Season 3 | Episode 4
Josephine Elia, MD >> Being a parent myself. I don't know that we want to I even think about those things right. So it's the worst thing that a parent wants to think about that their kid might be sick in any way. Kids have a need to protect us. And they have a need to make us happy, and if they feel like they're not being happy and or they're telling us things that may make us unhappy they will.
Joe McIntyre>> Welcome to the Merck Manuals Medical Myths podcast. Thanks for joining us. I'm your host, Joe McIntyre, and today we're going to take a short break from myths to cover an extremely important topic, children's mental health. I'm fortunate to welcome a very esteemed guest to talk about it with me. Dr. Josephine Elia, MD is a psychiatrist, with a specialty in child and adolescent psychiatry at Nemours Alfred I. duPont Hospital for Children in Delaware. Dr. Elia, thanks for coming on the podcast.
Josephine Elia, MD >> Thank you, thank you for inviting me.
Joe McIntyre>> Now on this episode will talk about topics that help parents to identify and address signs of mental health challenges and children, and also offer actionable advice for how to help children understand and process these challenges, including when to see a medical professional. Now Dr. Ely up. Let's start off with a fairly simple question perhaps. Children are often said to be resilient, or often more resilient than adults. Is that actually true when it comes to their mental health.
Josephine Elia, MD >> Well, resilience, it's the ability to bounce back, right. So, we can look at brain development to help us answer this. The brain isn't fully developed until the mid 20s and it develops in sections. The last part of the brain to mature, is the frontal cortex, the part of the brain that is needed for planning, organizing, reasoning, and impulse control. Now, adults are able to process and organize information, Judge risky behaviors factor and consequences of their actions. And all of these tasks are done in the frontal cortex. It's one of the reasons the rates of car accidents are higher in teams, and don't actually come down to the adult rates, until about age 25. Now, in addition to the fact that the brain develops in different stages. The brain cells are also developing connections, and they form large networks of connections, so that each of the brain cells can communicate with one another, and talk to one another. These connections, however, are not static. What are constantly adapting and changing new connections are formed. Other ones are broken. And then this allows for a healthy brain function to happen, and it's what gives the brain, you know some of this resilience being able to adapt to one circumstance versus another. These connections are in constant change, and don't fully form until you know adolescence or late adolescence. And when they're not working well, then it's very difficult to adapt to new situations or to be resilient when there's some event that has caused some regression. Other things that plays a big factor is life experiences, a child who's living in a home where there's at a quick food, eat, where the home is in a neighborhood that is safe, and parents are healthy, and can provide warmth and care. These children are able to manage and bounce back from stressful events, much easier and quicker than children living in adverse situations without an adult that can model, and can help them process whatever might be going on. Therefore, to answer your question in a long about way, both from a brain perspective, from the maturation from the connections between the different brain cells, as well as from an environmental perspective. Children do not have the capacity of an adult brain, to have that level of resiliency that an adult may have.
Joe McIntyre>> Now, do you often feel, Dr. Elia that signs of mental health struggles are more often ignored in children, because it's often easy to dismiss it as a sign as a kid being a kid or a kid being difficult or fussy or whatever it may be.
Josephine Elia, MD >> So that's a really, really important point. I don't know that he's signs that we may label as difficult or fussy, or one of my least favorite description uncooperative. I don't know that they're ignored, necessarily, because these things cause a lot of external trouble, in a sense, however, would I would say, then we're often seeing is that they're often misinterpreted or miss diagnose or give you an example of a kid's that we've been treating, obviously, We're not going to give any identifying information, but they reflect many cases that we see, was an 11 year old boy, admitted to our hospital. And the reason he was admitted was because he needed to continuously, go to the bathroom to pee to urinate. The reason we were called our console team was called, was because staff was having a difficult time managing him. And you know he became the difficult kid on the unit, because he was running constantly from his room, running to the bathroom, and his staff tried to stop him, he would get very aggressive. It was very clear when we saw him that he really did not need to void and to pee, because he had just void it. So when we saw him, and, and saw him compulsively trying to run in to the bathroom. We obtained a thorough history from the parents, and discovered that around Thanksgiving, about, about three weeks three to four weeks earlier. This 11 year old who had who had been functioning optimally and going to regular school had developed a fever, a cough, and an ear infection. A week later, his behavior acutely changed abruptly changed. He began having periods where he had difficulty talking. He was having staring episodes had become this difficult oppositional fussy child, and oddly was curling up with a blanket, and wanting to sleep on the, on the door, pushing, rather than going to sleep in his own bed. Anyway, these behaviors again this is looked like an oppositional kid, and even an aggressive kid. But clearly, that was not the case. We checked some blood work and I identified some inner bodies that were very high, that were related to a strep infection. We also got a brain scanned, where there was some swelling in some of the midbrain regions. And we know that there's some infections that can cause can cause some brain changes that can bring out these behaviors. So we started treatment quickly, the treatment that was really effective was plasma for receipts, where we basically, you know cleared the blood from all of these antibodies. And within two weeks, the brain swelling had stopped the boy's behavior returned to normal, and he was discharged to home at his baseline behavior and went to school the next day.
