Pediatric Anxiety Disorders: Stephen P. Whiteside

[Speaker] Dr. Steven Whiteside: That's one of the most common questions that we get.

There's probably two things to think about. The first is being more nervous or afraid than we would expect.

If a child is doing something for the first time, like the first time they have to give a book report in front of the class or they're going to a summer camp for the first time or transitioning to middle school and they're going to meet a bunch of new kids.

[Music]

[Host] Kristina Orlova, LMFT: Welcome to the "OCD Whisperer" podcast. Today with me I have Dr. Steven Whiteside, who is a board-certified clinical psychologist, professor of psychology in the Mayo Clinic College of Medicine and Science, and director of the Pediatric Anxiety Disorders Program at Mayo Clinic in Rochester, Minnesota. He received a B.A. in psychology from Northwestern University and a Ph.D. in clinical psychology from the University of Kentucky before completing a predoctoral internship in pediatric psychology at the Geisinger Medical Center and a postdoctoral fellowship in child and family medicine of psychology at Mayo Clinic.

His research focuses on improving access to evidence-based care of pediatric anxiety disorders and obsessive-compulsive disorder. He has published over 80 scientific articles and most recently authored "Anxiety Coach: A Parent's Guide to Treating Childhood Anxiety and OCD."

Welcome to the show Dr. Whiteside.

Dr. Whiteside: Thank you, Christina. I'm really excited to be here.

Host: Absolutely. You and I briefly were just touching base before we jumped on here together about this book you've written, "Anxiety Coach: A Parent's Guide to Treating Childhood Anxiety and OCD."

I mentioned that I think this is an amazing resource for parents. There are so many parents who struggle and suffer with, "How do I help my child?"

I would love to hear from you: How does the parent-coached exposure therapy differ from other approaches of how to work with kids?

Dr. Whiteside: That's a great question. Thanks for jumping right to the heart of it.

There are two — maybe three — things that we really focus on that are quite different from what most other people do. The first is that we focus on exposure. The main component of the treatment for anxiety or OCD is helping kids learn through their own experience that what they're afraid of is unlikely to happen and just as important that they can handle feeling nervous, worried, uncomfortable or — in OCD — disgusted until those feelings go away.

They don't have to avoid. They don't have to do rituals. Parents can't talk their kids out of it, and we can't talk their kids out of it. The kids can only learn that through their own experience.

Exposure has been around for a long time. It's well documented as the most important part of treatment, but it's uncomfortable. It's hard work, and it's hard to get access to that. So that's No. 1. We focus exclusively on exposure.

The second thing that we do a little bit different than many people is that lots of therapists will just work individually with the child. Parents drop them off and maybe are in the session at the beginning and the end to update on what's going on or hear a progress report, but most of what is done is with the child.

We think that all kids will be more successful if they have someone to help them at home. We think that parents want to know what to do to be helpful. So we always work with kids and parents together in the session, basically the whole time. We're flexible people. We'll meet with them individually as needed to discuss difficult issues. For the most part, we're working with parents and kids in the session together so that we become experts at exposures together so they can continue the work when they're at home.

Host: That's wonderful. I think that's so empowering for parents. I think you're right that some parents say, "Here, help my kid get better," but the truth is, you're with your kid all the time in between. So let's help you help your child get better.

I'd love to know from your approach, well what is it? How do you do that? What do you cover, or if you can give us anything about it?

Dr. Whiteside: The first part of our approach is making sure that we're on the right track.

In "Anxiety Coach," the first section is about what is an anxiety disorder and OCD. Because if what a child is experiencing is not best described as anxiety and OCD, then exposure is not going to be the right treatment.

We first start off working with kids, and we work with kids and parents from the beginning — partly because kids rarely come in to ask their parents to go see a psychologist. Especially younger ones. That doesn't happen. Parents rightly see the concerns, and they bring them in.

We talk together and try to decide is a child more nervous, worried and afraid than we would expect them to be. It's not that life is stressful so they're anxious. It's not like they don't have the skills to handle the situation. They are overly anxious because they're suffering from an anxiety disorder: OCD.

Based on that understanding, that sets us up to do treatment.

What we need to help them learn is that what they're afraid of probably won't happen. We spend a session — usually one appointment, sometimes two — learning about how anxiety works. How do rituals or avoidance keep those fears around? How do parents and kids set up an exposure, do it and learn from it? And then how do they take those planned exposures and generalize them to handling anxious situations when they pop up day to day?

That's usually the first session or two.

Then after that, we begin each appointment just reviewing what they've done. What exposures have they done since we saw them last.

Then we spend about 20 to 30 minutes with the kids and the parents planning. Here's what we're going to do to face our fears. I've got social anxiety, so we're going to walk down and introduce ourselves to store clerks. Or I've got OCD fear of germs, so we are going to walk around and touch doorknobs around the hospital floor.

We do that until their anxiety comes down and they learn it's not so bad. Then at the end, we debrief on how it went and we make a plan for what they're going to do for the next week before we see them again.

The third thing that's a little bit different is we do a lot of treatment in group settings. We have two therapists and we've got six kids, sometimes less, sometimes a little bit more, and their parents in the session together. We follow that same format, but kids are also learning from other kids about what they've worked on — making it very clear that anxiety and OCD is a normal thing that lots of people experience. It's nothing to be embarrassed about or have to keep secret.

Host: That's amazing. That sounds like a lot of solid work. Just for my understanding and for anybody listening, is that the kind of program you walk folks through in the book?

Dr. Whiteside: Yes.

The first part of the book asks, "What is an anxiety disorder?" That definition of being more nervous and afraid than we expect.

Then there are a number of different anxiety disorders — social anxiety, OCD, generalized anxiety. We walk through what those are. Then we talk about things that sometimes get mistaken for anxiety disorders, like stressful situations.

Then the second part of the book is walking through that model of how we start to learn exposure. We give a little bit of background on the history of exposure therapy and the research supporting it so that people have a sense that it's not something we made up. It's something that's been around for a while.

We talk about the parents' role. Then we get more and more specific.

There are different types of exposures, doing activities versus repeating scary thoughts, here's how you set them up, here's a general course of what we'd expect — that it might take a couple weeks to get up and running. Then after about six weeks of doing exposure, we then plan to start tapering off.

Host: OK, that's wonderful.

Dr. Whiteside: Then the third part of the book puts both those together.

We go through each of the diagnoses — social anxiety, generalized, panic disorder, OCD, separation anxiety, etcetera and talk about and apply what we've already learned in the first two sections.

How do you know when that's the right diagnosis? How do you set up exposures? How do you follow through? How do parents coach their kids through it? What are some of the markers that you're on the right track? And what are some of the common pitfalls that get in the way and that might suggest that you need to find more help?

Host: That's a lot of information that you're covering in that book. That's always incredible to me when somebody takes all of this clinical experience, all the training and condense it into these pages. I'm sure anybody listening, something that can catch somebody's attention, how do anxiety disorders differ between everyday nerves and worries? What could people look for?

Dr. Whiteside: That's one of the most common questions that that we get. There are probably two things to think about. The first is being more nervous or afraid than we would expect.

If a child is doing something for the first time, like the first time they have to give a book report in front of the class or they're going to a summer camp for the first time or transitioning to middle school and they're going to meet a bunch of new kids — those are all situations that we expect kids to be nervous.

Some are more than others, but those are situations we expect kids to be nervous in.

Being nervous, worried, is a normal — and a good normal — part of life. It keeps us safe. It helps us make good decisions.

An anxiety disorder is when kids are more nervous than we would expect.

So, yes, they're nervous the first day of school. But now we've been to school for six weeks and they're still really scared and nervous to separate in the morning. Which is more so than we would expect them to be because other kids aren't as nervous and there's nothing going on, there's no one bullying them at school, they're doing fine academically. It's this anxiety about separation.

Then the second part is it's also normal to be more nervous and worried than you need to be. I mean, some people worry more than others. I'm just more fearful. There's nothing wrong with that unless it's getting in the way of that child's life.

That's the second piece: that the fears and worries have to be excessive, that they're making life hard, they're distressing the child, they're making the child upset. And/or, especially with kids, it gets in the way of a parent's life or is distressing them. When it feels like it's causing a problem, then that's the time that we need to start working on it.

Host: So those are some really clear signs parents can look for. Are there other signs that you can name? Because you touched on it a little bit in terms of, especially like you said, kids that are younger. They're not going to say things like, "Oh, this is getting in the way of work or a relationship." It can present a bit differently in the pediatric population than in teenagers or adults.

What are some of things that parents can look for that might be earlier signs? Like, hey, this might be a clue to maybe see a specialist or get an evaluation?

Dr. Whiteside: Yes. Yes. Especially with younger kids, when they're not able to use their words and describe it or have insight into their own experience. One thing that we use as our guide is the child's actions and behaviors. If kids are refusing to do things that are reasonable expectations, that's typically a problem because they're not doing the things that they need to do. Just refusing to do things doesn't mean it's anxiety. It could be good old stubbornness or an anger outburst. But if they're not doing things that seem like they would be fun — that the child would enjoy and want to do or they're really resistant to doing it but when they get there everything seems to go fine and they enjoy it, but then the next time the same thing happens — that's behavioral resistance.

It is a sign that maybe a child is suffering from anxiety if they have lots of questions. Questions that suggest the child is thinking and worrying that things aren't going to go well:

• "Are people going to like me?"
• "Is dad going to be home on time?"
• "Do you think that this plane is going to be safe?"
• "Are we going to get into an accident?"
• "Is my sister going to be OK when she's sick?"

There are lots of questions, particularly when it's the same or similar question over and over again that you've already answered. Believe the child's anxiety, but then the question comes right back up. That's another sign that kids are being nervous and worried.

Also, if they're tearful, crying and upset — sometimes irritable around things that seem like they would be enjoyable — is another potential warning sign that a child is suffering from anxiety or OCD.

Host: That actually leads me to another question which I know a lot of people, especially folks who listen to this podcast and in general have, which is why can OCD be challenging to accurately identify and correctly diagnose? Because obviously this is still quite a big issue for folks. What's your thought on that?

Dr. Whiteside: I don't know that I have a clear good answer to that one. One thought is when you've been working in it for a long time, like we have, and you've seen lots of it, and you talk to people with it, it starts to make a lot of sense.

OCD makes a lot of sense to me. That you have this thought, you get upset and so you tap something three times. I've heard it many times. It just makes a lot of sense. You have these bizarre thoughts of hurting people and it's common OCD. But if you're not familiar with OCD, those things can be alarming and seem unusual.

"Why is this child having these thoughts? Are they delusional? Are they suicidal because they keep thinking they want to kill themselves and having these thoughts? But if you're familiar with OCD, you know you're they're not because they're really upset and scared by the thoughts, so they're pushing themselves away from knives and any sharp objects.

So that's one. If you're not familiar with it, it seems unusual and it's hard to understand something different, something worse.

Also people can tend to focus on the repetitive nature and the behavior. Self-stimulating behavior in autism or other repetitive skin picking, hair pulling can get confused with OCD because of people repeatedly asking for things over and over again. Like repeatedly asking to have their video games is sometimes classified as a repetitive behavior and thought to be OCD.

I think part of it is just outside of most people's normal experience and the focus on the repetitiveness rather than the kind of the way the obsessions and compulsions work together throws people off.

Host: I think that's actually a really interesting and good point because not all repetitive behaviors are OCD or compulsive in nature.

And, to your point, if you don't know it — when you don't know OCD and you don't understand it — it could seem strange. Or you might not even realize it. That's the other thing. You might have a way that it's showing up that you're not just haven't really seen or even heard of, so you wouldn't even think of it as that.

I'm thinking about like sometimes morality things; about being overly rigid and having these intrusions; about doing things the right way; or relationship OCD, where it can show up between friends or toward your sibling or towards perhaps, if you're a teenager and you're trying to date, somebody you might not realize — this is another way it can show up?

Dr. Whiteside: You bring up two really good points.

One is that sometimes with those examples that you have, sometimes therapists or health professionals want to dig into it. You're having these intrusive thoughts about stabbing your mother and you freak out and then you ask for reassurance that you wouldn't do it. It's clear OCD. But someone not familiar with OCD might say: "There must be underlying issues or anger toward your mother, and we've got to really delve into those. Tell me how you really feel."

So kind of getting way off track and doing things that are not helpful and can potentially be harmful or at least frustrating because it's not working.

And then, especially if they're a teenager, starting to date, and they're having intrusive sexual thoughts or other intrusive thoughts that they're embarrassed about. They may not want to share it with their parents or share it with anybody. And that makes it harder to get to identify when people are uncomfortable sharing their thoughts, which is one reason that OCD is sometimes referred to as a hidden epidemic because people are just embarrassed and keep it to themselves.

Host: Yeah, absolutely. As you're saying that, I certainly have a couple of clients that I've worked with where it was teenagers. That was a big piece, feeling just really embarrassed and uncomfortable around sharing thoughts. If you think about it, this is what's true out in the world in terms of that there is stigma. There is judgment.

