Intro: Welcome to Pediatric Voices, Duke Children's podcast about kids' healthcare. Now, here's our host, Dr. Angelo Milazzo.

Angelo Milazzo, MD (Host): Hello and welcome to Pediatric Voices, a podcast that dives deeply into conversation with the people who make up the Duke Children's Health Care team. I'm Dr. Angelo Milazzo, a Pediatric Cardiologist and a Professor of Pediatrics at Duke Children's and a co-host of the show. I'm here to bring you expert insights about timely topics in children's health.

On this episode of Pediatric Voices, we'll look at the topic of resilience and the challenges facing our children today. Resilience has become something of a buzzword in the last several years. In healthcare, we've been very focused on discussing the resilience of our workforce, the resilience of physicians and nurses and other healthcare professionals, and that's particularly with respect to the COVID pandemic and its wake.

 To be fair, we've had those conversations going back to the time before the pandemic. And we've been thinking about the concept of resilience as it relates to the professional and personal lives of healthcare workers. But today I want to talk with my guest about resilience and threats to resilience as it applies to our patients, and particularly to children, to adolescents, to teens, and to young adults. Fortunately, I have the ideal guest to help us sort through this today. I'll be talking with my colleague, Dr. Gary Maslow. Dr. Maslow is a Child and Adolescent Psychiatrist, so that means he has completed training in pediatrics, in psychiatry, and specifically in child and adolescent psychiatry.

Dr. Maslow is both an Associate Professor of Pediatrics and an Associate Professor of Psychiatry and Behavioral Sciences in the Duke University School of Medicine here in sunny Durham, North Carolina. He is the division co-director of Child and Family Mental Health and Community Psychiatry. Dr. Maslow is a tireless advocate for the mental and behavioral health of children and adolescents, as well as young adults.

He has a very rare skill set and is trained, as I said, both in general pediatrics and as a child psychiatrist, so he's uniquely positioned to provide mental health care in the context of patients' general medical care. And that's something we'll dive into a little bit with Dr. Maslow today. Welcome Dr. Maslow. Gary, it is a tremendous pleasure to have you on Pediatric Voices.

Gary Maslow, MD: Thank you, Angelo. It's so nice to be here. Thanks for inviting me and thanks for doing the podcast. It seems like a great opportunity.

Host: Absolutely. So Gary, I like to start with my guest's origin story, whenever possible. So tell me, how did you first get involved in children's health and in children's mental health?

Gary Maslow, MD: I think I go back to starting as a camp counselor and working with children at summer camp. I was a summer camper for many years in New Hampshire. Go every summer. It seems kind of crazy, but when I was nine, my parents sent me off to New Hampshire for two months at a summer camp.

And, I kind of never looked back. It was always such a wonderful experience. And so you know, in college and as a camp counselor, just seeing young people, you know, kids develop and go from being you know, a nine or ten year old to a teenager who had gained all these skills and competencies, whether it was socially or, you know, learning how to sail a boat or hike and be, outside, playing tennis, like any, any set of skills; summer camp was kind of a cool place to see one year what happens, and then you see them next year. It's sort of like a snapshot where you get to see all the growth that's happened over a year. So, I think my interest in pediatrics and being a pediatrician really comes from that experience of seeing kids grow up and then in medical school and college, I, volunteered in the children's hospital and did various service kind of projects.

And I was pretty sure I was going to be a pediatric oncologist. That was kind of just very interested in all the families I've met in the hospital who had kids with cancer, and just this, you know, kind of the process of getting going from being a cancer patient to being in a cancer survivor and what it takes to do that.

And I remember very vividly, I was in New Hampshire for medical school, I went to a small town for the summer between my first and second years of medical school, I met with a pediatrician named Skip DeVito, and I was talking about wanting to be a pediatric oncologist, and Skip was a general pediatrician, and he basically said, you know, there are kids with other conditions than cancer, and there was sort of like almost an aha moment of, wait, that experience of being a caring for someone with a serious illness is not unique to one condition, and it's really something that goes across primary care, all the different specialists, and so, that sort of was a moment of okay, if I want to really understand how do you help children and families in general go from being a child with a serious illness to a child who is thriving or a child facing other adversity, to a child that is thriving or a family that's struggling to a family that's thriving, like, what is the process?

