Therapeutic Interventions for Pediatric Anxiety

View episode transcript

Featured Guest: Emily Bilek, PhD

Objectives

• Review the application of cognitive behavioral therapy for anxiety.
• Integrate the use of exposure response prevention therapy into OCD treatment.

Resources

• Behavioral treatment for kids with anxiety. (Child Mind Institute)
• Cognitive behavioral therapy for anxious children: From evidence to practice. (Worldviews on Evidence-Based Nursing)
• Cognitive behavioral therapy with exposure and response prevention in the treatment of obsessive-compulsive disorder: A systematic review and meta-analysis of randomized controlled trials. (Comprehensive Psychiatry)

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Transcript

Dr. Christina Cwynar:

Hello, and welcome to our podcast, Breaking Down Mental Health with myself, nurse practitioner, Dr. Christina Cwynar, social worker Syma Khan, and child and adolescent psychiatrist Dr. Heidi Burns. We are joined today by Dr. Emily Bilek to discuss therapeutic interventions for pediatric anxiety. Dr. Bilek is a clinical psychologist and a clinical associate professor in the Department of Psychiatry. She is also a clinical lead of the department's Child OCD and Anxiety Disorders program. None of the speakers here today have any conflicts of interest or disclosures. We are excited to have you here today.

Dr. Emily Bilek:

Yeah, thanks. I'm happy to be here.

Dr. Christina Cwynar:

Last season we had a guest speaker, Dr. Arango, who discussed cognitive behavioral therapy in general, but also shared with us how CBT is applied in depression. Dr. Bilek, could you start us off by reminding our listeners what cognitive behavioral therapy is and then share a little bit about how it can be helpful for anxiety?

Dr. Emily Bilek:

Sure. So CBT is a skills-based treatment and as you noted, it is used for a wide range of disorders. So depression, anxiety, other concerns as well. And it really hinges on the idea that for any emotional experience that we have, there are three components. There's a cognitive component or what we think in our minds, there's a emotional or feelings component, what's going on in our body, and a behavior, something that we do, usually in response to the strong emotion that we're feeling.

And so for anxiety, just to give an example, my son is seven and he has recently been very clear about the fact that he's afraid of bees. If he was going out into the yard for example, he might have the thought, "I wonder if there's a bee. There might be a bee, it might sting me." So that would be his worried thought in that situation. And then he might have a feeling, uncomfortable feeling of maybe his heart starts racing a little bit more, maybe he starts to sweat, just the discomfort that comes with being afraid. And his behavior might be to run away if he sees a bee, to maybe not go outside in the first place.

And so as you can see with anxiety, there are sometimes unhelpful thoughts and unhelpful behaviors that we engage in when we're feeling anxious. It's not that helpful for me to think when I'm going outside, "Oh my gosh, maybe there's a bee, maybe it's going to sting me." If I'm always on hyper alert, I'm not probably enjoying the outside, et cetera. It's also probably not that helpful to avoid the backyard completely, to run every time I see a bee. And so we think about this, the unhelpful behaviors, the avoiding things that are basically safe enough but that we want or need to do, those are big characteristics of anxiety.

So coming back to CBT, CBT teaches skills to help kids and adults learn and use more effective, more helpful thoughts, focus on more helpful thoughts in the situation. Maybe if my son is feeling scared outside, he might think, "I will probably not be stung, and even if I am, I could cope." So CBT will teach kids through a skill called cognitive restructuring, teach kids to learn how to come up with thoughts like that. And then the main skill in CBT for anxiety is to start approaching fears rather than avoiding. Of course there's other skills in CBT for anxiety as well, things like relaxation, problem solving, very important, but that's sort of the core of it.

Syma Khan:

Thanks so much for sharing that really helpful overview of what cognitive behavior therapy is and understanding that it's a skill-focused therapy and really focusing on teaching youth and their families too at times, strategies to manage those feelings and those behaviors that are occurring that can really cause a significant impact on functioning and ability to engage and do things kids enjoy.

One phrase when we talk about CBT, I hear a lot also is thinking traps or unhelpful thoughts or automatic negative thoughts. Can you elaborate a little bit about what those are within CBT and then what approaches people use to help manage those in a therapeutic setting?