I don't think we can say that there will never be judgment. I mean, it's human nature and, so, people — I think everybody — just wants to be liked and get along. But then when you're having this intense internal experience, how can you kind of put it out there and feel safe and comfortable? You're going to be hurt right? How can you, let's say the younger kids might show it, like you were saying, behaviorally. But if you're a little bit older, like a teen, I guess how do you think teens could maybe let their parents know or kind of get some help?

Dr. Whiteside: One hope, with this "Anxiety Coach" book is that we describe OCD and other anxiety disorders. Hopefully, seeing it written down like this happens often enough that somebody wrote it down in a book, so I am clearly not the only one. It is not as bad to talk about it, and maybe I'm not going to tell my mom all the details, but I will suggest, you know, that OCD — I'm having some thoughts like that. Hopefully, the book can be helpful in that way.

It's also — and I can't take credit that this was our main goal — a side benefit of working in groups is that you're just with other kids going through very similar things and that none of us like to be alone. We all feel better when we're with somebody, especially with people with shared experiences, and that's the real benefit of the group.

Now that being said, many people are nervous about starting the group, especially if they have social anxiety. But also with OCD, I'm not going to share these thoughts with a bunch of other people. But once they get into the group, most people find it a supportive and valuable experience.

And, also, when we're working in groups, certainly people have symptoms or thoughts or things they are afraid of that are not appropriate to share with the rest of the group or not necessary. We're focusing on kids doing exposure with parents, so they kind of break off and they work alone. We certainly don't have to share everything with the rest of the group. We keep lots of things private as needed.

Host: That's wonderful. Actually, that does bring one more question I'd like to ask. Which I'm sure anybody listening now, especially as a parent might be wondering. What are the outcomes? What are the results? Can you speak to that? What can people expect? What kind of results can they have from the parent-coached exposures?

Dr. Whiteside: That is a great, fair question. We have we have some pretty good answers to that, but a lot more research needs to be done in general around child mental health in particular and, even more specific, around our program.

There are a couple studies that we've done that help answer that question.

The first is that we recently completed — and we're kind of just working on writing it up and submitting it — a research trial where we randomly gave kids either our parent-coached exposure therapy or traditional CBT that has a lot of nonexposure anxiety management strategies and doesn't include parents as much. What we found, and these are kids with anxiety and/or OCD, is that parent-coached exposure therapy was more effective. Kids had more improvement with parent-coached exposure than traditional CBT.

Improvement was a lot faster because we jumped into exposure. After six sessions, there was a big difference between the groups. CBT started to catch up once they started doing exposures. But we started exposures early so their kids got better faster. And, also, they needed fewer appointments. The kids in the parent-coach exposure group, even though they had more improvement, attended about a little over one fewer appointments. That's the best research that we have suggesting that our approach is more efficient and effective than standard CBT.

We also have, because exposure therapy is so hard to find, a five-day intensive treatment program at Mayo Clinic in Rochester, where families with kids who have anxiety or OCD and can't find treatment closer to home can come and stay in Rochester for a week. We've got nine appointments between Monday and Friday, and we do a lot of parent-coach exposure in a group setting.

We don't expect OCD to be fully treated after one week, which is why we work with kids and parents together. We want to train them to continue to do exposures — just the two of them — because they don't have a therapist at home. That's why they came to us. So that parent and child continue to do exposures for the months after they've left.

The best study we have about that, based on when we're doing it individually rather than a group, is that kids with OCD improved after three months — improved about as much with our approach with that, you know, five-day intensive as they do with other more traditional once-a-week exposure-based treatments in the research literature.

Host: That's great. I really love that supporting the community with the kind of more immediate network, which is your immediate family members, and making sure that they have the tools and understand the "whats" and the "hows" and get that empowerment right so that they can they can go and problem-solve this and work together.

Dr. Whiteside: That's one of the reasons that that I wanted to write this book. Because we've been working with kids and families for probably close to two decades now. Not quite. It's not that old yet, but it's obvious to me that parents can learn to do this. And kids and parents can learn to do this together. And, so, everything we do is directed so that it's understandable to kids and parents. We just want to get that information to them directly — to as many kids and parents as we can through this book so that, hopefully, there's some that have more mild symptoms and reading this book is enough to get them on the right track. But, you know, the reason we have a job is because it's hard to face your fears and do anxiety and OCD treatment.

Probably more realistic for a lot of families is that this book helps them learn what to look for. When they are searching for a therapist they can know whether or not that therapist is on the right track doing exposures or if it's not a fit because they're doing something less directive and less likely to be helpful and worth that family's time.

Host: Yeah, that sounds great. Just for anybody listening, you'll have the link to this book in the show notes so you can you can access it. You can get it.

Thank you so much for your time and please let folks know who are listening how can they find you if they'd like to find you?

Dr. Whiteside: I've got a website through Mayo Clinic: Stephen Whiteside at Mayo Clinic.

We also have another website. It's called Anxietycoach@mayoclinic.org. It has all of our educational materials in terms of videos and interactive worksheets, and it's got a Find Help tab that has information about our five-day intensive treatment program, contacting Mayo Clinic and lots of other organizations that are great for helping families connect with therapists.

Host: I love it. Beautiful. Thank you so much for coming on the show.

Dr. Whiteside: Thank you. I really enjoyed it.

[Host] Dr. Meg Meeker: Well, it's no secret that anxiety is a top concern for parents today. We've tackled it head-on in previous episodes, from exploring its potential link to social media to recognizing the signs and equipping ourselves as savvy parents. But there's a vital aspect we haven't delved into enough: the pivotal role of the family in addressing anxiety and other mental health challenges in our kids.

Well, today, we're shifting gears to zero in on the powerhouse that is the family unit when it comes to our children's well-being. My guest is Dr. Stephen Whiteside, author of "Mayo Clinic Anxiety Coach: A Parent's Guide to Treating Childhood Anxiety and OCD," available now for preorder and releasing on April 16. We'll be tackling common questions parents have, such as who are the best people to help coach kids through their fears, when families should meet with a mental health professional and how anxiety disorders differ from everyday worries, among others.

Welcome to Parenting Great Kids, Dr. Whiteside. I'm so excited to have you here. The show is just for me.

Dr. Stephen Whiteside: Thank you. I'm excited to be here as well. Thank you so much for having me.

Host: You bet. You've written other books before, but this book is really directed toward parents. You said you've written books for therapists, but this is for parents. I think you're going to sell millions and millions of copies because parents really need a lot of help.

Now you are a board-certified clinical psychologist, professor of psychology at Mayo Clinic and director of Pediatric Anxiety Disorders at Mayo Clinic. How often do you treat kids, and how often do you just teach psychologists how to treat kids?

Dr. Whiteside: My primary role is a clinician. So that is my day job. That is what I'm supposed to do most days. I work with kids and their parents who are dealing with anxiety and obsessive-compulsive disorder — OCD — most days of the week.

Host: Awesome. You're not just an academic person. You are a hands-on clinician. What prompted you to write about coaching kids through anxiety?

Dr. Whiteside: There's probably a few directions that led us to that. First, there are a couple things that make our approach to childhood anxiety disorders and OCD a little bit different than others. And one of them is that we work with kids and parents together the entire time. And, of course, we will meet with them individually here and there as needed to talk about things that are sensitive or just need to be addressed. But, in general, we are working with them together the whole time.

And then the second piece that makes what we do a little bit different is we really focus on experience, helping kids face their fears — do what's called exposure therapy — so that they learn through their own experience that what they're afraid of probably won't happen, and they can handle feeling anxious.

Based on that experience day in and day out for probably close — oh, unfortunately, probably more than 20 years now — I have seen parents and kids learn to be exposure experts. Writing a book to teach parents to be exposure coaches was very consistent with the model of how we've been working with families for years.

Host: I love, you know, the approach of desensitizing kids, but let's back up a little bit. First of all, as a pediatrician, you're kind of the gateway. A lot of times parents will come saying, "I have a 7-year-old. I have a 13-year-old, and I'm concerned that they're worried all the time. I'm concerned they may have anxiety." What kind of questions do you ask, and what should parents be looking for in their kids?

Dr. Whiteside: That's a great question, and that's where we start the book with. The first section is what is an anxiety disorder? When do you know that it's time to get help? Because if we don't accurately understand a child's experience and what they're going through, if we're wrong, then we're probably going to recommend the wrong treatment.

And that's not only not going to be helpful, but it's going to be frustrating and make it less likely that child's going to — the family is going to — seek help again if they've had a negative experience. It's really important to get off on the right track.

It begins with kind of a shared understanding of what an anxiety disorder is, and that simply kids feeling more nervous, worried or afraid than we would expect in a situation. We want to separate that from a couple things. First is stress. Some kids are anxious and worried because life is stressful. There's a lot of arguing at home or they're being bullied at school or they're failing their classes, and we would expect most kids to be anxious and nervous in that situation. That's different. We need to help them solve that problem.

An anxiety disorder is when things are going smoothly. Parents are healthy and doing well, but the child is still worried about their well-being and whether the family is going to stay together. Kids are well-liked at school, but they're so shy and nervous that they're afraid they're going to make mistakes. They get very nervous talking to people. Or they're getting As, but they're still always worried that they're not doing well enough.

The child is worrying more than they need to. That's the first piece of whether or not it's an anxiety disorder. And then the second piece is simply, is it causing problems? Is fear and worry making life difficult for the child or the parents? Because parents are very important in kids' lives.

Is it getting in the way of social interactions, doing things with the family, being successful in school? And if it is, then it's probably enough of a problem that we should work on it.

Host: But what if it isn't? What if you got a kid who's functioning fairly well and they're covering up pretty well, but they feel they just kind of got this motor going on underneath where they have to get good grades and they have to be the best at everything and they're afraid of letting people down?

Now they're functioning well, but they feel like something is propelling them forward and they're anxious all the time, and they don't know what to do. How do you know if that's an anxiety disorder or just a personality in a kid?

Dr. Whiteside: I'm glad you brought that up. That's really important because when there — the technical definition of an anxiety disorder or mental health problems is, one, that it causes problems, or two, that it's really distressful and upsetting. Especially with anxiety, where kids are nervous about things, so they're working very hard to make sure that no mistakes happen. That distress piece can be really important.

But, oftentimes, when we peek beneath the hood, we see that there is some interference. They're very nervous and worried about making sure that their grades are good enough, that they don't disappoint people. And, yes, they're functioning, but they're not really sleeping enough because they're spending way too much time at night doing homework. They're not doing relaxation activities. They're not hanging out because they're so worried about being good enough.

We can see that there are problems in other areas, even if those problems are not having enough time to socialize and just relax and have downtime.

And part of it comes with, you know, talking with — it doesn't all have to be solved at the beginning. That's one of the nice things about exposure therapy and behavior therapy in general: The side effects are mostly that it's sort of hard work and takes some time.

But these are the things that you learn in therapy: take small steps and stick with things even though they're hard and do things that are challenging, are good life lessons for all of us. The downsides of starting therapy are pretty low.

And if you get started and it seems pretty clear that this child's focus on being successful is really consistent with who they are, and they don't see it as a problem, and the parents are just wanting to check things out, and they think that the child's doing fine, then we don't have to do anything about it. But now they know that we exist. And if down the line it slips into being more problematic or distressing, it's easier to find us and get back in.

Host: Awesome. What I'm taking away from what you're saying is that there are different groups of anxiety issues in kids. I've seen, for instance, kids are going along fine and then COVID hit, and now they're a mess. And then there are kids who, ever since they were quite young, are acting like the kids you and I've just been talking about — the kids with a sort of motor and, "I just have to, have to." And then there are the kids who just have these sort of panic attacks and then they're better. And then they have these panic attacks. How do you separate out the kids with anxiety and when they need treatment and when they don't need treatment? And then is the treatment for each of them the same?

Dr. Whiteside: When we meet with families for the first time, our first goal is to decide with the family, the child and the parents is what the child is experiencing best described as an anxiety disorder?

And, again, that means being more nervous, worried or afraid than we would expect them to be of everyday activities and circumstances.

The second step is then being more precise with the diagnosis. And the reason we go in that order is because, fortunately, we treat all anxiety disorders the same, including OCD. There's a lot of overlap between them. If you have one anxiety disorder, you probably have more than one, and that's not particularly helpful — to be given a bunch of different labels for kind of one issue that you're dealing with.

We try to make families aware of that — that don't worry if you have social anxiety and generalized anxiety disorder. It's all different versions of the same thing. We'll treat it all the same.

Fears and worries tend to change over development. What we see in younger kids is frequently separation anxiety. They're very nervous about separating from parents at nighttime, for going to bed or to go to school, and specific fears such as fears of animals, fears of the dark. And then as kids get older and social interactions start to be more important — later elementary school, getting into middle school — then we start to see more kids with social anxiety disorder, very nervous about talking to other kids.

And then as they begin to be teenagers and start having more of an ability to think about and worry about the future, and worry about all the things they need to handle, generalized anxiety disorder — where kids are just worrying very frequently about lots of different topics to the point that it makes them feel bad physically — becomes more prevalent.

