Stakeholders Perspective

Interview with Dr. Kuo

Dr. Kuo is a professor of internal medicine and pediatrics at the DGSOM at UCLA, and of health policy and managment at the Fielding UCLA School of Public Health. She’s also the chief of medicine/pediatrics at UCLA.  We discussed her involvement in the Needle Anxiety Program (NAP) at UCLA, and learned about needle anxiety in the neurodiverse and disability community.

Dr. Kuo Interview: Full Transcription

June 14, 2021

Interview Lead: Julie Grassian [JG]

Interviewee: Dr. Alice Kuo, Needle Anxiety Program [AK]



JG (0:00-1:00): Hi Dr. Kuo, I’m Julie, as you know and I’m working on the COVID Vaccine confidence grant as well as Michelle, Laila, and Lucia who are all also on this call. First, I’ll just introduce Dr. Kuo. Dr. Kuo is a professor of internal medicine and pediatrics at the DGSOM at UCLA, and of health policy and managment at the Fielding UCLA School of Public Health. She’s also the chief of medicine/pediatrics at UCLA. Her research interests include access to and delivery of developmental services, cognitive and language development in young minority children, and services for children and adults with autism and other neurodevelopmental disabilities.

So, we’re going to talk with you today about the Needle Anxiety Program (NAP) at UCLA and we’re interested in learning about the program generally and what you’ve learned about needle anxiety in the ND and disability community during the pandemic. That’s kind of what we want to touch on in this interview.

AK (1:00-02): Sure, no problem

JG (1:03-1:13): So, I’ll just go ahead and jump into the questions. So the first question we have is: how do you explain what needle anxiety is to your patients and their family members?.

AK (1:14-2:20): Well, so I take care of both patients with disabilities and without, and I think needle anxiety cuts across all populations. In the general population, it is up to 10% of patients who have needle anxiety of some form or fashion, which would actually lead to some change in health behavior. Having an anxiety about needles or procedures to the point where you avoid or delay scheduling a follow up appointment or a particular procedure or things like that. So studies have shown that’s up to 10% of the population. I have not yet seen this studied in disabled population, but I suspect it is higher. 10% in the GP is already significant. So I think having a solution, a way or strategy, to approach decreasing the anxiety around a procedure that involves needles would help everyone with this concern and not just disabled populations.

JG (2:21-2:28): Great, thank you. And the next question is: why is it important to discuss needle anxiety with your patients in respect to COVID-19?

AK (2:30-3:15): Well, I think that because COVID-19 is a new vaccine, there are lots of concerns and hesitancies and anxieties surrounding that particular vaccine in the first place. And so, as we’re seeing across the country trying to immunize as many people eligible patients against COVID-19, we are seeing efforts stall due to some of these hesitancies, concerns, and anxieties. So, if needle anxiety is contributing to people not getting the COVID-19 vaccine, I think we definitely want to address that one because that is perhaps a little bit easier than some of the other concerns that people might have around this vaccine. 

JG (3:16-3:24): Okay, and are there specific groups of people who tend to have needle anxiety, and if so, what are the main reasons that they usually give for why they have needle anxiety?

AK (3:25-5:03): I don’t know that they know exactly which people tend to have needle anxiety, but in my clinical experience I do think that it is patients who tend to be anxious in the first place. So, a number of my patients are being treated for anxiety and it’s not surprising that some of them have a specific phobia or fear of needs. But I will say that I also have patients that have no history of anxiety but just have a single sort of fear of needles. So I’m not sure who they know is exactly at risk for having needle anxiety, but as I’ve mentioned it’s pretty common. I see in particular in association with the 11 y/o vaccine for all children, so there at the 11 y/o child visit, there are a couple of booster shots and vaccines that have to be introduced. And that’s where, all of a sudden, you’ll see both boys and girls with needle anxiety that will come more evident. I think at this age group, not …. You know, in this age group in particular, we don’t want to restrain the child as we may have when they were 4 years old. What’s interesting is that I’ll have parents that are surprised when their 11 y/o has needle phobia because they don’t remember that in the 0-4 y/o age group that there were problems with giving vaccines at that time.

JG (5:05-5:11): Okay. And, how would you describe needle anxiety within the disability community and neurodivergent community?

AK (5:12-5:43): Yeah, so I think in this population it’s a little bit different because we know that individuals with neurodevelopmental disabilities may have sensory concerns, and so because the vaccination involves a needle that does puncture the skin. And on top of the anxiety of neurosensory issues this population may have increased challenges with receiving a vaccination or getting blood drawn.

