The immune-compromised vs. COVID; war's impact on kids; ADHD guide for parents: Upstate Medical University's HealthLink on Air for Sunday, April 10, 2022

Host Amber Smith: Coming up next on Upstate's HealthLink on Air, an important discussion with the chief of infectious disease about why people with compromised immune systems still need to protect themselves from COVID-19.

Elizabeth Asiago-Reddy, MD: ... When we're thinking about how sick someone is likely to become when they encounter COVID, there are a whole host of conditions that raise the risk of severe COVID ...

Host Amber Smith: A psychiatrist discusses the effects of war and becoming a refugee on children and adolescents.

Nayla Khoury, MD: ... One of the most important factors for a young person to support resiliency is the emotional and physical presence of at least one supportive adult or caregiver ...

Host Amber Smith: And a professor of neuroscience tells what to do if you think your child has attention deficit hyperactivity disorder. All that, and a visit from The Healing Muse, coming up after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, a psychiatrist talks about forced displacement and war and the impact on children and adolescents. Then, a neuroscientist gives some expert advice about what to do if you think your child has ADHD. But first, people with compromised immunity still need to be taking precautions against COVID-19.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." People with compromised immune systems are more vulnerable to viruses, including COVID-19. In this interview, we'll focus on issues that matter to the immunocompromised with Dr. Elizabeth Asiago-Reddy. She's the chief of infectious disease at Upstate and an expert in how the immune system functions. Welcome back to "HealthLink on Air," Dr. Asiago-Reddy.

Elizabeth Asiago-Reddy, MD: Thank you very much for having me.

Host Amber Smith: I've seen estimates that 3% of people in the U.S. are immune compromised. What are some of the reasons a person's immune system may not be functioning properly?

Elizabeth Asiago-Reddy, MD: Actually, especially in the United States, the major reason why people have immunocompromise is due to treatments that we are actually giving them for another health condition. So examples of that include chemotherapy for cancer, medications that are given to people with, for example, an organ transplant. So if you have an organ transplant, you need to take medication to suppress the immune system so your body doesn't reject that organ. And also people who have autoimmune or inflammatory conditions such as Crohn's disease, for example, lupus, those individuals need to take medications to calm down the immune system and prevent the types of responses that are making them sick.

So those reasons are actually the most common reasons why people are immune compromised. Additional other causes include the HIV virus, which is known to cause immune compromise. Although how immune compromised people are when they're living with HIV really depends on their treatment status. And then also certain people are born with immune system problems. So there are rare conditions, but certainly they do exist, where someone might be born with a defect in the immune system that places them at increased risk of infection.

Host Amber Smith: Is there a difference between those with compromised immune systems and those during the pandemic that we've seen described as "high risk." People with diabetes or heart disease, they were categorized as being at high risk, but are they high risk because their underlying disease impacts their immune system, too?

Elizabeth Asiago-Reddy, MD: Yes. I like to look at this in two separate ways. One is, what is the risk of somebody becoming very severely ill or even dying if they acquire COVID? So that's the first question. And the second question is, how likely is it that someone will respond adequately to a COVID vaccine? And those two questions are interrelated, but they're, slightly different. So, when we're thinking about how sick someone is likely to become when they encounter COVID, there are a whole host of conditions that raise the risk of severe COVID. And, when you're looking at the whole population, that includes things that are very common, such as obesity, diabetes. Those ones have really actually been involved in some of the lion's share of the severe complications that we've seen with COVID because those are very common conditions. Another one that we really can't forget about is age. So, if you look at it as a condition, age is probably what is most significantly associated with elevated risk when it comes to COVID. So we know that compared to, for example, an 18-year-old, an 85-year-old, is 10 to 15 times more likely to die of COVID. So it's very significant as we age. And then numbers of conditions, people who have multiple different conditions at the same time. As you add on conditions, you get higher and higher risk of severe disease.

Now, the ones that I was mentioning earlier, the severe immune compromised. People who have severe immune compromise, who include those individuals who are actively taking chemotherapy or taking medications to suppress their immune system, who have organ transplants, an innate immune disorder or an uncontrolled HIV infection. Those individuals have two significant problems. One is that they are at significantly increased risk of very severe COVID, if they do catch COVID. And number two is that they also do not mount as good of a response to the vaccines as others. And what I mean by that is something called immunogenicity. So immunogenicity is how well our body makes antibodies after we're given a vaccine. The better job our body does of making antibodies, the more likely it is that we will be protected when we encounter a particular condition, the condition that we are vaccinated against. So, the severely immune compromised individuals are less likely to mount an immune response. So their immunogenicity to the vaccines is weaker and, that's an additional risk factor for those individuals, because it could be that even though they go through the full vaccine series, they might not be as well protected as others.

