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Physician executive Mona Potter discusses her article “When anxiety runs the show: How medication can help kids thrive.” In this episode, Mona explores how clinical anxiety differs from everyday worry, why it can become paralyzing, and how medication can be a key part of restoring balance in children’s lives. She emphasizes that medication alone isn’t a cure, but when combined with cognitive behavioral therapy, it can create the mental space kids need to learn coping skills and regain confidence. Mona also explains the importance of giving treatments enough time to work, understanding the difference between helpful and harmful anxiety, and considering the risks of doing nothing. Listeners will walk away with compassionate, evidence-based guidance for supporting children when fear takes the lead.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Mona Potter. She’s a physician executive. Today’s KevinMD article is “When anxiety runs the show: How medication can help kids thrive.” Mona, welcome to the show.

Mona Potter: Thanks for having me, Kevin.

Kevin Pho: All right, let’s start by briefly sharing your story. Then we’ll talk about your KevinMD article.

Mona Potter: Sure. I’m a child and adolescent psychiatrist. I’m co-founder and chief medical officer of In Stride Health, where we work with kids, teens, and young adults who are diagnosed with anxiety and OCD. My story is after almost two decades in academic medicine, we built In Stride to expand access to specialty pediatric anxiety and OCD treatment that works and is covered by insurance. This is something that we saw firsthand in the trenches was a real problem for families and for clinicians. We are really hoping to contribute to tackling the pediatric mental health crisis.

We chose anxiety because pediatric anxiety is the most common psychiatric diagnosis in kids and teens and across the whole lifespan. In its more moderate to severe forms, it can be absolutely debilitating. We’ve seen over and over how it can completely derail a kid’s development. It shrinks their world and it overwhelms the family system. We’ve also seen how treatment can really help kids and families get back on track. They get their lives back, and it is an amazing feeling as a doctor to be able to do good in a kid and family’s life. The sad part is that not enough kids and families are getting that right help when they need it.

Instead, things keep spiraling. By the time they get to treatment, they’ve accumulated disabilities and challenges, and it’s so much harder to treat them in their system. Our hope is that we take this treatment that works and think about the whole bio-psychosocial formulation and develop that treatment plan that addresses all of the vulnerabilities in all of these categories. At In Stride, we have a care team. It’s a psychiatrist, a therapist, and a coach working together as a coordinated care team with the pediatrician, with the school, and with the family. We’re all trying to understand what’s driving the anxiety and using that whole toolbox to provide that surround sound. My article focused on the biology, the medication component of what we hope is a more comprehensive approach to helping these kids and families.

Kevin Pho: All right. Before talking about the article, tell us some numbers in terms of the prevalence of anxiety in the pediatric population and maybe some root causes why those numbers are increasing.

Mona Potter: There are lots of epidemiological studies. I think the most recent that we’ve been seeing is by age 18, about a third of kids will at some point have had a diagnosis of anxiety or OCD. Again, this ranges from anywhere in the mild to the more moderate to severe.

What I’ve been seeing clinically is that anxiety, even before the pandemic, was already starting to escalate. Also, when kids were coming to us, they were coming in more disabled. The anxiety was bigger and more severe. There are all kinds of things that we talk about that can be contributing to this. Again, we think about bio-psychosocial. There’s the biological vulnerability, and then when you have the biological vulnerability and add to it environmental stressors and attacks on the psychological system to manage those stressors, you can see how it accumulates over time.

Kevin Pho: Typically, how would these teens and kids present to their pediatrician? What would their most common story be?

Mona Potter: Anxiety can present in a lot of different ways. For younger kids, oftentimes it presents more physically. They might notice that the kids are going to the nurse, the school nurse, complaining of a headache or a stomach ache, or physically staying in class.

Other kids might present more behaviorally. Again, especially when they’re younger, they might not have the words to say, “I’m feeling anxious.” Instead, it might come out with meltdowns or refusal to do things or with what seems like willfulness when it’s really fear-based. Again, we think about anxiety as a spectrum of how it presents: the physical component, and then we talk about our stress system (fight, flight, freeze). You might have that typical avoidance of things that are stressful or looking for reassurance that everything’s going to be OK. You also might find kids who get angry and irritable because that fear is so overwhelming and consuming.

Kevin Pho: Now, in your article, you make that distinction between everyday worry and clinical anxiety. How can parents recognize whether anxiety has crossed that line?