And so that was sort of where this idea of studying general pediatrics as well as child psychiatry came from and really focusing on that notion of development and how do we help young people through adversity develop and in the direction that they want to go.

Host: Gary, what I find interesting about that answer is in the first place, it's so consistent with what other guests have said. It seems like many pediatricians are shaped by early experiences. Whether it's growing up as a kid, whether it's in high school or college or these extracurricular things, summer activities, camps, and things like that. So that's very consistent. I enjoyed hearing that. The other thing your story points out is the influence of a mentor. I think, um, we should point out that medicine is probably one of the last great apprenticeship systems. And many of us have been influenced by the suggestions, the work, or just being around, you know, bright, engaging, articulate people.

And we're heavily influenced by these mentors in terms of the way our careers get shaped. So I'm sure that experience with Skip was probably something you still point to. It sounds like still a reference point for you and your work. So that's really interesting.

Gary Maslow, MD: Yeah, I think, that's true. I think, to be working with children and families, you kind of have to reflect on your own experiences and, and be able to ground that work and, in that kind of similar experience with, when you talk to other folks, you hear about their different experiences in childhood and young adulthood that shaped them,

Host: Absolutely. It's absolutely true. So let's get into today's topic a little bit, Gary, and let's start with getting your overall take on the concept of resilience and maybe some general thoughts about the specific challenges to resilience that our kids are facing today.

Gary Maslow, MD: Right? So the idea of development is that you have different tasks that need to be achieved to make it to the next stage of development. And so if you think about like anything, whether it's child development or just learning a skill, you can't just jump to doing the skill. You really need to learn the component parts of it.

And so when I think about resilience and think about development, it's really saying, okay, if I wanted to learn how to hit a baseball, or kick a soccer ball, or some of the sports metaphors are often the easiest, but learn how to cook something, bake a really great cupcake or cheesecake, there's so many different steps to the actual task. But you can't just go in and say, okay, I'm going to make this cake. I really, you know, need to learn about how to mix ingredients. I need to have the right equipment. I need to have a notion of how to do it safely. How to use the oven. I need to have the facilities, right?

Like, if you're going to bake a cake, if you don't have an oven, you're not going to be able to do it. And so, development is really about the context and the environment interacting with an individual. And then how they work within their environment to grow. And that environment is not just the, you know, it's the built environment. So it's like the physical surroundings, but it's also the social environment. And so when we think about resilience and growth and how those things intersect, it really comes down to what are the components of the environment that support young people? What are the components of the environment that are unstable and pose risk for them.

And then how do those things interact to either promote positive development or get in the way to lead to risk and challenges. One of the cool ideas that I've been lucky enough to be exposed to and think about is something called the notion of positive youth development that actually situates the young person, the child, the teen, the young adult in the center of that.

So they're an agent of their own development, and we need to see them as agents of their own development, not just these empty vessels upon which forces act. And so how do you both support the environment, promote resilience through the environment and the social environment? How do you promote resilience through decreasing risk and the factors that can cause negative outcomes?

And then how do you actually build strength within young people so they have the capacity when they face challenges to navigate them? So all that to say, your question is what is resilience? And I'm going to say resilience is really the capacity to navigate challenges and risk because of internal factors and strengths, as well as supports in the environment that allow you to make it through.

If you think about like a river, right? Like there's a river that you have to go down and you're at the top of that river and you don't really know what rapids are coming. You don't know if there are trees hanging over it. You don't know if there's a drought and you're going to have to carry your, you know, kayak or canoe. What resilience is, is that capacity to come to a challenge and figure out how to navigate that challenge and then know, and also know when to ask for help and say this river is dry at this spot. I need help carrying my canoe to get back in the river and, and if you're alone, that's much harder.

But when you have a supportive environment and a network of people who you can call on, you can have someone who helps you forage that canoe, get you back in the river, gives you some fresh water, and then, you know, you get back to going downstream.

