Hello, everyone, and welcome to the

Mayo Clinic.

My name is Paige Partain.

I'm a general pediatrician here at

Mayo, and I also have a special area

of interest in pediatric mental

health.

So we're going to talk a little bit

today about mental health

in general as it pertains

to the COVID 19 pandemic.

This is something that we're all

really dealing with, probably both

personally and professionally.

These health concerns are very real

and they are becoming more pressing

with each passing day.

Very recently, the American Academy

of Pediatrics and the American

Academy of Child and Adolescent

Psychiatry, as well as the

Children's Hospital Association

all declared a state of emergency

around youth mental health as

it relates to this pandemic.

So my goal today is really to

give you an overview

of some of what we know about mental

health as it deals with depression,

anxiety, eating concerns,

attention concerns and then spend

a little bit more time arming you

with some tools for what these

patients might look like in the

office and more

importantly, what you can do to help

them.

When we think about mental health

trends in general, we have

some good nationally representative

data that tells us a little bit more

about what's been going on since the

start of the pandemic.

As you can see on the slide,

the top graph represents total

number of visits in US

emergency rooms.

This is data coming from 47

different states.

And you can see a distinct drop

in emergency room visits in March

of 2020 at the start

of the pandemic with

shelter-in-place orders.

But interestingly, at the same time,

when you look at the bottom graph,

the proportion of emergency room

visits that were related to mental

health complaints rose quite

drastically at that same time.

So we might have been seeking care

less, but more of the care that

ended up in the emergency room was

related to mental health concerns.

We also see some nationally

representative data when it comes

to learning, in particular,

how that impacts mental health for

both kids and for adults.

In a recent Morbidity and Mortality

Weekly Report, data

were able to show us

that any amount of virtual

learning, whether that was complete

virtual learning or combined

with in-person learning, was

associated with several poorer

outcomes or poorer reports

of mental health from both kids and

adults.

When we think about depression

specifically in the course of this

pandemic, there isn't

really as much data as we would like

to have. We have lots of

studies that give us snapshots

of what's been going on.

But when we look at truly

longitudinal research, there's

not as much as we'd like to have.

The few studies that we have

have some pretty mixed results, some

showing initial increases

in depressive symptoms, as we might

have expected, some showing

small decreases or showing

no changes whatsoever.

More recently, we have some data

specific to the United States,

and this comes out of New York.

There was a study that looked at

adolescents and compared

their depression and anxiety rating

scales pre-pandemic to those

post-pandemic.

What the researchers found was

depression increased post-pandemic,

most specifically in April

and May of 2020,

aand then showed some decreases in

the following months.

Of the data that we do have coming

from the United States that's more

longitudinal in nature, one of

the most compelling studies that

looks at suicidality as

it relates to adolescents.

This study showed that

post-pandemic, there was

a significant increase in

the proportion of adolescents

presenting to an emergency room who

said they had any suicidal

ideation in the months

prior to their emergency room visit.

Now, this was for teenagers

presenting to the emergency room for

any number of complaints.

They weren't necessarily coming to

the ED for a mental health concern,

but all were given questionnaires

and asked about incidents of

suicidal ideation or any prior

suicide attempts.

What you can see on the graphs is

pretty compelling in terms of

increases for suicidal ideation

and reports of prior suicide

attempts after the pandemic.

For instance, on average post-COVID,

almost 16%of adolescents

reported that they'd had any amount

of suicidal ideation in the three

months prior to their emergency room

visit, and over 4% actually

reported that they'd had a suicide

attempt in that same timeframe.

When we think about data

specifically related to anxiety,

we also find kind of a

paucity of any specific information.

When we look back at two of the

studies we've discussed already that

gave us some longitudinal data on

adolescents, there were some

questionnaires specifically relating

to anxiety symptoms.

And as you might expect, there was

a demonstrable increase in anxiety

symptoms for teenagers

post-pandemic.

This was shown in a couple of

different studies and with a couple

of different questionnaire methods.

One other area that we'll

cover in the talk today is eating

disorders and disordered eating.

Anecdotally, as a physician who

takes care of patients with eating

disorders, I can tell you that the

pandemic has definitely increased

the incidence of eating disorders

and any changes to

a kid's eating.

