Advice for Parents of Children with Anxiety Disorders

From The Quarterly, Summer 2015

Daniel S. Pine, M.D., a member of the Foundation’s Scientific Council, is the chief of the Section on Development and Affective Neuroscience in the National Institute of Mental Health Intramural Research Program. His research focus is pediatric mental illnesses, including the biology and drug treatment of mood, anxiety, and behavioral disorders in children. Dr. Pine has also served as the chair of the Psychopharmacologic Drug Advisory Committee for the Food and Drug Administration and chair of the Child and Adolescent Diagnosis Group for the DSM-5 Task Force. (The task force is composed of scientists and doctors who oversee and update the DSM—the Diagnostic and Statistical Manual of Mental Disorders. This important handbook is used by health care professionals in the United States and much of the world as the authoritative guide to the diagnosis of mental disorders).

We asked Dr. Pine what advice he could offer parents concerned about a child with a possible anxiety disorder. We also talked with him about what the latest basic science research says about the causes and possible treatments for anxiety.

How can you tell if a child’s anxiety is normal or a part of an anxiety disorder?

There are three things that we usually look at to tell the difference between abnormal anxiety that is part of an anxiety disorder, and the anxiety that children, or really anybody, experiences as a normal part of life. The first and probably the most important thing we look at is whether there is impairment—anxiety that interferes with a person’s ability to function and leads to avoidance. Most people feel anxious when they’re in a new social setting, or when they’re starting out a new job. But someone with an anxiety disorder may miss work because they’re so nervous, or they’ll refuse to go to school or attend a party, for example.

A second thing we look at is what we call extreme distress— whether a person is experiencing distress beyond what is typical. There is some amount of clinical or subjective judgment in determining whether stress is extreme.

The third thing we look at is whether abnormal anxiety goes on for many weeks or months. A person with abnormal anxiety is persistently worried or afraid of the same thing over and over again.

Are anxiety disorders on the rise among children?

These are very difficult things to track, because diagnosis is heavily based on what people tell us. As the stigma attached to mental disorders goes down and our understanding of these conditions improves, people are more willing to talk about them and they’re easier to identify. There is some evidence that anxiety disorders are on the rise, but there’s also evidence that suggests we are better at identifying or targeting these problems. There’s no convincing evidence that rates of anxiety disorders are increasing.

Is a pediatrician the first person a parent should consult if they think their child has an anxiety disorder?

Pediatricians are usually a wonderful place to start. They vary in how much they know, and in how comfortable they are in talking about these types of problems. But they may be able to refer their patient to a knowledgeable therapist. Schools are often very familiar with local therapists experienced in cogitative behavioral therapy (CBT). Another place to find a therapist trained in CBT is an advocacy organization such as the Anxiety and Depression Association of America or The American Academy of Child and Adolescent Psychiatry.

What are the most common treatments for children and adolescents with anxiety disorders?

There are generally two types of treatments that seem to be equally effective: cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitor (SSRI) medications. The best study that compared them directly in kids found one is no better than the other, and that combining the two works better than using one or the other alone. Cognitive behavioral therapy is a really wonderful treatment, but the therapist has to have some experience delivering it. Specific techniques need to be followed. There are not that many therapists in the United States who are readily available to apply those methods.

In situations where a family doesn’t have access to a well-trained therapist, CBT wouldn’t be the first choice. It would be better to use an SSRI rather than try to do CBT with a therapist who isn’t well-trained and experienced. Pediatricians are often comfortable prescribing SSRIs, but we don’t completely understand how these medications help children with anxiety disorders. Because of this, I think some parents are uncomfortable using them.

Are there any connections between substance abuse and addiction, and anxiety disorders in children?

There is a whole range of mental health problems in children that accompany substance abuse. It’s quite common to see substance abuse in anxiety, but it’s also quite common to see it connected to other kinds of mental health problems. We are not sure about why substance abuse problems occur with anxiety. Some adolescents may have problems with anxiety, and find that when they use illicit substances they feel that their anxiety gets better. They’re engaging in behavior that some people call self-medicating. But there are other adolescents who have no problem with anxiety and they begin using an illicit substance and then they develop anxiety that follows directly from the illicit drug use. It’s really hard to say why this happens. Right now we don’t have any firmly established mechanisms that link the two in most cases. Some adolescents have problems with substance use and problems with anxiety that are completely unrelated.

If someone has an anxiety disorder in childhood, will he or she continue to have the disorder as an adult?

For any mental disorder, we really do not have the ability to confidently state which are going to go on and change very little, which are going to get somewhat better, and which are going to completely disappear. Some disorders like autism, for instance, tend to be more persistent. Many children with autism will have at least some level of problem throughout their lives. But the story is very different with anxiety. A large group of children with anxiety will do completely fine when we follow them over time. And we really do not have a very good ability to predict which children will do better, although there are some things that we think can help us predict this.

What do doctors and scientists look for when they try to assess a child’s prognosis?

The kinds of things that do help us are by and large clinical observations, which are more useful, at least right now, than measures of brain function, hormones, or physiology. For instance, kids with more extreme anxiety problems tend to do worse over time than kids with relatively mild problems, although that’s not an absolute. Another factor is the level of avoidance. Kids who tend to avoid things tend to have more persistent anxiety, compared to kids who are anxious but will not avoid the situations that make them afraid. A third factor has to do with the behavior of parents. When parents are particularly encouraging, their kids tend to do better.

What kind of encouragement do these parents give their children?

These are parents who can help their kids face the situations that make their children most afraid, and encourage their kids to not avoid the things they’re afraid of. They are parents who look for situations and circumstances and experiences where kids are going to have to deal with their anxiety. Those kids tend to do better with their anxiety compared to kids whose parents are doing absolutely everything they can to prevent their kids from ever getting anxious.

What has basic science research revealed about the possible causes or treatments for anxiety?

One thing concerns something we just talked about: facing fears. There’s an idea called extinction that people think a lot about in basic science research on anxiety. Extinction is a process that we study where organisms such as rodents and non-human primates learn how to overcome their anxiety. One of the things we know about extinction is that it’s an active process; to extinguish a fear, organisms have to be exposed to the fear. Beyond just learning how to cope, maybe one of the reasons why kids who face their fears do better over time is that they have opportunities to develop extinction. Research on extinction is starting to be helpful because people are coming up with new ideas about how treatments like CBT might be adjusted to increase extinction learning. Another avenue that’s been promising in neuroscience is that we now understand a lot about “information processing biases” in anxiety. We’ve learned that people with anxiety tend to pay undue attention to threats in their environment. This has led to novel ideas about how to treat anxiety, including using things like video games to train attention. This is something we’ve tested with combat veterans who have post-traumatic stress disorder (PTSD).

Are these kinds of extinction and attention bias treatments available to patients yet?

This kind of basic science research has had relatively little impact on how we treat individual patients. Right now, these are just new ideas, and while they’re promising, the most exciting ideas are not yet ready for prime time, they’re not routine treatments that can be applied in all patients just yet. For instance, in our PTSD study, it’s not clear how robust the findings are. There’s some concern that if the training is not done in the right way, it could make symptoms worse. We don’t understand those kinds of things well enough. However, I think one of the nice things about basic research on fear and anxiety is that there’s tremendous “cross-species conservation.” What that means is that the relationship between brain and behavior in anxiety is very similar in rodents, non-human primates and people. Because of those similarities, which occur more so in anxiety than in other mental health problems, I think we are getting closer to finding novel treatments for anxiety than we may be in other disorders.