Autism, Poop, and Depression – PediaCast 020
Announcer 1: This is PediaCast.
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Announcer 1: Hello moms, dads, grandmoms, grandpas, aunts, ancles, and anyone else who looks after kids. Welcome to this week's episode of PediaCast. A pediatric podcast for parents. And now, direct from BirdHouse Studios, here is your host, Dr. Mike Patrick Jr.
Dr. Mike Patrick: Hi, everyone, and welcome to PediaCast. It's episode number twenty, and this is a pediatric podcast for parents. This is Dr. Mike, coming to you from BirdHouse Studio and I would like to welcome everyone to the program this week.
We have four great questions from moms and dads lined up here for ya. We're gonna be covering autism, one more little thing about baby poop, I know several episodes ago we had a whole 40 minutes on baby poop but, this is just a brief comment that I did want to include in the program.
We're going to talk a little bit about anti-depressant medicine in teenagers, and then talk about dealing with toddler bedtimes. That's all coming up on the show this week.
Don't forget if you have a question that you would like us to address, you can get a hold of us at the webpage just go to Pediacast.org, and click on the Contact link. You can also email me at email@example.com or you can call the voice line at 347-404-KIDS.
Also I want to remind you that the information presented in PediaCast is for 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, call your doctor and arrange for a face-to-face interview and hands-on physical examination.
Alright, let's go ahead and move right on in to our very first question this week, and this one comes from Marty.
He says, "I wanted to start by saying I love the info in your podcast and specially appreciate the fact, that it includes explanations for why doctors recommend certain things. I do have a question for you; I have a four and a half year old son with autism. He was initially diagnosed at age two and a half with PDD, which is Pervasive Developmental Disorder, 'not otherwise specified' by a Developmental Pediatrician, and he is currently in a special-ed class at school and receives speech therapy at school and outside of school. I know he has other developmental issues but don't know what professional should guide his overall autism care for lack of a better word. When we see his regular pediatrician, it's just for well child checks, shots or when he has a cold, etcetera, and autism related issues aren't really addressed. I know that some children with autism require occupational therapy, psychiatric care, etcetera. And we have some behavioral issues that we don't know how to address, and we need to know where to turn. I guess my question is, do I need to find the pediatrician who's comfortable guiding us on these issues, or should we have a different professional overseeing developmental issues? Thanks for your help. Sincerely, Marty."
Well Marty, thanks for your question it's a great one. You know, for a lot of these behavioral problems, most pediatricians are really severely lacking in terms of training with regard to these. And the reason for that is because, when you go through a residency, really a huge focus on it is what is dealt with inside the hospital. And so, the kids who are actually 'in the hospital', you know for dehydration or in the Intensive Care Unit or they have certain infections. You learn to deal with that stuff really well but the behavioral stuff; you know is really dealt with on an out-patient basis.
And some programs, you know are very strong with that and others are very lacking in that. The program I guess that I went to was sort of medium; you know if you sought out the developmental clinic and did electives and that sort of thing, you did get exposure to it. But I think that's changing over time so that some of the newer pediatricians that are just coming out of residency, hopefully this is, an area that's going to improve to some degree.
Now, in a perfect world we would have a lot more Developmental Pediatricians and Child Psychiatrists to deal with these kind of things but unfortunately, it's not a very popular area for doctors to go into and recruitment of new talent can be tough in some areas, in fact, in a lot of areas.
So I guess what I'm trying to say is that, you know cut your pediatrician a little bit of slack and it may be difficult to find another pediatrician, you know, who is going to be better versed at dealing with these things.
Now let me just sort of tell you how I do it. I'm kind of lucky because I practiced in an area where I have several children's hospitals that I can refer to, and one of our children's hospitals actually has an autism clinic.