Host Amber Smith: You mentioned about the immune system in older people not working as well. It made me wonder, are babies born with a fully functioning, powerful immune system, or does it take time to sort of develop after they're born?

Elizabeth Asiago-Reddy, MD: Babies are, generally speaking, also immune-compromised individuals. Uh, they're unique because they are developing their immune system very rapidly. And so they're sort of in their own special category in terms of how immune compromised they are. But neonates, which is during the first month of life, are particularly at risk for severe illness and infections. And up to the first six months of life, babies are higher risk for a lot of different infections compared to, as they get older. Maternal antibodies are one of the prime ways that babies are protected against infectious diseases. And those maternal antibodies are transmitted through the placenta prior to birth, and then they're also transmitted during breastfeeding.

So, this is one of the reasons why maternal vaccination during pregnancy is so important when it comes to COVID. Because that's actually been demonstrated that infants born to parents who are vaccinated have actually detectable levels of antibodies against COVID when they're born. And those antibodies appear to, by and large, persist all the way through six months of life.

Host Amber Smith: Regarding immunogenicity, is there an affordable way for someone to be able to tell whether their vaccination is working?

Elizabeth Asiago-Reddy, MD: Unfortunately, there is not a very clear-cut way. So you can go and ask your primary care provider or even your specialty provider to do a COVID antibody test on you. And there are two major COVID antibody tests that are commercially available. One looks at the spike protein, and the other looks at the nucleocapsid protein. All the vaccines that we have available are against the spike protein. So anybody who has either been sick with COVID or who has had a vaccine, ideally should have a positive test for the spike protein. The nucleocapsid protein is not part of the vaccines. So if that one tests positive, that indicates that the individual has had a natural infection. So you can get some sort of a sense if you have a positive antibody for either of those. The problem is that, that is not a perfect assessment of what will happen when you encounter the virus, because the commercial assays only go up to a certain level. They only have a certain amount of antibody that they're assessing. And then also, they're only looking at that one particular antibody, whereas the antibodies generated during vaccination or infection and are much broader than the one antibody that's being examined. So. I will say that with the currently available, so for example, the spike protein assay that we're using here at Upstate, the cutoff for that is 250 international units per mil (milliliter). And if you have something that's 250 international units per mil or higher, you don't know how much higher after that. And the available data suggests that as the virus mutates, we probably need higher and higher levels of antibodies to be fully protected.

So it leaves the gray zone where we just don't have a good sense for how well protected somebody might be after doing that test. On the other hand, I can say that if somebody does not have a positive spike protein antibody test, and they have been vaccinated, that is very concerning, that they will not be adequately protected. Or, even if they have a low titer. So let's say, I just mentioned that 250 international units per mil. Let's say they get a result of 50. That would also be very concerning to me that that individual would not be well protected if they encountered the virus.

Host Amber Smith: So given that the vaccine maybe isn't working as well in people who are immune compromised, what are the recommendations for vaccination?

Elizabeth Asiago-Reddy, MD: So for those individuals who fit into the moderately or severely immunocompromised category, and those are the individuals that I mentioned previously, they would be recommended to get three doses of an mRNA vaccine upfront. So the mRNA vaccines include the Pfizer vaccine or the Moderna vaccine. The typical primary series for that is two shots separated by either three or four weeks, in some cases now eight weeks. Then after receiving their second dose, you would wait 28 days and give them a third dose. After that, they are still in the pool of people who would be recommended for a booster after five months. So they end up, with the current situation that we have, with a total of four vaccines, if they've received an mRNA and a vaccine series -- three as part of the primary series, and then their five month booster.

The Johnson & Johnson vaccine is a bit different. There's no specific recommendation for immunocompromised people that's different from others. So that now is recommended as a two dose series with a primary vaccine followed by another vaccine after two months.

Host Amber Smith: Where does this new medication I've heard of Evusheld, where does that come into play?

