Feature

Clinging to mom's leg at preschool drop-off, fearing monsters under the bed—worries are a common part of childhood. But for many children, worries are something more. Anxiety disorders are the most common mental health disorders among children and adolescents. Nearly 32 percent of adolescents in the United States have an anxiety disorder, according to national survey data reported by Kathleen Merikangas, PhD, at the National Institute of Mental Health, and colleagues (Journal of the American Academy of Child and Adolescent Psychiatry, 2010).

Yet anxiety is woefully underdiagnosed, say multiple experts who treat children with the disorders. "The majority of children with anxiety never receive treatment," says Golda Ginsburg, PhD, a psychologist and professor at the University of Connecticut Health.

One reason for that might be that anxiety symptoms are so variable. Kids with generalized anxiety often feel overwhelmed with worry, and some have physical symptoms such as headaches or stomachaches. Others have intense social phobias that prevent them from doing things like going to birthday parties or participating in extracurricular activities. Some have specific phobias—fear of the dark or of dogs, for instance—while still others experience obsessive-­compulsive disorder.

Often parents, teachers and even some health-care professionals don't realize the severity of a child's anxiety or recognize that it should be treated, says psychologist Wendy Silverman, PhD, director of the Yale Child Study Center Program for Anxiety Disorders at Yale School of Medicine. "There's this idea that kids will outgrow these problems [related to anxiety], but the evidence doesn't support that."

Without treatment, childhood anxiety is likely to persist, negatively affecting a child's social and family functioning and overall quality of life. Anxiety disorders increase the risk of adult disorders, including future anxiety as well as depression, substance use disorders and suicide, according to data from more than 9,000 respondents in the National Comorbidity Survey Replication, reported by Ronald Kessler, PhD, at Harvard University, and colleagues (Archives of General Psychiatry, 2005).

"Anxiety is often viewed as a gateway problem," Silverman says.

While childhood anxiety is still underdiagnosed, research over the last couple of decades has begun to paint a clearer picture of anxiety in kids, including the role that family factors play in the development of anxiety, and what interventions can help to treat it. "We know a lot more than we knew in the 1980s and 1990s," Silverman says.

Warm bubble wrap

A variety of factors, both biological and environmental, increase the risk of anxiety disorders in children and adolescents. On the biological side, genetics, gender and temperament contribute to childhood anxiety risk. Anxiety runs in families, and girls tend to be more susceptible than boys. A body of research pioneered by Harvard University developmental psychologist Jerome Kagan, PhD, shows that infants and toddlers who are behaviorally inhibited—clinging to parents, hiding, failing to explore their environments—are more likely to exhibit anxiety later in childhood. Environmental factors such as childhood trauma, abuse and early life stressors also boost the risk of developing an anxiety disorder.

Among children, separation anxiety, social anxiety and generalized anxiety are the three most common types of anxiety, Silverman says. In adolescence, panic disorder is relatively common as well. The median age of onset for childhood anxiety is about 11, according to Kessler's data.

Some of the most significant risk factors for anxiety appear to be family-related. "We know children whose parents struggle with anxiety are at elevated risk," Ginsburg says.

Anxious kidsWhile genes likely have something to do with that link, anxious parents are also more likely to model fearful behaviors for their children, Ginsburg explains. "Parents can interact with kids in ways that increase or decrease their anxiety," she says: Consider the difference between a parent who says, "Don't forget the bug spray," versus the one who yells, "Don't go outside, there's a mosquito! You'll get Zika virus!"

Even if parents don't model anxious behaviors, they can inadvertently accommodate their child's anxiety, which research shows can make symptoms persist and worsen. Often, that behavior comes from a place of good intention. "When you see your child frightened, your natural instinct as a parent is to protect them and reassure and comfort them," Ginsburg says.

But sometimes, parents go too far in trying to protect a child from any situation that might provoke anxiety—never leaving them with a babysitter, for example, or constantly getting involved with a child's teacher in an attempt to make the child's life stress free. In such cases, the child never develops the skills to overcome challenges, says psychologist Anne Marie Albano, PhD, director of the Columbia University Clinic for Anxiety and Related Disorders. "When parents are doing a lot of negotiating to remove anything that upsets the child, that child is at greater risk of anxiety."

Kenneth Rubin, PhD, a psychologist and founding director of the Center for Children, Relationships and Culture at the University of Maryland, and colleagues have shown how such parental behaviors can combine with child temperament factors to increase anxiety. In a highly regarded longitudinal study, he and his colleagues found that behaviorally inhibited toddlers were more likely to become socially wary preschoolers if their mothers were intrusive (Child Development, 2002). In the lab, he watched those parents intrude in their children's play, often smothering them with hugs and kisses to a degree that prevented the kids from exploring their environment and engaging in age-appropriate play. "It was like they were covered in warm bubble wrap," he says.

A dose of prevention

While parental behavior certainly isn't the only factor that contributes to a child's anxiety, it's a useful one to target. Parental anxiety and accommodating behaviors can be treated and changed. Furthermore, because anxiety runs in families, it's relatively easy to identify which children might be at a greater risk of developing the disorders.

With that in mind, Ginsburg and colleagues tested a family-based model aimed at preventing the onset of anxiety in children of anxious parents. They recruited 136 families with children ages 6 to 13. At least one parent in each family had an anxiety disorder, but the children did not.

Half of the families participated in an eight-week program that taught techniques to identify and reduce anxiety, as well as parenting and problem-solving strategies. The control group received pamphlets with information about anxiety disorders. One year later, 5 percent of children in the intervention group had developed an anxiety disorder, compared with 30 percent of the children in the control group (American Journal of Psychiatry, 2015).

