Elizabeth* noticed that her now 8-year-old son was different, almost from birth. “My son is a really intense child. Starting from infancy, he could have four- or six-hour screaming fits,” she says. This single mother says that living downtown on September 11 only heightened her gifted child’s anxiety. “The week afterward, he drew a picture of a guy screaming, “NO BOOM!”, and on another page he drew a phoenix,” she recalls. Now in the second grade, which is more academically oriented and structured than his previous class, he is disruptive and engaging in what Elizabeth says his teacher calls “attention-seeking behavior”. “If someone bothers him, he doesn’t hold back. If a kid trips him, he’ll bring them to the floor. He feels more than most people,” she says. Elizabeth is in the process of having her son fully evaluated, both so that she can make sure that his school gives him what he needs, and to have him diagnosed before the school labels him.
Elizabeth’s story is common among parents of children with anxiety disorders. Some experience separation anxiety so severe that they cannot be comforted enough to concentrate on their school work. Some have anxiety that manifests as aggression, while others take their anxiety out of themselves through self-destructive behavior like cutting or anorexia. Some suffer full-blown panic attacks. What is clear is that anxiety-disordered children do not experience worries and fears in quite the same way as a typical child.
How Anxious Is Too Anxious? Patricia Saunders, Ph.D, director of Graham Windham’s Manhattan Mental Health Center, says, “The best criterion that clinicians use for diagnosing anxiety is ‘Does it interfere with a child’s functioning?’ Does it disrupt sleep, create an excuse for not attending school, does it interfere with ability to make friends, and is it around something that doesn’t make obvious sense?” Persistence (of the anxiety) is also a symptom, she says. “Anxiety looks different at different ages. Little kids have a much narrower repertoire for expressing their fear. It’s really hard for little kids to explain separation anxiety, and yet it’s pretty normal. When kids start to experience language, they are more able to express fear to the parent. The most important advice for parents is to take the anxiety seriously. Don’t ever try to talk them out of it, or dismiss it. The worst thing you can say to a child of any age is, ‘Oh, you shouldn’t feel that way.’ It cuts off an avenue of relationship with the parent.”
In his new book, The Worried Child: Recognizing Anxiety In Children and Helping Them Heal, Paul Foxman, Ph.D, says that anxiety is the most common emotional disorder in this country. It is estimated that 25 percent of the population will develop anxiety disorders that would benefit from professional help. Anxiety outranks other emotional problems, including depression and substance abuse, in frequency. And, as any parent knows, anxiety often manifests as stomach upsets, headaches, sleep disturbances and other health problems. Most people know what unhealthy anxiety looks like in adults. A person who is afraid to leave the house, or suffers insomnia because he can’t stop worrying, is clearly in need of some counseling, medication or both. But children are different. How do you know which fears are developmentally appropriate, and will be outgrown, versus those that are developing into crippling problems? Parents often attempt to answer this question by comparing their children to the children of their peers, and that can be a mistake. “There’s a real danger in parents going by what is assumed to be ‘baseline behaviors’,” Dr. Saunders says. “One child, because of who they are, may just have a more reactive nervous system. For one child it may take three to four weeks to get over (an anxiety-provoking situation). For another, six months. We also want to look for a pattern. Anxiety reactions are generally not isolated.” Dr. Foxman’s book includes a helpful chart of normal childhood fears at different ages. “At 5, separation from the security figures, bad people, things that people can do that are bad, bodily harm, and animals are top concerns,” he says. “From 9 to 12, the typical concerns and sources of anxiety are tests, physical appearance, school performance, thunder and lightning, bodily injury, and death. At 13 to 15, concerns start to focus on family and home issues, preparing for the future, personal appearance, social relations, and school. Also, we’ve identified political concerns. There’s an awareness of different political views and more global awareness.” Interestingly, Dr. Saunders notes that anxiety can be manifested very differently depending on the race, ethnicity or social class of the child. “I see huge differences that are mostly socio-economic. Kids who are white, upper-middle-class tend to be more direct in their expressions of fear. Kids from poor, marginalized families tend to respond to anxiety and fear more with aggression. It’s much less obvious that these kids are scared out of their minds because they are getting into fights all the time.”
