Struggling Kids & Teens (with Robert Findling, MD)

Dr. Robert Findling is Chair of the Department of Psychiatry at the Virginia Commonwealth University School of Medicine. Here he discusses recent advances in pediatric mental health, including his own research on aggression and schizophrenia in young people. Dr. Findling also shares his thoughts on the crisis of teen suicide, the lingering impact of COVID-19 on children’s mental health, and the need for early and collaborative interventions.

00:00 Introduction
00:46 Clinical and Research Journey
02:56 Aggression with impulsivity and reactivity (AIR)
06:48 Precision Pediatric Psychiatry
15:34 Schizophrenia
20:31 What Kids Need to Thrive
23:10 Teen Suicide
25:09 Role of Schools and Primary Care
30:58 Loneliness Epidemic Among Children
32:32 Improving Access to Pediatric Mental Health Care
40:00 Bipolar Disorder
43:24 Future Research and Hope for Young Patients
45:11 Conclusion: Importance of Early Intervention

This discussion is for educational purposes and does not substitute for individual clinical judgment or patient care.

Senior Producer: Jon Earle

Transcript

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DR. THEA GALLAGHER:
Welcome to NYU Langone Insights on Psychiatry, a clinician's guide to the latest psychiatric research. I'm Dr. Thea Gallagher. Each episode I interview a leading psychiatric researcher about how their work is shaping clinical practice. Today, I'm pleased to welcome Dr. Robert Findling, chair of the Department of Psychiatry at the Virginia Commonwealth University School of Medicine. In our conversation, Dr. Findling shares some recent advances in pediatric mental health, including his own research on aggression and schizophrenia in young people. He also shares his thoughts on the crisis of teen suicide, the lingering impact of COVID-19 on children's mental health, and the need for early and collaborative interventions. Dr. Findling, thank you so much for being on the Insights on Psychiatry podcast.

DR. ROBERT FINDLING:
Well, thank you for having me.

DR. THEA GALLAGHER:
Can you give our listeners an overview of your work as a clinician and researcher?

DR. ROBERT FINDLING:
Sure. The way I got involved in research really was basically by patients who would come before me for whom there weren't really great answers about how to help them. And so that is usually what's driven my work as a scientist my entire career, which was patients who usually had the best questions and I was just fool-hearted enough to try to answer.

DR. THEA GALLAGHER:
Yeah, and I think that's a great way to be motivated to do research, coming from a place of wanting to bring research to practice. And so often we see the idea that it takes so long for the transition of a finding to actually be utilized in practice. Have you felt that to be the case with your research or are you able to utilize the research you've done in practical ways in your work?

DR. ROBERT FINDLING:
Oh no, things take forever, but being a physician, you're used to delayed gratification, right? By the time you've finished high school and you get four years of medical school, then you got five years of residency and then four years of college, that's 13 years. We're pretty good at delaying gratification. When we were starting to do our studies with lithium, the contract was issued from our government as a request for proposals in February 2005. The lithium did not have its labeling changed by the regulatory bodies until October 2019. So things take a while and nothing happens fast, and in many ways I could imagine, that's why so many people might not want to do this. If you take good care of a patient, they'll say thank you, look you in the eye and smile. This is all about delayed gratification in hopes that over time you can make a difference in a patient's lives, but on a much bigger scale.

DR. THEA GALLAGHER:
And can you talk about a couple of the projects you're currently working on?

