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Teenagers: Emotional Health and Wellbeing with Dr Elisa Song

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Teenagers: Emotional Health and Wellbeing with Dr Elisa Song

The health of today's teenagers is being eroded by a multitude of factors. Once upon a time adolescence was a passing phase of growth and development necessary to cross the threshold into adulthood. However, modern teenagers are dealing with much more than a change in body shape, hair and voice. Today's teens are navigating an unprecedented invasion of their psychosocial sphere with gaming and social media bringing forth a new dimension of bullying, harassment and body shaming. Furthermore dietary choices, recreational and pharmaceutical drugs, environmental pollutants and a lack of exercise, sunshine and fresh air are all playing a part in the assault to their microbiome, immunity and neurological systems.

Ahead of her visit to Australia in August 2019 to present her seminar series 'Holistic Children's Health' we are joined today by Dr Elisa Song to share her expertise on the subtle nuances we need to be across when taking a functional medicine approach to working with adolescents. 

Covered in this episode

[00:55] Welcoming back Dr Elisa Song
[02:03] Children vs. Teen vs. Adult
[08:18] Food allergies
[09:36] Epstein Barr Virus
[13:30] Nuances of working with teens
[16:54] The teenage microbiome
[22:39] Teen Suicide
[25:28] Factors influencing mood and behaviour
[34:12] Motivating teens to action change
[40:50] Acne and low dose antibiotics
[44:35] Dr Elisa Song's 2019 Seminar Series in Australia


Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining us on the line again today is Dr. Elisa Song, who's a holistic paediatrician, paediatric functional medicine expert, and Mumma to two crazy, fun kids. In her integrated paediatric practice, “Whole Family Wellness,” she's helped thousands of kids to get to the root causes of their health concerns and help their parents understand how to help their children thrive with their body, mind, and spirit. 

Dr. Song created Healthy Kids, Happy Kids to share her advice and adventures as a holistic paediatrician and Mumma. You can follow her blog at Healthy Kids, Happy Kids and get even more tips and inspiration from her on Facebook and Instagram

Warmly, I welcome you back to FX Medicine, Elisa. How are you? 

Elisa: I'm great. How are you? 

Andrew: So great to have you on the program again. It's been a while. It's been a little while.

Elisa: I think it's been almost a year, right? But I'm excited to be coming back to Australia in the fall. Well, my fall, your spring.

Andrew: Yeah. That's right. 

Elisa: Yep. 

Andrew: Now, you're going to be covering something a little bit different this time as well. So, we're going to be talking about teenage health rather than younger children. I guess as a paediatrician, how do you differentiate between children, teenagers, and eventually to segue into where you would pass them off to, you know, another specialist?

Elisa: Well, that's a great question because as I have my kids going off to college will often ask me, "How long can I stay for?" And so, typically, once they're graduating from university and 21 and heading off to be executives or interns somewhere I'll try to pass them off. So, I usually see kids until they're about 21. 

I do have some kids that have chronic conditions that I may see for longer periods. Children with PANS and PANDAS, which was the topic of our first podcast last year. Many adult psychiatrists and practice docs, internists, even adult functional medicine practitioners are just not that familiar with managing children with paediatric-specific chronic conditions. And even children with autoimmune illnesses that may be a slightly easier transition to an adult functional medicine practitioner. But for kids who do have complex chronic conditions, I might see them for longer, but typically at 21 I'm moving them towards transitioning to an adult doc.

Andrew: Yeah, I think that... I mean, even right there is a glaring difference between the U.S. and Australia, in when we consider a child becomes an adult. You know, in America depending on the state, it's usually 21, right? I think some states are 18.

Elisa: Yes. I mean, I think that would go mostly well. Every place the drinking age is now 21, but the driving age varies from maybe 14 to 16. 

Andrew: Right. There's a vast difference in development from even 15 to 21, emotional, let alone mental or physical. And yet in Australia, there's sort of age of 16 is that age where they're able to handle their own affairs. That's that sort of legal age. 

So, I'm wondering whether paediatricians in Australia would hand over their patients to another specialist or general practitioner at a younger age than the U.S. 

Elisa: Oh, that's interesting. That is very interesting because now, as I've been doing research for this, the talk that I'll be giving on teenage anxiety and really looking at adolescent brain development and maturity, it's fascinating. So many parts of our teenagers' brains really don't mature until the late 20s.

Andrew: Yeah.

Elisa: Especially most importantly that prefrontal cortex that has everything to do with logical and rational decision making.

Andrew: What's that?

