Above: Jean-Michel Basquiat. Three Pontificators, 1984.
Photo: Banque d’Images, ADAGP / Art Resource, NY
Why has debilitating anxiety become so common among the young? And why is it still so often overlooked?
June, a fifteen-year-old boy who a few days later became my patient rode his bike to Venice Beach, laid it in the sand, and stripped down to his boxer shorts. Then he started to swim and kept swimming, following the sun as it dipped over the horizon, until the busy boardwalk sounds had faded and all he could hear was the rhythm of his gasps. The boy, whom I’ll call Joseph, explained all this to me days later, after he had been rescued, taken to a psychiatric emergency room, and discharged to his parents, Honduran immigrants who spoke little English. “I figured that eventually I would get too tired and then just basically drown,” he told me with a chilling indifference. “But typical me, I can’t even die right.”
Over the next few weeks, I learned that Joseph was beset by worries large and small. Would he ever grow taller than five feet six? Could he ever bring a girl home to see the apartment where he slept with his brother on a foldout sofa in the living room? At school he was timid and craved only invisibility, even though in my office he was unafraid to use big, grim words (schadenfreude, lugubrious) and talk about the Margaret Atwood novel he was reading. His mother took his shyness for defiance and complained of his refusal to run simple errands for her, such as stopping by the butcher on his way home. “And he’s not friendly,” she told me. “He won’t even say hello to his aunts.” But he was soulful and handsome, and I wondered whether in a breakfast club of sophisticated misfits, a teenage tribe he never managed to locate, he might have found the courage to raise his eyes off the floor. Instead, the overwhelming impression he conveyed was of perturbation: a fish out of water, a boy pulled out of the solace of the Pacific Ocean. Joseph was suffering from an anxiety disorder that had pushed him to a dangerous brink.
If you have read my articles in Vogue about actors, designers, and chefs, you may be surprised to learn that I am also a psychiatrist. (How I got from fashion to psychiatry and back again is a story for another day, though I’d argue that the professions are not as disparate as they might seem.) There is no mental illness I see more frequently in young people—because there is no mental illness more common in young people—than anxiety. According to some estimates, up to 20 percent of children and adolescents will suffer from anxiety, panic, phobias, or their close cousins: obsessive-compulsive disorder, body dysmorphic disorder, and post-traumatic-stress disorder. And yet anxiety remains among the most easily missed illnesses in all of pediatric medicine; by some estimates, four out of five children with anxiety will never be treated for it. Consider that anxiety is a risk factor for school failure, drug addiction, and incarceration, as well as for depression and suicide, and you have something approaching a public-health crisis.
So what’s going on? For starters, we have opened our eyes. Child psychiatry has its fashions, like any other profession: In the early part of the last century, research focused on delinquency and psychosis; then came ADHD, depression, OCD, and bipolar disorder. It may be the case that the wealthier and more stable we become as a society, the more easily we turn our attention to what are known in psychiatry as “internalizing” conditions, marked by their quiet symptoms and retreating behavior. “Finally we have the capacity to worry about worry,” says John Walkup, M.D., director of the Division of Child and Adolescent Psychiatry at Weill Cornell Medicine and NewYork-Presbyterian Hospital and codirector of the hospital’s Youth Anxiety Center.
For a while, anxiety in children was thought to be innocuous, even cute. After all, aren’t most kids afraid of monsters or the dark? Who doesn’t get nervous when reading in front of the class? And yet any parent knows that the opposite is no less true: Kids want attention; they want to be called on; they want to show off. They try and fail, then climb back on the horse and remember how much fun it is to ride. Gradually research emerged that described a child who was unable to separate from his parents without being overcome by fear, who was racked with vague worries about the future, who was terrified of scrutiny or failure, and whose intense and persistent anguish might lead to avoidance, isolation, and a failure to hit the major goalposts of development. In 2008, clear treatment recommendations finally appeared via the CAMS (Child/Adolescent Anxiety Multimodal Study) trial, which taught us that the best way to treat anxiety in children is with cognitive-behavior therapy, SSRIs (medications like Zoloft and Prozac), or, better still, both.
But laypeople and professionals alike have pointed to something else at play in the anxiety epidemic, or rather a pair of paradoxical factors: We are both putting stress on our children and trying to protect them from the uncomfortable feelings that can be an appropriate response to stress. This sends a confusing message—that the world is dangerous and that kids don’t have the tools to manage those dangers. It is probably worth mentioning here that the most socioeconomically disadvantaged children have always lived with excessive stress: unsafe neighborhoods, inconsistent sources of food and shelter, few routes out of cyclic poverty. In this context, as everywhere else, whether children develop anxiety disorders is determined by an interaction between their genes and their environment (including what they learn from Mom and Dad or other early role models). But stress is trickling upward, as anyone who has a child worried about getting into college understands. Fifteen years ago, I laughed when a friend told me that if her two-year-old daughter didn’t get into the Episcopal preschool on the Upper East Side, she could kiss Harvard goodbye. This is a fear bordering on a conviction for many New York parents, and a version of it can be found in families everywhere. Because anxiety is contagious, a generation of children is worried too. And when, as in Joseph’s case, the predicament of the present hangs over them like an impenetrable fog, they are at risk of committing acts of desperation.