DR. ROBERT FINDLING:
So one of the projects we're working on is what I would consider a real labor of love. I've seen as a clinician and then worked with these youngsters who really have serious aggression as children and they really get into all kinds of trouble. And there's always been a gap in what we call these youngsters. These highly troubled children who get into all kinds of trouble, even in their first decade of life, carry a lot of different needs. And there was really not a great diagnosis that people felt comfortable about, which is why what we've been calling or diagnosing them with a label has changed so much. So one of the first things we did years ago was say, "Okay, these youngsters, are they really a distinct group of patients?" And after looking at several large data sets with consistent results, I can tell you that there really is a group of youngsters that are quite distinct by their real challenges and the real problems that they have with aggression.
But it's not just broadly speaking aggression, but really reactive aggression. It's not premeditated aggression, it's not pre-planned aggression, it's really reactive aggression. So because it really didn't fall into any bucket, we decided to call this group of children suffering from what we called AIR, A-I-R, which is aggression that's impulsive and reactive. So first step was, "Does it exist?" And the short answer is, "Yes, they really do exist." And we've published some papers. So I can now tell anybody that, "Yeah, these kids really do exist. They are a distinct body of children, but they don't really fit into any diagnostic category." And that's important because we are faced with these children all the time and we actually have lots of different data to help them, it's just because we've been inconsistent in what we've called them and how we've characterized them that we don't have a consistent message for clinicians or the families.
So the next step that we're doing is pretty much like the American Psychiatric Association does with any diagnosis is we are taking it out on a field trial. You go into your clinics, you see if you can identify kids who have difficulties with behaviors, and then find out are they really a distinct group or entity? And we're in the middle of that work right now. And I think that's really very exciting because in fact, at the end of all considerations, this probably accounts for about one and a half to 2% of children. And these children oftentimes have really, really bad outcomes because it's so hard to grow up in their shoes. They know that other children fear them and don't like them. They know that the teachers don't like them. They know their parents think that they're bad and they're heartbroken when they're younger and they toughen up when they get older, unfortunately.
And they oftentimes just give up on the things that we want all children to want to aspire to. So this is a group that is near and dear to my heart, and I'm delighted to say that we've done research in this group as far as treatment is concerned, but more importantly, we'd like to be able to identify these youngsters more effectively, more rapidly, and more precisely so they can get the appropriate assessments and treatments that they really do deserve.

DR. THEA GALLAGHER:
And that's been a big theme of this podcast. You are using the word precisely, like precision medicine, and I think it does start with the proper diagnosis. And Dr. Findling, are you saying that you feel there will be a new diagnostic criteria for AIR different maybe from ODD or ADHD? What are the differences that you see with this population particularly?

DR. ROBERT FINDLING:
Well, I think the important part is they're certainly distinct because they're not characterized by restlessness, they're not characterized by being oppositional. What they really are characterized is by reactive, aggressive behavior. And then people would say, "Well, how is this different from, let's say, DMDD?" And the reality is DMDD is a mood disorder. And so ultimately these youngsters are characterized not only by the explosive episodes they have, but the mood states that they live with between episodes. These youngsters do not suffer from a mood disorder. And one of our papers specifically looked at it, do these kids really have a mood disorder? And the answer is, "No, they don't have a mood disorder." In fact, their mood between episodes is just fine. Thank you so much. I mean, it's almost like very short fused, explosive children who just really can't help themselves. In fact, much of the work that was done in this patient population was actually done at NYU a long time ago.
And these children used to be called childhood onset conduct disorder. And that term "conduct disorder" fell out of favor because people really think of conduct disorder now as a group of youngsters with proactive, preplanned, sometimes predatory behaviors. And these children do not have preplanned, predatory behaviors. They really are short fused, very explosive, but between episodes are really just doing fine. And so in many ways, these youngsters have difficulties with reactivity, whereas a lot of other youngsters who suffer from similar symptoms have disorders of mood and mood is a disorder of homeostasis. So really what we're looking for are youngsters who are fine until... And then you can fill in the blank. And then oftentimes they really just can't help themselves. And what we want to do is identify them quickly and then ultimately once that's done, develop appropriate interventions, both non-pharmacologic and pharmacologic, in order to give them the help they need and put them back on the right path.

DR. THEA GALLAGHER:
And the interventions, is that the next step, next phase of the research? Or has that already begun?

