An Innovative Model of Treatment for Pediatric Anxiety
By Kathryn Boger, McLean Hospital
Note that a version of this article has been given by the author as a TEDx talk in April, 2017 in Waltham, MA.
Imagine that you’re at a crowded mall with your 4 year-old child. The two of you just walked into the food court, and you take a minute to reach into your pockets for some money. When you do, your child’s hand slips out of your own. And then you look up and your child is gone. You shout his name and furiously scan the crowd. You see bright lights, children having tantrums, and people everywhere, but you cannot see your child. You run from store to store and still can’t find him. Your heart begins to race, your breathing speeds up, and your stomach drops. Your brain starts to run through the horrible things that could’ve happened to him. You’ve lost control of the situation.
Then suddenly you spot him across the food court, peering over the counter at a frozen yogurt store. You race over to him and give him a huge hug and a little admonishment for scaring the life out of you. Your body and mind immediately begin to settle. You regain control of the situation.
Most of us have been through at least one highly anxious experience in our lives. But then the situation resolves or we use our skills and resources to manage it. The mind and body recalibrate, we adjust. But imagine if there were no relief. What if you walked around every day with your heart pounding in your chest and with the feeling that you were gasping for air? What if your brain was constantly telling you that the scariest, most horrible things were going to happen and that the world felt like an out of control and unsafe place?
Now imagine that you’re 7….or 10…or 15 and that this is your daily reality. This is what we need to understand about anxiety and what it’s like to experience it. The word “anxiety” has become so overused that it no longer seems to capture how debilitating it can be when it reaches the level of diagnosis.
Anxiety becomes diagnosable when it is persistent and extreme and gets in the way of living a normal life. A child can experience anxiety before tests, for example, and this might even help him to prepare and improve his performance. But if the anxiety starts to pervade his life, repeatedly causing him to ruminate late into the night, experience chronic stomach aches and headaches, and avoid studying and maybe even school altogether, he could receive an anxiety diagnosis.
Our current generation of youth is suffering from anxiety more than any previous generation. We don’t yet understand why, but experts have hypothesized that, in addition to better assessment and recognition, social media, school pressures, parenting practices, and larger societal changes have played a role. What we do know is that anxiety is currently the most common psychiatric disorder in children and adolescents. Epidemiologic data indicate that 13% to 20% percent of youth in the United States meet criteria for an anxiety disorder (Albano, 2013). That’s nearly one in five children who are struggling to learn, interact, and enjoy life because of an anxiety disorder.
Sadly, 80% of children with anxiety disorders are not receiving treatment (Merikangas et al., 2011), likely due to issues of access to care and stigma. Even fewer children are receiving treatments that have demonstrated efficacy in research because it can take so long for the treatments evaluated in research labs to be adopted in community clinics. If anxiety is not effectively treated, it tends to be chronic. This is a major problem because anxiety disorders can be destructive to children’s social, emotional, and academic functioning and can be the “gateway” to other destructive issues, including behavioral disorders, depression and substance use disorders. This places a massive toll on our children, families, and educational system.
To bring these facts to life, I’m going to describe the journey of Kim*, a teenager who struggled with severe anxiety. She gave me permission to share her story. Kim had an anxious temperament from the beginning. A shy child, she had difficulty separating from her mom in preschool. In the second grade, Kim witnessed a man cough up phlegm in a restaurant, and two weeks later she developed a stomach bug. This developed into an overwhelming fear of vomiting. From there, the anxiety began to cascade. Kim started having panic attacks when she went into public places where she could get sick, and she began to restrict her eating to avoid the possibility of vomiting.
Kim began to pull back from the things in her life that caused her anxiety to flare. She stopped going to stores and restaurants, and then she stopped going to school. She was hospitalized twice for refusing to leave her house or eat, and she had been put on a feeding tube. When I met her, she was 14, had been out of school for nearly two years and was spending her days at home alone, essentially confined to her bedroom because of anxiety. She had become depressed and was so out of practice of socializing with others that she had developed social anxiety as well. So the question is, how can we help a child like Kim reclaim her life from anxiety?
