We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH learn. Welcome to Mind the Kids. I'm Dr. Jane Gilmour, honorary consultant clinical psychologist and child development programme director at UCL. I'm Umar Toseeb, Professor of psychology at the University of York, focusing on children and young people's mental health and special educational needs. In each episode, we select a topic from the research literature and in conversation with invited authors, sift through the data, dilemmas, and debates to leave you with our takeaways for academics and practitioners. Today we'll be discussing the relationship between parents and children's anxiety. This episode asks Anxiety, does the apple fall far from the tree? OK, so, Umar, what interests you about the topic of anxiety? Well, with reference to this paper specifically that we're going to talk about today is the role of parents. Because some of my recent work we've been looking at how difficulties, whatever those might be like social, emotional, or cognitive are transmitted from parents to children. And I've been thinking about genetic and environmental influences. So parents pass on genes to their children. Well, certain genes and genetic variants increase the risk of certain mental health conditions. But parents also help to create the environment around their children. And also the children help to create the environment that they share with their parents. So parents and children share genes, but they also share the environment. So I'm just really interested in how difficulties are transmitted from parents to children. And it's really difficult to disentangle those genetic effects from those environmental effects, because, I think, it would come as no surprise to anyone that those things don't work in isolation. And it's not just a case of this or this. It's a combination of both, but it's trying to figure out how they work together. And I mean, that absolutely is a scenario that is very familiar in the clinical world. So a classic clinical example would be a child referred with anxiety and a parent who wants to do the right thing. They only want to support their child. But the communication at home can exacerbate the situation. Anxiety can be contagious. And so there might be a situation where a young person's life and school is being impacted by their anxiety. They start to withdraw from life experiences. And that shrinking world is powered by their avoidance. And what sometimes happens in terms of communication and family processes is, for example, let's say a child's been off school because they've had a bug. They're definitely well and ready to go back. But then they say, I don't want to go back to school. What happens if I get ill again? So one scenario might be that parents respond with, it's going to be OK. It's going to be OK. Don't worry. It's going to be OK. Now you can hear from my voice. I'm telegraphing anxiety, even although my words are apparently aiming to defuse the anxiety. So the parents are modelling anxiety in that moment. The other scenario, which might be one that many of us are familiar with too, is that parents let the child stay at home. So what? Well, have another day off. Let's just make sure you're OK. But what message is that sending? Because that means that it's too dangerous to go to school, stay at home where it's safer, and the child invariably stays well. And by avoiding school, they are reinforcing that anxious feeling because they finish the day safe. And the parent who may share that environment, share those genetic vulnerability to anxiety, may end the day with a reinforced sense of anxiety, too, because they say, well, everything's OK. We're all safe and well at home. We haven't had to venture out into the inverted commas dangerous world. So that communication you can see where everybody's intentions are good, there can be a lot of mixed influences, whether those are genetic or environmental. I also wonder the role of what we set as the template or the default for how we deal with or learn to deal with certain emotions because typically it would be your home environment, which tends to be your default. And then my conversations with various people, friends who are my age, for example, and one of the things that we've talked about as we've got older is you grow up thinking that the way that your family deals with stuff is a completely normal way, and that's the way everyone does it. But then you go out into the world and live with other people and live in house shares and go to uni and realise that that was not typical of how everyone deals with things. And that's not to say that you're doing it wrong, it's just your default was the way your family and parents were dealing with things. Yeah, absolutely. And I think learning and considering what impact that has had on you is something that young adults really do. They pause and reflect. It's a very typical discussion that age 20 plus, going to college or uni thinking, oh, gosh, my parents did this and as a kid, I thought that. But maybe there's another way to do it, not necessarily right or wrong, but noticing the power of those communications, those implicit messages that are around in a family environment as well as our genetic vulnerabilities. So it's a really quite potent mix. It's a spicy soup, I would say. I also think about parent blaming. So I mean any type of research which links parents parenting to children's outcomes has the potential to be then taken as parent blaming. And I think that every time I have this conversation or do any writing on this topic, I'm always really cautious about how I phrase things because we're not here trying to blame parents. It's not what we're trying to do. We're trying to understand the relationship between these various characteristics and the various people in the household. And parents also are human beings who have their own things going on. So I think that when I try and explain this during