Josephine Elia, MD: You know being a parent myself i don't know that
we want to even think about those things right so it's the last thing that a parent wants to think
about that their kid might be sick in any way kids have a need to protect us and they have
a need to make us happy and if they feel like they're not being happy and or they're telling
us things that may make us unhappy they won't Joe McIntyre: Welcome to the Merck Manuals Medical Myths Podcast
thanks for joining us I'm your host Joe Mcintyre and today we're going to take a short break
from myths to cover an extremely important topic children's mental health i'm fortunate to welcome
a very esteemed guest to talk about it with me and Dr.
Josephine Elia. Dr. Elia is a psychiatrist with
a specialty in child and adolescent psychiatry at Nemours A.I Dupont Hospital for Children in
Delaware. Dr. Elia thanks for coming on the podcast. Thank you thank you for inviting me. now on this
episode we'll talk about topics that help parents to identify and address signs of mental health
challenges in children and also offer actionable advice for how to help children understand and
process these challenges including when to see a medical professional now dr elia let's start off
with a fairly simple question perhaps children are often said to be resilient or often more resilient
than adults is that actually true when it comes to their mental health well resilience i it's the
ability to bounce back right so we can look at brain development to help us answer this the
brain isn't fully developed until the mid-20s and it develops in sections the last part
of the brain to mature is the frontal cortex the part of the brain that is needed for
planning organizing reasoning and impulse control now adults are able to process
and organize information judge risky behaviors factor in consequences of
their actions and all of these tasks are done in the frontal cortex and it's one of the reasons
the rates of car accidents are higher in teens and don't actually come down to the adult rates
until about age 25.
Now in addition to the fact that the brain develops in different stages
the brain cells are also developing connections and they form large networks of
connections so that each of the brain cells can communicate with one another and talk to one
another these connections however are not static but are constantly adapting and changing new
connections are formed other ones are broken and then this allows for a healthy brain
function to happen and it's what gives the brain you know some of this resilience being
able to adapt to one circumstance versus another these connections are in constant change and
don't fully form until you know adolescents are late adolescence and when they're not working
well then it's very difficult to adapt to new situations or to be resilient when there's
some event that has caused some regression then the other thing that plays a big factor
is life experiences a child who's living in a home where there's adequate food heat where
the home is in a neighborhood that is safe and parents are healthy and can provide
warmth and care these children are able to manage and bounce back from stressful events
much easier and quicker than children living in adverse situations without an adult
that can model and can help them process whatever might be going on therefore to
answer your question in a long about way both from a brain perspective from the maturation
from the connections between the different brain cells as well as from an environmental perspective
children do not have the capacity of an adult brain to have that level of resiliency that an
adult may have now do you often feel dr elia that signs of mental health struggles are more often
ignored in children because it's often easy to dismiss it as a sign as a kid being a kid or a
kid being difficult or fussy or whatever it may be so that that's a really really important point
i don't know that these signs that we may label as difficult or fussy or one of my least
favorite description uncooperative i don't know that they're ignored necessarily because these
things cause a lot of external trouble in a sense however what i would say that we're often
seeing is that they're often misinterpreted or misdiagnosed i'll give you an example of the
kids that we've been treating obviously we're not going to give any identifying information but they
reflect many cases that we see it was an 11 year old boy admitted to our hospital and the reason he
was admitted was because he needed to continuously go to the bathroom to pee to urinate the reason
we were called our counsel team was called was because staff was having a difficult time
managing him and you know he became the difficult kid on the unit because he was running constantly
from his room running to the bathroom and if staff tried to stop him he would get very aggressive it
was very clear when we saw him that he really did not need to void and to pee because he had just
voided so when we saw him and and and saw him compulsively trying to run in to the bathroom we
obtained a thorough history from the the parents and discovered that around thanksgiving about
about three weeks three to four weeks earlier this eleven-year-old who had been functioning optimally
and going to regular school had developed a fever a cough and an ear infection a week later
his behavior acutely changed abruptly changed he began having periods where he had difficulty
talking he was having staring episodes had become this difficult oppositional fussy
child and oddly was curling up with a blanket and wanting to sleep on the on the dog cushion
rather than going to sleep in his own bed anyway these behaviors again this this looked like
an oppositional kid and even an aggressive kid but clearly that was not the case we
checked some blood work and i identified some antibodies that were very high
that were related to a strep infection we also got a brain scan where there was some
swelling in some of the midbrain regions and we know that there's some infections that can
cause can cause some brain changes that can bring out these behaviors so we started treatment
quickly the treatment that was really effective was plasmapheresis where we basically you know
cleared the blood from all of these antibodies and within two weeks the brain swelling
had stopped the boy's behavior returned to normal and he was discharged to home at his
baseline behavior and went to school the next day whether you're a parent or a seasoned
professional a medical student or a caregiver the merck manuals has the right
medical information in the best format and it's always free easy to access
and readily available for you now what questions should parents ask either
of you a psychiatrist or their pediatrician to gain a better understanding
