your four-year-old child the two of you
just stepped off the tilt-a-whirl and
you’re feeling dizzy and giddy and you
reach into your pocket to get some more
tickets as you do your child’s hand
slips from your own and then in an
instant your child is gone you scan the
park you shout your child’s name
you see colourful lights greasy food
carts tantruming children but no child
he’s vanished so your breathing starts
to speed up and your heart starts to
pound and your stomach drops your brain
runs through the horrible things that
could have happened to your child you’ve
lost control of the situation and then
suddenly you look across the park and
there’s your child your mind and your
body immediately begin to settle you
regain control of the situation many of
us have been through at least one highly
anxious experience in our lives but then
the situation resolves or we figure out
how to manage that situation and our
anxiety abates the mind and body
recalibrate we adjust but what if there
were no relief what if you walked around
every day with a feeling that your heart
was pounding in your chest and that you
couldn’t breathe what if your brain was
constantly telling you that the scariest
most horrible things were going to
happen and that the world felt like an
out-of-control and unsafe place now
imagine that you’re 7 or 10 or 15 and
that this is your daily reality this is
what we need to understand about anxiety
and what it’s like to experience it the
word anxiety has become so overused
everyone has it right that the word No
anger seems to capture how debilitating
it can be when it reaches a level of
clinical diagnosis and I should be clear
worries and fears are a normal part of
childhood development and many children
go through phases where they fear the
dark monsters thunderstorms even
automatic flushing toilets that used to
get me as a child and stress is
everywhere in a recent survey of about
750 youth nearly 8 and 10 reported
experiencing stress on a daily basis but
what I’m talking about
is something very different anxiety
becomes diagnoseable when it’s extreme
and it gets in the way of living a
normal life if a child is up night after
night ruminating if that child
experiences chronic stomach aches and
headaches and avoids people or places or
things that child could receive an
anxiety diagnosis and needs treatment as
you can see from the red line in the
graph anxiety is the most common
psychiatric disorder across development
as compared to behavioral mood and
substance use disorders and if you look
across the bottom of the graph you can
see that rates of anxiety increase
across development epidemiologic data
tell us that 13 to 20 percent of
children and adolescents meet criteria
for an anxiety disorder in the US
according to the National Institute of
Mental Health 80 percent of these
children are not receiving treatment so
let me see that again
that’s nearly one in five children who
are struggling to learn to interact and
to enjoy life because of an anxiety
disorder and 80% of them are not
receiving treatment sadly even fewer
children are receiving treatments that
have been supported by research without
appropriate treatment anxiety tends to
persist into adulthood and this of
course matters because anxiety is
destructive to children social emotion
and academic functioning it can be the
gateway to other disorders including
depression substance abuse and
behavioral problems this place is a
massive toll on our children our
families our educational system and on
our society the story I’m going to tell
today is about the debilitating nature
of pediatric anxiety and our attempt to
address this problem it’s also a story
about building on best practices to
develop outside-the-box solutions Kim is
a teenager who struggles from severe
anxiety and she gave me permission to
tell her story Kim had had an anxious
temperament from the very beginning she
was the child in preschool who would
grip her mother’s leg at goodbyes and
she was painfully shy in the second
grade
Kim was at a restaurant and she
witnessed a man caught up phlegm into
his meal two weeks after that she
developed a stomach virus and began to
vomit uncontrollably these two events
triggered an overwhelming fear of
vomiting you may be surprised at this
example because nobody likes vomiting
right but for Kim this fear was
all-consuming and we’ve actually seen
many children in our clinic whose
anxiety began with this specific fear
for Kim she started to have panic
attacks when she went into public places
where she thought she could get sick and
then she started to restrict her eating
to avoid the possibility of vomiting as
the anxiety began to cascade Kim pulled
back she stopped going to stores then
restaurants and then she stopped going
to school when I met her she was 14 and
had been out of school for nearly two
years she was spending her days at home
alone essentially confined to her
bedroom because of anxiety while her
mother was out working to support the
family she had become depressed and she
was sold
of practice of interacting with other
teenagers that she had developed social
anxiety kim was hospitalized twice
because of these symptoms and she was
actually put on a feeding tube and she
had been seeing her outpatient therapist
on a weekly basis for years without much
change Kim’s mother watched helplessly
as her daughter became debilitated by
fear and by sadness the question is how
can we help a child like Kim reclaim her
life from anxiety cognitive behavioral
therapy or CBT is currently the gold
standard therapy for anxiety many of you
probably heard of CBT it’s a structured
form of therapy that teaches people to
manage their feelings by modifying their
thoughts and their behaviors the
cornerstone of CBT is exposure and
that’s the behavior part exposure
essentially means facing one’s fears and
a gradual and structured manner to learn
