David Baxter PhD
Late Founder
To Be Young and Anxiety-Free
By ANDREA PETERSEN, Wall Street Journal
September 2, 2008
Last fall, 12-year-old John Morganti was a very anxious kid. He was too scared to ride the bus to school or have sleepovers at friends' houses. He had frequent stomachaches, hid out in the nurse's office and begged his mother to let him skip school.
"He would get so scared, he would be in a little ball in the corner," says John's mother, Danielle Morganti, of Pittsgrove, N.J.
John was later diagnosed with an anxiety disorder and underwent a treatment known as cognitive behavioral therapy. By spring, he had largely recovered and was happily taking the bus and playing with friends at parties.
Historically, anxiety disorders were seen as something that primarily hit teens and adults. Anxious kids, many experts thought, would simply grow out of their fears. But now, many doctors believe that John's illness was caught at the ideal time. Indeed, there's a new push by doctors and therapists to identify children afflicted with anxiety disorders -- even those as young as preschool age -- and treat them early.
The move is being spurred by new research showing that treating kids for anxiety when they are young may help prevent the development of more serious mental illnesses, including depression and more debilitating anxiety disorders. Doctors think treating early may also prevent some of the potential complications of those disorders, including substance abuse and even suicide.
"The best way to treat chronic medical problems like cardiovascular illness and diabetes is to catch them early," says Daniel S. Pine, chief of child and adolescent research, mood and anxiety disorders program at the National Institute of Mental Health. "If we want to do that with anxiety disorders, we need to focus on kids."
In a study published in August 2007 in the Archives of General Psychiatry, young people ages 14 to 24 who had social anxiety disorder were almost three times as likely to later develop depression than those without the anxiety disorder. Another study, published in 2004 in the Journal of Consulting and Clinical Psychology, followed children ages 9 to 13 who had been treated for an anxiety disorder. Those who still had the disorder seven years after treatment drank alcohol more days per month and were more likely to use marijuana than those whose disorder had resolved.
Some doctors believe that treating kids when they are young, especially between ages 9 and 13, could also enhance -- and extend -- the positive impact of treatment, since the brain is still developing. "You get a little more bang for your buck," says Ronald E. Dahl, the Staunton Professor of Psychiatry and Pediatrics at the University of Pittsburgh. "You may get more enduring effects because you are hitting this window with more brain plasticity."
Anxiety disorders tend to emerge earlier than other mental illnesses. The median age of onset of an anxiety disorder is 11, compared with age 30 for mood disorders, such as depression, according to a 2005 study published in the Archives of General Psychiatry. Anxiety disorders are also the most common mental illnesses. The same study estimates that 28.8% of people will have an anxiety disorder in their lifetime, compared with 20.8% who will have a mood disorder.
The most prevalent anxiety disorders in kids are social anxiety, separation anxiety and general anxiety disorder. Children with separation anxiety are inordinately scared of being away from Mom and Dad and are consumed with fear that something bad will happen to them. With social anxiety, children are afraid of interacting with peers, and often have a hard time doing things like raising their hand in class, making friends and going to birthday parties.
Those with generalized anxiety disorder are like "premature adults, they are the worriers," says Philip C. Kendall, the Laura H. Carnell professor of psychology at Temple University in Philadelphia and a pioneer in the use of cognitive behavioral therapy in kids. "They worry about the mortgage and the ozone layer and things well beyond their years and level of understanding."
Of course, most kids have fears without having a full-blown anxiety disorder. And some anxiety is healthy: It makes sense, for example, to be a little nervous before a big test. Doctors and psychologists do caution that the increased focus on childhood anxiety could lead to an overdiagnosis of the problem. What makes anxiety a true illness is when it interferes with normal functioning or causes serious emotional and physical distress. "Does the level of fear or anxiety that my child has prevent them from doing things that other children my child's age can do?," says NIMH's Dr. Pine. "Then parents should think about having their child evaluated."
There are effective treatments for kids with anxiety disorders, usually consisting of medication, therapy or a combination of the two. Antidepressants such as Prozac (fluoxetine) and Zoloft (sertraline) have been shown to alleviate anxiety symptoms in children. A 2001 study published in the Journal of the American Academy of Child & Adolescent Psychiatry, for example, followed children aged 7 to 17 with anxiety disorders. Among them, 61% of patients taking fluoxetine showed "much to very much improvement" compared with 35% taking a placebo.
