I have been a member of the APA for many years, and benefit tremendously from the APA’s publications, research papers, and educational materials, such as the podcast below. Children involved in a divorce do tend to experience worry, anxiety, and some depression, and these symptoms and illnesses are often situational, and not long lasting. Other children can be affected by anxiety disorders that are more chronic, more severe, and require proactive treatment.
Fear and anxiety are part of most normal children’s lives. But how do we know when anxiety is a problem in need of professional help? In this episode, Golda Ginsburg, PhD, talks about how to recognize the signs of an anxiety disorder in your child and what are the most effective, evidence-based treatments.
Golda Ginsburg, PhDGolda Ginsburg, PhD, is a professor of psychiatry at the University of Connecticut Health Center and has been developing treatments for anxious youth for more than 20 years. She led the largest national longitudinal study of anxious youth in the United States to examine the long-term outcomes of anxiety treatments. She is following up with a study of the long-term effect of family-based treatments for the children of anxious parents. Earlier in her career, Ginsburg was a professor of psychiatry at Johns Hopkins University School of Medicine. She received her BA from California State University in Northridge, and her MA and PhD from the University of Vermont.
Audrey Hamilton: Not too long ago, anxiety disorders were considered by many to be a personal weakness rather than a true illness, especially in children. Thankfully, this stigma is on the decline. But, finding appropriate treatments for children isn’t always easy. In this episode, we speak with a psychologist who has been researching the best treatments and assessments for anxiety disorders. She tells us what parents, teachers and anyone who works with kids needs to know. I’m Audrey Hamilton and this is Speaking of Psychology.
Psychologist Golda Ginsburg is a professor of psychiatry at the University of Connecticut Health Center and has been developing treatments for anxious youth for more than 20 years. She led the longest national longitudinal study of anxious youth in the United States to examine the long-term outcomes of anxiety treatments and is now following up with a study to examine the long-term effect of family-based treatments for the children of anxious parents. Welcome, Dr. Ginsburg.
Golda Ginsburg: Hello. Nice to be here.
Audrey Hamilton: I want to start by talking about what an anxiety disorder is. How is it defined? I think a lot of people worry when their child is anxious in certain situations, such as starting in a new school, for example. But, it might be helpful for them to understand the difference between everyday anxiety and anxiety that is a problem in need of professional help. Can you talk about that?
Golda Ginsburg: Absolutely. It’s a great question and one that I hear from parents all the time because anxiety is an emotion that we all experience. And in fact, anxiety can be quite helpful to us. It protects us from dangerous situations. In the school context, it helps us study when we have a test coming up. So anxiety is something we want to make friends with in a way.
But there does come a time when anxiety becomes problematic. The definition, just to go back to your first question, the definition of what an anxiety disorder is, for anyone who wants to look at it, is in the Diagnostic and Statistical Manual that’s published by the American Psychiatric Association. And it’s essentially a list of symptoms that occur and also impair the functioning of children. So that said, there isn’t a blood test that you can get to know whether your child or even an adult has an anxiety disorder.
So we looked at these symptoms and again as I said because anxiety is something we all experience, we can look to what I think are three key symptoms to identify the signs. The first set of symptoms are physiological symptoms. So, somatic complaints. What we know is that children and adults too who struggle with anxiety report headaches and stomachaches where there’s no medical cause. So, that’s one sign that parents can look for as they’re trying to sort out is this anxiety that’s problematic or not.
The second is that we see these children engaged in ways of thinking that if we can get them to articulate what their thoughts are, the themes are full of fear and danger. All the kids are going to laugh at me. I’m going to fail my test. What if my mom or dad dies? So those kinds of thoughts are what we notice and again, another sign the child’s struggling with anxiety.
The third is in their behavior. And the most common and most problematic behavior is avoidance. So as children struggle with anxiety, they begin to avoid what they’re afraid of. So if they’re afraid of taking tests they’ll avoid going to school. If they’re afraid of something terrible happening to their parents, they’ll avoid being away from their parents. They’ll sleep with them. So avoidance is a big behavior to look for.
So those are the three signs that parents can pay attention to. That said, we might all if we’re, say, afraid of flying, we might worry the plane’s going to crash or we might start to feel butterflies in our stomach as we’re going. But, it doesn’t really impair our functioning. We take the plane anyway. So when we start to see children’s lives being impaired by these symptoms, that’s when it begins to cross over that line to being helpful and adaptive to being harmful and something that warrants further evaluation and perhaps treatment.
