Episode 61: School Refusal, Digital Media, and Medication and ADHD – Dr. Keeban Nam

LD Expert Podcast - Episode #61
School Refusal, Medication, and Other Tough Questions - Dr. Keeban Nam

 

Jill Stowell: Is your family facing a problem with school refusal? Are you concerned about the time your child spends on digital media? Are you struggling with the question of whether or not to go the medication route with your ADHD child or teen?

I am so glad you joined us today because we are going to tackle some of these really tough issues that are coming up for parents and kids today. Welcome to the LD Expert Podcast, your place for answers and solutions for dyslexia and learning differences.

Jill Stowell: Today we’re discussing school refusal, how digital media is impacting young people and families and questions around ADHD and medication with psychiatrist Dr. Keeban Nam. 

I am your host Jill Stowell, Founder and Executive Director of Stowell Learning Centers and author of Take the Stone Out of the Shoe: A Must-Have Guide to Understanding, Supporting and Correcting Dyslexia, Learning and Attention Challenges.

At Stowell Learning Centers, we work with children and families just like yours, helping parents understand what’s going on when bright students struggle in school and what can be done to change that permanently.

We understand that having a child with dyslexia or a learning challenge can be very lonely for a parent. You feel like you’re the only one whose child is struggling and you don’t know who to talk to. This podcast is for you. We will equip you with knowledge and practical tools for understanding and helping your child.

If this episode brings up any questions for you, I invite you to go to StowellCenter.com and give us a call. Today we are privileged to have Dr. Keeban Nam with us.

Dr. Keeban is a board-certified psychiatrist with Oak Health Center, specializing in working with children, adolescents and young adults. Welcome, Dr. Keeban.

Dr. Keeban Nam: Hi. Thank you for having me.

Jill Stowell: Well, I am so anxious to dig into all these questions. But first, just tell us a little bit about your approach and your practice.

Dr. Keeban Nam: Yeah. So I’m a psychiatrist as you mentioned for children and adolescents. I do also see some adults typically in the younger transitional age group. But whenever I have an evaluation with a child or a minor, essentially what I’m trying to understand is the extent and the details involving the relevant concerns when a family is approaching me.

So I will try to understand what other co-occurring concerns there might be, especially if we’re dealing with a complaint involving the school environment that may pertain to attention and disruptive behaviors or difficulty engaging in tasks. I do try to understand if there are some co-occurring concerns involving anxiety, some developmental or neurodevelopmental issues.

Because of the medical training that I have, I will also try to understand if there are some medical reasons to explain some of the challenges or if there are relevant factors from the medical history that may also be involved in the present concerns.

Then also in addition to that, some family-related issues, some parenting concerns, temperament of the child, sibling relationships. So all of those factors will be definitely something that I’m curious to understand if I am trying to have an evaluation with a new family of a child.

Jill Stowell: I just think that approach is so important because every issue that we see – I look at it. We’re really seeing symptoms and there’s a much, much bigger picture underneath. So yeah.

Dr. Keeban Nam: Very much so.

Jill Stowell: Yeah. I want to jump in and talk about school refusal. This is actually a term that I heard first in a conversation with you and since then, I’ve heard it so many times. So I would really like to get your take on kind of what’s going on with school refusal and how widespread the problem is.

Dr. Keeban Nam: There’s so much to be said about school refusal at the moment. It was a topic that was relevant even before the pandemic and historically, we would understand it to be something related to anxiety and it would have different manifestations, often somatic.

A child might complain of some headaches or stomachaches or feeling ill, uneasy or downright they might express feeling unsettled or uncomfortable about attending school. We would often understand it to be in the context of major transitions such as going from kindergarten to elementary school or from elementary school to middle school.

The pandemic has definitely presented a lot of multilayered changes to this landscape. So obviously there is the notion that it has presented a major disruption in routines and what was happening traditionally in the school environment, but also from the standpoint of understanding education to be a piece-wise process. We lay the foundations and then we build on that to present the next set of learning tasks.

If we have a whole year that is taken out of that, that foundation is going to be a little bit fragile and so a lot of the school refusal that I see now may also be pertaining to the challenges involved in learning what is present when the foundations that were supposed to happen the year prior may not have been as detailedly explored or learned as it should have been in the year prior.

