ADVICE ON MENTAL HEALTH: Helping Children and Adolescents With Emotional Problems

ADVICE ON MENTAL HEALTH - from Brain & Behavior Magazine, August 2024 issue

Q&A with Daniel S. Pine, M.D
National Institute of Mental Health (NIMH)
Chief, Emotion and Development Branch
Chief, Child and Adolescent Research in the Mood and Anxiety Disorders Program
BBRF Scientific Council
2011 BBRF Ruane Prize for Outstanding Achievement in Child & Adolescent Psychiatric Research
 

It's often hard for a parent or teacher to determine if a child has a problem with anxiety that needs to be referred to a doctor. Dr. Pine suggests when and how they should proceed, while explaining the range of possible symptoms and behaviors, and a variety of treatment types that are often recommended. He deals with the question of medication, advising an open yet conservative approach. He also talks about issues that can arise when parents and teachers meet to discuss a child's problems.

What does anxiety look like in children and adolescents?

Anxiety is a common part of life. We all have anxiety. Children in particular, as they develop, have anxiety, which can present in many different ways. Mental health professionals really have a concern when a child has an anxiety disorder. Anxiety disorders are probably the most common mental health problem in childhood with at least 10% of children being affected at any moment in time.

One of the tricky things for parents, teachers, and even children is to tell the difference between normal anxiety that is an expected part of growing up and an anxiety disorder. The simplest rule is to notice when anxiety prevents a child from doing things that other children can do. If a child can't give a presentation in school because they're too nervous to speak, that's a suggestion of an anxiety disorder. Other signs to watch out for include if a child can't go on overnight visits to friends or can't spend time alone in their room or can’t take part in a sporting event because they are too worried about performing well.

If it's affecting their functioning, that's when you cross the line into a disorder as opposed to the normal anxiety that any child will feel.

That's exactly right. The usual way we see that effect on functioning is through avoidance, meaning that children don't want to do things that make them afraid.

Often as a parent or an educator, we may want to help that child. But it may not be helpful to assist them if it means helping them to avoid the activity that we may think brings on the anxiety. What should we do?

That is an excellent question and an excellent thing to think about. We do a lot of research on children who show mild or not quite clinical signs of anxiety, and we follow those children over time as they grow up. We’ve found there are a lot of things that predict what's going to lead to persistent anxiety.

When we follow children who have minor problems with anxiety whose parents encourage them to face their fears and attend the kind of events that make them afraid, we find that those children actually do better over the years. They have lower rates of anxiety compared to the children who are not pushed to do the things that make them afraid.

Now, it's a difficult call for many parents about how much to push their child, and if you're a parent or an educator who is unsure, a mental health professional can be particularly helpful. A good place to start is with your pediatrician. Pediatricians are quite familiar with the full range of behaviors, and they're also able to help a parent find access to mental health professionals who can work with them to push their kids the appropriate amount.

How young can a child be when these kinds of symptoms get in the way of their functioning?

We see the signs of anxiety even during preschool, but it's quite rare for anxiety to interfere with a preschooler's ability to function. It really becomes much more common in the early school years, and in those years, anxiety tends to present itself as worry about specific objects or specific situations like being alone or being separated from parents.

As kids approach adolescence, we see that anxiety tends to shift and focuses on social issues. For kids in the 9-14 range, we see social anxiety as the most common form of anxiety. Then a few years later, we see general worries about competence—how well you're going to do in school, how you're doing in sports, how you’re doing with peers—"do they like me?” Anxiety happens all throughout childhood once school begins, and we see different flavors in children of different ages.

Tell us a little bit about the treatment. You go to the pediatrician; the pediatrician may suggest going to a psychiatrist, a psychologist, or some other mental health professional. What is a mental health professional going to do?

The first thing we want to do is help children learn how to use constructive thoughts to control their anxiety. There is a whole range of techniques children can learn with a therapist. The second thing we want to do is make a list of all the things that worry the child. You want to work with a therapist who's going to help the child and their family do what we call “exposure.” That means facing your fears. You're going to want to start with something that's slightly anxiety-provoking, and have the child use those new skills that they've developed with their therapist to control their anxiety. Then as they learn how to navigate a mildly fearful situation, you want to gradually increase the exposures. We call this form of therapy cognitive behavioral therapy (CBT) or exposure therapy. That's usually the first-line treatment that most people recommend.