DR. ROBERT FINDLING:
Well, the first phase of the research we're doing now is really determining specific, accurate, evidence-based, research driven diagnostic criteria because ultimately we want to put the right label on the bob, and what I would tell you is there've been a lot of research in youngsters who look like this that date back for many, many years. Most recently, two groups have specifically done clinical trials in youngsters who essentially fall into this category for which there wasn't a great single diagnostic entity. And we know that the approaches are typically, at least pharmacologically, very rational and seem to be at least evidence-based and has informed the field. But what's been missing is how do you identify who these youngsters are precisely. And that's really our goal because ultimately there are good studies that I think we can bring to bear to help these youngsters now, both non-pharmacological treatments, behavioral interventions, as well as medicines that can be very helpful for these kids.

DR. THEA GALLAGHER:
Well, this seems like an exciting trend and something I imagine that was born out of your clinical practice, maybe seeing some kids that didn't fit these criteria of other conditions and then feeling like, "Okay, we have to find a home and a label so that we can know what to do with them in the future."

DR. ROBERT FINDLING:
Well, they've carried lots of different names, and with that lots of names came a lot of precision. I'm old enough to have seen lots of things happen. So when I started my career, these kids actually did carry the label of childhood onset conduct disorder. And it didn't take long before people said, "Well, conduct disorder is really meant for people who do preplanned, purposeful things that we wish they didn't." And I was like, "Well, yeah, but there's no other home for them." And our current mythology still has a diagnosis called childhood onset conduct disorder, but it's never used because conduct disorder is never used unless you think something else is really driving them. It's a different expression of bad behavior. So that fell by the wayside. And then for a while there was a lot of discussion about calling these youngsters having bipolar disorder, but they don't have bipolar disorder simply because these youngsters do not have the cure feature of bipolar disorder, which is spontaneous mood episodicity.
So although many of the behaviors in child psychopathology are nonspecific and apply to lots of different kids, what really drives the diagnosis of bipolar disorder is whether or not the youngsters have spontaneous mood episodes. And that's not mood swings. Mood swings are precipitated, but whether or not one day they'll be very, very sad, very, very blue, perhaps even suicidal. And then several days later they are not sleeping and really overly active and wildly impulsive and getting themselves into all kinds of harm's way and maybe being very aggressive during these periods of time. But the mood episodes are occurring without real precipitants. And then people were concerned about the overdiagnosis of bipolar disorder because of how it was being applied. And so then a lot of thought has been calling these youngsters perhaps suffering from disruptive mood dysregulation disorder or DMDD, but that also is a mood disorder.
The patients that I've seen, and I see these patients all the time, and they account approximately for, let's say, 25 to 30% of children with ADHD are really in a neutral mood, they are euthymic until something sparks them off, maybe a youngster cuts in line from them in school, maybe somebody accidentally bumps into them, and then bad things happen. And it's really sad because these kids can't help themselves. And this explosiveness, this impulsive reactivity that really gets them into harm's way with schools, school systems, with peers, families, and it really negatively impacts their lives.
And again, if you meet these children when they're young enough, before they truly do believe they're bad, they're heartbroken, and it's just incredibly moving, and then ultimately they say, "Okay, I'm a bad kid. I guess that's what life has in store for me." And it's horrible because no child deserves to go through life or transition from having the world as their oyster to believing that they're bad and having their choices and their lives impacted by that. So in many ways it's important, at least in the studies we've done in this patient group, to identify them as children and giving them a chance to pull out of this.

DR. THEA GALLAGHER:
It's making me think of almost learned helplessness. If you're labeled as bad and that you can't change and this is who you are, you kind of end up just finding that-

DR. ROBERT FINDLING:
You grow into it.

DR. THEA GALLAGHER:
Yep. You grow into it and that becomes your identity. And it sounds like you have so much passion about this group of kids and it seems like an exciting, I don't know if the word is trend, but an exciting area of research that will hopefully help, like you said, a pretty significant subset of kids. Are there other trends or is there other research that you're excited about with regard to kids and teens?

