This week on Nevada Week, several experts say children are facing a mental health crisis in the wake of the pandemic, but there's no "one size fits all" solution.

So where do parents and caretakers start?

Plus, two leaders in Alzheimer's research in our state update us on efforts to help patients suffering from this widespread disease.

♪♪♪ Support for Nevada Week is provided by Senator William H. Hernstadt and additional supporting sponsors.

Welcome to Nevada Week; I'm Amber Renee Dixon.

May is Mental Health Awareness Month, and according to an April report from the Centers for Disease Control and Prevention, the COVID-19 pandemic worsened the mental health issues that adolescents had already been experiencing.

Joining us to talk about what they're seeing right now in the children they work with is Janet Nordine, a licensed marriage and family therapist and a registered play therapist with the Center for Connection, and Sheldon Jacobs, a licensed marriage and family therapist as well as the vice president of the National Alliance on Mental Illness in Southern Nevada.

Thank you both for joining us.

Sheldon, I will start with you.

What issues were you facing prior to the pandemic, and what has changed since the pandemic?

(Sheldon Jacobs) I would say prior to the pandemic, a lot of the kids I was treating were struggling with depression, was a big one, and milder forms of anxiety.

But since the pandemic, anxiety has been through the roof.

I've been receiving phone calls pretty much on a daily basis from parents indicating that their kids are struggling with excessive worrying and just a lot of anxiety, and I think that's directly related to the pandemic.

-And I'll ask you, you have mentioned to me as well that you're getting a lot of calls from parents regarding anxiety issues among their children.

What are they experiencing, these kids, in terms of anxiety?

What's causing them anxiety, and is there a difference between what issues children are facing versus teens?

(Janet Nordine) Yes.

I am seeing a lot of anxiety because of the isolation children experienced during the pandemic.

Still, even after a full year of school acclimating back to being in an environment with other peers, bullying is a big deal which is causing anxiety and depression, also dealing with parental relationships.

You know, if our parents aren't getting along well, then the child is having more anxiety as well, and I've seen this amplified since the pandemic and since we've been reacclimating ourselves back into life.

-I would imagine parental issues are something you're seeing as well, the pandemic-increased stress among everyone.

-Absolutely.

I think with kids, they tend to replicate what they see at home, so if parents are stressing out and they're dealing with other various issues, those kids are going to take on that stress, that anxiety that's being manifesting inside the home and they're going to easily replicate it in other settings like school.

-And that would perhaps be something from a parent maybe losing a job as a result of the pandemic.

Have you been dealing with children who have lost loved ones from the pandemic?

-Yes.

I have several clients that have lost grandparents and extended family members to the coronavirus and other issues that happened during the pandemic, and it's been a lot of grief and loss work.

-What do you say to these children that you're speaking with?

-What I say to them is it's okay to not be okay.

It's okay to be feeling the feelings that you're feeling or struggling with the problems and issues that you are experiencing, that you're not alone.

So it's really just trying to normalize it as much as possible and really just commending them on wanting to get help and to receive the support.

-Would you suggest that be the approach that parents take with their own kids?

Where should they start with this if they are unsure whether their child is experiencing mental health issues?

-I ask parents to just ask the basic question: Are you okay?

How are things going?

Not to have leading questions or not to ask black-and-white, yes-and-no questions, having an open-ended dialogue.

Just that question "are you okay" tells the child that my parent is paying attention to me and they're really interested in what's happening in my life.

-Have you noticed a difference between the issues that teens are facing versus children, and what should the approach for parents be based on the age of their child?

-I would say yes.

With the teenagers, I see a lot of issues connected to like social media, issues connected to just, you know, the tablets and the video games and some of the isolation that stems from that even.

With the younger kids, you know, I think the issues are a little bit different.

You know, I see more of the externalized behaviors with the younger kids, so acting out in school, acting out at home, not telling the truth on a regular basis or things like that.

Whereas the teenagers, a lot of times they tend to internalize what's going on, so they tend to keep it within themselves.

Not all teenagers, but a good number of the ones that I treat.

-And children don't often have-- or sometimes do not have the vocabulary with which to express themselves adequately.

