Anxiety in Children and Teenagers – PediaCast 432

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  • Dr Anna Kerlek visits the studio as we consider anxiety in children and teenagers. Anxiety is the most common mental health condition in the pediatric population, affecting every age from toddlers to teens. Join us as we explore causes, symptoms, treatment and prevention.

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  • Anxiety in Children and Teenagers

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Announcer 1: This is PediaCast.

[Music]

Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello, everyone. And welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio.

It is Episode 432 for May 14th, 2019. We're calling this one "Anxiety in Children and Teenagers". I want to welcome all of you to the program. 

0:00:57 

May is Mental Health Awareness Month and you hear about awareness months  all the time, right? May is also National Physical Fitness and Sports Month, Skin Cancer Prevention Month, NF Awareness Month or Neurofibromatosis Awareness Month.

And by the way, we did a PediaCast CME episode last week on that one. Neurofibromatosis is a genetic condition and we covered that in a Continuing Medical Education podcast that was aimed at healthcare providers and worthy of Category 1 Continuing Medical Education Credit, free Category 1 credit. And the shows and details for that are available over at pediacastcme.org. And wherever podcasts are found, you can find PediaCast CME. But the reason that we did that one is because May is Neurofibromatosis Awareness Month. 

It's also Asthma and Allergy Awareness Month, Celiac Awareness Month, Cystic Fibrosis Month, Correct Posture Month. I'm not kidding. That's a real one. High Blood Pressure Education Month, Lyme Disease Month, Lupus Month, Stroke Month, Better Sleep Month, Clear Air Month, Hepatitis Awareness Month, Vision Health Month and the list literally goes on and on.

0:02:12

Now, don't get me wrong. These are all important things and there are only 12 months in a year. If you want an entire month to raise awareness about a particular health condition or problem, you're going to run into some competition and there's going to be lots of other things that month.

However, having said all that, Mental Health Awareness Month is special. And it's special because they started their awareness month before it was cool to have an awareness month back in May of 1949. This was one of the very first awareness months in health care. 

And it's also one that is near and dear to our hearts here in Nationwide Children's Hospital because the mental and behavioral health of kids and teenagers is very important to us. Now, everything that affects kids is important to us. I mean, our motto is Everything Matters, but mental and behavioral health is one of those things that often gets overlooked, even though one in five kids suffers from a mental health illness. 

0:03:17

Many of these conditions go unrecognized and untreated and then can lead to other mental and physical health problems down the road and even into adulthood when they are not identified and managed appropriately during the younger years.

There is a collective movement within this organization to raise awareness, get people talking about mental health in kids and teenagers, which is really the goal behind Nationwide Children's On Our Sleeves movement, which you can learn more about at onoursleeves.org. We not only want to raise awareness, we want to talk about these things. We want to discuss the fact that one in five kids are suffering and challenged by mental health problems. 

0:04:03 

We want to identify those children and really connect them with the help that they need. And that then is the driving force behind the growth of our behavior health programs and the construction of our Big Lots Behavioral Health Pavilion which opens next year in 2020 and will be America's largest behavioral health treatment and research center really dedicated to improving the lives of children, teenagers, and their families.

With all of that in mind as background, I really wanted to do something special for Mental Health Awareness Month this May on PediaCast. And I settled on anxiety, which as it turns out is the most common mental health problem that begins in childhood. So we're going to take a look today at anxiety across the entire spectrum of pediatric ages from babies to toddlers and then on the school-aged children and teenagers. 

We'll explore what causes anxiety, what is it, why is it there, how can you recognize that anxiety is going on. A lot of kids won't say, "Hey, I'm anxious or I'm worried about something." It comes through as behaviors. And so how can you recognize when your child is really impacted and challenged by worry and anxiety?

0:05:18

And then, once you figured that out, what do we do about it, how can you prevent it? Is that possible? And it's not always possible to prevent but it is always possible to recognize and get help.

So in a typical PediaCast fashion, we are going to take in-depth look at childhood anxiety with a level of detail you are unlikely to find anywhere else. And to help me do that, I have a terrific guest joining me in the studio, Dr Anna Kerlek. She's a child and adolescent psychiatrist here at Nationwide Children's Hospital and we're get her settled into the studio momentarily.

First though, I do want to remind you PediaCast is in social media and we'd love to connect with you there on Facebook, Twitter, and Instagram.

0:06:03 

And I do want to give you a quick heads-up. I will be unplugging from Facebook and Twitter and will not have a new post or a new podcast for you and unlikely to have posts on Facebook and Twitter next week. You may still catch me on Instagram, but that's about it. 

And the reason is that our family is going to take advantage of Mental Health Awareness Month and vacation next week in California, kind of unplug, and visit Mickey Mouse and his friends at Disneyland, which as it turns out is a week too soon. We're going to miss the big reveal of the Galaxy's Edge, the new Star Wars Land at Magic Kingdom at Disneyland in California, which literally opens the week after we're there.

That's a bit of a bummer but who knows, maybe someone in Robert Iger's office listens to PediaCast and will invite us to a special preview night or something. Anything is possible, right, with a little Disney Magic. I will hold my breath.

However, just in case, it really is easy to get in touch with me whether it's for a Galaxy's Edge preview party at Disneyland or a topic suggestion for PediaCast. Maybe you have a question related to child health or parenting, something along those lines, whatever it is you like to know or let me know about, simply ask. And it's easy to get in touch, as I said. Just head over to pediacast.org and click on the Contact link.

0:07:26

Also, a quick reminder, we see this with each and every episode because it's important. The information presented here is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination. 

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement which you can find at pediacast.org.

So let's take a quick break. We'll get Dr. Anna Kerlek settled into the studio and then be back to talk about anxiety in children and teenagers. That's coming up, right after this.

0:08:06

[Music]
 
Dr. Mike Patrick: Dr. Anna Kerlek is a child and adolescent psychiatrist at Nationwide Children's Hospital and an assistant professor of Psychiatry at the Ohio State University College of Medicine. 

May has been Mental Health Awareness Month in the United States since 1949. And since anxiety is one of the most common psychiatric disorders with an onset during childhood, I thought this would be a great opportunity to invite Dr. Kerlek to the studio and chat about anxiety in kids and teens.

