Chapters Transcript Video Healing from Within: Mind-Body Approaches to Pediatric Anxiety and Depression Thank you all for being here. Um, this morning we are thrilled to have with us, uh, Doctor Fatima Barragan, who is an integrative pediatrician at the UCSF OSHA Center for Integrative Medicine. Um, my name is Sarah Blatcher. I'm one of the pediatric chief residents, and it's my pleasure to, my pleasure to introduce her. Um, our guest today completed her pediatric residency at UCSF and her fellowship in pediatric integrative medicine at Stanford University in conjunction with the University of Arizona, Andrew Wheel Center for Integrative Medicine. Uh, she founded and is currently the director of Clinica Buena Vista at Zuckerberg San Francisco General Hospital, which provides integrative care to underserved children. She also works as an integrative medicine pediatrician through the UCSF OSur Center, using evidence-based modalities such as nutrition, mind-body techniques, lifestyle changes, and other holistic practices to provide care to children with complex needs. As a fun fact, she's also a yoga and fitness instructor, but of course, today, she's here to talk with us about integrative approaches to treating pediatric anxiety and depression. Without further ado, I will hand it right on over to her. Thank you so much, Sarah. I hope everybody can hear me OK. We'll go ahead and get started. So as Sarah said, my name is Fatima Berrigan and today I'll be talking to you um about mind-body approaches to treat pediatric anxiety and depression. I have no disclosures. And I'd like to start with the land acknowledgement. So we would like to acknowledge the Ramaushaloni people who are the traditional custodians of this land. We pay our respects to the Ramatuhuloni elders, past, present, and future who call this place the land that UCSF sits upon. Their home. We are proud to continue their tradition of coming together and growing as a community. We thank the Rama Ramatuni community for their stewardship and support, and we look forward to strengthening our ties and continue our relationship with mutual respect and understanding. So I'd like to start with an opening guided meditation, and we do this at the OSHA Center every time we have a big clinical meeting, and it's really helpful and I would love for you to participate and join me so you get a little bit of a sense of what we do in our clinic when we do this with our children as well. So if you are open to it, Please join in. All you have to do is listen to my voice and if not, you can practice the send meditation, which is just turning off all sounds and just focusing on your breath. But for those who are open to trying the guided meditation, go ahead and let's start with some shoulder rolls. And on these Tuesday mornings, you know, we can All feel a little bit stressed and a lot of us hold their stress on our shoulders, so yes, perfect. Go ahead, roll your shoulders back, roll your shoulders forward. Make sure your feet are planted on the floor if you can, and if you feel comfortable closing your eyes, go ahead and allow your eyes to close. Otherwise, pick a point that you can stare at the entire time. And we'll start by bringing all of your awareness into your breath. So notice every inhale. And every exhale. Notice when the breath begins. And when it ends, and we'll take 3 big deep breaths together. So go ahead and inhale in. And exhale out. Do that one more time, big inhale in. And exhale out. Biggest in hell yet in Helen. And exhale out. Perfect. Now I want you to bring into your mind's eye a memory or a hope of a happy thing you would like to happen in your life. And I want you to go ahead and play that. Visualization, that memory, that hope in your mind as if it was a movie, and place yourself in that space now. No All the sounds that are happening there in this happy place that you have chosen. No But sensations you feel. On your feet, on your skin. Notice where in your body. You can feel joy to be in this happy place. Go ahead and take a look around there. See what colors. are there. See what sounds. You can hear. And perhaps you can even catch a smell of your surroundings. Perfect. See if we can taste something there. What does this joy in this happy place. Feel like for you. I'll give you a couple moments here. To do whatever it is. That you want to happen. And to feel the joy that you have in this place. Excellent. Now, we'll all come back and bring our awareness back to this room, back to this space. Listening to the sounds that are far and close by. And when you're ready, you can open your eyes and feel a little bit of that relaxation that can happen when we give ourselves some time to focus on our breath. And on and on our senses. So I hope that was a little bit of a good practice for you and you get some sensation of what these medications can do. So today I'll be talking to you about integrative medicine, and we'll talk about the prevalence of anxiety and depression in pediatrics. We'll go into the neurobiology of anxiety and depression and talk about some evidence-based integrative medicine approaches to treat an anxiety and depression and We'll discuss the nutritional interventions that can happen here, sleep medicine, screen time, and monitoring and exercise, and how exercise and mind-body practices can also help with that. We'll dive a little bit into the literature about acupuncture and hopefully we have some time for a good discussion in Q&A at the end. And I also like to start with something funny, and here's Waldo, uh. Be very worried that Google would like permission to use his location. So the most common question that I get is, what is pediatric integrative medicine? And integrative medicine is when we take everything that we know of in conventional medicine or what we know as Western medicine, and we add other types of complementary or alternative medicine. And what makes integrative medicine is when we mix those two together and focus on using