 | ||
 |
- | Centers of Excellence |
|
||
|
- | Clinical Services |
|
||
|
- | Clinical Specialties |
|
||
|
- | Request an Appointment |
|
||
Summer is winding down, it’s time to start shopping for fall clothes, and the first day of school is right around the corner. For most children that thought is enough to cause a flash of anxiety. For some children, the response is much more than a flash. Child psychiatrist Margo Thienemann, MD, directs the anxiety clinic at Lucile Packard Children's Hospital. She and Phoebe Moore, PhD, are currently conducting two studies that focus on childhood anxiety. According to current estimates, one in every 10 children in the Bay Area suffers from an anxiety disorder, a psychiatric diagnosis marked by an inordinate fear of ordinary events. Here, Dr. Thienemann talks about children and back-to-school anxiety. Question quick links: Question: Are you seeing more children with anxiety? Dr. Thienemann: We are seeing more children who are having many kinds of anxiety. Since we announced the study, a lot of school-refusing children have been coming in. Which makes sense, as summer is closing, and people begin thinking about it. It's a very troubling problem. We had one school call about a child who’s been out of school for a year. We've seen children whose parents have had to quit their jobs. It causes real hardship on a family. Many of these kids are excessively anxious about taking tests, speaking out loud in class or being bullied. Before we assume that their fears are exaggerated, we always have to make sure we're not sending them into a dangerous situation -- that in fact they are not being bullied. Back to top Q: What types of anxiety are common in children who won’t go to school? Dr. Thienemann: About a third have social anxiety, which means they're afraid of social humiliation or embarrassment. These are the kids who are afraid to stand up and write on the board in front of other kids, afraid to speak out or draw any attention to themselves. A third have separation anxiety; they're afraid to leave their parents for fear something will happen to themselves or to their parents. The rest have a kind of generalized anxiety, usually with physical complaints. Most often, they will present to their pediatrician or family doctor with stomachaches or headaches. There's also panic disorder, which involves physical symptoms that frighten the kids who get it. You feel you can’t breathe, your heart beats hard and fast, you get shaky, you get sweaty, you have to go to the bathroom and you think you're going crazy. But we almost never see that until a child reaches puberty. Back to top Q: Is anxiety a learned response? Or is it something hardwired at birth? Dr. Thienemann: There’s a temperament type called behaviorally inhibited temperament. These children are slow to warm up to new circumstances, and when they’re faced with something new they freeze or withdraw. They have higher resting heart rates and a higher blood pressure response to stress. Most kids with this problem don't become anxious, but it does increase the risk toward anxiety. Back to top Q: As babies, are they unusually shy? Dr. Thienemann: Yes. Newborn nursery nurses can pick them out. This behavioral inhibition seems to be a durable trait for years – at least through the teenage years. It doesn't destine you to be anxious, but it’s one risk factor. Another risk factor is genetics. Anxiety runs in families, and twin studies bear that out. If one identical twin is anxious, the other is very likely to be anxious. With fraternal twins, it's also likely but a little less so. Having a depressed parent also places children at increased risk for having an anxiety disorder. Back to top Q: Is it also possible that an anxious parent will model anxious behavior? Dr. Thienemann: Yes. We learn a lot about the world through our parents, and if they are telling us to be afraid or they're acting afraid we’re going to learn that. But children can also train their parents to be overprotective. When you are raising an anxious child you treat that child differently. You don't say, `Let's go to the circus!' or `Let's go to the beach!' You curb your activities. You don’t expose them to things that may be stressful but ultimately help you grow. Back to top Q: What's the difference between normal shyness and an anxiety disorder? Dr. Thienemann: It's the degree. For something to be a disorder, it has to interfere with normal activity. If your shyness keeps you from doing things you like to do or if you can only do them with terrible discomfort, that's a problem. The difference between childhood fears and phobias is a similar example. It's very common for kids to have transitory fears. But once fear interferes with life – when a child won't go on the playground due to a fear of bees -- that's a problem. Back to top Q: Are girls more prone than boys? Dr. Thienemann: Much more prone, at a rate of two to one -- which is the same as for depression. And girls who have social anxiety disorder are at a higher risk of getting pregnant, because they're not assertive, they aren't practiced in the social skills. Growing up, you have to learn to negotiate a relationship, to learn to say no, I don’t want to do that, I’m not going to drink right now. Anxious girls and boys are also more at risk of substance abuse; they use alcohol or other drugs as a way