Elizabeth Asiago-Reddy, MD: So Evusheld -- or it's tixagevimab/cilgavimab -- is a monoclonal antibody cocktail. So there are two different antibodies in it, both against the spike protein. And, initially this product was tested as something that could be used to immunize people who basically hadn't gotten a vaccine, so it was actually studied around the same time that vaccines were being developed. And initially it was studied in all comers. So, it was an adult study, but there was no specific inclusion criteria that related to severe immune compromise. It was just looked at it as, is this a product that can help prevent COVID? So, what this product is, is it's an intramuscular injection that's given. So it's two different antibodies. It's given in the gluteals. And it's one dose on either side, and that's every six months. So it actually is a very long-acting preparation that lasts in the body for six months. The initial data -- again, this is with all comers, so people who had potentially healthier immune systems than the folks who are using this now -- they showed a 78% reduction in risk of acquiring COVID after having received this product, compared to individuals who received the placebo. So it is highly effective. And it appears to function, at this point, as far as we can tell, against all the circulating variants of the coronavirus.

Host Amber Smith: "HealthLink on Air" has to take a short break. Stay tuned for more information from Dr. Elizabeth Asiago-Reddy about how COVID-19 affects people with compromised immunity.

Welcome back to "HealthLink on Air." This is your host, Amber Smith talking about COVID-19 and the immunocompromised with Dr. Elizabeth Asiago-Reddy. She's Upstate's chief of infectious disease.

If people with compromised immune systems have had to be cautious during the pandemic and sort of behave like they're unvaxxed, just to be safe, what about the people who live with them or have close contact with them? Do they all want also need to be as vigilant?

Elizabeth Asiago-Reddy, MD: Ideally. COVID, by and large, is an infection that spreads within families and close contacts. So we know over and over again from experience that times when people are gathering together with others, not necessarily in giant crowds, but in groups for special events, holidays, et cetera, we see significant spikes in the community. So yes, absolutely. If you are living with somebody who is severely immune compromised and your immune system is okay, it's still important for you to keep in mind that you could be a vector to that person whose immune system is not as healthy

Host Amber Smith: The mask mandates have pretty much ended, even as another variant is becoming a concern. What do reasonable precautions look like now for someone with compromised immunity? Should they still be masking?

Elizabeth Asiago-Reddy, MD: I would argue yes, and particularly in the environments that we know are the highest risk. So those include enclosed, poorly ventilated environments where you're around other people who are unmasked. Those are your highest risk locations. And ideally if possible, you want to use a mask with a higher level of protection, such as a well-fitting KN95 mask or N95 mask in those types of situations.

Host Amber Smith: I'd like to ask about what happens if someone with compromised immunity becomes infected with COVID-19. Are they automatically more likely to need hospitalization?

Elizabeth Asiago-Reddy, MD: Yes, on average. But we do have, now, several treatments available to those individuals to help prevent them from becoming severely ill. So, first of all, even though we discussed that moderately to severely immune compromised individuals might not mount as good of an immune response to vaccines. They still can definitely mount a vaccine response.

So number one is that we don't look at someone with severe immune compromise and say, "oh, it's not even worth doing the vaccine because it's not going to work." We should definitely still, absolutely 100%, pursue vaccination. And many such individuals will mount an immune response, especially if they follow the full series, like I reviewed. Then again, those individuals, we would hope would be people who are eligible for the monoclonal antibody product, Evusheld, that you had mentioned. So hopefully that would help them, even if they were to get sick, that they would already have some antibodies on board to help alleviate the severity of the illness. But regardless, at the point when somebody actually tests positive, who falls into one of these categories, we have a couple of different options for treatments at this point. So this is something that I bring up with all my patients, but I really emphasize with my patients who have a compromised immune system: please call me, if you're sick. Number one, get tested ASAP. And number two, call me and let me know if you test positive, because I want to make sure you access treatment.

So the options right now, actually the first preferred option is a pill that is nirmatrelvir ritonavir, and the brand name for that one is Paxlovid. And that has been shown to reduce the risk of severe COVID by 88% in unvaccinated adults. So these are people who have significant risk. And in fact, those individuals included in the trial had other medical conditions as well, that would place them at higher risk for severe disease. So this product performed very, very well. It's. A five-day course of medication, and it's all pills. It does have some interactions with other medications. So it's very important to review with your healthcare provider, whether or not you can take this medication depending on what other medications you are taking.