Coping With Anxiety In A Stressful World Richard Gallagher, Ph.D., director of the Parenting Institute at NYU’s Child Study Center, says that it also is important to view children’s anxiety in the context of changes brought about by September 11. “They are under more pressure with less support than they have been before. Not just from the direct effects but indirect effects of 9-11. I think that people in general are more anxious. They are more tuned in to the news. More tuned in to the possibility of danger occurring. It has affected our school system. It has affected parents with their resources going toward thinking about that. It’s showing up in the statistics. We have indications throughout New York City that there are more behavioral difficulties than there were before 9-11.” If you have a child you believe is suffering from unhealthy anxiety, the most important thing is get help. Fortunately, experts agree on what works best in helping to alleviate anxiety in children and adults.
Getting Help “We do know that the best method to dealing with it right now is cognitive behavior therapy,” Dr. Gallagher says. “It works to help kids spell out and describe the ideas that they have that are leading them to be fearful of the situation. It helps kids cope with situations by learning strategies for relaxing their bodies and their minds, helping their ideas be as rational as possible. Kids get guided and supported ideas to help them confront the situations that they are anxious about. It is done in a very systematic, but supportive and directed way.” Dr. Gallagher notes that the Association for the Advancement of Behavior Therapy (www.aabt.org) has listings of clinicians who practice this type of therapy. Parents also need to understand when medication might be necessary, and whether it is safe (see sidebar). Dr. Foxman believes that television advertising featuring popular antidepressants, such as Prozac and Zoloft, has been a double-edged sword. “The good part of it is that it has contributed to public awareness. The combination of that and high-profile individuals coming out of the closet about anxiety or depression has been good in getting people into mental health services,” he says. “The bad side is that medication is the cash cow for the drug industry and they have sort of created a market for these drugs. The patients are asking for the drugs. I personally don’t think that medication alone is a good solution. It’s a good temporary measure so that people can learn new skills to manage their anxiety.”
Support For Families As distressing as it can be for a child to live his days under the cloud of needless worry and fear, it also can be extremely stressful for the family members who love him and have to deal with what appears to them to be irrational behavior. And children with anxiety disorders frequently also have other kinds of mood disorders. Dr. Foxman says, “This may be frustrating for parents but it’s so important for a parent to understand why a child is acting this way. Is it (the behavior) anxiety based, or are they acting against the parent by being resistant or oppositional? Forcing a child to do something that creates anxiety increases the anxiety and there’s no mileage in it. There’s absolutely no benefit for the parent or child.” Janet* has an 11-year-old daughter who was diagnosed with attention deficit hyperactivity disorder (ADHD) at age 5. Later her doctors discovered that she had mood and anxiety disorders. This New York City mother says that dealing with her daughter’s mood swings can be trying. “It can be very stressful. At times I must walk on eggshells. I have learned that I must really choose my battles. As a single mother it is sometimes extremely difficult. However, I also have a tremendous amount of patience, or so I have been told,” she says. “I know that my daughter does not like to feel the way she does but is unable to control her disorder, although through therapy she is beginning to deal with it somewhat better. It’s a very, very slow process.” Elizabeth says she learned early on to block out the stares from passersby when her son would have tantrums in public. “What I learned early on was to not pay attention to anyone else’s reactions to him. I just had to focus on him. He loses his cognitive capacity when he’s frustrated. It seemed like it would never stop,” she recalls. Dr. Gallagher also notes that the family should expect to get guidance and help in finding support and resources from the clinician who is treating the child. “We think that any good child or adolescent treatment also involves the family. Any good therapist will include that as part of the package,” he says.
