Cat Naclerio, Psy.D. (00:00)

We know the pain is real. Like those nerve endings are super sensitive. They're acting up and it's causing pain. So the pain is definitely real. And it's happening and it's in the gut.

Dr. Courtney (00:07)

Yeah.

Dr. Courtney (00:17)

Welcome back to Kids These Days, insights for every stage of child and family development. I'm Dr. Courtney Lynn, and I will be your host. We've all been there. It's 7.45 in the morning, the shoes are almost on, and then you hear it. Mom, my stomach hurts. As parents, our fear immediately kicks into high gear. We start scanning. Is it a virus? Did they eat something bad, or is it about the math test today? It's a stressful, confusing cycle.

especially when medical tests come back normal, but your child is still curled up on the couch in real pain. Today, I am so thrilled to welcome my friend and go-to expert for all things GI, Dr. Kat Niclerio. Dr. Niclerio is an assistant professor at the University of Colorado School of Medicine and a pediatric psychologist in the Digestive Health Institute at Children's Hospital Colorado.

She spends her days helping kids and families navigate the complex world of gastrointestinal conditions by strengthening the mind-gut connection. of two little girls, which means she brings both high-level clinical expertise and a lot of in-the-trenches heart to this conversation.

Today we're talking about why your brain and your gut are essentially text messaging each other all day, how to spot medical red flags, and why the path to healing the gut often starts with regulating the nervous system. Dr. Kat, I am so glad you're here. Let's dive in.

Dr. Courtney (01:46)

Good morning, Kat. How are you?

Cat Naclerio, Psy.D. (01:48)

Hi, it's good to see you.

Dr. Courtney (01:51)

So good to see you too. I'm so excited. It's nice to, I don't know, I know we worked together at the hospital, so it's nice to full circle now. Reconnect.

Cat Naclerio, Psy.D. (01:59)

I know, I know,

we've been going back and forth for a while, so this is gonna be fun.

Dr. Courtney (02:04)

Yeah, yes. And for everyone to know, Kat is my go-to person. Whenever I see a kid who is having GI issues, I always like to run things by her and get her perspective, because she is expert in all things GI.

Cat Naclerio, Psy.D. (02:18)

Yeah.

vice versa. feel like Courtney's my go-to anxiety person when we need someone to help with the anxiety piece. We're like, Courtney, gotta pull you in.

Dr. Courtney (02:22)

Right.

Yeah,

it's nice to be able to collaborate with people across disciplines. And it's nice. love, know, especially at Children's now. And I think not just at Children's in Colorado, but in other states, having psychologists on the medical teams is just such an important, I don't know, like growth phase. I don't know exactly the year that all of that started, but I think it's so helpful.

Cat Naclerio, Psy.D. (02:32)

Yes.

Yeah, I think we're really shifting to this more.

comprehensive kind of whole body, mind body kind of way of treating kids, which is really nice. And especially in the GI world, super, super helpful when we're thinking about a lot of the conditions that pop up. So I feel really lucky that I get to work with an awesome team that really values the role of psychology and behavioral health. And I think we work hand in hand really well together, so it's awesome.

Dr. Courtney (03:22)

Yeah, no, it is so important. feel like all, you know, even it's nice having ⁓ psychologists in primary care, right? Because most of the time when parents have a concern, they go to their pediatrician. And so it's nice to have psychologists who can kind of see the, like you were saying, the behavioral health pieces of it that come along and the stress, the parenting stress, like it's really stressful for your kid to have stomach pain or GI issues.

Cat Naclerio, Psy.D. (03:49)

yeah, it's awful, right? Seeing your kid in pain and being uncomfortable and not wanting to do things and not wanting to hang out with their friends or go to school or do their activities anymore. It's really, really terrible. And so we get that piece for sure.

Dr. Courtney (04:02)

Yes. Well, I love that you connect or that you even started to talk about how there is a shift more in integrating psychologists as part of that to this, you know, kind of whole child perspective, whole body perspective. And so I know we're going to focus a lot today on like stomach pain and anxiety and when your kid has a stomach ache, what that means. but I'd love for you to maybe talk about, know, especially with gut stuff, how you see that kind of mind body connection.

Cat Naclerio, Psy.D. (04:32)

Yeah, totally. So I think our role really is to help kids and parents understand that.

The brain and the gut specifically are super, super connected and they are sending messages back and forth to each other all the time, right? And so how I explain it to kids, they're like, they are chit chatting and they are text messaging or tick talking or whatever platform you like, your brain and your gut are doing it.

