Anxiety in Kids and Teens – PediaCast 516

Show Notes


  • Dr Ariana Hoet and Dr Kristina Jiner join us as we consider anxiety in children and teenagers. We explore the cause, diagnosis, management and prevention of this common condition, which impacts millions of families every year. We hope you can join us!


  • Anxiety in Kids and Teens




Announcer 1: This is PediaCast.




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's Episode 516 for April 14th, 2022. We're calling this one "Anxiety in Kids and Teens ". I want to welcome all of you to the program.


So, we have another important topic for you this week as we consider anxiety in children and teenagers, which is a very common thing in normal times. But we all know that these are not normal times.




We're still feeling the effects of a global pandemic. There's a war in Europe. And kids and teens continue to deal with schedules in schools and sports, and friends and bullies, and family tension, and in many cases, jobs. It's a lot. And then, you throw in an underlying anxiety disorder into the mix and things can become really difficult very quickly.


So, what can parents do to ease the burden? And what is the role of primary care providers, and schools, psychologists, psychiatrists, counseling, and medication? We'll consider as we share everything that you need to know about anxiety in children and teenagers.


To help us do that, we have two terrific guests joining us in the studio today. Dr. Ariana Hoet is a pediatric psychologist at Nationwide Children's Hospital and Dr. Kristina Jiner is pediatric psychiatrist at Nationwide Children's.




This is their first time in the studio together, but it will not be their last. They're going to be joining us on a regular basis, as we consider a wide range of pediatric mental and behavioral health conditions moving forward.


Anxiety is the topic today. But we will have much more to explore together in the weeks and months ahead, as we add our Behavioral Health Panel to the podcast mix. And you'll hear from that panel for the first time today. So that is exciting.


Now, as a reminder, behavioral health has always been an important topic on PediaCast. And if you head over to SoundCloud, you'll find a Behavioral Health playlist with over 25 episodes on it. So, hours upon hours of trustworthy content as we explore behavioral health concerns relevant to children and teenagers. And to help you find that playlist easily, I'll put a link to it in the show notes for this episode, 516, over at 


All right, before we consider anxiety, let's quickly cover our usual reminders. Don't forget, you can find us wherever podcasts are found. And if you like what you hear, please remember to subscribe to our show so you don't miss an episode.




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So, let's take a quick break. We'll get Dr. Ariana Hoet and Dr. Kristina Jiner settled into the studio. And then, we will be back to explore anxiety in kids and teens. It's coming up, right after this.




Dr. Mike Patrick: Dr. Ariana Hoet is a pediatric psychologist at Nationwide Children's Hospital. She serves as clinical director of the On Our Sleeves Movement, more on that to come. And she's an assistant professor of Pediatrics at the Ohio State University College of Medicine.


Dr. Kristina Jiner is a pediatric psychiatrist at Nationwide Children's and an assistant professor of Psychiatry at Ohio State.




They're both passionate about treating and supporting children, teenagers, and families impacted by mental and behavioral health conditions including anxiety. That's what they're here to talk about, anxiety in kids and teens.


So, let's give a warm PediaCast welcome to our guests, Dr. Ariana Hoet and Dr. Kristina Jiner. Thank you both so much for visiting us today.


Dr. Ariana Hoet: Thank you for having us.


Dr. Kristina Jiner: Yes, great to be here.


Dr. Mike Patrick: Really appreciate both of you taking time out of your busy schedules. And as it turns out, I mentioned this in the intro to the program, but we really have a new series within the series of PediaCast. We're going to be doing quarterly episodes on mental and behavioral health conditions with both of you. So, the audience is going to get to know you pretty well and we're really excited to embark on this journey together.


Before we get into anxiety, I did want to talk a little bit about the difference between psychology and psychiatry, since Ariana, you're a psychologist, and Kristina, you're a psychiatrist. So why don't we just start with sort of who you are, what your role is within the mental health field? And Ariana if you want to go first and tell us about psychology.




Dr. Ariana Hoet: So, on my end, first psychology, I went to graduate school to get to the training and practicing where I am today. So, I had to do a doctoral and clinical psychology. And that's why I am able to practice as a therapist, do evaluations for things like learning disability or diagnostic evaluations. But unlike a psychiatrist, I do not prescribe medication.


Dr. Mike Patrick: Okay, so really, your emphasis is more on counseling. I think folks have probably heard about cognitive behavioral therapy, talk therapy, those kinds of things. That's really where you specialize.


And then, how is a psychiatrist different from a psychologist, Kristina?


Dr. Kristina Jiner: Sure. As a psychiatrist, I'm a medical doctor, a physician. So, I trained at medical school first and then went on additional training in psychiatry and then child psychiatry.




And in addition to evaluating for mental behavioral health issues, I can also prescribe medication. I have some training in therapy. But doesn't always spend majority of my time doing it.


