Rob Steele, MD (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm your host, Dr. Rob Steele, Executive Vice President and Chief Strategy and Innovation Officer at Children's Mercy Kansas City. Before we introduce our guest, I want to remind you to claim your CME credits after listening to today's episode. You can do so by visiting cmkc.link/cmepodcast and click the button that says claim CME.

Today, we are joined by Dr. Meghan Kanya to talk about addressing general anxiety in the primary care setting. Dr. Kanya is a licensed psychologist at Children's Mercy Kansas City, and Clinical Assistant Professor at UMKC School of Medicine. Dr. Kanya has always found passion and meaning in empowering and amplifying underrepresented voices and experiences in breaking down barriers, regardless of the context. Her current work focuses on treating preteens and teens with anxiety and depression in Children's Mercy's new Depression and Anxiety in Youth Clinic, or DAY Clinic, see what we did there? Depression, Anxiety, and Youth, DAY Clinic. She is also heavily involved in community outreach and engagement and advocacy work due to her strong personal belief that everyone deserves mental health education, resources, and support. Across these roles, Dr. Kanya actively works to promote diversity, equity, inclusion in healthcare particularly related to mental health. Dr. Kanya, thank you for joining us today.

Meghan Kanya, PhD: Thank you so much for having me.

Host: So, I heard through the grapevine that you have both a dog and a cat. And I'm sure you get the question all the time, and I find it interesting to ask this of the psychologist, but do either one cause anxiety with each other or do they get along?

Meghan Kanya, PhD: They get along pretty well. It's actually kind of funny. My dog is more of like a cat dog, where he does some cat-like behaviors a lot. And then, my cat is more of a dog cat where he does more dog behaviors. So, they actually get along pretty well. The dog is quite a bit older than the cat too, so it's very much like a big brother, little brother situation where the dog gets very annoyed by the cat. Because the cat just wants to play all the time. And the cat is like chasing around big brother like, "Oh, let me see what's going to happen next."

Host: That's fantastic. Great. Well, we may come back to that here a little bit later in the podcast, but let's jump into your work here at Children's Mercy and just talk about anxiety and the prevalence of anxiety. I think our audience probably knows, holy cow, anxiety and depression, very high levels in the population in general, certainly with teens. But as a practitioner, talk to us about just the level of anxiety and depression within the population and maybe even give it into context over the last several years.

Meghan Kanya, PhD: Yeah. We have known for a really long time that youth can also experience anxiety and depression, similar to adults can, and that their version of anxiety and depression tend to look a little bit different than what we see in adults, because of their growing and developing nervous systems and bodies and everything else.

We have seen since COVID, so in the last three to four years, we have seen rates of particularly anxiety and depression explode within our youth to the point where most studies at this point that are starting to come out about the prevalence, have suggested that our rates of anxiety in our youth have doubled since COVID. So, most recent estimates say that approximately 20-25% of our youth at this time currently could be diagnosed with an anxiety disorder, and about 30-40% of them will be diagnosed with an anxiety disorder by the time they're 18.

Host: Wow. I mean, that truly is epidemic proportions. Can you give a sense of the acuity as well? Obviously, the levels or the numbers of children that experience anxiety and depression has gone up, but I imagine the acuity has as well.

Meghan Kanya, PhD: The acuity definitely has, and I think one of the spaces that we're seeing the acuity, I think, hit the most is in the school setting, where we're seeing just unprecedented rates of school avoidance and school refusal behaviors as well where schools are really struggling to get kids to school and stay in school and everything else, because of some of the anxieties that are coming out related to both COVID as well as some global events that are happening and national events that are happening. It is a hard time to be a youth right now.

But in terms of acuity, I think something else that I always think about kind of adding to the acuity is that we don't have enough mental health services out there right now either. So even when we think about the idea between prevention and intervention, we always kind of have an eye towards prevention, understanding that if we're able to prevent some of these things from occurring in the first place, then we don't have to do intervention. And it's way easier for everyone, and the world is just a happier, easier place. But at this point, we don't even have enough providers and enough mental healthcare structure in our country, in our state, to be able to provide services to all the youth that are meeting the level need for intervention, let alone preventing it from escalating in the first place.

Host: Yeah. That's really great perspective. You touched a little bit on school avoidance or refusal. Maybe you could give our listeners a little bit more definition to what that is. I've got some teenagers. Of course, they would like to avoid school. They don't rise to the level truly of school avoidance and refusal, thankfully. But maybe you could give us a sense of what does that really look like.

Meghan Kanya, PhD: So, there definitely is a difference between school refusal, school withdrawal, and then we also have this idea of truancy that's out there. And all of those labels are kind of similar buckets, but they might be used in different ways. So typically, when we're thinking about truancy, it's more of that legal term. It can encapsulate school withdrawal or school refusal or school avoidance, or just even like medical conditions, needing to miss school a lot, all of that would kind of fall under that legal bucket of truancy.

But when we think about the school avoidance and the school refusal, really that is a youth-initiated behavior or emotional experience where they are refusing to either go to school or stay in school, and that there is an emotional or behavioral avoidance of being in that school setting or interacting with school material.

