Child and Adolescent⁠ ⁠Psychiatrist⁠, Jess Shatkin, M.D.

0:00 Hi, it's Doctor Robert Seikherdwood, Episode #20 of the Doctor Podcast Show. Thanks for tuning in again, We appreciate it. Today, I'm really pleased to have a great guest, Doctor Jess Shatkin. Dr. Shatkin is a professor of psychiatry, child psychiatry and adolescent psychiatry at the NYU Grossman School of Medicine and the NYU Langone Medical Center here in New York City. Doctor Shatkin is one of the country's leading experts on pediatric and adolescent psychiatry, and this is a very important topic these days, so I'm really glad he's able to be here with us.

0:41 Thanks very much for coming today, Jess. I really appreciate it. This is, yeah, this is a great topic these days. It's in the news all time there. There seem to be problems with kids and adolescents, so you can help us understand that better. I'll do my best. Tell us what got you interested in in psychiatry specifically, and even more specifically in child and adolescent psychiatry. Well, I sort of come by it, honestly, because my dad was a pediatrician who then became a child psychiatrist in the late 60s and the youngest of five kids.

1:12 I think a lot of things were going on at home and a lot of things in his pediatric practice. After a decade that he didn't know how to handle marijuana, use infidelity amongst the parents of the kids. He was seeing for Pediatrics, general Pediatrics, and he wanted to be able to do more and there was an opportunity to go back and train in psychiatry and child psychiatry. I was three years of age when he went back to training. So I have a lot of memories as a child of going to the emergency room and you know where he was moonlighting and things, to have dinner with him so we could be together as a family.

1:41 But take on point is I grew up with these interviewable conversations after the age of six or seven. We were talking about why people do what they do and how people make the decisions they make and what happens when things go awry for kids and adults. I started my career in public health. I thought I'd go into medicine, but I. You have an MPH. I have an MPH right? Yeah, Master public health. Yeah, so when I finished college I I became aware of the social determinants of health. While I was in college I studied history.

2:07 I did the pre Med courses. I didn't really like the pre Med courses and you know, present company excluded. I didn't really like the pre Med students. It was too much like this, you know. They were too focused on getting. Very narrow folks. Yeah. And I, you know, I wanted to learn about history in the world. I wanted to date. I wanted to do the kind of things that, you know, college students want to do as well as study. And I also learned about public health. HIV hit when I was in college. I was at UC Berkeley.

2:31 I had friends get sick and die at a very young age, and I decided that that seems to be the way to help people more was through public health education and program development. So I did. My MPHI worked for a number of years, not in mental health, but at 29. I went back to to school and I did Med school at 29. Thought I would go into family medicine, maybe internal medicine, Pediatrics. I liked those. But when I hit psychiatry, and maybe this is a reflection on my upbringing, but when I got to those rotations, I just knew what to do.

3:01 It was just it was natural. It was natural and it was the easiest. Everything else I had to work hard at. I mean, I worked hard at that too, don't get me wrong, but this just flowed naturally. So you started your training at age 5. Exactly. That's incredible. And you had all those extra decades of knowledge and experience from your father. So now you're you're practicing psychiatry, child, adolescent psychiatry regularly. You see a lot of kids, a lot of adolescents. What are the most common problems that you see in children and adolescents?

3:35 So it depends on where you're seeing kids in terms of exactly what your most common thing might be. For example, in an emergency room or inpatient facility, you might see certain things. I work in outpatient care, so I tend to see a lot of the bread and butter of child psychiatry. I see a lot of anxiety, a lot of mood disturbance, mostly depression, some bipolar disorder, what we used to call manic depression. I see periodic psychosis. I don't work with a lot of people who have chronic schizophrenia these days.

4:00 It's sort of a different clinic setting than what I have. I see a lot of ADHD and learning problems, a lot of parenting difficulties. I have a sort of some specialty in sleep. So I work a lot with people around sleep problems. I'm very interested in why adolescents take risks. And so I see a lot of risk taking, drug use, some eating disorders. I mean it really runs the gamut of what we see. But I think the the most common things are what we all tend to see. The thing I neglected to say was trauma.

4:26 And trauma exists sort of all over the place. I think of trauma in psychiatry as sort of the syphilis of today. You know, syphilis could present as anything and maybe Lyme is that way. Now. It's actually the same kind of bacteria, spirochete. These things present in all sorts of ways, and I think trauma can have no effect. It can have lifelong effects. There's no comparable good thing that can happen to you that can change your whole life, but there are traumatic events that can change your whole life.

4:51 So these are emotional, traumatic events. Yeah, abuse. Ongoing abuse. Neglect, physical or sexual abuse. Witnessing bad things in the home, having a family member incarcerated, having a mother who is abused and and doesn't know how to protect herself. We see kids like this all the time and it takes them sometimes times a while to find it. I'm not, I'm not keen on like everybody's been traumatized and it's, I mean, yes, maybe a little bit, but but the big tea trauma, the big stuff, sometimes it takes a while to get to it because people aren't they, they sort of discounted, they don't want to think about it or acknowledge it.

5:26 Right. So all these conditions you mentioned seem to be more common in in recent years, in the last five or ten years. And now with the pandemic, it seems to be even more common. Somehow the pandemic triggered a lot of this I saw today. I was reading this morning very disturbing article. The government did a survey in 2022 and it showed that about 16% of adults are hooked on drugs or alcohol of some type. And even more upsetting was 20% of adolescents in 2022 had a major depressive episode or disorder.

6:04 What? What's your take on that? Are we just diagnosing it better or is there increased incidence of these conditions? I think mostly it's not an epidemic. An epidemic is unexpected, comes out of the blue. Mostly I think we're just getting better at identifying it. There are some stressors, and you mentioned a number of them, the epidemic or the the the pandemic of COVID being a big one. And there's some other things we can talk about too, that might be pushing the mental health problems that we're seeing.

6:34 But every generation we've been studying since World War 2 has more mental health difficulties than the generation before. So whether it's trauma, whether it's depression, anxiety, our best study of adolescents nationally reports that 32% will meet criteria for an anxiety disorder during the ages of 13 to 18. Around 15 to 17% will meet criteria for a major depressive episode at some point by the time they hit 18 years of age. So these are big numbers and substance use and all the other things we talked about come into play.

7:04 So I don't think it's all de Novo. I think we're getting better at recognizing it. I think we're getting better at talking about it. I think kids and families are getting better at acknowledging it. And so they come forward a little bit more easily. Still, most people who struggle don't get treatment. Still most people who get a treatment don't get an evidence based treatment. So we have a long way to go in terms of making it better, but we do identify it better than we used to and we see it more clearly.

7:29 The pandemic's a big push, you mentioned that. Yeah. How does the pandemic 'cause this? Or how did it 'cause it? So interestingly, once the pandemic occurred, we saw a drug use and suicide attempts go down a bit in the first year or so. Initially there was some increase in violence, a self injury I should say. It's an increase in anxiety and depression, of course. But some of the extreme outcomes like suicide and and drug use went down because people were so isolated and they were around people at the time.

7:58 But of course, we saw higher rates of moodiness, depression, anxiety. Kids got behind in school, which led to more anxiety when they came back to school and more worries. And so I think that isolation was was key. Those families that kept up their routines, still had breakfast at the same time, still got online, had the access to get online because a lot of families didn't have that access, took a shower every day, you know, those families tended to do better. And it was predictable. I mean, I was telling all my patients, keep getting up at the same time.

8:27 Keep having your meals at the same time. Keep going to bed at the same time. Don't become a night owl, you know. Do the things that you. Normally do so. A sudden disturbance in your routine triggers brain chemistry changes. And a lot of these things maybe, I mean isolation certainly affects us whatever the chemistry changes are, we probably don't know very well. But undoubtedly this kind of isolation, not being with peers, only seeing peers online where you're comparing yourself to them and constantly feeling down about it.

