A Q&A With Dr. Kendra Read

Anxiety affects 30% of children and adolescents at some point in their lives. Of those, 8.3% are severely impaired by it.

Anxiety in children can be a part of normal development, but unhealthy levels of anxiety can lead to significant distress and impairment in school, social and home functioning.

Unfortunately, patients with anxiety disorders do not always receive the help they need. When they do receive treatment, it is often insufficient or not evidence based.

We spoke with Dr. Kendra Read, an attending psychologist within Seattle Children’s Psychiatry and Behavioral Medicine department, to find out how providers can identify childhood anxiety, which treatment options are most effective and what information they should provide to parents. Read on to learn more.

What does childhood anxiety look like? How can providers identify children who would benefit from treatment?

Read: Anxiety can present in many ways. Stereotypically, it looks a child who is visibly distressed, shaking and expressing their worries, but that’s not always the case. Here are some signs to look for:

  • Patterns of avoidance. A child who is anxious will do their best to avoid the source(s) of their anxiety. If they are successful, they may not show signs of distress, although the avoidance itself is problematic (e.g., avoiding talking or going to school).
  • Emotional outbursts in the face of anxiety-provoking situations.
  • Withdrawal from social opportunities and/or performance anxiety.
  • Excessive reassurance seeking from trusted figures like parents or teachers.
  • Poor attention. Anxiety can affect a child’s attention, causing them to seem inattentive. Consequently, it can be confused with ADHD.
  • Physical complaints: Headaches, stomachaches or sleep difficulties. Children with anxiety may also experience eating problems. They may feel nauseated from anxiety or refuse to eat because they’re afraid they’re going to throw up.

It can be hard to determine whether a provider should pursue a medical evaluation or consider anxiety as the cause of physical symptoms. Families are sometimes more willing to accept a medical diagnosis rather than a psychological one.

I encourage primary care providers to refer patients to Children’s Psychiatry and Behavioral Medicine department for an evaluation if they have any suspicion of anxiety. If the family still wants to explore medical possibilities, that can happen concurrently.

How important is early intervention?

Treatment of children who are diagnosed with an anxiety disorder is sometimes delayed because teachers, providers and/or parents assume the child will simply grow out of their anxiety. However, data shows children don’t overcome anxiety disorders without support.

Delaying treatment allows patients to continue practicing avoidance and engaging in anxious thoughts and behaviors. Anxiety grows, and treatment can become more difficult. As with most things, early intervention is best.

Access to care is a big issue, but err on the side of referring patients for an evaluation early on. We can always provide helpful information to families, even if they don’t meet criteria for an anxiety disorder or they can’t start treatment right away.

How can providers ensure children with anxiety receive appropriate treatment?

Even when children receive treatment, they don’t always get evidence-based therapy.

Cognitive behavioral therapy (CBT) is the gold-standard therapeutic intervention for kids with anxiety disorders. The most important part is “exposures” — the practice of facing one’s fear. Relaxation skills were historically incorporated into all anxiety treatment manuals, but we don’t emphasize them in our groups. Research shows that they are not tied to treatment outcomes and it sends a confusing message to kids (e.g., “anxiety is totally normal but calm your body down!”) Instead, we want kids to remain mindful during anxious situations and learn to ride the wave of anxiety.

Many parents and providers are surprised to learn we want to elicit anxiety in youth during exposures so that they can learn to “ride the wave” of anxiety rather than avoid it. Our goal is not to eliminate anxiety altogether (that would be problematic, as anxiety is an adaptive feeling for most of us) but we help youth and their families learn to cope with it.

This therapy can be challenging. Most compassionate, caring people balk at the idea of making a child do something that makes them anxious or uncomfortable, but research has shown CBT without exposures does not sufficiently treat anxiety disorders.

This therapy is short-term, problem-focused and skill-based. We help kids face their fears by starting with small challenges and working up to the top of their anxiety hierarchy. While we start with easier tasks to gain success and engagement in therapy, we eventually address the hardest and scariest fears or worries. If we don’t, we’re modeling avoidance ourselves.

What should providers tell parents about anxiety in children?

First, providers should not support an anxious child’s avoidance. Often, parents will ask their provider to write a letter excusing their anxious child from school or other things that they are fearful of or worried about (e.g., requests to be homeschooled or enroll in an online school due to anxiety). These allowances only serve to perpetuate the child’s avoidance and gives them fewer opportunities to learn that these events are not as frightening as they think they might be and grow in terms of conquering their anxiety. Instead, providers should refer the family for mental health support.

I also encourage providers to introduce families to the idea of cognitive behavioral therapy and let them know how helpful it can be.

Additionally, I want them to emphasize that anxiety is a totally normal feeling; we all have it to some degree. Anxiety keeps us safe at times, such as preventing you from walking across the street against the traffic light. But, it can grow too big, like a false alarm in the body. Our goal in treatment is to bring down the level of anxiety but not to get rid of it all together.

Finally, it’s important that parents and families know anxiety is not a lifetime disorder. With appropriate treatment, children can learn to cope with it so that they no longer meet criteria for an anxiety disorder.

How is Children’s improving access to care for children with anxiety?

We’ve redesigned our therapy model within our department to improve access to care by implementing a stepped care model. When a patient is referred, we do an initial evaluation. If the anxiety disorder is the primary concern, the family is routed to   our anxiety group series — a nine-week group that provides helpful information and facilitates skill-building for both youth and their parents. Our group was also recently redesigned to allow for more exposure practice within the group series.

At the end of group, the patient’s progress is assessed by group leaders to determine if additional support is needed (e.g., short-term individual therapy, intensive treatment, etc).

Resources for patients and families: