Pediatric Meltdown

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The medical world is accomplishing great things; for example - Rapid Whole Genome Sequencing. A cutting-edge concept that has cut diagnoses of rare diseases from weeks and months to days and hours. It’s called Project Baby Deer and it’s focused on implementing evidence-based precision medicine and pediatrics to facilitate rapid whole genome sequencing for sick inpatients, neonates and children across the state. The project was born out of a collaboration between Dr. Caleb Bupp, Dr. Andrea Scheurer and Dr. Joseph Fakhoury. Your host, Dr. Lia Gaggino talks with these 3 clinicians about this groundbreaking initiative that is helping to provide better care for children across the state. If you know someone who is in medical school, you’ll need to share this episode with them.         

[00:33 -28:07] Intros / What is Rapid Whole Genome Sequencing?

• Michigan’s “Baby Deer” project was designed after California’s “Baby Bear” project.
• The genetic code is made up of billions of adenine (A), cytosine (C), guanine (G) and thymine (T)
• Variations in the code is what makes us unique.  
• In the past, sequencing was expensive and slow, but technology has made it faster and cheaper.
• Entire genetic code can be sequenced in hours with accurate results.

[28:08- 35:40]  Benefits of Genetic Testing for Children  

• Genetic testing can provide important information about a child’s risk of developing a particular health condition in the future.
• Genetic testing is faster and cheaper than ever before.
• Genetic testing can help reduce the cost of care by providing more accurate diagnoses and treatments.  
• It can also help identify inherited traits and conditions that could affect a child’s health.
• Knowing the cause of a medical issue helps make better decisions on how to treat it

[35:41 -46:04]  The Benefits of Collaboration

• Bronson and DeVos hospitals collaborated to develop a comprehensive consent process, as well as a system for sharing and analyzing the data.
• The two hospitals have also developed a system for follow-up care, ensuring that any positive results are followed up on and that any negative results are discussed with the family. 
• The collaboration between Bronson and DeVos has made rapid WGS accessible to more families and has helped to improve the quality of care for those families.
• Although the cost is a main barrier to expansion, the collaboration between the two hospitals will provide rapid WGS to patients in need.

[46:05 - 1:02:49]  What is Rare Disease Day? 

• Rare Disease Day is the last day of February, the rarest day of the year.
• It is a day to raise awareness and hope for the 300 million people worldwide who live with a rare disease.
• It is a day to highlight the need for research, support, and advocacy for these diseases.
• It has been happening every year since 2008.

[1:02:50 - 1:08:48]  Closing segment Takeaway.

You can reach Dr. Joseph Fakhoury

Facebook: Joe Fakhoury | Facebook

Instagram: @jfakhoury.515

LinkedIn:

https://302.buzz/PM-WhatAreYourThoughts

Patient Confidentiality is a complex subject and more times than not, the answer to the questions will begin with “Well, it depends….” Dr. Elizabeth Alderman, a pediatrician, shares her journey into pediatrics and how she has handled this issue in her own practice in the state of New York. Both Dr Gaggino and Dr. Alderman talk about the frustrations that healthcare providers face when they must decide on the best course of action to take, particularly when there are concerns about the safety and wellbeing of the adolescent patient. Listen in as they discuss navigating these complexities requiring a delicate balance between respecting a patient's confidentiality, ensuring their safety, and complying with legal and ethical obligations. 

[00:33 -15:50] Opening Segment / Adolescents and the 21st Century Cures Act

• The 21st Century Cures Act has provided adolescents more access to confidential healthcare
• It has made it easier for adolescents to receive mental health services without parental consent  
• It has expanded access to contraception and sexual health services without parental consent
• It has provided more protection for adolescents with chronic illnesses to be able to access care without parental consent.
• It has also strengthened HIPAA protections for adolescents.

[15:51- 31:08] How can healthcare providers ensure confidentiality for adolescents?  

• Have a routine part of the visit that discusses confidentiality and set expectations between the healthcare provider and the patient.
• Have a conversation with the parents or guardians about leaving the room if needed during sensitive conversations.
• Read the After Visit Summary before giving it to the patient to ensure that no sensitive information is included that should not be seen by parents or guardians.  
• Work with the EHR vendor to set up rules around the patient portal that honor state law privacy exceptions.
• Encourage patients to ensure that their own email is linked to the patient portal instead of a parent or guardian’s email.

