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Join child psychiatrist Shivana Naidoo as she explores the delicate world of mental health in children and young adults. Delve into her unique perspective on how mental illness can be part of normal growth, the evolving role of diagnoses, and the importance of nurturing each child’s potential. Discover insights and strategies for helping “Cactus Kids” thrive and encouraging young individuals to transcend the labels, focusing on their true selves.

Shivana Naidoo is a child psychiatrist.

She discusses the KevinMD article, “The Cactus Kid: an analogy for parents and youth who are living with mental disease.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Shivana Naidoo. She’s a child psychiatrist. Today’s KevinMD article is titled “The Cactus Kid: an analogy for parents and youth who are living with mental disease.” Shivana, welcome back to the show.

Shivana Naidoo: Thanks so much for having me, Kevin.

Kevin Pho: So Shivana has been on multiple times. Go to KevinMD.com/podcast; in the upper right-hand corner there’s a search icon, and you can search for her name and prior episodes. But today, let’s get right into your latest KevinMD article. How did it come together?

Shivana Naidoo: Absolutely. As a child psychiatrist, I see kids every day, and part of my work with kids is to help them understand what they’re going through, why they’re going through it, and how to understand that thing happening to them as part of their life. What I found, and this is how the article really came together, is that lots of young people would come to me saying, “I have ADHD,” or “I have bipolar,” and parents would come and say, “My kid can’t go out, because they have anxiety.” I started to recognize, and I think most psychiatrists and therapists who work with kids realize this, that how we speak to our kids impacts how they think about themselves. So I wanted to draw an analogy to have people think about the process of mental health and how it really impacts the development of a child and that child’s understanding of their own development.

So I drew this analogy of a cactus. I live in Arizona. I used to live in New York City, where there are roses all over the place, and now in Arizona I’ve come to appreciate the unique desert flora and fauna, which include cacti. It made me think about how the environment of the desert has shaped these cacti to grow these prickles, these burrs, that make them really hard to live with. I think a lot of parents experience this with their own children. They feel that having anxiety, ADHD or bipolar disorder makes a child really hard to parent, which it totally does. It is very difficult to parent a child who has a mental health disorder. And by perpetuating some of these labels, I think we actually encourage these kids to grow more prickles, grow more burrs and have a harder time letting people in.

If you read through the article, it speaks about how we can reconceptualize this: What can we change in the environment to help what used to be a rose, and is now a cactus, grow back into something more beautiful, softer, gentler and more authentic? Because I think about the kids I’ve worked with who go through mental health issues, and how they must feel. They don’t feel good. They feel the prickles on the inside. They don’t feel good about themselves, and it’s really challenging for them to grow up and figure out who they are.

As young people, especially teenagers in the 12 to 18 period, if we go back to developmental psychology and developmental stages, this stage is identity versus role confusion. This is where they form who am I, what am I, why am I the way I am, and who am I bringing forth into the world as an adult. I think this is also where a lot of the issues with taking medications, going to receive treatment and declining treatment come into play, and that’s not just for mental health. It happens with neurology, with cancer, with hypertension, with diabetes, with all sorts of juvenile disorders where young people have to take responsibility and take medication. There’s this back-and-forth about whether to take something external to make them good or whole or healthy. This dynamic of identity versus role confusion comes into play: Who am I, and what am I, with or without this medication, this external thing?

That’s where this article came from: to have parents and young people think about this critically. As the current youth mental health crisis continues, more and more young people are facing what it means to live with depression, which is one of the leading causes of disability in adulthood, and more and more young people are coming to terms with what it means to navigate life with undermanaged mental health disorders. Who are they as young people? Who will they be as adults? What does their future look like? I think how we speak to our kids, as professionals, as physicians and as parents, affects how kids think about themselves and about our future. The future of our world, in my mind, really depends on this discussion of identity.

Kevin Pho: So before we talk about reframing childhood mental health, give us some examples of the things parents and peers would typically say to kids who are dealing with behavioral health issues, just to illustrate some of the issues you’re mentioning.

Shivana Naidoo: Oh, yeah. Even with young people who maybe don’t have a mental health disorder, I think in colloquial American culture we describe difficulty focusing as, “Oh, it’s just my ADHD acting up.” We describe typical mood swings, feeling down because we’re disappointed, as, “Oh, it’s my bipolar. I must be bipolar, because I’m crying and I don’t know why.” So it’s not just those of us who are dealing with mental health disorders. In normal life, we have normalized using these labels to understand who we are.

