Anxiety disorders are among the most common childhood and adolescent mental illnesses. According to the Centers for Disease Control and Prevention, about 7% of children ages 3 to 17 have been diagnosed with an anxiety disorder, the umbrella term that refers to phobias, panic disorder, separation anxiety, social anxiety and generalized anxiety disorders.
Researchers and clinicians theorize that anxiety among today’s children and adolescents may be intensifying for a variety of reasons, including increased pressure to succeed in school, growing up in the age of social media and living in a world where mass shootings frequently dominate the headlines.
Unfortunately, despite the number of American youth dealing with high levels of anxiety, only 1 in 5 is being treated for these disorders, according to a 2018 Child Mind Institute Children’s Mental Health Report.
Anxiety experts caution that this lack of care could undermine future mental health since children and adolescents with anxiety disorders are at higher risk of depression, behavior problems, substance use and even suicide later in life.
Youth anxiety also increases an individual’s risk of educational underachievement in young adulthood and functional impairment in areas such as health, social relationships or work in adulthood.
“We know now that anxiety is a marker—a gateway, if you will—for a host of other mental health disorders,” says Philip Kendall, PhD, director of the Child and Adolescent Anxiety Disorders Clinic at Temple University and the developer of Coping Cat, an evidence-based cognitive-behavioral treatment program for children with a range of anxiety disorders.
Psychologists also know that the earlier anxiety is addressed, the less likely it is to lead to more serious mental health issues that aren’t always quite as easy to treat successfully. “There have been enormous advancements in the last 50 years in terms of recognizing anxiety disorders and developing evidence-based, first-line treatments for them,” says David H. Barlow, PhD, founder of the Center for Anxiety and Related Disorders at Boston University.
In addition to conducting research and developing treatments, psychologists are also working to increase awareness among policymakers and the public about the risks of untreated anxiety and the need to reduce the stigma associated with seeking psychological treatment. Success in these areas is only possible when basic scientists, applied scientists, educators, clinicians and policymakers build on each other’s work.
“More than any other health-care professionals, psychologists really take the most comprehensive approach to anxiety disorders, from exploring the origins to processes to individual differences to ensuring available treatments and the long-term prognosis for those with anxiety disorders,” Barlow says.
Over the past decade, some of the most promising research around the causes and development of anxiety disorders has been led by developmental psychologists. One study, for example, led by Jennifer Urbano Blackford, PhD, of Vanderbilt University, examined brain responses to unfamiliar faces. Participants were young adults who were either highly socially inhibited or highly socially uninhibited, according to self-reports. Using fMRI, the researchers found habituation of activation of the amygdala and hippocampus to repeated presentations of the faces (which had neutral expressions) among the uninhibited participants, but they did not observe such habituation among the inhibited participants (Social Cognitive and Affective Neuroscience, Vol. 8, No. 2, 2013). “Individuals who familiarize more slowly may find encounters with new people overwhelming and thus avoid new social experiences, whereas those who adjust more quickly may be more likely to seek novel social experiences,” Blackford says.
In a later study, her team also found differences in patterns of prefrontal cortex activation between inhibited and uninhibited 8- to 10-year-olds (Journal of the American Academy of Child & Adolescent Psychiatry, Vol. 55, No. 9, 2016).
Social psychologist Johanna Jarcho, PhD, an assistant professor of psychology at Temple University, has collaborated with University of Maryland psychology professor Nathan Fox, PhD, to examine how social reticence—a personality trait characterized by shy, withdrawn behavior—in a young child may lead to poor social functioning later in life. In their study, participants between ages 2 and 7 were put into high and low social reticence groups based on behavioral observations and mother-reported questionnaires. Then at age 11, the children performed an fMRI-based task in which they interacted in a virtual classroom as the “new kid” in school. The researchers found that only participants in the high social reticence group showed increased activity in areas of the brain involved in processing distress when they anticipated feedback from unfamiliar peers (Psychological Science, Vol. 27, No. 6, 2016).