All day every day and so when your gut feels something it sends it up to your brain and when your brain is feeling something it sends it down to your gut And the way that they do this or the way they communicate the pathway they do this through is through your nervous system or these nerves that go all the way down the GI tract and those nerves Can get really sensitive for a million different reasons. Sometimes it's food that makes it sensitive. Sometimes it's illnesses like a bad

GI bug can make those nerves sensitive, but stress and anxiety can also make the nerves in the GI tract sensitive. And when they get sensitive, they can act up and cause belly pain. Sometimes they can cause nausea or bloating, fullness, those kinds of feelings or sensations. And it can be really uncomfortable. Even though the actual GI tract is working perfectly fine, like it's still doing all the things it needs to do.

processing, digesting food, taking in nutrients, kids are still able to grow, be healthy, all those kinds of things, but they just feel really uncomfortable. And so they look terrible, even if they're still healthy and growing and great, they just look really crummy and that can be really hard as a parent to see that or be side by side with that.

Dr. Courtney (06:22)

Yeah, I am obsessed with that visual that you just gave. I just love the imagining, like, your brain and your gut just texting back and forth or sending Snapchats. which I also think it is kind of, like, separating yourself from what's going on too. Like, our whole, we are not the pain. The pain is, you know, a part of what is going on. And just imagining.

I don't know, the gut is like a little sensitive and cranky and it's, you know, it's temper tantrum is bloating and digestive issues and it's just really upset.

Cat Naclerio, Psy.D. (06:58)

Totally.

I say that all the time. I'm like when you're sad or your brain feels an emotion and it's sad like you cry or you want to go eat ice cream or something like that, right? When your belly is upset it like

gets nauseous or it gets crampy or it gets, yeah, sometimes constipation, something like that, right? Like that's how your gut is showing its emotions. And it doesn't feel good. It doesn't feel maybe as cathartic as a good cry does necessarily.

Dr. Courtney (07:26)

Right. Right. Yeah. Being constipated does

not feel cathartic. It's the opposite of feeling cathartic. Yeah. You're like, it's just, yes, yes. that's so great. And just thinking that, I mean, like you were saying, all of the nerves in the gut and how those nerves can get sensitive, right? Our GI system has like an emotional body of its own. Like it's its own unique thing that is having all of these experiences.

Cat Naclerio, Psy.D. (07:32)

It's awesome. It's super awesome.

I think that's super key for two reasons. One, I think the biggest thing when patients and families walk in is like, they think this is on my head, the they being like doctors, school, other systems, things like that, right? And it's not, it's definitely not.

in their head. We know the pain is real. Like those nerve endings are super sensitive. They're acting up and it's causing pain. So the pain is definitely real. And it's happening and it's in the gut.

Dr. Courtney (08:23)

Yeah.

Cat Naclerio, Psy.D. (08:27)

And so we absolutely know that that's true. And two, think like nervous system regulation is really buzzy right now. You're going to see it all over social media. But that's really going to be the key here is like that's how we get through the pain is going to be

Dr. Courtney (08:35)

you

Cat Naclerio, Psy.D. (08:42)

nervous system regulation. Getting those nerves to calm down, to chill out, to relax is how we get the belly to be feeling better and to kind of not be acting up and being a sensitive or temper tantrumy is really going to be how we get kids to to feel good again.

Dr. Courtney (08:59)

Yes. Yeah, a few episodes

ago, I had Dr. Laura Vanston on the show, and we were talking about the gut-brain connection, and she does a lot of gut health. But I think especially the way that you're describing it, there's keeping it physically well, and then also just the nerves and the sensitivity. As you're saying this, I'm like, I hope parents can take a deep breath of, we just have to get our nervous system, not just like, oh, it's so easy, just, but.

Yeah, there is, you

Cat Naclerio, Psy.D. (09:29)

Fair enough.

Dr. Courtney (09:30)

know, hopefully some solution and recognizing, like you said, it's not in your kid's head. It really is, you know, a pain that they're feeling.

Cat Naclerio, Psy.D. (09:39)

for ⁓

Dr. Courtney (09:41)

How can parents then differentiate, like, this is pain, like, nerve sensitivity, and there is maybe some versus, like, something medical going on? Or I know both of, as we're talking, like, OK, both of those things are probably connected, right? It's medical and emotional. It's like both. But yeah, what are your thoughts on how parents can kind of tease those things apart?

Cat Naclerio, Psy.D. (10:06)

Yeah, it's super messy and it's really hard. And I always say like, first and foremost, trust your parenting instincts here. Like you know your kid best. And so if something seems off, go to your pediatrician, you know, talk to your trusted people because you know.

Dr. Courtney (10:08)

Yeah.

Cat Naclerio, Psy.D. (10:24)

what your kid is like and if something seems different or wrong, right? I think the big things to look out for when it comes to kids especially is like major disruptions in their functioning. So if we're seeing like their appetite is really, really different or they're just not eating anymore or their sleep is super off, they're losing a ton of weight, fevers, diarrhea, vomiting.

blood in the stool, like those are the big, big things that I would say like, you know, let's start getting medical providers involved. If generally they're sleeping good through the night, they're getting in their meals, you feel like their energy and their activity level is kind of keeping up okay, you might think to yourself like this might be.

more stress-related kind of stuff versus having other types of medical contributions that could be coming into play here. The pain is still real, I think, regardless of where we're coming in from. But if there's other medical stuff that needs to be treated also, then you might see some of those other kind of red flags going on at the same time.