Dr. Mike Patrick: And you can also admit kids to a hospital if you would need to and kind of manage them from a medical sort of standpoint, in addition to behavioral counseling kind of stuff too, as well.


Dr. Kristina Jiner: Yes.


Dr. Mike Patrick: All right, so that's kind of the difference in psychiatrist and psychologist. Let's go ahead and move into the topic at hand which is anxiety. And Dr. Jiner, what do we mean by anxiety? What's a good definition for that?


Dr. Kristina Jiner: Sure, so I think anxiety is the body's reaction and that includes mind and the rest of the body's reaction, to a situation that is stressful, situation that's new or unfamiliar or dangerous. So, it includes both how the body physically feels, as well as how the mind thinks about it. And anxiety also includes worry or concern about a future dangerous situation or future unfamiliar situation.




Dr. Mike Patrick: So, to some degree, anxiety is normal human response to lots of things. So, what's the difference between what we would consider normal anxiety and when now that anxiety is a problem?


Dr. Kristina Jiner: Absolutely, that's a very great point. So, as I always tell everyone, anxiety actually keeps us alive. So, worries about getting hit by a car is what kind of prompts us to look both ways when we cross the street. So how do we know when that crosses over?


And so, there's kind of two things I look for. One is the anxiety that's showing up in a situation that isn't dangerous. It isn't a reason to have fear. Or the situation may be is somewhat dangerous or somewhat fearful but the response to that is above and beyond what is expected.


And the kind of overarching theme is their impairment? So, is this causing me you a problem or child a problem in day-to-day life?




Dr. Mike Patrick: That makes sense. So, when there's an issue with the child's behavior, with their sleeping, their eating, their mood, their schoolwork. If it's something that their anxiety is impacting the quality of their lives and the quality of the lives of people of their sphere of influence, then that's a problem, right?


Dr. Kristina Jiner: Absolutely.


Dr. Mike Patrick: And Dr. Hoet, how common is this condition of anxiety and who's affected by it?


Dr. Ariana Hoet: So as Dr. Jiner said, we all can feel some form of anxiety, stress, fear. When it comes to anxiety disorder, it's one of the most common diagnosis in children. So according to the CDC, about 4.4 million children are affected by anxiety disorders and that was before the pandemic. So that may have even increased since then.


Dr. Mike Patrick: Yeah, absolutely. So, I think that ends up like being 10 to 20% of the population. So that's a lot of folks who are impacted by anxiety. And I would suspect it's one of the more common things that you, see?


Dr. Ariana Hoet: Yes, absolutely.




Dr. Mike Patrick: I wanted to kind of go through the age groups and just see what anxiety looks like at each age group and then what are the most common sources, and sort of what are some good treatment strategies, some management strategies.


And I wanted to start in babies and toddlers because there's a condition called separation anxiety. And so that affects babies as they get to kind of get used to who's around them and who's mom and dad and who's members of the family and who were strangers. Talk a little bit about anxiety in babies and toddlers.


Dr. Ariana Hoet: I do think it's important. We start since infancy in babies and toddlers because we all feel emotions at a very young age. And so, a perfect example is this. An infant can recognize the difference between a face that they know and a stranger's face.


And so, you're going to have that stranger-danger that we call, right? That fear if they see someone new. And toddlers are also going to start feeling that separation anxiety for the same reasons. They know what's familiar, and who's new and they have that fear of the unknown and then new things.




Older toddler, you may start to notice specific fears, too, the dark, things like that. They start to understand a little bit more. And so, they're going to show a little bit more of that fear. But it is incredible and even for me as a parent, I've been surprised how my two-year-old is starting to show certain fears and how she describes it too. It's incredible.


Dr. Mike Patrick: Absolutely. So then, when would you consider the separation anxiety normal and when is there a problem with it?


Dr. Ariana Hoet: It's normal again at the toddler stage. If we start to see that it continues past toddlerhood or, as Dr. Jiner said, it becomes impairing. So, a child may experience fears separating from their parent, maybe nervous at first, maybe cry. But then, if it's taking a very long time for them to calm down, where we cannot do anything without being together, then that's when we start worrying, that it's a little bit more than the normal anxiety.




Dr. Mike Patrick: That makes sense. We think about the kid who they're going to a new babysitter's house and so they basically cry all day when mom is gone. But the hope is that after a week, they start to get used to the people that are in this new place, and so that's just going to sort of get better on its own. But if it's interfering with, you know, mom gets called back from work to come pick the child up and then that starts to happen over a long time, and then mom's job is in jeopardy, then now it's impacting the family. And we may need to figure out some strategies, right?


Dr. Ariana Hoet: Exactly. I always look for progress. Is the child crying for less and less periods of time? Are they becoming more used to the new environment? And then, just like you mentioned, if it's so severe that we have to leave work to come get the child, that's another indicator.




Dr. Mike Patrick: So, what kind of symptoms would you see especially as we get into more toddlers where you might start thinking this is becoming a little too much to manage?


