Bright Nights Community Forum: Identification and Treatment of Anxiety Disorders in Children and Adolescents

Thu, 01/09/2014 - 11:56am

When: September 24, 2013 at Multi-Purpose Room

Anxiety disorders can be disabling and are surprisingly common, affecting up to 30% of all youth. While transient fears and anxieties are a normal part of child and adolescent development, if the anxiety causes excessive distress, leads to avoidance, and/or interferes with school performance, activities, or relationships, this could be an indication of an anxiety disorder. The good news is that effective treatments are available. Learn more about anxiety disorders in youth and adolescents, including the latest treatment options, at this forum featuring Kate Fitzgerald, MD, Assistant Professor in the U-M Department of Psychiatry, co-director of the Pediatric Anxiety and Tic Disorders Clinic, and a U-M Depression Center faculty member. Dr. Fitzgerald's presentation will be followed by questions from the audience and a discussion with expert panelists, including Depression Center faculty members Joseph Himle, PhD, MSW and Elizabeth Koschmann, PhD, along with Karen Nicholson-Muth, LMSW, a private practice clinician in Ann Arbor. This event is cosponsored by the U-M Depression Center. For more information on the Center, visit the Depression Center website at www.depressioncenter.org, or contact Trish Meyer, 763-7495, or meyerpa@umich.edu.

Transcript

[00:00:00.00]
[00:00:25.46] SPEAKER: Good evening, and welcome to the library. I'm [? Jenny Iad ?] from the community relations and marketing department at the Ann Arbor District Library. Before we get started, I just have a couple of quick reminders. There's some evaluations scattered around the room. They're yellow, white, in large sheet, small sheets.
[00:00:43.77] One is for the library. One is for the Depression Center. If before you leave this evening, if you would please fill those out, and just leave them on the back table. We'll sort through them. But it gives us a lot of good information about topics you may want to hear in the future, what's the best way to-- what advertising reaches you the best. If you'd let us know those things, we'd appreciate that.
[00:01:07.89] As you think of questions this evening while we're having our presentation, there's three by five cards around the room also. If you would write your question down, Andrew from the Depression Center and I will be walking around the room. Just hold your card up, and we'll come get it, and we'll bring it to our presenter for the evening, and she'll address your question to the panelists. We get through a lot more questions this way. We get a lot more information answered and have a lot more discussion.
[00:01:40.28] We are filming the event this evening, too. This program will be available on the library website aadl.org as a video on demand in about three weeks. If you go to the Event section of our website, you'll find all the Bright Nights forums.
[00:01:57.64] And if you have a cell phone, this is a good time to silence it. Tonight's program is a Bright Nights Community forum cosponsored by the University of Michigan Depression Center. There are four forums held at this location throughout the school year, all addressing topics relating to depression. For more information, you can visit the Depression Center website at depressioncenter.org.
[00:02:23.58] Tonight's forum will be moderated by Dr. Kate Fitzgerald, assistant professor U of M department of psychiatry, co-director of the Pediatric Anxiety and Tic Disorders Clinic, and faculty member of the Depression Center. She'll begin with an overview of the topic, and then the panelists will join her on stage, and then we'll bring in the questions, and we'll have a discussion. I'd like to thank all the panelists for joining us this evening, as well as all of you. And please help me welcome Dr. Fitzgerald.
[00:03:00.52] DR. KATE FITZGERALD: Thank you very much. It's great to be here. And I guess just as a lead off, I want to mention right off the bat how common anxiety is but how treatable, and that's going to be the main message of my presentation.
[00:03:17.36] Generally, four goals for tonight. The first is how do you differentiate normal anxiety-- because everybody feels anxious from time to time-- from disorder? Diagnosing anxiety disorders in youth, or what can we really think anxiety will look like in kids?
[00:03:33.76] And then, what is the treatment? Can my child be helped? What's the prognosis? Will my child always have these problems? And then just touching a little bit on, what made my child ill?
[00:03:46.71] So going back to the first one, differentiating normal anxiety from disorder, that is, could my child be ill? And to start with, anxiety serves a purpose. It's not always a bad thing. I mean, we have anxiety for a reason.
[00:04:02.71] And as you can see here, this guy back in the day-- the caveman-- it's the fight or flight response. When there's danger, you should have your heart rev up. You should be more alert. We may not have dinosaurs or bears chasing after us much nowadays, but there are situations.
[00:04:20.94] Crossing a busy street, your heart should go up. You should open your eyes a little bit. You don't want to get run over. And even aside from those rare instances where fight or flight is appropriate, there's also more common everyday occurrences with lower grade anxiety where anxiety can be helpful.
[00:04:38.90] So you see here two examples. Here's a girl studying for a test. Having a little bit of anxiety, just means you care. It makes you want to work a little bit harder, so you can do well. Maybe a little bit of anxiety about that piano recital, that's what's helping you to really practice hard, so you can learn it and do well.
[00:04:59.99] But when does this normal-- even sometimes helpful-- anxiety become a disorder? And that happens when the anxiety is intense-- so really excessive-- out of proportion to the situation, frequent-- it's happening all the time-- distressing, of course, difficult to control. So no longer is it helping you and you're using it to do better, it's really getting in your way.
[00:05:26.08] And getting in your way can take different shapes and forms, but very commonly with anxiety, getting in your way means avoidance. So the anxiety isn't driving me to study harder. It isn't driving me to practice piano. Rather, I don't even want to touch a book. Maybe I don't even want to go to school. You're avoiding whatever the trigger is, the thing that makes you feel a little bit nervous.
[00:05:50.88] And you can imagine if a child has anxiety across the different stages of development, there are a number of possible consequences. So here you see little preschoolers gathered around the sand table. Well, if you're too anxious to separate from your mom, anxiety here can get in the way of just developing those very early social skills. How do I share? A little bit older, can get in the way of developing friendships, can certainly get in the way of developing extracurricular, fun activities that you enjoy, can get in the way of school, and with family life. So many areas of development where too much of anxiety can interfere.
[00:06:35.22] I started off by mentioning how common anxiety is. It's really shocking. There have been large epidemiologic studies now-- so looking at 10,000 children and adolescents-- that have shown that as many as one in three 8 to 17-year-olds will have an anxiety disorder by the time they reach adolescence. So it's the most common psychiatric illness of childhood, the common cold of pediatric psychiatry, if you will.
[00:07:04.77] And in adults, if you're looking from there and looking backwards, you find that the median onset of adult anxiety was 11. So that tells us that most anxiety does begin young, and it can persist.
[00:07:23.10] So, in addition to anxiety being common and predicting more anxiety or increasing risk for anxiety, we also know that early onset anxiety predicts depression. So, not everybody who's anxious will get depressed, but it is a risk factor.
[00:07:39.27] And then as you can imagine, having anxiety and or depression increases risk for many areas that have functional consequences in life, such as school failure, dropout, substance use and abuse, relational deficits, whether it's with friends, peers, family members, teachers, employment certainly. It's hard to get a job if you're too socially anxious to get out there and go for an interview. And then in rare cases, suicide, thinking more about when it bleeds over into depression.
[00:08:11.50] So all of this taken together is telling us what? We need to intervene early. And so that brings me to the next bullet point in my talk, which is, how do you even know if you need to intervene? What does anxiety look like in kids?
[00:08:27.13] So for this, I've just made a few little case studies where you can see what different types of anxiety might present. So here, this is a specific kind of anxiety called separation anxiety, and this tends to be the anxiety disorder that has the youngest age of onset. So here, we have nine-year-old Sally, and she refused to go to school after Thanksgiving break. So, very common after Thanksgiving break, when there's been some break from school, this is when separation anxiety really rears its head. It's hard to go back. I've been home for a while.
[00:09:02.71] So now Sally's staying awake almost all of night worrying about going to school. Before school, she cries and screams that she cannot go. Sometimes these kids will really pull out all the stops, tantrum. And part of it, it's they're upset, but part of it is that works. If you really have a tantrum, mom and dad might agree to let you stay home.
[00:09:22.93] She's complaining of headaches, stomach aches, and vomiting, so with separation anxiety, very common physical symptoms. And certainly if a parent sees, oh my gosh, you vomited, you must be sick, it will make them more likely to do exactly what the kid wants them to do, to avoid having to go to school. But in the long run-- and we'll talk about that-- avoiding is probably just going to make that anxiety that much stronger.
