We are indeed fortunate to have an opportunity to speak with Dr. Albano about her work at the Columbia University Clinic for Anxiety and Related Disorders (CUCARD). In the interview that follows, Dr. Albano takes us into the world of anxiety disorders with a review of many of the clinical aspects of anxiety disorders, as well as some useful information for parents. In addition, Dr. Albano discusses the impact of anxiety disorders on teenagers as they move into adulthood.
Q: What are some of the hallmarks of anxiety disorders?
A: Let me first say that I do not believe that anxiety disorders receive their due respect by our systems of care. Part of the reason for this is because many healthcare systems like the National Institute of Health (NIH) and others often focus on serious mental illnesses such as the psychotic disorders, bipolar disorder, depression, and substance abuse disorders. They do this primarily because in most epidemiological surveys those conditions show a high prevalence as well as a high cost and burden to society.
Anxiety disorders do not always show up on surveys as a drain on healthcare systems or having a high economic burden on society – while the fact is that they do. More people are suffering with anxiety disorders then we might think, and more people suffer with them on a long-term basis.
Anxiety disorders begin very early in childhood. Parents manage them mostly at home as they deal with their child’s separation anxiety, their fear of other people, and with social anxiety. As the child ages, they learn ways of avoiding and strategizing to minimize their own anxiety. Over time when those children reach adulthood, we see people who have often missed valuable opportunities in their lives and are unhappy because they have not lived up to their real potential in life.
Q: Can you elaborate on how this happens?
A: We’re not talking about bad parenting here, but quite often parents will force their child to participate in things they do not want to do or go to, or force separations on their child who will have to endure something uncomfortable. Then during High School, the child will do what is compulsory to get the grades they need and satisfy their parents. However, they will be suffering through these situations. Once they hit adulthood and have their own choice, they learn to avoid the things that cause them stress. A prime example is when a high school senior does not apply to the colleges they might very well get accepted at, because those colleges require a personal interview. Because of a fear of being in an interview situation, perhaps due to a social anxiety disorder, they manage their stress by applying to a lesser ranked college because they do not require a face-to-face interview. We see a lot of missed opportunities where students are not living up to their potential because they are avoiding things that they believe they cannot accomplish – and it’s all because they have an unresolved anxiety about people, places, or things which have in-turn lowered their own self-esteem.
What the research studies do not show is the fact that young adults are underemployed or undereducated because they made decisions to avoid challenges. These are silent disorders that go on for years. Unless you have savvy parents and adults around the adolescents who can tell whether they are experiencing unbearable stress and are making decisions based on avoidance, it doesn’t come to light for a lot of people.
Unfortunately, these situations with adolescents catch up with them as adults. As time goes on and because anxiety comes in multiples, we see their initial anxiety and avoidance behaviors combine with other anxiety disorders and depression. Often, we see adults who have made avoidance decisions based on anxiety beating themselves up about their situation, and as a result develop secondary disorders such as depression and substance abuse – and those are the conditions they are seen for treatment in adulthood.
Q: So, these unresolved childhood anxieties never go away and re-appear in adulthood in the form of other disorders?
A: It’s all about looking back at what people have missed. If you look at the work of Dr. Ron Kessler with the National Comorbidity Survey – what he finds is that anxiety is highly comorbid with many adult disorders. He has also found that conditions like social phobias, the third most common anxiety disorder, are not necessarily the focus of treatment because by adulthood it’s the substance abuse or depression that dominates the course of treatments. He has also found that most people with these disorders are not living to their potential, they are not working to their potential, they are in unstable relationships, and they have an overall diminished interest in life. That is the saddest long-term outcome of anxiety – that the person is not living to their potential.