the best evidence-based therapies that are available. I want to acknowledge that a lot of what integrated medicine is comes from traditional cultural medicines that have been practiced for thousands of years. For example, Ayurveda is a very powerful mode of medicine, and that that's been practiced for over 5000 years. And traditional Chinese medicine records go back to 3000 years when people started to notice meridians in different acupuncture points. So all of these are incorporated and are now what we call integrative medicine, but these traditions and these cultures have been practiced for, for a long time. So culture cultural medicine is the sum total of the knowledge, skills and practices based on the theories, beliefs, and experiences indigenous to different cultures. And I'd like to tell you a little bit about my culture. This is my grandma and my mom, um, and my grandma used to always tell us to go pick up specific plants, and I later learned that these were Arnica and that was a great way for her to help us with bruises or muscle aches that we had. And my mom. Always used chamoLT for us when we had an upset, upset stomach or gastritis and that was always very, very soothing to us and it turns out That there's actually scientific data to back the use of these uh modalities, and here's a couple of studies. Uh, for example, there is a perspective double blind study uh used to use a tea for colic, and when they looked, there was a total of 33 infants. Um, 57% of them had improvements or eliminated their colic by using the tea and Only 9% or only 26% or 9 of those participants, um. We found that placebo was also helpful. So It can be very safe and it can help a lot of patients. So, what are the treatment modalities that we use in integrative medicine? We really look at whole systems healing traditions we use. Ayurveda traditional Chinese medicine or other indigenous medicines that we learn depending on the cultures uh of the people that come to us. Uh, we look at mind-body therapies include, which include mindfulness, meditation, breath work, movement therapies, and use a lot of food. As medicine and sometimes we use dietary supplements as well. So we'll dive into the biochemistry of how pediatric integrative medicine can function. And we look at epigenetics, so our epigenetics or epigenome is all these modifiable factors that can affect us on top of what our DNA is, right? So things such as diet, development, what our environment is, all these things play a role on how our genes are. Transcribed, and every time an epigenetic factor methylates one of these histone tails that are in our chromosome, it allows it to either become more active to be transcribed, or it can close up to be repressed. So all of these external factors are actually giving information, uh, to our genetic transcription, which impacts our health. And here's just a few examples of what these outside factors can be. So it could be how you're feeling, the amount of stress you're exposed to, diet, diseases, different types of environments. Your microbiome, there's a huge amount of data now coming into um play and learning about how the microbiome actually modulates a lot of our behaviors and, and a lot of our own genetic predisposition and These are just a few of the many examples of how the epigenome can be modified by what we call um these external, external factors. So, I wanna say that. And my intention for, for the following uh presentation is that You get a little glimpse of what we do in integrative medicine for anxiety and depression in pediatrics, and people have built their full careers on this, so there won't be such a deep dive, but I hope that you learn a little bit about what you can do in your own practice and, and what I've tried to do here is give you a perspective of What you can do for both low income and low resources areas and, and for those who have a little bit more resources as well. So when we look at the prevalence of anxiety and depression, we all know that these have been increasing over time uh in children. And as you can see here, this is the National Survey of Children's Health from 2022 to 2023. And it surveyed over 100,000 children and families within the entire United States, and you can see that as children get older, anxiety and depression prevalence also increases, um, and that is something we continue to see and I see and practice. But we know that this isn't. New. This actually has been happening from around 2010, and this is a graph showing the, the incidence of major depression episodes in the last year in US teens, those from 12 to 17, and you can see that we started around 2010 and a 12%. Um, and when we get now, this is in 2022, we go about 28%, which more than doubled for teenage girls, and for teenage boys, so it's the, it's much lower, the percentage is much lower. It also doubled from 5% to now 11.5%, but this has been happening. Since around 2010, this is not something new um that we haven't seen. And the teens are not alone. You can see here that from the age or, or the Gen Z from 18 to 25, they also have this huge increase in anxiety and more of the millennials um have also increased in in anxiety. So there, there's definitely something happen, happening that has been impacting us all. So I'd like to start with a clinical case and talk to you about Jojo. So Jojo's a 16 year old with a history of anxiety and intermittent panic attacks. He worries that his face is asymmetrical and that he is too ugly. He's concerned that his friends will think of him differently and will not want to be his friends anymore. He worries too much about making mistakes at school, and when you give him the uh GAD questionnaire and the PHQ 9, he scores for moderate anxiety and moderate depression on both of those. For his family history, both his parents have anxiety and depression, and his grandmother has type 2 diabetes. In his head's assessment, you find out that he lives with his sister. He's in 10th grade and he