Elisa: Exactly.

Andrew: I'm a male. I don't have that.

Elisa: Well, you know, what's interesting too, this is not to be sexist at all, this is in the research, but research does show, when you look at brain scans of adolescent girls and boys, boys do tend to lag at least two years behind.

Andrew: Oh, yeah. 

Elisa: In, you know, prefrontal cortex development and overall synaptic pruning. 

So when we think about that and we think, well, how are schools then preparing our kids to make those healthy decisions? How are we preparing our kids to make those healthy decisions and really expecting them to be independent at 16, or 18, or 21 when their brains have not fully matured, when they're really not fully capable of making those rational life decisions that they're expected to be making?

Andrew: Yeah. And indeed, we'll be discussing some of these issues a little bit later. But I would imagine, though, that that would present certain issues even within those sort of age groups that we've been discussing. The differences in examination, presentation of various diseases and disorders, but I guess, especially compared to what most people would see a paediatrician for, and that's their younger children compared to the teenage years. There must be some real differences in what you see and indeed how you examine not just physically, but also lab assessments. 

Elisa: Yes. And you know, there is actually a specialty here in the States. I don't know if this is a specific paediatric specialty in Australia? But we do have a specialty in adolescent medicine.

Andrew: Really…

Elisa: And that's on board certification. So, because we know the teenage brain thinks differently, acts differently…

Andrew: Yes. 

Elisa: The body acts differently, there's so many different changes, and the way we need to approach our teenagers, the specific tests and the way we need to really manage their health conditions is very different than what we might do for a toddler or an elementary school age kid. 

Andrew: I would indeed implore anybody in Australia listening to this. If you have a patient in the teenage years, you want somebody who's not just interested but expert in these sort of differences in presentations and requirements and needs. I think that's a real interesting and great idea that the U.S. have done. I think that's fantastic.

Elisa: Yeah. You know, I actually used to think I wanted to be a specialist in adolescent medicine specifically because they're just... I mean, teenagers are so incredible and they have so much possibility, but then, of course, there's so many frustrations too associated with working with teenagers. 

But if you do really understand what's going on with their brain, it helps us to really understand how to talk to teenagers so that we really can make an impactful difference in their lives and help them make those good decisions even when their brain is not really wired necessarily to do that. 

Andrew: Well, of course, one of the things which creates the way that we think is not just our behaviours and our environment, but indeed our food. So, I've got to ask you the question around food sensitivities. Now, you know, we commonly say food allergies. Can we delve a little bit into this food allergy sensitivities? Do they present differently in teenagers versus younger children? 

Elisa: You know, not necessarily. because we're looking at... In functional medicine, of course, we look at food sensitivities as it relates to leaky gut or increased intestinal permeability. And there's so many extra-intestinal manifestations. And I think the main difference is that teenagers can now vocalise how they're feeling and may be able to really more clearly state what their physical and emotional symptoms are related to particular foods. And, of course, we know that kids and teenagers are going to present with mood disorders differently than adults and younger children may manifest depression and anxiety in a different way than teenagers.

Andrew: Yep. 

Elisa: But it would still be anxiety or depression or, of course, maybe their eczema or the sleep disturbances or their abdominal pain. So, it's not necessarily different manifestation, it just may be experienced a little differently, if that makes sense? 

Andrew: Yeah. And what about things like not necessarily looking at different presentations, but the prevalence and the types of viral infections in times of, say, hormonal surges? Dr. Mark Donohoe and I have been discussing, at length, Epstein-Barr virus. And it seems to occur more frequently around that teenage years. It was whimsically called kissing disease at one stage, you know. And it can have devastating effects for certain people, and it seems to be this perfect storm that happens. Is not just the virus, but whatever else is happening at the same time?

Elisa: Yeah. I rarely, when I check Epstein-Barr titers in young children, do I find them positive. Although some of the children with PANS and some of the children who are presenting with what really looked to be mitochondrial dysfunction will have very elevated Epstein-Barr titers, which I'm always surprised about when I have a young child. 

But for teenagers, of course, Epstein-Barr is so much more prevalent and common. And in fact, just this spring, you know, a few months ago, it seemed that Epstein-Barr was fairly epidemic in the schools here because I was seeing mono you know..

Andrew: Yeah. 