8:56 And that's that's another factor that had been coming up years before COVID, from 2009 to 2019, even before that. But certainly we've been tracking closely the media's impact on kids since then. Their use of media and screens has gone way up. A lot of that is social media, which makes you feel, if you look a little bad about yourself. How many people are watching this? How many people are seeing that? How many people give me a like or a thumbs up, constantly comparing yourself and you ask somebody, hey, what are you doing tonight?

9:24 You want to go hang out in the park? And they say sure. And then they say, oh, actually I can't, I got too much work to do. And then you look online later on Snapchat or Snap Map or whatever it is and you see that they're in the park and they didn't invite you and you feel bad. It's more reason to feel isolated physical activity, some of the basics. You know, we know that exercise is as good as medication and therapy for mild and moderate levels of depression and anxiety, right? Kids today run a mile 90 seconds slower than they did 30 years ago.

9:49 Really. Only about 20% of kids get recommended amounts of exercise. Hugely important. A few I can go on and on. There's so many things like this that have collapsed. Few of my psychiatrist's patients. I'm an ophthalmologist, but I have some patients with psychiatrist and they tell me that exercise is as good as most of the antidepressants I mean. At least for mild and moderate degree. For mild, yeah, for people. And they hit moderate, high levels of moderate problems, severe problems. The medicines don't work for everybody, but we have a lot of strategies.

10:17 We can use a lot of different medicines, a lot of other treatments, a lot of therapies that are good, but exercise is really important. How does exercise do that? Does it release some chemicals in the? Brain, I mean, you probably know as well as I do endorphins matter, I think, but we don't know how much. Cannabinoids are probably involved in that as well. And then there's also the good feeling, just the the whatever that comes from, is that neurochemical? Yes. But it's also probably I've gotten my day off on a good foot.

10:45 I've gone exercise. I feel good about that. Accomplishment. Yeah, I did something. And when I exercise, that's what I. Feel and and for many people, it's being in nature. For many people, it's being around other people in the gym. For many people, it's being with their dog. You know, whatever it is that they do to exercise, I play tennis on the weekends. During the week I go to the gym or I take a jog, so I'm outside or I'm in the gym with other people. And on the weekends, Saturday and Sunday, I have a tennis game each day.

11:10 And and that like, I look forward to that. Like that's a big part of like, that's a one of the high points of my week. Right. And it also reduces stress. Now you mentioned about social media that there's increasing media attention to the fact that certain social media, especially Instagram and TikTok have been criticized in creating problems in children and adolescents. What's your opinion and take on that? I think the longer we can keep kids from using large amounts of social media the better. Before we had social media in 1998, there's a study showing that by the time kids started middle school pre pre Internet when we had cable though, they were already witnessing something like 8000 rapes and 100,000 murders on television in their life by the time they hit eighth grade.

12:01 I mean the numbers are really high and so where social media sort of allows you to immerse yourself in it more makes it more personal. You can search for what you want. You know, young people are having less sex today than they used to because they're having a lot of sex online. You know, they're they're doing a lot of porn and other things like that. And actually that's probably not very good for them to not be having sex in, you know, whenever they're ready for it as consenting adults, you know, as opposed to being online and being isolated, it's another way to sort of be apart from each other.

12:29 So I think that we're seeing a lot of effects that that we're just getting to understand now. But certainly obesity is on the rise for adults and kids. A lot of that I think has to do with being on screens, sitting still. High school students are spending over 8 hours a day on average on screens for entertainment in a day and eight. Hours a day? Yeah. Wow. It's they don't have. Time to go to school. It's 8 hours and 22 cents, according to comment, 22 cents, 8 hours and 22 minutes according to Common Sense Media.

12:55 And for middle school kids, it's about 5 1/2 hours. Not for school purposes, not writing papers on a screen. This is the time. They're just on a screen, Entertainment one type. And like, what did we do when we were kids? I mean, I went to the park, I went up the street and I found people to play, you know, football. I played guitar. I watched an hour of TV. If I if my parents would let me get away with it. There's only one TV in one room and it was well policed. So you didn't sit there all day and watch television?

13:22 Nine channels. Yeah, exactly. Yeah. I think I had 13. Good for me. That was about it. Yeah. It's not. Right, so seems like isolation causes a lot of mental problems. I think it's a good. Humans are meant to socialize and interact with each other. IRL, as the kids say in real life, as opposed to. You know all these terms that I'm not familiar with IRL. That's a good one. As opposed to on screens. And I think some screens are fine. I'm not. I'm not Draconian. I'm not like, oh, we can't look at anything or you can't.

13:54 No entertainment's great, but 8 1/2 hours a day, that's, you know, do the math. That's 40% of your day. That's a lot of time. That's a lot of time, and there I've read that for some reason young girls are more adversely affected by social media than than boys. That seems to be something people are saying, and I don't know that I I can tell you that I noticed that clinically I think both are affected. But I think that the idea of measuring up against other people and girls are very in tune on average to the emotional impacts of relationships in a way that women and girls clue into that better than men generally do.

14:31 And so I think that watch any two men at a party and and they will have their, they'll be, they'll sort of stand like this, almost parallel to each other, right? They won't sit like this and stare at each other, but look at women, they'll be looking right in the other eyes. They'll be closer. They'll be looking right across from each other. We have different. Skills different. Interactions and different ways, yeah. So you mentioned all these conditions. How do you diagnose these conditions? Let's say a parent brings in a 12 year old with some issues or problems.

15:01 How do you determine what the diagnosis is? Luckily, these days now, having been a doctor for 25 years, it's it's easier than it used to be. So you know, you get used to patterns like you do. You know you see certain things, you've seen them before. Yes, it could be a red herring. So you take your time and you make sure you're not missing anything. Cuz 9 times out of 10 or maybe 99 times out of 100, it'll be just what you think. But there may be a time when it's not. So you need to have enough time with people.

15:25 Most of the time you'll get it right from the time you meet them in the waiting room and walk them back to your office because you you see how they're dressed, you see how they walk, you see how they talk you you get a sense of how they interact with their family members, you know, whatever it is. But and that's the, that's the sort of, you know, gist that we have of of just knowing you've seen the pattern or maybe you've broken it down to three diagnosis instead of the thousand that we have. You know, because you're sort of in the neighborhood now.

15:49 But you ask your questions, you assess from the kids if it's an adult, from the adult, if there are collateral people like teachers or parents to talk to, that's helpful. You may use rating scales. Some of the rating scales that we have are pretty good. They've been tested and are reliable and have a good rate of fidelity. That means if I use them here or someone else uses them in California, we're likely to get the same answer. So we use some rating scales, sometimes just to confirm what we're thinking, sometimes in advance of someone coming in, so we can save some time for them and for us.

16:19 We may do some testing related. There's not a lot of testing we can do in biological testing in psychiatry yet. There are correlations, but there are certain things like depression may show certain blood values that we can look for, but anxiety and ADHD generally won't. So we're only ruling out anything medical that could be accounting for these symptoms. And again, we only chase down that rabbit hole if we think there's enough physical symptoms of something going on that suggests this could be something physical in nature.

16:46 I I interviewed A geneticist about a month ago. Yeah. And there are lots of genetic tests now for various psychiatric disorders. They do any of those on occasion. Really. Because they still don't tell us what to do, right? They still don't really help us. Like we can do brain scans. We could do a functional MRI or or a structural MRI to look at various changes that we are likely to see with ADH HD. But it won't make the diagnosis or people who have had chronic schizophrenia, but it won't make the diagnosis because I mean schizophrenia is not a hard one to diagnose generally speaking.

17:19 You know, you want to rule out other things that it could be, but the symptoms are so predictable for most people that it it's not usually hard to figure out but the end, but there's a there's a gross brain deterioration with that disorder and atrophy and we can see that pretty clearly. But it's not only specific to schizophrenia. So there are things that we might look at one day, but right now, not so much. There are genetic tests that we can use to determine which medications people can metabolize well by looking at their liver enzyme profile.