Dr. Courtney (11:19)

Right.

That makes sense. Yeah, the big red flags of losing weight or fever. Then you're like, OK, there could be a significant medical concern going on. But generally, they're doing OK and they're having this stomach pain, maybe stress is at least part of the picture. Yeah, OK. What would I guess I'm thinking, you know, what advice would you give to parents?

Cat Naclerio, Psy.D. (11:52)

picture.

Dr. Courtney (12:01)

If they have gone down the road of getting all these tests done, Their child is having stomach pain, so they've run all these tests, they've seen a GI, and nothing is getting better, and there's not someone wonderful like you integrated on the GI team to point them in the right direction. What would you say a good starting place would be for those families?

Cat Naclerio, Psy.D. (12:23)

Well, this kind happens a lot. think the like all my tests are coming back normal You can't find what's wrong with my kid Scenario that can come up which I know is super frustrating Also, I always try to frame it as like a really good thing for parents a lot of the times when parents finally

meet me it's like they've done tons and tons of testing and like lab work, stool studies, procedures and everything's come back normal and they feel like how is that possible like my kid has now missed so much school and they're in so much pain and how could they not find anything wrong with them like it's obvious there's something going on right

You first of all, I'm like I get it It would be so nice to like point to something and be like, yep That's the thing like two weeks of antibiotics and they're off and running and like let's go and we fixed it and it's no big deal, right? and that would be great and The things that they're looking for are usually like big bad ugly things that you don't want your kid to be having right? Like they're looking for chronic inflammation. They're looking for Obstructions they're looking for you know

Dr. Courtney (13:13)

rate.

Cat Naclerio, Psy.D. (13:35)

the intestinal's twisting and things like that. They're looking for bad parasite. I mean, they're looking for stuff that you really don't wanna have to be dealing with. So really trying to help parents reframe in their mind, like those normal results really are good signs that the GI tract is healthy, that the kids really are able to get in good nutrition, that they're growing properly, like that everything is working the way it's supposed to be working. And so to take that deep breath of like, okay, like things are going in the right direction.

two, and I think this is really an important piece, we don't have the medical equipment right now to date to look at the nerve endings in the GI tract. So they can't look at those nerves and say, like I can see right here that those nerves are super sensitive. And those are the reasons why your kiddo is having pain because those look like they're like overfiring right now. Right. And so that's not satisfying because they can't.

do that process with you and therefore they, you know, cross off a bunch of different diagnoses and tell you it's not this, it's not this, it's not this and therefore we think it's this other thing and you're left feeling kind of like, but that doesn't mean that they don't know what's going on or that like.

you know, your pediatrician doesn't know what's going on or your GI physician doesn't know what's going on or anything like that. It's just like, again, they wanna kind of make sure it's not anything serious that requires, you know, lots of medications, other types of procedures, those kinds of things. And then from there, they're still able to diagnose and understand kind of the big picture of what's happening and be able to tell you things like.

prognosis and how long it's gonna take to get better. And if there are medications that would be helpful to use alongside things like behavioral strategies and stuff like that. So they're still able to make a comprehensive treatment plan and all those kinds of things. And so again, getting parents to kind of like refocus on like, this is okay. Like the fact that you're having this experience of like everything's normal is still good. We're still in a good spot. And then third is...

there are still lots of good things that you can do to kind of help with the pain. And I think that's where integrated behavioral health or meeting with a mental health specialist can be super helpful because figuring out ways to help that nervous system relax, figuring out ways to help the kids learn how to manage pain so that they can feel comfortable again is going to be super, super important. And our big focus always is

get kids back into their lives before focusing on how to take away pain. And so I think everyone has this big idea, like, need to figure out what this is and I need to take it away from my kid immediately. Like, how do we just get this to go away? And that can sometimes actually make pain worse in the long run. So a lot of the times it's like that kind of like.

what we resist persists kind of thing. Like the more like we try to fight this thing, it actually feeds it and gets it bigger and bigger and bigger. And so when we switch our mindset a little bit to like, I understand that this pain is real. I understand this is really uncomfortable for you, bud. And I want you to live a life that you love. And I want you to get back into the things that you enjoy. And I want you playing with your friends. And I want you going to taekwondo or dance or football or whatever it is that you do.

Dr. Courtney (16:44)

Mm-hmm.

Cat Naclerio, Psy.D. (17:11)

That is the mindset that's gonna get the pain to really be getting it improving and you're gonna be seeing benefits from there. And so helping parents strategize around that, because it's not easy, but it is sort of how we move forward. And so I think it's like that kind of stepwise process that we sort of help families navigate.