DR. ROBERT FINDLING:
Well, I think one of the things is it's hard to do and I know that. And one of the things that we're very proud of is another very vulnerable group that has meant a lot as throughout my career, both clinically and as an investigator, is youngsters with schizophrenia. And it's important to know that... When I started as a child psychiatrist, there was almost no methodologically rigorous data about what to do with these youngsters. We all kind of did something, but we really didn't know very much about that. And then over the last maybe two decades, things have changed and changed a lot. And now we know a lot about how to do this and now we're conducting studies all over, looking at this patient population. But one of the hardest parts about this patient group, interestingly enough, is how we conduct our studies.
The primary measure of symptomatology for this patient population was driven from an instrument called the PANS, the positive and negative syndrome scale. And the interesting thing about the PANS is it's 30 items long and to really get a good handle on what's going on with the youngster, you have to speak to the youngster and you have to really assess them. And then you have to ask the families how they're doing as well. It could be a very arduous, very time-consuming, and certainly not clinically friendly, nevermind the burden associated with conducting clinical trials in this patient group. So what we set out to do is could we do an equally good job of assessing these folks with much fewer questions? And that's exactly what we set out to do and that's what we've demonstrated.
We took the 30 item PANS and found that you can get equal precision in outcomes and equal coverage across symptomatology with only 10 questions, and 10 questions is a whole lot less than 30. And it allows less burden and also a greater ability to focus on those 10 questions rather than specifically dig in and drive in to make sure you get it right. But when you get 30 questions, questions 28 and 29 and 30, most people are pretty tired, not just the participant and their family but the interviewer. So we really think that this seems to be a real promising ability to not only facilitate the conduct of clinical trials, but a more focused measure that clinicians can use when faced with these very vulnerable children or teenagers.

DR. THEA GALLAGHER:
And it sounds like getting everyone on the same page about, again, diagnosis and the diagnostic measures, which are some of the core elements of moving toward evidence-based assessment and practice.

DR. ROBERT FINDLING:
Oh, absolutely. And I've spent a lot of my career doing pediatric psychopharmacology and honestly, the hardest part about pediatric psychopharmacology is making sure you're providing the right treatment to the right patient. Once you get the right patient, the treatments sort of take care of themselves, which is really kind of nice. I mean, they're very circumscribed in what they can and cannot do, but at least it's a lot easier to hit a target if you know what you're aiming at. And sometimes the hardest part about this field is really knowing what you are indeed aiming at. Because as I alluded to early in our chat, most symptoms of child psychopathology are nonspecific.
So much of the art of this field is spending time with a youngster, spending time with their families, and making sure that you have a clear understanding of the patient so that you can understand what you're hoping your treatments can and cannot do, all of which is really very important. And it's absolutely changed the way I practice as a clinician as well and when I evaluate a family, because it's made things so much more structured for me as I proceeded. And I don't evaluate patients in the same format I did when I trained initially as a medical student or as a resident or a fellow or even in the early parts of my career. It's evolved over time and I've found it very, very helpful.

DR. THEA GALLAGHER:
And we've been talking about these specific groups, these maybe micro groups. If we're going to move into the macro, what are some unique mental health challenges that kids and teens are facing right now maybe in the healthy population?

DR. ROBERT FINDLING:
Well, at the end of the day, I think the world has changed, but kids have remained the same. And so they're equally vulnerable to the same things they were before, but the means by which to bolster their strengths, foster their resilience, or unfortunately make things challenging for them have evolved. And so, again, I think it's really important... As I tell anybody, relationships matter. Kids are social beings and their relationships with peers, with their family, and in their community all play a part in who they see themselves and see themselves as a place in this world.
And gosh, although I could certainly talk about all the things that anyone can talk about that are uniquely challenging to modern day children and their families, children are still the same. And at the end of the day, things that impact them today, although different, really are just variations on old themes. There really is nothing new under the sun. The way we can support them or unfortunately have them get hurt have just changed, but they're variations on the same thing. Kids are still kids in many ways. And we know what kids thrive with and we know what's hard for kids to face.
And I'm not unrealistically optimistic, but again, I've practiced in different parts of the country. Everyone talks about kids in this city or kids in that... Kids are still the same. Their environments may be a little bit different. Their weather patterns in which they go to school may differ, but they're still the same. And they're social creatures that need to thrive and making sure they have what they need to thrive is equally important. And it's sometimes very hard when the things that can harm them are right in their hands with a phone, as I talk into one now.