does well and he's on the basketball team, denies any history of substance use and has never been sexually active, but he does endorse that in the past month, he's had some passive suicidal ideation. He's never had a plan, has never attempted to, to, uh, hurt himself, but he just thinks that sometimes I think of what it would be like if I wasn't here anymore. Uh, for his physical exam, you know his vital signs are within normal limits. His face is completely symmetrical to you. There's no visual, um, disproportion there and his BMI is within the 50%. So you diagnosed him with moderate anxiety and depression and you noticed that he was previously referred to behavioral health to start CBT, but he's was placed on a wait list and his parents don't yet feel ready to start SSRIs. So what do we do, right? We know for a fact that all the data shows that the best treatment for anxiety and depression is combination treatment, which includes psychotherapy and antidepressants. And so right now, Jojo's on a wait list for psychotherapy and his parents are not yet ready to start antidepressants for him. So what else could we possibly offer this patient and this family to help him? And one thing I do in my practice is I sort of walk this journey with families. I am a huge component of using our Western medicine, our Western knowledge in helping patients specifically with anxiety and depression. And sometimes my role is to walk families into an acceptance of maybe we're at a point where we need to try these medications that we know have been shown to help so many other families and children as well. But what else can we do in the Pediatric integrative medicine world to help Jojo. And that's where integrated medicine treatment modalities come in. So today we'll talk about nutrition, sleep, screen time, exercise and yoga, and some uh evidence for using acupuncture or traditional Chinese medicine for, for the treatment of anxiety and, and depression. So nutrition is key, and when I do a nutrition intake, I really dive deep into what my patients are eating or have access to, cause sometimes, uh, what you have access to may may be the foods that you're eating and that that can't change. So that's also really important to me. Um So I do a 24 hour diet recall. I start with breakfast and I always ask, um, about the time that they're having their, their meals cause you might be surprised at what you find. Um, I ask about their favorite snacks, foods that they avoid, favorite fruits and the servings that they have per day, favorite vegetables, meats, dairy intake, and fluid intake. So let's take a look about at what Jojo said. So for him, he says he skips breakfast most days for lunch, he had a cheese sandwich with chips at school, and that's around 12:15. For dinner, he had burger, fries and a soda. That was around 6:30 for snacks, he had goldfish, granola bars, and uh sake's chips. Foods that he avoids is most leafy greens. For fruits, he likes apples, bananas, and strawberries, and he has one. 0 to 1 of those uh servings per day, and vegetables, he can tolerate cucumbers, bell peppers, and carrots, and he'll have 0 to 2 servings per week. Uh, in terms of meat, he does like beef, pork, and, uh, chicken and dairy intake. He, he takes in cheese and milk and fluids. He only gets about 16 ounces of water per day and sometimes more during his basketball practice. So this is a pretty This is a pretty common Diet for my adolescence that, that I see in my clinic. I don't know if you all have had the, the same experience and I've noticed that more and more teenagers are skipping breakfast. And when they actually end up having a meal as much later in the day, and, and most of the time, this meal is not necessarily uh a very nutritious meal um that's available to them. So I really focus on Discussing with my patients what the importance of, of having a good, what having good protein intake is and how that affects your body. And when we look at the data, we see that Adherence to a Mediterranean diet, rich in foods and vegetables and omega 3 fatty acids, has been linked to reduce anxiety and depressive symptoms and youth, and this is a systemic review of multiple randomized control studies and cohort studies um that have shown that this is true. So. When your diet is better, you feel better, and there's other studies showing that greater ultra-processed food consumption is asso associated with increased odds of depressive and anxiety symptoms. So our recommendation for Jojo would be to start the anti-inflammatory diet that is high specifically for him and tryptophans and the anti-inflammatory diet starts with the base of your main food consumption to be. Fruits and vegetables and increased fluids with water and It also includes whole wheat, um, healthy fats such as avocados, virgin olive oil, and it goes all the way up to using different types of, uh, spices and, and healthy sweets such as dark chocolate or cacao, cause we know all of these things impact your microbiome and feed into your epigenetics of how your body is going to behave. So, why is this high and tryptophan diet important? So I'd like to talk to you a little bit about nutrition and neurotransmitters. So tryptophan is an essential amino acid that must be obtained from diet and tryptophan is what is necessary in order to make serotonin. And so we need that um amino acid as the basis of making both serotonin and melatonin. And serotonin is made actually mostly in the gut. 90 to 95% of the body's serotonin is produced within um the cells of the intestinal wall. And there's a lot of cofactors that are needed in order for this process to happen, right? So in order to go from tryptophan to 5HTP we need vitamin D, folate, iron, all of these cofactors to be present. In order to help us make the things that help us feel better, such as serotonin. So what are foods that are high in tryptophan, right? So you, you probably have all heard about turkey and, and, and why you get sleepy. After you eat