It’s kind of a multidisciplinary approach so that you have occupational therapy, physical therapy, you have developmental pediatricians that are all you know in child psychiatrist that are all involved with this clinic. They also have speech therapy, so that's probably the perfect set-up to have an actual autism clinic that you could send someone to, and you know, maybe you see him once every six months or so, you know, something to that nature. As long as things are going well. Obviously if there's a particular problem, then you would see them much more often than that.
The program that I'm talking about just got started not too long ago, so there have been some kinks in the works in terms of, pulling it all together. But I think in a perfect world, a children's hospital associated autism clinic, is something really that all Children's hospital should have. And I think we're moving in that direction but, you know, it’s slow going.
So let's say you don't have that type of set-up. I think, what most pediatricians are going to do is look at all the different developmental issues that can happen or be a problem, and get someone to address each of those, and in that sense the pediatrician is sort of acting like the quarterback, you got all the specialists out there and you're involved in making sure you get to the right place but then, you're not going to be able to actually do the developmental interventions like the specialists can.
So what kind of things am I talking about? Well, you can kind of divide developmental issues in to several categories and this does not only go with plain autism but it also goes with any developmental disorders.
Number one you've got your fine motor stuff and this is just a little manipulation stuff; picking things up, as they get older learning to button, buttons and snaps, and dress themselves, and eating with utensils, and usually the Occupational Therapists are the ones who are going to deal with that.
Now obviously, ones that are associated with the children's hospital are going to have a lot more experience in terms of dealing with the kids who have these problems. But sometimes, community hospital once if there is not a children's hospital close to you, they may have good experience with kids as well because they see them frequently.
And you have to excuse me I'm going to take a drink here or quick.
[Laughter] I have to explain, I'm going on vacation and i didn't mention this in the last episode and I've got a little bit of cold but, I would want to still be able to get to your questions while I'm gone.
So I'm recording several of these episodes. So I can continue to get them out to you, but dealing with this cold and lack of time in terms of post-production, you just have to bear with me.
I promise when we get to the middle of December, we'll be cooking along and the shows will have much better quality for you.
OK, so we got the fine motor stuff that's Occupational Therapy.
The gross motor things, these will be physical therapy and this is helping kids to run, jump and play, going up and down stairs, walking, and just that more of the big muscles instead of the little muscles.
And so, if you have kids who have physical delays associated with autism, whether if it's personal fine motor stuff, dressing themselves or running around and playing, they're all clumsy. These are all things that Occupational Therapy and Physical Therapy could help them out with.
I think all kids with all those kind of issues should see OT and PT. And again, your pediatrician should have a good feel of which departments help kids the best that's close in your area.
Now the next one would be verbal and speech, and so you get them involved with the Speech Pathologist and again, that's something that’s pretty easy for your pediatrician to arrange.
Also, vision and hearing, it's important when you have a kid with developmental disabilities they have you know, problems anyway and then if they're also have vision or hearing problems, boy just really complicates things and compounds the problems.
So I think they really should have at least a yearly checkup with the eye doctor so that, if they have started to have any visual problems it's caught immediately.
So you know, at least once a year with a pediatric ophthalmologist and you might have to travel to a children's hospital to see one of those but, they are going to be much better at figuring out the acuity and if they need glasses, if they're near sighted or far sighted or if they have astigmatisms. So I would definitely see a pediatric ophthalmologist at least once a year.
And then, they should have at least one hearing assessment done probably every two or three years with an audiologist. Just to make sure that hearing is going ok, obviously if you have a concern, before that time, you know, you could obviously do it sooner.
Now, in terms of the personal and behavioral kind of stuff, I guess I should say not personal. Personal would be like, fine motor and occupational therapy that we talked about.
But a lot of times these kids have what we call comorbidities with their developmental disorder so they may have ADHD, they may have anxiety problems, it could be obsessive-compulsive tendencies, and all of these things could be to the point where they need some medicine to help them out. And this really is where most garden variety pediatricians are going to have a little bit of trouble.