So in many ways, it has presented again a very multilayered challenge that we’re dealing with. I have definitely seen a big rise in concerns involving school avoidance or difficulties making it and engaging in the school environment, even up to the high school levels.

As I mentioned, in many ways we understand it to be related to anxiety. I think there’s much to be said in that learning disabilities and ADHD have a hand-in-hand manifestation with anxiety, especially if the material that is being approached is something that is overwhelming to the individual. So that’s kind of what I am up against at the moment.

Jill Stowell: Right. As teachers and kids went back to school after the pandemic, talking to teachers, they were expected to do curriculum for their grade level and so many teachers I talk to said these children are coming in with no foundation from the year before.

So teachers were getting second graders who had no foundation for reading at all and so I think there has just been a general anxiety kind of across the board. Certainly for our students with learning and attention challenges, we’ve always seen that there’s anxiety connected with feeling lost or behind or like you’re expected to do something that you can’t do.

So we’ve always seen that. Have you seen that it has just really been exacerbated by those years of the pandemic and that this is a much bigger issue than before, especially in our learning and attention-challenged population?

Dr. Keeban Nam: Yeah, absolutely. I think we have so much to be said about adults adjusting to a disruption to this level. So I can only imagine to what extent it’s impacting children. I see them day to day and the conversations are challenging. Families are struggling. They don’t know how to attend to this complexity that we’re dealing with as we try to readjust back to life as it used to be.

In effect, I think it’s hard to say if we can really accomplish getting back to life as it used to be. We may just have to really find a new norm and so trying to adjust to a different set of understanding and reset our expectation in itself is presenting also some stress and anxiety.

Jill Stowell: Right. Maybe that’s part of the key though is understanding that we do have to do a reset, not trying to go back to exactly how things work but kind of do a reset now. So do you have some advice or how do you approach school refusal with parents and students?

Dr. Keeban Nam: Yeah. So again historically I was trained to encourage parents to find ways for the child to get back into a routine of things as quickly as possible. The real struggle about anxiety is that anxiety fosters more anxiety or avoidance fosters more anxiety and anxiety presents with avoidance.

So if we’re dealing with a situation where a child is avoiding school, ultimately the longer that period of time gets prolonged, it becomes that much harder to get back into a pattern of things where the child is able to engage meaningfully.

So that is still a bulk or a foundation of the recommendations that we might give. We need to try to find a way to get back into things such that there’s a routine going on. However, I think the big important factor that we need to keep in mind again amidst all this big disruption that we had with the pandemic is that we haven’t had a chance to really catch up on things, as you were saying.

Even in a classroom teaching, teachers are expected to teach the curriculum of the current grade level but there are gaps that we haven’t been able to fill. So I think from a psychological and emotional standpoint too, we need a chance to really validate those feelings and acknowledge this is really hard for the child. We understand even more to a personal level. This is really challenge for you to make it to school. It can be scary to get back into a big classroom environment and not only that. You’re learning things that you were supposed to learn last year that you haven’t been able to really acquire and so it can be scary. It can be uncomfortable and we need a chance to really reconnect with those emotions.

There are some recommendations from the ACAP, the Academy of Child and Adolescent Psychiatry that tells us it’s OK to try to find ways to readjust in a gradual manner. Maybe find ways to introduce changes gradually and also if there are ways to introduce some choices for the child to have a sense of control wherever it may be reasonable and practical to implement those choices, to present that to the child, so that it doesn’t become a battle of wills. It doesn’t become a control situation where the child might feel even more so at a loss because of the circumstances that are being dictated upon them.

Jill Stowell: Yeah, and I think you said some really important things there. I think that we don’t listen to kids enough. We know how things should be and so just acknowledging where that child is and that this is scary. I get that. This is a tough thing and I’m going to be right there alongside you as we figure this out.

I think that is really important and of course we all feel more secure with routines. But as parents, giving ourselves a little grace that we can do this in small steps and it’s not that you’re a bad parent. If your kid is not feeling good about going to school, that we’ve got to figure out one piece at a time and each little change is something to celebrate.

