This weeks question is from Rebecca,
“My 9-year-old daughter has always been what I would describe as a worried or more anxious child. But in the past year, with COVID, it has really ramped up. She has developed fears around doing things that didn’t use to be a problem for her, including going to school. She is more clingy to me and concerned when I leave the house, and bedtime has become more frustrating because she doesn’t want to sleep alone.
I raised these concerns with her pediatrician, who said she has an anxiety disorder and gave me a referral to a local counselor who works with kids. He also told me that she probably needs medication and offered a prescription which I was not interested in at the time. Now the counselor has met with her a few times and tells me that my daughter doesn’t really open up in sessions and has severe anxiety that will require medication to treat. I feel conflicted about all of this because I’m not sure anyone is really looking at what’s going on, and I don’t want her on medication if there are other things that can be helpful. Are there alternatives to anxiety medication? Thanks for any insight you have.”
In this episode, I will discuss how to communicate with your child’s provider when you don’t agree with their recommendations, especially when it comes to prescribed medication. There are many, very effective, non-medication treatments for anxiety. I will also briefly discuss the many inputs that may be causing the child’s anxiety. Ultimately it’s important to trust your gut, parents often know best when it comes to their kids.
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How to navigate non-RX treatment for anxiety with the prescriber
- A definitive mental health diagnosis from a brief appointment is generally not appropriate
- There should be an extensive evaluation process before any mental health diagnosis including looking at all possible underlying issues
Honor your intuition if the practitioner recommendation doesn’t feel right
- Ask more questions and/or seek out multiple opinions
- Remember, in the initial visit(s), a diagnosis is almost always subjective
- There is quite a bit of opinion and perspective on the part of the practitioner in terms of how they’re viewing the symptoms, how they conceptualize a diagnosis, and suggested treatment
Some anxiety is a normal human response
- When anxiety impacts normal life activities, it’s time to look deeper
- Anxiety can stem from many things in children and adults. For example, the birth of another baby in the family, death, divorce, change of school, being bullied, etc.
- It is common to see anxiety across the board for adults and children during the pandemic or when life has been turned upside-down
Evaluation of possible underlying issues
- Rule out any infections or physiological issues such as trauma
- Consider lifestyle factors such as nutrition, sleep quality and quantity, screen time, physical activity, and outdoor time
- In the vast majority of cases, when you address these underlying kinds of issues, psychiatric medication is not something that’s needed
What are the first-line approaches for child anxiety?
- Counseling or psychotherapy with professionals who are licensed and have specialized training in working with children
- Medication should not be a first-line recommendation for child anxiety and should only be considered if the child is not making progress after receiving multiple good-quality therapy sessions
- Education for parents in groups or individual therapy for tools to support the child
- Very few children are ready to engage and open up during the first handful of therapy sessions
- If the child is not opening up over time, medication is usually not the answer, rather it may mean it’s not a good fit with that therapist or approach
- Remember, it is the therapist’s job to figure out how to help the child open up
- It is not the counselor’s place to say the child needs medication, and definitely not in the first few sessions
- If medication is truly needed, it should be referred out to a licensed prescriber for further evaluation
Are medications appropriate for kids with anxiety?
- Psychiatric medications are not well-tested in children
- Psychiatric medications are ineffective at best for most kids with anxiety or mood issues or behavioral challenges
- At worst, psychiatric medications can cause a lot of very serious side effects, which is not something that gets advertised a lot
- Even for the very small percentage of kids who truly do have a very significant benefit from these types of medications, the real benefit comes from combining with good psychotherapy and skill-building to give kids tools and strategies for managing the challenges and complexities of life or managing their mood and anxiety
Episode intro … 00:00:30
My child has become overly anxious … 00:00.59
Navigating non-RX options with your doctor … 00:02:29
Honor your intuition … 00:04:36
These things can cause Anxiety …00:07:06
Evaluation of possible underlying issues … 00:09:04
Medication for child anxiety… 00:11:22
Counseling strategies … 00:15:12
Are there alternatives to anxiety medication? … 00:19:00
Episode wrap up … 00:23:45
Dr. Nicole Beurkens:
Hi everyone, welcome to the show, I am Dr. Nicole, and on today’s episode, I am answering a question from a listener. I get so many questions from all of you each week, and this is a great way to provide answers that many of you may find helpful. If you have a question you’d like me to consider answering on a future episode, email it to firstname.lastname@example.org and you just might hear it on an upcoming show.