But the use of antidepressants in children has come under fire because of recent evidence showing an increase in suicidal thoughts in kids taking the drugs. Partly as a result, many doctors and psychologists employ as a first line of treatment cognitive behavioral therapy, or CBT, which is often just as effective as medication.
With CBT, children work with a therapist to learn skills to help them cope with their anxiety. The main component of treatment is so-called exposure therapy, where children deliberately -- and gradually -- enter the situations that cause them anxiety and learn to tolerate those uncomfortable feelings. During therapy sessions, children prepare for these exposure homework assignments, anticipating the feelings they might have and coming up with ways to deal with them.
Kids start by tackling situations they find easier to handle and slowly move up to those that are most frightening. Children then often receive rewards -- such as a sticker, or an ice cream cone -- when they complete a task. Parents can be crucial to the success of the therapy, since they often need to prod children to do their exposure tasks and have to resist the urge to rescue their kids when they get anxious.
Recent studies indicate that about half to 70% of kids treated with CBT will have a significant improvement in their function and decrease in their anxiety symptoms. A course of therapy usually consists of weekly sessions for 14 to 16 weeks. Some children will need longer-term treatment or will need treatment in combination with medication. And since symptoms can re-emerge, children may need "booster" sessions of therapy later.
The cost of the therapy varies widely, from less than $100 a session to more than $200 a session, depending on your geographical location. Parents should seek therapists specifically trained in cognitive behavioral therapy. The Association for Behavioral and Cognitive Therapies (http://www.aabt.org) is a good resource.
Two years ago, when Natalie Piracini of Brookline, Mass., was finishing third grade, the now 11-year-old was overwhelmed by fears, her mother says. The girl avoided play dates with friends and riding her bike, and cried before she had to go to school. Her fear of scary masks and spiders often prevented her from going shopping with her mother and playing outside. Her anxiety would spike during math tests, and her schoolwork suffered.
Natalie was initially diagnosed with attention deficit disorder and put on Ritalin. But Natalie's mother, Jackie Piracini, said the medication just made the child more anxious. A year later, Natalie was diagnosed with generalized anxiety disorder and began cognitive behavioral therapy as part of a program run by the Judge Baker Children's Center in Boston, a children's mental-health treatment and research organization. The therapist first had Natalie tackle her fear of spiders. Natalie was shown pictures of spiders, then videos of spiders. The recovery process was slow but "soon, I was seeing her catch a spider, put it in a cup, name it and set it free," says Ms. Piracini.
Ms. Piracini says overcoming a fear of spiders gave Natalie confidence and soon many of her other fears diminished. Natalie underwent therapy for a year and she still struggles at times with anxiety. But she is now able to participate in many activities with other kids. "I do softball and basketball, and I have a lot of friends on my team," Natalie says. "I can do a lot of stuff I couldn't do back then."
There are several risk factors for developing an anxiety disorder in childhood. Kids whose parents have had an anxiety disorder are at increased risk. Studies in preschoolers have shown that young children who are clingy and don't explore their surroundings are more likely to develop an anxiety disorder by adolescence.
Doctors say that in kids with anxiety disorders, the process of managing fear has broken down. Anxious kids "catch fears easily, don't extinguish them properly and don't retrieve memories of successfully combating them," says John S. March, chief of child and adolescent psychiatry at Duke University Medical Center. The goal of cognitive behavioral therapy is to tutor the brain to restore that fear-management process.
When Ms. Morganti and John were working on his fear of riding the bus, the two started by driving to the bus stop and then going home. Next, they walked to the bus stop. The plan was for John then to get on the bus and ride it just one stop. But John was able to skip that step and instead rode the bus all the way to school. Soon, John was also being weaned from the frequent phone calls he used to make to his mother.
Though he still gets anxious sometimes at slumber parties, Ms. Morganti says her son has made tremendous progress. "I'm actually excited to go to school now," John says.
WHAT TO LOOK FOR
Here are some signs that doctors and psychologists say should prompt parents to seek an assessment for their child for an anxiety disorder:
By ANDREA PETERSEN, Wall Street Journal
September 2, 2008
Last fall, 12-year-old John Morganti was a very anxious kid. He was too scared to ride the bus to school or have sleepovers at friends' houses. He had frequent stomachaches, hid out in the nurse's office and begged his mother to let him skip school.