JG (5:44-5:53): Alright thank you, and now I’m just going to ask more specific questions to the NAP, can you just give us a general overview of what the program is?

AK (5:55-9:52):Yeah, so about 3 years ago now, I have been caring for predominantly disabled population of patients in my practice, getting routine blood work or giving vaccinations was becoming more and more of an issue. And I went around and I tried to explore places that my patients could get these procedures done that would not be compromising their regular healthcare. So I think again it all comes down to the fear needles to the point where they’re not getting the care they’re supposed to be getting. And that, to me, leads to a service disparity. So if we look at vaccination rates for disabled children, they are likely to be lower than the general population and needle anxiety could be contributing to that. So that’s the disparity that I wanted to address. As similarly, getting blood drawn in overweight, disabled patients with diabetes in the general population you typically do this every 3 months. But in talking to other PCPs, if patients have needle phobia or are not easy to get blood from, the provider is okay with not getting the blood drawn every 3 months and so that is a deviation from standard of care that I’m not that comfortable with. 

So I reached out to the Emergency Department who routinely gets blood from disabled patients and they have a number of methods of doing that and asked if we had these types of patients, would they be able to go to the ED to get their blood drawn. And the ED said no don’t send them to us because they will have to wait and we…. In the priority something like this would be very low priority so they would likely have to wait a long time, which is not great for a disabled patient or neurodevelopmental patients who might be overly stimulated or overwhelmed with a lot of noise and having to wait. 

So then I went to the outpatient surgery centers and I talked to the anesthesiologists and I said well, would it be possible to have them do it with an anesthesiologists because they’re so skilled and they could do a little light sedation. And the answer there was well, if we did that, the patient’s family or the patient would be charged for the OR time in the same day surgery center. And then insurance wouldn’t necessarily cover it. Which means the patient would be stuck with a bill of several hundred dollars just to get their blood drawn or a vaccine administered. So that didn’t seem like a viable option either. 

And so basically it came down to our evaluation and treatment centers which are sort of.. More advanced urgent care centers with an RN staffing and the ability to give IV fluids and IV medication. And so we started exploring the possibility of doing these …… (cuts out here).. We have 3 of them and they have extended hours which is nice because they are open 8am-9pm on weekdays and 9am-5pm on every weekend and holiday. So they are open 365 days a year which is great access. And then, going through the protocol took us probably 2.5 years to get it approved by all the different entities at UCLA that would need to approve our administration of an inhaled benzodiazepine in the urgent care sites.

JG (9:54-9:56): What would you say is the main purpose of the program?

AK (9:58-12:26): Well the main purpose is to be able to provide strategies for patients with needle anxiety or trypanophobia, which is the official DSM-5 term, to be able to receive basic vaccination and blood draws for lab tests. So you know, most patients routinely receive these interventions in the routine care that they receive in the primary care office. And so, maybe 90% of the patients have little to no difficulties receiving these procedures. But for the 10% that experience difficulty by being in the needle anxiety program, we can for example, provide numbing cream, like emla, and topical local anesthetic that can help numb the skin. We also have devices called the buzzy bee, which is a device imagined by a pediatrician that you put in the freezer, and so its cold but it vibrates. And You place that on the skin of the patient near where you’re going to be giving the injection or drawing the blood and it keeps it numb. And if none of those strategies work, then we resort to a light sedative which is delivered through the nose via a nose spray. So it’s called inhale midazolam or [didn’t get]. And when we have to do this, what’s nice about midazolam is that it’s short acting, and so once you are able to spray it in the patient’s nose, within 10-15 minutes they are lightly sedated. They completely breathe on their own and they even respond to questions, but they’re just not as anxious and we’re able to do the procedure. And then the anesthetic wears off in about 15 minutes, so it’s sort of ideal for this sort of situation. They’re in the clinic so they are completely monitored. It gives the patient the dignity and the ability to undergo these procedures without a severe anxiety reaction.

JG (12:27-12:33): And are these interventions for any patient with needle anxiety or is it for a specific different communities of people?

AK (12:35-13:28): It’s for anybody with needle anxiety over the age of 7. So we have had non-disabled patients be in the needle anxiety program as well. In fact our very first patient was a 30 year old female with no disability who just had never … has always had needle phobia. And then, even this past clinic, Friday, I had a 16 year old that needed blood work drawn, and she does have ADHD but no sensory issues and no other neurodevelopmental conditions and as soon as I mentioned the blood draw she just broke down in tears in the clinic and was adamant that she would not be able to give blood without some sort of intervention and that’s when I explained to hear about the needle anxiety program which she will use later this summer to get her blood test.