Elisa: In school after school. And children presenting with tonsillitis and prolonged fatigue and flu-like symptoms, and sure enough positive for Epstein-Barr. And what we worry about, of course... And I think that perfect storm is just right. Because Epstein-Barr we know is mito-toxic, and that's what can trigger the chronic fatigue and the chronic pain and the ongoing symptoms. But then, of course, teenagers are very often living lives that are mito-toxic, without antioxidant-rich diets and too much sugar and not sleeping well and not really protecting their energy reserves. So, that is that perfect storm there, I think, for many teenagers.

Andrew: Yeah. So, I mean, this is something that really interests me. Do you think that the perfect storm is something that is required, or do you think it's this genetic preponderance for an issue with EBV? I'm wondering, you know, like, we always like one cause, and that's not going to happen.

Elisa: Yep. 

Andrew: With EBV because you get so... 

Elisa: No, it's not. 

Andrew: The vast majority of us have had EBV and ostensibly haven't necessarily had an issue with it. We just have it within our gene pool now, you know? But for some people...

Elisa: That's right.

Andrew: ...it can be devastating.

Elisa: Yeah. Yeah. I think it's both, and I think it's almost always that genetic background on top of your lifestyle that's pushing you over the edge. 

Andrew: Yeah. 

Elisa: And I have some kids who are, I mean, in the picture of health and they develop chronic fatigue symptoms. 

Andrew: Ahh. 

Elisa: Other kids too seem to sail through. So, I think it is both. Because I don't know that I yet have the clinical skills to necessary predict which teenager in front of me is going to develop problems.

Andrew: Right. Yeah. And to me, it's a big call out, though, that there is a real need for integrative medicine to be aware and alert in these teenage years.

Elisa: Absolutely. I think that for a lot of teenagers, and we were talking offline before about how I'm more and more seeing children with the signs of, well, clinical signs, yes, but laboratory evidence, even without obvious clinical signs of hypothyroidism, subclinical hypothyroidism, even Hashimoto's thyroid antibodies present. And also seeing signs of insulin resistance even for these teenagers who are athletes and who are thin, and you would never even think that they would have insulin resistance concerns. But these are concerns I think that we do need to be aware of, especially if a child is presenting with any sort of a chronic physical or emotional health concerns.

Andrew: So, I guess, the question there is, which part do you unravel? Like, do you look at a stressor creating the insulin resistance because of, say, increased cortisol? Do you look at purely the diet as the thing that causes everything? Or do you have to sort of prioritise which is the most important for each patient and weigh each sort of section up, if you like?

Elisa: Yeah. You know when I come to Australia for the seminars, and we'll be talking really a lot about strategies and working with the teenage patients because it's not like with a child where you can run any stool or urine test and even potentially blood testing that the parents would like for that child and for an adult who you'll just go and willingly do any testing that you want to. For a teenager, it's really important to prioritise testing, it's really important to prioritise supplements, and it's really important to prioritise your treatment plan. 

Because you may just have one or two opportunities to make an impact on that adolescent's health and well-being before they decide that they're going to keep going with it. So, really trying to prioritise, "Well, where do you think the biggest bang for the buck is going to be?”

Andrew: Yeah. 

Elisa: What is going to make the biggest difference right away so that they start to feel that, 'Hey, maybe this person in front of me, even with their credentials, has something that they can offer me and that I'm actually going to take time to listen to and change my behaviours for'?"

Andrew: Yes. Such an important factor. Because, as any parent with teenagers knows, it's hard sometimes to get through to them, and you have to prove to them that it's going to make a difference for them.

Elisa: Yeah, yeah. 

Andrew: Because, like, I've got two extremely intelligent young men as sons and, boy, during the teenage years, particularly one of them, who's mostly like me, talk about refusal, belligerence in the face of even stark evidence that there was an issue was amazing. It was really amazing.

Elisa: Yeah, yeah. Well, I think teenagers too are so... So many teenagers are used to being looked at as troublemakers, as irrational, as unable to make good decisions and not trustworthy, that if you have a practitioner telling you all the things you should not be doing and all the things that you're doing wrong, that's immediately going to put up a wall. 

And I think part of that feeling of not being good enough, not being able to do enough and really stressing about it is one of the major fuelers for the anxiety that we're seeing in our teenagers. I think that...I'm seeing so many kids who just feel like there's too many things to stress about. 

Andrew: Yeah, for sure. 

Elisa: And I feel like my job, as their practitioner, because many of these kids are not going to come willingly, right? They're coming because their parents are making them come. 

Andrew: Yes, yes. 

Elisa: So, if I'm going to connect with them and have them trust me and have them agree to a treatment plan, I have to come at it from the point that I believe that they can actually take their health into their own hands, and I believe that they can make these good decisions for themselves, and I believe that they can actually take a step by step forward in the right direction.

