Podcast: Your Most Popular Questions About Anxiety in Kids and Teens
Jenn talks to Dr. R. Meredith Elkins about symptoms of anxiety in kids and appropriate treatment options. Meredith discusses healthy and unhealthy levels of anxiety in kids, shares similarities and differences between anxiety disorders and mood disorders, and answers audience questions about how, by helping our children with their anxiety, we can also help ourselves.
R. Meredith Elkins, PhD, is a clinical psychologist specializing in the cognitive behavioral treatment of anxiety, mood, and related disorders in children, adolescents, and young adults. Dr. Elkins has established integrated lines of research encompassing the development, identification, and treatment of anxiety disorders in childhood. Dr. Elkins is currently a program director at the McLean Anxiety Mastery Program (MAMP), an intensive group-based outpatient program for children and adolescents with anxiety disorders and OCD.
Jenn: Welcome to Mindful Things.
The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.
So, hello folks. Good morning, good afternoon, good evening to you. And wherever you’re joining us from in the world, thanks for taking some time out of your day to join our conversation that’s all about anxiety in kids and teens.
I’m Jenn Kearney. I am a digital communications manager for McLean Hospital, and I have the distinct pleasure of having Dr. Meredith Elkins as my co-host today.
Before we dive in, and I’ve got plenty of questions for her about anxiety, I’m actually really happy to share with folks tuning in that it’s natural for us to have anxiety. Like, that’s something that our body naturally creates.
So, therefore, all kids and adolescents actually have and experience anxiety, because we’re supposed to. But when kids have a lot of it or don’t know ways to manage it, it can actually impact education, relationships, social life, development, so on and so forth.
So it’s tough, right? It can be tough for kids to explain how anxiety makes them feel. It can be tough for adults to sometimes explain how anxiety makes them feel. That expression of anxiousness can also sometimes be mistaken for a mood disorder depending on how that manifests in your kid or teen.
So how do we know if it’s healthy? How do we know if it’s unhealthy? How do we know when to talk to somebody? I’m really excited to have Meredith with me today.
So, we’re going to talk all about levels of anxiety in kids, what’s normal, when you should seek care, similarities and differences between anxiety disorders, what those look like, mood disorders, how they might manifest in the same ways or not, and how, if we’re helping our kids with their anxiety, we can also help ourselves along the way.
So, I’d like to introduce her before I start throwing questions at her. If you are unfamiliar with her, Meredith Elkins, PhD, is a clinical psychologist that specializes in cognitive behavioral treatment of anxiety, mood, and related disorders in children, adolescents, and young adults.
She has established integrated lines of research that encompass the development, the identification, and the treatment of anxiety disorders in childhood.
And she is currently a program director at McLean’s Anxiety Mastery Program, which we sometimes refer to as MAMP, we might do that during the conversation, so sorry about that in advance, which is an intensive group-based outpatient program for children and adolescents with anxiety disorders and OCD.
So, whoa, Meredith, hi.
Meredith: It’s a mouthful, isn’t it?
Jenn: I was like, whoa, alright. Thank you so much for joining me. I’ve got 100,000 questions. So, I want to get started by asking, what are some of the differences between that “healthy” and “unhealthy” anxiety response in kids?
Meredith: So, great question, and I think that you already got us started off well by identifying the fact that anxiety is universal. Anxiety is one of those universal human emotions that exists across cultures and societies.
And like all the universal human emotions, we understand them as being present in modern humans because they were selected for over our evolutionary history. So, if you think back to our early human ancestors, the person who went over and saw the saber-toothed tiger and was like, “Ooh, kitty,” and tried to pat it, what happened? He got smoked, right?
And he didn’t get the chance to then have babies who have babies who have babies who have babies with anxiety versus the one who was cautious, whose internal alarm system went off and who ran away, did have the chance to reproduce and pass his more cautious genes and tendencies down to us.
So I think first and foremost, we need to understand that this is actually an adaptive, natural, normal, and harmless response. I think that oftentimes when I say that to parents that anxiety is actually harmless, they’re like, “No like that’s not my experience, that’s not my child’s experience, you’re full of it,” but I think it’s a really important distinction.
The physical feelings that we have when we are anxious or when we’re panicking feel really overwhelming. They are not dangerous, they will not hurt us. Even the concern of like, “Oh, if I have a panic attack, am I going to pass out? Am I going to have a heart attack? Am I going to die?”
Your heart needs to be beating almost twice as fast to have a heart attack versus having a panic disorder. So the symptoms in and of themselves are not dangerous. Really it’s the sort of sequelae of the symptoms, right?
So, it’s kind of what we do that might actually make the symptoms more dangerous, right? So, if you’re panicking and you bail from school and, kind of, a kid who elopes from school, like, that is dangerous, right?
Or if you self-medicate with anxiety, I’m sorry, with alcohol or with drugs to try to decrease the anxiety, that is dangerous. If the kind of anxiety-driven thoughts that come up in your mind when you feel really anxious kind of impact depression and sort of how you feel about yourself, that can be more dangerous, right?
But the symptoms in and of themselves are normal, natural, they’re harmless, and they’re designed actually to keep us safe.
I mean, I think we’re not worried about saber-toothed tigers anymore, but think about how, if you didn’t have any anxiety, you wouldn’t study for your test, you wouldn’t brush your teeth before you went on a date, you wouldn’t look both ways before you cross the street.
So, research actually shows us that the ideal level of anxiety is this moderate amount of anxiety. We need a little bit of anxiety, not only to keep us safe, but to kind of motivate us and keep us moving forward.
So, I think throughout this conversation, we’re going to really be trying to distinguish between, kind of, what is helpful anxiety and what is unhelpful anxiety, and oftentimes we want to figure out whether the anxiety alarm…
I often think about, like, our anxiety response or sympathetic nervous system as like a fire alarm going off.
