Dr. Mojgan Makki 9:22
It’s tricky. Yeah. I want to say I hope not. I hope they don’t need to take medications all their life. But I also would say, if, if they have a disorder, and if it’s a disorder that they were born, kind of like if someone ends up having a childhood diabetes, and you know, do you would think that we’re doing all the right things with making sure they get treatment early on, but making sure they get our education about how to manage the diabetes by exercise and diet. They would probably still need to take anti diabetic medications or insulin, but it won’t have that severe often the impact in their life. So it, it’s really depend on case by case, there are some. Some folks and some kids who are born with chronic and severe mental disorder conditions, you know, we have childhood schizophrenia, we have childhood bipolar disorder. So they more likely end up to be on some kind of medication and treatment as they get older. But the journey can be different depending on like, what they do with it, whether or not they learn how to manage, they learn how to recognize their symptoms, they learn how to manage stress, they learn how to be preventive in life, and to avoid stressful environment, avoid triggers, you know, like don’t enter into the journey of substance use disorder. And just by being more attentive to their life, we are able to help so that we will have a positive or a more positive outcome. And that positive outcome, if it means that they have to take a medication. I think that yes, it’s not perfect, but at least it’s a blessing, that there’s staying stable, and they’re happy, and they’re able to reach the goals and dreams that they had in their life.
Dr. Leigh Weisz 11:51
Absolutely. Well, and it’s very interesting what you said about substance abuse, because, of course, you know, some people who are not prescribed medication will figure out other ways, you know, to treat their symptoms, and not always, in the healthiest of ways. So, um, that’s a really good point.
Dr. Mojgan Makki 12:10
Yeah. And I have to say, Dr. Weisz that there are also folks that, you know, that I started tweeting, like, their anxiety at age five, or six, and like, you know, you and I have worked together, and we’ve had some of those little young ones. And really, with the education, treatment, and helping them to foster healthy life, you know, healthy life as far as emotionally healthy, avoiding on needed stresses, making sure that they have a good nutrition, making sure they have positive activity, you know, we also see that they can grow out of the disorder, they may still be having temperament of like an anxious person and worrying type of a person, but they would recover and they would no longer be in the category of disorders. So they may be able to read off of medication in a supervised environment.
Dr. Leigh Weisz 13:23
Of course, yes, parents should never, you know, wean their kids off themselves, they should always consult with the prescribing doctor, but, but yes, it sounds like there’s obviously success stories where it really makes a huge impact, and it’s not lifelong, and others were, you know, it is lifelong, for good reason. And hopefully, you know, we’re, we’re getting the child into a trajectory for healthy living. Yes, yeah. Can you tell us a success story, a time that you’ve treated a child or a teenager? And maybe like, what, what’s the kiddo came in, you know, in terms of their symptoms, and kind of what you know, what you feel like the medication really helped with? I know you have too many to choose from, but anything that would be helpful to illustrate kind of when it’s when it’s really effective.
Dr. Mojgan Makki 14:16
Yeah, so um, I can think of many good stories. I I think that one thing that comes to my mind, for all of them, there’s like one common factor with all of them. And that is commitment to treatment, commitment to the relationship. Collaboration, you know that I think that I, as a child, adolescent psychiatrist, I am there to observe and make recommendations but it really is a collaborative team. And that I would not be successful in making good recommendations, if I’m not getting a good history from my parents, if I’m not getting the parents, like if they’re not bringing the kid to the appointment. And I know that all of those take a lot of time and effort. But it’s really like putting the village together, bringing schools, bringing therapists, parents, and then centering, putting the patients in the center and providing this 360 holistic support for the child. And I think that plus time is really the key to success. So rarely, I have clients that would like to see for the first time, and then I’m like, Okay, I think this is the diagnosis. And I think this was the medication or the treatment plan we need to do. And it usually takes at least six to 12 months to see some reduction of the symptoms. And I think you and I know that if we start medication, and they come like in one week and say, Oh, my God, the child is like very different. We all make pause and say, Okay, let’s, let’s just hold off, I’m not get too excited, because then medication treatment usually takes at least two months or so to show its result. So patience.
Dr. Leigh Weisz 16:42
Patience is one of the ingredients to success, I’m hearing from an operation collaboration, right, like willing to be in the long term relationship to really get it right.
