Teen (& Preteen) Page!

GREAT QUESTION!

The truth is that I understand many of the symptoms that you are experiencing, from a personal perspective. 

I was an adult before I was diagnosed with Generalized Anxiety Disorder (GAD) and Obsessive Compulsive Disorder (OCD), so I know how it feels growing up with constant worrying, how much this can keep you from enjoying things, and hearing from well-meaning relatives "Just don't worry about it (yep, if I could do that so easily, why would I torture myself with worrying about everything!)

I also did not get diagnosed with ADHD until I was an adult, and as I think back to all of my years of schooling, I am convinced that the only way I was able to function and do well was because part of my OCD is a lot of organization (reminders on sticky notes, daily things to do on dry-erase boards, the list goes on!)

Of course, the biggest diagnosis I received as an adult (42 years old, in fact) was Asperger's Syndrome (autism spectrum disorder, mild). This one changed my life, because it put every memory of my childhood to early career in a much different perspective. Unfortunately, it also exposed me to absolutely inhumane, malicious bullying and discrimination, from the least-likely sources! So, while I have never had major depression and therefore cannot directly understand what that would be like, I have had more than enough experience with situational depression, and it makes me extra-dedicated to wanting to help my patients to overcome these disabling symptoms as quickly as possible!

One of the positive things about having ASD (yes, there are positive things!) is that the associated OCD also provides me with many of the characteristics that make me a great problem-solver, which in pediatrics means the ability to pick up on the smallest detail and be able to make a diagnosis that no one else may have considered (or to rule one out)! This is my "Aspie Super Power"! 

Oh, and did I mention I spontaneously come up with a lot of great (bad?) puns and jokes?

It is absolutely your body, and you should be able to discuss your honest feelings openly. That is why I believe that all children and teens, to the best of their developmental and communication abilities, should be empowered to contribute their own feedback about their symptoms and their medication treatment plan during every appointment!

That of course means 2 things--You have to be Willing to Talk to Me, and You have to be Honest about Your Comments! 

Part of empowering kids and teens is that your opinions, feedback, and observations about your medication are just as important, or in many cases, moreso than feedback from others, even your parents because, while they may notice subtle things that you do not, it is ultimately your body that has the symptoms and is taking the medication, so being able to get your imput is vital to insure that your treatment plan is the most effective that it can be to improve your symptoms. 

Speaking of Speaking Up, I really need to hear your concerns about medication. It is not enough to say "I hate medicine" or "You can't force me to take any medicine!" Often, this attitude is the result of many previous trials of medications without noticing any benefits, or worse yet, having uncomfortable side effects! My treatment style is to quickly and safely increase the dose of medication to get the dose into the lowest end of the range where it is most likely going to produce noticeable improvements in your symptoms! At that point, I just fine-tune the dose until you get the best results with the least side-effects. My goal is to listen to your reasons for not wanting medicine, and to then correct any misinformation you may have (like from the dreaded "popular but not-medically-informed internet sites) so that you can better understand the medication that I am recommending, and my reason for choosing it. There is usually not one medication that is the "only one" or the "best" for a diagnosis. Since there are many to choose from, I can be usually be flexible, but sometimes there may be a specific reason that drives my decision-making.  I will explain this in detail to you and your parents or guardian so that we can all come to an agreement for treatment. 

SSRI medications include Zoloft (Sertraline), Prozac (Fluoxetine), Celexa (Citalopram), Lexapro, (Escitalopram), and so many more...

SNRI medications include Cymbalta (Duloxetine), and a few others...

The first thing that is very important to know about these medications, which is not a side effect, is that they do not work overnight! When on an effective dose (which is usually much higher than the starting dose), SSRIs can take 4-8 weeks to reach the peak of their benefits. Many times, however, close contacts, ie parents, siblings, etc, may notice some subtle improvements as early as 2 weeks.

The message here is "Hang in There" and Keep Taking Your Medication as Prescribed!!