large amounts of turkey, uh, perhaps in in Thanksgiving or, or things like that, it may be that you're giving more precursors for the making of melatonin. So it may help induce sleep a little bit better, but things like cheese, um, eggs, nuts, and seeds, tofu and oats are also very high in tryptophan as well, and provide that precursor for your body to be able to produce serotonin. There's also lab workup that, that I might take um in depending on when adolescents were last seen or children were last seen for their old child visits, and I always take a look at vitamin D, uh, iron studies. I, I will sometimes order her and to see what their iron storage have been and can look at their omega 3 fatty acid profile. Um, and I always like to rule out anything like hypothyroidism or hyperthyroidism that can mimic uh mood disorders there. And the reason for some of these like vitamin D is because as we know, those are also cofactors that are affecting the, the synthesis of serotonin, and the majority, unfortunately, of us, especially after the COVID pandemic, um, are either vitamin D deficient or insufficient. So that's always something that I know can make a big impact in these, in these children. Um, I always start with using food as medicine, so if, if a patient doesn't need a supplement because their dietary intake is great, then I don't recommend these, but I have a lot of families who come to me and they're like, Doctor Berrigan, my child's a really picky eater. What can I do? Um, what can I give him? And, and this is a multivitamin that I recommend which also has iron that is a chewable uh vitamin that has been Um, really well accepted with the children that I work with and with families. And I also recommend, um, omega-3s. Um, omega-3s are antioxidants and, and have, here's another systemic review and meta-analysis uh from GAA of how they can change the severity and symptoms of anxiety. So now let's focus on sleep. So what is a healthy sleep duration, and here's um the recommendations from the Academy of Sleep Medicine that have been adopted by the American Academy of Pediatrics. And we know that as we age, the amount of sleep that we need. decreases, but it's still really significant for, for us to dive deep into how much our children are actually sleeping. So from 4 to 12 months, children should sleep anywhere from 12 to 16 hours and that decreases um as they become. 3 to 5 years of age, now you're at 10 to 13 hours and for People like Jojo, he needs 8 to 10 hours, right? So the, uh, kids who are 13 to 18 years of age would need 8 to 10 hours for optimal health in, in that stage of life. And, and for the rest of us that are 18 and over, we'll need at least 7, probably closer to 8 to, to feel rested. So what's the data behind uh sleep disturbances and anxiety and, and depression? So we know that sleep disturbances are significantly associated with the onset of depression and adolescence, and here's a systemic review that's uh and meta-analysis that looked at different types of studies and pulled them together and still found an association there. Um, and then in this last study, I really want to highlight what the author said. They said we observed that more. More people reported sleep problems that were, and the more sleep problems they reported, the more related they were to mental health problems, which was consistent across reporters uh across different reporters, different sleep questionnaires and all domain of all domains of their. Psychopathology, bolstering the robustness of the associations detected, and notably, these are in line or very similar to what we see in the existing literature in adults. So let's take a look at what our sleep intake was for Jojo. So when I do a sleep intake, I, I ask very detailed questions cause I found that sometimes either kids want to tell you the right answer or what they think the right answer is, and sometimes, uh, parents kind of feel bad about what the answer is if they don't know and uh it It can just get tricky. So I'm very specific about what your bedtime is, mostly on school days, right? Cause sometimes I hear like, oh, but on the weekend, I sleep a lot longer. Um, so I wanna see what is the most consistent. Pattern of sleep for, for my patients. So I ask what your bedtime is. And for Jojo, his bedtime, bedtime, he typically goes to bed is around 11:30 p.m. I then ask, how long does it take you to fall asleep or what's the time you actually fall asleep? And that can differ. Some children have had, um, tell me that they go to sleep at 9:30, but they don't actually fall asleep till around 11:30, which is, is a big difference there. And um for him, he actually falls asleep around 12 a.m. I asked him what do you do before you fall asleep, and he said he checks his phone and I ask, do you sleep with your phone next to you? And he says, yes. And this is important because I've also had different um adolescents and younger children say, oh, I'm not sleeping well, and I wake and I ask, do you wake up a lot at night? And they'll say, yeah. And I, if I follow that with asking what do you do at that time when you wake up, a lot of them say like, oh, I pick up my phone and then I, I get distracted and I just, I'm on my phone until I get sleepy again and go back to sleep. Um, but our phones emit blue light, which we'll talk a little bit more about later, which activate our photo receptors to tell our brain to stay awake longer. So it, it actually does the opposite than we hope that we do, um. And then follow up with what's his wake up time on, on school days and for Jojo, his wake-up time is around 6:30. He doesn't have any night awakenings and he doesn't snore. And this is another screen for possible uh symptoms of OSA. I see a lot of children with ADHD uh who end up having uh OSA, so this is, this is something that I'd like to screen for. So for Jojo specifically, He's getting 6.5 hours of sleep and is nowhere near what the recommendation would be for someone his age. So what's