It’s a maddening Tuesday morning, with our grab-the-lunches-coats-and-backpacks, hustle-them-out-the-door routine in full swing, when I notice that one of my two daughters has disappeared. Ten minutes tick by as I search for Payton, who’s 10, before I find her hiding in the closet, crying. When she first started avoiding school, around age six, I thought it was a game. Headaches and stomach aches came first, but hiding in the closet was clearly an escalation in her anxious behaviour. I check my watch. There will be late slips again today for both my girls. How will I explain this at the office?
Many children can manage a healthy bit of anxiety in life, but for others, like Payton, it becomes a force that interferes with development. I see her anxiety as an invisible opponent — a mental illness that creates paralyzing physical symptoms. She’s more than a worrywart. When Payton complains of an upset tummy or feels headachy, she is literally sick with worry.
The onset of clinical anxiety is typically around six years old, usually at the same time children start school full-time; symptoms can escalate around age 10. Generalized anxiety disorder (or GAD) affects about three to five percent of youth and often occurs with one or more of the other types of anxiety (such as separation anxiety, obsessive-compulsive disorder, or social anxiety). More girls than boys struggle with anxiety disorders. Payton and I characterize her anxiety a “worry bully,” who sits in the corner and is always telling her to expect the worst. But the good news is that today we have a better understanding of children’s anxiety than we have ever had before, and there are ways to help our children wrestle it into submission.
What is an anxiety disorder?
Essentially, it’s any worry that’s out of control. But adults, including specialists, teachers and doctors, often misread children’s anxiety as a learning disorder, depression or attention deficit hyperactivity disorder (ADHD). A study published in the Journal of the American Academy of Child and Adolescent Psychiatry in October 2010 identified anxiety as the most common adolescent mental disorder, with more than 30 percent of the 10,000 adolescents surveyed meeting diagnostic criteria. (Nineteen percent had experienced behaviour disorders; 14 percent had experienced mood disorders.) Children with anxiety can appear oppositional or irritable, because they are so distracted by worries. They can be explosive, moody or tearful.
Here’s what anxiety can look like. Jack, 10, is a sensitive child attending a French first-language school in Kitchener, Ont. Recently, private assessments confirmed he is gifted. Last year, his mom, a teacher, celebrated the final day of school before the summer break. But her son couldn’t. He furrowed his brow, started wringing his hands, and hunched his shoulders. When she asked why he wasn’t excited about summer, he answered, “In two months I still have to come back.”
Meghan is a mother of seven-year-old twins. Her son has autism, and she’s seeking an anxiety disorder diagnosis for her daughter, who finds change stressful, has trouble getting to sleep, and has an intense need to know what to expect next. After a change in a daily routine — like a rescheduled, midday doctor’s appointment — her daughter peppers her with questions. “So what time are you coming again? When is that? What if I’m in gym class? What if I’m at recess? How will you find me then? What if the car breaks down? What if we get out early? What if you forget?” Meghan says parenting her daughter requires extreme patience. “I have to sit down with her and address each and every one of her concerns. It could be two or three questions, or it could take 45 minutes. You never know.”
Nine-year-old Jasmine has stomach aches every day before school starts. She tells her mom that her head often hurts, too. She can’t bring herself to eat lunch in front of the other children, and although she’s a straight-A student, she never raises her hand to speak in class. If she is called on by the teacher, her heart beats too fast, she gets knots in her stomach, her face flushes, her hands sweat, and she thinks she will faint. Her mother fields calls from the school secretary every week, reporting that her daughter is sick and wants to go home. But Jasmine never has a temperature and nothing irregular shows up in checkups or on X-rays.
Lynn Miller, president of the Anxiety Disorders Association of Canada, and an associate professor of educational and counselling psychology at the University of British Columbia, says it’s possible to find children who have an anxiety disorder as young as age four. “These children are often very intuitive, very sensitive and clever,” she says. “Most are also people pleasers. ” Like both Jasmine and Payton, Miller says the youngest children also frequently experience anxiety as tummy aches.
“It’s a typical response to a perceived threat,” she explains. This is rooted in biology and survival skills: An anxious feeling triggers the stomach to respond physically, making a child feel as if they need to vomit or defecate. Their bodies respond as if in survival mode.
