Melanie Cole, MS (Host): Welcome to Long Live Childhood, a pediatric health and wellness podcast presented by Rady Children's Health. I'm Melanie Cole. And today, we're looking at our children and their stress levels. Because in this day and age, with everything we know, there seems to be a mental health epidemic among our kiddos and into their tweens and teens. And so, we're going to talk about that today. And as parents, what can we do to help them when they are feeling stressed? And how do we even really know that is what's going on.

Joining me is Dr. Sarah Gubara. She's a pediatric psychologist at Rady Children's Health in Orange County, specializing in trauma, suicidality, and program development focused on systemic mental wellness interventions.

Dr. Gubara, thank you so much for joining us today. As we think of our kids and what's going on in the world today, do you feel that the fact that they are more worldly, smarter, they know what's going on around which we did not know, that they are more stressed as a result of the built environment, what's going on in the world and the pressures that they have that maybe I, who am quite a bit older than you are, did not have?

Sarah Gubara, PhD: Yeah, thank you for having me. I think there's absolutely more of a cognitive and emotional load than we had growing up. And I think the other thing is the access is 24/7 now. Whether it's concerns about school or friendships or life, they're all kind of bleeding into one another. I think, you and I had the pleasure of having compartmentalization built into our lives.

Melanie Cole, MS: We didn't know what was going on barely in the town next door. Unless we were watching the news, we didn't really know. But these kids know everything. As a result of that and what you just said, are you seeing more anxiety disorders and even eating disorders, but more disorders among our children as far as anxiety and mental health issues?

Sarah Gubara, PhD: Yeah, there's been a distinct shift since COVID. We're seeing so many more emerging concerns, some that were often reserved until college, right? So, it used to be that higher education institutions were often the first to see signs of mental health concerns. But we're seeing that skew younger and younger year after year.

Melanie Cole, MS: So then, tell us what we're looking for, Dr. Gubara, when we think of our children and we see them getting stressed out about homework or making new friends when they're little, or whether they're tweens and teens, what are some of the less obvious signs, things that we might not notice that we should be paying attention to?

Sarah Gubara, PhD: So, what I always recommend for my patients and their families that some of the least obvious signs that a child is under a lot of stress is going to be behavioral changes. So, the first thing that I ask families to look for and we call it low frustration tolerance. So, is your child suddenly becoming more irritable? A lot of times people think if we're diagnosing depression, that it's sadness. It's often marked irritability, being quicker to anger, melting down over some of the smallest things, and then pairing that with maybe pulling away either from activities that they enjoy doing or socially isolating themself, not wanting to go to school. So typically, behavior changes are the first that we see.

And then, the second are some of the physical complaints, right? The psychosomatic complaints. All of a sudden, more headaches, more stomach aches, more muscle tension, changes in appetite. Those are the quickest ways. And especially the younger the child, those are the two things that you want to first look for, are those behavioral changes, those physical changes or physical complaints.

And then, thirdly, this is more of an advanced one is if you notice them daydreaming more, right? They're having trouble remembering instructions that you've given them. You've asked them to wash the dishes four or five times, and this one is hard for parents because what I'm asking you to do as a parent is really to balance discipline in a potential diagnosis, right? So, sometimes parents may see that as disrespect, but it's often a sign of something is going on.

Melanie Cole, MS: So, how do we gently open up that conversation? Obviously, we have to be age appropriate and we know our little kiddos, so if they're littler five, six, seven we have to know where they are in that whole spectrum of anxiety or understanding and whether we can talk to them about these things and that they're going to get what we're trying to say. But there are certain tips and tricks as they get older. We can be more direct. But can you go through the ages just a little bit with some of those tips and tricks to opening up that conversation with our little ones, and then how we can be more direct but not scare them away?

Sarah Gubara, PhD: So with our little littles, with our little ones, one of the most helpful things to do as you start opening up a conversation about what's going on, because sometimes they may not know. So, one of the greatest things that you can do is witness and report on those observations, right? So, "Hey, I'm noticing that you are feeling really cranky and sad. Do you want to sleep or do you want to take a bath?" So, kind of mirroring back to them what you're experiencing and that helps a little bit with—the fancy term is affect identification, but it helps them have more awareness of, "Yeah, you're right, mom. This is what I'm feeling." So for our littles, that can be really helpful.

For our older kids, so we're looking at like 12, 13 into the teens, what can be most advantageous is to wait for a transition period. So, let's say they're coming home from school and you notice they're really agitated. Let's give them an hour, right? No chores, no responsibilities. Give them an hour or so, whatever feels right to decompress. And then, just say, "Hey, I've noticed that you seem to be a little bit more irritable what's going on?: And if you're not getting much, which is typical, then you give a choice, right? "Is it school or relationships? We don't have to dig in. Just let me know which category or theme we're talking about." If you don't have that relationship with your child, that's going to take some time to cultivate that, right? But you want to choose a calm, low pressure moment. Start with observations of what you see, and then using open-ended prompts. Not yes or no questions. "Is this related to this teacher or is this related to school?" Because then it becomes the more questions we ask, the quicker irritability starts to flare, right?