If it is a doctor who's used to seeing these things and not having a lot of support in terms of child psychiatry, and counseling in psychology support, it may be a pediatrician who's a little bit more comfortable in prescribing medicine for these things.
In terms of ADHD, you know that one's so common I think pretty much, all pediatricians are going to feel comfortable there, but when you start to get in to other issues, where you might have to use the Resperdal and antipsychotic type of medications, then it gets a little more tricky or if you're starting to deal with bipolar or depression stuff. It is really tough because, there just aren't a lot of specialists in those areas that can help you out. But I think, the best thing for that would be a child psychiatrist if you have one in your area, or you may have an adult psychiatrist who sees a lot of kids and does feel comfortable seeing kids, so that's the specialist that we try to refer to when we're dealing with behavioral issues that go beyond just sort of garden variety ADHD.
And in the next portion that kids are going to have trouble with in terms of disabilities developmentally is education. And really, this is where the school, you want to get them involved and if you can't get them involved in the head start program even before kindergarten, I think that's helpful and it's just so right from the get-go, the school's involved and they know what kind of developmental issues you have and then they can apply for the extra funding that they need from the government and be able to provide those services for you.
So I guess, you know, I don’t feel like I'm answering your question all that well other than just sort of bit to describe the system.
But I think that, as long as your pediatrician knows where to send folks in terms of Occupational Therapy, Physical Therapy, Speech, Vision and Hearing, Child psychiatry 'if needed', and then to make sure they're plugged in to the school, then you know, that's really the role of the pediatrician and then you're seeing them for your well checkup.
So I guess the only real issue when your pediatrician is going to be, are you plugged in to those things if you need them rather than the pediatrician doing those things for you.
And I guess the one word, there's going to be the biggest problem is with the behavioral and child psychiatry and of course as you mentioned Marty in your question, the behavior is a known issue.
So you know, I guess in these kids, you might want to try when you talk to your pediatrician or when you go on for the well checkup, let the receptionist know that you have some behavior questions and to please pick a spot on the schedule when you might have a little bit more time.
For instance, if I have a kid that my nurse knows he's going to have some of these issues and the well checkup's going to take longer than normal. They may take out a sick office visit spot right after the well checkup spot just to give us a little bit more time.
So you might want to let your pediatrician know when you make the appointment, that you'll gonna need extra time to talk about behavioral things.
You know, simple behavioral modification techniques. Most pediatricians are going to feel more comfortable talking about those things but, if he get into the realm where more medicines are needed then it may be that you'll have to get a referral to a child psychiatrist.
So again, I think the best case-scenario or these multi-disciplinary autism clinics that are starting to gain popularity, it does become a bit of an issue with funding and getting reimbursed for these things.
But I think that as we go on and sort of figure out how to deal with autism in a better way is more and more kids are diagnosed with it. Not necessarily because there's more autism is out there but because we're better at identifying who these kids are and what kind of help that they need.
So Marty, I hope that answered your question and if you have something more specific that I didn't get to, feel free to shoot me an e-mail and we can certainly talk about any specific behavioral issues that you might be having. I can give you some suggestions, if I know a little bit more about what behavior problems you are having because, I've been blessed and that my two kids seems I've dealt with a lot of behavioral stuff at home and it's just that talking as a dad rather than a pediatrician, I can help out with some of those things.
And actually we're going to get to that later on in this program when we talk about bedtime and toddlers.
Alright, moving on to question number two. This comes from Maria in Evanston, Illinois. She says, "Hi Dr. Mike, I like your podcast very much," thank you, "and your baby poop episode was good but I think you might have addressed the difference between breast feeding, and formula poops. Who knows, maybe it will encourage a few more women to breast feed. Thanks for a great listen, Maria."
And Maria that's a great point. You know in general, for those of you who have not seen the difference between breast milk poop and formula poop; the breast milk poop almost smells good, if baby poop can smell good. It has kind of a sweet smell to it whereas the formula poop tends to have more of a rank smell. Although, to some degree that's gonna depend on what bacteria are populating the inside of the intestine and as babies get colonized with different bacteria in the intestine, the smells can change a little bit.