to feel less nervous in social situations. Back to top Q: How does a parent identify a problem when their son or daughter may have been shy throughout life? Dr. Thienemann: You typically see a lot of anxiety when kids enter school or change schools. It's a different atmosphere with many more non-family interactions. In primary grades, in a classroom, anxious children are no longer accommodated the way they were at home. In middle school, you no longer have just one or two teachers but five or six. In the junior year of high school, some parents tell their kids, `This year really counts! Your whole life depends on it.' Well, that would be really scary -- if your whole life depended on just one year. I think problems get noticed when kids enter school, because they have to function in a less flexible environment than home. They’re no longer in a situation where they're going to be accommodated all the time, the way that their family has consciously or unconsciously decided to do. Back to top Q: What's the best approach for parents to take? Dr. Thienemann: If parents have a catastrophic take on life or they’re over-controlling, that doesn't help. It also doesn't help to criticize. You’ve got to encourage your child to take reasonable risks. I try to model for the parents, tailoring my expectations for small successes at a time. For example, I had one little girl as a patient who had selective mutism, which meant she would only speak when she was alone with her mother. She couldn't laugh or sneeze or even cough in front of anybody else. I had a pack of M&M’s, and every time she was able to clap, then stamp her foot and then blow a little horn, I gave her a candy. Trying things that are a little more frightening each trial is called graded exposure. This girl was able to do it with the positive reinforcement or M & M’s and our encouragement. You start with something little and gradually desensitize yourself to things that are scary. Back to top Q: You have two childhood anxiety studies underway. Where does your research fit in to this equation? Dr. Thienemann: The first study is a 12-week group treatment where parents will meet with a therapist for two hours a week, be assigned some reading and work with their kids. The second study, which is headed by Dr. Moore, will track anxious parents' and children's heart rates, breathing, temperature and galvanic skin response as they interact during various conversations. Back to top Q: Why did you undertake these studies? Dr. Thienemann: One reason is that parents spend the most time with their kids. Another reason is that there are not enough people able to do therapy with anxious children. We’re hoping to expand our ability to help children with this problem. I love my job. I like the opportunity to get in there early, hoping to change the course of people's lives. I feel very luck that I'm practicing medicine at this time and place and that we have effective psychotherapies and medications. Back to top Q: A couple months ago, the Food and Drug Administration issued a warning that Paxil, a drug commonly prescribed for anxiety and depression, not be used in children and adolescents. This warning came after reports in Dr. Thienemann: Many kids have been prescribed Paxil - usually for anxiety, depression, or obsessive compulsive disorder (OCD). And we're discussing these warnings with everyone who comes to the clinic. Most of my patients have decided to shift to something else. Paxil is the least comfortable of the selective serotonin reuptake inhibitors (SSRIs) medicine to discontinue. When people stop it abruptly or miss doses, it may make some people throw up, feel sick and have electrical shock feelings through their body. Some people have reported suicidal thoughts after missing doses. It's also the most likely of the selective serotonin reuptake inhibitors (SSRIs) to cause weight gain and sleepiness. Studies have been done showing that some of the other SSRIs - Zoloft, Prozac, fluvoxamine and Anafranil - are safe and effective for OCD or anxiety disorders. Back to top Q: Do you ever use therapy by itself to treat children with anxiety disorder? Dr. Thienemann: My preference is to use therapy alone. Controlled studies show that 70 percent of children with anxiety disorders are much improved after 14 weeks of cognitive behavior therapy (CBT). We often use CBT and medication together. Medicine may allow you to do the graded exposure necessary to get rid of the anxiety. Back to top Q: That's a tremendous success rate. How's it done? Dr. Thienemann. First, we work with children early so they can identify their thoughts: Is this a realistic thought or an anxiety thought? Okay, I keep thinking the plane is going to crash, but I know this is my anxiety thought because planes almost never crash. Next, we work on their behaviors, usually unnecessary avoidance. If they can learn how to expose themselves to what they’re afraid of, they can expand their capacity to do things. If you can think like that, you can get over your anxiety. And that leaves you way ahead of the game. Lucile Packard Children's Hospital is located in Palo Alto, adjacent to Stanford University Hospital, approximately 20 miles north of San Jose, CA and 40 miles south of San Francisco.
Lucile Packard Children's Hospital Copyright 2008 Lucile Packard Children's Hospital. All rights reserved. |
|||