DR. THEA GALLAGHER:
In some ways you're saying kids have stayed the same, they are the same, and there is maybe a consistency there. What we're not seeing a consistency in sadly, and you've spoken to this, but the rising rates of teen suicide. What are your thoughts and concerns about this change that we are seeing?

DR. ROBERT FINDLING:
Gosh, if I had the answer to that for sure, I would tell you it. It's not just the rate that troubles me honestly. We're also seeing this occurring in ever younger children. Death by suicide used to be pretty much the purview of teenagers, tragic, but teenagers. We're seeing higher rates in younger children. And I wish I knew the answer to that, but to me that's the most distressing, quite frankly. I mean, it's tragic anytime it happens and it's absolutely awful. But what worries me is things that were unheard of before... Preteen death by suicide is occurring, it seems, at a higher rate than before. And that really, really is disconcerting. And I wish for the life of me I knew why. I'm sure we could all hazard... Smart people could all hazard kind of guess. How could that be with 10 year olds? Are they learning things from the website? Are they learning things from friends? Are they more readily victimized because of technology? All of which are completely reasonable suppositions that I wish we had the clearer answers to.

DR. THEA GALLAGHER:
And we don't have a lot of answers. Like you're saying, there are some guesses, and I think it is very, like you're saying, scary to see the numbers of the ages going down. At this point, do you have any kind of suggestions or hopes for what we could start to do to maybe answer this call as psychiatrists and therapists? What should start to happen? I mean obviously more research would be great to understand why, causal factors, but is there anything that you think should be happening as far as intervention goes?

DR. ROBERT FINDLING:
So I'm going to point out that I'm a pediatrician as well. So from my perspective, a lot of this happens at the primary care setting or even in schools. I think there was a time that perhaps this was somewhat minimized. "Oh, they'll grow out of it. Oh, it's just a phase." But phases come and go and something that's protracted, prolonged, leading to disability, all of which phases don't have, really should be at least taken a gander at. I can't remember ever when someone would come into our office and say, "Doc, I'm glad you spent time with me and my family. I think we came too soon. We didn't have anything to worry about." I can't ever remember that happening. It's usually, "Gosh, I wish we had come here sooner." And in many ways you have to find that balance between being responsive but without necessarily jumping the gun.
But I don't think we're jumping the gun more than we really should. Most people who come to me come to me for a reason. And again, I just want to highlight, we're talking about suicide a little bit, but the leading cause of disability in children in the United States is depression, number one cause of disability in children and adolescents. I think the age range in these studies are 10 to 24 years of age. Number one cause of disability is depression. And then three out of the top five causes of disability in late childhood, adolescence, are behavioral health concerns, depression, bipolar disorder, schizophrenia. So we don't only focus on things that cause loss of life, which is absolutely horrific and tragic, we have things that impact people's lives at a level of disability that is protracted and prolonged and really needs to be taken with the seriousness that they deserve.

DR. THEA GALLAGHER:
So you're saying we have all these other challenges, and do you feel like they're contributing to the rates in suicide as well, like bipolar depression, some of the conditions you were just listing?

