Anxiety

For Anxiety, Single Intervention Is Not Enough

illustration on the concept of anxiety. Features a male with hands held to forhead in slumped possition. Mans face is scribbled.


No matter which treatment they get, only 20 percent of young people diagnosed with anxiety will stay well over the long term, UConn Health researchers report in the Journal of the American Academy of Child and Adolescent Psychiatry.

“When you see so few kids stay non-symptomatic after receiving the best treatments we have, that’s discouraging,” says UConn Health psychologist Golda Ginsburg. She suggests that regular mental health checkups may be a better way to treat anxiety than the current model.

The study followed 319 young people aged 10 to 25 who had been diagnosed with separation, social, or general anxiety disorders at sites in California, North Carolina, Maryland, and Pennsylvania.
They received evidence-based treatment with either sertraline (the generic form of Zoloft) or cognitive behavioral therapy or a combination of the two and then had follow-ups with the researchers every year for four years.

The follow-ups assessed anxiety levels but did not provide treatment. Other studies have done a single follow-up after one, two, five, or 10 years, but those were essentially snapshots in time. This is the first study to reassess youth treated for anxiety every year for four years.

We need a different model for mental health, one that includes regular checkups.

The sequential follow-ups meant that the researchers could identify people who relapsed, recovered, and relapsed again as well as people who stayed anxious and people who stayed well. They found that 20 percent of patients got well after treatment and stayed well, rating low on anxiety at each follow-up. But about half the patients relapsed at least once, and 30 percent were chronically anxious, meeting the diagnostic criteria for an anxiety disorder at every follow-up. Females were more likely to be chronically ill than males. Other predictors of chronic illness were experiencing more negative life events, having poor family communication, and having a diagnosis of social phobia.

On the bright side, the study found that young people who responded to treatment were more likely to stay well. The study also found no difference in long-term outcomes between treatment types. This means that if there is no cognitive behavioral therapist nearby, treatment with medication is just as likely to be effective.

The study also found that kids did better if their families were supportive and had positive communication styles. Parents should talk to their child and ask the therapist questions: Why do they suggest this treatment? (It should be supported by evidence.) Have they been trained in cognitive behavioral therapy? How can we reinforce what was learned in therapy this week?

But parents should also be aware that a single intervention may not be enough.

“If we can get them well, how do we keep them well?” says Ginsburg. “We need a different model for mental health, one that includes regular checkups.”

Breaking the Cycle: How Anxious Parents Can Protect Their Kids from Becoming Anxious Adults

By Kim Krieger

Infographic showcasing logical and illogical fears oppressing a nervous child figure


A woman who won’t drive long distances because she has panic attacks in the car. A man who has contamination fears so intense he cannot bring himself to use public bathrooms. A woman who can’t go to church because she fears enclosed spaces. All of these people have two things in common: they have an anxiety disorder, and they happen to be parents.

These parents sought help because they struggle with anxiety, and want to prevent their children from suffering the same way. Anxiety tends to run in families, with 30 to 50 percent of children of anxious parents growing up to be anxious themselves. But that does not have to be the case, according to new research by UConn Health child psychologist Golda S. Ginsburg.

Ginsburg and colleagues at Johns Hopkins University tested a one-year therapy intervention as part of a study of 136 families where at least one parent had anxiety and at least one child was between the ages of 6 and 13.

The study, published in the August issue of The American Journal of Psychiatry, found that therapy-based intervention works. Only 9 percent of children who participated in a therapist-directed intervention developed anxiety after one year, compared to 21 percent in a group that received written instruction, and 31 percent in the group that did not receive any therapy or written instruction.

Children of anxious parents have up to a 50 percent chance of growing up to be anxious themselves. But that does not have to be the case.

Both inborn temperament and life experiences play a role in whether an adult has anxiety. The more negative experiences a person has growing up, the greater the likelihood he or she will struggle with anxiety as an adult. But there is also a component of anxiety that is learned, taught inadvertently by parents who model the behavior. It’s these learned behaviors and thought patterns that interventions can help change, according to Ginsburg.

“The finding underscores the vulnerability of offspring of anxious parents,” says Ginsburg. She wants to do something about that vulnerability. “If we can identify kids at risk, let’s try and prevent this.”

Most of the adults who participated in the study struggled in school and didn’t tell anyone. They didn’t raise their hands, or they got sick before exams. They might not have had any friends. As adults, their anxiety still limits their activities and sometimes those of their family members, and they are very motivated to help their children avoid the same.

Physicians can often identify children at risk before they develop an anxiety disorder. Such kids are often hyper-aware of aches and other bodily sensations, and are frequent flyers at the doctor’s office and emergency room. For example, such a child might think “my heart is racing — I’m having a heart attack!” when a less anxious individual would think “my heart is racing because I just ran up a hill.”

Other signs of children at risk for anxiety include avoidance of school, parties, and other social situations, as well as unusual worries.

“Anxiety and fear are protective and adaptive,” says Ginsburg. “But in anxious kids they may not be, because these children have thoughts about danger and threat when there really isn’t one.”

For such a child, meeting a new peer for the first time can be paralyzing. Trying an unfamiliar food might summon worries of being poisoned. To cope with this kind of debilitating anxiety, children start avoiding whatever provokes the anxious feelings. If they’re afraid of the dark they might insist on sleeping with all the lights on. If they’re afraid of failing they won’t try new things. In extreme cases, they may refuse even to leave the house.

I’d say we need to change our model of mental health to a checkup method. Like going to the dentist every six months.

One of the ways to reduce anxiety is to do a reality check. It’s a way to recognize when a fear is healthy and worth paying attention to (a growling dog) or unhealthy (a possibly poisoned birthday cake).

In the study, some of the families participated in eight, hour-long sessions with a trained therapist over a period of two months. Others were just given a pamphlet that contained general information about anxiety disorders and treatments. Still others received nothing at all.

The families who participated in therapy were taught to identify the signs of anxiety and how to reduce it. They practiced problem-solving skills, and exercised safe exposures to whatever made their child anxious.

“We taught the kids how to identify scary thoughts, and how to change them,” Ginsburg says.

If you are interested in collaborating on such a study or have patients who might benefit from a family intervention, contact Golda Ginsburg at Gginsburg@uchc.edu, or call her office at 860.523.3788.

For example, if a child is afraid of cats and encounters one in the street, the child can first identify the scary thought: “that cat is going to hurt me.” Then the child can test that thought — is it likely that cat will hurt me? No, the cat doesn’t look angry. It isn’t baring its teeth or hissing, it’s just sitting there. OK, I can walk past that cat and it won’t do anything.

In general, children who participated in the intervention had lower anxiety overall than children who did not participate in the intervention with their families.

Now the researchers have funding from the National Institutes of Health for a follow-up to see whether the effects are maintained over time. Ginsburg wonders whether there would be value in providing regular checkups for families on mental health issues. She is considering approaching insurers about offering this kind of service to families at risk, to see if it lowers their healthcare costs overall.

“I’d say we need to change our model of mental health to a checkup method,” says Ginsburg, “like going to the dentist every six months.”