The most common side effects from all of these medications are Gastrointestinal symptoms, most commonly Nausea, especially when you haven't eaten for several hours. When taking these medications, DO NOT SKIP MEALS, or your nausea will progress to vomiting! Sometimes you may even feel nauseated during the normal amount of time that you would be between meals (such as in school before lunch). You might want to carry a small, non-messy snack to eat between class periods to get rid of the nausea. And yes, unlike the nausea and vomiting from a GI virus (gastroenteritis), for this nausea, you actually want to eat something to make it go away!  Occasionally, some people may get diarrhea, either alone or with nausea. The good news, however, is that these side effects usually resolve after about 2 weeks once you are on a steady dose (not continuing to titrate, or increase).

If you read the package insert, or search online for a credible website (WebMD, Cleveland Clinic, NIH, NIMH, NAMI, etc), there are a lot more side effects listed. This is because, in the research studies that are part of the long process for a pharmaceutical company to get a medication approved by the Food & Drug Administration (FDA),  they are mandated to report any side effect that occurs in at least 2% of those taking the study medication (or that is reported at least 2% more often than for those taking the placebo-- identical-appearing but with no active ingredients). This does not necessarily mean that the medication really did cause those side effects, or that it will occur in most people, it only means that the pharmaceutical company was obligated to report it to get the drug approved for use in the United States.

There is another category of possible side effects to these medications that are not usually discussed with teens, especially in the presence of their parent or guardian. These are the sexual side effects, such as difficulty achieving an orgasm or difficulty achieving ejaculation. This is not to suggest that anyone reading this page is sexually active (or should be), but whether you are sexually active now, or will be at some time in the future, it is important to understand that these types of side effects may occur.  If you have further questions, or are concerned about this side effect, please request to speak to me confidentially during the next appointment (and this will remain confidential, as mentioned above!). 

In the meantime, DO NOT REFUSE to take your medication!! (because stopping many medications suddenly can cause serious side effects, including new or worsening suicidal thoughts or attempts, even if you are not taking them for depression!). If this is a significant cause for concern, there may be other treatment options that we can discuss that may be less likely to cause these types of side effects.

As a Pediatrician, I need to provide a WARNING that ANY of these products discussed CAN BE FATAL, especially in younger children! KEEP ANY AND ALL DRUGS, NICOTINE PRODUCTS, ALCOHOL, AND MEDICATIONS OUT OF REACH AND PREFERABLY IN A LOCKED BOX OR CABINET!!!

OK, now for some useful definitions from the National Institutes of Health (NIH) to understand the terms that are used--

• Delta-9 tetrahydrocannabinol (THC) is the most abundant form of THC in the Cannabis sativa L plant, which actually  contains at least 125 different cannabinoids. Delta 9 (or just THC) is the cannabinoid that is associated with the "high" or "intoxicating effects" of marijuana by temporarily altering a person’s mood, thoughts, and perceptions.
• Marijuana, or "cannabis" refers to the dried leaves, flowers, stems, and seeds from the C. sativa L plant. These parts contain >0.3% THC, and therefore produce the intoxicating effects associated with marijuana.  
• There are also many Non-Intoxicating cannabinoids in the C. sativa L plant, including cannabidiol, or CBD, which is otherwise known as "Hemp".
• Hemp--refers to the parts of the C. sativa L plant that contain CBD, but much lower amounts of THC (<0.3% THC), and are therefore "not intoxicating".

However, just because CBD (otherwise known as hemp), is considered "not intoxicating" because it does not produce the typical "high" associated with marijuana, cannabis, or THC, does not mean that it does not cause side effects!

While science is still learning all of the possible effects that CBD has on various organ systems, there are some POTENTIALLY SEVERE SIDE EFFECTS THAT ARE ALREADY KNOWN:

• Liver damage
• Interference with other drugs that you are taking, which may lead to toxicity from the increasing the levels of the other drug in the body, or decreasing the effect of the other drug in the body.
• Drowsiness or sleepiness
• Diarrhea or changes in appetite
• Changes in mood, such as irritability
• Potential risk of harm to an unborn baby (Do Not Use While Pregnant or Breastfeeding!)