DR. ROBERT FINDLING:
What I would tell you is I don't think so. I think the prevalence of these conditions seem to be pretty stable over time for the most part. There is some evidence that earlier aged onset of bipolar disorder may be contributing to some degree. But again, I think the increased rates of suicide might really be related to other things. Again, I would wonder how much is that somebody's doorstep or information that if you're really serious about this or really thinking about it, there are websites I've been told that really focus on just these sorts of awful things. And maybe there's information that's readily available that used to not be readily available. And I think that may be part of it, but I mean, if we knew we'd do something about it.
But more importantly, I think the most important aspect of all of this is to catch the horse before it's out the barn door. I mean, if a youngster's starting to struggle, don't wait till they're drowning before you throw them a lifeline. Throw the lifeline out when they're just falling into the water. And I think that's really what I would say. And if you throw them a lifeline and they're still on the boat, no harm, no foul, but most importantly, don't wait until they go under. If they're looking like they've just fallen in the water, help them out.

DR. THEA GALLAGHER:
And it looks like you're hopeful that maybe at the primary care level or at the institutional level with schools, hopefully more education and awareness and connection to resources can happen before it's too late.

DR. ROBERT FINDLING:
Schools can't do it all. I mean, I think schools can help identify, but then of course then what? My mother was a New York City public school teacher and I know how tough it is to be a school teacher because I used to hear it from my mom all the time. And she was actually a school teacher in the Bronx. And I'll be the first to tell you, I'm not saying teachers need to do more, but I think what we need is to have systems of care that if a youngster who's struggling is identified, then what? And it's that then-what, that I think those bridges that still are not effectively built and by expecting schools to do too much, it's just too much.

DR. THEA GALLAGHER:
And yet, like you're saying, it's a good place to catch maybe or at least it's a place where kids are probably having the most exposure. And it could be a place where hopefully we've more integrated care, not putting more pressure on our educators, but having embedded practitioners or other people in these systems where just I guess putting the importance and financial backing for mental health, even with younger children.

DR. ROBERT FINDLING:
Schools are where the kids are, but it doesn't mean it's a teacher's responsibility. It just means that's where the kids are. It's an opportunity.

DR. THEA GALLAGHER:
Yeah, absolutely. And you have flagged loneliness as a significant problem for young people and I feel like loneliness has been the theme of the last year with regard to the Surgeon General warning and just realizing how much loneliness has an impact on one's mental health. What are your thoughts here about loneliness specifically for young people and then connected to effective interventions?

DR. ROBERT FINDLING:
Well, I think you hit the nail right on the head, which is a lot of these youngsters are not liked by their peers. A lot of youngsters struggle to make connections and youngsters are social creatures, teenagers are social creatures. And what do you do when you can't find a sense of someone who you can talk with and feel that they understand you, give you a sense that you belong? You don't have many choices. And it's an awful place to be in as an adult, it's even worse when you're a kid. And so, again, sometimes the interventions are not any more sophisticated than helping a youngster put in social circumstances where they can thrive, where they can succeed, and they can be accepted for who they are, even if they're not exactly like other children.

DR. THEA GALLAGHER:
And finding maybe ways to connect, ways to feel less lonely and alone will be really important when we're talking about mental health in young people. And you've talked a lot about also improving access to pediatric mental health care. We were talking about maybe integrating it into the school system or primary care. What is the research telling us about the best ways to expand access?

DR. ROBERT FINDLING:
I think the short answer is systems of care. I think in many places it's driven by doctoral level folks, and don't get me wrong, doctoral level people have a lot to offer, being one myself, but we don't talk enough about it, at least in my opinion, advanced practice nurses, nurse practitioners, or physicians assistants, certainly trained therapists and social workers are also mightily part of this whole work. So I think the point is systems allow you to get the right patients to the right people in the right time and not taking your most hard to come by intervention the way you might not need one. Again, if you have a youngster with some social skills challenges, they may not necessarily have to spend time with a doctoral level person to help with running a group necessarily or some kind of afterschool program.
So again, I would tell you that it's about thinking about a broader system and a broader array of providers who can really help address this. When we're talking about child psychiatry, there are only 8,000 child psychiatrists in this country. And again, we're retiring at faster rates than I think we're generating them. 8,000! And this has been a priority of the Child Psychiatry Academy for as long as I can remember, the workforce shortage. And we started out with 8,000 and we kind of stayed at 8,000. So to presume that we're going to somehow substantially markedly increase this number as to having the child psychiatrists, the guild with which I'm most familiar, to meet all these needs is probably not realistic. So what do you do? Well, you look for other people who have skills, dedication, motivation, and have them part of a team. And that's how you address a youngster. This is an uphill battle for a lot of these youngsters. And the idea is to get them before they fall too far astray.