0:09:02 

Let's give a warm PediaCast welcome to Dr. Anna Kerlek. Thanks so much for stopping by today.

Dr. Anna Kerlek: Thank you for having me.

Dr. Mike Patrick: I really do appreciate it. Let's begin with just a simple definition. What is it that we mean by anxiety?

Dr. Anna Kerlek: Sure. First, I'd like to take this opportunity to differentiate between fear and anxiety. Fear is the adaptive immediate reaction to something that is actually really scary. The classic example, a huge bear or something to that effect. It is something that all people should and do have.

Anxiety is a perceived emotional state because of what we worry about, the unknown. So I like to call it worry in children. It seems to be a better term that they understand more or that parents can use without it something as pathologic, so I use the word worries a lot.

And worry can be a specific thought or generalized thoughts about things that worry them or it could be more of a global feeling in their body. That sort of headache, nausea, "Mommy, my stomach hurts." And sometimes kids can't label that as well.

0:10:18

Dr. Mike Patrick: And to some degree, isn't it true that even worry, there can be a normal component of that if you're going into a situation that you don't really know what's going to happen? And, so it really becomes a problem more when it's constant and sort of starts to interfere with your daily life and function as opposed to a normal response to a given situation. Is that true?

Dr. Anna Kerlek: That is absolutely accurate. I would say that's the case with all children and disorders that I treat. We all have worries. Like you mentioned, if I didn't have that worry, I wouldn't get up in the morning that I need to go to work or study for that test that got me into medical school. So it is adaptive. As you said, it just depends on a degree and if it interferes with functioning which could be academics, social, just actual body development. It really depends on if it's impairing.

0:11:10

Dr. Mike Patrick: We, also, in addition to parents, we have a lot of pediatric providers, pediatricians, nurse practitioners, physician assistants who take care of children. And for those folks, they've probably heard of the Diagnostic and Statistical Manual number 5, DSM-5 which is the current version. And in that, they list seven anxiety disorders that are seen in children. 

Just kind of walk us through what some are those are that providers may see and then with a little explanation of what those things mean for parents.

Dr. Anna Kerlek: Sure. Initially, in young children, as young as seven, eight, nine months, again, they're not typically coming to see me at that age but they will be seeing their pediatric provider. 

At that age, you may see a classic separation anxiety, which is normal. They don't want to leave their caregiver. It is a typical reaction to have a crying outburst, not want to leave their caregiver. Again, that's not pathologic. It can be very challenging for the caregiver which they needing to drop the child at daycare, but it isn't pathologic.

0:12:24

What you reference in the DSM-5 are some of the more problematic presentations, separation anxiety, let's say in a older toddler or school-aged child. They don't want to go to school. They're constantly following their parent around in the house, even to the point or not being able to the restroom. So that can be problematic both for the child who needs to academically and socially go to school but also for the parent, how do I manage a child who literally clings to me.

Dr. Mike Patrick: That then cause worry in the parent and they have their own anxiety that they have to deal with because of the situation. I'm sure you see that frequently as well.

Dr. Anna Kerlek: Sure. A lot of anxiety is driven internally by the child themselves but we do know there is a genetic component. So anxiety does run in families. About 30 to 40%, we would say is accounted for by our family tree, which obviously leaves a larger percentage due to the child themselves, their temperament and environmental stressors and reinforcers.

0:13:32

Dr. Mike Patrick: One of those in the DSM-5 is generalized anxiety disorder, how is that different than just the occasional worry?

Dr. Anna Kerlek: So generalized anxiety has two components. One is feeling that worry in their body and their specific criteria. The more common thing we hear about in psychiatry would be the cognitive worries. And those range from worrying about mom's physical health, is she going to the doctor? Does she have an illness? Do I have an illness? What about that test tomorrow? I don't know what the schedule is on the weekend. Tell me what that is.

0:14:10

It's literally everything you can think about in your day-to-day life. There's a worry about the next step.

Dr. Mike Patrick: Yes, I can see that would become very disabling in terms of functioning and being out and about and doing the things that kids are supposed to be doing.

Dr. Anna Kerlek: And I think that's when they come in for treatment, when it becomes impairing at school in particular. But like I said, there are normal typical everyday worries that start in childhood. They worry about the monster under the bed or things being out of order. Sometimes, you'll have parents come in, a three and four-year olds, they have to have the same routine at bedtime and these animals under bed have to be lined up for certain way. We think that that's pretty typical. And so not to be worried in that case.

0:15:00

Dr. Mike Patrick: Another one in the DSM-5 is social anxiety disorder. How is that different from generalized? 

Dr. Anna Kerlek: It does focus more on the interactions with others, tends to present more so as they enter school. Not as much in toddler years and it really amplifies mostly in middle schools or that peak adolescent age. 

But it is the concern and worry about what other people think of them, but it's beyond that. I worry about that as well, most of us do. Did I say the right thing? I wish I could go back in time and undo. But does it prevent me from going to school auditioning for that play, trying out for that sport? That's when it becomes more of a problem.

Dr. Mike Patrick: And then panic disorder. I think that's one more parents have heard about. What is panic?

Dr. Anna Kerlek: Panic disorder itself is when you had a panic attack and then repeated ones after. And again, I think it's important to note that in the DSM-5 and in a way that I think about it, it is very discrete. 

0:16:06 

So that means, it's 5 to 15 minutes of having those body symptoms of heart palpitation, shaking, the feeling like one is going to die or pass out, stomach aches, etc. It doesn't last all day. If it last all day, we're thinking about something different. And panic disorder I would say presents most commonly in older school-aged children and teenagers. It's not typically seen before that.

Dr. Mike Patrick: And it can be very dramatic in these folks will not understand what this is, which then can cause more generalized anxiety about these panic attacks.

Dr. Anna Kerlek: Or they'll present to the hospital just like adults do with chest pain. The child will come in thinking...

Dr. Mike Patrick: Hyperventilating.

Dr. Anna Kerlek: Hyperventilating or they feel like they're going to die and it really does feel like that, and to not minimize. 

0:16:59

But a large part of the treatment of panic disorder is exposing the child to something that's really making them fearful or even the bodily sensations of the panic disorders. So spinning in a chair so that, "I feel dizzy. That's mean I'm going to die." And if we expose them to that feeling of actually being dizzy and, "Look, I'm sitting with you in the office. You did that. I'm so proud of you." Give a positive reward and let's practice that again. "I'm okay. I didn't need to go to the hospital."

