Kids' mental health looks different now than it did a decade ago. More kids are struggling with anxiety, OCD, and ADHD, and parents are often unsure whether what they're seeing is normal or something that needs professional help.

In this episode, Dr. John Parkhurst, a child psychologist at Northwestern, helps us understand what's really happening with kids right now. He explains why anxiety spikes during puberty, how to recognize the difference between typical worry and an anxiety disorder, and what sets anxiety apart from OCD. We also talk about ADHD, executive function, and the treatment options that actually work from therapy to medication to combined approaches.

As a child psychologist with expertise in anxiety disorders, he's worked in this field for over a decade and conducts research on how to help primary care physicians better identify and treat mental health challenges in kids. In this episode, we get into the specifics of what anxiety actually looks like, how it differs from OCD, and why the distinction matters for treatment. We also discuss ADHD, the role of hormones during puberty, and what the research shows about which treatments work best.

Highlights

• Anxiety in kids shows up differently than you might think. It can look like avoidance, freezing, or kids getting reactive and emotional, not just saying they're worried.
• The difference between anxiety and OCD matters for treatment. Anxiety is a global worry response, while OCD is specific intrusive thoughts paired with compulsions.
• Anxiety spikes during puberty, with generalized anxiety disorders commonly emerging around ages 8-12.
• Cognitive behavioral therapy and medication are both effective treatments for anxiety and OCD. Combined treatment often works better than either approach alone.
• ADHD is harder to treat with therapy alone. Medication is typically more effective, but environmental structure and parenting strategies also matter.

If you're seeing signs of anxiety, OCD, or ADHD in your child, remember that these are treatable conditions. Cognitive behavioral therapy and medication are evidence-based options that work. Talk to your pediatrician or seek out a child psychologist who can help you figure out the right approach for your child.

Understanding what your child is experiencing is the first step. If you've found this episode helpful, please subscribe so you don't miss upcoming conversations that matter to you and your family.

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Hey y'all, it's me, Dr. Smeena Raman, Gyno Girl. Welcome back to another episode of Gyno Girl Presents, Sex, Drugs, and Hormones. I'm Dr. Smeena Raman. I've been thinking a lot about where we are in life these days and in this part of our history, where we have many generations in the same household going through massive changes from a mental health perspective, massive hormonal transitions that are happening at the same time. I always joke that...

with my husband that like, you I'm in perimenopause and my kids are going through puberty and that's why we're clashing each other left and right. But I think there's some huge dynamic shifts that happen with estrogen, testosterone, how it's working on our brain and how it works on our development. And we're also on top of that seeing a true mental health crisis with our kids in this country related to all the stresses that we see between, you know,

this rush of activities and try to get into certain colleges versus alcohol drugs being involved versus anxiety and depression related to social media and who knows what AI is gonna do to us. So today I'm so happy and excited to welcome Dr. John Parkhurst who is a child psychologist at Northwestern. He's gonna help us make sense of all of this and full disclosure, he is my kid's therapist. So he's not allowed to say it but I will.

Thanks.

Thank you, John, for being on my podcast. Welcome.

Thank you.

So, don't, know, like my tagline is, or my name is the gyno girl because, you know, my kids and my husband love superheroes. But we also love a good origin story. I always want to know like what draws people into the work they do. So like what brought you into the world of child psychology? What was like your entrance into this arena? Because I think it takes

a real special person to deal with some of the issues when such vulnerable populations are really experiencing them.

I appreciate this question.

And along the lines of a good origin story, think a lot starts with your parents and for me it was my mom. So I grew up in a, as an only child and my mom worked really hard and she was a special educator. And so I had a lot of early exposure to working with kids with differences, including autism, learning disabilities, ADHD. And from that, I kind of took those interests in working with those populations and kind of being able to kind of sit

Yeah. Yeah.

with some of the challenges that these families experience, but also try to help navigate some of those challenges to kind of improve trajectories. And I think that was really what was the tip of the iceberg into kind of child psychology and learning about how do we work with children and families to kind of address some of these.

whether it's mental health challenges or differences or disorders, how you wanna think about it, but really help people kind of get to their best state, the state that they wanna get to.

Yeah.

You know, it's interesting. had a patient just tell me yesterday about her childhood traumas that she was experiencing. She's in her mid 50s, so she grew up in the 80s. And just how, you know, the trajectory, like I think with all the traumas that we see, you know, things happening socially and whatever, you know, she told me that her trajectory totally changed because of the openness of her parents to the fact that, yes, I was, you know, she was sexually abused and she finally told her parents about it. And instead of

of like in the 80s when you might've been like, no, we're not gonna talk about it. You're gonna just keep it inside. They got her right into therapy. And I think that like, it was, she's a different person today because of that interaction and interjection earlier on. And so I think that speaks volumes to your parents even to really open you up to this world of helping people that struggle on a day-to-day basis.

Do you see, I mean, how long have been practicing for?

it's 12 years I think, 10 to 12 years, out of fellowship at least.

Yeah.

And so do you think, have you seen a difference in the last, like from when you started to now, like, cause probably in the last decade or so there's been more uptake of social media, more uptake of like, you know, other social issues that kids that, you know, COVID we can talk about separately as well, but have you seen a big change in how things are clinically with the kids that you take care of? Like.

Yeah, and I think it reflects what you were saying too, Samina, which is...

There is also an increased awareness, I think, now for families and children to be able to talk or start to bring some light to mental health challenges, which is for the longest time really lived in the dark, right? They've just not been something that families talk about and certainly there's some cultural implications to this, I think because it's more talked about now, that it's allowed for some of these conversations to happen.