Dr. Courtney (17:34)

Yeah, well, you said a million wonderful things. OK, the first thing that really stood out, I think, is, yeah, even if those tests come back all negative, that's great, right? We can almost take a deep breath. There is not something that is going to impact their growth, impact their ability to absorb nutrition, all of those things that you said. And just because those tests come back negative doesn't mean it's in their head. ⁓

Cat Naclerio, Psy.D. (17:37)

Yes.

Dr. Courtney (18:03)

honestly, after you explained in the beginning, the way that you explained it was so perfect about our gut having emotions, I was like, we can end the episode there. Like, mic drop. It was perfect. ⁓ That we're not saying, OK, because these things came back negative, that means it's in your head and you need to see a psychologist. It's almost like those things came back negative. We don't have tests to look at nerve endings.

Cat Naclerio, Psy.D. (18:11)

Done. Everyone's good. ⁓

Dr. Courtney (18:30)

and the way the nerves are firing and functioning. And that seems like, because we've ruled out all of these things that potentially it is part of the nervous system and the nervous system is still physical, right? That is not saying it's in your head. It's saying, you know, it's still a medical thing that is actually happening. And some of the strategies that we might use to then help the nervous system calm down and regulate our

behavioral and mental health and nature, but it doesn't mean that, you know, your child is making this up or you're the, you know, quote, crazy parent that's getting your child all these tests. Like none of those things are true. And I just appreciate, yeah, the way that you said that was really helpful.

Cat Naclerio, Psy.D. (19:16)

Yeah, yeah, yeah, yeah. Because I think, again, going back to when you are a parent and you see your kid in pain, that's like one of the worst experiences. And I think really empathizing with that, and especially if you're seeing your kid really.

stopping the things that they like to do or what they're expected to do, right? I think that's when parents get really freaked out when they're like they really liked going to school or they have all these friends and all of a sudden they don't want to play with them anymore. Like they loved going to their extracurricular activities and now they're telling me that they don't want to do it, you know, and I think that freaks parents out for sure, 100 percent, right? And so that's when they want to get help and I think

Dr. Courtney (19:53)

Right.

Cat Naclerio, Psy.D. (19:58)

I get why sometimes the experience feels minimizing if you feel like they just keep telling me everything's okay and I still see this kid on the couch who's like curled up in a ball and doesn't want to do anything, right? And so I don't know what to do with these like conflicting pieces of information. And so sometimes it is, you know, somebody...

outside of medicine a little bit who's like, okay, like how do we put it all together? Like how and how do we kind of move forward with this to help parents be able to coach their kids back to the life that they love?

Dr. Courtney (20:33)

Right, right, and I love that you were saying really continuing to do the things that you love, even if there is some pain as part of the process, and I'd love to talk about that more, because I'm thinking with anything, right? If we're in pain, and then we sit on the couch and focus on the pain, not only are we going to be more aware of the pain, but I don't know, it'll probably get worse, because we're not doing, we're not moving, we're not getting that social connection with our friends that like, release this happy c**k.

chemicals and makes us feel good. So it's just this never ending cycle, but it is really hard as a parent. Like you're saying, when you see your kid in so much pain, like, I don't know, how do I send them to school when they're doubled over and their stomach hurts? You know, so how do you kind of start that process with parents and get parents to see that you're not invalidating the pain by, know, trying to get their child back to the daily functioning, but

It actually is helpful and this is part of the solution to all of it.

Cat Naclerio, Psy.D. (21:37)

Yeah, this part is hard. It is really hard, especially depending on like how much avoidance or sort of how much withdrawal we're working with. But the first place I think that we start with to sort of practice a lot of this stuff is reducing parent check-ins, which sometimes can feel like a really big shift for families. so...

Dr. Courtney (21:39)

Right.

Okay.

Cat Naclerio, Psy.D. (21:58)

I get really clear with this and I actually talk about this directly with the kid more than I even talk about it with the parent because it can feel a little jarring to the kid. But I'll tell them like, this is coming from me. This isn't coming from mom and dad. This isn't mom and dad's decision. They are not the ones saying that this is why it's happening. This is me. Dr. Katz the one saying this. They are no longer going to ask you about how you're feeling or what your pain is like.

And it's not because they don't care and it's not because they don't want to know, but it's actually because when they ask you about your pain, it makes your pain worse. And so instead you can tell them about your pain. And I especially want you to tell them about your pain if something feels different or worse, but mom and dad or mom and mom or whoever caregivers are, are not going to ask anymore about what pain is. Cause a lot of the times we get into these cycles where a parent or a caregiver is like,

you know, in the morning, okay, how are you feeling? Does it hurt now? And then a few hours later, okay, does it feel any better? Did anything change? How are you doing now? And then an hour later, okay, we tried some medicine. Do you feel like you're feeling better now? Do you think you could get up and go do something now, right? And all we're doing is training that kid to become super hypervigilant of their pain sensations, right? And now they're just constantly scanning. Am I okay? Am I safe? Am I feeling anything? And if I'm constantly scanning my body,

Dr. Courtney (22:55)

All

Cat Naclerio, Psy.D. (23:21)

I'm gonna find something. I'm always gonna find something. I always tell kids, I'm like, if I sit here long enough, I can make myself feel nauseous. Like if I think about nausea, I'll make myself feel nauseous, right? And so parents have the best intentions, but sometimes they're just reinforcing this by being like, how are you now? We're at zero to 10. The doctors are always asking zero to 10. So like, are you four? Are we at a five? Oh, we're at a three. Okay, great. Okay. So like, okay, let's see. And then an hour later, you know, we're still doing it.