JG (13:31-13:39): Okay great, and for the different patients you have used these interventions on, were there overall successes? Can you explain a little more about that and the successes of the program?

AK (13:41-15:40): Yeah so I would say we’ve done it on about 20 patients since we started the program last August, and Kendall will give you a better idea of the successes. From my understanding from having a couple of them is that it works well when the parents are .. or the family member who brings in the patient also supportive and calm and understands exactly what’s going to happen and is well coordinated. We do our best to reduce the anxiety in other ways without necessarily using the inhale midazolam if necessary. So sometimes parents are comfortable giving a small oral sedative before they come and we .. you know the parent is convinced that we’re going to need the inhale midazolam but because this is such a controlled environment and our staff are so amazing that the mild oral sedative that they take an hour before they come to our clinic is often enough, and then we don’t even actually end up giving the inhaled midazolam. I think what’s really nice and maybe even just symbolic about the needle anxiety program is that we restored the dignity back to the patients, and that the parents are amazed that the experience can be different from what they’ve had in the past. We’ve had patients drive as far as 2 hours to participate in this program, and for their adult child who is you know, 6 foot 4 and 200 something pounds, and the thought of getting enough adults to hold that individual down to be able to draw blood or administer a vaccine is really undignified, and they are just really amazed that this can be done in such a calm setting. And I think this restores that patient dignity.

JG (15:42-15:51): That’s great and if any patient comes in that is under 7, is there somewhere you can refer them to, or what happens for those patients who have needle anxiety but they are under 7?

AK (15:52-16:41): Well, so I think that the challenge is that, for children under 7, we understand that developmentally, many children don’t like to get shots or needles or have their blood drawn. In general, again those children are a little bit smaller and so restraining or talking them through or having them sit in their mom’s lap or parent’s lap is often enough for us to be able to do the procedure. If not then the inhaled midazolam comes without any risk, but I think when we talk about the risk/benefit, it’s greater in a child over the age of 7 and under the age of 7 I would say we would have to evaluate on a case by case basis. But honestly I think that the practice in pediatrics for younger children is to restrain by the parent in a loving way, you know through a hug or a bear hug or something like that.

JG (16:52-16:58): Alright, thank you. And how can patients learn more about UCLA’s needle anxiety program or access more services?

AK (17:00-17:41): Well we’re developing all of those materials now so we hope to be able to share resources to other institutions interested in implementing a similar program at their institutions and their health system. Here at UCLA we also are planning to let other primary care providers know of this service. I think, sort of, providers who take care of many disabled patients already know because we get those referrals. But, you know, we haven’t yet advertised widely until we develop those materials this summer.

JG (17:42-17:53): Okay, and as you’re developing those materials, are there any recommendations you would provide to other providers to assist with their own patients who have needle anxiety outside of this program?

AK (17:54-19:30): Yeah I mean I think one thing that we have tried to do through ambulatory nursing is to train all the medical assistants to acknowledge patient’s anxieties around procedures. What we’ve heard from patients is that it doesn’t help to hear a nurse say, it’s not going to hurt when it is going to hurt. And it also doesn’t help to have a nurse rush through the procedure and not even acknowledge a patient’s distress around getting their blood drawn or the needle. And so we have implemented some training to have our medical assistants take a smidgeon longer with some of these anxious patients because maybe that’s all they need. So really our model is sort of a pyramid model, where we’re hopeful that 85-90% of patients don’t really need any special accommodations. Training ….(didn’t hear)…. to be a little more compassionate will help everyone. And then the remaining 10% who are needle phobic, hopefully some of them will benefit from having a nurse or medical assistant who is just a little more compassionate. If we need to do the numbing cream or the buzzing bee that’s available in almost all of our primary care clinics that give vaccines. And then, hopefully a smaller 1-5% who may even need to be referred to the official needle anxiety program and receive even more intervention

JG (19:31-19:43): Okay thank you for that information. So that’s all the questions that I have, but I do want to ask you, is there anything that I haven’t asked that you think would be important to share with the neurodivergent community or just anything about the program in general?