Host: So I think that sets the stage really well. I love the way you described this concept of the, the factors which impact resilience and with this focus on the environment. I find that to be fascinating because we could define the environment in a number of different ways. And I suppose in your work as a both as a general pediatrician and as a psychiatrist, you actually have insight into the full spectrum of those environmental factors, right?

So can you talk a little bit about how your experiences as a general pediatrician provide that additional sense of perspective?

Gary Maslow, MD: I was in clinic on Friday, and I saw children and young adults with a range of different environmental resources and the way their environment influenced them was directly related to how healthy they were. There were several patients who had autism. Again, it's a common condition, has different manifestations, but it's, there are specific things you do for that condition.

And there was, you know, one young person whose family had faced a significant deficits because of poverty, did not speak English as a first language, and they were really struggling to navigate the health system. And just for him to be able to get the basics met, was really challenging, even within the school system to be able to get the right services through school, the right services in the community.

And we have lots of team members who are trying to help them. But because of those, both the poverty challenges, as well as challenges related to language, this young person was not able to have what he needed and his family was not able to have what they needed. And his mom is incredibly supportive, incredibly caring and can really help him be calm and make it be settled. But all the other, other things that are out there, she's sort of on an island. And similarly, I saw two other young people with autism who don't have those challenges; who have, you know, in general are making, have reasonable salaries for the family, they speak English, they're connected. They have a large community that's able to support them. And then those resources actually multiply. They're actually not additive. They actually are magnifiers. They're catalysts. And these young people now are in really great school settings with specialized instruction and getting access to other resources, including some very, very high value state resources. And so that's not exactly resilience. I know it's a different than resilience, but it is the notion that things in the environment that are out of our control, shape what services and what supports we may get access to. And so when you think about being a general pediatrician, you see everyone and you see that the I mean, I've seen just the challenges that come from different environmental and social challenges that result in worse health outcomes.

Really, I think we all talk about social determinants of health, social drivers of health, but it's beyond just the way affects your, you individually. It's just, it's a systematic failure to meet the needs of the most vulnerable patients and people that I would say I see and really want to keep struggling against because we can talk about those internal factors to navigate these crises and these challenges, but wouldn't it be great if they didn't have to face some of these challenges and the built environment and the social systems and the supports were actually in place so they could focus on the higher order, higher order challenges?

I guess the last thing I would say is it goes back to, I'm not related to Abraham Maslow, but I can always pitch another Maslow's work. So Abraham Maslow had that hierarchy of needs and really the notion that if you want to get to self-actualization and thriving, you don't just jump to that. You really have to have your basic needs, your safety needs met. You need to have access to social supports and caring relationships. And that's the foundation upon which you work towards self-actualization and thriving. And so I think that the same notion applies here. You can be the most resilient person in the world, but if you don't have the substrate to be resilient around, you're still going to struggle and still suffer. And so I think, we want to build those capacities, but we simultaneously have to be thinking about the structures in our system that prevents people from, from being able to thrive.

Host: Gary, you talked about the social determinants of health and just for our audiences' sake, these are the factors that physicians are becoming increasingly concerned with, that influence health in a way that may be less direct than we typically think. So, beyond your blood pressure and your height and weight and these physical factors, social determinants are whether you have access to food and whether you have transportation and your socioeconomic status in general and other factors that may influence your ability to access care.

What I want to ask you is, do you find that issues around resilience transcend in some ways, some of these determinants? And that is, do you see these challenges across the board? Are they proportional to challenges and socioeconomic factors, or do you think they transcend them entirely?

Gary Maslow, MD: So, yeah, I mean, I think that there is, there's the notion of adverse childhood experiences or ACEs. And those are basically a set of negative things that can happen in childhood. Some of them are social driver based, some of them are more trauma based. The research is really powerful that the more of these ACEs that count, the more challenges you're going to have with physical health as an adult, as well as mental health as an adult. And certainly during childhood that happens as well. And so, I think the key finding, at least for me, from ACEs, which is again, very much like simplifying a very complex like thing, topic is that both additive and potentially at times as you get more and more adversity, it's multiplies.