Now, onto today’s question, which is from Rebecca. She writes: “Hi Dr. Nicole. I love your show and listen to every episode. I’d be so appreciative if you could answer this question about my 9 year old daughter. She has always been what I would describe as a worried or more anxious child. But in the past year, with COVID, it’s really ramped up. She has developed fears around doing things that didn’t used to be a problem for her, including going to school. She is more clingy to me and concerned when I leave the house, and bedtime has become more frustrating because she doesn’t want to sleep alone. I raised these concerns with her pediatrician who said she has an anxiety disorder and gave me a referral to a local counselor who works with kids. He also told me that she probably needs medication and offered a prescription which I was not interested in at the time. Now the counselor has met with her a few times and tells me that my daughter doesn’t really open up in sessions and has severe anxiety that will require medication to treat. I feel conflicted about all of this because I’m not sure anyone is really looking at what’s going on, and I don’t want her on medication if there are other things that can be helpful. Are there alternatives to anxiety medication? Thanks for any insight you have.”
Rebecca, thanks for sending in this question, and I know that this will be a valuable response for many of the listeners of this show, not just with kids who have anxiety, but parents in general who are concerned about maybe rushing to a prescription medication or who are concerned that their child’s real issues aren’t being identified when they’re talking with practitioners about potential treatment. So I’m going to structure my response to this question, not around what might be helpful from the standpoint of treating the anxiety, because certainly there are many, many things that could be helpful there, but I’m going to really focus on what I think the root of the question is, which is how parents should handle it when they feel like healthcare providers or professionals are just rushing to medication, or they feel uncomfortable with recommendations that are being provided for treatment. So I’m going to focus my answer there, recognizing that there are many very effective non-medication treatments for anxiety.
So Let me start with the overarching idea that I think is relevant here, that a professional giving a diagnosis of any condition, whether that is a mental health condition, whether that is a neurodevelopmental condition, any type of condition, just on the basis of a brief office appointment or parent report, is generally not appropriate. Now a healthcare provider can certainly say “Boy, that sounds like your child might have an anxiety disorder, let’s look at that more closely. Let me do some more evaluation or discussion of that with you or let me refer you to someone who can look at that”, but really it’s not appropriate, especially for children to just be giving out a diagnosis for the moment without really looking at what’s going on. So I want that to be the first take-away message from this episode, that if your child is experiencing symptoms that might correspond to any particular diagnosis or a condition, those are things that should be looked at carefully. There are evaluation processes that we should go through, and we really should be looking at all of the underlying issues there. So that’s take-away number one.
The second big picture thing that I want all of you to take away from this is that any time you don’t feel comfortable with a recommendation from a professional related to your child, you should tune into that feeling that you’re having and honor it. There is a reason you are having that feeling. Now it may be that you end up deciding that you do feel comfortable with the recommendation that that’s going to be the best approach. But I find that parents have a good intuition or a good gut-sense of what resonates and what’s appropriate for their child and the situation, so if something doesn’t align for you, if somebody is giving you a recommendation or telling you that you or your child needs to do something and it’s not sitting right with you, like something about that just doesn’t feel right, I want you to honor that. And it’s easy to not do that as a parent, because you think “Well, who am I to have an opinion on this? These are professionals, they know.” But anytime you feel something isn’t quite right, anytime you feel like a recommendation isn’t appropriate or you have more questions, I want you to ask questions. I want you to seek out multiple opinions. It’s important to remember, with these kinds of things with kids, whether we’re talking about anything in the realm of mental health symptoms, developmental symptoms, those kinds of things, that these are subjective diagnoses that we’re talking about. There is no objective test, blood test, pencil and paper test, questionnaire — nothing objective that says “This is definitively what’s going on with the child”, and there also nothing objective about “This is the treatment that’s required.” These are all subjective things, meaning there is quite a bit of opinion and perspective on the part of the practitioner in terms of how they’re viewing the symptoms, how they conceptualize a diagnosis, what they have been trained in or what they believe are the important treatment options, so just remember that that there are lots of different opinions on these things. And if somebody is giving you a perspective or a recommendation that doesn’t align with your thoughts or beliefs or what you feel is most appropriate, seek out other opinions.