AK (19:44-20:50): I would say that you know, because this protocol has been vetted by so many entities, we had to get approval from ambulatory nursing, from the emergency department, from the anesthesiology department, and all of our entities that oversee our urgent care, this protocol has been looked at by so many eyes. You know, I want to say that it’s safe and that many people have considered alternatives to doing this. But in the end, I think ultimately our goal is to not deviate from standard of care for any group of patients, and so if this intervention is what is needed in order to do that, then I hope patients will take advantage of it and that it’s safe and that the benefits far outweigh the risk of using an inhaled sedative in order to be able to have the procedure done.

JG (20:51-20:55): Great, thank you. Well that’s all my questions for you unless you have anything else to add.

AK (20:57-20:58): No, I think that’s about it.

JG (20:59-20:55): Perfect, well thank you so much for taking the time to talk to us about this program.


Interview with Dr. Eric Curcio

Dr. Curcio is a primary care physician and he specializes in internal medicine and pediatrics right here at UCLA health. He received his medical degree from New Jersey medical school, and he completed his residency at UCLA School of Medicine. We learned about Dr. Curcio’s perspective as a physician working on the needle anxiety program. Additionally, we discussed what we can learn from this program as we try to increase vaccine confidence in the disability community

Dr. Curcio Interview 6.21.21

Wed, 6/23 1:03PM • 29:39


patients, anxiety, people, vaccines, phobias, needle, procedure, child, support, hear, important, program, bit, distraction techniques, parents, disabilities, reassure, community, nervous, ucla



So we’ll go ahead and get started. Hello, Dr. Kersey. Oh, we’re really excited to welcome you in to interview for our program to discuss the needle anxiety program at UCLA and just learn a little bit more about needle anxiety and what you’ve learned about it specifically within the context of the neurodivergent community and the disability community as well during the covid 19 pandemic. So I’m My name is Laila and I’ll be interviewing you today along with LUCIA JUAREZ, Julie grassy and and Nicholas Shaw, who are also working on this program. And we’re specifically interested in learning about your perspective as a physician working on the needle anxiety program and what we can learn from this program as we try to increase vaccine confidence in the disability community. Before we get started, for anyone who’s watching this video, I would just like to introduce you. So Dr. Eric crucio, is a primary care physician and he specializes in internal medicine and pediatrics right here at UCLA health. He received his medical degree from New Jersey medical school, and he completed his residency at UCLA School of Medicine. So with that being said, Are you ready to get started? Dr. Chris, you? Absolutely. Thank you. All right. Wonderful. So first, we would just like to hear a little bit more about the needle anxiety program. Could you tell us a little bit more about the goals of the program in particular?



Yeah, absolutely. So this, you know, this was a project that we had kind of really a problem that we knew that we needed a better solution for for years now. And it probably was about two years in the making between when we first envisioned it. And it kind of serves as a multi pronged approach, really, we knew that basically, we could be doing a better job with procedures for everybody really, you know, there’s so much anxiety that doesn’t get talked about, and probably a common reason why people maybe skip out on those physicals or missing appointments, people who have, you know, serious, deep seated phobias, or needles. Now, there’s certain groups, particularly disadvantaged by this, I think what we saw that really prompted us to find this was a lot of clothes and myself, take care of patients with a variety of medical conditions, a lot of developmental delays for diversity. And those patients in particular, we’re really getting yourself out to collect medical treatments for these kids, adults, medication that they need to be monitored, every test that you’d look back, and you can see years have gone by, and none of these tests have been done. And when you look at the billets, who would always be you know, unable to get unable to get blood. Because you know, those those patients are, you know, particularly high risk or not being able to explain or understand the procedures. And it was really a problem that we had, what would have been done beforehand would be this sort of wait until they needed something major that required like Asia, so maybe they were going in for major dental work or something. And when they went in for that you can quickly do their blood vaccines and everything else. But that’s a district as you might wait years. For that sort of second tier of the program, you know, the first year was really just coming up with ways everybody to have our nurses trained better to training procedures, patient control and how they wanted to play on wanting to distraction, they wanted us things like that, we came up with the second of our program, which include things like the buzzy for children and other distraction techniques, there will be one of our colleges to be involved in kind of do the type of the whole things. And then the area that’s probably gotten the most attention, or which are the most challenging case, most of the reviews for vocational development really couldn’t understand. And that’s doing it as a base case of anxiety medicine that can be done right before the procedure and really have a calming effect. For everybody, for sure. We have had quite a bit of success, new Alto, I think kind of came up with the ideas behind it and identify the need and then I do a lot of work more on the implementation operation. So, you know, we did a fair amount of literature searching to see how other health systems had handled this. There’s a ton out there, you know, we kind of base our model with a few things we found from dental literature for doing sort of mid level procedures for patients with dental phobias or developmental issues. There are a couple of case studies of pediatric echocardiograms used for set, but we couldn’t really find much of anybody. We used it for this specific but it’s logical as they will translate. supports those protocols were able to find and then almost a year ago started doing our first Three August last year. Okay, so after about two years of figuring out all the processes getting anesthesia, ambulatory nursing and everyone else is, first and foremost, we needed to save safely, we needed to have emergency plans in place. But what we found and what we all spread in the literature is done right. And protocols followed it really is. We haven’t had any negative attraction. Yeah, that’s a little bit at the back.



