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By: Caitlynn Iddings, MD

 You don't have to be a pediatrician to see the large impact the COVID 19 pandemic has been having on our children and teens. Multiple studies released over the past 10 months show that anxiety, depression, substance abuse, child abuse, and suicide attempt/self-harm are on the rise since March 2020. As a General Pediatrician I can attest to the large rise in office visits to address concerns of anxiety, depression, nervous tic disorders, and overall underachievement in school which has been ever more prominent even since school started back this fall. Of course, I don't think this really surprises anyone or should. In general, adults also report increased anxiety and depressive symptoms. I think personally as a parent I like to give myself the false reassurance that I have been superior in sparing my children from any excessive anxiety surround the virus, but let me be honest, kids are sneaky. Their presentation of anxiety and depression are not as typical as what we see in adults. 

Let me explain why kids may be more depressed and anxious than we realize and the science behind why this may be. There is a specific area of the brain known as the "Pre-Frontal Cortex" (PFC). This is the area of the brain that is responsible for multiple functions. It is the "football coach" or the "orchestra conductor" part of the brain. The most typical psychological term for functions carried out by the prefrontal cortex area is "executive function." Executive function relates to the ability to differentiate among conflicting thoughts, determine good and bad, better and best, same and different. It is responsible for recognizing future consequences of current activities, working toward a defined goal, predicting outcomes, knowing expectation based on actions, and social “control.” It allows the ability to suppress urges that, if not suppressed, could lead to socially unacceptable outcomes. 

Back before we better understood brain anatomy, doctors often would take the "clinically insane" person and do something called a frontal lobe lobotomy where they would scramble the forebrain or prefrontal cortex to make patients "more controllable." Sometimes lobotomy would leave a patient docile and childlike, with significant inability to care for themselves but often this would leave patients with a variety of issues including difficulty sleeping, apathy for previously enjoyed activities, significant personality changes, inability to sustain focus or commit things to long term memory, and increased reckless behaviors such as impulsive gambling, eating, thrill seeking, etc.  In depression not only is there under activation of the PFC across all age groups, but its volume has been found to be reduced as well in persons who are more prone to depression. A depressed person with an underactive prefrontal cortex of reduced volume is not going to demonstrate the rational problem-solving abilities of someone without such deficits—this causes the brain to have a reduced capacity to support resilience. 

Why does the prefrontal cortex matter specifically regarding kids, the pandemic, and mental health? The PFC is one of the last parts of the brain to physically mature. This is why a 4-year-old struggles with patience and the concept of "time" and why offering toddlers "delay reward or gratification" is rarely effective in mitigating undesired behaviors. For a toddler and young elementary school aged child, the ability to think days, months, or even years into the future is virtually impossible. This isn't for lack of intelligence but simply because their forebrain is still so relatively immature. So, if you tell your 4-year-old "Maybe next Christmas we will be able to go see Santa in person when Coronavirus is gone" they have no ability to conceptualize what a year from now means. They may start to ask you every day if it is next Christmas or if "coronavirus is gone yet" (if only, right?!?!). In their little mind it sets an unattainable goal that can lead to anxiety and sadness. In young kids the following can be signs or symptoms of struggling with anxiety or sadness:

  • fussiness and irritability, startling and crying more easily, more difficult to console
  • difficulty falling asleep and waking up more during the night
  • Feeding issues such as reflux, constipation, loose stools, or frequent complaints of belly pain
  • Increase separation anxiety, being more clingy, hesitant to explore and play 
  • hitting, biting, and more frequent or intense tantrums 
  • bedwetting or frequent accidents when they have previously been potty-trained
  • constantly looking for words or affirmation or urgently expressing needs while seeming unsatisfied when needs are met
  • And conflict and aggression or themes of illness or death during imaginative play time   

