- [Jeff] Welcome to "Healthy Minds".

I'm Dr. Jeff Borenstein.

Everyone is touched by psychiatric conditions, either themselves or a loved one.

Do not suffer in silence, with help there is hope.

(soft music) Today on "Healthy Minds".

- Anxiety disorders are one of the most, if not the most common problem, that children and adolescents face in life.

But at any one point in time, probably around 10% of children and adolescents in the United States will be suffering from an anxiety disorder.

And when we follow kids over time and look at the overall rate, we see that a much higher rate of children and adolescents, well more than 20% or one in five, will suffer from problematic anxiety at some point during development.

- That's today on "Healthy Minds".

This program is brought to you in part by the American Psychiatric Association Foundation (gentle music) and the John and Polly Sparks Foundation.

(gentle music) Welcome to "Healthy Minds".

I'm Dr. Jeff Borenstein.

Anxiety, we all experience anxiety, even children and teenagers, but how can you tell if a youngster's anxiety is normal or a potential problem?

Today I speak with leading expert, Dr. Daniel Pine.

(gentle music) Danny, thank you for joining us today.

- Absolutely, Jeff, it's great to be here.

- I want to jump right in and ask you about anxiety in children and teenagers.

- So anxiety usually involves a phenomenon where somebody experiences fear related to their concerns about danger, and having fears and worrying about danger is a normal part of childhood and a normal part of adolescence.

These fears or anxieties change as kids age.

So early in life, kids might be afraid of particular things like shots when they go to the doctor or being separated from their parents.

And as kids grow into young adolescence, their fears and their worries change.

So they might worry about social things, what other kids think of them, and then when they approach adulthood, they change again, where kids might worry about things like abstract phenomena, like how successful they're going to be or what's going to happen to them.

These kinds of fears and anxieties are a normal part of life and they're a normal part of development.

We worry and we think that a child or an adolescent might be suffering from a clinical problem, an anxiety disorder, when these fears and anxieties prevent the child from doing things that other kids can do.

So to just pick one example, some children or early adolescents who might be worried about what other kids think of them will actually stop doing things where kids they don't know might be present.

So they'll have a hard time going to school on the first days of a new classroom, or they'll have a hard time going to social settings.

And it's really when anxiety prevents kids from doing things that other kids can do, that's when we start worrying that a clinical problem is present.

- How common is that sort of, do people get over that borderline into where there is a clinical problem?

- Anxiety disorders are one of the most, if not the most common problem that children and adolescents face in life.

Now, there's some gray or blurriness in the boundary, so it's hard to get an exact estimate.

Also, anxiety disorders tend to come and go with time, but at any one point in time, probably around 10% of children and adolescents in the United States will be suffering from an anxiety disorder.

And at certain times, such as during stressful times, those rates can be substantially higher.

And when we follow kids over time and look at the overall rate, we see that a much higher rate of children and adolescents, well more than 20% or one in five, will suffer from problematic anxiety at some point during development.

- These are very, very common conditions.

What should a parent do if they're concerned that their child is having significant anxiety?

- Usually the first thing to do when you're worried about any health-related problem with your child, including a mental health problem, is to consult your pediatrician.

And that can be useful for a few reasons.

For one, pediatricians have a pretty good idea of the boundaries of typical behavior and behavior that's associated with psychopathology.

Number two, pediatricians are often a wonderful place to get early information about what are simple things that you can do.

But then number three, pediatricians are often an excellent conduit for parents and families who are looking for other sources of treatment.

- A natural reaction of parents, of all of us, to somebody who may feel distressed with a particular activity is to help them avoid that activity, and I'd like you to speak toward that.

- Yeah, one of the hardest things as a parent is to know how far to push and how much to push your child.

We do know from following children over time and from a wealth of basic science research in a range of species that it's important that people be able to face the things that they're afraid of.

So we know in children, children who have mild anxieties that are subclinical, that are maybe just beginning to impact the child's functioning, we know that kids who face their fears and we know that kids whose parents encourage them to do the things that might be difficult, those kids tend to have lower rates of anxiety disorders when we follow them over time, compared to the child whose parents make sure that the child is never exposed to a stressful event.

So on the one hand, we do know that it's important for children to face their fears and to confront the things that are stressful for them.

On the other hand, there comes a time in all children when a stressful event is too much for them, and this is really where parents can benefit from the help of a therapist or another mental health professional.

The therapists have a lot of experience kind of titrating that balance between working with a child so that they're fearful and exposed enough to the things that are stressful so they can get over them, but not so afraid and not so stressed that the child will be traumatized.

- Tell us a little bit about the treatment.

What should somebody expect after they've been evaluated, diagnosed?

What happens next?

- So usually there are two treatments that have been shown to work substantially well for children with anxiety disorders.

One treatment involves a form of psychotherapy or talking therapy that we call cognitive behavioral therapy.

And the data are quite strong for this treatment that they work quite well.

The way that this treatment works is that a child will develop a relationship with a therapist and the therapist and child will make a list, kind of a hierarchy of the things that the child fears.

And the therapist will teach the child new cognitive techniques to use when they're feeling afraid or worried that the child can deploy to calm themselves.

And once the child has learned those, what the therapist will do, it will help the child face and confront increasingly frightening scenarios along their hierarchy.

And probably more than half of children will respond to cognitive behavioral therapy.

Now, cognitive behavioral therapy is not easy in some ways.

For one, there are not nearly enough trained therapists, so in many areas, parents and families will have a hard time finding a trained cognitive behavioral therapist.

But then for another, a child has to really cooperate and want to work on their problems for cognitive behavioral therapy to be most effective.

And there are many other things parents can do psychotherapeutically, but another thing they can do and the other established treatment is to consider treatment with one of the newer antidepressant medications.

And these can be either SSRIs, which stands for selective serotonin reuptake inhibitors, or SNRIs, selective norepinephrine reuptake inhibitors.

And these treatments are similarly efficacious as cognitive behavioral therapy.

They have some disadvantages in that all medicines are associated with some side effects, and that applies for these medications as well, including a rare but concerning association with thoughts about suicide.

So for that reason, many parents prefer cognitive behavioral therapy, which is reasonable.

On the other hand, for kids who do not have access to cognitive behavioral therapy or for kids who are unwilling to undergo cognitive behavioral therapy, antidepressant medications are an excellent second first-line treatment.

- Parents may be concerned, okay, we're starting medicine and now will the child have to take it for the rest of their life.

What does that mean?

What do you say to parents?

- So there's a few things that we know about how long a child should take a medication.

The first thing is that a medication only should be continued if a child has a substantial benefit from that treatment.

So if a child is taking a medication and really isn't making a difference for their anxiety after a month or two, then there's no reason to continue it.

The second thing is we have pretty strong data for children who continue to take a medication for as long as a year, so parents can be reassured that there are unlikely to be any long-term consequences from taking a medication for as long as a year.

After a year is where the data become a little unclear.

We've followed many children for many years when they're taking medication and there's no obvious sign of a concern.

So on the one hand, if a child needs to be on medication for more than a year, parents can be reassured that there isn't anything we know that is definitely concerning on the one hand.

On the other hand, we know far too little about how medications work and what their effects are on the brain as it grows and matures.

Moreover, we know that most anxiety disorders will not persist for longer than a year or two.

And clinicians differ in terms of how comfortable they feel with long-term treatment in light of those unknowns.

My own feeling is that most children after a year at least deserve consideration of a trial off a medication.

This doesn't mean that the child has to come off the medication, but many, if not most children, after a year, or at most, two years of treatment, can do really well overcoming their anxiety disorder once the medication is discontinued.

- I want to ask you about the risks of not treating anxiety.

What may happen to a child if it's just left untreated?

- There are a few concerns we have about not treating a child who's suffering from anxiety.

One is we know it's quite distressing for a child and it leaves marks in terms of the risk that that child might face for a future anxiety disorder.

So helping a child to overcome the things that are impacting them related to their fears is one reason why it's really important to treat the anxiety disorder.

However, we also know that anxiety disorders are often the harbinger of other problems that children face.

So one of the most concerning is an episode of what we call major depressive disorder or mood disorders.

We know that anxiety disorders in children are among the most powerful predictors of mood disorders, particularly major depressive disorder, as children become adolescents and adults.

So there's some hope that if we effectively treat anxiety disorders in children, we're going to impact that risk for mood disorders in adolescents and adults.

Finally, there's a range of other conditions, both other mental health conditions, but also medical conditions, like respiratory illness or cardiovascular disease, where we know that there's a connection with anxiety.

And while the connection might not be as strong as the one between anxiety and depression, we also think that alleviating anxiety in childhood has a range of other health benefits beyond potentially reducing the risk for major depressive disorder.

- I'd like you to speak about the role of social media, which gets a lot of attention, and its effect on children with regards to anxiety.

- So there's been a lot of discussion about social media, and that speaks to the fact that it is a dominant force in the lives of children.

There's been a particular focus on the relation between the use of social media and mental health problems.

So one thing is pretty clear, that social media is clearly a place where mental health problems are expressed.

So children who are suffering often express aspects of their suffering through social media.

And children who are exposed to risk also face those risks through social media.

The thing that is less clear is, what is the causal role of social media?

Is social media actually exacerbating mental health problems?

And if you read the newspaper or some of the other recent events, you might come away thinking that the story here is relatively clear, but that is not the case, it is not clear that social media is causally related to an exacerbation of anxiety.

And I think we need to be very careful about jumping to conclusions.

The best way that we understand these relations is by following children over time and looking at relations between mental health problems and use of social media.

And what the limited longitudinal data we have suggests is that there is a clear relation between social media and mental health problems, but a strong part of that relation might involve the expression of psychopathology that is caused by other factors through social media.

- One of the factors that certainly can affect a child is the issue of bullying.

And I'd like you to speak about that and how that relates to anxiety disorders.

- So when we think of mental health problems, we usually break down the things that cause them into two broad factors, genetic on the one hand, environmental factors on the other.

And different mental health problems have different mixes of these genetic and environmental problems.

Problems like ADHD and autism spectrum disorders have a preponderance of genetic influences, though they also have environmental influences.

And problems like anxiety have a preponderance of environmental influences, though they also have an influence from genetics.

When we think about the environmental influences that shape risk for anxiety in children and adolescents, exposure to stress is one of the greatest and most impactful environmental risk factors for anxiety disorders.

And of the kinds of stress that children experience, stress from peers is one of the most important things that we see.

And finally, when we're thinking of stress from peers, bullying is one of the most concerning factors that predisposes to anxiety among children and adolescents.

So what that tells us is that bullying is one particular example of a whole range of things that are likely to be very important in creating risk for anxiety.

And if we want to reduce the problem of anxiety, working hard to reduce bullying, to prevent it, and to help kids when they're exposed to bullying and other kinds of social stressors, that's one of the most important things we can do to try to combat this problem.

- So if a parent finds out that their child is being bullied, that is a risk factor.

If a parent sees that the child is functioning at school, their grades have changed, social functioning has changed, those are all signs that maybe something's going on and they need to look a little further into it.

- Yeah, there are a couple things parents can think about in that context.

One is, again, increasing awareness about the reality of problems related to bullying.

That's very important.

And many years ago, maybe when I was a child, if things like that would happen and there might be a sense that, well, children will work it out on their own, we now know that that is not the case.

So it's very important that educators, mental health professionals, and parents work hard to make sure that everybody knows that bullying is not acceptable and that we need to do all we can to stop it.

- I just want to mention what I think is an important point.

When we were growing up, if we were bullied, it was in the school yard and then you'd go home and be safe.

Now you go home and it continues online.

So you're not safe, it's just continuous.

- Absolutely, absolutely.

And you know, again, going back to the point about social media, bullying is the problem.

So social media isn't necessarily the problem.

Now, on the other hand, exactly as you say, social media gives another opportunity for bullying to occur, which is particularly problematic.

So the point I was going to make is that the appropriate response from the school should be great concern when they learn about bullying, it should be doing everything they can to protect the child, to treat bullying as a systemic problem that just must be eliminated, and to take the concerns from a parent very seriously.

- When parents are speaking to their child, of all ages, what types of things should they be asking?

What should they be saying to get a sense of how the child is coping, whether or not the child's having significant anxiety?

Give us a little guidance.

What should parents do?

- Sure.

So one thing that parents should pay attention to or think about is that reports of all problems from children evolve in a certain context.

So working on your relationship with your child by spending time with your child, doing the kinds of things that your child enjoys, has lots of benefits.

It increases enjoyment in your life, it encourages a child to live in healthy ways, but it makes the child feel safe in terms of discussing topics with parents.

Second, some people worry that if you ask children about upsetting things, that it will cause problems for the child.

And we now know that that is a myth, that is not the case, that parents should feel free and should feel encouraged to ask their children about things that might be bothering them or things that the parent has noticed that could be upsetting to the parent or to the child.

And then number three, particularly among young children, it can be difficult for them to understand certain abstract concepts, so concepts like stress or emotions.

So parents are often on the most sound footing when they can talk about specific behaviors.

And the behaviors we really think about in children who are having problems with anxiety are avoidance.

So children who won't do things that other children are doing, parents should think about, why is that child reluctant to do these things?

And they should think about things that are scary or frightening to the child.

So if parents are working on their relationship with their children and creating a warm, loving environment where children feel safe, and parents are spending time so that children are familiar with what it means to talk with them about things that are disturbing to the child, when the child is having problems doing things, when they're avoiding things, parents can feel reassured that that child will be more likely to talk about those things that are bothering the child.

The last thing I would say about this is just because a child is avoiding something, that does not mean that the child has an anxiety disorder.

It's very common for children to avoid all kinds of circumstances.

Children who are having normal anxiety, once they're helped by their parents, once their parents encourage them, maybe offer to bring the child to the party directly, children who are healthy can gradually overcome those fears on their own and can reduce the avoidance on their own.

It's when avoidance persists for many weeks or months, that's when parents should really start worrying that maybe their child is suffering from an anxiety disorder.

- Danny, I want to thank you for joining us today.

The information you shared is so important for all parents and families to hear.

Thank you so much.

- It's been great, Jeff, and I really appreciate having the outlet to talk with you about these vitally important issues.

(gentle music) - If your child is experiencing significant anxiety that may be affecting their functioning at school or in social settings, seek help.

Remember, with help there is hope.

(gentle music) Do not suffer in silence.

With help there is hope.

(gentle music) This program is brought to you in part by the American Psychiatric Association Foundation and the John and Polly Sparks Foundation.

(gentle music)