Dr. Mojgan Makki 16:56
Yes, willingness to know that this is not a quick, quick fix, and that it needs building relationship and recognizing that in that relationship, for for me who just met the child, I may have some ideas of what it is like, but I rely on my parents and my my family to educate me and to bring like, ideas and thought process of what it’s really like. For them. What is it that they really see. And I think that some of the things that we do that we are very much like aligned together yet, collaboration and kind of understanding details of the symptomatology. So for example, I will tell you one of the common chief complaints I get, especially for the younger kids, like grade schooler is school anxiety. Right? And they don’t come and say I have school anxiety, they calm and it’s like sometimes it’s oh my god, I have really bad headache. I can’t go to school. Sometimes there’s I had really bad stomach. And so it really becomes our job to make sure that what is really the headache. Is it a biological headache? Is the child struggling with some like vision problems, and that they really need to see an optometrist to make sure that they don’t need glasses, or are they having like childhood, migraines. And once we rule out all medical causes for the symptomatology, then we start looking at isn’t somewhat related to stress. And the child may say, No, I’m not stressed school doesn’t make me anxious. But the child may not really know, the, the, you know, the connection of what.
Dr. Leigh Weisz 19:08
And if and if the parents are doing their homework that you’re assigning them to document and track and notice patterns and if the stomach aches, or the headaches are only happening right, right before school, you know, that would be an interesting pattern.
Dr. Mojgan Makki 19:23
Like a consideration right to say that, okay, well, it’s happening. Most days that we’re like trying to go to school. It happens on the drop off. Yeah, but it doesn’t really happen during the holidays. We don’t have any throwing up episodes. We don’t have any headaches during the holidays. Yeah. And so then the next conversation is to talk about how stress can affect us in so many different ways. Right?
Dr. Leigh Weisz 19:54
Well, and it’s interesting I always tell kids and adults alike you know, there’s a reason the gut feeling, you know that people have that expression that, you know, we do feel feelings in our stomachs. And kids especially are prone to feeling, you know, nervousness in their in their bellies. So it does feel real. It’s not that they’re making it up. But the question is right, is it a stomach ache because of getting the flu? Or is it a stomach ache because of, of anxiety and stress?
Dr. Mojgan Makki 20:23
Yes. And so remembering that we have stress receptors, everywhere in our body, we have it on art. Again, we have it in the head, we have it in the stomach, we have a tender heart. And so when the body and the body is very sophisticated, but in some cases not so much, though, when you get like a stress, the body is not gonna know that, Oh, am I in fight on flight mode? Because I just got a virus and I like ate some bad food? Or am I scared? Because I see like something that’s really scary in front of me, or am I, this this anxiety, the body ends up recognizing that, oh, I am stressed. And the stress receptors are pretty much everywhere from head to toe. They’re everywhere. So one person may feel bill may have more sensitive stress receptors in the head. Some may have it in the lightheadedness, dizziness, proprioceptive receptors, some may have it in their heart, and they would feel the palpitations. They would go through cardiology and they keep getting EKGs and echoes. And it’s like everything is fine. And some may have it in the stomach. So it’s not that the person is making it up. Right? It’s just that that’s where they feel the stress. Right?
Dr. Leigh Weisz 21:59
Absolutely. So what are cases where a kiddo like doesn’t want even go to school? And this is the presenting issue. And you know, because of the debilitating tummy aches, for example.
Dr. Mojgan Makki 22:12
Yeah, I mean, I think that most of the, you know, at Rush where we started that the toddler infant clinic, most the chief complaints are like to either goal avoidance or can you guess?
Dr. Leigh Weisz 22:28
NASSCO? refeeds. Okay. Separation anxiety?
Dr. Mojgan Makki 22:33
Either. Or irritability.
Dr. Leigh Weisz 22:35
Oh, I was gonna say if separation has their little. Okay. irritability.
Dr. Mojgan Makki 22:38
Yes. Yeah. Well, I mean, I would call the school avoidance as part of separation.
Dr. Leigh Weisz 22:45
Connect. It’s a form.
Dr. Mojgan Makki 22:47
Yeah, it’s connected. So irritability, or avoidance. And you and I know that there is three models of what is it fight, flight, and freeze, right. So we either become as a child irritable, where we are exposed to an anxiety situation, or re freeze and so we go into avoidance. So fight, flight, or we end up with like a panic attack, like an internal panic attack.
Dr. Leigh Weisz 23:34
Yeah. Right. Right. Not literally running. But you know, wanting to Yeah, right.