At CUCARD and through some of the organizations we are affiliated with like the Anxiety Disorders Association, we try to educate families to not look at anxiety in childhood as just a phase. It’s a hard thing for parents to notice and for pediatricians to wrestle with. Yes, anxiety is a normal emotion. In fact, it is a necessary emotion that is evolutionary based in the “fight-or-flight” response. However, abnormal levels of anxiety are problematic and can take a child off their developmental track. With that in mind we educate people to look at how the child is functioning, in light of the anxiety. This helps the parent, teacher and pediatrician to refer a child when the child isn’t learning to master the situation – be it separation, speaking in class, handling peer interactions. If they aren’t learning to do that on their own by certain ages, there’s a problem. One of the biggest things that happen is that parents especially, continue to take control and do things for the children and teenagers that these children should be doing for themselves. When the parents manage these anxieties for their children it gives the child and the family the illusion that the child is functioning – but they’re not.
Q: Are the schools more willing to address these issues with the children?
A: That depends. We find it varies from school to school. For the most part, children in a classroom who have externalizing issues like ADHD or Oppositional Behavior become the squeaky wheels that get noticed – because they occupy the attention of the teachers.
Q: Haven’t we all had a teacher that put so much fear into us that we felt like hiding in the back of the class, hoping they wouldn’t call on us or make us figure out a problem on the blackboard in front of the whole class?
A: That’s true, and we try to teach parents to listen and read between the lines of what teachers say during parent-teacher conferences. Often a teacher will say, “Oh Mary is such a sweet girl – I don’t even know she’s in the classroom.” Don’t feel good about that! Why shouldn’t Mary be known in the classroom? Why isn’t she speaking up?
Other things parents hear from teachers are, “Oh, he’s so quiet, anything I ask him to do he does – he just does it automatically – I never have to worry about him.” We then ask, “Why not?” What we know is, that kids suffer for two to seven years with anxiety disorders before they are even noticed. We want parents to pay attention to these subtleties that are mentioned by teachers. We don’t want their kids to be jumping up and down in class being rowdy, but we want their teachers to know their voice and that they are there.
Q: What about kids that are terribly fearful of taking tests or exams?
A: The thing about school is that it is a wonderful diagnostic laboratory. Every day, kids have to go between eight in the morning until three thirty in the afternoon and through the course of their development they are bombarded with developmental challenges. They have to learn how to raise their hands, ask questions, get along with other kids, become part of the peer group, and how to negotiate multi-tasking. All of these things happen during the course of school and for the kids with anxiety, they are very clear about telling us time and time again, “I sit in school, I watch the clock, and I wait for the bell to ring.” They are doing that with their stomach in knots, by trying to avoid eye-contact with the teacher, and they are making themselves as invisible as can be.
When a kid comes home and the parent asks, “How was school today?” and the child just says “fine,” parents really need to find out what that really means. It might mean “fine” because nobody bothered me, and that’s something we don’t want children to experience in that way.
Q: When many of us think about childhood disorders we think of childhood depression, anorexia and bulimia, self-mutilating disorders such as cutting, and of course substance abuse.
A: Here’s the thing to know. Time and time again research in the United States, Europe and New Zealand has demonstrated that anxiety starts first. Typically, anxiety is the gateway disorder to these other conditions. The most famous and long-standing study here in the US, completed over 25 years ago by Dr. Peter M. Lewinsohn, is The Oregon Adolescent Depression Project. They started following kids from around 14 years of age and found that these kids had anxiety first, with depression then appearing in adolescence. Other groups have found the same pattern. The anxieties seem to start early, and as the child is unable to manage the anxiety, gates are open to other types of concerns that they might be vulnerable to that flood in. You see by 12 years of age in girls, that if they’re not managing tough emotions, the risk of an eating disorders or a non-suicidal self-injury can set in. It appears that these manifestations can develop (especially for the non-suicidal self-injury) as a means to gain attention, but also as a way to regulate their emotions. In these cases, there is a strong relationship to obsessive ideation and compulsion, which is anxiety based.
If a child has an anxiety disorder by the time they are fourteen or fifteen they are more likely to be developing major depression or a mood disorder – not necessarily of the bipolar type, but definitely in the realm of depression or dysthymia. Research has shown that if you have anxiety early (at around twelve to fourteen years of age), by the later years of adolescence, you see the substance abuse issue come into play. Kids learn that drinking, cigarette smoking, or marijuana use, are ways to relieve their anxiety and allow them to enter social situations that are otherwise difficult for them. Eventually that combination of anxiety, depression, and substance abuse, sets kids up for high-risk behaviors and suicide attempts. Suicide attempts usually occur in a state of high negative emotions and are a very impulsive act.
