Kids' Wellness Matters Podcast Ep. 8: Helping Kids Navigate Anxiety Disorder

February 23, 2024

Anxiety disorders are on the rise in children and teens, but there are resources and evidence-based treatments to help kids who are struggling lead productive, happy lives. In this episode, two Lurie Children’s experts, child and adolescent psychologist John Parkhurst, PhD, and clinical social worker Mallory Hilliard, LCSW, CADC, explain the signs, symptoms and causes of the anxiety disorders. They explain how family support and potential interventions, including therapy and medication, can manage the disorder and help kids thrive.

“How we handle stressors is probably how our child is going to manage stressors. And if we start to see challenges with our children in managing stress or anxiety in the face of a stressor, like starting school or talking with people, we need to think about how we respond to it and be calm and consistent.”

- John Parkhurst, PhD

Show Notes

Alfieri and Sanchez both treat anxiety disorders as primary care pediatricians and say while the condition is impacting more children than in the past, they often see transformations in the health and wellbeing of kids after timely and appropriate treatment interventions.
Guests Parkhurst and Hilliard are experts in treating anxiety disorders within their positions in the Pritzker Department of Psychiatry and Behavioral Health at Lurie Children's Hospital. Their expertise includes child and adolescent psychology and outpatient psychiatric services, including coordination of care programs focused on mood, anxiety, and ADHD.
Hilliard says the mental health crisis impacting children and teens was accentuated by the COVID-19 pandemic, but that the demand for children's therapy services had increased before the pandemic. Parkhurst adds that the pandemic heightened the severity of mental health challenges, with social isolation and disrupted routines intensifying existing problems. Both say the current mental health situation in children is a crisis that demands attention and action.
The experts explain the early signs and diagnosis of anxiety disorders, onset ages, and symptoms, emphasizing the importance of early identification and tailored interventions. They explain the difference between normal stress responses and more severe anxiety that impacts daily functioning.
Some reasons for a rise in the number of children seeking care for anxiety disorders is the decrease in social stigma around gettin mental health care. The experts point to social media and other external stressors in the lives of children and teens that can exacerbate feelings of isolation and inadequacy. Normalizing mental health discussions and seeking support is key to helping children manage these feelings, they say..
The genetic and environmental aspects of anxiety disorders are explored as well as the impact of family dynamics. Supportive, informed parental responses to children's anxiety, advocating for interventions that address both individual symptoms and broader family patterns can be essential to the holistic care of a young patient.
Parkhurst and Hilliard discuss treatment options for anxiety disorders, including cognitive-behavioral therapy (CBT) and medication. They emphasize CBT's efficacy, outlining its principles and recommend 12 weeks of CBT before trying medication.
Parents play a critical role in their child’s treatment, and can support them by fostering a healthy environment, promoting bravery and independence and not dismissing children's feelings of anxiety.

Transcript

[00:00:00] Nina Alfieri, MD: Welcome to Kids’ Wellness Matters. I'm Nina Alfieri, MD.

[00:00:07] Rob Sanchez, MD: And I'm Rob Sanchez, MD. We are both parents and pediatricians at the world renowned Ann and Robert H. Lurie Children's Hospital of Chicago.

[00:00:15] Nina Alfieri, MD: On this show, we'll chat with a wide range of experts about caring for children from newborn to young adult. Because Kids’ Wellness Matters.

[00:00:29] Rob Sanchez, MD: In today's episode, we hope to give some context to recent news headlines and research about the rise of anxiety disorders in children and teens, and we'll share some evidence-based treatments that are proven to be effective in helping kids lead productive, happy lives.

[00:00:42] Nina Alfieri, MD: I love treating anxiety in clinic because it's one of those things where, first of all, you get to know your patients so deeply. But second of all, there's great treatments for it. And with the right treatment, you can really see people's lives turn around.

[00:00:55] Rob Sanchez, MD: I know exactly what you mean. Anxiety can be something that's part of our regular lives, stressful situations, you know, having healthy responses but then really identifying ways where, hey, maybe this is a little bit more of a difficulty and how we can be supportive and, guiding folks families through that is something that I really, enjoy getting the chance to do.