Yeah, it seems like you’ve developed a really comprehensive program that caters to the needs of a lot of different types of patients. I’m curious, kind of, in your experience working with these patients, what are some of the underlying reasons that patients have provided surrounding their needle anxiety?



Probably when you ask most people who have that the needle anxiety most can’t give you a good reason why they have it. There’s just a subset of people out there that have these phobias, they might have had a bad experience, they you know, there’s a subset of people about what we hear of somebody who every time they get their blood drawn has a fairly high chance of passing now. It’s beyond their control. It’s not an anxiety issue. It’s just a visceral response their bodies have where all their heart rate and blood pressure. But like many phobias, so people really know why they have, it’s not usually a bad experience from memory, but probably something maybe dating back to childhood maybe years that they can’t even remember. So the phobia side, probably about half of the patients that we see are more in that group as you’ve been putting off, putting off drugs because of that. And then the other half is really more than the the neurodevelopmental disabilities, these are patients that can’t understand necessarily what’s happening, or maybe have already VHD or other hyperactivity kind of conditions, particularly a lot of different things. And then that group, it really is just trying to make your hands as pleasant as possible as productive experience for them. Because once they learn that this place is associated with pain, or this place is that scary place where people come in and hold me down aggressively or something like that. It’s really hard to undo that kind of damage. And now they’re going to have this you’re probably walking into every medical office, because they all kind of look the same young, potentially for the rest of your life. So we want to do what we can not pretty more phobias, inadvertently from negative experiences, if we do hear that a lot of parents that the last time you had blood drawn, we had such a setback in their anxiety levels spiked so much, because yeah, they went, where were they had a bunch of people grab them and hold them down? And wait, no, that’s great.



Yeah, thank you. And I’m curious to hear for you, the other providers or for anyone listening? What is kind of something important to know regarding working with families or patients with disabilities regarding needle phobia, while still promoting vaccinations and inoculations?



Yeah, I mean, for starters, I’d say the most important thing is nobody likes surprises. As much as in development, well, the patient in mind, the more we can explain up front, maybe you walk through the scenario, talk through how it’s going to go. I think, you know, a lot of times parents do the opposite sometimes, or caregivers will do the opposite, where oh, I don’t want to upset so we’ll just get on them last night. Nobody likes that, right? It just breeds this just make that phobia that much worse. You know, there are books about this pamphlet, there are online resources out there that you can use to really talk through how this is going to talk about if it’s a play that we’re going to do. We’re gonna feel a little spritz of fluid in your nose, maybe try that at home with a nasal spray over the counter just to kind of really build that confidence of knowing what to expect. So I think we found that the cases go fast, when when patients know sort of what’s coming. They’ve talked about it before they’ve walked through it as much as they can. So that honesty is definitely an important step. We also want our families to know that this is not a cure, all right. But if there’s somebody who’s so extremely anxious, this one one dose of anxiety analysis, that we tend to repeat doses, because that gets more into the safety side of things. So it’s not going to work for everybody. But we figure if this work for you know, half two thirds of cases, that will still have to figure out that other case, probably working with those right now.



Wonderful, thank you very much. And just to kind of elaborate from that question, can you tell A little bit more about how you communicate with patients directly surrounding their needles anxiety or getting shots in particular.