If there are significant drug interactions that exist, the next option that we are going to is now monoclonal antibody infusions, and those monoclonal antibodies have had to be changed a couple of times throughout the course of the pandemic in order to respond to the variants that have occurred. We're constantly monitoring which variants are circulating and what monoclonal antibody treatments we're offering to people who are sick so that we target, ideally, the best treatment for them. So those are really the two primary options. And then there are a couple others to include -- IV (intravenous) therapies, additional IV therapies or additional oral therapies. But the, the top two are really the ones that I had mentioned.

Host Amber Smith: If someone is taking a medication -- chemotherapy or something that suppresses the immune system -- do they generally discontinue that while they're infected and being treated for COVID?

Elizabeth Asiago-Reddy, MD: Not usually. And most of the time that's because they really need it, right? So occasionally you'll come into a situation where somebody maybe is taking, let's say, steroids for a condition where it might be okay to stop the steroids for a period of time, to allow them to respond better. That's a possibility. But honestly, in most cases, we're in a situation where the patients really need those medications that they're taking, and it's not realistic to stop them. Or even if we did stop them, it wouldn't result in a quick enough immune rebound to make a big difference. So it's really the supplementary treatments that are going to be especially important for those patients.

Host Amber Smith: We've heard more and more about people who are infected with COVID, they survive, but they develop these symptoms that linger, the long-haul COVID patients. Is there any reason to suspect that someone who's immune compromised is at greater risk for having the lingering symptoms of COVID?

Elizabeth Asiago-Reddy, MD: That is actually not very clear, that this group of individuals, severely immune compromised people, are at higher risk for long COVID. It looks like, actually, people across the spectrum of immune health are at risk for a long COVID, and we're still accumulating data on who is at highest risk. Certainly individuals who have very severe illness are at high risk for having long COVID. That having been said, we've seen long COVID develop in quite a high proportion of people who even had mild illness. So, some of this comes to the case definition for long COVID, which is -- I find it to be a bit flexible -- it's any symptom that is not attributable to another cause that is present three months after a documented COVID infection. And that's pretty broad. So, you know, you could have a range of somebody who is experiencing more fatigue than they did prior to their COVID infection, or you could have someone who is really debilitated with multiple different symptoms requiring specialty care. So that I feel like the spectrum is actually, at this point, a little bit too broad. So I will say that if you have severe illness, yes, you are more likely to be continuing to experience symptoms three months after the original infection. And from that perspective, knowing that severely immune compromised people are more likely to have severe illness, then it is a risk for them. But long COVID, I would say is still tricky, and we're still learning a lot about it.

Host Amber Smith: How optimistic or pessimistic right now is the infectious disease expert community -- yourself included -- about where the pandemic is, where it's going and how long it will be around?

Elizabeth Asiago-Reddy, MD: So how long it'll be around is probably the easiest one. I would say for the long, foreseeable future, this is with us to stay. So that's number one. Where we're at right now, I mean, we have to admit that we are in a much better place in terms of the likelihood that any given person who acquires COVID is going to end up in the hospital or dead. I mean, a much better place.

But what do I think is going to happen? I mean, the virus is tricky. So there's a whole bunch of things that have happened. It's invaded animal populations. It's living within animal populations. It's living within populations of every human throughout the world. So, do we have the potential for some random strain to come and be significantly more severe than what we would have anticipated? Yes, it exists. But I think it's becoming less likely just because of the background immunity that exists the world over.

Host Amber Smith: Well, thank you so much for making time for this interview, Dr. Asiago-Reddy.

Elizabeth Asiago-Reddy, MD: Absolutely. It's my pleasure. Thank you for having me.

Host Amber Smith: My guest has been Upstate's chief of infectious disease, Dr. Elizabeth Asiago-Reddy. I'm Amber Smith for Upstate's "HealthLink on Air

How the trauma of war affects children. Next, on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Children in the middle of a war experience a persistent threat to their physical and mental health. And there may be long-term consequences for their development, as well.

I'll talk about the impact of trauma in a forced displacement and what can be done about it with Dr. Nayla Khoury. She's a child and adolescent psychiatrist at Upstate. Welcome back to "HealthLink on Air," Dr. Khoury.

Nayla Khoury, MD: Thank you so much.

Host Amber Smith: We always hear about how resilient children supposedly are, but how strong and how long must that resiliency be to survive a military invasion or a war, like what's happening in Ukraine?