Audrey Hamilton: Now anxiety symptoms aren’t always the same in all children, correct? For example, what do we know about how anxiety manifests itself in girls versus boys? What accounts for those differences?
Golda Ginsburg: Yes. So there are – so if you go to the Diagnostic and Statistical Manual there are several kinds of anxiety disorders, if you will. And really, the differences have to do with what the children are afraid of. And we do see some patterns across development. So younger children will more likely be afraid of separation from their parents, whereas older adolescents or older children and into adolescents will have more social anxiety. And in some ways, this could be a reflection of typical developmental fears that go awry.
So as teenagers develop a consciousness about what their peers think about them – typical – a child struggling with anxiety will blow those fears out of proportion to the situation. And then that anxiety begins to impair their functioning.
When we look at girls versus boys, once a child has an anxiety disorder, we don’t see many differences between boys and girls. Prior, what we call subclinical, we see more girls expressing fears in general than boys. Not sure we know the reasons. Some suggest it’s hormonal or biological. Some suggest that it’s social in the way that girls are raised. When we look at the relationship between femininity, for instance, in anxiety we know there’s a positive or correlation. So, it’s probably a combination of the two.
Audrey Hamilton: Now, your research focuses on anxiety treatments. Now as a parent, I imagine it’s very difficult to decide what the appropriate treatment for my own child is, but your research suggests there are some best practices overall using evidence-based treatments, such as cognitive behavioral therapy and medications. What has your research found on that?
Golda Ginsburg: We conducted the largest – what’s called a comparative clinical – trial. So, comparing different treatments to see which one is the best. And in the largest trial that we did, which is 488 children were involved and adolescents were involved in the study, we compared Sarafem, which is an SSRi, selective serotonin reuptake inhibitor to cognitive behavioral therapy, which is a talk therapy, which teaches children specific skills to how to manage and reduce their anxiety, in which exposure or facing your fears a key component to that treatment. And the combination of the two to a pill placebo, so a fake inert pill.
And what we found, after 12 weeks, was that the children who received the combination treatment did the best. So about 80 percent of those children were what we called “responders” meaning that they showed clinically meaningful improvement in their anxiety symptoms and in their functioning. Both cognitive behavioral therapy and medicine alone were more effective than the inert pill. But there was no difference between the two of those monotherapies.
Audrey Hamilton: So one wasn’t better than the other?
Golda Ginsburg: One was not better than the other.
So, as a parent struggles with what treatment is best for their child, they have choices and depending on their own preferences and their child’s and the severity of their child’s anxiety, they might pick one of those three.
Audrey Hamilton: I know for some parents, giving medication is something they’re reluctant to do to their child. But, what I’m curious, I think a lot of it is they wonder whether my child will be on this medication forever. Is an anxiety disorder typically a long-term problem? Can someone grow out of it, for example, or will they always need to monitor it and seek treatment so if medication is part of the treatment, you know, is it riskier to give drugs to children than to adults?
Golda Ginsburg: Yeah, terrific questions. I’m not sure we have all of the answers. So, let me start with, is it risky? We have no long-term data on the impact or negative consequences of medication for anxiety. We just don’t know. We are completing a study right now looking at this and I know my colleagues at other universities are doing the same thing. Because it’s data that’s essential. We don’t have it yet.
That said, the study that we’re completing right now, which actually follows children up to nine to ten years after they were initially enrolled in a treatment study for anxiety suggests that a good proportion of these children continue to struggle with anxiety.
Thirty percent are chronically ill over time and we need better treatments for that group. About half of them, half of these children are relapsing, so they get better but then they get worse. And then they get better and then get worse. So, we need better ways to monitor and understand why they might get worse over time, but then rebound.
And then about 20 to 25 percent get well and stay well. So, I think the bottom line is it is a chronic illness. It is also possible that a good proportion get better and stay better, but that we need a better system of monitoring and like we do in dentistry, for instance, we have annual check-ups, or my insurance plan lets me go every six months. So I think we need to think about mental health using a different model. Something akin to what we do for other illnesses. Well-baby checks or dentistry so that we can catch children prior to them relapsing.
Audrey Hamilton: Now, anxiety is the most common psychiatric disorder among young people, even more than ADHD and depression. Do we know why it is so common? Is it more prevalent in more recent generations and if so, why?
Golda Ginsburg: I’m not sure why it’s so common. I think there’s certainly a lot to worry about today, but I think there are some studies that show it is more prevalent today. It’s hard to tease apart whether that’s because the methods and the tools we have to identify children are better. And so we’re just doing a better job or whether actually the prevalence has been increasing over time. I think it’s hard to know.