What can we do here uh to help Jojo. So, The best thing that we can do is to help them develop a good sleep routine and good sleep hygiene, and this, this, these recommendations really sometimes I make a specific encounter just to speak about what are we gonna do with your sleep. So I, I, I may have follow-up encounters to say, hey, how is your sleep going? Which of these targets have we met, which of these haven't we met? And It can take time, not just for sleep but also for, for nutrition. So this is not uh a thing that we can cover all in, in one visit, but it's something we continue to revisit at each follow up. So for sleep hygiene, we talk about waking up and, and going to bed at the same time. We talk about uh limiting the amount of caffeine if there is any intake. Um, I don't know if you guys have heard of the Celsius drinks. They actually have 200 mg of caffeine in it. So I've had some uh Leons come and say like, Oh, well, I can't sleep. And when I do my intake, they'll, they'll tell me like, Oh, I, I drink uh Celsius every day, um, after school. And I'm like, OK, well, that, that has a lot of caffeine and will keep you up. And so it's, it's, it's really important to, to decrease that caffeine. Half life is around 8 to 10 hours. So even if you have coffee, um, Or a cup of coffee at noon, at, at around 8 p.m. you still have half of that caffeine active in your body. So we, we really focus on this and, and helping, um, I try to help the child and the family create a routine that can be Doable in their situation and in their home. And when that doesn't help, there are a couple of supplements that we can use to sort of aid in that process. So sometimes I've used melatonin, and I really like to use melatonin in the physiologic dose, uh, which means what we naturally produce in our bodies before, um, the of sleep, and that's around 0.5 mg or, or to 1.5 mg. And I know that you may see melatonin over the counter and it's like 5 10 mg. We may think that more is better, uh, but actually, it, it's not necessarily better. There's a lot of newer studies showing That, uh, it sort of becomes like an insulin resistance type of picture where the receptors don't pick up as much of the melatonin that is available there. And with higher doses, you might actually get more of the side effects that can happen with high doses of melatonin, which can include really vivid scary dreams. So if, if you've given that to a family before and they stopped using it, uh, it may be because they were taking, taking too much. And so, The half-life of melatonin is around 45 minutes, so 45 minutes to an hour, you get the peak amount of melatonin um in your, in your body, in your blood system. And depending on what the issue is with sleep, that should guide when you're giving the melatonin. So for example, If I have a patient who has delayed sleep onset, so they say, well, I try to go to bed, you know, at 9 p.m. but I can't fall asleep till 11, then I try to help their circadian rhythm by using melatonin and I give it around 3 hours. I say take. Get around 3 hours before and those really small doses to help reset your own natural circadian rhythm to be able to produce more of that melatonin later when you are going to bed, um, to feel more sleepy earlier. I also get those that say, I I can go to sleep, um, but, but when I'm in bed, I just don't feel sleepy, uh, right away. And so I say, OK, and for those cases, I say you can take the smallest, uh, the most minimal effective dose about 1 hour before bedtime. And then I get, uh, some children and, and some families who tell me, well, they can go to sleep, but then they wake up in the middle of the night. So what can we use at that point? And, and for them, We, I say you can give the extended release form of melatonin, which can be helpful cause it takes a little bit longer for the body to process it. So it all depends on what the specific situation is for the child and the family. I also like to use magnesium, and there are many different types of magnesium, uh, citrate and glycinate are, are one of the ones that I would like to talk to you about today. Um, citrate is more Bioavail with, it stays longer in the gut. So if you have, for example, a child that uh also has constipation because their diet is low in fiber and, uh, in fluids, then citrate can, magnesium citrate can act as an osmotic agent and pull more fluid into the gut that can allow that to process more um smoothly there. And magnesium glycinate, it's another type of magnesium. And this is more uh bioavailable within the blood system. So, so this actually can go further. So it just depends on what the child needs for, for their own specific symptoms of what I recommend there. And like I said, there's many more types of magnesium and each of them has different uh benefits and, and that's when talking to, to your local integrative pediatrician might be really helpful if you have more questions about that. So what are the effects of the COVID pandemic on adolescence? This is another thing uh that I get questions a lot and I actually have seen it in practice. I, I trained during COVID, um, so I got to experience this firsthand, uh, noticing the changes and what types of patients would come into the emergency room before and after COVID. So we know that the COVID pandemic really affected our adolescence, uh, both in mental health and sleeping patterns, and here's a study out of the University of Michigan showing the percent of parents who'd noticed new or worsening problems, uh, new or worsening of an existing problem in their adolescent, and we can see that for the most part. Girls for some reason were more deeply impacted compared to boys, um, both in terms of anxiety, depression, and sleep issues, all which um parents noticed a higher percentage of, uh, during the COVID pandemic. And we know that the sleep problems also worsened, and here is a study showing uh the percentage of respondents saying they had worsened sleeping problems, uh, during