Temple Now

Story by Dan Morrell, SMC ´04'

Illustration by Trish Hooven Brown

Anna has proudly played the tuba in her high school marching band since ninth grade. But after missing a practice or two in the course of a week, she announces to her parents over dinner that she is giving it all up. Her parents are puzzled; until recently, Anna had always loved the band. What was happening?

Teen passions come and go, but giving up something she has enjoyed for years might signal a more severe emotional condition—especially if she is paralyzed by thoughts of failure or hopelessness, or if she fears some imminent danger befalling her as a result of performing with the band.

Until about age 13, depression rates are very low in children, saysLauren Alloy, professor of psychology and principal investigator of theMood and Cognition Lab at Temple. But they start to skyrocket around age 15. By the time children turn 18 and are legal adults, rates of depression among them have grown, too.

Of course, kids today face stressors never imagined by their parents, according to Philip Kendall, Laura H. Carnell Professor of Psychology. "When youths are faced with stressful parental discussions about things like the economic crisis and school terrorism, they are expected to somehow make sense of these experiences as if they are adults—but they are not yet adults," says Kendall, who also directs Temple´s Child and Adolescent Anxiety Disorders Clinic.

"They are forced to be both adults and longterm children," he says, noting the fact that children now live at home much longer than previous generations did.

Self-doubt and anxiety come with the territory of being a teenager. But how can parents distinguish between an adolescent´s normal emotional reactions and those that might be problematic? What can they do to help?

AVOIDING AVOIDANCE

Like Anna giving up the tuba, anxiety not only manifests itself in what a teen is doing, but also in what he or she is not doing. "Avoidance is a key word for anxiety," Kendall explains.

In other words, anxiety disorders in youth disrupt everyday life, sometimes paralyzing the social lives and activities of children and teens. In order to ease such anxiety, Kendall focuses on connecting thought processes to actions, or cognitive-behavioral therapy (CBT). He has been developing and using CBT to treat anxiety in children for more than 30 years. "When we combine [thought and behavior], we get a good one-two punch," says Kendall, who co–authored one of the earliest books on the subject, Cognitive Behavioral Interventions: Theory, Research, and Procedures, in 1979.

When a child visits a psychologist for the first time, the therapist begins to build a relationship with the patient through conversation— about things that are fun, things that are scary and thoughts that pop into patients´ minds, both good and worrisome.

"If a child says, ´I´m afraid to raise my hand in class because I´m afraid I´ll say something stupid,´ we´re not going to challenge that right away," Kendall says. "We have to get them comfortable with paying attention to their own inner dialogue before we start to challenge it." With his younger patients, Kendall uses pictures of cats in an approach he calls "Coping Cat." Images of frightened felines with hair on end can help children understand how their own emotions manifest physically—such as a rapid heartbeat or a stomach in knots—and offering them vital ways to identify anxiety before their thoughts spin out of control.

That skill eventually results in the abililty to manage anxiety that was previously uncontrollable. "The first half of treatment is about building skills—recognizing when you are tense, recognizing that it is normal, and recognizing your inner dialogue and problem–solving," Kendall says. "Then we say, ´Okay, let´s try to apply them.´" He likens the process to piano lessons: Children are taught a few chords, a few scales, and then must practice on their own.

Once a patient can gauge physical symptoms of anxiety, he or she learns to identify what kinds of thoughts match them, such as internal negative predictions about stressful situations. Then, the pair works together to change the child´s inner dialogue from something like, "What if I die doing this?" to "The world won´t end if I feel scared," or, "I can do this."

In the end, the approach can liberate anxiety–addled youths. If a child is afraid to sleep at a friend´s house, call a friend on the phone or participate in an afterschool activity, then he or she has only succeeded when all three fears have been conquered.

"We don´t want them to only feel better about themselves," Kendall says. "They have to do the things they used to be afraid of." For example,¹ 7–year–old Mike is extremely afraid of the dark, reacts badly to loud noises and has a deep fear of the unknown, whether it is in the school cafeteria or at a friend´s house. Clearly, Mike´s life—not to mention his parents´—became increasingly limited as those fears overwhelmed him.

Using BCBT (brief cognitive behavioral therapy)—a series of eight sessions for both parents and children, rather than CBT´s usual 16—a therapist was able to alleviate his anxiety. After making Mike feel comfortable, and teaching him how to identify anxiety and soothe himself before he became overwrought, the doctor helped him construct a hierarchy of fearful situations. She then assigned Mike increasingly difficult challenges that forced him to confront his fears one by one. Within eight BCBT sessions, Mike´s anxiety had decreased significantly.

Mike is just one example of how successful the CBT method can be. Recently, Kendall and his colleagues determined that in combination with antidepressants, CBT is significantly more effective than either form of therapy alone. The largest–ever National Institute of Mental Health study to evaluate treatments for anxiety disorders in youths, their six–year investigation examined 488 children who were treated with either CBT, a particular antidepressant, or a combination of CBT and the antidepressant. Eighty–one percent of children who took both the antidepressant and participated in CBT improved, as opposed to 60 percent of those who only underwent CBT. (Fifty–five percent underwent a change for the better when they used only an antidepressant.)

