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Scott Webb: Mental health is becoming a prominent topic as the pandemic progresses. And on today's podcast, pediatric mental health specialist, Jonathan Palmer, talks about children's mental health, including signs parents should look for, how to improve mental health and how mental health relates to a child's physical health.

Welcome to Celebrate Health, a podcast from San Juan Regional Medical center. I'm Scott Webb. So Jonathan, thanks for joining me. I know you recently received certification as a pediatric mental health specialist. So tell us about that specialty and how does it help children in the community.

Jonathan Palmer: So I'll tell you some specific things about the specialty, but kind of why I did it. I have worked in pediatrics for about eight years now, more if you count training time as a family nurse practitioner, have five children on my own and see patients with developmental concerns and lots of concerns about kids' mental health with depression and anxiety, issues with ADHD, autism. So I thought, you know, "I need to get better at this." We do a lot of it anyway, my partners and I, and we're one of the biggest pediatric groups, if not the biggest, in New Mexico. So I thought, "I need to get better." And I had a little lull with the pandemic where I wasn't quite as busy as I was used to this summer. So I did a fellowship and that was with the Pediatric Nursing Certification Board, who is a nationally credentialed board. And this certification that I went after is nationally credentialed as well. And it's called the Pediatric Primary Care Mental Health Specialist, so not a pediatric psychiatrist or a mental health nurse practitioner, I had thought about going that route, but wanted to focus more on children than adults.

So I did this certification and it means that I've done work after my grad program, specializing more in mental health and had to do a fellowship, study and take boards. And I found out just earlier this month that I passed those boards. And so I'm certified to do this and it basically means that I have the experience to identify these concerns and get people in with the proper specialist, if it's not us and get the help that they need through psychiatry, through counseling, through programs with school, all kinds of things just to help them out. And then of course, we as pediatric providers can manage medications like ADHD medications that we do all the time, some medicines for autism and definitely for depression and anxiety.

Scott Webb: Yeah, well, this is great because a couple of dads getting together, you know, hunkering down here trying to help our kids, which is great. And maybe especially right now, why is mental health in children such an important topic?

Jonathan Palmer: Well, you know, it's always been important. And I think society as a whole or our society is not looking at it so much as a disease anymore or something to be ashamed of or something that shows weakness, whether it be parents or the children themselves, but it's something that needs treated, something that we can help with. We always say, if you have strep throat, you're going to go in and get medication to get your strep throat treated. If you have mental health issues, you need to get treatment as well. That doesn't always mean medication, but sometimes it does.

So I think it's just come to light during the pandemic as a another pandemic that really the impact that the pandemic's had on the children has been greater in a mental health form than it's been a physical form or people having problems with the COVID itself. So I think it's really helped people to see, "Well, our kids are struggling," and if the parents are struggling, we know the kids are going to be struggling too. So we kind of approach it definitely as nurse practitioners as well from a holistic standpoint of we need to treat the whole family here.

So a lot of the advice I give is for parents to get help as well and help them to see that there is no stigma associated with that. You trying to get help to parent your kids is a noble thing, because it is the hardest thing that any of us could ever do, to parent these children and help them get through the challenging times right now, but help them get to adulthood to be successful productive members of our society. And, you know, I think there's this big pandemic as well of child suicide and adolescent suicide that affects our youth greatly. And they hear about it all the time. They talk about it. And so I think it's imperative for us as parents and as providers to really be knowledgeable in these areas and know how to get help and know who to turn to.

Scott Webb: Yeah, and you mentioned a little bit, touched on a little bit some of the issues that children have been dealing with, but what are you seeing specifically in your practice? And are there some issues that are more common than others?

Jonathan Palmer: Yeah, there are for sure. So with the little ones, we see the ADHD. And even before that, we can start to see signs of autism in these children as that's becoming so prevalent. So we help them from the very get-go, starting with these developmental screenings at very young ages to catch things as they come up. And one of the complaints I get from parents is that prior providers or people they've seen in the past just weren't listening or taking it as seriously as the parent wanted them to take it.

So one of the things we really push is referral to early intervention and encouraging parents to ask for referrals, especially if they're not patients that see us, but start with your provider and ask for those referrals, say, "I'm concerned that they have this, that and the other. And I'd like a referral to a speech therapist or occupational therapist or physical therapist, or a referral to a mental health specialist." And I think that if we ask for those things as parents, we'll be more likely to get them and not be dismissed. And I know that happens, but I don't think they're a majority of the patients. I think it unfortunately happens some of the time. But they can really reach out and do that. But so through the pandemic, parents have become acutely aware of what their children are struggling with because they tried to be the teachers. So they were able to see these kids that couldn't sit still and couldn't focus or had other behavioral issues. And so that helped them to want to reach out, to get more help because now they're the parent and the teacher.

And it's crazy some of the interventions that we would typically prescribe for patients struggling with behavioral problems at a young age and even the older ones that are really struggling with depression, anxiety, and suicidal ideation are things like don't be isolated, get out of your room, get out of the darkness, get sunlight, get exercise, participate in sports, go to your youth group, participate in clubs at school, and all that was shut down. So all the things that we wanted for these kids to do just collapsed around them. And then we're like, "Oh, they're fine. They have a phone that they can play on for 12 hours a day. That's fine, right?" So then that creates a whole mess of other problems.