Dr. Mike Patrick: I can imagine that some parents would be a little bit resistant to exposing their child to the thing that they are worried about.

Dr. Anna Kerlek: And there will be. I can almost guarantee a spike in potential anxiety or behaviors related to their anxiety. Initially, when you expose a child, that can happen. However, with trained licensed professionals, they do know how to gauge that. 

0:18:01 

And if we make what's called a hierarchy of all of the fears, let's say, we would never jump in with the one that's at number 10. We would jump in with something at number 1 or 2 that this child feels like, "Oh, I might be able to do this.", and "Let me try it today."

Dr. Mike Patrick: This is not a try-it-yourself at home kind of thing. You want a trained professional to walk you through this sort of thing because you could end up making things worse than improving them.

Dr. Anna Kerlek: I would say it's super important to engage with a licensed professionals initially but then also just to provide caregivers with that feeling of empowerment. They're the coach at home. Fifty-five minutes in the office once a week is going to provide you with that education, with the tools to even start that conversation. But the parent is really the one who's going to be the coach for that remaining seven days of the week.

Dr. Mike Patrick: I mentioned that anxiety and the anxiety disorders are one of the most common psychiatric disorders with an onset in childhood. Is that true, first? And hopefully I said the true statement. And then just how common is this? And are there particular folks who we could expect to be more affected than others?

0:19:11

Dr. Anna Kerlek: So yes, you are correct in that anxiety is the most common presentation in children of I would say mental health symptoms and then also the diagnosis itself. One in ten presents with symptoms. I would say the going comment would be that one in five have impairing symptoms. Excuse me, I said that backwards. One in five present with symptoms, one in ten present with more impairing symptoms that might require intervention.

Dr. Mike Patrick: So somewhere between 10 to 20% of all kids and with about 10% having more significant life-affecting symptoms with that.

Dr. Anna Kerlek: Correct.

Dr. Mike Patrick: I mean, that's really common when you think about all the folks who are listening here. 10 to 20% of you are dealing with this at home and are your kids getting the help that they need? And then, the next question how do I find that help? And we'll talk more about that. And how do you know when you need help?

0:20:10

Let's just kind of step through the different age group and talk about what causes anxiety at this different age groups or what things are associated with anxiety. And then, we'll talk more about how they appear, what symptoms, and how we can manage and prevent them.

You mentioned that you can see anxiety down to ten months of age, little babies being anxious. How does that appear and what do we do about it in babies and toddlers?

Dr. Anna Kerlek: Some of the classic psychologist might call that behavioral inhibitions, fancy way of saying that temperamentally shy or inhibited child. Parents will to me with their eight-year-old and say, "Ever since they were in my womb, they were an anxious kid", the same way we hear about that with other disorders such ADHD and hyperactivity.

0:21:04

But, generally, our society sort of support this, helps families through that difficult separation anxiety. I wouldn't use that term even in that age group because it is so common. 

But I do want to take a moment just to reflect on what you said that anxiety is the most common disorder. However, it's not the most common reason kids come to see mental health professionals and child psychiatrists. Because in the inherent nature of it, they're inhibited children most often. So they're the kid in the back of the classroom not causing the disruption.

The aggressive, oppositional defiant child is the one who often makes their way to my office. And unfortunately, the first grader who's anxious about making mistakes in class, which then inhibits some of their learning, they often don't make it to the child psychiatrist until years later.

0:22:05

So I would just encourage families even with toddlers and young elementary school children to be labeling emotions, talking about their own emotions in the home. When I make a mistake at home of how maybe I should have reacted differently, I'll say, "Mommy was angry and I did explain to you. I wish I would have done this differently. Do you understand why?" And we'll have a conversation about it. And we should be doing that with all of our emotions because kids need to learn that, as well as their ABCs.

Dr. Mike Patrick: I think it's a great point. And as adults, when we talk about anxiety and worry, we have an idea of what we mean when we think about how we feel inside when we feel anxious and when we are worried. And as you mentioned, you can feel your heart beating faster, thumping in your chest. You may be breathing a little faster. You may have a little bit of a dry mouth.

0:23:02

And these kids, though, can't necessarily express that feeling as, "Hey, I'm anxious" or "I'm worried." And so, in response to those feelings, they may start to act out in terms of being oppositional or doing things that get them in trouble. In the younger kids, it may show up as eating and sleeping problems. And so, all of these things that we see as problematic behavior may have at their root a feeling of anxiety that these kids can't really express. Is that...

Dr. Anna Kerlek: Absolutely. I would say especially when you commented on the eating and sleeping. As parents, that's all we care about, making sure that they are getting the right amount of sleep, which usually were vastly incorrect in how much children should have, 9 to 12 hours of sleep at night. But nutrition, the picky eater, perhaps they are a picky eater and there are other contributing factors but maybe they're also worried about having stomach ache because every time they drink milk, they get a stomach ache. And they don't know, and it's just sort of vicious cycle.

0:24:08

So asking children, again, it will depend on their age, how they can respond but not just assuming that they're being difficult, that they're being oppositional.  A lot of kids who are tantruming or having that type of difficult behavior, actually, anxiety is the real cause.

Dr. Mike Patrick: Belly ache and that's a tough one because there's so many real medical causes. Not that anxiety is not real medical cause. Excuse me for saying that, but organic causes. I mean, there's really physiologic causes of abdominal pain that we don't want to miss but it can also be caused by anxiety, right?

Dr. Anna Kerlek: Absolutely. I feel like my job as a physician is to differentiate between those and constipation. That's usually the cause of belly pain. And so we don't want to dismiss that. That's always a child who's presenting. Of course, there could be the less common zebra, as we say. But more often than not, it's constipation.

0:25:07

Maybe they have a particular allergy we haven't discovered yet. But to ask those questions and to be screening for worries and anxiety is a part of the medical workup.

Dr. Mike Patrick: Yeah, absolutely. With toddlers, really, any sort of problem behavior could potentially have its root anxiety. Maybe, maybe not, but if it is interfering with your family's life, this is something that you really ought to talk with your pediatrician about, right? And to see is this someone who could use the help of behavioral health or psychiatry services?