Nayla Khoury, MD: That's a really good question. First of all, war is an awful experience for anyone to live through: children, families, entire communities; it upends daily life. I've fortunately not lived directly through war, but I'm interested in this topic in part, because of my family's experience, living through decades of civil war and immigrating here to the U.S.

With the current situation in Ukraine, we know that more than 3 million Ukrainians have lost their homes, and it's estimated that more than half or at least half are children. And we know that many more are impacted indirectly. Children and families in neighboring countries and around the world are watching the war, potentially reliving their own experiences of trauma and may be living in states of fear.

So in terms of resiliency, this is an important and really complicated question. We think about resiliency as the ability to rebound after adversity and even to thrive, to transform in meaningful ways, and so it depends on prewar factors like poverty and previous experience with trauma and violence.

It depends on the young person's unique experience of the war itself and on what happens afterwards in terms of how families land, where they land, and how the community responds to where they are in terms of welcoming them or discriminating against them. And in general, resiliency depends on the family's ability to maintain a sense of normalcy during very abnormal times.

Nayla Khoury, MD: We also know from a lot of research on trauma and resilience that one of the most important factors for a young person to support resiliency is the emotional and physical presence of at least one supportive adult or caregiver, and that this can mediate or moderate a lot of the biologic and emotional effects of stress.

Host Amber Smith: So in the heat of the moment, when things start, and you're fleeing, this, you know, fight or flight response that comes on, how long does that stay on before it's damaging? Because I guess, initially, fight or flight is what saves us or helps us save ourselves. But at some point it's dangerous -- right? -- to have a constant state?

Nayla Khoury, MD: Fight or flight response, the stress system in our body, is a normal way of adapting to stress, and war or the experience of war or abnormal times, when that sense of stress can go on for long periods of time. But I do want to say there are lots of young people who live in perpetual states of high stress response because of community violence or violence in the home, and war is another potential time. So there's no exact time answer in terms of how long is too long. I do have to say, we know that many young people are quite resilient. So even in the face of a lot of fight or flight stress for hours, days, weeks, months, young people can bounce back. But a lot of it has to do with what support systems they have to help them make meaning of the stressful experience, so it's complicated.

Host Amber Smith: In Ukraine, those children who are fortunate enough to escape and become refugees are likely not going to be living predictable lives for a while. What type of kid is best able to roll with it in those circumstances?

Nayla Khoury, MD: You're asking in some ways about the predictors of resiliency. And so there are individual characteristics that can predict resiliency, such as a young person's maturity, their flexibility of mind, their ability to be mindful, sense of self-efficacy and hope. There's also a lot of family factors in terms of positive relationships and attachment, terms of caregivers.

And then in terms of communities, the sense of belonging and identity is hugely important in terms of predicting which communities will be resilient in the face of forced displacement.

Host Amber Smith: What about the infants, the little babies that are less than a year old that are in Ukraine. Now, will they have memories of the war or sheltering in the basements or any long-term effects, or are they too young?

Nayla Khoury, MD: It's hard to predict the long-term effects of war and trauma on an infant, and it depends in large part on the caregivers around them. So an infant's first task in the first year of life, besides mere survival, is learning about safety in the world in the context of their primary caregiver relationship.

So, do they have verbal memories of sheltering in basements? No. Most infants don't have verbal memories before they can speak or have language. Might they have visceral memories associated with intense anxiety? They might, so it depends a lot on the ability of their caregiver to maintain a sense of regulation or safety, no matter where they are.

Host Amber Smith: Well, the scenes of destruction that children and adolescents see and the experiences they have while fleeing for their lives, are those memories that are likely going to stay with them forever or does severe trauma mess up someone's ability to remember traumatic things accurately?

Nayla Khoury, MD: Trauma and stress does a lot of things to our stress hormone system, our immune system and things like memory, learning and regulations. So it can impact how a young person organizes their life or their narrative. But some of what we focus on in trauma-informed therapy is helping kids and adults and families put together the narrative of traumatic events with the emotions in a way that helps them make meaning and grow from it.

So, I guess it's to say that memories themselves don't have to be haunting and can even be growth promoting, but certainly we can imagine there's lots of destruction that will impact many kids and many families in significant ways.

Host Amber Smith: Are they likely to have nightmares and trouble sleeping?