What we find in the research is

not a lot of data, though

more recently, in 2021,

there was a study published in

Pediatrics that showed

admissions to an inpatient

medical unit for stabilization

of eating disorder patients actually

more than doubled in the months

following the pandemic when they

compared to the months of the same

year prior.

So what we felt anecdotally,

as we're caring for patients, we

were able to demonstrate with

information and studies like this.

What we do know as it relates to

eating disorders in the pandemic

is that in general, the

pandemic itself comes

with a lot of changes

that would typically exacerbate

symptoms for patients who have an

eating disorder.

So a big disruption

to day-to-day activities,

more time on social media,

more media attention

to things like the quarantine

15, more

levels of stress at baseline

as we're dealing with fear about

getting sick from COVID, fear

of spreading the illness to others.

The last thing that I want to touch

on today is ADHD

or attention concerns.

Similar to what we've seen across

the board, there's not a lot of

specific prevalence data as

it relates to ADHD before

and after the start of the pandemic.

We know that for patients who

have ADHD,

there were surveys that showed

the pandemic led to several

different problems.

When they surveyed children with

ADHD and their parents,

what was seen in the studies is

increased reports of social

isolation, a lot of

difficulties engaging with online

learning, motivation difficulties,

and a lot of reports of boredom.

We might predict that a child with

ADHD might benefit

from at-home learning where they

have a calmer environment

and not as many distractions in

place.

But this wasn't actually something

that was able to be demonstrated in

studies for kids with ADHD.

So what I'd like to do now

is take a little bit of time to

concentrate more on what these

patients might look like when

they're coming in to see you in the

office and then

talk about some things that we can

do to help them.

In general, when we think about

mental health for any teenager,

there are some evidence-based things

that we know can help.

One of the biggest things that we

can do as physicians and as parents

is encourage in-person schooling

wherever we can and when

it can be done safely.

There's ample evidence to show us

that this is good for children's

mental health across the board.

When parents ask what they can do

day to day, I talk to them about

maintaining consistent routines.

So that's consistent bedtimes,

consistent times of their waking up

in the morning, whether it's a

distance learning day or an

in-person schooling day, making

sure that they're getting consistent

meals over the course of their day.

There is some new evidence

about use of telemental health

services that shows that this

can be helpful for teenagers as a

way to access mental health care

in the course of the pandemic, but

to do it in a safe way.

One thing we want to be careful

about as it pertains to these

services, though, is that we're not

exacerbating some of the disparities

that already exist.

Some teenagers don't have access to

a computer with an internet

connection at home, or they might

not have access to a private bedroom

where they could sit and talk with

their therapist, so these

kinds of telemental mental health

services would probably not be as

helpful for them in the long run.

When you can encouraging schools in

your community to partner with

mental health providers has really

been shown to improve outcomes

and access to care for both kids

and teenagers.

We have a couple of schools here in

my area that have embedded

counselors and providers from our

local community, mental health

providers, and I find that those

patients are much more able

to access therapy services

and have much better outcomes in

the long run. Whenever we can

working to partner with families

and help reduce some of the economic

burdens that come with the pandemic,

as we know that these are tightly

correlated with other mental health

troubles, so that might mean

leaning on your team at work, having

social workers help families

out to make sure that there's not

food insecurity, that they're not

struggling to pay their bills

or to keep the lights on, that

they're not struggling with an

internet connection for their

children who are trying to do

distance learning.

And one of the biggest things that

comes up when I ask my

colleagues and some of the

therapists that I work with, what

they talk to families about in this

time, across

the board, everyone tells me, adjust

your expectations.

It's not really fair of us to have

this ideal in mind, this

pre-pandemic ideal in mind, for

what we would be doing day to day

when we're navigating something

that's totally new and different.

What we need to do is be forgiving

to ourselves and recognize that

we're all doing the best that we can

to get through this and

to stay well as we're getting

through it.

I want to talk now about a

specific patient case.

This is a

kid that presents

to your office. It's a 13-year-old

boy, and he's billed as 'behavior

concerns.' When you

sit down and you talk with him and

his parents in the office,

his parents say,

you know, they're becoming more and

more concerned recently.

He's super irritable.

He's started acting out more, and

this really isn't, this really isn't

their kid. This isn't the way he

typically acts.

They feel like at home, they're

starting to kind of walk on

eggshells around him because they

don't really know what's going to

set him off.

Mom initially kind of brushed

things off. She really felt like,

well, he's 13 now.