Andrew: I want to go back to a thing that you mentioned about diet. You know, teenagers typically have that high-carb diet, they're high energy, they're going through those growth spurts of life, and indeed, we've seen in various papers a change in the microbiota during various phases of life. And indeed, we're talking about food talking to our microbiota. So, how important is the microbiota, not just their gut conditions, which we tend to just compartmentalise these things to, but their mental conditions?

Elisa: Well, the listeners of the FX Medicine podcasts are intimately aware of the gut-brain connection.

Andrew: Yeah, sure.

Elisa: So, a lot of this is going to be a review, but what's fascinating to me is that, you know, it is true that by the time we're about two or three years of age, our gut microbiota is fairly similar to that of an adult. 

Andrew: Yep. 

Elisa: But what I hadn't realised beforehand was that we have these changes, these stages of rapid changes in our gut microbiome during infancy, but also during adolescence and during aging, during our years of senescence. And it's at those times that those rapid changes in a gut microbiome actually mirror the synaptic pruning and the changes in our brain developments, that kind of neuro-plasticity that's occurring in infancy and in adolescence and during senescence. And it's during these times where we can see any disruption to that gut microbiome can have significant and long-term, even lifelong impacts on neuro-development and neuropsychiatric disorders like autism, or ADD, or schizophrenia, or anxiety, or you know, Alzheimer's disease. So, there's this mirroring there that's really important to know. And so the gut microbiota, it's not necessarily even because of antibiotics. 

Now, what is fascinating, though, for teenagers, and now this was a rat study, but we know rats are very similar to adults, right? And which is why they're used in so many studies. And so this was a rat study, but it looked at exposure, a single exposure to LPS, lipopolysaccharide, during puberty. 

Andrew: Yep. 

Elisa: Right? And when these rats, adolescent rats, were exposed to lipopolysaccharide just once, those rats had enduring and lifelong depression in females and anxiety in males. It persisted into adulthood. And so what is lipopolysaccharide? And I've been really interested in LPS and how this affects the gut. 

Andrew: Yep. 

Elisa: But LPS is that endotoxin that's derived from Gram-negative bacteria in our gut. Like E. coli or Klebsiella or Citrobacter. And what happens when we have a leaky gut is that LPS can leak into our bloodstream and bind to these LPS, lipopolysaccharide-binding proteins, so you have these LPS-LBP complexes that then would deposit in various places, the brain, the gut, the joints, and cause all sorts of inflammatory trouble. And where they deposit can then really manifest as what we're seeing clinically. And so we know that this metabolic endotoxemia has been associated with chronic physical illnesses like autoimmunity, diabetes, cardiovascular disease also.

Andrew: Non-alcoholic fatty liver disease. Yeah, the whole gamut.

Elisa: Yeah, yep, exactly. But also they found it in anxiety and depression, which is fascinating.

Andrew: Right.

Elisa: And so, right, and this is where we're really looking to see how can we make sure that we preserve our teenagers' gut microbiome and gut regulation? Because that is going to be one of the keys in preventing that progression into anxiety disorders or major depressive disorders. 

And with these rats, so they also gave these rats probiotics after they were exposed to LPS.

Andrew: Yeah. 

Elisa: And probiotics did actually was able to prevent a lot of the enduring changes, prevent the LPS-induced inflammatory changes that then led to anxiety and depression in those adult rats. So, we see this evidence, and there's a lot of evidence, but this to me was profound, and even looking at antibiotic use in adolescence, even just one course of antibiotics in adolescence was linked with a higher risk for depression and anxiety. 

And so adolescents bring with them a whole different set of issues because you may have these children, these younger children who were healthy, who, parents will say, "Well, they were never on antibiotics their whole life." Great. They never had a Strep throat, they didn't have ear infections, they didn't have sinus infections, but then they're placed on low dose daily antibiotics for their acne. 

Andrew: Ahh, right. 

Elisa: So, what is that doing to their gut microbiome? Right? And so, we have to think about really, how are we managing not just anxiety and depression, but what are we doing to really prevent that from happening? Because we really are seeing in our teenagers, in the U.S. and Australia, an epidemic, an increasing epidemic of adolescent anxiety and mood disorders. And what's really disturbing to me is the surge in teenage suicide. 

So, and as we were talking before, I looked up the U.S. numbers and the Australian numbers, and by far, teenage suicide is one of the leading causes. It's actually the second leading cause of death for teenagers in the U.S. Homicide is actually the third.