[00:09:46.68] Interestingly, case in point, if she attends school, she's less anxious until bed time. So she gets there, she gets over the hump, and she's maybe a little bit distracted, and maybe even having fun with her peers and what she's learning.
[00:10:02.04] Social anxiety is another very common type of anxiety. And it's particularly in adolescence, so a little older onset than separation. And here in the little case study, 16-year-old Julie worries what others think of her, so that's the hallmark of social anxiety. Am I being judged? What do they think? Do they think something bad?
[00:10:23.79] She spends hours before school getting ready. So, to guard against having anybody judge her harshly, she's got her hair going, her teeth are white. She's spending lots of time.
[00:10:34.71] With new peers, she blushes, and she feels that her mind goes blank. So it's not just the way she looks, but the way she comes across. What if I don't have anything smart to say?
[00:10:45.31] She's an excellent tennis player, but she did not try out for the high school team, so here's that avoidance coming in. If I play tennis, I'm going to have to interact with these other people. People will maybe judge me if I hit a good shot or not.
[00:10:58.02] She has begun to skip speech class and prefers to sit alone in her car in the school parking lot. So here you can see how it's an obvious link between anxiety and depression. This kid starts out socially anxious, but it's so strong that she can't even attend the speech class. She's all by yourself in her car. It's robbing her of that opportunity even to be with her peers.
[00:11:25.59] So generalized anxiety is another common form of anxiety that you'll see across childhood, maybe a little bit more in adolescence. And this is the type of anxiety-- I think of it as everyday worries. So worries every kid has, probably adults-- most adults have, but just excessive, too much.
[00:11:45.36] And so here, this is 17-year-old Andy. He is a high achiever. He gets straight A's and captains the track team, but he worries about grades, if he will get into college, and if he treats his teammates fairly, so clearly excessive. This guy's got straight A's. He's captain of the track team. What's he got to worry about?
[00:12:03.66] But he does, and he finds these worries exhausting. He often experiences muscle tension and fatigue, and he feels guilty about snapping at family members. So very common with your-- he's so wrapped up in worry that he's irritable, and he's more likely to get mad at his mom, and his dad, or his siblings, particularly when he's trying to concentrate on his homework. So concentration too can be impaired. You've got all this worry wrapped up in your mind, it's hard to focus and get things done.
[00:12:35.91] Specific phobia among all of the anxiety disorders is actually the most common, and many people just blow it off. And a lot of us walk around with specific phobias of blood, or maybe of insects, that if you can avoid blood for the most part, it doesn't get in the way. But there are certainly specific phobias that can be very severe.
[00:12:56.15] And here in this example, we have Bobby who is a six-year-old boy, and this boy is afraid of bugs. So he stays inside to avoid them. When he has to go outside, he covers his head with his blankie, and mom says that the fear of bugs is ruining Bobby's summer, because he will not go out to play with his siblings or his neighborhood friends.
[00:13:19.17] So again, it's just bugs. What's the big deal? But the big deal comes in when it's causing avoidance, and now this is affecting his ability to socialize. He's six. He needs to learn how to play with his neighborhood friends.
[00:13:34.54] Now, panic disorder, another form of anxiety, a little bit less common in children, but certainly does happen. And I think of panic disorder as almost fear of fear itself.
[00:13:47.70] So here we have 13-year-old George. He's playing hockey when he experienced a sudden episode of dizziness, heart racing, and numbness. So first off, he's playing hockey. You're supposed to have your heart race. Your heart beats faster when you're exercising, but he's misinterpreting it as this could be a bad thing.
[00:14:08.95] Because of this interpretation, this could be I'm sick. His parents take him to the ER, but no medical problems are found. But George is so terrified from this one experience that he'll have another attack, that he now leaves the ice during games. So, again, avoidance, due to fear that his heart is being too fast, and he might lose control. So often very physical symptoms, heart racing, shortness of breath, dizziness, thought that, am I going crazy? What do these physical things mean?
[00:14:43.86] Obsessive compulsive disorder, some might say that this is a little more unusual type of fears, but they also, interestingly enough tend to be fears a lot of kids have, even healthy kids. They'll have fears on this continuum.
[00:15:00.60] Here's an example of one of these types of OCD worries about being poisoned. So this is an 11-year-old boy, and that's a pretty common age for OCD, late middle childhood. He worries about getting poisoned, and because of this worry, he's repetitively asking his parents, will I get sick? So lots of reassurance seeking, involving the parents in this concern that he has, trying to make them make him feel better.
[00:15:30.11] At school, he must tap his desk in squares, so irrational-- he might even know that-- but to decontaminate it before eating lunch or a snack. And here again importantly, Billy knows the tapping doesn't make sense. So a lot of times these kids have a ton of insight. I don't know why I have to do this. I just have to. So because he knows it doesn't make sense, he's embarrassed, and he tries to do it when others aren't watching. So with OCD, I mentioned being poisoned, very often fears of harm, cleanliness, germs, superstitious thinking almost.
[00:16:09.58] And then the last one on my list of anxiety disorders I just wanted to discuss with you is PTSD, or post traumatic stress disorder. And by definition, this is one that you have to have had a trauma to have this type of illness.
[00:16:26.82] And here in this case, it's a 13-year-old boy Nick who was molested when he was only three by a teenage neighbor. In the past, he used to have nightmares and avoid older boys, so, again, the avoidance of the trigger, the traumatic memory. The nightmares are less frequent now that he's 13, but he continues to have trouble falling asleep.
[00:16:49.14] So he's hyper aroused. He's vigilant. He's watching, even at night time when he's supposed to be relaxing and falling asleep. He is distractable and too busy, racing through school work and becoming easily frustrated. Mom reports that when he's angry, Nick will ask, why did my neighbor do that? So it's almost like he's having this emotional memory of a time that he felt out of control.
[00:17:14.69] So just brief snapshots of different types of anxiety and how they can present in youth, to get me to the question of treatment. And if you know kid or you have a kid who has any of these types of anxiety, can they be helped? And the answer is really a definitive yes. There's a number of high quality evidence based treatments that are available, and I just wanted to share with you some of the best research that's been done.
[00:17:46.66] These two studies that I'm going to talk about are federally funded studies that were done in 400 or more kids, funded by the federal government. And here, this one is called the Child and Adolescent Multimodal Study. And what they mean by multimodal is they did two types of treatments.
[00:18:04.01] They used cognitive behavior therapy-- which is very commonly the type of talk therapy that we use in children-- a medication called Sertraline-- which works on serotonin in the brain-- and the combination, compared to placebo is the yellow one on the end there. And what was found is both the medication-- the Sertraline-- and the CBT-- cognitive behavior therapy-- did better than the placebo, and the combination did even better than that. So you can see here-- I don't know is this a-- oh, cool. I've got a pointer.
[00:18:39.87] You can see here, that's the combination. That's the meds alone. That's the therapy alone. And that's the placebo. And on the side here, it's what percentage responded.
[00:18:49.83] So 80% responded to this first time treatment. It's three months with cognitive behavior therapy and Sertraline, and this is just a first try at treatment. So in medicine, 80%, you're pretty much-- if not hitting the ball out of the park, you're doing pretty well. This is a good response.
[00:19:10.79] So, people worry a lot, I think, over the last 10 years, because there's been a lot of media about well Sertraline, Prozac, selective serotonin reuptake inhibitors, does that cause suicidality? I mean, do I really want to give my child that, because could that even make them think of wanting to die?
[00:19:29.08] And here in this study-- as all of these studies-- that was tracked very closely. There were no suicides in any group, and even the just new onset thinking of wanting to die or non-suicidal-- self harm, cutting, that type of thing-- was almost 0%. There was no difference between-- this is meds, and this placebo. It's actually a tiny little bit-- I mean, not even statistically significant higher in the CBT groups.
[00:19:59.38] But bottom line here, in these anxiety disorders, no suicides, very little evidence for even an increase in suicidal thinking, which you would expect. If it's making you better, you should be having less of that. This study breaks out specifically kids who had obsessive compulsive disorder. And again similar findings, a little bit lower response rate, suggesting OCD maybe a little bit harder to treat.
[00:20:26.08] But-- oops, sorry. Go back. There we go. Sertraline and cognitive behavior therapy were used better than placebo combination best of all.
[00:20:37.56] So a take home point from these is we typically do recommend cognitive behavior therapy first. If there's not a response to that or the anxiety is really severe, really getting in the way, we'll partner it with a medicine like Sertraline, a selective serotonin reuptake inhibitor.