While the world has never been more competitive, it has also never been safer, despite what politicians and news outlets might have us believe. Often when I explain anxiety to a child—which is an important early component of therapy—I start by describing the conditions under which we might imagine that it evolved. A caveman sees an approaching lion, and anxiety, if he’s got it, spurs him to fight or to flee. Meanwhile, his relaxed cousin gets eaten and fails to pass his anxiety-free DNA to the next generation. Anxiety, then, is an ancient and essential signal. It is a motivator. It can lead to ingenious solutions to menacing problems, and it tends to be accompanied by self-doubt and self-exploration, which give depth to the human experience. Anxiety about a deadline and a paycheck is spurring me as I write this.
But how much anxiety is too much? In a pathologically anxious person, threats get miscalculated; normal life experiences are avoided; and over time, a sense of oneself as unable to live in the real world leads to demoralization. A more typical person can cope with a high degree of anxiety, when it comes. A useful example might be Gulf War veterans; 10 percent of them—those in whom traumatic events can be thought of as having interacted with an overly sensitive alarm system—developed PTSD, while 90 percent of them moved forward without debilitating symptoms. Regardless of whether a child is experiencing a typical or a pathological degree of anxiety, the treatment is the same: repeated, controlled exposure to the threat—whether it’s spiders or school or speaking up—which over time leads to habituation and desensitization. Exposure therapy, the subcategory of cognitive-behavior therapy designed to recalibrate that internal alarm system by helping the patient see for herself that the perceived threat isn’t so threatening after all, has the advantage over medication of being potentially curative. I got over my fear of flying by flying a lot, which was miserable until it wasn’t. Exposure is the way forward, unless, like Aretha Franklin, you own a particularly luxurious bus.
And yet the idea of exposing a child to a noxious stimulus undoubtedly chafes at our protective instinct, especially in this era of helicopter parenting, allergy alarmism, and the like. Most psychiatrists I know fear that by sheltering our children or making all sorts of allowances for them, we may be cultivating a generation of hothouse flowers too rare and precious for real-world air. “It’s easy with an anxious kid for parents to accommodate to the anxiety,” Walkup explains. “The kid gets more and more delicate, and sooner or later the family can’t approach him with any task. Parents of anxious kids don’t empower their kids when they do that.”
A good deal has been written about the shift toward protecting college students from painful experiences by policing micro-aggressions and by instituting “trigger warnings” that alert students to the presence of potentially distressing content. Many clinicians who treat anxious children with exposure therapy wonder if it is realistic or helpful to try to make of college a distress-less utopia markedly different from the world for which it is meant to prepare its students. Though we may wish to promote sensitivity and respect, learning to tolerate what is frightening or odious is tantamount to building resilience, that buzzword of the moment. As D. W. Winnicott, the influential English pediatrician and psychoanalyst, wrote, “Mothers, if they do their job properly, are the representatives of the hard, demanding world.” Our society has yet to determine whether alma maters ought to serve a similar function.
Recently I asked a sixteen-year-old girl—whose social-anxiety disorder had remitted with a course of the SSRI medication Celexa—to look up from her iPhone for a moment and tell me how she felt Instagram and Snapchat had interacted with her illness. “It’s nice to be able to say, ‘Wow, there are people out there who are like me and are into what I’m into,’” she said. “But it’s so easy for people to be mean.” Certainly, social media have provided a crucial sense of connectedness to children who may feel isolated, but there are risks that attend not having adult support in interpreting so much unfiltered content. “In the past, information was buffered,” explains John Piacentini, Ph.D., director of the CARES (Child Anxiety Resilience Education and Support) Center at UCLA. “If there was a tragedy, for example, it was placed into context or experienced safely with the family. Now it’s a nonstop dose, and it’s easy for kids to confuse their subjective experience of reality with reality. This can really wear kids down if you think about it from a stress perspective.”
The good news is that we have gotten much better at identifying anxiety in children, and we know that early diagnosis significantly improves outcomes. This places the onus on parents—and teachers and coaches and nannies—to get kids through the clinic door. Most anxiety disorders in children arise before age twelve, and any family with a history of anxiety should have heightened suspicion. And yet the persistent, if fading, stigma around mental illness (more pronounced in some cultures than in others) remains a barrier to treatment. Anxiety disorders are also a barrier per se, as anxious kids frequently keep their worries hidden, and they tend to be frightened of medicine and its potential physical side effects while also fretting over the exposure tasks that are essential to therapy. But no barrier may be more alarming than the scarcity of providers. According to the American Academy of Child and Adolescent Psychiatry, there is one child psychiatrist for every 1,800 children with mental-health problems in need of treatment. Fortunately, we have also begun targeting anxiety in systemic ways that show real promise, including school curricula that incorporate mindfulness programs and coping-skill development. Children who are attuned to their emotional states and have a skill or two to summon in moments of distress quickly learn that the world is not as rough as it seems.
At the start of the school year, I met an eight-year-old girl with braids and patent leather shoes, whose grandmother brought her in when she started having tantrums. Two rowdy male cousins had just moved into the house, and they disrupted her rigid, orderly, and in my judgment anxiety-driven need for rules to be followed to a tee. She was an excellent student and a competitive ice-skater but had trouble maintaining friendships. She could not leave her bedroom until the part in her hair was perfectly straight, but this never made her late for school. In a matter of minutes I learned that the girl had been born addicted to methamphetamine, and that she had been adopted by her maternal grandmother at age three after a period of severe parental neglect. I admit I was surprised that her grandmother shared all this in the girl’s presence. Eight is young. But her grandmother, who must have read something in my expression, said, “She knows that she’s safe and that she’s loved, so this stuff doesn’t bother her.” I asked the girl what she thought of her unusual life story.
“I think it makes me interesting,” she told me. “And sometimes, when I feel frustrated, I remember that I’m really lucky.”
I can’t imagine a more auspicious way to start.