dyslexia to medical concerns like crohn's and colitis my hope is that by the time you finish viewing this program you are both more aware of the struggles that these kids face silently on a day to day basis and how you as a student or you as a parent can help through the school to get a andie to a doctor who works at both pediatric south and children's hospital she's a physician specializing in pediatrics and has had almost forty years of practice in the field after graduating from the university of rochester school  medicine and dentistry how are you i am great so i know as a pediatrician that you working a lot with the physical aspects of children but how much do you get regarding mental learning disability stuff like that from your job well i think that's actually the greater part of what we do because most children are well and although we do some anticipatory guidance what i find is that the mental health and the behavior problems and the emotional problems are the things that bother children and young adults every day so i would say that probably eighty percent of what we do has to do with either our parents difficulties in this area children and young adults so you would say that the mental aspects of it do affect the physical aspects and they might even come in for that kind of stuff absolutely many mental health issues cause physiological changes that will cause true disease or true symptoms and sometimes the children and younger and adults are not really where of th so they will come in because of the physical manifestation that stress or emotional problems cause or nowadays people are much more aware of the emotional aspect depression anxiety certainly a d h d and the common directly for that so it is very helpful when the parents are more aware that there may be an emotional component the other thing is also true if you have a physical problem it always has an emotional component to it as well because of the consequences of whatever a physical problem you have and you cannot lead or help a child attain good healthy young adult unless you address asked both aspects of the problem right so let's say that once  child comes in he's been sick for a while you only see if the physical problems but it is your job to identify what the mental problems are but are you then able to prescribe medications for the mental issues are you only able to do it for physical you know but i think that  you're putting the cart before the horse if somebody has a physical problem we're going to obviously investigate what it is and try to figure out how we can either mili raided or fix it to get them back to good health then the mental health aspect of things has often to do with our the physiologic changes for instance somebody who gets an ulcer a gastritis or reflux because the stress so that will take direct medical intervention as well as changes in diet and attitude but if somebody is having a secondary or an adjustment reaction and emotional problem the first response is not medication it's to give them other tools to deal with the emotional distress and the consequences of that that they're experiencing so we never do medication alone so you just said you don't have any medication alone so originally would prescribe on prescribed therapy or situations like that  are you the one who then reaches out to find this therapist or do you say you need a therapist these you go look for one that's a good question because many many people have initials after their names so the education differs but what's even more important is the fit between the therapist and the young adult that i'm seeing because it doesn't matter what initials if you don't click with them you're not going to open up you going to shut down and it will be absolutely meaningless so i do have their piss counselors that i've worked with for a long time and i know them and then i try to match up who is going to be a good therapist geographically gender wise for the individual that i'm seeing and then usually what will happen is we'll start the therapy  and they will sign permission so that the therapist can talk with me and together it's a team decision it's the young adult is in on it that parent isn't at the psychologist or it's or therapist and then i'm in on it too so i work in concert with them and sometimes if they don't get what i call out of the whole meeting they're totally miserable and the therapy is not bringing things along then we'll talk about adding medication and at that point as a junkie of therapy and i will do that see do prescribe is ok  do you work with the therapist in order to create the diagnosis or is that something that you do on your own and then allow the therapist to work with what the patient who has a diagnosis or a specific criteria for most of the mental health and emotional diagnoses and the put out by the diagnostic and statistical manual of mental disorders which comes out about every ten to fifteen years as a group a psychiatrist gets together and tries to come up with common symptoms and the intent of that is to try to group kids so that they can study what's going to be an effective therapy but i tell you i never really do a checklist because anything on the checklist an individual will have more one symptom and less of another so for me it has to do with how something is affecting the functioning and how severe they are so i can give the diagnosis there's no question about that and i usually refer them to the therapist with a certain diagnosis in mind but therapy there are different types of therapy so there's cognitive behavioral therapy there's different therapy for reactive disorders for post traumatic stress disorders so you know that's not my specialty but i try to refer them to a therapist who i know is comfortable and proficient in those areas but the diagnosis is further refined by the therapist that i refer them to and he said diagnosis when you say that i know for a fact that schools are able to administer tests through the guidance office in order to i guess diagnose what it may be whether it's a dyslexia or some other issue is that the same thing that you're doing or is that something else different different it is an interesting dichotomy here because you have in one thousand nine hundred seventy five the individuals with disabilities act which  provides that all children all individuals get a appropriate education but the criteria to get help which would be like an i p under that are very specific criteria depending on what the diagnosis is but they exclude medical conditions even a a d h d a sort of can be either and i e p or what's called a five zero for service agreement the i'd individuals the disability act is actually a federal law and therefore the these schools get some funding and some support and their very strict criteria is about identification and what they can do so that's where somebody would get a psycho educational evaluation by the certified school psychologist to determine if they meet criteria for a learning