Dr. Ariana Hoet: Yeah, toddlers may not yet have the language to tell us what they're feeling. Or they don't even know that they're feeling worry or fear or anxiety. So sometimes, it comes out as behavior, the crying, the tantrums, anger. And so, any change in behavior that we're noticing around these new activities is an indicator.


Avoidance, too. If they don't want to do activities that normally you see that they like to do or they don't want to be around certain people, that's an indicator.


And then for children, and really adults, too, anxiety can be very somatic, so we feel it physically. Experiences of pain like, "My belly hurts," those are all indicators that stress is happening.




Dr. Mike Patrick: And that may be how a parent first picks up that there's something going on, right? Because their child's saying, "My belly hurts all the time," but they don't have vomiting or diarrhea or fevers or anything else. There are physical things that can also do that, but certainly anxiety ought at least to be in our mind as a possibility, right?


Dr. Ariana Hoet: Yes, absolutely. I think especially the toddlers, they can describe to you when they're feeling something in their body a lot more easily than to say, "I am afraid of this new person," or "I'm afraid of this situation."


And I mentioned my two-year-old earlier. That's what's happening. If we're reading a book where there's screaming or something that's scary, she will start saying, "Belly," and touch her belly. And she doesn't know that's why her belly's hurting but indicates to me, "Oh, she's feeling nervous about what we're reading."


Dr. Mike Patrick: Yeah, that definitely makes sense. And then, what do you do for these kids once you figure out, "Okay, this is an issue. They really are having anxiety. It's impacting their life or their family's life"? From psychologist’s perspective, what can we do about that?




Dr. Ariana Hoet: So, two big things, one is we want to normalize and validate the emotion and label it for them. So, "Yeah, your belly feels different right now. That's because you're afraid. That's because you're nervous." Point it out in yourself and in characters in the books or movies so that they start having the language and understanding of what their body is feeling.


And the other big thing is we want to continue the exposure, continue doing that thing despite the fear. So, "Yes, I can tell that you're really nervous right now. And we're still going to do this," because if we avoid, if we hide from that fear, it's just going to get worse. And so, we want to keep pushing our little ones to try those things.


Dr. Mike Patrick: And letting them know, "Okay, at the end of the day, I'm going to come back and I'm going to pick you up. And then maybe we'll do something fun and exciting that you could have to look forward to." Just that positive reinforcement. Because when you come and pick them up, then you started that pattern, right? It's going to be much more difficult the next day when now, you can't go pick them up, right?




Dr. Ariana Hoet: Yes, absolutely. If you pick them up early because they're feeling afraid, then we unfortunately reinforce that. And so again, that fear is going to grow. Versus empowering them and showing them, "You can handle it. Here's some idea. Here's some strategies."


With really little ones, it's harder to teach those strategies, but something like blowing bubbles, reading a fun book, dancing to music to distract them and help them relax can be really helpful.


Dr. Mike Patrick: And the parents may need some help with this too, right? Because I imagine seeing your child like waving to you at the window and they got the tears coming down and you get the mom guilt, that "I'm leaving my kid here and they're upset." Sometimes, moms need to talk these things out too, right?


Dr. Ariana Hoet: Oh yes, absolutely. It's really hard to do when you're almost have to remind yourself like, "I am doing this to help them learn these skills that will help them later on." I'm only helping.


Dr. Mike Patrick: Yeah, very important. From a psychiatry perspective, Kristina, is there anything additional for these young kids that they may or may not need?




Dr. Kristina Jiner: So typically, we would not think about kind of a medication. Definitely, as you were talking about, helping parents. And so, sometimes, parents may need to work with a therapist if a parent already experiences a lot of anxiety themselves, making sure they're taking good care of themselves. Because we know that anxious parents, oftentimes, that can translate then to anxious children. So, helping parents see that.


And so sometimes, what we're doing on a visit is recognizing it in the parent and helping them seek services for themselves, to be able to take good care of themselves.


Dr. Mike Patrick: Kids really do pick up on those little non-verbal body language kind of stuff in an amazing way. And so, if a parent's really anxious about something… Maybe a parent's anxious that it's thunderstorm. Maybe they were in a tornado when they were a kid or something that makes them be very anxious about storms. And then it's easy to see what the kid looks to mom for comfort, "Is everything okay?" and then they can start to have those same anxieties. It is important to think about the parent too, right?


Dr. Kristina Jiner: Absolutely.




Dr. Mike Patrick: Let's go ahead and move on to school age children. Now, the school age kids, they have a lot more reasons to be anxious, right? What are some of the more common causes of anxiety in school age kids?


Dr. Kristina Jiner: So now that we're in school age, schools is probably one of the biggest ones. And all that comes with school. So, whether that's separation from our loved ones, whether that's worry about, "Am I good enough? Am I doing well enough in school? Am I going to make friends? Am I going to fit in? How are the people going to treat me?"