Dr. Mojgan Makki 23:39
What just having like a panic attack. So those are the manifestations. And so they were the ability. And having a panic attack is such a difficult experience, that we usually end up seeing the fight, or the freeze, because our kids are super smart. And so they learn that if I push myself to go to school, I’ll end up with a panic attack. Right? And like, it could be an episode of vomiting. And that’s no fun, because everyone is looking at you. And everyone is, you know, there may be some judgment around there. And there may be some embarrassment around there. And that makes it even more difficult to go back to school. Though it comes mostly with fight or the ability I don’t want to go make me go yelling, screaming fighting power, struggle or appearance, or freeze and avoidance.
Dr. Leigh Weisz 24:47
Sure, and if they avoid kind of the thing that’s making them nervous, or the thing that’s scaring them in some way. And they and they get away with it. Sometimes very well intentioned parents are like oh my gosh, like Take the day off, you know, but then they never really can face the fear as if this if it becomes a pattern, right? And so they never can get out of the cycle, because they’re just rescued from it. And immediately when the parent says, You don’t have to go to school, they’re like, Oh, okay.
Dr. Mojgan Makki 25:18
And so when you think of medications, like if we want to circle it back to like, when do we think medication is right? Let’s say that these fight, and freeze moments are so extreme, that we are not able to park our kids into going to school, right? Because nobody wants to go through like feeling of that extreme anxiety. It’s super uncomfortable feeling. And even our adult patients struggle tolerating that feeling. Yeah, and of course, kids have less ability to tolerate adverse feelings and situations, they haven’t grown those protective mechanisms. So it’s really difficult. So we use medications, when appropriate, to lower some of the fight and flight responses. And, you know, going back to like success stories, they come in, and they’re like, unable to go to school because they either become so irritable, or they end up having so many, like.
Dr. Leigh Weisz 26:30
Severe pain or something.
Dr. Mojgan Makki 26:32
maybe you’re or, you know, vomiting, incidences. And so we then use the medication to lower some of those fight and flight response. And we recognize that this anxiety is not something that you take an anti inflammatory, you take an aspirin, or you take like Advil or something, and that it goes away. It’s up the process, the we use the medication to lower some of the fight and flight symptoms, to lower some of that upset stomach. But we also recognize that the child will likely continue to have to feel anxious.
Dr. Leigh Weisz 27:19
Or have some level of anxiety, but it isn’t, you know, maybe it was a 10. And you lower it to a more manageable number. So I can at least get to school, because they want to, but they can’t if they’re in that panic mode.
Dr. Mojgan Makki 27:32
So let’s say if it’s a 10, good idea to put it on a number. So if it’s at 10, or 12, we hope the medication can lower it to like, let’s say six and a half. And then we say now, the part of work that’s important, is to engage in therapy so that we can learn how to use our mindfulness abilities and exercises, how to use our breathing, how to use the terrain, ourself from the anxiety thoughts to call the body. Right. And that way, we can actually go to school and be comfortable to feel to still feel right to learn.
Dr. Leigh Weisz 28:24
Do you know, okay, enough to learn in school? Yeah, no, I think that that’s, it seems to me, that’s a common one, you know, that the anxiety leads to avoidance, and potentially school refusal or school avoidance, or I have a kid who I’ve worked with who just has really severe separation anxiety symptoms, but only with relates to, you know, drop off at school. And, you know, obviously, medication really helped in her instance, because, you know, every single day, it was consistent that she would be tardy, and she was a good student, she was smart, she was motivated, she was a good kid who wanted to be there, but couldn’t get herself there. And all of the little challenges we did and all the tools didn’t seem to be enough, but with the medication, it wasn’t a magic fix. But then she was able to really actually use the tools that she knew all along. So it was a really, that was a powerful one for me.
Dr. Mojgan Makki 29:23
Yeah, to lower it so that then they can use the nonmedicinal coping strategies, further empowered themselves. We always talk about how even with medicine, we would expect the child or the patient to still feel anxiety, right. And let’s say like if we have someone who has phobias, you know, let’s say there is phobia of height, there is phobia of elevator there is phobia of getting on a plane and now We have the 17, 18 year old, who really wants to go to college on one of the coast. But the phobia of the air plane is really so difficult that they have they’re actually reconsidering the opportunity to be at the school that they want to be. So those are the times that we say, you know, let’s use some medication to lower some of the fight and flight responses. But then you still have to work in therapy to do some like exposure management, because you’re still going to feel the heart pounding, the butterflies running, and then you can use some of the breathing exercises, or the distracting your thoughts from anxiety to manage in the moment.
Dr. Leigh Weisz 30:57
Absolutely, absolutely. No, that makes a lot of sense. So when a family comes to you, and the parents say, Okay, I think we’re ready. What are some of the areas that parents should be prepared to talk to you about so that you can best formulate the treatment plan? And? And also, is there any kind of new cool research or technologies that you use to figure out which medications might respond better?