Dr. Anna Kerlek: I think also we don't necessarily want or have time or the resources to bring in a three or four-year-old for mental health evaluation. Again, if it and I often use quotes with my fingers, so if it's only fear of monster at night, probably not a reason to come in. Unless the child is getting three hours of sleep because they're unable to function. 

0:26:10

It really just depends on how impairing the symptoms are. But the evaluation process I think is valid no matter what age and we do have early childhood mental health specialists.

Dr. Mike Patrick: I'm probably spending more time on this than I had originally thought about, but especially if those kind of kids, it doesn't necessarily rise to the level of we need professional help, what are some simple things that parents can do at home when they do have these fears? So when they're not going to sleep because they're worried about a monster in the closet. So how, as a parent, do you handle that?

Dr. Anna Kerlek: It's always that find balance. As you know, with all things in pediatrics, I would say that we don't want to dismiss. It's never, "Oh everything is fine. Everything is okay." That's not helpful, right? Because they know that, "Everything is not fine in my head and in my body. So my caregiver doesn't understand. They don't pay attention to me. They don't understand."


0:27:09

So that's one end of the spectrum. And then, the other end of the spectrum can be just as problematic, potentially more so. And in that we sort of allow the child to rule the roost and cause significant disruption, especially if there's other people in the home. 

I think more along the lines of OCD which does come a little later, it often becomes a family illness. Because if a child won't touch his doorknob, how are they going to get in and out of each room? Well, they ask their brother, the brother helps. Mom has to turn on the shower head because they can't touch that. "Well, we got to have Johnny shower today, so I guess I'll do that, right?" So becomes a true family illness. Those are the two wide ranging ends of the spectrum.

So the answer to your question, if you don't feel like it rises to the level of needing medical or clinical specialists, there are some pretty good resources out there in the community. Meaning, print or various websites. Of course, you want to maybe ask your pediatrician some of their recommendations.

0:28:26

But there's some great books even just for that labeling of emotions or workbooks for kids that I would recommend. One of the ones that I like in particular is the text or the small child book, What To Do When You Worry Too Much. I would say that's for primarily five, six, seven, eight-year-olds. And it's very readable with your caregiver workbook that I think is a really great tool that doesn't require a therapist walking you through it. 

Dr. Mike Patrick: And we'll put a link to that in the show notes so folks can find it pretty easily. 

0:29:04

And I'm just thinking back as a parent when my kids would have something like this, just sort of making a game out of it. Well, I mean, kids like to play games. And so, positive reinforcements, sticker charts, earning things as they really sort of face their fears, but you're doing it in a supportive way, not necessarily in an immersive way or forcing the issue.

But as you had mentioned before saying like, "When you do face your fear, when you do stay in your room, maybe you come out. You're allowed to come out a couple of times at night. But the third time, then you're not going to get the sticker in the morning if you do it the third time." 

But then, a lot of really good positive reinforcement, "I'm so proud of you. There was not a monster in your closet and you stayed in your room and fell asleep." Just sort of keeping on the positive and then helping them play game and earn things. Am I making it worse by doing that?

Dr. Anna Kerlek: Absolutely not. I think generally that's…

Dr. Mike Patrick: So my kids are okay? 

0:30:01

Dr. Anna Kerlek: Good tactic to have. It doesn't work for all kids but I also think that it often doesn't work because caregiver maybe only tries it for one or two nights. These are things that sometimes takes weeks to reinforce. 

But also, the child has to be invested and obviously a four-year-old, that's a strange way to describe it but they have to care about what the reward is, right? So if it's sticker chart and they're like, "That's silly," maybe that's not the way to go with that child. Maybe it's, "If you do X, we can do a park time tomorrow." It has to be usually very immediately after their success. Night time is tricky, right, because there's little bit of a time lapse.

But if it's, "You didn't run away screaming from your neighbor's dog," and we can immediately provide that positive reward and praise them, then they link those two just the way we link negative things together. But if you link those two behavior and reward together and say like, "Yeah, I can do this tomorrow again."

0:31:05

Then, there's that fine line where, now, maybe I'm exhibiting those behaviors to get the reward that I want but it wasn't real. I mean, there's really some nuance here, isn't there? I mean, parents have to use their gut.

Dr. Anna Kerlek: I have a family that I worked with years ago that one of the caregivers said, "I shouldn't have to reward my child for brushing their teeth." This is a little bit different situation, but it can relate. And I said, "Well, you've tried these things and they haven't work. So let's try this. You can call me up tomorrow or actually not tomorrow, in two weeks after we tried this every day." And say, "Dr. Kerlek, you didn't know what you're talking about."

"But what you've tried so far hasn't been working. And, yes, I think in 30 days, 60 days from now, absolutely you shouldn't reward your 10-year-old for brushing their teeth. But let's try it now and we can fade it out. Because there's going to be another behavior. There's always the next step that you're going to want to target and we'll move on from brushing teeth and we'll go to the next step."

0:32:07

Dr. Mike Patrick: And this kind of thing, we aren't innately born with as parents on how to do this. So this is where like the workbooks and things can be helpful if you're having trouble at home. But if it does become something that it's causing... I probably shouldn't say it's causing anxiety. I mean... 

Dr. Anna Kerlek: Contributing.

Dr. Mike Patrick: These things are contributing to family dysfunction and anxiety, then you really should reach out and get some help in terms of coaching and guidance. And there's no shame in that.

Dr. Anna Kerlek: Well, thank you for saying that. I think times are definitely shifting in the reduction of stigma and families being more open about getting some guidance, especially in these early years, the first ten years of life. It's really just parent guidance. We didn't get that playbook and maybe we, ourselves, didn't have the most exemplary role models of parents. And so, how do we know what to do?

0:33:05

So I will give you another text that I recommend to families. It's call Freeing Your Child from Anxiety by Dr. Chansky. She's a PhD. And I think it's just a really readable book for parents. It's longer, goes through all of the different presentations of anxiety. But then, it also references some of the cognitive behavioral therapy techniques that maybe we will talk about today.

Dr. Mike Patrick: And we'll put a link in the show notes for that book as well. That gives us a great opportunity then to move on to school-aged children. And as kids matriculate outside of the home and start to attend school and other kids their own age in a more meaningful everyday kind of way, this provides many, many more opportunities for anxiety to present itself. So, talk about some of the associations with anxiety in school-aged kids.