And then I think you're absolutely right that there has to be an element of this massive social experiment that we've been undertaking related to technology and social media and how that certainly churns and sometimes plays upon some of the challenges or what we might even expect for our adolescents to already have to go through and deal with is, I'm sure we'll talk a little bit more about this later, but we recognize kind of that the adolescent brain maybe is not always

equipped to make the best decisions or makes emotional decisions. And also it's kind of has maybe an over emphasis on what others are thinking, especially in adolescence. And then when you add this full access to how other people are viewing and perceptions that you might be kind of reflecting from the internet and or like, you know,

different medium, I think that it brings up the big question about how much this hit is related to some of these external factors are related to anxiety or what we see as kind of like more overt anxiety symptoms or more discussed anxiety symptoms because the prevalence, know, yes, there's maybe some increase, but it's hard to, you know, nail down a specific cause.

we're discussing.

Yeah.

because of the taboo around it for so long. Yeah. No, I want to get deeper into that in a little bit, but something you said just sparked a question for me. When you talked about like you're dealing with, you know, kids that were neurodivergent or autistic early on. I mean, that question would hold true, true. Like, you know, we hear a lot more about autism. We're seeing probably, you know, larger number of kids being diagnosed with it, not necessarily a larger prevalence of it, because there's probably some that have been,

underdiagnosed. So I guess the first question is, do we know what causes autism? Is it Tylenol? No, just joking. No. In the OB-GYN, I'll say it's not Tylenol.

Definitely. I mean, again, it makes it so challenging where we can kind of where people can build some spurious claims because it feels like there's this mystery around.

some of these disorders, which is why I'm so incredibly hopeful for our advances in genomics, right? And what we're able to do, not just in terms of treatment, but a better understanding of the gene culprits and what is turned on versus what's not turned on, and how the environment can play an impact of what genes are expressed. But I think there's, I think, you know, more to like the practical point of this, the thing that also doesn't get talked about within autism

autism in particular, well just staying specific to autism is that the diagnostic code has also shifted, you know, in this time. So what you're doing is you've kind of described a population and then you've also expanded the range of how people can fit within it and kind of describe it.

Mmm. Yeah.

Right. Because it's huge range, right? Right.

broadly. Yeah. As it kind of went from a single disorder to a broader spectrum of disorders, right? And so I think that in addition to like community awareness, I think has resulted in some of this escalation of maybe the process.

Yeah. And I think that we see associations like, you know, know in the OB literature, there's associations in like paternal age and associations with, know, spectrum disorders. But again, we can never say causation. I think you're right. It's probably multifactorial.

there's multiple concerns around it. Is the way that we're kind of swallowing on the topic of sort of autism spectrum, is there a way that we're dealing with it now, like from a treatment perspective that's really different than in the past? Like, I think there's just been such a vast, and I think there's so many different types of autism that we're dealing with that, but can you speak to how we are dealing with treatment nowadays?

Yeah.

Well, you I think what you just pointed out, too, is I think families for a long time have had this experience of, we've just got somebody in our family who's quirky that we've never called, you know, autism or autistic. And so I think now we're kind of our language has become more medicalized. And so that is, think, part of this broader shift, too. But to your question about treatment, I think we are. You know, it's been interesting for me. This is not the world that I

Right. Yeah.

Hmm.

you know, spend the most time in. I'm speaking kind of just what I see in the community.

And what we're seeing is that because we've expanded this range, there's also a heavier need for services and services that have been designed for individuals with autism. There is some pushback around what are best approaches, but started for our kids that were very much at the level three, level two, which is like higher severity autism. So like what you kind of hear about is like applied behavior analysis. And so those treatments were really started around kids that had

more severe levels of autism have now been expanded. But, you know, it's kind of gets a bad rap in some ways because people think, you're just like training a specific action, really essentially, really true behaviorism. And you're trying to help an individual produce a, you know, a desirable outcome if you can do well.

of your porn sky.

And I think some opponents to this treatment will kind of say, like, are you trying to shape them into social norms? Are you trying to shape autistic people into social norms or people with some level of autism? And so it ends up in some degree of a kind of a culture clash, as we've seen with other disorders in the past. It's an interesting discussion.

Yeah.

Yeah, no, that's very true. Yeah.

Well, I wanted to talk to you about something that I see my patients struggling with a lot and truthfully myself as someone that's in period menopause and we know that, you know, our brains are so dependent on our hormones, estrogen, testosterone plays such a big role, you know, and so as women in middle age really have a collision of things happening where their, you know, hormones, their estrogen levels become more erratic. Their sleep deprivation becomes a real issue because of

various stressors in their lives. might be in the sandwich generation of dealing with kids and their parents at the same time of dealing with careers and husbands or divorces or whatever. So think it's a very stressful time for everything to collide. But then you see the same thing happening, you know, with kids going through puberty. Do you see sort of an uptick in anxiety during that transition? Like in general, do you see more anxiety OCD kind of present itself in this population? How much do you think we're

play a factor.

well...