In related work, University of Maryland developmental psychologist Kenneth Rubin, PhD, and clinical psychologist Andrea Chronis-Tuscano, PhD, have examined how temperament in childhood affects later development of social anxiety disorders—and how parents’ reactions to their children’s temperament helps prevent or advance a disorder. Chronis-Tuscano and colleagues, for example, have found that children who exhibit inhibited behaviors—extreme shyness or anxiety around new people, for example—throughout infancy and early childhood are more than three times as likely to develop social anxiety disorder later in life (Journal of the American Academy of Child & Adolescent Psychiatry, Vol. 48, No. 9, 2009). Rubin and his team have also found that parents’ reactions to their inhibited children can help prevent or advance a child’s anxiety. For example, when parents respond to shy and anxious toddlers and preschoolers with warmth, sensitivity and encouragement to approach new situations and people—as opposed to allowing them to avoid social situations—the children are more likely to develop healthier social relationships later on (Child Development, Vol. 73, No. 2, 2003).
To steer parents toward prevention, Rubin and Chronis-Toscano developed the Turtle Program, an eight-week interaction therapy for parents and young children that allows for parents to encourage children’s social behaviors when they are with peers.
“We really try to help parents see that in the short term, swooping in to alleviate their child’s anxiety by declining birthday party invitations or withdrawing from extracurricular activities, for example, may help the child feel better in the moment, but over the long term, it’s not helping the child develop the social competencies and experiences that are critically important for growth,” says Chronis-Tuscano. “The longer the social inhibition and anxiety go untreated, the larger the gap you see between the social behavior of the inhibited child and their peers who don’t have anxiety.”
In a preliminary study of the Turtle Program conducted by Chronis-Tuscano and colleagues, parents and teachers reported improvements in anxiety symptoms among child participants, and parents were observed being more positively responsive to their children (Journal of Consulting and Clinical Psychology, Vol. 83, No. 3, 2015). A large-scale study now underway could help establish the program as an international standard that could also be taught to early childhood teachers, Chronis-Tuscano says.
“Helping teachers understand this issue and how to deal with it can make a big difference because anxious kids aren’t raising their hands to ask for help when they don’t understand something or to contribute their ideas, which negatively affects their academic progress,” she says.
Reaching more children with technology
Psychologists are also exploring ways to deliver social anxiety interventions to a wider audience. One way is through internet-based cognitive-behavioral therapy (iCBT), which allows children and others in therapy to get immediate access to evidence-based interventions. The interventions are delivered largely via computer, with varying degrees of mental health practitioner involvement.
“We’re able to get places easier and provide evidence-based content to a wider audience than we would ever be able to with traditional face-to-face interventions,” says clinical psychologist Muniya Khanna, PhD, founder and director of the OCD & Anxiety Institute in Pennsylvania and a research scientist at the Children’s Hospital of Philadelphia.
In partnership with Kendall, Khanna developed Camp Cope-A-Lot, the online version of Kendall’s Coping Cat protocol. Camp Cope-A-Lot is a 12-session iCBT for 7- to 13-year-olds with anxiety disorders. Users participate in activities that teach them how to manage stressful situations involving new people, new surroundings and new foods with “Charlie,” an anxious personified cat. The final six sessions—which require assistance from a therapist—introduce exposure to uncomfortable situations. An evaluation of the program by Kendall and Khanna found that 81% of participants no longer met the diagnostic criteria for their anxiety disorders, compared with 70% of participants in traditional CBT and 19% of participants who used computer activities but did not receive CBT from a therapist (Journal of Consulting and Clinical Psychology, Vol. 78, No. 5, 2010). The program has also been shown to be effective in community mental health settings (Storch, E.A., et al., Depression and Anxiety, Vol. 32, No. 11, 2015).
Kendall and Khanna have also developed an empirically supported online training program (Child Anxiety Tales) for parents of anxious youth and a free informational website for parents and professionals who work with anxious youth and their families (Coping Cat Parents).