DR. THEA GALLAGHER:
Yeah, it sounds like using more people collectively with more eyes on the kid and also with maybe, like you said, not top of license providers, utilizing a lot of very talented and successful providers in more of a team approach. And that sounds like a very new way to think about addressing these issues so people aren't working just in a vacuum themselves.

DR. ROBERT FINDLING:
And that's what we're doing here in Richmond. I'm lucky enough to be a chair of this department here and we've spent quite a bit of time recruiting licensed therapists at the master's degree level. And we've also hired quite a number of physician assistants as well as nurse practitioners, all of which into our team, as well as of course physicians and psychologists as well, really because there's never going to be enough of any single profession. So we're really trying to make sure that we make sure we're there for the patient, not the other way around. And I think that's important. And yes, that's a little bit selfless perhaps, that you've done all this training and you perhaps want to have a solo office practice but then you are oftentimes limited to the number of people you can help. And so we've taken more of a public health approach to our delivery of care and we find it attracts a certain mindset in the practitioners who deliver this kind of treatment.

DR. THEA GALLAGHER:
And you've seen it be successful where you are?

DR. ROBERT FINDLING:
Yes, we're very fortunate. And to that, we've been able to really increase the numbers of people we've been able to take care of. And the team is more fun because now, of course, we have different people with different backgrounds and different perspectives, and they have a vibrant addition to what we've done here. They're also invaluable in the way they learn... They've been taught how to approach patient care and we learn from each other. It's really very gratifying, being part of a broad interdisciplinary team that collaborates and actively all grabs the rope and pulls together to get it across the line.

DR. THEA GALLAGHER:
And it sounds like also an intervention that will prevent against burnout for your clinicians too. When you're working collaboratively in a team approach, you can rely on each other in that way.

DR. ROBERT FINDLING:
Absolutely. And it's not only helped with our outpatients, we have inpatient units as well and we've been able to improve outcomes there as far as reducing length of stay so youngsters can be in less restrictive environments, reduce the amount of readmissions that we've had, reducing time in the emergency room for those who present in our emergency circumstances. And any metric we can think of, it really has benefited from working collaboratively across multiple disciplines because, again, more hands really lead oftentimes to less stress and less burden and less work.

DR. THEA GALLAGHER:
And are you hoping that this will also lead to greater prevention and greater resilience for the patients?

DR. ROBERT FINDLING:
Well, prevention is certainly part of this, and we know who vulnerable patients are. We're not quite fully at a primary prevention role as behavioral health, but certainly I can think back to doing a lot of primary prevention just out in the communities, the things that are available after school, the programs that are also involved in school that really foster a sense of community, all good for kids. Think about the preclusion for bullying that is now part of so many school systems. Growing up once upon a time, bullying was part of growing up that was supposedly just part of kid stuff. Honestly, I think that's not generally acceptable in most places anymore.

DR. THEA GALLAGHER:
I think it sounds like this approach is really, again, trying to catch it early and work toward eventual greater prevention and building greater resilience in kids. And as we wind down, I know bipolar disorder has been a big focus of your research, including an award-winning paper on the use of lithium in pediatric patients, what have we learned in recent years about how to treat bipolar I in young people?