Of course, a healthy dose of anxiety is normal. If we never felt any anxiety, we might not achieve things such as running a marathon, acing a test or delivering a dynamite presentation. Increased adrenaline can propel your healthy anxiety into a gold medal performance. But adrenaline in the bloodstream also causes the body to release cortisol. (Both adrenaline and cortisol are crucial to the fight-or-flight response.) Cortisol affects neurotransmitters in the brain, which are used by brain cells to carry information, and the disruption may cause confused thinking or disorganized behaviours. In children, anxiety that interferes with a child’s everyday living in one of the three domains — at school, at home or with friends — is a disorder needing treatment. The day Payton hid in her closet to avoid going to school was, to us, a clear signal she needed more help.
How to treat it
The key to helping a child thrive is early intervention. After an anxiety disorder diagnosis, Miller says even very young children can participate in their own treatment. When Payton was first diagnosed at age six, we tried multiple approaches. Art therapy and play therapy each had a turn, but they seemed limited. When we inquired about cognitive behavioural therapy (or CBT), a therapy aimed at teaching a patient how to change behaviour patterns, the standard reply was that it couldn’t be used before age 10 or 11. Miller disagrees, and recommends CBT as the first line of treatment — it can be adapted to work for patients as young as four. The Canadian Psychiatric Association and the Canadian Medical Association also support CBT as the first course of action.
Relaxation techniques, meditation, deep breathing and calm music at various times throughout the day can also help ease tension. Having a clear road map or blueprint of the day can help anxious children feel less stressed. For visual learners, it may be in the form of a pictogram schedule; for others, it is simply a verbal rundown of what to expect. With Payton, we have also used deep breathing techniques and relaxation CDs produced by Lori Lite, a mom and owner of Stress Free Kids. Her company makes books, lesson plans and CDs with soothing music, which my daughter listens to at bedtime. It helps her shut out the noises in her room and the worries racing in her head. Lite’s deep breathing techniques have helped both of our kids, and we use them at any time in the day when they’re feeling or acting overstimulated. (The technique is simple: Put your hand on your tummy and feel it going in and out, while breathing through the nose.)
Positive statements are another one of Lite’s favourite go-to tools. “Positive self-talk can reduce anxiety in minutes. Negative self-talk can increase it just as fast,” she says. (Negative self-talk is the inner critic in a child’s head: “I’m stupid. I can’t do this. I stink at math.”) Positive mantras developed by, or with, the child and repeated throughout the day can help override worry. It can be as simple as: “I can do math. I am good at it.” I’ve found it helps to get to know what triggers my daughter’s anxious thoughts.
Changes in routine, school work that isn’t perfect, airports, emergency drills at school — these all stress her out. Payton is also not a child who can function overtired or hungry. Some other treatments for children’s anxiety disorders include controlled exposure (which is repeated, gradual and planned exposure to the thing or event that the child is anxious about), and improving sleep-management skills with meditation or yoga.
Medication may be necessary if nothing else is breaking the pattern of anxious behaviour. After several years of trying to help Payton tackle her “worry bullies,” the day she hid in the closet I knew we had to start talking about medication. Our family doctor referred us to a child psychiatrist, who ran a series of assessments to determine a diagnosis. (A psychologist can also assess for anxiety, but they can’t prescribe medication.) After Payton told the psychiatrist she felt worried at least 45 percent of her day, and described the panic attacks she had every day before school, we decided on a combination of continued CBT, talk therapy and medication. A brief course of an antidepressant such as Prozac or Luvox is safe for children, we learned.
In families with an anxious child, parents may feel as if they have to walk on eggshells. (I sometimes liken the experience to living with a pint-sized powder keg.) But that approach doesn’t do an anxious child any good; anxiety can feed itself if you dwell on it or give it too much attention.
Anxiety often runs in families, so if you suspect your child may be suffering from it, it may be a good time to assess your own anxiety levels and coping techniques. Other family members may need management strategies. In my family, our children are both adopted, and neither my husband nor I have anxiety disorders. (Most experts and doctors we’ve seen surmise that Payton’s anxiety is something she inherited from her biological family.)
This year, Payton is 11, and in grade six. She’s a typical tween, and happy about school again. In the spring, our family doctor will start to stagger her off the medicine to see if she just needed a short-term bridge. For a few years, a part of my daughter seemed broken, and we tried to treat it a million different ways. None seemed to work for very long. But now, we’re seeing her make friends and her confidence is flourishing. I know generalized anxiety disorder will always be in Payton’s life, but it no longer holds her prisoner.
This story appeared in our November 2012 issue with the headline “Worried sick” (p.40). Join our community message boards to talk about Kids’ Health with other parents!