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Melanie Cole (Host): Welcome to Long Live Childhood, a pediatric health and wellness podcast presented by Children's Health of Orange County. Together, we can keep kids happy and healthy.

I'm Melanie Cole. And joining me is Dr. Wendy Gray. She's a board-certified pediatric psychologist with Children's Health of orange county. Dr. Gray, welcome back. I'm so glad you could join us for this topic as we talk about anxiety in kids and teens. And my goodness, I feel like there is a mental health and anxiety epidemic, not only among our kids, but you know, among adults too, but we're here to talk about the kids. So tell us how common, what are you seeing right now? And how much anxiety is considered normal for our kids?

Dr Wendy Gray: Well, thank you for having me back. I would say that anxiety is extremely common. And if you think about the things that we just went through over the past two to three years, a lot of unknown and uncertainty, that really is a breeding ground for anxiety. So anxiety is incredibly common. And I think I'd like to start out by saying anxiety isn't necessarily bad. Anxiety is our body's warning signal that we need to pay attention to something, that there's something threatening in our environment or something threatening in the future. However, sometimes that warning signal becomes overactive and it reacts in situations that generally aren't life-threatening. So I'd say that anxiety is normal. The goal is never to get rid of anxiety, but to manage it. And when it starts to move beyond the normal level of anxiety, that's when we start thinking about, is it impairing a child's functioning? Is their anxiety so bad that they're starting to develop stomach aches, difficulty sleeping, school avoidance, nightmares? Is it impairing their ability just to do the things that they need to do just to be a normal kid or a normal teen? So if it's ever getting in the way of them doing something or living a normal, healthy life, that's when we start to think we kind of moved beyond what is the typical level of anxiety we would expect anybody to have.

Melanie Cole (Host): Well, these are certainly unprecedented times. And when the kids were home, being schooled online and all of that, certainly I saw it in my own two children that were not in classes, that anxiety level, and as it rises. Tell us about the different type of anxiety disorders that are out there right now and what we're looking at with our kids.

Dr Wendy Gray: Sure. There are a lot of different anxiety disorders. So one of the ones that is most common is generalized anxiety disorder. So these are our kids that are worriers just in a lot of different areas, They might worry about their own safety, their family's safety, things that might happen in the future, any threats to their health or just physical safety. So these are our chronic worry warts, would be a best way to describe it.

Our younger kids may have separation anxiety, and that's really just a really big fear of being separated either from their home or their primary caregiver. So you typically see this in the preschool, toddler age, especially as they're transitioning to school and spending time away from home for the first time. Specific phobia, that's really those kids that are afraid of a very specific thing, and that includes adults as well, so a fear of heights, a fear of spiders. Here at the hospital, we might deal with a blood, injury, injection phobia. So these are the kids that are terrified of needles and some may actually pass out because of that fear when they're in that situation.

Social phobia or social anxiety, those are our kids whose anxiety is primarily triggered by performance situations or social settings, so being in a group or a party with other people they don't know, having to give a speech in front of others. So any sort of performance situation will trigger their anxiety. And we do see a lot of social phobia as we moved to the online schooling where you see your face on the screen, everybody else sees your face and it's even scarier to talk in front of the class when you can see all of those eyes looking at you at the same time.

We also have panic disorder, which is really the kids that tend to have the classic panic attack, this intense wave of anxiety that's incredibly overwhelming and they may have a rapid heart rate, difficulty breathing, sweating, just this sense of impending doom, something bad is going to happen.

Selective mutism is another one that didn't mention earlier. Those are our kids who have trouble speaking in one specific setting. So they may be highly verbal at home, but the second they move out of the home setting and they're at school, they maybe present as incredibly shy and unable to speak. So, they may feel frozen and some people may think that they're non-verbal because really like their mouth clamps shut and the anxiety is so high that they lose the ability to talk.

Kind of in the anxiety disorder umbrella, but a little bit further out, we have conditions like OCD, where you have an intense, intrusive, disturbing thought that spikes up your distress and anxiety. And then, you have to engage in some sort of behavior or mental act or ritual to help that anxiety lower. So as you can see, there are a host of different anxiety disorders and it is possible to have more than one.

Melanie Cole (Host): Well, that was a very comprehensive list, Dr. Gray. Thank you so much. So when I asked you how much was normal, you gave some parameters. But now, I'd like you to separate that out a little bit for red flags, signs of anxiety and depression for parents or caregivers that can signal, "Hey, you know what? It is time to call in a professional." What are some things we're looking for in our kids that would say this is not normal anxiety?

Dr Wendy Gray: So the first thing that comes to mind as a parent is thinking about how long would it take to do a specific task in a typical situation? So let's say you have a kid who has separation anxiety. Dropping them off at daycare or dropping them off at school for a child without an anxiety disorder would be a pretty easy brief thing. But if you're engaging in these rituals to try to help them deal with the anxiety, you're engaging in a lot of reassurance-seeking, "It's okay. Mommy will be back. I promise." So those prolonged goodbyes are really hallmark signs of something needs to be done for separation anxiety.