[00:01:16] Nina Alfieri, MD: Yeah, absolutely. And I think so many more people struggle with anxiety than we even know. It's so common. Since we have so many great treatments for it, getting started early and helping kids learn coping mechanisms can really set kids up for a lifetime of success and resilience. And as they're growing up and the world seems harder, they're already equipped with all of these tools. to face the world. And I just, I so admire the bravery of kids and their parents for coming forward and walking that journey with us.

[00:01:46] Rob Sanchez, MD: I was able to have a great conversation,with some members of the Lurie Children's Department of Psychiatry about what things parents should be watching out for, when to seek help, and also to learn about things that they can do in their own homes to, talk about this topic and to work with their children to lead healthy and successful lives as they cope with things like anxiety and stress.

[00:02:05] Nina Alfieri, MD: It's such an important conversation and I'm really looking forward to learning from your discussion today.

[00:02:10] Rob Sanchez, MD: My guests are child and adolescent psychologist Dr. John Parkhurst and clinical social worker Mallory Hilliard. They are experts on anxiety disorders, and they're going to share some insights on what anxiety really means and what parents can do to help their kids who might be going through a hard time. Dr. Parkhurst and Mallory both work within the Pritzker Department of Psychiatry and Behavioral Health here at Ann and Robert H. Lurie Children's Hospital of Chicago. Dr. Parkhurst also coordinates our Mood, Anxiety, ADHD Collaborative Care Program, and Mallory is our Director of Outpatient Psychiatry Services. Welcome to you both.

[00:02:46] Mallory Hilliard, LCSW, CADC: Thanks for having us, Rob.

[00:02:48] John Parkhurst, PhD: Thank you.

[00:02:48] Rob Sanchez, MD: So start off by telling me a little bit about the work that you do. What population do you work with, and what types of diagnoses and level of acuity are you accustomed to dealing with?

[00:02:58] Mallory Hilliard, LCSW, CADC: So, I typically see teenagers, school aged kids, who are coming in a pretty acute crisis state. They're either seen in our emergency department or on our consult team and really, really struggling with an acute presentation, a lot of kids expressing suicidal ideation, a lot of anxiety that's gotten so bad that they're avoiding activities like school or seeing friends and trying to treat that in as short term as possible, which we know is not always the case with anxiety. And then at the outpatient department in general, we're seeing kids as young as two all the way up until the age of 18. And we're seeing kids for just about everything, a lot of ADHD, a lot of anxiety, a lot of depression. We're doing individual therapy services, group therapy services, and medication management.

[00:03:45] John Parkhurst, PhD: And my role with the department is really about outreach. It's really about working with primary care providers to make sure that the work that we're doing, both in the hospital and more acute settings, is really built as a downstream system so that we're capturing kids or identifying kids with mental health concerns as early as possible, so we can provide treatment before they ever have to show up to a psychiatry department. Oftentimes they're treating concerns like anxiety, ADHD, depression, pretty common presentations that might be more amenable to treatment in primary care.

[00:04:16] Rob Sanchez, MD: You know, we hear the term mental health crisis used in the media and amongst our colleagues. Do you think it's fair to label the current state as a mental health crisis for kids?

[00:04:25] Mallory Hilliard, LCSW, CADC: I think it's absolutely fair to label it that. I think that this was a long time coming, that, even before COVID, we were seeing just an increased demand for therapy services for children and adolescents. And that's a very niche and specific population to work with. And so, I think that when a lot of mental health agencies were closing or were underfunded and we saw this huge spike in need for psychiatric care and behavioral health care for children and adolescents, it really sent everything into a crisis state. But I also think that labeling it a crisis helps really highlight how significant this problem is. It's really helping draw more attention to the need for mental health care for children and adolescents. I think that it's really highlighting just where we need to continue to expand access to care and access to services.

[00:05:17] John Parkhurst, PhD: You know, a question I get asked very often is about how COVID had an impact on mental health and youth mental health. And I think the demand and the access to service was already a challenge prior to COVID. But I think what COVID did is increase potentially the level of acuity and the stress that families and children are under. Thinking about less social interaction, reduced structures, all of those things that can certainly impact and exacerbate existing mental health concerns. And so it just added stress and pressure to the system, I think, increased the acuity of the children presenting to us.