Educating policymakers and the public
Unfortunately, despite the availability of life-changing interventions for anxiety disorders, too few people know about them. “There’s not as much effort as there should be on educating the general population about mental disorders, emotion dysregulation and mental health, and because of that we still have this very, very severe stigma,” Barlow says. “We need more people bringing attention to this issue.”
Psychologists are working to do just that. From a public education approach, they are working to help people better understand the mechanisms behind anxiety and why it’s important for parents to help children face their fears, rather than accommodating their children’s anxiety, says Anne Marie Albano, PhD, director of the Columbia University Clinic for Anxiety and Related Disorders.
“Parents are feeling uncomfortable about their children’s anxiety and it prompts their own anxiety so that they then take over,” says Albano. “We have to help parents step back some as well as help kids to step up.”
Clinical psychologist Lisa Damour, PhD, agrees, pointing to the large gap that has emerged between how psychologists think about anxiety and stress and how it is perceived by much of the public.
“In our broader culture, stress and anxiety have nothing but a bad name, and people believe they should be prevented and avoided at all costs,” says Damour, author of the 2019 book “Under Pressure: Confronting the Epidemic of Stress and Anxiety in Girls.” The reality is that anxiety is a very normal and protective emotion—and psychologists and other mental health professionals have a plethora of tools to treat anxiety if it gets out of control. “In my experience, though, this strikes the public as completely new information and it’s put me on a mission to keep getting the word out about anxiety and about how avoidance feeds the anxiety,” she says.
Schools are a natural place to teach those lessons, says Jonathan Comer, PhD, a professor of psychology and psychiatry at Florida International University. “We need to work more to help educate school professionals by providing them with strategies for helping students develop coping skills in situations that make them uncomfortable.”
When a child receives an anxiety disorder diagnosis, schools often respond with accommodations that might, for example, allow an anxious student to rest in the nurse’s office or to get more time to take tests. But while well intentioned, such accommodations can promote avoidance of the things that make kids anxious, Comer says. When psychologists are working with schools, they help build appropriate ways for children and teens to challenge their anxiety.
“So, maybe in the short term, there might be a plan that allows the anxious child to take frequent breaks, but then you also have a long-term plan for reducing that accommodation,” Comer says.
On a broader level, psychologists are serving on national and international committees to create new road maps for anxiety treatment. In 2017, Khanna joined about two dozen psychologists, psychiatrists and other mental health professionals to develop a consensus statement and recommendations for research and dissemination practices around iCBT for anxiety in youth (Internet Interventions, Vol. 12, No. 1, 2018). Their paper lays out the need for consistent measuring and precise reporting of iCBT programs and recommends ways to get these programs into the hands of clinicians for routine use.
“The more we have these conversations and the more we push ourselves to really ask the tough questions about how to maximize reach and how to make this feasible and affordable and accessible to both the nationally underserved and those in rural communities, the more we can make a difference in tackling this huge societal issue,” Khanna says.
Psychologists apply their expertise on anxiety from all areas of the discipline, including:
Researchers are exploring topics such as brain neurocircuitry and temperaments that make someone more likely to develop an anxiety disorder.
Psychologists design tools to assess anxiety levels and broaden interventions to reach a wider audience of those at risk of reaching clinical levels of anxiety.
Clinician-scientists develop and test interventions for anxiety in the lab and real-world settings.
Clinical psychologists treat patients with anxiety disorders and the parents of children with anxiety.
Faculty train students in the most effective treatments and work to reduce stigma around seeking treatment.
Anxiety and Depression Association of America
Understanding Anxiety in Children and Teens— 2018 Children’s Mental Health Report
Child Mind Institute
Raising Independent, Self-Confident Kids: Nine Essential Skills to Teach Your Child or Teen
Moss, W.L., & Moses, D.A. APA, 2018
Novotney, A. (2019, December 1). Better ways to combat anxiety in youth. Monitor on Psychology, 50(11). https://www.apa.org/monitor/2019/12/combat-anxiety