Professor Wendy Silverman So, my name is Wendy Silverman. I'm a Professor at the Child Study Center at Yale University School of Medicine, and at the Yale Child Study Center I direct the Anxiety and Mood Disorders Program for children and adolescents, and I spend most of my time providing clinical supervision and conducting research and consulting with families about their child's anxiety. Well, this is a really good question and it's a really difficult question for parents. As parents, we want our children to be enjoying their childhood and when we see things that are happening to our children that concern us, it is something to start paying attention to. What do I mean by that? Well, we would like our children to have friends and to get along with other children. We also hope that our children will do well, reasonably well, in school and in their academics and to move on academically, and we also hope as a family, that we can do things together that bring joy and laughter to us. And when a child begins to have trouble doing those things, having trouble with friendships, not doing as well in school, preventing family from doing fun activities, then that starts being a concern and we start looking to see if anxiety could be related to why the child is having problems in these areas. Now, how do I know if it requires attention? Well, one of the things we pay attention to is what I call FISH. FISH is an acronym, it stands for, okay, if my child is not doing something that I would like them to do, like, let's say, do things with other kids, how frequent is that? If it's once every couple of weeks, okay, but if it's regularly and on a daily basis that they refuse or have – express trouble doing things with other kids, that's a pretty high frequency. We also look at FISH, I and S, which is the intensity and the severity of it. If – it's one thing if the child maybe has some trouble going to school in the morning and might say, "I don't want to go to school," but then, they eventually go. But if it becomes so intense and severe that the child begins to have temper tantrums and refuses to get out of bed, and well, is it – or if in school, starts running out of school, that's pretty intense and severe. And last but not least is H, how long has it been going on? What's the duration? If someone tells me, "Well, it happened one time," that's not much duration, but if it's been going on for a long time, for – and for several weeks or even months, then that's when these – this problem, this what we call impairment of the anxiety could be a problem. First, we should point out that anxiety in general in children, adolescents, including in adults, is one of the most prevalent problem of all the problems that people can suffer from, and anxiety, particularly, begins early in life. In fact, it's – sometimes, people call it a gateway problem. It's a gateway problem because children as young as four/five/six, have problems of anxiety that might include phobias, or might include something referred to as selective mutism. And then, a little bit – and then even by seven/eight we see something called separation anxiety, and if these early anxiety problems are not handled and treated, often other anxiety develops. So, for example, we might then see other, more severe problems with anxiety, which we can – you know, something referred to as social anxiety and generalised anxiety. And then anxiety typically precedes other problems like depression, and depression as we know, also leads to many other problems like substance abuse. So, I hope what I'm – so the reason why it's so important to treat it early is because it is viewed as a gateway problem, it begins early in childhood, and the sooner we can address it and nip it in the bud, it could, first of all, help the child's current functioning, but also could prevent anxiety and later problems that develop from that. So, the treatment with the strongest evidence is something called cognitive behavioural treatment, and cognitive behavioural treatment has the strongest evidence. It probably has about 40 to 50 clinical trials, it's been shown through reviews of reviews – something called meta-analysis, as being the most effective treatment. So, CBT works, first, by understanding what is the child's main anxiety problem? Because there are many different types of anxiety problems that children can have, and then, the key component of this is something that we call – with children, we say, "Face your fears." Because the main problem of anxiety is that, almost anxiety problems, children stay away, they don't do the things that make them very anxious and nervous. So, for example, if a child has social anxiety, they stay away from social evaluative situations. If a child has separation anxiety, trying to leave the parent is almost impossible. A phobia, they stay away from anything that makes them nervous. So, there is this very strong avoidance, staying away. So, a main component of it is gradually helping children to learn how to face those things that make them nervous and scared. That's the behavioural part of it, and then, a second important piece of this is when children face their fears, first of all, by doing it more and more, it's – you know, we call it a curve. It goes up, but then, the more you stay in that situation, the more it goes down, your fear and anxiety. It also starts wor – the Therapist can also start helping children to understand, "What did you think was going to happen?" "Oh, I thought everybody was going to laugh at me," or "I thought I was going to throw up." "Did it happen?" "No, it did not happen." So, there's – a part of it is cognitive processing and helping children to realise that their worst thoughts and fears did not happen as a result of doing those exposures. And the more children practice and practice, and face their fears with the help of a supportive Counsellor or Therapist, the more likely this is a way to help children no longer be as afraid and anxious. It's been studied the most and through, you know, many trials and many reviews, it's been really shown to be the strongest psychological evidence-based treatment. It's important to note, though, that it doesn't help everybody. A lot of it depends on the child and the parents and the Therapist working together to do the things relating to facing your fears, and that's hard. It's hard to face your fears, it's a really, really hard thing we're asking people to do. So, it can be really, really challenging to do this, and that's why upwards – in most studies, we see about 60, sometimes as high as 80% of children, responding really well, but not everybody responds well. And, frankly, we need a lot more work in trying to make the eff – positive effects more sustainable and last longer than they currently do. So, as strong as CBT is, it's – we still need a lot more work to try to improve CBT and other treatments for children with anxiety. So, think about – this is a – I know this seems really simplistic, but it's actually – sometimes, you