[31:09 -42:16]  Empowering parents in conversations with their teens

• Recommending parents bring up topics like sex and drugs with their teens
• Assessing whether parent involvement is appropriate in each situation  
• Discussing the limits of confidentiality
• Role-playing conversations with parents

[42:17 - 50:37]  How to Ensure Adolescents Receive Confidential Medical Care 

• Make sure to know what state laws you are working under related to birth control, STI testing, mental health and prescribing medication for mental health disorders.
• Look for links and resources related to state laws and reproductive rights.
• Look for handouts related to adolescent confidentiality from the Society for Adolescent Health, AAP or your state’s AAP chapter.
• Always be mindful of how your words will be interpreted by a patient.

[50:38 - 59:26]  Closing segment Takeaways

Don’t forget to sign up for Dr. Gaggino’s February 24th Beta Training

for Professionals who want to re-think the mental health services they offer

Up Your Game - Improving Kid's Mental Health Care

Links to resources mentioned on the show

State by State Variability in...

https://302.buzz/PM-WhatAreYourThoughts

The challenges of mental health in children are complex, to say the least. One of this podcast’s favorite guests, Dr. Mark Sloane is a long-time pediatrician with decades of experience in this field, returns to talk about the challenges of persuading primary care physicians to pursue additional education, the effects of trauma on children, and the demand for more training in medical school and residency. There’s also a discussion on the impact of screening on mental health and the use of SSRIs in children.

[00:33 -15:31] Opening Segment /Importance of Mental Health Treatment

• We’re introduced to Dr. Mark Sloane, and we hear about how his journey into pediatrics.
• Primary care doctors need more mental health training. 
• Pediatrics have evolved over the last 20-30 years and needs to be accepted.
• The Authority Health Project is providing training to residents to integrate trauma-informed care into their practice.

[15:32- 29:12]  Traumatic Stress and Mental Health  

• Serotonin genetics significantly increases the risk of PTSD with traumatic exposure.
• Prenatal stress, especially from domestic violence, can increase the risk of anxiety disorders.
• Epigenetic factors can be used to assess a newborn's risk for anxiety and other mental health issues.
• Mental health medications are often seen as a last resort for treating traumatized children.
• Trauma therapy is essential for treating underlying mental health issues in traumatized children.

[29:13 -49:31] Building Relationships and Connection: The Magic of the Room

• The Power of Relationships- The importance of building relationships as the cornerstone to emotional wellbeing.
• Going Beyond Compliance- Facilitating environments where kids feel safe and supported rather than simply compliant.
• Adopting a Team Approach- Understanding the need for team effort and how it can help foster parents and staff to create successful outcomes.
• The CTAC Model Evolves- Examining how the CTAC model has evolved over time to include physicals, fetal alcohol syndrome screens, and more.

[49:32 -58:45]  Advice for the New Medical Professional

• Focus on connection with patients
• Meet the needs of the community
• Listen to veteran doctors / Get a mentor
• Build incentives for trauma screen completion

[58:46 - 1:05:22]  Closing segment Takeaway

Don’t forget to sign up for Dr. Gaggino’s February 24th Beta Training

for Professionals who want to re-think the mental health services they offer

Up Your Game - Improving Kid's Mental Health Care

Links to resources mentioned on the show.

Bruce Perry

https://adoptioncouncil.org/publications/meeting-children-where-they-are-the-neurosequential-model-of-therapeutics/

Book: What Happened to You?  

https://302.buzz/WhatHappenedToYou

Andrew Garner – Thinking Developmentally

https://302.buzz/PM-WhatAreYourThoughts

This is a very special episode where I (the Pediatric Meltdown producer) get to interview your host, Dr. Lia Gaggino.  There are lots of great things happening in 2023 and we thought this would be a great way to tell you about all of it as well as getting to know your host a little bit better.  We’ll talk about what made her fall in love with Pediatrics as well as her decision to step down from the practice. There is a sneak peak of some episodes coming up, an overview of the “Up Your Game” event she is planning at the end of February (the link to join is below). And we do a rapid-fire random question and answer game that gives you a little more info on the doctor… Do you like the same dessert????          