Now, that's not an easy thing to do. Partly because the therapist has to have some skill and experience in helping children learn how to face the feared thing or situation. For some children, it's simply too difficult. For those children, the other treatment we consider is to prescribe an SSRI [one of a group of similar medications like Prozac or Lexapro that are often prescribed for depression and anxiety in adults].

There's some debate about whether or not we should consider those as first-line treatments. If an experienced therapist is available and a child is willing to engage in cognitive behavioral therapy, most people recommend starting with that. Yet, there are not enough experienced therapists who can do this, and not all children will comply. If therapist who can administer CBT to a child cannot be found, I think it's perfectly reasonable for the child to be treated with one of the SSRI medications.

What advice do you give to parents who are—appropriately— concerned about giving their child medicine, especially on an ongoing basis.

We have a lot of information about the safety of SSRI medications in the short term, meaning for one to two years, and this information suggests that the benefits far outweigh the risks. It is important to consider that there are considerable risks to the child when they have serious anxiety that is left untreated. The benefits of overcoming their anxiety in the short-term are greater than the risks of not treating, in my view.

We could debate if it makes sense to start with cognitive therapy first. It probably does, but again, parents can be reassured of the safety of medication over one to two years. Where things get trickier is if you use medication beyond two years, and different physicians, therapists, and scientists feel differently about this. Anxiety has a very good prognosis. Most children can overcome their anxiety, and it might come and go, but most children can get to the point where their anxiety is substantially better. For children who have responded to a medicine and are doing well, after a year, I like the idea of beginning a trial period in which the child is not taking the medication. It’s not that we know with certainty that there’s something bad about taking the medication over the long term, but we have less information.

Not everybody agrees with this. Some think that anxiety can be chronic, and if you get a child well, they recommend that the child remain on the medication for a number of years. They point to the fact that there is no evidence that the medicine is harmful if taken over many years. I tend to be more cautious, mostly speaking to concerns that I hear from many parents, and also because many children come off the medicine and they do fine. Some experts feel otherwise. My view is that you can always put that child back on the medicine for another year if symptoms recur after stopping the medication. I feel more comfortable, and many of the parents who I talk to feel more comfortable, with that strategy.

I should add: this is why organizations like BBRF are so important. It's very important that we continue to do more research, particularly on the long-term safety of these medicines so that we can be more definitive.

I want our readers to understand: you've dedicated your career to research. With what we currently know, we can help a lot of people, but we still need to learn more.

Yes. One other really important thing to note is that there's a very strong relation between having anxiety in childhood and developing depression in adolescence and adulthood.

Although it is the most prevalent psychiatric condition, we are quite effective in treating anxiety. We have a much harder time treating major depressive disorder in adolescence or in adulthood. A lot of people, including me, think that it is appropriate to treat childhood anxiety (and use medicine when CBT is not available) because not only do you help children in the short-term, but you might reduce the chance that they're going to develop major depressive disorder years down the road, which will be harder to treat. With major depressive disorder, the options are much fewer and the duration of the remission once we achieve it is not as robust.

It's a very important point you're making. We in the field of psychiatry haven't in the past focused as much on prevention as other fields in medicine. That’s a reflection of where we are with the science. If somebody has high blood pressure or high cholesterol, which we can easily measure, then we treat that to decrease the risk of a heart attack down the road. You're saying that a benefit of treating anxiety with talk therapy, or medicine, or both, is not only helping the child in the here and now, but it also potentially decreases the risk of developing depression down the road.

That's exactly right. Your point about prevention is absolutely right. By treating anxiety not only are you potentially inoculating that child against later risk for depression, but you are also making a big difference in the immediate life of that child.

You mentioned at the beginning that anxiety is very common. One out of 10 kids has anxiety in any given moment in time.

If we follow kids over time, I think it's probably double that, at least.

Has the rate increased over time?

That's a tough question to answer because a lot of things can change the rate. For example, efforts from BBRF and other organizations have helped the public fear psychiatric problems less, thus reducing stigma—so people are more willing to talk about problems, including anxiety. That could in some ways artificially inflate the rates of anxiety disorders. There was concern that some subtle upticks we saw maybe 15 or 20 years ago might have been related to that. The data that we have now, though, suggests that there probably has been a genuine increase in anxiety in the years immediately before the pandemic, and quite clearly during the pandemic. It's pretty clear even among relatively conservative scientists, like me, that the problem is worse now than it was definitely 10, but probably even 5 years ago.

I don't know that I would go as far as to call it an “epidemic,” because the rate of increase hasn't been that profound. But some experts do say that. People like the Surgeon General or other important, prominent spokespeople for the health of the nation do talk about anxiety in that way, and I think that reflects agreement among many people who follow the research on this that the problem has gotten worse.