teaching, I use something called the Family Stress Model. Conger and Donnellan in 2007. People can look that up, but they-- Paint us a picture. Paint us a picture with your words. What would you describe? So the family economic pressure, for example. So the financial stress that a family might experience, if they have come from a low income household, is associated with higher levels of parental, emotional, and behavioural difficulties. Now that can lead to child maladjustment through two routes. The first one is that those parental mental health difficulties, let's say, are associated with lower levels of nurturing parenting and involved parenting, which then lead to-- are associated with child maladjustment, or the parental difficulties are associated with higher levels of interparental conflict or conflict between the parents, and low warmth and support towards the child, which is then associated with lower levels of nurturing and involved parenting, which then leads to child maladjustment. And it's a nice framework because I think that it helps to not parent blame because it contextualises parents within a broader system of they've got their own things going on. And as we've talked about lots of times on this podcast, the Bronfenbrenner's ecological systems framework situates the child within wider society. And actually, that's the same for parents. Parents behaviours and how they interact with the people around them are also situated within the wider system of society. So these are all complex systems that interact with each other. And parent blaming is just not what we're trying to do here. And it's not the right thing to do either. Yeah, but I think I like that model because it's very much saying, any one of us in a stressful situation experiences stress. That's what a human being does. But I think the idea that and certainly it's my clinical experience that when parents get a chance to reflect about, for example, the messages that they're telegraphing with their nonverbal communication, they are very much wanting to change that, but it's not something that would cross their mind. So if I say as a parent, it's OK, don't worry. I might believe that I'm doing the right thing, but actually I haven't had a chance to say, well, my tone of voice telegraphs everything that I need to know. So if I say this in a low and slow tone of voice, I am being reassuring. I'm being an anchor for my child. If I say it's OK, it's OK, don't worry. Actually, what your child is picking up is things are-- there's something to worry about here. So that difference is really one that parents will get on board with if they have the chance to pause and reflect. And if you're in a very stressful environment, it's hard to find reflective time. So I think we are definitely on the same page. It's not about blaming. It's about giving parents information that might allow them to shift their experience and their child experience. So there's one more thing that I just wanted to touch upon before we bring the guests in, which is the focus that we're going to have on clinically anxious parents and anxiety disorders in children rather than anxiety as a whole. Because I say this to students a lot, anxiety is not always a bad thing. It can be adaptive. There are certain situations where it's completely fine and expected to be anxious, and if you weren't anxious in those situations, that would be maladaptive. So it's context dependent. But also the severity matters and the duration matters, and whether it's causing impairment, et cetera, matters. So I'm glad that we're talking about clinically anxious parents and anxiety disorders in children because it's the extreme end that we're referring to here, and those kinds of the anxiety that causes a functional impairment. So stops children and adults doing things that they would ordinarily be able to do. Yeah, well, listen, I think there's a lot to talk about. There's a lot to get into. I think we need our guests, expert I. Yes, let's do it. So today, we're joined by Dr. Sigrid Elfström from the Department of Global Public Health, Karolinska Institute, Sweden. Sigrid is the lead author of the paper, a detailed investigation of anxiety disorders in children of clinically anxious parents, a population-based study published in the JCPP. Welcome, Sigrid. Thank you so much. And let's start with some context. So you're based in Sweden. Yeah. And how is Swedish mental health care set up? As in, how are the different systems of mental health care for children and young people linked? Because I have read a number of papers where they've used Swedish national registries to research. And I've always wondered how that works. If you just give us a flavour of how mental health care is set up in Sweden. Yes, OK. So in Sweden, mental health problems are treated both within primary care and within specialised psychiatric care, depending on the severeness of the problems. And so for children, like mild cases of anxiety, moderate cases would be treated typically within primary care. And then more severe cases would be within psychiatric care. And so we have those national registers that you have talked about. We have a long history of good public registers in Sweden. But the National registers they only cover specialised care. So not primary care. But in Stockholm we also have a good coverage of primary care in another register. So in this study, we have linked registers so that we can access both the primary care data and the specialised psychiatric care data, which makes this study unique compared to a lot of other research because we do also have access to those milder cases. And I think most cases of anxiety is treated within primary care and not in secondary care. So I think it's important to also include those milder cases when doing research. It's very-- I mean, there's a lot of data envy, I think, around the world when we look at the Swedish registries. But it's particularly inviting that