Mona Potter: I think it’s important for all of us to understand anxiety happens on a spectrum. In the mild end, it’s a very normal part of being human and it can be helpful and protective. I do not want to over-pathologize. Our goal is not to get rid of anxiety, but instead our goal is to say, “Let anxiety show up, let it motivate, let it do its thing, and then let’s move on from it.” Again, in its mild form, it informs us that something matters. It can help us prepare for a test; it can help us avoid danger. It is part of how we survive and even sometimes thrive. But again, it comes, it motivates action, and then it resolves. When it resolves, it gives our minds and our bodies a chance to recover from that episode.

But when clinical anxiety comes along, it is a very different beast. Clinical anxiety does not motivate; it paralyzes. It doesn’t come and go; it persists. It creates this filter through which the child experiences the world. It makes things scarier than they are. It tells the child that they have less agency and ability than they do. It then starts shaping their identity. It starts shrinking their world.

What I say to parents is that we all have feelings. Feelings are important; they communicate to us. We want to make sure that we’re identifying these feelings and recognizing what action urge comes from these feelings. When it’s productive, and it doesn’t always feel good, but it’s productive, that’s great. But when it starts becoming unproductive, when the anxiety starts calling the shots, when the anxiety starts causing a child to make a decision that is not consistent with what they’re expected to do or what their values are, that’s when it starts becoming something that we really want to make sure that we’re identifying and getting help for.

Kevin Pho: As you said before, your KevinMD article talks about one facet of that holistic approach to anxiety. It is titled, “When anxiety runs the show: How medication can help kids thrive.” Now, tell us about your KevinMD article for those who didn’t get a chance to read it yet.

Mona Potter: Let me start with a story. A 13-year-old kid: smart, kind, talented. A soccer player comes into my clinic, and for the past couple of weeks, she’s stopped going to school. She’s stopped going to soccer practice and games. She’s stopped hanging out with all but one of her friends. This is a kid who used to love learning, pushed herself to compete, and begged for sleepovers. Now the thought of leaving her house and engaging the world completely sparks panic and derails her and the whole family.

Her parents are so loving, and they’re so worried, and they’ve tried everything. They’ve tried therapy, they’ve tried breathing exercises, they’ve tried reward systems, even tough love, and nothing was working. Things are spiraling very quickly. What often happens is one of two things. One, parents are very reluctant to start medication because it is a developing pediatric brain. It is important that we are cautious about what we’re giving to this pediatric brain. It is very understandable to be reluctant and to be cautious about considering medications.

Or what I might also see in my practice is a child comes in and they were started on medication. But we call it the “demoralization titration,” where they started on a low dose and they’ve been staying on a low dose. The parents are coming in saying, “We’ve even tried medication and that’s not helping, and we are at a complete loss.” Why I wrote the article is to encourage us to see medication as a tool and to think about when we use it, to commit to using it as the tool that it is. Because again, anxiety untreated is devastating for a child. It derails. When we treat, let’s make sure that we’re being thoughtful and deliberate about using the tools that we have.

Kevin Pho: And when you talk about medication, tell us about your approach from the perspective of a pediatric psychiatrist, what classes of medication we’re talking about, and what would give you the decision to start medication in a particular case.

Mona Potter: For me, when a child comes in and we’re trying to make the decision, “Do we start medication or not?” the question is not, “Does this child have anxiety or not?” The question is, “How is the anxiety showing up for this child? What have they tried?” Again, it’s looking at the bio-psychosocial piece. And so at In Stride, we start with the therapy evaluation, and we do try to have the child and the family engage in therapy first. What we consider when we consider medication is when we notice that the child’s anxiety has such a high volume that it is difficult for that child to be able to even learn the therapeutic tools or engage in the exposure therapy: the behavioral part of the therapy that has been shown in research to be the active ingredient.

Again, I talk through the risk and benefit of medication, but also the risk and benefit of not using medication. If what we’re trying is not working, then we want to say, “Is this a time for us to think about medication as a possible tool?” Think about it as if we’re addressing the biology. What we want to do is turn down the intensity of anxiety with the medication. The medication’s role is not to get rid of the anxiety. It’s to say, “Let’s turn it down enough so that this child, instead of avoiding because anxiety is so overwhelming, this child is approaching life. This child is trying the skills. This child is giving themselves a chance to be uncomfortable and see that they can get through it, that they don’t have to avoid things just because anxiety tells them they can’t do it.”

Kevin Pho: And what particular classes of medication are particularly suited for the pediatric population?

Mona Potter: The gold standard in our child psychiatry world for anxiety treatment is the class of SSRI: selective serotonin reuptake inhibitors. I reference frequently the CAM study. It’s a landmark randomized control trial that had four arms. It had cognitive behavioral therapy, it had an SSRI (they used sertraline), it had CBT and medication together, and then placebo. What they found is that the combined CBT plus SSRI outperformed all of the other arms.