Q: Do you believe the roots of anxiety disorders in children are genetic in nature or are they learned in infancy through the parent infant interaction?
A: We do know that anxiety does tend to run in families. There are certain disorders such as panic disorder, the specific phobias, social phobia, and obsessive-compulsive disorder, where you find high family aggregations. If a parent has panic disorder their child will not necessarily develop panic disorder. There is probably something genetic as well as environmental that both add up to put a child at higher risk for developing the disorder if the parent or the first-degree relatives have the disorder.
The next thing we know is that just naturally, some kids are born with what is called an “inhibited temperament”. We see this in infants where some are easy to soothe while others are difficult to soothe. The children with anxiety tend to be clingy, they don’t explore their environment, and they have a tough time with new situations. What researchers have found is that children with these types of temperaments are at a higher risk for anxiety.
Kids are not growing up in test tubes; they are growing up in the world around them. One of the big things that has been demonstrated is that a certain type of parenting style will predispose a child to being more anxious than not. That is the over-protective, over-controlling parent. These parents believe that if the child struggles and doesn’t get the positive results that they want, they will be damaged in some way or that they will miss out on incredible opportunities in life – and maybe it’s true that they would. It is not necessarily inappropriate for the mother of a 5-year old girl who comes home saying, “The kids wouldn’t play with me today” for the mother to try to facilitate the kids’ playtime the next day. However, if she is still doing that for her daughter when she is ten, then there are problems. There has to be a point where Mom helps the daughter figure out how to solve this problem, how to evaluate if perhaps these aren’t the kids I should be playing with, and how to find new friends. Parents of anxious kids stay involved too long and typically continue to do the work for their child, and the kids never learn these sills on their own – skills like being in one group of kids and not another, that tests at school are challenging, and that teachers have different personalities that we may or may not be comfortable with.
One of the things we see quite often, especially with children who develop school refusal behaviors, is “demonizing” the teacher as being “too loud,” “too strict” and such. The parents will then spend a lot of time trying to move the child from one class into another, move the child to other schools, and to the furthest extreme, ultimately home-schooling the child. We then try to tell the parents “Are you going to do this when they are adults – with their bosses?” Children have to learn to deal with all types of personalities while they are young.
Q: Do you find that many parents try to shield their children from stressful situations because they believe they are truly helping them?
A: Sure, absolutely, and this is a very important point. We don’t blame parents. Anxieties begin so early in a child’s life. Parents will tell you specific situations of how distraught and upset their child was in front of them because of some situation. The natural response of the parents is to soothe, reassure, and protect the child. It’s not the child, but rather the anxiety that is present, that interacts with the parent’s own anxiety about what’s going to happen to their child. It becomes a vicious cycle of discomfort vs. overprotection, and before you know it the parent’s don’t know how to get out of it without a fear of harming the child if they stop intervening. By the time the child reaches adolescence some kids may become so anxious that when the parents do try to transfer control of the anxiety to them, the child will act-out in such a way that may put them in danger with a suicide attempt or something else that is terribly harmful.
Most parents are doing the best they can. At the clinic we believe that every child is different. And in families with many children – for the one or two that are experiencing anxiety – the parents may have to learn a different way of parenting that particular child, that doesn’t come naturally to them. That is where the treatments that we have available for the children (depending on their age) will have more or less parent involvement. The parent involvement is geared to helping parents become coaches for the children to learn to use their anxiety coping skills. Also, and especially the older the children get, helping the child to meet developmental milestones that other kids their age are doing on their own. This is especially important for adolescents.
Q: Do you meet with the children individually at the clinic or only with the parents?
A: It depends on the age. Typically, it is the child with the parent between the ages of three to six years of age, and then from age seven and older we do less child focused intervention and focus more on helping parents develop coaching techniques. By adolescence, we are trying to encourage the teenager to be the person who is taking control of their own treatment. The parents and the teens are then brought together specifically around the issues relating to the parent’s role in being drawn into the teen’s anxiety and maintaining it. We also bring the parents into the session when they are preventing the teen from taking on challenges such as making appointments with the college counselor, going to the doctor on their own, and other skills they need to master before going on to college.