[00:33 -05:39] Let’s start at the Beginning. 

• She went from “hippie” to intern.  
• She did her rotation in pediatrics and loved it.
• And why she stepped down from practicing.

[05:40-11:07] Her involvement with the American Academy of Pediatrics  

• She’s served in several capacities on the AAP including president, vice president, and board member. 
• Lia talks about the AAP and their outreach to other countries.
• The AAP policies that came about due to the pandemic  

[11:08 –18:49] Lia Talk about the Podcast

• We share our favorite episodes.
• What kind of subjects we can look forward to hearing in 2023 
• Lia is “very picky” when it comes to choosing the guests for the show. 

[18:50 - 28:33] Let’s hear about the new Newsletter and Event

• The newsletter will go out twice a month and will highlight past and future guests, polls, articles of interest, etc.
• The “Up Your Game” Event (02/28/23), is for clinicians to understand how they can help kids with mental concerns.   
• A quick game of “word association”

Sign up for Dr. Gaggino’s February 24th Beta Training

for Professionals who want to re-think the mental health services they offer

Up Your Game - Improving Kid's Mental Health Care

You can reach Dr. Lia Gaggino

Website & Newsletter:  https://medicalbhs.com/

Facebook: Dr. Lia Gaggino | Facebook

Instagram: @pediatricmeltdown

Twitter:  @gaggino

Linkedin: Lia Gaggino, MD, FAAP | LinkedIn

Links to resources mentioned on the show

American Academy of Pediatrics

Home (aap.org)

Other episodes you may like:

Episode #01

Words Matter-Talking about Weight & BMI

https://302.buzz/PM-WhatAreYourThoughts

Ehlers-Danlos Syndrome…. Ever hear of it? Well, they say that it’s the most common illness that you’ve never heard of. Jayne Mattingly makes a return appearance and gives Dr. Gaggino an update on her health and life since she was last on the podcast. She will talk about how her condition has progressed and gives an honest account of what life is currently like for her. It’s emotional, it’s raw, and it’s real.   

[00:33 -13:39] What is Ehlers-Danlos syndrome (EDS)?

• It is the most common illness that you've never heard of.
• There are 14 different types of EDS, the most common being hypermobile EDS.
• It is a genetic condition and is becoming increasingly more common.
• People with EDS may need to use mobility aids and make changes to their living space or lifestyle to accommodate their condition.

[13:40- 24:23]  What Impact Has EDS Had on Jayne's Life?  

• She’s now a wheelchair user and has had to move into an accessible home.
• She’s had 14 brain and spine procedures and surgeries.
• She’s had to switch her focus from recovery coaching to training and educating professionals to become eating disorder recovery coaches.
• Jayne created a nonprofit called the AND Initiative which gifts mobility aids and provides resources, education, and advocacy for those with disabilities and chronic illnesses.

[24:24 -32:10]  What Are Some of the Difficulties Associated with EDS?

• The world is not as accessible as one might think when one becomes disabled.
• Grief is experienced with the small things, such as getting dressed in the morning or using a shower chair.
• Navigating a world that doesn't understand can be isolating.
• Loss of independence or having to rely on others for help.

[32:11- 39:09] What Are Some Ways to Support Those with EDS?

• Educate yourself about EDS and learn about its symptoms and treatments.
• Listen and ask questions about how you can help them manage their EDS.
• Offer assistance but when the answer is “no thank you” .... Believe them.

[39:10 - 46:59]  Closing segment Takeaway.

***Don’t forget to sign up for Dr. Gaggino’s February 24th Beta Training

for Professionals who want to re-think the mental health services they offer

Up Your Game - Improving Kid's Mental Health Care

Where to get in touch with Jayne

Instagram:  @jaynemattingly

Twitter: @jayneimattingly

Linkedin:

https://302.buzz/PM-WhatAreYourThoughts

Dr. Lia Gaggino asks pediatric neurologist Dr. Sarah Dixon some interesting questions about a phenomenon called “TikTok Tics”.  Ever hear of it?? Yeah…. Me either.  But it is, indeed, a real thing.  We’ve all seen TV shows or movies where someone with Tourette’s spews out a string of curse words and many people think that is the definitive symptom of the disorder. It is more complicated than that.  Dr. Dixon talks about the different types of tic disorders and offers up some good news for kids and their parents who are struggling with the challenges of tics that most tics will fade away.  