In general, I would say the second you start experiencing bodily symptoms, so the kid who keeps calling home from the nurse's office, because they keep having stomach aches on the day of a test or difficulty with sleep; so if you start to see grades dropping, school avoidance. I like to think of anxiety and depression as just ugly cousins. So usually, the anxiety sets in first and then when the anxiety isn't managed well, that's when these kids generally start to fail in some critical area of their life. So grades may drop, they may start to lose weight. And generally, the less effective they feel like they are in their lives, the more likely depression is going to settle in right after it.

Melanie Cole (Host): So then speak about treatment for us, Dr. Gray. What are some of the available treatments for this spectrum you've described of anxiety disorders?

Dr Wendy Gray: So for classic anxiety, the most evidence-based, so that means we've done a lot of research, we know this is what works best for managing anxiety disorders is anything within the umbrella of cognitive behavioral therapy. And that really targets the thoughts. I like to think of them as filters that we see the world through. We all have filters and those of us who are anxious tend to have anxiety filters. So we'll see situations as more threatening, and more dangerous than they might technically be. So cognitive behavioral therapy targets those thoughts, but then it also targets the anxious behaviors. So a classic example would be a child who has, let's say, a fear of spiders. We're not going to put them in a room with a tarantula right away. But what we might start with is helping them stay in a situation, let's say, looking at a picture of a spider and their anxiety is naturally going to rise. And what a kid with anxiety would typically do in that situation is escape. "I don't like this. I don't want to be here. I want to get away." And what that escape does is reinforce that anxiety, "Whew. That really was dangerous. I'm so glad I got away from that." But if we can keep a kid in that situation and teach them how to tolerate their anxiety, they will realize that, "Huh, the thing that I thought was dangerous is actually not as dangerous as I thought. It's actually pretty okay. It's not comfortable, but it's okay." So cognitive behavioral therapy targets the thoughts and the behaviors that contribute to and maintain anxiety.

Now, as kids are getting a little bit older, there's a lot of great stuff coming out with acceptance and commitment therapy, because there are some things that are seriously scary and there's no way you can change your thoughts about it. It is scary, but you have to change how you behave or respond to the situation. So I've seen great outcomes with acceptance and commitment therapy with our adolescents and our young adults. It's not something that's really been adapted quite yet for children.

So those would be the two hallmarks. And then within that umbrella, there are very specific treatments for each disorder.

Melanie Cole (Host): Well, then, Dr. Gray, you've given us so much to think about. And as a parent, I know, and I see it in my kids, the anxiety, the palpable nervousness about a lot of things going on in the world today. What can we do as parents? I asked you about what we can do when it's time to seek a professional and the treatments that are available, but what can we do, practices that we can teach our children or work with our children to help them deal with some of the anxiety, deal with some of the stress and the things that they see around them? How can we help?

Dr Wendy Gray: Well, I think that, first and foremost, the best thing parents can do is really model good coping skills themselves. So, you know, generally, kids who are may also have anxious parents as well. That's not always the case. But if you think about a kid that's got a radar for anything threatening, they're going to pick up on any anxiety around them. So if we, as parents, can model good coping skills, such as practicing deep breathing or saying, you know, "I'm feeling a little nervous right now, but let me think about whether or not that thought is true or what's going on. Let me practice some relaxation or go for a walk." The more we can model healthy coping skills, the better.

The other thing is we want to encourage our children to develop bravery and resilience. So we don't avoid things just because they make us nervous. Sometimes it's the things that make us nervous that help us grow the most. So we want to encourage bravery in situations where it seems realistic. If a child is afraid of heights, we're not going to make them jump off of a diving board that's really high up, we have to build up to something like that. But we also don't overly accommodate and try to pave the road for our child, because although that helps them deal with in-the-moment anxiety, long-term, they're not developing the skills that they need to deal with anxiety. And we as parents may not always be there to protect them from the things that are scary.

The other thing I would say is also reminding kids that, again, anxiety is not the bad guy. Our goal isn't to get rid of anxiety, but it's to help manage it. So the better we are at managing it, the lower that anxiety will become or the smaller it will become over time. So anxiety is our warning system, our warning system is just a little out of whack. So we need to fine tune it. Any time we see our kid doing something that would normally trigger anxiety or they're brave in any situation, we definitely want to praise them. "I am so proud of you for being brave and doing that thing, even though it was scary. High five." So the more we reinforce a behavior, the more we praise it, the more likely we're going to see it. So we definitely want to reward them or encourage them whenever they do something brave.

Melanie Cole (Host): I still have a couple of more questions, Dr. Gray. And one of them is sleep. Because as we're trying to be good role models, which is what you were just telling us to do, that involves exercise. I'm an exercise physiologist, so I've always tried to impart that to my kids, they see me on my treadmill and they see my naps and they see all these things that I do, but sleep is a little bit more elusive for our kids. And especially, today with all the social media and their phones and all of the things that are distractions for them to go to sleep or get that good night's sleep. So what do you want to tell us about that, sleep, social media, how those things are contributing to the anxiety that our children are feeling and how we can help them with that part of it?