Reducing Anxiety At Home There also are many practical tips that parents can employ, whether their child is truly anxiety disordered, or merely internalizes stress a bit more than the average kid. Michele Borba, Ed.D., author of Don’t Give Me That Attitude!: 24 Rude, Selfish, Insensitive Things Kids Do and How to Stop Them, says there are several things that parents can do to make home life less stressful, including whittling down extracurricular activities and monitoring the media’s influence on your child. “Look at your calendar. We sometimes get so overwhelmed by it all we don’t see how all the stress is affecting our kids. Track a week or few weeks’ schedules and see what it looks like. Get rid of at least one thing. It will amazingly simplify your life. Choose the thing that isn’t that important to (your child),” she suggests. Dr. Borba also says parents often don’t realize that the flow of information into the home can be a problem. “If your child is more anxious and stress prone, watch out about the news watching,” she says. Also important, Dr. Borba says, is realizing that children observe and react to the anxiety they see around them. “Before you try to change your kid, change yourself (if you’re anxious). A walk or listening to soothing music can help. Turn the phone or the TV off. The routine will help your child and you,” she says. “Instead of just making your kids learn an anxiety-soothing technique, learn it yourself.” In fact, according to Mark Krushelnycky, M.D., clinical assistant professor of psychiatry at the NYU School of Medicine, sometimes children’s anxiety disorders go untreated because their adult relatives suffer with unhealthy anxiety as well. “People may just say that’s just their personality, that’s the way they are. It may not seem so unusual to other family members,” Dr. Krushelnycky says.
Communicating with the anxious child Parents with anxious children often struggle with disciplining them. It may be a problem with discipline, in fact, that leads the parents to seek professional advice, as sometimes anxious children also are oppositional and confrontational. “One reason why parents may want to seek professional consultation is because they want to know ‘is my child just being a brat, willful and spoiled?’” Dr. Saunders explains. Dr. Foxman, who notes that many of his anxious adult patients were physically abused by their parents, knows that discipline is a difficult issue for most parents. “The problem with discipline is that parents are frustrated and out-of-control when they are trying to influence their children’s behavior,” he says. But if you think that you can get your child to conquer her anxiety by forcing her to “sink or swim,” Dr. Foxman says that’s a bad idea. “Parents make a big mistake by forcing their children into situations that make them anxious believing that they’ll ‘get over it.’ The child will experience, in effect, a feeling that ‘see, I knew this was uncomfortable for me, and this just proves it,’” he says. Dr. Foxman says it’s also important to speak honestly with these young people about peer pressure and sexuality, drugs and alcohol. “Some of the personality traits that are quite common in children who have anxiety, such as being inhibited, may make them unable to cope with sexual pressure,” he says. All of the experts agree that anxiety, when treated early and properly managed, need not impair your child’s life. Parents also should realize that while some anxiety is rooted in biological factors that cannot be controlled, upbringing does play a role in how well you and your child respond to stress. “The single most important way to immunize against anxiety would be to have strong family connections with positive self-esteem. And if you think about self-esteem, you realize that it begins in childhood with positive reinforcement from primary caregivers,” Dr. Foxman says. He adds: “That communication, if it continues and is open, makes you feel more prepared to handle the stressors of life because you feel like you are more able to handle things emotionally.”
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Medicating Anxious Kids: Are Antidepressants the answer?
When anxiety disorders are crippling enough to disrupt your child’s day-to-day functioning, a doctor may prescribe medications to help her get back on track. But with the media continuing to sound the alarm about the possible harmful side-effects of popular antidepressants, you may not be sure if the cure is worse than disease. Mark Krushelnycky, M.D., clinical assistant professor of psychiatry at NYU School of Medicine, says families often need to be counseled extensively before they agree to medicate their child. “There still is quite a bit of apprehension about putting a child on medication. It’s clear that we don’t have all of the answers. I also think that there is a lot of negative information,” Dr. Krushelnycky says. In fact, a recent advisory by the Food and Drug Administration cautions physicians, their patients, and families and caregivers of patients about the need to closely monitor both adults and children with depression, especially at the beginning of treatment, or when the doses are changed with either an increase or decrease in the dose. The FDA has been closely reviewing the results of antidepressant studies in children since June 2003, after an initial report on studies with Paxil, and subsequent reports on studies of other drugs appeared to suggest an increased risk of suicidal thoughts and actions in the children given antidepressants. There were no suicides in any of the trials, and it was unclear whether certain behaviors reported in these studies represented actual suicide attempts, or other self-injurious behavior that was not suicide-related. Dr. Krushelnycky treats anxiety-disordered patients in his practice mainly with a type of antidepressant known as selective serotonin reuptake inhibitors (SSRIs). Popular brand names of these drugs include Prozac, Celexa and Zoloft. “In thinking about how anxiety disorders affect kids, what we are starting to feel much more comfortable about is that children with untreated anxiety are more likely to develop depressive disorders. Some of the medications (used to treat the condition) are the same. But there’s more controversy right now because of some of the warnings that are coming out,” he says. Generally, these drugs are only prescribed in addition to cognitive behavioral therapy, which has been shown to be the most effective treatment for anxiety disorders. However, Dr. Krushelnycky says, there are instances in which these drugs clear the path for patients to accept therapy.