Nayla Khoury, MD: Nightmares and sleep disturbances are one potential symptom of trauma and are classic symptoms of post-traumatic stress disorder, which we diagnose if symptoms have persisted after at least a month. And that's duein part to the fight-flight response that has a hard time calming down. Other reactions could involve more physical or somatic complaints like headaches or stomachaches or other types of anxiety and dysregulation.

Host Amber Smith: Many kids have lost their homes, perhaps their parents, other people they loved. And these are things that would be challenging to cope with under normal circumstances. Does the fact that they happened during war or as the result of war complicate the trauma and healing?

Nayla Khoury, MD: It certainly may complicate the trauma, and I think it depends on a young person's narrative and how they make meaning of war. War is devastating, and it can also sometimes bring communities together in terms of having a shared sense of ideology, mission or purpose, which can sometimes help, even in the face of intense and immense grief, anger, and so much loss.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with psychiatrist Dr. Nayla Khoury about the impact of forced displacement on children and adolescents.

How is this likely to impact the long-term development? I wanted to ask you that question as it relates to preschoolers and also teenagers.

Nayla Khoury, MD: It depends a lot on the kids' and young person's experience, you know, whether they end up in a refugee camp or as immigrants in other countries. So there's a lot of different factors in terms of the migration experience that might impact how safe and how stable and how supportive a young person's environment is, going forward. So when it comes to learning about mental health and behavioral health of refugees, there are few studies that actually look at young people living in refugee camps, but the few studies that are out there show that up to 80% can experience symptoms like depression, anxiety, post-traumatic stress and behavioral challenges, particularly under 8 years of age. Among adolescents, there is more concern for risky behaviors and exploitation in terms of trafficking, as well as substance use, acting-out behaviors, things that might be just riskier behaviors, in adolescents.

Host Amber Smith: Now survivors are going to grow up knowing or learning that (Russian) President Putin ordered the invasion and some of them have Russian friends and family members. So is this bound to complicate those relationships?

Nayla Khoury, MD: I don't know how many people believe that President Putin speaks for all Russians or that all Russians are behind this war. And in fact, I think people are able to see the differences there. But I am aware that the amount of misinformation, particularly in Russia, may absolutely complicate relationships in terms of how people are able to understand or empathize (with) what's happening in Ukraine and how that may be impacting relationships.

Host Amber Smith: We've talked mostly about the children and adolescents who find themselves in the middle of this war. I wonder, though, since we turn on the television and we see footage, it almost feels like we're on the front line in real time, whether there's any significant impact on the kids here who view the news coverage?

Nayla Khoury, MD: Absolutely. There can be. So there's a lot of helpful guidance out there for families in terms of how to talk to their children about what's going on in Ukraine and in the war and how much to limit media exposure. So especially among the youngest children, watching that direct TV, if it can be helped, may not be necessary, but of course, some families might feel the need to know what's going on as much as possible.

So trying to limit exposure and then, especially with school-aged kids and adolescents, finding ways to talk about what's happening so that families and parents can be there to support their young people, their kids, as they make sense of what's going on.

Host Amber Smith: Being so far away from what is happening can lead to feelings of helplessness.

Do you have any suggestions for how to lessen that feeling?

Nayla Khoury, MD: I think helplessness is a great word that many people are experiencing as they watch what's happening. And for many who are from Ukraine as well, who may not be able to go back and help fight the war, I do know that there are lots of ways to help and hold hope from afar.

Some of that is just contributing financially. Some of that is contributing and being involved in nonprofit organizations that are doing work. And some of it is continuing to focus on your work of everyday life to connect to a sense of mission and purpose.

Host Amber Smith: Many of the people who are leaving Ukraine are finding refuge in adjacent countries. I believe the U.S. is going to be accepting refugees from Ukraine as well. What can be done to help promote healing and resilience among the kids who were displaced and will find themselves in a new country for their new home?

Nayla Khoury, MD: First and foremost, the basic triangle of survival is making sure that kids do have home, shelter, food, access to education.

So all of that is vitally important. And then the climate that kids and families find themselves in, in terms of being welcomed or being seen as other or discriminated against, also has a huge impact on a young person's wellness or well-being. So it's about connection and belonging and helping to create infrastructure for supporting those things no matter where these Ukrainians end up living.

Host Amber Smith: Once the children are out of danger, once they have a safe place to call their home, maybe once they're back in a school setting of some sort, what issues are likely to surface within them?

Nayla Khoury, MD: Well, it could be all sorts of things. And I think some of what we try to tell parents and adults is really to allow any expression of feeling to be present.