This is just a teenage thing.

But his dad is becoming increasingly

worried over time, especially

because he told them he didn't

really want to go out for the soccer

team this year, that it just sounded

boring and stupid.

When you ask a little bit more about

his day-to-day routine, you

find out sleep is kind

of troublesome.

He's often up pretty late at night,

going to bed one o'clock or two

o'clock in the morning and waking up

frequently, and then his parents

feel like he just sleeps all day,

especially if there aren't specific

learning needs or classes that he

has to log into for the day.

From an eating standpoint, because

he's sleeping so much, he's often

sleeping through breakfast.

He'll sometimes take a break between

his classes to eat a small lunch

and then typically will eat dinner

with his family at night.

When you talk with him one on one

to get a sense about what's going

on, he tells you, "I just

feel off.

I don't feel like myself.

My friends are just really

annoying, and I don't really like

spending time with them anymore." He

appreciates that he's been more

irritable and that there are small

things at home that really kind of

set him on edge.

When you ask him a little bit more

about these times

of sort of low mood or

these times of irritability,

he discloses to you that he has had

some thoughts actually about not

being alive.

He describes these more as kind of

passive thoughts, thoughts about

what might happen if I died.

I just wish I wasn't around anymore

so that I didn't have to deal with

these kinds of things.

But he is clear that he's

never had a specific plan to

take his own life or any plan

to hurt himself.

And more along those

same lines, you ask, gosh, who could

you reach out to if those things

changed in the future?

And he feels pretty confident that

he could talk to his older brother,

who's 17, if these

things started to worsen.

In a broader sense, he's

an otherwise healthy teenager.

The family history is notable for

a mother who suffered from

postpartum depression, but

otherwise not a lot of mental health

history.

So when you think about this visit

in the office, it's not something

that might initially jump out at you

as being concerning for depression.

We can all really think about the

typical DSM criteria

for depression when we think about

low mood, when we think about

worthlessness, especially

if a patient's coming in telling us

that they're thinking about not

being alive.

Depression is always going to be at

the top of our list.

But more often now what I'm seeing

with teenagers in the office

is irritability.

This is a really crucial way that

teenagers present with depression

in the office.

So while very often hear things like

this, they're just so touchy.

I just never know what's going to

set them on edge.

So irritability is really something

that I would want to clue you

in to think more about depression,

especially for teenagers.

Another really key thing to look for

is isolation.

The pandemic is bringing us lots of

that regardless.

But if you have a teenager who is

seeking out even more isolation

even in the home setting, I'm

hearing a lot of "Well, she just

doesn't even want to come out of her

bedroom." This kid's

already pretty isolated from

friends, from school, from

activities. So if they're then

choosing to isolate themselves

further in their bedroom, we should

really be concerned about what's

going on with their mood.

Specifically when we think about

anhedonia, that's another

really key thing that clues me in to

think about mood.

So there's not a lot

of opportunities that we have right

now for teenagers to get involved in

things. When they have the

opportunity to do something, whether

it's a sports, a

music venture, a club,

if they're feeling like they're not

as interested in it or they don't

want to do it, that's something that

really raises red flag symptoms

for me.

So when this teenager presents

to your office and you become

increasingly concerned that they're

suffering from depression, what are

some of the things that we can do to

help them? Broadly, you can think

about all the general interventions

that we already thought about, and

then there's a few other things that

we can do specifically for mood.

There's some good evidence that

we can really spend time focusing on

their social networks and

the rewards that are out there for

them. So making it a priority

for teenagers to be able to connect

with their friends, to be able to

connect with the activities that

they enjoy in a safe way.

We want to, in the home

setting, help encourage them to

have a sense of belonging in the

family group, and so sometimes

what that means is redistributing

the way things work in the house,

giving the teenager a way to

really contribute and

be a part of the family unit when

that might not have been something

that they did in the past.

And along those same lines, helping

them find any kinds of activities

that give them purpose.

There's really good research

and evidence that shows us when

we're doing things for others,

our mood improves So

I've encouraged families to look

into ways that the teenagers

can volunteer, can help

with relief efforts.

Can you spend a day at home

making care packages for people that

you know and love and dropping them

off on their doorsteps?

These are the kinds of things that

will help get teenagers through

their day to day and give them more

of a sense of purpose to help with

their mood. There's some evidence

looking at digital media

specifically for self help around

mood.