In one respect, that normalization is helpful, because it makes those of us who have bipolar disorder, anxiety or ADHD, for example, less stigmatized. But on the other side, unfortunately, it keeps us from having a normal range of reactions that’s OK and part of the human experience. I can cry and not be bipolar. I can be unfocused and not have ADHD. There are times when I’m going to be overwhelmed and not focused. I think it forces the spectrum of human experience into these diagnostic boxes, which they were never intended to do. The DSM-5, which is kind of our psychiatric bible, was designed as a way for psychiatrists and professionals to speak a language that captured certain symptoms, and it has now been adopted by culture to explain life. That’s not really how it’s supposed to be.

Kevin Pho: Go into more detail about how this language, these terms, this verbiage affects these children.

Shivana Naidoo: Where I work right now, I work in a PHP, which is a level of care between outpatient clinic and inpatient psychiatric admission, so we fit in between. It’s a very rare but fantastic form of treatment for high-intensity kids who have high emotional needs and are high acuity. We have a lot of young people who are avoiding school. It’s September, school just started on the East Coast, and a lot of kids have a honeymoon phase where school is good for a couple of weeks, and then they don’t want to go back, because school is so horrible. My own son said this morning, “I don’t want to go to school.” But school avoidance is a very big challenge for a lot of young people, in high school, middle school and elementary school, and it’s been exacerbated by COVID.

A lot of young people, and parents, will say, “My anxiety prevents me from going to school.” Yes, and your anxiety is part of normal development. We evolved with it inherently, to help protect us from fearful and dangerous situations, but school is not that dangerous situation. We will leave school shootings to the side, because some kids do have fears because of that, and that is a true and legitimate fear. But in general, I think a lot of these young people are not going to school because of other fear factors that get exacerbated. It prevents them from finishing school, from socializing, from being able to test the waters and demonstrate their ability to be successful in life, because school is where kids test themselves, show themselves and learn how to grow. So that’s just one example of how the idea of anxiety, and attaching themselves to having anxiety, gets in the way of their success.

I think that’s also the case with a lot of young people who have mood disorders. They will explain that people don’t like them because of their bipolar. I have had several young women, for example, with true bipolar disorder, not just saying “bipolar,” or with depression, get into and out of many relationships and blame the mental health disorder as the reason they can’t have a good relationship. And then that disorder becomes them: “my bipolar” versus “I have bipolar.” “My bipolar makes me not a good girlfriend. I’m never going to have a partner who cares about me.” And that perpetuates into who they feel they’re worthy of being with or having in the future. So it has long-lasting impacts on the hopefulness of youth and their potential for growth.

Kevin Pho: Now, they are getting exposed to this language, like you said, from parents or peers. What about social media, which is the other area where kids get a lot of exposure? What are you seeing on social media in terms of perpetuating this language?

Shivana Naidoo: It’s interesting, because I do think one of the benefits of Gen Z youth is that they are trying to fight against the stigma of mental health, more than before. Lots of influencers and lots of celebrities are talking about their own mental health struggles; Selena Gomez just had her biography out. I think that is helpful, again, in opening the door to talking about the human experience and the fact that we all go through ups and downs. But I also think there’s this fine line, as I touched on before, between normalizing ups and downs and having a diagnosable, impairing disorder. I think it is better to talk about it than not to talk about it. It’s better to discuss what a label means than to ignore that it’s there at all, and that’s also the case with suicidal thinking and thoughts. It’s Suicide Prevention Month here in September.

But I do think that where we get our information is also important. I truly value everyone’s individual experiences, and they are oftentimes representative of a greater collective, but not necessarily what the greater collective is. That’s why we still have to have some form of evidence-based intervention and assessment, and there’s still value in what the trends are, versus just one individual experience. One person may strongly identify with a certain diagnosis, and that serves them well, but that may not be the case for everyone. Although there’s a subset of the population making great strides in talking about mental health disorders online through social media, there are also many who are still trying to understand and wrap their minds around what it is, and other peers who still think, “That’s weird. That’s strange. They don’t fit in. They’re just odd. They’re emo,” whatever the language is. So I think we still have a long way to go, but we’ve made great strides.