DR. ROBERT FINDLING:
So when I was in Cleveland, I joined a department that had a large mood disorders program for adults and bipolar disorder is a heritable condition. So I was asked, as the newcomer, to start seeing a lot of these children who happened to have parents with bipolar illness. And I was starting to see youngsters with challenges I had never seen before. And I was fortunate enough to be mentored well and I started trying to understand and describe who I saw and then started doing treatment research to figure out what we can do to help them do better. So again, in many ways, this was an opportunity handed to me that I was mentored through. And as far as medicine treatments were involved, it just happened to be a place at the time that had a lot of focus on basic pediatric pharmacology. And I was offered to be mentored by the pharmacology team and they mentored me as well.
So again, a lot of what I was able to do was certainly the result of mentoring and then understanding the simplest facts, which is you shouldn't study a medicine until you're sure you know how to dose it. And that's how we approached our work with lithium. But in 2024, there are lots of medicines we have shown to be safe and effective in youngsters with bipolar disorder and certainly lithium, about which very little was known of any rigor, is now approved by the Food and Drug Administration for children as young as seven years of age with bipolar I disorder. Now, we don't see children who are seven years of age with bipolar disorder very often, but again, if a lot of your referrals to your practice come from offspring whose parents have mood disorders, that's what you see. And so in many ways, it wasn't really we went out looking for them.
They ended up coming to find us simply because of our affiliation with a very large adult mood disorders program. So it was purely by happenstance, quite honestly. But it also then led to some interesting, to your point, prevention studies because what we wanted to do is obviously parents would say, "My youngsters starting to have the troubles I did when I first started having this. What can I do?" And we were able to run two studies specifically looking at possible interventions in this patient population and we were able to complete them. So again, I think it's led us down multiple paths. You treat who you see and I was lucky enough to have good collaborators as well as affiliations with adults who suffered from mood disorders themselves who were really concerned about their children. And certainly as an investigator, I was a beneficiary. But I'd like to hope that that work also helped lots of kids. And that's really why you get to get up and go to work in the morning.

DR. THEA GALLAGHER:
Yeah, that is a great motivator. For my final question, any ongoing or future research projects that you're excited about or hopeful for as you see the future unfold? I know we talked about some troubling rises in suicide, but anything you're hoping for as we kind of look into the future?

DR. ROBERT FINDLING:
Yeah, we're hoping, first of all, to maybe in the not too distant future look at a unmarketed medicine as a novel treatment for autism spectrum disorder. And we're just starting that body of work hopefully in the next several months. And this is a pharmacological treatment. We talked about looking at these youngsters with AIR. One of the things that's been problematic is figuring out how do we measure the severity of these youngsters' challenges so we can tell if they're getting worse or better. Well, we're actually working up and working to collect data to develop a specific instrument to evaluate this form of impulsive aggression in young people. And so we're very excited about that because you can't tell how you're doing with a challenge unless you can measure it and measurement matters a lot. And then I think the other thing is we are hoping to, with some collaboratives, look at some secondary analysis of some of the data we collected as part of these large lithium studies that ran for quite some time.

DR. THEA GALLAGHER:
Again, it sounds like there's some exciting work, and I love going back to your point of what inspires you to get up in the morning, making change, helping people, and making their lives that much better and fulfilling and fulfilled. And I'm sure it's exciting also, being on the pediatric and adolescent side, being able to help people at a young age that will hopefully follow them into adulthood.

DR. ROBERT FINDLING:
Gosh, couldn't tell you. You now understand exactly why I went into this field.

DR. THEA GALLAGHER:
Wonderful. Well, thank you so much for being on the podcast. We really appreciate it.

DR. ROBERT FINDLING:
Thank you, ma'am.

DR. THEA GALLAGHER:
Thanks so much for that conversation, Dr. Findling. If you enjoyed this episode, be sure to rate and subscribe to NYU Langone Insights on Psychiatry on your podcast app. For the Department of Psychiatry at NYU Langone, I'm Dr. Thea Gallagher. See you next time.