the COVID pandemic compared to prior. So let's focus now on a little bit uh on screen time and the effect that can have. So my intake for screen time, uh, I also like to go go deep and see uh what, what patients are using here. And a lot of the times I just ask by saying like, hey, do you have your own tablet or, or, or phone or any type of device, and if you do, which one is it? Um, most of the time I get that they have their own phones, and when they do, when they tell me that, and I say, OK, great, do you have it with you? And 99%, 99% of the time they just, you know, pull it out of their pocket cause it's really close by. And I say, Great, can you open up your, uh, your screen time app and tell me what your most common apps are used and they, they at first they're, they're kind of Worry that they're gonna get in trouble based on the information that they're going to give you. And I always, uh, talk to them about saying like, look, there's no wrong answers here. This is just more information for me to be able to help you. And if you tell me the, the, what's going on in your life, then I can Go back and assess where we can modify things to help you feel better and, and usually that can help ease um them being very honest about what, what they use. So Jojo here, very common um response that I get in my adolescence. He spends an average of about 44 hours per day on his phone. And if you look at the screen time app on either an Android or an iPhone, it'll actually give you a, an average for the past few weeks and for the day and it'll tell you what were your most commonly used apps and that's what I ask. And for, for Jojo, his word TikTok, YouTube, and Spotify. Jojo also likes to play video games. And so I ask how many um Which are your favorite, and his favorites Fortnite and Roblox, and he spends around 2.5 hours per day on that. And then I asked, do you watch Netflix or do you watch movies with your family? Do you do anything else? And he's like, Oh yeah, sometimes I I watch like 2 to 3 episodes, um, of my favorite TV show, and we calculated that to be about 1.5 hours. So for him, his total screen time was 8 hours, and this is not counting any educational work. And we know that Jojo is not alone. Here is uh some data looking at how much time. Teenagers and those who are the preteens, those who are 8 to 12, spend on Mobile devices that does not include using them for school or homework, and those who are 8 to 12 use it around 4 hours and 44 minutes, and those who are 13 to 17 they use it for around 7 hours and 22 minutes. And this is not. You know, this is not only happening in those studies, this is also happening um during this also happened during the COVID pandemic, and here's a study by Jason Agana, who's a researcher and um adolescent provider here at UCSF. And what he did in his study here was look at total screen time and looked at what of what uh adolescents were using um and how that differed between sex. So I know there's a lot of data um here, but we'll go through it 11 step at a time. So if you look at the red box, this tells you depending on whether they identified as male or female, uh who was spending Time and uh using which things. So we see that males were spending more total screen time than females, and that was because they were playing more of those multiplayer game games or or single player games. And when you break it down into race and ethnicity, we noticed that uh black Americans were using uh Or Jason noticed that Black Americans were using uh higher amounts of, of screen time compared to, to other races, and this also correlated with the parent level of college education and annual household income. So the more educated you, your parents were, the less hours you spent on screens and the higher the income that you, your household had, the less time you spent on screens. So the use of electronic devices and can impact on so many things, uh, including your sleep and uh like I've shown you before, sleep is key in order for us to feel regulated, especially in the developing brain. So when they asked, uh, children, what are you using, uh, if you're using an electronic device, and you can see here that the majority of them use their phone at least and uh Or an hour before going to bed. And when that same study looked at sleep duration, so if you noticed that if you spent more than 4 hours of uh of your day on screens, you were more likely to sleep less. And that is also something I see in my patients too. So what are some tips to help children with screen time? I always talk to parents about being a role model. It is really hard for children and adolescents to Change their habits, um, especially with screens because screens actually work in the same, um, In the same area of our brains as, as, it's called the ventral touchmental area, which is the area that functions in um in people who have addictions to either gambling or or different drugs. That area gets activated with the same hit of dopamine, um. When we use screens. So every time we see an alert, every time we see a, a bright or hear a bright sound or we see how many likes we have on pictures, that area is getting activated, so it almost become, becomes this addictive, um. Pattern and, and this addictive thing that when you try to take it away, like, it can, you can see the withdrawal reaction almost. Like kids have an identity, um, and they feel safe with this device and it's become part of who, who they are. And I think we need to learn as providers that the phones aren't gonna change, right? Devices aren't gonna change, but how can we develop a healthy relationship so that Kids don't have the, the secondary or negative effects that, that can come from spending so much time on, on screens. And so I always tell parents, one, be a role model if, if they notice that you are also, um, we're, we're not, we're also human, right? Like we also use these things and it's important for us to have limits on ourselves so that they can