Andrew: Oh, God.

Elisa: Unintentional injury is the first. So, it is these accidental or intentional deaths that are the leading causes of death in adolescence by far. 

You know, when you look at influenza deaths among teenagers, let's see. I'm just looking here at the 2016 data in the United States. Influenza and pneumonia were the ninth leading cause. There were a reported 189 deaths due to influenza and pneumonia. Well, you look at suicide, 5,723 deaths in that same year. 

Andrew: Gosh, yeah. 

Elisa: So, we need to... This is a public health crisis. 

Andrew: Yeah, absolutely. 

Elisa: And Australia is not far behind. In Australia, when I looked at Australian numbers, Australia was... Let me see, the first cause of death was...I'm going to look here at my list here, actually, intentional self-harm. So, suicide was the leading cause of death in Australian youth age 15 to 24 years of age. 

Andrew: Wow.

Elisa: The leading cause. The second leading cause was being a car occupant in a motor vehicle accident. 

Andrew: Got you. Right. 

Elisa: Right. And so we... And of course, as we were talking briefly before, I mean, the suicide rate is twice as high, maybe even higher for indigenous Australians of Aboriginal and Torres Strait Islander descent.

Andrew: Yeah. I've got to... This really is a public health shame about how we're dealing with indigenous health. Because we're not. We're not asking, we're not consulting. We're dictating to our first nations, our first people how they should be looking after their health and giving them things, which are actually doing the exact opposite. You know, high sugar, high-fat foods that are the wrong fats and poorly looked after. Processed. 

Elisa: That's right. Absolutely. And that goes for really any of the underserved populations. They are being neglected worldwide, and so I think there needs to be a wake-up call. If we are going to function as a society and as a community, we really need to understand how to help even the least privileged of our society, I think, especially so.

Andrew: Back to our topic, though. From a functional medicine standpoint, what are some of the other factors that might affect mood in teenagers?

Elisa: So, in terms of teen-specific issues, especially for teenage girls, one of the things that we need to think about is also hormonal contraception, right? The birth control pill. Because we know that the birth control pill has been associated with dysregulation and disruption to the gut microbiome. But then there was a really disturbing study that came out just in 2017 that found that oral contraceptives were linked with increased risks for suicide by twofold at least, especially for teenagers. So, teenagers between about 15 to 19 years of age had the highest risk of suicide after starting hormonal contraception. And this was even without a prior history of anxiety or mood disorders. So, that's one factor. 

When children... When our teenagers...and I'm seeing a lot of teenagers who wants to be on the pill not because they're having sex, but because they want to manage their acne or because they have really bad cramps or because they're really moody. And so we know... Or they have signs of PCOS. There are so many other ways from a functional medicine standpoint that we can address holistically PCOS acne…

Andrew: Yeah. 

Elisa: Really, all of those dysmenorrhoea that we want to try as much as possible to avoid oral contraceptives simply for that reason. So, that is a teen-specific issue that we need to be aware of, and then may be triggering and causing your teenager’s anxiety. So, if they're on the pill, you want to think, "Well, could it possibly be related to the pill?" Because I've had children when we're watching really acutely and aware of these risk factors, we can see the changes in their mood after starting the birth control pill, now we know, "Okay, this is not the right answer for this child." 

And then specifically for teenagers, of course, teenage years are a time of really reaching out more to their peer network, pulling away from their family and their parents. And so, we see with teenagers this massive surge in screen time use and social media use. 

Andrew: Yeah. 

Elisa: And this is where it's been controversial because so many people want to blame social media for all of our adolescence ills. And I absolutely believe it's part of it because there's cyberbullying, there's the comparison game, we know that there's been studies looking at Facebook, and Instagram, and Twitter, and Snapchat, and these social media platforms, and they've all shown there’s decreased happiness ratings after looking at your feed. 

But at the same time, social media can play a really positive role in connecting people, teenagers socially. And so it's really, when I looked at some of these studies at really how much the screen time and how much does social media really affect our teens, it absolutely can increase teen anxiety and even risk for suicide ideation and even suicidality. But the most protective factor was face to face communication. 

Andrew: Wow.

Elisa: The in-person interaction. That was the most protective. And the other thing that was protective was exercise, right? And so these things that were really not...where we need to focus on... And I would say, with functional medicine, functional medicine practitioners, functional medicine and integrative medicine, they are the medicine of the future. We need to change our healthcare system. But at the same time, we need to be careful that functional medicine doesn't just become about testing and about supplements. 