The other challenge is our stages of understanding. Below age 12 and above age 12 are very different ways of thinking, and of course every child has their own individual trajectory; there are lots of very advanced 12-year-olds and very immature 12-year-olds as well. But on social media, who is giving that information and who is absorbing it is variable. A very young child exposed to that kind of language, and what they think it may mean, is very different from an older child who can manage it, really think about it and be critical. So that’s the other thing to watch for our youth: How capable are they of being exposed to whatever the idea is and then thinking about it, versus just taking it as fact?

I’ll give the example of my own kids. My kids are young; they’re five and eight. For my five-year-old right now, everything is fact: Whatever they see on the computer is real. My eight-year-old is beginning to question how real it is, and he’s only beginning to question it because my husband and I are encouraging him to. If we didn’t know what he was watching and just let him watch it, that would just be what is. So I think we have to really engage with our children and remind them to be critical about what they observe, and curious about what is being shown and how real it actually is.

Kevin Pho: So in terms of next steps, and you started talking about this, being more critical about what we see and what we hear, how can we, as you said before, reconceptualize that framework? What are some solutions to the issue you bring up?

Shivana Naidoo: Oh, I wish I had a solution. It’s tough. I think the first thing is awareness: We as parents have to be aware of what our kids are watching. And two, we have to teach critical thinking skills, which I think schools sometimes wait a little too long to teach. Very early on, we need to have young people think about where they are getting their information. What is the trusted source? Is it a trusted source, and if it isn’t, where can we turn to get a trusted source? So I think we need to build natural curiosity into the minds of our youth, versus just accepting things at face value. And I think, unfortunately, that’s not being mirrored in our adult world, either. Too often, we as adults take information at face value and don’t go the further step. So starting to question and be curious, and encouraging that innate curiosity, that scientific thinking that all kids have, is what we need to continue as they grow older.

Kevin Pho: And from a parent’s standpoint, what can parents do to address behavioral health issues in youth? Is it simply not using that type of language and verbiage? What kind of advice can you give parents about talking to their children about behavioral health issues?

Shivana Naidoo: Absolutely. I always encourage parents to first listen to themselves, and I’m working on this; I’m not perfect, because sometimes the things that come out of our mouths can be very stigmatizing and polarizing, versus opening a door. We want to open a door. Very often I’ve heard parents say things like, “I want to kill myself,” because of whatever situation. It’s a colloquial phrase, but for a depressed child, it might not be the best thing to say. Or, “It’s my ADHD. My ADHD is acting up. I can’t focus on this right now,” when it’s 7 o’clock on a Thursday night and you still have work the next day; of course you’re going to be unfocused. So minding your language is an important thing.

The other thing, I think, is to create opportunities that open the door for youth to speak to you, at any age, whether that’s at the dinner table, driving in the car or sharing a meal. Find the time to put your phone down and really focus on them. I think I’ve said this on other podcasts, too: I have a very talkative five-year-old, and I have to remind myself to do that. But it’s so important to look them in the face and say, “Hey, I hear you. I see you. I value you.”

I also have two courses on my website, Do Better MD, where I have workshops particularly for parents, to learn how to talk to their child if they’re concerned about suicide and what to do to keep their home safe, because it’s really difficult to know what to do. When we as parents are aware that our child is struggling with whatever it is, from suicide all the way down to anxiety, we are really jostled. We want to do the right thing, and we don’t want to do the wrong thing, and oftentimes we just do what comes naturally, which may not always be the best thing. I think that as parents, if we know better, we can do better. We can help our children feel better by giving them the tools, knowledge and guidance to take a different path.

Kevin Pho: We’re talking to Shivana Naidoo. She’s a child psychiatrist. Her KevinMD article is titled “The Cactus Kid: an analogy for parents and youth who are living with mental disease.” Shivana, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Shivana Naidoo: My take-home message for this particular article would be this: With youth who are struggling with some mental health challenge, when we’re not yet sure whether it’s a disorder or just a phase, let’s be curious about it. Let’s ask about it. Let’s not label it too quickly. The other take-home is that, as parents, let’s be aware of how we speak to our children, and let’s encourage them to see themselves as a rose, even if they’re experiencing a cactus phase. And finally, I do have some workshops if you’re really concerned about your child having suicidal thoughts, so please look at my website for those, and always go to a pediatrician, or call 988 or text 741741, if you’re really concerned about a mental health crisis. We as a nation have risen to the challenge of addressing the current youth mental health crisis, and help is here.

Kevin Pho: Shivana, thank you again for coming back on the show and sharing your time and insight.

Shivana Naidoo: Thanks so much, Kevin. I appreciate your work. Thank you for all you do.