Anxiety--When Worries Mess With Your Life

ANXIETY

WELCOME TO OUR PODCAST ON PEDIATRIC ANXIETY.

• HOW HAS CARING FOR CHILDREN WITH MENTAL HEALTH CHANGED IN YOUR PRACTICE? 
• WHAT IS ANXIETY?
• WHAT DOES “DEBILITATING” LOOK LIKE?
• SO YOU WOULD SAY THAT ANXIETY  EXISTS ON A SPECTRUM? 
• WHAT IS THE MOST COMMON TYPE OF ANXIETY?
• ARE THERE OTHER TYPES OF ANXIETY?
• DO THESE DIFFERENT TYPES SHOW UP AT DIFFERENT DEVELOPMENTAL STAGES? 
• DOES ANXIETY LOOK DIFFERENT AT DIFFERENT STAGES OF LIFE?
• WHAT ARE MIMICS TO ANXIETY?
• ANY CONCURRENT MENTAL HEALTH PROBLEMS WITH ANXIETY?
• HOW COMMON IS ANXIETY? 
• WHY DO YOU THINK WE ARE SEEING MORE ANXIETY TODAY?
• IS THERE LESS OF A STIGMA ON ANXIETY THESE DAYS?
• WHAT ABOUT INCREASED PRESSURES KIDS FACE THESE DAYS? 
• ANY SPECIFIC EXAMPLES HERE IN UTAH
• WHAT CAN BE PROTECTIVE WITH THESE INCREASED PRESSURES? 
• WHAT COMMON SYMPTOMS MAY PRESENT AS  ANXIETY?
• WHAT HELPS TO SEPARATE ANXIETY SYMPTOMS FROM OTHER REASONS FOR THE SYMPTOMS? 
• NATURE AND NURTURE COMPONENTS TO ANXIETY?
• WHAT IS THE EVALUATION PROCESS FOR DIAGNOSING ANXIETY?
• IS THERE MORE COMPREHENSIVE EVALUATION THAN THAT? 
• LET’S TALK MORE ABOUT SPECIALISTS WHO HELP WITH DIAGNOSIS AND POSSIBLY TREATMENT? 
• WHAT IS A NEUROPSYCHOLOGIST?
• WHAT IS A PSYCHIATRIST?
• HOW DO WE TREAT ANXIETY?
• WHAT ARE THE NON-MEDICATION OPTIONS?
• HOW DO PATIENTS FIND A COUNSELOR WHO IS BEST FOR THEM?
• WHAT ARE THE MEDICATION OPTIONS?
• IS THERE GENETIC TESTING TO GUIDE MEDICATION DECISIONS?
• HOW HELPFUL IS THE TESTING 
• HOW LONG DOES THE TESTING TAKE?
• ARE THERE SIDE EFFECTS TO KNOW ABOUT?
• SOME HAVE HEARD ABOUT INCREASED SUICIDE THOUGHTS.
• ARE THERE CONSEQUENCES TO NOT TREATING?
• EXPECTATIONS AFTER DIAGNOSIS?
• ANY FINAL ENCOURAGEMENT YOU WOULD GIVE TO PARENTS AND CHILDREN?
• ANY BOOKS OR APPS THAT ARE AVAILABLE?
  • Stem 4 Apps
    • Move Mood—manage low mood and depression 
    • Calm Harm—track and resist self harm 
    • Worth Warrior—self-worth and eating issues
    • Calm Fear—help to manage anxiety 
    • SafeUT--Safe Utah app super critical for being able to report concerns as well as get help
  • Books—books that utilize counseling therapy principles
    • Happiness Trap 
    • Mind Over Mood 
    • Don’t Let Your Emotions Ruin Your Life 
    •  Beyond the Blues 
    • Think Good, Feel Good

Transcript

ANXIETY

WELCOME TO OUR PODCAST ON PEDIATRIC ANXIETY.

As I said in our last podcast, I have looked forward to spending some time talking about mental health.