Since particularly COVID, we have seen increases in the school avoidance and school refusal behavior, which has been really problematic, just in terms of youth being able to get the education that they need to be able to move on to future grades and prepare appropriately social, emotionally for life and independent living skills.

When I think about the current trends of school avoidance and refusal in our youth, I kind of relate it back to almost like another controversial topic of work from home for adults. And I think of them as being really similar. Just like during the pandemic, adults realize, "Oh wait. I can do my work from home and I still have all this free time to be able to get my laundry done and go run errands and spend time with people outside of work." youth realize the same thing, right? Youth were suddenly doing virtual school. And they kind of started to question, "Why do I have to be at school for eight hours when I can get all this work done potentially in half a day?" Especially for our youth that maybe are more academically inclined or have more of the academic prowess, right? And then, what we also saw during the pandemic was that all of our kids who had social anxiety or anxiety related to school, they suddenly were doing great from virtual learning, because all of a sudden the things that they were anxious about were no longer factors because they weren't in school.

So since trying to get youth to return back to school, we're seeing similar kind of resistance on both of those levels. So similar to adults, we're seeing some resistance of, "Wait, do I have to do school all day? Wait, I was doing a really great job just like on my own." And like, I had all this free time and it was cool. And then, we also have a lot of resistance from our anxious youth who are suddenly being put back into a situation where they are constantly in fight or flight, right? Like, their body is constantly emotionally activated while they're in the school setting, which is really adverse. And it would make, I think, any one of us want to avoid that situation.

Host: Yeah, great perspective. So for those families, particularly the parents, when they're showing up in the primary care office, and they don't have Dr. Kanya right there down the hall to help out, what advice can you give to our primary care colleagues when it comes to school avoidance, when those parents bring those behaviors up in the primary care office?

Meghan Kanya, PhD: I think the first place that I like to start as a provider is just trying to understand from the family what their priority is. Whether their priority is I want my child back in school or I want them in school, or whether their priority is more as long as school work is getting done, it's fine whether we do virtual or in person, because you really want to be able to meet the family where they're at. We know that families are less likely to follow through on recommendations. And youth are less likely to have buy-in if it's not something that aligns with what they're wanting or that is aligning with what their lifestyle is. It might be really hard for parents to get their kids to school and parents might prefer kids doing virtual school, just because of the hassle of getting them up, getting them to school, having to pick them up, and all of that rigmarole.

I think that's always step one, is to figure out from the family, what is your preference? What are you wanting? And then, trying to identify what is the function of the school avoidance behavior? So again, what is the youth getting out of it? Because they're getting something out of it. The youth are getting in trouble for not going to school. So, there is some kind of benefit they are getting from avoiding school. And we want to figure out whether that's a kind of avoidance of negative affect or anxiety. So again, "When I stay home from school, I'm not anxious. I'm not depressed. I'm not getting bullied. Things are great." Or whether it's a "There's something really fun at home that I'd rather do instead of school." "Oh, I'd rather be at home because then I get to play video games all day because no one's home to supervise me. And, you know, I can get away with it." So, trying to figure out the function can help then in terms of our intervention. Because if we're thinking it's more of an anxiety-based function, we might try some anxiety-based interventions, like medication or like therapy, versus if it's more of that, "Well, there's fun stuff happening at home that I want to be a part of," there are other behavioral techniques we can use to try to encourage that youth to be in school.

Host: Yeah. I mean, those are great pearls of wisdom, because I mean, even just speaking as a parent, not a pediatrician, you come as a parent with sort of biases of why you think they are exerting those behaviors, really asking the question and getting it to really understand why that is and what they're getting out of it, as you say. Really great advice. We should not assume what that is. We should try to really ask the question. Wonderful.

You know, we've been talking about those children that we really strongly suspect have anxiety and depression. But what about those ones that we aren't necessarily suspecting? And what kind of screening tools? I know we are using some screening tools here at Children's Mercy, but what about those in the private practice offices or in the primary care setting?

Meghan Kanya, PhD: Yeah. There's two kind of main questionnaires that I would use for screening, especially in the primary care offices. They are open source questionnaires too, so they are free use. So, any primary care provider out there should be able to access them via the internet and use and score them for free as well. And so, there's no additional burden financially on the clinic. But the first one is the GAD-7, or it's spelled G-A-D-7, which is an eight questioning questionnaire that the youth fills out about their symptoms of anxiety and how often they're experiencing them. That questionnaire is only normed for ages 11 and up. And so, you will want to just be careful that that's more for our preteens and teens versus more of our younger youth.

If you do have younger kids, kind of more of that middle childhood coming into your office as well, you might also look at the SCARED measure, which is the Screen for Child Anxiety Related Disorders. That one is for ages 8 to 18, but it is a little bit longer, so it's about 41 questions. But you are able to get both the youth's perspective, and then they also have a parent version as well. So, you can also get the parent perspective, which can sometimes be really helpful, especially in our younger kids, because those youth might not necessarily be thinking about their own experiences as anxiety. So, it might be helpful to get that kind of second perspective of, "Oh, but actually I do think you're a little bit anxious" or, "Oh yeah, like I do actually hear like a lot of reassurance-seeking" or, "Oh yeah, that is a problem for you on most days."