GLASS HALF FULL

While teenagers test their burgeoning independence, they also are bombarded with potential emotional perils. Take the child who does not get invited to a classmate´s party. According to Alloy, a teen prone to depression might see that act as a sign of something bigger—that no one likes her, that she will never make any friends or that there is nothing she can do to change her situation.

That thought process illustrates Alloy´s "hopelessness theory of depression." Essentially, those prone to a more negative view of themselves and the world are more vulnerable to bouts of depression when faced with certain stressful life events.

Alloy and her longtime colleague Lyn Yvonne Abramson at the University of Wisconsin–Madison first advanced the model in the late 1980s and have been testing and refining it ever since. "Not everyone who experiences stressful life events becomes depressed," Alloy says. "So one of the questions I´ve been fascinated with—from the time of graduate school until today—is: why do some people get depressed when faced with life stress and others don´t?"

In short, it is a matter of personal interpretation. Specifically, it is something Alloy calls "negative cognitive style," which can manifest itself in a few different ways. An example: You lose your job. If you have a negative cognitive style, you might view yourself as cursed—there is some constant, unchangeable factor that caused you to lose your job, and there is nothing you can do about it. You also might see the event as only the first of many dominoes to fall, turning it into a catastrophe you imagine might lead to your inability to pay your bills and mortgage, culminating in the loss of your family.

"You don´t have to interpret it that way," Alloy says. "You could make much more benign, much more positive interpretations of a very stressful event." She suggests blaming the sluggish economy, or attributing the job loss to the fact that you were the last person hired and the company was following internal policies.

Alloy´s theory has been tested extensively. In a landmark 14–year study conducted by Alloy and Abramson and published in 2006, college freshmen were screened for negative and positive cognitive styles. Researchers followed a select group of students from both categories, checking in periodically with tests and interviews to measure stress levels and look for signs of general hopelessness.

In the end, those with negative cognitive styles were seven times more likely to suffer a first–time onset of a major clinical depressive episode. As a result of the study, researchers can potentially predict not only who might develop depression, but also when its onset might occur.

PREPARE AND PARTNER

Outside a clinician´s office, both parents and other adults can augment a child´s treatment. Kendall notes that parents can help by talking with their children regularly, in order to better understand the motivations behind their children´s actions.

For example, if a parent suspects that his or her daughter is claiming to be sick because she wants to avoid the anxiety of a school day, Kendall suggests taking her temperature. If it´s under 100, send her to school, with contact information for the nurse. "When you do it that way, it takes the decision out of the parents´ hands," Kendall says. So, parents are not the bad guys for sending her to school, and they are not letting her avoid a situation, either—a fair but firm way to help a child confront her fears.

Alloy has found that parents can be effective in another way: Their outlooks can shape those of their teenagers. In an expanded version of her initial study, Alloy included the subjects´ parents. She found that when a teen suffered some kind of setback, a parent´s less–than–sunny interpretation of why it happened would negatively affect the child´s responses to such events.

"Essentially, the parents´ inferential styles influenced the development of the cognitive styles in their sons and daughters," Alloy explains. "If parents give feedback that is more benign, children can develop more positive inferential styles."

So, if a child is upset about being left out of a classmate´s bar mitzvah because he believes he is simply (and perhaps forever) unlikable, Alloy would advise his parents to offer a more neutral or positive explanation: The invitation was lost in the mail; perhaps only relatives were invited; maybe their son´s classmate is simply a jerk.

Both Kendall and Alloy note that other adults in a child´s life—aunts, uncles, teachers and even friends—can act as buffers, helping slow the mental snowball to catastrophe and keeping children´s thoughts from turning dark immediately. "It´s almost as if they become informal cognitive–behavioral therapists," Alloy says.

In fact, those outside sources can have an even more profound effect on a child´s outlook than their parents. "Even parents with the intellect, the skill and their hearts in the right place have played different roles for their children for, say, 15 years," Kendall says. "Not that there is anything wrong with those parents. Sometimes, it just takes a different person to make a difference for that child." Sometimes, it has to be an uncle, a sports coach, a psychologist—anyone other than a parent. But as Kendall notes, that should not keep anyone from trying.

Dan Morrell, SMC ´04, is a Boston–based writer and editor. His work for The New York Times, Fast Company, Slate and other publications can be found at danielmorrell.com.

1. "Mike" was the subject of a recent study: Beidas, Rinad S., Kendall, Philip C., Mychailyszyn, Matthew P., Podell, Jennifer L. (2013). Brief cognitive–behavioral therapy for anxious youth: the inner workings. Cognitive and Behavioral Practice, 20(2), 134-146. dx.doi.org/10.1016/j.cbpra.2012.07.004