Dr. Jack Krasuski: Dear colleague, welcome. It’s Dr. Jack Krasuski here this afternoon with Dr. Marco Grados. Dr. Grados, thank you so much for joining us here at the Wild Dunes Resort outside of Charleston. One of your talks today was about anxiety disorders and youth. What would you like to tell us? Give us the highlights of what you believe is important for us clinicians to know about treatment? What does our current knowledge base direct us towards?

Dr. Marco Grados: Thank you for the question. Thank you for the invitation. Anxiety disorders in youth are important for a few reasons that are quite salient today. One is, they’re on the increase. I had mentioned in the talk there may be different reasons, not the least of which is the increased scrutiny of everyday life through social media and the higher understanding of parents and the public about anxiety it seems, so more and more children are coming to clinics for the treatment of anxiety, the evaluation of anxiety and even primary care. Many of our projects currently in our institution have to do with working with pediatricians. I did talk to a few of the attendees here who were pediatricians, which is interesting and good to see because they present there with the anxiety disorders. Often, they come to the therapist and psychiatrist at the second or third stage of their journey through treatment.

Impact of Early Appearance of Anxiety Disorders

The second thing to say is that it is a condition which appears early in life, whereas schizophrenia, bipolar, even major depression will appear in late adolescence or early adulthood. Anxiety disorders appear early in life. Often they impact the trajectory of the child in a way that yet unknown, however, we suspect that they may make those disorders that appear later in life more likely to occur and they occur in more severe forms because the anxiety was not treated at that stage. Having said that, it impacts the child at the time of the occurrence of the disorder and in many ways. It affects social life, affects grades, sometimes they refuse to go to school. It affects self-esteem and quality of life.

We have a phenomenon that we talk about in children with anxiety in our clinics called accommodation, and it goes both ways. The children are anxious, and the parents are anxious, so the quality of life of the families are very much affected in many ways.

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Cognitive Behavior Therapy Interventions

The interventions, this is the third point, are quite effective. We know that 70% to 80%, even in moderate to severe cases of anxiety, do very well with appropriate treatment. Here’s where we run into the dilemma from for health services where we know that the cognitive behavior therapy interventions, along with the SSRIs, especially for anxiety, medications are quite effective. The access to them is not easy for families, especially for CBT. I did mention and talk about CBT being a good tool in the lab, in the efficacy studies where everything is very structured or regulated, but when you go into the community not that many therapists are well trained and deliver CBT according to the manual. There are lots of variations and families may not getting the real CBT.

Dr. Jack Krasuski: Right. Even a therapist who clearly identifies themselves as providing CBT and trained in CBT, they will often not integrate exposure therapy, as you were pointing out, and exposure therapy is only one part of the behavioral therapy. A therapist could be giving cognitive restructuring cognitive therapy, and even some aspects of behavioral therapy, like relaxation, so they really are [00:04:31] mating CBT, they are giving it, but for a lot of anxiety disorders, as you pointed out, it’s the exposure which may be the most effective, the mechanism of change and yet often that isn’t given. My joke is sort of like the other stuff you can kind of do sitting down. The exposure you have to kind of get off your butt. I’m not surprised that sometimes it kind of falls by the wayside.

Dr. Marco Grados: It does, and at many levels you have to do what you just said, because you just have to physically do it. It can be the hardest to do.

Dr. Jack Krasuski: Right. There is a resistance because you’re exposing the person to anxiety. Obviously, people with anxiety, they’ve probably often perfected the maladaptive, but the coping mechanism of avoidance and escape, and now you’re trying to break that, so there’s going to be resistance, sometimes even from parents, let alone from the patient.

Dr. Marco Grados: Yes. The parents both feel the stress. You’re causing my child distress. Are you really asking me to do this?

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Dr. Jack Krasuski: Right. Right. Give them a pill. Give them a pill instead.

Dr. Marco Grados: And they do have homework to do.

Dr. Jack Krasuski: Right.

Dr. Marco Grados: It is an art as well as a science. But it is challenging to do exposure. I will also add, especially for children, often they do not have the cognitive wherewithal to go to deep cognitive restructuring or those cognitive techniques that adults can use better, so even more critical for children to engage early in more exposures than adults.

Dr. Jack Krasuski: Thank you. Great point. The other thing that was very important for me to learn from your lecture was you pointed out that in medication trials of anxiety the placebo response is quite a lot lower in depression. One implication of that is that anxiety disorders tend not to just resolve on their own. As you mentioned, the treatment, when done right, can be extremely effective. At 80%, that’s awesome. We should celebrate that, and yet without treatment, it can often continue. It starts early in life, right there, these temperamental predispositions and it just can continue. Also, thank you for pointing out that the early childhood anxiety can then actually lead to this cascade of other psychopathology. I think that’s very important, so I thank you for that, for that lesson.

Mechanisms to Prepare Children for Later Years

Dr. Marco Grados: As you’re talking, of course, my brain is going, yes, this is correct, and then also to mention that the mechanism of neuroplasticity is higher in children, and there is research to show this. That is why we favor the exploratory therapy. But it also could be a common mechanism for other disorders, so if you deal with that mechanism early in life, you’re more prepared, because the vulnerability will be there. Depression also has a genetic basis and also bipolar and schizophrenia. Especially bipolar and depression may respond to neuroplasticity mechanisms as well. We’re preparing these kids for later that may be less severe than it could have been otherwise.

Dr. Jack Krasuski: If you could put it in a nutshell, what would you recommend to us clinicians when it comes to treating anxiety disorders? I mean, obviously there are nuances between different ones, but as a class, what would you say would be the take-home message for us when treating anxiety disorders?

Child Psychiatrists and Pediatricians

Dr. Marco Grados: On the pharmacology side, the SSRIs are pretty well established. There are choices between them and there is also a hierarchy of which you should probably try first. That’s more or less worked out and even pediatricians should be encouraged with support from a child’s psychiatrist who prescribed these for anxiety disorders. Many states have tip lines where the pediatrician can call support from a child psychologist. We have it in Maryland. It exists in Pennsylvania. It started in Massachusetts. Encouraging and empowering pediatricians to do this as well as educating everybody in the field. That’s the first thing.

The second thing is harder, right, the access to CBT, having pediatricians as well as child psychiatrist networks that they can operate when they are confident that children are going to get established structured CBT as it should be.

Dr. Jack Krasuski: Yes. That’s not going to be easy, but at least now you’ve alerted us to what question to ask or how to vet the therapist that we prescribers may want to kind of collaborate more closely with, so that’s important in itself. Dr. Grados, thank you so much for this brief talk, I’ve learned a lot, and also just for joining us for your two presentations. Thank you again.

Dr. Marco Grados: Thank you for the opportunity.

Dr. Jack Krasuski: Thank you.