So there are things like

computerized CBT programs,

and there's some research that shows

us that these might be helpful for

teenagers.

So in particular, if they're

struggling to talk with you about

something, maybe encouraging them

to engage in some of these

self-help modules could

be beneficial.

Physical activity is another thing

that's absolutely crucial.

Finding time to get up and to

move.

If you're like me and you live

somewhere where that's not always

possible outside in the Minnesota

winter, there's lots of resources

available online looking at

in-home workouts.

One of my favorites is called Move

and Thrive. It comes from folks at

the University of Minnesota.

I like this because they're really

body-positive workouts for

adolescents at all stages.

So this isn't just the

typical gym workout.

This is things anyone can do in

their home to get up and get moving.

It's important, in addition to that,

to just make specific time

for activities that they enjoy.

And that might mean sitting down and

scheduling, 10

o'clock reading time, 10 o'clock art

time, whatever it is that

really makes that teenager tick, we

want to make sure that they have

time to work that into their

day-to-day schedule.

And finally, there's really

mountains of evidence that look

at individual psychotherapy

and/or medications for

depression, specifically for SSRIs;

so if

this is something that you're

worried about for a teenager, take

time and talk to the family about

connecting to an individual

therapist.

Talk to them about the possibility

of using a medicine to help with

their mood.

I want to take a couple of minutes

as well to talk specifically about

suicidality and what we can

do in those cases, because I think

when it comes to any kind of mental

health concern, this is the one that

really makes us all feel on edge

as providers.

When you think about things like

telemental health, there's actually

not quite as much evidence for that

as it relates to suicidality.

It sort of remains to be seen if

televisits or safety check-ins

over a video visitare really

something that can help decrease the

risk around teenage suicidality.

So when you have them in the office,

we really want to make the most of

the time that we have.

The biggest thing that I emphasize

to providers is to safety plan

and not just safety contract.

By that, I mean, in our medical

training, a lot of us were taught

to make a safety contract with a

patient; to have them either

verbally or on a written piece of

paper promise us that they're not

going to hurt themselves, that

they're not going to take their own

lives. When it comes to adolescents

in particular, there's not

really great evidence that shows

us that this is beneficial.

So what we really want to do is

actually take time planning for

the worst.

I'll often talk to my patients about

a just-in-case plan.

I'll tell them, I believe you

and I know that you're telling me in

the office today you're not having

those kinds of thoughts, but I also

know things can change really

quickly. So I want to make a plan

just in case that changes down

the road.

So who could you talk to in

those moments? Who could you reach

out to?

Let's make sure that it's a

responsible adult who has the

ability to take you to

a hospital for evaluation if you

needed it to be.

I don't mind if teenagers want to

reach out to their friends in those

kinds of instances, but I don't want

to put that whole burden on another

teenager. I want to make sure that

we have an adult who can help get

them where they need to be.

As we're thinking about adolescents

who've had prior suicide attempts

or who have previously had

hospitalizations for suicidality,

other things that we want to think

about is what's the biggest trigger

for them? What's something that

really puts them in the worst

places? And are there things that we

can do about these triggers to try

and decrease their risks?

And in the broad scheme of things,

how do we keep them safe in

their home environment?

So that's securing all the things

that could be used to hurt them,

specifically firearms, making

sure that they're either out of the

home or locked and secured,

medications,

both prescription and

nonprescription, specifically

Tylenol and ibuprofen, we want to

make sure are locked and safe.

Things like

sharps, whether that's knives,

razors, etc., we want to make sure

are behind a lock so that if

and when things become more

overwhelming for them, they don't

have this access to anything

that they could use to potentially

take their own life.

And finally, some of the resources

you can see here are ones that I

like to give to all of my patients.

A lot of times teenagers might

struggle to identify a person that

they could reach out to if they were

having thoughts of not being alive,

thoughts of taking their own life.

And so I make them take

out their cell phone in the office

and take a picture of these phone

numbers, or put these phone numbers

saved in their contacts

so that they have a way to reach out

if they're feeling like they can't

physically talk to someone

in their lives, like their parents,

their sibling, their counselor.

These are resources that are

available 24/7. There's

a text line, there's

a national suicide prevention

line. So these are all ways that

we could keep them safe in the worst

case scenario.