• HOW HAS CARING FOR CHILDREN WITH MENTAL HEALTH CHANGED IN YOUR PRACTICE? 
  • As my youngest patients have aged over the years, my practice evolved to take in much more care given for mental health diagnoses, especially during the COVID pandemic. [numbers suggest as high as a 3x increase based on who you ask]
  • There is always a reason for every problem.  Children don’t malinger—they want to play.  If they are limping then something is wrong.
• WHAT IS ANXIETY?
  • My best summary about mental health is that when worry rises to the level of anxiety respectively as these worried feelings and experiences become incapacitating or debilitating
• WHAT DOES “DEBILITATING” LOOK LIKE?
   
  • Concerning thoughts can become more severe, intrusive and frequent
  • Disorder at the point of being intrusive and it affects our ability to function in our normal lives.
• SO YOU WOULD SAY THAT ANXIETY  EXISTS ON A SPECTRUM? 
  • YES.  All of us have some degree of worry—it is an important part of being successful as humans.  When that worry rises to the level of being intrusive in our lives, becoming incapacitating and debilitating in our play, in our home or school, then we start talking about anxiety as a condition.  Like all mental health diagnoses, all of us are somewhere on a spectrum of anxiety—little to lots—but the key is how much this worry about future events affects our ability to function.  [Depression has been called worry about things in the past; and anxiety is worry about the future]
• WHAT IS THE MOST COMMON TYPE OF ANXIETY?
  • Most common is generalized anxiety disorder—when we talk about an anxious kid, then this is what we most commonly refer to.
• ARE THERE OTHER TYPES OF ANXIETY?
  • Also Social anxiety,  separation anxiety, panic disorder, and specific phobias of all kinds.  OCD or obsessive compulsive disorder recently moved into it’s own category but is definitely a cousin to Anxiety
• DO THESE DIFFERENT TYPES SHOW UP AT DIFFERENT DEVELOPMENTAL STAGES? 
  • separation anxiety can be one of the earliest manifestations for young children of anxiety that later becomes generalized anxiety disorder
• DOES ANXIETY LOOK DIFFERENT AT DIFFERENT STAGES OF LIFE?
  • YES BUT A COMMON THREAD IS IRRATIONAL FEARS—FEARS THAT DON’T MAKE SENSE—THAT IS A KEY
• WHAT ARE MIMICS TO ANXIETY?
  • Shyness, lacking social skills 
• ANY CONCURRENT MENTAL HEALTH PROBLEMS WITH ANXIETY?
  • Depression is the most common, ADHD, Learning disorders also contribute to anxiety.
• HOW COMMON IS ANXIETY? 
  • Statistics being what they are, can vary, but 5 million children have a serious or incapacitating mental illness, about 20% of the children on a given year are diagnosed with a serious mental illness and anxiety makes up a large part of this group.  A lot of crossover between diagnoses—about 30% will have BOTH anxiety and ADHD 
• WHY DO YOU THINK WE ARE SEEING MORE ANXIETY TODAY?
   
  • Our understanding of mental illness is that there is a very strong genetic component with environmental triggers—so the amount of mental illness should be relatively stable—but triggers can vary to bring out anxiety—the covid pandemic was an example of that. 
• IS THERE LESS OF A STIGMA ON ANXIETY THESE DAYS?
   
  • I believe there is an improved transparency to discussing and diagnosing anxiety—a removal of the stigma from the mental health space, to just a part of health—which is wonderful because the earlier you can help a child, the better outcome we see 
• WHAT ABOUT INCREASED PRESSURES KIDS FACE THESE DAYS? 
  • General society pressures—over scheduling and over pressuring young athletes, young dancers in competition and performance at earlier ages 
• ANY SPECIFIC EXAMPLES HERE IN UTAH
   