Guessing how much hormones play a factor. I'm not sure I'm equipped for putting a stamp to that, but I will say that prevalence rates, you think about like anxiety disorders, and I think about anxiety sort of broadly, I think maybe a best way to do this is thinking about it along a chronological spectrum. the earliest presenting, typically the earliest presenting anxiety is sort of separation anxiety disorder. And what you think about with that is your kids that have a hard time transitioning

the school that have this like fear reaction to new places or novelty or new caregivers. And then the next, and that's typically occurring around this like six to eight window when they're more commonly diagnosed or identified with separation anxiety. And somewhere in there is also like this six to seven window, you're more likely to also see specific fears or phobias. And so these are big reactions to small stressors. So think about the kid that is worried about being

Yeah.

and has a big reaction to bees. that's kind of common also in this early age group. But right along the time that you were talking about, which is this, like the kickstart of hormones and testosterone for boys and estrogen for girls is this increased prevalence of anxiety disorders, specifically generalized anxiety disorders, which start to come online kind of in this, like, I think about it as like an eight to 12 span. And that's what I see the most clinically.

but you start to see this emergence of these like worry warts if that makes sense. So we do think there's there has to be a relationship with how our brain is taking in information and then how our brain is also reacting and what's what you know how these hormones are functioning within our body. And just to finish that that thought you know if we think about social anxiety which is most commonly identified around like this 12 to 13 but this middle school to early high school

Yeah.

period, think again this all lines in like a very tight window around when our kids are also maybe kind of getting doused with some of these these hormones.

Yeah, no, that's true too. And so what should like...

So there are a lot of parents out there that might not be even aware of, you know, if their kids are anxious or not, or, you know, what kind of anxiety they're experiencing. We'll talk about OCD separately. But I think, you know, what I see sometimes is, you know, because it also depends on how they grew up, right, and the culture that they came from. you know, in my parents' immigration culture, you you don't talk about mental health stuff that's like, you know, soft science or whatever, you know, whatever. You just don't mention it. It's not talked about.

And so, because I remember even when I talked to my dad about my kids and he was like, you're making too much of this, you know, it's not a big, you know, and I'm like, no, but when your kid comes to you and distress, you have to act on it one way or another. But I think that like,

how like how so first of all how how can some of the parents identify if they're not familiar with sort of these social anxieties or generalized anxieties are there cues that they could start seeing in their behavior and then the other question is like what's the best way for them to support it before they get into any kind of treatments?

Yeah, you made it a point earlier and I will emphasize this is that I think knowing yourself as a parent I think is a great starting point which is if you already know that like maybe you've experienced anxiety in your life or

you know, kind of emotional control or volatility is just kind of how you react or how you do, see even how we do with sleep deprivation. I think helps us understand how we have to practice our parenting. I kind of say that like a practice sense because I think we're all in some level of practice. think about myself as trained in this field, but as always kind of thinking about trying to be reflective of my own parenting and what I can adjust. like, so if you already, and I talk, I do a lot of work with

Mm.

Yeah, yeah.

Sure.

pediatrician. you already know that you've got a family member, a first-degree family member in particular that's experienced anxiety, then we probably have a higher likelihood that this child might experience some level of anxiety. We have to be a little bit more sensitive to how we would get ahead of this or address this for our family. And if we're thinking about anxiety globally, probably the most simplistic way to kind of describe anxiety responses is the fight-flight-freeze that everybody's kind of heard is these responses.

So, and this I think is interesting to point out. So the most common one that we think about with anxiety is this flight, which is kind of avoidance, right? Like if something is scary or you're scared about it, you're gonna resist it or not wanna do it. Think about like the kid that doesn't wanna get dropped off or get daycare. And oftentimes this is very temporal and short lived in kids. Like to be scared or nervous about

that something is very normative, but how long it lasts, especially if we know we've got a family history of some anxiety, how we can educate the parents on how to address that. And then I'll also point to the fight and freeze, because we certainly see our kids that get kind of deer in the headlights kids, response. And then what often doesn't get talked about and just gets looked at as bad behavior is some of our kids that are anxious are reactive. You know, they get really emotionally

know, disranked. And so I think we can sometimes just look at that as like bad behavior or tantrums or things like that which might be appropriate but we also have to be thoughtful about understanding it potentially from an anxiety point as well.

next week.

And so when it becomes sort of debilitating, because I feel like, you we all get anxious about things before tests and going out to meet new people or whatever. And I think those are more normal. if it becomes sort of debilitating to your kid or they're not leaving or they're not able to function in their normal capacity, what's a standard? I mean, I guess how what's the best treatment in terms of anxiety in those situations? And you can talk about both medical treatments and more like cognitive behavioral stuff that you might be doing.

Yeah.

Yeah.

Yeah. Well, so, you know, I think we also our biggest work often, especially in the early age bands for kids with anxiety, is how is helping the parents kind of adjust their practices to, for example, encourage greatness. Right. Like and that might be even something that's more preventative than we've got disorder. Like if you think about how many parents face the challenges of transitioning their kids to independent sleep, the challenges like that you might present

Yeah.

Yeah.

with new environments. And so how we kind of set up like the intention of being brave and how we talk about that with our kids and how we allow for some space for them to learn in these new environments. Because this is the only way, I mean, not the only way, but probably the strongest and most impactful thing that we can do for our kids with anxiety is to give them the experience of being anxious about something and then doing the thing that they are anxious about, realizing, hey,

That's not as bad as I thought it was. I can do that. So it's really the behavior that has to lead. It's the same thing with all of us. mean, how many adults that don't really like getting on planes. You can't get good at getting on planes unless you start getting on planes eventually. So you could talk about it all day long, but you gotta do it.

Right, right, Yeah. That's the sensitization.

