Transcription:
Anxious Kids

Dr Greg Fritz: Anxiety has become one of the most common mental health disorders among children and adolescents. In the United States according to the CDC, anxiety affects somewhere between 14% and 30% of children aged three to seventeen years old to varying degrees. A 2021 study in JAMA Pediatrics indicated that the prevalence of youth anxiety has actually doubled during the pandemic.

Anxieties manifest itself in different ways in children who struggle with anxious feelings. Some may develop behaviors like nail biting or skin picking. Others may experience feelings of panic and have trouble breathing or break out into a sweat. Or some kids suffer in silence, experiencing sleep disruptions or stomach aches or other physical symptoms. We've all experienced anxious feelings at one time or another, but sometimes these feelings become larger than life. And when that happens is when you want to take action.

Dr. Jennifer Freeman, Director of the Pediatric Anxiety Research Center here at Bradley, joins us today to talk with us about anxiety. Welcome, Jen.

Dr Jennifer Freeman: Thank you.

Dr Greg Fritz: This is Mindcast: Healthy Mind, Healthy Child, a podcast from the mental health experts at Bradley Hospital, who are the leaders in mental healthcare for children. I'm Dr. Greg Fritz with my colleague and cohost, Dr. Anne Walters.

Dr. Anne Walters: Jen, so glad you could join us today to talk about anxiety in almost all areas of life. People of all ages recently have faced uncertainty and, of course, uncertainty leads to anxiety. It's hard to count on things lately. And this feeling of not being in control is taking its toll. We're seeing it in our patients as young as three. Children are showing up in childcare settings and schools seeming quite stressed.

Our challenge now becomes treating these children for their anxious feelings before it becomes more serious. And so perhaps our first question to you should be How do we distinguish between anxiety symptoms that are a normal and expected part of development and anxiety that is pathological and requires treatment?

Dr Jennifer Freeman: I think that's kind of the million-dollar question that most people ask when it comes to thinking about whether these anxiety symptoms are in need of more care and need of a specialist. Anxiety is normal. And the thing that we need to remember is that everybody, kids, adults, anybody is supposed to be anxious sometimes, and it's a normal, hardwired part of our reactive system. If someone's chasing us, if a tiger is chasing us, you should be anxious. If you see a red light, you should have a little anxiety, so you know to stop your car. And the challenge is figuring out when is that too much.

And so we think of a lot of things when we're trying to figure out, does it fit into this category of, I don't even like the word normal, but of normal anxiety, if we want to use that, is it getting in the way of somebody functioning? That is the very first thing that I think about. It's okay to have a little anxiety. It's developmentally expected at all different ages to have different kinds of anxiety. So if you're four, it's pretty typical to have bad dreams. If you're, you know, five or six or seven, it's pretty typical to be anxious about leaving your parents to go to school. And if you're in middle school, it's normal to have social worries. But are those things getting in the way? Are they stopping a child or a teen from doing the normal things that they should be doing in their life, from socializing with other kids, from eating, sleeping, grooming, leaving the house, leaving their parents, if it's an age when they should be doing that? So interference is kind of the first thing I think about and distress. How distressed are they? How upset are they? Is this something that just lasts a few seconds, a few minutes? Or is it something that's eating up the entire family for hours at a time, for days at a time? Or is that all anyone in the house talks about? And then, we have to do something else. We have to think about something else.

The other thing that I think is really important is how different is this from this kiddo's normal kind of experience? Is this a kid who's always been wired really, really tightly and is just prone to worrying about things? And then, it's more just developmentally, how do I parent this kid versus is this a change? Did something change over night or over weeks or over a longer period of time that's making them have a harder time, again, sort of doing those things we would expect them to be doing?

Dr Greg Fritz: So we hear a lot about different types of anxiety, you know, like separation, anxiety, phobias, social anxiety, obsessive compulsive disorder, et cetera, all those different types. I always think it's interesting to figure out whether there are really fundamental differences in the types of anxiety that dictates specific treatments, or are the overarching similarities more important? I mean, I guess it's the question of are you a lumper or a splitter in this? But certainly, we do both. How do you look at it?

Dr Jennifer Freeman: I think that's just great question and I'm going to be tricky and I'm going to say I'm a lumper and a splitter because, overall, I think the overarching similarities are more important when it comes to thinking about these disorders. And the reason I think that is because of treatment. So from a treatment perspective, What we know to be the best treatment or at least the biggest core component of all treatments for anxiety is exposure therapy, a specific kind of cognitive behavioral treatment. Exposure is the right treatment for all of those different anxiety disorders that you listed, even OCD and PTSD, which technically are not anxiety disorders in DSM-V, but we lumped them into that because the treatment is really similar. That doesn't mean it looks exactly the same, but the core component of that treatment looks the same. And so that's where in some ways the splitting of hairs of what we name it, like what name we give it is less important to me in some ways, but here's where the splitting needs to happen.