We have some children who are kind are wandering to more perfectionism, "I have to do perfectly on these assignments." And then there is just all that comes with being out and about in the world, traumatic experiences. Even hearing others talk about traumatic experiences can cause some anxiety.


Dr. Mike Patrick: And there's just so many different things that can do it, right? I mean at school; it may be the schoolwork. It could be they're having difficulty with that. It could be interactions with teachers, interactions with friends.




You figure your kids got anxiety and it's related to school. Maybe they're avoiding going to school. How do you get what exactly the anxious point is for them?


Dr. Kristina Jiner: So, we talk a lot about kind of trying to, you know, "What are some fun parts of the day?" So, we always try to start with the good. It may take some coaching and things. I always tell kids, "I never hear anything bad about gym, recess, or lunch." So, we can usually start there.


And then we then move in to, "Okay, so, is it math? Is it language arts?" And then asking questions about, "So is it hard to ask questions?" If a child in math really not understanding, is that what makes it so hard? You don't understand. Are you afraid what your friends might say if you ask question?


Or is it more socially? And then we might hear a little bit about, "Oh, I like recess, but people don't want to play with me anymore." And so, trying to sort out what part of the day it's coming in. And then we can ask more detailed questions on what is it, what's kind of going on?




One thing we tell parents is kind of looking at time of day. So, if you have a child who's showing up in the school nurse's office, is there a particular time you're getting that phone call? Every day at 2 o'clock, for example. That can help prompt you to ask, "Around 2 o'clock, what's going on?" And that can help provide some clues.


Dr. Mike Patrick: And a lot of this is just having a conversation, right? As you said, going through the day, start with the good parts of the day and see what goes. That's a great technique.


What kind of symptoms would point us to the fact that your kid could have an issue with anxiety that's becoming a problem during the school age years?


Dr. Kristina Jiner: Absolutely. So, as Dr. Hoet was saying in babies and particular toddlers, somatic symptoms. We see a lot of that in the school age. Headache, stomachache are probably the most common. Also, the general "I don't feel well," "I don't feel good." Frequent nurses’ visits during the day without any other symptoms of illness.




I see just kind of two groups. We have children who are kind of sadder, down, shut down, don't really want to talk, or engage. Then on the hand, you can have children who are more externalizers. And that they are acting out that can look like aggression, that can look like disrespectful interactions with the teachers or peers. It can look like running out of the classroom.


And so are kind of some of the big things I look for. Certainly, changes in sleep and appetite are another big one that kind of tells something's going on.


Dr. Mike Patrick: And then, once you figure out something is going on, how do we handle that one from the psychology perspective?


Dr. Ariana Hoet: I think that depends a lot on where we are in the range of anxiety. If we have a kid that's showing that normal fear, anxiety, it's having a conversation. So as Dr. Jiner mentioned, trying to figure out the root of the anxiety. What thoughts are you having? Are you feeling like you're going to be judged by your friends? Are you afraid you're going to fail a test? And trying to understand where that emotion is coming from.




Anxiety is also very connected to our physical body. And so, we feel that muscle tension, the pain. So, helping kids learn relaxation strategies, those belly breathing exercises, progressive muscle relaxation exercises.


And then again, the exposure phase. Keep doing those things that we're afraid of little by little. Sometimes, they require some baby steps. When it is more severe anxiety, where it's really getting in the way of school success or socializing, we start to think about therapy and maybe implementing things like an IP or a 504 plan at school. So that maybe a child has the ability to take a break during the school day to practice those relaxation exercises. Or maybe they have the ability to have more time for a test so that they can be a little bit less stressed about that.




Dr. Mike Patrick: Anxiety can also go along with other mental health issues and behavioral health issues. How do you tease out whether it's just plain anxiety over something that's happening at school that your child is not engaging well with? Or if they really have a learning problem, that could be the underlying cause of their anxiety or attention-deficit hyperactivity disorder? How do you know when it's just anxiety and when maybe there's some other things going on as well?


Dr. Ariana Hoet: That's one of the things that we have to figure when we’re doing a diagnostic assessment with a child because a kiddo who's anxious may have difficulty focusing, maybe having a hard time learning. And so, we have to figure out is that difficulty focus coming from too in my head and nervous and thinking about all these things that make me nervous? Is it that ADHD and it's harder to focus? Or is that, "I'm not learning. It's hard for me to learn. And that's why I can't focus."




Or, "Because I'm having a hard time learning, then I start feeling nervous because I know that something is getting in the way of my success. And so now, I start to develop this anxiety about school." So, we do have to tease that apart with the different questions that we may ask a child, a parent, or the teacher.


Dr. Mike Patrick: And this is a good reason to get professional help, when your child has anxiety because it can get pretty complicated. And really, we get into the which came first, the chicken or the egg? And difficulty concentrating can cause anxiety. Having anxiety can cause difficulty concentrating. So, it really just becomes a looping pattern. And to stop that, you really do need to see someone who's a professional and can help you through.