Dr. Emily Bilek:

Yeah, thank you so much for asking that because I think I glossed over this part where I make it seem as though it's really easy to identify a helpful thought. That's a whole process. So the first part is to identify what the unhelpful thought is, and those are often referred to as automatic negative thoughts. With kids, we sometimes call those ants for fun. We can identify what those thoughts are and see if we're falling into very common thinking traps.

These thinking traps, especially for anxiety, the two most common ones are overestimating the likelihood that something bad will happen and underestimating our ability to cope. So that's like if I'm on a plane and I say, This plane is definitely going down," that's overestimating the likelihood. Or if I'm about to give a speech and then I think to myself, "I'm going to mess up and it's going to be the end of the world," that's underestimating my ability to cope.

With kids we come up with nice names that are a little bit easy to remember for these type of thinking traps that just our brain is programmed to fall into, things like all or nothing thinking. That's when you really expect that either this can go great or it'll be a disaster. Any kind of error is a disaster. We also have jumping to conclusions. That's assuming you know what's going to happen or how bad it's going to go.

So once we can show kids about these different thinking traps, then we can help them identify when their thoughts are falling into thinking traps. Even just doing that as an individual, when I say, "Oh, I'm falling into a thinking trap when I think that the plane's going to go down," that gives me some distance from the thought. I'm taking a moment to say maybe it's either not true or maybe it's not that helpful. And that is a first step into getting toward that helpful thought.

Then in the context of cognitive restructuring, what we have kids do, adults do, whatever, is ask themselves some hard questions, things like what else could be true in this situation? What else could happen? What would you tell a friend about this situation if they were in this situation? And by going through some questions, the child can identify maybe a more helpful way to relate to the original thought, which can again get them unstuck from that thoughts portion of the CBT model.

Syma Khan:

One question that I had in follow up was what situations would you recommend using CBT? Like what would be a good case example knowing that people experience anxiety in many different ways?

Dr. Emily Bilek:

Yeah, great question. So I would say that the nice thing about CBT is it is pretty effective and has shown to be pretty effective across the range of anxiety disorders. I'm sure you're aware that there are many different types of anxiety and you might have social anxiety or you might as a child might have separation anxiety or a phobia of bees, for example. There's also generalized anxiety. There's other types of anxiety related to panic. The good news about CBT is it tends to be effective for all of these types of anxiety.

In terms of a case example and how we might use CBT, I gave that example with something concrete like bees, but I think it can also be helpful to think about it with something maybe a little bit more abstract that comes up a lot for kids, which can be social anxiety. I am going, and this is a timely example because kids are about to go back to school, they're thinking, "I haven't seen these kids in three months and I'm going," and the thought that might come up is, "What if I have no one to sit with at lunch? How will I cope if I have to sit alone or what if people laugh at me?" So those would be some unhelpful thoughts that might come up in the context of social anxiety.

Same types of physical feelings, maybe also some discomfort in the stomach or we hear about headaches and tension and things like that. And then the behavior is of course similar. Avoidance, wanting to stay away from the lunchroom. I can't tell you how many of the patients I work with have never been in their school's lunchroom and are eating in the art room or eating in the counselor's office, which is lovely that those are opportunities for them, but it's just a very clear example of avoidance. "I don't know if I could cope with being in the lunchroom." And so then to apply CBT, we would use things like cognitive restructuring to identify that thought of, "I don't know if I could cope in the lunchroom if I had no one to sit with."

We're not trying to be overly positive, have the child think something that they don't believe, "Oh, I'm going to run into the lunchroom and have 10 friends come up to me and the lunchroom's going to be the best experience ever." We want it to be helpful and maybe it's something like, "I may not have anyone to sit with on the first day, but maybe I'll see someone I know and I can ask if I can sit with them. Or maybe over time I will find my group. I probably won't find them if I never go to the lunchroom, but if I start to go, I might be able to accomplish that." So that would be one way that you might come up with a more helpful thought. And then for the behavior, it's doing the opposite of the avoidance. Having kids in a structured systematic way make plans to go into that lunchroom and maybe even find someone to sit with.