That's why it's important for you as a registered play therapist, you are able to interpret what they're feeling through how they are playing.

What are you seeing from children?

How are they playing, out of curiosity, that will indicate what's going on?

-I see for example in a dollhouse, a child may put all the furniture I have in the whole dollhouse but only one person, and that usually represents themselves.

That will tell me they're feeling alone or lonely.

Or maybe they've put all the furniture and all the animals, because that's who they feel safest with.

Or the parents are external, somewhere else, not even in the home but they're in the picture but not in the dollhouse.

I also do a lot of expressive art where I'll ask a child, can you draw what you're feeling?

Can you draw that anxiety?

Make a picture of it.

What does that look like?

Because they don't have the vocabulary yet to express exactly the inner world that they're feeling, but they can put it out on paper, and it's amazing what they come up with.

-You are trained in talking with children and teens and perhaps pulling those emotions out but not all parents are, so for a parent speaking with a teen who may just say oh, I'm okay, what is your strategy for parents?

-Actually, the biggest one is not even talking but just listening.

I think as parents, and sometimes it's a hard job, but a lot of times for parents, we tend to get reactive when our children are telling us something that maybe is a little bit uncomfortable.

So I think the biggest thing that a parent can do is to just listen to what they're saying and just be supportive.

Let your children know you're there for them and provide them that sort of comfort and just that feeling of being safe.

I think that's key, and I think that, you know, if you're able to establish that, I think your teenagers will be able to feel more comfortable and feel more willing to open up to you.

-That takes work.

Remind me again, Janet, what the question is that parents should be asking, and is that question applicable for both children and teens?

-I really think it is: Are you okay?

Like how does that feel just to an adult when somebody asks you, how are you?

How are you doing?

What's really going on with you?

That tells the child my parent is looking at me.

They know what's going on.

They see something in me that may be off, and then to follow up with "help me understand that a little bit better."

Not to get your tool belt out immediately and try to fix it and give advice, but just really listen, like Sheldon said.

That's the most important thing.

-What are the words you're listening for to determine whether it's a serious issue?

-I would say especially parents know their kids better than anybody, so any subtle changes in vocabulary or behavior.

So if they're saying things like I'm going to hurt myself or I don't want to live anymore, or if they're, you know, fixated on death or dying, that can be a sign that something more underlying is going on, or even just words maybe questioning themselves or, you know, overly critical of themselves.

It can be negative self-talk is also a common one.

So any subtle changes in language or behavior I think is a sign that maybe something more underlying is happening and you may need to dig further as a parent.

-The word "suicide" often scares a lot of parents.

There's a thought that if I bring that up with my child, I might plant a seed in their brain that this is something they should be considering.

What would you say to that?

-I would say it's exactly the opposite.

It's like a pressure cooker where you've released some of that steam where the word has been brought up.

It's not a taboo or secret anymore, and now we can really address it and look at it in a way that isn't scary and we can talk about the big feelings we're having.

If kids are feeling suicidal, that doesn't necessarily mean they want to die.

They need a way to express themselves and to get help.

-When you do hear from a child or teen that they're considering self-harm or suicide, what is the first step you take?

I would think I got to take immediate action.

I mean, then I think that's where parents end up in the emergency rooms with their children which is not helpful, or is it?

-Well, action is a positive thing, but I think before you even go to that place, I would say listening, see what's going on first, being supportive, understanding.

You know, one thing that we do not want to do is we do not want to retraumatize a child that's, you know, having a crisis or is struggling.

So just being as supportive as possible and hearing them out, listening, and then from there kind of assess the situation.

And then if you need to take them to get seen, whether it be if they have a therapist or if it's going to an emergency room to get assessed so they can potentially go to a psychiatric hospital, you know, that's usually kind of, you know, under extreme circumstances.

-Extremen circumstances, and the governor has announced some funding for crisis stabilization centers, up to six according to the Review-Journal, that will act as psychiatric types of emergency rooms.

But let's say you've established yes, there's something going on with my child, I'm going to get them help, what's the likelihood of them getting an appointment anytime soon?