Like, when I was younger and I lived in an awful, like, awful apartment in Boston on a grad student salary, that it had the fire alarm that went off anytime the shower was on and there was steam, and so you’re jumping up because you think there’s a fire and there’s nothing there.
So, a lot of times we think about how, like, is your alarm reaction going off because there’s actually a threat to your life or your wellbeing? And if the alarm reaction is justified, then we’re good to go.
It may not feel good, but it’s actually adaptive. So, when anxiety kind of becomes unhealthy is when that alarm is going off and there’s no fire, but it’s become internalized that this is a really dangerous situation, right?
So, consider a kiddo with separation anxiety who struggles to be away from mom and dad and experiences this panic reaction every time parents go out to get the mail. Their alarm is actually going off. They’re perceiving that there’s a lot of danger there when there’s actually not.
And so that’s kind of, we want to think about, like, is the intensity of the reaction justified based on the circumstances, and sometimes as parents, we really need to help our kids to sort of learn what is justified and unjustified anxiety.
Jenn: I know you’ve said the word symptoms several times. There’s some for, like, the fight or flight response, and there’s, if a car is screaming down the road at you, you’re going to jump back onto the sidewalk.
I’m curious though about, like, what would be some of the more common symptoms of anxiety in kids? And then, as they age, do the symptoms actually change the more that they learn and develop?
Meredith: Yeah, great question, and I think we should be thinking throughout this conversation that everything is a spectrum and that there’s individual differences within the spectrum. So, I wouldn’t say that the anxiety symptoms themselves would change.
I mean, again, think about, all the physical experiences that you have when you’re anxious are all the result of kind of your sympathetic nervous system kicking into high gear? And they’re the same symptoms that come up if you are exercising or if you’ve had too much caffeine or if you’re having sex, right?
It’s everything to do with just sort of sympathetic arousal. So, your heart rate’s going to increase, you’re going to be sweaty, you may feel dizzy, feel some tingling and numbness, and there might be some stomachaches or some headaches.
So, all of these symptoms are kind of across the board. I think the difference with kids is how they perceive them and communicate about them. You are less likely to have a six-year-old come and say, “I’m having an anxiety attack,” right, than you are to have them say, like, “My tummy hurts.”
And so a lot of times what we... Or you’re less likely to have a young person say, “Gosh, I’m having these ruminations. I’m really thinking about, like, what’s going to happen at school today and all these what if questions.”
You might just see more, like, restlessness and irritability. So, I think what they’re experiencing and, sort of, what they’re displaying or communicating may be different. So, especially for young kids, stomachaches and headaches are super, super common.
So, we talk about, like, kind of that feeling of butterflies in your stomach. And again, as with all of these reactions, this is normal, this is natural, this is harmless, and there’s a reason for it.
If we think about, and I’m belaboring this a bit because I actually think that the psychoeducation is really important for parents to be able to communicate to your kids.
Your stomach is actually upset when you’re anxious because we have a finite amount of energy in our body. And if our body is preparing us to fight or flee, then our digestion takes second fiddle, right?
We don’t need to be digesting your turkey sandwich when we actually need to use, like, our major muscle groups to run or to fight. So, what you just ate for breakfast is just sort of sitting in your stomach, digestion slows down, so you feel sick, and sometimes you actually have an upset stomach or you vomit.
And that, again, is because your body is doing what it was designed to do, which is give you the energy to fight or flee. It becomes a symptom of, like, an upset stomach. So, pay a lot of attention to kind of upset stomachs, to headaches, to things like that.
And then as kids get older and they have more of an understanding of an anxiety response, they may be able to communicate more about their physical experience.
But I think it’s really important for parents not to pathologize the experience of normative anxiety, which I think is actually really hard because the message that we get in our culture is, like, just relax, be happy, don’t worry about it.
And so I think implicit in that messaging is that if you are not experiencing positive affect and low anxiety and happy mood all the time, that something’s wrong with you.
And I think instead and really important to reframe to kids, like, “Oh, okay, it’s the first day of school and you feel like you have a stomachache.
That makes so much sense because you’re nervous and your body thinks that there might be something dangerous. So this is a totally normal response, and it doesn’t feel really good.
So, let’s think about some coping strategies that you can use and continue to be brave,” right, rather than, “Oh my gosh, stomachache. You don’t have to go to school.”
Jenn: Do you think that’s similar when, like, an adult says to a kid, “You have nothing to be afraid of?”
Do you think that that would, like, instill shame or feelings of embarrassment around anxiousness or fear that the kid may be experiencing but can’t actually explain?
Meredith: Yeah, so, I think that’s a great question, and it’s going to have kind of an annoying and nuanced answer. So, sorry for that.
So, I had said at the beginning, we want to help our kids identify, like, when anxiety is justified, like, when this is actually a dangerous situation and when it’s not.
So, to some extent, if you’re dropping your kid off at soccer practice and they’re afraid you won’t come back, it makes sense to communicate to them, like, “I’m coming back, you will get home.” This is an okay situation.
But we also don’t want to kind of invalidate their anxious experience, right? And be, if it’s like, “Oh, you have nothing to worry about, just relax.” The secondary effect of that is that kids are sometimes like, “What’s wrong with me that I can’t relax,” right?
So, always start with validation. And what I mean by validation, because I think that this term is, like, thrown around a lot in modern parenting, but really what I mean by validation is communicating to your kid that what they’re experiencing makes sense and that it’s okay.
So, not saying, “You don’t have anything to worry about here,” but saying, “Okay, it makes sense that you feel anxious, because you’re afraid that daddy’s not going to come back and pick you up.
Let’s talk about what’s actually going to happen,” and then giving them more information so they can see, they are less likely to have to worry about that without, sort of, undercutting them and just being like, “This is silly, you don’t need to worry about it.”
Does that kind of distinction make sense?
Jenn: Yeah, no, that’s super helpful. I’m curious too, ‘cause you’ve talked about some different types of anxiety. Do different types of anxiety have different symptoms?