Yeah, yeah. Yeah, you have to do it. And and so I think that like so do you find that the anxiety that people the kids are experiencing now?

are almost worse because we're talking a little bit about social media. It's so funny because I emailed you the other day. was like, look at this video. Do you think this is something about my son? you were like, I'm not on social media. And I was like, that's truly the hallmark of somebody that's trying to keep their brain healthy. It's like they're not on social media.

or a bad business person, whichever one you want to think.

Well, yeah, I mean, there's, but I feel like it was, it was so, I was like, see, and I told him, I don't even tell my son, I'm like, see, he's not even doing it. You see how strong he is mentally. No, but do you think that, you know, in this age of social media where you're getting chronic, like these dopamine hits and these videos of like something that's entertaining you and the attention span that people are feeling, is it making it harder to treat patients for you in your office or?

Hahaha

Is that part of the regimen where you tell them, let's get off of social media for a little bit because this is giving you.

Well, I know if I'm working with a teenager trying to convince them to get off social media is probably a losing battle. So I'm not starting with that.

Right. Or even the phone. Maybe it's not even the social media apps, but it's kind of like all the stuff that you do on the, guess it's mainly social media and YouTube.

Yeah, it's so hard. think what you are speaking to are our evolving, how do we work with kids and families? And I think having tight and clean messages about how do we approach or address challenges? Because I think we do have a little, we all do have a lesser degree of cognitive capacity because we're taking in a lot of stuff right now. And so that's actually the thing that I

Okay. Sure.

I kind of wish I was better at it. like, man, good, high quality TikTok content might not be a bad thing if we could figure out a way to really optimize it for evidence-based treatments. Because I think people need those messages. And I think parents need those messages about how they can kind of reinforce strong or strengthen their parenting practice around kids that might be anxious or how their own emotions kind of present to their parenting so that we can address that. I don't know if I'm answering your question, but I do think

Right.

we have to continue to find ways of getting in front of this. We can use these platforms for prevention in some ways. And I think a question that was buried in your last comment that I didn't answer was, what's great about anxiety is we really do have some good treatments for this. So for kids that have an anxiety disorder, which are those kids that

you

Yes, there's anxiety symptoms, but it's not just a test and they forget about it. It's more they're worried about the test two or three before. And then they're worried the week after about how they did. And they're just churning. And you can see that it's getting in the way of things like sleep or the time that they spend with their friends. you know, there's that functional impairment and there's a frequency and potentially the chronicity. So this kind of situation keeps repeating. We haven't figured out. That's when we start to creep into this disorder charge, when we

there are good minutes.

we start to think about more of our explicit treatments that we have in mental health, as opposed to like prevention, what families can do. So, and that's where like cognitive behavioral therapy, medication management, there's options within that that are relatively well studied, especially in terms of childhood insight.

Sure.

Do you think that people that kids that are anxious or have like a true anxiety disorder, because like you said, we're all anxious at some point. Do you think that this is something that they'll ever grow out of or is it just like they just have to learn the tools to kind of get through it so that at any stressful juncture in their life, where like, do we know that you can cure an anxiety disorder?

Well, I think the data would say that if somebody presents with an anxiety disorder or OCD for that matter, or really in life, it will probably resurge at different points in their life. But what we can do is we can treat it or address it to a point that it's not functionally impactful. If you think about it as like,

Mm-hmm.

I think everybody kind of experiences these normative times of stress, like transition to school. And so our kids with anxiety disorders are more likely to tick up or really have more distress or fall into some patterns that are less helpful during those times of distress. But that doesn't mean we can't kind of get back to a homeostasis or a nice baseline for these kids to like, you know, you function pretty darn well. I mean, that's really the goal.

not just assume, not just be happy enough with good enough, I guess in a way. Because I think what happens a lot with anxiety, because it's pretty functional sometimes too, it can be helpful, right? Like anxiety really drives the study for that test. mean, think about the amount of physicians that you might know that have a level of anxiety.

Yeah.

Yeah, sure.

can be really helpful. We just got to be monitoring the level of impairment that comes with it. And if it is something that they're just kind of living in this internal distress, that's something we need to address.

Yeah.

We talk a little bit where we mentioned OCD, sometimes I think people just assume OCD is like the excessive hand washing kind of person. Can you talk about like what truly is the obsessive compulsive disorders that we're seeing in kids? And I've mentioned it before, because I talked about some of the stuff in other podcasts, how do we best give them the tools for treatment in their, because again, it's not something that's

curative but you know how can we then you know help them with the best tools for management of their obsessive thoughts or their compulsions.

Yeah, well, it put a

I'll put a line around this to help people understand the differences between OCD and anxiety. So anxiety and OCD are, our medical language, are commonly co-morbid, so it's not uncommon for anxiety and OCD to present together. So somebody might have an anxiety disorder and also have OCD symptoms. But OCD is thought about in a slightly different category because anxiety is like overactive threat response. So again, back to this fear fight flag.

or freeze.

Whereas OCD is a little bit more of this like typically a more specific intrusive thought or in a compulsive response. So the O's and the C's, so the specific fear or thought and then a specific response to that thought. So that's like the compulsion. So you kind of look for them differently. Whereas like our kids with anxiety might be a little bit more globally anxious on edge fear response. Whereas OCD is a little bit more

specific. mean, certainly it can kind of span out there can be multiple O's somebody experiences, but it's typically in a tighter bucket, if that makes sense, O and a C. You see more repetitions, rituals, urges, kits that get stuck in kind of like the OCD frame. And also to put a frame around it too, OCD more commonly presenting around like that age 10 to 12. So a little bit later than you might see generalized anxiety, like prevalence like point

Yeah.

of being diagnosed but still kind of in that same ballpark.

What do you the prevalence of adolescents and teenagers that have OCD is it?

You might have to fact check me on this, but I think it's about 2 to 3 percent. So it's than anxiety disorders. But it's in a lower range of true OCD. what's tricky about it is...

Yeah.

because there is such a bleed over into anxiety disorders generally, that kids that kind of can get identified with, for example, perfectionism, they can be really rigid about, I've got to make sure my homework looks exactly right. I've got to do things in this one order. So sometimes those rituals, which can just be perfectionism, can also be misidentified OCD. So it's kind of like, do you, you got to pull it apart a little bit more.

Yeah.

little bit of a nuance and that's something I'd expect any parent to do.

Do you, because I think there's so many different ways that OCD can present in kids. You know, there's the like the whole idea of this harm OCD, which I think younger kids might have.

But.

Can you talk a little bit about that in terms of what it was a parent do if they hear their kids either wanting to harm themselves or thinking that someone is going to get harmed in the process and then they have a ritual around it?

Oh, that's an interesting one because I think anytime you hear your child say anything related to harm, your flags go up and like, oh, are they wanting to hurt themselves? Are they thinking, you know, is something bad gonna happen? You start thinking about like suicidality, right? And every.

Yeah, that's not really what it is, right? Like they're not actually suicidal. It's just like they're having

But it's hard to suss out, right? And this is something I feel like I've worked with, you know, I've worked with pediatricians on and they see, you know, certainly high volumes of kids with anxiety. And then, but you hear that from a child that you can't not have a visceral reaction. And so teasing that out, I think is where it gets, you know, it's like, I sometimes wonder about how much we should ask our parents to know. But I think asking and being curious, as opposed to reacting is the first step, which is like, okay, you know, when does this thought

Yeah.

Yeah.

come up or, you know, and just kind of exploring it about like, and when I always say to parents is it's usually not about the why. So if you start with why, especially with younger kids, you're going to get an I don't know.

Yeah, yeah, no, right, because they don't know, right? It's like a hiccup in their head.

Yeah, and I think that's to your point about like harm OCD where it is this like fear of somebody, typically a caregiver, but it's fear of somebody getting hurt or harmed or even doing something accidentally to themselves. And so it becomes this, it can become a obsessive or intrusive thought. And that can result in some level of ritualistic behavior, but it may not. And so that's the other thing that makes OCD a little bit hard is the C's aren't always

apparent apparent like a mental checking but that sees so you're not reassurance

Right. Yeah. Or even just asking for reassurance, right? Like nothing's going to happen if this happens, right? Is this going to happen if this happens? You know, like that kind of thing.

And that's a great point, I think, to when you were seeing kids with.

reassurance that can certainly mean anxiety, but it could also mean kids that are, know, kids with OCD, which again makes it a little bit hard to tease apart for parents. But I think, you know, to your, to like, to the question that you were asking, I think being inquisitive, asking some questions without an emotional reaction and focusing more on the, how does it, like, how does, how does this make you feel? Which I mean, great therapist question.

Bye.

the what, who, trying to avoid the why will get you a little bit more content so you can kind of feel a little bit more comfortable. This is not something that there's an intention around that they hurt themselves. That is the type of that is coming up.

Yeah, I think that's what becomes hard is do you reassure them that if their compulsion is to get reassurance from their appearance, do you continuously reassure them by saying, no, it's not going to happen that way? Because then are you just feeding the OCD? So that's the hard part that I feel like parents face.

Well, I think that's a great point because it's tricky because our first I think one of our first instincts as a parent is to reassure and to make our kids feel better. We want to reduce the distress. Right. That's our that's like our nurturing nature that we all I think have as parents. And I think what you learn is is how frequently it's coming up. Like reassurance in itself is not necessarily a bad thing. Reassurance repeatedly or reassurance that is limited

Yeah.

Okay.

them from like future from their next step that they need to take developmentally to be independent that's where reassurance can start to gonna be a downside or reassurance in the case of OCD where it's we're just becoming part of that ritual and so I think parents get key into like the frequency of which it's happening or if it stops them from like a action set that they might take like like they're playing with their friends but they got to get up and come and ask you about and seek reassurance and then they got it they go back

So the fact that it's disrupting something that might be some activity that they're engaged in, that would be a flag.

I had a patient recently who, a very high achieving medical student, she had skin picking as her compulsion, or maybe it was pulling out her hair or something like that. But I was seeing her in the context of disorder of eating and her menstrual cycle.

But I kept wondering to what extent this was just a manifestation of her OCD. You know what I'm saying? I do you see that? I know all of these can probably just overlap, but I'm just thinking about like.

girls and women who have like disorder eating, they're seeking control in some capacity. Like how do you tease that out as a clinician and like the treatments, are they really just trying to desensitize you to what might happen if this happens kind of thing or like how do you look at that as a clinician?

It's a great question. I think you're you're highlighting again the distinction of Between like anxiety broadly or anxiety disorders broadly and where OCD lives because OCD Lives is now categorized. It's not even categorized with anxiety disorders categorized under these like repetitive behaviors, right? So like skin picking hair pulling Tourette tick like these all living in this kind of camp where

Thank you.

So you start to think about like OCD or, you know, some might even think about like almost heretic OCD, right? Like it becomes the compulsion, but it also is linked with the tick or the, so the compulsion kind of becomes part of the tick. it's, you know, even if the urge isn't there, it's kind of just becomes this harmful behavior or the repetitive behavior that you're engaging with that, you know, we have to try and help them address.