17:47 But that still doesn't even tell you whether they will do well with the medicine. It just tells you whether they can make sense of the metabolism of it. So we rarely do that too, only when we've sort of not had a good experience with a few medications or there's a pattern we're starting to see develop, right. So at this point, it's mostly history. It's mostly getting to know people. Now there are, I'll tell you about a kid I saw recently who I've known for about a year and it took about a year to make the diagnosis of autism because the this is, this is an adult, I say kid, but it's a, it's a young adult, right.

18:17 And the history is filled with some degree of trauma and some a lot of depression and a lot of family strife and some violence in the home, all this stuff going on. And so it takes a while sometimes to make that diagnosis cause the kids quirky. You know, the young adult is quirky but not you know frankly autistic in the way that we might think of it, the Rain Man or something that's much more autistic, the kids totally verbal, dresses well, presents well as good eye contact. So, but I think that this is a a very helpful piece of the diagnosis because this child couldn't get along well with the family and couldn't roll with the punches and really stood out in the family.

18:53 And I think that this kind of background that the the diagnosis of autistic is much of autism is much more consonant. It's high functioning autism, bright person, but it really does help to make things more clear And I think that now that I understand that I can be much more helpful and that took, that took a lot of sessions to get to that point a year that's yeah, yeah that's not usual. Right. On the average, how many visits with a child or adolescent does it take you to make a diagnosis and be pretty certain of what the diagnosis is?

19:24 Usually it's one visit, an extended evaluation. Usually it would be, you know, a couple of hours with someone, depending on the environment you have with them in the emergency room, maybe you wouldn't make a proper diagnosis. It's just sort of enough to I see the symptoms, we're going to treat the symptoms to help them either be hospitalized or go home. And maybe we understand the full diagnosis or don't. But in a typical evaluation, you're donating about three to five hours to that if you're going to do it well.

19:47 So it may be one visit or two or three, but it's a chunk of time. And that will involve some reading scales, 90 minutes with the parents, an hour or two hours with the child, depending on their age, talking to the teachers. And that's if you're doing a thorough evaluation, right? I've worked in clinics that are publicly funded where I have to do that in an hour, 60 minutes, maybe 45 sometimes. So you can get closer, you know, you, you zoom in, but you may not get the exact answer there. But in the full three to six hours, I might see somebody.

20:14 You know, when my dad was was a psychiatrist, he would typically see people for two months before you make diagnosis. Because billing wasn't based on diagnostic codes back then. So you didn't have to have a diagnosis. You just said I'm seeing this person for an extended evaluation, an hour or two hours a week for eight weeks and then we'll figure out where we're at and what we can do. We're much, you know, the good news is the diagnosis help us to identify good treatments and the treatments are pretty reliable.

20:37 They're not perfect, but you know, we have 900 evidence based psychotherapies. We have a lot of medicines. I don't know how many, but many dozens and dozens we can use. We have other treatments that we can use. We have a lot of sort of residential centers and school supports and things that we can do. So we can get pretty close most of the time pretty quickly and then if we need to narrow it down, that's what this extended. Period is for right? So now you made the diagnosis. How do you decide what the treatment is?

21:03 Is it just speaking with the child and the family for a while and. Well, it's never, it's never that. I think in the old days it used to do that, right? Or is it medications? Or is it a combination? And how do you decide which medication you're using? All really good questions, and we have some good algorithms and nothing's perfect. So once a diagnosis is made, you have to decide how you're going to present this to the family and how you're going to present this to the child. And one of the ways I start is by saying, no matter what I tell you, and it depends on who I'm talking to and what their age is and all that, right?

21:38 But you're the same kid or your child's the same kid as he was or she was or they were 10 minutes ago. But you're gonna get a diagnosis from me. And what does that mean? I need a diagnosis so AI can make a bill because you gotta have a diagnosis to bill so that we can keep track of the progress so we know what this is and what it's likely to do over time. And so that I can choose some evidence, informed treatments that are going to help because certain things work for certain things and don't work for other things.

22:03 So if I know it's ADHD versus depression, I'm going to make different medication choices right now. Medication is part of the story. We will typically like you probably start with the least invasive thing, right? You know, So the least invasive thing is usually some sort of therapy. There are, as I said about 900 evidence based psychotherapies, but most are based on cognitive behavioral principles in some form or other. How do you think through this problem and how do you behave around this problem?

22:31 I love the cognitive triangle, which is a little tool. That, or it's a pictorial sort of a thing that Aaron Beck created. This is this idea that on one end of the one point of the triangle are your thoughts or cognitions, on another point are your behaviors, and on another point are your feelings or emotions. And there's imagine double headed arrows between all these three points. Anything happens in your life, you get depressed, you get anxious, somebody ignores you in the hallway when you walk past them.

22:58 Anything can happen with an event or a diagnosis, and you're going to have thoughts, behaviors, and and feelings about anything. And depending on how closely you're paying attention, you know one will outweigh the others. Different things will happen. But I can't tell a depressed person to stop that. Stop being depressed. That doesn't work. Doesn't work. But you can do things to affect their thinking, their cognitions, and you can do things to affect their behaviors, and those things will feed the emotions and make things better.

23:25 So they're all connected, and if you influence one point of the triangle, it affects the other points. Yeah. And so I often explain, collaborate to patients and I draw this for patients and we talk about what they'd like to work on and we have different strategies for addressing those things. Little kids don't do the cognitive piece very well because they're not metacognitive. They don't abstract. So if they believe something, it often must be true. Whereas adults can question their biases and their thoughts and their thinking that is sometimes distorted.

23:52 And so we can talk about the over generalizations and the fortune telling. They engage in the mind reading they think they're engaging in. That can all make a big difference and behaviors make a big difference. Getting people active and out and doing the things they like, deciding what their passions are and chasing that down. And that's very hard to do when you're anxious or depressed. Yet when we do it, we get better. Right. Do you see a lot of OCD or obsessive? They do, Impulsive disorder they do.

24:17 Is that increasing also? I don't know that that's increasing. I haven't seen any studies that would suggest that's increasing. Again, I think we're better at identifying it. 30 years ago, most people didn't know what OCD was, right? I mean, they didn't. And I could tell you some funny stories about how people were diagnosed, but often it was schizophrenia or some psychotic disorder because they were having thoughts that sounded crazy in some cases. You know, I remember seeing a guy who the first OCD case I saw, he said, I know this is crazy, but I feel like there's a camera watching me wherever I go, a camera like that.

24:50 And I know this is crazy, but I feel like it. And he said, and you'll have to excuse me, and I know this seems crazy. I hope you don't lock me up, but I have to look under my chair right now to make sure there's not a camera there. I know there's not, but I have to look. And it's that sort of pathological doubt that helps you to make that diagnosis. It was ego dystonic in the words of the old guys in our field. It doesn't feel like what I want. It's not ego syntonic, which is it feels like who I am.

25:12 It's ego dystonic. It doesn't feel like who I am. I know it's wrong, but I can't stop thinking about it. That's OCD and we got into a big argument me and another another doctor, because I said to this doctor that's OCD and they said no, it's schizophrenia. I said no, it's not he. He knows the difference between what he's you know and and that's the kind of thing that. He knows the difference, but he can't help but he can't. Stop. Anyway, yeah. And the treatments are different and but there's a therapy treatment.

25:36 And back to your initial question in this vein was, is it therapy or medicine, either or both. And usually we start with therapy, the least invasive, although it takes more time often. And there's homework often. And we will start with an evidence based therapy if we have one. We have a great one for OCD and for any anxiety disorder, we have a pretty good one for depression. We have a pretty good one for insomnia. We have a pretty good one for eating disorders, you know, these kind of things. We can do a lot, but at some point it's either too severe or doesn't get better enough and then we will add medicine and that's and then we'll take it from there.

26:06 We may have to do more things than that down the road. Yeah. Can you define evidence based a little bit? Yeah. I say that term a lot. Right. I see that that's present. Now in all of medicine, everything has to be evidence based. Clearly that's the case, but in psychiatry where it's more of a discussion and talking, how do you determine what's evidence based? Are there clinical trials of? Tons. Tons of trials. The medicines have evidence now, right? The evidence for the medicine varies. Sometimes it's much better than placebo, sometimes it's not right.