Because one of the foundations of functional medicine is lifestyle medicine. And for our teenagers, that is especially important. I'm going to be doing a lot of talking about how we can talk to our teenagers about understanding why it's so important to make these healthy lifestyle decisions and the impact directly to them because the more you can educate teenagers... Teenagers are smart, they're questioning the world, they're wondering why it relates to them, and really what they need to do to be in this world and be thriving in this world. So if we can educate them about the whys and not just tell them what to do, that will make a difference. Maybe less so and not as much as we'd want to in the short run but absolutely in the long run. 

And of course, we have our new addictions. You know, it's not just video game addiction, but we have this opioid crisis in the States with teenage addiction, and I don't know how much that is a problem in Australia, but I'm guessing you're not too far behind? And of course, there are these e-cigarettes, these vapes and these juuls that are rampant. And teenagers don't think that juuling or vaping is a problem. Because it's not smoking a cigarette, but we know it's a gateway into nicotine addiction and other addictions. And of course, sugar. I mean, sugar is the most...

Andrew: There’s an addiction?

Elisa: Yes. Sugar is the most dangerous legal drug that our kids can use. So, we have these addictions that really, our teenage brains are so primed for addiction because the way that their amygdala is firing and kind of, craving that dopamine, and their prefrontal cortex is not yet able to inhibit those impulses. And so those can become a spiral that kids have a really hard time getting out of. And addiction medicine is a completely different specialty of medicine. That if your child, if you have a teenager who is addicted, they don't just need a functional medicine approach, they really do need that specialised addiction medicine approach. 

But these are specific issues that we need to think about for teenagers. And as we think about these issues that can help guide us into thinking about, "Well, what kind of testing might we run? How can I get my teenager to buy into certain supplements and identify which supplements to target?" You know, I mentioned before, we talked about sugar, and how addictive sugar is, just as addictive as cocaine or nicotine or alcohol. But of course, that sugar addiction in kids and that chronic overconsumption of sugar really sets the stage for insulin resistance which we know is associated with anxiety. 

And then we're also seeing, as I mentioned before, that thyroid function can be really dysfunctional. And unless you're looking for it, you're not going to find subclinical hypothyroidism because that's not a test that's routinely run in teenagers. So, there are some tests when a teenager comes in and I have the opportunity to do some blood work that I will run.

Andrew: You spoke earlier about the OCP. They're not necessarily using it to have sex, but indeed to control their acne. But one of the constituents of there is Medroxyprogesterone acetate, which can cause insulin resistance. Then you've got issues with thyroid, you've got insulin resistance, and then you've got a weight problem, then you've got, you know, possibly polycystic ovarian syndrome in hand with that. And then you've got a body image issue. And then you've got an issue of social isolation or a lowered self-esteem, and then it just compounds and compounds. 

I'm just wondering, like, it really is becoming evident how important it is to look at our younger population in an integrative fashion or in a holistic fashion rather than just there is a disease or disorder and I need to treat that disorder. You need to go right back.

Elisa: Yeah, absolutely. 

Andrew: Just amazing.

Elisa: And I would say, we really need to start with really understanding, as parents, even before we become parents, you know, how to set that stage for health starting from when our children are toddlers. Well, even in-utero because we know preconception, right? There can be a lot of epigenetic programming that occurs for that baby. And so we need to step back and think, "Well, where do I start?" We can start from the beginning. And the beginning is even before than we think. But for teenagers, when you have a teenager in front of you, and we can't roll back the clock, but we can really help them see where the future could be headed if they're not willing to make that change.

Andrew: One of the biggest ones, of course, is going to be their diet. But yeah, I mean, I was... I don't know why I'm weird this way. I just always liked things like sauerkraut, and only because, I'll always remember, because it was part of a Reuben sandwich, and yet I just liked that sourness. But so many other teenagers don't like these fermented foods. They're into the, as you mentioned, quite high protein, high sugar. How do you gently nudge them towards things like fermented foods? How do you gently nudge them away from increased screen time, for instance. And to get back to a normal sleep pattern when you've got...we know about teenagers being that reverse sleep pattern? They're awake during the night and asleep during the day.

Elisa: Yeah. Yeah. With even that, I think really getting to know your teenager and see which is going to be the easiest thing to change for them? Because if we're asking them to get rid of the candy and the soda, and not use their screens at night, and start eating sauerkraut, they'll just walk away, saying, "Well, I'm not going to do any of that." 