And so if you have one chronic illness and otherwise you don't have to fight against several other areas of adversity and your family and you can work together and you can navigate that with support from your school and from your healthcare providers; someone with relatively few resilience skills will likely get through that and hopefully develop more resiliency as they go.

The problem is, if you have the condition, you're dealing with poverty, your family is in conflict, you have some other trauma or loss; now you're having to try to respond to each of those things at the same time, and then your family is struggling with all the other things that they're struggling with, so they're not necessarily able to support you as much. I think that idea of cumulative risk is what I think about when we think about how to support individuals who have chronic physical health, individuals who have mental health, and their families, because ultimately, the source of most resilience comes from the social relationships in the community and the family, and that children who have supports and have a family that has members who are doing well, that buffers a lot of it. And when we think about the topic today and the pandemic, one of the huge consequences of the COVID-19 pandemic was how hard it has been for families and for parents who have lost income, who've struggled with jobs because of whatever disruption from their industries because of the pandemic, parents with their own health problems, you know, 400,000 orphans because of COVID right or and many more who lost other caregivers or relatives.

And so the, that cost of the pandemic in the caregivers well-being, the caregivers health, then affects the children and young adults that they're caring for. And so, I remember one of my, again, you talked about mentors, there's a wonderful psychologist named Deborah Lovato, who's based out of Brown, and talked about that if you had one dollar to spend on pediatric therapy or mental health, you'd spend it on the parents.

You would take that dollar and you would do therapy for parents, not so that they could better parent their children, but so that they themselves could have their mental health addressed so that they could be present for their children because one hour of therapy in a room with a child is trivial compared to 80, 100 hours that a parent spends with their child during the week.

And so you help the parents, you help the family, that's what's going to help children the most.

Host: Gary, you mentioned social interaction as a factor and I don't know how we could have this conversation without thinking of social media and the way it has colored and really seismically changed our social interactions. You know, we're a decade and a half now past the introduction of the iPhone, and we have a whole generation of children who grew up with this technology literally in their hands and in front of their eyes every day.

I wondered if you could comment on the role of technology and the role of social media with respect to how it may buoy resistance, threaten resistance or both.

Gary Maslow, MD: Absolutely. Yeah. I mean, I think, that social media is, is a part of the fabric. And I think the key, from my perspective, again, not being an expert, but being more a generalist, is there are youth for whom social media is a lifeline, and for whom without social media, they would probably have much worse mental health and really be struggling.

And, you know, in particular, when you think about the LGBTQ community, there is really good data that having access to Facebook groups and other supportive spaces can be a lifeline and can allow for finding connections where you might not otherwise have found connection. At the same time, there's also the risk for that same group of young people to be taken advantage of or have scams perpetrated upon them or put in unsafe situations.

And so you have to balance that opportunity to make meaningful connection and decrease isolation and find guidance with potential risk and how do you do that is really, I think, very complicated. The AAP, the American Academy of Pediatrics, so our kind of like gold standard organization has a really nice family media plan.

I actually, my daughter is 12 and we're, she does not yet have a smartphone. I'm sort of dreading that moment and the idea of I've been going through that family media plan and I think we're going to sit down and we're, we're going to go through it. And what's really nice about that, it helps families navigate the milieu of okay, what are screen free zones like places that we don't bring our screens?

What are screen free times, where we don't have screens together? What are device curfews? Where are charging spots? How do you, how do you allow for the children to have, you know, the young people have their own voice in what they value and have the adults follow through on the same guidelines because I find myself sometimes, something's going on with work and I'm waiting for an email and I'll be at dinner and I'll be pulling out my phone and checking it and my daughter calls me on that and I think, I think that notion of it's not just how to protect teens and from social media, but help them have attention that isn't solely driven by the screen and by the social relationships on there. Similarly to ACEs. ACEs, again, being a set of negative factors, that can decrease someone's ability to thrive. There are resiliency factors that can improve your opportunities to thrive. If you just do one of those things, that usually is not enough. It's again, additive and multiplicative. So if you have good social media relationships, but you are really isolated in other parts of your life and you're not being physically active and you're not, you have a really terrible sleep hygiene and you're not connected to school; just because you have one domain that you're doing well in and it's social media, you can't ignore all these other domains.

