can only help the teen to have parents and family members on board

Elise Fallucco 46:37

to

Alisa Minkin 46:37

to know how they can continue to support the teen to be able

Elise Fallucco 46:41

they can

Alisa Minkin 46:41

to remember these strategies

Elise Fallucco 46:43

be

Alisa Minkin 46:43

when you're in,

Elise Fallucco 46:44

to

Alisa Minkin 46:44

The heat of a moment of an,

Elise Fallucco 46:46

you're in

Alisa Minkin 46:47

Anxiety episode. Absolutely. And I always say you are entitled to see progress in your therapy. It may not be overnight, but if your child's been in therapy for months and you're not seeing them get better or you're seeing them get worse, that's a big red flag. Advocate for better. Better.

Elise Fallucco 47:04

Yeah, and I... Absol-

Alisa Minkin 47:08

I think that you had said

Elise Fallucco 47:09

wanna

Alisa Minkin 47:09

this conversation about therapy,

Elise Fallucco 47:11

you had said in this conversation about therapy.

Alisa Minkin 47:14

Where you're saying... You made this excellent point about sometimes kids with moderate or high severity anxiety cannot engage in therapy

Elise Fallucco 47:23

anxiety

Alisa Minkin 47:24

really require medication to be able to bring down their overall level of anxiety so that they can sit in a room and talk about this thing they're scared of. If they-- if it is so overwhelmingly frightening,

Elise Fallucco 47:34

they, if it is

Alisa Minkin 47:35

you are not helping the child by

Elise Fallucco 47:38

you

Alisa Minkin 47:38

exposing them to a tsunami wave of stress and anxiety when they don't have the ability to even be present in the room to figure out how they're gonna cope with it. So again, that's part of a little bit of a trial and error between the therapist and the parents to figure out,

Elise Fallucco 47:56

the therapist and the

Alisa Minkin 47:57

Do we need something else to help this child be successful and get the most out of therapy?

Elise Fallucco 48:03

and

Alisa Minkin 48:03

Absolutely.

Elise Fallucco 48:04

of therapy?

Alisa Minkin 48:05

So one more thing, and then I know you have to get back to your busy schedule. One more topic I want to bring up, which is that when we talk about missing a diagnosis, we mentioned before that anxiety can also be associated with ADHD. It can also be associated with autism. We didn't mention autism at all, and I want to bring up autism and bring back ADHD and autism together, which is now being called AuDHD, at least on social media. It's not a DSM diagnosis, but they commonly co-occur, both autism and ADHD. And those diagnoses, if they have not been made, should especially be considered if the child is not improving. ADHD and anxiety

Elise Fallucco 48:45

Again, I- we focused on, the

Alisa Minkin 48:47

co-occur, and you bring up another good point of autism and anxiety commonly co-occur.

Elise Fallucco 48:52

of autism and anxiety

Alisa Minkin 48:54

right now there's-- I love that there's increased public

Elise Fallucco 48:57

now there's--

Alisa Minkin 48:58

awareness

Elise Fallucco 48:59

that there's

Alisa Minkin 48:59

of autism spectrum disorders and neurodiversity.

Elise Fallucco 49:02

autism

Alisa Minkin 49:03

love the new branding of neurodiversity. Yes.

Elise Fallucco 49:05

I

Alisa Minkin 49:05

We had talked about that

Elise Fallucco 49:06

of

Alisa Minkin 49:07

years ago. Yes, decades. Yes.

Elise Fallucco 49:09

that years ago when I was in training. Yeah,

Alisa Minkin 49:12

Yeah. But children and teens and people with autism very commonly have specific anxiety or, have high levels of anxiety,

Elise Fallucco 49:20

or, have

Alisa Minkin 49:20

they may,

Elise Fallucco 49:21

of

Alisa Minkin 49:21

depending upon how fu- high-functioning they are, they may be presenting to their pediatrician mainly with anxiety without anyone knowing that there's underlying autism spectrum.

Elise Fallucco 49:31

knowing that there's

Alisa Minkin 49:32

and so that's an excellent point to make sure that you

Elise Fallucco 49:35

and

Alisa Minkin 49:35

consider,

Elise Fallucco 49:36

that's an

Alisa Minkin 49:36

Neurodiversity before you have a- With a good therapist. I had a therapist who I contacted, and again, it's extra for a pediatrician to be reaching out to therapists, although I wish that we got paid for doing this. But I did that, and the therapist said to me, "Hey, have you thought this kid might be on the spectrum?" And it did not occur to me in my short visit, and that was a really helpful tip. And so that working together, should you be able to do that, or even as the parent, you working with a therapist and bringing it back to your pediatrician for a referral would be an avenue for picking up that missed neurodivergent diagnosis. So thank you so much for doing this with me. I know you gotta get back to seeing your patients, but I really appreciate it. Thank you so much for doing this with me.

Elise Fallucco 50:24

This was my pleasure. I'm so excited to get a chance to be on your podcast. It is an excellent resource for parents and for families, and I...

Alisa Minkin 50:34

with

Elise Fallucco 50:34

have such a

Alisa Minkin 50:35

behavioral

Elise Fallucco 50:35

helping kids and families with behavioral problems or behavioral health problems, and so I'm so glad that you've taken

Alisa Minkin 50:42

problems or behavioral problems. So I'm so glad that you've taken that on and focused on ASAM. And I want you to know that just while I was waiting for you to enter the room for this talk, I already shared your podcast with two other pediatricians, and I'm gonna continue to share it because it is so helpful to have some support out there for the very hard work that we're doing in the trenches as pediatric clinicians. Give you guys a hug again. All right. Thank you so much. Thank you.

Elise Fallucco 51:06

Thank you for

Alisa Minkin 51:06

It was. It was a pleasure.

Elise Fallucco 51:07

what a great, fun conversation.

51:13

Thank you for listening to Kids Matter. Raising Healthy, happy Children Takes a village, and I'm grateful you are part of ours. If today's conversation resonated with you, please share this episode with another parent, grandparent, teacher, or anyone who cares about kids. Together we can build a supportive community our children deserve. I'd love to hear from you. Share your thoughts, questions, or suggestions for future topics at Kids Matter podcast@gmail.com. With no explanation for your voice truly matters. Until next time, keep advocating for the children in your life because kids really do matter. They are our future. I'm Dr. Elisa Minkin and this has been Kids Matter. Please note that while I am a pediatrician, I am not your child's ped. This podcast is for informational purposes only and does not constitute medical. For any medical concerns or decisions. Reach out to your child's healthcare professional.