Cognitive-Behavioral Therapy (CBT) is currently considered the “gold standard” therapy for anxiety. A meta-analysis of evidence-based treatments for pediatric anxiety disorders demonstrated that individual CBT, group CBT, and group CBT with parent involvement currently have the highest level of research support (Silverman, Pina, & Viswesvaran, 2008). CBT is a short-term form of therapy that teaches people to manage problems by changing their thoughts and actions and developing skills to manage their emotions. The cornerstone of CBT for anxiety is exposure. This essentially means facing one’s fears in a gradual and structured manner. The goal is to help the brain learn that what you’re most afraid of isn’t going to happen, or that if it does, that you can handle it.
CBT traditionally takes place in the office once a week for 50 minutes. This has been our standard of care for 50 years, and it works for some children. But for children like Kim, with more severe and entrenched anxiety, it can be extremely difficult to gain traction in weekly 50-minute sessions in the office. In fact, research indicates that nearly half of children and adolescents who participate in weekly CBT for anxiety do not get better (Walkup et al., 2008). Over the years, my colleagues and I have seen many children who have been in weekly CBT for months and even years, and they are still stuck. The longer these children are stuck, the farther they fall off the developmental curve and the harder it is for them to get back on track. These children aren’t failing treatment. Our best treatments are failing them.
So my colleagues and I set out to develop an innovative solution to this problem. Three years ago, with the support of McLean Hospital, we started an intensive group-based program for children and adolescents with anxiety called the McLean Anxiety Mastery Program (aka “MAMP”). In designing this program, we expanded the length of CBT sessions, offered them more frequently, and conducted more CBT sessions outside the office so that children could engage with their real-life fears. Our goal was to maximize children’s treatment progress in order to minimize their losses in terms of their academics, extra-curricular activities, and social lives. We designed the program to be group-based because we wanted to reach more kids, and we knew from the literature that there were no differences in outcome between individual and group CBT in the treatment of pediatric anxiety (Silverman, Pina, & Viswesvaran, 2008).
This model of intensive CBT for anxiety and OCD in kids has been tested by several research studies, and outcomes have been favorable across the board (Ollendick et al., 2009; Santucci et al., 2009; Storch et al., 2007). In all of the studies, intensive treatment resulted in symptom reduction, and when there was a comparison sample, intensive CBT has demonstrated superiority to weekly CBT in a shorter period of time. So it’s clear that, at least in the research setting, intensive CBT is a viable option.
At MAMP, we treat children and adolescents who present with social anxiety, speciﬁc phobias, panic attacks, separation anxiety, agoraphobia, and obsessions and compulsions These youths participate in treatment four afternoons a week for two and a half hours at a time, largely in the community. In the course of a month of treatment at MAMP, youth receive nearly a year’s worth of weekly therapy. In addition to participating exposure and CBT skills groups, children and adolescents also participate in weekly family work and medication consultations. While much of the treatment is group-based, each child’s treatment is tailored to his or her own needs and goals. For example, in any given exposure group, various staff members might be coaching various children: one child with panic disorder might be being coached to purposely induce and practice tolerating panic symptoms by breathing through a straw and spinning in circles; another child with social anxiety might be being encouraged to ask silly questions of strangers; a third child, who has agoraphobia, may be encouraged to wait in line at a crowded store. Children also have the opportunity to observe their peers’ exposure work and to provide encouragement and support to one another.
What does MAMP treatment look like in practice? Here’s what it looked like for Kim:
After being housebound for nearly two years, Kim was literally unable to enter our clinic. So, for the first few days, we conducted sessions in the car. Each day, we would meet in the family’s Toyota and teach Kim about her anxiety and some strategies to start facing it. With daily support in the car, Kim gradually learned to tolerate her panic symptoms and she built the confidence and trust to start engaging in treatment in a meaningful way.
I remember the first day Kim decided to get out of the car. She came inside the building and joined the group. A seemingly small step. But, in fact, a huge exposure for her. Her face was red, her lips were trembling, and she was hyperventilating. Her mom was terrified too, and frankly I was experiencing some vicarious anxiety. But Kim did it.
Once Kim was in our daily CBT skills groups, she gradually built the resources to cope with her extreme anxiety. For example, when she found herself thinking about throwing up, she reminded herself that this was unlikely but also manageable. She learned to calm her body before bed each night using relaxation strategies and to use mindfulness to stay more present during the day. She also practiced interacting with other peers in the group – a powerful experience after being socially isolated for so long.