All right, the next patient that I

want you to think about is a

15-year-old girl.

She's coming into the office

specifically for sleep difficulties,

and you talk

with her a little bit more.

And what she tells you is, "Gosh,

this has been a problem off and on

for as long as I can remember, since

I was young." And she

feels like now, no matter how much

sleep she gets, she's just

super tired, all

during the day.

In more detail, you're sort of

talking through things and she tells

you, "Well, I generally get to bed

by 9 or 10 o'clock at night,

but it takes me a while to fall

asleep. It may be 11

o'clock or midnight by

the time I actually fall asleep."

And then after that,

she tends to wake up once

or twice at least a night, and it

takes her another 30 or 45 minutes

to get back to sleep.

She's feeling like because

of this, things at school aren't

going very well.

Her workload is really starting to

pile up, and she feels

just really overwhelmed when she

looks at her whole list of

assignments and everything that she

has to get through in order

to try to catch up or to stay on

track. From a family history

and past medical history standpoint,

things are relatively unremarkable.

She's a pretty healthy girl.

She has a normal BMI, so

she wouldn't be at higher risk for

things like obstructive sleep apnea.

Her family history is notable for

a mom who suffers from depression

and is treated with an SSRI

and a dad who has intermittently

in his life gone to individual

psychotherapy for help with anxiety.

So this is a patient

that's designed to show you

different ways that anxiety might

present in the office.

I think it's pretty straightforward

if a patient comes in saying,

"I'm feeling anxious, I'm feeling

worried.".

We all know how to look into that a

little bit further.

But I think some of the more common

ways that patients might present to

the office without saying anxiety

would be things like sleep

difficulty, trouble getting

started on things, trouble with

feeling so overwhelmed with things

that they just don't know where to

start, or just sheer avoidance.

So that might be the teenager who's

saying school is

so hard. I just don't know where to

start. I'm just not going to do

that, or I'm feeling so

stressed about being around

a group of folks, that I'm just not

going out or doing anything with

my friends.

When you think about younger

children, the things that you would

look for, certainly

any of the things that we've

described so far, but more

specifically for younger children,

I'll often hear things like

asking lots of questions.

So for very young children,

preschool, kindergarten,

that's the kid that will pepper you

with questions all throughout the

day. Where are we going?

When are we going to get there?

Who's going to be there? How are we

going to get there?

What if we get in a car accident?

That's to me, an indicator that

there's probably some underlying

anxiety.

These kids are also a little bit

more likely to present with things

like behavioral outbursts.

Just getting super overwhelmed

and all of a sudden

becoming upset, kicking, screaming,

refusing to do things.

And they may also be more likely

to present in the office with sheer

physical symptoms.

So these might be the kiddos that

come into the office saying

that they're really struggling with

frequent headaches or frequent

stomach aches, even to the point

that they're missing lots of school.

And you do an excellent medical

workup and you're really not finding

a physical cause for their symptoms.

That's the time that I want to back

up and start thinking about whether

anxiety might be an underlying

driver.

When it comes to things that we can

specifically do to help with

anxiety, there's really

good evidence for individual

psychotherapy and for medications

specifically, is SSRIs.

When you think about how to help

younger children, It's really

important, I think, to have

age-appropriate conversations with

them. So not just

giving them simple reassurance,

but also trying to help

give them some control where you

can.

So if there's an opportunity

for them to decide

what they're going to wear the next

day, or pack their bags for the next

day so that they feel less stressed

about things, giving them those

small bits of control.

And I think probably one of the

hardest things for us to do as

adults is to try to be a good role

model when it comes to anxiety and

stress, in particular,

younger kids, but really all ages

of kids and adolescents are always

watching.

So taking that time when you're

really stressed or you're really

overwhelmed to take a deep breath

and say,

I think I'm just going to go for a

walk and I'm going to come back

and I'm going to look at this work

a little bit later, or I think

I'm just going to go take a warm

bath and I'm going to

get to bed early and try to get up

tomorrow morning and see if I can

finish this assignment that I'm

working on for work.

Our kids really take that to heart,

and that's how we start to teach

them some of the coping skills that

they need to deal with their own

anxiety.

When you're thinking about helping

kids access treatment for anxiety,

I think it's also really important

to help them know that

exposure is a necessary

part of that treatment.