How accessible is mental healthcare for children?

-Unfortunately, it's not as accessible as we would like it to be.

I know that I have a waitlist.

I know other therapists that work with children have a waitlist.

If I get a call from a parent that says my child is suicidal, I'm going to try to really work with them to get them in a little sooner than the waitlist.

-Okay.

What's the reality from your perspective?

-It's the same, unfortunately.

That's our reality right now.

There's a lot of children and families that are in need.

I think that's been exacerbated because of the pandemic, so I think that a lot of clinicians in the community have waitlists, unfortunately.

But there's some that do not as well, and I think sometimes it's a matter of just searching.

Just kind of like, you know, if you're going to a hairstylist or a barber, you know, finding the right one and sometimes it can be a process.

The unfortunate thing is, you know, if your child is in a crisis, that can make things a little challenging and frustrating.

-Also as part of the governor's announcement, a new 9-8-8 hotline will be established in July.

What impact will that make instead of someone calling 9-1-1?

-I think the impact is going to be huge, because a lot of times when families call 911, usually they're met by a law enforcement officer, and all respect to our law enforcement officials, they do a great job with the training that they have, but they're not licensed clinicians.

So I think, you know, with this new number, you're going to have licensed professionals responding which will I think also be a deterrent from, you know, kids going into the juvenile justice system.

-Thank you both so much for your time on this important topic.

We move to Alzheimer's disease now.

It's likely you've known someone impacted by the brain disorder that attacks memory and thinking skills.

According to the Alzheimer's Association, about 1 in 9 Americans aged 65 and older has Alzheimer's and that among the 50 states, Nevada is one of the fastest growing in terms of Alzheimer's disease populations.

A 30% increase in Alzheimer's patients is expected in our state by 2025.

Those statistics further highlight the importance of a partnership between UNLV and Cleveland Clinic Nevada.

A National Institutes of Health grant made the partnership possible in 2015, and now a recent grant extension will allow the two groups to continue building upon their Alzheimer's research.

Joining us to talk about what's been accomplished and what hope there is for Alzheimer's patients is Dr. Aaron Ritter, staff neuropsychiatrist at Cleveland Clinic Nevada, and Jefferson Kinney, founding chair of the Department of Brain Health at UNLV.

Gentlemen, thank you so much for being here.

I want to start with you, Dr. Ritter.

Nevada, one of the fastest growing states with Alzheimer's disease population.

Why?

(Dr. Aaron Ritter) Well, the biggest risk for Alzheimer's is age, and the great thing about Nevada is it's got great weather so people are moving here, but they're moving here at a time when we have an elderly population.

So that's why we're seeing a lot more cases of Alzheimer's disease.

It's just a common disease that happens after the age of 65.

So our center and UNLV, it's a commitment to the community to better care for people with Alzheimer's disease.

We're really excited about this grant and this opportunity to continue to advance the science of Alzheimer's.

-Jeff, I think I said Jefferson earlier but you said I could call you Jeff.

-Absolutely.

-Since the start of this partnership, what have you accomplished, what's most notable, and then what do you want to accomplish in phase two?

(Jefferson Kinney) So that's a really good question, and there have been a lot of accomplishments in the project.

These grants are designed to not only foster research and also foster patient care but also to help develop the next generation of researchers to continue to expand on the research.

So we've had a number of investigations as part of the first phase of this grant that have led to some really interesting novel discoveries about differences between men and women in Alzheimer's disease.

There have been some basic research advances about new mechanisms that may be driving the disease, and probably most noteworthy is we have created a very strong, well characterized cohort that is used for a lot of these studies.

So we have members from the community who are invested in part of the projects with us, and what we collect in these projects is data that advances our understanding of the research.

So as we move into this second phase, the real opportunities is to continue the growth that we've had, to really drive new science and new discoveries, and also really have an impact in Southern Nevada for patient care.

-I understand "biomarkers" is something you're after.

What is that, and how will that help?

-Yes.

We've managed in the first part of this grant to develop a biomarker laboratory that allows us to look at blood samples from patients to look for markers of the disease, and these are really a needed thing in Alzheimer's research, the ability from a blood sample to do a test, and I think we're very close to this, to test for a good predictor that the disease is coming because that means you can start to intervene earlier.