Dr. Heidi Burns:

Let's switch over to another topic. We had talked about the diagnostic criteria for OCD last week, Obsessive Compulsive disorder. Why don't we talk a little bit about the treatment for that, specifically exposure response prevention therapies?

Dr. Emily Bilek:

Yeah, wonderful. So, OCD is like anxiety and it sounds like you guys have talked about the diagnostic criteria recently. One way I like to think about OCD is sort of in its relation to anxiety. So OCD is characterized by sudden intrusive, very frightening or aversive thoughts. These are what we call the obsessions. These are intrusive thoughts. And then because it's so fear-provoking, behaviors to make that feeling reduced, to start to feel better, to get relief. If we come back to the bee example, there's some similarity there. My son has the thought of, "I'm going to get stung by a bee," and then he avoids because that's too scary. With OCD, I would say the big difference is that the intrusive thoughts either come out of nowhere or maybe they're related to the situation that you're in, but they are not logical and they're really sticky. You can't make it go away.

And so kids or individuals with OCD, do dramatic or drastic things or again, things that are not super logical to try and make that fear go away to make themselves feel better. It's always easier to understand with an example. If I am someone with OCD and I have a fear of contamination and germs, I might think that if I touch the doorknob, I'm going to be contaminated. And that's my intrusive thought and I can't make it go away with logic. I can't reason my way out of it. And so I do things to try to make myself feel better, maybe repetitively washing my hands until I feel like the anxiety or the fear has gone away. And again, it's not related to my hands being objectively clean, it's just when it feels safe.

This is a long way of getting to your question about what is ERP and how does it relate? Exposure and response prevention often referred to as ERP. It really is a component of CBT and it really is like the CBT we do for anxiety, but without the cognitive pieces, because you can't really logic yourself out of OCD. So instead we focus on having children systematically approach their fear, do the opposite of what their OCD tells them to do, and then resist the urge to engage in the compulsion. So a child who's avoiding door handles because they're afraid of being contaminated and washes hands repetitively or excessively, the exposure would be to ultimately holding on to the door handle. That's the exposure piece. I'm going to invite in this intrusive thought that I'm contaminated. And then the response prevention is to not wash your hands afterward.

Syma Khan:

One thing I've heard within ERP often is kind of identifying or creating a hierarchy of fears for children and youth. So helping gradually increase their exposure to things that are distressing to them. Would you like to just share a little bit about that process?

Dr. Emily Bilek:

Yeah, that's a great question because it is a important part of the treatment and it can be a challenging process. So sometimes called a hierarchy, with little kids I like to call it a ladder because it's an easier word for them to understand. But the goal is just as you said, to come up with things that are difficult, but doable and at different levels of difficulty. So sometimes we'll just brainstorm them. What are things you've been avoiding? What makes it easier? What makes it harder? Would it be hard to touch the doorknob? Would it be hard to stand close to the doorknob? Would it be hard to lick the doorknob? And obviously some of those will be easier or harder for the child, and we usually put them in order like a ladder and the things at the top are the hardest. And we work our way up because once you do easier things, you start to believe that you can do the harder things. You see that it's working.

I mentioned licking the doorknob. I'm not saying that we always do something like that, but with OCD in particular, we often over correct. Again, doing something that's reasonably safe, but that is going to really drive home the point to the child that their feared outcome is not going to come true. And so sometimes by overdoing it, it really unlocks a whole bunch of behaviors that they've been avoiding that are more normal in their day-to-day.

Dr. Heidi Burns:

Syma, I'm glad you brought up that hierarchy, that latter piece, just so that people don't go out and start having their anxious child or their OCD child just go straight for the top most scary thing and that can even worsen it, right?

Dr. Emily Bilek:

Oh, totally.

Dr. Heidi Burns:

If you're not doing this in a gradual way with a professional.

Dr. Emily Bilek:

I would say that is totally true because if you pick something too hard, then the child is going to avoid, right? If they're not ready to do it, if they don't find it doable and they avoid, then it reinforces that fear. The other thing I'll say is for parents, we don't want to force our children to do exposures for a lot of reasons. I mean, the child should always have consent, but also because it can really make the relationship with your child more difficult since you aren't their professional. So I do say you don't want to force them to do exposures, but you do want to give them lots of opportunities. So you can make opportunities for them to face their fears without forcing it of them.