Dr. Courtney (23:22)

Wait, wait.

Cat Naclerio, Psy.D. (23:50)

⁓ And so I try to set that expectation like really early on of like we're cutting that out. And then it gets to like, we gotta get back into our normal routines and schedules. And a lot of the times with...

When pain comes up, sleep can get really messed up, like sleep schedules can get thrown off, or having a hard time falling asleep, so now we're sleeping in a lot in the morning and things are getting shifted, so trying to get sleep back on a regular routine. And then from there, it's like, can we get back to school? And the key here is like, anything is better than nothing. So, can you go hang out for lunch for an hour today?

Dr. Courtney (24:08)

Right.

Cat Naclerio, Psy.D. (24:33)

Can you go meet with the counselor and find out about an assignment that you missed or something like that, right? Any little bit is going to be super helpful so that we can get back into, just like you were saying, those routines. Like we get so deconditioned so fast when we're hanging back and not doing the things that we're supposed to be doing or the things that we wanna be doing.

And so just really trying to get back into those schedules, those routines, those expectations can be really, really great for not only like our physical kind of mentality, but also our mental mentality of like, this is normal. Kids like predictability, kids like schedules, whether they will say that out loud or not, they need that regularity. And so the sooner we can get back to that, the better they'll start feeling.

Dr. Courtney (25:26)

Yeah, as you're saying that, I'm like, my gosh, it just snowballs. It snowballs so quickly because I'm imagining, you know, the very well intentioned parent who wants to validate their child's pain and understands that they're in pain. So they'll stay home. And then that throws off the parents work schedule if they're working and they're frustrated. And then you talked about sleep. It's like if the child's not sleeping and it's impacting the parents sleep. I mean, it just can really impact.

everyone and to be able to take a step back and like take a deep breath and like you're saying, you know, kind of have almost like a systematic plan of how we're going to do this in some ways can maybe give parents that like hope and structure to of, know, this is what we need to be doing to get back on track. But I can see how one day of missing school, you know, once a month can turn into once a week and can really

take off without any expectation. That wasn't what we meant to happen, meant to have happened.

Cat Naclerio, Psy.D. (26:32)

Totally, and

I think like you said, it's with the best intentions, right? You're like, yeah, it's gonna be really hard for you to be in school today if you feel so bad. take the day, rest up, and then we'll try again tomorrow, right? And I think part of the problem is then kids get nervous about getting back to school, right? They missed everything that they learned. They feel weird about kind of re-entering that environment, having to explain to the other kids why they were out or why they don't have their homework assignment.

Dr. Courtney (26:51)

yeah.

Cat Naclerio, Psy.D. (27:01)

because they haven't caught up yet. And so then guess what happens when they start getting stressed about going back to school, those pain signals start acting up again, because that brain is just sending that all right down back to the belly, right? And so then they feel like, I'm not ready. I still feel bad. I'm at a six out of 10, or I'm at a seven out of 10 pain. Like I can't go back to school today. I gotta stay home. I'm still sick, right? And so then we stay back again. And then this whole thing kind of...

Dr. Courtney (27:09)

pain.

Cat Naclerio, Psy.D. (27:29)

builds off of itself and can explode really fast. And so it doesn't feel good, but missing school can be one of the biggest things that prolongs pain. And so getting back to school can actually help quite a bit because that missing of those expectations.

really adds to the stress piece of it and the stress piece of it is only going to make the pain worse. And so trying to get them back to school is going to really help the cause in the long run.

Dr. Courtney (27:59)

Right, know. Anxiety in general, right? Like not going to school in general. There's like social implications, academic implications, physical. Like there's just so many things by missing school that it can really impact kids that I can see to your point. It makes the pain, it makes the anxiety, it makes the stress, it makes all of it worse by doing that. Yeah, yeah.

Cat Naclerio, Psy.D. (28:19)

Yeah,

kids hate being singled out for that kind of stuff and so they don't want to be that kid that's walking back in being like, ⁓ a deer in headlights, like, what did I miss, what's happening? And then they have this little alarm system in their belly going off being like, things are not going well here. You don't feel good.

Dr. Courtney (28:30)

great.

Right. Yeah. Yeah. I

feel like a common theme in every episode that we've done so far is helping children with their emotions just requires so much from parents. Parents have to regulate their own emotions. It is so hard. I say it every single time. But it is just so hard. It sounds good. OK, yes. All of this makes sense. We'll get this plan. And then it's, you know.