Yeah.

Yeah. And so I think, yeah, it's, I think it's so hard because then one of my friends had a patient, a kid who was OCD who couldn't leave that. That was sort of what, so it's like, she didn't even know how to treat her child because part of his obsession was around not like the fear of leaving. I mean, that's whole like an agoraphobia thing, but it was like he had OCD to something that she couldn't actually leave the house for. And so.

Talk about a way, a piece to identify when it's getting in the way, OCD and or anxiety, it can generate these responses that really start to limit our children and it can be addressed if we have the right treatment for it.

If we've got the right type of professional, we've got the right type of treatment, and our parents are kind of aware of what they're seeing in terms of the frequency or how impactful the anxiety is, or OCD is kind of impacting their choices.

And how long do you think it takes to kind of break one of these cycles that people get into, right? Like, it vary the amount of the rigorousness of the therapy and how long you're doing it or the homework that's done in therapy or all of it?

Yee-haw.

No, it's great question because in this is some of the some of the research I've been involved in recently is, know, we kind of know we've got two like core treatments for anxiety disorders and the same is true for OCD. So cognitive behavioral therapy is the recommended treatment for anxiety disorders. And the core ingredient of cognitive behavioral therapy is really this idea of exposures. If you think about treatment for OCD, cognitive behavioral therapy is still the recommended

to treatment for OCD and exposures is also like the core ingredient of how do we get kids better. And so there's really not, I mean, there is some distinction when you get into like the professional world about like how you might approach treatment or exposures to this, but some of the core components of what you do in treatment for OCD or anxiety are very much the same. And we're just talking about the behavioral treatments. you know, we just did a larger trial, you know,

us and a few other groups across the country. And we looked at how treatment, essentially we were looking at, we know the efficacy trials for...

the child adolescent multimodal studies of CAMHS. It's the large trial on anxiety disorders for kids. that study had like four, I'm wondering how detailed you could hear, Salina, so I'm trying to stop myself in common sense language, but like...

Yeah.

What we've identified from these efficacy trials is that we can get kids better with CBT. We can get kids better with med and Med plus CBT so combined treatment is typically better for kids with anxiety disorders Similar treatment there's a similar study for kids with OCD and but you got to think about these are efficacy trials So we're deciding we're trying to determine at that phase whether these treatments work and so what normal people have access to is

you

Yeah.

very different from an efficacy trial.

If you're going to be, you know, some like one of the world experts in CBT and you've got structured weekly therapy for 12 weeks. Yeah, I feel pretty confident we're going to get better. But what do people have available in their community is a very different thing. And that's essentially what we looked at in this in this trial that results are coming out here. But I think what we could say is that we we I think there should be a push for all of us is treatment.

Sure.

That's true. Yeah.

providers to try and move people towards evidence-based treatments and can we get our efficacy quality into people that you know accessible to everybody. If that makes sense.

Yeah, I guess, yeah, and I'll tell, and I'm wondering like, you know, to what extent if someone is sort of in a more traditional CBT pathway, like are there trials looking head to head at medication versus CBT and what it looks like?

Yeah, well the CAM study did that and they used Sirtuline, which is Olof and they looked at it head to head against CBT and within 12 weeks they were pretty comparable. They actually didn't separate. So men only versus CBT is pretty head to head. So that's really interesting for parents, right? Because like it's, and we know most parents are kind of resistant to wanting to start with a medication.

The issue, and what's also cool about the CBT piece of this is that the kids that when we looked further out, like after the trial was done, they just did CBT for 12 weeks. So if you can think about like a 12 week trial, you're really, you're running and pushing and trying to get these exposures in and trying to get the families engaged. It's for expert therapists, but the CBT actually lasts a little bit longer, right? Like you actually have some skills and strategies, whereas like if you stop taking the med,

Yeah.

Yeah.

you're not gonna get much of a benefit. What was interesting though in that particular trial, which is about 460 kids-ish, if I remember correctly, the combined group just did better. They did about a 15 % swing better than both CBT alone and...

and see what's really going on.

and and that was also, you we're thinking about the med piece too that's really interesting and germane to our conversation about what we have primary care, what we're asking primary care to be able to do or treat is that they were titrating that medication. So they were actively trying to push that medication up to an optimal dose. Whereas we know or what we see happens a lot in primary care or where most people

get their mental health care is that we get a little bit of a benefit, but we may not push towards like really big outcomes or the outcomes that would be probably most meaningful. Like again, we get, we're pretty good at getting good enough, but maybe we should be satisfied with that.

Yeah, good. Right. Yeah. So you think ultimately they did better when they had the combination. Did they get better sooner pretty much or?

In that trial, got better. It wasn't better sooner, but it was, I want to say it, I would have to go back to the study, but all the outcomes looked at 12 weeks and then 24 weeks, and then there was a longer term trial, and the treatments that, the kids that had the most durable impact were the combined patients.

Okay.

But again, we know we have two treatments at least and multiple.

know, three core SSRIs that all have efficacy for treating anxiety disorders in kids. And we've got cognitive behavioral therapy, which works pretty good if you can do it with fidelity. So can we get medication treatment to fidelity or like the titrate to optimization, guess? And you get really high quality CBT and is there support to kind of do the work that it does take?

Yeah.

That's so interesting. What about when you think about other kids and what their mental health challenges are around ADHD? Because I know you treat that in your office as well. Because some of that overlaps, right? Like lot of the, if you have your Venn diagram, they all have some overlapping sort of characteristics. But for the most part, is the best way to go for ADHD medication? Or do think that people get good success with?