Host: In diagnosing and treating anxiety disorders, it seems like you start out pretty broad. You know, the kids will come to me. They're nervous and worried, maybe have the motor running and so forth, and then I say, "OK, it's time to go to a psychologist and figure this out."

I love that you say that it's critical to get an accurate diagnosis because, you know, anxiety — other things can sort of mask as anxiety. Or anxiety can be a result of something else. You know, if you're being bullied or you've got depression or something else is going on, you know, or a learning issue, when you can't understand what's going on at school, you have anxiety because of that.

Then you decide, OK, is it anxiety, and then where does it fall? Is it generalized? Do you have specific phobias? Is it separation anxiety? And at that point, is that where someone like you would sort of untangle things and say, "This is specifically what we're dealing with, and now let's go down the path of treating that," or can you start kind of not knowing exactly where the anxiety is coming from?

Dr. Whiteside: I think one of the answers is everything that I do as a child psychologist when it comes to anxiety and OCD is pretty straightforward. And our goal is to describe things and present things in a way that kids as young as 7 can understand and their parents can understand. And, yes, I've been doing it for a long time, and it takes expertise and experience. But our general thought is families can learn how to do this.

And part of the inspiration for writing the book is there's probably a lot of families out there who anxiety is a mild problem and that if they have some direction and some permission and some reassurance that these are the right things to do, they can probably work through this on their own, identifying it, sorting it out and making a plan.

But there are a lot of families probably with more severe anxiety or OCD. A book is probably not going to be enough. A self-help app is probably not going to be enough. You just simply need somebody who has done this time and time again and feels confident and can help you sort through it, plan it and follow through with your treatment plan.

And hopefully this book will educate families, like, "Oh, I know what I need to look for. So if I go to a therapist and they're not doing what I'm looking for, now I know that I need to probably go look someplace else."

Host: Well, and that's a great point because, again, you can get the diagnosis right. You can have, you know, say my child is in sixth grade. They have a social phobia. They go to school. They're scared. They sweat. They can't focus. They don't want to go to school anymore. And if you don't get him to a therapist who knows how to treat phobias and anxiety, you can wait six months. And I've seen that happen, and it's so frustrating. And then the kid doesn't want to get help anymore.

Let's talk about that kid. Sixth grade, doing fine in school. All of a sudden, starts a new year. He's a month in, and he's not wanting to go to school. Everybody hates him. They all stare at him. He's scared. And his parents are noticing that he just is kind of miserable and doesn't want to go to school. Pick it up from there. Where would — if that kid lands in your office with the parents — you start, and how do you treat them?

Dr. Whiteside: We ask them as a family, "Tell me about what brings you in," assuming that parents are going to start things off. Kids very rarely, if ever, say, "You know what? I think I need to go talk to a psychologist."

No. Parents see the problem. Parents initiate things. We start with the parents and get a general sense and then start with just some breaking-the-ice questions with kids and then ask them for their perspective.

For the most part, kids are appropriately insightful and invested and are able to answer these questions. And, some kids are older and younger, and some kids can give us more details than others.

But some of the things that we're wanting to know is this fear of going to school in this example new? But is it new because it's just more extreme? Like, every beginning of year is hard. New activities. He's always been sort of shy, but now it's become problematic.

Then that sort of helps us feel more confident that we need to work on social anxiety as opposed to, "Oh, he's always been the life of the party. Now all of a sudden, he's totally anxious."

Still could be an anxiety disorder. You know, this transition to a bigger group of kids in middle school or what have you. But also, we want to make sure that we're looking at other things. Are there some peer problems that are leading to this anxiety?

We often ask kids, "What are you nervous about?"

They say, "School."

I say, "OK, what at school?"

"Just school."

"That's fine. What about your teachers? Your teachers make you nervous?"

"No."

"Schoolwork? Is schoolwork hard?"

"No, that's pretty easy."

"What about the other kids?"

"Oh yeah, I hate having to talk in class."

And just kind of questions like that to figure out what is it that's hard for them. That kind of guides us to identifying the situations and activities that make them anxious, and that leads to diagnosing social anxiety because it's interacting with peers versus general anxiety because they're worried about schoolwork. And that label — that diagnosis — directs us to making a treatment plan to help them break those fears down and practice facing their fears.

Host: You help them pinpoint it. OK, you are afraid of these two kids or you're afraid of going into the lunchroom and having to sit alone. You pinpoint it. Then what do you do? Do you make him go and sit in the cafeteria alone day after day and gut it out? Or how do you, once they identify the fear, how do you get them past that?

Dr. Whiteside: To help make that plan, what they need to do to face their fears, to help make that bridge from, OK, now we've got this label — this category, this diagnosis — of social anxiety, what does that mean specifically for what I need to do? And in that first section of the book where we're learning about anxiety disorders, the next step is taking their experience and putting it to the avoidance cycle.

What specifically sets off an anxiety? Is it giving presentations or is it more informally having to find someone to talk to in the hallway or sit with at lunch?

It's an anxiety disorder, so these are situations that most kids can handle. What does this child expect to happen that makes it scary? That people are going to judge me. I'm going to make mistakes. What are the thoughts, the fears they have that make these safe situations scary? And then we look at what have you been doing to avoid?

Sometimes it's like, "I completely avoid. I don't join extracurricular activities. I'd love to play soccer, but I don't because I'm too nervous. And I'd like to avoid school, but my parents won't let me, so I just keep my head down. I don't talk. I avoid situations where there's chitchat going."

And we identify that avoidance that keeps the fear around, and it's that plan that sets us up to help them face their fears.

Host: Can an 8-year-old identify that? I'm thinking of, you know, the sixth grader, seventh grader, eighth grader. In my experience, you're right, they'll tell you. They talk if you push them and push them. They'll say, "I'm afraid of this person" or "I'm afraid of this kind of thing."

But if you have a 7-year-old or an 8-year-old, and they don't want to go to school, and there's some avoidance behavior, can they articulate what they're avoiding, and can they articulate what they're afraid of?

Dr. Whiteside: It depends. With younger kids, it's more difficult. And all kids develop at different ages or at different trajectories. But that kind of goes back to why we are working with kids and parents together because I agree with you. I think it would be sort of ridiculous for me to sit with an 8-year-old for an hour and figure out what they're afraid of and then bring the parents in and tell them. That's not going to go very well.

This process is kids and parents working together, and most parents really let their kids lead.

And when we're doing this, we do multiple treatments in groups because it allows us to get people in quickly. It also makes people nervous at first, but it's very comforting and normalizing to see and hear a bunch of other normal people going through a similar situation as us.

And if you're working on social anxiety, it's pretty handy to have a bunch of kids around to practice talking to.

But in those groups I say, "Here we've got this binder here. Let's go through this step by step. Fill it out. I don't care who writes. It's great if kids write. If parents — it's more efficient for you to do." And parents, for the vast majority of the time, have their kids take the lead. And there's, especially with all fears, partly, what are you afraid is going to happen?

"People will laugh at me."

But sometimes there's not a specific fear. It's just, "I don't know. I just can't handle it."

OCD is a great example. Some people are afraid, "If I touch a doorknob, I'll get germs and then I'll get sick and I'll die, so I have to wash it off."

Other people say, "It's just gross. If I touch something other people have touched, I'll have grossness all over me. I know it's not going to hurt me, but I can't handle it. It's too gross. I have to wash it off."

And we apply that to all fear. "I'm nervous talking to people. I know they're not going to start yelling at me, but it just makes me nervous, so it's easier to avoid." And that's a very reasonable expectation. "I think it'll be too hard. I can't handle it" or "I can't handle it alone."

In between, "What specifically do you think will happen?" Or "It's just too overwhelming." Pretty much all kids and parents can come up with some reasonable expectations. And it's helpful because when we do exposures, when we face their fears, we're setting them up to test those beliefs.

Do people actually laugh at you when you stumble over your words? Does your anxiety keep building and building and building, even when you're asking questions. Or does it actually start to go down and become more manageable with practice?

Those are the hypotheses. Those are the experiments that we're testing when we help kids face their fears.

Host: In involving parents, because this is a big, important part of what you do, do you keep parents involved from the beginning to the end? Like, OK, I'm going to help you — help your child — identify what they're afraid of. Then I'm going to help you help them through this.

Is there a point where you just go alone with the kids, or do you keep parents involved the whole way along, like exposure therapy and everything?

Dr. Whiteside: Yeah, the whole way.

You know, as we talked about before, the parents are the ones bringing them in. The parents are usually the ones starting the process off by making the appointment and explaining to us why their child's here.

We just talked about how the parents and kids are learning about how anxiety works and applying that model to their experience. They then learn how to set up, do and end exposures together. And then our treatment sessions are parents and kids doing exposures in the session with less and less hands-on assistance from us.

And we set it up from the beginning that the goal is: It starts with us. It is not fair for me as a therapist to say, "Hey, you go and do exposures on your own. It'll work, trust me." We have to do them in the appointment.

That's why it's great to have groups. They will practice asking questions or presenting in front of other group members. Then they leave the office and they ask questions at the desk or go around and touch germs or sit in a room in the dark to practice separation from their parents. And then they learn together. Kids learn they can handle it. Parents learn that their kids can handle it. That's step 1.

Step 2 is kids and parents doing this on their own between appointments. And step 3 is kids doing it eventually independently.

But they're not going to get there unless we help them in the session and parents help them between sessions. We're working together the whole time.

Host: From watching exposure therapy and therapists who have done this with kids, it's very hard. It's hard for me to see kids doing things like standing in elevators or if they have a cleanliness phobia, learning to eat something with a little bit of dirt on it or whatever.

What are the issues that parents face or blocks that parents may face in helping their kids during exposure therapy?

Dr. Whiteside: I like to, somewhat tongue-in-cheek, or maybe this is just very self-serving because I am a parent as well, we have a five-day intensive treatment where we kind of smoosh this all into five days. And we've got one time where parents meet separately from the kids, and we just talk about how to get along when we don't see eye to eye on our plans.

And with the parents, I will somewhat jokingly say, you know, the kids, they're working hard. They're facing their fears. But it is like doubly hard for us as parents because we are not only facing our own anxiety about our child not being successful but also just the terrible feeling of, "My child is uncomfortable and upset, and I could fix it, but I'm not allowed to." Because as parents, we very appropriately love helping our kids feel better. We love fixing things for our kids. That is a very rewarding experience. And when you're coaching your child through exposure, you just can't do it. And that is a rotten experience. Parents are learning in the session that they can successfully do this so that they leave feeling more confident they can keep doing it at home.

Host: And they need support, like you said. They need support too in going through this.

What are the common mistakes that parents make from beginning to end in dealing with their kids with anxiety?

Maybe Mom and Dad will come in, 10-year-old's having anxiety about a bully at school or soccer, whatever, and Mom goes, "I'm really kind of worried about — I don't want to stereotype here." This is just my experience. Mom goes, "I'm just really worried about that" and Dad says: "Oh, you know what? He's just oversensitive. He needs to just deal with it and move on."

What are some of the common mistakes that you see can trip parents up along the way?

Dr. Whiteside: And what you just described right there pretty much sums it up. It's important to make it clear, and I know you don't mean this, but, coming from me, I have to be very sensitive about these things. They're not really — I'm a parent myself. We make tons of mistakes. Normal parenting, we make tons of mistakes. And if we didn't, our kids would be very fragile because they wouldn't know how to deal with people who weren't perfect. Making mistakes is a good part of parenting. And the way parents go off track is either not pushing hard enough and accommodating and doing things for their child, or pushing too hard, or kind of going back and forth between the two of them.

Part of what leads to an anxiety disorder is that kids are nervous and they avoid it, and they don't learn that they can handle it. And parents very naturally get sucked into that.

And parents, a lot of what they are doing are helping their kids avoid because they need to keep life going. And we need to get to school. We need to get this done. And if it involves me helping my child or doing this or helping them avoid that, that's what we have to do to keep life going, which is fine.

But when we're in treatment, we're not focusing on keeping day-to-day life going. We're focusing on what can we do right now that will make things better in the future while also keeping life going.

Host: And I think there's that balance. You know, you don't want to overread every child's emotion and go: "Oh-oh, this is a problem. Now they're worried. Now they're going to have anxiety," which I see.

And then the other extreme is you just sort of dismiss every feeling and fear and worry they have. I mean, that really doesn't help either.

We only have a few minutes left, but I do want to touch down on one thing because this is pretty prevalent. Kids since COVID, kids of all ages, have — I've seen a surge, and I'm sure you have too, in anxiety and depression.

Where does the surge in anxiety come from in kids because of COVID and the isolation? What makes them so anxious?

Dr. Whiteside: None of us really know. Even before COVID, it was pretty well documented that there's an increase in anxiety and depression. That was already happening. And then with COVID, that disrupted everybody's lives. And we see, like you're describing, I see a number of patients who come in who seemed like they were on the anxious side — nothing wrong with that — but they were getting by. But then all of a sudden, they were isolated for a year or so, and they didn't have peer contact. They were doing school from home. They weren't separating from parents. And then all of a sudden, that's just a lot of avoidance. And then when they had to get back to school, it was just much more frightening.