The parent is thinking about, now I'm missing work and I'm going to be behind. all of that kind of stress too. It's just, it's a whole, you know, systems. It impacts everyone.

Cat Naclerio, Psy.D. (29:14)

Yeah, like

roll my eyes because this is like, as a psychologist, I like understand all this so much and I tell these things, right? And it sounds like so like professional and then as a parent, I'm like, I get tested with this multiple times a day. Trust me, it's much easier said than done and I live that every day. It's so messy in practice and it's so hard in practice and it's just, you know, we're looking for like.

Dr. Courtney (29:20)

Bye.

Bye.

Right.

Yeah.

Cat Naclerio, Psy.D. (29:40)

broad strokes here, it's never gonna be perfect. And like, we're really trying to approximate how we do.

Dr. Courtney (29:42)

Right.

I yeah, no it totally makes sense right I could see you're like all right you can stay home with a stomachache I'm gonna go and help these kids get back to school with their stomachache. It's too much like I gotta go to work. Yeah

Cat Naclerio, Psy.D. (29:55)

Exactly! Except the amount

of times that that's happened where I'm like, you're home, I'm gonna go get all these other kids to go to school. See you later, bye! Great.

Dr. Courtney (30:04)

Right? It's

real. It is real for sure. Yeah, I know sometimes things come out of my mouth. I'm like, I'm pretty sure I just told a parent today to like not say that and here I go. It's hard. It's right. Yes.

Cat Naclerio, Psy.D. (30:09)

100%.

yeah, yeah, yeah, it's fine, it's fine.

But it's okay because it helps me empathize with everybody where I'm like, been there, get it, we're in this together. We're doing this side by side, we're doing this work side by side.

Dr. Courtney (30:23)

Yup.

Yep, yep, we're all doing our heart best. Right,

right, no, I love that. ⁓ Okay, so like part of it, getting them back to school, getting them back to the things. Tell me about the like nervous system regulation piece. I can see how that is regulating to the nervous system as well, just the stability and predictability. ⁓ But yeah, other like nervous system specific things.

Cat Naclerio, Psy.D. (30:45)

particularly, yeah.

Yeah, great point. So you can't just like dump them in and be like, luck. So yeah, here's what we're really thinking about relaxation strategies to really help with pain management. And so a lot of the things that we practice are things like diaphragmatic belly breathing, that is one of our most favorite, favorite tools in the GI world. It's sort of like your best.

Dr. Courtney (30:52)

Thank

Right, yeah,

Cat Naclerio, Psy.D. (31:15)

bang for your buck quick nervous system reset. And so we literally talk about how it'll take you from. ⁓

Dr. Courtney (31:19)

Yeah.

Cat Naclerio, Psy.D. (31:24)

flight or fight or flight to rest and digest. You go from your sympathetic nervous system to your parasympathetic nervous system. And that is exactly what we're looking for ⁓ when we are trying to do nervous system regulation. So we do a lot of practice around belly breathing in our sessions. And we like very commonly referred to physical therapy to help with that too. And they do tools with like biofeedback and things like that. And so we're really trying to

kids.

learn these skills from lots of different perspectives, teaching in lots of different ways to see kind of what clicks and help them understand how important that kind of tool can be for so, so much of GI symptom management, pain, nausea, ⁓ lots of things that can help with. And then lots of other relaxation strategies. So we do like a lot of guided imagery, visualization work, progressive muscle relaxation to help

Dr. Courtney (32:18)

Mm-hmm.

Cat Naclerio, Psy.D. (32:23)

with like tensing and releasing the muscles when we're feeling uncomfortable. We do a lot of grounding work to kind of help if they're sitting in class and they notice that they're starting to get a little tense or stress, how can they like kind of quickly calm themselves down without, I always talk about like you know some of these relaxation exercises you do at home because they're like full body things and it's very obvious that you're doing a coping skill right? Some of them like a five four three two one is like a kind of nice quiet one that you can do in your mind.

Dr. Courtney (32:50)

Okay.

Cat Naclerio, Psy.D. (32:53)

without it.

Raising lots of attention and it can still kind of help you bring yourself down without all the other kids looking at you being like hey You're doing a coping school right now, right? ⁓ and so we try to problem-solve like when are good times to do different types of relaxation skills in different settings those kinds of things to kind of help kids have a variety of tools to help with pain management We talk about different kind of like add-ons or supplements that they can do so once we do breathing we'll talk about

Dr. Courtney (33:02)

Thanks.

Cat Naclerio, Psy.D. (33:23)

different apps that they can use to help with breathing. we love like Breathe to Relax for some of our older kids and then the Sesame Street app for breathing is actually really cute for the younger kiddos. ⁓ And then I just talk about relaxation like kind of more generally. like if...