[00:33 -19:24] Understanding Tik Tok Tics

• They are commonly seen in older adolescents developing tics for the first time.
• These movements have previously been referred to as "functional tics."
• They fall under the larger umbrella diagnosis of "functional neurologic disorder" (FND)
• FND is a subconscious habit-driven or learned behavior that causes distress or diminishes quality of life.

[19:25- 24:03]  Understanding Functional Neurologic Disorder (FND)  

• FND is not associated with structural, chemical, or electrical neurologic disorders.
• It represents an abnormally learned motor plan.
• FND often affects children who are skilled at quickly learning motor or academic tasks.
• Treatment includes cognitive behavioral therapy and multidisciplinary approaches.

[24:04 -27:47]  Understanding the Different Types of Tic Disorders

• Provisional Tic Disorder: characterized by one or more motor or vocal tics for less than a year.
• Chronic Motor or Vocal Tic Disorder: characterized by one or more motor or vocal tics for more than a year.
• Tourette Syndrome: characterized by two or more motor tics and at least one vocal tic for at least a year.
• Tic disorders are thought to be a spectrum of conditions rather than unique disorders.

[27:48-37:59] When to Refer to a Neurologist for Tic Disorders 

• When the patient is bothered by the tics
• When there is a suspicion of a comorbidity
• When the examination findings are abnormal
• When the tics have been present for more than a year or are increasing in frequency or complexity.

[38:00 - 46:10]  Closing segment Takeaway

***Don’t forget to sign up for Dr. Gaggino’s February 24th Beta Training

for Professionals who want to re-think the mental health services they offer

Up Your Game - Improving Kid's Mental Health Care

Links to resources mentioned on the show

Tourette Association of American website - 

https://tourette.org

TicHelper - Online, self-guided therapy program for tics: 

https://302.buzz/PM-WhatAreYourThoughts

When you hear Dr. Joey Skelton speak about his patients, it’s clear how deep his commitment runs.  He looks beyond the numbers as he believes that each patient deserves to be treated like an individual being. Today's discussion is on childhood obesity. But don’t make the mistake of rolling your eyes and thinking “oh, yeah… it’s a problem” .... This is a different kind of discussion with a different kind of doctor.  You’ll hear some things in this episode that you’ve never heard before. Dr. Gaggino asks some difficult questions and Dr. Skelton teaches us about another way to look at kids and obesity.         

[00:33 -19:54] Opening Segment

• Dr. Skelton quit his gastroenterologist practice to focus on obesity research and education.
• He believes that understanding the entire family is important in addressing obesity and wants to dive deeper into research in this area.  
• His program is set up so that families can start when they are ready, and it takes into consideration that they may have a lot of other stressors in their lives.
• Number one referral he makes is to a counselor for issues around anxiety or depression, and number two referral is to a mental health resource for parents who may be struggling with similar issues.
• Our bodies are naturally inclined to gain weight as a means of preparing for potential famines or wars.

[19:55 - 35:37] A New Way of Looking at Obesity. 

• Recognizing the complexity of factors that can impact behavior change, such as access to food, work schedules, and lack of cooking skills.
• Addressing obesity can be difficult when a parent is already overwhelmed with other stresses in their life.
• Restricting or limiting portion sizes and encouraging certain foods can lead to negative outcomes, such as increased weight gain and conflicts over food.  
• BMI is a screening tool and should not be used as a definitive diagnostic tool for obesity.
• Keeping the focus on the person, and behaviors related to preventing diabetes rather than just focusing on weight loss can be more effective.

[35:38 -46:07]  HAES (Health at Every Size) fights against Preconceived Notions

• Listening to podcasts and reading stories from writers in the movement can be emotional and eye-opening.
• Writers such as Virgie Tovar and Aubrey Gordon share their personal experiences of how their weight affected their interactions with friends, the healthcare industry, and society as a whole.
• It's important for healthcare providers to approach patients with a weight-neutral mindset, focusing on overall health rather than weight.
• Creating a safe and non-judgmental environment for patients is crucial in weight-inclusive care.
• Advocate for recognizing that people can be in larger bodies and still be healthy.