  • Specific society pressures in Utah—Lone Peak syndrome—high school in the shadow of BYU and expectations for performance and perfectionism that may not be there in other more laid-back societies. 
• WHAT CAN BE PROTECTIVE WITH THESE INCREASED PRESSURES? 
  • Need to give our children opportunities to develop resilience, to experience hard things and learn that there is a hopeful end to hard experiences.
• WHAT COMMON SYMPTOMS MAY PRESENT AS  ANXIETY?
  • HEADACHES, STOMACHACHES, OPPOSITIONAL BEHAVIOR 
  • PSYCHOSOMATIC SYMPTOMS—BRAIN CREATES FOR US REAL SYMPTOMS; AND THERE ARE LITERAL CHEMICALS PRODUCED WITH ANXIETY WITH RECEPTORS IN THE INTESTINES THAT CREATE REAL ABDOMINAL PAIN 
• WHAT HELPS TO SEPARATE ANXIETY SYMPTOMS FROM OTHER REASONS FOR THE SYMPTOMS? 
  • PATTERN HELPS PREDICT THE PROBLEM—WEEKENDS VS WEEKDAYS—Sunday night before school the stomachache comes on each week.
• NATURE AND NURTURE COMPONENTS TO ANXIETY?
   
  • 1/3 OF CASES GENETIC FACTORS—GENETIC PREDISPOSITION 
  • ENVIRONMENTAL FACTORS—NOT FROM OVERPROTECTIVE PARENTS
• WHAT IS THE EVALUATION PROCESS FOR DIAGNOSING ANXIETY?
  • We screen every child from 11 years of age and on—screening tool GAD-7 to help pick up anxiety that isn’t readily apparent as well as to help diagnose anxiety when parents are concerned 
  • However, parents often bring in kids with anxiety manifesting earlier in life and we are sensitive to a parent’s concern to evaluate earlier if a child seems excessively anxious. 
• IS THERE MORE COMPREHENSIVE EVALUATION THAN THAT? 
  • If we can easily treat and find success for a child then I am okay with this being the extent of the evaluation.  
  • But for more challenging cases, I strongly recommend an evaluation by a neuropsychologist to make sure we have the right diagnosis which is the most important step to developing the right roadmap for treatment. 
  • There are also many confounding diagnoses—depression, learning disorders, ADHD; inadequate sleep (all aspects of brain function are worsened with poor sleep), infrequent food intake, poor hydration.  
  • I have 5-6 diagnosis boxes to put patients into, but neuropsychologists have many more diagnostic tools and diagnosis boxes for patients. 
• LET’S TALK MORE ABOUT SPECIALISTS WHO HELP WITH DIAGNOSIS AND POSSIBLY TREATMENT? 
  • I am happy to help start the process of helping with mental health challenges with my patients but I am not the specialist in treating mental health.  
  • What I am is available to my patients and I care for them and I know that most mental health specialists will be many months away from being available 
• WHAT IS A NEUROPSYCHOLOGIST?
  • These are usually PHD level providers. They are not physicians.  They cannot prescribe medication. 
  • For the most comprehensive evaluation I recommend evaluation by a neuropsychologist to make sure we are working on the right diagnosis--most thorough and comprehensive evaluation of mental health and brain function including learning disorders 
  • ESPECIALLY IF WE ARE NOT HAVING SUCCESS IN TREATING—ARE WE TREATING THE RIGHT PROBLEM? 
  • Also several neuropsychologists who I refer to and I have parents see who is covered by their insurance:
• WHAT IS A PSYCHIATRIST?
   
  • These are physicians with specialty mental health training who are the best qualified in prescribing medications for mental health concerns. 
  • Schedule early with child psychiatry: 
  • Find a child psychiatrist covered by your insurance and schedule with them for the earliest appointment. 
  • Option to cancel the appointment if I can help them sufficiently, but good to have the appointment in case more help is needed than I can give.
• HOW DO WE TREAT ANXIETY?
  • General—counseling / therapy ALWAYS, with or without medication early based on the parent / child desire.  Medication later if needed.
• WHAT ARE THE NON-MEDICATION OPTIONS?
  • non-pharmacologic, CBT or cognitive behavioral therapy—I always try to start with this first.  
  • Then, if the family and therapist feel that medication is necessary, I can help with that or refer to a child psychiatrist.  
  • With good therapy, most children do not come back to me for medication.  
  • There are some parents that want medication only as a last option, and some that have a strong family history of anxiety and view the benefits of medication favorably and early on.  
  • Both approaches are good and my job is to help a child and parents with their goals for treatment.
• HOW DO PATIENTS FIND A COUNSELOR WHO IS BEST FOR THEM?
   