Yeah, absolutely. So, you know, this might be a lengthy process, it might just be at the time of the visit, if it was sort of an unexpected thing. But you know, a lot of times people will either directly voice concerns or caregiver or family might, but a lot of times it’s more in the subtleties of you say blood and you see the kind of recoil or say, Oh, can we do it another day or something like that? Get this going on? And then just try to have an honest conversation. You know, I see maybe a little bit nervous about about the vaccines you have a bad experience before? Did you have your, because like you felt the need, or maybe it’s just about vaccines in general, or about medications or something else, you kind of need to know, if it is about measles, I think it really is referring to a lot of patients, families know that this is something that we’re just rushed off or eyes and say, Oh, really critical. But no, this is something that we identify the problem with common kinds of scenarios, we built this program around it. And I think a lot of times, knowing that are nurses trained in this, this is taking you off, you passed out once paid, we’re gonna have, we’re gonna have you lie down, we’re going to watch for a while afterwards, just those kinds of things alone that we’re going to, we’re going to take it to her, I think, again, if it’s something that’s going to be more of a planned thing, where we’re going to bring them back now for that we’ll talk about, you know, why we do this, how it works, what to expect. It’s a funny feeling, getting this, we should create into those what we’re hearing, burn is quite the right word, but it’s an odd sensation, I think. So making sure patients go to expect that. And, you know, encouraging them to, you know, whatever is going to help calm them down the most might be something like a buzzer, or distraction technique, or kid this may be accepted on the videos, whatever else helps them calm down. Maybe there’s a buddy who really liked us. And with headphones on and distraction that way. Maybe that’d be what kind of gets.



It’s kind of like anything else. I come up with a plan that everyone comfortable with.



I see and has this sort of communication or this sort of approach changed when you’re talking in context of the COVID-19 vaccine or just in the pandemic times in general. Yeah, I mean, COVID certainly heightens everything a fair bit more, when you look at the rate of young people who are passed out after vaccines is not almost certainly related to the actual vaccine itself. It’s more related to both knees and everything, the rates much higher for this, I think it just speaks to that extra level of anxiety. But everyone really has about COVID. You know, there’s a lot of information on where money news is often not that accurate. political issues and other things, it’s really just left people are undecided extra nervous. They’ve heard that somebody they know how to really bad reaction to the second dose, and now they’re extra nervous about it. But you know, we look what’s happening here now that we finally sit down and allowed reopenings No, that’s pretty much thrown out. So people at the same time know it’s important. So it creates this kind of dissonance, I think where they know they need to do it. But they’re also extremely nervous about getting it is a good opportunity. I think he just talked about all these different features of comfort, reassurance. Even more for that I hate to have no fear of needles being are the reason why somebody chooses not to get a COVID back. If there’s things that we could easily do that would probably make a pretty, pretty benign. What we often hear from patients, you know, there’s sort of mental image of them, you know, walk themselves through this in their mind of how horrible it might be, when they actually do the procedure, especially with respect to filming now, they said maybe, you know, whatever else is going to help them. The end result oftentimes is Oh, it wasn’t that bad. And it turns out the vast majority of patients, ie your patients as well as very diverse developments, patient, the best journey don’t ever get to that theory but don’t end up needing the anxiety medication, really just behavioral approaches can take care of most. But COVID has definitely shifted the spotlight I think on all the founding teams



and kind of um he’s you know, many interactions I’m sure you had. Do you have any particular anecdotes or particular Patient interactions through this program that you would be comfortable sharing with us and with the neurodivergent community.



Yeah, absolutely. I from last recap, one have a 14 year old with a rare genetic condition that was part of it has a developmental disability component to it. But had had to go before with vaccines, whatever, we had actually talked about maybe getting too much history. But we ended up bringing him in with that there for support with distraction techniques, but you know, the iPhone out and favorite videos playing on Tick tock, if I remember, right, and, you know, dealt with those distraction techniques or numbing medicine, he had a completely pleasant experience, barely even notice that he had gotten the vaccine by the time was done, and left her you know, with a smile on his face, not having that negative association. And that’s gonna make our lives much easier next time, he needs a boost for vaccine. But I think, for the family to kind of see that, you know, with these interventions, having supported president holding down a restraining, or those kind of things, that we were able to do it safely, that we were able to get it done and not in any sort of stressful or more anxiety ways. But I think we all if you ask the other doctors, I think we’ve all got examples of these. If you think or one of our politics was the passion project, we did a lot of training with the nurses, the medical assistants, in our office, office across.



Ya know, it seems really important to build an environment in which you’re not provoking further anxiety, but helping to ease the patient while also providing them with with quality care and getting them all the procedures and all their occupations that they need. And so when it comes to context of younger or for neurodiverse patients in particular, how do you as a physician weigh the benefits and the risks of the COVID-19 vaccine for those patients that may have needle anxiety?