Dr Wendy Gray: So social media has so many great parts of it, and it can help us foster connections with other people, especially those we may not see every day. But on the flip side, it also is a breeding ground for comparison, or this fear of missing out. |I just logged in. I see everybody else having a wonderful time. Why did they not invite me?" It really triggers a lot of anxiety thoughts. And one of the things I tell my adolescent patients in particular is a lot of times we're not feeling well and our go-to is to go to social media. But I've never seen anyone say, "Wow, after that half hour or hour in social media, I feel so much better." If anything, it makes us feel worse. So the more you can disengage from the screens when you're feeling anxiety, unless you're using an app, let's say the Calm app or the Smiling Mind app is actually a fantastic app that provides a lot of different meditations and it's free, the more you can engage in exercise and really just engage with the world around you, the better off you will be. It'll provide a much better benefit for you than social media ever will.

So I do think that, at a certain time, when we think about the amount of sleep that a child needs, the school age child, usually somewhere between 10 to 12 hours at night; an adolescent, somewhere between, let's say right around 9 hours. So few of them are getting that sleep. And sleep is really our body's ability to kind of recharge the nervous system or immune system. It really is our ability to repair and restore. So if you're not getting enough sleep, it's like you're not putting enough gas in your gas tank and you really want to make sure you get a good night's sleep without distractions, without screens, ideally maybe half hour to an hour before you go to bed, because that wakes up your brain and what you were trying to do when we go to sleep is calm everything down. So exercises like the breathing or guided imagery or progressive muscle relaxation. We have created so many videos on CHOC's website that can guide kids and teens through those exercises. And those are really meant to help us calm our brain. Journaling, baths, reading things like that can also help us calm down if you need something that doesn't involve a screen.

Melanie Cole (Host): Wow. So informative and really great advice. I think all parents should really listen to what you're saying, Dr. Gray, and take this to heart. Now, as we finish with your best advice, I'd like you to tell us how a parent or caregiver can go about finding a good therapist for anxiety and for their kids. Because I can tell you, my daughter suffers from some of those anxieties and it is not easy. Even with televisits now, it is not easy to find mental health professionals because you guys are in short supply compared to the epidemic of mental health crisis we are experiencing in this country. So what do you want us to know about looking for a good visit, a telehealth visit, finding a good therapist for ourselves and certainly for our kids?

Dr Wendy Gray: Right. And it is certainly a challenge finding a therapist at this time. I would say that the first place to look as a parent would be what mental health resources are available through your school. Some schools have made fabulous investments into the mental health infrastructure of their district, and you could possibly receive those services more quickly and for free. So, if that is an option, I would try to go there first and they can really deal with lower levels of anxiety, general coping skills. Most of those providers will be either trainees, so they are working on their master's or their doctorate, or they are master's level clinicians like licensed marriage and family therapists.

In general, when you are looking for a therapist, you're going to want to talk to them first. Ask them, "Okay, how would you treat an anxiety disorder? And what are the specific modalities you would use?" If they say, "Oh, talk therapy or, you know, we'll just work on it," you don't want a therapist that's going to just serve as a dumping ground for your kid to talk about what they're anxious. The kid, adult, teen, we have to be learning a skill in therapy because our ultimate goal is to give our patients the skills that they need so that they don't need to continue coming to us. So our job is to put ourselves out of a job. So you want a therapist that's going to talk about, "Oh yes, we're going to use cognitive behavioral therapy" or "We'll use the Coping Cat treatment," which is an evidence-based anxiety disorders treatment in school-aged children, or, you know, "We're going to use acceptance and commitment therapy in this way." and if you can get good examples of what they would do or what it would look like, even better. So. If you can find someone that's certified in the treatment of childhood anxiety disorders, that's fantastic. But you just want someone who has a good, solid training in cognitive behavioral therapy. So that would be my biggest ask of any therapist.

And finally, my best advice to parents is you want to support your child. And we definitely don't want to make it a negative interaction. So we don't want to criticize or blame or yell at them for being anxious, but we do want to empower them and give them the skills that they need to be successful. So my best advice would be don't be afraid to reach out for help. Generally, anxiety will not get better if it's just left alone. So if you are concerned, say something to someone, whether it's your pediatrician, your child's teacher, reach out. Ask friends, word of mouth can be a fantastic way to get good recommendations. But if you're worried, seek out the support. Don't just stay silent and allow your child to kind of suffer on their own.

Melanie Cole (Host): What great advice. Such an informative and important podcast you gave us today. Thank you, Dr. Gray, for joining us again. What a great educator and guest you are. for more mental health tips and more information on anxiety in kids and teens, please visit choc.org/mentalhealth. Thanks so much for listening to Long Live Childhood, a pediatric health and wellness podcast presented by Children's Health of Orange County. Together, we can keep kids happy and healthy. Please remember to share on your social channels as we're all learning from the experts at CHOC together. I'm Melanie Cole.