[00:20:54.72] And I think in-- well I'll quickly go over this. I mentioned suicidality. Some controversy as to whether that really even is an issue as much in anxiety. There may be a small signal in depression. What we do see much more commonly here are some GI upset, so you see here decreased appetite, diarrhea. These are with medications obviously, not with the cognitive behavior therapy, nausea.
[00:21:23.07] In younger kids there may be some increase in motor activity, but accepting this one, all the GI stuff, if that even happens, tends to go away once kids get used to the medication. So not a plug for a medication, but just letting you know some of the more common side effects that you can see.
[00:21:46.51] So take home point from this, SSRIs-- selective serotonin reuptake inhibitors-- are effective. Even though they're called quote antidepressants, these types of medicines seem to be even more effective for pediatric anxiety disorders than for depression, and there's just some statistics backing that up.
[00:22:06.89] But are they equal? So there's several different ones you've probably heard of. There's Prozac Fluoxetine, Celexa Citalopram, Zoloft Sertraline, several others on top of that. And it appears, yes, they're probably equal across the population, but not necessarily for an individual.
[00:22:26.40] So what I mean by that is if one of them doesn't work, that doesn't necessarily mean another one of these same medicines will not work either. Here's an example of a study that looked at Fluvoxamine-- another one of these SSRIs-- and of those who didn't respond to that one, over half responded when they were switched to a different medication. So if you don't succeed at first, try again.
[00:22:56.86] Again, SSRI safety. So having talked about what does anxiety look like, what are possible treatments for it, what if you don't do anything? Will my child just grow out of this? The answer to that is sloppy.
[00:23:14.78] Yeah, some might, some will, some won't. It seems that separation fears and everyday worries may become a little bit more manageable with time. Social phobia, that social anxiety fear of being evaluated tends to be less responsive to quote just going away, growing out of it. It also probably depends on how much anxiety, not only how severe, but how many different types of anxiety at the same time.
[00:23:44.16] So here you can see, if you have one anxiety disorder, about 30% will persist on into adulthood. Two, 45% will persist. Three, 60%. So the more anxiety, types of anxiety, the more likely the anxiety's going to persist, and then also the number of episodes. Maybe you had anxiety once at 5, again at 10, again at 15. More than one episode predicts greater chance of persisting into adulthood.
[00:24:16.36] What made my child-- oh and I should-- I want to go back to this. I think all of this is to say it's worth thinking about evaluation and thinking about treatment, because the earlier you treat, the less likely you are to get persistence, the more likely you're going to give a child a chance to manage anxiety.
[00:24:39.39] So what made by child ill? That's a million dollar question here. There's likely some genetic pre-wiring, if you will, genetic vulnerability in the brain. So, if a family has a history of anxiety disorders, there's going to be a greater likelihood that their children will have anxiety as well, but that interacts, of course, with environment.
[00:25:04.94] So what kind of stresses? What kind of trauma? Even with everyday events. Did I move somewhere? Did my best friend move away?
[00:25:12.64] And these likely impact the brain in terms of the way that the brain functions. By the same token, using psychotherapy, cognitive behavior therapy teaches the brain to function in a healthier manner. Exercise and SSRIs. So a number of things can contribute to anxiety, but through treatment, we can help normalize the way the brain is functioning and have less anxiety as a result.
[00:25:46.26] So what can a parent do? To start, speak out. Normalize, even for your child, matter of fact language.
[00:25:54.48] This is very common. I said one in three. That's a huge number of kids. It's not just you that's suffering.
[00:26:01.53] Learning, like you are doing tonight. How do you recognize anxiety? What does it look like? You may be the main source of information for your child, so I think being matter of fact and open. This is not something that's your fault. When your child has symptoms, you can tell them, again, this is common. You are by no means alone. This is absolutely not your fault.
[00:26:25.05] And one of the phrases I like to use is, it's your brain sending a false alarm. And this false alarm is worth doing something about. It's getting in the way of how you're enjoying life, and how I am as a parent. And so let's help each other by pointing out when that false alarm is going off, really labeling the anxiety, trying to isolate it.
[00:26:48.13] And last but definitely not least, this is treatable. You do not need to suffer. I can help, and we can go get some help together. And the last thing here is a plug.
[00:26:59.41] We always are doing clinical research at U of M to try to understand anxiety better, and are happy to talk to you about opportunities for research that you or your kids might like to participate in. And there's a little guy doing some research, looking at genes, brain function.
[00:27:22.52] Research is what led us to this information about what works for anxiety. So again, we're happy to partner with that, as well as providing just care. So, please share your questions and your comments.
[00:27:46.01] And I'm just going to pass it down to the next panelist.
[00:27:49.95] ELIZABETH KOSCHMANN: Hi, I'm Elizabeth Koschmann. I'm a researcher, also in the psychiatry department. I am really interested in access to care, and how we can get what we know works for treating anxiety into the community so that if you're a family that can't get to a clinic or can't get to an outpatient therapist, what kind of support services might be available in the school setting or in your primary care provider's office that can be useful even short of therapy.
[00:28:16.40] KAREN NICHOLSON-MUTH: I'm Karen Nicholson-Muth, and I'm a private clinician, downtown Ann Arbor, and I see a lot of adolescents, and children, and college students who have anxiety disorders, and mood disorders, and ADHD, as well, also ASD, too.
[00:28:33.93] JOSEPH HIMLE: I'm Joe Himle. I'm a faculty member in the Department of Psychiatry and at the the School of Social Work here at University of Michigan. I see patients, and I do a lot of teaching on cognitive behavioral therapy. But I guess most of my time is spent doing research on cognitive behavioral therapy for adults and children with anxiety problems, I'm particularly interested in ways to get best practice treatments to community members.
[00:29:04.08] DR. KATE FITZGERALD: So these are great questions. I will try to zip through them, so we can get to them all. This first one has two parts to the question.
[00:29:14.67] The first part is, how do you determine when anxiety needs to be treated versus no treatment? And that one really goes back to if the anxiety is causing functional interference. Is it getting in the way? So it's distressing most likely, if it's getting in the way. Is it causing problems at school, fights at home, making it difficult for a kid to make friends? Joseph.
[00:29:44.87] JOSEPH HIMLE: I think there's something that underlies the question too, and that has to do with this pausing and contemplating about getting treatment. It almost speaks to this idea, could your child be worse off for coming to see one of us, this idea that getting help should be really carefully thought through if a young person's having an anxiety problem, because boy, making that step to go to a therapist or go to a clinic, woo, that sounds really risky, in a way. But actually, I think we can say pretty clearly from the studies that have been done with kids and anxiety disorders and from our clinical experience that we don't help every child, but almost never are children and families worse for the wear for coming. And so therefore, in some ways if you're on the fence, it probably is just better to come, I think.
[00:30:43.57] SPEAKER: [INAUDIBLE].
[00:30:45.43] DR. KATE FITZGERALD: And then the part two of this same question was, for anxiety with a clear genetic component, how similar is the timing of start of symptoms among family members? Do the same treatments tend to work for different family members?
[00:31:03.15] So, how similar is the start of timing? Often, very similar, but there's no cut and dry answer to that. If one of these guys want to take it they can. I would also say even the type of anxiety doesn't have to be the same. Mom or dad may have OCD, kid may have that, but they could also present differently, like social anxiety or separation anxiety.
[00:31:29.65] With timing, that's another really interesting thing about anxiety disorders, is they often have developmental occurrence. And I was trying to touch on that in the vignettes. So for example, separation anxiety, specific phobia early OCD, GAD, later social anxiety, more in adolescence. So it may follow this different-- it looks slightly different with the different phases of development.
[00:31:56.29] And then, do the same treatments tend to work for different family members? I like that question a lot, because that is exactly how we choose among the different SSRIs. There's three different ones that say you're seriously considering, Zoloft, Prozac-- what's the other one?
[00:32:15.88] JOSEPH HIMLE: Paxil.
[00:32:17.10] Thank you, Zoloft, Prozac, Celexa. You would choose based on did a family member have a great response. And if you don't know or there isn't a family member, that's not the end of the world. We'll pick one of them, but that's a-- if you have that information, that is helpful to guide decision making.
[00:32:35.75] JOSEPH HIMLE: I had a point a little bit about the onset issue, do they start at the same time? I actually do think that from a genetics point of view, a familial point of view, when it comes to these anxiety problems, if you have a child with an anxiety disorder, chances are pretty good that they have family members who have anxiety too, and they probably got in childhood also. That's particularly relevant for obsessive compulsive disorder where there seem to be two varieties in OCD. One is a early onset variety where lots of family members, or it's common to see family members who share OCD, and then a later in adulthood onset obsessive compulsive disorder where almost always there aren't family members who share the problem. So, there seems to be more heritability in early onset anxiety disorders, childhood onset anxiety disorders, compared to adult onset disorders.
[00:33:37.62] DR. KATE FITZGERALD: OK, so here's one for-- I think Elizabeth is going to like this one. As a school social worker, how can we best help kids, for instance, teaching them about anxiety?
[00:33:47.99] ELIZABETH KOSCHMANN: Yeah, I love that question. So, I'm actually studying right now a model of how can we get support to school based health professionals, including social workers, but also guidance counselors, school nurses, teachers, administrators, so that when students are in the school setting that have anxiety, they have some tools and resources to turn to. I just want to say before I even respond to the question that I've been talking a lot with school counselors and other school professionals lately, and the need is overwhelming. Kate mentioned the one in three number. It is really about 1/3 of students that are having some at least low level anxiety, if not more significant anxiety. And the school based staff are really wanting tools and really wanting ideas for how to respond, so I love the opportunity to answer the question.
[00:34:42.95] If I had my way and I could design the Ann Arbor Public school system, I would start in kindergarten teaching kids about mental health, and health, and coping skills, teaching kids relaxation strategies, teaching kids how to tune into their thinking so that when something is making them nervous-- like separating from a parent-- they can start to have some self awareness at a really young age.
[00:35:08.43] I'm having this worried thought right now. Maybe that's the worry monster planting that thought in my mind. Here's some other ways for me to think about it. Maybe there'll be a friend in that place. Maybe my parent will be available at the end of the day. Maybe it won't be as bad as I think. And the kids can really use those tools throughout their course of schooling so that they can be really self reliant.
[00:35:29.44] Since I don't run the Ann Arbor Public schools and I don't have the ability to suddenly infuse the school system with that curriculum, I would say if you are working in a school or you are communicating with a school employee, encourage them to look into some basic strategies that they can teach students. So, rather than when an anxious student shows up in your office having them sit there, and calm down, and maybe avoid a class or avoid an exam, really try to turn them around fast, get them to recognize the worries that they do have, and get them to maybe come up with some tools that they can rely on time and time again to get them right back into the thing that was triggering the anxiety in the first place.
[00:36:13.04] And just by facing their fears, just by doing the thing that got them feeling nervous in the first place, they are on their own going to start to tackle some of that anxiety, not all but probably, but some of it, by really having the successful experiences, tackling the thing that makes them nervous. I would say that would probably be my biggest recommendation. I would love to talk to any school based professional that's here tonight later in the evening after the talk about opportunities to partner with us, about how to become involved in our project working with schools.
[00:36:47.71] DR. KATE FITZGERALD: I think related to that question, is there a specific intervention appropriate for the school setting? And on the Depression Center website, I saw a reference for a CBT manual written for school social workers. Is there--
[00:37:02.21] ELIZABETH KOSCHMANN: I don't know. CBT encompasses treatments for a variety of disorders, so a CBT manual would be a little bit complicated to think about only because we'd want to know what we are addressing with the CBT. That being said, there is great similarity across treatment approaches for depression, and anxiety, and other mood disorders that all come from that cognitive behavioral theory base. So there may be. I'm not familiar with that, but I can certainly look into it.
[00:37:32.59] The first part of the question--
[00:37:34.62] DR. KATE FITZGERALD: The specific intervention appropriate in a school setting. I think you already addressed that.
[00:37:39.38] ELIZABETH KOSCHMANN: Yeah.
[00:37:39.88] DR. KATE FITZGERALD: That's the CBT.
[00:37:40.37] ELIZABETH KOSCHMANN: Yeah, there are some models that are appropriate for different difficulties, so if it's-- for example, if there is a kid who's been exposed to a trauma, abuse, or community violence, there are definitely evidence based manuals specifically targeting responding to post traumatic stress disorder, which is one of the anxiety disorders Kate mentioned in the school setting. Otherwise, I think the most evidence based scientifically supported model of responding would be cognitive behavioral therapy, which can be implemented certainly in a school setting.
[00:38:16.41] DR. KATE FITZGERALD: OK, so here's a good one for Joe and Karen. Do you recommend exposure therapy?
[00:38:23.44] JOSEPH HIMLE: Go ahead, Karen.
[00:38:25.25] KAREN NICHOLSON-MUTH: Yes, I do, but it depends on the patient and the family. It really also depends on the symptomology, and so I see a lot of kiddos that have OCD, and usually I do recommend ERP.
[00:38:40.29] DR. KATE FITZGERALD: Exposure--
[00:38:41.77] KAREN NICHOLSON-MUTH: Exposure response prevention therapy. But I'll do it very gradually with the patient so that it's not too scary. I just recently had a kiddo who had ASD-- which is autistic spectrum disorder and obsessive compulsive disorder-- and I find that exposure response prevention therapy doesn't work as effectively with ASD comorbid with OCD. So I'll do more of a reward implementation for them, because I think neurologically their brains might not desensitize as well as just a standard neurotypical anxiety disorder patient. So it really depends on the family and the patient.
[00:39:27.03] JOSEPH HIMLE: I think exposure therapy has a ominous sound to it. Doesn't it? But really it does involve something that we all have experienced in our life, and that is, if we've been apprehensive or uncertain about something and we do it enough-- I'm sure you were uncertain the first day you went to work, the first day you went to school, first day you tried a new sport, first moment you met new person-- that there's an accommodation that occurs. Your body begins to slow down.
[00:39:54.61] So exposure therapy doesn't have to sound quite so procedural. I mean, it really does involve practicing what scares you, and thankfully, we as humans have-- almost all of us have a built in ability to become less nervous about something if we practice it enough. However, I think it is true that you can do exposure therapy in a way that makes it work a little better. I think occasionally confronting something you're afraid for a few moments probably doesn't work anywhere near as well as confronting or practicing something for a long time.
[00:40:34.00] I do think there's probably a dosing for exposure therapy that makes it work best, and so when I see patients who have, quote, tried exposure based treatments or when a parent might say, my child has tried to do that, but she's still or he's still afraid, usually it has to do with getting the dose a little bit better. I think that when you get an antibiotic, there's a dosing that goes along with it. If you had chemotherapy, there's a dosing. It's probably a good dosing for behavioral exposure therapy too, and that dosing would be easier to more difficult. But to have continuous good every day practice.
[00:41:16.62] And I think part of it also for a young person is selling them on this concept, helping them to understand that you're going to actually ask me to do things I'm afraid of, so I become less afraid. To young people, that doesn't always make a lot of sense. It just sounds to kids often that that's just another adult trying to tell me something to do that I don't want to do.
[00:41:37.54] But I think pulling apart examples from their life, like hey, when you were first learning how to ride a bike, how did that feel, and how is it now? What would that be like if talking to people were easier like that, too? And I know it's difficult for you now. Or what if when we leave the house, it's easy like riding a bike, what would that be like for you?
[00:41:59.77] To see that, hey, it's worked for them in their life, and it makes some sense to them based on their experiences as a kid, that I've practiced things, and lo and behold it got simpler. I think exposure therapy is not always a lot of fun, but I do think it fundamentally works for most people.
[00:42:20.78] KAREN NICHOLSON-MUTH: Yeah, and do too, and I see such a rapid improvement once they start the exposure therapy that it's so beneficial that it just-- the brain learn so quickly, and then they're more apt to do it more and more, that they are desensitized, and they feel like they can conquer their fears. It's really impressive how much progress you can make in a short period of time really, if you do it right.
[00:42:49.60] JOSEPH HIMLE: And I think it's interesting also that if somebody's really afraid, really afraid of something, it's awfully hard to get over it without some practice. I mean, sometimes people think their way around it-- which is fine-- or sometimes people just age out of it. But I do think that if you're really clinically afraid of something, it's pretty hard to get much better without doing it. It's painful, but it works pretty well.
[00:43:14.83] DR. KATE FITZGERALD: So you used the term, Karen, exposure and response prevention. So that is a specific subtype of cognitive behavior therapy where exposure is you're engaging that thing that makes you fearful. It's a subtype for OCD, obsessive compulsive disorder. So, say, the thing that makes you fearful is poison like in the little example. So exposure would be touching something that you're pretty worried about could be poisonous. So, say, like the lawn after it's been fertilized.
[00:43:48.33] And then response prevention is preventing the compulsion, the thing you want to do to get rid of that poison, like washing your hands. So just to give you an idea what is exposure and response prevention, and that links into this next question, which I think is also-- well, any one of you guys could answer, but maybe particularly Karen. So as a parent who has a child with OCD that they want to help, how do you address repetitive patterns at home? So for example, touching things a repetitive number of times.
[00:44:22.79] KAREN NICHOLSON-MUTH: Well, first off all, I'll usually give a lot of psycho-education to parents about OCD, and obsessions, and compulsions, so they're aware of when their child is doing an obsession or a compulsion. And then I'll probably do a worry bully type of externalization for the child, and so then I'll teach the parent to increase awareness for the child by pointing out that this is the worry bully that's making you do these things and that we want to fight it.
[00:44:58.10] And so the parent can really start to help the child dependent upon how young the child is. Usually with adolescence, adolescents are a little bit more in an individuation process, and they don't really want their parent to point it out as much. But if the child is young, then the parents can really help them become more just self aware of it, and so that the child can start to fight the anxiety, the worry bully.
[00:45:28.73] JOSEPH HIMLE: And I think like anything there's a limit. If I was working with a young person or living with a young person with obsessive compulsive disorder and they were touching this door handle, that light switch, whatever they might be doing that's repetitively touching, and I saw it, would I spend the whole day following that child around, saying, hey, that's an OCD thing? Hey, that's an OCD thing. You ought to stop that. Maybe you ought to stop that. And just continually reminding them.
[00:45:59.26] I think that a good role for a parent is to point out a reasonable amount of times-- especially if the kid is young-- that hey, it looks like the OCD is getting ahead of you a little bit. Or it looks like the OCD is bossing you around a bit. I wonder about your behavior therapy.
[00:46:17.65] But try not to-- help your kid by maybe trying to nag the OCD away, I just don't think that works very well. I think in the end, the kid's got to learn the principles, and you can be there as a helper. But at the end of the day, it's pretty much their battle.
[00:46:39.57] DR. KATE FITZGERALD: And just to break down obsessions and compulsions a little bit more, most commonly, they do come together. You have an obsessive concern, and then you do the compulsion to try to counteract it. But sometimes you see it just one or the other.
[00:46:54.49] So for example, like with the touching things example, that came from that card. You could have a compulsion, but there's not really a fear or a worry that's driving it, but it just feels right. I've got a touch, tap, or rub in this certain way, because it's just not quite right. And, again, that's a similar approach to what Joe is describing, that this too sounds like looks like it might be your OCD.
[00:47:19.82] Can you resist that? Can you practice not touching tapping? Or touching tapping just wrong.
[00:47:27.47] JOSEPH HIMLE: That suggests that obsessive compulsive disorder, the behavior's not always fear. It can be a discomfort.
[00:47:35.28] Maybe an example might be, what would it be like for you now if when you came in we put honey on your hands, and it was all stuck together, your fingers were stuck together? It'd probably be annoying and difficult. You'd be thinking, gosh, I can't wait to get to this sink to wash this off. I'm spreading it everywhere.
[00:47:52.22] It wouldn't be that you were afraid of the honey. It was just bothering you a lot. I didn't seem right until you get rid of it.
[00:47:58.04] I think that for some kids their OCD feels like that. It's not frightening or dangerous. It's just so uncomfortable. It doesn't feel right, and they want to find some way to get back to feeling right, and that could be anything from a residue on your hands all the way up to feeling like you have to touch something again and again.
[00:48:20.44] DR. KATE FITZGERALD: OK, so next one, I don't really understand panic disorder. Can you talk about what it is and its treatment?
[00:48:27.74] So, panic disorder is the one that I mentioned. It's like fear of fear itself, with fear almost being defined as your physical reaction, the fight or flight response. My heart's racing. My hands are sweaty and clammy. Maybe I'm dizzy. I have a stomach ache, very physical feelings. And then being afraid that that's going to happen again.
[00:48:51.97] So a lot of times when somebody has had these physical symptoms of panic, they'll be worried about going into the situation where that panic first occurred. So like in my example, the kid was afraid of going back and playing hockey, which we all know, of course, that's going to get your heart racing, but he was misinterpreting what the heart racing was really about. But it could be other situations, too.
[00:49:15.56] It could be I get these physical panicky feelings when I'm crossing a bridge, or when I'm in a crowded room. Very often these physical panic symptoms occur in situations that it would be hard to get out of. And when people feel that physical panic, they often feel like they have to escape. So, then they become avoidant of not just the place that maybe that panic first happened, but also of a situation that might be hard to get out of, like a movie theater, crossing all the legs.
[00:49:52.69] A panic attack is these physical feelings. Panic disorder is when the panic attacks come again, and again, and again, and there's avoidance associated with I don't want to risk something I might do being either associated with triggering another one of these things or associated with it's hard to get away from that physical feeling. Do people want to add to that?
[00:50:16.10] KAREN NICHOLSON-MUTH: I just, I see a lot of symptoms of panic disorder come out when kids are doing sports like soccer, gymnastics, where they have difficulty breathing, and then they feel like they might be having a panic attack. And so you really want to help them differentiate between whether or not they're just having physiological symptoms versus psychological sometimes, and that's a lot of the treatment, as well as emulating those sensations by spinning them in a chair or hyperventilating and creating it again, so that they again get desensitized to this feeling, and then they know it's not going to kill them.
[00:50:59.84] ELIZABETH KOSCHMANN: Just to pick up on not going to kill them, I just wanted to say that I think that education goes a long way too with thinking about panic. I worked with a young girl last year who had panic attacks whenever she had to think about her body. So if she were thinking about her breathing or thinking about her muscles, she really didn't like that thought in her mind, and it made her heart rate, and it made her feel flushed. And she fainted many times in the past in schools, and in science museums, and any time when she had to think about the human body.
[00:51:33.58] And we got a lot of mileage out of just talking about the worst thing that could happen if she did faint. Which is probably the most dangerous piece of fainting would be if you're on a bike or driving and that happens. But chances are if you're sitting at a desk or you're sitting in a presentation and you faint, you might just bump your head a little bit or get a scrape on your knee, but you're not going to die. And as soon as she learned a little bit about that and also learned that if you feel like you're about to faint and you lie down and put your feet up, you can do a lot to prevent the fainting.
[00:52:10.70] Also, let her feel really empowered. So it's just a few little pieces of information about the human body and physiology got her a big step of the way towards realizing it wasn't so bad.
[00:52:23.80] JOSEPH HIMLE: I think it is interesting to think about what a panic attack is for a minute. I think most people probably sitting here have had one time in their life when their body got stirred up, and it didn't make any sense. They weren't exercising. They hadn't run up a big hill. They just found their heart was pounding, and they felt a little short of breath, and they felt fearful and like they ought to get out of that situation, and it didn't seem to make much sense. There was no real threat there.
[00:52:51.99] And it's a sudden eruption of physical feelings, and they're typical ones, rapid heart rate, shortness of breath, feeling flushed and hot, and a urge to get out of the situation. Maybe you feel like you just can't get enough air.
[00:53:06.06] But for many people, it just happens once or twice, And you think, oh, I just haven't had enough rest, or maybe I had some caffeine. I don't know what happened. I've just under a lot of stress. And you go on about your business.
[00:53:16.68] So I think an occasional isolated panic attack once or twice in your life, most people have an experience like that. But for kids and adults who have panic disorder, they come more frequently. And then they often really do get afraid of their body.
[00:53:30.03] They become on watch for changes in their body like, oh, gee what was that? Oh, my heart starting to pound. Wow, I hope it doesn't get worst. All I can't get my breath here very well, and I'm starting to feel a little hot.
[00:53:40.68] Oh my god, I hope I'm not having a panic attack here. What if I have to leave? Gee, I wonder if I'm going to pass out here or go crazy.
[00:53:45.98] And in cognitive behavioral therapy involves two really essential pieces there. Can I practice the sensations that scare me? So I get bored with my heart pounding, and bored with being dizzy, and bored with being short of breath. And can I work on those thoughts, like am I going to die, go crazy, pass out, et cetera. When you work on those two things together, I think that it makes a big difference for panic disorder.
[00:54:07.70] And nicely also, the medicines are helpful, too. But often people have panic disorder onset a little bit later than early childhood, but there's no question that the later teen years and into the 20s your vulnerability goes up for having your body just create these things, this sensation for no good reason. And it's pretty scary at first.
[00:54:33.48] DR. KATE FITZGERALD: OK, so this next one, what is your personal experience with SSRIs for children? What symptoms did you treat with what results?
[00:54:41.67] So, certainly for panic in addition is one example. In addition to treating with exposure based cognitive behavior therapies where you're practicing having the symptoms, you're practicing being in a situation, you might have the symptoms, SSRIs-- selective serotonin reuptake inhibitors-- can be very effective. They can be effective across the anxiety disorders, so it's really not specific to any particular type of anxiety.
[00:55:09.47] What's the bar, what's the threshold for saying, OK tried CBT, now I also want to do a SSRI is really a very individual decision. It tends to be related to how severe is the anxiety. I mean, is it really impairing the kid's function to where they used to be getting A's and B's, and now they can't even go to school? That's an extreme example. So I think everybody's threshold for that is a little bit different.
[00:55:38.38] What symptoms with what results? I've seen pretty remarkable results. I mean, generally what you're counseled with the SSRIs is it takes two to four weeks to kick in, and I think that is a good rule of thumb. I don't know if there's been any research on this, but I've seen-- I think more in children than in adults-- more rapid responses, like a week, two weeks, and they already feel better. Maybe not all the way better, but they're starting to feel better.
[00:56:06.85] And then I think the other piece that I had mentioned in the presentation that's important is if you go to an SSRI and you've made that big decision and it doesn't work, it's really frustrating, but don't give up, because there's other fish in the sea when it comes to these medications. And even if the first one doesn't work, there's a very good chance that the second or third. There's multiple different SSRIs out there. Very good chances other ones will work.
[00:56:35.49] JOSEPH HIMLE: I was thinking that maybe one of the things I might like to say about the medicines too is that we're pretty fortunate here in Ann Arbor that we have people like Karen, for instance, who have this great skill in cognitive behavior therapy for kids or in ways and psychosocial treatment, psychological treatment for kids with anxiety problems. But in a lot of areas in this country, there's just really-- there aren't many Karens around. And the only real evidence based treatment that we have available to us for a kid in those circumstances might be a serotonin reuptake inhibiting medicine, so I think they play an important role.
[00:57:13.73] I think also it certainly is great to have other options. But I do think one of things that's been probably quite harmful is this continual message that they might be dangerous, and I've not prescribed a single medicine in my life.
[00:57:29.98] So I think I can come from an objective point of view. I think that that's probably hurt a fair number of kids, this idea that, oh, you'd better watch out. This is dangerous. I'd love it if every kid have access to top quality behavior therapy for their anxiety problems, but unfortunately, that's really difficult to access. So for some people, the medicine is their only really scientifically supported choice.
[00:57:54.72] KAREN NICHOLSON-MUTH: Yeah, and I usually recommend CBT first, but then I do-- I mean, my experience with kiddos who have tried an SSRI with the combination of CBT, I just see my patients be a lot more receptive to the therapy, the exposure therapy, or the CBT practices on if the anxiety is severe enough. So I usually do go that route.
[00:58:21.55] JOSEPH HIMLE: I think most of us would prefer to avoid medicine if our treatments were better. Our cognitive behavior therapies are good, but they're far from perfect, and they're certainly not easily accessible. And some kids and families don't want to hear about it. They just don't want to do it. So it's nice to have more than one option.
[00:58:36.83] DR. KATE FITZGERALD: And generally when I do prescribe a medication, because I am lucky that I'm in the Ann Arbor area with people like Elizabeth, and Karen, and Joe, I will as much as I possibly can encourage the family, the child to continue in cognitive behavior therapy even if they've been frustrated by three, four weeks, or however much that it hasn't gone well, because ultimately, I like to think of the therapy as learning. I mean, it's a very durable effect. Once you learn it, you've learned it.
[00:59:04.92] And it may be that you still have fluctuations in anxiety and even there would be cause for going back for a booster session of CBT. Now, I say that knowing that there are many, many people that are on SSRIs as maintenance, and that's fine, too. But generally speaking, if I can partner with the CBT, that's always my first choice. And if I go to a medicine, I'm still pushing for the CBT if I can get access for a child.
[00:59:35.08] So here's a more specific question. My eight-year-old son is very stressed out by timed math tests that are given every morning in class. Now, he has anxiety about going to school. How should I handle this? Do I talk to the teacher?
[00:59:52.31] ELIZABETH KOSCHMANN: I can respond to that. I think talking to the teacher is great. I think communication with teachers is essential and helps us as parents and helps our kids feel like there's really good communication. So for that part of that question, yes, definitely talk to the teacher.
[01:00:07.34] What I would say is that timed tests are not going to go away as the kid gets older. They're going to persist. Many of us still dread timed test, but they're a necessary evil for a lot of things. So my recommendation would be help your eight-year-old think about what is so upsetting about a timed test, what's the very worst thing that could happen, and infuse your child with an understanding that there may be some things that that kid really excels at, like untimed tests, and that timed test may be something that are just not a particular strength, and that we all have strengths and weaknesses, and that with practice, maybe he'll get better at taking timed tests. But in the beginning, if he's not very good at them, it is not a disaster, and help him-- was it a him? Did I just make that up? I'm not sure if it was a him.
[01:00:56.55] DR. KATE FITZGERALD: Yeah, it was a him.
[01:00:58.11] ELIZABETH KOSCHMANN: OK, help him think through what the different outcomes could be, what his worst fear is about, what might happen in that timed test. And I sometimes-- thinking about exposure-- in therapy recommend the worst outcome. I prescribe the disaster.
[01:01:16.20] So I might say to the kid, on purpose, don't answer a single question. Blank out. If that's your worry that you're going to blank out when you have a timed test. Blank out, or stop halfway through . Don't finish, and see what happens.
[01:01:29.65] And if you're a parent who is supportive of do your best and that's good enough, and if you have a teacher that's responsive and you could communicate with, I think it's OK for an eight-year-old not to ace a timed test. And that's a really important message to send to students. So rather than going the route right away at age eight of let's make an accommodation, let's get him out of the timed test, let's give him extra time, push that kid to-- like we all are talking about-- really face that fear, and do a little experiment to see what happens if it doesn't go well.
[01:02:01.55] KAREN NICHOLSON-MUTH: Yeah, I think lowering the pressure is key and then practicing the timed test over and over again, the exposure.
[01:02:08.82] ELIZABETH KOSCHMANN: Yeah.
[01:02:09.22] JOSEPH HIMLE: Could even practice them at home. I do think as a parent having raised a few kids now, I think where there are some times when you're asked to answer the call. Your kid is having a struggle, they have an anxiety problem, and you're in this situation. Do I try to protect them from it, or do I try to send them the message, I know that this is difficult, but let's go forward? I know that this is difficult, but let's do some extra, as opposed to, I know this is difficult, maybe we can find a way to soften it.
[01:02:43.57] And I think that it's a hard call, and it's a challenge to be a parent of a kid with an anxiety problem. It's a challenge to be a parent of any sort. But I think that that is an interesting lesson learned, and that is, are you going to be generally a parent who says, scary challenge, let's go for it, or generally a parent that says, scary challenge, let's protect you from it. I know there's always going to be some reason why on a particular day it's better to side step than to confront. But I do think on balance, we can do a lot for our kids by being the sort of parent who models and also generally encourages, it's scary, let's go toward it.
[01:03:34.52] ELIZABETH KOSCHMANN: I just want to add, we all talked about that there's a really big genetic component to anxiety, so if you happen to be an anxious parent, and now you have an anxious kid, and we are trying to follow the advice of let's really face these challenges, it can be really hard. But there is a great opportunity to say to your kid, hey, I feel nervous too. Let's make a list of some coping skills we can practice together. You come up with a task that I have to face my fears about. And it's really fun when the kids come up with the activities for the parent, like OK mom, you go into the coffee shop, and spill your coffee all over the floor, and see what that feels like.
[01:04:09.36] JOSEPH HIMLE: Love that one.
[01:04:09.97] ELIZABETH KOSCHMANN: Really hard to do, but it makes it fun. It makes it exciting for the kid, and it helps them see that what they're going through is really normal, and even their terrific, strong, all powerful parent can struggle with anxiety too and can overcome it. So there's an opportunity in that if you're that anxious parent trying to face a fear with your kid.
