Lisa Goldstein, MD Child and Adolescent and Adult Psychiatrist

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1 Lisa Goldstein, MD Child and Adolescent and Adult Psychiatrist Past President, Pennsylvania Branch of the International Dyslexia Association April 2018 No disclosures, No conflicts.

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3 When Learning and Emotional Needs are Intertwined Attention, Anxiety and Mood in children with Learning Differences

4 But my child already has a learning disability You want me to see a what? Of course he s anxious/depressed, who wouldn t be? We don t need a therapist/psychiatrist! my child needs to learn to read!

5 But life is complicated! more than one diagnosis is common treat what you can treat don t leave anything on the table make life easier

6 It might not be an illness or disorder a child who is failing can be demoralized a child who is disengaged or bored may look inattentive a child who is acting up, being the class clown may be covering and look like they have ADHD or are oppositional bad is usually better than dumb a child who is avoiding school, may be avoiding a place where they can not be successful 6

7 The job of a student is to go to school when they can t do that as well or as easily or just like everyone else then there are consequences 7

8 If you are lucky! 1.identify the learning need 2.apologize for not teaching them the way they learn 3.give them the services they need 4.the apparent psychiatric symptoms go away 8

9 Usually learning and emotional needs are intertwined 9

10 You can t wait for one to get better before you treat the other you can t treat one without the other you need to treat them both at the same time 10

11 Why don t people get mental health treatment? 1. Awareness 2. Access 3. I don t believe in that! (mental health, medicine) 4. Stigma / Shame 5. Isolation

12 Combat stigma and isolation one family at a time!

13 Ask yourself - is there more going on? is your child making progress? enough? are they benefitting as much as they should from intervention? are they suffering? what do they have to lose?

14 How would you feel if your child s life was easier? even if they still had a learning disability?

15 So what else can you do? Treat the other things they have!

16 We know how to treat: ADHD Anxiety Depression This could make your child s life better, and will likely make learning easier!

17 ADHD common things occur commonly 5%of kids have ADHD BUT 30% of kids with Learning Disabilities have ADHD and 30% of kids with ADHD have learning differences not all inattention is ADHD 17

18 ADHD Attention (with or without hyperactivity) Hyperactivity Impulsivity social skills weaknesses 18

19 Anxiety (of course it makes sense) 10% of kids different flavors at different times 19

20 Depression (is relatively less common) vs. demoralization (which is more common) 20

21 Intertwined! 21

22 A child s job is to go to school! It is more difficult to treat their depression or anxiety before they are experiencing more success and receiving adequate support in school 22

23 A child s job is to go to school! Your child can not learn optimally if they have ADHD, Anxiety or Depression that is not being treated 23

24 Treatment (in no particular order) Medicines 24

25 ADHD Medicines 70% of kids will respond to the first class of medicines you try Ritalin (methylphenidate) Adderall (mixed salt of amphetamines) Intuniv (Tenex/guanfacine) or Kapvay (clonidine) Straterra (atomoxetine) 25

26 ADHD stimulant common side effects Sleep > melatonin? appetite > ice cream? ask your doctor! 26

27 Anxiety and Depression Medicine: SSRI s (selective serotonin re-uptake ihibitors) We use the SAME first line medications for treating Depression and Anxiety and PTSD

28 SSRI s Prozac, Zoloft, Celexa, Lexapro Try 2

29 SSRI side effects The most common side effects are GI side effects sexual side effects are common - talk about it! wait to to increase the dose until the side effects have gone away BLACK BOX warnings and the risk of suicide

30 SSRI s are not the only antidepressants BUT SSRI s are the only medications with evidence for treating depression/anxiety in children and teenagers

31 How do you know when to get treatment? Anxiety and Depression Treat when symptoms are interfering with functioning Life, school, relationships Treat when your child is suffering and treatments can make life easier Treat when your child needs treatment to access their education

32 I love treating Anxiety because it responds to treatment! People get BETTER! In most cases, start with a specific kind of talk therapy - Cognitive Behavioral Therapy - CBT Collaborate with the therapist to decide if and when to start medicine SSRI s + CBT is often more effective than either alone

33 SSRI s for Anxiety SSRI s are the same as for depression combination treatment: CBT + medication anxious people are often very sensitive to side effects - use them more cautiously start low / go slow

34 How long do I treat? Treat for 6-12 months from the time you are in full remission remission not just response is the key - the goal is to be all the way better Timing matters - don t stop medication at stressful times

35 How to stop? Do it with your doctor! If you stop abruptly you will usually experience withdraw symptoms by the third day upset stomach, anxiety, suddenly worse mood, even thoughts of suicide - your teen won t do it too often! When you are ready to discontinue, do it slowly. Depending on the dose, I might taper by half of the smallest pill monthly. Adequate treatment to remission and slowly tapering off will decrease the risk of relapse

36 Treatment does NOT have to mean medication!

37 Don t forget psychotherapy! Cognitive Behavioral Therapy (CBT) is an evidence based treatment many therapists use some CBT your thoughts and your behavior change your feelings so learn some new behaviors (skills) and learn to challenge your automatic (negative) thoughts

38 CBT CBT is the evidenced based treatment for OCD there is evidence for CBT for Anxiety and Depression there is evidence for CBTi for insomnia there is evidence for trauma focused CBT CBT + Medicine for Migraine is the evidence based treatment in children and teens

39 other Psychotherapy CBT is NOT the only kind of therapy find what works for you and your child families sometimes needs help if your therapist is older, like me, we might not give it a name research shows that talk therapy and what good therapists do is more similar than different (BUT use CBT for anxiety/ocd)

40 Supplements The evidence for supplements in mental health is not very strong, but I use them (The placebo effect in children and teens is strong) Fish Oil / Omega 3 fatty acids with more EPA than DHA, 1-2 grams per day, in the fridge for fishy burps ( a new prescription form Vayarin) Vitamin D3 (with or without checking a level first), IU per day Deplin to augment antidepressants (methylated folate)

41 SLEEP If I could treat only one symptom. I would target sleep there are so many reasons that better sleep improves life, attention, mood, anxiety

42 SLEEP there are MANY treatments sleep hygiene CBTi OTC Melatonin tenex and clonidine (especially with stimulants)

43 Sleep Hygiene go to sleep and wake up at the same time every day have a relaxing bedtime routine no screens a half hour (one hour!) before bed try a healthy snack with a little carb and protein (milk and cereal, peanut butter and banana) read something boring enough (books on tape) listen to something relaxing (music, meditation, podcast Sleep with Me)

44 Exercise = PLAY Exercise!!! 30 minutes of exercise 5 times a week is as good as medication for mild to moderate depression and the a great way to manage anxiety and improve attention RECESS!!!

45 Focus/relaxation/acceptance mindfulness based meditation biofeedback yoga relaxation guided meditation

46 Keep our brains SMART S - sleep M - meals and fluids A - activity/exercise R - relax T - triggers thank you to Dr. Christina Szperka, CHOP Headache Center

47 Technology It s not all bad: binge watching and breathing Online communities can provide comfort, connection and information (Tumblr) Find a relaxation or breathing app or create a relaxing play list My app suggestion - HeartRate+ Coherence - trains heart rate variability theoretically increases parasympathetic tone (rest and digest) and decreases sympathetic tone (fight of flight) paced belly breathing (6 per second/prolonged exhale)

48 Technology but games are created to be addictive what kind of brain does your child have? BE CAREFUL! 48

49 When should you consider a psychiatrist? If you are worried about your child s safety When you are not sure what is going on When you have multiple co-morbid diagnoses - for example tics, ADHD and OCD or Anxiety and ADHD. When there is a strong family history of bipolar disorder or concern about mood swings

50 Remember this is a child There is more to life than reading! What is your child good at? What gives your child joy? 50

51 There is more than reading with your eyes and writing with your hands! VOCAB Haiku 51

52 Do what works for you! don t be afraid to try new things don t keep it a secret give back (lemons into lemonade!) Thank you to PBIDA! - that s how we give back

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Depression and Anxiety in

Depression and Anxiety in Pediatrics: A Primary Provider Focus JOSEPH BECKER DO FAAP SPRING 2017 NJSSNA Disclosures No financial disclosures I am a Pediatrician not a Psychiatrist I am married to a nurse