From a psychiatry perspective, are there medical indications for treatment with medicine during the school age years?


Dr. Kristina Jiner: Absolutely. So, it's something we look at. First and foremost, as Dr. Hoet was saying, the coping skills, the therapy. We start always with that.




And then, if we find that the anxiety is so impairing, it's just the child is not able to make it into the school, they're not able to do day-to-day things, then we use medication. Or if a child has been working in therapy, working hard, doing their very best, families helping support that, we're not seeing the progress, then we would look to medication.


Again, as I always tell everyone, medication is simply a tool to help the child do all the other things that they're doing. Medication cannot replace therapy. They need to be done concurrently together but it really just helps kind of take the edge off, so life is a little easier.


Dr. Mike Patrick: Yeah, that makes sense. Is there a certain age which you start thinking about medication? Is there too young for medicine or is it not age-driven at all. It's really more what the problem is.


Dr. Kristina Jiner: So, I think there is, we're more hesitant, of course, the younger the child. So certainly, we would pursue and push more for therapy options in our three, four, five-year-olds.




We feel a little more comfortable, we have little more research once we begin with older children. But still again, those therapy techniques are really important. But we do consider medication for a child if it is that impairing, as you really know, lower age limit, if you will.


Dr. Mike Patrick: Do you see depression with anxiety in school age kids? Or is it an either-or kind of thing?


Dr. Kristina Jiner: So that's a great question. And again, another one of kind of those chicken versus the egg. So, if you have untreated anxiety for long enough, it can morph into what looks like depression. A child who's now hopeless, "Things are never going to get better. Doesn't matter what I do, I'm always anxious, I'm always going to feel this way," versus a child who has anxiety that's clearly there. But there's also a separate depression.


And so sometimes we're sorting those out. What we know is that one of the wonderful things is that the treatment, whether from a therapy standpoint or medication is very similar for both. So, we treat one, it's naturally going to treat the other. But we do have that question of which is which.




Dr. Mike Patrick: And so, it's not just adults. Kids can have anxiety and depression as well, and even very young kids, right?


Dr. Kristina Jiner: Yes.


Dr. Mike Patrick: Let's move on to teenagers. Now, we have even more reasons and causes for that stress and then anxiety in the teenager's lives. Ariana, what are some of the common causes of anxiety in our teenagers?


Dr. Ariana Hoet: We think about the same thing that school age children are experiencing, the social acceptance and possible social anxiety, the pressures of school and performance. Adolescents start to think about their future and that can be really stressful. They also are more aware of what's going on in society. And today's adolescents are very in tuned because of social media and access to so much information, and that can be really stressful.




Dr. Mike Patrick: Absolutely. There's also issues of gender identity and sexual identity that can come up in the teenager years. Do you see a lot of that causing anxiety in kids?


Dr. Ariana Hoet: Yes, I think adolescent years are a time for just developing your identity, sense of self in general, so whether it is gender or sexual identity. Also, children who are of diverse racial or ethnic backgrounds, if they're experiencing racism, that's going to impact how they feel in the identity, the self that they're developing. And so, all of those factors also weigh on an adolescent's experience.


Dr. Mike Patrick: So, we asked this question for the younger kids. What about at this age, in the teenage years, how can parents best get a handle on what might be causing anxiety in their child? If they've thought about that, there's so many things that it could be. Maybe your child doesn't want to talk about it. How can you help those conversations along?




Dr. Ariana Hoet: Yes, I think that's why it's so important to build the habits of talking to our kids from a young age, right? Making it normal and comfortable, where every day we're checking in and talking about many different things. So that when something difficult comes up, like "I am worried about your mood or your behavior," then it's a little bit more natural.


And then, just asking directly, "You know, I've noticed your grades have gone down," or "I notice you don't want to do social events anymore. Is there something going on? Are you feeling nervous?" And then trying to ask those questions to get out what's going on.


Dr. Mike Patrick: That makes sense. What kind of symptoms would cue a parent into thinking about anxiety in their teenager?


Dr. Ariana Hoet: Similar to what we've been discussing, any changes in behavior where now a child is avoiding certain situations, showing that irritability, difficulty focusing, difficulty with sleep, I hear in a lot of teens that experience stress and anxiety, changes in appetite. So, you know as a parent you may know your child best, and if you start seeing any of these changes, that can be your cue.




Dr. Mike Patrick: The sleep thing, not only can anxiety cause you to not sleep well, but if you're not sleeping well, that can also cause anxiety, right? Again, another one of those vicious cycles.


Dr. Ariana Hoet: Absolutely.


Dr. Mike Patrick: What advice do you have for teens who may be having insomnia?


