Excerpts

CHAPTER 1 "I Can't, I'm Too Scared" UNDERSTANDING CHILDREN'S FEARS AND WORRIES From the children: When I was little my mom worked the "graveyard shift" at the hospital. Every night I was so worried that meant she was going to die and I'd never see her again. When people tell me to lighten up, that things aren't so bad, it makes me feel much worse. They must think I actually like being this way. Views from parents: It is very hard to see my daughter in pain and so scared. Before we got treatment, I felt there was nothing I could do to alleviate her pain. I felt so helpless, being the parent and not knowing what to do; that was the worst feeling. Teachers think I'm nuts because my daughter is picture perfect at school. She's the model student--never a problem. But at home she totally falls apart, her anxiety is so intense, it makes normal life impossible for us. I wish they could see her at home so they would understand what I'm talking about. Anxiety in Children: Too Much of a Good Thing? "Don't run into the street, stop climbing on that, careful, that will break." These are words that most parents have to say over and over again, but that most parents of anxious children will probably never have to utter. In fact, parents may find themselves kept in check by their worrying child-- "Did you lock the door? Is the gas tank full? Did you send in the permission slip?" Though it can often be confusing or frustrating to parents that their child must feel every wrinkle in the day and race ahead to prepare for every eventuality, we must understand that anxious kids are just doing what their brain tells them to do. Anxious children are highly cautious, overcorrecting for the possibility of danger. In fact their wiring has them seeing danger when it's not there. Born with a mind that casts tall, scary shadows on ordinary things, they spend their days enduring great distress over things that their peers don't even notice. Anxious kids may recognize that they are different, but they don't know why, assuming that this is just how they are. Because we don't see things as anxious kids do, we may be impatient, judgmental, and perhaps even overprotective, but not necessarily effective. The more that we can understand about what our children are seeing and feeling when they are anxious, distortions and all, the more we can empathize. If we don't empathize, we lose our audience. They won't stick around for the lesson, because they think you don't understand the problem in the first place. Children's fears are a source of concern, distress, and even embarrassment for parents. When it's their child who is hiding in the corner at the birthday party, in tears at the school play, or unable to go on the school camping trip, parents are stuck. Rather than getting mobilized to help, parents often feel an urgent need to find the "off" button for those fears to simply stop. What fuels that concern further are two thoughts: first, "this shouldn't be happening, my child shouldn't be afraid," and second, "I don't know how to fix it." It is this two-part punch that fear delivers to parents, immobilizing their helpfulness response and leaving both them and their kids at a loss--or more often in a "you should," "I can't" contest of wills. This chapter introduces the concept of fear--how it functions as an essential safeguard for survival. Fears and worries can help children put the brakes on in situations with which they are unfamiliar. Rather than hurling yourself into a swimming pool when you don't know how to swim, a good dose of fearful "what if?" can keep a healthy degree of caution in the picture until that is no longer needed. In addition, this chapter explores the differences between normal fears and anxieties, and takes an inside look at how anxiety shapes a child's experience. Finally, it presents different models for how fears and anxieties develop, exploring the influence of such factors as genetics, temperament, and experience. The bottom line is that children come by fears honestly. The more parents understand that fear is nothing for them to fear, the more they can be instrumental in helping kids out of these glitches. Fear: A Normal and Necessary Part of Life Fear is a necessary function for our survival. Because our natural inclination is toward growth and development, we would not survive as a species if it were not for our ability to hold back and appraise and avoid danger. It is a protective mechanism and a normal part of development. The focus of anxiety changes for children over time as their world broadens and they encounter new experiences that they have not yet mastered. Babies are afraid of a loss of support and loud noises, toddlers who are learning to run away themselves are afraid of separation and things bigger than themselves, and young children are afraid of the results of their emerging imagination, especially at night--monsters, burglars, and other bad guys. Adolescents fear social scrutiny and begin to look beyond themselves to the world community and such abstract issues of safety as war, and success in the future. Fear can be considered the emotional response that occurs in the interim between confronting a new situation and actually mastering it. In the same way that adults may be fearful of a new piece of technology until we have figured out how it works--and may entertain unrealistic scenarios of blowing up the computer by pushing the wrong button--kids' fears and anxieties are fueled by an active imagination trying to piece together an explanation for how the world works. A little information goes a long way. A four-year-old