of their child's mental health you know being a parent myself i don't know that
we want to even think about those things right so it's the last thing that a parent wants to think
about that their kid might be sick in any way and i think things are a little bit better now
than they may have been in the past with you know all the information that's out there but in
general during the routine pediatric visits it's kind of critical for there
to be a give-and-take conversation with a parent and the pediatrician or whatever
clinician is working with the family so that if there's issues they can be discussed and i
think as as physicians you know as clinicians we have learned that we need to do a better
job in even asking the questions ourselves so an example i can give you is that one of
the things that are being implemented across all like health care institutions at this point
is that we have to screen for kids if they're if they're having any thoughts of
wanting to hurt hurt themselves and in the past never even you
know imagine doing such a thing and some parents can get upset about that when
we do that screening and understand the blue cell but the reason these are done is because often if
you don't ask the question if you don't bring it to the table then it's something that they may not
be able to talk about or bring it out themselves likewise in our primary care offices our
pediatricians are doing screens for depression for anxiety i think we're doing a little bit
of a better job in helping parents with earlier identification and also putting things on the
table with regards to depression parents often are not the first ones to to notice these symptoms not
because they're not the the symptoms aren't there but we do not and again as a parent we do not want
to think that our kids not happy and i think in part we need to not see it so clearly so even
when we do studies you know to look for either epidemiological studies or treatment studies we
know that the parents are not the best reporters and then here in the hospital when we have
a kid who does come in and they you know they've hurt themselves uh parents are always
devastated and we try to to to comfort them by letting them know that this is typical often
the parent is not the first one to be aware kids have a need to protect us and they have
a need to make us happy and if they feel like they're not being happy and or they're telling us
things that may make us unhappy they they won't so our institutions are beginning to do a little
bit of a better job and at least trying to screen for some of these now you do mention anxiety
and depression and how difficult it is for parents often to identify that what are some
of the signs and symptoms that children may display when they're suffering from a mental
illness like anxiety or depression some symptoms of anxiety or depression they can differ
during the different developmental stages so for anxiety when kids are little the main
thing that you see is separation anxiety and separation anxiety at certain developmental
stages it's totally normal right so when a kid around 18 months of age doesn't want to leave
your side and screams their head off when you're leaving them even if it's to go to the downstairs
or whatever that's very normal likewise when the first day of kindergarten i think teachers have
a lot of experience with those parents trying to drop the kids off and sometimes the anxiety is
not on the part of the kid it's on the part of us because we can't separate from
the child but in a healthy kid once they're you know you
dropped them off at the school and teachers will tell us the minute they walk
in the class they have forgotten about you and they don't think about
you for the rest of the day so when does it become more problematic
so it becomes more problematic when a kid cannot adapt and when they're experiencing
you know the severe anxiety after they've walked in the classroom after they've seen the
teacher and their classmates and then in the really severe cases is where kids avoid school
and can't even get to school and then as kids get older some of the other anxieties disorders can
come out you can get more of the social anxiety where you know the kid is a chatterbox at home
and talks you know all the time but the minute they come out of the comfort zone of home they
can't talk anymore they become mute essentially uh in the classroom they cannot raise their hand
even you know when they know the answers in groups they can't talk at the lunch table they're
fearful of eating in front of the other kids and then you know they get into the avoidance of
participating in activities with others now you know there's some things that can get confusing
so we'll have a kid that is not able to talk you know in the classroom but they have the
lead in the school play so that in in situations where they may be in large groups but there's no
personal really you know connection they can do quite well and i think of you know what i should
say all of us have a certain level of anxiety so anxiety itself is not bad it's actually
you know a quality that helps us it helps us to prepare for for events right it helps us to
prepare for exams it helps us to um you know to relate to each other in in in positive ways so
it's really when we get to some of the extreme ranges that it can cause difficulties and then as
as kids get older we don't see as much separation anxiety but we see more of the generalized anxiety
where some kids become fearful of everything and everything is a catastrophic event
even things that they can't control and again all of us have some degree of that
but it's when it becomes extreme when it gets into avoidance behaviors when it interferes
with doing all the things that are necessary you know to to get through the day and the good
news is that there's treatments for anxiety there's all the the cognitive behavioral therapy
treatments there's the breathing exercises there's all sorts of of activities that can that one
can do to help to decrease these and then when these are not enough we have medicines that
can be very helpful and that are very safe so if the symptoms are severe treatment can make a
big difference dr elia i have a few more questions that i want to throw your way so if we can i'm
going to ask that we stop here and we'll take an even deeper look into the topic of children's
mental health on a second episode in the meantime i want to thank our listeners for tuning in to
the merck manuals medical myths podcast be sure to subscribe to this podcast on apple podcast
google podcast spotify or wherever you listen in of course be sure to check out part two of our
discussion with dr elia until then i'll leave our listeners with the message we always do with merck
manuals medical knowledge is power pass it on