0:34:05

Dr. Anna Kerlek: So this is one you're going to see some of that beginning of social anxiety. It's inherent in being in a classroom with 25 other children, moving from classroom to classroom, potentially a recess -- "How do I navigate recess when I've got first through fifth graders on the recess playground?" Even if children have been in a daycare caregiving setting before, the school certainly presents new challenges. So the social anxiety, as well as general anxiety, presents more so in school-aged children.

You may be asked to speak in front of people, read in front of people. So again, a lot of that is typical to feel anxiety those first few times here, being asked to do these things. But once you feel successful, the majority of children will be able to do that than without much difficulty. It's when then they are unable to do that moving forward where it becomes a problem, even to the point of what we may call selective mutism, which is a category in and of itself.

0:35:03

Dr. Mike Patrick: Yeah, tell us about that.

Dr. Anna Kerlek: So that's…

Dr. Mike Patrick: That was on my DSM-5 list, by the way. We just didn't get to it.

Dr. Anna Kerlek: Sure. Well, definitely, it's uncommon and rather challenging I think to understand because the child often, almost always, speaks to a caregiver or their siblings but does not speak with selected people or the majority of other people, even grandparents or other close family members. They may not speak to them. We don't really understand selective mutism potentially as well as some of the others.

Dr. Mike Patrick: And it is common for kids especially to have some shyness when they're sort of outside their normal social experiences. And as I think back to my own kids, they could just talk, talk, talk, talk when they're at home. But you do get them in a group and they're really just short answers.

But to some degree, that's normal. But then when it becomes you're having trouble functioning with family members and you're not forming relationships that are important within a family.

Dr. Anna Kerlek: Not going to the birthday parties.

0:36:08

Dr. Mike Patrick: Yeah. Then, that's when you do need some help.

Dr. Anna Kerlek: Exactly. Again, that slow-to-warm-up temperament is common. One of my children has that, but it is important sort of to keep practicing and show them they survived. They actually did really well, giving that positive praise. And now, you might say that less.

Dr. Mike Patrick: As we think about the school-aged kids who are challenged with anxiety, what sort of symptoms? Again, they may not say, "Hey, I feel anxious" or, "I feel worried all the time." What does that look like from a parent point of view in their school-aged kid where you may be thinking, "Hey, anxiety could be an issue here."

Dr. Anna Kerlek: So, I may think of that kind of a different pockets. From an academic standpoint, you might think when kindergarten and first grade, they seem to be plugging along in a typical fashion, learning how to read.

0:37:03 

And then again, this is where the differential sort of overlaps, maybe there is a learning disorder, maybe there are other contributing factors. But if grades start to look different or you're getting emails home from the teacher because they're "refusing to participate" when that wasn't the case last year, obviously there's something going on, but I would say it's not necessarily just an oppositional behavior. There might be an underlying learning disorder and/or anxiety.

Dr. Mike Patrick: And I think that's a good point that these things oftentimes are isolated. And again, here where's it's good to get professional help and educational professional help, too. So we talk about psychologist, psychiatrist, behavioral health folks, but the educational experts are also going to be an important component here too because if you have a learning disability that's not being addressed properly, that can certainly be then associated with anxiety in the kid who wants to do well. 

0:38:04 

They want to please their parents. They want to get good greats but they're not able to do it because of the underlying disability or ADHD or whatever else thing there is. And then, anxiety comes along for the ride.

Dr. Anna Kerlek: I would just like to highlight what you said that kids want to do well. And that is just something to remember that kids want to please. They're not trying to be difficult or be unsuccessful. 

And so, if we can work with teachers and school administrators to potentially do some psychological testing, at least on my end, make sure I'm talking to the teacher trying to understand what that oppositional behavior look like in the classroom, maybe there's something else deeper there.

Dr. Mike Patrick: For both the toddlers and the school-aged kids, let's say we are at a point where we have behaviors that are interfering with daily life and function for the child themselves and/or for the family. And we've decided that yes, there is a component of anxiety here. How do we go about managing these kids? 

0:39:07 

How do we get the anxiety under control? And I'm not so much as what can parents do at home. But I mean, when it really arises to the level of, "Hey, we need some professional help here. What does that help look like?

Dr. Anna Kerlek: Sure. I'll just a step back for a second. Your pediatrician would probably have some people that they work with or agencies in the community that they may refer to specifically or suggest. At times, it can be helpful to call your insurance directly and say, "What is the behavioral health panel look like? Can you give me some recommendations in my hometown?"

Definitely, I would say the one take-home message from today would be if you'd want a licensed professional, that's licensed counselor, social worker in the mental health field, psychologist which is either a PhD or PsyD, and/or depending on the family dynamics, maybe a marriage and family therapist.

0:40:12

But those sort of disciplines are ones that are appropriate for the initial evaluation, making some recommendations, or potentially a child  psychiatrist if you have that available to you. There's just not a lot of us. And so, I always hesitate to make that the first line but, of course, that is what I'm trying to do.

Dr. Mike Patrick: And this is an important point that each community is going to have a unique set of resources. And so, your pediatrician, your child's healthcare provider, whoever that is, is going to be your go-to because they see so many other kids with similar problems. And they have experience with who we have sent folks to and had good results, and maybe who we don't want to necessarily send kids too because they're more adult oriented.  Your pediatrician is going to have a lot of insights and wisdom on that and is really good go-to person to find out where to go for help.

0:41:04

Dr. Anna Kerlek: Absolutely. So then, the other thing would be making sure that that person is trained and is comfortable in cognitive behavioral therapy. That's an evidence-based psychotherapy that we know directly will help your child in conquering some of these worries.

Dr. Mike Patrick: That's big words there. So break that down first. What is cognitive behavioral therapy? In a nutshell.

Dr. Anna Kerlek: Do all your six years of training in two seconds. CBT, which you may hear out in the community as Dr. Mike said, so cognitive behavioral therapy has sort of basic ideas, the cognitive or the triangle. So, we have our thoughts, our feelings, and our behaviors. Those are the three major components of our life and what we're going to be targeting in our therapy.

So thoughts,  feelings, and behaviors are all related. It's hard to tease them apart and so we're going to work on all of three of those aspects.