"He would get so scared, he would be in a little ball in the corner," says John's mother, Danielle Morganti, of Pittsgrove, N.J.
John was later diagnosed with an anxiety disorder and underwent a treatment known as cognitive behavioral therapy. By spring, he had largely recovered and was happily taking the bus and playing with friends at parties.
Historically, anxiety disorders were seen as something that primarily hit teens and adults. Anxious kids, many experts thought, would simply grow out of their fears. But now, many doctors believe that John's illness was caught at the ideal time. Indeed, there's a new push by doctors and therapists to identify children afflicted with anxiety disorders -- even those as young as preschool age -- and treat them early.
The move is being spurred by new research showing that treating kids for anxiety when they are young may help prevent the development of more serious mental illnesses, including depression and more debilitating anxiety disorders. Doctors think treating early may also prevent some of the potential complications of those disorders, including substance abuse and even suicide.
"The best way to treat chronic medical problems like cardiovascular illness and diabetes is to catch them early," says Daniel S. Pine, chief of child and adolescent research, mood and anxiety disorders program at the National Institute of Mental Health. "If we want to do that with anxiety disorders, we need to focus on kids."
In a study published in August 2007 in the Archives of General Psychiatry, young people ages 14 to 24 who had social anxiety disorder were almost three times as likely to later develop depression than those without the anxiety disorder. Another study, published in 2004 in the Journal of Consulting and Clinical Psychology, followed children ages 9 to 13 who had been treated for an anxiety disorder. Those who still had the disorder seven years after treatment drank alcohol more days per month and were more likely to use marijuana than those whose disorder had resolved.
Some doctors believe that treating kids when they are young, especially between ages 9 and 13, could also enhance -- and extend -- the positive impact of treatment, since the brain is still developing. "You get a little more bang for your buck," says Ronald E. Dahl, the Staunton Professor of Psychiatry and Pediatrics at the University of Pittsburgh. "You may get more enduring effects because you are hitting this window with more brain plasticity."
Anxiety disorders tend to emerge earlier than other mental illnesses. The median age of onset of an anxiety disorder is 11, compared with age 30 for mood disorders, such as depression, according to a 2005 study published in the Archives of General Psychiatry. Anxiety disorders are also the most common mental illnesses. The same study estimates that 28.8% of people will have an anxiety disorder in their lifetime, compared with 20.8% who will have a mood disorder.
The most prevalent anxiety disorders in kids are social anxiety, separation anxiety and general anxiety disorder. Children with separation anxiety are inordinately scared of being away from Mom and Dad and are consumed with fear that something bad will happen to them. With social anxiety, children are afraid of interacting with peers, and often have a hard time doing things like raising their hand in class, making friends and going to birthday parties.
Those with generalized anxiety disorder are like "premature adults, they are the worriers," says Philip C. Kendall, the Laura H. Carnell professor of psychology at Temple University in Philadelphia and a pioneer in the use of cognitive behavioral therapy in kids. "They worry about the mortgage and the ozone layer and things well beyond their years and level of understanding."
Of course, most kids have fears without having a full-blown anxiety disorder. And some anxiety is healthy: It makes sense, for example, to be a little nervous before a big test. Doctors and psychologists do caution that the increased focus on childhood anxiety could lead to an overdiagnosis of the problem. What makes anxiety a true illness is when it interferes with normal functioning or causes serious emotional and physical distress. "Does the level of fear or anxiety that my child has prevent them from doing things that other children my child's age can do?," says NIMH's Dr. Pine. "Then parents should think about having their child evaluated."
There are effective treatments for kids with anxiety disorders, usually consisting of medication, therapy or a combination of the two. Antidepressants such as Prozac (fluoxetine) and Zoloft (sertraline) have been shown to alleviate anxiety symptoms in children. A 2001 study published in the Journal of the American Academy of Child & Adolescent Psychiatry, for example, followed children aged 7 to 17 with anxiety disorders. Among them, 61% of patients taking fluoxetine showed "much to very much improvement" compared with 35% taking a placebo.