I care less about the specific name of the diagnosis, but where it matters is we think a lot about what is the child's core fear? What is the core thing that is really causing impairment for this kid? And that's where you do need to think about some of those more specific content pieces that are driven by diagnosis. And so the example that I use a lot is we see lots of kids. I know Dr. Walters sees these kids all the time, who won't go to school, they're having so much trouble going to school. And the parents say, "I can't get so-and-so to get out of the car and go to school and walk into the building. And I don't know what's going on." And if you just sort of look at that at face value, you would think the right treatment would be obviously to get this kid to go to school, hopefully. But looking at a child who's standing outside the school and refusing to go in doesn't tell us anything about what they're afraid of. So that child could be afraid of talking to other kids. They could have social anxiety. And so if we just send them into school and don't practice or help them get set up appropriately to talk to other kids, they're not going to get better. If that child has OCD and is worried about a contaminant in the school building, and we say, "Go in and talk to your friends," and we don't talk about the contaminant or figure out what that is, that child isn't going to get better. If they have separation anxiety disorder, then the issue is that they don't want to get into school because they don't want to leave their parent and on and on and on. It could be a specific phobia. It could be something else. It could be generalized anxiety disorder. They could have some real life worries at the moment about whether they're safe in that school building that might not be an anxiety disorder.

Dr Greg Fritz: That's a really good way of looking at it as the core fear, identifying that rather than some necessarily diagnostic term.

Dr Jennifer Freeman: And that's really how we think about it in treating kids. And I think that's a helpful lens to sort of get at what is really causing the problem.

Dr. Anne Walters: And then the followup, I guess, that's implied, is we have to ask children what they're afraid of.

Dr Jennifer Freeman: We sure do.

Dr. Anne Walters: When we flip that conversation, it is so fascinating because what has been assumed might be an interference isn't actually what ends up being the case at all, whether it's, as you mentioned, a separation whether kids are frightened in school, because there's a lot of reasons to be frightened about being in school. And so going a little further with that, if I'm the parent of an anxious child, should I seek treatment for them or myself sooner rather than later? Or wait to see if they'll outgrow the problem?

Dr Jennifer Freeman: I am a firm believer in taking these things on sooner rather than later. I really think when it comes to child anxiety, almost more so than any other child mental health condition, we know it's extremely common. And even though there is some normative piece to it, it's really treatable. And so if we help kids and the parents early on, there's less of a chance of this developing into a whole set of other problems. Anxiety disorders in kids that don't get treated, we have lots of good data to suggest that they lead to kids developing all sorts of other problems that lasts for a lifetime, depression, substance use, other things that are that much harder to treat as kids age. And anxiety itself is harder to treat as you age. And again, I talked before about taking on an entire family. The more it latches on and changes all of the ways in which a family operates and does daily activities, the harder it is to change.

Dr. Anne Walters: And I think that you mentioned the family treatment, which I do think is really important because, in some ways, we ask families to do something that's a little counterintuitive, right? Parents, we think, "Oh, we should protect our child if they're feeling anxious. We want to reassure them." And I have a feeling, I know what you're going to say about reassurance, but perhaps our listeners would want to hear that as well.

Dr Jennifer Freeman: Yeah, I think that's another just really, really important part of thinking about how to treat kids with anxiety. Parents who are taking care of their kids with anxiety, you're right, the thing that we are also hardwired to do as parents is to comfort our kids, to take care of them, to protect them, to make them not feel distress. And kids who are anxious, who are anxious beyond what we would expect them to be, who are experiencing excessive amounts of anxiety or fear or avoidance, there are ways to be validating of those feelings. And it's really, really important as a parent to be validating, not to say, "You shouldn't feel that way" or "That's not real," or "You don't really have a stomach ache," because they do, but not to let that be a reason to help that kid avoid whatever the situation is. And so, coping and distraction and avoidance are all words that get complicated in this vein. We, in our center and myself as a clinician, work really hard to help parents both validate their child's distress and then help not accommodate it, help them fight against it, so that they are not avoiding something and not losing out on being a kid. And that's hard as a parent. We are teaching parents and kids to tolerate being distressed. The goal here is it's okay to be anxious and you got to do whatever it is anyway.

Dr Greg Fritz: So you just mentioned the center, that's a remarkable treatment program for kids with obsessive compulsive disorder, OCD. Would you tell us a little more about the core principles and approaches that you take in that group? Because it's nationally recognized and is a real gem that has helped a number of kids.