[01:04:28.59] DR. KATE FITZGERALD: OK, that was great. That ties in perfectly with this next question, which is, how much can parental anxiety slash depression affect or cause a child's anxiety? So we talked about that genetic component. I think what these guys are saying is something that we all have. Our first knee-jerk reflex to our kid is we want to protect them. And recognizing that sometimes in our effort to protect them, we're sheltering them in a way that's reinforcing the anxiety, saying, OK, if that's scary, you don't have to do it. When in fact, in the long run, they would do even better if we said, that's a challenge, maybe it feels scary right now, but I know you can do this, and helping to push them out there.
[01:05:14.55] I can think of a specific example that for some reason is coming to mind right now with this of a child who had a fear of thunderstorms, always checking out the newspaper. What's the weather going to be tomorrow? And the parent totally well intentioned, wanting to do right by this kid was like, OK, well let's go to the internet and spend some time there researching about thunderstorms, and what are the weather patterns in Michigan, and what's going to happen tomorrow.
[01:05:44.03] And you can imagine that almost reinforced like oh, mom's taking this seriously. I really do need to worry about the weather if we're sitting down for 30 minutes at the computer, rather than, you know what? It might rain tomorrow. I got you an umbrella.
[01:06:04.11] JOSEPH HIMLE: I do think all this talk about encouraging, going toward fearful things, I imagine some of you might be out there thinking, oh, it's easy for them to say. You ought to see my kid in the morning when the school bell's about to ring. Or you ought to my kid when I talk about inviting a friend over.
[01:06:22.57] So I do think that we absolutely understand it's not always so simple. And you might think, oh, that's right, Himle, your kids might not have been as afraid. You ought to see what's going on me. That's absolutely fair. And I think that that's what people like Elizabeth, and Karen, and Kate are here for.
[01:06:44.45] DR. KATE FITZGERALD: Yeah, it is very hard to do as a parent. That is definitely-- like teaching your kid anything. My dad tried to teach me tennis, and I hate tennis. It's better to go to-- sometimes just get the coach, the objective non-family member.
[01:06:59.49] KAREN NICHOLSON-MUTH: It is hard to parent. I think it's really important to model the conquering your fears for your children so that they are able to emulate that.
[01:07:13.56] JOSEPH HIMLE: I also think that question also speaks to this idea, is it really my fault that my kid has got this anxiety problem? Did I cause it with my bad genes, or did I cause it with my early parenting, or did I cause it last week when I helped him not go to school in the morning? I think that none of us really know the exact answer, but I do think that anxiety disorders, like obesity, like some forms of diabetes, like high blood pressure in some people, there's a myriad of contributions, the kid's temperament and natural capabilities, the parenting experiences, their other environmental experiences at school and out in the community.
[01:08:02.70] There's probably never going to be a simple reason as to why your kid's in this situation, but I think that you could just come to the conclusion that it's not really your fault as a parent, and there's a myriad of reasons why a kid ends up with an anxiety problem. But thankfully we got some people to help, and it's the rediscence to get help. The worries about what would it be like for my kid if they went to a counselor, or the worries about what would it be like for my kid if they took a medicine, what would happen? I mean, that's the purpose of these kinds of forums. It's for you to also-- if you are a parent of a kid with an anxiety problem, for you to see that we're not all that different. And that we're-- I think your kid will be in good hands and that the medicines and the therapies are probably worth a try if they're struggling.
[01:09:01.68] DR. KATE FITZGERALD: So here's another one. Can stress and anxiety bring on chest pain and tightness? What form of anxiety would do that? So, absolutely is the answer. Chest pain and tightness would be a common physical symptom of a panic attack like we talked about before, but there's certainly other anxiety disorders that chest pain and tightness could occur in.
[01:09:31.33] I think a lot of times when people experience chest pain and tightness, they interpret it as something's wrong with my heart. I mean, by all means, get a medical work up. But if it's negative and you're still getting chest pain and tightness, anxiety might just be what's causing it. And could it be more generalized anxiety associated, panic specific? And then getting a handle on that anxiety, it might be helpful to come and talk to someone about it.
[01:10:05.79] OK, so my daughters were separated from me at ages six, nine months, and three years due to a prolonged hospital stay of my husband due to the swine flu. Would that count as stress or trauma?
[01:10:23.75] So, I mean, I think you would need to know a lot more about the case to understand is that stress or trauma. How did these kids react to this? What were there other supports? While mom was away taking care of dad who was in the hospital, were grandma and grandpa there? What was the nature of the situation, and how does the child remember it?
[01:10:46.42] I mean, some may just keep on going on and not even think twice about it. On the other hand, if they're-- particularly the three-year-old who was old enough to remember-- is having nightmares about it, or intrusive thinking about it, or is very, very worried about themselves or their parents again becoming sick, yeah, it's worth questioning could that have been one of these myriad factors-- as Joe mentioned-- that might have contributed to the emergence of some anxiety. So I wouldn't say that in and of itself, oh my gosh, that's going to trigger a problem, but looking at it in the context of how the child is acting now and what kind of story have they told about that time period of when their dad was sick and their mom was helping him in the hospital.
[01:11:35.20] ELIZABETH KOSCHMANN: I just want to add too just a word about resilience, that we often have the perception that if something really awful does happen to a kid that that will cause an anxiety disorder or post traumatic stress disorder, and there's actually very good research that kids are extremely resilient, and that if they're experiencing one isolated trauma, many kids can handle a trauma without it developing into a disorder of any kind. They might experience a short term spike in worry, questions about the experience, wondering about the future, and then over time those worries can gradually dissipate, and the kid can return to normal functioning.
[01:12:17.23] So even if you have a kid who did experience a trauma and did even experience it as traumatic in the moment, that is not an automatic gateway to a disorder of some kind. When those traumas start to add up and now we're looking at chronic trauma over the lifespan of different forms in which safety was not a guarantee, and reliability of a parent was not a guarantee, and there was violence, and the kid maybe didn't know where their next meal was coming from, or didn't know who they could trust, then it's more common to see that develop into a more post traumatic stress disorder looking kid. But when you just have one isolated experience or even a few, it is really possible and actually quite common for kids to do just fine.
[01:13:04.64] DR. KATE FITZGERALD: The majority.
[01:13:05.59] ELIZABETH KOSCHMANN: Definitely.
[01:13:06.63] JOSEPH HIMLE: I think that actually brings up an interesting issue that talks about what becomes in fashion as a treatment or as a psychological intervention. There is this strategy that was tried for a while to add a psychological treatment to everyone who experienced some terrible trauma. So if the building collapsed, we'd go through some kind of therapy together as a way of preventing the development of a post traumatic stress experience.
[01:13:38.08] And actually that wholesale application of a psychological treatment to people who have had a traumatic experience, maybe if anything it might leave unbalanced people worse. So I do think it sends this message that traumas have always been part of human experience and that people can recover naturalistically on their own, adults and kids.
[01:14:01.56] So I do think that a lot of times in my career I've had people call me on the phone, or friends, or family, and say, oh, this terrible thing happened to my son. Who should I get him to see? What should I do now? As if since this terrible happened, you got to do a psychological treatment now.
[01:14:20.25] I think the answer to that is probably a no in most circumstances. Give that person a chance to recover. Most people do. If they fail to recover and weeks have gone by, then I think it's another story.
[01:14:32.46] ELIZABETH KOSCHMANN: That's not to say if you're a parent and that's been your experience it's inappropriate to ask for how do you go through those first initial months. You can definitely talk to somebody, and say, how should I answer my kid's questions? Should we talk about it or not? And maybe the help is not for the kid, as Joe is saying. It might be for you to know what to do in those first few months, and then at the end of that, those first few months then you can make your decision about is there a concern.
[01:14:55.94] JOSEPH HIMLE: Because I think a lot of people cope with trauma via dialogue with family members, friends, and also just a sense that family members and friends are available, that there is support available if they need it.
[01:15:10.00] DR. KATE FITZGERALD: OK, so these are two questions that came in that I think are asking the similar thing, which is about exercise. So could you expand on the role of exercise in treating anxiety, number one? And then second, any thoughts on diet?