Also important to remember when we’re talking about anxiety, whether it’s anxiety in children, anxiety in adults: It can stem from many things. So a child exhibiting anxiety symptoms — first of all, that is normal up to a certain point. All kids, all people experience anxiety sometimes, but certainly when it’s getting to the point where it is impacting the child’s ability to function in normal life activities, which is what Rebecca alluded to in her question, that there are some functional challenges now with the anxiety, that’s something that we want to look at. And we want to say, “Boy, what’s going on here? What could be causing this significant increase in the frequency and the intensity of these symptoms?”, and there can be lots of underlying issues. In this case, it seems pretty connected to the start of the pandemic, which boy does that seem pretty normal in terms of what we’re seeing from so many kids. Not unusual at all in a circumstance where there is a lot of sudden change, especially lots of information and new things around a virus and all of these kinds of things that are being talked about, and life has been turned upside-down for kids. It’s very, very normal that we would see an increase in anxiety, and we’re seeing that across the board with such a big increase right now in the number of kids, teens, and adults who are experiencing this.
So it may be that Rebecca’s daughter is experiencing a significant increase in anxiety due to situational factors. Situational factors or situational events, which are things that we can pinpoint and say “Ah. This child is living through a major pandemic. Her life has been turned upside down, that’s increasing anxiety. Other examples of situational things could be the birth of a new baby in the family, or a death in the family, or a divorce or a change in school, or being bullied. Anything situational going on in the child’s life that can increase that. So it may be that that is the big trigger that has increased Rebecca’s daughter’s anxiety. But we also want to look at other kinds of factors when a child is experiencing a significant increase in anxiety. AS I’ve talked about in previous episodes previously, we want to rule out that there are infectious issues going on. Illnesses, viruses, bacterial infections, fungal infections, things on a physiological level that can be increasing anxiety. We also want to look at: Are there traumas? Is there something maybe that parents are aware or unaware of that’s happened that has been traumatizing for the child? Are there situational events, as I mentioned? Are there just relational challenges? More stress in the child’s environment or the child’s life? Have there been changes in nutrition status? Are there changes in sleep? Either quality or quantity of sleep. Is the child having issues with the amount of screen time? Maybe not getting outside or getting enough physical activity. These are all things that the research shows can either improve or worse anxiety symptoms in people. So when a child is experiencing a significant increase in anxiety, we want to look at all of those pieces to say “What’s going on here? What are the factors that could be impacting this?” So certainly, those are all things when you bring a concern about anxiety symptoms to a healthcare practitioner, those are things they should be asking about and investigating. Those are things they should be referring you to other people to talk about if that’s not something they specialize in. Those are all things that should be looked at before any recommendation of “Oh, this child needs psychiatric medication for this”, because here is the thing: In the vast majority of cases, when you address these underlying kinds of issues, psychiatric medication is not something that’s needed. And on the flip side, if the child has an underlying physiological health issue, an infectious issue, something like that going on that is really causing the anxiety symptoms, you can give them all the psychiatric medication in the world and it’s not going to solve the issue. So it’s really important that we’re getting to the root of what’s happening here.