And even though we're a few years out from the isolation, some kids are still struggling to get back in because they are struggling to break those patterns of avoidance. And that has prevented them from kind of building their confidence again.

We see a lot of kids who COVID tripped up and need help catching back up and getting back into the stride.

Host: What about the kids who weren't anxious before? They were healthy. They were fine. And then COVID hit, and all of a sudden they're alone. Is there something about just being alone, or loneliness or detachment from friends, that triggers anxiety, even if they didn't have an anxiety just sort of going in it?

Dr. Whiteside: Unpleasant, traumatic experiences or even less traumatic but unpleasant, stressful experiences can trigger anxiety and depression, .especially peer interactions. It's so important to development. And being isolated from peers, can lead to feeling nervous being around them when you get back to them but also can more immediately lead to feeling down and depressed because you've lost such an important part of your daily life.

Host: Dr. Whiteside, you've been talking about exposure therapy. What is exposure therapy and how does it work?

Dr. Whiteside: That's the essence of what we do. Planned exposures are facing your fears.

You simply set up an experiment for a child to do something that makes them nervous, so that they can learn that what they were afraid was going to happen is probably not going to happen, and that they can handle feeling nervous until they feel better. And when things don't go smoothly, they can handle that too.

For a child with social anxiety, that might involve starting conversations or giving a presentation in front of the group. OCD is a nice, solid example, or a clear example. If you're afraid of contamination, go around and touch public surfaces and rub the germs on you. Separation anxiety, we have kids do things independently.

General worry is a little counterintuitive. When kids worry about lots of different things, it's the thought itself that sets off their anxiety. We have them repeat scary thoughts until those thoughts get boring.

And that's the essence of what we do. And probably the most important thing to keep in mind with planned exposures is that you have to do them repeatedly.

Doing it just once and seeing that you live through it is probably not enough. You have to do it again and again and again within that 20-, 30-minute period to see, you know what, I was terrified the first time, but now I'm bored, and I really wish this was done because it's just sort of silly and nothing bad's happening.

That repetition of doing it over and over again is one of the main differences between planned exposures and just dealing with anxiety-provoking situations in everyday life.

Host: I love it. But as a parent, that's very uncomfortable because part of the kid getting over the anxiety is becoming anxious and becoming frightened and getting in that situation where: "I can't do it. I can't give a talk in front of all these people."

"Yes, you can."

And that's hard for parents to watch because when they face their fears, kids are uncomfortable, which means parents are uncomfortable. But I love what you say. The more you do it and you repeat it, you absolutely can get over anxiety. Is that a correct statement?

Dr. Whiteside: Yes. We usually talk about learning to manage anxiety because we're all anxious. There's nothing wrong with being anxious. That's a normal part of life.

And we are not getting rid of anxiety. We are lowering it so it's not problematic and building our confidence that we can handle it and do what we want to do.

But in terms of being challenging for parents, I agree 100%. And that is why parents are involved in the session because it's not fair to say: "Go home and have your child do this. Trust me, it'll work. It worked here. It'll work at home."

Parents plan it with their child, watch their child do it, and wrap it up with their child afterward to learn from it. They — parents — are like: "Yeah, I can do this at home because I saw it work here, and I feel confident that my child can handle this, even if they feel anxious at home. We did this together. We can do it again."

Host: Absolutely. And if it rears its head in a couple of years, or five years, 10 years, you know. Parents know. "Look, you can get over this. You've done it before, and we can do it again."

Finally, I said I was going to do just one question, but I have one more because I deal with this: healthy avoidance and anxiety about going to school because of a bully.

What do parents do? This is asked all the time. "My kid doesn't want to go to school. There's a bully in the class. Teachers aren't doing anything." How do you help kids with that?

Dr. Whiteside: That's a really important question. And that probably goes back to the essence of what an anxiety disorder is and why we have to get them right — the difference.

If it's anxiety disorder, things are going fine socially, but they're nervous of making mistakes. We have to help them face their fears. The difficulty lives within the child. They are more nervous. They need to learn that things are not as bad as their anxiety tells them.

With a bully, the problem is not with the child. The problem is occurring in the school setting. The problem is outside the child. Someone's mistreating the child, and that is causing them stress. And most kids would be upset and stressed in that situation.

We don't face our fears. We don't expose ourselves to being bullied. As you put it, healthy avoidance. We need to ideally fix the situation.

And bullying is not something that kids themselves can fix. It is something that we — the society, whether that's parents or, with younger kids prior to fourth grade or so, parents — can intervene, talk to the school. At older ages, if parents intervene and other kids know that this child's parents intervened, that probably is going to make things worse.

But it's the responsibility of parents to teach their kids not to bully. It is the responsibility of schools to set up environments where bullying is not accepted. It's the responsibility of other kids to intervene when kids are bullying.

But, obviously, with your own child, you can't change all those things.

The things to do with bullying are healthy avoidance. Bullies are more likely to target kids who are perceived as weak or alone. Treating any anxiety so the kids are more confident is helpful.

Having kids have one or two friends that they can be with makes it less likely they will be bullied. And if they are bullied, having just one friend who you can talk about how much this stinks is resilient and helpful.

Bullies are more likely to pick on kids when adults are not around, so staying in a situation where there is a teacher supervising makes it less likely to be targeted.

Host: Well, unfortunately, that might be increasing. I hope not. But, you know, things in classrooms are constantly changing, and I know that's a real big concern for a lot of parents.

My guest today has been Dr. Stephen Whiteside. He is the author of "Mayo Clinic Anxiety Coach: A Parent's Guide to Treating Childhood Anxiety and OCD." And we didn't even get to talk about OCD.

The book is chock-full of help for parents, walking them through, OK, here's how you know anxiety is not just worry. It's something more serious. And then how to get involved, how to go through a step-by-step program, and then how to find help for your child.

And I think it's a really, really important read because there's so many parents who are watching their kids and concerned, you know, about anxiety developing in their kids.

Dr. Whiteside, this has been so great. You've taught me a lot. I know you've taught a lot of our parents a lot. I sure appreciate you coming on the program today. Thanks so much.

Dr. Whiteside: Thank you so much for having me. It was a real joy.

[Music]

[Host] Dr. Scott Hoy: Welcome to the "Psychology Talk" podcast. I'm your host, Dr. Scott Hoy.

The "Psychology Talk" podcast is a unique conversation with experts in the field of mental health from around the globe. Topics include hypnosis and mind-body treatments, ethics and cultural diversity, psychotherapy and psychiatry, emerging treatment modalities, and much, much more.

While you're listening, please give us a like and subscribe to the show. It helps us to continue to provide excellent programming. And, now, here is the episode.

Host: Hello and welcome to the "Psychology Talk" podcast. Today, my guest is Dr. Stephen Whiteside.

Dr. Whiteside is a board-certified clinical psychologist, professor of psychology in the Mayo Clinic College of Medicine and Science, and director of the Pediatric Anxiety Disorders Program at Mayo Clinic in Rochester, Minnesota. He received a B.A. in psychology from Northwestern University, around about here in Evanston and Chicago, and a Ph.D. in clinical psychology from the University of Kentucky. His research focuses on improving access to evidence-based care for pediatric anxiety disorders and obsessive-compulsive disorder through the development of effective and efficient treatments facilitated by technology.

He's written several books, some of them including "Exposure Therapy for Child and Adolescent Anxiety" and "OCD, Exposure Therapy for Anxiety: Principles and Practice," which is in its second edition, and "The Mayo Clinic Anxiety Coach: A Parent's Guide to Treating Childhood Anxiety and OCD," which is what he will mainly be discussing today on the show.

Dr. Whiteside, welcome to the "Psychology Talk" podcast.

Dr. Whiteside: Oh, thank you so much for having me. I'm excited to be here.

Host: Well, excellent. Well, yeah, thank you for taking the time out of your busy schedule to do this. What we kind of like to do sometimes is open up the floor, and you can kind of go a little bit further into who you are, how you got into this work you're doing and kind of let people know you as a person.

Dr. Whiteside: Oh, that would be great. So, I'm a child psychologist, and I've been working at Mayo Clinic in Minnesota since 2001. I specialize and focus on working with kids with anxiety disorders and obsessive-compulsive disorder.

The way I became a psychologist is not exciting whatsoever. I was in college at Northwestern there in Evanston, and everyone was becoming physicians and lawyers and engineers, and none of those really seemed interesting to me. And both my parents are clinical psychologists, so I was like, they seem to have a good life, they like their job, they supported my sister and I well, so I seem to have an aptitude for it. So I went toward psychology, and that's how I ended up where I am now.

Host: So, sort of a family trade, as it were.

Dr. Whiteside: Yeah.

Host: OK. Did you pick up any ideas or tools of the trade from them? Are they working in academic settings, clinical settings, private practice?

Dr. Whiteside: So my dad was in the counseling services at the University of Michigan.

Host: OK. Yeah, I'm a former Michiganian — or Michigander, as they say. Yeah, so I'm from there. So, yeah. And I lived in Ann Arbor for several years. Very good.

Dr. Whiteside: And then my mom was in private practice and focused on working with families and divorce mediation. And, so, my mother, would say, yes, that they did have an influence on me. Our approach to child anxiety is very much working with kids and their parents together, and I think my mom would take credit for that family focus.

Host: I think there's something to that because as I was reading through the book and kind of preparing, it always — when I talk to people who work with children primarily, having worked with some children in private practice and group practice — a chore to get the parents on board with the treatment team sometimes. Sometimes, I mean, you can kind of weed people out, but oftentimes it seems like they're dropping kids off to get them fixed, which is sad. It's sad for the parents. It's sad for us as the clinicians to be given that task. And it's sad for the children ultimately, right?

So it's kind of a systemic thing, but it seems like your model that you developed at Mayo Clinic is really about working with the family and teaching them how to help their children.

Dr. Whiteside: Yes, that's exactly right. There are a number of reasons behind that, but the main one is we just all do better when we're working together. There's no reason to handle anxiety or other mental health challenges on your own. Anxiety is very normal and common, and problems with anxiety is one of the most frequent mental health problems. So we want to remove that stigma and that kind of sense that you have to deal with it on your own.

And, so, we work with kids and their parents together. We work in groups. And part of it also is it's hard. Facing your fears, making changes to any behavior that you do, doing something differently is hard. And we think that all kids will be more successful if they have someone at home to coach them through it. And with kids and teens, that person is most often parents.

So we work with kids and parents together so everyone's on the same page. This is what is keeping the problem going. This is what we have to do. And we'll make a plan. We'll follow through together.

Host: Excellent. Well, it totally resonated with me when I was looking through the book. Maybe you can help to differentiate, for people in the audience who aren't professionals, or more clearly delineate for some professionals who don't work in anxiety or OCD, what those two things are, what the symptoms are, and what the difference is between those two disorders and just regular nerves or rumination.

Dr. Whiteside: That is a great question. I love that question because that's where we start in the book. The first section is: What is an anxiety disorder and OCD? Because understanding that sets us up for how we do treatment. Understanding what an anxiety disorder is, kind of what the fundamental challenge is, leads to why we do treatment through exposure.

So the definition we use of an anxiety disorder is when kids feel more nervous, worried or afraid of something than we would expect them to. And I should mention, we lump OCD in with anxiety disorders. It's no longer officially an anxiety disorder, and sometimes OCD doesn't involve fear and worry just as much as disgust or a "not-just-right" feeling, but we sort of lump them altogether because we treat them the same.

So the first thing we want to distinguish anxiety disorders from is stress. An anxiety disorder is when you're feeling more nervous and worried than we would expect you to, as opposed to stress, where you're in a bad situation. Kids are bullying you or you're failing a class or there's a lot of fighting and anger at home. Something stressful is happening in life, and you're anxious and nervous about it, but so would any other kid because that's a stressful situation.

We treat that much differently. In those situations, we try to help solve the problem, maybe help them avoid some of the more difficult areas. Whereas with an anxiety disorder, everything's going reasonably fine. Life is never perfect, but no one's bullying them. Everyone's generally nice to them, but they're still very shy. They're getting good grades, but they're still worried that they might fail, even though they never have. They're worried parents will get divorced or the house will burn down, even though things are stable at home.

In that case, the problem is overanxiety and worry and fear when their situation doesn't warrant it. When that's a problem, that leads us to treat it with exposure.

And the other difference between, like you alluded to, what I mentioned before is everyone is worried and nervous. Anxiety is a very appropriate, necessary feeling. It helps us prepare for things. If we're worried about doing well on a test, it helps us study, helps us look both ways before we cross the street, put our seat belts on.

And, also, feeling too nervous or worried at times is also normal. Sometimes we're irrationally anxious and nervous. We have a fear of the dark or heights. But as long as it doesn't happen too often, doesn't get in the way, doesn't make our life more difficult, then it's not a problem we have to work on. It's when that fear and worry is too much for the situation and makes our life difficult. That's when we call it a problem, and we decide together to work on it.