They also found that CBT alone and medication alone were about equally efficacious, and they found that all three arms outperformed placebo. How we interpret this research is that for mild cases of anxiety, starting with therapies, particularly CBT (cognitive behavioral therapy), is a very reasonable approach. As the anxiety starts getting more severe, as it starts interfering, that combination treatment can help address the multiple factors that might be causing the anxiety.

Again, SSRIs are usually the first-line treatment. Within the SSRIs, there is no major difference. Each medication might have slight differences. For example, fluoxetine has a longer half-life, and so in somebody where you’re worried about compliance, you might consider that medication. Although, if you’re worried about a family history of bipolar disorder, you might not consider fluoxetine because it takes longer to get it out of the system. You might consider medications based on some of the factors or if a family comes in saying, “We’ve had two generations who have really benefited from this particular SSRI, we’d really like to try this.” There is something to be said about treatment expectations. I will ask if they have an aversion to any specific medication or if they found others who have benefited from it, and work collaboratively.

Because what we also find is compliance is one of the biggest barriers to effective medication management. When we prescribe, patients will not take the medication as prescribed. From the get-go, ensuring that we do the work to help them understand why they’re on it, what the treatment targets are, what the side effects are, and have an open communication will hopefully improve that compliance. Because if they’re not taking it, it’s going to be very hard for it to be effective.

Kevin Pho: How do you talk to families about what to expect during a medication trial and how to gauge progress?

Mona Potter: Again, I’m very clear about treatment expectations. We are not looking for this to suddenly make everything better. That is not the goal. The goal is to turn down the volume of the anxiety so that we can now start approaching, start feeling uncomfortable, and be willing to sit in that discomfort.

One is being very clear about the expectations. Two is saying that these medications generally are quite well tolerated, and now they’ve been around for long enough and we’ve used them in children. There are some that are FDA-approved, some that are not, but we have now used them for a long enough period of time that we have seen that they’re generally a safe class of medications to use in kids.

That being said, we are always cautious when we’re medicating kids. We want to make sure that we have open communication and that if you notice anything, you talk to me about it. Oftentimes what we notice is, kids (and people) with anxiety disorders are also very sensitive to side effects.

I will often say, “Do you want me to run the whole list? Or how do you prefer we talk through the side effects?” Because what I also don’t want to do is make them anxious by running an entire list. I’ll usually, before starting a medication, ask about frequent side effects. I’ll ask about headaches, I’ll ask about stomach aches, so I have a baseline. We can decipher if headaches or stomach aches down the line are truly side effects or if they’re part of the anxiety disorder picture.

Kevin Pho: Now, in those cases where the medication is successful as part of that holistic strategy, how do you determine how long they stay on medication for?

Mona Potter: Particularly because these are kids and adolescents. Their brains are so malleable. They’re growing and developing. Again, if they’re engaging in therapy, they’re shifting the way they’re responding to anxiety and retraining their brain. This is what I talk about with families: We are wanting to give them a chance to grow up and experience the world as they are, not filtered through anxiety. It is very reasonable, especially with a first trial of medication, to expect that this is not a long-term sentence, and we should try a taper. Once things are stabilized, we borrow from adult literature on this one. What we generally talk about is after six to 12 months of stability, sometimes 18 months depending on how severe it was, we want to start discussing a slow and thoughtful taper. Stability means they’re going to school, they’re functioning, they’re still feeling feelings. But when that anxiety comes up, they know what it is, they know how to manage it, and it is not dictating their behaviors or decisions.

After that point of stability, I’ll say, “Let’s try a slow taper.” I say taper because worst case scenario, you find a lower dose that is as effective at managing that anxiety. Best case scenario, you slowly taper and you’re able to take the child off of the medication, and now they’re engaging in the world with the new skills that they’ve learned. When we treat, we aim for remission, not response. I think it’s a very important distinction, and this is what our research shows us too. When you aim for remission, that is when you have a better chance of long-term change.

Kevin Pho: We’re talking to Mona Potter, psychiatrist and physician executive. Today’s KevinMD article is “When anxiety runs the show: How medication can help kids thrive.” Mona, let’s end with some take-home messages you want to leave with the KevinMD audience.

Mona Potter:A The take-home is that pediatric anxiety is very common. It is. It can get very debilitating, not just for the child, but also for the family. It is also treatable, but through a bio-psychosocial model that involves the entire system that surrounds the child.

Kevin Pho: Mona, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Mona Potter: Thank you for having me.