Okay. The next thing I want to touch on here is that medication should not be a first line recommendation for child anxiety or for any other child mental health symptom the vast majority of the time. In fact, there are almost no exceptions I can think of to this rule. The only exceptions would be something very extreme and life-threatening that may be going on. But medication should not be a first line recommendation for child anxiety. The research is clear about that. We know that we have many, many other approaches that should be utilized first and medication should be looked at only if the child is not making progress, if they have had long enough to receive good quality therapy. So medication shouldn’t be something that’s put on the table the first time you bring your child in for an appointment to their primary care physician or any other healthcare provider, and it also shouldn’t be something that a counselor or therapist is recommending after just a couple of sessions. So what are the first line approaches that we should be recommending for child anxiety? Well, things like counseling or psychotherapy, specifically with professionals who are licensed and have specialized training in working with children. Too many times I’m seeing kids referred to practitioners who either don’t really specialize in kids or don’t specialize in the issues that the child is dealing with. So that’s important that they are receiving not only the right types of approaches, but that they are receiving it from a professional who is skilled in providing those approaches to parents and to families. Also, parent education and parent training should be a first line recommendation. Now that does not mean at all that parents cause anxiety symptoms or any other symptoms in their kids, but parents do play a very key role in helping to address symptoms that are going on in kids and in supporting children with these symptoms and challenges. So we need to be referring parents to either group programs or individual therapists or professionals who specialize in providing parents with education in formation strategies and support around these issues, in this case it would be anxiety. Something like the SPACE approach to childhood anxiety is a great example of a parent-focused intervention that has very, very good research evidence for improving anxiety symptoms in children. We have done two previous episodes of the podcast on SPACE, that would be a great example of something that I would recommend to Rebecca and any of the rest of you who have a child who is experiencing anxiety. And I should say, going back to when I mentioned counseling or psychotherapy as a first line intervention, again, we want to be looking at things like cognitive behavior therapy and those types of approaches that have a very good research basis for supporting anxiety reduction in kids. We want to look at mindfulness-based therapies that also have very good research support. We want to be looking at the developmentally-focused play therapies, trauma informed therapies. Again, depending on what the issues are, there are many effective research-based interventions that counselors and therapists can be trained in to really help them address this in kids. So counseling and parent education and training should really be the first line interventions along with looking at the root causes of why it is that this has suddenly become more of a problem and if there are specific things there in the realm of physiological health issues, nutrition, sleep, stressors, those kinds of things.
Okay. When we’re thinking about counseling then, because Rebecca has mentioned that she brought her daughter for a few counseling sessions. Let’s look at what should be happening in those sessions, because it is certainly my opinion as somebody who provides psychotherapy to children and works with parents and families, that it would be very rare, if ever, that I would find it appropriate for a counselor or a therapist to say to a parent after a few sessions “Your child is going to need medication, they have a very severe problem.” First of all, it’s not the counsellor’s place to say the child needs medication. If they really do think that that may be an important part of the treatment plan, they should be talking about referring the parent to somebody who specializes in medication treatment, which would be a licensed prescriber. Somebody like a physician or a physician assistant or something like that, who specializes in using these medications for children. But again, that shouldn’t even be on the radar, initially. Because what should be happening initially in counseling therapy is that the therapist should be spending time getting to know the child, helping to build a solid relationship and good, positive rapport and trust. Now, it can be the case that sometimes a counselor, a therapist and a child just aren’t a good match, personality-wise or otherwise. That’s okay. You can usually tell that after a handful of sessions if it’s just not going to be a match. The therapist should be talking with you as the parent about referring to someone who might be a better fit. You know, as I say to patients or parents that I meet with to talk about potentially starting treatment, I am not everyone’s cup of tea, and neither is any other therapist. We don’t take that personally, and parents should know that you should continue to seek out somebody who is going to be a good fit for you and your child. So sometimes it can just be a relational issue. Rapport just isn’t going to happen between that professional and your child. But in your initial sessions, that really is what the focus is. If a child is not opening up, as this therapist said to Rebecca, “Oh, your child is not opening up, she’s not talking in sessions, that means her problem is severe and she needs medication.” I really take issue with that. That is not appropriate at all. First of all, it is the therapist’s job to figure out how to help the child open up. I know very few children who show up to the first handful of therapy sessions ready to engage and interact and open up and talk about all their deepest fears and concerns, especially kids with anxiety. So that’s not atypical at all. That would say to me that the professional maybe isn’t skilled or doesn’t have the techniques or the knowledge to work with a child at that age who is struggling with those issues. To me, that says more about the therapist or the professional than it does about the child, so I think that’s important to know. In those first sessions, first handful of sessions, first 10 sessions, the therapist really should also be getting to know the parent, talking with you about your observations, giving you some tools and strategies, giving some homework even to the child and to the parent to work on and practice some tools and some learnings together. So that’s another component that should be happening. So all of these things that should be looked at and should be occurring in therapy before a recommendation or a pronouncement is made that “Oh, your child’s problem is very severe and they need medication.” I just really take issue with that, I think this is a case where Rebecca and any of the rest of you in this situation need to find a new therapist to work with.
So I guess the other thing that I want to touch on here is this idea that medications are a necessary or appropriate part of treatment for most kids, in this case kids with anxiety. I have done several episodes on medications for children and what the research says about that, but I’ll just summarize here to say that it’s really important for parents to understand that psychiatric medications are ineffective at best for most kids with anxiety or mood issues or behavioral challenges, any of those types of things. At best, they’re ineffective. And at worst, they can cause a lot of additional problems. Psychiatric medications are not well-tested in children, they’re not researched. The research that has been done typically has been done for a very short period of time. We do not have good long term research on the use of these kinds of drugs for children. The exception would be stimulant medication like Ritalin or Adderall that are used more for ADHD and those types of issues, although even then there is mixed evidence in the research literature and certainly there is no one size fits all about those medications benefitting kids either. But in this case, we are talking about anti-anxiety medications, typically called antidepressant medications, SSRI medications, things like Prozac, Paxil, Zoloft, Lexapro, these kinds of medications, sometimes for acute anxiety or panic, things like benzodiazepine medications which are anti-anxiety medications like Ativan or Xanax or Valium are used. Those are definitely not something that we want to be jumping to for children, except in a very acute or short-term type of situation, but typically, and Rebecca didn’t mention it in her question, but typically what’s being recommended when a healthcare practitioner says “Oh your child has anxiety, let’s try a prescription”, we’re talking about the SSRI medications like Prozac, Paxil, Zoloft, those types of things. And what you need to know about that is that the research evidence is very, very mixed. In fact, a lot of the research that has been done has shown minimal to no beneficial effect from these medications. But the research is clear that there is a tendency to a lot of side effects anywhere from mild to very, very serious side effects from these drugs, and that’s not something that gets advertised a lot. So I think it’s important for parents to understand that there are much more effective treatments, as shown by the research for childhood anxiety, than utilizing these medications. And for medications that have such a low level of efficacy in the research trials that have been done, and no good long term data, and can create significant problematic side effects, why go down that path when there are other, more effective things that can be done. Now I am not suggesting that these medications never help children and teens. I do believe there is a very small percentage of kids who truly do have a very significant benefit from small doses of these types of medications, but it is certainly not something to jump to right away, and it is important to understand that even kids who benefit from these medications, the real benefit comes from the combination of these medications with good psychotherapy and skill-building to give kids tools and strategies for managing the challenges and complexities of life or managing their mood and anxiety. So these medications should not be used by themselves, they should be used in combination with other approaches, and the vast majority of the time, it’s the other approaches that are going to be a lot more effective. So to me, jumping to medication just doesn’t make sense, given what we understand about the potential risk to benefit ratio and the fact that the research shows that these medications just aren’t helpful for a significant number of kids.
So I think that’s important for people to know as well, and Rebecca, it sounds like you probably have some sense of this, and that’s why you’re really hesitant and were really disappointed that both your daughter’s primary healthcare provider and the counselor jumped right to wanting to do that. So I think that you are on track with your concerns about that. I hope that these kinds of main points and pieces of education that I have provided all of you give you a helpful way for thinking about how to approach treatment with these kinds of things, and what you can do if providers are making a recommendation, particularly around medication that you’re not comfortable with.
So, Rebecca, I hope that this is helpful for you, I hope this is helpful for any of you who are concerned about treatment recommendations that you are being given, especially around medication. Remember, if you have a question you would like to hear answered on a future show, please email it to email@example.com. You can put “Podcast Question” in the subject line, and that will help us out. Thank you as always for listening. And I look forward to catching you back here next time on our next episode of the better behavior show.