[46:08 - 53:37] Dr. Skelton’s recommendations

• Screening labs should begin around age 10, taking into account risk factors such as family history and physical findings.
• Look for opportunities to address issues of weight and health in a size-acceptance spirit.
• A mindset shift is required to recognize that health behaviors are often influenced by social drivers and the environment. 
• The need for education, support, and understanding for patients, rather than using tests to scare families.

[53:38 - 59:24]  Closing segment Takeaway.

Don’t forget to sign up for Dr. Gaggino’s February 24th Beta Training 

for

https://302.buzz/PM-WhatAreYourThoughts

Child abuse has long been a troubling and widespread issue, and sadly, it seems to be getting worse. Munchausen by Proxy (MBP), often known as somatic illnesses or medical child abuse, is one particularly nefarious kind of child maltreatment. Children's health and safety may be seriously impacted by this type of child abuse. Clinicians must be aware of the symptoms and warning signs of MBP in order to safeguard children against this condition. Dr. Nasuh Malas returns to the show to talk about this issue and give practical advice for clinicians.         

[00:33 -11:27] Any New Findings Regarding Somatic Disorders and Munchausen By Proxy?

• Somatic disorders, such as somatic symptom disorder, are characterized by physical symptoms that cannot be explained by a medical condition, and are often caused by stress or depression.
• Studies have found that individuals with somatic disorders are more likely to engage in Munchausen by proxy behaviors than those without the disorder. 
• These findings have important implications for the diagnosis and treatment of both disorders, as well as for preventative measures against child abuse.
• Early detection of somatic disorders in parents or caregivers is crucial in order to identify potential risk factors for Munchausen by proxy.
• Mental health professionals should be aware of the link between somatic disorders and Munchausen by proxy when assessing patients for these conditions.

[11:28- 25:17]  What the Psychiatrist can offer?

• Psychiatric assessments are used to identify and diagnose the underlying psychological and emotional issues that may be driving the patient's symptoms.
• Psychiatrists can also provide psychotherapy, which can help the patient better understand and cope with their symptoms, as well as explore the underlying causes of the disorder.
• Psychiatrists may also recommend lifestyle changes or other forms of therapy to help the patient better manage their symptoms.  
• Collaborative care is often recommended for treatment of somatic disorders, as a team of healthcare professionals can provide comprehensive care for the patient.
• Psychiatry is a crucial part of the treatment for somatic disorders, such as Munchausen by Proxy (MBP), as it offers a comprehensive approach to the diagnosis and management of psychiatric disorders.

[25:18 -34:57]  Red Flags to Watch Out For 

• Red flags for Munchausen by Proxy include: disregarding medical advice, iatrogenic injury to the child, isolating the child from normal routine, fading or lying about symptoms, and meeting psychological needs through the child's illness
• Children with somatic symptom and related disorders may develop an identity of being physically ill, which can be reinforced by their caregiver
• Caregivers may selectively accept certain aspects of a child's evaluation and treatment and disregard evidence that does not fit their belief about the child's condition 
• It is important for healthcare professionals to be aware of these issues and engage with families in a way that addresses their concerns and promotes the well-being of the child
• The continuum between somatic disorders and Munchausen by Proxy can be difficult to navigate, but it is essential to consider both physical and psychological factors in the evaluation and treatment of the child.

[34:58 - 43:32]  Recommendations from Dr. Malas

• Have handouts available for patients and families to learn more about somatic symptom disorders
• Consider working with...

https://302.buzz/PM-WhatAreYourThoughts

As Dr. Gaggino looks back on her episodes over the past year, she gives out kudos to some of the standout guests of 2022. She also has some reminders of past episodes that you may have missed or may even be worth another listen, (just scroll down to get those links) and there’s a sneak peek at some of the exciting things to come in 2023. If you haven’t already, make sure to tap on that follow button and to ensure that you’ll never miss an episode, get that automatic download every Wednesday morning. Dr. Gaggino has been working hard to get some fantastic shows lined up for you. 2023 going to be an AMAZING YEAR…            

[00:33 -2:11] Children's Mental Health and Depression

• Children are struggling with mental health issues, and it is our responsibility as adults to support them
• Building strong relationships and creating a sense of belonging can be healing for children and families  
• It is important to educate ourselves and seek out help from professionals when needed