Dr. Ariana Hoet: We talk about a few things. One of my favorite things to talk about in therapy is scheduling a worry time. So, your brain will worry and keep you awake and think too much. But if you start scheduling a time, maybe an hour before bed, where you sit down and you allow yourself to worry for 15 minutes or plan ahead, think about what you're going to do just let your brain go, and then you're done. You do something that's distracting, relaxing, help yourself lying down, and then get to bed.


That kind of builds the habit of telling your brain, "This is the time to worry," if you do it at the same time every day. So, it keeps you from being in bed and worrying too much.


Dr. Mike Patrick: And don't do it in bed.




Dr. Ariana Hoet: Don't do it in bed. We want your brain to learn that my bed is the place to sleep only. So, if you're worrying and it's been a long time and I can't fall asleep, get up, go worry somewhere else.


Dr. Mike Patrick: Yeah, maybe even a different room in the house. You can have your worry closet.


And then in terms of management, how do we go about, from a psychology perspective, managing anxiety during the teenage years?


Dr. Ariana Hoet: So again, it depends on that continuum, right? If it's not at the anxiety disorder stage, then we talk about those physical relaxation exercises. Keeping yourself on a schedule, on a routine, can be really really helpful if you're experiencing stress.


So, making sure you're going to bed at the same time every night, making sure you're scheduling physical activity, wind down time, even that worry time, if necessary. Trying social distractions, we know that having social connections, and a social network is really helpful and protective against stressors.




And then, if it does get to the place where it is an anxiety disorder, that's when we recommend certain therapies, like cognitive behavior therapy, exposure therapy or the discussion for medication.


Dr. Mike Patrick: I want to head back there to the social media thing, and you were saying that being connected with your friends and family who may be far away and being able to network and engage online can be a great thing. But we know that you can also kind of overdo that too, right? What is a good way to sort of moderate how much social media time that a teenager's getting?


Dr. Ariana Hoet: It's two big questions that I like parents to think about, one is how much time, right? It's all about a balance, if I'm spending too much time on social media, then that means I'm not doing something else. So, if your teen is pretty active doing a lot of social activities, extracurriculars, and spending some time on the internet, then that's okay.


The other thing that I like parents and teens to think about is "What is the purpose of social media? What am I doing when I'm on it?" If I am on social media and I'm connecting, I'm learning, I'm doing something fun, I feel good while I'm on it, great.




But if I start to do some comparisons and feel like, "My life is not as fun as this person," or "I don't look as good as this person," or I start to feel left out, "Certain group of kids went to a party and I didn't get invited," if I just kind of feel yucky and sad or anxious after being on social media, that's an indicator that I have to start using it differently.


Dr. Mike Patrick: Great. And again, that's just a conversation you have to have. And the earlier you start having those conversations, the easier it will be when your kids are teenagers, right?


Dr. Ariana Hoet: Absolutely.


Dr. Mike Patrick: And then, from a psychiatry perspective, especially during the teenage years, you may be more likely to use some medications, right?


Dr. Kristina Jiner: Absolutely. So, we do are more likely to use them. And I would say also too, some of the thing we screen for in psychiatry at the teen years are slightly different. Substance use being one of the big ones. Oftentimes use to treat the anxiety from the teen's point of view but can also worsen it.




So, before I'm going to think about using medication, I want to screen very closely for that. And if it is there, kind of address that, too.


Addressing sleep, as we talked about, is a big one. So oftentimes, that's what I'm focused on first. And because good sleep leads to lots of great things during the daytime, including being able to cope. And so often that's what we're targeting for before we even go after the anxiety.


Dr. Mike Patrick: Do you see many kids with maybe undertreated ADHD in the teenage years than having anxiety because of school issues, friend issues, substance abuse issues? That if their ADHD was under pretty good control, it might not be as troublesome?


Dr. Kristina Jiner: We do see that quite frequently. And in fact, in some cases, we'll start to pick up on new cases of ADHD that we didn't realize were there until we start to see the anxieties spike. And then, we dig a little deeper and realize, "Oh, that might be what's going on."




And you can't focus and so your peers are excelling in class and you're really struggling to keep up. And so, we really look for that, too. And again, that diagnostic assessment to say might there be something else going on that if we adequately treat that, then we see the anxiety naturally gets better on its own?


Dr. Mike Patrick: There are some families that may be resistant to medications for ADHD, but also for anxiety for depression. I'm sure you kind of walked through with them sort of risk-benefit to help them make informed decisions.


Dr. Kristina Jiner: Sure, so we always talk about there's benefits to medication, but there is risk. And at the same time, we talked about there are benefits to not starting a medication, but there's also risk. And so, we're weighing those risk versus risk.


And I walked parents through kind of my thought process, "This is what we're seeing with your child. And I'm concerned that if we don't do something different," and that something different can be many things, "We might see worsening of symptoms."




And we do know with anxiety, and I don't think this gets talked about enough, but if anxiety's severe enough, we will start to see things like self-harm, suicidal thoughts, suicide attempts. And so those are the things that we definitely want to prevent. And so, we'll talk about the risk versus risk.