So our children and teens and young adults have grown up in a world of technology and devices that is different than generations before them because technology is so much a part of our lives and has been a part of their lives from the very beginning. Do you think that that is contributing to school refusal? Does it play a part?

Dr. Keeban Nam: Oh boy, it’s a big topic. I think it’s challenging to say that there’s a direct causative relationship and no matter how much we may try to design research studies to see to what effect digital media plays a role in current mental health struggles, again it’s hard to really tell to what extent there’s a direct process in which digital media is causing these issues to occur.

We have correlative findings with the rise of digital media and technology. We have definitely seen some challenges related to mental health, attention and focus-related concerns, anxiety-related concerns. It’s a big topic of mine that I’m really passionate about.

I think for individuals who have – the very first thing that comes to mind is to what extent digital media and technology has presented an element in which it’s a different form of communication. If I think about even this podcast and this conversation that we’re having, the very notion that it’s being recorded presents a different kind of understanding and expectation than if compared to if it was a face-to-face, real time conversation. I have to be mindful of in what ways this is going to be remaining in an archive of history.

So imagine to what extent digital media has presented a layer of communication for digital natives that is completely different from how conversations and communication used to be prior to that, the extent to which an individual has to filter what they have to say and what they have to do and how they have to behave in front of a theoretical crowd or an audience.

The extent to which we have to present ourselves likable, perfect, without any blemishes. All of those things present a situation where we create distance with this idea of feeling authentic and genuine from who we are outside of a context in which we are being seen or recorded.

So in my opinion, there’s definitely some theoretical basis to understand that anxiety has increased in relation to the introduction of technology and digital media. 

There’s obviously so much to be said about social media and the ways in which young people communicate and also the fact that there’s bullying going on through these mediums. There are ways in which people communicate that are so different from what we might say to each other face to face if we could see the individual’s response to some of the harsh things that we might communicate.

So all of those factors have definitely changed the way in which we communicate. I think the most important thing is to really understand this is a different way of communicating from face-to-face interactions. We just got to really understand that and keep in mind that if we just focus on this style of communication that is digitized, we miss out on the ways in which we might be able to deepen our sense of self-understanding, compassion, authenticity, genuine interactions, et cetera.

Beyond that, I think it’s also important to keep in mind that again, digital media and technology is designed in such a way that it’s really grabbing our attention 24/7. I often tell my patients and families that if I see a notification on my phone, I am compelled. I am an adult. I am an expert in the subject of recommendations involving digital media and technology. I myself feel tempted and compelled to get rid of that notification.

So there’s a design in the process that really encourages me to in a way be distracted, find a way to get rid of this notification right away. So reinforcing a mechanism of immediate gratification and I think all of those processes are really making it challenging for individuals growing up in this day and age to hone in skills involving patience, delayed gratification, attention and concentration.

Jill Stowell: I mean social media and digital media is a part of how we live and particularly our young people and I can see as you’re talking what a deep impact that could have on someone’s identity and anxiety, if they feel like they have to be on all the time, and they have to be perfect. 

In addition to that, there is a real addictive quality. So a lot of families even long before the pandemic were very concerned about how much time their kids were spending on digital media and the struggle to get them off. I mean to the point that parents would hide the devices at night and kids would get up and find them in the middle of the night. So they weren’t getting enough sleep and things like that. Do you have some general guidelines for parents about how to manage digital media?

Dr. Keeban Nam: That’s a big subject in and of itself as well. So when I bring up these concerns to families, I think the major knee-jerk reaction is for families to say, “Oh boy, this is really scary and I would rather not have my child grow up with this kind of influence,” and we cast a lot of negative judgment towards technology and digital media. The reality of it is that it's still very much ingrained as part of our lives.

A lot of the parents who are parents for young children nowadays actually have grown up with some technology in their hand as well. So we understand in what ways it’s impacting our lives as parents. What I want to try to caution towards is let’s try not to jump to the conclusion of getting rid of it completely because that’s not going to necessarily work out as a conversation in the family.