So what we don't want to do

as we're trying to help kids through

this is to help them into

methods of total avoidance.

That's something that's going to

make their anxiety worse in the long

run. So if

you think about an anxious child

who's feeling nervous about leaving

the home, nervous about going to

the store, nervous about going to

school, it would feel really

easy just to keep them at home and

never have them go anywhere.

But the reality is that's probably

going to make their anxiety a good

bit worse.

We will do them better to try to

stick to a routine, even

if it's something that makes them a

little bit uncomfortable.

And then try to help them find those

coping skills in the moments when

they're feeling really overwhelmed

as they go through that exposure.

Similar to depression, there are

some computerized online

self-help modules for kids

with anxiety.

One of my favorites comes from the

Mayo Clinic anxiety coach,

and it includes some

tips for parents, as well as some

individual self-help tips, if you

have a really motivated teenager who

just wants to try to work on their

anxiety. When we're thinking about

next, a patient with ADHD, I

think it's maybe less helpful to

give you a clinical vignette of how

they might present.

These are things that we see really

commonly, especially in primary

care. What I'd like to focus

on instead would be

what are some of the signs that a

patient who has ADHD is

really struggling in the pandemic?

We've seen some of the evidence

about how they might struggle or why

they might struggle.

But I want to give you some of my

pearls for

sort of unusual ways that it might

look or present in the office.

So some of the things that really

stick out to me when I have a

patient with ADHD are,

first and foremost like usual,

teacher concerns, especially

in the distance learning setting.

If teachers are telling you that

they're concerned about a child's

attention or a child's academic

performance, that's something that

really raises my level of concern.

Teachers have a lot less ability to

observe kids directly in the

distance learning setting, and so

if it's obvious enough to come

across to them in that setting, it's

really something that we probably

want to try to address.

When I'm talking with parents and

they tell me that they're having

to give a significant amount more

parental support around assignments,

around focus, that's a clue

to me that their

ADHD might not be under optimal

control and that they're really

struggling in the setting of the

pandemic.

When I hear about social

difficulties, in particular

kids that are really struggling to

connect with others, they

feel that the distance learning

is really challenging for them.

The screen isn't really very

engaging and they're really missing

their friends.

That tells me that

their ADHD is probably increasingly

problematic.

From the standpoint of actually

getting work done,

I find that individuals

with ADHD will often tell me

they're taking a lot more time

to get through their assignments if

they're struggling, or that

they're really struggling to finish

that final step.

So it's pretty common that I'll hear

from a kid with ADHD that

they finished their assignments or

they did the project or the report,

but they forgot to send it in.

So when their parent is trying to

help them and is looking at their

list of assignments online, they see

a lot of missing assignments, a lot

of incompletes.

That's a clue to me that the ADHD

is really contributing in a

significant way.

The last thing that really sticks

out to me when I think about

ADHD, and specifically

distance learning, is unstructured

online learning.

So it's one thing to expect a kid

to focus with a teacher

on a Zoom call or a Google

chat.

It's another thing to expect

that same patient with ADHD

to be able to organize themselves

and methodically get through a list

of assignments that's posted online

without any specific structure.

So as I'm talking with families, if

I'm hearing that that's the way that

their learning is set up,

I'm going to take a little bit of

extra time to make sure that we're

really controlling their ADHD

symptoms and leaving

them in a good place so that they

can get through all of this.

Very often what that also involves

is trying to help encourage

the parents to advocate for their

child to get extra time,

one on one with individuals

at the school, to have

some time for planning to get

through these activities, so that

we're not leaving the child

treading water on their own.

There are a couple of other tips in

general that I think are helpful for

kids with ADHD, both

during the pandemic and just in

general. If you have a lot of online

assignments, I like to encourage

them to print them out into

paper assignments.

That concrete paper assignment is

going to feel a little bit easier to

get done often than something

that's online or engaged with a

screen, setting timers when you

can. So making a plan

for the day and saying we're going

to spend 20 minutes working on math

and I'm going to physically set a

timer that you're going to sit here

and work on your math worksheet

until it goes off.

That's a really nice concrete way to

help them plan and execute

what they need to get done for their

work, Helping them get those extra

supports or check ins from the

school, as we briefly touched on

already.

Giving them time to take movement

breaks over the course of the day.

So that might be just 5 minutes

every half hour that they get up

and run a lap around the house and

come back and sit back down.