You can understand the disease earlier.

These biomarkers can also be used to tell whether or not new treatments are being effective in patients that have the disease.

So we have built this very large framework to do a fairly unique model of evaluating patient samples that come from our clinical cohort for us to both examine existing biomarkers that others develop but also generate brand new ones here in Nevada.

-Dr. Ritter, back to the specifics of this grant.

It is the Center for Biomedical Research Excellence Award, and it's specifically meant to benefit historically underfunded states.

Why is Nevada underfunded, and why should it not be?

What makes this population here unique and beneficial to your research?

-So anybody that's lived in Nevada long enough knows that a lot of times in the past, we've had to go to California or New York or Seattle to participate in groundbreaking research, and that's just been the reality.

It's kind of the way the medical community has evolved.

That we're bringing grant work here, we're bringing scientists here, new scientists, we're collaborating with a brand new school of medicine, a brand new Department of Brain Health at UNLV, the Ruvo Center, it's 10 years old.

That's all it's been here.

So we're wanting to bring the science here because that's where the patients are.

That's where the people of Nevada are very interested in advancing the science of Alzheimer's disease.

So we have the patients, now we have the scientists and we have the science to be able to make some real big strides in understanding this disease.

-And what about the socio-economic makeup of the population here, and you're also going out into rural communities, correct?

-Absolutely.

So historically Alzheimer's disease research has been done in big cities with this kind of very homogenous patient population, and that's not right.

Our goal is to reflect sort of the great diversity of the state of Nevada.

We have people that come from all over the world to be in this great city that we have, so we want to be able to reflect who actually gets the disease because this is a disease that is prevalent all over the world.

We don't know why people get it, but people get it in China, they get it in Africa, they get it in Australia, they get it in the United States, and so to be able to understand those differences that may be contributing to the disease, our goal is to enroll people that look like our neighbors and our community members.

So that's also, you know, the nice thing about bringing a grant here to the state and to involve the big players in the city.

-You mentioned we don't know why people get it, but people from all over the world get it.

What is the cause of Alzheimer's?

-I wish we could actually give you the answer, right?

This is one of the largest questions in this disease, and there has been tremendous progress for decades now.

We are learning more and more every year.

Our group, other groups, are really advancing the basic biology understanding, but also the things that contribute to it.

This includes there are risk factors that make someone more likely to develop Alzheimer's disease and trying to understand that association.

There's the core pathologies of the disease that we are still trying to decode, but the advances are moving fairly quickly and this is also translating into new treatments being developed fairly quickly.

-How long has the idea existed that the cause of Alzheimer's is related to plaque buildup of proteins in the brain?

-Since the very first doctor that described this, Dr. Alzheimer, 1908.

So he was able to-- one of his patients, he was able to secure the ability to do an autopsy, and he saw these plaques and tangles.

That's still what we're talking about with Alzheimer's disease research.

So it's been 100 years.

We've made some advances.

We kind of understand what these plaques and tangles are and what the potential genetic components are, but we don't know why they accumulate.

And we see patients all the time at the Ruvo Center that have no family history and they may develop the disease even early on, and we have no idea why that's the case.

So it has to be something in the environment.

It has to be something in the brain's internal environment that predisposes people to the disease.

I think there's a misconception that this is a genetic disease, because there is a genetic form of Alzheimer's that doesn't skip generations.

But for 95% of the population the risk is age, and everybody that plans live over the age of 65 is at risk for this disease.

Age is the number-one risk factor.

-So you go back to in addition to age, the plaque buildup, and you think let's get rid of that plaque buildup, which is what drugs are currently doing.

There was a drug, Aduhelm, approved by the FDA that did just that.

But then in one trial, it showed it had no real impact on improving memory, preserving memory.

Another trial, it didn't work at all.

Medicare is not going to cover it for most people.

Also, the Cleveland Clinic is not going to prescribe it.

So why?

-It's a difficult question to answer.

So we know that these plaques have a role in the disease, because that's what the genetic version of the disease is.