26:41 One of the problems with all of our studies in medicine in general though, and not just psychiatry, but every field, is that we often compare the active treatment to placebo. But our better studies would be compare it to a placebo and a treatment that you know works for this thing. You know, these new medicines come out and they're versions of the old medicines. They might have slightly different side effect profile, maybe a better side effect profile, but they're basically the same thing as the other drug or very similar to it.

27:04 They hit the same part of the brain, nothing new there. And we've been doing that recycling a lot of treatments for a long time and evidence based treatment is one that we know works better than doing nothing or better than some other treatments that you're using. But it works and and in therapy we have protocols and we actually have protocolized therapies. You know if you're doing it really in the evidence based mode, you're doing step one, then Step 2. You might even as a therapist have a the the papers in front of you as to what we're going to do today.

27:30 Because this is what has been shown to be helpful in studies, but most of us don't do it that way. We might learn that way. And then we sort of break into an eclectic blend of I'm a human being, you're a human being. Here's some tools that I know will work. How can I find a way to get that across to you? What is it going to be helpful to do homework? Bring in your sleep log. Let's look at that. Bring in your mood log. Let's look at that. Open-ended psychotherapy of the psychodynamic type that started with Freud and moved on to many other thinkers can be helpful, and every interaction has psychodynamic components.

28:08 If we want to think about it, it can be helpful, but it's not an evidence based treatment by itself. There's not a talk therapy where it's just talk that will reliably treat depression or anxiety or anything else. We have to do stuff too. In other words, insight alone isn't enough. And sometimes, often times, insight doesn't matter at all. Whether you know why you're depressed or not, it doesn't make much of a difference. You might want to know. And if you can isolate it to patterns of your behavior, then you can change those behaviors.

28:39 But now that's behavioral therapy. That's not psychodynamic. You're changing things, right? Based on your understanding. That understanding may help you, but it's not necessary to understand before you change your behavior. Sometimes you just need to change your behavior. And the same thing with any other approach. So IA, lot of people, you know, see people, doctors come in and they want treatment. I see a lot of adults. We're in New York, people in the money world, people, lawyers and they're smart people and they wanna know why, why, why?

29:08 And we'll talk about some of that, why. But if they wanna feel better, they've still got to do something right. Very interesting. Rethink what they're doing. Rebehave, You know, something like that? So you ask patients to keep logs of their moods and sleep and things like that? Depends on what we're working on. Figure out, yeah, what's going on. If they're depressed, definitely they're mood and sleep. If they're having insomnia, definitely their sleep. If they're anxious, we might look at their anxiety levels throughout the day.

29:35 We're looking for patterns. We're trying to figure out what bothers them and when, right. And we're also looking for them to do some hypothesis testing. I think this is going to be difficult. Let me sort of predict how difficult it's gonna be, then let me do it and see how it was and then bring it in and you look at the data, well, actually, you know, you thought it would be an 8 out of 10, but it was a six. What do you think? Right. Which psychiatric disorders cause sleep problems? You mentioned that you're a sleep expert.

29:58 Every one of them. Everyone. Name a psychiatric disorder. Anxiety OCD They. All. Not everybody will, but whether it's trouble falling asleep, staying asleep, or getting up too early, they all can for sure. Kids with ADHD notoriously fall asleep late. They're overactive until late at night and then they have a often disruptive sleep, and then they exhausted in the morning because they didn't get enough sleep. Right. People with depression. One of the core symptoms of all mood disorders is sleep problems.

30:27 Anxiety frequently comorbid with sleep problems, but not a a necessary symptom. People with autism. 90% of adults with autism and about the same of kids have trouble with sleep in one form or another. I just name it, you know. And sleep supposedly cleans out the chemicals in your brain. Toxins. You're not sleeping enough. Your Your brain doesn't refresh or reboot for the next day. Right. There's that. There's memory concentration, attention that that sleep helps with. There's downloading your memories from your sort of your your day storage, your hippocampus to your temporal lobes, your permanent storage.

31:06 There's calming your amygdala, your threat center, which is calmed with sleep. There's a lot of things that sleep does good for. It helps you not overeat sleep eating. Getting 8 hours sleep is a great diet. You know you eat less than you sleep 8 hours. Right. Going back to medications from I've noticed in recent years that there's more warnings of most of the antidepressants that in young children they can cause suicide or suicidal ideations. Why is that, and why are we finding that out now? So first, the data is not very good.

31:40 So the increased risk from a child taking an antidepressant and having thoughts of suicide is maybe maybe 2%. So it's not terribly high, it's about 2%. With placebo, it's about 3.8 or 4%, based on the conglomeration of studies from about 25 years ago for having thoughts about suicide. So it's maybe 2% higher or so if you take a medicine and if you don't. Now that's one big study that was done when this concern came up and the black box warning you're talking about was growing every antidepressant.

32:13 However, there's so many other studies that throw that into question. Sometimes just putting someone in therapy. Actually, if there's one study showing that people who go into therapy who never said they were suicidal before they started therapy for depression, but after 10 weeks of therapy, 11% of them said they had thoughts of suicide that they hadn't had before. Why is that? Is that because they're thinking about things they haven't thought about before? Is that because they're facing the demons in the closet for the first time?

32:36 I don't know. But that may happen. And, you know, it's very hard for us to know. The the other thing is what happens if you don't treat someone's depression? I mean, that's what I think about a lot of times, right? So I haven't had a lot of suicidal thinking in response to people taking antidepressants. It can happen for sure, and I've seen it. And then we stop the medicine and they feel better, but it's not common. But it is why you need to see people and not just give them medicine and throw them out into the wild for a month or three months or whatever and then check in again.

33:07 Most people will be fine that way, but that's not the ideal. Is there an increased incidence of eating disorders? I'm seeing a lot of that more in media and reading about it. Or or has that been around for a while, but there was a stigma about discussing it? I don't know. I mean, I haven't seen any study that has convinced me that we're seeing more eating disorders. I think that there is a change that's worth talking about though. We've always eating disorders have a very low incidence, which is the number of new cases you see in a given time.

33:37 Like the incidence of anorexia is like you know, one in 1000 per year. You don't get a lot of it. However, the prevalence or the ongoing is about 6 per thousand because once you are maybe even higher than that, it might even be a percent and a half because once you get it, you tend to hold on to it. It's not easy to get rid of. It's chronic and so we see a very low incidence of anorexia and bulimia, but we see a high prevalence, they hold on to it. So not too many acute cases but a lot of chronic cases.

34:03 We want to get on that one that that's sort of a four alarm fire because the longer you hold it, the longer you are to keep it. And so do we see more of it? I don't know what we have appreciated in I I don't think so of of the severe stuff, the anorexia and bulimia. However there are other eating disorders we've started to appreciate that we didn't appreciate before. Binge eating disorder is a new one. Over the last decade. And 1/2 that, we're like, oh, some people just binge and they don't purge.

34:27 And that is very distressing for them. And they gain weight and they feel bad about themselves. And that often is tied to anxiety and depression. We used to think that anorexia or nervosa, the only way to have it, was to be emaciated. You had to lose an extraordinary amount of weight if you were a woman. You had to have interruption in your menstrual cycle. You had to have this idea that you were heavy or looked bad or didn't still need to lose weight. Even if you knew you were underweight. You just were driven to lose weight.

34:53 And we've been able to appreciate that Some people have just all those symptoms, but they're not emaciated. They're not underweight, so they go from being heavy or even no normal weight to being low normal weight or underweight, but they might even be a normal weight. They might have even been a person who was what we would call obese or overweight, and they lost 30 lbs. But it happened pretty drastically. And all the same cognitions or thoughts of eating disorders and behaviors are there, but they don't look like they have anorexia in the stereotypical way.

35:22 So we call that a typical anorexia. So we've started to appreciate that, and that can be every bit as disturbing as anorexia nervosa. Yeah, I remember when I was an intern many weeks ago, I had a patient who had severe end stage anorexia nervosa. She was down to 55 lbs. That's very severe. And then she died during my rotation in medicine because she just couldn't survive anymore, just refused to eat. And back then the treatments weren't as good. So that's a scary. It's the highest mortality over 30 years in psychiatry, really like 18 to 30% of people will die if they hold on to that disorder, very high mortality.