disability or for giftedness or for something along those lines but things like a d h d or mood disturbances or autism spectrum disorder these are medical other diagnoses and it goes through the arm of a different sort of evaluation which is not quite as strict the other thing about a five zero for service agreement which these individuals get is that the schools get no federal government funding for it and that they have to come up with modifications and accommodations because the whole idea is to try to look at what's preventing a young person from learning and performing functioning in activities and to provide them to the support but also within the cont do administer an i q test which has a variety of different subtasks where they can look at the pattern of that and also what they are and then you get a performance and a verbal and you get a full scale i q they will then perform some achievement test to see where you come out with what you're learning and if there's a discrepancy between your potential as related to your i q and where your performance is you have to have a certain discrepancy before you meet criteria for instance for a learning disability but they also look at why so they look at a great deal of processing issues auditory processing visual processing to take a look at what lends itself to the gap between the two so that they know where they can  provide support the psychologists will grade it and then they will have a meeting with the parents and they'll come up with a plan but nothing can be implemented under a p l s the parents agree and sign permission for it now the same is not true of the five before service agreement they have to inform the parent but the parent does not have to agree if it's placing the two other children at risk for instance so it seems like an i p and if i will for different things mean you just said they were child versus these the school population as a whole and you know i'm not a psychologist probably you should talk to them about that what if from my perspective what usually happens is i have a very bright young individual  who's grades are going down because of a mood disturbance in the preoccupied by depression or anxiety and we always want to make sure that there is not a co existing learning problem as well as an emotional problem if i have somebody who has depression anxiety mo about thirty percent of the time they're going to have something else going on and you cannot address one without the dressing the other so the psychoeducational evaluation is done to make sure that there are no unmet educational needs to make sure that the individual has as much educational support that they need in the classroom to succeed and then we need to look at the other piece of it as well so we're just going beyond medication what other i guess accommodations within the the five zero four or the ip can be offered to these these kids yet depends on the school district there is now counseling available in many of the schools beyond the school guidance counselor why they don't do therapy they may do extra time for tests do it in a quiet quieter setting if somebody has anxiety related to performance they may have an individual not have to take all the more than one exam on a day to take in complete and stretch out so what they're trying to do is to decrease the triggers that might increase anxiety that is interfering in the performance of that individual and how long would it take to get one of these after the process of testing if you have a five zero for service agreement i can get the process rolling even before they see the psychologist because i can give a diagnosis so we always want to have therapy going along with accommodations at school but only if it's interfering in the performance ok if somebody is anxious but shutting it in and there's no problems at school then we also want to be cautious here because we don't want to make that individual feel more isolated or different than anybody else to fine line right i was just about to say it in a situation where they might have high anxiety or social anxiety wouldn't making it so that the only the take one test per day in a situation where they had to make up tests later on a bigger problem it can it can you know i know you're going to get to that in the further questions but this is all about the health and well being of the individual so cannot be a cookbook thing and i try to have the young adult be in on this discussion about what would be acceptable to them because i don't want to do anything for them because i can make the problem worse so there's extended time there's for testing does that also apply to standardized testing yes yes you can get extended time for standardized testing but they have tighten that up because as you know a lot of  people abuse that to get extra time to give them the edge so you need to have accommodations for three months prior to the testing and you have to have ad support in place you can't get to your junior year and i got eighty eight she i need extra time on my test right so you have to go to the school psychologist and then do you work with your guidance counselor after that i would imagine you have to in order to it's a team all right so after the testing is done they have a team meeting with the parents the school psychologist the special education the teachers the principals and then they have the parents come in and usually the individual will be there as well to go over the results and then to be in the planning process and then they come up with the recommendations and the parents have a chance to review it and see if they agree or don't agree and sign off on it now i know you also work at children's hospital some of the time what sort of accommodations you have for children who are out of school for an extended amount of time or they want to very well we no longer work at any of the hospitals because  pittsburgh is working towards a hospital this model where they have in house hospitalists who take care of the patients that are admitted you say that you repeat your question again sam i'm sorry so the r kids who are extended have extended time at the hospitals or are unable to make it to school are there accommodations in place for them or is it really just the first ok so it depends on how long we expect that if someone is going to be out for an extended period of time we have the homebound  instruction which is limited educational support i think the maximum is eight hours and it does it for english and for mass was not everything but it will provide some educational support while they are unable to participate and  to attend classes now when they go back to the schools goal is to have you graduate and have you learn the material so certainly they will meet the students and and decide what you need to do to make up the work what you can perhaps take a test and show mastery of what you need to take extensions for can you finish it in the summer time so that the goal of the school is