 

Ultimately what we’re trying to have is more conversations, understanding each other’s perspectives, help the child realize what kind of influence this piece of technology is having for them. Not just dictating it for them but asking questions, helping them reflect. What do you think this is contributing to you? Do you see any potential negatives in the influence that digital media is having for you?

 

So having open-ended conversations about what kind of influence it might have. So that will be the main important piece of background caveat that I would like to introduce before I go on. Let’s not jump to the conclusion of taking it out of our lives completely but keep an open mind. Be curious about what it is doing in our families.

 

Jill Stowell: Yeah. I think that is so important. You were actually on a panel discussion about this and I was at that event. A teenager shared that this is her form of communication and so if it is taken away completely, that’s a huge void for her because that’s how she communicates with people and I think as adults, we’re trying to do the best for our kids and we look and we can see all the negative influences and challenges with it and I think it is tempting to say, “Well, we’re just going to take that away. It’s not good for you,” but I think it’s also important to see that other piece, to know that wow, that’s where their friends are. That’s how they communicate and so yeah, it’s a double-edge sword there. Yeah.

 

Dr. Keeban Nam: It is and not to mention that that is the main medium through which our young folks make relationships and have social interactions but also that the standards that we are dealing with are not going to be standard as age goes on, as years go on. As these young folks grow up to be the next generation of adults, I’m sure the expectations and standards will be different compared to what we have right now, which is different compared to what we had 30 years ago. We can compare generations from present to past and going into the future.

 

I think there’s something to be said where the norm will evolve as time goes on. But with that being said, one important thing that I’ve tried to encourage and keep in mind even for young people is to protect sleep. That is one foundational piece of the puzzle that I really want to encourage.

 

No matter to what extent this tool is providing gratification and open social interaction, opportunities to have social interactions and networking and engaging in friendships, I think it’s really important to ensure that sleep does not get damaged or disrupted. It’s one critical element that plays a lot of functions in mental health, in development, in growth, brain development as well.

 

So I try to keep that in mind for families. You know, have important conversations about how this might impact the sleep in particular and if the child says that this is a big temptation. Do have conversations about what you can do to ensure that it doesn’t present a temptation during sleep. Maybe it is important to keep it out of the room or have it off completely in the middle of the night. But have a mutual understanding that if that is not going to be adhered to, then you will have to find alternative solutions to ensure that the device is something that the child can continue to enjoy or have a luxury of using.

 

Then the second element, as I was mentioning earlier, because it is a different form of communication that digital natives have, I think it’s important to let them know. Hey, besides this, we have a different way of communicating that a lot of your parents have grown up with. So let’s keep in mind that is also an important form of communication. Let us have face-to-face conversations. Let us have opportunities to be open and vulnerable to each other.

 

Let’s take opportunities to have arguments. I know that people don’t intentionally have arguments but it’s actually an important piece of interaction that helps us to problem solve in a relationship, to gain perspective in a relationship. When you have arguments, you actually have an opportunity to see the other person’s expressions. Even some hurtful words that you might hear and you have an opportunity to make repairs following that. That might be actually more important than not having an argument at all.

 

So it actually creates opportunities to have some foundational ways of engaging in social interactions that may be otherwise not present in a digitized form.

 

Jill Stowell: As families, everybody is busy of course and we’re all pretty connected to our media. So I think exactly what you said about making sure we also have face-to-face communication is something that we probably have to be more and more intentional about. It’s making sure we have those opportunities.

 

Dr. Keeban Nam: Absolutely, yeah.

 

Jill Stowell: Well, I want to switch gears a little bit here and talk about ADHD. We see that there are many reasons for students to have challenges with attention. In fact when students come to us, most of the time they do have attention challenges around school and homework. But once their underlying processing or learning skills are stronger and supporting them better, then the stress on the attention system is reduced and they’re able to focus and attend better.

 

Well, true ADHD though where attention control is actually the root of the problem is different and it needs to be addressed differently. So could you talk a little bit about the impact of ADHD on a family?

 

Dr. Keeban Nam: Yeah. So it’s one of those conditions that historically has not been understood very well and I think a lot of adults have grown up into society perhaps having had some of those symptoms related to ADHD but never really quite understanding why they were struggling so much or what was contributing to difficulties and maintaining a long-term goal or maintaining a job or trying to accomplish some of their long-term goals that they had established.