36:00 So that that's why I say it's a four we know or five on fire. Yeah. Do we know what causes it? Still still know. I mean, there's correlations. You know, we can see certain things over time, but we have no way to predict it. We see certain personality styles that go along with it, or certain ways of solving problems, certain sort of types of people. But those are stereotypes, which means they hold a lot of times, but not all the time. Right. All right. The next thing I want to ask is about gender dysphoria.

36:26 That's become also very. Confusing for all of us, right? Yes, and something to really wonder about in. The news recently, actually a couple of weeks ago, I I had an interview with two surgeons who do a high volume of transgender and sex change surgery, thousands of cases. And we talked about this. Yeah, that we talked about that for a while. Do you think there's an increased incidence of that in recent years and and why is that? Certainly we're seeing it more. So I guess an increased incidence of.

37:01 Now there's there's a couple things in your question. Is it gender dysphoria or is it just transgender Because you can be transgender or you can be non binary and not have dysphoria associated with it. Not say like I'm struggling with this. I don't know what to do. I'm depressed because of it. I'm in the wrong body, etcetera. Or you can you can also just say yeah, I'm, I'm, I actually am another gender or I'm don't have a gender. That's how I feel about myself. That's who I am. I'm sure of it and I'm not too distressed about it or I'm a little distressed but it's not so much that it's getting in my way of life.

37:32 So I think we're seeing many more people show themselves and their their gender sort of diffusion, you know, than we used to see in the past, that's for sure. We think the percentages are are pretty low, you know, under a percent, half percent, .6%, you know, something like that. And you know there's always been, you can think about songs from childhood that you know or or or Broadway shows or other things that were, you know, referencing this population, these these people who men who dress like women cross dressers or people who would want to be another gender.

38:08 You hear about this, and I've been hearing about this since I was a child in some way or right? For decades, yeah. But it wasn't that common. But. It wasn't that common. You didn't see it. I didn't notice today on the walk here, but it's now. I walk in New York City constantly and I think I see people on the street all the time who are like, oh, I think, I think that was person was born a man. I think that person was born a woman because you just, you can see it sometimes physically or how they dress or or maybe not how they dress but how they look, you know, what their body looks like in contrast to how they're dressed.

38:37 And that. I think we see a lot more in New York but elsewhere too. I was in Virginia recently and we would say these days assigned female or at birth or assigned male at birth. We don't. There's we're trying to be careful with our language about, you know, how we talk about these things. And I I saw an assigned male at birth who appeared as a female and it was in a small town in Virginia and I was really surprised to see that. So I think it really is all over because people like that in the past wouldn't have come out in that way and been so revealing.

39:08 So I think we're more tolerant, which is good. Right. I think we're seeing it more. I think the numbers maybe are a little hidden because people still don't totally talk about this. Even when we look at some histories of tribal societies and things, we see that there were sometimes men who you know would dress as women or vice versa perhaps or behave in that way. So I think some of this has been going on and probably has been in the genetic code forever. We see certain higher rates have been among certain populations in the autistic population see a very high rate of this studies range from about 5 or 6% to about 20% of people on the autism spectrum have some gender sort of bending in some way.

39:47 They either sometimes feel their non binary or they sometimes feel their one gender and not another not the one they were born with assigned. So there's a lot of there's a lot of curiosity about it now and I think we're trying to find our way through it with sensitivity and and thoughtfulness sometimes. I mean, we do see, I'll tell you this much higher rate of psychiatric disturbance amongst. People with gender dysphoria or people who are trans and and that's it doesn't make a lot of sense in some way to put lesbian, gay, transsexual, queer questioning all in the same group, because these are different things and these are different people and they have different things.

40:22 But I think we we lump them in some ways in our thinking at least in terms of data, because we see a lot of the same sort of difficulties with them as a minority group. Right. In the interview I did, there was also a pediatrician there who specializes in treating adolescents who are taking puberty blockers and hormones of various types. He mentioned that he didn't think it was necessary for these people to see a psychiatrist, that it was sufficient to just see a social worker or some sort of therapist before they start taking these medications.

40:58 What? What's your opinion on that? Yeah, I I think, I I wouldn't say they need to see a psychiatrist because not all psychiatrists are the same, You know, I think they need to see someone who has some specialty knowledge of what to look for when it comes to gender dysphoria. That could be a social worker, that could be a marriage family therapist. That could be a psychologist, a psychiatrist, but someone who knows what they're looking at. I see, you know, someone who works with that population on a regular basis and can make sure that this isn't anxiety, depression or something else talking.

41:26 They can have anxiety and depression and still be gender dysphoric, but let's make sure that we treat that or we're getting on top of that. And it might be the anxiety and depression is because they're they're feeling gender dysphoric. And so that may be treating that will make that go away, but you need someone who's seasoned and who understands what they're looking at. The two surgeons who are in that program mentioned that they don't feel there's an increased suicide rate in people who've had transgender or sex change surgery.

41:52 Do you know is there data on that? There is some data on that, and I've seen a little bit of mixed data, but most of the data suggests that people who have a sex change feel better and that they don't regret it. The vast majority don't regret it. There's a small percentage that that will regret it, but most don't. And so I think that's why we want to assess because we want to make sure this is really right for you and this is what you want. And then 'cause it's not fixable, really some of these things, once you have surgery, the puberty blockers are fixable.

42:23 The reason we do that is if we get the signal early as a child's headed into puberty that they're really uncomfortable with this, then we can delay puberty and and that's the advantage we can give ourselves and them really a little more time to decide if this is right. And while their brain is maturing, they can take a little more time. Now these puberty blockers are not without their own potential side effects and even some potential long term side effects. So we have to be thoughtful about that and think about how long we want to do that.

42:51 So again, you want to get a Move on if you can, but. So you mentioned brain maturing, That's an interesting term. And I've, I've heard different things. I mean, some people are mature at 17 or 18 and then there's studies, I think, that show that the brain really doesn't mature until you're about 25. What do you feel about that as an adolescent psychiatrist? It depends on what you mean by maturing. So if you're talking about the brain looking like an adult brain, you're talking 25 to 30. If you're talking about someone being able to make really good decisions, 131415.

43:27 But if you're talking about how those decisions are influenced by others around them, it's a different question still. So for example, you can take a 15 year old and you can teach him everything about your various retirement options and you can say make the best selections for me and his selections will be based upon the knowledge. And based upon the knowledge he can make decisions as well as you can. Now you have experience which he doesn't have and you have seen some things so you may be more cautious or whatever.

43:54 But the the he can handle all the knowledge and he can be think logically or she can and do it, or they can and do just as you might do, but put another peer in the room with them or put put an alcoholic beverage into them or some caffeine or something like that. And their decisions now just become so scattershot. So whether it's the peer presence and we can talk about why that is, or whether there's pain present or whether there's substances all these underslept, all these kind of things make it much worse for a younger brain.

44:26 And they're new to these things that never experienced them. So neuroanatomically, the brain continues to change dramatically until about 23, lots of changes. After that, it really slows down. There's still some changes you can see between a 35 year old brain and a 23 year old brain, but those changes become much more slow. Just when we graduate medical school. Right. Perfect timing. Makes sense, Yeah. So I think that those changes have to do with how much white matter we have, which is the fast tracking in the brain.

44:57 It's it's so Gray matter. You're born with more Gray matter than white matter. And Gray matter is my brain can be anything. It's this, it's this incredible sponge. It's soaking up everything and and kids are connecting neurons and not growing neurons. You're born with 100 billion and that's about what you get. But the connections between them are growing at thousands of connections per second from the time they're born until they're about 9:00 or 10:00, because you don't know what you're going to be when you grow up.