Another significant issue with using Hemp or CBD products (whether edibles, vaping, oils or creams, etc.) is that they are NOT REGULATED as  "medication" by the FDA, which means that there are no stringent requirements for their safety or purity (in fact, any "supplements" or vitamins that are sold also do not go through the vigorous approval process by the FDA). These CBD or Hemp products may actually contain higher levels of THC than 0.3%, and/or they may contain contaminants such as pesticides, heavy metals, bacteria, or fungi!

To add to the mix, there are now also Synthetic cannabinoids, which are lab-made substances that are chemically similar to compounds found in the cannabis plant. However, these products contain much higher levels of THC than marijuana, and can produce severe, potentially life-threatening side effects!!

Some common names for these include "K2" or "Spice".

The Short-Term Effects of THC (Cannabis): Some people who use cannabis (THC) may feel "happy or relaxed", while others may notice altered time perception, impaired thinking, impaired memory, and impaired body movement. It can also cause some people to become highly irritable or restless, or to develop sudden anxiety or panic, fear, distrust, or even hallucinations. These usually occur with using larger amounts of THC (either with heavy or frequent use, and/or using Synthetic cannaboid products). THC also results in elevated heart rate and blood pressure, which could lead to cardiovascular events such as stroke or heart attack. 

The Long-Term Effects of THC (Cannabis):

 Heavy or chronic use of THC may cause severe vomiting, reflux, ulcers, or pancreatitis.

As with cigarettes and nicotine vaping, smoking marijuana or vaping THC can cause severe lung damage, including chronic bronchitis. 

==There is also a link between smoking or vaping Cannabis and an increased risk for Head, Neck, or Throat Cancer!

TEENS AND THC/CANNABIS---

The teenage brain is still growing and developing, so it is vulnerable to being altered in both positive and negative ways. However, known results from research has only shown negative effects on the developing brain. There are still many long-term studies being done to better assess the overall effects, cannabis has been associated with poor working memory, poor verbal memory, decreased mental processing speed, and the resulting decrease in academic functioning. Long-term use has also been shown to cause significant problems maintaining employment or achieving higher education in young adults (likely due to chronic effects such as decreased motivation, which contributes to a cycle of continuing use, less motivation, worse cognitive functioning, more use, less motivation and cognitive functioning, and on and on!). 

During use of Cannabis, the person may experience psychosis, where they have "lost touch with reality." They may feel paranoid or have hallucations, and these may increase the risk of harm or death to themselves or others.  When a teen or young adult has an episode of psychosis associated with Cannabis use, they are at increased risk of developing psychosis or schizophrenia later in life (likely higher in those with a family history of these). 

Cannabis Withdrawal Syndrome

After chronic and heavy use, many people have symptoms of withdrawal, including: 

• anger, irritability, aggression 
• feeling nervous or anxious
• restlessness
• decreased appetite or weight
• depression 
• insomnia
• experiencing strange or unsettling dreams
• headaches or abdominal pain
• sweating
• tremors

What About The Benefits of "Medical Marijuana" for Anxiety, Vomiting from Chemotherapy used to treat Cancer, etc?  Many people, especially since it is legal in many states, have become complacent about cannabis use, and many "swear by it" as a "Cure-All" for everything from anxiety, depression, ADHD, etc. etc. 

First, it is very important to understand that, even though it may be dispensed as "Legal Medical Marijuana", IT IS STILL NOT REGULATED BY THE FDA AS A MEDICATION!!  So all of the problems associated with the lack of FDA regulation (as noted above) are also true for every "medical marijuana" product. 

Regarding Cannabis as a "Cure-All", the current Scientific Research Studies have NOT demonstrated that Marijuana/ THC/ Cannabis has ANY proven medical benefits EXCEPT for:

• a severe type of seizure disorder that begins in very young infants and results in significant developmental and intellectual delays. These seizures (Lennox-Gastaut Syndrome) also do not typically respond to any of the normal medications used to treat other types of seizures. 
• Increasing appetite in patients with HIV and AIDS
• Treating extreme vomiting due to certain chemotherapy therapy regimens for the treatment of cancer.

(Source: https://nida.nih.gov/research-topics/cannabis)