Q: What kinds of issues do three and four-year-olds have to cope with?
A: We see obsessive compulsive disorders as early as three. We also see separation and social anxiety issues coming up, because so many parents who both work or are a single parent are having to leave their children in day-care at these young ages. We work to help the child to be comfortable being around other kids and being left in the care of people other than the parent in the day-care setting. Selective mutism is also a big issue which is the refusal of the child to speak outside the home. This is an important issue to resolve because kids need to be willing to verbalize their needs in the day-care setting when mom or dad isn’t around.
Q: Let’s talk about adult anxiety. When do you classify someone as adult – before college or during college?
A: That’s a good question. There is a developmental psychologist at the University of Maryland by the name of Jeffrey Jensen Arnett, PhD, who has coined a new developmental stage called “emerging adulthood,” which I fully agree with and work with on a clinical basis. The traditional classifications included children and adolescents. Then between ages 18 to 21, all of a sudden they were adults. What is the definition of an adult? It’s an independent person who is working, taking care of all of their own needs, in a relationship, and so on. Well, that’s not always happening between 18 to 21 years of age. In fact, more and more individuals are remaining dependent on their families into their late 20’s and early 30’s, and for many reasons.
When we look at the anxiety disorders and when depression is also involved, people are remaining dependent on their families as well as mental healthcare systems for support. Emerging adulthood is typically mid-adolescence around 15-16 years of age when they are supposed to be meeting certain developmental tasks, and it continues until these tasks are met, which could then take them into the mid 20’s early 30’s. These tasks involve managing your own emotional needs, your own financial needs, being in a job or actively working towards an occupation, being in and sustaining a meaningful relationship, and understanding and being secure in your identity.
We talk about milestones for babies – when they walk, when they talk, etc. People never really talked about the milestones for adolescents – and these are very important too. In the old way of looking at things, we thought that high school was getting you ready for college or for the workforce – one or the other – and from that point you were expected to be on your own. It doesn’t really work that way. We have to pay more attention to young adults because they are not meeting these developmental tasks, and if they are it’s over a longer period of time. There comes a point in time when there is an awareness that they are not keeping pace with their peers. You often see depression and hopelessness setting in around this issue.
Q: When a young adult or someone even in their late 20’s or early 30’s suddenly suffers a major bout of depression – do you look at that as having its root cause in missed developmental stages from adolescence?
A: From the cognitive behavioral perspective we really want to understand the person’s history. What have been the patterns that have brought them to this point of difficulty? What are the systems of support that they use, and how they use them – because maybe some of these systems have broken down? Or maybe these support systems have been less than helpful to them and they haven’t realized it. What in the “here and now” is contributing to their problem?
Typically, a breakdown involving a depressive episode or when panic attacks develop, isn’t an all of a sudden thing. There has been a pattern that has been established. Our work is to help the individual at 28 or 30 understand that pattern and teach them how to develop a healthier way of coping. We help them recognize how they have avoided, escaped or used safety behaviors to keep them from having to deal with issues that are difficult for them.
Q: Or maybe they have been self-medicating for many years?
A: That could be. In alcohol treatment programs you find that after the person reaches sobriety their anxiety is roaring, because all those years they have been using alcohol to manage their anxiety. Something has broken down in their system of trying to manage their emotions that is not working for them anymore either because of their age, maybe a circumstance has changed, or something.
But the good news is that old dogs can learn new tricks. We work with adults who go all the way up the age spectrum. One of the most rewarding things is when we have individuals with agoraphobia who have been housebound or haven’t gone outside the little radius of their neighborhood, and after working with them we receive postcards from places they are traveling to. When you release someone from that anxiety, they are able to get much more out of life.
When it comes to anxiety, we tell everybody that it is “the great liar.” It has had you locked up and has actually minimized your world. By challenging your anxiety you then develop the freedom to make more choices for what you want to do as opposed to what you’re afraid to do.