But in general, breast poop is going to smell better than with formula. The other thing is, a lot of times, I find with a breast-fed baby is that they don't poop nearly as often and it's not because they're constipated, it's because there's less residual left over. We talked about this at some one point during an episode in the past, I recall. When babies are breast-fed, more of the breast milk, it's absorbed by the intestine so there is less residue left over. So a lot of these babies will go longer between bowel movements, so you're not having to clean them up as often with breast-fed babies. Now on the other hand, you see some breast-fed babies who tend to have bowel movement every time that they breast feed but they tend to be small bowel movements. Not very much, they don't smell too bad.
So I think overall, breast-fed babies probably do have an advantage over formula babies in terms of the niceness factor of their bowel movements.
OK, thanks Maria, appreciate that.
Let's move on, question number three.
This one comes from Lyn and she had a question that we addressed on an earlier program, and she, there was a second part to her question that I put off, and I'm going to go ahead and address that now.
Lyn says, "I have recently found and subscribed to your podcast and wanted to let you know that I found this to be most informative and relevant. You would ask about topics of interest from your subscribers so I thought I'd throw out my question."
"I have an eight year old daughter who is diagnosed with ADHD, three years ago. She has taken Strattera for two plus years, all I wanted to know if this drug, because of its similarity to antidepressants could cause suicidal tendencies in children. Thanks so much and best wishes for your continued success. Lyn."
Well, Lyn thank you very much. I think before in a previous episode when I had read your question I said, "Oh boy, that's a hot topic." and it is.
I was hoping to have someone from Lilly to interview and talk a little bit about Strattera but my Strattera rep is still working on it, and I'm going to go ahead and address it now though, for you because I didn't want you don't have to wait too long.
Let me just say this, when I was going through residency with antidepressant medicines, it was never a surprise that there was associations with antidepressants in teenagers and suicide risk. This is something that ten years ago, we learned about, and we knew about it. So, when they started to come out in the media, you know, it was a big surprise to parents but I think to most doctors, it really wasn't a surprise because it's something that we have had in the back of our minds and knowing that it is a risk.
And the way that I look at it is this, if you have a teenager who has really serious depression and they have thought about hurting themselves and killing themselves at some point in the past, they can be so depressed that they have those thoughts but, they don’t even have the energy or the conviction, I guess you could say, to act on those thoughts.
But when you start them on the antidepressant, you start to lift them out of that depression and there's going to be a time when you've lifted them out enough that they have more energy, but not quite enough that they don't get rid of those thoughts. So for the first month or two that they're on any antidepressant, you do have an increased suicide risk because, now that they have those thoughts to begin with and you're lifting them up and they're going to have more energy, there maybe or more likely to act on those thoughts.
But then, once you get out about two months or so and things are really cruising along and going well, it becomes much less likely that that's going to happen. And I think most doctors, when they start teenagers on the antidepressants and even before these things came out in the media, talked to parents about this. You know they said, this is an issue, this is why it's an issue, this is why you need to watch for signs and symptoms of it. And a lot of doctors will have a teenager sign a contract that says, "if you feel like hurting yourself, you will tell someone and you identify who it is that they're going to tell and make sure that everybody understands exactly what's happening. And that during the first two months, they need constant supervision."
Its not that these medicines put suicidal thoughts into someone's mind, it's just that if someone had thoughts of suicide as they get more energy, as they get their depression began being treated, then they're more likely to act on it.
Now the studies that showed this increase risk of suicidal tendencies with the antidepressants, I will say this, I don't think and I don't have the numbers here in front of me, but we have seen just within the last few months have had several drug reps in our office, giving us presentations on this. So this does come from research, I'm not making this stuff up. I just don't have the actual studies in front of me at the moment but, if you look at the studies, you'll find that the kids who they looked at to see if they had increased suicide tendencies, these studies were done:
Number one and an in-patient setting, so these were kids with such serious depression that they were actually hospitalized and not treated on an out-patient basis. So, these were kids with really serious depression, where they looked with this. And that makes sense because if you already had the suicidal thoughts in your mind to begin with, your depression is probably a lot worst and you're more likely to be in in-patient setting.