And then finally making sure that

they're being compliant with their

ADHD medication if they're taking

one, and making alterations

to their medication regimen as

necessary. So particularly

in the distance-learning setting,

the kind of traditional long-acting

stimulant medication, for instance,

might not be the best fit.

They might do better with a short

acting stimulant that's really

focused during the time when they

have their online classes,

or that they could use for a shorter

period of time when they're sitting

and working on their assignments

on a day when they're not

doing face-to-face

or computer based learning

with their teacher, and then making

extra time for these kids to have

some socially rewarding peer

interactions.

That's something that they're really

going to miss, particularly in the

distance learning setting, and

it's an area where children with

ADHD will often struggle to begin

with. So we really want to make sure

that we're giving them the

opportunity to have those

interactions even in the settings

of increased

social isolation.

And lastly, I always want to make

sure that I'm thinking about

comorbidities or my patients with

ADHD.

We have really good research and

evidence that tells us that

any child with ADHD has

an increased risk for things like

anxiety disorders, depression,

that they have higher rates of

learning disabilities compared to

children without ADHD.

So we always want to be thinking

about those things as possibilities

if we're seeing new or concerning

symptoms developing.

All right, the last patient

example that I want to talk through

with you is

a 12-year-old girl.

Now she's coming to your office

because of weight loss and

you're looking back at her growth

curve. She's always been kind

of a thin build.

Her BMI was around the 20th

percentile since age 4

or 5, but more recently

she's been getting comments from

others at school, and

her parents have noticed that she's

looking noticeably

thinner than that.

And when you check her growth chart

now, her BMI has dropped quite

significantly. She's now less than

the fifth percentile for her age

and for her weight.

When you talk to her a little bit

more about the weight loss, she

says, "Gosh, no, it wasn't anything

that I was doing on purpose."

She's not really having a lot of new

symptoms, things that would make you

worried about an underlying medical

disorder. She's not having abdominal

pain or vomiting or blood in

her stools or hot

or cold intolerances, she just says,

"I'm not really hungry."

And so when you talk through what

she's eating in a typical day, she

says, "Well, I'm up pretty late

at night, getting my assignments

done. So often I'm kind of sleeping

through breakfast and then getting

up just in time for my Google meet

that's at 10 for school.

And then after I finish those,

sometimes I'll get lunch on my own.

But you know, my mom works from

home so often she's in meetings

during the day, so I'm kind of

grabbing things on my own at lunch,

and then,

you know, we do sit down for dinner,

usually all together at

the end of the day as usual."

But her mom sort of interjects at

that point and says, "Yeah, but

you're not really eating as much as

you used to." She's noticing that,

kind of, the plates not really empty

and that the portion sizes in

general are a good bit less than

what she was eating previously.

Interestingly, she's also started

taking up a new exercise regimen

since the start of the pandemic.

She's getting up every morning when

she doesn't have school and

going for a 3-mile run

because she said it just helps her

feel better in general.

And Mom was, you know,

initially pretty happy that she

started to show some interest in

exercise because this was a girl who

wasn't particularly interested in it

before. Sports weren't really her

thing, and so

she didn't really get up or get

moving much at baseline.

Her mom, though, is starting to get

increasingly worried because she's

feeling like the exercise is kind of

ramping up. So initially it

was just getting up and going for

some walks.

Now it's runs that are getting a

little bit longer.

And then, you know, she tells you

that last week she was pretty sure

that when she went downstairs

to the girl's bedroom, she found her

doing an online workout

video that included like a

30-minute abs section,

as well as some other resistance

training that she was doing there in

her bedroom.

When you think about her mood in

general,

she says she feels OK,

maybe a little bit more irritable at

baseline, and maybe not

sleeping as well.

But she tells you she's not

otherwise feeling super anxious,

feeling super down, and she's

an otherwise healthy kid

with a family history that's pretty

unremarkable other than her older

sister, who's had treatment for

anxiety.

This is a really common presentation

that I find actually in my patients

with eating disorders.

So when I think about the

classic ways that eating disorders

present, it's usually not that hard

to pick them out if they're really

going by the classic symptoms.

If you have a patient who's coming

in saying, "I want to lose weight,

I look too fat.

I don't like how I look."

Those aren't typically patients that

we're going to miss.