Q: Is this notion of challenging your anxieties something new?
A: Not at all.
Q: Is Cognitive Behavioral Treatment (CBT) the treatment of choice?
A: Absolutely. Across the board in research and clinical trials, CBT is effective for the anxiety disorders. It is the way to go, and it is built on a notion that has been around forever – you fall off the horse and you get right back on it. What CBT does differently from other forms of therapy is that it brings the horse right into the office. We take our patients out into the world as much as we can to face the things they are afraid of. We do not just do office work; we do a lot of exposure to the things people are afraid of in real time. It is through the actions of encountering what they are afraid of that they learn how they may have overblown (in their mind) how bad it would be – but mostly they learn they can manage it no matter how bad it is. This type of process is called “exposure.” During this process the question the therapist asks the patient is, “how much, at what pace, and at what level of intensity are you comfortable or stressed out at?” This way there is a learning experience for them that they can manage themselves. It is not throwing somebody into the pool at the deep end to sink or swim – that is a myth. It is more like collaborating with the patient (even at the very young ages) about stressful challenges they are willing to take on and working with them to do that.
Q: Didn’t they used to call that therapeutic approach “systematic desensitization”?
A: Yes, it is built on the work of Dr. Joseph Wolpe who developed systematic desensitization – he’s like one of our hero’s and is the founding father of this approach.
Q: So, if you are phobic of snakes (let’s say) do you show the patient a picture of a snake?
A: Actually, we don’t do that anymore, we go right to the real snake. Certainly, if we are working with a very young child or if the anxiety level is so extreme, we may first use a picture of the snake, but if possible we move as quickly as possible to get to the real thing. It has been found that for the phobias, you can treat them in about two and a half hours. A single session treatment of phobic disorders is pretty well established now for kids and adults.
Q: Can you comment on the average length of treatment for the anxiety disorders.
A: For the acute phase of anxiety disorders where we strive to get on top of the predominant symptoms such as separation, social, generalized anxiety, and OCD in about 15 sessions.
Q: Do you also prescribe medications to help people along with their anxiety disorders?
A: Our colleagues in Psychiatry do. We often see kids and adults who have been on medications or are currently on them, and we work with our psychiatrists and with the patients to maintain a stable medication regime if that is what they are on. The bottom line is that if they are coming to us, the medication hasn’t done enough. We will work on reducing some of the anxieties the patients come in with and work to possibly taper the medications off, while working on how to manage their symptoms, and reducing their medication levels.
After the traditional 15 session course of treatment, patients will come to us under periods of high stress and we will do some booster sessions. In that sense it is not necessarily just a short-term relationship but the acute beginning work certainly is.
Q: On the CUCARD website (www.anxietytreatmentnyc.org) you list that you treat a condition called Trichotillomania (TTM), a disorder that causes people to pull out the hair from their scalp, eyelashes, eyebrows, or other parts of the body, leading to noticeable bald patches.
A: Yes, we do see a fair amount of children with Trichotillomania (TTM) and some adults. They will pull eyebrows, the hair on their head, and sometimes the hair on their legs. We believe that this may be an “impulse control” disorder. Some kids will say “I feel good when I pull.” Most people pull without being aware they are doing it. TTM is not treated directly as an anxiety disorder as such, but more as “habit reversal training” that helps an individual learn to be aware of everything from the motor movements to the emotions behind the pulling behavior. This gives them a way of substituting a competing response that is more beneficial to them than the pulling.
Q: With the soldiers returning from the battle, are you seeing a lot of PTSD in the clinic?
A: Because we are located in mid-town Manhattan, we do not see that many veterans at our clinic – more I am sure at Columbia University Hospital which is located in uptown Manhattan, and at clinics closer to where returning soldiers live. However, we have worked with the NYS Office of Mental Health in developing approaches that focus more on helping the family “re-constitute” in adapting to a veteran that has returned home and is now living with their families. Veterans are mostly seen individually through the Veteran’s Administration (VA) system, whereas veterans, they are covered for all or most of these services.
Q: In closing, is there a message you would like to leave with our readers about anxiety disorders?