 

So as ADHD is gaining some deeper understanding and common understanding in lay population, we are seeing a lot of conversations again coming along within families. One of the most common concerns that I hear from parents of young children who have ADHD is to what extent it becomes something that rises to the attention of the teacher at first.

 

So that’s where we might hear some of the concerns come about in the beginning. The child is having difficulty engaging in tasks. The child is having trouble collaborating and participating. They might be too distracted. They might be talking to their neighbors, getting out of their seat often.

 

All of these concerns maybe in the beginning, it might be something that a family may be inclined to think, “Well, my child is still young. So we could understand why they have some of these challenging forms of relating and engaging in a class.” But as the child is aging, it might potentially be something that continues to present an ongoing obstacle in the learning environment.

 

As I’ve mentioned before, because the learning environment is something that is based on foundation building, if something is not present or if it’s fragile in the foundation, then the building blocks going forward are going to be more precarious.

 

So we might encounter some of that being a part of the puzzle, part of the challenge related to ADHD. Within the family setting, we might also hear a lot of difficulties staying in conversation, engaging in conversation with parents, listening and adhering to expectations. A lot of challenges getting ready on time for school for example, a lot of challenges adhering to sleep routines.

 

So that can add to tension and resentment and conflicts within the household as well and it becomes stressful at some point. But going forward, you can also imagine a repeating process of these patterns of behaviors and symptoms can ultimately lead a child to also experience some other co-occurring issues related to, again, depression, anxiety, self-esteem issues.

 

So one of the biggest challenges that we might have from a public health standpoint related to ADHD is how it might impact mental health down the line. Is the individual going to experience depression? Is the individual going to experience challenges maintaining a job? Is the individual going to have even challenges actually driving and potentially have risks of accidents and injuries?

 

So we actually see some of these concerns be a real issue within the population that will have ADHD and it is a major discussion that I might bring up to families that we need to keep in mind. If this doesn’t go treated, then we may have a situation where you have to face a higher risk related to these concerns.

 

Jill Stowell: And how do you approach treatment of ADHD with families?

 

Dr. Keeban Nam: So from a research standpoint, medication does end up playing a big part of treatment related to ADHD. I say from a research standpoint. Research is always based on quantifiable measures. So they will try to look into or they have tried looking into ratings of symptoms related to inattention and ratings of symptoms related to hyperactivity.

 

When we explore how a medication impacts those symptoms, they have actually found that they have telling changes or remarkable changes after receiving treatment with medication compared to just psychosocial or therapeutic interventions.

 

So medications have become a large subject of conversation when it comes to treating ADHD. But with that being said, because I believe a child has a developing brain, I try to encourage families to engage in habits and tools that will train skills of life and as I mentioned earlier, there have been plenty of adults who probably had ADHD growing up who have somehow made it into adulthood and are functioning members of society. They likely have found ways of adapting to their certain challenges and circumstances that have helped them along the way despite these concerns.

 

So even though it might be an impairing diagnosis, there are habits and tools that we can develop along the way that really allow a child to better engage with expectations and demands.

 

Jill Stowell: We do find that when it really is that true biological ADHD, addressing the biochemistry and pairing that with training, it seems to be the most effective. I certainly am not an expert in the biochemistry part but I know there are some different ways to approach it.

 

Many families, many parents don’t want to medicate. It can be very scary for them to even have that conversation.

 

So when are parents allowed to consider that? Sometimes I think they just feel like they’re going to be a really bad parent if they do that or they don’t do that. So when are they allowed to consider medication or when should they?

 

Dr. Keeban Nam: It’s a tough answer.

 

Jill Stowell: Yeah. 

 

Dr. Keeban Nam: Generally if a family presents with a concern of is this the right approach or not, my response to them is I don’t necessarily come to the resolution that a decision is right or wrong. We have to weigh in pros and cons. It might be a good decision to proceed with the medication if we weighed the benefits of how it might impact the child, compare that to the potential risks and we believe the benefits to truly outweigh those risks.