Host: OK. Wow. How does it differentiate? Like, I think the book kind of does a really good job explaining this, but maybe you can unpack that for the audience: the difference in anxiety across the ages from childhood to adolescence. How do they manifest?

Dr. Whiteside: One answer is that pretty much most anxiety disorders can occur at any age. And the main anxiety disorders are generalized anxiety disorder, which is just worrying about lots of different topics frequently to the point that it causes physical and emotional distress; social anxiety disorder, feeling more nervous and worried about being judged or having embarrassing situations happen interacting with others; separation anxiety, being nervous about being away from parents or other caretakers. Those are the main ones.

And then obsessive-compulsive disorder: having intrusive thoughts about things being wrong or unpleasant thoughts or being contaminated with germs, and having to do something over and over again to feel better — check, count, wash your hands.

Other anxiety disorders include having panic attacks for no reason, being afraid of being in crowded places, which is agoraphobia, or specific phobias.

And, so, in younger kids, we're more likely to see separation anxiety disorder, like nervousness about being away from parents or specific phobias of the dark.

Once kids start to get school age, social anxiety starts to occur more because friendships and peers become more important in their lives. It's developmentally appropriate that parents and family — they start worrying more about what other people think about them, if they're doing things right.

And then as kids get to be older — teenagers — they start to worry more about the future, and generalized anxiety sort of becomes more frequent.

Host: OK, and, so, is the approach different? Like, basically, I think what you do is mostly exposure therapy with people, right? And it's kind of hard to get deep insights from teenagers or children, so I guess insight therapy is not quite what you're looking to do for buy-in or whatnot. But how does the exposure therapy work in child and adolescent treatment for anxiety and OCD?

Dr. Whiteside: The basic treatment for anxiety, like you described, was exposure therapy, which basically means helping kids face their fears over and over again, small steps at a time, so that they can learn through their own experience that what they're afraid of is unlikely to happen. Even if things don't go perfectly, they can handle it, and their anxiety tends to go down and go away, even if they stay in a situation and don't avoid.

Again, that kind of comes back to our understanding of what an anxiety disorder is. It's when kids are overly afraid of something or overly worried about something. And, so, we can't talk them out of it. Their parents can't talk them out of it. If they could, they would never come and see us. We wouldn't have a job.

So our job is to help give kids repeated experiences that what they're afraid of is not as bad as their anxiety tells them.

Host: So, for instance, in exposure therapy, for those of you who don't know, typically you start with a subjective unit of distress, like a hierarchy. And obviously you can do that a little bit more intellectually with an adult or a teenager, but how do you do that with an anxious child, for instance?

Dr. Whiteside: So the first step, as you mentioned, is coming up with a list — a fear ladder or fear hierarchy — of items that they're going to do exposures to.

I always like to use a fear of dogs, partly because I was afraid of dogs. I love dogs. We have a dog. When I was a kid, I was afraid of dogs. And it's also just so straightforward. It's easy to talk about and picture someone being afraid of dogs and how you work on it.

So a fear ladder for a fear of dogs might begin with watching videos of dogs barking. It kind of makes you a little uncomfortable, but not too anxious. And then standing outside the room while someone handles a dog, and then gradually getting closer and petting it, and then walking it, and then doing the same thing with a bigger dog or a younger dog or a dog that's less well trained or barks louder. And then do an exposure where you pet dogs out in public or go to a dog park and be around dogs.

So a fear ladder is a list of activities where you are specifically doing things that make you nervous to challenge your anxiety.

And then, trying to put that in order, sometimes it's pretty straightforward. But, in general, you want to try to start with easier things and work up to harder things, just because that's what most people are up for.

And we like to use numbers to rate how anxious things make people. We often use zero to 10 with kids, just because it's a little bit more manageable than zero to 100 — so subjective units of distress.

And, so, we actually have stopped having them rate each of the items at the beginning on the SUDS rating to put them in order because, as you allude to, it's just too difficult. And they can generally put them in order from easier to harder without putting that rating on them.

And in the end, life never goes as structured as you think it's going to, so you kind of just end up jumping around and skipping things or adding things. So we put less effort and time into putting together the fear ladder just right because we know that we're probably not going to follow it that closely anyways.

Host: OK, gotcha, gotcha. Do you tend to utilize the child's own language when they're describing things, which is probably a good thing to do with any patient, but …

Dr. Whiteside: Yeah, we try very hard just to use very plain language. And that's one of the nice things about working in anxiety, is, you know, we have lots of psychological terms, but you really don't need them. You can communicate most of these concepts — facing your fears — in pretty straightforward language.

That being said, we do use the word "exposure," which is not a very intuitive word for most people. But, you know, after we repeat it over and over again, it's fun to hear kids and their parents talking about exposures after a few sessions of having done it. They get that lingo down pretty clearly, pretty quickly.

Host: OK. And you kind of use the same format with adolescents, but probably pulling out that scale, zero to 10 or zero to 100?

Dr. Whiteside: Yeah, we definitely use the rating scale zero to 10 when we are doing exposures for everybody, for kids and for teenagers. So we have them rate how nervous they are that their fear is going to come true. You're about to pet the neighbor's dog. How nervous are you that it's going to bite you? Zero, not at all. Ten, terrified. They give us a rating.

And then as they're petting the dog, we ask them regularly, "How nervous are you now?" And we use that scale for a couple of reasons. One, just putting a number to your anxiety just by itself makes it more manageable. Rather than it's always: "I'm anxious. It's always terrible," it's: "Well, I'm pretty anxious, but it's only a 6. It's not a 10. It's been higher before. I feel a little bit more confident already that I can handle this."

And also, when your feelings change gradually, it's hard to really notice that. So having a scale in front of you where: "Oh, I'm at a five, and it was at a six before, so things are going in the right direction. I'm feeling better."

Host: Yeah, kind of externalizing stuff so you can not have it in your head jumbling things up.

Dr. Whiteside: Yeah.

Host: OK. So kind of categorizing it, making it more manageable, rather, you know, raising awareness, conscious awareness of it.

Dr. Whiteside: Yeah, a big chunk of it.

Host: Yeah, sounds like it. Well, what about OCD? How does OCD, you know, first of all, how is it difficult to accurately diagnose OCD in children and adolescents? It can be a little bit tricky in adults, but how does that manifest with the work you're doing?

Dr. Whiteside: So OCD is where we began our program. In Rochester, we have a five-day intensive treatment program where kids who don't live close to Mayo Clinic and aren't able to find good exposure therapy close to home come and stay in Rochester for the week. And we have nine appointments over five days: one on Monday, where we learn and make a plan, and then two a day Tuesday through Friday, where we begin with easier exposures and hopefully work our way up to the most challenging exposures.

And we began that program working with kids and their parents when the kids have obsessive-compulsive disorder and began working with them individually. So that's where a lot of — and that was part of the reason we started working specifically with kids and parents together, because we were only with them for five days, and then we expected them to go home and continue the work that we had started.

And it seemed pretty unrealistic to expect a child or a teenager to continue to plan and do exposures on their own. So from the beginning, we started enlisting parents to teach them to be exposure coaches so that the family could continue after they went home.

And, so, OCD is partly challenging because it's very heterogeneous. There are lots of different flavors of OCD. There's straightforward anxiety-based OCD: "If I touch these germs, I'm afraid I will get sick and die, so I have to wash my hands."

And then there's OCD that doesn't seem to really have anxiety at all: "If I touch these germs, it'll just be so gross I can't handle it. I'm not nervous. I'm just disgusted, so I have to wash my hands."

And, "If I touch something, I have to touch that with the other hand." Some people are afraid something bad will happen if they don't fix it. Other people are like, "It just doesn't feel right, and I just have to do it to feel better."

So that presents challenges because there's lots of different presentations.

Especially with younger kids, one of the main features of OCD is insight that: "I know this doesn't make any sense. I know I'm probably not going to get sick, but it's just really scary, and to be on the safe side, I might as well wash." "And that's the quickest way to feel better and might as well wash so I don't get sick. But I know in the back of my head, it's probably not going to happen."

Although, of course, there can be OCD with limited insight. But with kids, especially younger ones, it's hard for them to say that. If you ask them, "Well, do you really think you're going to get sick?"

"Yes."

"Do you want to wash your hands?"

"Yeah, I want to."

You know, a compulsion is something you feel you have to do, feel compelled to do, so that something bad doesn't happen. And with kids, it's harder for them to articulate that.

Host: OK. And kind of backtracking here a little bit, you're mentioning obsessions and compulsions, so maybe a brief description of what it is to have OCD. Like, what are the symptoms?

Dr. Whiteside: Oh, yeah, great. No, thank you for pointing that out.

So OCD, obsessive-compulsive disorder, has two main portions. One is obsessive thoughts. And those are obsessions, which are thoughts, urges, impulses that things are not right, that you need to do something.

So the most common is fear of germs. So if I touch a public surface, I have this feeling or this thought — this worry — I'm going to get sick and die, or that this is really disgusting.

Or some people have the thought, "If I walk through a doorway while I'm thinking about cancer, that means I'm going to get cancer," and I've got this really intrusive thought that something bad's going to happen to me or someone else. That's the obsession piece.

And then the compulsion is a repetitive behavior done to relieve that. So I've touched the doorknob. I feel very sick — I'm sorry, very nervous, I'm going to get sick — so I wash my hands over and over again, thoroughly, to make sure that I have no chance of getting sick.

Or I walk back through the doorway over and over again with a good thought of health, so to counteract that negative thought. Or I check things over and over again to make sure I haven't left on a light or left something plugged in.

And it's that repetitive compulsive behavior makes people feel better, but they're stuck in the cycle that the only way to relieve the distress from the compulsion is to do the ritual. And then the compulsions happen more and more, so they do the rituals more and more. And it takes up more and more time and leads to chapped, bleeding, red hands. And that's when it becomes a disorder.

Host: Yeah. OK. And like you said before, even a child will understand it doesn't make sense?

Dr. Whiteside: Most of the time. Especially with younger — well, you know, people are different. And there's a wide range. But I would say the vast majority of the time, kids, regardless of how well they can articulate, realize they don't want to be washing their hands or checking things or having these worries, and understand — they may not be excited about it — but understand that if I do this treatment, I face my fears and I don't do the rituals, they can understand how they will eventually start feeling better.

Host: OK. I mean, it's an A+B= C kind of situation. It's logical but not rational. It's not rational logic.

Dr. Whiteside: Yeah, that's a great way to put it. I've often thought that, you know, I've been doing this for a long time, so I hear about it a lot. And through writing books and teaching people and explaining things, you think about it a lot. You think about OCD a lot. I think about anxiety a lot.

And, so, I went over these things a lot in my head. And, so, sometimes when talking to a family who OCD is new to them and they're coming in with their child and like: "It just doesn't make any sense. Why are they doing these things? They're washing their hands, but they don't straighten their room."

And, like, for me, it just — it's just so clear because it's logical. You know, this is what they're afraid of — this, not that. And when they're afraid, they do this and they don't do that. And it just makes complete logical sense, although, as you pointed out, it's not rational at all, because there's no danger from germs from door handles, and that's not more dangerous than having dirty dishes in your room.

But, yeah, it's very logical but not rational. I like that description.

Host: It seems to me that evolutionary psychology could probably explain a lot of where it comes from.

Dr. Whiteside: Yeah. You know, a lot of the most common — well most common fears in general — but also sources of distress in OCD are things that are very important to survival. So avoiding gross, disgusting things that might be contaminated or have germs that would make you sick.

Lots of OCD symptoms are around violent or sexual behavior, you know, behaviors that are very — instincts and behaviors that are very fundamental to the survival of us as a species.

Host: Yeah, exactly. So they do make sense. They're logical, but they're not rational.

Dr. Whiteside: Yeah.

Host: Real quickly, kind of going back to the book a little bit, we talked a little bit about the model of coaching parents in this process. What does the homework look like? And then we'll step back into the idea of the book. What does the homework look like for both the parents and the child or the adolescent?

Dr. Whiteside: So the homework is primarily exposures.

So the idea of our treatment for anxiety and OCD is that the most important activity to be doing is breaking the cycle of avoidance, either avoiding by not going to a social activity or running away from a dog or clinging to parents, or washing one's hands repeatedly or doing other rituals, because that avoiding stops you from learning that your anxiety or OCD has lied to you.

So the No. 1 thing we can do is do little experiments where we face our fears, break OCD's rules, and don't do any avoidance or rituals, and learn that things turn out OK. So that's where we need to be spending most of our time.

So we spend all our time in session doing exposures, and we ask kids and parents to work together to plan, do and learn from an exposure between appointments.

And we go back and forth about how many times specifically. We would love them to do it every day, but we're all busy. So we try to say, try to do three planned exposures where you're taking out a piece of paper and you're recording it, and you're specifically doing something that makes you uncomfortable as an exposure and sticking with it repetitively until you learn that it's not so bad.

And that is the main homework that we ask them to do.