A: Yes, I would like to tell your readers that anxiety disorders are very treatable conditions, that there is a great deal that we can do to help them, and that they should never give up hope in dealing with their condition. In addition, I really want to thank Mental Health News for devoting an entire issue to anxiety disorders, and for helping the community better understand what anxiety disorders are all about.
Anne Marie Albano, PhD, is Associate Professor of Clinical Psychology in Psychiatry within the Division of Child and Adolescent Psychiatry at the New York State Psychiatric Institute/Columbia University College of Physicians and Surgeons, and Director of the Columbia University Clinic for Anxiety and Related Disorders. Dr. Albano received her Ph.D. in clinical psychology from the University of Mississippi and completed a postdoctoral fellowship at the Phobia and Anxiety Disorders Clinic of the Center for Stress and Anxiety Disorders at SUNY-Albany, under the mentorship of David H. Barlow, Ph.D. She has held past positions as the Assistant Director of the SUNY Phobia Clinic, Assistant Professor of Psychology at the University of Louisville, and the Recanati Family Assistant Professor of Psychiatry at the New York University School of Medicine.
In 2008, Dr. Albano received the Rosenberry Award in Behavioral Sciences, The Children’s Hospital, University of Colorado at Denver, honoring her work with children, adolescents and families.
Among her professional activities, Dr. Albano is president-elect of the Society for Clinical Child and Adolescent Psychology of the American Psychological Association and is past president of the Association for Behavioral and Cognitive Therapies. She is an Associate Editor of the Journal of Consulting and Clinical Psychology and a past Editor-in-Chief of the journal Cognitive and Behavioral Practice. In March, 2010, Dr. Albano will co-chair with John Walkup, M.D., “Anxiety Disorders in Children: Integrating Research Into Practice”, a full-day symposium sponsored by the Anxiety Disorders Association of America. She currently serves as a member of the ADAA Scientific Advirsory Board. Dr. Albano is a Founding Fellow of the Academy of Cognitive Therapy and a Beck Institute Scholar. She is board certified in Clinical Child and Adolescent Psychology.
Dr. Albano devotes her career to the study of anxiety and mood disorders in children, adolescents, and young adults. She has been a principal investigator on two of the largest clinical trials funded by the National Institutes of Mental Health, examining treatments for children and adolescents with anxiety and depression. In the Child/Adolescent Anxiety Multimodal Treatment Study (CAMS), 488 children ages 7 to 17 years with separation anxiety, social anxiety, and generalized anxiety disorders were treated with either cognitive behavioral therapy, medication, their combination, or pill placebo. Results indicated that all three active treatments were superior to pill placebo, with the combination treatment having the greatest advantage. These results tell us that anxiety in children and adolescents is highly treatable and that children do not need to suffer with these disorders (Walkup, Albano, et al., 2008, New England Journal of Medicine). Dr. Albano is also a member of the Treatments for Adolescents with Depression Study (TADS) Team, having served as a contributor to the TADS Cognitive Behavioral Therapy manual and also as a principal investigator for this monumental research study. The TADS results found that for adolescents ages 12 to 17, the combination of cognitive behavioral therapy and medication results the greatest response rate in recovery from moderate to severe depression, followed by medication alone (TADS Study Team, 2004, Journal of the American Medical Association). Cognitive behavioral therapy alone takes several weeks longer to reach an effect, suggesting that use of CBT alone in milder cases of depression is indicated as a first-line treatment. Overall, Dr. Albano’s clinical and research careers have centered on developing and disseminating effective treatments for anxiety and depression in children, adolescents, and young adults.
As a teacher, Dr. Albano is actively engaged in the training of mental health professionals at the student and post-degree levels. She is a clinical supervisor at Columbia University for psychology interns and for residents and fellows in psychiatry, while also teaching within the post-degree continuing education program. Dr. Albano is a frequent invited lecturer around the United States and also abroad. In collaboration with Kimberly Hoagwood, PhD., Dr. Albano is the Director of clinician training and consultation for the Evidence Based Treatment Dissemination Center (EBTDC), a program sponsored by the NY State Office of Mental Health focused on training OMH clinicians in evidence-based treatments.