45:19 You could be a gardener, a baseball player, a doctor. You don't know. So your brain needs to be able to soak up everything. That's why kids are so good at languages. When they get exposed at a young age, they hear the accent. It becomes a part of how their brain is set up. But around 9:00 or 10:00, your brain starts to prune, you start to trade in, and anything can happen. Brain for an efficient brain. And the adult brain works about 3000 times faster than a kid brain because the white matter, which are these insulated Mylan tracks, have been set up.

45:43 And you go from having these little country roads that are sort of like a brain that's sort of loosely linked by frontage roads and an occasional railroad track to a brain that is like the LA super freeway. The lanes are really thick and long and fast. There aren't that many of them. Great analogy. Yeah, there aren't that many freeways, but they move really quickly and you can, and they're connected really well, so you get really good at doing what you've learned to do. You get if you if you learned a second language by the time you're eight or nine, you're going to be great at languages with age, if you learn to throw a baseball by 8 or 9, or learn to ride a bike or or swim, you're going to continue to develop proficiency in that area.

46:15 If you keep doing it, if you've never played piano by the time you're 25, you can still become a good piano player. The brain is flexible, but you're not going to ever become what you could have been if you started at 5:00 or 10:00. And it's not just the years. It's what your brain is capable of doing. So that doesn't mean throw in the towel, friends. That doesn't mean like if you haven't learned the language or you know, but my dad started studying Spanish. He never learned a foreign language, started studying Spanish around 70, and he always sounded like a gringo.

46:40 I mean, he had pretty good Spanish, but he always sounded like he was just like right out of, you know, a commercial, you know, a guy trying to sort of make up a language or speak a language with an accent he didn't have. He couldn't do it. But the earlier, if he'd learned it 7:00 or 8:00 or 10:15, undoubtedly he would have been had a much better accent. Right. Yeah, I know you're a big proponent of preventive measures to prevent a lot of these conditions we discussed. Tell us about that. What are they?

47:08 So I'm big on prevention because because we we're never going to have enough child psychiatrists, we're never going to have enough child psychologists, take a long time to to do what we do and a lot of training and a lot of patience and tolerance and a lot of risk, and it's not for everybody. And then on top of that, we just don't have the capacity to train enough people and the need is enormous. So we've got about 10,000 child psychiatrists. We estimate the need or at least three times that. We don't even know how many child psychologists we have because we don't track it.

47:35 Child psychiatry is considered, if not the most, one of the most underserved medical sub specialties. So that's one thing. We're never going to have enough. Secondly, we know a lot about prevention, so we can do a lot to prevent these things. I mentioned exercise before, right? Exercise treats mild and moderate depression and anxiety as well as medicine or therapy. Why isn't everybody exercising an hour a day? You want to prevent stuff? Make them run. Make them play basketball. I mean, make them, you know, I'm being facetious, but give them something they enjoy doing that's physical.

48:03 Help them find something that they can do that's physical. And it can be walking to vigorous walking, but it should be something that cardiovascularly stresses them a little bit, and that will help them sleep better. It will lower their anxiety and stress if they're outside. Being outside has an impact on people, right? I mean the light nature, you know, everything else. It also prevents near sightedness We. Found. Yeah, right. Just recently, right? People being on screens, they're looking at screens all the time, right?

48:29 Which is pretty interesting. Somehow the sun does that, and in Scandinavia there there's a name for it. I forget where people spend time outdoors, in the woods or in the forest, and it it helps them feel better. Oh, I got to ask about that. Yeah, some Scandinavian friends. So so I don't know but but the exercise is 1. Sleep is another. Sleep is a no brainer. Kids are chronically under slept. As our adults we know a ton about sleep. We know that if kids sleep as they should, as we recommend that they will have less anxiety and depression, less obesity, better concentration, better school grades, better SAT scores, fewer driving accidents.

49:04 And I'm not talking small changes here. I'm talking like 1/2 a point in your total GPA, like from a three to a 3.5, or like a 20% drop in automobile accidents if you sleep 8 hours as opposed to if you don't. So how many hours should kids sleep at certain age? Can you break it down? Sure, it depends on the age, but you know infants should be sleeping most of the day the first year of. Life, you know, right? They do. 18 hours a day, something like that. But by a year of age, 2 years of age, it usually gets down to about 14 hours a day.

49:31 And that goes on for a couple of years. That includes naps. Oops sorry, I'm buzzing. That would include naps and other things. As kids hit school, school, age, years, they'll typically sleep about 9 to 12 hours. 9 to 11 depends on the kid and what their needs are. And by the time they hit middle school you still want them having about 9:00 to 10:00 and that really should hold till about high school. About 9 hours is ideal. Through high school 9 1/4 hours, adulthood about 7 to 9 hours. And we have kids in high school averaging about six 6 1/2 and they're exhausted.

50:05 They have more automobile accidents, they drink more. Caffeine makes them even worse. And part of this has to do with school start times, so prevention start schools later. For high school kids, it's hard to do in our society. There's a lot of reasons we don't do it, but when we do, all those good things I said happen. So instead of staying on TikTok and Instagram at night, you should go to sleep, right? It's very hard to turn off those things. It's much harder to try reading a book in bed, which we don't recommend anything in bed besides sleeping sex.

50:30 But let's say you're reading in bed and you know you're trying to read a novel. After 20 minutes, 10 minutes, if you're tired, you're going to put down the novel. Even if it's a good novel, try watching television. You'd keep it on for two hours, three hours and keep watching. I was going to say David Letterman, you know, whatever it is you watch, he's he's long retired now. But you know, a movie, a television show, a game you're playing, the light keeps you awake. It's so much less energy to stay awake while watching as opposed to reading, right.

50:54 And there's many other preventative things we know about parenting strategies that work. We know about screen time limitations that are effective. We know about school based clinics that can be helpful. All of these things you. Interact with schools and teachers. Or or you do, you do. And with parents, obviously you have. To everybody, Yeah, it's nice to like kids if you're a pediatrician, but you really got to like parents because that's who you really end up working a lot with, too. Right. That's very important.

51:23 What about one of the things that's occurring now? We have lots of immigrants coming into the country. They're different culture. They have different ideas. How do you deal with that? You're not used to interacting with them? They may have different ideas. Sure, but that's like. Society. Yeah, but we live in the most diverse country in the world and we're in the most diverse city in that diverse country, right. So we're used to it. I get on the subway and there's four languages and you know, the 3000 smells, you know, in one subway club.

51:50 I mean, it's crazy. So, but that's cool. It's part of the reason we're here. You know, we like the diversity. I like the diversity. So it's challenge. You know, we have translation services at Bellevue for like 120 languages. You know, it's you don't get those every day, but you you get some pretty, pretty uncommon languages spoken. So I speak pretty good Spanish, so I can cover a lot of ground with that. But other than that, yeah, it's a challenge. It's it's another challenge. Tell us about some advancements that you see coming in in pediatric psychiatry, adolescent psychiatry, in terms of behavioral or cognitive or medication?

52:30 Events. So as far as therapies go, we don't really truly need a whole lot more of them. I mean that is we're not using most, most people, there's some terribly terrible statistics, but most people who have a psychiatric disturbance don't get treatment. And amongst those who get, it's only about 10% of kids get treated who have a psychiatric disturbance, proper treatment. And even amongst that 10%, only about 2% get an evidence based treatment. So most aren't getting one of these treatments that we know works.

52:58 Is that because of their socio economic state or? Their parents, it's where they're going for care. It's how the people who are treating them are treating them. It's the it's the kind of therapies and and treatments that the people they're seeing now. So, and that's partly because most people who get care for child psychiatric problems don't get care from a child psychiatrist or a child psychologist. They get it from a pediatrician. They get it from a family doctor. They get it from an internist, you know, because they're just aren't going to get it from a social worker or psychologist who isn't trained to work with children.

53:26 You know, they, they get it from people who don't know how to work with kids and their families. So they're not getting those treatments. So that's a big problem. And even amongst those who know those treatments, still sometimes it's hard to use those treatments because of the pushback we get from the family or the kid or whatever. They don't want to do that, take that, you know, go through that treatment, do that thing. So it can be a real struggle. Most of medicine is chronic care. You know, a lot of these people are going to recycle with one different problem later on, even if this one gets better.

53:52 Some of it's a moving target. But they're, you know, I say we don't need a lot of new psychotherapies because they all the evidence based ones work pretty well and we have a lot of them. We can we can make them better for sure. Don't get me wrong. And it'll be nice to have more, but no therapist can know more than about 5 therapies. You just can't like keep all these things in your head. So you start to blend them eventually, no matter what medicines we need new medicines, we have some that work and we have a lot of versions of them, as I said in the beginning of our talk, right.

54:20 But we've just gotten, for example, ketamine treatment, which is has a place. We're trying to figure out what that place is and how to use it best, but it can make a difference without electric convulsive. Ketamine's good for depression. It can be. Hearing that, yeah, we're using. That yeah, for for severe depression that isn't responding to other treatments. Some people find it very helpful and is that? Given orally or intravenously. Usually intravenously, yeah, there is a there is an intranasal form, but it hasn't been studied very well.

54:47 I see the the four is. Better what kind of doctor they go to to get that? Treatment, psychiatric we we don't know how to use needles too. We went to medical school. But it's true that most psychiatrists who have these kind of these kind of setups usually have a nurse or someone else would do that for them. Maybe a phlebotomist, because they don't do it all the time. But you could, as a psychiatrist, certainly do it in your office. Because it could cause reduction in breathing and. Yeah, you could have problems.

55:12 So someone who's a medical person needs to be there. But again, again, that's usually the psychiatrist. Often they'll have a nurse who administers, if they might have four people at once getting care. They see them for 15 minutes to check in. They put them in a room with a chair, like a chemo chair. The nurse comes in and places. The doctor monitors and goes around, you know, and the nurse does too. And if there's a problem, there's they. They shouldn't know what to do. And and in order to do that kind of thing a psychiatrist would typically take a little extra sort of a booster training and something because they've not been doing that for like I haven't put an IV in someone in 20 years, right.

55:44 I was really good at it and I knew I'd do central lines and all that stuff. So you know, I mean I I had lumbar punctures. I did dozens and dozens. So I I would, you know, I don't walk into that these days. But if I had to I'd, I'd have a steady hand. I think I'd just need to get a booster. What's your opinion on the legalization of marijuana? That's. Gone on such a good question. Yeah, because I You can't walk down the street here in New York City without smelling marijuana. Everyone is smoking, including some young kids I see smoking on the corner carrying their school bags.

56:15 So is that good? Bad. You're not. Sure. Well, all all the use is not good. I mean, I think that there's a part of me that says when we're that we should make everything legal at the age of 26, because your brain is pretty well formed, right? And the statistics show that if you haven't tried alcohol or drugs, by the time you're 26 years of age, there's almost no chance you will. There's just almost no chance. People rarely initiate after the age of 26, like under 1% of people initiate. So we tend to initiate much earlier.

56:47 But that's also our brains, much more geared for novelty and excitement and trying to keep up with everybody and trying to address the things that our brains want at that age. Medicine with dopamine and testosterone and oxytocin. It has to do with pain receptors. There's all sorts of reasons that, you know, I wrote a whole book on this called Born to Be Wild and tells you all why people take these risks. But but these kinds of things are rare. Later in age. However, just by having it around in society, people are going to find it.

57:13 In fact, there the studies are a little bit mixed, but it looks like from the states that first legalized marijuana, Colorado, Washington, Oregon and California, that the increase in young people's use wasn't that high. It went up a little bit, but it wasn't that that great of an increase. The big increase happened with young adults. They're the ones who really used a lot more. Young kids can't buy it. I mean, they're not supposed to be able to buy it, right? Like they should, not supposed to go to the liquor store.

57:40 So in fact, kids were using more marijuana before liquor, and they still are. Statistically, kids tend to use more marijuana before they're 21 and then after 21 marijuana use tends to go down and alcohol use goes up. We're seeing a change in that. We're seeing marijuana use kind of continue and be higher amongst people over the age of 21 because they can buy it and get it. But the young kids bought it illegally and it's still available illegally and it's still cheaper illegally. If you go to one of these shops where you can buy it in New York or in these states, they have taxes and other things, so it costs more, you know?

58:06 So you might get 10 gummy bears, marijuana gummy bears for $30.00, but you can buy them on the street for a buck each, you know. So why not pay $10? And you can pay 30 and kids can get them. Right. Do you think they aggravate conditions that kids have? So if you have kids who are depressed or anxious or have. So then there's. That right. Does the marijuana make those conditions worse? And there's recent talk about causing psychotic breaks in in kids. So it's really variable and and we don't have the answer.

58:36 First of all, you don't know what's in the marijuana. Even the stuff you buy in the store, you don't know what's in it. I mean, they're not testing it like they're testing Prozac. They're not. You don't know exactly what's going on there, right. It's natural. It's safe bowl. You know, it's natural. And it grew out of the ground with whatever pesticides they used and whatever manure was on it and everything else. But is it safe? I don't know. You know, most of it probably for you or me. If we use it once a week, once a month, or an adult does, sure, I guess we could say that's OK.

59:05 But for kids whose brains are developing so much before the age of 25, there's absolutely much more that it can derail. So it's it's a. High risk for It's a high under 25. Yeah, it's a high risk. The brain is more spongy, like I was saying it's. It's more changeable and. And it could potentially cause permanent. Well. Wiring effects hard wiring. We know that marijuana use often predates a lot of marijuana use predates the onset of psychosis. Now the marijuana could make them psycho psychotic, or it could be that they were vulnerable to it and found marijuana.

59:39 There's a lot of sort of which came first, chicken or the egg. But we see it and a lot of the schizophrenia you see among 18 and 20 year olds, first onset, you see it in the context of a lot of marijuana use. So it's not just using it once, it's. It's it's not. The Daily Regular. Use. But it may be that again, certain people are vulnerable and maybe wouldn't become psychotic if they didn't use this stuff. So that we don't know. But there are people who believe strongly that it's making it worse and making it.

1:00:06 More pronounced and and happening at a greater rate because of that. But we haven't seen huge increases in schizophrenia or something. Certainly we see a lot more hospitalization and ER visits with psychosis. That's definite, and that's relatable to marijuana for. Sure, that's that's pretty frightening. Yeah, so I don't have a. Way from that. Yeah. So I don't have a great answer for your question. I mean, my answer is keep your kids away from stuff as long as you can. But what we don't have in our society is a way to teach people to use substances.

1:00:33 You know, I mean, we don't have a way to teach people to drink. You're not to drink to 21 to 21, then 21 go do what you want to do. And we don't really teach people. We need to find a way to teach people how to use marijuana and how to use alcohol because they do. They use it right. And so we need, this is where parents really are important. Do you let them drink at home? You know? Well, most of our studies suggest that if you let them drink at home, that is not protective for them. And in fact, countries where the age is lower have much higher uses by and large of alcohol abuse.

1:01:01 Germany, France, Italy, England, their alcohol rates are higher, abuse rates, their their alcohol injury rates are higher, their binge drinking rates are higher. So putting it off is good, but we got to help them learn to use it responsibly. And that's a that's right now that rests with parents and that's a tough thing. I've got two adult kids and thankfully they're both in pretty good shape. And it was work and this was part of the work. Right. How do you teach them? You know, and I my I have my method.

1:01:30 But it may not be your method. You know. We need society to help us with that. You mentioned one of the books you wrote. You've written a couple of books. Can you tell us about that? Yeah, So I wrote a book in 2017 called Born to Be Wild, Why Kids Take risks and how We Can Help Keep Them safe. And it's a it's a brain book, but it's filled with stories and it's filled with sort of methods and and ways that parents and teachers and practitioners can use to help manage risk. The reasons that we think kids take risks are not the reasons they take risks.

1:02:01 And I go through that at length in the book, most of us think are taught, in fact, that kids take risks because they think they're invincible. And that's not the case at all. So that's how the book begins and then it gets into really why they do take risks and what we can do about it. The other book I've written is coming out in its third edition in January of 2024 and that's called Child and Adolescent Mental Health a practical all in one guide. It's a 600 plus page textbook, but it's a very practical textbook and it's.