Host: OK. And, so, how does the book present that to an interested parent? Like, how does the book's format kind of parallel that?

Dr. Whiteside: OK. So the book is in three sections.

And the first section is about what an anxiety disorder is. And we approach that in two different ways. One is through categories, labels, descriptions. So we use the DSM — the diagnostic manual for psychiatric disorders — that describes the anxiety disorders I went through before: generalized anxiety disorder, social phobia, etcetera. That's a really helpful way to look at that because we, as people, like categories, like to label things. That's how we make sense of the world. And using DSM to put a diagnostic label is helpful.

But our treatment is mostly on understanding how the symptoms work. What makes you nervous? How do you respond? And then what happens afterward that keeps this behavior going?

So the second way we look at anxiety disorders and OCD is through the avoidance cycle. What sets off your fears? What do you expect to happen that makes a safe situation frightening? How do you avoid? That stops you from learning through your own experience it's not so bad.

And understanding that avoiding and doing rituals makes you feel much better, which makes you more likely to do it again and makes the cycle go around faster and faster and get worse.

And then we talk about, well, if we're not sure if this is an anxiety disorder. We also want to make sure that there aren't other things that maybe look like an anxiety disorder or would complicate working on an anxiety disorder.

So we go over some other frequent comorbidities, like depression or behavior problems or difficulties with eating or difficulties with social communication, autism spectrum features.

So that first section is really focused on helping parents understand: Is what my child is experiencing best described as an anxiety disorder, and is there anything else that describes it better or needs to be addressed before we work on the anxiety?

Host: So the differentials. Got it.

Dr. Whiteside: Yeah. And then, so, based on that, if a parent feels pretty comfortable that, yeah, I think anxiety disorder or OCD best describes my child's experience. And the second section of the book is explaining how we treat that through exposure therapy.

And we start off with a little bit of history about where exposure therapy comes from. I want to make it clear this is not something that I made up. It's something that's been around much longer than I have. There's a lot of clinical use, there's a lot of research documenting how it's effective, and talk a little bit about the theories of how exposure works and why facing your fears helps break that cycle and helps you learn through your own experience.

Host: OK.

Dr. Whiteside: So we start general. Then we just get more and more specific. And then we talk about the different types of exposures because you can do exposures to things out there in the world, like petting dogs, or sometimes what makes you anxious are intrusive thoughts or worries, so we have to do exposures to the thoughts themselves.

And sometimes, like with panic disorder, what sets off your anxiety are physical feelings, and we have to do exposure to those feelings.

So we talk about different types of exposures, planned exposures versus kind of doing them in the moment, and then just keep getting more specific — like here are the specific steps for setting up, doing and learning from exposure and staying motivated.

And then we end that section with a sort of general timeline: This is kind of how treatment for anxiety works in our clinic over the weeks and months to give you a general sense of kind of what to expect when you're working on it.

Host: OK.

Dr. Whiteside: And then the third section is kind of putting those two pieces together. So we've got a chapter on each anxiety disorder — social anxiety disorder, OCD, generalized anxiety disorder — and it walks through the steps that we present in the second section of how you set up, do, and learn from exposures for each of the different anxiety disorders.

And the overall goal is that hopefully some families are experiencing kind of the beginning of an anxiety disorder or a mild anxiety disorder, and just reading this is enough to help them just sort of make a natural shift to facing fears and stopping avoiding. Or they're able to use that to kind of actually do some of this on their own in a structured manner.

Probably, maybe more reasonable is that it helps people learn that: "OK, this is what an anxiety disorder is. I now feel like I understand it. I have a sense of what I need to look for for treatment," and it helps them pursue treatment with a therapist and make sure they get good care from the beginning.

Host: OK. Excellent. OK, so you do kind of admonish them to use a therapist at some point, if necessary?

Dr. Whiteside: Yeah. You know, I think it would be irresponsible to think that somebody with significant anxiety could just read a book.

I mean, a very important part of what we do is teaching people here's how an anxiety disorder works and here's how we treat it. And then the second part is exposure — sort of weird, so helping them learn how to do it.

But then the third piece is it's just hard, and they just need someone who's confident because they've done it time and time again, that helps steer them through and helps them be successful.

And there's probably no--there's no replacement for a seasoned therapist or an expert helping you through the process. So it's probably not realistic that you could just do it with a book.

Host: Well, with that in mind — I mean, thank you for not putting me out of business or yourself out of business. With that in mind, I know that technology is something that you've been utilizing more at the clinic. How are you doing that? And, obviously, I don't think you expect people to be put out of business for chat therapy or something. What kind of technology are you utilizing at the clinic to help people?

Dr. Whiteside: Yeah. So I've been working for a long time to try to figure out how to use technology to better deliver child mental health care.

And I would — I think probably I have sort of an old-school, antiquated view of how to use technology, and that is basically just to support people doing therapy, support people helping kids, rather than replacing.

I think technology — I see the way we've been trying to develop it — is most helpful for delivering information or exchanging information.

So there is a good evidence base on what is the best way to approach anxiety disorders and OCD: exposure. Here's how you do exposure. Most people don't know that. Laypeople don't know that. Many generalist therapists don't have an expertise in that.

So how do we give that information to everybody? Kids themselves, family members, pediatricians, who are the main people that families see when they have mental health concerns, generalist health providers or mental health providers? How do we give them the expertise to get as close as possible to evidence-based care?

And then, also, how do we gather the information from the family? So we need to know: What are you afraid of? How do you avoid? And, so, we gather information from them.

So technology is a way to make it easier for us to explain, "Here's what you need to do," for the patient to explain, "Here's what bothers me," and put together a treatment plan.

And then, the second piece is that empowers families to do as much as possible without us, so that we can see more people. And it's less burdensome for them to work with a therapist.

Host: Gotcha.

Dr. Whiteside: But as mentioned, I don't think technology can replace working with somebody, because you just fundamentally need somebody who's warm and expert and knowledgeable and calm to say, "You need to do this, and I'm going to help you do it."

Host: OK. Somebody coaching or somebody guiding in the process, a Virgil to their Dante.

With that being said, I assume — you mentioned videos for exposure, for instance, to dogs. Is that something that, like, do you have an array of videos available through your website, through the clinic, so that people can go through and use them? Or do you suggest them to people, or how do you do that?

Dr. Whiteside: That is a great question, and it's really a funny question because what we're doing right now is like an amazing technological advance, and I don't even think of it as technology.

I mean, talking to someone through video conferencing, that's not technology. That's just something you do, you know? Watching …

Host: Right, yeah.

Dr. Whiteside: … not technology. That's just the way things are, you know. That's a great perspective — that we use technology all the time and don't even really think about it anymore because it just becomes so ingrained in daily life.

But the most frequent way we use videos is for kids who are afraid of throwing up. And, so, hearing sounds, seeing people be sick, seeing people throw up makes them very nervous that they will then throw up.

So those are the most often videos that we use. And we use websites that are — there are websites out there who have accumulated those videos in a therapeutic context.

Host: So, this isn't like TikTok videos of somebody on a …

Dr. Whiteside: No. Sometimes we will have parents on their own go to YouTube and just look up vomit videos. But there's this great website that we use that has a lot of information, including probably around 20 videos, from super-easy cartoonish things to disgusting videos of adults throwing up.

Host: OK. Nothing I ever searched for, so it doesn't come up in my YouTube feed. But it does sound kind of slightly entertaining. I'm not disgusted. I actually have the opposite reaction. I usually laugh.

Dr. Whiteside: Yes, some of them are very entertaining.

But that also is another advantage of working with parents, because sometimes when doing exposures, you do things oftentimes that kids don't normally do.

Kids do not normally watch videos of people throwing up or go around and touch public surfaces a lot or go up to, you know, people at stores and start conversations or return something. So we ask kids to do things or repeat upsetting thoughts that make them nervous.

And one of the advantages of working with parents and having the parents set up and do the exposures with them is that we are vetting everything that we do so that the family feels comfortable with it.

We don't ever do something that the parents don't feel comfortable having their child do. And if they do have reservations, we talk about it beforehand. And if we can talk through it and decide, "Yep, this is what needs to happen," we do. And if we say, "Nope, this is not consistent with our family's preferences and values," then we find another way to approach facing the fear.

Host: OK, excellent. And staying on the topic of the clinic, have you, like, with regards to this particular model, tested this against treatment as usual — just normal exposure without the parents versus having them in as a cohort or confidant?

Dr. Whiteside: Thank you for asking that question. That's a great one.

Yes. So we have one — what I think is a well-done controlled — trial that we completed. We began in 2020, and we wrapped up in 2022. And we are in the process of revising and submitting the first manuscript for that. And we have some other papers coming out of it.

So we did a study where we compared our parent-coached exposure therapy to the traditional cognitive behavioral therapy that has been used in the majority of research on childhood anxiety treatment, including the biggest, most comprehensive studies. So all the therapy was individual: one therapist working with their child and parents.

And in our parent-coached exposure therapy, the therapists worked with the parents and the child together and educated them and made a plan through sessions one and two, began exposures in sessions two or three, and then did parent-coached exposures in the session, with homework to do exposures between sessions for as long as needed until they were better.

In the other condition, therapists worked with the child individually for the most part. Parents came in the session at the beginning and at the end, kind of getting updates about how things were going.

For the first six sessions, the therapist taught the child how to recognize anxiety and to relax and do cognitive restructuring and make a plan to handle anxiety. And then, the second six sessions, they began doing exposure.

Host: OK.

Dr. Whiteside: And what we found is that the kids who had parent-coached exposure therapy were much better in the middle of therapy, after six sessions because they'd been doing exposure. They were much better than the kids who had the traditional CBT.

And then even at the end of the study, when both of them had the opportunity to have some exposure, the kids who got parent-coached exposure were still a little bit better, had improved more than the kids who had CBT. And on top of that, the kids in the parent-coached exposure therapy had attended fewer appointments than the ones with CBT.

So that study that we did suggests that our treatment is more efficient and effective than traditional CBT.

Host: Were there any follow-ups, six-month, year, anything like that? Has that happened?

Dr. Whiteside: No, we haven't done that. So this was just the first study that we did. We are planning to do a chart review follow-up through the medical record — see kind of what's happened to them afterward.

Host: Yeah. OK. I mean, usually if it's continuing, it's going to manifest in other issues. Do you ever see comorbidities, and how do you parse them out? And how much of that might be primarily affected by anxiety or OCD?

Dr. Whiteside: Yeah. That's a great question because nobody falls into the nice, neat, clean boxes of diagnoses that we have to work from.

The first part about comorbidity is kids often have more than one anxiety disorder or anxiety and OCD. So that's easy to deal with because for all anxiety disorders and OCD, the treatment is exposure. So we can lump those together as one thing that we work on.

The second piece is some of the most common comorbidities that we see are anger outbursts and lack of cooperation, depression, feeling sad and down.

We often see a lot of eating issues, so restricted eating, having lost some weight, and then also social communication difficulties, autism spectrum problems, kids who have difficulty understanding social cues, difficulty interacting with others.

And, also, being in a medical center, we also see a lot of kids who have chronic pain or they have other medical issues that they're dealing with.

Host: OK, which may or may not be somatization from the anxiety and the other things.

OK.

Dr. Whiteside: Yeah, so when deciding on what we need to treat, the first question is: What is most distressing and causing most problems for the child?

And, so, we look to them. And we don't expect them to answer it on their own, but they are the expert on their experience, and their parents have more expertise about their child than we do.

So we work together to take their experience and our understanding of mental health issues and come together with a priority: What is the main thing that's causing problems? And then we work on that.

And if it's an anxiety disorder, but there's other comorbidities, we then decide, is there anything that's going to stop us from doing exposures?

So if a child gets angry and is oppositional, we probably need to work on that first before we do exposure therapy.

Host: OK.

Dr. Whiteside: Even if they are only angry and oppositional when they're anxious, but when they get anxious they throw such a fit and they're so uncooperative, we need to use behavior management, rewards and consequences to get them to be more cooperative before we can be successful with exposure therapy.

Host: OK. So you will definitely take a child with those issues — work on shaping the behavior that way and then …

Dr. Whiteside: Yeah. You know, kids can have more than one problem. Some kids are just generally oppositional and stubborn and have big emotions, but they also have an anxiety disorder.

And again, we may say, "Look, we've got to get the general cooperation. If they're not cooperating with doing their homework, they're not going to cooperate with facing their fears. Let's address the cooperation first, even though we know the anxiety is a bigger problem. We can't successfully work on that until we get cooperation.

Host: Gotcha. Yeah. You're also kind of setting up a yes set for the behavior, for the cooperation. Like, you know, oh, we'll do this, they'll do that, the next one gets easier.

Dr. Whiteside: Yeah. And behavior management is also, like, a general part of our treatment from the beginning. We call it the motivation plan.

So how — facing your fears is difficult — do you stay motivated? You take small steps rather than requiring big steps. A lot of parental warmth and attention for brave behavior and removing attention for anxious behavior, setting goals and rewarding progress, and mild consequences for not completing exposure.

So those general principles are integrated into our approach from the beginning.

Host: Are the behavior management issues also attended to with the parent involved in it?

Dr. Whiteside: Yes. Even more so with behavior. Especially with younger kids, with behavior management, we're focusing mostly on working with the parents, helping them put into place a plan that they can use day in and day out at home to change their child's behavior.

Host: And just so we can offer it to the audience out there, how are behavior management issues involved in the book, and how might they be as a predecessor or a precursor to the exposure therapy? Are they at all addressed much in the book?

Dr. Whiteside: So we talk about lack of cooperation and anger outbursts and when that's severe and persistent, qualifying for a diagnosis of oppositional defiant disorder. We talk about that in the first section of the book when we talk about differential diagnosis.

We talk about the motivation plan in the second section — small steps and attention and rewards and consequences.

And then at the end of the second section, when we talk about problem-solving, troubleshooting, if things are not working well or there are other things getting in the way, kind of what to look for. We revisit behavior management there as well.

Host: OK, excellent.

Dr. Whiteside: But, mostly, if behavior problems are the main thing, then we need to do that before we do this book, and here are some directions for finding help for that.

Host: So resources. Yeah, I was going to say. Smart.

Well, the book is wonderful. Is it available now?

Dr. Whiteside: It will be coming out shortly this year, so it's not available yet.

Host: OK, so in the next couple of months. OK. But I've had the luck of actually reading it ahead of time. I've had the review copy. And it is "The Anxiety Coach," right? "A Parent's Guide to Treating Childhood Anxiety and OCD," and it's from the Mayo Clinic itself?

Dr. Whiteside: It is. So I work at Mayo Clinic, and it's put out by Mayo Clinic Press.

Host: Excellent. And can people reach you, Dr. Whiteside, on the internet if they're interested in contacting you for clinical work or consultations?

Dr. Whiteside: Yes. "Dr. Stephen Whiteside at Mayo Clinic" will bring up a couple different official Mayo Clinic websites. I also would mention that we have a resource, mayoclinicanxietycoach.org, that presents all the general education aspects of our treatment for anxiety and a library for building fear ladders, some descriptions of exposure, and also has a description of our behavior management program. And that's a freely available website.

Host: Excellent. Well, thank you so much. It's been a pleasure speaking with you today. Hope to have you back sometime soon.

Dr. Whiteside: That was great. Thank you so much.

[Music]

Host: Thank you for listening. Did you know the "Psychology Talk" podcast is all over the world wide web? Well, not entirely all over, but we are in social media and we do have a website. Pop over to www.psych-talk.com to find out more about the show.

All material is copyright the "Psychology Talk" podcast. Opinions of our guests are not necessarily those of the host or the show. Material is provided for entertainment and informative purposes only. If you need a mental health professional, please seek one out. Music is provided by the band Saranati.

[Host] Dr. Angela Mattke: Hello, everyone. I'm Dr. Mattke, and you are watching "Ask the Mayo Mom" on Mayo Clinic's Facebook Live. I'm a pediatrician at Mayo Clinic Children's Center in Rochester, Minnesota. Twice a month, I host a show about pediatric health topics where we take and answer your questions live.

May is Mental Health Awareness Month, and this week is Children's Mental Health Awareness Week. Anxiety disorders are the most common mental health illnesses among children in the United States and they also our focus today. We will be discussing how to recognize anxiety and help your child get the appropriate treatment.

Joining us for the discussion today is Dr. Stephen Whiteside, a clinical psychologist and expert in the treatment of pediatric anxiety disorders and OCD. Dr. Whiteside is a professor of psychology at Mayo Clinic and the director of the Pediatric Anxiety Disorders Clinic. Please send your questions under the Facebook Live video feed, and we will try our best to get to them during our live video broadcast.

Dr. Whiteside, thank you so much for joining us today.

Dr. Stephen Whiteside: Thank you for having me. It's my pleasure.

Host: This is a really pervasive problem that we see — both of us — in our practices a lot, and it affects a lot of children throughout the United States and the world, right? Yes. How did you get interested in anxiety disorders in children?

Dr. Whiteside: Oh, that's a good question with probably a number of factors. One of the mentors I worked with when I was doing my fellowship here was an expert in anxiety disorders. I'm also a little shy and anxious myself. It maybe came naturally to me. It's also a treatment that really works. Anxiety can really get in the way of kids' lives, and it can cause a lot of suffering. But if you give them the right treatment, they can really blossom and feel a lot better. That's rewarding.

Host: We were talking just before the show about how satisfying it can be when patients can get this treatment, and it really changes their life. They can go out to do things that they weren't able to do before.

OK. Let's dive in to talk a little bit more about anxiety disorders. What does anxiety look like in children?

Dr. Whiteside: Anxiety disorders cover a number of different fears and worries. Then we have a number of different diagnoses and labels for mostly — just kind of focus on — what the child's afraid of. Kids who are afraid of being away from their parents — separation anxiety — or kids who are overly shy or social anxiety disorder. Anxiety disorders look a lot like they do in adults — that kids feel very nervous in a situation. And parents often pick up on it because they try to avoid. When kids try to avoid often, they will get sad or scared and cry or get angry sometimes to resist. Parents usually come in when it's causing a problem with life. Going to school is a big ordeal because a child's very nervous about going and resists going. Or whenever the family tries to do a new activity like join soccer or dance, that child gets very upset and resists going. And after they go, they have a good time. But the next time it's time to go, they get upset again.

Host: We have a nice diagram that kind of describes this. Can you walk us through that cycle of fear?

Dr. Whiteside: Sure. This is one of the pieces of material we use to help families understand how anxiety disorders work. We use an example of fear of dogs because that's a pretty common fear. It's pretty straightforward, concrete, easy to understand, whereas other fears like general worry or obsessive-compulsive disorder are less than intuitive. They're hard to understand, but they'll work the same. In the diagram we have here, it's how a fear of dogs works. Starting at the top and going around clockwise, the boy sees the dog and then he reacts. He starts to think, "This dog is going to bite me," and he gets scared. No one likes to feel scared, so he runs away. After he gets away, he feels a lot better. He feels relaxed, relieved, but because he continues to believe that dogs are dangerous, the next time he sees a dog, the whole thing repeats itself.

The three things that we really want parents to recognize here is it's not the dog that makes him nervous, but it's his expectation that it's going to bite him. If we can help him change his beliefs, then he would feel less anxious. But we can't just talk ourselves out of things that we believe because our beliefs are based on our experience.

Then we talk about the importance of avoidance. If the boy always runs away from dogs — never spends time with dogs — he never has a chance to learn that they're not so bad. Finally, we talk about how that's a very normal reaction because none of us like to feel anxious. Running away, if it makes us feel better, it's automatically reinforced or rewarded. We're likely to do it again and do it more. Not only big dogs but small dogs — avoid situations that there might be dogs. That's a quick way to feel better.

Host: Yeah, absolutely. How early can you start to see some of these symptoms of anxiety in children?

Dr. Whiteside: Well, you know, most things, anxiety included, are there's some parts of it that are inherited. Some of us have dispositions to be more anxious than others and those can really be present from the beginning. Kids are just more reactive, and they get anxious in situations. And when they get anxious, they have a much bigger emotional reaction than other kids do. Typically, the kids that come in to see us are school-aged. Around elementary school, in kindergarten throughout teenage years. Early on the fears that we see are mostly separation anxiety. When kids start to go to preschool or kindergarten — they have difficulty separating — are when we start to see kids.

Host: How about some of like the kind of more typical development anxiety we see in kids, like when does separation anxiety become a problem as opposed to kind of a normal developmental milestone we see with kids with their social emotional development?

Dr. Whiteside: The answer to that really comes down to impairment. How much of a problem it is, and that varies by family. Some families are pretty tolerant, and, you know, their schedule or they're used to a certain amount of anxiety around social situations or new activities, or separation isn't a problem. Whereas, for other families, they have a much lower threshold for when that gets in the way. If it's distressing to parents and kids because every time, every day we try to go to school it takes five minutes to peel them off your legs. Then that's a problem that we probably should talk about. Whereas, you know, at the beginning of the school year, there's a couple weeks of increased tears, but then the child is able to move on and settle in. Then it's probably not problematic.

Host: We say they're pretty common anxiety disorders in kids, but how common are they in children? And does it change in frequency or that we see them in teenage years?

Dr. Whiteside: The estimates vary. Probably a reasonable estimate is somewhere between 10% to 15% of kids have an anxiety disorder. If you are more specific that the problem with anxiety gets in the way of life significantly, then that percentage drops. Some estimates are as high as 20% of kids having trouble with anxiety and that kind of includes all anxiety disorders together — specific phobias, social anxiety, generalized worry.

The presentation of anxiety tends to change over childhood as kids grow older. Younger kids are more likely to have separation anxiety because, you know, it's a pretty typical experience and for kids that are more anxious, they have more extreme social or separation anxiety.

Specific phobias of animals and bugs are also more prominent in younger kids. Once they start to get into middle school and more teenage years, peer relationships start to be much more important. The anxiety starts to attach to social interactions. Extreme shyness and social phobia becomes more prevalent. Then when kids get older and they start to worry more about achievement in school and the future, generalized anxiety becomes more of an issue.

Host: What does generalized anxiety look like in a child?

Dr. Whiteside: Generalized anxiety disorder is kids who worry a lot about many different topics. They worry most days and when they have those worries, it's hard to stop worrying. Frequently when adults or kids worry a lot, it affects the way they feel. They're irritable more often because they're feeling stressed out about their worries. It's hard to sleep. They just feel more jumpy and easier to startle. It's hard to sit down and kind of relax.

With kids, things that parents can look for are lots of what-if questions. The family is going on a vacation. It's a kind of a fun activity that they're going to do. But the child's immediately worried about "What if we miss the flight?" or "What if this happens?" "What if we don't like where we're going to be?" Kids who are doing well at something but worry about it anyway. Kids who tend to get good grades but are still worried about getting their work done on time, even though it's not due for a few days or worried that maybe they didn't get an A. It's worrying when they don't have to.

Host: Sometimes people will term that as "perfectionism." Is perfectionism a form of anxiety disorder, or does it sometimes just go along with it?

Dr. Whiteside: Perfectionism can be both I think, and that's a good question. Sometimes it's clearly anxiety. Some kids are perfectionistic because they're afraid if they don't get straight As or if they don't do really well or if they ever get in trouble, that would be terrible and they are not going to get into school or people are going to be angry at them. Other people are perfectionistic because it's more comfortable for them. They want straight As and they're not nervous that they're not going to get them. They just are not living up to their expectations. And it makes them irritable or angry or upset because you haven't met the standards that they've set for themselves. Perfectionism can go both ways.

Host: You talked about a couple different types of things: phobias, social anxiety, generalized anxiety. Are there any others that you see in children of different types of anxiety disorders?

Dr. Whiteside: We see a lot of kids with obsessive-compulsive disorder, which is not technically an anxiety disorder anymore but often includes fear or worries such as kids who are afraid of germs from public surfaces. If they touch a doorknob they'll wash their hands over and over again. Other kids who feel nervous about things being not just right. They'll rearrange and tap and touch things over and over again. We see many kids and we treat them the same.

Social anxiety, separation anxiety, generalized anxiety, specific phobias are the main ones. Sometimes another anxiety disorder is panic attacks. Kids can have intense anxiety episodes that come out of the blue. They're not set off by being away from their parents or social situations. They don't really know why they have them and that anxiety attack itself is frightening and they're worried about having them again. That doesn't happen that often in kids. It starts to happen in adolescence and is more common in adults.

Host: What about post-traumatic stress disorder? Is that considered an anxiety disorder, or is that going to be something different?

Dr. Whiteside: Post-traumatic stress disorder, like OCD, used to be an anxiety disorder. Now it's in a category of its own. But frequently PTSD has a lot of anxiety. It's something very frightening and traumatic that has happened and the child continues to feel nervous about it. They have flashbacks or memories that when they have them are overwhelming and very frightening. They avoid situations that are safe now, but remind them of what happened in the past.

Host: You talked about OCD, and we have a great audience question. It says, "Could OCD in the teen translate to an additional kind of anxiety problem or anxiety disorder in adulthood? Do you see those kind of cooccurring?"

Dr. Whiteside: That's a great question. Anxiety disorders in general tend to cooccur. If you have one anxiety disorder, you probably have another. And that probably can relate to the way we describe them and diagnose them. And OCD also fits in there in that kids who have OCD often have other anxiety disorders.

Most adults that have anxiety disorders — I think that estimates about 80% — had OCD as a child. OCD tends to persist. Many anxiety disorders persist. If you have anxiety as a child, or OCD, you're at risk for continuing to have problems with it as an adult. Although by no means does everyone who had anxiety continue to have them.

Host: Great. We'll get to the interventions and treatments that you do in a little bit. You mentioned a couple things about what causes anxiety. You talked about genetics. Is there anything else that we think contributes to anxiety?