  • 4 items to choose a counselor paragraph. 
    • Right insurance 
    • right age 
    • right problem 
    • right fit
  • I have several good counseling groups who I refer to 
  • Call or check on website to see: 
    • 1, who is covered on their insurance; 
    • 2, does the counselor work primarily with patient's age group; 
    • 3, they help with the concern we have; and 
    • 4, they are a good fit for the patient--hobbies, interests, so they have something in common--best chance for a good therapeutic relationship 
• WHAT ARE THE MEDICATION OPTIONS?
  • I can be available for help with medication.
  • Goal is to give this smart brain the optimal chemical environment to function at it’s best.  
  • I often use the metaphor of prescription glasses—someone has eyes that can function perfectly but need help focusing the light where it belongs and 
  • medication helps this wonderful brain to function at it’s best by giving the right chemical environment optimizing the brain’s own chemicals to work at their best
  • Anxiety—red glasses
• IS THERE GENETIC TESTING TO GUIDE MEDICATION DECISIONS?
  • I like to do pharmacogenomic testing as part of prescribing.  These tests tell us how an individual metabolizes each medication we might choose. 
  •  This helps us understand which medications are most likely to work and least likely to cause any side effects. 
• HOW HELPFUL IS THE TESTING 
  • Studies show a decreased number of medications attempts needed to find the right medicine—average is 2 instead of 5 without the testing 
• HOW LONG DOES THE TESTING TAKE?
  • 2 week turnaround from testing to results.
• ARE THERE SIDE EFFECTS TO KNOW ABOUT?
  • At the beginning some can have some stomach discomfort or nausea.
  • Some have some dizziness.
• SOME HAVE HEARD ABOUT INCREASED SUICIDE THOUGHTS.
  • This does not mean that taking this medication will give kids suicide thoughts.  The early studies looked at severely depressed patients who were already suicidal at baseline and medications gave a little more energy to act on their previously existing thoughts.  
  • People have heard that taking these medications can lead to increased suicide risk but these medications will not make them suicidal and are helpful in doing exactly the opposite—helping with their anxiety and depression.
• ARE THERE CONSEQUENCES TO NOT TREATING?
  • if someone truly needs medication—they have a physiologic / physical deficit of the brain chemicals or neurotransmitters to feel normal— 
  • and if they don’t find an appropriate treatment, then they may discover illicit treatments later in life—marijuana is very calming, alcohol is very numbing to emotions—and they can discover those and those become their treatments.
• EXPECTATIONS AFTER DIAGNOSIS?
  • Trial of medication for the next month.  Follow-up in 1 month 
  • Repeat PHQ-9 (depression)  and GAD-7 (anxiety) testing 
  • Counseling with a therapist is a very important part of treatment to give tools to manage anxiety and depression. 
  • Rx Match testing--pharmacogenetic testing to guide prescribing.  Genetic testing to know which medications will work best, which will cause side effects, and which medications will not be effective. 
  • If medication works well then will continue and possibly increase dose. 
  • If medication does not work well or side effects are problematic then will change class of medication.
• ANY FINAL ENCOURAGEMENT YOU WOULD GIVE TO PARENTS AND CHILDREN?
   
  • For the patients: Work to understand the WHY of taking medicine, no one is perfect, take to be your best self, glasses metaphor, take for yourself and not for others 
  • For both parents and children: AN INconvenient truth—no one is perfect, we all have problems 
  • For parents: For those that don’t know what depression and anxiety feel like—it is very helpful to understand the many factors that contribute to these conditions—physical, physiologic, psychological, spiritual and it is okay and important to get help using all the resources available.

• ANY BOOKS OR APPS THAT ARE AVAILABLE?
  • Stem 4 Apps
    • Move Mood—manage low mood and depression 
    • Calm Harm—track and resist self harm 
    • Worth Warrior—self-worth and eating issues
    • Calm Fear—help to manage anxiety 
    • SafeUT--Safe Utah app super critical for being able to report concerns as well as get help
  • Books—books that utilize counseling therapy principles
    • Happiness Trap 
    • Mind Over Mood 
    • Don’t Let Your Emotions Ruin Your Life 
    •  Beyond the Blues 
    • Think Good, Feel Good