Transcription:
Addressing Anxiety and Depression in Teens

Melanie Cole (Host):  Many Children have fears and worries and may feel sad and hopeless from time to time. And although these fears and worries are typical in children, persistent or extreme forms of fear and sadness could be due to anxiety or depression. Today, we’re talking about treating anxiety and depression in pediatrics. This is Pediatrics In Practice with Children’s Mercy Kansas City. I’m Melanie Cole. And with me is Dr. Shayla Sullivant. She’s a child and adolescent psychiatrist at Children’s Mercy Kansas City and an Associate Professor of Pediatrics at the University of Kansas City. Dr. Sullivant, I’m so glad to have you join us today. Doing what you do, do you tend to see the problem of anxiety in kids getting worse or better over the years?

Shayla Sullivant, MD (Guest):  I think that we see with treatment, it gets better and it’s one of the things that responds better to treatment than anything that we treat in mental health in pediatrics. But early intervention is really key.

Host:  Well it certainly is and when we’re talking about our teens, it’s just so important. So, are there some screening tools available to the practitioner, to the primary care provider and the pediatrician?

Dr. Sullivant:  Some people like to use a tool called the SCARED and that is useful for identifying some of the different anxiety disorders that we see in children and adolescents. The PHQ9 is a depression screening tool that’s often used. There are many more resources available and the AAP website has a lot of links depending on what works best for your practice.

Host:  Well then if they’ve got these screening tools available, before they would use them, what are they to look for? What’s the clinical presentation? Is there a way for the pediatrician to spot the signs, the common and not so common signs of anxiety and depression or do they rely on history and the parents’ perception of how the child is behaving?

Dr. Sullivant:  I think that the majority of young people with anxiety or depression often present with a lot of physical concerns. So, what we often hear about are stomachaches, headaches, just not feeling well, frequent sickness especially on a Sunday night maybe before a long weekend returning to school and so those are some obvious signs and I think often parents aren’t aware because anxiety tends to be more of an internalizing disorder that they may not be aware how much their son or daughter is struggling. And so, really asking those questions I think is really an important start.

Host:  Are there some common anxiety triggers and causes for kids that you would like other providers to know so that they can counsel their patients and their patient’s parents about what could set that child off, what could trigger that anxiety?

Dr. Sullivant:  Certainly every child is different. I think we live in a pretty competitive environment today and so I do see a lot of young people who struggle with having really high goals for themselves and high expectations with regards to their academic performance and what college scholarships they are going to receive. We know that social anxiety is the most common form of anxiety that we see in adolescents. And so, often, that will impact day to day functioning.

But I’m also hearing kids that are really having a lot of fears related to some of the drills happening in the classroom setting regarding intruder drills and preparedness in that manner. So, it can come in really many different forms.

Host:  Well then what would you do for these kids and what would you recommend that pediatricians do in regards to referral? What are some of the treatment options available?

Dr. Sullivant:  Sure so I think the first thing is acknowledging what’s going on and what’s normal and what’s not. Like you said earlier, having some level of worry or sadness is a normal part of life but when it starts impacting day to day functioning, that’s when we want to intervene. And typically the first step is counseling or some type of therapy. That’s usually where we start, and we do not always use medications in these situations.

Host:  Well thank you for clearing that up. When are medications indicated and when is cognitive behavioral therapy and different types of therapy, when are those indicated? What’s the level that you look to as you go through these treatment options?

Dr. Sullivant:  Well one of the things we want to look at is how much the individual is able to use some of the coping skills that they are learning in therapy. And how much they are able to get on board with some of those things they are learning from the therapist or that their parent is trying to help them with at home. So, for example, I may have a psychologist refer a patient to me in my practice because they are trying to teach them some coping skills and the patient is just experiencing such a high level of anxiety that they are not able to utilize those techniques or practice them.

It's different in every scenario but often we start with those nonmedication techniques and if they are not proving to be helpful enough; then we start with the medication as well. And typically the SSRIs are our frontline options for young people with anxiety.

Host:  So, when you are talking about the SSRIs, when is it imperative Dr. Sullivant for providers to initiate treatment for children and adolescents with depression or anxiety? What should they be aware of as a timeline to really say yes, we need to start these meds?

Dr. Sullivant:  Well I would say one thing that’s really clear is when a child is missing school, we need to be looking at intervening. I’ve had patients referred who have been missing school. They are struggling with school refusal related to anxiety or depression, maybe they are so depressed they are having trouble getting out of bed, that is a scenario where they are not going to get better on their own and we really need to intervene with medications. But I would argue for many individuals that needs to be sooner than that and it really comes back to that is it impacting day to day functioning. So, if we have someone that’s no longer participating in the activities that used to bring them joy, certainly anyone that’s becoming chronically depressed, not finding any kind of pleasure in things, difficulty with sleep, difficulty with energy levels, changes in appetite; all of those things need to be considered and certainly if they are not trending in a positive direction, medicine can often be very helpful.

Host:  When you are advising primary care providers and pediatricians on the ways to help this family that’s going through the anxiety and depression; how can they advise their patients? What do you tell them about advising parents in ways to calm that child down when they become anxious, something that they can do right there on the spot that the pediatrician can really help the parent to do on a day to day basis?

Dr. Sullivant:  Sure, well I think one of the things is actually to get some education on it and it’s somewhat difficult but some of our natural parenting instincts that tell us to protect our son or daughter when they are struggling are actually not very helpful when it comes to supporting a young person who is facing anxiety. So, for example, if your child is having a fear of going to school because they are really struggling socially, or they feel like people are laughing at them; staying home doesn’t make that better. We actually need to find a way to help them push through the anxiety. So, we may have an individual that goes to the school office to get supports during the day or they join a social skills group at school to help them build some connectivity. Really helping them find some meaning in their day to day life is going to be really important but we don’t want to try to just run away from the anxiety because that doesn’t prove to be helpful.

Host:  Well that was a really great explanation and so important for other providers to hear. In summary, Doctor, what would you like other providers to know about treating anxiety and depression in kids and when you feel it’s important that they refer?

Dr. Sullivant:  I think that it’s really going to depend on the provider. I’ve worked with some pediatricians who are just so comfortable managing these situations and I can tell you that I think most patients would prefer that their pediatrician address their depression or their anxiety within their office. Most people don’t really want a referral to someone like me unless that pediatrician is feeling like it is beyond the scope of their practice.

So, I think that is really variable but when you feel that the patient’s needs are beyond what you can manage, then I think it’s really appropriate and time to reach out to get some help. And that might be talking to a mental healthcare provider yourself to get some pointers on the best next step whether it be medication or therapy, or it may be actually transitioning the patient to another provider. I think there can be lots of different approaches that work really well, and I think when we talk to each other more and we coordinate efforts; our patients really have better outcomes.

Host:  Thank you so much Dr. Sullivant for joining us today and sharing your incredible expertise on this topic that is so important to both pediatricians and parents. This has been Pediatrics in Practice with Children’s Mercy Kansas City. For more information on developmental and behavioral services at Children’s Mercy please visit www.childrensmercy.org. Please remember to subscribe, rate and review this podcast and all the other Children’s Mercy podcasts. I’m Melanie Cole.