Well, so this I think is a great question as we've kind of been focused, we're talking a lot about anxiety disorders, right? Because I think there's, so an overlapping or symptom that is common in both ADHD and anxiety is challenges with attention. And it's challenge with attention and for different reasons, right? Like you've got a kid that's highly anxious, they're gonna have a hard time attending to what's going on in class because they're kind of stuck in their own world

Right.

or what's going on with their classmates. And then you also, with an ADHD, of course, symptom is the ability to sustain attention despite distraction, to be able to regulate their attention. And ADHD is a common disorder, typically it presents a little bit earlier and it's across settings. Anxiety is a little bit unique because you might see it kind of really show up more in one setting, but they are also commonly comorbid. So just like we talked about OCD and anxiety being comorbid,

Yeah.

ADHD and anxiety.

And then probably OCD is right there too, right? Because the OCD kids can't concentrate. Yeah.

in the mix. It's in the mix, you know, and ADHD and anxiety are probably as far as childhood disorders, like it's about like 40 % overlap might have to be career for another disorder, one of those that other disorder. So it's really, it is interesting when you're trying to figure out the puzzle and what is the best treatment approach for your child. And you're thinking a lot about what the big impact is, like, this getting in the way of school? Is this getting in the way of their socialization? And so the

Yeah.

Those are the pieces that parents are often piecing apart. But there are treatment options for ADHD. I would say therapeutically, ADHD is a core challenge. It's harder to treat with a type of therapy.

First, we've got these medications for ADHD are pretty good medications, as we've been here for a long time, and they can work. And I say that as a psychologist who want all of my behavioral treatments to really impact somebody's ability to sustain attention.

Great.

But really the treatments for kids with ADHD related, like therapy treatments for kids with ADHD, especially at early ages are more focused on like, how do we structure their environment? like what was talked about as like parent management treatment or therapy. And it's environmental structures, it's setting up like good rewards for beings that are hoped for and that kind of stuff.

you

Yeah, yeah. And then what about this whole trying to, you know, the independence or what is it called? Executive function. They both, it seems like that's kind of like an issue across the board as well. How do you teach someone executive? Please tell me.

Yeah.

Yeah, great. Yeah. You know, honestly, I

I think executive coaching is something that everybody could benefit from. It feels like it needs to be taught a little bit more discreetly sometimes in schools. And I think our kids with ADHD really benefit from developing those structures. And for adolescents, you almost have to find some degree of desire to commit to it. I see lot of parents of children with ADHD that they struggle at this transition point.

I know, right?

Yeah.

in schools, like either elementary to middle, where there's more like classes and transitions and they've got to organize their stuff. But we get stuck because the message from school typically is let them be independent often, right? Let them start doing it themselves. And we want to let them start doing it themselves, but we can also drop off a clip if we completely give into that. So finding the right scaffolding, which essentially is what executive functioning training is, right? Like we're trying to help them build like a structure for them to

organize their folders. We're trying to build a structure for thinking about what you have after school and what time you need to up. These are things that parents can do and we just have to be thoughtful about when we start to give the reins over a little bit more and are we prepared for that. It's not just an on or off because if we make that on or off decision I think we're all going to be displeased with the outcome.

Yeah.

Yeah.

I was told, because there are all these things online. There's different coaches for executive functioning. But then they're you're just assisting them to get, like a coach is like a, and someone that's gonna, I don't know. I've looked at all these things. In case you were wondering. This is a very personal question for me. Hang on.

Yeah. you know, it's, it's, you know, it's, I think about it kind of like a tutor, right? the, the evidence around executive functioning, training and tutoring isn't quite there yet. I will say for ADHD is like thought as like big impact outcomes, but I think that just speaks to, in emerging science less than it, it's not helpful because there are some good programs out there. Boston children's has made it like a really nice curriculum.

And I think the question is like, how much can you do with your child? is it, if it's causing emotional turmoil, then yeah, that's where, you know, I'm like having a tutor. I mean, there's a reason my mom got me a French tutor, right? you know, in high school, because it was like, okay, you know, she was in education. She knew that at least that the conflict wasn't worth it and her trying to pull me through it.

Mm-hmm.

Yeah.

Yeah.

Yeah.

It's not going to be beneficial for either of us or our relationship.

That's interesting. Okay, I want to ask you some before we end, I want to talk to you about some of the newer technologies like AI. I think like we can't ignore AI. AI is part of everyone's life.

I don't think I told you the story, when my son turned 16, he had flu. He had full-on influenza, so I took him to see his pediatrician for an assessment. And it was interesting because he used chat and GPT to understand what his symptoms should be and this and that. And so he has full conversation with the pediatrician without me interjecting at all, like a zero interjection. And I was floored by the, and I'm like,

did you know all the things to say? He's like, yeah, you know, was talking to Chad GPT about it. And they're like, he's like, make sure you mentioned this and this. And so then it made me think like, you know, is this like a communication tool for some of the kids that maybe don't have the, you know, you know, think communication is a big issue for this generation as a whole, right? Like, I think no one's talking as much. Everyone's texting. Nobody picks up the phone. Like, you know, I mean, I'm older than you, so I know the days when we had like a, you know, phone that would pick up.

pick up and, I remember seeing like play phones on the street, whatever. Like it's, I think that it's a different generation. They don't have the communication skills. So I have a lot of hesitation around AI in the use of, the medical field, but I, this was one aspect I was like, wow, like it's helping them communicate.