I mean, it could be anxiety and fear that we see. It could be acting-out behaviors or regressive behaviors, like a kid who used to be able to toilet themselves and is now unable to do that. There's all sorts of different ways kids can express stress. And so being open and aware that all of it is possible, and anger -- anger can come out in all sorts of scary ways.

So some of the guidance we give to parents is thinking about safety first. So how to let your young child know -- and this is, I think, true of our kids who are not even directly affected by the war -- letting them know that they're safe, having predictable routines, then allowing expressions of feeling, following our child's lead in terms of what they might need, enabling them to tell a story of their experience when they're ready to, and that can be verbally, it can be done using pictures, and then connecting with community in whatever way that might be, whether it's through song or other rituals. So those are some of the practices that I think can be helpful.

Host Amber Smith: I was going to ask how important it is for playtime and recreation, which, you might not think about that necessarily when you're running for your life, but once a child has safety and they're out of danger, do they still need to have play time in their day?

Nayla Khoury, MD: Absolutely. Play is how a child learns about the world. And I think some of the impacts of trauma, of all different sources, is that young people often don't get a chance to play. They're so worried about survival that their play is restricted. And so yes, ample space for play is vitally important.

Host Amber Smith: I know you've done research in trauma, but I wonder: Is the trauma of war different from the trauma of a fire or a hurricane that forces someone out of their home without warning?

Nayla Khoury, MD: Yeah, it can be. And I don't have a great answer for this. I've looked at trauma from natural disaster, trauma from war trauma, from terrorism. There are a lot of similarities. We do see some more what we call "externalizing behaviors" sometimes in war, armed conflict, kids who've experienced that, so kids who may then go on to have more aggressive behaviors than other types of trauma. But I think there are just so many factors that go into predicting how a young person's going to respond. It is very hard to know.

Host Amber Smith: Well, thank you so much for making time for this interview, Dr. Khoury.

Nayla Khoury, MD: You're so welcome. Thanks for having me.

Host Amber Smith: My guest has been Dr. Nayla Khoury. She's a child and adolescent psychiatrist at Upstate Medical University. I'm Amber Smith for Upstate's "HealthLink on Air."

Here's some expert advice from Dr. Stephen Faraone, PhD, from Upstate Medical University. What should a parent do if they think their child has attention deficit hyperactivity disorder?

Stephen Faraone, PhD: The first thing that parents should do would be to discuss their concerns with their pediatrician. Pediatricians are usually very knowledgeable about ADHD because most of them treat children with ADHD in their practice.

If the pediatrician tells you that your child doesn't have ADHD, then you have two options. One is to agree and wait and see what happens in the future, to monitor. But I would monitor the situation if you have concerns.

The second is to evaluate what the pediatrician told you, because there are some pediatricians who have a negative attitude toward ADHD, and if they seem to have a negative attitude about the disorder, you might consider going elsewhere. And where would elsewhere be? Well, the next step would be to go see, ideally, a child and adolescent psychiatrist, because these are clearly the world experts in ADHD, though it can be hard to get an appointment. And therefore you might want to consider seeing either a clinical psychologist who specializes in children or even another pediatrician. But I have to emphasize, if you're concerned about your child, because they're not doing well in school, or if they're not socializing with other kids, they're showing real impairments, I would not take "no" for an answer unless you get a very good answer, because you don't want your child falling behind.

One of the things that always worries me... I should say. I'll tell you why I'm worried about this. Because years ago we did a study looking at the time between the first diagnosis of ADHD, actually the first diagnosis of any childhood psychiatric disorder and the first onset of symptoms. The average distance is about four to six years, which is a huge gap in a child's life. Can you imagine on average, four to six years, not being treated for a disorder? What happens then is that things only get worse because having the disorder complicates the child's life very much.

I'm always in favor of being very clear on why somebody thinks your child doesn't qualify for the diagnosis, when you seem to have clear evidence that there is a disorder there. You can also talk to the teacher, get information from the teacher about the child's behavior. Teachers have a good perspective. It is possible that some parents are just really nervous about how their kid's doing.

I wouldn't, for example, say my kid has ADHD just because they're doing poorly in school. ADHD is a specific set of symptoms. Kids do poorly in school for lots of reasons. Kids with ADHD also do poorly in many situations. If your child only has ADHD symptoms in one place, like at home or in school, that's not ADHD. That has something to do with the situation that needs to be resolved.