[00:05:55] Rob Sanchez, MD: Is that reflected to what you're seeing in clinic in terms of when children do present, is that acuity significantly higher in recent years?

[00:06:02] Mallory Hilliard, LCSW, CADC: I think that just at the level of stress and not even with COVID, right, but with everything else that's going on around the world, around the lives of the young people that we're seeing, it's just incredibly, incredibly stressful. And so it's raising the acuity of what we're seeing in our emergency department or when families are calling our intake line to try to get scheduled for an appointment. Not to say that there wasn't this level of acuity before, but I think it's more of the volume of kids coming in and families coming in in this acute crisis state that's really, really spiked in the past few years.

[00:06:36] Rob Sanchez, MD: Can you explain a little bit more about what is meant by mental health crisis and where exactly do anxiety disorders fit into that definition?

[00:06:44] John Parkhurst, PhD: So anxiety disorders are the most commonly presenting mental health concern. And what's, I think, unique about anxiety disorders is that they are more likely to be identified earlier than other mental health concerns. So if you think about separation anxiety and generalized anxiety, especially separation anxiety, you're starting to identify that more commonly around like five, six, seven, eight, with specific phobias, and then generalized anxiety, somewhere between like eight to ten is common presentations. Anxiety is unique because it is something that I think everybody experiences to some degree, but not everybody experiences to the level of acuity or the functional impact is the word that we would use. It's like, how much is this anxiety getting in the way? And is it above and beyond what is expected given the stressor that the child or family is faced with?

[00:07:31] Mallory Hilliard, LCSW, CADC: I mean, I'm not gonna lie, guys. I was a little anxious being asked to do this because public speaking sometimes makes me feel nervous, right? But, I had to identify, like, okay, what am I thinking about? Am I having imposter syndrome right now? And really just saying, okay, this could be a normal response and a normal reaction to something that can feel very anxiety provoking. And then I did my little power pose and everything was fine. But, to John's point, that there are absolutely expected things that are going to make us feel anxious. Expected things that we're also going to have a fear or an aversion to, right, like, don't draw my blood at my PCP's office. I will get upset and anxious. But I also am not avoiding that task.If I was so anxious that I was avoiding going to the doctor, or avoiding getting my labs drawn, or avoiding any sort of medical care, that's when it's becoming problematic. And what we're seeing in children and adolescents is that there is a lot of that avoidance piece, where they get stuck in this cycle, where they're avoiding the situation that is causing this level of anxiety and it's to the point where they might be failing school or they might have no friends. It might be increasing their chances to develop more depressive symptoms as a result of all of this. Developing suicidal ideation, developing panic attacks. So that's kind of also how we're differentiating what might be an expected reaction to something that is unpleasant or fearful versus in an anxiety disorder when we're seeing that increased level of acuity and crisis where it's really just disrupting and impairing the lives of the young people and the fate of their families as well.

[00:09:04] Rob Sanchez, MD: So often you see conflation of depression and anxiety and while adjacent under mental health disorders, they are different conditions. Can you define for us what anxiety is and how it differs from depression?

[00:09:17] John Parkhurst, PhD: Sure. Anxiety and depression are, the word we use in medicine is comorbid, but what this really means is often co-occurring. So disorders may present together, but I think what Mal was also highlighting earlier is that untreated anxiety can also be a risk factor for developing an oppressive disorder or substance use disorder, or having an impact on people downstream in their ability for educational attainment and employment. I think that's why we think about anxiety disorders, as maybe being a place that we can often start and identify challenges. And so to define the answer to your question a little bit more clearly, you know, depression, my way of thinking about it is when people have lost the spark. But really it means, somebody who has a depressed mood and less interest in the activities they typically would be able to engage in or want to engage in, and then they stop doing those things. They stop actively pushing. Anxiety disorder is more like an overt stress response sometimes with physical symptoms, sometimes without, but a pervasive worry or response to a stressor that results in some level of avoidance, similar to the functional impact that we described.