know, keeping things simple is really smart to do, or – but think about the old idea of when you fall off a bicycle. What is everybody told? Everybody's told, "If you fall off the bicycle, get back on the bicycle," and what's the reason for that? The reason is because when we stay away from things, what happens? We feel relief; we feel good. "Phew, I didn't have to do those things that made me nervous," and that is what keeps the avoidance behaviour going. That's why we keep staying away from things, because staying away from things brings about relief, but we stay away from things. This is the core reason why cognitive behaviour therapy involves exposure, because the more we can face these things and the more we do it, our fear, you know, the up – it goes up, it goes down, and we begin to learn. It also gives children a feeling of self-efficacy and a feeling of mastery and that they can cope. So, as a parent it's really important to understand that, because a lot of times parents, they mean extremely well, but it's hard as a parent to see our child scared, nervous, crying, having a tantrum, if they're younger. So, our feeling as a parent is to protect them, "Okay, you don't need to go and do those things that's hard for you," but all that does is keep the cycle going. So, parents need to understand that as much as it makes the child feel good in the short-term, and it actually makes the parent feel good in the short-term ‘cause they feel like they're protecting their child, in the long-term it only serves to keep that avoidant behaviour and anxiety going and going and going. So, if you understand that important function of avoidance and how it's really important to try to reduce that, it's really important to let parents convey to their child that they have confidence. "I know it's hard for you to do this, but I'm pretty certain you can do this," and to be really supportive, and to also be a model yourself as a coping model. No-one is asking a parent to be, you know, a super-person and always, you know, fearless, but to the extent that you also demonstrate and model your own difficulties in managing and coping with stressful and anxious situations, that's also a helpful thing to do. But again, yeah, empathy, acceptance, support, is really important. One thing to add is, you know, we have found in our research that parents, because they have this need to want to protect their child, they often in – you know, they mean well, but they might step in and help their child and, kind of, intrude on their child. And that, kind of, undercuts the child's feeling of autonomy and feeling that they can handle it. So, another part of it, besides the acceptance and the support, is to try to provide autonomy to the child, rather than our instinct to perhaps jump in and save them. Oh, wow. Well, this is – I love this question, because so many things, frankly, but I'll tell you the two main things currently. One that's been an ongoing project, it's a two – it's a project that's going on at Yale, where I'm affiliated, also at my previous institution at Florida International University in Miami. It's a two-site study funded by the NIMH. My collaborator at FIU is Doctor Jeremy Pettit, and what this is, is – remember I'd said we're trying to enhance anxi – CBT and tried to figure out how we can enhance it? Really quickly, another really important part of anxiety is attention. People who are anxious, they attend to threat much more than people who are not anxious. So, immediately we attend to threat. So, there's a new experimental treatment, it's called attention training, some people call it attention bias modification training, and we're looking – and we have a lot of data showing that this can be helpful, and it may be a useful adjunct to CBT, by retraining children's attention. And it involves no face-to-face therapy, it's com – it's delivered fully on a computer screen, and it's only two sessions for four weeks. So, the – it's a very short, innovative approach to training anxious people's brain away from threatening stimuli. That's one thing we're doing, that – and that's been going on for a few years now. The other one that we're about to get off the ground is we're developing a digital intervention, something that people can, you know, access on their phones, on their com – laptops, on their iPads. And what we're doing is we're planning to do CBT with children, but we're also going to be developing on this intervention tools that parents can access that involve exactly what I was talking about, teaching parents how not to let their child avoid, teaching parents how to be more autonomy-granting. And the idea is that if parents have this tool with them regularly, all the time, maybe we'll be able to enhance the effects of CBT by improving parents' behaviour. What it involves is the child sits at a computer screen and they're presented with a threatening face or non-threatening face, and this stimuli is something that anyone doing research in this area, we're all using the same stimuli. It comes from Danny Pine at the NIMH in the United States, and it also – along with Yair Bar-Haim, who is at Tel Aviv University in Israel. They – and they, actually, are collaborators with us on this project, and they developed this stimuli. So, it's presenting on the computer screen, just like the way we're looking at Zoom. You see me, you see you, but imagine that you have a threatening face like this, and I'm like, you know, like that. And all we do is we put a probe by the threatening face, I'm sorry, by the non-threatening face, we do that all the time, but this is happening at 450 milliseconds. So, we just tell the child, "Wherever you see the probe," which is like an arrow, we always put the arrow by the face like this, and it happens so fast, like this, like this, like this, literally, like, you know, I – you know, 400 – like 250 milliseconds, they get – and that's the attention retraining. So, you're looking all the time. I'm doing this ‘cause that's, basically – the idea is that I'm telling, like, the brain, "Look at where this probe is, and click on the mouse whenever you see it." So, that's why it's, kind of, cool because – and that's why it's, kind of, cool that we're doing it in Miami and at New Haven, because it also could be particularly helpful for, like, you know, for family – for children, first of all. We're doing it with children with social anxiety, I should say, because these are kids who are particularly reticent about speaking and talking about their problems, and we're also – the nice thing about it is it involves no language. It's just totally stimuli on a computer screen. So, it also – some people have suggested that it also could be really helpful for, you know, non-English speaking populations. So, we do have a very, very large Hispanic population in Miami, and not as much in New Haven, so we'll be able to also compare if this is something even – you know, whether or not there were some obvious, kind of, differences with regard to populations.