Dr. Mike Patrick: A couple of episodes ago, we talked about suicide in teenagers. And I just want to bring it up again now because I think it's so important. Talking to our teenagers about suicide is not going to put that thought in their heads, right?


Dr. Kristina Jiner: That is absolutely correct. So, study after study has shown that discussing it is not something that's going to make it happen. And so, we encourage talking about it. We talk about it in the office in a very open way. And encourage parents to do the same with their teens and encourage teens to talk to adults about it as well, too.


And knowing that they tell teens, "Nobody wakes up in the morning and says, 'Hey, I think I'd like to have these thoughts today.' So, if they show up, you're not in trouble. You didn't do anything wrong. It means that something is going on. We need to learn more about it." So really encouraging that open dialogue.




Dr. Mike Patrick: Yeah, definitely makes sense. We talked about with the littler kids, that they're really paying attention to the parents and their reactions and behaviors toward things. Teenagers are doing that as well. And so, this may be a great time that if you as a parent do have anxiety, depression, just not feeling right, trouble at work or trouble in relationships, that you can really be a model for your teenager by getting help yourself. And your teenager's going to see "Hey, mom is in counseling. Then maybe that's something that I need, too."


Dr. Kristina Jiner: Absolutely. And it also will affect the relationship with your teen. And so, modeling your parent who's seeking treatment, seeking help, talking about these things, almost normalizing discussion of it, normalizing treatment for it can really help the team be like, "You know what, I can do this."


And I talked with a lot of teens about, we talked a lot about depression, not quite as much toward anxiety sometimes. Lots and lots and lots of people are feeling anxious. So really understanding that "Hey, I'm not the only one. My parents are facing it. They're getting help. I can get help too and feel better."




Dr. Mike Patrick: In my immediate family, we're on three different SSRIs kind of medications. I won't mention who or which ones, certainly. But we all need help, and especially in the time of pandemic and wars and going back to school after you've been home for so long, and the different models of schools. These are hard days, right?


Dr. Kristina Jiner: Yes, these are. And no one can do anything alone, right? So, we're not alone, we have tools. We have resources.


Dr. Mike Patrick: Yeah, absolutely. What about kids with chronic illnesses? Are those special case? You have kids with diabetes that may have really bad asthma, kids with cancer for sure, eating disorders.




There's a lot of just underlying medical conditions that can manifest anxiety or make anxiety that was there worse. Or maybe even cause anxiety. Do you see that relationship a lot?


Dr. Kristina Jiner: We see that quite a bit. I think asthma's a perfect example. Not being able to breathe is going to generate a lot of anxiety for a person. And then, even when your breathing is fine, your brain may worry. Am I going to start having trouble breathing again? And that can actually start symptoms that look very much like an asthma attack. And when you try to treat it, we find no, it's anxiety.


So, we encourage folks that we need to talk about this, right? So, in addition to asking a child, how's your breathing today, how's your blood sugar today, how are we doing with that, but to ask about that anxiety. Because it's real, it's there. The child may not have been able to put it into words yet, until you give them the words and help them understand like, "This is pretty difficult. We can help with that just as much we're helping with the breathing or blood sugar control."




Dr. Mike Patrick: And that's one of the great things about Nationwide Children's Hospital is we just have such a great behavioral health program that those kids who are seeing a cancer doctor, seeing a sports medicine doctor, seeing their doctor for diabetes, they really can get plugged in to counseling pretty easily because everything is so integrated here, just really fantastic.


That leads me to the On Our Sleeves movement. And I know Ariana, you are the clinical director of On Our Sleeves. Tell us about that movement.


Dr. Ariana Hoet: So, On Our Sleeves is the movement for children's mental health. Our mission is to provide free evidence-informed resources to every community in the US. And so, what that means is we are putting out content and information whether to our website or our e-community or through teacher curriculums that is all based on evidence and science. And it's really created by the experts here at Nationwide Children's Hospital.




Dr. Mike Patrick: But really nationally facing so that anyone can go to and get information. And there's tons of resources at that site, right?


Dr. Ariana Hoet: Yes, there is so much information and it is free, and anyone anywhere can have access to it. And we really focus on that mental wellness. And just like we talked about healthy eating and exercise with children, we want us to also be talking about how to keep a child mentally healthy.


Dr. Mike Patrick: And we'll put a link to On Our Sleeves in the show notes so folks can find it pretty easily, Episode 516 over at


And then, we have our Big Lots Behavioral Health Services at Nationwide Children's, which is really very large behavioral health program, really one of the largest ones in the country. Tell us, Kristina, more about that.


Dr. Kristina Jiner: So, we have a very comprehensive team approach across a continuum of care. So, everything from your traditional outpatient service, whether that be therapy or psychiatry to more intensive programs, our personal hospitalization program, for example.