“The meds will allow them to feel comfortable and allow them to engage in psychotherapy,” he says. “A lot of what makes cognitive behavioral therapy effective is significant exposure to things that provoke anxiety. For them to feel comfortable going through that process, it’s helpful to have medication on board to make them available for that.” Dr. Krushelnycky says that although these drugs are tolerated very well by children and teens, there are some side-effects, such as “symptoms that would be associated with a flu-like syndrome (such as) upset stomach, changes in bowel habits, sedation, headaches, or feeling a little tired.” He notes that it is important for the child to be closely monitored when the medication is started, or changes are made in the dosing, so that you and your child’s doctor can be sure that the drugs are doing what they are supposed to do and that side effects remain tolerable.
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Columbia’s ‘TeenScreen Program’ IDs At-Risk Youth
If your child were depressed, anxious or obsessive compulsive, would you know it? What if you didn’t have to worry about the issue at all because testing for mental health was as routine in our schools as making sure your child can see the blackboard or hear the teacher? The Columbia University TeenScreen Program is putting computerized mental health screening programs in front of middle and high school students in New York City and dozens of states. Its staff hopes that this screening will be able to identify at-risk kids who are not yet known to the school’s counselors or administrators. Tiffany Haick, training director of the program, says, “Our model is so different because it is a preventative. It’s catching the kids they are not seeing, who are performing adequately, but are slipping through the cracks. “We know that only one-third of kids suffering from depression are treated. Our goal is universal screening, not just referred kids.” As an example of the way the program might work in a school, she says, “We are really pushing to screen the entire ninth grade to lower the stigma and normalize it.” The TeenScreen Program was developed over 12 years ago under the leadership of David Shaffer, M.D., the director of Columbia University’s Division of Child and Adolescent Psychiatry. It creates partnerships with schools and communities and helps them to implement their own screening programs to identify at-risk teens and pre-teens. The program is now used in high schools and other settings in 26 states, where Columbia University assists communities in creating local screening programs. All materials, consultation, training, and technical assistance are available free of charge. Haick says that both students and their parents must consent to the screening. And while student consent usually ranges between 95 percent and 100 percent, about 20 percent of parents do not consent to having their children tested. Some schools use incentives to promote the test, such as making it an extra-credit assignment in a health class. Additionally, in schools where parental involvement is limited, schools use passive consent: that is, notifying the parents that the screening will happen unless a parent specifically opts his child out of the program. TeenScreen’s 10-minute self-administered questionnaire asks the students demographic questions, basic questions about their vision, hearing and teeth, and then moves into questions about social phobia, panic disorder, generalized anxiety disorder, obsessive compulsive disorder, depression and suicidal ideation. There are also questions about substance abuse. This questionnaire is not a diagnostic instrument, but it does indicate which students require further evaluation and it highlights the disorders for which students are likely to be positive. Students who test positive for some disorders are advanced to the second stage, where they are assessed by a mental health clinician to determine if further evaluation or treatment would be beneficial. If professional services are recommended, TeenScreen staff help the youth and his or her family with a referral. After the screening, says Haick, “The administrator will pull the report out and look at the child. Everybody gets some face-to-face interview, lowering the stigma for the children who do have some problems.” Haick says that a poll the organization recently commissioned showed that parents want more of this kind of screening in schools. “Ninety percent of parents felt that schools should be in the business of identifying these problems and that not nearly enough was being done to identify these problems,” she says. Another very interesting survey finding was the respondents’ idea that this would be more helpful to other parents. “Parents falsely believed that they would know what’s wrong with their child, but didn’t think that others would know what is wrong with theirs,” Haick says.