at the aquarium is afraid when she hears that she's going to see the sharks because she is old enough to learn that sharks are dangerous, but not old enough to understand that she will watch safely from outside the tank. An eight-year-old is beginning to understand about germs and disease but can't yet grasp how unlikely it would be to get sick just from engaging in normal activities. Temporary fears are part of life. Anxiety is the tense emotional state that occurs when you can't predict the outcome of a situation or guarantee that it will be the desired one. Even in the best circumstances children experience some worry. Anxiety becomes a disorder when a child automatically exaggerates risks and underestimates the ability to cope with a given situation. Anxiety is debilitating to children, causing not only chronic fatigue and other physical complaints, but also decreased academic functioning and even school attendance, and strained peer and family relations. Typical Developmental Sequence of Fears in Children Infancy: In response to a growing ability to differentiate familiar faces (parents) from unfamiliar faces, stranger anxiety (clinging and crying when a stranger approaches) develops around 7 to 9 months and typically resolves by end of first year. Early Childhood: As a healthy attachment to parents grows, separation anxiety (crying, sadness, fear of desertion upon separation) emerges around one year of age and improves over the next three years, resolving in most children by the end of kindergarten. As children's worlds expand, they may fear new and unfamiliar situations and real and imagined dangers from such things as big dogs, spiders, or monsters. Elementary School: With access to new information, children begin to fear real-world dangers--fire, burglars, storms, illness, drugs. With experience, they learn that these risks can exist as remote rather than imminent dangers. Middle School: Growing importance of social status leads to social comparisons and worries about social acceptance. Concerns about academic and athletic performance and social-group identification are normal. High School: Teenagers continue to be focused on social acceptance, but with a greater concern for finding a group that reflects their chosen identities. Concerns about the larger world, moral issues, and their future success are common. Who Is the Anxious Child? Anxiety has many faces. Some children appear visibly stressed, others keep their anxiety under cover and worry silently, still others are angry-anxious kids, reacting to their limitations with frustration. Demographically speaking, prevalence rates range from 5.7 to 17 percent of all children.1 Rates of anxiety disorders tend to increase slightly with age; however, most studies of anxiety disorders draw from a sample of children over seven years old, so the prevalence of anxiety disorders in very young children is unclear. Girls tend to be diagnosed with anxiety disorders more often than boys, though more boys may be brought to treatment, as the outward signs of anxious behavior--crying, shying away, overt distress--may be less socially acceptable in boys than girls. The consensus across numerous studies of anxious children is that the majority of them have more than one anxiety disorder occurring at the same time, which is referred to as "co morbid." If left untreated, anxiety symptoms become more disabling over time, and the course is considered to be chronic with fluctuations across the lifespan. Though children with anxiety disorders are as impaired as children with disruptive disorders, they will often stay below the radar of the adults around them and go undiagnosed because their symptoms don't interfere in the classroom, but rather are internalized. The seriousness of anxiety disorders is often downplayed by the public--anxious children may be seen as simply needing to lighten up. The invisibility of the symptoms makes them no less detrimental to the child. Anxious children may have fewer friends because of social fears, or because their free time is consumed by worry or rituals. They may spend inordinate amounts of time preparing for an event, trying to fall asleep at night, getting their homework just right, getting reassurance about their safety. They may not go out for a sport to avoid the risk of being humiliated. They may not go to friends' houses, not consider college because of panic or separation concerns. At home, family life may lose its sense of spontaneity and fun, as participating in ordinary events may be too anxiety-provoking. From morning till night, with little exception, worried kids are bombarded with a myriad of "what ifs." With so much on their minds, we might marvel at how well anxious kids are able to hold it together. Causes and Correlates of Anxiety All parents spend time worrying and wondering about what caused their child's anxiety. Many entertain the dark question of whether they somehow brought this anxiety on their child--either by their own behavior or by genetic transmission. The second issue is easier to address--as we'll see below, there is a strong genetic link for anxiety disorders, but as we know that genes do unto the next generation as has been done to the previous one, we have no choice in the matter. The genetic recipe folds the bad into the good. It does help to understand the physiological nature of anxiety, as it helps parents and kids maintain a no-fault approach to the problem. We would never blame our children for their asthma or diabetes--or blame ourselves for passing it on, and so it should be with anxiety disorders. What we'll see