And so that's sort of where I think the family media plan is a really nice way with teens to and family just to kind of talk about, okay, you have all these other components of your life. This can't be the only component. And if it is, we really need to work on limiting that to some extent while you find other opportunities. Which are hard conversations because it's easy sometimes to say, okay, go, you know, occupy yourself and we're not going to monitor or track what you're doing. But just like you would not send it, you know, send someone off and say, okay, go spend five hours just wandering around and not checking in and letting me know what you're up to; for like a 13 year old, that's what you sort of do when you just don't pay attention to what they're doing on social media. It's like, you've just dropped them off, not even at a mall. You've dropped them off at a parking lot and said, okay, I hope you get home safely and don't tell me where you've been, like we wouldn't, we wouldn't do that.

So I think that notion of balance and having access to different components of meaningful interactions is really important.

Host: Gary, for families who are listening to the show, who may have concerns raised by our conversation, who may believe their children are having issues with resilience or being able to navigate the perils of modern childhood, what would you recommend as your basic advice or first step in terms of getting some help?

Gary Maslow, MD: I think that the notion of understanding what your goals are for your child and what their personal goals are and then where are they in terms of those goals and those goals could be as simple as getting a good night's sleep and being physically active or could be, you know, graduating high school or could be getting a job. Whatever specific thing they're looking at and kind of doing a, a status check of where they are and if they're way off course from their perspective internally or your perspective, as a parent, talking with, again, starting with a pediatrician is a great place to start, but talking with like, okay, my goal was for my child to be able to go to school every day and be able to make friends.

Andght now they're really struggling to wake up and go to school and they're really struggling with their friendships. And that's a change. Then talking with a pediatrician about what are the causes of that? Is this depression? Is this actually there's you know, they got mono, is this something else going on?

I think that idea of essentially hearing from youth about what their goals are, what their motivations are. And then if you or they feel like they're not on track, stepping back and saying, okay, what is the, what is the underlying cause? Because it could be a health cause, they could just be sick.

It could be, um, a mental health condition like depression or anxiety, or it could be that they feel lost and, we may treat each of those things differently. So there are many ways, roles for therapies, but again, most of those therapies, whether it's cognitive behavior therapy, or other kinds of therapies that are more talk therapy, there's a role for that, but it really is targeted towards specific conditions.

If you do that kind of, you know, review and feel like your child's just doesn't know what they want. That's okay. Like, they don't have to necessarily be on a course, if that's where, where you all agree, but if, if, you're kind of deviating from what their definite, thriving is a very personal definition, like none of us can say, just look at someone from an outwardly and say, oh, that person's thriving or that person's struggling. I think it's really such an internal thing. The only other thing I would say is we know what things support positive development. And support development of resilience like there's really clear evidence about what those things are. There's multiple national reports and that's connection to their parents and their caregivers and having meaningful relationship where they have time together on a regular basis.

So that's why, like, family dinner is such an important thing. So, parents taking time to be present for children and doing non-directive activity where you just are spending time doing something that child wants to do, even a teenager. Watching a show, going on a walk, playing the game, learning about what they're interested in and not doing it in a we're going to do this because I say we're going to do this way.

That's really important. So those, those core relationships, having other adults outside of the primary caregivers as meaningful relationships. So fostering the relationship with uncles and aunts, fostering the relationships with coaches, with teachers, those other non caregiver, adult relationships are also protective.

And that's where mentoring comes in. That's where, you know, Girls and Boys Club for many children come in, like finding those non caregiver adult relationships is critical and then participation in activities. So whether that's school, so school connection, like being connected to school is actually a really positive factor in terms of children who have high rates of connection to school, less depression, less substance use, less drunk driving, like all the things that we're trying to, like all these risks, it's not about teaching kids don't do that.

