- [Jeffrey] 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.

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Today on Healthy Minds.

- Well anxiety disorders are the most common psychiatric disorders in childhood.

And in fact, about 20% of kids have anxiety disorders.

Oftentimes, parents may see that their child is anxious, assume it's going to just be a transient developmental phase they're going through, or they accommodate the child's anxiety with the hope that it's a transient developmental phase when I think referral for intervention is in fact an important thing to do.

- That's today on Healthy Minds.

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

(gentle music) Welcome to Healthy Minds.

I'm Dr. Jeff Borenstein.

Anxiety and depression can occur in children as young as three years old and early intervention is extremely important.

Today I speak with leading expert Dr. Joan Luby about anxiety and depression in children from a very young age to elementary school age to the teenage years.

Joan, thank you for joining us today.

- Thanks for having me.

- I wanna jump right in.

Anxiety and depression in childhood is such an important topic.

When can these types of symptoms begin to appear?

- So what we now know based on research that's been done over the past 20 years is that clinical anxiety and depression can really be identified as early as age three.

And we should identify it as early as possible because we think that it may be more treatable earlier in life.

There's a lot of reason to believe that there may be earlier signs of risk even prior to age three and that's an area of active research.

But in terms of when it manifests clinically and might be picked up by a mental health clinician, three is really where we have the most validation.

- And what type of symptoms should a parent look for in a child at that age if they're concerned that they may have anxiety or depression?

- Well, I think anxiety is probably gonna be much more evident to a parent or a teacher or a caregiver, because when kids are anxious, they become very inhibited, they express their fears, they may not wanna go out, they may be very clingy, they may become very withdrawn and quiet, they may sort of freeze when they're confronted with new situations.

So anxiety will be impairing and I think pretty likely at the clinical level parents will notice it because they will find that children can't engage in the kinds of daily activities that they're expected to engage in.

Depression is a little bit harder to pick up on and I think is much more likely to be missed by a parent and caregiver.

And that's because young children are sort of inherently joyful.

They tend to sort of burst in to play and enjoy activities in play.

And as opposed to an older child, adolescent, or adult who's depressed who might be really notably withdrawn or sad, you're not gonna see that as much in a young child because they will brighten, they will still appear joyful, or not necessarily, you know, persistently sad.

Although sadness, certain sadness and irritability are symptoms.

But things that I think are going to be more important are if the child is not engaging, is not experiencing as much pleasure as they usually do, not as motivated to engage in things that they usually enjoy, doesn't enjoy the foods that they're normally really enjoy, doesn't wanna play with friends, doesn't wanna go out on Halloween, and that symptom persists over a period of 10 days to two weeks, that's problematic.

Other symptoms that people I think should be particularly attentive to are children who have excessive shame and guilt, take responsibility for things that aren't their fault.

If they make a mistake they have a harder time getting over it.

And then you can see disturbances in sleep, appetite, and energy just like you see with older individuals.

- What should a parent do if they're seeing these types of symptoms in their child?

- I do think it's really important for parents to take these symptoms seriously, not just ignore them, not just think this is a phase and they'll grow out of it.

Of course if if it's very transient then I wouldn't be concerned.

But any kind of symptom along that line that persists over a series of two weeks or longer, I think is clinically concerning.

If you think the child really is not thriving, not just they don't have to be sort of doing very badly, but it's also sort of not thriving in the way that you might expect because in early childhood there's such a steep developmental trajectory and children are expected to sort of grow and learn and really engage in activities.

If that trajectory looks like it's not progressing because of these symptoms, then I think parents need to take children for a mental health evaluation.

- And parents know their kids.

They could tell if there's something that might be off, and if you feel that way, get that evaluation.

- Exactly, exactly.

- And tell us what happens in such an evaluation with these younger children.

What's the evaluation like, and then what's the treatment?

- In the best of circumstances, the evaluation would be done by a clinician who has expertise in early childhood mental health.

And if that's the case, the standard of care really is for an evaluation to be done over a series of several sessions in the context of play and in what we call a dyadic format, that is the caregiver and the child are seen together.