in this section is that like any aspect of a child, anxiety is the result of the knitting together of multiple influences. No one factor accounts for all. "Bad parenting" can't cause these problems, and good parenting alone can't fix the problem. If there are changes you want to make, your child's difficulties may spur you on to turn over a new leaf, but understand that this will only help the process; it will not be the reason why there was trouble in the first place. In fact, what look like "strange parenting practices"--accommodating a child's fear--are often an effect of having an anxious child, not a cause. Nature? Nurture? Our understanding of the causes of anxiety in children comes from an appreciation of the interaction of multiple factors. These include (1) genetics and brain physiology, (2) temperament, (3) parenting style, and (4) environmental factors including traumatic events. All of these inputs have both sensitizing as well as buffering influences. Genetics: Born to Be Anxious? It is commonly said that evolution selects for anxious genes--and when considering the survival of the species it's not hard to see why. Too many false positives are better than one fatal oversight, but when you scale that down to the individual child's narrow shoulders it doesn't make it comfortable for the owners of those anxious genes. Genetics researchers have found some support for the genetic transmission of anxiety. Children of anxious parents are seven times more likely to develop an anxiety disorder than children of non-anxious parents.2 Although the evidence for familial transmission is strongest for panic disorder, genetics explains about 30 to 40 percent of all transmission. Thus, while genetics make a significant contribution, the majority of children with anxious parents do not develop an anxiety disorder. Genetics determine your overall vulnerability or susceptibility to anxiety. Children may be born more sensitive and reactive, with lower distress tolerance, but other factors intervene to tip the scales. There are likely multiple genes that contribute to a child's anxiety disorder, not one identifiable gene for anxiety. The genes affect how different cells in the body's alarm system operate--the sensitivities, reaction times, and absorption rates. We now take a behind-the-scenes look at that system, and at some of the areas that have been identified as central to our processing and experience of fear, threat, and anxiety. The Anatomy of the Brain: Wired for Worry At the center of the brain's defense system--let's call it the "anxiety works"--an almond-shaped cluster of cells, the amygdala, operates within the limbic system, the system responsible for processing emotional experiences. The amygdala is a lifesaver--pulling us back from the curb to avoid a speeding car--fast, but not always accurate--alarming us over a stick that looks like a snake. Thus, it may also be the culprit when it comes to anxiety disorders, signaling us to jump to dire conclusions when there is nothing to fear. The amygdala is like a first responder--it quickly assesses the emotional significance of cues and activates nearly every system in the body to survive a perceived threat, whether that means to fight or run for your life. When the perceived danger has passed, the prefrontal cortex, which acts like brakes in the fear circuit, signals the amygdala that it's time to downshift so that the body can then return to its baseline or steady state. Evolution selects for cautious genes by favoring easy starts to the fear response, but not easy stops. One area of ongoing anxiety research concerns the role of serotonin, a neurotransmitter, or brain messenger chemical. When danger and all-clear messages are not transmitting efficiently, excessive anticipation and prolonged distress may result. The Selective Serotonin Reuptake Inhibitors, or SSRIs, are the medications that are most prescribed for anxiety disorders. These are discussed further in Chapter 3. Temperament and Behavioral Inhibition "Temperament," according to Ralph Waldo Emerson, "is the iron wire upon which the beads [of life] are strung." Many anxious children appear to be sensitized to change and risk from birth and as a result have a curbed approach to exploration. This predisposition is a blueprint for prediction children's needs and experiences in any given situation. Their extremely cautious style is no one's fault. Dr. Jerome Kagan, at Harvard University, identified this trait, which he calls behavioral inhibition (BI), in children as young as twenty-one months old. They react to even the most minor changes in their environment - a new mobile cup - with distress, while other infants respond with excitement or delight to the same changes. Dr. Kagan found these inhibited children had a higher than average likelihood of developing an anxiety disorder later in life. Environmental Factors: Stressful Events and Parenting Factors Stressful Events. Not all children who develop an anxiety disorder have a traumatic event in their history - in fact most do not. However, in our world today, children and adolescents are commonly exposed to traumatic experiences. As many as 15 to 20 percent of children and adolescents will encounter a significant traumatic event during their youth. Though many studies suggest that the majority of children who undergo trauma do recover without incident, a child who has experienced a traumatic event is twice as likely to develop some type of difficulty, whether this is anxiety, depression, or a behavioral disorder. All children faced with stressful or traumatic situations may