see, oh, I can do this, uh, my parent is not necessarily using this all the time. Um, we, we talk about setting time limits that you can stick to and monitor usage. It's really hard to say, OK, I'm gonna go from using the screens, you know, 8 hours a day to only 4 hours a day in the next week. It's, it just like with any other type of addiction, you have to work at it slowly to have the best success. Um, I always talk to them that you might not make it the first week that this, this goal that we had, um, I usually start with decreasing by 15 minute intervals, so, um, that in a month you actually can decrease your screen time by an hour. Um, and it is a slow process and, and say, you know. You might not make it the first week, but we keep trying. Um, I advise parents to provide an alternative activities like going outside, taking a walk, riding your bike together and practice screen-free days and, and the hope is to get to screen-free weeks if possible. So what can we do to help teens and adults with, with smartphones and social media. One of the things you can do, and these are examples that I found, of phones I found online, so I think this is a, this, I know this is an um An iPhone. So if you have an iPhone, you can, you can do this. You change your notification settings. So, um, you go to settings, you, you go to notifications and you can click on each of the apps that you have downloaded and turn off the notifications because we know that uh eyes on screens equal. Uh, monetary benefits for these apps, right? So they will do everything they can to try to get you to come back onto the screen and, and I, but we all know this with our email, um, and those little red bubbles of, of our emails that ding us every time we see that there's something new and guess what, we go back and, and check in. Um, but if you don't need that, if that's causing you to spend more time on something that's not helping you, this is a way to, to turn that off. Um, I also advise, uh, adolescents and, and younger and young children if they have a phone and they use it as an alarm to stop using their phone as an alarm. Um, again, if you're sleeping with your phone next to you and waking up in the middle of the night and seeing them, um, it can, it can Keep you awake. Those photoreceptors that I was talking about before that get activated by blue light, give a direct message to, to your brain and the circadian rhythm center, uh, to stay awake. And so the way to decrease that is to go to settings, displaying brightness. You can turn on your night shift and I always like to turn it on. Uh, to, you, you, you can schedule it for sunset and sunrise sort of to modulate the typical, uh, day pattern. And you can reduce your blue light exposure here, you go to more warm and that decreases the amount of blue light you see in your screen. So I'll go quickly through these. I wanna have enough time to have um some, a good discussion about this. So what are mind-body practices that have shown to help children, so we know that exercise. Specifically, uh, aerobic exercise has the, has the best effect on helping improve symptoms of depression in children, and it can happen best if you do it at least 3 times a week for about 40 to 50 minutes. And we also know that yoga improves symptoms of anxiety and depression. Among youth. And here is um a study, this is again a systemic review. So a lot of those studies pulled together showing that you can improve these symptoms. And these things don't have to be used as solo therapy. You can continue to use CBT, you can continue to use the SSRIs that you have or what other treatment modalities you're using to treat. Anxiety and depression in your children and add in these different modalities that can help. Uh, this is an adult study, uh, using yoga and CBT which showed a significant difference in depressive symptoms at the end after a twelve-month period and those who use both yoga and CBT instead of CBT alone. And I'll talk to you a little bit about acupuncture and how acupuncture reduces anxiety. We have a lot of studies in adults, um, as you can imagine, the studies in children for acupuncture and adolescence for acupuncture are much, uh, smaller, one, because there's not a lot of providers who, who are able to practice these modalities on children and 2 is because those providers who are practicing and using those modalities and in, in children and adolescents aren't unnecessarily getting funded to do the type of research that we would require in order to accept this as a treatment modality that we can use, but um. We can see here in, in the, in this systemic review and meta-analysis that when you compare the use of acupuncture uh with placebo and these 20 different studies, acupuncture uh was significantly uh able to reduce the symptoms of anxiety. So how can you access pediatric integrative medicine? You can refer to your local pediatric integrated medicine centers. We're really lucky here in the Bay Area. We have a good hub of different centers to access. We have the SAT Center, the OSHA Center, the new Wellness Center for youth work with chronic conditions at UCSF. at CSFG we have Clinicabonavida and at Santa Clara Valley Health Center, we have Clinicaad. Both of these clinics were clinics that I helped fund at uh federally qualified healthcare centers to give integrated medicine access to populations that were underserved. And of course, Stanford where I did my training has their pediatric integrative medicine clinic there. uh, for referrals for, for the UCSF centers, you just type in either IP3 or integrative medicine, and those populate in your order set. So what are the types of services that we offer? We already talked about nutrition and counseling, sleep and rest. Um, we talked about the healthy boundaries with screen time and social media. But there's other procedures that can be offered at these, at these centers and programs. I do a lot of vericular therapy and you might have seen some people using ear seeds