The Key to Combatting Anxiety in Adults? Start With Children

Maria Nordin, Disorientation II and I
LEFT: DISORIENTATION II
RIGHT: DISORIENTATION I
MARIA NORDIN
WATERCOLOR ON PAPER, 2016.

Anxious kids turn into anxious adults. Behavioral neuroscientist Dr. Jee Hyun Kim explains how treating early fear-based anxiety in children can change that.

Recently my nephew David was born. Anticipating how stressful it may be for my sister and her husband, I flew to Sydney as David turned three weeks.

My desire was to feed and care for the new parents; I have never been maternal nor a “baby person.” I like mature people. Many signs of “maturity” largely involve experience, learning, and memory, so it’s not surprising that younger people tend not to be mature (of course there are always exceptions, like my husband, who is six years younger than me). For example, my younger students tend to struggle with delay of gratification. They often miss deadlines or take months to submit a piece of work, and often the latest of the lot expect feedback the day after they submit. As I give them more responsibility and they start training their own research interns, they experience this aggravation firsthand, and many learn to change their own habits as a result.

When such learning can be accessed later, it is referred to as memory. Memory is a past that becomes a part of oneself. Memory is pervasive. From riding a bicycle to loving our friends and family, memory may be what makes us who we are.

 
Childhood onset of anxiety disorders is a strong predictor for other mental disorders later in life.
 

Three days after meeting David, I was able to change his diaper and help him release gas from his mom’s milk by holding him against my body. More surprising was the change that came over me. The first time I held him for more than 10 minutes, I wept as I promised to love him unconditionally. I told him that we’d have our disagreements, but that I would accept him and be his auntie no matter what. As the tears streaming down my face hit David’s plump red cheeks, his face broke out into a smile. He knew my heart.

I was an anxious child, living in fear that I had to do something or be someone to deserve love. I do not want David to grow up with the same fear.

THE
PSYCHOLOGY
OF FEAR

Anxiety disorders are neurodevelopmental disorders. While the median age of their onset is 10 to 11 years, they can be diagnosed in children as young as three.1 What’s more, childhood onset of anxiety disorders is a strong predictor for other mental disorders later in life.

Despite the significant implications of childhood anxiety, developmental research represents only 5–15% of anxiety studies in the last three decades. This may explain why we lack effective treatments, and why only 20–30% of afflicted children receive mental health services.2 The brain develops dramatically during childhood, which may explain the occurrence of many mental disorders, including anxiety. However, our lack of knowledge about the biology underlying childhood anxiety makes it difficult to reduce and prevent.

In 1893, Sigmund Freud and Josef Breuer first suggested that hysteria (the term they used to refer to an anxiety disorder) is a previously experienced fearful event that remains in one’s memory, triggering anxious thoughts and maladaptive behaviors— what we may refer to as “coping mechanisms,” like substance abuse.3 All these years have indeed shown that fearful experiences, over and above an “anxious personality,” form a critical facet of clinical anxiety.

Maria Nordin, Disorientation VI and IV
LEFT: DISORIENTATION VI
RIGHT: DISORIENTATION IV
MARIA NORDIN
WATERCOLOR ON PAPER, 2016.

The most widely accepted model for studying such fear experience in the context of anxiety is Pavlovian fear conditioning. Pairing an initially neutral cue (like a sound) with an aversive stimulus (like a shock or a very loud noise) later allows the neutral cue to trigger physiological fear responses without the aversive stimulus. But the fear-conditioned response can later be forgotten or reversed by repeated exposure to the cue without any bad consequences. This process is referred to as “extinction,” and forms the basis of exposure therapies in the clinic.

Anxiety disorder patients do not forget fear after extinction compared to healthy controls. “Renewal” refers to the return of fear in a physical context other than where extinction occurred. In these cases, patients may feel fine after exposure therapy in the clinic, but feel anxious at home or work.

“Reinstatement” refers to cases where an extinguished fear returns when the patient is reminded of the initial event. For example, you may have been in a huge car accident that made you too afraid to drive. After therapy, you kick your fear and drive just fine—until you get into a smaller accident, which triggers the original memory of the huge accident and brings back the paralyzing fear of driving.

Lastly, “spontaneous recovery” is when the patient becomes increasingly likely to relapse as time passes since exposure therapy. For example, you may have had a dog phobia that was treated. The day after treatment you are unafraid of dogs and feel great. One month later, however, you may suddenly feel too afraid to leave the house in case you run into a dog.

These types of relapses following successful exposure therapy show that “extinction” is really a matter of replacing an old memory with a new one. Thus, the new “safety” memory directly competes with the old, traumatic memory—leaving the door open for relapse when the fear memory triumphs.