As we grow older our prefrontal cortex continues to mature, but there are plenty of studies that suggest the PFC does not reach full maturity until close to age 25 (especially in males!). Therefore, it doesn't matter how smart your middle school or teenager is or how high of a score they manage to get on their ACT or MAP testing. Good judgement is just NOT something they can easily excel in, at least not YET.  Studies show that as adults we tend to think or activate the prefrontal cortex, or the "rational part" of the brain and teenagers process more information with the amygdala or the "emotional part" of the brain. In adults the connections between these parts are well established but in teens those connections are still being made, and not always at the same rate for each child. Therefore, when we ask a teenager "What on earth were you thinking!?!?" we are often met with blank stares because it isn't as much about what they were THINKING as what they were FEELING at the time. They intrinsically lack a brake pedal when it comes the being able to stop and think though long-term consequences of their actions.  They are hopelessly "near sighted" beings. 

As adults we all recognize what it is to have a bad day. Overslept the alarm, late to work, bombed the big presentation, spouse calls upset because the pipes burst, the dog got hit by a car, daycare calls and the baby has a fever and needs picked up early. The rational part of the brain allows us to think more long term though. Adults who are not clinically depressed or anxious themselves know today was bad but tomorrow is another day and can be better. Adults can typically compartmentalize, adjust, and rationalize (assuming they have a healthy and functional PFC). When a teen has a bad day (failed their math test, got kicked off the basketball team, girlfriend dumped them, parents grounded them because they failed their test) thinking of the future can be a challenge. The ability to reason that a good day could be just around the corner is impaired and the perfect storm for impulsivity and overreaction is set up. This makes teens much more likely to act on thoughts of self-harm and suicide than their adult counter parts. All the big emotions in the moment can be overwhelming and without the appropriate support system, teens are struggling even more. 

Unfortunately, with the pandemic one bad day for most has become a string of bad days. Kids and teens have also had their social support systems ripped away by taking away in person school, in person sports, in person music activities, and in person religious group meetings. Most have been home, isolated, and lacking the ability to see a possible tiny light at the end of the tunnel. In teens a couple weeks of seeming down due to a perceived disappointing or bad event is to be expected.  But as a parent if you see a significant mood or behavioral change that lasts more than 2 weeks, it could mean something else is going on. Classic signs of depression and anxiety in older children and teens include:

  • mood changes that are not characteristic for your child including excessive anger or rage, irritability, increased conflicts or fights with family or friends
  • changes in behavior, such as stepping back from personal relationships. If your ordinarily outgoing teen shows little interest in texting or video chatting ‚Äčwith their friends, for example, this might be cause for concern.
  • a loss of interest in activities previously enjoyed. Did your music-loving child suddenly stop wanting to practice guitar, for example? Did your All-Star basketball athlete suddenly quit and refuse to go to practice or see their friend?
  • A hard time falling or staying asleep, or starting to sleep ALL the time
  • Changes in weight or eating patterns, such as "never being hungry" or constantly overeating
  • problems with memory, thinking, or concentration.
  • less interest in schoolwork and drop in academic effort
  • changes in appearance, such as lack of basic personal hygiene (within reason, a lot of teens are not dressing to the 9s for their virtual zoom classroom meetings)
  • increase in risky or reckless behaviors such as drug or alcohol use, sneaking out at night 
  • thoughts about death or suicide or talking about the world being better without them in it. 

 If you notice some of the red flag symptoms above in your child don't hesitate to reach out for help. School counselors and teachers may be helpful in gathering information as to the level of concern you should have. Ask your child if there is anything bothering them. Be willing to be a listening ear. Often times our impulse as parents it to immediately "try to fix" the problem presented but for teens they often don't want you to fix it.  They want validation that they are hurting or confused. They may not talk to you but may talk to a friend or another responsible adult (youth pastor, teacher, athletic coach) so sometimes reaching out to these people to see if there is any reason for concern and need for further medical or mental evaluation is key. The rule in pediatrics is that if you are worried or concerned as a parent, we as Pediatricians want to see you and your child and help evaluate what needs to be done. Remember depression and anxiety typically are multifactorial and therefore, require a multifactorial approach. Pediatricians have been equipped with validated screening tools and resources to get your child plugged in to a mental health provider or provide other medicines or therapy that could drastically improve your child’s overall mood and quality of life during this very stressful time. 

Lastly, it is time to destigmatize mental health issues as well. As a parent if you are open about the importance of mental health and supportive of your child it will make all of the difference in their ability to approach you or someone they know to ask for help. If a child has a sore throat and fever and gets brought to the doctor and diagnosed with strep throat, they would get medicine to treat the symptoms and also help clear the infection because it is understood that untreated strep throat can be potentially deadly or have life-long consequences. If a child is severely depressed or anxious it should also be encouraged to bring them in to get them therapy or possibly medication that they need to prevent potential deadly or life-long consequences.

All kids need to learn how to cope with challenging things. One of the best possible gifts a parent or care giver can give to a child is to allow them to learn coping skills. These are things all people have to learn eventually to be capable and productive members of society. I always say it is better to learn these skills when you are 10 years old and have fewer responsibilities than when you are 20 or 30 or 40 years old. It’s about equipping kids to be resilient and giving them the mechanism to excel even when their prefrontal cortex has not quite caught up yet.  COVID has taken so much from us as a society. It is time to start regaining ground and getting kids the help they truly need to come out of the other side of this pandemic with less trauma and less baggage. But no one can do that alone, it takes a team, and we have a pretty spectacular team of people waiting to give kids the tools they need. Give us a call to schedule an appointment so we can help!

 References:

·         https://www.healthychildren.org/English/health-issues/conditions/emotional-problems/Pages/Childhood-Depression-What-Parents-Can-Do-To-Help.aspx

·         https://childmind.org/article/signs-of-depression-during-coronavirus-crisis/

·         https://www.psychiatrictimes.com/view/new-findings-children-mental-health-covid-19

·         Duan L, Shao X, Wang Y, et al. An investigation of mental health status of children and adolescents in china during the outbreak of COVID-19. J Affect Disord. 2020;275:112-118.

·         Loades ME, Chatburn E, Higson-Sweeney N, et al. Rapid Systematic Review: The Impact of Social Isolation and Loneliness on the Mental Health of Children and Adolescents in the Context of COVID-19 [published online ahead of print, 2020 Jun 3]. J Am Acad Child Adolesc Psychiatry. 2020;S0890-8567(20)30337-3.

·         https://www.neuroscientificallychallenged.com/blog/2014/5/16/know-your-brain-prefrontal-cortex

By Scott Tracy, MD, FAAP
January 24, 2019
Category: Uncategorized
Tags: Untagged

Depression and suicide are difficult topics to think about but in today’s world it is a very important topic to discuss. We must recognize that teenage suicide has become a bigger public health concern over time. It is the second most common cause of death in persons ages 10-24 years and the rates are on the rise. Studies show that the rise of smartphones and social media are contributing factors for this increase. Now don’t get me wrong, I use technology as much as anyone else and it is a wonderful thing to an extent. Social media and cell phones have led to sleep deprivation, cyberbullying, and FOMO (fear of missing out) in young people who dont understand how to develop healthy boundaries. This can quickly lead to thoughts of depression and anxiety. One study showed that the teens who spent a significantly higher amount of time on their phone were 70% more likely to have suicidal thoughts than those who spent the least amount of time on their phones. So if you have thought of limiting your childs screen time, this should be the motivation you need to act!

We take our patient’s mental health seriously at PAA and you may notice that we are handing out a short questionnaire at your adolescent’s checkups (12 and up). We are screening for depressive symptoms that may not otherwise be recognized. Your child may get a longer questionnaire if they screen positively on the initial questionnaire. Please allow your child to answer these in confidence and if you get the sense that your child would be more likely to open up to us without you in the room, feel free to excuse yourself to the waiting room. 

