About 40 million American adults have an anxiety disorder each year. Rates are rising among young people and the use of anti-anxiety drugs is soaring. What can be done to reverse this mental health crisis?
Part of the answer soon may be to start putting more at-risk preschoolers—and their parents—in therapy.
A growing body of research is suggesting that treating kids who are at risk for anxiety disorders and depression—and their families—early may help keep mental illnesses at bay. And the move with the biggest impact (both in dollars saved and misery averted) will likely be to focus on anxiety. Anxiety disorders are the most common mental health issues and are among the earliest to arise; they can set in as early as age three. They are also increasingly being thought of as gateway illnesses. Depression, substance abuse and even suicidal behavior often begin as out-of-control anxiety.
There’s a good chance that my eight-year-old daughter will struggle with anxiety. Having a first-degree relative—a parent or sibling, for example—with an anxiety disorder bumps a person’s risk of developing one up to five times that of the general population. When I was a twenty-year-old college junior, I was diagnosed with panic disorder, an illness characterized by repeated episodes of a racing heart, shortness of breath and blinding terror. In a period before my diagnosis, I had been nearly paralyzed by fear: I skipped my finals, dropped classes and spent more than a month shaking on my parents’ sofa. I’ve grappled with anxiety ever since. My father deals with depression; my aunt, bipolar disorder. My grandmother heard voices and, plagued by paranoia, once tried to burn down her own home with her husband and children inside. She spent three years in a psychiatric facility.
I’d certainly like to spare my own daughter the pain of mental illness. And, now, researchers are developing programs with the aim of preventing anxiety disorders. At-risk children are usually taught social skills and how to approach the situations (asking another kid to play, doing show-and-tell) they already fear. This “exposure” is the main component of cognitive behavioral therapy, the most evidence-based non-drug treatment for anxiety disorders. The research is still in its early stages, and it could be years before the programs are widely available to families, but some results are encouraging. Researchers at the University of Connecticut and Johns Hopkins University tested an eight-week therapy for healthy kids who each had at least one parent with an anxiety disorder. During the following year, 31% of kids who didn’t receive the therapy developed an anxiety disorder, whereas only 5% of kids who received treatment developed one.
Researchers are also developing programs for preschool children who, because of their shy, socially reticent temperaments, are at greater risk of developing anxiety. About one third to one half of these “behaviorally-inhibited” children will go on to have anxiety disorders—most often social anxiety disorder—by adolescence. In the prevention programs, parents are often treated, too. Parents of anxious kids often become controlling and overprotective in an attempt to ease their children’s distress. The trouble is, this sends the message that the world is a dangerous place and that kids can’t cope on their own. Also, when parents allow their children to avoid scary or distressing situations, the kids have fewer opportunities to learn to master their fear. So parents are taught to refrain from rescuing their anxious children and to push them to confront scary situations.
I recently spent a spring Saturday morning at the University of Maryland sitting in on the final session of a program for behaviorally inhibited children. Six preschoolers sat in a circle, legs crisscrossed on colorful foam mats. It was the final meeting of the “Turtle Program” and a shiny gold sign exclaiming Congrats Grad! hung on the wall.
“Can anyone remind us about some of the new things we’ve learned in circle time?” asked Danielle Novick, one of the program’s leaders.
Marie, a little girl with curly brown hair and silver sneakers, shyly raised her hand. “Being brave,” she says.
“Good job,” replied Novick. “Thank you.” She leaned over and put a sticker on Marie’s knee, a reward for speaking up.
I watched this exchange from an adjacent room via a one-way mirror. The program is actually a study being conducted by researchers on the efficacy of an eight-week treatment to prevent anxiety disorders in behaviorally inhibited kids. The children in this group had all scored in the top 15% on a scale of behavioral inhibition. Many already had difficulties making friends, going to birthday parties and speaking up in preschool.
In the group, the children practiced introducing themselves, asking another kid to play and asking and answering questions. They learned to express their emotions and to negotiate conflict—first using puppets, which can be less stressful. The children also learned deep breathing, or what the program calls “balloon breathing,” to help cope with anxiety. Ken Rubin, one of the lead investigators of the study, says that even as early as age four, behaviorally inhibited kids often have poor social skills, are being rejected by their peers and are internalizing negative feelings about themselves. “We’re trying to interrupt that whole process,” said Andrea Chronis-Tuscano, the other principal investigator.
While the children were in circle time, their parents were in a room across the hall, where they were taught to ignore anxious and avoidant behavior and to praise brave behavior. Parents are also coached on how to create a fear hierarchy for their children consisting of incremental steps culminating in an ultimate goal. For example, if the ultimate goal is to ask another child to play, a first step might be to say hello to another child. The idea is for each step to be achievable, so that children have success and can gain confidence. The parents are coached on how to set up bravery practice (which is basically exposure therapy). They help their children to practice things like talking to a teacher or doing show-and-tell during the group. Therapists coach parents in the moment via earpieces, secret service style.
The researchers take pains to emphasize that they are not trying to change these kids’ personalities—to turn shy and introverted children into extroverts. “Impairment is really the key,” says Chronis-Tuscano. “We know how important social relationships are to people’s happiness and success in life, and we don’t want their inhibition to hold them back from doing anything.” In an earlier small pilot study, the Turtle Program reduced anxiety symptoms in behaviorally inhibited kids. Before the treatment, nearly three-quarters of the kids met criteria for social anxiety disorder. Afterward less than a third did.
As a preschooler, my daughter was spirited and joyful, obsessed with Mary Poppins and her hot-pink scooter. She was also reserved and cautious. She hovered along the perimeter of birthday parties and music classes. But in the last couple of years, she’s become markedly more confident. Still, if there’s anything that worries me, it’s her outsize fear of many kids’ movies. She’s not only petrified of movie monsters and villains but also hates it when anyone in a movie is nasty or mean. We got through only a few minutes of The Wizard of Oz. She made me turn it off at the appearance of Miss Gulch, the nasty woman who snatches Toto and later transforms into the Wicked Witch. I worry that these fears are an omen of greater anxiety to come. Researchers have found that phobias raise the risk of developing other anxiety disorders and depression. I myself had a childhood phobia of clowns.
So I’ve tried some of the prevention strategies. On the advice of child psychologist Ronald Rapee, a pioneer in the prevention of anxiety disorders in preschoolers, I took my daughter to see the movie Paddington, the movie about the talking bear that loves marmalade. (A free online version of Dr. Rapee’s “Cool Little Kids” program is available at coollittlekids.org.au). But, by the first scenes, when an earthquake levels the wayward bear’s home in Peru and kills his uncle, my daughter had scrambled onto my lap. When the evil taxidermist played by Nicole Kidman captured Paddington and threw him into a black van, my daughter began sobbing. We can go,” I said, and moved to get up. “No,” she wailed. So we stayed. But when the lights finally came up at the end, another mother shot me a judgmental look and proclaimed loudly, “That poor kid was so scared.” I felt awful and embarrassed, like I was a terrible parent. I told my daughter how proud I was of her.
At the time I wasn’t sure what, if anything, I accomplished. As with everything else in parenting, I’m winging it. But just a few weeks ago, my daughter, husband and I watched the original Ghostbusters from 1984. And when the demons attacked, I was the only one who had to close my eyes.