Generally speaking, if you're evaluating a child under the age of six, the clinician shouldn't be going to the waiting room, saying hello to the parent, and then taking the child back to see them alone.

They should see them in the context of the parent-child relationship because that's really essential to the child's functioning.

And that's where you're gonna see the most realistic and valid manifestations of the child's behavior.

So that evaluation should be done in a play setting.

It should be done with the caregiver.

It's often done on more than one occasion because there's a lot of context specificity to the way a child behaves and then sometimes an actual DSM diagnosis.

And then a treatment plan would be given.

In general, for all kinds of psychopathology in preschool children below the age of six, psychotherapies are going to be the first line of treatment.

So generally speaking, like with the evaluation, the psychotherapies are often gonna involve the child and caregiver together.

And those are usually the first line of treatment.

- One type of treatment that I know you've and your colleagues have been involved in developing relates to this parent child working together in therapy, could you tell us about that treatment?

- Yes.

So in the early 1970s, a psychologist named Sheila Eyberg developed a treatment called Parent-Child Interaction Therapy.

That treatment has been around for quite a while and it's been validated and tested.

It's known to be very effective and it's known to have sustained effects over time.

It utilizes a couple of techniques that we found really compelling.

One is that there's live coaching of the parent as they're interacting with the child through a bug in the ear.

And the other is that it sort of uses a teach coach approach to really give the parent skills that they can then carry forward after the therapy is done.

I think that's one of the reasons why it's so effective.

We basically took that treatment and those techniques and we modified it and added a novel component to it which we call the emotion development module.

The emotion development module really gets at how to teach parents to be their child's emotion, external emotion regulator and emotion coach, and how to help their children develop emotionally.

And it uses this teach coach approach and the bug in the ear.

And it is a parent child relational intervention that can be done in a clinic with a one way mirror, or we've adapted it more recently to a Zoom approach where it could be done in the home.

- And when you say a bug in the ear, that means that basically the therapist has, there's an earpiece for the parent and the therapist is giving some guidance really training the parent so that in many ways the therapy is ongoing with or without the therapist there.

- Exactly.

And so what I think what's really important about it is that the parent and child are seen together in a playroom and there are emotionally evocative events going on.

So when you come in to see a therapist using a more standard approach, you might talk about something conflictual or something that made you frustrated, angry, or sad last week, but you're recollecting it from last week.

You may be distorting it a little bit in your memory.

You may not feel the active hot emotion at the time you're talking to the parent.

What this does instead is it takes the parent and child, it evokes an emotionally difficult or challenging situation, and then the therapist coaches the parent in real time, live, on how to interact differently with the child.

So in that way, I think it is much more effective.

And it really, the therapist sees what the parent actually does as opposed to what they say they do.

- And why is it so important to have an early intervention?

Why is acting sooner rather than later, why does that make such a big difference?

- So we increasingly understand that most major psychiatric disorders, there are some exceptions, but many are probably have a developmental origin much earlier in life.

And the reason why this is so important is because the developing brain has much more what we call neuroplasticity or ability to change in response to environmental events earlier in life, particularly during the preschool period.

That's a period of time that many people have referred to as a sensitive period when the brain is most responsive to psychosocial changes or the psychosocial environment.

- So don't wait, get an evaluation, get help for your child when you're concerned.

- That's right.

- How common is anxiety, depression in this younger age group?

- Well, anxiety disorders are the most common psychiatric disorders in childhood.

And in fact about 20% of kids have anxiety disorders.

And I do think even though anxiety disorders, as I said earlier are much more self-evident to parents and caregivers, whether parents and caregivers seek help is another matter.

And I do think oftentimes parents may see that their child is anxious, assume it's going to just be a transient developmental phase they're going through, or they accommodate the child's anxiety with the hope that it's a transient developmental phase when I think referral for intervention is in fact an important thing to do.

- I think that two important points about addressing it early, the other is the issue of accommodating.

And I wanna have you expand on that because it, in many ways common sense may say, your child's anxious about this, so let's just accommodate the situation and they'll grow out of it.