0:42:01

Dr. Mike Patrick: Each of those thoughts, behavior, and actions, you sort of isolate out each one and think about how it affects the other. Is that...

Dr. Anna Kerlek: Sure. It's actually a prime...

Dr. Mike Patrick: They have some insight into why you're behaving the way that you are. How young of a kid can get that concept?

Dr. Anna Kerlek: It's a good question. I think for more mature or cognitively able children, I would say, sometimes, we're able to use some of the techniques as young as four or so. We do that, not with all children of that age. But definitely by school age, CBT is the go-to for anxiety as well as many other condition.

Dr. Mike Patrick: I am not an expert on this at all. I'm kind of have the parent mind here of an average listener.

Dr. Anna Kerlek: Perfect.

Dr. Mike Patrick: Is it true then that if we feel that a problem... Oftentimes it's really the behavior that, as you say, brings this to light, that this is an issue. 

0:43:02

And so, if a thought leads to a feeling or a feeling may lead to a thought, and then ultimately either of these things lead to a behavior. If we can identify where it starts, whether it's a feeling like generalized anxiety which has a chemical beginning, which then can lead to a thought, which leads to a behavior, then maybe if we understand that feeling, then we can change our thoughts, which then will change our behavior.

And on the other hand, if it starts with a thought which leads to a feeling, if we can recognize that thought and change it before we have the feeling, then that can affect the behavior. Am I saying…

Dr. Anna Kerlek: That's a great job. Yeah, I'm very impressed.

Dr. Mike Patrick: I didn't even research this.

[Laughter]

Dr. Anna Kerlek: Well, very good. Hopefully, it sounds like you learned a little of that along the way parenting, as well as maybe in medical school. We provide a lot of education within what we call CBT. So, not just for the child or for the parent trying to understand those thoughts, feelings, and behaviors, which comes first. 

0:44:02

And sometimes we might not know initially. And that's why even though it is a somewhat manualized treatment, that there is sort of we do this module, then we would run at this module, those first three to five sessions sometimes are really just getting to know the child providing some education about what CBT is because they have to buy into it, as well as the family.

Dr. Mike Patrick: And then, a family counseling would be a component for a lot of folks too, right?

Dr. Anna Kerlek: Absolutely. And also towards the end when we're talking about relapse prevention, parents being the coach knowing when to bring their child back in, and I don't think if that as a failure. Let's say six months later after completing treatment, we have some bumps along the way. We just come back in for a booster session. Sometimes, that's all we need. It doesn't mean that they failed.

Dr. Mike Patrick: Just like any other disease. I mean, there's progression and there's peaks and valleys. And sometimes, you need your medicine adjusted, I mean, with other illnesses.

0:45:01

Speaking of medication, is that a part of treating anxiety in this young kids and school-aged kids?

Dr. Anna Kerlek: It can be. Evidence would say that we are very selective and those younger than the age of eight or nine. And I'm very cautious still under the age of 12, only because we have such great success with CBT alone. And so, if we know that that psychotherapy works, that should be first line.

Occasionally, the symptoms are so severe that it's hard for the child to even engage in that exposure which they would get to or various other reasons why. They just cannot engage. We may recommend medicine a little bit sooner.

Dr. Mike Patrick: We haven't really talk about depression but that is one of the things that can sort of go along with anxiety and it can go either way. So if you have feelings of depression, that can then lead to anxiety about your feelings of depression. And the other way too if you're dealing with anxiety and no one knows what it is and you're getting in trouble at school, then we can have depression symptoms.

0:46:09

And so, treating a primary depression issue may also help treat their anxiety. And in that case, maybe medication could be more helpful.

Dr. Anna Kerlek: Exactly and vice versa. I would say the more common presentation is the latter one you described. That years go by of mild to moderate anxiety, for whatever reason the child isn't brought in for psychotherapy or medication intervention. And it often kind of evolve into a more depressive picture. 

One can imagine that with many things, ADHD included, "I'm not good at this. I'm bad at this" over years of that, either feeling that or being told that, sometimes that does happen and depression presents.

Dr. Mike Patrick: And so, some of the medications that we use may not be aimed at the anxiety itself but at the other conditions that go along with it, like ADHD depression.

0:47:01

Dr. Anna Kerlek: And then that's whole, "That's why you come and see me." Because anxiety and ADHD together, although very common, can present some challenges. And which do you treat first?

But along those lines, we do have evidence-based medication interventions that are effective in children and adolescents. And those are the serotonin reuptake inhibitors.

Dr. Mike Patrick: These are, again, each family situation and each child is really unique, and this isn't fast food medicine. I mean, this really you need to sit down and tease out what's going on with the kid in order to serve them best.

Dr. Anna Kerlek: That is why my initial evaluations are probably longer than most, 90+ minutes to try and really screened for all of the things that we just talked about, in addition to trauma in particular, and some other conditions. But I would just like the highlight the trauma piece since that can be a common presentation.

Dr. Mike Patrick: We could talk about this for hours, really. 

[Laughter]

Dr. Mike Patrick: And in terms of toxic stress and resiliency...

0:48:04

Dr. Anna Kerlek: Poverty.

Dr. Mike Patrick: And we've covered lots of those on PediaCast in the past but I have a feeling we're going to need to have you back for part two at some point.

Let's move on to teenagers. And so now as we go through adolescence and into middle school and high school, we have a whole new set of potential things that can go along with anxiety, what are some of the things that teenagers in particular are dealing with?

Dr. Anna Kerlek: I would say it's more of a continuation of the school age presentations, with social anxieties that might be peaking in middle school. Often if treatment is employed, then that can improve in high school. Also, depending on the community and the various high schools can be a positive change for them. 

Generalizing anxiety certainly continues. I would say of all the disorders we've talked about today that inherently presents in all age groups continues on to adulthood and can be the most challenging depending on how long it persist.

0:49:09

And then, panic disorder is when that often presents in teenagers and it really does feel like it comes out of the blue. And then, there's the worry that I'm going to have another panic attack. And so it just perpetuates the problem. 

And then, I would just like to highlight that this is often that the timeframe that age group where that anxiety might sort of evolve into the more depressive picture that may or may have presented otherwise.