Host: I think you mentioned, but those evidence-based screening tools are found online. For our listeners, we'll put those up with the podcast so they can do that. We've talked about the tools for the primary care folks. What about the tools for the child or the parents themselves? So now, a child has symptoms of anxiety and/or depression, what do you typically start with, assuming there isn't some major crisis going on, but ones that you could give some tools for the child while they're at home?

Meghan Kanya, PhD: I always like to start off just normalizing that, number one, anxiety is a normal human emotion and any treatment that we're doing of anxiety disorders, the goal is not to eliminate anxiety forever or completely, because anxiety is something that evolutionarily we need to survive. Anxiety is the thing that gets us up and out of bed in the morning because we need motivation to move. Anxiety is what keeps us on track. Anxiety is what lets us know what we care about so that we can put more energy and effort into it. And so, I think like just in general where we want to start off just normalizing, this is a normal thing

Number two, I always like to normalize that anxiety can't kill you, that unless you have a pre-existing medical condition, there has been no documented deaths from anxiety alone, right? As bad as it feels, as much as every cell in your body might be telling you, "You're going to die, you're going to die, you're going to die," you will not die. The worst that's going to happen is you're going to throw up, pass out, or just be really tired, that eventually your body is going to relax because it has to. It's going to run out of energy.

The last thing that I like to normalize is that battling anxiety, managing anxiety is very much a skill. It's not a one and done. It's something that we have to practice continuously. I often relate building anxiety, and sometimes I call them brave muscles with my younger kids, to kind of like weightlifting. You're not going to go the gym on day one and try to lift 300 pounds, right? You're either going to get hurt or you're going to get frustrated and embarrassed and never go back. Similarly, we're not going to start with the most anxiety-provoking thing to throw someone into because they're going to panic, they're going to hate it, and they're never going to do it again. We're going to start small, right? We're going to start with 10, 15-pound weights, and we're going to practice with them. And once we get really good at those, and they become really easy for us, we're going to bump up a weight. And eventually, we'll get to that 300-pound deadlift, but we're going to work our way up to it. Similar with anxiety, where we want to start small and manageable so that our kids have successes, so that they can trust in the process, and they can have buy-in along the way, versus being flooded by their emotions.

Outside of those kind of more talking point and theoretical things, I love the idea of grounding tools. So grounding tools, the idea is that a lot of times anxiety pulls us into the future, right? It's a lot of what-if thinking. We can't do anything about the future right now. We can try our best to plan for it, but we can't actually do anything about it. Part of treatment of anxiety is grounding us in the here and now. It's grounding us in the present moment where we actually can do something and have power. And one of the easiest ways to do that is to use our five senses, because we can't sense things outside of the present moment, right? Like, I can imagine what a pumpkin pie on Thanksgiving tastes like or smells like, but I can't actually taste it, right? I can only taste it when it is in my mouth. And so, focusing on the five senses can be really grounding.

Additionally, anything that brings in that prefrontal cortex or that front part of the brain, so anything like analytical or kind of like thinking-related can also be really helpful at overpowering or kind of counterbalancing the emotion parts of our brain. And these can be really simple things like counting. Look up and count how many ceiling tiles are on the ceiling when you're in the classroom, right? Or look down and count how many floor tiles are down the floor. You might count how many people are wearing red shirts around you. But not on Chief Fridays, right? And then, if you're outside, you might count how many birds you hear singing. So, there are a lot of different ways that we can bring in kind of that front part of the brain in really easy ways that allow us to stay present and not get lost in the emotion.

Host: Yeah. Wow. Those are some really great practical things that parents and their children can implement. Those are fantastic. Well, Dr. Kanya, I really appreciate your time and your expertise. I think that you've really enlightened us even more with regard to the epidemic that we're having in mental and behavioral health for children, but focusing specifically on anxiety.

So, according to the Pew Research Center, half of all pet owners are dog owners. And about 24% have both dog and cat. So, you're in the 24 percent area. So, my question then is who actually rules the house? Is it your dog or is it your cat?

Meghan Kanya, PhD: It is my dog.

Host: And he's the older one. Is that the deal?

Meghan Kanya, PhD: He is the older one. He's also got a couple more pounds on him than the cat does.

Host: Very good. And I imagine he helps lessen your anxiety at home.

Meghan Kanya, PhD: Definitely.

Host: I know the pets and the dogs that we have here at Children's Mercy do wonders for the anxious parents and children that we take care of here. So, Dr. Kanya, thank you again for your time. It's been fantastic talking with you. And we will wrap up this podcast. I want to thank Dr. Kanya. Just as a reminder, claim your CME credit for listening to our show today. Visit cmkc.link/cmepodcast and claim your CME credit with the Claim CME button. This has been another episode of Pediatrics in Practice, a CME podcast. See you next time.