The other issue is that they counted it as a positive risk for increased suicide thoughts if the child did anything to try to hurt themselves whether it be seriously-fatal type thing or not. So if you have a kid who very superficially cut their wrists, you know, to get attention not because they really wanted to kill themselves. That's going to come up as a positive, now did the medicine make them do that? That's up for debate. But I think most of us don't feel that it's the medicine putting these thoughts in the kids heads. It's as I explained before.
So in answer to your question Lyn, because Strattera does have an antidepressant-type effect and so when you have kids with ADHD who have sort of a mood anxiety or depression issue along with it. It does become a good medicine to use. Unless a kid had severe depression symptoms and had suicidal thoughts before they started the Strattera, my personal opinion on this is that the increased risk of suicidal tendencies is going to be very minimal. But again, I'm not putting myself out there saying, "no it won't happen", but talk to your doctor about it, make sure that you know your child very well and that there's an open line of communication. So that if they started to have those thoughts, they have someone that they can come to and trust and talk to, and not feel like they're going to have someone be really upset at them.
So, I hope that helps and answers your question about Strattera and suicidal tendencies. I think the key with this is just to keep in mind that these medicines don't put thoughts in kid's heads. They just keep it more likely that they'll act on thoughts that they already had. That's the bottomline.
Ok, let's go ahead and move on to our final question of this episode but, I'm going to take another quick little break and take a drink.
Again normally, I would go back and pause and edit all that out, and I promise, in episodes that come in mid to late December and beyond that will be the case but, I just want to get your questions answered before I leave for vacation.
OK, question number four, this comes from Heather, "Dr. Mike, could you talk about sleep problems? My two year old has been fighting sleep time and many nights joins us in bed which means we don't get any sleep. Help, what suggestions can you offer to parents? Thanks."
Heather, my twelve year old daughter Katie, when she was two years old she was just absolutely terrible with bed time. I mean, it was the biggest fight in the world. So, this is me talking now as a dad, not necessarily as a pediatrician because, this happened at home and you know what we did that what really helped us a lot?
Now this, I'm talking first about just getting her to be in bed, you know what I mean. It's not, "mom I need this, dad I need that, I'm going to get out of the room, I'm coming down the stairs".
What we did and this did end up working pretty good is we went to a toy store one day and we found this huge set of Polly Pockets that was dirt cheap. So, we bought the set and we let her pick out, it had like little houses and each house had a little figure that went with it and there must have been ten of them in this set.
And we told our daughter, that we're going to make a sticker chart and she was allowed to call us at night. And she didn't even get any one these things, she saw them there and they went to our closet. She knew we had them in the house but she wasn't allowed to play with them. We told her that, "We're going to make a sticker chart when you go to bed, when you call us for a drink, for this, for that, or you come out of your room, or anything, you're going to get a little 'X' in the square for that day. If the next morning, if you only had one or two x's then you got to put a sticker for the night before on your chart. If you get three x's you're out, three strikes you're out, you don't get to put a sticker in the next morning".
And then what we did is, I think the first night we told her so that she could see the association, we said that, "If you do that, if you only call us twice, you don't call us a third time then in the morning you get to put a sticker on your chart and you also get to pick out one of those houses in that Poly Pocket's box that you can play with, that you can have, only one of them".
So, she did that and she was very motivated because she knew this was in the closet, we just bought it and she saw it. So she had something that she was working toward. And we told her the second time that she called us, "if you call us again, you are not getting that Poly Pocket house in the morning". And she believed this because, we have a history with our kids of actually following through with any threats that we give. So, she knew we were serious that if she got three strikes, she was out, no Poly Pockets. She could try again the next night.