Yeah, I mean, well, we know the benefits are potentially huge, right? We know that, you know, patients with autism patient with developmental delays, we’re seeing worse outcomes with COVID. pretty consistently, they were getting diagnosed later, they were getting tested later. And we wonder why that is. I mean, it could be it might even be anxiety that’s kind of playing in on patients, or parents or or caregiver who’s now even more afraid to bring them in, because now they’re gonna get this nasal swab that we know is comfortable, oh my god, they’re gonna go into the hospital, we know how disruptive that can be to their routine, because disruptive to anybody, and especially somebody who maybe can completely understand what’s happening or something like that. It’s weird. But, you know, what’s the end result is that, you know, we’re hiring to death batteries, ventilator use in patients with those types of disabilities. So, you know, the benefits, and the risks of not getting it early, or the risk of not getting the vaccine and for COVID risk road are huge. So I think it’s a hurdle that needs to be overcome and taken seriously to build that support. But, I mean, it’s so important, I think that, you know, patients not put off, you know, important medical procedures out of fear of something that we’ve done, right, probably shouldn’t be all that fear provoking, at least most people.



Thank you very much. And we’ve discussed kind of the context of younger patients and neurodiverse patients, but I’m sure you work with patients across a kind of all age groups. And so how does your approach to discussing middle anxiety and more broadly, their care as well, along with the ramifications of any sort of procedure vary depending on the age of the patient?



Right. I mean, there’s, you know, obviously, everything you do has to be developmentally appropriate for whoever you’re talking to. I think, you know, it highlights the need for family centered approach a lot of times for bc it’s a very different discussion group talking about their newborn. who, you know, we’re a couple of months old means x y&z Oh, that’s reassuring Mom, it’s going to be maybe letting mom nurse right after the procedure to calm down maybe letting her hold the child on her lap rather than you know, being on this table or something more intimidating or mom feel more removed from the situation. And then the discussion is going to be different with a school aged kid where maybe we can encourage them to tell the child ahead of time because now the child knows is asking that question you never want to ride on the building. It’s just there. And maybe if the if we know this as a child as a major issue with vaccines Trying to get prep them ahead of time use those that are out there. If it is a an older patient with a neurodevelopmental disability or something like that it really is meeting them where at the level they’re at with the understanding, they have giving them a chance to answer any questions that they have, and get those concerns addressed. And still being there to support the families, because oftentimes, they’re equally as nervous about the whole situation. But we see needle anxiety through the entire age spectrum, we have plenty of patients, they’re young 70s 80s, who also still hate needles, doesn’t go anywhere. For most people, if you’re one of those people that are affected by a disease probably be there, you know, maybe you have to deal with your whole life.



Right? Yeah, thank you very much. And you mentioned, particularly for children, kind of incorporating their parents into that procedure, or just building an environment in which they’re more comfortable. I’m curious if you have any other advice specifically for a parent or a caregiver, to assist their children that have needle anxiety, either at home or at the clinic?



Yeah, I mean, it’s, you know, family is important part, probably, regardless of age to for a lot of people have a support person, there can be huge. at any level. Again, I think it’s just time to think about, what could we do that would put, you know, this patient that they’re most comfortable, and maybe it’s going to be bringing a support object, or if we have a favorite toy, or if we have something that we can bring in a younger kid that we can have with us for support. On occasion, we’ve had people bring their emotional support animals, if that’s like, that kind of helps. Great, you know, whatever it’s gonna be. And it does have to be customized by the points because everyone’s going to have different distraction. That is that they were people want to meditate, some people have a really tough time doing that. And now more and more we go more with music or something else, there’s no kind of one size fits all approach, I would say.



Right, and I’m just gonna move a little bit more broader and just hear from kind of your experience working with patients. What are some kind of comments, questions or factors about needle anxiety, that, in your opinion, are the most important when it comes to raising awareness, either about the issue that needle anxiety itself, or just to the fact that there are resources for people who have needle anxiety amongst the community? If you have any thoughts or opinions on that?