you have both the primary and the secondary level care. And that allows you to get some nuance in your observation of anxiety. If I was a parent taking part in the study, could you-- if we just think about your study specifically, how would you describe the findings in straightforward language so that we can think we with contextualised Sweden, let's contextualise the findings? OK, so if I were to communicate the results to a parent who was highly anxious or experience anxiety, struggling with anxiety, I would say that-- I mean, there is a slightly higher risk that your child will experience similar kind of difficulties, but this is population-based data. And for the individual family, for you, this is not at all deterministic. It's a risk level, but doesn't say anything about how things will turn out for your child because there's so many factors that are weighing into if that specific child will develop anxiety problems. I really like the way you're saying it's not deterministic. It's a bit like, look out when you're crossing the road. It's not inevitable that you'll be-- a car is coming. But just be aware. And I think that's a very important piece of information for parents, particularly anxious parents because we're thinking about parents that are vulnerable to potentially threat, in particular to the idea of considering it as a risk is really nice. I think I found it particularly interesting about the relative risk for children of clinically anxious parents compared to children of parents who weren't clinically anxious. So I think your numbers that are in the paper is 4.3% of children of clinically anxious parents have an anxiety disorder compared to 3% of children whose parents are not clinically anxious. And if we think relatively-- I don't know-- is that a 1.5 fold increase? In terms of absolute values, that's still quite low. So I suppose if we're talking about communicating this to parents, it's like, yes, your child might be at increased risk of developing an anxiety disorder, but actually, it's still very low. Yeah. Yeah, and perhaps lower than we might have predicted, I guess. Yeah, so if we look at the previous research, the reported risks have been much higher. And I think that's because there are many reasons why. But one of those, I think, is that we have used old data. I think in registry-based research, you often want to use as much debt as possible. But then maybe you end up using data who is 50 years old, and then maybe the patients who were seen in psychiatric care with anxiety several decades ago. We can't really translate those findings to the typical patients with anxiety today. It was probably much more severe cases. So it's really important when we talk about anxiety disorders. This is a common outcome. A lot of people are seeing seen in health care with this. They are diagnosed with these disorders. So to keep in mind what was the methodology, who were taking part in this study. Because just saying this is the risk for families with anxiety disorders, it's too vague. It could be a lot of different things and a lot of different severity levels. I'm trying to think of people who have an anxiety disorder who don't necessarily make it to primary or secondary care. I wonder if you can give us an indication or if you can speculate how-- what-- that 3% and 4.5% number, how many more people would be out there with a diagnosed diagnosable anxiety disorder that don't get to primary or secondary care? So I would imagine that certain demographics would more likely to access that care. There will be inequalities in identification and diagnostic processes. Do we know what kind of margin of error we've got there? So I think it's a really tricky question to answer. Prevalence studies are also quite difficult thing to conduct, and the numbers you come up with will also depend on different things like how does the team who are doing the prevalence interviews or whatever how are they assessing if something is clinically significant or not and stuff like that. So it's really hard to say like what is the true numbers of anxiety disorders out there. I can't answer that. But what I can say is that there are, of course, a lot of individuals with high levels of anxiety who could benefit from care, who does not seek care. And when it comes to seeking care for milder problems, like you do in primary care, there is an overrepresentation of people from stronger socioeconomic backgrounds. And so within psychiatric care, it's not really the same because here you see that there's an overrepresentation of people with socioeconomic difficulties. And that's, of course, quite easy to understand, since maybe you have a harder time working when you have more severe symptoms and so on, but to seek help at an early stage, that is something that people who have a lower education and are born in Sweden, and there are several different factors, weigh into who is seeking support at an early stage. So even if we have free health care in this study, all groups are not equally represented in the data. And that reminds me of there are themes certainly in largely in Western Europe and Northern America, but certainly in the UK, where there's a significant rise in the probable anxiety disorders in young people. It's levelled off somewhat in very recent years. But it was a significant acceleration and also a rise in health seeking behaviours. And it's really just what made me think about what you were talking about in terms of socioeconomic advantage and so on. How might that impact your finding or findings, or what might you predict? So first, it's tricky to say, does the rise in seeking health care does this equals that there's a rise in symptoms. It's a tricky question because maybe it's a different norms. We talk about our symptoms in a different way, and we are more prone to recognise it as something that we can seek help for and care as a greater access now than a few decades ago. But what we see