[00:10:23] Rob Sanchez, MD: Do you think that the rise in numbers of kids being diagnosed with anxiety can partially be attributed to the fact that, societally, we're more comfortable talking about mental health these days? Is there less of a stigma around seeking mental health services, so the diagnoses may be going up as a result?

[00:10:39] Mallory Hilliard, LCSW, CADC: I think so. I think that normalizing mental health as a health related concern has really helped us talk more as a society and talk with young people and saying that your fear response might be a little bit disproportionate to the thing that's triggering that. However, anxiety is very common. Depression is very common. And I think once we frame it that way, then it helps people buy into treatment a little bit more because I think that that stigma of, Oh, now I have to go to therapy, right? Or I have to take meds for this, is removed where we're just absolutely normalizing it. And I think that it's also helpful that schools, pediatrician offices, they're incorporating a lot of work and discussion around mental health so that it doesn't feel as isolating because that's what depression and anxiety is also going to do to somebody, right? Make them feel isolated like they're the only one with this problem. They're the only one with this thought pattern. It's just not necessarily true.

[00:11:34] Rob Sanchez, MD: Absolutely. Can you speak to what are the different types of anxieties that someone can be diagnosed with? And, any tips or notes that you might have about how to recognize those are things that you might see in your clinic.

[00:11:46] John Parkhurst, PhD: Early ages, 4, 5, 6, I'm starting to look for separation anxiety, outsized fear of being apart from a caregiver, having a hard time transitioning to new environments. 6, 7, I'm looking for specific phobias, an outsider's reaction to a specific stressor, that can oftentimes present with a lot of physical symptoms like stomach ache, headache, tension you know, outsized response. Generalized anxiety, presenting a little bit more from that 8, 9, 10. These are our worry warts, kids that are often worried about specific safety or disappointing others or being perfect. Presenting after that, and we aren't really talking about obsessive compulsive disorder, but people have previously put obsessive compulsive disorder on the same spectrum of anxiety disorders. And so OCD or obsessive compulsive disorders, also often presenting around that 10 age frame. So just something to think about in relation to, and is pretty highly co occurring with other anxiety disorders. So something to think about, but not necessarily an anxiety disorder uh, as we define it now. But back on to the anxiety disorders, that 11, 12, 13 middle school time period is where you're more often to diagnose social anxiety. So this is kids that are shy and embarrassed, again, creating a level of functional impact. And people talk about panic disorder. Oftentimes when panic disorder, when you're really diagnosing it as much later into adolescence. So this is like our 17, 18, 19 and maybe early twenties. And what I think people often describe related to anxiety are physical symptoms, and they describe that as panic. And physical symptoms, it's these centerline symptoms or midline symptoms. So stomach aches, tightness in your throat, tightness in your chest, rapid heart rate, tension, headaches, and so you'll often see kids presenting in primary care with physical symptoms, and they might call it panic. Oftentimes that's really a thought, a response to a thought, and they've worked themselves up into this. And so I kind of think about it: is it panic from the bottom up or is it panic from the top down? Panic from the top down is usually starting with a specific thought and then churning. So like, I've got a test tomorrow, and then you build yourself up into physical symptoms. And panic, like true blue panic, is often starting from the bottom up, where it's really starting with like a physical reaction, and it kind of comes out of nowhere. And as I was indicating, usually happens later in adolescence, so you're less likely to see that with kids.

[00:14:02] Rob Sanchez, MD: sometimes these things can be more prevalent in certain families and that can lead to questions about, you know, genetic components. Do we know if there is a genetic component to anxiety?

[00:14:11] John Parkhurst, PhD: You brought up an important point here is that we've got genetics and then we've got the environment. And probably both have some level of equal impact. So in terms of anxiety disorders, as far as heritability from a first degree relative, it's somewhere between 30 to 50 percent heritable. It's hard to define specific anxiety disorders for heritability. I think in terms of the environmental element, it's really important to consider because if you've got an anxious parent, they might respond to anxiety that a child is presenting in a way that is maladaptive or at least not productive. So if we've got a parent who's anxious about that child's first day of school, they might be more likely to pull them back. And then it becomes this cycle of behavior that's not gonna help them progress developmentally. And so oftentimes we're working with the families to make sure that their environment is not necessarily maintaining behaviors that aren't going to be productive and can actually start working against the presentation of anxiety.