really to be that the students advocate are not our adversar depends on how sick the person is how sick they are at home how much are they able to do the work so for everyone is individual but yes there will be accommodations even after they go back to school including partial attendance you know go back a couple days a week a back half days gradually edge into a full day things like that you know we've been talking a lot about the mental side of it i'm going to shift over more of the physical examples of it that i use really crohn's and colitis there are combinations in place for that situation yes it depends not so much on the disease but it depends on the symptoms and that may depend on whether they have a flare up or are there on their control so there would be things written into a five zero for service agreement where you could say doing a flare up this person should be allowed to be late without being marked dog may need to miss school without the parents having to go in front of the magistrate may need extra time between classes to use the bath and may be allowed to leave the classroom at any time things like that we accommodation in social anxiety can also play into that i mean if you had to raise your run to the bathroom and have diarrhea or throw up you know that's kind of hard for you here in school cardiac problems for instance where they may not be able to have full physical education or the limited in the physical activity again with something internal that's not obvious and i think those are the hardest i would have to agree with you so you said there it seems to be a lot regarding the stomach what about the combination of both for example people who believe make or have eating disorders and they they're they have a mental from but they're also physically inclined to have a disorders how do you believe that our school should be able to handle those situations that the work closely with the physicians and the psychologist to see what they need you know our goal is control and if these kids are going to the bathroom and throwing up after every meal then it's likely that the weight is going to go down and they will need more intensive therapy which will preclude them from going to school until they're more under control if you could change one thing about our school system right now regarding how we accommodate children what would it have to be i actually wouldn't i think they do a very very good job it's a dynamic process and what i find is they are very open to trying something and then having important say well this is not really working we need a lot more of that what we have to struggle with a little bit is to have the individual student again i don't mean identified i mean as being an individual to the school district and to the personnel so not a person with irritable bowel or a person with inflammatory bowel disease but a patient and then to go  oh ok let's see where does he have problems or she has problems what can we do to help it let's work together to come up with a plan and then have a periodic reevaluation so once somebody is seen and on the radar it works so i know you mentioned teams earlier between therapists and doctors and parents do you believe that teachers like the teachers on day to day your english or science or math should also be in on that in order to i guess assist them in situations where they might they might not be asking for help because they don't  that they need it right because they don't want to be different than anybody else right ok and this also comes up with sort of hipaa violations the need to know and how you share information but yes i think that teachers can be supporter but if you're the teacher's pet or they pay attention to you that can backfire and then you're different than everybody else so it really depends again on the individual but the teachers can facilitate a warm and caring environment for instance if somebody has a social anxiety disorder and we're working on it that maybe somebody who will say the teacher don't call on them don't have them do a presentation in front of the class ok let's make other accommodations they can do it  privately they can videotape it put something to lower their anxiety to make them be able to meet that expectation but not under the same circumstances right and you mention hippo what exactly is that well that's  privacy act that protects any medical information from anybody from going to people who have no need to know so i can see you i can see another patient and i'm not about to tell anybody anything unless you sign permission now what's interesting about that is after fourteen years of age an individual has the rights to their own mental health control so they can hand out they can tell or well they can always tell but they do not have to go to therapy they do not have to take medication if they don't want to they don't have to go to counseling so it is another very touchy situation because if i myself and the parents see that this is an individual needs help but they refuse it you know say if i mean i personally i don't think fourteen is old enough to be able to either handle your medication or decide which able to take i don't know do you think that age is too young i do i think they're very concrete and  like teenagers at that age they think that nothing applies to them individually and you can have this sort of magical construct by what you want to believe is true and it doesn't apply to other to you what applies to other individuals so it's a it's a situation where as a primary care physician i can work with them over time and very often though open up to me and we'll talk about it and we'll talk about what medication or web therapy will do and how to be beneficial and how a therapist is are best friends because they can tell them anything without having you know people come down on them so it's sometimes it takes a bit of time it's not like you identify and everything's hunky dory right used to mean you see that on a regular basis yes either that or also parents who are very resistant per parent's generation and for my generation is a huge stigma against mental health depression anxiety is seen as a character weakness and makes you less than you are somehow you're less of a person so for some parents it's extremely difficult to admit that this isn't a problem most them say well just don't be sad they didn't think of that and yes i probably plays into the parent mission of the i e p right less of the ip for reasons  don't know it's much more accepting to think of and i support see i'd like to think of that kind of thing as that your brain works in a different way and that schools in general teach one way and if that's not the way that your brain works then you're going to have difficulty because a learning disability means you have at least normal intelligence and other under other circumstances you would achieve so something's holding you back and basically when you're in school you're penalized by not only doing the