Interview conducted by April Cashin-Garbutt, BA Hons (Cantab)
What proportion of children and young adults suffer from anxiety?
Prevalence rates hover around 10%, although the actual percent varies depending on the specific anxiety disorder, sample, method of assessment, etc.
Anxiety is the most common psychiatric disorder among youth. Other disorders include ADHD—attention deficit hyperactivity disorder, depression, conduct disorder or oppositional defiance disorder.
Why do you think anxiety disorders are particularly common in children and young adults?
I don’t think we know for certain. There are a lot of contributing factors. Like many other illnesses, we know that anxiety disorders run in families so there’s a genetic or biological component. There are also environmental contributing factors such as exposure to negative or stressful life events, and specific parenting behaviors. Lots of things come together to increase the risk for anxiety.
How is anxiety treated in children and young adults? Does this differ from the recommended treatment for adults with anxiety?
There are 2 evidence-based treatments for youth—cognitive behavioural therapy and medication – this is similar for adults. With youth, involvement of parents is also key part of treatment.
Obviously the dosage differs. SSRIs, the Selective Serotonin Reuptake Inhibitors, are what are most commonly used to treat both anxiety and depression. The dosage will differ depending on the child’s age, weight, height, and so forth.
The largest study that we have to date is the CAMS study. In that trial, what we learned was that kids who receive a combination of both medicine and CBT have the best short-term outcomes (i.e., after a 12-week treatment trial).
Many families have preferences for different treatments. If we compare medicine alone versus CBT alone, there really are no differences in response rates between those mono-therapies. Parents, again, may choose to start with CBT and see how far the child improves. Perhaps the child improves completely or sufficiently enough and they don’t want to add medicine.
For some kids, the parent chooses to start with medicine. Again, right now, it seems that the combination of the two is the best. It leads to the most kids getting better. 80% of the kids who receive the combination compared to 60% in each of the trial therapies showed clinically significant improvement after 12 weeks.
Please can you outline the ways in which parents are involved in the treatment of anxiety in children?
Again, practitioners will vary in how they involve parents. In my experience, parents often wonder how they can help their child. Sometimes what their parental instinct tells them to do, which is often times rescuing their child if they show fear and anxiety, in the long run turns out not to be very helpful.
Parents need to be involved in the treatment to learn how they can help their children. Of course that is less relevant with adults.
Please can you outline your recent long-term analysis of children treated for anxiety? Why and how was this research conducted?
We conducted a follow up assessment of the youth treated in CAMS—to assess:
Whether early treatment reduced risk for disorders as kids got older
This study follows up the initial randomized control trial that compared medicine, CBT, the combination, and also pill placebo. We re-contacted those participants, as many as we could find, and the study is ongoing.
The paper that is published in JAMA is the first assessment of these kids. Now we’re just six years after they began treatment in the CAMS trial. We will continue to reassess them for another year or so.
We did diagnostic interviews, we measured symptoms, functioning, how they were doing in school, work, marriage, socially, across the board. Of course we wanted to know how well the treatment worked over time, but we also wanted to see, if they responded to the initial treatment, did it lower the risk for them to develop a disorder over time.
This is because anxiety disorders are thought of to be gateway disorders in that they are a risk factor for adult psychiatric problems.
What were the main findings of your study?
About half of youth were disease free at the follow up and about half of youth who responded to treatment relapsed by the follow up. Treatment type did not affect outcomes.
Did the relapse risk vary depending on the type of treatment received?
Were you surprised by this?
Yes and no. There are other studies for instance in the field of depression that also showed the type of treatment did not predict who relapsed. On the other hand, because the combination treatment did so well acutely, after the treatment trial of 12 weeks, we thought perhaps those kids might do better in the long run, but it didn’t turn out that way.
Your research found that girls were nearly twice as likely as boys to have a disorder at the follow-up. Did your study provide any explanation as to the reason for this finding?
Yes, girls were at greater risk—we need to figure out why.
Do you have any hypotheses at the moment of why this would be?
It may be that girls are entering into adolescence and we know that adolescent and young adult females have higher rates of anxiety and depressive disorders. We may be seeing the higher rates because they tend to have higher rates in these illnesses as they get older anyway.
It may be related to puberty and hormonal contributions. Social roles and gender role orientations may also play a part. Women’s style of coping tends to include more worrying and ruminating. Women also experience more negative life events. There is a lot more to learn.
Does your research suggest that gender-based treatment approaches may be beneficial for children with anxiety?
Well given the higher risk for girls we clearly need to pay attention to gender with respect to relapse—there were no gender differences in acute treatment response.
Girls might be more vulnerable over time, especially as they enter into adolescence and young adulthood. We need more vigilant monitoring of symptoms and relapse prevention strategies for girls.
What further research is needed to increase our understanding of anxiety and how long-term relief can be achieved?
My priority is to develop effective relapse prevention programs. We will also need to do more longitudinal studies.
What do you think the future holds for anxiety treatments for children?
In addition to relapse prevention, our current treatments, while good, could use improvements and recent findings from the field of neuroscience will shape future treatments.
The National Institute of Mental Health, which funded the study, and the National Institute of Health, its parent organization, have placed a high priority on learning from the brain, and how brain circuitry, functioning, etc. can inform our understanding of etiology and treatment of these disorders.
In the area of anxiety, we are learning more about how, for instance, biased attention influences anxiety levels. People are developing and testing computer-based cognitive bias modification programs to see if we can alter the way the brain works to reduce symptoms and improve functioning.
Where can readers find more information?
There are many websites:
About Dr. Golda Ginsburg
Golda S. Ginsburg, Ph.D., Professor of Psychiatry; Division of Child and Adolescent Psychiatry, The Johns Hopkins University School of Medicine.
Dr. Ginsburg has been developing and evaluating interventions for anxious youth for over 20 years. Most recently she developed and tested a family-based intervention aimed preventing the onset of anxiety disorders in the offspring of anxious parents.
She also developed a modular school-based treatment for anxiety disorders. She is leading the largest national naturalistic follow-up study of anxious youth in the USA to examine the long-term outcomes of youth treated for anxiety.