ROOTING OUT
ANXIETY IN
CHILDHOOD

Remarkably, studies of juvenile rodents show that exposure therapy may erase the original fear memory and permanently prevent relapse early in life. Specifically, juvenile rodents do not display renewal, reinstatement, or spontaneous recovery, whereas all three relapse phenomena are observed as rodents approach the adolescent age.4 It is now widely accepted in the scientific community that extinction erases conditioned fear memory in juvenile rodents.

However, a question remains—do these rodent findings translate to humans? Recent findings indicate the answer is yes. While studies that overtly examine fear learning and extinction in children (defined here as eight years old or younger) are scarce, some studies examine how an anxiety disorder changes as kids get older. For example, dental phobia, a common anxiety in children, is acquired from past experiences rather than from having a fearful personality. In previously dental-phobic children, the earlier the painful dental experience, the more likely their dental phobia will decrease over time.5 In other words, the earlier traumatic experiences occur, the more likely it may be for neutral experience to “dampen” the fear memory.

 
Although fear is readily acquired early in development, fear may also be easily treated during this period as young brains develop.
 

Perhaps the best indicator of extinction permanently reducing fear in children is cognitive-behavioral therapy (CBT). CBT focuses on developing personal coping strategies such as meditation and changing unhelpful belief, thought, and memory patterns. Extinction is the fundamental process underlying exposure therapies (confronting fear-eliciting cues in a safe environment), which often form a component of CBT. As with rodents, younger age predicts a better outcome following CBT for children suffering from generalized anxiety disorder, social phobia, and separation anxiety disorders.6, 7 The same holds true for children consistently suffering from PTSD: They reliably show more effective and long-lasting CBT outcomes, compared to control groups and other types of therapy (e.g. relaxation, supportive therapy, and client-centered therapy).8, 9

To summarize, although fear is readily acquired early in development, fear may also be easily treated during this period as young brains develop—changing the nature of extinction from something that competes with the fear to something that erases it.

WHY
ANXIETY
IS HIGHER
IN GIRLS

It’s widely recognized that anxiety disorders occur more commonly in women compared to men. But what many might not realize is that this divide emerges early in life: By six years of age, girls are twice as likely as boys to have a clinically diagnosed anxiety disorder.10

Many rodent studies have historically pooled males and females during the juvenile period, perhaps on the assumption that without psychosocial factors (which we expect rodents not to experience), sex differences are not a factor before puberty. Interestingly, all the rodent studies that observed no relapse following extinction exclusively used males. Therefore, when my laboratory explicitly investigated sex differences in juvenile rats, female rats readily relapsed their fear following extinction, whereas male rats did not.

This suggests that genetic factors, such as sex, may play a role in anxiety disorders in children. This doesn’t necessarily suggest “predisposition” to anxiety disorders due to your X or Y chromosome, though. A recent important discovery termed “epigenetics” has shown that while our genes remain the same throughout life, how the component of each gene is expressed is affected significantly by the environment and our lifestyle. This is why identical twins can start to look different as they grow. And epigenetic changes to our gene expression are mediated differently depending on our sex, with females showing higher pools of chemicals promoting epigenetic changes.

 
By six years of age, girls are twice as likely as boys to have a clinically diagnosed anxiety disorder.
 

In addition, recent human studies show differences in gray matter volume and gray matter mass based on sex starting from eight years of age. In 1,189 children and adolescents aged 8–23 years, females reached the more mature level before their male counterparts in every single measure (gray matter density, volume, mass, and cortical thickness).11 Additionally, regardless of actual age, social anxiety is elevated in girls who show biological signs of puberty early, though the exact reasons why aren’t understood.12

Could this earlier maturation explain why girls are more prone to relapse into anxiety, much like adults? If we continue to paint anxiety disorders with a broad brush, rather than researching differences based on age and sex, we can never expect to adequately treat it.

HOW WE CAN
TREAT ANXIETY
EARLY

The good news is that taken together, the evidence indicates that treating anxiety disorders early in life may permanently reduce fear and prevent subsequent relapse. Yet despite the availability of treatment facilities, only 20–30% of afflicted children and youth receive mental health services.

The easiest way to reduce persistent anxiety disorders in children would be to encourage the use of these services, whether through marketing campaigns, mandatory screenings at school, or other initiatives. Ideal public policies would remove barriers to receiving mental health services, such as accessibility, cost, and lack of research.

For example, government support could mandate resident therapists with CBT training in each pre-, primary, and high school (or groups of schools). In the U.S., only one school psychologist serves roughly 1,500 primary and high school students.13 The U.S. has an enormously high lifetime prevalence of anxiety disorders, at around 30%, which is much higher than other countries, such as Israel (around 5%) and Spain (around 10%). Notably, Israel has one school psychologist for every 600 primary/high school students.

School psychologists should be present in preschools, such as the one my nephew will attend in a few short years. A randomized clinical trial demonstrated that CBT was effective for early childhood post-traumatic stress disorder for children three to six years old. Those researchers recommend that all adaptations of CBT for preschoolers involve parents, age-adjusted metaphors, and imagery through cartoons and drawings, as well as other approaches that adopt the child’s worldview.

Anxiety is predominantly observed in childhood and adolescence, thus funding bodies should challenge studies that exclusively examine adults to include younger cohorts. If we do not shift our focus to anxious and fearful children, we have no reason to expect significant breakthroughs in identifying effective treatments for this prevalent but preventable mental disorder.14 I grew up with anxiety, and still have to combat relapse into thinking that I need to work hard to earn love—but I hope that David won’t have to.

Maria Nordin, Disorientation V and III
LEFT: DISORIENTATION V
RIGHT: DISORIENTATION III
MARIA NORDIN
WATERCOLOR ON PAPER, 2016.
 

ABOUT THE ARTIST: Maria Nordin lives and works in Stockholm, Sweden. She studied at the Royal Institute of Art, Stockholm in 2010 and has since received the Beckers Art Award and had a solo exhibition at Färgfabriken in Stockholm.

 
Sources:

1 Kessler, R. C., Angermeyer, M., Anthony, J. C., de Graaf, R., Demyttenaere, K., Gasquet, I., & de Girolamo, G. (2007). Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization’s World Mental Health Survey Initiative. World …, 6(3), 168–176.

2 Merikangas, K. R., He, J., Burstein, M., Swendsen, J., Avenevoli, S., Case, B., 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 & Adolescent Psychiatry, 50(1), 32–45.

3 Breuer, J., & Freud, S. (1956). On the psychical mechanism of hysterical phenomena (1893). The International Journal of Psychoanalysis. 37: 1–13.

4 Ganella, D. E., & Kim, J. H. (2014). Developmental rodent models of fear and anxiety: from neurobiology to pharmacology. British Journal of Pharmacology, 171(20), 4556–4574.

5 Davey, G. C. (1989). Dental phobias and anxieties: evidence for conditioning processes in the acquisition and modulation of a learned fear. Behaviour Research and Therapy, 27(1), 51–58.

6 Ginsburg, G. S., Kendall, P. C., Sakolsky, D., Compton, S. N., Piacentini, J., Albano, A. M., et al. (2011). Remission after acute treatment in children and adolescents with anxiety disorders: Findings from the CAMS. Journal of Consulting and Clinical Psychology, 79(6), 806–813.

7 Thirlwall, K., Cooper, P., & Creswell, C. (2016). Guided parent-delivered cognitive behavioral therapy for childhood anxiety: Predictors of treatment response. Journal of Anxiety Disorders, 45, 43–48.

8 Deblinger, E., Stauffer, L. B., & Steer, R. A. (2001). Comparative efficacies of supportive and cognitive behavioral group therapies for young children who have been sexually abused and their nonoffending mothers. Child Maltreatment, 6(4), 332–343.

9 Scheeringa, M. S., Weems, C. F., Cohen, J. A., Amaya-Jackson, L., & Guthrie, D. (2010). Trauma-focused cognitive-behavioral therapy for posttraumatic stress disorder in three-through six year-old children: a randomized clinical trial. Journal of Child Psychology and Psychiatry, 52(8), 853–860.

10 Lewinsohn, P. M., Gotlib, I. H., Lewinsohn, M., Seeley, J. R., & Allen, N. B. (1998). Gender differences in anxiety disorders and anxiety symptoms in adolescents. Journal of Abnormal Psychology, 107(1), 109–117. http://doi.org/10.1037/0021-843X.107.1.109

11 Gennatas E. D., Avants B. B., Wolf, D. H., Satterthwaite T. D., Ruparel K., Ciric R., Hakonarson H., Gur, R. E., & Gur, R. C. Age-related effects and sex differences in gray matter density, volume, mass, and cortical thickness from childhood to young adulthood. The Journal of Neuroscience 37(2), 5065-5073.

12 Blumenthal, H., Leen-Feldner, E. W., Babson, K. A., Gahr, J. L., Trainor, C. D., & Frala, J. L. (2011). Elevated social anxiety among early maturing girls. Developmental Psychology, 47(4), 1133–1140.

13 Jimerson, S. R., Stewart, K., Skokut, M., Cardenas, S., & Malone, H. (2009). How Many School Psychologists are There in Each Country of the World? School Psychology International, 30(6), 555–567.

14 Kim, J. H. Reducing Fear During Childhood to Prevent Anxiety Disorders Later: Insights From Developmental Psychobiology. Policy Insights from the Behavioral and Brain Sciences.