that that worst-case scenario fear
likely doesn’t happen or that if it does
CBT takes place in the office once a
week for 50-minute sessions this has
been our standard of care for 50 years
and it works for many kids but for
children like Kim with more severe and
entrenched anxiety it can be extremely
difficult to gain traction in weekly
50-minute sessions in the office in fact
research indicates that nearly half of
children and adolescents who participate
in weekly CBT for anxiety
do not get better over the years my
colleagues and I have seen many children
like Kim who’ve been in weekly CBT for
months and even years and they’re still
stuck the longer these children are
stuck the farther they fall off the
developmental curve and the harder it is
for them to get back on track these
children are not failing treatment our
best treatments are failing them
so my colleagues and I broke from
tradition three years ago with a support
of McLean Hospital we developed an
intensive group based program for
children and adolescents with anxiety
called the mclean anxiety mastery
program or MAMP in designing the program
we increase the length of CBT sessions
we increase the frequency of these
sessions and we increase the number of
CBT sessions that were taking place
outside the office in the community so
that children could engage with their
real-life beers at man children
participate in treatment for afternoons
a week for two and a half hours at a
time largely out in the community they
also participate in weekly family work
and medication consultation sessions and
in the course of a month of treatment at
man children receive nearly a year’s
worth of weekly outpatient therapy so
what does this look like and practice
well I’ll tell you what it looked like
for Kim after being housebound for two
years Kim was literally unable to enter
the clinic so we met her in the car and
with daily support in the families
Toyota Kim gradually learned how to
tolerate your panic symptoms and she
built the confidence in the trust to
start engaging in treatment in a
meaningful way and I can remember the
day the Kim decided she was ready to
leave the car she came inside the
building and she joined group a
seemingly small step but for Kim this
was a huge exposure her whole face was
red her body was trembling and she was
hyperventilating but she did it once Kim
was engaged in our daily CBT skills
group she gained the skills and the
strategies to start managing her extreme
anxiety for example she learned how to
use relaxation strategies to calm her
body at night and she learned to use
mindfulness to stay more present during
the day Kim also gained the practice
interacting with other children and
group which was a powerful experience
for someone who had been so socially
isolated Kim’s family was also involved
in treatment
her mother had daily contact with the
treatment team and over time she learned
to step back as her daughter was
struggling with anxiety rather than to
reach in and protect and Kim met weekly
with a program psychiatrist for
medication consultation sessions the
foundation of Kim’s treatment was
exposure we exposed her to Harvard
Square the noise the traffic the people
can you imagine what this would be like
after being housebound for two years we
wrote on buses and subways we went to
stores and restaurants and Kim ventured
farther and farther out of her comfort
zone each day and finally Kim was ready
to face her big fear we exposed her to
vomit and yes I spared you that slide we
made a fake vomit mixture that Kim
looked at and smelled and ran her hands
through and then one day Kim was exiting
the subway after an exposure she started
to feel a little queasy and then she
threw up all over her feet for Kim this
was a pivotal moment in treatment she
faced that worst-case scenario fear and
she saw that she could handle it with
this type of daily intensive support Kim
was finally able to get unstuck the team
and I credit the intensity and the
flexibility of the treatment model in
helping Kim reclaim her life in about 6
weeks time
had we tried to treat her once a week
for 50-minute sessions in the office I
honestly don’t know where she’d be today
so where is Kim now two years later Kim
is back in school and she’s attending on
a daily basis she’s taking honors
classes and she has a job as a cashier
at a local store her mom even emailed me
last week to tell me that she had won a
regional science fair Kim is now going
to museums to hockey games to stores and
restaurants
she still has bouts of anxiety but she
doesn’t let them hold her back from
living a full life and I think what
strikes me the most is that Kim is now
allowing herself to appreciate the
smaller more subtle things that truly
make a meaningful life recently she was
in the car with her mom and they were
listening to the car radio and she said
I’m not sure if the songs are better now
than they used to me or if I’m just able
to appreciate them more so do we have
this figured out not yet our own
research at map shows that kids do
experience significant improvement over
the course of treatment but we don’t yet
know the optimal dose of treatment or
whether it varies by anxiety disorder we
have a lot more to learn and more work
to do but at least we have some renewed
hope for children like Kim and now as an
audience you’re probably waiting to hear
your takeaway I of course want you to
better understand the challenges that
children with anxiety face and this new
model of treatment but I also want to
ask you to consider breaking from
tradition when facing a serious problem
or a challenge in your workplace
wherever that may be get together with
colleagues and build on best practices
by developing a new model and testing it
even if it’s messy and I mean fake vomit
messy or means risk and failure if it
affects the life of just one student
like Kim it could make all the
difference thank [Applause]