Rubin and his colleagues at the University of Maryland are also exploring prevention strategies in younger children. He and psychologist Andrea Chronis-Tuscano, PhD, have developed and are testing an intervention for preschoolers who are socially inhibited and have trouble engaging with their peers, in hopes of preventing social anxiety disorders down the line.

During the eight-week program, educators help the children practice interacting with one another in small group settings. They work on skills such as introducing themselves, making eye contact, playing games together and expressing their feelings. Meanwhile, clinically trained specialists meet with the children's parents across the hall, coaching them on strategies to support and encourage their anxious children in healthy ways.

The study is ongoing, but a preliminary evaluation found that when compared with children in a waitlist control group, kids who participated in the program had lower levels of parent-reported behavioral inhibition, and lower levels of anxiety symptoms as reported by both parents and teachers (Journal of Consulting and Clinical Psychology, 2015).

Rubin and colleagues are hopeful that with further evidence, such programs could be adapted for preschool and Head Start settings to help quash early anxiety before it becomes socially debilitating for a child. "Children need to interact with other children to become socially cognitively aware," he says.

Lasting effects

Researchers are also exploring the best ways to help children and adolescents who are already experiencing anxiety disorders. In a large multisite trial known as the Child/Adolescent Anxiety Multimodal Study (CAMS), Ginsburg, Albano and colleagues compared treatments among 488 children ages 7 to 17 who suffered from social anxiety, separation anxiety or generalized anxiety disorder.

Children in the study received either the drug sertraline, cognitive-behavioral therapy (CBT), a combination of the two or a pill placebo. About 60 percent of children who received sertraline alone or CBT alone showed significant improvement, compared with about 20 percent of the placebo group. And about 80 percent of children who received the combination therapy had a significant reduction in anxiety symptoms (NEJM, 2008).

While those improvements were encouraging, Ginsburg says, only 46 percent to 68 percent of participants receiving combination therapy achieved remission during the study, depending on the measure used (Journal of Consulting and Clinical Psychology, 2011). And in a naturalistic follow-up six years later, nearly half of the children who initially responded to treatment during CAMS had relapsed (JAMA Psychiatry, 2014).

But from the glass-half-full perspective, about half of the sample was in remission six years later. Those who responded well to their initial treatment during CAMS were significantly more likely to be in remission, and have lower anxiety symptoms and higher functioning six years later, regardless of the type of treatment they initially received. (Children who received placebo were later offered treatment, so a placebo group wasn't evaluated in the follow-up study.)

Those results suggest that interventions to treat childhood anxiety can have lasting effects. Still, Ginsburg says, more work is needed to figure out how to help more children recover from anxiety, and how to make sure that recovery sticks.

Silverman is hopeful that future treatments for childhood anxiety will become more targeted and personalized. One focus of her research is trying to pinpoint individual differences, such as which children might be more responsive to medications, or whether a particular child is more likely to benefit from individual therapy or a family-based intervention. "There are probably certain children and families that will do better in one type of approach than another," she says.

Meanwhile, there's room for new treatments and new combinations of treatments, Silverman adds. In one effort to identify such therapies, she's testing an intervention known as attention-bias modification training in children and adolescents. The approach builds on the evidence that adults and kids with anxiety are overly attuned to potentially threatening stimuli in their environments, such as angry faces. Silverman is testing a game-like computer-based training program that helps kids learn to ignore threatening stimuli and focus instead on neutral stimuli.

Research is also needed to figure out how best to combine and sequence possible treatments, Silverman adds. For instance, should attention-bias modification be done before CBT? At the same time? Or only after other treatments have failed? "You can have all these different permutations," she says. "The idea is to develop a few evidence-based treatments, refine them and figure out which children would benefit most from them."

For now, there are still big questions about how best to help children overcome anxiety over the long term. Many children with anxiety cycle through periods of wellness followed by relapse, Ginsburg says. Transition points, such as starting middle school, are known to be problematic for anxious children. So psychotherapists, for example, could do more to prepare kids to anticipate and prepare for those upsets. "In dentistry, we go for a checkup every six months. We have 'well baby' checkups for kids. We don't do that in mental health, and I don't think that serves the families that need it," Ginsburg says. "Waiting until there's a crisis and then going for help is problematic."

Albano adds that psychologists must ensure that children are receiving evidence-based treatments specific to anxiety. "A lot of times we see kids who have been in therapy for several years, but issues like school functioning or family functioning have taken the focus, and anxiety was never directly addressed. Kids should be getting the direct CBT-based intervention to deal with that anxiety," she says. "I'm not slamming other forms of psychotherapy. Rather, psychologists have to partner with one another to help kids with anxiety."

Albano also urges her fellow clinicians to think beyond their offices to figure out how best to help children. "As psychologists, we have to think out of the box and go where the kids are," she says. That could mean reaching out to schools or afterschool programs, leading camp-style summer programs for children or offering weekend hours convenient for more families. "We have to meet the kids where they're comfortable and make it easier for them to get treatment," Albano says.

Further reading

The Burden of Anxiety Disorders in Pediatric Medical Settings: Prevalence, Phenomenology, and a Research Agenda
Ramsawh, H.J., Chavira, D.A., & Stein, M.B. Archives of Pediatric Adolescent Medicine, 2010

Naturalistic Follow-up of Youths Treated for Pediatric Anxiety Disorders
Ginsburg, G.S., Becker, E.M., Keeton, C.P., et al. JAMA Psychiatry, 2014

Stepping Toward Making Less More for Concerning Anxiety in Children and Adolescents
Silverman, W.K., Pettit, J.W., & Lebowitz, E.R. Clinical Psychology Science and Practice, 2016

Remission After Acute Treatment in Children and Adolescents With Anxiety Disorders: Findings From the CAMS
Ginsburg, G.S., et al. Journal of Consulting and Clinical Psychology, 2011