It's actually giving them meaningful connections to other institutions. And so certainly, yeah, school being out with virtual school and all the other things that, that ruptured a lot of those connections. And so how do you rebuild them? Participation in sports and having coaches and then other activities, you know, whether that's summer camp or other kinds of, boy scouts or scouts now, girl scouts, like whatever those connections are what we can help our children have and the challenge is how does social media fit into that? We don't know yet. But if, if you were just to say we have these six or seven types of connection, caregiver connection, school connection, peer connections, mentor adult connections, teen group connections and social media. That's one of six and if you have red lights on all of them except a green light for social media, that's not going to work.

But if you have green lights on most of them and a green light on social media, that's fine, right? And that's, I think that notion of sort of this connection inventory is what I think I would, what I think about in terms of what we can do. If someone has a specific concern and a clinical need, we can address that and we can try to figure out how to help them once they have a problem, but upstream from that, before you hit that patch of rough water, upstream, you can think about, okay, here are the things, here's how you, how you learn to paddle and put on your life jacket.

And here's the group you're going to travel with, because it's much harder to do it when you do it alone. And I think that fundamentally is the lesson all the research on positive youth development; it's supportive caring adult relationships, longitudinal over time. And there's some, often some skill building and kind of growth in specific task you're working on.

And that task can be learning how to sail. That task can be learning how to throw a ball. That task can be writing an essay. The task is not the point. It's really the relationship and the longitudinal connection. So, and social media doesn't necessarily have longitudinalness to it.

Host: Well, I love that answer, Gary. I love that starting point for our listeners because it's pragmatic. It focuses on relationships. It focuses on the positive. It focuses on skill building and coping mechanism building. So I think that's a fantastic and very rational and relatable piece of advice for our listeners.

So I want to close you out, Gary, with a bit of a curve ball. I like to ask our guests on the show that if they weren't doing what they were doing, if they were doing something else; so even though it would be a great shame if you weren't a pediatrician and a pediatric psychiatrist, what would you have done or what would you be doing with your life?

Gary Maslow, MD: Yeah, I think one of the great things about being at Duke, and being in an academic setting is I probably have five different jobs. I'm, I'm a pediatrician who sees patients. I'm a teacher and a professor who teaches students, and then I'm a writer who works and does research on youth development. And then, you know, have kind of administrative leadership roles as well. And so, you know, each of those are, I imagine not doing all four of them a lot. And what would it be like just, you know, to be a pediatrician and truly able to to be fully committed to that versus to be, you know, being more of a professor.

And so I guess if I wasn't a practicing clinician seeing kids, I imagine I'd be in teaching of some sort, whether that's teaching, you know, this kind of stuff, like youth development or teaching sailing or something else, but I think, I guess I think of myself fundamentally as a teacher. My parents were both teachers. And that idea of the value of teachers and the importance of teachers, I think, would sit. So, yeah, I think, and I don't know if camp counselor counts the teacher, but I counted as a teacher.

Host: Well, your aptitude as a teacher certainly comes through in this discussion. And, you know, I certainly appreciate it. Cause I always feel like I learned something when I meet with you or talk to you. So, from that perspective, your answer makes complete sense to me. Gary, thank you for being a guest on the show. I hope you'll come back and talk with us again about other topics in mental and behavioral health. Thank you so much.

Gary Maslow, MD: Yeah. Thank you so much for having me and thank you for doing the podcast.

Host: Pediatric Voices is brought to you by Duke Children's Hospital and the Department of Pediatrics at the Duke University Medical Center in sunny Durham, North Carolina. Pediatric Voices was created by my friend and colleague, Dr. Richard Chung, and by me, Dr. Angelo Milazzo. Debbie Taylor provides a huge assist and keeps us organized.

Our podcast is produced by the amazing people at Dr. Podcasting. Thanks to our chairman, Dr. Anne Reed and the team at Duke Children's for their continued support. You can find our podcast and please hit the subscribe button wherever you find your favorite shows, Apple podcasts, Google podcasts, Stitcher, tune In, iHeart Radio and Spotify. You can connect with us online at dukechildrens.org, at Facebook/Duke Children's and at Twitter/Duke_Children's. We'd love to hear from you. You are the most important part of the show. So leave us a review. Thanks for being a part of today's show.

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