Dr. Mojgan Makki 31:30
How much time do we have?
Dr. Mojgan Makki 31:33
10 minutes or so?
Dr. Mojgan Makki 31:35
All right. So I think, yes, there are some directions, and more like advances in science, we still have a long way to go. And in that sense that we still have a long way to go, one factor that I think is really important is to recognize that let’s say I have a four year five year old six year old, and I look and I say, Okay, this looks like ADHD, or this looks like anxiety. One factor to always be mindful is that it may look like something else, in a year or in a two. And so a child is constantly changing and growing. And so it’s really important to keep the diagnosis old pattern, and to never say that this child is has anxiety disorder, and then like close the door to any other possibilities or changes in the diagnosis. And to also recognize that if those changes occur, it’s not because the clinicians made the wrong diagnosis at the time, it’s just because the child’s psycho growth, the neurobiological growth is such that it may look like it’s ADHD at one age, and then it may become anxiety at another age, or they may grow out of it. So always keeping the door open for, for getting more education, about diagnosis and the symptomatology, and keeping that always in the back of our head that matters may evolve. So with that said. And the reason I say this is that if I think it’s an anxiety disorder, but like I start with some medications to target anxiety, and I’m not getting the usual response that I want to get, I have to go back. And these are like practice guidelines, I have to go back and redo my evaluation and make sure that I did not miss diagnose, or that I didn’t miss anything in my diagnostic formulation.
Dr. Leigh Weisz 34:04
That makes sense. And a lot of times they look the same, right? There’s symptoms overlap, and it is hard to tell. Right?
Dr. Mojgan Makki 34:10
So especially kids.
Dr. Leigh Weisz 34:12
Yeah. And so how they respond to a medication is more indication, more information, you know, to really understand what’s actually happening. Right.
Dr. Mojgan Makki 34:21
But what are some of the factors that is really helpful is family history, medical and psychiatric disorders. So and relating to, you know, not just the not just the siblings or the parents, but also like grandparents, great uncles, and just getting a good history and or breaking that family history to the appointment. If you had family members who struggled with anxiety, obsessive compulsive disorders, what type of treatment has helped them because there is facts and science to say that if a, if a sibling or a parent has responded best to certain type of medications, it’s likely that the child would respond to those. And then also for us to know a diagnosis, if I have family history strong of ADHD, I may think that what looks like anxiety may actually be ADHD. So it’s really important to have that family history, as well as the medical family history. As we know, some autoimmune diseases. Some patients with autoimmune diseases are more likely to have psychiatric disorders, autoimmune diseases, such as diabetes, tideway, diseases are all the way to arthritis types of disorders, skin conditions with like lupus types of disorders. So really bringing all the family history, the more you have, the better picture the clinician, the child adolescent psychiatrist will have, then there are some. And we always say whatever decision is made, make sure that the medication is started at a low milligrams, so start low, go slow. This is not a marathon, right? Or actually, this is a marathon, not a sprint? Yes. Not, it’s if we start at the high, those there is more likely that our patients will have side effects. And then we end up saying that they didn’t tolerate the medicine. And you basically say no to one medication, where the real problem was that it started too strong and too high. And so they ended up having side effects to it. Right? Right, that makes us start slow, go slow. This is a marathon, not a sprint, right? I have folks that come and say what about there is like a past, who’s the if my child would do better, but like one medicine better than other. And we know that there are different companies who do that. And I would say those tests can help. It’s usually helpful if we have gone through a couple of different treatment strategies. And for one reason or another, nothing either has worked, or we end up with side effects, or even at the lower lower doses. So those are some of the tests that we can see, are these patients metabolizing the medications differently than the average population.
Dr. Leigh Weisz 38:02
So it’s not like something you go to right away. But it’s again, it’s in your toolkit. If someone’s not responding the way you would expect, or you’re really not getting something that works after several medications, then you can have this. Okay, what about with ADHD, I was reading about some recent research and brain scans to be able to diagnose versus just having typically we do a psych testing, and we do again, a thorough psychiatric consult. Where is the field in terms of the scans at this point?
Dr. Mojgan Makki 38:32
Yeah, it’s, it’s really moving forward. We are not where we can really rely on those for treatment. It’s still in the research part where we are really trying we are seeing like, you know, if we do functional MRI fMRI or glucose MRIs, we see that folks with ADHD have different activities and different parts of the brain we see sometimes like, we think the same with like OCD, we see it with cats on two rods, we see it with many of the psychiatric and medical conditions, but we are still trying to group them together. And so we are not at the place where we can say okay, if if there is more signaling on the left hippocampus, that means you respond better to type of treatment. We’re not there yet. We’re still kind of putting them in different categories.
