Anne Marie Albano, PhD, professor of medical psychology and psychiatry at Columbia University, New York, and director of the Youth Anxiety Center at New York–Presbyterian Hospital, discusses strategies for treating childhood, youth, and young adult anxiety with Nick Andrews.

Dr. Albano (@AnneMarieAlbano), who also is director of Modern Minds, an anxiety and depression program in Charleston, S.C., spoke with Nick (@Nick_Andrews_) at @TEDMed 2020.

Dr. Albano has no conflicts of interest.

Take-home points

• Early identification of activity avoidance is essential because it is difficult to reverse the cycle of escape and avoidance, and this is all the more difficult with school avoidance.
• Parents should validate that facing anxiety is difficult and that the child might be afraid. The parental role is to help problem-solve ways to manage anxiety, continue to provide exposures, and help the child cope with their fears rather than to accommodating and enabling.
• In 2008, Dr. Albano and colleagues published a randomized, controlled trial in the New England Journal of Medicine showing that sertraline, cognitive-behavioral therapy, or a combination of both are all more effective treatments for anxiety than placebo. The treatment effect degrades over time as the developmental challenges change, so children will need booster sessions or must return to treatment.
• Young adults sometimes misinterpret "normal" emotions of apprehension with overwhelming anxiety that disincentivizes them to engage in activities. Therapy teaches children to "ride the wave" of anxiety and continue to move toward new experiences.
• Dr. Albano is currently developing a program that uses virtual reality to role-play difficult developmental experiences that cause anxiety and help young adults learn how to advocate for themselves and problem-solve through anxiety.

Summary

• Dr. Albano noticed that, when parents do not push children to participate or let them get out of activities, this can exacerbate the child's anxiety. Early identification of avoidance is essential because it is difficult to reverse the cycle of escape and avoidance, and this is all the more difficult with school avoidance.
• As a strategy, parents can offer children a choice of activities and push for the child to choose one of them. Parents should validate that facing anxiety is difficult and the child may be afraid. The parental role is to help problem-solve ways to manage anxiety, continue to provide exposures, and help the child cope with their fears instead of accommodating and enabling.
• The psychotherapy treatments focus on "riding the wave" of emotions that come with new or intimidating experiences and pushing toward exposures. Young adults sometimes misinterpret "normal" emotions of apprehension with overwhelming anxiety, and this confusion disincentivizes engaging in activities.
• Dr. Albano has always integrated parents into treatment. Working with parents means finding the balance between the parents swooping in to help or rescue the child with coaching, setting limits, and pushing children toward experiences that will be exposures to anxiety.
• The biggest challenge is the extent to which technology tethers parents to children and builds dependency.
• More research needs to be done on what types of children progress with specific types of treatment, how long to stay in treatment, how to transition out of treatment, and when to offer booster sessions. Dr. Albano wants to expand treatment out of clinics and to the places in the community where anxiety happens and is at risk of hindering child development.

References

Walkup JT et al. N Engl J Med. 2008 Dec 25;359(26):2753-66.

Kagan ER et al. Child Psychiatry Hum Dev. 2020 Apr 6. doi: 10.1007/s10578-020-009883-w.

Hoffman LJet al. Current Psychiatry Rep. 2018 Mar 27. doi: 10.1007/s11920-018-0888-R.

Chen A. For kids with anxiety, parents learn to let them face their fears. NPR. Morning Edition. 2019 Apr 15.

McGuire JF et al. Depress Anxiety. 2019 Aug;36(8):744-52.

Show notes by Jacqueline Posada, MD, who is associate producer of the Psychcast and consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest.

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