[01:15:26.80] So we'll let all you guys address that, too. But to me, exercise, I mean, there's just there-- absolutely. Exercise and healthy diet is going to help everything, anxiety and depression. With that said, there haven't been these large trials like NIH funded comparing exercise versus no exercise that I'm aware of. So while I think it can ameliorate anxiety disorder, I wouldn't count on it to fully treat the anxiety disorder. Do you guys have more to--
[01:16:01.21] KAREN NICHOLSON-MUTH: I mean, I usually recommend exercise quite a bit. If someone is exercising and eating right and they're still having a lot of anxiety or depression, then I would probably recommend medication along with the therapy. But, yes, I think exercise is very effective--
[01:16:22.78] ELIZABETH KOSCHMANN: There is--
[01:16:23.19] KAREN NICHOLSON-MUTH: --for anxiety and depression.
[01:16:23.42] ELIZABETH KOSCHMANN: --research on exercise and depression that's actually going on here--
[01:16:28.88] KAREN NICHOLSON-MUTH: It helps.
[01:16:28.99] ELIZABETH KOSCHMANN: --that it's actually very helpful, so that is a good link.
[01:16:31.75] DR. KATE FITZGERALD: And that's another question actually, clinical research. So Dr. Rich Dopp is studying exercise and depression.
[01:16:39.50] ELIZABETH KOSCHMANN: And I believe he's actually taking participants for his research, so you can go on to the U of M Clinical Study site and look up research trials linking depression and anxiety, and you'll find Dr. Dopp's research. And if you're interested in being involved, there are opportunities to be involved.
[01:16:55.40] DR. KATE FITZGERALD: Yeah. So I think what I was saying is definitely exercise, and exercise helpful. Would it be a standalone treatment? I don't know if I would go there.
[01:17:03.11] KAREN NICHOLSON-MUTH: It could work. I mean, maybe.
[01:17:05.27] DR. KATE FITZGERALD: Maybe.
[01:17:06.14] KAREN NICHOLSON-MUTH: I'm pretty conservative about medication. If exercise increases the serotonin enough, then that's great.
[01:17:13.79] JOSEPH HIMLE: I do think that when a kid has an anxiety disorder and they show up in someone's office for help, it makes reasonable sense to consider exercise as part of a treatment plan. I also think that we all have an obligation to know the treatment literature well and to present to the family the best evidenced options. So I think exercise as a primary intervention for obsessive compulsive disorder, for social anxiety, for generalized anxiety, this is what I would recommend as our treatment. I think that we probably wouldn't want to say that.
[01:17:59.91] On the other hand, could we sometime down the road find out that generalized anxiety in kids is treated just as well with exercise as is with this cognitive behavior therapy? I guess we could find that out, and that would be great. It's a lot easier to access that than it is cognitive behavioral therapy, cheaper too. But as it stands right now, I think that we would consider exercise to be adjunctive, as opposed to a core treatment.
[01:18:28.75] DR. KATE FITZGERALD: So, when do you wean a child off of medication? What are the long term residual side effects? So for the first one, generally what we do is we treat to wellness for one year. So the goal is, if you start a medication, you're probably not going to get a response straight away. So maybe not starting the clock then, but 12 months under your belt of really feeling like this anxiety is under control and well managed. And at that point, definitely trying to wean off, but doing it really gradually.
[01:19:01.23] So for example, a common dose of Fluoxetine is 20 milligrams, sometimes 40, sometimes all the way up to 80. But I would decrease by 5 milligrams per month, and draw that out over as many months as it takes, because if the anxiety comes back, I want to catch it in time that I can deliver more cognitive behavior therapy and or-- depending on the patient's choice-- go back up on the medication.
[01:19:30.73] What are the long term residual side effects? So there's been some recent discussion in the literature that the SSRIs-- the Selective Serotonin Reuptake Inhibitors-- may increase your risk long, long term of osteoporosis, so bone fractures. That's still a little bit controversial. It seems to depend which one, Celexa not so much. The other ones more.
[01:19:55.04] Other than that, I won't say that there won't be something discovered again. Similar to what Joe said, we could do the perfect longitudinal study and study a big group of people for 50 years and find something out. But right now, there haven't really been work suggesting that there's really negative-- maybe this osteoporosis thing-- long term residual side effects.
[01:20:18.79] The other thing I would mention that I think is very interesting, as we know that depression links to reduction in the volume of the hippocampus, which is a part of the brain that is responsible for memory partially and that depression itself reduces that volume, but being on an SSRI that has treated the depression is protective, preventing volume loss. So it may be that the illness itself has long term residual side effects, and by treating to wellness with a medication, you're preventing these downstream negative consequences that could come from nothing to do with medication, from not treating the illness.
[01:21:00.35] JOSEPH HIMLE: It's also conceivable, if you have untreated anxiety problems and it persists over your lifetime, you might acquire a style of living that could hurt your health as well, like avoiding exercise because you're afraid to do it, or maybe using a lot of alcohol or other substances in order to self treat your anxiety problem. So when you actually add it up, when it comes to depression and the physical effects for many people of not treating it or anxiety, the physical effects that can come from untreated anxiety problems, I might have to say that those effects are probably easily as likely as some kind of long term effect from the medicine.
[01:21:48.80] But we might discover something. And that would be really sad if we did. We might also discover that there's some health benefit. I think it's just hard to know. But I do think that we've had some of these medicines around for decades now, but there is always that little sense of what could come. I think they seem very safe. And there are also side effects to doing psychotherapy too, getting yourself scared. And I suppose that's not comfortable either, but I think that all the treatments require a little bit of effort.
[01:22:24.44] KAREN NICHOLSON-MUTH: Yeah, I usually like to do a cost benefit analysis of medication and really if there's more benefits than cost, then I think it's worth it.
[01:22:36.32] DR. KATE FITZGERALD: So this is a good one, younger kids. I'm a preschool teacher and realize that separation anxiety happens, but what do you say to a parent who enables a young child when tantrums, shortness of breath, and vomiting occurs at school? Are three to four-year-olds too young to worry about anxiety disorders?
[01:22:55.33] So, no, as this person has experienced. But I'll let one of the CBTers-- if they would like-- take that one.
[01:23:04.34] ELIZABETH KOSCHMANN: Go ahead. You want to go?
[01:23:06.76] KAREN NICHOLSON-MUTH: Well, they're having tantrums and [INAUDIBLE].
[01:23:10.20] DR. KATE FITZGERALD: So tantrums, shortness of breath, vomiting at school, and the preschool teacher perceives the parent as enabling this.
[01:23:18.66] ELIZABETH KOSCHMANN: [INAUDIBLE].
[01:23:21.35] KAREN NICHOLSON-MUTH: Is the teacher-- what is the teacher to do?
[01:23:25.39] ELIZABETH KOSCHMANN: [INAUDIBLE].
[01:23:25.77] DR. KATE FITZGERALD: Yeah, what is the teacher supposed to do? Or you can can [INAUDIBLE].
[01:23:29.74] ELIZABETH KOSCHMANN: So I'll just quickly-- so I feel like I'm in this in a different realm right now, because I have a toddler. And I've spent a lot of time reading sleep training books, and it's not that different, that if you really read the most evidenced based response to sleep training a toddler or baby, you get to a point where you're in it. You decide now we're going to address the crying at night, getting in their crib.
[01:23:52.82] Some kids will get to the point where they're throwing up in their crib. The evidence points to sticking with your sleep training plan, that you let the kid throw up, you let them scream, you might let them scream for an hour, and as a parent, it's torturous. It's really painful to watch your kid get that distressed, but if you stick it out, the vast majority of kids will learn to sleep in their crib without any distress.
[01:24:17.85] And the same is true for preschoolers and separation anxiety, that if you're a teacher and you have a parent who is really distressed when their kid is screaming, crying, and vomiting as a three or four-year-old, that is very understandable. It makes sense. We talked about wanting to protect your kid. I think your best strategy if you're a teacher and you're observing all this is to try to really infuse that parent with information so that they can understand the process, they can understand the mechanism, and they can learn a little bit about inadvertently reinforcing that behavior rather than confronting it and maybe expecting its resolution.
[01:24:55.70] KAREN NICHOLSON-MUTH: Yeah, and I would teach the parent to do really simple goodbyes, not prolong the goodbye, and just a very tangible intervention, and to be very confident with saying goodbye, that everything's going to be safe, everything's fine, and so then the child can internalize the mom's security with it.
[01:25:18.06] JOSEPH HIMLE: All those are good answers.
[01:25:20.07] DR. KATE FITZGERALD: That's it? Thank you very much. I think we're done with our time. We really appreciate your coming.
[01:25:25.18] JOSEPH HIMLE: Thanks for coming out.

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September 24, 2013 at Multi-Purpose Room

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