1:02:26 All about Is this meant for the public or is this for other physicians? Yeah, it's really so. It's for anybody who's not a child psychiatrist. I mean a child psychiatrist can read it too, but we learn this stuff. So it's it's, I mean, and I do have a lot of my trainees because I run the training program in shock psychiatry at NYUA. Lot of them read it as part of their preparing for the boards because it has what they need to know, but it's written in a in usable language for someone who's educated, you know and and reads well, you should be able to get through it and understand the concepts.

1:02:55 It's all about, you know, what causes these things as best we know what happens if you do and don't treat them, how we diagnose them and how we treat them. And so that comes out in its third edition. I don't know that I'll write a fourth, but but it's, you know, I've done it a lot of. Work a lot of work. This, this last edition was a lot of work. I added a few new chapters, but also just the data. We're getting better at learning things and so there's more. Data to go through information. Yeah, these are available on Amazon.

1:03:21 Yeah, wherever. Amazon, the book publisher. Whatever one's published by Penguin, one's published by Norton. So if you type in your name Jess Shatkin on Amazon your. Book by me or it comes up if you will come up offer comes up and. Right. You mentioned you're also head of the teaching program at NYU. Tell us about that a little. Bit so my title at NYU you you gave my professor title. Thank you. I'm also the Vice Chair for Education for my department. We're the department of Child and adolescent Psychiatry.

1:03:47 And in fact there are only two departments of child and adolescent psychiatry in the country. One is a real and one is at NYU. Everywhere else it's a division of General Psychiatry. So and and the good news about being a department is we have a lot more autonomy and we can run things at our own volition more easily than going to the chairman of psychiatry and fighting with our colleagues in geriatric psychiatry and addiction psychiatry and and you know maternal child health psychiatry. So we can sort of have a lot more autonomy and we handle that well.

1:04:14 And one of the things we do is to run a lot of training programs in psychology and psychiatry. We have an internship externship and a post doctoral program in psychology and we have fellowship training in child psychiatry for those who've already trained in adult psychiatry. And we support the medical students and general psychiatry residents and the pediatricians and they're learning about psychiatry. So I run all those training programs or let's say I I run the child psychiatry one specifically but I manage or Co manage the psychology and the and the other ones in my I. Don't think you're getting enough sleep.

1:04:42 I do pretty well. I do pretty well. But yes, it's I'm busy. As busy as I want to be, but I do. So in addition to seeing patients and yeah, but I also run this program. I probably see 10 to 15 patients a week. So I'm not seeing patients probably like you are, I don't know or somebody's seeing. Patients all the. Time. Yeah, I did in the past. But these days I don't. I do a lot of program administration, a lot of teaching. I am the chair of a department at the College of NYU. I built a department at the College of Arts.

1:05:11 Downtown undergraduate NYU. What do you do there? So there I run the Department of Child and Adolescent Mental Health Studies cams. I developed the department. I run it. We have 54 unique college courses. We offer about 80 courses a semester because many of those courses have repeated sections. You know, so we'll have 10 sections of one course or something, right? But we offer typically about 180 courses a year to college students We taught. Last year, over 6500 students were one of the biggest departments.

1:05:39 We're a minor, not a major, but I managed that. I teach this semester. I'm teaching three courses myself at the college. Really. I teach psychopathology. I teach a course on resilience and I teach. We have a grand round seminar, all right, but so that's that's fun to do. And then I do a lot of clinical supervision for the fellows and teaching of them and that kind of thing. And writing, as you say, I write some papers every year. Write these books. So now I understand between 3:00 AM and 6:00 AM every night when you get the break, you're you're also a musician.

1:06:09 Is that right? I love playing music, so that's about that. Yes, I'm. I'm actually the funny point. I just turned 60 and I'm at the point in my life. 50 Thank you. Yeah, you look awesome. Thanks. I appreciate that. But I'm. I'm at the point where I'm really trying to figure out what I'd like to spend my time doing. I've been playing music forever, but it's been a hobby. I maybe when I was 13 I hoped to be one of The Beatles but that I think by 20 I got the message which wasn't yeah, good question genre Paul, you know.

1:06:36 But I would have taken either but I will say Paul's LED quite a life. I think that it would have been really fun for me to have done something like that and to devote it. I don't think I have the confidence in my capacity and I don't think I have the support in my world at home to think that that was actually doable. But of course, nobody in my world wrote a book either. So you know, you find your way to things. And I I always play guitar, always had it around from the age of 15 on. I wrote songs and I I've gotten better slowly at all that stuff.

1:07:09 And when COVID happened, we have a we we rent an apartment in the city, but my wife and I and family, we own a house upstate, just 60 miles north. Everybody says upstate. It's like around the corner, but it's it's really in the woods, you know, outside of New York City, it's the woods and just like anywhere. And so maybe it'll be the middle of, I don't know, Alabama. So we have a house. And during COVID, we wanted to make a change to our house and build some studies. And I said I'm going to build a studio as well.

1:07:33 And there were people waiting for work. So we were able to hope. Fortunately, we're able to put people to work. So we built a huge part of a a a build on over our garage and we made a couple of studies from me and my wife and I made a studio and I started then recording. I'd always I'd done a little bit of recording, but I always wanted to learn more. So I used I had I I was really sort of isolated in that house for 15 months. So I started studying how to record and I started buying gear which I'd always been doing, and I put up my first CD just about a month ago.

1:08:02 Wow, that's awesome. What's it called? The band I called Dalmatian Smile, I've I grew up with Dalmatians and I have a Dalmatian, and Dalmatians do smile. They make this kind of grimace that we call a smile. So I call the band Dalmatian Smile, and the album is, I think your dad was right. And so it's 45 minutes of 10 songs of music. It's on every every digital server you can find music, YouTube, Amazon, iTunes, Spotify, whatever. So if they go to Amazon, look up your books just Shack and they can also find the.

1:08:28 Album They won't because it's not under my name. I want to be a little bit more anonymous than having. No, it's fine. I'm happy to have it have it linked to it's. Not anonymous. Anymore and that's fine, but but I didn't. I sort of didn't want it to be my name because I just think I'm doing medicine on this and I'm doing that over there. So I thought it would be nice to have it separate. So they just look up Dalmation smile and they'll find. Dalmatian smile, all right? It's it's rock'n'roll, it's Blues, it's folk.

1:08:54 And I'm three songs into the next CD already. I'm, I'm loving it. I'm learning so much, so my learning curve is very steep there and that's really exciting. I think the, you know, if I had to, if I had to characterize myself in one thing, I think the thing I've always liked to do is to learn. That's great. So you don't have time to play golf, right? I don't play golf. Awesome. Neither do I. You know, I always want to be a rock'n'roll star also, is that right? Yeah. Yeah. So do you play an instrument?

1:09:18 I don't. I don't. I never did because I went to medical school and that took up. All of my. Time. But now I'm doing this and it's a lot of fun and look out Mick Jagger. You look, you may never be a Beatle, but you can always learn an instrument, and I I will say that. Even at my age. I'm your age, yeah. May not be as good as I'll still be. A gringo like your father. Yeah, you'll be a gringo, but you might get good enough that you enjoy it yourself. And that's the thing. I mean, I think for me it's it's gives me so much pleasure to do it.

1:09:49 And I I I'm lucky that I have a career that contributes to other people's lives in a in a satisfying way. Most of the time, not always, but I like doing this for myself and I really do appreciate. It right. I think I had the music. Gene cuz one of my sons is an incredible musician. He plays guitar, he plays piano, He used to play drums. He does everything. Yeah. So I always say he must have gotten that gene from me and I just never did anything with him. So this has been a very interesting talk.

1:10:21 I learned a lot and I'm sure everybody out there has learned an incredible amount as well. I appreciate your taking the time today to come and talk with us. Of course, this is really outstanding. Enjoyed it very much. Thanks for having me and if you made it this long, thank you.