When patients come in looking like

this, I think it's maybe a little

bit easier to miss the signs

of eating disorders.

So some of the things that really

stick out to me and a case like

this, first and

foremost, any kind of new,

especially an intense exercise

regimen, especially if it's a

deviation from the norm, that

always catches my attention.

If you're finding that there's

any kind of new dietary

restrictions, so

a teenager who suddenly has

decided that they're going to go

completely vegan, whereas previously

they were eating meats and

other animal products, or

a teenager who decides that they

want to go on a keto diet, that's

something that kind of catches my

attention, and that makes me think a

little bit more about the possibility

of an eating disorder.

Often, these teenagers might not

comment on their own

appearance, but you might hear them

commenting on the looks of others.

So I'll have these patients

coming in and I'll ask their

parents, do they say anything about

themselves? "Well not really but she

calls her little brother chubby,

and she made a comment the other day

when I saw this person come on the

screen on the TV

that they were eating too much." So

if you're hearing those sorts of

things, it definitely gives me

reason for concern and a reason to

pause and look at things in a little

bit more detail.

And then probably one of the things

that sticks out to me the most is

the loss of appetite.

I would say that probably

90% or more of the patients

I treat in my eating disorder clinic

come in saying "I'm not hungry."

And that happens because as they

start to eat less, their body

naturally starts to down regulate

their appetite as it's trying to

decrease metabolic demands.

So very often it just becomes

this vicious circle where they're

not eating as much for maybe

a variety of reasons in the

beginning.

They start to lose their

appetite, which makes them less

inclined to eat at all.

And suddenly you've got a patient

sitting in your office who's eating

maybe once a day

and losing significant amounts of

weight. When we think about

patients with eating disorders,

specifically

in the setting of the pandemic,

there is some good research that

tells us that virtual treatment can

be helpful in terms

of maintaining progress in treatment

or in terms of even getting started

on treatment for a new diagnosis of

eating disorders.

So if in-person treatment

isn't something that's available

near you or your practice,

it would be worth looking into

virtual treatment options.

It's also especially important

to emphasize to these patients that

they stick to their routine.

We want to make sure that they're

going to bed at regular times,

getting up at regular times so

that they're getting all of their

regular meals throughout the day as

they're going through their

treatment.

For all teenagers, I think it's a

good idea to monitor media exposure,

but I think that this is especially

true for patients with eating

disorders.

More time isolated at home

and away from your friends leaves

you more time scrolling through

Instagram and Tik Tok.

And the research pretty clearly

shows us that that's not good for

emotional health, and then that can

lead to a lot more body

dissatisfaction for patients with

eating disorders.

Getting these teenagers in

for health maintenance visits, I

think, is another really crucial

way to find these eating disorders

and get them into treatment.

I can't tell you how many teenagers

that I've seen in the pandemic who

were due for a regular checkup

and then weren't able to come into

the doctor's office for several

months, and by the time I get them

into the office, they're 20

or 30 pounds less than what they

should be, and coming in with

really concerning symptoms, so

really advocating to get them in for

a visit and the office so that

you can check on them, get updated

heights, weights, vital signs

and get a better picture of what's

going on day to day.

So as you can see on the slide here,

we've covered several things over

the course of our talk today.

We talked a little bit about

prevalence and trends as

they relate to various areas

of mental health, and then spent a

little bit of time talking about

what it might look like in a patient

in both a typical sense and an

atypical sense.

And also covered some of the things

that you can do to help.

And what I would leave you with in

overall summary, is yeah, we

don't have a lot of data, but

we are seeing some studies that show

us what we might expect, which is

increasing concerns for

depression and suicidality,

specifically increasing

rates of anxiety and

increasing rates of disordered

eating, not just eating disorders,

during the pandemic, I think it's

important for us to recognize that

these patients may present in

different ways than we're

accustomed, so we're going to have

to have a higher index of suspicion

and really be thinking about these

things when we're seeing patients in

the office, and we can do our

best to help these families in

many ways by encouraging

structure and routine, helping

to provide them resources, whether

that's mental health treatment

resources or resources

to help them with bills, with

food, with some of the necessities

that they have in their day-to-day

lives, and then helping them

adjust their expectations and

recognize that we're all going

through something new and different

here, and we're going to have to

change the way that we approach that

so that we can all stay mentally

well.

So thanks very much for your time

today.