work but also figure out how to do the work and very often you're inefficient you have to figure out another way so that when that's much easier for parents to understand that they have two jobs and by getting long support we can take away that and they're just left with the learning that's much more acceptable for whatever reason so parents don't seem to accept medications to accept a less than peace at least it depends on whether it's a family history and most often there's a family member either one or the other or siblings or grandparents who have struggled with mental health issues whether they were diagnosed or not so parents see the difficulty but they most of them do not want medication right away unless they've experienced benefit from themselves that's ok that's what i want to read i want them to get therapy and then see how long it's going to come if the data shows that at least for adults you have equal effectiveness with cognitive behavioral therapy and with medication the difference is that behavioral therapy takes about six eight months to kick in that's a long time for somebody who's in the hole and the second thing is when you do the cognitive behavioral therapy it depends on the mental health and the ability of the individual be able to use those kind of skills because what i find is that the kids a very good at it in the office and then when they need it you know it doesn't work which is really frustrating and it's hard for me to get a teenager to stick with it so  hypothetical situation in which we've gone to therapy we've and we should be ready for medication at this point but a parent's doesn't want it and at that point the kid is clearly struggling what sort of methods would you take in order to either convince the parent or show just how much the kid needs it though usually aware of how much the child is struggling but if not i don't start with that what i usually start with is is bring it back and educate the parents as to this being genetically based neurotransmitter a chemical imbalance and i talk about pathways in the brain and about when you have a pathway to go through that goes with the brain you can have a good path where you can have a bad pathway so that's why you practice in sports so that you're going to get better and better so that if you start here it automatically is going to go that way because the brain will wrap that particular pathway in insulation called a mile and she still goes automatically reproduc which is great is slowing a baseball not so great it is triggering off inappropriate anxiety for instance because the longer it goes on the deeper it gets so explaining what's happening and that we can see this an  microscope and we know it's happening and that if we block the pathway it will unwrap that insulation so sometimes backing up backing up back enough and continuing to meet with them and talk about when a haitian does and doesn't do in the safety profile and all that it's just working with them a little bit so let's assume that they have the accommodations maybe they have medication what can they do beyond just what's available to them in order to help them so  question the big thing is to take care of the basics sleep is a huge potentiate meaning lack thereof and if you look at yourself and you look at your peers around you hardly anybody gets the eight to ten hours of sleep that you would fire as a teenager yeah ok you don't need less sleep as a teenager you get less sleep and lack of sleep is a huge potentiate or for irritability over reactivity mood problems lack of concentration memory you know how you get on that declining slope of the learning curve if you stay up to two or three o'clock to to try to finish something so sleep is important exercise is important yeah so you can put an hour a day out you already strapped for time so take the stairs when you can take the exercise when you can you need sunlight or at least i tell people to take some vitamin d because you all have vitamin d deficient by the way you're indoors way too much it eating how many of you guys don't eat breakfast and you need to graph if you need to get some fluids to get your hydration get your blood supply circulating to give some nutrients to your brain so really i can for size how much taking care of the basics is really important been really helpful thank you should do it do we have a little time as want to do mention one more thing ok the biggest problem with this is this whole sense of self within the school and belonging to a certain group if you have a physical disability it's out there so people know what they get when you're included in a group because it's a static problem when you are in high school you know you struggle a little bit and then you try to find like minded individuals for something that's important for you and that becomes the group that you become part of so whether it's an athletic group it's a theatre group as foreign languages you find people that you're comfortable with and within that group once you are accepted this gives you a huge buffer because within a group you're allowed individuality they inforce they encourage your exploration encourage the positive things that holds the group together when you have a mood disturbance or something it's on the inside nothing shows on the outside ok and the individual will put up this facade this fake front because you don't need that much to get along fine how are you everything's fine but behind that they have an increasing sense of distance from what's going on so they're struggling and they're going about life now you can do that for a while but what happens is eventually their behavior changes so they may be more quiet they don't take pleasure in things so they may not call out they may be less engaging and the group will accept that to a certain extent but after a while it seems odd to the group so what they're going to do is not ask them not sit with them so what's going to happen is going to become increasingly more isolated and alone and that really adds to the despair and the anxiety and the isolation so what i would say is as a student if you see somebody whose behavior is changing reach out to them i reach out to  them and and in a quiet not the hallway i went up to take them go someplace do something go for coffee i don't really care but just touch base and try to be there for them i'm here for you do it if you want to you know talk that's fine you know to have somebody that cares and is willing to take the effort to see beyond what superficially they're i think that can be tremendously helpful yes thank you you're very welcome thank you for being here dr oz and i hope all of you enjoyed our show and learned a little bit more about the accommodations that are available to your to you and your care of physical and learning disabilities and how you can access them through your school guidance office for more questions as your guidance counselor what kind of accommodations are right for you thank you and we'll see