Dr. Leigh Weisz 39:42
It sounds very exciting and promising but still in the research phase is what you’re saying. Yeah, okay, so we have to be patient and you know, we’re not in the sprint part is still in the marathon helping. Okay. Okay. I guess my last question for you is is, um, you know, I imagine parents are worried about putting their kids on medication and worried about side effects. Can you speak to, you know, what are common side effects for, you know, kids with, again, who are getting treated for anxiety or depression? Things that you know you would share? And how scared should they be? You know, is it smaller than it used to be people obviously are very, I would say, hesitant?
Dr. Mojgan Makki 40:27
Yeah, um, I think the first part to be really attentive is education. You know, so in our clinical work, we see we see folks that are more conservative. And then we also see folks that are more comfortable about starting medications, and you know, children, adolescents, adults, all of that, I think that it’s really important to have good education and a good understanding of what is the role of medication, it’s, it’s not a good idea to overuse medication, it’s not a good idea to under use medication, but really to have an understanding of what is a good place for the use of medication? What can we expect from the medication? What is the course of treatment, if I start this medicine now, we know with some of like our medical treatments with antibiotics, we know that if you’re taking an antibiotic for a tooth infection, you take it for 15 days, if you’re taking it for bronchitis, you take it for four or five days. So just being knowledgeable having an education that what is the course of treatment? And what are some of the symptoms that we’re monitoring? And what is this monitoring process? Do they expect to see recovery? Or is it just a reduction of the sentence, though, I think for all of our parents, I recommend to be patient with the process, and dedicate your appointments, to get educated and to ask all of these really, really important questions. And don’t, don’t be too quick about getting a prescription or starting a medication unless there is something that’s life threatening, that can’t wait. But if we have a child who’s been through this, for a year or so making sure that we engage, we engage the child into this as to helping the child to understand why am I taking this medicine? What is this medicine going to do? What is my role, my role as a child in this in this picture? And so it requires a lot of conversation, and just to be patient with it. And to make sure that our children understand that we are not thinking that they’re not good enough? No. And that the medicine is not their to change.
Dr. Leigh Weisz 43:21
The medicine gets credit, let’s say if their success rate went to school, like it’s not, you know, that helps but no, I you, you’re still doing the hard work, you still get credit.
Dr. Mojgan Makki 43:30
And you know, like I hear sometimes my kids come and complain and say like, you know, I was having an anxious day. And look, my I was asked, Did you take your medicine? Little things like that, to recognize that even with medicine, we are human beings, we have to have ups and downs. If we don’t have ups and downs. We shouldn’t worry. Right?
Dr. Leigh Weisz 43:55
Right. Right, because that’s what prepares us for future.
Dr. Mojgan Makki 43:58
Which can be which can be one of the side effects of medications. We can talk about that on our next podcast or two.
Dr. Leigh Weisz 44:07
Okay, how can people find you what is what is your website, just so people know kind of where you’re at?
Dr. Mojgan Makki 44:15
Yeah, so I am Psychiatry Studio. And I am blessed to be working with some of my dear colleagues from St. Louis, where I did my initial training at Wash U and my amazing staff, Sara and Jackie and Gwen and Laurie and without them, I wouldn’t be able to do all the cool stuff that we do. So we are in St. Louis and in Chicago and my my focus right now is actually being at the schools and providing education and support for the school systems but that’s who we are. But also for just general education about child and adolescent psychiatry. Families can go to American Academy of Child Adolescent Psychiatry or the Illinois Chapter where I am a board member. And the American Academy has a really nice website, and there is a part that is packed for families. And there you can look at some of the common questions and concerns about children’s psychiatric conditions and disorders.
Dr. Leigh Weisz 45:40
Wonderful. Well, thank you again so much, Dr. Makki, for being here today. Everyone, please check out more episodes of our podcast, go to copingpartners.com and click on podcasts and articles. And thank you as always, for tuning in.
Dr. Mojgan Makki 45:59
My pleasure. Thank you for being such an amazing partners through my journey and thank you for inviting me.
Dr. Leigh Weisz 46:08
Likewise, it’s been a pleasure.
Outro 46:11
Thank you for listening to The Coping Podcast. We’ll see you again next time and be sure to click Subscribe to get future episodes and check out our podcast page at copingpartners.com