Dr Jennifer Freeman: So our center is a group of many, many researchers and clinicians, multidisciplinary team of actually 45 people at this point, that was once two. So it has grown and grown and grown over these years. And we really focus on researching new treatments for kids with both anxiety across the board and OCD. We have an outpatient program. And we also have a partial hospital program and intensive program for kids with anxiety and OCD that we started in 2012. And the core focus of that partial program, which I think is more what you're asking about is, "How do we think about kids for whom outpatient treatment is not enough, kids for whom once-a-week treatment with an outpatient therapist isn't cutting it for some reason?" And there are lots of barriers to getting better with an hour a week of treatment. And sometimes that's severity, sometimes it's comorbidity, sometimes it's other barriers, getting to treatment, getting to the hospital in addition to economic barriers and family level barriers and mistrust of our entire system, that might make a lot of sense.

So we developed this program to pool all the resources that we possibly could together in one place to have psychiatrists, psychologists, bachelor's level staff, doing group therapy for hours and hours a day, and medication management and intensive family therapy and individual therapy, and to have treatment also happen outside of the home. So we developed this system of including home visits, alongside a partial level of care, so that kids were really getting help. We talk a lot about treating anxiety where it lives. We need to treat anxiety in real life spaces where these kids are. And sometimes that works really well in my office or in our hospital setting, and sometimes it doesn't. Using this model, we can go help someone who's stuck in their literal shower, help them get out of that shower or help them get out of their bed. We've done that a lot. Help them go to school, literally get out of the car and go to school. And it's like having a longer reach. You can't see me. I'm spreading out my arms. I have very short arms, but this treatment gives me a very much longer reach.

Dr. Anne Walters: You're also a devoted and accomplished researcher in the area. What do you think are the most pressing questions about pediatric anxiety disorders or OCD that need clinical research to be answered?

Dr Jennifer Freeman: There's a whole world of biological questions and questions about cause and etiology and genetics and neurology that are super important. That's not the kind of research I do. So in a clinical research vein, I think there are a couple of key things that are really important. One piece is just treatment augmentation for these kids who are at the most severe ends of the spectrum, who we see many of, who don't get better with our traditional treatments, be them behavioral or psychopharmacological treatments. We need to think about what else we can do. And so some folks in our group, for example, are thinking about non-invasive brain stimulation. those kinds of augmentive treatments and other behavioral strategies that we can add. Or thinking about what are more specific nuanced ways that things like sleep, which are pretty easy to intervene on, might change the way treatment works or treatment outcome works, or even medications work. So that's one area of research.

For me personally, the area that I am devoting most of my time to is thinking about how we can get these treatments out there to more kids. How do we take on this gigantic children's mental health crisis and take our treatments outside of our hospitals and our academic medical settings and treat kids in the communities in which they live? And so this model of combining a bachelor's level staff with a psychologist in a team-based approach, which is what we've done in our partial program that we're now doing at an outpatient level as part of our research program, I want to take that to the masses. And that's a big piece of our research initiative at the moment, is how do we get that out there into the world?

Similarly, how do we train more people to do exposure treatment? There are not enough clinicians to do the treatment that's needed. And that's true across the board in all areas, but it's especially true highly skilled people who know how to do exposure are limited even in our small state of Rhode Island. And so we want to train more people to have the skills to treat these kids.

And then last, we really need to think about the diversity of the samples of kids that are included in the research that we're doing. The traditional randomized controlled trials that have been done in anxiety and in OCD are quite limited in terms of racial and ethnic and gender diversity of the kids and the teens. So that doesn't actually represent all of the kids in this nation and we need to do a better job of that. And I think these studies that if we could get more into the community could be more representative of all kids.

Dr Greg Fritz: That's quite an agenda. Jen, thanks so much for being here today. We could spend 10 times as much time talking about these questions in detail, and that suggests that we should have you come back and really bore into some of these specifics at another time. But if a parent is listening right now and suspects that their child is struggling with an anxiety of one form or another, what could they do to be helpful right now?

Dr Jennifer Freeman: I think in a perfect world, I would say reach out, find a therapist, just get some advice. And the reality of our current world right now is that it's very hard to find a therapist in the community. I would still suggest that. And I think even just talking once or twice to someone with some expertise in this area can really help put put you on a path towards addressing these kinds of concerns early. If you can't connect with a therapist, there are a lot of great resources online through some of our professional societies. And so the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, the American Psychological Association, the International OCD Foundation. I could go on and on, but there are many, many parent tip sheets, especially for someone just starting looking, just wanting a little bit of information. That can be found online if you're looking through a reputable organization. You don't want to just Google it and take the first thing you see.

Dr Greg Fritz: Right. Well, Thanks again, Jen. That's very helpful. And if you found this podcast helpful, please share it with your friends and contacts on your social channels. And check out our entire podcast library at bradleyhospital.org/podcast for other topics of interest to you. This is Mindcast: Healthy Mind, Healthy Child, a podcast from the experts at Bradley Hospital. I'm Gregory Fritz with my colleague, Anne Walters. Thanks for listening.