And one thing that comes to mind for me is if a kid’s anxious about doing well in school and they have a little bit of, like, a perfectionist attitude, does that manifest differently than being anxious in social situations where you don’t know anybody?
Meredith: Absolutely, so, from folks who are in medicine and behavioral and emotional health, we classify anxiety into discreet disorders. And anxiety disorders, again, we identify disorders when there are three things at play, right?
‘Cause, again, everybody’s got anxiety. So, what we’re really looking at is the intensity of the symptoms. So, how intense is the experience of the symptom for the kid? How long have the symptoms been lasting? And how distressed are they by the symptoms?
And, so, again, it’s totally normal to have some anxiety in social situations. Again, that’s adaptive because humans survived in groups. It is, we have evolved to be social creatures. We don’t want to be ostracized by our society.
Therefore, we feel some anxiety when we think we’re being negatively evaluated. But, so, when does it get higher and meet criteria for what we call social anxiety? So, social anxiety disorder is really driven by this, kind of, this intense fear of negative evaluation by other people.
So, that, kind of, is the primary concern. It’s less of, “I’m worried about friendships in general and whether everybody’s happy and getting along.” It’s much more of, “I think that people think that I’m stupid or dumb.”
Or, I’m sorry, that’s synonymous, that “I think that people think I’m stupid or that they think I’m unattractive, that they don’t like me, that they’re judging me,” and that’s the, kind of, primary source of the fear.
Then there’s more, then there’s generalized anxiety disorder. So, these are, like, the “what if” kids. So, even if things are going well, even if it’s summertime, there’s no pressures, these kids are worried about their future, their health, their parents’ health, climate change, wars in the Ukraine.
If it’s something that they can worry about, they’re worrying about it, and this is also associated with a lot of, like, rest, a lot of somatic symptoms, like restlessness, irritability, sleep disturbances, stomach aches, headaches.
These are kind of, like, the “what if” kids. We also see, you know, I mentioned separation anxiety. So, that’s really a focus on fear of separation from caregivers or loved ones, either because of a fear that something bad is going to happen to the child or to the caregiver, and that really becomes the primary fear.
And then we have panic disorder, which is, panic attacks can co-occur with any sort of anxiety disorder, but panic disorder is the experience of repeated, unexpected panic attacks that can occur, kind of, like, in the absence of other stressors, sort of, out of the blue.
And then there’s this change in behavior or real fear of future panic attacks occurring. And I think the panic, the experience of panic is very much like the, kind of, fear of fear.
What you actually become afraid of is your own natural, normal, harmless, anxious response, but it, kind of, because it feels so overwhelming, you become, sort of, afraid of your own experience.
So, there are a number of different categories of anxiety and they sort of change in frequency throughout development. So, you are much more likely to see young kids with separation anxiety, social anxiety/selective mutism.
So, a child has the ability to speak, but restricts their speaking to only certain people. And then as kids age, we start to see more of the emergence of generalized anxiety.
So, it’s kind of, like, as kids start to realize that, like, “Wow, the world can be a kind of scary place,” then they may start to have more of these ruminative worries, these “what if” concerns.
And then in adolescence is where you really see the peak of panic disorder onset and more social anxiety, again, because the adolescent brain is particularly attuned to social and peer interactions.
So, the, kind of, presentation of anxiety may sort of change over time and it sort of may make, it may meet diagnostic criteria at different times during development. And we see children as young as preschool aged children who can meet diagnostic criteria for different anxiety disorders.
So, it really can occur, sort of, across the developmental spectrum, which is difficult, right, because so many kids are struggling with anxiety. But to that effect, we understand it really well, and we have really good treatments for it because it’s such a high base rate class of disorders.
Jenn: One of the things that struck me about what you said was, when discussing social anxiety and selective mutism where kids are more inclined to only speak to the people that they feel comfortable speaking around, whether it’s fear of negative evaluation or a different reason.
How can you tell if your child is just shy or if it’s social anxiety or selective mutism?
Meredith: So, here’s where we come back to that intensity, distress, duration, sort of, how long has it been a problem. And also we think about, sort of, functional impairment.
So, there are some kids who are shy. We call this, the fancy word for it is inhibited temperament. These are just the kids who, sort of, kind of, came out of the womb, like, with a little bit. They’re a little bit more cautious.
They’re not the kids who are just, like, jumping up, raising their hands, saying, “Me first,” pushing to the front of the line. And there’s absolutely nothing wrong with that. So, really what you want to think about is, is this interfering?
Is this getting in the way of them being able to make and sustain friendships, advocating for themselves. Like, young kids, can they tell their teacher when they need to go to the bathroom, right?
Or older kids, if there’s a bullying issue, will they be able to go to an adult? So, those are just some examples, but we are really looking at, like, how much is this interfering in their day-to-day life?
So, some questions that I may ask to gauge that would be, in what ways is anxiety sort of telling you that you need to do things that you wouldn’t ordinarily do, or, on the flip side of that, what things aren’t you doing that you would be doing if anxiety weren’t part of this?
And so those questions, thinking about either yourself or your child’s experience of anxiety, how much of an impact is it having on their day-to-day functioning? I’m an anxiety specialist, and I cannot do cockroaches.
I just cannot do that, right? And fortunately I don’t have a cockroach problem in my house. And we live in Massachusetts, not a lot of cockroaches just everywhere. So, I don’t have to deal with that. It doesn’t cause a lot of functional interference.
If all of a sudden, I did have to deal with cockroaches in my day-to-day life, I would have to have some treatment, right? I would have to actually deal with that. So, sometimes parents will come in and say, my kid’s really afraid of X, Y, and Z. And then the question is like, “Okay, but how is that interfering in their life?”
And if it actually is leading to significant interference, they’re not meeting, kind of, developmental, academic, and health goals and standards because of that, then it warrants intervention.