And then, other thing you want to do is model a solution. Like, "Okay, it sounds like you've had a really bad day. Do you want to take a nap?" And then, maybe we can talk about it after dinner. You guys live together, right? So if you are living with your child, there's no pressure to need to investigate and get to the bottom of it in that moment, especially if your child is overwhelmed. So, pace yourself. You can revisit it later. Just let your child know, "Hey, we're going to discuss this after dinner or tomorrow morning," whatever is low stakes for you.

Melanie Cole, MS: Wow. Those were some great tips. Now, when we think of also home care, before we talk about when it's time to talk to our pediatrician, some home care things we can do in our house to try and keep a calmer environment, we know that our kiddos don't sleep as well when they've got the blue lights all around and their phones and their homework is online, so we can't exactly cut the online thing like we used to say, "Two hours of screen time." Well, we can't say that anymore, because there's a lot online that they have to do. But what are some things we can do around the house? Music, relaxation, exercise, taking walks, any of these kinds of things. Will they help with some of that stuff?

Sarah Gubara, PhD: Before any of that, before music or relaxation, you have to make sure that the foundational basics of how our bodies work are attended to. And that's everything from balanced eating to sleep. So, I want to make sure that we focus on that. So, limiting screen time is one thing. But a lot of my patients are like, "Yeah, I had Cheetos for dinner last night," and not really hydrating. And so, when you place your body in a lot of stress because you're not sleeping and you're not eating and you're not hydrated, that's going to make irritability stronger.

So, the first thing is we want to keep routine steady, right? Predictable bed times. This is easier when they're younger, but predictable meal times, predictable times for homework. You want to be able to structure life for your kid. You can have flexibility in whatever format you want.

And then, the second component of that is building in short breaks. That could be unstructured play if it is video games, that could be walking the dog. Whatever it is, we want to make sure that there's a little bit of physical movement and some calming rituals built in within that structure, that "I take a bath or shower every night before bed," or "Mom has a rule that there's a 20-minute reading time" or there's quiet hours in the house. Once we start to notice that mental health is impacted in any way, that structure and routine is going to be so protective. It's going to have a stress buffering effect for your child.

Melanie Cole, MS: That's so important. And then, Dr. Gubara, when do we reach out? I mean, we obviously like to start with our pediatricians because they are—boy, what a godsend the gold standards to helping us raise our children happy and healthy. And that's really what it's all about. So, when is it that we really need to reach out to them, red flags for something that's really more serious, and then they will then in turn tell us, maybe we need to set up an appointment with a professional?

Sarah Gubara, PhD: Yes. So, remember the three categories I want you to focus on are behavioral changes, physical complaints, and any cognitive changes. So, the minute that your child starts saying that they have headaches or stomach aches, or they are particularly overwhelmed during their menstrual cycle or sleep issues, that is absolutely one you want to consult with your pediatrician.

 Because once we have interference with those daily factors, of course, we're going to notice changes in mental health. So, that's when you want to go to a pediatrician, that's when you want blood work to be done, because sometimes there's a medical component because that irritability could be related to your sugar not being well balanced—your sugar levels, excuse me.

Melanie Cole, MS: It's true. All of those things really come together. So, I'd like you to wrap this up because you've given us a lot to think of and great tips and a lot to think about, and those red flags that we need to really pay attention to, to know that our child is under more than just the average stress that kids and all of us are under. Give us your best advice, Dr. Gubara, for happy and healthy kids and trying to keep that stress. I mean, we can't protect them completely. There's going to be bullying, there's going to be homework, there's going to be friends and drama and things going on with our kids. But I'd like your best advice as the expert that you are at helping our kids navigate so that they have the resilience to weather those kinds of things that are going to come at them.

Sarah Gubara, PhD: My best advice to parents is don't be a hero. Don't be a hero. Trust the teams that we have in place. Trust your healthcare providers and look for a team that can support you and your child. The last thing that I want is for a child to say to their family, "Hey, I want to disappear. I don't want to be here anymore. I can't do this anymore." And you see a sharp drop in school and performance and families try to manage that themselves all the time. You want to make sure that you bring your child in to talk to a licensed professional. There is no shame in it. We do this every day. This is what we've devoted our career to.

So, what I'll say is don't be a hero. When your child has strong emotions that seem overwhelming or hard for you to manage, sometimes people will start guessing and they try so hard. And please let us be there to support you and to navigate this journey with your family.

Melanie Cole, MS: Thank you so much, Dr. Gubara, for joining us today and really sharing your incredible expertise. And thank you so much for tuning into Long Live Childhood, a pediatric health and wellness podcast, brought to you by Rady Children's Health. Together, we can keep kids happy, healthy, and thriving. If you enjoyed today's episode, please consider downloading, subscribing, rating, and reviewing Long Live Childhood on Apple Podcasts, iHeartRadio, Spotify, and Pandora. Your support truly means a lot. I'm Melanie Cole. Thank you so much for joining us today.