What should you do if you suspect that your child is depressed or suicidal? Look for the following symptoms: excessive sleepiness or insomnia, loss of joy in previously enjoyable activities, appetite loss, decline in academic performance, or dramatic personality changes. If your child is actively suicidal, you need to seek immediate attention for them at an emergency room or inpatient mental health facility to keep them safe. If you suspect that your child is struggling with depression, try to talk to them about it. We are happy to have you come and talk to us about these issues or concerns in the office as well and we can help get you connected to mental health experts. Medication can sometimes be indicated for these issues but getting in to therapy and counseling is the way to find the root of the problem and to work towards curing the illness. Also make sure that you safely secure anything that could be used as a weapon in the house (guns, knives, etc). 

So what can you do as a parent to help your child? Be open and honest with your child. Let them know that perfection is not expected of them and that it is ok to not be ok. Most importantly of all, be available, attentive, and a good listener. Put down the phone, turn off of the TV, and be fully present to have a serious discussion with them. Teenagers may act surly and grumpy but deep down they are craving for acceptance and attention as they figure out their place in the world. Your job as a parent is to be able to help support, encourage, and guide them.

Depression and suicidal thoughts are something to take seriously in adolescents and it can be difficult to tell if an adolescent is struggling with this. In a recent study, as many as 18% of adolescents reported to have seriously considered suicide. That’s almost 1 in 5! The study also found that over 50% of parents were unaware of their adolescent’s thoughts of suicide. It is difficult to help your child fight a battle when you are not even aware there is a battle to be fought! With the appropriate recognition and willingness to talk to your child, I believe that this statistic can be improved. So keep an eye out and be aware that our adolescents need us to be ready to jump in to the battle and help them fight more often than we think!

If you or someone you know is struggling with depression/suicidal thoughts, please use the following resources for help and information  www.suicidepreventionlifeline.org or call the National Suicide Prevention Hotline at 1-800-273-TALK (8255)

By Scott Tracy, M.D., F.A.A.P.

 

Resources:

Parent-Adolescent Agreement About Adolescents Suicidal Thoughts, Jason Jones et al, Published in Pediatrics 1/2019

Increases in Depressive Symptoms, Suicide-Related Outcomes, and Suicide Rates Among U.S. Adolescents After 2010 and Links to Increased New Media Screen Time, Jean Twenge et al, Published Clinical Psychological Science 11/2017

When I was in fifth grade, a friend and fellow classmate came down with hepatitis A.

I knew that he enjoyed exploring the sewers around his home looking for lizards.

Since there was no vaccine against Hepatitis A at that time, I had to have a big shot of immunoglobulin to prevent me from catching it from him.

Fortunately, we now have a vaccine against this incurable condition that has afflicted Kentucky especially hard this year.

Hepatitis A is caused by a virus that attacks mainly the liver. It is caught by exposure to the bowel movements of those who have the disease.

An infected person not washing his hands properly and then touching food that others eat is one of the main ways that this happens. Water and other items can also be contaminated with the virus.

The hepatitis A virus can survive freezing. Food needs to be heated above 185 degrees for at least a minute to kill it.

Properly chlorinating water and using an appropriate fresh bleach solution on surfaces also can destroy it.

Symptoms of hepatitis A include fever, fatigue, nausea, vomiting, joint pain and loss of appetite. Jaundice, where the skin or eyes turn yellow, can also occur.

Bowel movements can become clay-colored, and the urine can become dark if this happens.

Younger children may not have any symptoms with the infection, but if they do, symptoms more commonly include severe stomach pain and diarrhea.

There are usually 2-6 weeks from exposure to the time any symptoms of the disease start showing up.
Symptoms can last anywhere from less than 2 months up to 6 months in some people. On rare occasions hepatitis A can cause liver failure and death (mostly in older people).

Although there is no cure for hepatitis A, it can usually be prevented. The vaccine against hepatitis A is routinely given to toddlers but can be given to most people a year of age and older.