Whereas often that's not the case and accommodating ultimately doesn't help.

And I'd like you to speak about that.

- That is a really interesting and important point and particularly in the area of anxiety where oftentimes, you know, anxiety is something that runs in families.

So sometimes, if you have an anxious child, you also have an anxious parent.

Sometimes that anxiety in the parent sort of unwittingly reinforces the anxiety in the child by over accommodating.

And so yeah, the accommodation is something we frequently see with anxiety.

If a kid has a certain fear, parents will often sort of just let them avoid the things they're afraid of.

And of course parenting has that really challenging element to it where you have to both accept the child where they're at, but still continue to encourage them to challenge themselves to grow, to expand, to conquer things that they find challenging or difficult or are fearful of.

- It's important the therapist really is a coach.

We don't learn about this in school.

We don't, people aren't reading a book about it, but if it's an issue for a family, then some coaching for the parents can make all the difference in the world for that child.

- Absolutely.

I mean, an example that comes to mind is we run into a lot of young children who have a lot of what we call behavioral rigidities.

Where they will only eat off a certain plate.

They have to have their milk in a certain cup.

When they go to bed, things in the room have to be set up in just a certain way.

And many parents will accommodate those things because it's so much easier to accommodate those things than it is to, you know, deal with whatever kind of dysregulation or tantrum the child might have if you don't accommodate them.

But then if you continue to accommodate these things the child doesn't develop the type of flexibility and adaptability that they need to then cope with the challenges they're gonna face as they they grow and develop.

- Yeah, very important point.

I wanna shift gears, move up in age a little bit, and talk about anxiety and depression in elementary school age children.

Could you tell us about that?

- Anxiety in school age is a really important thing to tackle because that is, that can really prevent a child from the type of social immersion that they need so much to be able to master socio-emotional development and even cognitive development as well, if a child's not comfortable in a school setting or in a learning setting.

There are also children who are very perfectionistic and over controlled and very hard on themselves.

And that's an anxiety that can cause a lot of distress as well.

Now when we get into school age for anxiety and depression, in addition to therapies, there are a number of medications that can be used that we know are safe and effective.

And in many cases, a combination of both medications and therapy may be the best way to approach the situation to enact the most rapid and powerful change.

- I wanna talk about an important topic which is suicide and suicide prevention and thoughts of suicide even in these younger children.

Tell us about that.

- I mean that is something that we have come across in some of the research studies that we've been doing, because we were studying depressed young children for many, many years and we've collected a variety of different study samples.

In more recent study samples that we've collected, we were very, very surprised to find much higher rates of expression of suicidal ideation, either active or passive.

That is saying I wish I was never born, or saying I want to kill myself, in addition to self-harming behaviors in children as young as four and five.

And we really had not seen this in our past study samples.

It surprised us.

We now know that suicidality in childhood is increasing in rates.

No one is exactly sure why, but the idea here is that it's arising younger, it's increasing in rates in our society.

And again, like the idea of identifying anxiety and depression very early, I think suicidal thoughts and behaviors are fundamentally a maladaptive way of coping with distress.

And in that sense, it's important to address it early to teach children more adaptive ways to cope with stress.

- Very important point.

And obviously if a parent is concerned about a child verbalizing these kind of thoughts, that would certainly be a time to get an evaluation to make sure the child is safe.

- Absolutely.

I mean, we have parents, parents have two different kinds of reactions to this in my experience.

They either discount it and view it as an attempt to get attention and they don't take it seriously, which in many cases is a mistake, or they become very panicked about it and take the child to the emergency room.

I think probably neither of those reactions is what's in the best interest of the child.

But I do think when a child expresses these thoughts and feelings, regardless of what the parent thinks the objective is, it's important for the parent to engage the child, to ask questions, to find out what the child is feeling, so that they can really be aware of the level of risk, what the thought process is, and to try to help the child work it through.

- If the child is bringing this up, it needs to be addressed.

- Exactly, exactly.

- I wanna now shift gears again and move to the teenage years and anxiety and depression.

Tell us about that.