But the use of antidepressants in children has come under fire because of recent evidence showing an increase in suicidal thoughts in kids taking the drugs. Partly as a result, many doctors and psychologists employ as a first line of treatment cognitive behavioral therapy, or CBT, which is often just as effective as medication.
With CBT, children work with a therapist to learn skills to help them cope with their anxiety. The main component of treatment is so-called exposure therapy, where children deliberately -- and gradually -- enter the situations that cause them anxiety and learn to tolerate those uncomfortable feelings. During therapy sessions, children prepare for these exposure homework assignments, anticipating the feelings they might have and coming up with ways to deal with them.
Kids start by tackling situations they find easier to handle and slowly move up to those that are most frightening. Children then often receive rewards -- such as a sticker, or an ice cream cone -- when they complete a task. Parents can be crucial to the success of the therapy, since they often need to prod children to do their exposure tasks and have to resist the urge to rescue their kids when they get anxious.
Recent studies indicate that about half to 70% of kids treated with CBT will have a significant improvement in their function and decrease in their anxiety symptoms. A course of therapy usually consists of weekly sessions for 14 to 16 weeks. Some children will need longer-term treatment or will need treatment in combination with medication. And since symptoms can re-emerge, children may need "booster" sessions of therapy later.
The cost of the therapy varies widely, from less than $100 a session to more than $200 a session, depending on your geographical location. Parents should seek therapists specifically trained in cognitive behavioral therapy. The Association for Behavioral and Cognitive Therapies (http://www.aabt.org) is a good resource.
Two years ago, when Natalie Piracini of Brookline, Mass., was finishing third grade, the now 11-year-old was overwhelmed by fears, her mother says. The girl avoided play dates with friends and riding her bike, and cried before she had to go to school. Her fear of scary masks and spiders often prevented her from going shopping with her mother and playing outside. Her anxiety would spike during math tests, and her schoolwork suffered.
Natalie was initially diagnosed with attention deficit disorder and put on Ritalin. But Natalie's mother, Jackie Piracini, said the medication just made the child more anxious. A year later, Natalie was diagnosed with generalized anxiety disorder and began cognitive behavioral therapy as part of a program run by the Judge Baker Children's Center in Boston, a children's mental-health treatment and research organization. The therapist first had Natalie tackle her fear of spiders. Natalie was shown pictures of spiders, then videos of spiders. The recovery process was slow but "soon, I was seeing her catch a spider, put it in a cup, name it and set it free," says Ms. Piracini.
Ms. Piracini says overcoming a fear of spiders gave Natalie confidence and soon many of her other fears diminished. Natalie underwent therapy for a year and she still struggles at times with anxiety. But she is now able to participate in many activities with other kids. "I do softball and basketball, and I have a lot of friends on my team," Natalie says. "I can do a lot of stuff I couldn't do back then."
There are several risk factors for developing an anxiety disorder in childhood. Kids whose parents have had an anxiety disorder are at increased risk. Studies in preschoolers have shown that young children who are clingy and don't explore their surroundings are more likely to develop an anxiety disorder by adolescence.
Doctors say that in kids with anxiety disorders, the process of managing fear has broken down. Anxious kids "catch fears easily, don't extinguish them properly and don't retrieve memories of successfully combating them," says John S. March, chief of child and adolescent psychiatry at Duke University Medical Center. The goal of cognitive behavioral therapy is to tutor the brain to restore that fear-management process.
When Ms. Morganti and John were working on his fear of riding the bus, the two started by driving to the bus stop and then going home. Next, they walked to the bus stop. The plan was for John then to get on the bus and ride it just one stop. But John was able to skip that step and instead rode the bus all the way to school. Soon, John was also being weaned from the frequent phone calls he used to make to his mother.
Though he still gets anxious sometimes at slumber parties, Ms. Morganti says her son has made tremendous progress. "I'm actually excited to go to school now," John says.
WHAT TO LOOK FOR
Here are some signs that doctors and psychologists say should prompt parents to seek an assessment for their child for an anxiety disorder:
- If a child's fears prevent him or her from doing things other kids the same age normally can do, such as go to school, go on sleepovers and make friends.
- Chronic complaints of headaches or stomachaches, when no medical cause is found.
- If a child is in a lot of distress because of his or her fears.