Well low and behold, she did it. And she got the Poly Pocket, she picked out the house that she wanted and then we upped to the anti, and we said, "ok, the next one's going to cost you three stickers. So, you gotta do a good job three nights, get three stickers and then you can pick out another one". And that worked pretty well, I think maybe, It took her four nights to get the three stickers you know, something like that. And then we upped it to five, ok from now on, you got to get five stickers. I think we kept it at five, and so over the course of several weeks, she earned the set of Polly Pockets.
And it worked really well because then, by the time we got done with the ten sets of them, she was pretty much had broken the habit of calling us for a bunch of things so, I think that really worked.
And now, you don't have to follow it exactly like that but if you come up with some kind of motivation that's something that they can actually see the cause and effect and it's almost, game-like and something that they can work toward, then you're sort of in the mind of a two year old. And they really get into that sort of thing.
So I find sticker charts work really well. The sticker is the immediate reward and then getting so many stickers to be able to do something you like. Now it could be a toy like we did, it could be a trip to Chuck E Cheese, it could be a trip to the park, it might be just dinner out with dad. I mean, there are a lot of different things that you can do to make it, instead of to get those stickers, and that usually works pretty well.
Now in terms of getting up in the middle of the night and I think I talked about this during our Episode 13, when we talked about phobias and kids being scared of the dark. For our kids, what we did is, when they would come in the middle of the night, we would say, "that's fine but you need to sleep on the floor, next to the bed. You're not getting in the bed and sleeping with us". And we were very adamant about that, it seemed like a good compromise and the kids, you know, they sleep on the floor, they still get a good night sleep. You know, it's amazing the positions they get themselves into. Anyway, so being on the floor is really not too big of a deal, but that way, you know if they were scared of something or they really want to be with you, it’s in the middle of the night, ok fine, but you're not going to disturb my sleep.
You know, you're going to sleep on the floor. And you know maybe I'll have my hand hanging down, so you can hold on to my hand. You know, something like that. But I found that, that worked pretty well and I do know in the office I've given these hints to parents before and have a lot of them come back with positive feedback that, that sort of thing really did work well for them in terms of doing the sticker chart and also in the middle of the night coming in and sleeping on the floor.
So, Heather, I hope that helps with the question and again, anyone out there who has a question, feel free to let me know about it.
You can go to the website at pediacast.org and click on the Contact link and get a hold of me that way. Also firstname.lastname@example.org is the email address or you can call our Skype line at 347-404-KIDS.
Keep in mind, if you ask your question now, I won't be able to get to it until more or late December or early January, just FYI because it's going to take me that long to get caught up with all the questions.
Also keep in mind that we're going to be doing a little bit less of the explaining different disease processes and looking at research studies because of these questions. But, really I do prefer this, I love answering questions and talking about why we do the things that we do.
We do these questions as research things come up. I'll mention them as we go along.
I'd like to thank all the listeners out there, you're great. You'll notice if you go to the website at Pediacast.org in the side bar, we have a new feature that shows you how many listeners we have. Keep in mind that, that number is only the number of listeners who are subscribed through a feed. So, if you are coming to the website and just clicking on the Pediacast player and listening at your computer or you're clicking on the Play Now or the Play and Pop Up or the Download links at the bottom of each episode, you are not being counted in that number of listeners.
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OK, so thanks for all the listeners, new and old. Really appreciate you guys. Really, really do. I would like to also thank my family for allowing me to actually spend the time to put this thing together. Also thanks to Vlad over Vladstudio.com, he's responsible for the artwork that you see at the site. He's an amazing Russian artist and you really should visit him at Vladstudio.com.
OK, like to tell everyone that, well I guess, that's it. OK, until next time. This is Dr. Mike saying, "Stay safe, stay healthy, get your Christmas shopping done, and stay involved with your kids".
So long everybody.
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