And so if you can figure out which thing or things are kind of the lowest hanging fruit that are going to really help that child to move forward in the right direction. And for some kids... You know, I mean, this one child who...this one teenager I just saw that the only thing I said was, "For two weeks, for two weeks, we're going to get rid of that Boba tea." I don't know if you have boba tea, that tapioca tea, bubble tea. Do you have that in Australia? It's basically one of those sugary tea drinks. 

Andrew: Right. 

Elisa: Right? It's like a Starbucks Frappuccino, but it's the fancy new one, this bubble tea or Boba tea, tapioca tea. 

Andrew: Got you.

Elisa: So, this teenager was having maybe three a week. So, I said, "You know what? Let's just try having water or sparkling water, but a non-sugary drink and get rid of the Boba tea. That's it. Just get rid of the Boba tea and then you come back to me in two weeks and tell me how you feel." 

Andrew: Right.

Elisa: And then we make a little contract saying, "Anyone can do anything for two weeks if you just put your mind to it. You have to have a plan. If you're going to go to Boba tea with your friends, you have to have a plan of what you're going to drink instead.

Andrew: Yeah. 

Elisa: And not just go there and expect that you're going to have the willpower to not do it." And that's all we did. 

For another teenager, the one step we did was we made an arrangement, a deal, that he would keep a cell phone out of his room at that time. That it would stay in the living room and charge in the living room, and he wouldn't look at it until the morning because he was getting out to look at it and text. Right? And so figuring out what's that one thing you can do first? And with your teenagers, you may be meeting with them for shorter time periods but more frequently to figure out, "Well, how did that work for you? Let's try this next step." And instead of coming up with a 10-point plan and I'll see you in 2 to 3 months, coming up with a 1 or 2-point plan and maybe I'll see you back in 2 to 3 weeks.

Andrew: I've got to ask a question about you as a practitioner now. How do you handle a continued frustration with, "Oh, okay. So, you're back again and you're still are looking at your phone at 3:00 in the morning and you went back to Boba tea," or the sort of failures of compliance, if you like? How do you as a practitioner handle him? Do you internally just say, "I have a white light. It's not affecting me. Okay, let's do this again"? Like, how do you protect yourself? 

Elisa: Yeah. I mean, it can be very frustrating. And sometimes what's really frustrating is more...I don't want to say undermining, because parents really want the best for their kids, but when parents are nagging and saying, "Why can't you just do this?" you know, blaming the teenagers, and I can see the teens rolling their eyes. Then that's not very helpful because, I mean, if you've ever been told what to do, it never goes well, you know, even as an adult. 

And so one of the things that I do and I do it gently, but I will call teenagers out on if they've made a promise and not followed through, or if I see that I'm talking to them and you can tell that their eyes are glazing over, I'll say, "Look, I can tell that you're totally disinterested. You're not going to do what I just asked, are you?" And then they'll look at me and say, "Well, I probably won’t." Then I'll talk to them about, "Well, let's talk about what you are willing to do." 

Andrew: Yeah. 

Elisa: And for teenagers who consistently aren't making any changes… this one teenager, I looked at him because he was in a very different place when he came to me his junior year. Failing at a school, really from being a remarkable student in middle school and even freshman year doing really well. Wanting to go to college, you know, having a career path, wanting to be an architect, so failing out, and really being at risk for not graduating from high school. And after, I don't know which visit, maybe it was the third visit, I looked at him, I said, "Hey, are you really interested in getting better? 

Andrew: Yeah. 

Elisa: Do you really want to go to college?" And I asked him to think about, "When you were that 13-year-old, 8th-grade kid looking ahead towards high school and college, if you saw who you are today, would you have wanted to become this teenager?" 

Andrew: Ooh, yeah. 

Elisa: Right? And of course, he said, "Absolutely, no," because that wasn't his goal. That wasn't his dream teenager to be. And I knew that. And I had a good relationship with him and his family, so I could call him out on it and I could say, "Look, you and I know this is not the kid you want to be. It's just that you're stuck now in figuring out how to move beyond that. So, you have to trust me that this one step you need to take now. And then we'll figure out the next steps."

Andrew: That's such powerful words, Elisa, "You need to take this step now."

Elisa: Yeah. I mean, sometimes we have to be a little directive in a loving way. But with teenagers, a little wiggle room, and their brains will interpret it as, "Oh, it's not necessary." 