and, and this by far is, is one of the safest and most uh used and preferred treatment modality uh by my patients. So if kids say, I don't I want, you know, I'm afraid of needles. I don't want to use needles. Acupressure seeds work on the same points in the, in the ear and are able to stimulate those points without the needles and, and those points get stimulated for, um, anywhere from 3 to 5 days while the seeds stay, stay on. And it's a very safe treatment modality that we can offer our children. I also give a lot of free apps and links. Again, this is to make integrative medicine more accessible to everyone, not just those that, that have high monetary means. Another thing that might be offered in, in the in the centers is medical hypnosis and, and this is something else that can just promote relaxation and help with, with different types of pediatric diagnosis. We use supplements and herbal medicine as well, and this is just a short list of what uh our patients may have access to. So in conclusion, I want to say that pediatric medicine combines both traditional and complementary therapies to promote wellness and that these can be used for many types of diagnosis including those uh patients who have anxiety and depression. Um, we know that there's evidence behind the use of sleep medicine, exercise, even acupuncture, uh, to improve the symptoms of anxiety and depression. We need to continue to work together and fund, um, and, and conduct the research that is needed to show that these practices are safe and can be used with children. And with that, I'd like to thank you for listening. I'd like to thank all my mentors, um, and colleagues who have shown up to support me, and here's my motivation of why I do the things I do. This is my niece and nephew. I have 7 total, and um they show me every day that there's many things that we would need, uh, in order to make their world a better place and, and help them heal in any way that they can. I'll take any questions now? Oh, I can't hear you, Sarah. I cannot hear you now. Yes, I can hear you now. OK, great. So thank you for that wonderful presentation. We got a lot of great questions. One of them was um a request that you show the list of foods that are high in tryptophan again while we're talking, if you're able to do that. And in the meantime, just a reminder to everybody to click the evaluation link in the chat in order to get CME credit for attending this talk. Um, one of the questions a couple of the questions that we have are in regards to melatonin, and questions include what's the lowest age that you would recommend using melatonin for, um, and then a secondary question about melatonin. There have been some studies and warnings recently that melatonin supplements have a range of actual doses in them, and is there a brand that you particularly like or trust? Yeah, that, that is such a great question. So, for the brand, it, it really depends on what you have access to. I actually like prescribing it through our own um orders. So if I prescribe it, then I am more confident that if it's carried within the pharmacy, it's gonna actually have the amount of supplements that, that it says, and I think this is where we have to work to really press our FDA and own healthcare system to regulate, um, and not necessarily call melatonin a supplement because melatonin is a, is a bioactive, almost hormone, and, and it functions that way in our bodies, and I think it It is such a great thing to, to bring up in terms of, of the brands. There is a brand called Now, and I, I really like to use that one because it has it at the shortest or the smallest, 1 mg dose, um, that I feel comfortable with using. But most of the time, I prescribe it um through our orders, and that's, that's what I use. Um, can you repeat the second part of that question? Yes, if there's a youngest age that you would recommend using melatonin. Yeah, I usually, uh, don't use it in, in, in children younger than 3. And if I use it, uh, for a young child, I always go for the lowest effective dose. And so I start very, very small and I coached the patient, the parents into saying like, how are you gonna be able to tell if this dose is enough for your child? Excellent, thank you. And I think we have time for just one more question, which is, do you have a specific um free app that you might be able to recommend for um kids who have otherwise, you know, not as good access to meditation, mindfulness, um, and if any of those are um have information available for Spanish-speaking families as well? Oh, I love that question. So my first language is Spanish and, and, and I really focus on bringing a lot of these treatment modalities to To Spanish-speaking families. There is a free app you can download, download Insight Timer. I love that app, there's a ton of free meditations there. There is a portion that you can subscribe to. Um, I actually have it downloaded in my phone and I don't subscribe to the paid for, uh, portion of it, and I just use the free meditations that are available there. But actually, YouTube has a vast amount of, of free meditations and if depending on what you need it for, you can type in meditation for stress relief and espanol, for example, and, and. It will give you some, some of the options there. So, so the resources are available and it's just, it's, it's about having the right links that you feel comfortable sharing. So the ones that I have, I have a lot of dot phrases, both for the foods high and tryptophan, both for sleep hygiene and, and reducing screen time. Um, and I I give these links and, and the patient instructions after so that they have something accessible uh for their own treatment. Fantastic. Thank you so much for every, all the information that you've given us today. We really are appreciative and there's a bunch of comments in the chat echoing that sentiment. So thank you so much for being with us today. Thank you so much for having me. It was a pleasure to be here. Created by