The vaccine consists of a series of two doses given at least six months apart. Side effects include local reactions with redness and tenderness, a low-grade fever, headache and fatigue.

For those who have been exposed to a known case, the vaccine can be given to those up to 40 years of age.

This usually will prevent the person from coming down with the disease if given in time.

Immunoglobulin injections can be given to those less than a year of age and those over 40, as well as for a few higher-risk groups.

Dr. Charles Ison, F.A.A.P.

As seen in October 2018 issue of Lexington Family Magaizine 

 

August 28, 2018
Category: Uncategorized
Tags: Untagged


 

Keeping your children safe is not only a parents, but also a pediatricians, number one priority. One of the most important areas to review safety and ensure you are doing everything you can to protect your child is in the car. 

Why is this so important?

According to the Kentucky Office of Highway Safety, combining all unintentional injury deaths among those between 0 and 19 years, motor vehicle traffic–related deaths were the leading cause. Each year thousands of young children are killed or injured in car crashes. In 2015, 31 children age 15 and under were killed in motor vehicles on Kentucky roadways. 55% of those were unrestrained.

- Research shows that REAR-facing child safety seats are over 70% more effective in reducing fatal injury. That means it is over 5 TIMES SAFER to be REAR-facing! Check your manufacture guidelines to see how long your car seat can be rear facing. Not only are rear facing car seats improving safety, but appropriate front facing car seats and booster seats lower risk of injury by up to 60% in comparison to a seat belt.

How do I choose a seat?

- You will find many different car seats to choose from and you can spend countless hours reading about each of them. No one seat is considered “the best" or "safest." The best seat is the one that fits YOUR child's size, is correctly installed, fits well in your vehicle, and is used properly every time you drive.  Educate yourself on what type of seat you are looking for and the manufacturer guidelines of height and weight. The following are different types of car seats you will see as your child grows and general guidelines of when to use each of them.

Image result for types of car seat

The following is quick, helpful information for common questions regarding car seat safety:

1. MIDDLE of the BACK seat is the safest place to ride for all children younger than 13 years. Sometimes it is difficult to install a car safety seat tightly in the middle. If the vehicle seat is narrow or if the vehicle does not have lower anchors for that seat, it is safest to put the car safety seat in a position where you can install it tightly with either the lower anchor system or seat belt; in some cases, this may be on either side of the back seat rather than the middle.

2. Place the harnesses in your rear-facing seat in slots that are at or below your child's shoulders. Ensure that the harness is snug! You should not be able to pinch any slack between your fingertips. Ensure the chest clip is in the center of chest, even with the child's armpits.

3. Bulky clothing, such as winter coats or multiple layers, can compress in a crash and leave the straps too loose to restrain your child, leading to increased risk of injury. Ideally, dress your child in thinner layers and wrap a coat or blanket over the buckled harness straps to keep them warm.

4. Even if you have a larger toddler, it is much safer to ride rear facing up to when your car seat's manufacture requirements for height/weight will allow. Do not change them to front facing because you fear they are uncomfortable. Children's joint spaces are not completely formed and they are actually very comfortable riding with their legs bent.

5. If you are unsure if your car seat is installed appropriately, go to your local fire department and they will ensure it is installed correctly. Read your manufacture installation guidelines to help you with a step by step process to ensure correct installation. You may want to call the fire department first as not every station offers this service.

6. Your child can safely use a seat belt when you can answer YES to all 5 questions below!                                                                                                                                     

    1. Can your child sit straight against the back of the vehicle seat?                                                                            

     2. Can your child’s legs bend at the knee on the edge of the vehicle seat?                                                                 

    3. Can your child sit comfortably in the vehicle seat without slouching for the whole                                                                trip?                                                                        

    4. Does the lap portion of the seat belt sit down on your child’s hips, touching the thighs?                             

    5. Does the shoulder belt stay at the center of your child’s shoulder, crossing the collarbone?  

- Check out the following websites recommended by the American Academy of Pediatrics for further information: www.seatcheck.org. http://thecarseatlady.com/. www.healthychildren.org

By: Dr. Ashley Meenach, F.A.A.P.