Dr. Mike Patrick: We haven't mentioned bullying specifically but that's something that both school-aged kids and teenagers. And especially with our online presence and really, you don't have a time like when we were kids when you are really offline for a long time, literally. But now, not only do we have social conflicts and bullying that can arise at school but also in the evening online, it can happen as well.

0:50:05 

Just speak to that and how parents can identify when kids are being bullied but also when maybe their kids are being the bully. Which is if we could identify either of those issues, we could help kids more.

Dr. Anna Kerlek: Well, I think as  you mentioned, there's been some other podcast that have talked about bullying and/or the interventions that we can have. What I would say is how it relates to anxiety is that inability to turn things off. And so if you're already a warrior at school, I really recommend that we try and minimize the social media presence or other type of electronic use in the evenings, to try and have that worry button or volume level turn down. 

It's hard to focus on the task at hand, whether that's an academic thing or their soccer game that they're going to in an hour, if they're worried about what's so and so said about them on Instagram.

0:51:06

Every family is different and has different needs and schedules. But I would recommend trying to minimize or eliminate social media especially during the week.

Dr. Mike Patrick: And this is one of those instances where if you're not communicating with your kids, you're not going to understand what sort of things are happening. And not that we want to necessarily as they're getting more and more independent that we want to be intrusive, but you also want when there are issues for kids to feel safe. And that it's a natural conversation that parents can have with their kids.

And the earlier you start that sort of a no-judgement zone of being able to talk to each other about difficult topics, the earlier you start, the easier it is as they get older, hopefully. And then, you're more likely to understand that there's a bullying. I made it sound like you're either bully or you're being bullied but a lot of kids, it's same...

Dr. Anna Kerlek: It's often a combination.

Dr. Mike Patrick: Yeah. So, you have both of those  things.

0:52:00

But by communicating as a parent, that can really help understand what's going on at another level. And I'm sure that as you meet with families for the first time, it's one thing you talk about right is talking together and communicating these days.

Dr. Anna Kerlek: I also ask about what some people call a social media diet. Just like we ask about where you guys eating? Do you eat together? What time is dinner time and bed time? Tell me all, and individually -- if I'm able to talk with the child and adolescent alone -- what are the things that you're doing online? What interactive game are you playing for how long?

Has mom ever sat down with you and looked at that interactive shooter game with you? Or heard of the things that are coming through their ear buds as they talk to each other?

Like you said, it's really about the dialogue that begins early in life. That is always preventative. There is that fine line between there should be absolute parental controls on what is available to a child. A kindergarten shouldn't have full access to the internet and be able to watch any YouTube video they want.

0:53:06

But at a certain point, knowing that they have access at the library and potentially other places where there aren't parental controls, it's more about that dialogue. What is appropriate for someone your age? And hey, if you do go to that website, and you're like "Whoa, maybe that isn't something I feel comfortable with," probably, you shouldn't go on that. You're not in trouble if you can tell me about it. And we can talk about why that made you uncomfortable. Then, I'm happy that you came to me.

Dr. Mike Patrick: Absolutely. And then with teenagers, we're going to see more issues perhaps with sexual identification and gender identification and that can cause anxiety. Or there can be anxiety surrounding those sorts of issues, and then that can be difficult to talk about with parents. And so, I'm sure that's something that you have come across in terms of the challenges in helping these kids.

Dr. Anna Kerlek: In a very short answer with a complex comments, I would say that being as open and supportive of your child regardless of all of those things that you mentioned, sexual identity, gender identity, we do have scientific evidence that the support of a family is the primary difference in success in their functional ability and future success, and less mental health devastating outcomes, including suicide.

0:54:28

And so, if a parent provides that support to their child, even if they're experiencing the stress out in their community, their town that maybe isn't as open to that or a particular person at school, we do know that their home being supportive is that primary predictor of success.

Dr. Mike Patrick: So landing in a home environment where people love you and support you and accept you even when it makes the parent feel uncomfortable is ultimately really good for these kids.

0:55:02

Dr. Anna Kerlek: Yes. In short, I think while although we may not fully understand where some of these feelings or emotions are coming from, our identifications, we do know that the support that they can provide to their best of their ability is what we'll predict successful outcomes.

And that also can be, ideally, it isn't their home where they spend a lot of time but just to highlight that there are many other people, that favorite teacher, that guidance counselor, that person in their religious institution can provide that support as well.

Dr. Mike Patrick: Yeah, absolutely. As we think then and you had mentioned suicide, talk about anxiety and suicidal thoughts. And is there a relationship there? And how can parents tell that that may be an issue with their child?

Dr. Anna Kerlek: I would say in and of itself, suicidal thoughts is not one of the criteria or symptoms of anxiety. The vast majority of children even with clinical anxiety disorders do not have suicidal thoughts. 

0:56:09

That being said, I think it can, over time if gone untreated, evolve into more of a depressive picture. Or, I will just highlight that sometimes, there are... We have not talked about obsessive compulsive disorder which is in that category of in and of itself in the DSM. There can be variations of OCD that focus more on violent thoughts, sexual thoughts, religious thoughts, sometimes self-harm thoughts that are complicated. And then I would just want to make sure to have that child seen by mental health professional.

Dr. Mike Patrick: Yeah, absolutely. And we didn't even mention eating disorders which also anxiety can go along with those as well. That's why we need have you to come back because there's so many…

Dr. Anna Kerlek: I'll be happy to do that.

Dr. Mike Patrick: There's so many things that we could cover with this. As we wrap up, I'm going to have a ton of resources for folks in the show notes. So, people, head over to pediacast.org, look for Episode 432. The two books that Dr. Kerlek mentioned What To Do When You Worry Too Much and Freeing Your Child From Anxiety, we'll have links to both of those.

0:57:19

I've done lots of behavioral health podcasts over the years. And I created a playlist over at SoundCloud. If you go to SoundCloud and you search for PediaCast, you'll find the Behavioral Health playlist. And we have some of our parent episodes and some of our Continuing Medical Education episodes in there. 

Just to give you some examples of the topics that we have for you -- Teenagers and the Opioid Crisis. We had Self-care and Wellness for Moms, Winter Time Blues, Cutting and Self-Harm. We had a whole podcast on a teen suicide with one of our suicide researchers, Dr. Jeff Bridge and Dr. David Axelson.  
And then, we had some of our Continuing Medical Education ones -- behavioral health services in the medical home, second victim syndrome, critical reflection, work life balance. We've talked about mood disorders, anxieties, schizophrenia, ADHD, oppositional defiant, aggressive behavior.