Dr. Christina Cwynar:

As you just mentioned, parents and helping support children with anxiety. Could you talk a little about SPACE?

Dr. Emily Bilek:

SPACE, which stands for Supporting Parents for Anxious Childhood Emotions, it is a parent-focused treatment, a parent-delivered treatment for anxiety. By that, I mean the child does not attend the therapy. And it is therapy that has been developed by Eli Leibowitz, Dr. Eli Leibowitz, I believe he is out at Yale. And the treatment really centers around the fact that for parents with anxious children, the parents are often pulled into the anxiety, asked to do things to accommodate the child's anxiety, or just because a parent facilitates so much of a child's life is really the person who decides whether the child approaches or not. So if a child is begging not to go to school, at the end of the day, the parent is to some extent the one who decides if the child goes to school. And we believe that by accommodating the anxiety, by doing what the anxiety wants, which is to avoid, parents can unintentionally maintain or sometimes exacerbate the anxiety.

Children are going to ask for reassurance. They're going to say, "Are you sure it's going to be okay?" And as a parent, all you want to do is give them that reassurance, but with anxious children and when it comes over and over again, it stops being helpful. So this treatment, SPACE, is focused on helping parents learn skills to support their child and provide warmth and validation, but not provide accommodation so that the child can get better. And there's research that shows that even without providing any therapy to the child, families who go through the SPACE program, the child does reduce their anxiety.

Syma Khan:

I think that's so helpful to hear because I think it can be so distressing for a parent to see their child anxious, overwhelmed, and so that accommodation feels natural. I'm being supportive, I'm being helpful. But within anxiety, it creates that cycle where the youth feels reinforced that this is something unsafe and I need that validation. And so it kind of almost provides parents a space to be able to learn strategies that they can also then teach their child by reassuring them in a way that's therapeutic or not reassuring them at times.

Dr. Emily Bilek:

But I think that's such a good point. What is therapeutic? What can parents say? Because I do think that especially with this reassurance we're talking about, when children ask for it over and over again and the parent provides it over and over again, at some point they get fed up and they probably say something unhelpful of like, "Gosh, can't you just do it?" And SPACE teaches this really beautiful model of walking the middle path, of validating the feeling behind whatever the avoidance behavior is or the reassurance is, and showing confidence in their child. So it might be something like, "You're asking if, I'm sure you're going to be okay. I can't answer that question, but I can tell that you're so anxious. I'm sorry you're in distress and I know you can do it. I know you can do this. I've seen you do it before." So it's those two pieces that Dr. Leibowitz talks about of validating the feeling and conveying confidence in your child's ability to proceed with whatever the task is.

Dr. Christina Cwynar:

I think as a mother myself, and I know there's a couple other of us around the table who are also mothers, it's really nice to hear that there's something else we can do in the home because as parents, we always want to help. So not to switch too much, but one of the, I guess, analogies we like to use with children or adolescents who have anxiety is the concept of riding the wave or the roller coaster, however you want to describe it. Could you share a little bit about those concepts?

Dr. Emily Bilek:

Yeah, absolutely. I think it's a great metaphor, especially for sitting with discomfort and not needing to do anything to make it go away. So I think when people use the idea of riding the wave or surfing the wave, the idea is that a wave goes up and sometimes it goes up really, really high. And if you wait it out, it will come down. A wave does not go up, up, up forever. It eventually plateaus and comes back down. And our emotions are like that. They can feel so uncomfortable, as if they're going to skyrocket forever. And oftentimes when kids are at that inflection point of where they're just feeling so uncomfortable or scared or whatever, that's when they avoid and in their mind it reinforces that was just going to get worse forever. And if they can learn to ride it out, to sit with that discomfort, not need to do anything to make it go away, they will eventually get to the point where it plateaus and goes down and they learn something else. That it didn't go up forever, that they could cope.