Dr. Courtney (33:29)

you

Cat Naclerio, Psy.D. (33:45)

reading a book is really relaxing for you, like making sure you're intentionally scheduling some time to do that, or if going for a walk and getting fresh air is relaxing for you, making sure you're intentionally scheduling some time to do that yoga, stretching, those kinds of practices, I think, in our over-scheduled society and way of doing things. Kids are at school, they're at their extracurriculars, they're doing their homework, they're scarfing down.

dinner,

they're doing shower, they're studying, they're going to bed, like everything is boom boom boom boom boom right? And I think it's really being like you need to find 30 minutes where you tell yourself this is my time to let my nervous system.

calm down a little bit and we're gonna do this without screens, we're doing this without a lot of extra stimulation around, we're doing this in a really meaningful, purposeful way, not in an avoidance way, not in a, ⁓ mom, I'm playing video games for two hours because Dr. Cat told me I need to relax now kind of way, but in a real scheduled, intentional, this is my time to let my nervous system kind of calm down way.

Dr. Courtney (34:47)

Right now.

Cat Naclerio, Psy.D. (34:56)

schedule it like an appointment kind of thing.

Dr. Courtney (34:58)

Yeah,

yeah, no, I appreciate the, it's not screens. That's not the part of it. That's distraction versus like regulation. then you made a great point. Sometimes it's actually schedule management in terms of taking things off of the schedule potentially, right? You know, I know on one end of the spectrum we might have getting kids back into school and on the other end it's like.

When does your nervous system have time to relax? Like do you need to do that extra private tennis lesson on top of the you know team practice four times a week? So it might be even like pulling back on some of those things. I imagine

Cat Naclerio, Psy.D. (35:37)

Yeah, or yeah, like is studying for your AP test for three hours versus two hours, where's the payoff kind of thing, right? Like really understanding, how much time we're spending on some of these activities and how much pressure we're putting on ourselves in certain activities. When do we need to peel back on some of this stuff? Yeah, I think we can see a lot of high achieving kids.

holding on to a lot of stress, internalizing quite a bit and helping them kind of understand like being high achieving is amazing, having lots of interest in hobbies is amazing, these are all superhero strengths that we want them to continue with and like they need to learn.

how to find time for them to release tension too. They cannot go through life so, so, so, so tense and internalizing, because they're gonna just crash out at 25 and that'll suck. So how do we teach them now while we have parents around of like, okay, this is so great and you need to learn how to take time for yourself too.

Dr. Courtney (36:33)

Great. ⁓

Right. you know, taking that rest time allows your brain and gut to like text back and forth and soak in some of the information. It's hard to remember everything when we're not taking time to rest and consolidate, you know, AP history information. Can you tell me, because this, I know you said like belly breathing is really one of the like best things that we can do. How can a parent differentiate between like deep breathing,

I'm moving like with my chest right now, like my kids taking deep breaths, they do deep breathing, but that's very different than belly breathing. And I'm imagining you work with a lot of kids and, know, send kids to PT where they might be almost like breathing into their chest versus like their belly is actually expanding. And that belly expansion is really what we need, is really what we're looking for.

Cat Naclerio, Psy.D. (37:37)

Yeah, that's the key there. I think if you see your kiddo puff out your chest, throw up their shoulders, anything really in the upper body, they're probably not doing belly breathing. So you really, you know, I always say like,

Dr. Courtney (37:39)

Okay.

Cat Naclerio, Psy.D. (37:54)

put my view isn't great, but put one hand on your chest and one hand on your belly. You really want that hand on the chest to be pretty still. And the hand on the belly should really be the one that's kind of gently moving out and in. It shouldn't feel forced. And so you don't want the kid to feel like they're pushing their belly out and sucking their belly in. Like you don't want to see like this dramatic kind of movement, but it really should kind of feel like this gentle rolling of like the belly's kind of.

expanding and then kind of slowly contracting back to the body.

and they should be able to kind of like feel their hand with their belly kind of going out and With little kids, what's, you know, helpful is you can lie them flat and put like a stuffed animal that they really like on their belly and as they're taking their breath in through their nose, they should be able to see the stuffy rise up on their belly. And so I often be like, okay, we're going to take stuffy for a roller coaster ride, right? So like now we're going to take a deep breath in and let's watch stuffy go up, up, up.

Dr. Courtney (38:49)

Yeah.

Cat Naclerio, Psy.D. (38:54)

and then we're gonna let the air out. Nessie's gonna go down the roller coaster, right? And so giving them visualizations like that, mean, teens can do that with like a pillow or any kind of like object and you can kind of have them like focus on it. But starting from that kind of laying down position can be a helpful place for them to see it and feel it first and then kind of moving them to an upright position once they get the hang of it can be helpful.

and so that can be really good. But yeah, anything moving from the upper body you're probably not doing belly breathing, so try to focus on the belly.

Dr. Courtney (39:27)

Right.