Otherwise, it might just be an up thing. It might just be a preference. It might just be a temperament thing.
Jenn: I’m curious. So, let’s do a wild example. If I’m an anxious person, which yes, I am an anxious person, what is the, like-
Meredith: You have a good company. So, it’s, again, 20% of people will meet diagnostic criteria for an anxiety disorder at some point in their life. So, you’re in good company.
Jenn: That’s good to know. I’m curious though, what’s the likelihood that offspring will also have anxiety?
I mean, like, obviously anxiety is one of those things, like, with your saber-toothed tiger reference, it’s something that it’s, like, actually allowed us to continue to procreate, but is there some sort of genetic or hereditary component of anxiety disorders that, if you’ve got one, if you’ve got a clinical disorder, is it something you should know about?
Meredith: So, regrettably, the answer is yes, there is a strong link between, kind of, parental anxiety and child anxiety. And the, kind of, rhyme or reason for that is not really easy to parse apart.
So, I think the studies have identified that there is often, like, a significant, like, purely biological, purely genetic component. But then, this is what’s really important, a lot of this is behavioral, environmental, and the result of learning and learned responses.
So, if you trend anxious, it is likely that your kid is going to, sort of, come into the world with a biological predisposition to kind of experience that alarm system, either more intensely or more regularly than other folks.
And so then there’s not much we can do about that. But the really important thing is that this isn’t a death sentence, that there is so much that we can do from a behavioral perspective to change our relationship to that response.
So, first and foremost, reframing that response as natural, normal, and harmless is the first way to go, right? We don’t want to just be like, “Well, mom’s anxious, you’re anxious, end of story.” No, this is something that is just, kind of, part of what makes you you and we need to help you learn to respond to that.
And so the even better news is that there’s been more and more research showing that even if your child won’t go to therapy or is just not interested in addressing this at all, that parents can actually intervene by changing the way that, parents’ response to child anxiety can actually change child anxiety, decrease child anxiety, and remit anxiety disorders.
So, I think the most important thing to think about is, in what ways are you as a parent perhaps accommodating your child’s anxiety and not giving them the opportunity to learn that they can experience this normal anxious response and be okay?
We don’t need to take all stressors away from kids, and, in fact, that’s actually more likely to lead to them having a diagnosed anxiety disorder in the future, if they haven’t had the chance to learn that they can have an anxious response and tolerate it, that all emotions, the emotions are kind of like the weather.
You can’t change the weather, the weather doesn’t care whether you like it or not, but it, eventually all storms pass. The same things with all sort of anxious responses. You will have anxiety, anxiety will increase, it will peak, and it will come down.
And if we can help kids to see, “Yeah, you were really anxious on that first day of school, and walking into the building, you felt awful. And what happened the longer you stayed there?
Okay, well, some people started being nice to you, you said there were some cool things that you were learning about, and then what happened to your anxiety over time? Oh, okay, it actually, it started to decrease.
Oh, it increased a little bit at lunch. Fair, that makes sense. Lunch can be stressful, and then what happened?”
And so really processing with your kids the fact that anxiety increases and that it can decrease and you can cope can help them to feel like they have more agency in dealing with anxiety when it arises, and that it’s not the end of everything, that they can cope with it.
And that’s what is a really important factor in exposure therapy, which is the, kind of, gold standard approach for treating anxiety disorders across the board. And the understanding behind that is that actually, avoidance fuels anxiety.
So, if you take one thing away from this talk today, I want you to remember that avoidance fuels anxiety. So, if there’s something that you are avoiding and it’s actually not an unsafe thing, it’s school or learning to drive or texting a friend, the more you avoid it, the harder it’s going to be to actually do that thing.
And so, actually, we cope with anxiety by actually leaning into the things that make us feel scared. And then we learn that usually they’re not as scary as we thought they would be or our worst case scenario doesn’t happen.
Even if it does happen, we live through it and that gives us this efficacy and this agency to move forward.
So, I realize that’s a really long-winded answer to your original question, which was, like, how heritable is this, but all of that is to say is that if you are a parent watching this or listening to this, and you’re like, “Oh my gosh, I’m anxious, my kids are doomed,” that’s not the case.
There’s so much about, like, the way that you and your children can learn to respond to anxiety that can really mitigate the development of anxiety disorders, even if you’re, kind of, like, a genetic hotspot for it.
Jenn: I think that’s super helpful though, and, like, you had so many valuable pieces of information within that answer, that it’s, like, no answer is ever too long an answer.
Meredith: You’re kind, I appreciate that. I think that might have been one...
Jenn: Do not worry about that whatsoever.
So, based on what you had said about exposure being one of the, it’s, like, the gold standard of anxiety treatment, would that also be applicable to selective mutism and kids? Or are there other ways to also address selective mutism?
Meredith: Yeah, so, selective mutism is again, yes, a behavioral response. A behavioral treatment for selective mutism would be indicated.
So, thinking about, selective mutism is hard and I’ll give an example of something that is relatively easier to treat to kind of make the distinction. So, if you think about the development of a dog phobia and how might that have developed over time, right?
So, typically, it’s because a person has encountered a dog, they feel a surge of anxiety. And so, what do they do when they feel anxious around something? They leave. They have a really awesome way to avoid the anxiety.
So, they’ve left that situation, their anxiety decreases, and they feel relief. And that relief actually reinforces more anxiety about dogs because you learn, “Wow, I’m not a person who can handle dogs, ‘cause I just had to get out of there. That was the only way I felt okay.”
So, next time you see a dog, because you actually avoided the dog the first time, your anxiety is actually going to go higher the next time. And so, you are more likely to avoid. And so, anxiety disorders often develop because of this well-meaning but repeated avoidance of a situation.
So, then it’s, kind of, we call it negative reinforcement. You don’t have to feel the anxiety as part of being exposed to that situation. And so, you feel less and less confident around that situation.
So, encountering a dog for somebody with a dog phobia may be, kind of, something that’s few and far between.