go through periods of greater sensitivity, clinging, and regression. This is not only normal, it is adaptive. It enables them to get the nurturing they need to recover emotionally and physically from a trauma. In Chapter 15, we discuss factors that sensitize children to stress or to help protect them from it, and how to handle stressful events in a way that enhances coping and serves as a buffer against adverse effects. In Chapter 12 we look at treatments for children who are experiencing a disorder knows as post-traumatic stress disorder. We would expect any child facing such stressors as illness, death of a loved one, being the victim of violence, losing a best friend, or facing parental separation, hospitalization, or divorce to have difficulties for a period of time. These events only compound and already heavy burden in an anxious child and may turn occasional anxiety into a full-blown anxiety disorder, or trigger some regression in a recovering anxious child. Family Enhancement of Thinking Style in Anxious Children . At a recent visit to my daughter's dentist, as I sat respectfully at a distance, the doctor was complaining about those other folks who "parent by helicopter," hovering over the child, making sure they were okay, constantly asking, "Now, does that hurt?" While his concern was how these "pilots" get in the way of the equipment, the real concern is how this hovering impacts kids' experiences in stressful situations like the dentist's chair. Though we know that parent interaction/instruction alone cannot cause anxiety reactions, studies suggest that family interaction can enhance the anxious child's perceptions about a situation, which in turn dictate or at least influence the child's actions. While parents may be trying to protect kids from potential danger, they may be inadvertently spotlighting them. To be sure, a child without anxious wiring will be able to shrug that information off and even think to himself, "there goes Dad, getting freaked out again," but to an already anxious child, this behavior reinforces the idea that these situations are scary. Rather than turning down the volume on that worry soundtrack, the child is now hearing it in stereo. It may be parenting by helicopter is a reaction to a child's anxiety, not a cause - a concerned parent's best attempts to respond to a child's worrying mind. In fact, there is a significant body of literature suggesting that several parenting factors are correlated with anxiety in children. What this means is that while we know that certain parenting styles accompany anxiety in kids, we don't know whether these are a result of or a cause of the anxiety. Studies have found that children with anxiety disorders describe their families as more controlling, less cohesive and supportive, and more conflictual than families of kids without a diagnosis. These studies always give me pause because parents may feel blamed by them. I see how very stable parents become understandably alarmed and distraught in response to distress in their child, not out of some bizarre desire to make their child anxious. A paper released in 2002 by psychologists Golda Ginsburg and Margaret Schlossberg of Johns Hopkins University School of Medicine, summarized over twenty studies of parenting factors associated with anxiety in children. With permission a synopsis of these findings is given below, listing the factors that either reinforce or reduce anxious behavior in children and certain correlations between anxious behavior in children and certain parenting behaviors; they were not designed to indicate which came first. As you're reading the following lists, keep in mind a recent interaction with your child. Go through them and see what is going well and what you need to work on. Parenting Behaviors Associated with Anxiety in Children * PARENTAL OVERCONTROL: intrusive parenting, exerting control in conversation, limiting of autonomy and independence in conversation. * OVERPROTECTION: excessive caution and protective behaviors without cause. * MODELING OF ANXIOUS INTERPRETATION: agreeing with child's distortion of the risk in a situation, reinforcing the idea that normal things in the world are too scary to approach. * TOLERANCE OR ENCOURAGEMENT OF AVOIDANCE BEHAVIOR: suggesting or agreeing with not trying something difficult. * REJECTION OR CCRITICISM: disapproving judgmental, dismissive, or critical behavior. * CONFLICT: (not as strong a factor) two out of five studies found fighting, arguing, and disharmony in family associated with high levels of anxiety. Positive Parenting Behaviors That Buffer Stress * REWARD COPING BEHAVIOR: focus on means, not ends, reward taking on challenges, recognize partial success. * EXTINGUISH EXCESSIVE ANXIOUS BEHAVIOR: reduce anxious behavior by not responding to it excessively, either with concern or anger. * MANAGE OWN ANXIETY: limit displays of distress, don't introduce parent's worries into the mix. * DEVELOP FAMILY COMMUNICATION AND PROBLEM-SOLVING SKILLS: open-house policy for positive communication and problem solving opportunities. * AUTHORITATIVE / DEMOCRATIC PARENTING STYLE: Authoritative / Democratic style - parents direct children's behavior while valuing independence - is associated with lower levels of anxiety (vs. Authoritarian style - parent's demand obedience, limit autonomy; or Permissive style - parents avoid any attempts to control behavior.) Excerpted from Freeing Your Child from Anxiety: Powerful, Practical Solutions to Overcome Your Child's Fears, Worries, and Phobias by Tamar E. Chansky All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.