References: https://www.aap.org, www. HealthyChildren.org, https://transportation.ky.gov/HighwaySafety

 

 

Let’s face it, we are in the age of technology and it is rapidly evolving. From tots to teens, kids are exposed to a multitude of electronic devices on a daily basis. While media can provide benefits including exposure to new ideas, a wide array of easily accessed knowledge for learning and increased opportunities for social contact and support, there are many negative side effects that can occur if used in excess or inappropriately.

As not only a pediatrician but also a mom, it is my job to keep up to date on technology, help educate parents on safety and how to develop healthy media habits early on. Most parents did not grow up with a cell phone and often feel “technologically challenged” when trying to work one or figure out what your child is doing on their devices. So, it is important to educate yourselves, so you can educate your child!

The American Academy of Pediatrics stands firm on their guidelines for media use in the home and can help guide a parent over when and how to introduce it.

-For children younger than 18 months, use of screen media other than video-chatting such as facetime should be discouraged.

-Parents of children 18 to 24 months who want to introduce digital media should choose high-quality programming/apps such as PBS, Sesame Street, ABC mouse, ect. for no more than 1 hour per day. Parents should use them together with children as opposed to independently, as this is how toddlers learn best.                                                                                  

 -For school aged children, media limits should be set and are dependent upon types of screen time being used. Co-view with children to promote learning and safety. Ensure 1 hour of exercise and 8-12 hours of sleep are achieved daily.

Why do we care? Brain development in the early years is enhanced by hands-on, unstructured, and social play to build language, cognitive, and social-emotional skills. Researchers have found that children with excess media exposure can have negative consequences long term. These consequences include behavior problems such as issues with attention, language and impulse control as well as delays in learning and social skills, sleep and even obesity. For example, a recent study in children aged 2 found that a child’s body mass index increased for every hour per week of media used. In adolescents, watching between 1-3 hours of media daily led up to a 27% increase in risk of obesity.

While we can better control what media children are exposed to early on, it becomes harder as they grow older. Not only TV but apps such as Twitter, Snapchat, Instagram and Facebook, etc. create different exposures and challenges for teens.  Presently, over three-quarters of teens report having their own cell phone and 76% of teens have at least 1 social media site. Four out of five households own a gaming device and 84% of them report playing a video game online via cell or gaming device.  Being exposed to social media sites and the internet in general may lead to exposure to alcohol, tobacco, sexual behaviors, violence, self-harm and disordered eating.  Exposure may lead to earlier initiation of these behaviors. For example, “Sexting” is sending/receiving inappropriate nude images or messages. It is estimated that approximately 12% of youth aged 10 to 19 years of age have sent a sexual photo to someone else.

Children today are growing up in an era of highly personalized media so parents must develop personalized media use plans for their children. Those plans must account for a child’s age, health, temperament, and developmental stage. Research shows that children and teenagers need adequate sleep, physical activity, and time away from media. Some of the following are examples to create a healthier media environment for your home:

  • Teach the value of face-to-face communication and be a good role model for your child. For example, have family dinners without electronics. You will be surprised how much more communication takes place without this distraction.
  • Sleep electronic free. Have a re-charge station that everyone puts their electronic devices into 1 hour prior to bedtime. This allows everyone, including your device, to re-charge overnight.
  • Families that play together, learn together! Keep electronic devices in an open room where family is present. Have your children show you what they are looking at on their device to help facilitate discussions and answer any questions they have.
  • Teach safety of electronic devices to your children. They underestimate the value of privacy and often lack the knowledge to understand the consequences of apps that detect locations or expose them to potential sexual predators online.
  • Use websites like www.commonsensemedia.org to help identify appropriate and safe apps for your family. 

 

 

By: Ashley Meenach, DO, F.A.A.P

American Acedemy of Pediatrics, www. aap.org





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