[2:12- 3:04]  Medications for Mental Health in Children

• Dr. Jeffrey Strawn’s episode #44 discusses the use of SSRIs for children's mental health
• It is important to feel comfortable with a few medications and seek guidance from a child psychiatrist if needed
• The National Network of Child Psychiatry Access Programs (NNCPAP) can provide resources and support

[3:05 -3:26]  Assessing Social Determinants of Health

• Dr. Kofi Essel's episode #74 discusses the impact of food insecurity on children's mental health
• Asking about food insecurity and advocating for resources can be a simple yet effective intervention
• Other social determinants, such as housing and access to healthcare, can also impact children's mental health

[3:27-4:48]  Psychoeducation for Children's Mental Health and Supporting our own wellbeing

• Dr. Colleen Cullinan's episodes (such as episode 26 on anxiety and episode #71 on depression) provide valuable information on psychoeducation for children
• Dr. Cullinan's four-part series on executive function and ADHD (episodes #88, #109, #119, and #120) is also helpful for understanding and supporting children with these conditions
• Dr. Kemia Seraff's episode #108 and Dr. Miko Rose's episode #69 offer ideas for maintaining our own well-being as pediatric clinicians
• It is important to take care of ourselves so that we can better support the children and families we work with

[4:49 - 10:57]  Connecting with Others in the Field

• The American Academy of Pediatrics (AAP) and state AAP chapters provide opportunities for connection and support with other pediatric clinicians
• The AAP's policy statements, clinical and technical reports, and continuing education offerings are valuable resources for staying up to date on best practices in pediatric care
• Joining a local or national pediatric group can be a great way to connect with others and find support in the field.

Links to resources mentioned on the show

Dr. Lia Gaggino’s Website    https://www.medicalbhs.com/   

NNCPAP.org                       :

https://302.buzz/PM-WhatAreYourThoughts 

Norrine Russell is the creator of a cutting-edge coaching approach for challenging children, such as those who are 2E, have ADHD, Autism, or Anxiety, as well as those who have learning disabilities. Since 2009, Connected Coaching has demonstrated success with hundreds of students.  Dr. Russell is an expert in child development, learning styles, special needs, and effective parenting practices. She has twenty years of experience developing positive youth development and parenting education programs. She combines her expertise to give parents and students the full support and resources they require to develop and prosper.  Listen in on the conversation between Dr. Lia Gaggino and Norrine Russell, PhD. This new concept could be groundbreaking.

[00:33 -13:41] Personal Journey from Academic Job to Youth Development 

• Her son’s diagnosis of ADHD and the Tampa Bay ADHD Parent support group
• The success of Russell Coaching as the largest student coaching practice in the country  
• The coaching Process
• Significance of multimodal treatment
• Gathering coping mechanisms used in Therapy

[13:42- 29:35] Access of Quality Psychiatric Care  

• How coaching works differently than traditional psychiatry 
• Current insurance model is not tailored to diagnoses or treatments like coaching
• How the symptom tracker helps in coaching  
• Difficulties pediatricians face in providing medical care
• Possible partnership between psychologists and pediatricians

[29:36 -45:59]  What the AAP says about ADHD     

• Understanding 504s and IEPs
• Finding local and national resources 
• The impact of COVID19
• Filling in the gaps of the education system
• Improved parent/student relationship when students have a coach

[46:00- 55:57]  Preparing for college could be a mental health transition   

• Looking ahead on what is needed for college life
• The change of schedules, daily routines, and moving out of the home to independent living plays a part
• Emotional Autonomy and the desire to do things on their own terms
• Tips on how parents can effectively advocate for their child’s ADHD
• A much more hopeful outlook on the next decade for those with ADHD

[55:58 - 1:16:00]  Closing segment Takeaway

You can reach Dr. Norrine Russell

 Facebook: https://www.facebook.com/drnorrinerussel

Instagram:@russellcoachingllc

Linkedin: Norrine Russell | LinkedIn

Pinterest: https://www.pinterest.com/russellcoaching/

 Links to resources mentioned on the show

 Website:  https://russellcoaching.com

Book:  Asking the Right Questions about ADHD Before, During, and After Your Child's Diagnosis

AAP Clinical Practice Guideline The Diagnosis, Evaluation and Treatment of children and adolescents with Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: