Transcription:
Managing Depression, Anxiety and ADHD in the Pediatric Population

Dr. Andrew Wilner: Thanks for joining me for another episode of Pediatrics In Practice with Children's Mercy Kansas City. I'm your host, Dr. Andrew Wilner. My guest today is Dr. Ram Chettiar, a child psychiatrist in the Division of Developmental and Behavioral Health at Children's Mercy Kansas City. Dr. Chettiar treats a variety of psychiatric conditions with interest in bullying awareness and the impacts of technology on mental health. He also educates medical students, residents and fellows.

Today, we will discuss managing depression, anxiety and ADHD in the pediatric population. Welcome, Dr. Chettiar.

Dr. Ram Chettiar: Thanks, Dr. Wilner. Thanks for having me today.

Dr. Andrew Wilner: Oh, thanks for joining us. You know, before we dive into this topic, I'd like you to clarify something for me. I know that ADHD is primarily a pediatric diagnosis, but what about depression and anxiety? Are these mental health problems as common in children as they are in adults?

Dr. Ram Chettiar: Yeah, so that's true. ADHD by definition needs to occur early on in childhood, before age 12 is what the DSM tells us. Depression and anxiety both have a lot of similarities in children and adults, but we have to remember that adolescents also carry with them some unique challenges. They have developing brains and the brain tends to develop into our mid-20s. They have additional social pressures that adults don't always experience, academic stress. Teens tend to be more in the moment. They have more difficulty with executive functioning tasks, such as planning for the future. And when you take all of these things in, teenagers tend to have unique challenges that lead to symptoms of depression and anxiety. And we find that rates of depression and anxiety tend to rise from late childhood through the teenage years and they tend to affect a larger proportion of teenagers and even adults.

Dr. Andrew Wilner: Right. So, you know, life is not easy these days. And I think for young people, the world has gotten even more complicated and more stressful. So how do you differentiate when a child's unhappiness with life is actually a depression that needs some sort of medical therapy?

Dr. Ram Chettiar: Yeah, it's a good question and it's a complicated question. That's when I tell parents and caregivers, when that red flag of yours goes up, when you feel that something's not quite right, you should listen to that feeling. Oftentimes in a quick appointment with a pediatrician, they're going to do some screening tools, but they're not going to understand kind of the nuances of how your child is.

So, one thing that I tell a lot of parents to look out for is look at abrupt changes in behavior or mood. If we see that your child has been trotting along and doing pretty well and all of a sudden, they have different habits with their sleep or appetite or their social situation. Those should be triggers to identify and seek help.

And when we're talking about help, depending on the severity of the depression symptoms, you can seek help a number of ways. One way might be just addressing lifestyle changes, making sure that the child is not on screens too much, making sure they're getting enough sleep. Beyond that, we have mental health professionals that are available.

They might be available through the schools such as a school counselor or in the community or a hospital like my own, Children's Mercy. And in these settings, we're looking at therapy as a very reasonable modality to address depression as well as medication. And there may be a role for medication. And in some cases, you might choose to do both therapy and medication to address these symptoms.

Dr. Andrew Wilner: I guess I'd be remiss if I didn't just touch on teenage suicide. It's my impression from the news media that this is an increasing problem. Is that accurate?

Dr. Ram Chettiar: That is accurate. Unfortunately, we do very well in a lot of areas in medicine, but mental health and teenagers is an area that we have struggled with. At this point, adolescent second leading cause of death is suicide, which, you know, by all accounts are highly preventable and treatable. We see that these rates have increased over time as well. So it is a troubling statistic. And there's a lot of reasons that could be playing a role and a part of which is obviously stigma, where people are often finding it difficult to seek appropriate treatment, despite having very effective treatments available. So we would like to identify kids that are at higher risk for depression, even anxiety for that matter, get them reasonable treatment early on. And we often find that these kids go on to lead very successful lives with a really wonderful prognosis.

Dr. Andrew Wilner: I know you have an interest in bullying. Does that contribute to depression and suicide?

Dr. Ram Chettiar: Yes. It's interesting because it's really evolved over time. Bullying has always existed and we can all probably pinpoint times in our childhood where we witnessed or we're a victim of bullying. Now we have social media, we have technological advances and bullying has really changed where kids these days unfortunately experienced bullying around the clock. You can't shut it off because they're on devices all the time. So we do have the physical bullying. We do have the cyber bullying. And we don't really have great strategies that are set in stone to address bullying. We all tend to address it different ways. Schools handle it different ways. And we do find that bullying can often lead to symptoms of anxiety or depression.

Now, when we're talking about suicide, that becomes a little bit more complicated. I would go as far as to say that kids who have had suicidal thoughts who have been bullied probably have some other factors playing a role as well. Maybe they have underlying depression. Maybe they have a history of trauma, abuse, neglect, things like that, which can complicate the picture. But bullying certainly doesn't help these kids who might be more prone to having suicidal thoughts.

Dr. Andrew Wilner: Let me ask you a general question. You mentioned earlier that children's brains are developing, I think into their early 20s, right? So I think a lot of parents have reservations about their children taking medication that might potentially interfere with the development of the brain. How would you address that?

Dr. Ram Chettiar: Luckily, we have a lot of data to work with. Medications that address mood, anxiety, and ADHD have been around for decades. We see that they are generally considered safe. We see people using them well into their adult years and having a higher quality of life because of the medications.

Now, we need to be thoughtful about medications. There's no medicine that does not come with side effects. And considering this, I always want to make sure that if we're using a medicine that is absolutely necessary, and if we can try more conservative measures or as an adjunct to medicine include therapy or behavioral strategies, that's always going to be important.

But we don't want to underestimate the benefit that medicine may provide as well. A lot of kids are undertreated for symptoms of depression or anxiety and even ADHD for that matter. And we're seeing it come out in the data that kids these days have quite a bit of burden related to mood symptoms as well as suicide as you mentioned previously.

Dr. Andrew Wilner: All right. Thank you. Let's move on to anxiety. How do you know whether a child has an anxiety problem or not?

Dr. Ram Chettiar: Yeah, anxiety can be a little tricky. So we characterize anxiety as someone who's having excessive worry. Now, these symptoms need to be chronic and, by chronic, I mean, at least six months. So if a child has excessive worries for more than six months, you might consider anxiety. But a lot of kids show anxiety in different ways. Anxiety might show up as difficulty falling or staying asleep, maybe increased irritability, decreased concentration, restlessness muscle tension, all of these things can be signs of anxiety. And again, I go back to, "Is this an abrupt change in my child who I know not to be a certain way?" If we're seeing these changes, we're seeing a child in discomfort and we can't clearly identify what might be going on, you might think about anxiety in a case like that.

Dr. Andrew Wilner: And is it the same approach, so with mental health, that there are behavioral strategies and also medication strategies?

Dr. Ram Chettiar: Yes. That's right. So with anxiety, there is a role for medication. There is a role for therapy. Interestingly with anxiety, when compared to depression, we find that therapy is even more effective than it can be for depression. So those with anxiety, I might even lean a little harder on therapy modalities such as cognitive behavioral therapy. We do find that the combination of therapy and medicine together is superior to either modality on its own. But there is highly effective treatment out there for anxiety and, generally, the treatment for anxiety and depression are similar.

Dr. Andrew Wilner: In terms of excess worry, it's sort of lighting up a bulb in my mind. That sounds a little bit some of that that could be a OCD, worrying about cleanliness or worrying that the clothes aren't put on properly or things aren't done in a certain order. What age, I guess, does that start to be a problem if it exists, OCD? And then how do you know, I mean, ordering things and having a specific way of doing things, kind of a sign of maturity? How do you sort that out?

Dr. Ram Chettiar: So this is a really good question, and we'll address OCD. When we think about any disorder that has symptoms of anxiety, you can usually bring it back to a child's developmental stage. For example, separation anxiety, when a child is going to preschool, it might be the first time they're separated from their parents. So we might see those symptoms pop up at that time.

When you talk about OCD, this is when kids are starting to get a better idea of their environment. They realize what germs are, how germs can make us sick, for example. They might have a fear now of somebody breaking into their home. So they're checking locks or checking lights and things like that.

So you can sometimes bring it back to a developmental stage. Now, checking locks, you know, it's probably a good idea to keep your doors locked, and I think that is reasonable. However, with OCD, you have to consider how compulsive is this behavior. Is a child checking a lock and then checking it again? And then they go to bed and wake up in the middle of the night and they're not sure and they check it another time. Now, it's disrupting our sleep. Now, it's affecting our mental health and wellbeing to an increased degree. So if you're doing it compulsively to the point that it's affecting your ability to take care of your other responsibilities and, for a child, that might be doing their schoolwork, being kind to your family and friends, eating dinner at the dinner table, you know, whatever it might be, then we determine is it worth treating. And OCD is also highly treatable. And again, there's very effective therapy strategies to help desensitize a child to the obsessive tendencies that they may have. And there is a role for medication in OCD as well.

Dr. Andrew Wilner: Well, that's reassuring. Well, let's move on to ADHD. I know that many people think ADHD is over-diagnosed, particularly in the United States. It's like you look at other countries and, you know, our incidence of ADHD is like a hundred times that of similar Western countries. Like how does that happen? So is it that we're ovediagnosing it? Or are they underdiagnosing it or what's the story?

Dr. Ram Chettiar: So ADHD is complicated because it's mimicked by a lot of other disorders, if you will. So the data would suggest we are actually even now undertreating ADHD. There's a lot of kids with ADHD that are not getting appropriate treatment for it. That being said, we are seeing higher rates of ADHD diagnoses. But you have to consider, are they maybe grouping other conditions into ADHD, such as someone with an intellectual disability or learning disorder? I know that sometimes it's hard to test for these things. So it might be easier to give a child in ADHD diagnosis because they're struggling academically.

We see that screens are abundant and kids are addicted to video games and social media and their tablets. And we are essentially inducing artificial ADHD symptoms in a whole generation of kids who are using screens excessively. Now, I wouldn't call that true ADHD, but the symptoms look very much alike. And related to that, we're also seeing that kids do not sleep nearly as well as they used to. And a large proportion of adolescents are sleep-deprived. And when we're sleep-deprived, you can imagine we're not going to concentrate well. We might be more restless, maybe even hyperactive for a young child.

So there are a lot of things that mimic ADHD that we may be calling ADHD prematurely. But that being said, we still need to be thoughtful about ADHD diagnosis because it is extremely debilitating and has very effective treatment, which can really be game changers in a lot of kids' lives.

Dr. Andrew Wilner: How old must a child be before you would make that diagnosis?

Dr. Ram Chettiar: So the key is identifying the child's developmental status. So, you could take a group of a hundred three-year-olds and I would say just based on ADHD criteria, 98 of them would probably qualify for a diagnosis. But we know that this is developmentally appropriate for three-year-olds to be hyper and impulsive and inattentive.

So if the symptoms are great enough that they are causing disruptions outside of what you would expect for a child's developmental age, you can diagnose ADHD even in early childhood. I've seen three and four-year-old kids with ADHD. Though it's extremely rare, you do want to consider their developmental age. But to have the diagnosis, they have to have symptoms prior to age 12.

So when I see maybe an older teenager or even a young adult come into the clinic and say that they have ADHD for the first time, at that point, we want to question the diagnosis and wonder what else could be affecting their ability to focus and concentrate.

Dr. Andrew Wilner: So to help parents and pediatricians, when they suspect ADHD, when do they refer to you? What's their next step?

Dr. Ram Chettiar: Oftentimes the recommendation might be coming from the schools or maybe it's a sports coach or organizer of another club or an activity. Parents live with their kids, they raised their kids and often don't identify some of these things as being issues. So it's often a referral from another adult.

That being said, if a child is falling behind in school or maybe the child is getting into things which could cause safety concern. Maybe they're running into traffic. Maybe they're doing things where they don't have good control of their body. They're sustaining a lot of injuries because they're not having good body control. These might be times that you might refer the child to the pediatrician or even a mental health provider to identify whether a child has ADHD.

The diagnosis is relatively straightforward. We think about, does the child have significant symptoms of inattention? Do they have symptoms of hyperactivity or do they have symptoms of impulsivity? And we can do these very quickly through scales. The important thing with ADHD is that the symptoms have to be present in more than one setting. So it's very easy to give a parent a scale, give a teacher a scale and that they both match. There you go, you might have your diagnosis and you can get started on treatment pretty quickly.

Dr. Andrew Wilner: Well, Dr. Chettiar, this has been really informative and enlightening and, as an adult neurologist, myself, really giving me a nice kind of overview of how you approach these mental health disorders in children. So I want to thank you very much for joining us on this podcast.

Dr. Ram Chettiar: Thank you. I really appreciate your time and the ability to talk to your audience.

Dr. Andrew Wilner: This has been Pediatrics in Practice with Children's Mercy Kansas City. Please remember to subscribe, rate and review this podcast and all the other Children's Mercy podcasts. To learn more about developmental and behavioral health services at Children's Mercy, please visit childrensmercy.org. I'm your host, Dr. Andrew Wilner. Thanks for listening.