Yeah, I mean, it’s, it’s tough, because one of the hallmarks of phobias, I think, in general is not wanting to talk about it, right, we tend to avoid things we’re afraid of. So a lot of times people really voice voice screamed, patients, just occurred around like anything else, just to be open and honest, you know, with, with your medical team, with the doctors, nurses taking care of you compared to they want to do what’s best for you, and they want to do it in a way that’s gonna make you most comfortable. And on the other side, I think providers, you might know, somebody didn’t know, oh, this is the third time you’re back, you spoken, get that blood work done. You know, and taking that step back to try to dig into why you might be surprised to find us. We’re just, we need help on the search for scientific transportation or get support or something like that. Or maybe it will uncover that bad experience that happened before or if you’re have one of these deep in phobias are that bad experience that happens as a kid or whatever it might be? Just people really kind of keep communication open both ways. Be aware that it’s a combination, to be aware that it’s a common cause why people are getting multiple health care. And then just



and then just based off of your experiences, what are some of the kind of biggest myths or stigmas surrounding the intersection between vaccine hesitancy and neurodiversity that should be broken?



Yeah, I mean, probably not so much related to the needle side of things. But we all know, there was a lot of air and fear put in by studies that were, you know, later discredited, specifically around the MMR vaccine and autism, and that kind of got broadened out to many other vaccines and things like that. And despite, you know, countless studies and excellent research, looking at huge groups, populations, this proving that, you know, beyond the shadow of a doubt, and you know, that study having its own, you know, ethical concerns and being recalled and retracted you that are still out there. And then the last thing any parent wants to do is do something that could possibly hurt their child or even the slightest stress. And I think because there’s misinformation on the web, Now for the people who can’t get any media on your site. And then you don’t see so much of polio and things like that, because Luckily, they’ve done their job and really low, it puts these tough positions where they see a lot of negatives. And the positives are quite as obvious. I think, you know, again, it’s having that dialogue it’s trying to get to the root of a person CERN’s was a good article they read was it’s being their friend told them is there some better direction, we could point them to give them some good information that is out there and give them you know, the things that reassure us as physicians that what we’re doing is, and I think a lot of times, you know, as parents read into that more, that can help reassure them, it’s scary. I mean, you know, nobody, when it comes, especially to taking care of family members, children, I think we’re even more more nervous. Anything that could cause harm, but every parent you’re at the end of the day wants to do what’s best for your child may have just put a navigate to the information that’s out there. And I think we should remember that and just try to move that dialogue further. That’s going to have the best outcomes given people. We think about vaccines to you, they are hesitant to maybe come up with a plan or take them one by one and look at the research data out there. And when most people see the real data there, it is pretty reassuring to hear the medical community is as confident as they are.



Right. And I just have one more kind of broader a specific question for you. I was curious to see if you had any advice for providers or other health care professionals who may not have a formal needle anxiety program on how to approach or communicate with patients who have disabilities and who have some sort of needle phobia?



Yeah, it’s tough. I think the lesson is that you don’t really need a very informal type program to do probably 80% of the work. They’re they’re quick skills that we already have. Time is one of the biggest things. And I think that’s something that all physicians with your you have, you should arrange your appointment times that are often dictated by the health system. And you know, when you’re rushing these things, first to go that taking that extra minute or two to really get to the root of a problem. But at the same time, we know, that’s what a lot of health disparities and for groups that, you know, are diverse disabilities. So you’re being thoughtful that you know, this needs to be addressed and maybe revisit periodically to check in is important, maybe scheduling those patients are a little bit of extra time, maybe doing that prep work ahead of time during email or something like that. A lot of the words pretty dumb for him be huge. But I think all of us are trying to provide the most equitable care that we can. And this is part of that duty, really.



Thank you very much. That’s really great advice. And hopefully, we’ll be able to, or the this type of program or this type of approach will be able to be implemented across the nation and be able to help people who have needle phobias. And then, yeah, and then just last thing, I was wondering if there is anything that I haven’t asked you or that we haven’t discussed today that you think would be important to share with the neurodiverse community? Um,



yeah, I mean, I think we touched on kind of a lot of the highlights. But again, I think the most important thing is just communication, right? You know, and this is, could be generalized to many, many things beyond this, but patients are often hesitant to have these conversations with doctors, probably fear of judgment or a negative experience that they had with another health care provider before but, you know, to get the best you can, the most important thing by far is to just have that open communication with your physician to be able to talk about the awkward things about the things that are inherently, you know, anxiety provoking, as tough as it is, knowing that, you know, nobody’s making any judgments everybody is working towards this goal is probably the most will help you get the most out of healthcare and in any setting, really.



Thank you very much, Dr. crucio. That was the final question that we have for you. But otherwise, we really appreciate you taking the time out to come talk to us and to our community as well about middle phobias and the program at UCLA and hopefully, more and more people will be able to take advantage of the program.



be great. Thanks so much. Let me know if there’s anything else I can help with. Wonderful, thank you. Bye now.