is that the rise in health care for anxiety it's mainly within primary care. It's not within specialised psychiatric care. And this could be an indication that maybe it's more the pattern of seeking help rather than people or that people have more psychiatric disorders. Could it be an indication of that just because we see the rise just in milder cases? Yeah. And I think for the results in this study, we could see that the risks were lower than what we have seen previously in previous research. And this also relates to that we are talking about a much more common exposure and a more common outcome today than if you would look in the health care registers a few decades ago. And then it will also be a less clearly defined group of individuals. And the risks we're talking about will also be somewhat more moderate. It's not a clearly defined group we're looking at, more people will stick for these kind of issues. Can I steer the conversation towards theory? So Jane and I discussed this before we invited you on, which was what are some of the reasons why children of clinically anxious parents are more likely to have a diagnosed anxiety disorder? What might be some of the processes through which that risk is transmitted? Yeah. And so I think it's really tricky to know what environmental processes in what way drives this intergenerational transmission. We should call it that. So we know if we look at behavioural genetic research, then the results are very mixed. And when it comes to child anxiety disorders, some twin studies have seen shared environmental influence. And twin studies have had observed genetic transmission. But then if we look at adoption studies and children or twin studies, which are different behavioural genetic designs, there are indications of direct environmental transmission, so something in the family environment make family members being more alike when it comes to anxiety. But the results do differ. So it's quite hard to say. And in terms of this study, we can't really say anything about what processes drive the anxiety transmission, intergenerational transmission. But I guess there are some clues that I think are interesting. And so one thing that I've been thinking a lot about is that in this study, and this has been the same in other registry-based studies, and the risk was higher if your mother was diagnosed compared to if your father was diagnosed. And I've been reading a lot to see, but from what I understand-- I'm not in behavioural genetics. That's not what I work with. But for complex behavioural traits, such as anxiety, it's unlikely that it will be more genetically transmitted from the mother than the father. So this could imply environmental transmission. And the reason that I think this is because children spend, on average, more time with their mother. And if an anxiety would be like environmentally transmitted from parent to child, and the parent who you are spending the most time with, who are more responsible for your upbringing, but would be the parent to also have the biggest influence on you, if that makes sense. Yeah, and it was interesting. Yeah, I think that's right. And mum, this is a stereotype. But it's is there's some suggestion that this is true, that moms are the CEO of emotions. So parents, even if they're spending equivalent time together, moms or the maternal figure or the main caregiver or talk about emotions and how you're feeling. And so that would make sense on that basis too. Yeah. Yeah. I just want to unpack this idea of general risk for mental health conditions versus specific risks. So I think that in your study it's specific risks. So the condition that you're interested in the parent is the same as the condition that you're interested in the child. So again, when I try and teach this kind of thing to students, we talk about something called homotypic continuity. So homotypic continuity is the same symptom or disorder persists over time. So within a child's life. And a heterotypic continuity is when the underlying vulnerability persists, but the outward manifestation as a disorder or symptom changes. So in childhood it childhood, it might look like behavioural problems. And in adolescence it comes as emotional problems and depression and anxiety. So when we're thinking about parent to child transmission, you looked at diagnosed anxiety disorder in the parent. Why not look at any diagnosed mental health condition? Because again, if think about genetics, there is a lot of overlap between genetic influences on the different types of psychiatric conditions. And then also, if we look at behaviorally or phenotypically, we have the p factor, which is the underlying vulnerability for various internalising problems. So why look at specifically anxiety transmitted as anxiety, not any mental health condition transmitted as any mental health condition or transmitted as anxiety? I'm glad to get this question because I think the same way as you. And right now I'm actually, together with colleagues, just started to work on a study where we look at a transdiagnostic transmission using registry-based data. And I think it's really important to do that is to get a wider picture. So, for example, in this study, even if we looked specifically at one disorder, at anxiety disorders, which I also think is interesting to do because this is a very common disorder. But then we also did adjust for other psychiatric problems in the parent. So this was a way to see is it more of a general risk, or is it a risk that is specifically associated with anxiety disorders. And what we could see was that when we adjusted for other parental psychiatric disorders, the risk was attenuated. And this indicates that, OK, so part of the risk is not specific to anxiety problems in the parent. It is a general risk. And this is something that we see in a lot of researchers as you were mentioning. But it was still a significant risk. So it's not all about general risk. It's