Yeah. Well, and I'm thinking, too, when kids are in class and maybe they, like, belly breathing is definitely something you're like, wait, my shoulder, I need to relax my shoulders. wait, like, let me make sure I'm, you know, breathing in my belly. It just can calm the nervous system so quickly as long as we're actually belly breathing. Right. It's hard. It can be a hard skill to learn, for sure.

Cat Naclerio, Psy.D. (39:46)

tuning it. Right. Yeah.

It is

and like I we always say like it's a skill like any other spell so like I'll be like what do you like to do like do you play tennis or do you do chess or what is your thing and they'll tell me like I play basketball whatever and I'm like okay so if you sat here and you told me like this is how you dribble the ball and this is how you shoot and this is like you know where you stand for a free point or whatever am I ready to go play in the NBA and they'll be like no cat of course you're not ready to go play in NBA I'm like great like what do I have to do in order to like get ready for a game and they'll like you have to put

Dr. Courtney (39:53)

Great.

Bye.

Cat Naclerio, Psy.D. (40:20)

And I'm like, okay, great. So what do you have to do with your belly breathing before you're ready for it to help with your pain? And they're like, I have to practice. I'm like, yeah, you're gonna have to practice this quite a bit. It's a skill. And so we always say practice.

Dr. Courtney (40:22)

Yeah.

Cat Naclerio, Psy.D. (40:34)

while pain is actually low first. Don't wait until pain is at a 10 ⁓ out of 10 and then go and take a deep breath, because you're gonna come back to me and be like, that didn't work. And I'm like, yeah, because you waited for the Olympics and you got upset that you didn't do anything beforehand and it busted out, right? So you have to really try to do it first when pain is kind of chill and then slowly build up and it's really regular. So we're like.

Dr. Courtney (40:48)

Right.

Cat Naclerio, Psy.D. (41:03)

to practice it every day multiple times a day as much as possible. Five deep breaths. shouldn't take very long. It should be quick, but you really do have to build it up like it's a muscle.

Dr. Courtney (41:13)

Yeah. OK, so kind of getting back in the routine of things, helping with the nervous system, relaxation, regulation, that is going to help those nerves in the gut be a little bit more quiet, not firing off so much. Yeah.

Cat Naclerio, Psy.D. (41:28)

Uh-huh.

Not very,

yeah. And knowing that there's so many things that can make the nerves in the gut fire, right? And so you can be doing everything right from a stress management point of view, and then they can have a big bowl of lasagna that maybe didn't sit right, and that can sometimes set it off a little bit too. And so just knowing that the gut is still working well, especially if you are working with your

Dr. Courtney (41:36)

Absolutely.

Cat Naclerio, Psy.D. (41:59)

you're a pediatrician or something and you have kind of checked things out, the gut is still working, everything is still healthy, and we just kind of keep working through the pain the more that you can kind of remain functioning, remaining in life, like they will move through pain episodes and just kind of keeping at it.

Dr. Courtney (42:17)

Yeah, right. It's like any emotion. We just want it to be like little bumps. Like we feel the emotion, we go back down, you know, feel pain. Okay, I ate lasagna, that didn't sit well. We're just regrouping with our gut. Yeah, yeah. What is one last thing for parents listening if they hear nothing else except what you're about to say? What do you want them to take away from all of this?

Cat Naclerio, Psy.D. (42:20)

you

Totally yeah. Totally yeah.

Yeah, think just really knowing one, the pain is real. It's not in their heads. It really is real. And really help switch that mindset from how do I make it go away to how do I get them back to living the life that they love. And from there, the pain will get

Dr. Courtney (42:46)

Mm-hmm.

Well, thank you so much. This has been so helpful. I feel like you've given so many good examples and metaphors, analogies, all the things that will bring this to life for many parents. So I appreciate your time.

Cat Naclerio, Psy.D. (43:16)

This is so fun. Thanks for having me.

Dr. Courtney (43:18)

Yeah, of

course.

Courtney (43:20)

I hope today's conversation gave you a new lens for those difficult school mornings. If there is one thing I'm going to remember, it is that the pain is real. It's so tempting for us to want to keep our kids home and focus 100 % on the pain until it goes away. But as Dr. Kat explained, the real healing happens when we shift our focus. When we stop being investigators and start being a steady, safe anchor, we give our kids the safety they need to get back into their lives.

their nervous system move from fight or flight back into rest and digest. This week, I challenge you to pause and look inward at your own reaction the next time your child mentions a stomach ache. Notice your own urgency to fix it or check in every five minutes. Instead, try to be that steady, calm presence that says, I know it's uncomfortable and I know you can handle this.

Helping them move from a focus on symptoms back to seeing themselves as capable of navigating discomfort is some of the hardest and most important work we do. If you're struggling with a child who is missing school or activities due to chronic pain,

Please check out the show notes for resources and to schedule a free consult with our team at Integrated Behavioral Health. Thank you for listening to Kids These Days. Remember, you don't have to be perfect to be a good parent. We are all learning about how to raise kids these days. We'll see you next week.