Yeah.

I guess my reflection on that is like how much of it is a tool that was like a learning opportunity to kind of bolster the confidence and having that conversation because like what I guess is we've talked about with anxiety disorders like and I think this is true in development is that what we want our kids to be able to do is to have safe experiences and exposures and grow to independence so that they try these

these things themselves or they do these things and realize that they can do them and grow some confidence and agency from that. Like I think that's what we really want out of our society. It's not something to do it for us, but something to help facilitate and encourage our kids that maybe would benefit from a little bit more structure to kind of do it themselves. I mean, that's the hard part of life and that's the good stuff of life is when you realize you can do it.

Yeah.

Yeah, Yeah, yeah, yeah. No, I think it's, and I just wonder to what, cause like, even, even I have patients who tell me like, well, I just love my chat GPT, it's better than my husband because, know, he just agrees with everything. I've named him, I've done this. Yeah. And so I wonder to what degree like,

you

Yeah.

You know, because some people use it in their own sort of like personal therapies. Like how would you use it as a tool to like augment your practice if you had to? Or would you? Or would you just say like, don't use JGPT? Because that's what people are doing now, John. I'm so surprised.

No. Yeah, yeah, yeah. It's interesting because I have not thought so much about this question, but it's a great question because now it feels like...

Yesterday I was talking with my spouse and they said, oh, you should just put that in ChatGDP. And I'm like, that's just like what people used to say five years ago. It's like, you should Google it. It feels like we just modified Google It. And I'm like, I want your advice. I don't want their advice. And your point is just going to agree with me. every idea is good.

Yeah, yeah, yeah. Yeah, yeah. And then they lie to you half the time too. just just came out that we are like 50 % of what check some of these search engines say are false, right? Like, even the references they give the false information. Yeah.

yeah, and really happy that people kind of got caught with those false references, you know?

Because it's a lesson. It's a good lesson. I am curious to see what is going to be the... Because as you've seen, countries are now bringing this decision, trying to make decisions for especially our adolescents. When's the right time? mean, we would have Australia's done with social media, They're social media until like, was it 16? And then they still need some more permission. So I'm just speaking

Yeah. Yeah.

Yeah.

Just yeah, wonderful, yeah.

broadly. very curious to see how the policy implications of all of this because I do think kind of some level of unrestricted or untrained access is probably not the right approach, but at the same time, like there's such power in this can be used for many different purposes.

And I think that's the question is I don't know that we have any true regulation. It's like a circus out there. so tell us what research you're involved in now and then how everyone can find you and all the things. Because I'll put in the show notes too.

I don't know.

That's like social media. Yeah

Okay.

Well, yeah, so I guess my big interest right now, which may not be interest to everybody else, but I've been working on anxiety disorders and anxiety trials. But with that bent of anxiety work is really about how do we help primary care physicians who are most likely to see kids with mental health needs make decisions and kind of move families towards treatment options and identify effectively. so like really, we're, I guess,

guess my big frame is for our kids that have mental health needs, how do we get as far downstream so we can be more preventative and help the caregivers that are at the front lines, which also includes parents, like have the most reliable training and way of identifying whether we're kind of in a space that we can intervene. that's my big.

So what are you telling your primary, because I have a lot of primary care listeners actually that like, you know, whether or not there's practitioners, family, whatever. So what would you tell them that are listening about their own patients? Like, you know, in terms of getting them better identified or access, I mean, are there certain questionnaires you like, or there's, know, what are you doing in that study that would be good beneficial for them?

Well, I can talk all day on this. I don't know if you want to open this one up, but, know, big work within anxiety is thinking about like integrated care models and how health systems can kind of work together so that physicians, primary care physicians who may not always feel comfortable or confident around mental health concerns have like a specialist consultant or expert so that they can facilitate some of that training. And so it's training, but it's not just training and then like go to it. It's more like training and who do

call if I have a question because that I think engenders some level of confidence and willingness to try to treat especially these common mental health concerns because I really believe that we should at least be able to effectively identify and treat ADHD, anxiety disorders, depression in primary care and then I think we start thinking about these other disorders that are associated and still relatively common like OCD. Like how do we start moving the needle and so getting

physicians comfortable and so if we're using those three conditions ADHD, anxiety, depression, it's like our common conditions. I guess I would encourage the physicians that are on this call to think about their practices on how they identify what are their treatment resources, where do they want to go because it's the need of their patient. And then look for your helpers like Mr. Rogers says.

Yeah, yeah, for sure.

I know. Awesome. Okay, so tell everyone where they can find you. I know, guess you're really not on social media, it sounds like, yeah, but.

I try and stay off of, mean, know, my own.

It's gonna come, John. It's gonna come a time where you're gonna have to get up. Yeah, yeah.

You're going to have to, I mean, you'll have to convince me. I'll take that. Well, so, you my primary role is I work at Mary Children's Hospital and then I have, and then I also know faculty at Northwestern and people can certainly connect with me through those routes. And I'm more than happy to communicate with others if they have, and I would be happy to provide like link.

for the show notes and stuff. Okay, cool.

All right, thank you so much, John. This has been great, very eye-opening. A lot of my questions were leading because this is stuff I expect from my own children. And then you're like, she's asking about so-and-so on her end. Anyway, for joining today. This has been very enlightening and I'm so excited to have you on. Thanks for listening, everyone. I'm Dr. Spina Ron-Gaeno girl. Remember, I'm here to educate so you can advocate for yourself. Please join me next week.

Thank you for the opportunity.