all there is also disorder specific patterns. And I think this is something that is super interesting and quite complex to understand because at the same time, something we saw in this study was even if we looked at distinct anxiety disorders, we could see that the child had the highest level of risk for developing the same kind of anxiety disorder as the parent. And this is contradictory, the risk is both general, but it can also be specific mechanisms. So I think we should look at both levels making it very complex. But yeah. So can we unpack that a bit because that was one of my next questions? So what you've touched upon there is if we assume that it's anxiety transmitting to anxiety in the child, the specific type of anxiety remains the same from parent to child, I think is what you're saying. Can you just tell us a bit more about that? As in like, what are the different types of anxiety that you looked at? And then what does that mean? So in this study, we were really specific about the diagnostic code. So in the registers ICD codes are used. So what you typically do in epidemiologic research is you use really big clusters with lots of ICD codes. You lump them together. You look at OCD, anxiety, stress related disorders all together and you say like anxiety and stress. But here we wanted to do a high resolution investigation of specifically anxiety disorders. And I'm glad we did because it was really interesting to see. I thought it would be much more vague, but we could see here that for social anxiety disorder and for panic disorder and for specific phobia, the risk was the highest for the child to develop the exact same anxiety disorder as the parent. And then a finding that is from a clinical perspective. And I've met anxious parents and their children in clinical work, and it was really interesting that if the parent had generalised anxiety disorder, the highest risk for the child was to develop separation anxiety. And this is a bit interesting I think. I think this is fascinating. And, as you say, I mean, what an interesting question to ask of that huge data set you could see. And this will wind Umar up because he gets very irritated with the diagnostic system for good reason. But here's my question. Do you think that that supports are current diagnostic system, whether that's DSM or ICD? Can that show or is there a tautology in the reasoning because of the recruitment and so on? Do you think that supports our current diagnostic system? I'm not sure how to answer that question. I do think that, for example, social anxiety, which were the highest risk between parent and child. I think that sometimes is like-- now I'm just speculating. But it's like-- Yeah, of course. --clearly defined thing that often you can see it early in childhood. It's often persist over time. It's harder to treat. I think it makes sense that it's I think that I also seen one study show that there are more specific genetic components for specifically social anxiety. Maybe that's something that is more clearly defined than, for example, generalised anxiety. And so what I was thinking about the relationship generalised anxiety and separation anxiety in the child is just generalised anxiety is often a part of that is worrying about your child. And then maybe you protect your child a lot. And then it makes sense that the child would get separation anxiety if you just speculate. That was why I mentioned that. But yeah, it's another question now than what the specific disorders. Can I add something to the mix here? So we've recently been looking in a project that we're leading on children with special educational needs identified in school. And we speak to parents and various other stakeholders. In England to get support for your child for their need, shouldn't be dependent on them having a diagnosis for anything, but in reality, usually they need a diagnosis for something before they can get support. And for some children, the diagnosis that they get is not directly predicting the support that they get. So it's just a passport or a passport to some sort of support. And in those situations, what sometimes happens is if a child has multiple needs, the parents might stop at the first one because then they've got that passport to support, and then the child can get the support that they need because the passport support is there. Is there a risk that that's what's happening here? So the parent are trying to navigate the mental health care system for their children. And the diagnosis that the child gets is somewhat dependent on the knowledge that the parent has of that mental health condition. So once they've got that diagnosis, then the support doesn't necessarily follow the exact condition but then tailored to the child's needs. So it's like, so is-- I think what I'm saying is, is the diagnosis that the child is being given indicative of their actual need, or is it the one that the parent is most familiar with? Yeah, maybe it could be, of course, that the likelihood that you will talk more about the child's social anxieties in your treatment will would be higher if that is what the parent is presenting with and what the parent is communicating to the psychologist at the primary care centre or whatever it could be. I mean, if you see a child in a treatment, we can hope that you would discover different. If there are other types of anxiety symptoms, they would also come up. But of course, it could be something that will affect the direction of the assessment you make at the first appointment, of course. And that could also then follow in the medical records as the assigned diagnosis. Oh, it's interesting. There's a lot in here, isn't there? It's absolutely fascinating. I think it's really made me think about family processes as well as anxiety and there's lots of processes and generalizable principles, not just about anxiety. Specifically, it's absolutely a fascinating paper and I really enjoyed reading it. I've