Luckily, now, even with Omicron surging like it is, we're able to get kids back into a lot of the activities that they were doing before. And I think this one's going to settle down fairly quickly and hopefully bring us back to a more normal life. That's our hope anyway, and we'll see what time tells and we have some good data from other countries that support that there is a sharp peak and then a sharp decline and things are going back to somewhat normal. And I think that's great news for all of us, but especially these kids that have been so isolated.

The problem is now they're used to it. So they're used to going to their room and just listening to music in the dark because that's how they're coping with how they're feeling, but that's not always the best thing. There's so many other things they can do to help feel better. And I think these conversations that families have had to, as they've seen their kids, "Wow, they're really isolated. They don't want to talk with the family. They don't enjoy doing the things they did. Are they depressed? Is there something else going on?" And I think it's emboldened more of them to talk about it and to really understand what's going on with their kids, to see it a little more and hear it, and then come in and get help and say, "This is what I'm worried about. And what can we do from here?"

Interesting to me that some of them didn't know they could even turn to their primary care provider as the gatekeeper, we sometimes call ourselves, that we are the ones that start the process and we get you where you need to be and where you need to go. And I hope we can embolden parents to really utilize those resources. And if they're not getting where they want to with their primary care provider, then they know they can reach out to other folks as well.

Scott Webb: Yeah, I think you're so right. And that's definitely something that I've learned over the years. You know, trial and error as a dad, learning to be more proactive and to advocate and, as you say, to sort of be emboldened to ask my children's primary care providers for things. And so when we think about the signs and symptoms that we should all be on the lookout for, what should we be on the lookout for? What should we hopefully be seeing in our kids? But as you say, if they're in the rooms with the lights off and they're listening to music, we just might miss some of these things. So give us some advice, give all the parents some advice, what can we be on the lookout for?

Jonathan Palmer: So starting with the young ones, we look for reaching developmental milestones, like are the two-year-olds starting to say 20 or 30 words? Are they interacting well with you? Are you concerned about autism? If so, we're screening for that. So that's very important to come in for your regular well-child visits, because we screen for things that parents might not even be thinking about. You know, we often hear, "You know, there was nothing wrong, so I didn't bring them in for four years." And that may be okay. Maybe those kids are doing perfect, but we screen for things all along the way as these kids are growing up.

As we get into the school age group, we are screening and listening for signs of ADHD, like kids that can't sit still, have a hard time focusing, have anger outbursts, other issues at school with peers, we're screening and looking for those things. At that age as well, we're also looking for kids that are going to the nurse frequently with stomachaches or headaches, or these things we call somatic complaints where what's going on in their mind and their brain is manifesting itself in the body. My mother recently shared a story with me that as a five or six-year-old, my dad had taken a new job and moved to a new city, leaving the seven kids with my mom in a different city, and she was taking me to the doctor frequently for stomachaches. And my primary care pediatrician sat down with my mom, she says and said, "This is all because he misses his dad. There's nothing wrong with his stomach. It's stress and anxiety." And even from a young age, I can recall feeling some of those things, going to a new school and always getting a stomachache and nothing was wrong with my stomach, but it was the stress and anxiety manifesting itself. So in the little ones, it's very important to look out for these somatic complaints and then let us evaluate them to make sure there's nothing else going on, because it's not all in their head, but a whole lot of it is. Some of these stomachaches and headaches have no physiological disease going on in the background. It's stress and anxiety, but sometimes there is, so we need to work that out as a team and figure out, "Okay, let's cover all our bases and make sure everything is normal like it should be," and then proceed forward with more mental health help.

Now, in the teenagers, I guess we see lots of isolation, kids dropping out of things that they used to enjoy doing, kids getting wrapped up in substance abuse because they're self-medicating and that's very common. Now, it's very common for kids instead of coming in for help to smoke marijuana every day, because it makes them feel better. They can get an escape. But it definitely impacts the developing brain and we don't even know all the ways that it can or will impact developing brains because it's unfortunately becoming so prevalent in our society. So a lot of the kids are self-medicating, so we look out for that.

We look out for teenagers that are, like I said, isolated or ones that may be cutting, that's something we see. Superficial cuts on their wrists or legs. I had one recently that was drawing really morbid pictures and that got her mom's attention and wanted her to seek help. Some will tell us that they're feeling down or depressed. And a lot of times they don't have the words to explain that, so we have to be on the lookout and see what's going on. But I would say a lot of it, the substance abuse, a lot of the teenagers engaging in really risky behaviors or sexual promiscuity can be a sign of some underlying issues, maybe even past abuse or dealing with depression and anxiety that they haven't let their parents know.

A lot of what we've seen this year is suicidal ideation. And sometimes the kids talk about that, sometimes they don't. So the best way to find out is to ask them, "Are you having thoughts of hurting yourself?" And if they are, getting the proper help, not freaking out about it. Sometimes we do need to get pretty amped up if they've made attempts and get them to the emergency room right away, or if we're really concerned, but definitely reaching out to their primary care to say, "Here's our concerns about what's going on." I mean, I have kids that come in and they don't want to talk at all. One the other day didn't say a single word. She'll talk to her mom and her mom can tell me what's going on at home and help us direct her treatment plan.