And so that's something a pediatrician might be telling you when they say your child doesn't have the disorder. And then once you get diagnosed, once you or the child gets diagnosed with the disorder, then depending upon who you see, you'll get offered a certain kind of treatment. Most pediatricians will offer medication treatment because that follows the American Academy of Pediatrics guidelines, except for preschoolers. And then preschoolers, the American Academy of Pediatrics recommends that one start with a course of family behavior therapy first, and if that doesn't resolve the problem within a few months or so, then to move on to medication.

But if your child qualifies for medication based on those guidelines, and your pediatrician says no. Again, you want a good answer why they're not providing the medication, because we know that the medications work.

Now, another issue that parents face is that they're really nervous about the medications, and frankly, I would be too. I raised three boys who are now in their thirties, but I was always concerned when they had to take a medication for any problem that they had in life. So these concerns are very reasonable, but remember, you're weighing your concerns about the medication with the concerns about what will happen to your child if their disorder is not treated. And I've just seen too many cases of children who did not get treated for many, many years because their parents were worried about the effects of treatment -- and they ended up having a very bad course in life that led to underachievement and all the negative outcomes we know that can be caused by ADHD.

So keep in mind that the medications for ADHD, particularly stimulant medication, they've been used for decades. I mean, the first one was approved by the FDA in 1960s. They were actually discovered in the late 1930s. Phentermine was discovered to help with ADHD back in 1937 or 39. So these have been used for years. Stimulant medications are even used to treat the elderly in cases, particularly where people fall asleep easily and so forth like that. And they've been shown to her safe in the elderly. So they've passed many, many, many safety tests for many decades. So I would urge parents not to be overly concerned about that. The main concern about the use of the stimulant medications is that they're not to be used in anyone who has a pre-existing cardiac condition, cause that can exacerbate those problems.

Host Amber Smith: You've been listening to Dr. Stephen Faraone from Upstate Medical University.

And now, Deirdre Neilen, editor of Upstate's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Laura Carroll from Washington, DC, writes about food, travel and fairy tales. She sent us a unique take on grief and how to handle it in her prose piece "Recipe for Lemon Cupcakes":

1. Take your grief. Form it into a small ball in your hands.

2. Zest a lemon or three or five. There are so many in your mother's kitchen, and you have to do something with them. They can't just molder in the fridge.

3. Chop the lemons and put them in a saucepan with sugar and water. Boil. Stir. Simmer. Stir more. It will eventually turn to marmalade

4. Add your grief to the marmalade. It's already bitter. It can take it.

5. Measure out your dry ingredients in a bowl, mix, and set aside.

6. Beat up defenseless eggs, and butter and sugar until light and fluffy. Add vanilla extract and lemon zest, and beat again.

7. You forgot to preheat the oven, didn't you? Turn it on now.

8. Add the dry ingredients to the wet ingredients in batches, mixing thoroughly and scraping down the sides with a spatula after each addition.

9. You have a cupcake tin somewhere, don't you? Find it, along with the leftover cupcake papers from several Halloweens ago. The ones with skulls.

10. Spoon the cupcake batter into the tin until each papered cup is half full. Carefully place a spoonful of marmalade in the center of each cupcake, then cover with additional batter.

11. Bake for 20 minutes at 350, or until a toothpick inserted in the center of a cupcake comes out clean except for the marmalade.

12. While the cupcakes bake, raid your parents' liquor cabinet. Pour yourself a glass of the single-estate cognac that your father never had the opportunity to drink, and bring the limoncello to the kitchen.

13. Beat up another defenseless stick of butter to make the frosting, and add more powdered sugar than you think the butter can hold. Keep beating it until it's mostly incorporated, then add a liberal dose of limoncello and watch the alcohol smooth out the frosting as you continue to beat.

14. Remove the cupcakes from the oven. Allow to cool.

15. Improvise a pastry bag from a Ziploc sandwich bag. Pipe the limoncello frosting onto the cooled cupcakes.

Host Amber Smith: 16. Share the finished cupcakes with your assembled family. Everyone agrees that they are delicious. No one comments on the bitterness of the marmalade inside.This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air": career opportunities for nurses. If you missed any of today's show or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org. Upstate's "HealthLink on Air" is produced by Jim Howe with sound engineering by Stephen Shaw.

This is your host, Amber Smith, thanking you for listening.