Joe McIntyre>> Whether you're a parent or a seasoned professional, a medical student or a caregiver, the Merck manuals has the right medical information in the best format, and it's always free, easy to access and readily available for you. Now, what questions should parents ask either a psychiatrist or their pediatrician to gain a better understanding of their child's mental health?
Josephine Elia, MD >> You know, being a parent myself. I don't know that we want to even think about those things right. So it's the last thing that a parent wants to think about that their kid might be sick in any way. And I think things are a little bit better now than they may have been in the past with, you know, all the information that's out there. But in general, during the routine pediatric visits, it's kind of critical for there to be a given to a conversation with a parent and a pediatrician or whatever clinician is working with the family, so that if there's issues, they can be discussed. And I think, as, as physicians you know as clinicians. We have learned that we need to do a better job in even asking the questions ourselves. So, an example I can give you is that one of the things that are being implemented across all like health care institutions at this point is we have to screen for kids, if they're if they're having any thoughts of wanting to hurt, hurt themselves. And in the past, we never even imagined doing such a thing. And some parents can get upset about that when we do that, screaming, and understandably so. The reason these are done is because often, if you don't ask the question which you don't bring it on to the table, then it's something that they may not be able to talk about, or bring it out themselves. Likewise, in our primary care offices, our pediatricians are doing screens for depression, for anxiety. I think we're doing a little bit of a better job in helping parents with earlier identification, and also putting things on the table. With regards to depression. Parents often are not the first ones to notice these symptoms, not because they're not the symptoms are there to know. And again, as a parent we do not want to think that our kids not happy. And I think, important, not see it so clearly. So even when we do studies, You know to look for. Studies have proven studies, we know that the parents are not the best reporters. And then, here in the hospital, we have a kid who does come in and they you know they hurt themselves. Parents are always devastated and trying to comfort them by letting them know that this is typical, often the parent is not the first one to be aware, have a need to protect us, they have a need to make us happy. And if they feel like they're not being happy, or they're telling us things that may make us unhappy they won't. So our institutions are beginning to do a bit of a better job in at least trying to screen for some of these.
Joe McIntyre>> You do mention anxiety and depression, and how difficult it is for parents often to identify that. What are some of the signs and symptoms that children may display when they're suffering from a mental illness like anxiety or depression?
Josephine Elia, MD >> Some symptoms of anxiety or depression. For during the different developmental stages. So for anxiety when kids are little, the main thing that you see is separation anxiety. Separation Anxiety it's certain developmental stages is totally normal. So when a kid around 18 months of age doesn't want to leave your site and squeeze your head off when you're leaving and even if it's to go downstairs, or whatever, that's very normal. Likewise, when the first day of kindergarten. I think teachers have a lot of experience. What were those parents trying to drop the kids off. Sometimes the anxiety is not on the part of the kid it's important because we can't separate from the child, but in a healthy care. Once there, you know, you dropped him off at the school and teachers will tell us the minute they walk in the class, they have forgotten about you. If they don't think about you for the rest of the day. So when does it become more problematic, so it becomes more problematic when a kid does not adapt. And when they're experiencing, you know the severe anxiety, after they walked in the classroom. After seeing the teacher and their classmates. And then in the really severe cases, is where kids avoid school, I can't even get to school. And as kids get older, some of the other anxiety disorders can come out, you can get more of the social anxiety. As a chatterbox at home and talks, you know all the time but the minute they come out of the comfort zone of home. They can't talk anymore, they become mute essentially in the classroom they cannot raise their hand, even when they know the answers. Oops, they can't talk at the lunch table, they're fearful of you being in front of the other kids. And then, you know, they get into the avoidance of participating in activities with others. Now, you know, there's some things that can get confusing. So we'll have a kid that is not able to talk, you know, in the classroom, but they have the lead in the school play. So that, in situations where they may be in large groups, where there's no personal real, you know, connection, they can do quite well. And I think, you know what I should say, was have a certain level of anxiety. So anxiety itself is not bad. It's actually, you know, a quality that helps us, it helps us to prepare for, for events right, It helps us to prepare for exams. It helps us to, to relate to each other in in positive ways. So it's really one we get some of the extreme ranges that it can cause difficulties. And then as kids get older, we don't see as much separation anxiety. What we see more of the generalized anxiety, where some kids become fearful of everything, and everything is a catastrophic event, even things that they can't control. Again, all of us have some degree of that, but it's when it becomes extreme when it gets into avoidance behaviors when it interferes with doing all the things that are necessary, you know to get through the day. And the good news is that there's treatments for anxiety. There's all the cognitive behavioral therapy treatments. There's the breathing exercises, there's all sorts of activities that can, that one can do to help to decrease these. And then, when these are not enough. We have medicines that can be very helpful and that are very safe. So, if the symptoms are severe treatment can make a big difference.
Joe McIntyre>> I have a few more questions that I'd like to pose to you so if you could. I'm going to ask that you sit tight, and we'll dive a bit deeper. In part two of our episode on children's mental health. In the meantime, I want to thank our listeners for tuning in to the Merck manuals medical myths podcast. Be sure to subscribe to this podcast on Apple podcasts, Google podcasts, Spotify, or wherever you listen to, of course, be sure to check out part two of our discussion with Dr. Eli. Until then, I'll leave our listeners with the message we always do with Merck Manuals, medical knowledge is power. Pass It On.