Dr. Whiteside: Like most things, there's genetics and there are the environments of nature and nurture. We talked earlier about that cycle for how anxiety disorders work. There are two things, maybe three things, in the environment that really contribute to anxiety. One is stressful situations. Sometimes, especially with post-traumatic stress disorder, something happens, and it makes a child nervous. And then they start to avoid. Rather than going back and spending time with dogs and learning that dogs are generally safe, after that scary incident with the dog, they avoid them and that anxiety grows over time.

Stressful situations can cause anxiety or contribute to anxiety. A general pattern of avoiding things that make you nervous over time can attribute to anxiety. There's been a lot of research on whether to what degree parents contribute to anxiety sorters. And probably the fairest way to look at that is that really hasn't panned out that. The good news is we never blame parents for the kids being anxious. Which will be important when my daughter grows up and is anxious.

Host: And same with mine.

Dr. Whiteside: But one thing that parents do tend to do that can contribute to anxiety is be overcontrolling, which in many cases may be a result of their child being anxious. They realize that to just make life go smoothly, they've got to kind of control things. But it also prevents kids from having those experiences that teaching them it's OK to fail and it's OK for things not to go well. I can handle it. They don't have those experiences. They don't learn.

Host: That really gets into a lot of that resiliency rate and why that's important.

Do you talk a lot to parents about how to let their kids fail and to experience those uncomfortable emotions and learn to tolerate them?

Dr. Whiteside: Yeah, everything we do, we include parents because we'll talk more about treating anxiety in a moment, but you can't just do things in a therapy session. You have to make changes between appointments and that's hard for any of us to do, particularly kids. We want parents to be aware of the changes their kids need to make and help them and parents change. So we reassure parents that it's not their job to make sure their child feels happy and feels good at every moment of the day. It's their job to let their child experience life and learn to become resilient. And that's hard because we always want to fix things. It feels good to fix things for your child. And when they feel nervous, you feel upset, and that's hard for us to handle. So we include parents so they can kind of learn that they can handle that with us.

Host: Absolutely. How do you go about making this diagnosis and who should be involved in the process? Is this a primary care thing? Is this something that should be done by a psychologist or a clinical psychologist? Tell us about that.

Dr. Whiteside: The primary care physicians and providers have a very important role in all mental health issues because that's where people go. Most people have a pediatrician. That or a family practice doctor that they work with, and that's who they trust with their child's health. So that's where they go. It's very natural for people to go to their family doctor first.

When diagnosing an anxiety disorder, the things that we keep in mind are that we want to make sure that the child is overly anxious about what they're experiencing such as a child who's getting pretty good grades but worries about them despite that. For a child who gets along pretty well with kids, they're generally well-liked but they're very shy about making mistakes. Those are anxiety disorders. Where a kid who is failing a couple classes and is really struggling in school and is worried about that, that's a problem with school and not with anxiety. Where a kid is being bullied or teased a lot and feels nervous about being around kids, that's a problem with being mistreated by other kids and not an anxiety problem. That's the most important piece to get right. Is this child overly anxious about a typical situation or is their anxiety developmentally appropriate because we'd all be anxious in that situation?

It's first identified by physicians often and then it's helpful to have a mental health specialist, whether it be a psychologist or psychiatrist or social worker — someone with an expertise in anxiety — to make that diagnosis. Kids need to be part of that evaluation because they're the experts on how they feel. But parents have a very important role in providing information not just about how the child's feeling recently but what have things been like over time so that we get an accurate sense of what the kid has been like and what their experience has been like.

Host: You've made the diagnosis. What are the treatment options and what's really most effective? What does the literature and the research that you've done a lot tell us about how to treat kids?

Dr. Whiteside: The most important and probably the most effective treatment is exposure therapy: helping kids face their fears and learning through their own experience that what I was afraid of probably is not going to happen and even if things don't go well, I can handle it and I can handle these uncomfortable feelings of being scared and nervous. That's not something parents can tell their kids when they have an anxiety disorder. We can't just tell people that and they magically believe that. Kids and adults need to learn that through their own experience. And exposure therapy is helping them do experiments to learn that.

Host: We have a nice diagram of that.

Dr. Whiteside: Let's go through that.

Here we have that same example of a boy who's afraid of dogs, and it starts same place up at the top. And we're going around clockwise. The same boy sees the same dog, and the same reaction: "The dog's going to bite me. I can't handle this. I'm feeling scared." But this time, rather than avoiding and running away, he stays with the dog. He pets the dog. He faces his fears. He does what we call an exposure. He exposes himself to what he's nervous about. And because what we're asking him to do is relatively safe. It's something people do every day. It goes relatively well and he starts to have a new thought: "Hey, dogs aren't so bad. I think I can handle this." And he starts to feel better, and that makes it easier to go up to the next dog.

We emphasize two really important things about this cycle for families. No. 1 is that the first thing that changes is his behavior. He's still feeling nervous. He's still worried something bad is going to happen, but he faces his fears despite that. It would be a lot easier and I'd be a lot more popular if we could just turn off the feelings and thoughts like a light switch. But we can't. We can't control our thoughts and feelings, but we can control our actions.

Fortunately, after you change your behavior, your thoughts and feelings start to change with it. The second point that this is not a one-time thing. You can't just pet one dog. "Hey, I'm over that. That was pretty good." He has to pet many dogs in many places until he learns he can handle most dogs most of the time. That takes hard work. It takes patience and persistence.

Host: And a lot of support probably from parents in this process. Right?

Dr. Whiteside: Yes.

Host: We typically think that therapy is going to be the most effective treatment for anxiety disorders in children. Is that correct?

Dr. Whiteside: A lot more research needs to be done to really understand what the most effective and efficient, and safe, treatments are. There is a lot of research. There are close to a hundred, if not more, studies looking at cognitive behavioral therapy, which involves exposure therapy and showing that that's more effective than not doing it in treatment.

Within cognitive behavioral therapy, there's more and more research suggesting that its exposures that are most important. And many people, many families, many kids are taught relaxation strategies, thought distraction and things like that, which make you feel better in the moment but don't really sufficiently treat anxiety.

Exposure therapy is probably the best treatment that we have. Medications are another option. In our clinic, we always like to start with exposure therapy because we think that's the safest treatment. It's one that can be time limited and you can learn strategies. And you can use those after you're done with treatment. If we don't have enough success with exposure therapy, then we have them evaluated by one of our psychiatrists to see if medication might be appropriate as a second line of treatment.

Host: I think that's a really important message for parents to hear because sometimes they don't want their kid to go on medications. I've had parents say they've been reluctant to bring them in because they're afraid we're just going to put them on a medication. But if we're really trying to treat the root cause of the anxiety, the therapy is going to to be helpful.

You've done some extensive research looking at all these studies together. Is that correct? And they've shown that there is a positive benefit than if we were to do nothing?

Dr. Whiteside: Yes. Oh, yeah. Clearly.

It's very clear that therapy is going to help more than doing nothing. Exposure therapy — helping children face their fear — is going to be even more effective than other types of therapy. The challenge, and it is a very real concern from a parent's standpoint, is that, first of all, there's limited mental health resources and the number of therapists who actually do exposure therapy is even smaller than that. When families go in, medication may be the most-accessible treatment option.

Host: What about parents and schools? What can they do to help their children navigate this process, especially during therapy?

Dr. Whiteside: Identification is the first piece. Most kids with anxiety disorders don't get any treatment. Some estimates are about a third of kids with an anxiety disorder who are identified get treatment. Identification and bringing kids in for help, that's probably the most important step.

Parents can play a role in that and schools can play a role in that as well. Unfortunately, advocating for treatment is probably going to be a big piece or advocating for the right treatment — parents understanding and learning that exposure therapy is a viable option. Exposure therapy is necessary. They're probably going to have to talk to the therapists and say you know, I've been reading about this exposure therapy. Is this something you do and if not, can you help me? Can you help me find someone who does, or can we learn this together?

There are a number of good resources out there. We have an intensive treatment program designed specifically for people who can't find therapy in their home areas where we've tried to take our exposure therapy program and collapse it into five days. Families can come in and spend a week with us facing their fears and then go home and continue it after they leave.

Host: We had a great question that came in about parents and schools and how they can work together, but they want to know if there's any specific tools that schools could use? Maybe getting school-based mental health specialists and stuff? Has that been something that's been successful in the treatment for children that have anxiety disorders?

Dr. Whiteside: You know, I think, exposure therapy, or therapy in general, and exposure therapy is, you know — takes specialized knowledge, but it's not overly complicated or really difficult — especially for someone who has a mental health background. It's something that they can learn to do. There is definitely a role.

Many kids, obviously most kids, go to school, and that's one of the most common places that they receive mental health services. Schools can play a large role, particularly with social anxiety or school-based anxiety because that happens in the school, where a lot of kids social interactions are. If there is a counselor or a school psychologist or school social worker who can help families do exposure therapy in the school or communicate to the parents that the child is working on their goals during the school can be very helpful.

Host: What about the role for 504s and IEPs and helping maybe accommodate the learning environment for children that have anxiety disorders? Is that beneficial to them, or could that be more harmful if they're avoiding some of these things that caused anxiety?

Dr. Whiteside: That can go both ways. IEPs and 504 plans that accurately identify a child as having an anxiety disorder and saying our goal is to have this child returned to all normal functioning, but they're going to need some time because they're going to have to face their fears and build their confidence is wonderful. Kids who are doing their best and parents who are getting as much treatment as they can but still their anxiety is causing some difficulties, 504 plans again and IEPs can be appropriate there as well.

And the other piece is when anxiety is more a reaction to stress. If a child has a learning difficulty or attention problems and those are causing anxiety, a 504 plan that addresses the root cause of the anxiety and the fears and the worries in that situation can be very important.

Host: Absolutely. A lot of times parents ask what they can do to help. Are there any tips that you would tell them — what they should do or maybe what they shouldn't do in these situations?

Dr. Whiteside: Most importantly is to be warm and supportive of kids. It can be really stressful when your child has anxiety because you have your hopes and dreams for them and you also have the daily tasks you have to get done. And if your child — if just going to school or getting dressed causes a lot of anxiety, that's really stressful.

When we get frustrated and angry, our kids get more upset and everything blows up. Doing your best to stay calm and being warm supportive is the first thing. Secondly realizing that there are things that can be done to help and getting your kids help is probably the second piece. Also realizing that anything you can do to help your child in a warm supportive way — face their fears, experience life, not avoid — is going to be helpful. That's easier said than done when kids have full-blown anxiety disorders because they can really push back and it's hard to handle on your own as a parent.

Host: We had one other audience question that gets at the root of this. How young can you start to do exposure therapies? This question was about separation anxiety disorder in toddlers. How early are you able to help children that are quite young with separation anxiety?

Dr. Whiteside: That's a great question. The principles of anxiety disorder treatment are the same across the lifespan, but the way we implement that varies a lot. The younger children are, the more parents need to be involved.

A teenager can be pretty self-sufficient in doing their own exposures. But they need a parent to make sure they're staying on task. For very young kids, for toddlers, and there has been research on how to treat anxiety in very young kids, it involves a lot of helping parents use general parenting strategies — attention, paying attention to brave behavior and removing attention from anxious behavior, having behavior management strategies to help kids face their fears in the situation, to help them manage their emotional reactions more. The principles are the same, but it's much more focused on teaching parents to support their kids through it.

Host: That makes absolute sense, thinking about their development. We're almost at the end of our time here. Are there any resources that you would recommend to families as they go through this process?

Dr. Whiteside: Yeah, there are a couple of websites for professional organizations. The Association for Behavioral and Cognitive Therapies — abct.org — and the ADAA are both two professional organizations where you can search for a therapist in your home area.

Host: So these are people that have explicit training in these areas?

Dr. Whiteside: Yes. The International OCD Foundation similarly focuses on OCD. They have a site you can search for therapists in your home area.

We have a five-day intensive treatment program that's designed for people across the country whose children's anxiety is enough that they want to get help and they can't find help closer to home. Those would be the main sources I would start with.

Host: Absolutely. What's the number if they wanted to contact to set up that five-day intensive appointment?

Dr. Whiteside: I think we have video on the screen.

Host: It would be Mayo Clinic. 855-MAYO-KID (855-629-6543) would be the number to call if they want to set up an appointment. They don't need an external provider to make a referral for this program. Is that correct?

Dr. Whiteside: You can self-refer, which I think is a nice feature.

Host: Well, that is all the time we have. Thank you so much for joining us and sharing all your knowledge about this.

Dr. Whiteside: Thank you for having me. I enjoyed it.

Host: It's been fantastic, and we'll have to have you come back again and talk about some other anxiety-related concerns.

Dr. Whiteside: Sounds great.

Host: Thank you, everyone who joined, and thank you, everyone who sent in questions today. Catch the next "Ask the Mayo Mom" on Facebook Live on May 17 at 11 a.m. Dr. Peter Ree, a hand surgeon at Mayo Clinic, will be joining us to talk about enhancing upper limb function in spinal cord and brain-injured patients. Thanks, everyone, and have a wonderful day.