Syma Khan:

And I think that riding the wave metaphor, surfing the wave can also sometimes help with panic. It feels like in that moment it's never going to end, it's going to be forever, I'm going to have a heart attack, but then reassuring that this is not going to cause an adverse medical outcome, and we know that that panic attack will end, it will feel like forever, but you will get through it and things will get better. So it's kind of helping provide that reassurance and maybe strategies to kind of manage the physical distress that may be occurring.

Dr. Heidi Burns:

Dr. Bilek, we've talked about a lot of really great concepts related to anxiety, and I'm wondering if you have any sort of quick tips or things to think about for a parent or maybe for a provider, a healthcare worker who might come in contact with a kid who's having anxiety or having a panic attack, something like that, things that they can do or they could say that might be helpful to children and teens with anxiety.

Dr. Emily Bilek:

Yeah, it's a great question, and I'm sure we're all aware of the increasing rates of youth anxiety. It's been referred to as an epidemic. So yeah, the odds are great that people will come in contact with the youth with anxiety, which is unfortunate. And there are really somewhat straightforward tips that people can follow to help their child to help someone else that they see in distress.

Coming back to panic, panic attacks that both of you have recently referenced. What I think about with panic attacks, when we see someone else in that type of distress, they feel like they're dying. It maybe looks like they are not going to make it through. It can feel as an outsider or especially as a parent, like you need to do something right now to take that away. And I think the most helpful advice that I've given to caregivers or to friends, people observing is to remain calm.

If you can project calm, you're going to be showing the person who's struggling that you're confident that they can get through it. You can project that in so many ways, do what's right for you, whether it's through a calm voice, whether it's through your words and saying, "This is so hard. It's going to pass and I'll be here with you as it does until it does." With children, similar things. And I think it's hard as a parent, as we've discussed, to not do something to take away your child's distress. And probably the most helpful thing you can do is to stay calm, be steady, and again, convey that confidence. They're going to get through this. They'll probably be stronger for it on the other side.

In terms of other general recommendations for dealing with children with anxiety, you don't need to use your kid gloves with them. They are really resilient. I think kids with anxiety are some of the toughest kids because they feel really distressed a lot of the time and they're making it through the day, so we don't need to tiptoe around them. We can project that confidence that they can do hard things. They're doing hard things all the time. And I like to remind my patients, like to remind my kids, whomever else I come in contact with, "Here are the things I've seen you do that are so hard. I know you can do this one too."

Syma Khan:

Dr. Bilek, if you had one thing you wanted people to take away from this conversation, what would it be?

Dr. Emily Bilek:

Yeah, I am maybe a little bit of a broken record because I always come back to approach. I think that everyone here can relate to this. At some point in our lives, we've had something that we were afraid of that we were either avoiding or doing really hesitantly that got easier with practice. You may not have had any therapy, but this is probably true for you. Whether it was learning to drive or drive on the highway, whether it was public speaking, making phone calls, I'm sure you can think of something in your life, diving off the high dive, something was hard at first and you did it and you did it and it got easier.

And that is all that we're asking kids to do, and that's all that I'm encouraging you to do is there is so much to be gained when there is something holding you back that something that is again, relatively safe that you want or need to do, turning towards it rather than away will probably bring you a lot more fulfillment, meaning, and pride than continuing to listen to that voice in your head that tells you that you can't do it.

Syma Khan:

I think throughout the season we've learned that anxiety is this very normal emotion, we all experience it. And I think really reflecting that these therapies and these resources are helpful when it feels like it's impacting us and impacting the youth that we work with, that they can't do the things that they enjoyed. And so it's I think, really helpful to kind of recognize that and then help normalize it in a way, and then also recognize that we've all learned skills throughout our own lives to be able to manage that. Yes, when I drove on the highway the first time, I was very anxious.

Dr. Heidi Burns:

Yeah.

Dr. Christina Cwynar:

Well, Dr. Bilek, thank you so much for your time and sharing your expertise with us. We truly appreciate it. Thank you to everybody for joining us this week. We hope that you join us next time. For nurses, social workers and physicians, you can claim CMEs and CEs at uofmhealth.org/breakingdownmentalhealth. We'll see you next week.