 

We might potentially conclude that it’s a good decision to wait or to defer medication treatment completely if we believe that those risks of adding a medication component might outweigh any potential benefits and there might be benefits on the other hand of trying to hone in some of those habits and tools that I was referring to without any influence of biochemical components.

 

So I try to really take the guilt out of the equation. It’s a challenging answer for parents to deal with if we just keep it at a black or white kind of perspective. I think it’s a much more nuanced answer.

 

There’s much to be said that medication may present significant benefits. There’s much to be said that there are real risks. Those are listed all in the bottle and the prescription and I will have a detailed discussion with families when I try to recommend it.

 

It’s not a risk that is common to all. It’s not 100 percent risk. So given those circumstances, I think it’s a careful consideration that we need to make on a case-by-case basis and it can also always be a moving target. A decision that we might make today doesn’t necessarily have to be the same one that we make tomorrow or a year from now.

 

So I think the most important thing obviously is to have a working relationship with the provider. If you trust your provider, if you trust that they’re giving you information that is reliable and informative and you’re problem solving together and it’s not just a dictated decision one way or the other, I think that’s the most meaningful kind of resolution you can find.

 

Jill Stowell: Absolutely and just I love that you’re saying it’s a moving target because it’s not something that OK, if I make this decision now, it’s going to affect them forever. We’re going to monitor it closely and I think it’s really – it’s just so important to really notice, as a parent really notice and check in with your child and see what they notice also.

 

Well, Dr. Keeban, I am just so grateful for you being here to share with us. These are really tough questions and I know our listeners are really going to appreciate this discussion and your insights. I’m sure I’ve left out so many things. But what would you like to add or leave our listeners with today?

 

Dr. Keeban Nam: I think when in doubt, it doesn’t hurt for a family to have a consultation with a professional. As I mentioned, if a child is struggling in an environment with peers, be it academically or even socially, and you would like to have an opportunity to check in with a professional to see what their opinions are, I don’t think in itself that would hurt. If you have established a good relationship with the provider, it will be a working relationship. It will be a problem-solving relationship and I don’t think a family should ever feel compelled to make a decision that they don’t feel comfortable with.

 

So I try to encourage at least that and if you feel that whatever recommendations I’ve shared with the family is not something that resonates with your values, you can always welcome a second opinion as well.

 

So having an opportunity to build a community around your child, the proverbial “it takes a village,” I think it’s a helpful consideration. Yeah. From there on, you can try to help the child make meaningful decisions as they grow along, keeping in mind that whatever we build foundationally right now is going to help along the way as they get older as well.

 

Jill Stowell: Wow, I really appreciate that. Thank you so much. What is the best way for people to get in touch with you?

 

Dr. Keeban Nam: Yeah. So as you mentioned before, I am a psychiatrist through Oak Health Center. It’s a complete outpatient practice that involves therapists, psychologists, psychiatrists as well. So we have a multilayered approach in terms of our treatment. We have a centralized phone line that receives referrals from patients. So you’re welcome to reach out to our main office. Our phone number will be listed through our website if you just look up “Oak Health Center”. That will probably be the best way to find an appointment or a conversation with me.

 

Jill Stowell: Perfect.

 

Dr. Keeban Nam: Would it be helpful if I shared that phone number here?

 

Jill Stowell: Sure. You can go ahead and share it and we can put it in the show notes as well.

 

Dr. Keeban Nam: Yes, OK. So that would be 949-258-3741 and again you can easily find the website online, Oak Health Center.

 

Jill Stowell: Fantastic. Thank you so much, Dr. Keeban. 

 

Dr. Keeban Nam: Thank you as well.

 

Jill Stowell: To our listeners, if you found this episode valuable, please share it. There are so many parents searching for answers to some of these really, really tough questions. So please pass it along.

 

Next week, our own Lauren Ma, the host of IEP Toolbox will be joining me to talk about misconceptions about 2E children and teens at school and on IEPs and how to develop their mental flexibility without driving them crazy.

 

At Stowell Learning Centers, we help children and adults eliminate struggles associated with dyslexia and learning differences. We want to make this journey easier for you.

 

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