[00:15:05] Mallory Hilliard, LCSW, CADC: Yeah, I agree. I think that a lot of the work we're doing. Yes, it is with the child or the adolescent, but it's also with the family too, right? We're working to provide that education and help them be aware of their own distress levels and anxieties. If we look at it from that approach of, you know, this is a group effort that again sets everybody up for a lot more success when it comes to treating anxiety disorders.

[00:15:29] Rob Sanchez, MD: You know, we spoke to the genetic component. We talked about the environmental component. What are some of those key factors that have contributed or caused a rise in anxiety in kids?

[00:15:39] Mallory Hilliard, LCSW, CADC: I think there are a lot of factors in play with this rise in anxiety. I do think that social media has impacted the lives of young people significantly. Some on the positive, some on the negative. I think that there's this anxiety of, well, the anxiety of FOMO, right? Like fear of missing out is real. And when all of your friends are hanging out on Snapchat or Instagram or whatever, the new app of the day is for social media and you're not there, then that might cause a significant level of anxiety and distress thinking, well, why don't they want to hang out with me? Like, my friends don't like me and it causes them this cycle of thoughts that are influencing the severity of the feeling. And they might act in a way that's maladaptive and unhelpful to that stress that could have been managed a little bit better. So I think that that's part of it. I get a lot of questions too from families about how much should I let my kid watch the news or teach them about some of these really impactful social situations that are scary. And having those conversations as well about, you know, we don't want to hide everybody from what's happening around us, but how can we also instill that feeling of safety and that I can manage this even though this is an upsetting feeling. I think that has had a huge impact as well.

[00:16:57] Rob Sanchez, MD: We know that treatment can vary from patient to patient. What can parents expect if intervention is necessary for their child who may have that diagnosis of an anxiety disorder?

[00:17:08] John Parkhurst, PhD: Anxiety disorders are pretty treatable. We've seen good success with cognitive behavioral therapy. Cognitive behavioral therapy for kids really is an active approach, and you're working with a therapist more like a coach. So think about this as a parent and child being involved initially in the goal settings, and making sure that they have a plan of what they are trying to do with anxiety. And so for kids with social anxiety, it might be building and starting conversations. For kids with generalized anxiety, it might be trying to reduce worry as related to being perfect with school and meet certain expectations. So setting goals and objectives at the outset is crucial. Then there's a level of education. That is like, what type of anxiety disorder are we experiencing? Could it be multiple types of anxiety that we're talking about? And then it's training the child, more specifically training in cognitive strategies to restructure thoughts and problem solve and understand emotions and how our body plays into or may present with physical symptoms of anxiety. So that cognitive triad of thoughts, feelings, and actions and how they all interplay as related to anxiety. What is hugely important here is that families know that they are still part of this in the sense that they need to understand their impact and how they support their child through anxiety, make sure that they don't continue to engage in patterns that actually might get in the way of the child getting better at anxiety. Probably the most crucial piece of any good cognitive behavioral therapy... Mal spoke about this earlier, but ultimately this comes down to being able to face our fears. So if we're not working to helping a child and family do the thing that makes them anxious, and then, change how their brain has been operating about, oh, this thing that I thought was super scary is actually not that bad so that they can start living an active and engaged life so that anxiety is not getting in the way or impairing or stopping them from being a kid.

[00:18:56] Mallory Hilliard, LCSW, CADC: I would add, the typical approach that we take is trying therapy first and cognitive behavioral therapy first for anxiety disorders. While we also recognize that there are children that are going to benefit from medication in addition to cognitive behavioral therapy. And this is where the selective serotonin reuptake inhibitors have value. and we have some good evidence that our treatments work and can get kids better to about a 70% likelihood that we can improve anxiety to remission. I like to explain to parents when they ask what's better starting on a medication or therapy. And I let them know that we're going to try therapy first. But Medication also has a lot of benefits, and I like to explain it that it's the glue that's going to help these concepts that we're talking about in therapy and that you're practicing outside of my office it's going to help them stick just a lot more efficiently and effectively than perhaps just with therapy or just with medication alone.