Obviously, COVID would be a clear- cut reason for the increase in kids having anxiety. Are there other potential causes for the problem becoming worse? To what extent does social media play into this?

Pretty much all mental illnesses are caused by many things, all interacting in complicated webs. That's clearly the case with anxiety.

Some problems like attention deficit disorder (ADD), ADHD, schizophrenia, and autism have a more prominent genetic component, even though they have an environmental component as well. We know this from research. Other problems like anxiety have a more prominent environmental component than a genetic component. The most potent thing we see in the environment is stress. Anxiety can manifest in children who are exposed to stress from just about anything. Stress that involves social things is particularly harmful, such as being bullied or absorbing the stress of family members. We think when parents are struggling or dealing with their own mental health issues, that stress contributes to a child’s anxiety. Hard economic times also creates stress for the child.

The issue of social media is a very interesting one. It's pretty clear that there is an association “cross- sectionally,” meaning that if we look at kids who are struggling the most, they tend to use social media the most. However, longitudinal research— research that tracks people over longer periods of time—suggests that not much of that is likely causative.

It's more likely that kids who are suffering seek out certain kinds of social media as opposed to kids who use social media and don't have problems. Some of those kids may get worse, but that's probably relatively rare. Still: social media is becoming such a ubiquitous part of life for children that it has become a major conduit for stress. Without question, the availability of social media has made it possible for children to be bullied in unique ways. We know that bullying is a big factor and risk for anxiety and mood disorders. I don't think it's social media per se, as much as all the things going on in society right now that are contributing to different kinds of stress.

Years ago, if we were bullied, it would be in the schoolyard and then you'd go home and you'd be safe and sound, whereas now if you're bullied, it continues when you get home on social media.

Absolutely.

If a teacher is aware that bullying is taking place, that would be a reason to think that the child who's been bullied might be at a higher risk of anxiety.

Absolutely. Teachers are in a difficult position because on the one hand, they're on the front lines, so they see a lot of things that other people don’t. On the other hand, teachers really need to involve the parents. I work a lot with schools, and not all parents necessarily think that mental health issues are the purview of the school. There arises the question of how to handle that in a delicate way, where, on the one hand, you are entirely working through the parents, and on the other hand, you're handling it when parents might not want to hear about it. That can be a difficult situation, and it's a place where I think having mental health experts within the school who understand mental health concerns can be really helpful.

What's the best approach for a teacher to engage the family in helping their child?

A place to start is to describe the behaviors that you're seeing and to see if you can get parents to the point where they can acknowledge that it's a problem and they want to get involved. That's usually the best first thing to do. The second thing you want to do is adjust your discussions based on the comfort level of the parent. Some parents will immediately want to hear about what can be done. Usually the pediatrician is the first place to go, and it's particularly helpful when there's some understanding of pediatricians one can take such problems to.

But not every parent can hear that, so in that situation, teachers can guide parents to someone within the school to speak with. Ideally that would be the guidance counselor. Wonderful guidance counselors are able to have those conversations with teachers and parents, and sometimes they have a little more experience with these situations. A teacher has to keep trying all different kinds of things, working with the principal and other resources at the school to try to get a parent to at least have an open ear. Eventually where you want to get to is the pediatrician.

What advice do you have for parents who have been approached by a teacher? What should they be listening for?

One big thing is to think about impairment. Ask the teacher about the signs of impairment and the activities that their child can't do. Secondly, you should figure out if this is a change. When a child has been having a problem for a while, it's more likely to be an indicator of a significant mental health issue. If it's a new problem, that’s less likely. In that instance, something has typically changed in the child’s environment. Teachers often have a sense of this. Has the friendship dynamic changed? Is the academic material more difficult? Is there something else about the activities in which a child is engaging? As a parent, you want to look for those clues, and you want to get to a place where you can discuss them with your child. A child just knowing that somebody's paying attention and removing some of those immediate stressors can significantly reduce anxiety.

The child knows people are aware of their problem, care about them, and are intervening. I think that in itself makes a very big difference for the child. They're not alone anymore. Having that conversation is helpful in its own right.

Absolutely. That's why I personally think, and not all schools agree with this, having conversations about mental health within schools can be a good thing because it shows that this is a common problem that many people face at different times in their life, and it's good to talk about it. But not everybody feels that way, and we need to recognize that.

Written By Peter Tarr, Ph.D.

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