So there are a lot of signs and symptoms to look out for. And like the American Academy of Pediatrics website has some great resources to look, and like I said, becoming much more prevalent. Here in our county, in San Juan county, we have some community resources on how to look out for these things as well.

Scott Webb: Really great information for parents today. And I know this is a kind of a heavy one, but what tips do you have, so we know what to be on the lookout for? But what tips do you have when it comes to improving our children's mental health?

Jonathan Palmer: So maybe the number one tip is that, as parents, we need to improve our mental health. And I love to exercise. I've been an avid meditator for years now, and that's made a huge difference in my life and something I'd share with the children, my own, as well as the kids here in my clinic as well. But there's so many things that we can do on our own. Get them involved. My kid's mental health treatment plan is sports and I have one that's very anxious and is really competitive and athletic and sports is definitely on her treatment plan.

Getting kids good sleep is paramount. It's the best medicine we know of. If kids sleep well, they're going to be happy and healthy and have a whole lot less problems. So that's something we really hit on in primary care, is figuring out how these kids are sleeping. So there's a lot of things that the parents can do. They've got to be engaged. And parents eating healthy exercising, sleeping well, not spending a ton of time on their phone as we set the example for the kids because the teenagers can see right through us. If we're hypocritical and we're on our phone all the time, but telling them to put their phone down, that's not going to work.

Scott Webb: That's that do as I say, not as I do, a famous sort of a parent approach, right?

Jonathan Palmer: Exactly. Yeah, but getting these kids involved will help keep them out of trouble too. Getting them into sports and band and other activities, church youth groups. Getting them around good kids, because there's so many good kids out there that want to do good things. And unfortunately, some of them fall into some bad patterns and they're not bad apples. They are good people and good kids and they just need the right opportunities and the right help.

And life is difficult. I mean, there's so many broken homes that are struggling and so many things that are going on that affect our own mental health and that of our children, that we just need to be diligent and get them all the help they can and really be supportive and loving and let them know that sometimes we get frustrated with their behaviors or with their choices, but it's not them. We love them. And we accept them and support them regardless of their choices, but we want to help them to make the best choices they can to be happy and productive and to be able to excel in life.

Scott Webb: Yeah. I think I know the answer to this one already, and we've touched on it a little bit, but as we wrap up here, when we think about mental health as it relates to physical health, kind of tie those things together and just what would be your takeaways today?

Jonathan Palmer: So the two are intricately connected, and I tell that to all the kids and all the parents, that we can't treat one without the other. A lot of the times we see kids that are depressed and down and anxious. They're not getting the exercise they need. Some of them get involved with stuff like that and they don't need any medication, they don't need counseling anymore because the mind and body are so connected and what's going on in our mind is manifested in our bodies. So we've got to work on both of them at the same time, and I would argue that it's not just that, but it's the intellectual things and spiritual things as well, that we treat those all together, the physical, the emotional, the intellectual, and the spiritual, and we treat the body and the person as a whole to help them be whole, and there's not one thing that's going to work for every person, but there's a whole lot of options out there that they can do.

Another great thing is it's awesome to watch these kids grow and develop, and it's hard as parents to see them struggle and to kind of take our emotion out of It and say, "They're not debating me per se. This is their brain developing. And I can help them develop or I can stifle that. I can help them with their mental health or I could make it worse," depending on the way we parent and I see it every day and I kind of chuckle and laugh. I'm like, they must not remember what it was like to be a teenager. Can we forget that stuff?

Scott Webb: It's hard. It was so long ago, Jonathan, you know?

Jonathan Palmer: Yeah. And you forget. I forgot that my brain wasn't really fully functional until I was 25 years old. So we got to give them a little slack too. You don't have to have the last word as a parent. You can just chat with them. I mean, my 14-year-old is a great example, like sometimes I just let her speak her nonsense.

And then sometimes I'll challenge some of the incorrect thinking, but sometimes I'm like, "Yeah, this is normal brain development for her," and this is a good step to help her with autonomy and to form these thought patterns and, you know, the concrete versus the abstract. It's an awesome time, but it is so challenging, so difficult. So we as parents sometimes need to step back and say, "All right, I got to work on myself. I need to take a walk for a minute. Then I can come back when things are cooled off and we can talk about this issue. "

Scott Webb: Well, this has been so great today and I am so glad to hear about your certification. I think folks in the area there, as you say, we're treating the whole person, but you are also treating the entire family, really that's your approach. And so this is such great information. So helpful to everybody. Congrats on the certification. I think everybody there is lucky to have you and your partners. So thank you so much and you stay well.

Jonathan Palmer: Thank you. I appreciate it.

Scott Webb: Call San Juan Health Partners Pediatrics at 505-609-6700. And thanks for listening to Celebrate Health, the podcast from San Juan Regional Medical Center. I'm Scott Webb. Stay well.