- Well, so the thing that is markedly different in the teenage years in the anxiety and depression domain.

I mean the rates of anxiety maintains stability at this high 20% level sort of throughout the developmental spectrum.

In the teenage years though, we do see an upsurge in the rates of depression and it appears to be more in girls than in boys.

There's a lot of investigation of this issue but nobody really quite understands why.

There's a lot of theories that it's related to puberty and hormones and things like this 'cause we know those features have a big impact on brain and social acceptance.

So the rates of depression start to go up to about 12-15% in adolescents.

So families where you have an adolescent, I think you have to be much more attuned to the probability or occurrence of a depression occurring and symptoms of sadness, self-deprecation, anhedonia, changes in sleep and appetite.

Those, parents should be very attentive to that in that age group, as well as of course suicidality because that's where those behaviors start to become much more dangerous and potentially lethal.

- Also if there's a change in the level of functioning if a student, if a child in school is a student at a certain level and that decreases, there may be really an underlying depression or anxiety underneath that.

- Absolutely, that's a great point.

Yes, that's a very good marker.

- Another issue potentially in this age group is the misuse of alcohol and other drugs.

And I'd like you to speak about that in the context of anxiety and depression.

- Yeah, I mean that certainly is something that, you know, arises in adolescence.

I think sometimes even in late school age.

And that can be, there can be a number of different ideologies to that.

Sometimes we see kids using alcohol and other, and illicit drugs as a way of treating an anxiety or depression like sometimes we see in adults.

Other times that's not the issue and it has more to do with experimentation, and social acceptance, and social pressures.

So there can be those two different sort of ways that a child might find themselves at risk for a substance use disorder.

But certainly in adolescence, parents need to be very, very attuned to that.

And obviously, we know that, you know, that that can have some serious dangers particularly given the lethality of a lot of the drugs available on the streets now.

- What should a parent do with their teenager if they're concerned about anxiety, depression.

How do they approach the teenager and what steps should they take?

- Well that gets a little bit trickier when you're dealing with a teenager as opposed to a younger child.

Because with a younger child, the parent can go to the child and say, I'm worried about you.

I think we should go see the doctor.

They can bring the child to the doctor.

That's harder to do with an adolescent, because you need the adolescent to actually have some motivation to be treated and you need them to sort of sign on or buy in to the treatment.

I still think a parent needs to express concern.

A parent needs to, if they really think a child is in any danger, then you would always take them in for treatment whether they're volunteering or they're agreeing to it or not.

But what's best is if the parent sort of makes these options clear and available to the child, they make themselves available for the child to talk about what they're going through, and they make it clear that the parent is ready to facilitate this type of assessment or this clinical care in a way that the child would find amenable.

- I think that's something that's important is communication between parent and child really starting from a young age where the child may be comfortable talking about their feelings, where the parent is asking about it.

So that it's a natural progression when they're teenagers they're still doing that, as much as a teenager may do that with their parent.

- Exactly.

I mean that's really the whole crux of the intervention that we developed.

It's the idea that parents don't put as much focus on their child's ability to understand, express, and regulate their own emotions.

And this is really needs to be a focus of parenting because it's a very important element of achieving happiness, and adaptive functioning, and preventing the onset of a number of mental disorders.

And the more you can facilitate these skills and abilities, the better off the child is, the better the parent-child relationship will be.

And in fact, you know, what we might even call emotional intelligence has been proven to be a much better predictor of healthy and successful outcomes, even than cognitive intelligence.

- In many ways, as important as reading, writing, arithmetic is, and social interactions with friends, this emotional type of understanding and communication may be the most important thing.

- Exactly.

I really, I firmly believe that's the case.

- Joan, thank you for all of the research and clinical care that you've done throughout the years and the work that you're continuing to do.

And thank you for joining us today.

- Thank you so much for having me.

- Thank you.

(gentle music) If you're concerned that your child has anxiety or depression, don't let them suffer in silence.

Help them get an evaluation and treatment.

Remember, with help there is hope.

(gentle music) Do not suffer in silence.

With help, there is hope.

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

(gentle music)