But with selective mutism, what we really see is that that develops due to reinforcement of not speaking, and think about how many times, just in a single day that could be reinforced because every time somebody says to your child, “Hi, how are you,” and they feel anxious and they say nothing, what happens?
An adult speaks for them, which then reinforces the fact that not only can I not speak for myself, but also somebody else has got this, so I don’t need to. And that happens over and over and over and over and over again.
So, it’s just so much harder to, kind of, like, do an exposure to that, to flip that. But what we do with selective mutism is actually start encouraging kids to speak for themselves in a graded way.
So, we would say, start with an exposure to maybe a person who is, like, a known figure, like a grandparent, maybe somebody with whom the child used to speak, but they no longer speak and have the grandparent ask the child a yes, no question, so they don’t have to give, like, an open-ended response.
And so, then, and then, kind of, through reinforcement with, like, rewards, start to reinforce the child actually saying yes, but the parent has to hold the line with not jumping in for the child.
And so, it’s hard, it’s a process, and we do this in a staged way, but ultimately, we have to get the kid to start speaking in small doses over time and learning that the speaking feels hard, but they can do it.
And the more they do it, just like with practice, with everything, the easier it gets. The hard part is for parents to sit with that discomfort when you know your little one is upset and you know if you just answer for them, this will all be over.
So, again, but that’s where parents, you have some control here, you have some power. The way that you respond to your child’s anxiety can change the way that they have to respond, right?
Jenn: Can you talk a little bit more about panic disorder and panic attacks in kids?
Meredith: Yes, so panic attacks are a really common experience. Again, I think that most, I don’t know the data at this point, but I think most people have had the experience of a panic attack even in the absence of panic disorder.
So, again, it’s really just your fight or flight response going off. Panic attacks feel like they last forever, but actually, we find that panic, and just to make sure that I’m being really, really clear, when we talk about a panic attack, it’s the abrupt experience of intense fear, and a very, like, physical response.
So, you’re going to see an increase in heart rate, which is associated with an increase in respiration. So, it feels like you’re having trouble breathing, but you’re actually just breathing more.
There can be dizziness, and, again, there’s a reason for that because when you’re breathing faster and harder, the ratio of oxygen to carbon dioxide going in and out of your body changes, which then, kind of, makes you feel a little bit woozy.
You can feel numbness, tingling, hot flashes or cold flashes, trembling, stomach discomfort, and often, it’s accompanied with cognitive symptoms. So, fears of losing control, fears of dying, fears of fainting can go along with it.
And, again, it sort of builds on itself because what happens is you start to experience these symptoms and then your body notices, “Oh man, like, my heart’s beating really quickly.” And as you attend to that, the more you attend to your heart beating quickly, it’s going to beat more quickly ‘cause you’re nervous about it, right?
And so, then you start to feel like you can’t breathe or that you’re choking. And then, you’re like, “Oh my gosh, something must be really wrong with me. My heart’s beating out of control and I feel like I’m choking,” which then, of course, just amps everything up more.
So, it really, really snowballs on itself. And then, again, what people typically do when they’re experiencing this rush of intense, uncomfortable symptoms is that they leave or change. They do something to, sort of, change their circumstances.
So, if I’m having a panic attack in the classroom, I feel like I need to get out of here, and, so, I go to the nurse’s office, or I text my parents and I get picked up.
And so, I actually, then in my mind, I’ve learned the only way I can cope with this panic is by leaving, by avoiding, which then makes it, then reinforces the notion that school is a place where I panic and I can’t go to school.
So, oftentimes we see in panic disorder that kids start really avoiding the places where they are likely to experience panic and their worlds just become smaller and smaller and smaller because not only am I afraid to have panic at school, but now I’m like, “What if I have a panic attack when I’m with my friends?”
So, I don’t want to be with my friends anymore. So, I’m just going to avoid that. And just everything, kind of, gets smaller and smaller and smaller. The treatment, the, kind of, the cognitive behavioral exposure-based treatment for panic is actually practicing feeling the symptoms of panic.
It sounds super sadistic and awful, but we actually have kids breathe through a coffee straw to mimic the sensation of not being able to breathe well and to get your heart rate up, or we’ll have them run stairs so that their heart is beating really quickly.
We’ll have them spin around an office chair so they feel dizzy, and we actually have them practice feeling awful because that helps them to learn that, like, these feelings feel awful, they’re not going to hurt me, I’m not going to die, and I can tolerate them.
And so, it’s actually, kind of, ironically by leaning into these symptoms that feel so miserable, your body actually adjusts. You, kind of, get bored. You’re like, “Okay, my heart’s beating quickly. So what? I’m fine.”
And so, actually by continuing to experience panic, particularly in situations where you feel uncomfortable, you start to learn that I can tolerate this. Easier said than done, right? Nobody’s like, “Sign me up for, like, a panic attack that I bring on for myself.”
So, it’s hard, it’s hard work, and we find that this can be, like, really effective in, like, 10 to 12 sessions to address panic disorder through this kind of behavioral approach, through what we call interoceptive exposure, which is exposure to the physical symptoms of panic. It’s not fun but it works.
Jenn: I’m curious, at a certain point, does it become more evident that a child or teen may be suffering from, like, an ongoing long-term generalized anxiety disorder or is there, like, a threshold of when kids are diagnosed with anxiety disorders?
Like, how young is too young? Is there a limit to when kids get diagnosed? That was, like, four questions in one, but thanks for bearing with me.
Meredith: Oh, no, of course. So, I think there really isn’t a lower limit. There’s been a lot of really great work done on preschool anxiety. So, again, we’re really looking at functional interference.
So, if a child seems to be exhibiting a lot of anxiety or distress and it’s interfering with their ability to, kind of, do the activities that would be expected for that time in their development, then a diagnosis can be applied.