0:58:15 

All of these things that we have covered in previous podcasts. And I'm going to put them all in one place again that playlist that you can find in SoundCloud.


And May is behavioral health, as I mentioned in the intro, that this is Mental Health Awareness month. We have a movement here at Nationwide Children's called the On Our Sleeves campaign. And this movement kind of goes along with the building and opening next year of our Big Lots Behavioral Health Pavilion, which will be America's largest behavioral health treatment research center just for children and teenagers.

And I'll put links to both On Our Sleeves and The Big Lots Behavioral Health Pavilion if you want to know more about those in the Show Notes for this Episode 432 over at pediacast.org.

0:59:03

But Dr. Kerlek, just give us an idea of the depth of the psychiatry and behavioral health services here at Nationwide Children's and what we have to look forward to with the Big Lots Behavioral Health Pavilion and what the On Our Sleeves Movement means. Just give us that.

Dr. Anna Kerlek: Thank you for the opportunity to speak here today, as well as I'm somewhat newer faculty member here. I've been here almost four years now, previously at New York City. And I came here knowing that this movement was starting and that this rapid expansion of our services, which includes all levels of care, therapy in the home, in the community, in schools, as well as in an actual hospital or what we're calling the pavilion. So there is such a wide range of services and that is why I came here.

The level of support from the hospital is really extraordinary. I've never heard of or worked anywhere where this is the case, which is why I think we are growing and expanding. 

1:00:10

But a building does not make the place. Definitely, the people are included in that and we are just so excited to have almost 30 child psychiatrists. I think almost 100 psychologists, 200+ licensed mental health clinicians, and hundreds of nurses and administrative support staff. When the email list goes out with over 600 people on it just in our division, it's really exciting for me to see us continue to grow. 

Dr. Mike Patrick: Yes, I know. Fantastic. And we'll put links for Behavioral Health Services here at Nationwide Children's. Really anyone in the country, and I'm really speaking to providers, if you have concern about a patient and you really don't have anywhere else to go, they can call our behavioral health services any time and get in touch with folks and to help get ideas from management, right?

1:01:07

Dr. Anna Kerlek: We do, for providers, have a consultation line. Primarily, it's used by those in Ohio and there are some other national places that do something similar, including other hospitals in Ohio. I think it is a growing movement to have a child psychiatrist as consultants to those who maybe don't have them in their community. 

Or I'll just also highlight there's some other services in early childhood mental health to help with kids who are at risk of getting kicked out of preschools. So it really rangers depending on the resources and people in your community. But I am proud to be here.

Dr. Mike Patrick: And we'll put links to all these things that I mentioned in the show notes. I'm also going to have links to some resources from the American Academy of Pediatrics and healthychildren.org including How To Ease Your Child's Separate Anxiety, Understanding Childhood Fears and Anxieties, Anxiety Disorders and ADHD, School Avoidance: Tips for Concerned Parents, Anxiety in Teens is Rising: What's Going On? and Depression and Anxiety During Pregnancy and After Birth, frequently asked questions about that for the moms and the crowds.

1:02:17

And again, all of these resources will be in the Show Notes for this Episode 432 over at pediacast.org.

So, once again, Dr. Anna Kerlek, child and adolescent psychiatrist here at Nationwide Children's Hospital. It's been a pleasure having you in this studio and looking forward to your return.

Dr. Anna Kerlek: Thank you for having me.

[Music]

Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. I really do appreciate that.

1:03:14

Also thanks to our guest Dr. Anna Kerlek, child and adolescent psychiatrist here at Nationwide Children's. 

One more resource that is going to be in the show notes for you this week for this Episode 432 over at pediacast.org and that is, we didn't mention the American Academy of Child and Adolescent Psychiatry, they have a terrific website. And, in particular within that website, they have a section called the Anxiety Disorder Resource Center, and I'll put a link to that in the Show Notes.

It has frequently asked questions about anxiety, facts for families, lots of  educational videos, clinical resources for pediatric providers to help them practice and manage and help kids and families who are challenged with anxiety. Also, lots of information about anxiety research and how professionals are trained to help manage anxiety in kids. 

So lots and lots of resources there. Again, the Anxiety Disorders Resource Center from the American Academy of Child and Adolescent Psychiatry. And again, I'll include that in our show notes this week over at pediacast.org. Episode 432 is where you'll find it.

1:04:19

Speaking of finding us, PediaCast is pretty much everywhere you can find podcast. Not sure how you're listening today but there may be an easier way to do it and to subscribe.

We are in the Apple podcast app, and iTunes, Google Play, iHeartRadio, Spotify, most mobile podcast apps, Stitcher, Tune In. Also SoundCloud where, again, we have playlists available including a Behavioral Health playlist with lots more episodes on mental health in kids and teenagers.

We also have our landing site where you'll find our entire archive of past programs, show notes, transcripts, our Terms of Use Agreements and the handy Contact page to ask your questions or suggest show topics. That's all available at pediacast.org.

1:05:02 

We also appreciate where when you leave reviews wherever you listen to podcasts. Those are always extremely helpful to others who come along and want to know, "Hey, is this program worth a listen?" Hopefully, we feel that you think that it is and can share that with other moms and dads through reviews in whichever podcast directory or place that you listen. 

Also, I want to remind you we have a program for pediatric providers called PediaCast CME, stands for Continuing Medical Education. It's similar to this program. We do turn up the science a couple notches and offer free Category 1 Continuing Medical Education Credit for those who listen. Shows and details are available at the landing site for that program, which is pediacastcme.org. 

Also available wherever you find podcasts, Apple Podcast, Google Play, iHeart Radio, Spotify, all of those places. Simply search for PediaCast CME. 

We love to connect with you on Facebook, Twitter, and Instagram.

One more quick reminder next week, I'll be mostly absent. No Facebook, no Twitter, no podcasting. I may still put a picture on Instagram now and then, sharing some family moments as we visit Disneyland in California and really unplug which is much needed mental health break after a very busy flu season here in the Midwest. It's time to recharge.

1:06:20

Thanks again for stopping by and until next time, which will be a couple weeks from now. This is Dr. Mike, saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.

[Music]

Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.
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