got an eye on the time, Umar. Have you got anything else that you must speak about before we wrap up and let our guests go? No, I think that's been a great conversation, and I think that in the interest of time, we should stop there. So all that's left now is to say thank you so much, Sigrid, for taking the time to speak to us about your findings and about the wider topic. It's been really, really interesting. Thank you so much for having me. It was great talking to you. Thank you. Before I forget, I just want to pick up on something that we discussed. And I just want to ask you about your clinical experience. So that last point that we-- the last point that I made that we talked about where the diagnosis the child receives does not neatly correspond to the support that they then are given. Is that your experience in clinical practise too? As in, is the diagnosis that the child gets-- is that just a starting point? And some parents will stop at that. And then the support will follow for a range of different things. But they might not seek further diagnosis. Or is it the case that people tend to seek diagnoses for every single condition they have, so that they can get support for every single condition they have? Well, I don't know the data, so I'm sure there are data describing this process. And remember, I work in a centre that's a tertiary referral centre. So families have been through CAMHs already. And so there is a dichotomy, I think, of populations, one where families may have a hypothesis or strong hypothesis that there's a particular condition. I also wonder, though, that I think depending on which tier of service you're in, that once one has a diagnosis or once a child has any diagnosis, they are in the orbit of mental health professionals. And so there must be that effect, too, that you're talking about. I do think there must be, and it sounds feasible, but it's hard to-- I don't know that I would be able to comment on that validly just because my current practise is not in primary care. I also do wonder that I think there are levels of acceptability for some diagnoses. So not too far. In the recent past, autism was not considered something that was acceptable, if you like in inverted commas. And the stigma has been drained away from autism in a quadratic way, which is wonderful on lots of levels. So families will not see it as the concern that they may have done even perhaps 10 years ago. But I do think there are some diagnoses that I think probably have more acceptability than others. And that's our job as mental health professionals to make sure that they're all considered equally. So I wonder if that's got an impact. But I don't know. It's difficult. It's a really interesting question. The other one that I was going to ask you was, and I think this is related, which is do we view the world in the framework that we're currently involved in? So like, if I think a lot about autism and ADHD and mental health conditions in general. So when I meet a new person-- I was on holiday recently and I met someone new, and the whole time we were having dinner, I was like, he has ADHD, he has ADHD. And it seems that my whole framework for trying to understand behaviours is now neurodiversity and what neurodivergent conditions this person have. I wonder whether the same could also apply to parents with an anxiety disorder and clinically anxious children, as in, do they view their child's behaviour through the anxiety disorder lens? So then they see a lot more of that, and then they seek support for that rather than it could be something else. And I think, I mean, I do think that's interesting, although it may be that there may be that effect. So a parent might recognise particular behaviours or indeed thoughts and think, OK, I know what this is because I'm living it too. But in most instances, certainly for a referral makes it to CAMHs. There would be a standardised protocol, and so that the health professional would be routinely looking at every single aspect of most presenting conditions so that one would perhaps iron out that bias. But inevitably there is. I mean, look, it's a bias. Shall we do our takeaways? Yeah. Go on. What do you think? What's your takeaway? Well, I think it was really interesting because I think although the effect was not as strong as we might have seen in the literature previously, there are genetic and environmental effects, and that means we can predict which young people will be most vulnerable to an anxiety disorder. And there are prevention programmes that exist. They are slightly vulnerable in terms of the quality of the data and the quality of the programmes. And so given that we know clinical anxiety in children can be predicted, there should be a greater focus on high quality prevention programmes. Prevention is better than cure. For me, I'm just going to sound like a broken record. Come on then, let's wind it up again. Which is and it's definitely the case here where the label that the child has been given. So in this case, an anxiety disorder does not capture everything else that they are experiencing and their full profile of needs. And in some instances-- I'm not necessarily saying in this paper, but in general, it can be problematic to reduce the child to a generalised anxiety disorder, for example, because it doesn't tell-- that doesn't tell you anything about their mood, their behaviour, their interactions with others. Well, a bit about their interactions with others. So we have to bear in mind that when we're thinking about these diagnostic labels and these groups that we're interested in, a child with an anxiety disorder and a child without anxiety disorder, that only really tells us about their anxiety. Well, not much about everything else. Yeah, fair point, well made. OK, let's call it a day there. That's all from Jane and me for this series. We'll be passing over to Clara from next week, and we'll be back in the autumn. [MUSIC PLAYING]