So, again, the purpose of assigning diagnoses is sort of twofold. One is to be able to, for medical and behavioral health professionals, to be able to quickly and clearly communicate about a set of symptoms.
So, for example, if I said, “Jenn, I have the flu,” you wouldn’t need, like, a rundown of all of the symptoms that I had, but you would just know, “Oh, okay. So, you’ve got a fever, vomiting, like, you feel like you’ve been hit by a truck,” right?
So, you know that. So, if I say to a pediatrician who’s working with a child who’s referred to our program, I say, “They’re experiencing agoraphobia” or “They have generalized anxiety disorder,” they kind of know what I’m talking about.
So, it’s in some way, it’s a shorthand. And another way, it’s a way to, kind of, characterize, at this time, this person is experiencing symptoms X, Y, and Z. They’ve been experiencing it for at least, you know, with panic disorder, you need to have these symptoms for at least one month without remission to have the criteria met.
For generalized anxiety disorder it needs to be at least six months, right? Every diagnosis has its own sort of set of, like, criteria. But it basically says, like, at this point in life, your symptoms are best characterized by or best represented by assigning a diagnosis of generalized anxiety disorder.
That is not a stamp for the rest of your life, because in those symptoms, if they remit and they can and usually do remit over time, especially with intervention, then you no longer meet diagnostic criteria for that condition.
You have a vulnerability to having a resurgence of those symptoms but it’s not like, “I have panic disorder, and it was assigned at age 13 and now I’m 78, and I’ve had panic disorder my whole life.”
There may be, like, episodes where the panic symptoms are most interfering. So, it’s not like a neurocognitive disorder, it’s not like a chronic illness, it’s something that is, like, a vulnerability that at times may be punctuated by and characterized by a certain diagnosis.
Jenn: So, how would a parent know if and/or when to seek professional care for their five-year-old that’s exhibiting signs of anxiety?
Meredith: So, first, I mean, again, you as a parent know your child better than any professional will ever know their child. So, you know when something’s up.
So, start with monitoring, monitoring and good data collection. I mean, I know I’m in academia, but, like, and just nerding out here, but good data collection is always really important.
So, keep a chart or a journal and, kind of, identify, sort of, clarify and identify what you’re seeing so you’re able to go to your primary care or your child’s pediatrician and be able to report, “This is actually what’s happening,” because they will ask, how frequently, what does it look like, and in what ways is it getting in the way of their day-to-day life?
So, if you’re able to say, “My 12-year-old has been experiencing panic attacks, they’re having two to three panic attacks a week for the past four weeks, they have stopped going to soccer practice, and they complain of a lot of stomachaches and they’re not wanting to go to school as much and they’ve missed six days of school in the past two months, right?”
Like, getting some of that concrete information can be really, really helpful. And then I would always recommend going first and foremost to your pediatrician.
This is the person who knows your child and your family the best and who has a sense of, like, what their baseline has been over time and is plugged in with your community so can help you identify resources if they feel like intervention is needed.
Jenn: So, does it seem like anxiety could get better without therapy or medication? We had a parent write in saying, the example of a six-year-old with a stomachache that you you’ve mentioned before is actually this person’s daughter.
Lots of visits to the nurse’s office, at camp, and school. Should the parents be prepared for what they’ve coined to be a longer term struggle or is there the possibility she might grow out of this or should they seek help and have some kind of combination of the two?
Meredith: That’s a really great question. And first of all, to the parent who wrote it, I’m sorry to hear that your daughter’s struggling. I’m a parent myself and it’s one thing to talk about this in the abstract, but when you see your little one suffering, it’s really hard.
Our deepest, like, talk about, like, things that we’re evolutionarily selected for, like, our deepest primal drive is to protect our kids from distress. And so, when you see your kid in distress, it’s really, really hard.
So, I think that, again, because anxiety is so, so common and so well understood, I think that there’s no harm in exploring, kind of, staged ways to intervene.
Even if you don’t think that your kid is meeting, even if a professional doesn’t think that your kid is meeting diagnostic criteria for an anxiety disorder, that doesn’t mean that you can’t intervene in, kind of, a preventative way.
So, I’m going to recommend a book for parents that we use as, kind of, like, the required reading in our intensive anxiety program, and Jenn, I don’t know if this is something that you all can disseminate afterwards, but it’s called “You and Your Anxious Child” and it’s by Anne Marie Albano, A-L-B-A-N-O.
It’s a really great read, it’s really accessible, it helps parents to, kind of, understand anxiety, to differentiate normative anxiety from anxiety that might be more problematic or clinical, and helps you as a parent to think a little bit about how can you intervene in, sort of, a stepped care way, and when is treatment indicated.
But, again, even with a six-year-old, you can start talking to them about anxiety. You can actually start externalizing their anxiety by, like, sometimes we identify the, like, the worry bully, or we have kids that, sort of, like, name their anxiety or draw their anxiety and start to differentiate it from themselves.
And so, kind of, and then practicing, like, pointing out, like, “Oh, is the worry bully here right now? Okay, so what’s the worry bully telling you is going to happen,” because we want to help kids... You can’t really intervene on anything unless you, sort of, recognize what’s happening.
And so, having kids, sort of, slow down and think a little bit about, “How do you know the worry bully is here?” “Oh, well, my tummy hurts.” “Okay, so your tummy hurts, and anything else that you feel in your body?” “Oh, I feel like, I feel a little shaky.”
“Great, really nice job. Okay, so we know that the worry bully is here. What’s the worry bully saying to you? What is he telling you is going to happen?”
And so, having your kid then start to identify if they can, if they have the language for it, what’s their anxious thought? What are they afraid is going to happen?
And then you can, sort of, look at that thought with them and say, “Okay. So, you’re afraid that the teacher’s going to yell at you ‘cause they disciplined some other kid the other day. So, okay, yeah, and it doesn’t feel good to be yelled at.