You develop these plaques at a higher rate and those people get Alzheimer's disease, the familial version.

So these plaques have a role.

Now we have a technology that can clear the brain from these plaques and in a trial of a year, and a year and a half, it didn't demonstrate the benefit we'd like to see clinically.

It's hard to show benefit in Alzheimer's disease, which is a chronic disease, in one year.

But we have a technology now that can clear these plaques from the brain.

That's a huge breakthrough.

That's a step forward for the field.

Whether or not it's the right prescription or medication for everybody right now, I think that's the question that we're wrestling with at the Cleveland Clinic.

That's the question that CMS is wrestling with, and that's the question the FDA is continuing to wrestle with.

So it's still a nice breakthrough for the field, but I think the point is we need to understand this medicine a little bit better and to definitively prove who this could be helpful for because it doesn't help everybody.

But there's some people that are helped by this medicine, that's what the data seems to show, so we really need more research.

-Yes, I think it's really also worth pointing out that this is the first of many, right?

So progress is by all means the first largest priority.

So this drug shows some promise, but there are several other in the pipeline similar to it.

There are also a number of other medications that target different aspects of Alzheimer's disease that are also in the pipeline.

So as long as the work is progressing forward, this is a breakthrough because it's been since 2003, I think, was the last FDA approved treatment for Alzheimer's disease.

This is a big step forward.

Now the goal is for all the other ones in the pipeline to develop and also to figure out how best to use this one and the other ones that are in development.

-Then you go back to the idea that perhaps the plaque buildup is not what's causing Alzheimer's.

Are there other hypotheses being floated around as the cause?

-There absolutely are, and what I think is a really important thing to point out here is how much the plaque is causative in the disease is 20 years ago, it was probably a larger proportion than what is thought these days.

The greatest breakthroughs in Alzheimer's disease research of the last 20 years has been that the field has started to diversify.

So groups are chasing the plaques, groups are chasing the tangles.

There are research projects, some of the research within my group is on inflammation in the brain, and it drives some of the Alzheimer's pathology.

So what we're really starting to learn is this is a complex ensemble of pathologies that gives rise to Alzheimer's disease and that there may be some variations in it.

So rather than focusing on a singular feature, the idea is to look at all the possible mechanisms.

And that's where the greatest advances that have have come, especially in the last 10 years, of how we are advancing a more diverse series of mechanisms.

-Dr. Ritter, I want to make sure you talk about the importance of having people come and participate in what you're doing in order to find a cure.

-Well, anybody that's ever had a family member with this disease knows the treatments we have right now, they're not going to cut it especially with the rates increasing, and that's because people are living longer.

We have better medications for your heart, for your lungs, for HIV, for cancer, so people are living longer.

That's a great thing.

But now we need to be able to translate that long life into long brain life, so we need to be able to advance the science to continue to do that, and we don't do that without participants in research studies.

So we have over 200 people that are participating in our study.

We're grateful to them.

We've been following some of them for seven years.

They come in every year, do a brain scan, they get blood drawn.

There's a lot of people that have contributed in the valley that can now contribute to Alzheimer's disease research and we're grateful for them, and they're helping us advance our science.

We had 10 people that participated in the Aducanumab study here.

They've advanced our science, so we're hopeful that we can continue to do experimental research here in the state and that the next treatments are better and we get to the point where we can actually really help patients.

This is a starting point.

I think this medication is something that we're very excited about.

Even if this gets approved and it gets available to the general population, we want to stop it before the symptoms start.

I mean, that's really kind of the goal and Aduhelm, at the best it's going to keep people stable.

I mean, at the very best, and we want to do that before the symptoms start, before before things kind of go awry.

-And just to clarify, Aduhelm and-- -Aducanumab.

They're the same.

They're kind of the same thing.

One is the generic and one is the brand name.

-Gentlemen, thank you both so much for your time.

(both) Thank you.

-And thank you for joining us on Nevada Week.

For any of the resources we discussed here including links to mental health and suicide prevention resources, go to our website at vegaspbs.org/nevadaweek.

You can also follow us on Facebook and Twitter at @vegaspbs.

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