[00:19:44] Rob Sanchez, MD: You know, parents might ask, when is medication indicated, what can they anticipate in terms of a timeframe or in terms of level of acuity?

[00:19:52] John Parkhurst, PhD: Oftentimes families have preferences as related to, like, there's a family history of anxiety that's pretty strong and or a parent might have been treated with medication and they have less aversion to the idea of medication. I think our best guess right now is with therapy, if we did therapy alone for our kids with anxiety disorders, that we need about 12 weeks, 12 weeks to really feel like you've got a sense of whether we're going to get some impact here, whether we're tracking. And we should be tracking it, right? We should be monitoring the progress on objective measures of anxiety, and the family should feel like the anxiety is improving, there's less avoidance, and if we're not seeing much improvement after that time, and yet we, still feel anxiety is really impairing, it's certainly a choice that families have to consider a medication that might supplement or support or be a little bit of that glue that can help elevate our ability to engage in cognitive behavioral therapy. But oftentimes you're not doing medication alone or in isolation, at least with children, until we've kind of gone through the cognitive behavioral therapy piece because we see it as the lowest possible side effect route of treatment. But, it is true that we still don't know there probably are some children that will. benefit from medication and therapy at the outset of care, depending on the severity and acuity.

[00:21:04] Rob Sanchez, MD: Are there things that can be done at home without professional and medical interventions that parents can work with their children?

[00:21:11] Mallory Hilliard, LCSW, CADC: I mean, I think the one thing I'm constantly explaining to parents and people in general is that when you see somebody who is experiencing anxiety and maybe having a stress response, please don't tell them to calm down or that they have nothing to worry about. That tends to make things worse. But, instinctually that's what people do. And so thinking, okay, what's the language I as a caregiver can be using if I see my kid having a little bit more distress than they typically do, right? Helping them name the feeling with school aged kids. I think it's helpful when parents separate the anxiety piece from their actual kid and almost give the anxiety a persona of its own and say, all right, what's your anxiety telling you to worry about? Is there something else we can be doing? Something that we can help distract from the situation? Something that we just need to let a little bit of time pass? But really helping them understand that even by validating the emotion and helping the young person label what they're feeling in that moment and being present versus dismissive is really going to be helpful in the home environment when trying to tackle anxiety.

[00:22:10] John Parkhurst, PhD: I like that, Mal. The piece that I would add is: You know, as we're working with families, we want to make sure that we have good schedules and healthy schedules and that we're modeling healthy behavior. So for example, we have a reasonable sleep routine for the household. We've got a reasonable eating routine for the household. We've got some time where we get to spend time together. That's quality uninterrupted, non technologically focused time where we get to engage with each other. We need some physical activity. So it's thinking about those core elements of wellness that a family should have and then model. Because that's the other thing that our families do is that how we handle stressors is probably how our child is going to manage stressors. And if we start to see challenges with our children in management of stressors or anxiety in the face of a stressor, like starting school or talking with people, we need to think about how we respond to it and be calm and consistent. We can certainly work on describing language. And then I think setting goals or setting like objectives, the word I always use with families is being brave. It's like, what's something we can do to push towards being brave or something that we can make that as a tenant that we think about. Doing something that's a little bit more independent within reason with structure and scaffolding that we can provide. Because I think that's how we grow strong, independent kids that are less likely to be anxious is good structure, good modeling, and then start to nudge the braveness.

[00:23:30] Rob Sanchez, MD: Well, I certainly want to thank you all today for joining in this important discussion, being brave in your own ways and coming on and sharing this important information with families and parents. Mallory Hilliard, Dr. John Parkhurst, thank you so much for joining us

[00:23:43] Mallory Hilliard, LCSW, CADC: Thank you for having us.

[00:23:44] John Parkhurst, PhD: Thank you very much, Rob.

[00:23:45] Rob Sanchez, MD: Thanks for listening to Kids' Wellness Matters.

[00:23:50] Nina Alfieri, MD: For more information on this episode and all things kids wellness, please visit LurieChildrens.org