So it makes sense that you might be worried about that. And let’s talk a little bit about, like, why might a teacher yell and, sort of, what can you do so you’re less likely to get yelled at?” That’s just a random example, of course.
But all of that is to say there’s a lot you can do as a parent to start to bring a conversation about anxiety to the forefront.
The other thing that’s really, really, really important as a parent to do from the get-go if you think that your kid may trend anxious is to model brave behavior, to model that when anxiety is telling us to avoid something, then that’s when we actually need to do the opposite.
Parents can share with kids about times where they felt really anxious. “I was supposed to give this presentation at work, and I noticed I was really nervous, and I wanted to just call in sick and stay home, and I went and what do you think happened?”
So, modeling that this is normal, that can be really helpful. And then think about the ways in which you as a parent might be changing your behavior to what we call accommodate the child’s anxiety.
So, are you, sort of, walking on eggshells in your home because you’re afraid that you’re going to distress your kid? And what is that actually teaching your kid? It’s sort of teaching your kid that they’re fragile, that they can’t handle anything themselves.
And so, we really want to think a little bit, like, it’s actually okay and actually healthy for your child to experience a little bit of distress.
This isn’t saying, particularly to this parent who wrote in, just, like, rip the rug out from under your kid, like, throw them into the deep end and, like, let them learn to tolerate anxiety, but in a gradual way.
If they are insisting that, insisting on sleeping, like, in bed with you, and that’s something that you as a family don’t want to continue, it’s not something that you would do if anxiety weren’t in the picture, then setting some clear limits and saying, this isn’t going to happen, and often starting a behavior plan where, like, the child isn’t allowed in the bed.
They can sleep on the floor next to you and we want to make this uncomfortable, right? ‘Cause we don’t want them to stay on the floor, we want them to get in their own bed.
So, like, sleeping on the floor in a sleeping bag and then gradually every night, moving back a little bit further away from mom and dad. And it’s going to be hard, you as a parent are going to have to tolerate your child’s distress and your own distress, and that’s actually the way that you show them that they can handle these things.
And to Jenn’s point at the beginning, any sort of behavior plan that I mentioned that might be a helpful exposure-based treatment for a kid who’s struggling with anxiety, please don’t do anything without talking with your pediatrician, without getting consultation perhaps from your school or from a provider within the community.
But I think the, sort of, the tone of all of this is that we really want to make sure that parents set the expectation that kids can be brave and face their fears. And we as parents have to learn to tolerate a bit of our distress when our kids are distressed.
Jenn: Yes, I think it’s super important to reiterate anything that Dr. Elkins has mentioned today, if it seems like something you’re curious in implementing with your own child, always talk to pediatricians, mental healthcare providers, whoever’s on their care team. Please do that first.
Meredith: Yeah, absolutely. If there’s any sort of, you know, if there’s a trauma piece or an attachment piece or something that’s not being considered here, then we go about exposures in a very different way.
So, again, always talk to the folks who know your kids best, but think a little bit about the ways in which you may be inadvertently, sort of, reinforcing your kid’s anxious response, okay.
Jenn: I’m curious if anxiety can present as being anger, defiance, or some type of, like, other type of explosive behavior from a kid.
Meredith: Yeah, it can. So, we see a lot of, again, think about, like, when you’re experiencing panic, everything is revved up. So, you’re going to snap, you’re going to lash out, you’re going to be irritable.
And so, yes, we do see angry or oppositional, like, oppositional responses as a product of anxiety. I think it’s really important generally to remember that just because anxiety might be at the root of a behavior, it doesn’t necessarily excuse a behavior.
So, if your kid is anxious and puts their fist through a wall, it’s not okay, right? It’s not okay for them to hurt themselves, to hurt other people, to hurt property. So, there can be firm limits that are established.
Sometimes we see in our program, families who feel like they’re really held hostage to their kids’ anxiety because they become distressed and dysregulated, and then they’re fearful about the consequences that the kid may have for themselves, against themselves, against siblings, just sort of dysregulation within the household.
And so, coming up with a planned response of, like, what is and is not appropriate in your home and what the consequences will be if the kiddo doesn’t use coping skills that you all identify ahead of time to manage the anxiety, to manage this response in an appropriate way, right?
We have to help the kids learn coping skills to manage their anxiety, but there also need to be consequences. And that’s, again, something really important to consult with your folks in your community, with behavioral health specialists to, kind of, identify.
But anxiety shouldn’t be a carte blanche to, kind of, hold a family hostage, even without meaning to.
Jenn: Between the work that you’re doing, all the research that you’ve done, the knowledge that you have, are you familiar with overlaps between anxiety and ADHD?
And oftentimes, if they are occurring together, are they treated separately or is there some sort of overlap in treatment of both of them?
Meredith: Great question. So, yes, we do see a fair amount of overlap. I think we see co-occurring anxiety disorders in about 25% of patients who have ADHD.
So, a really common co-occurrence, it’s also really, really tough to piece apart because if you think about the symptoms necessary for an ADHD diagnosis, trouble focusing, inability to concentrate, those are actually symptoms of, particularly of generalized anxiety, right?
Restlessness, difficulty concentrating. But neurocognitive tests actually suggest strongly that the basis, the mechanisms that lead to ADHD are distinct from those that lead to anxiety. So, while, like, the symptoms may appear the same, they’re caused by different processes.
So, sometimes they co-occur, it’s really hard are to pull apart what’s what, and then even more tragically, some of the main treatments for ADHD, which would be stimulant medications can actually exacerbate anxiety, ‘cause think about if anxiety is all about sympathetic arousal and then you’re giving a kid a stimulant, that’s just going to make them feel more anxious.
So, it’s a real challenge. Making it even more difficult is the fact that most ADHD is diagnosed by, kind of, like, self-report or parent report checklists, but, really, we recognize that the best way to clarify that ADHD is actually present is through a neuropsychological examination.