Andrew: Yeah. Elisa, you mentioned something a while back there, and that was regarding the use of antibiotics for acne, the low dose doxycycline, for instance, at 100 milligrams. So, that's below what's termed as the Minimal Inhibitory Concentration, the MIC. And I just remembered something that… it was a conversation that I had with a dermatologist. So, they were telling me about a patient who was on long-term doxycycline. And I was saying, "Well, but isn't that a non-issue because it's low dose doxy, it's only 100 milligrams so it's below the MIC?" And they said, "Well, it's below the MIC for an infection, but it's not necessarily below the MIC for your commensal bacteria," which was a huge light bulb moment for me. Massive issues here. It's another call out to really look earlier about interceding in an integrative holistic fashion rather than just going down the very simple, attractive drug route to a short term fix.

Elisa: That's absolutely true. Now, we can sit here as adults who've kind of moved beyond our acne days and say, "Well, let's try diet and let's do...make sure that we understand how to take care of our skin, and which tropicals to apply." 

But as a teenager, and seeing a lot of teens in my practice who do have really, really terrible cases of acne, and you tell them, "Look, the two foods that are going to be the most significantly correlated with your acne are going to be dairy and sugar, so let's try cutting it out." And they're looking at you thinking, "Well, I'm not giving up my pizza and I'm not giving up my Gatorade." Even for their skin, although some surprisingly will, right? 

But that acne especially if it's cystic and all over their face, in their chest, in their back, and it's prom, and they need to be in a strapless dress. I mean, it can be really not just physically scarring, but emotionally scarring and socially devastating. And so I have had kids, after we've had this discussion, decide that they do want to do the low dose antibiotics or that they do want to be on the Accutane temporarily. And so then we just have a conversation about, "Well, what does this mean? Let's understand whatever medicine or supplement we take." We always want to question, "Well, what are the side effects? And what are the potential adverse consequences? And how can we mitigate those? How do I, knowing that antibiotics are going to disrupt my gut microbiome, and increase my risk for later autoimmunity or mood disorders or whatever have you…

Andrew: Yeah. 

Elisa: How do I preserve and protect my gut microbiome?" And that means, "Okay, let's have a conversation about what kind of foods we can do that will help protect your gut microbiome if you're choosing to be on these antibiotics for a long term. Or taking probiotics and eating fermented foods and trying fermented foods if you haven't already had them as part of your diet and taking a little extra glutamine." 

These are just some of the things that they need to be aware of so that they're making a fully informed consent.

Andrew: Yeah. 

Elisa: Because unfortunately, in the conventional world and not knowing many of these well-intentioned conventional doctors, they don't really know the full story of what these adverse consequences are. So, if we can inform our teenagers and help them understand really how to make those good decisions, not just around their acne medicine, but even later on. You know, around their cholesterol medicine when they're adults. They're going to have those skills to really be good health care advocates for themselves for the rest of their lives.

Andrew: Now, you're coming out to Australia, as we said earlier, in August 2019. What can praccies expect, apart from just what we've spoken about, in the seminar series?

Elisa: So during the seminar series, and I'm really excited because I'll actually be in 5 different cities over a 10-day period, giving 2 seminars. The first is going to be on what we need to know from a functional and integrative perspective on teenage anxiety. Much of what we've spoken about today, but going a little deeper into some of the potential triggers that we need to understand and possible testing options and treatment options for our kids with teenage anxiety. Whether or not there are medications, because we know that only about 20% of kids will actually find long-term relief on antidepressant medications. 

And then the second, I'm really excited about, the second talk will be on clinical clues in paediatric functional medicine. Because there's such a paucity of functional medicine practitioners who are really comfortable in seeing and treating children. But there's such a need especially with the surge of childhood chronic disease. 

And so during this seminar, we're just going to be really taking a deep dive into how could we, even if our testing capabilities are limited, what are the signs, clinical signs and clues that we might see in a child, for the most common core biochemical imbalances, mitochondrial dysfunction, mast cell reactions, other signs of chronic immune dysfunction? And how do we know then if we can run tests, what test we may run, what supplements, diet, and lifestyle factors might we consider in their treatment plan? 

So, really, some of the pearls that I've learned over my past 15 years as a paediatric functional medicine doctor.

Andrew: I can't wait to see you again to hear the lessons that you teach because I always learn from every single thing that you say Dr. Elisa Song. Thank you so much for taking us through just the very tip of the iceberg with teenage health, but some really salient lessons that we need to watch out for and be aware of how, I guess, we are placed with talking with our teenage patients. Thank you so much for taking us through these issues today.

Elisa: Oh, yeah. Well, thanks for having me again on the podcast for the third time, and I'm so excited to come to Australia and see everyone.

Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook.


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