Or for those children who need extra care, we have our Psychiatric Crisis Department for evaluation. And if the need arise, we have in-patient psychiatric admissions that we can do to help a child, keep them safe, stabilize their symptoms.




Our department participates in other medical subspecialties as you were talking about. So, we have psychiatry over at the main hospital, consults with our teams as well as our psychologists who work with the different subspecialties. And so, we have a continuum of care that is pretty amazing and touches I think most, if not all parts of our hospital system.


Dr. Mike Patrick: And we'll put a link to the Big Lots Behavioral Health Services at Nationwide Children's in the show notes. And we also have our Mood and Anxiety Program at Nationwide Children's and we'll put a link to that program as well so folks can find it easily.


Lots of other resources in the show notes this week. We have articles, what we call here at the hospital, Helping Hands, which are handouts that go along with parents when they leave with more information about particular conditions.




And then, our 700 Children's blog has had a lot of posts related to anxiety. And so, I've collected an assortment of resources that folks will find in the show notes. Just some examples, anxiety disorders in children, just an overview, How to Ease Your Child Separation Anxiety, Sports Performance Anxiety and Preparing Your Child for Optimal Play, Panic Attacks versus Anxiety: What Is the Difference?


Which I should have asked, when we were talking about anxiety, we really didn't mention panic. How's a panic attack different than anxiety?


Dr. Kristina Jiner: Sure, great question. I describe a panic attack as all of a sudden and intense overwhelming sensation of anxiety. It's often accompanied by physical symptoms, shortness of breath, feels like your heart's beating out of your chest, dizziness, weakness, even some tunneling of the vision, vision going black. And those can be triggered, something can happen and cause a panic attack, but they can also come out of the blue, which is make them one of the most kind of scary situations if you can't figure out what caused it.




And over time, it can cause things where children start to worry about having more of them. And so certainly, we treat them and address them but not an uncommon thing we see.


Dr. Mike Patrick: I've interrupted myself here, but I think this is an important point to interrupt. And just like panic attacks can happen without necessarily there being a trigger, we should also mention that anxiety is the same way, right? Sometimes, you can't pinpoint what is causing anxiety. Sometimes, it's just there.


Dr. Kristina Jiner: Yes, and so we have many children and teens who describe "I don't know what I'm anxious about. I just feel anxious. I know I'm anxious." And so, even if we don't know what the trigger is, we can still treat it. We can still evaluate for it and help a child feel better.


Dr. Mike Patrick: A lot of physicians have anxiety. I think just as a baseline because we're built that way. And maybe that's how we made through medical school and so there's a lot of anxiety among us.




And I can say from myself, it's just like a feeling of just being revved up. And like you can't rev back down. Like, I just need to downshift, and it won't happen, but medication does help with that. So, I would just say that as a public service announcement and my wife would agree.




Dr. Mike Patrick: All right, so lots of stuff as I mentioned in the show notes. We also have Behavioral Health playlist on SoundCloud. It's just past episodes of PediaCast that have dealt with behavioral health issues. So, if you're interested in these topics, I'll put a link to the playlist in the show notes so you can find it.


Because we have definitely covered lots of behavioral health things in the past. And we will certainly cover more of them in the future. As I mentioned, both of you were going to be coming back as we do that, journeying on down the year.


But for now, I just want to thank both of you for stopping by and talking about anxiety with us. So once again, Dr. Ariana Hoet, pediatric psychologist, and Dr. Kristina Jiner, pediatric psychiatrist, both from Nationwide Children's Hospital, thank you so much for being here today.




Dr. Kristina Jiner: My pleasure. Thank you.


Dr. Ariana Hoet: Thanks for having us.




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. Really do appreciate that.


Also, thanks once again to our guests this week, Dr. Ariana Hoet and Dr. Kristina Jiner, both with Behavioral Health at Nationwide Children's Hospital.


Don't forget, you can find PediaCast wherever podcasts are found. We're in the Apple and Google podcast apps, iHeartRadio, Spotify, SoundCloud, Amazon Music, and most other podcast apps for iOS and Android.


Our landing site is You'll find our entire archive of past programs there, along with our show notes, our Terms of Use Agreement, and that handy Contact page if you would like to suggest a future topic for the program. 




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Don't forget about our sibling podcast, PediaCast CME. That stands for Continuing Medical Education. It's similar to this program. We do turn the science up a couple notches and offer free Continuing Medical Education credit for those who listen. Of course, that includes doctors, but also nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists.


And since Nationwide Children's is jointly accredited by many professional organizations, it's likely we offer the exact credits you need to fulfill your state's Continuing Medical Education requirements. Of course, you want to be sure the content of the episode matches your scope of practice.




Shows and details are available at the landing site for that program, You can also listen wherever podcasts are found. Simply search for PediaCast CME.


Thanks again for stopping by. And until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So, long, everybody.




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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