The foundation of Kim’s treatment was exposure. We exposed her to Harvard Square- the noise, the traffic, the people. Can you imagine what this would be like for someone who had been essentially house bound for two years? We rode buses and subways, we went into stores and restaurants, and Kim practiced talking to strangers. We did this on a daily basis, and Kim ventured farther and farther out of her comfort zone each day.
Finally, Kim was ready face her big fear: we exposed her to vomit. We watched videos of people throwing up. We created fake vomit by mixing mustard, salsa, eggs, and remnants of the previous night’s dinner that had been left in the sun to rot. Kim inspected the mixture, smelled it, and eventually put her hands in it. Kim took these gradual steps forward each day and practiced her exposures at home at night. And one day, after riding the subway for exposure, Kim was feeling queasy as she exited the station…and she threw up on her shoes. This was a pivotal moment in treatment. Kim faced her worst case scenario fear and realized that she could handle it.
Critically, Kim’s family was also involved in treatment. Kim’s mother had daily contact with the clinical team. Over time, she learned to step back rather than rescue her daughter as she struggled through exposures. In addition, Kim met regularly with a program psychiatrist for medication adjustments.
With this type of intensive support, Kim was finally able to get unstuck. The team and I credit the intensity and the flexibility of the treatment model in allowing her to reclaim her life in just six weeks. Had we tried to meet with Kim in the clinic on a weekly basis, I’m not sure where she’d be today. So where is Kim now, two years later?
Kim is now attending high school and taking honors classes. She has a cashier job at a local store, and she’s going to museums, hockey games, and restaurants. She still has bouts of anxiety but doesn’t let this hold her back from living a full life. What probably strikes me the most is that Kim has begun to allow herself to appreciate the smaller, more subtle things that truly make a meaningful life. Recently, while listening to the car radio with her mom, she commented:
“I don’t know if the songs are better now than they used to be or if I’m just able to enjoy them more.”
So do we have this all figured out? Not yet. Our own research at MAMP suggests that children and adolescents do experience significant improvement during treatment. But we don’t yet know the optimal “dose” of treatment or whether it varies by anxiety disorder. A few other intensive CBT programs for pediatric anxiety are cropping up around the country, and we are collaborating with our colleagues to brainstorm ways to adapt the model to fit individual needs. For example, we recently added home-based exposures for those children who are having difficulty leaving their homes.
We have a lot more to learn and more work to do. But at least we have some renewed hope for children like Kim.
*Name has been changed to protect confidentiality
Albano, A.M. You and Your Anxious Child: Free Your Child from Fears and Worries and Create a Joyful Family Life. Penguin Publishing Group, New York, New York, 2013.
Merikangas, K. R., He, J., Burstein, M. E., Swendsen, J., Avenevoli, S., et al. (2011). Service Utilization for Lifetime Mental Disorders in U.S. Adolescents: Results of the National Comorbidity Survey Adolescent Supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry, 50,1, 32–45.
Ollendick, T. H., Öst, L.-G., Reuterskiöld, L., Costa, N., Cederlund, R., Sirbu, C., . . . Jarrett, M. A. (2009). One-session treatment of specific phobias in youth: a randomized clinical trial in the United States and Sweden. Journal of Consulting and Clinical Psychology, 77, 504.
Santucci, L. C., Ehrenreich, J. T., Trosper, S. E., Bennett, S. M., & Pincus, D. B. (2009). Development and preliminary evaluation of a one-week summer treatment program for separation anxiety disorder. Cognitive and Behavioral Practice, 16, 317-331.
Silverman, W.K., Pina, A.A., & Viswesvaran, C. (2008). Evidence-Based psychosocial treatments for phobic and anxiety disorders in children and adolescents. Journal of Clinical Child & Adolescent Psychology, 37, 105-130.
Storch, E. A., Geffken, G. R., Merlo, L. J., Mann, G., Duke, D., Munson, M., . . . Goodman, W. K. (2007). Family-based cognitive-behavioral therapy for pediatric obsessive compulsive disorder: Comparison of intensive and weekly approaches. Journal of the American Academy of Child & Adolescent Psychiatry, 46, 469-478.
Walkup J.T., Albano A.M., Piacentini J., Birmaher B., Compton S.N., et al. (2008). Cognitive-behavioral therapy, sertraline and their combination for children and adolescents with anxiety disorders: acute phase efficacy and safety. New England Journal of Medicine, 359, 2753-2766.