Those are hard to find, expensive, et cetera. But I think this is just an area that needs a lot more study and clarification because yes, there’s overlap, the symptoms look pretty similar, the treatments can be counter-indicated.
So, it’s tough, it’s tough. So, working with your pediatrician and finding a child psychiatrist within the community who can help find...
If a kid really has significant struggles with anxiety and ADHD is in the picture, we really want to find a medication that’s not stimulant-based that might help with ADHD, come up with behavior strategies to help with attention and focus, lean on the school for a 504 plan or an IEP plan to help support educational progress.
It’s a really tough thing to parse apart.
Jenn: I would be remise to not ask you, based on how much experience you have between anxiety disorders and mood disorders, what are some of the similar symptoms between the two types of disorders in kids?
Meredith: It’s so much anxiety. So often anxiety and depression co-occur, and it’s, often it’s almost like, is this, like, a chicken or the egg thing? But a lot of times what we see is that kids are struggling with anxiety or with OCD and it feels out of control, they start to feel increasingly hopeless.
Again, if they’re avoiding more and more because of their symptoms, then their world gets smaller and smaller, which means they have less opportunity for positive input from the environment and they’re more likely to become depressed.
So, unfortunately, there’s a lot of overlap. So, again, difficulty focusing, having a hard time concentrating, fears of, like, being out of control, kind of a sense of hopelessness, concern that, generally feeling like people don’t like you, that can be part of social anxiety and certainly part of depression.
So, there’s definitely a lot of overlap. Again, I think I spoke about how the, kind of, gold standard approach to the psychological treatment of anxiety is cognitive behavioral therapy or CBT.
And really what we find is that cognitive behavioral therapy in concert with an antidepressant, so an SSRI specifically, is sort of the gold standard approach to treating anxiety disorders. Fortunately, SSRIs are also the leading medication treatment for depression.
So, often getting treatment for anxiety and depression, like psychological behavioral treatment for anxiety and depression, in concert with taking an antidepressant can be helpful.
Jenn: I know we’re bumping up against time. Do you have time for two more questions?
Jenn: Excellent. I want to be cognizant of the fact that just because we are talking about parents and kids does not necessarily mean that somebody who is caring for a kid is their parent. It could be a caregiver, it could be a social worker.
With that, I didn’t want to gloss over this question. A child in foster care is in the midst of potty training and doing well, but after visits with their biological mother, they always have accidents, and the person writing in wanted to know, could this be an anxiety-driven behavior?
Meredith: It could be an anxiety-driven behavior. It sounds like there are a lot of really tough feelings that are going on there.
I think, it’s the most important things there would just be, sort of, validating that they’re experiencing big feelings, and sometimes our bodies, you do funny things when we have big feelings, right?
Just a lot of compassion, validation, and expressing confidence that this is going to get better.
Jenn: Last but certainly not least, at the time that you and I are talking, there is a lot going on in the world, big, scary “adult things.” A pandemic, there’s conflict in Ukraine. There’s just, there’s a lot more uncertainty now than several years prior.
How can we help ease anxiety in our kids about these things that they might be picking up on without us actually realizing it?
Meredith: Yeah, it’s a, what a time to be alive, right? I think having an, it sounds so trite, but having an open dialogue with your kids is really important. Just because your kids aren’t necessarily bringing these things up to you or in front of you doesn’t mean they’re not aware of them.
So, first and foremost, kind of, pick your moment and process your own emotions first. I think you’re going to have the greatest likelihood of a positive and healing conversation if you feel like, kind of, you’ve put your oxygen mask on as a person, that you feel, like, kind of, calm and as in control as you possibly can.
And then sort of pick your moment, pick a quiet moment, sometimes, like, driving somewhere on a weekend when there’s less pressure, and just, kind of, for younger kids, saying just like, “I wonder what you’ve heard about the conflict in Ukraine,” or with older kids you, kind of, can assume that they are hearing it.
So, just, kind of, like, “What are your friends or your teachers saying?” And then just being like, “How do you feel about it?” We really want to first, like, reassure kids that they’re safe and that the adults in their lives are doing everything that they can to protect them.
Sometimes it can be helpful to use visuals of, kind of, showing a kid a map where Ukraine is, or, in the context of COVID, looking up community-based rates of transmission and talking then about, like, proactive ways that you can be safe, that you can, like Mr. Roger says, like, look for the helpers, those sort of proactive approaches that kids can take so it seems like they’re less at the mercy of just the universe.
But I think it’s also important to model your own feelings about it. So, you can be like, “Yeah, I feel sad. I feel sad because people are hurting,” or “I feel scared because these things are scary,” and that’s okay.
Again, going back to what we were talking about at the beginning, we don’t want to pathologize negative emotions. They’re part of our human experience. So, it’s okay for parents to sort of say, I feel these things and this is how I’m coping with them, like, modeling prosocial coping strategies.
But it’s important not to just give a blanket statement of, like, everything’s going to be fine, because if it’s not fine, then why would a kid trust you again? So, I think, like, giving facts, not giving too much more detail than they need.
Also, I think the media exposure is a big deal. This is not the time to be leaving CNN on all the time in the background, right? So, we really want to limit your kids’ exposure to this extraneous information so that they can make sense of it as much as possible in a developmentally appropriate way.
Jenn: I think this is the best way to wrap up this session. Meredith, I just want to say, thank you. You are truly, you have a wealth of knowledge.
I think one of the things that’s been really great about having this conversation is, like I said at the beginning, it’s learning how we can help our kids with anxiety and, in turn, help ourselves and you’ve given so much information that actually covered both.
I just wanted to say huge thank you for doing that.
Meredith: Oh, it’s my pleasure.
Jenn: This has been exceptional. And to anybody tuning in, thank you for hanging around for an hour with us to learn all about anxiety in kids and teens.
Like I always say, until next time, be nice to one another, but most importantly, be nice to yourself. So thanks again, Meredith and thanks everyone. Enjoy the rest of your day.
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