The Bipolar Child and Anxiety

27 Mar

 

Anxiety is often the first symptom that is clearly identified in children who have bipolar illness. It might be intense separation anxiety, OCD type behaviors, or frightening dreams, to name a few possible symptoms.  But in bipolar disorder the mood instability adds an additional layer of complexity and intensity. This is not an easy diagnosis to make.  There is controversy surrounding this diagnosis, which keeps company with other disorders, to add to the confusion. The term bipolar refers to a disruption in the regulation of moods, so that rather than maintaining a relative steady state, the child swings between periods of depression and periods of mania or elation. And sometimes children are in a mixed state that contains elements of depression and mania, where a pronounced irritability might be seen. Suicidal ideation and hypersexuality can also be part of the picture.  This condition is viewed as primarily a biologically based disorder with a strong genetic component.

There are some distinctive features in the experience of anxiety for a child who has to struggle with a mood disorder. What powers the child’s   experience of anxiety is the sheer intensity with which they experience their moods; they seem to have no serviceable “ brakes”, or feel that there is any control over mood. It is the internal experience of intensely fluctuating moods that produces the feeling of danger and lack of safety. But there is more. This intensity also comes with disturbing images. Many children with bipolar illness have truly horrendous nightmares. While all children will have a nightmare on occasion, they usually wake up before the robber enters the room.  For a bipolar child, however, it doesn’t stop there. The dream unfolds in the worst graphic detail. And the vividness of the dream may continue to preoccupy the child during the day, and then he/she may dread going to bed lest another similar dream occurs. The intensity of moods can create hallucinations and other impairments in reality testing.   A good description of having bipolar disorder as a child can be found in Intense Minds: Through the Eyes of Young People with Bipolar Disorder by Tracy Anglada, whom I also interviewed for my iTunes podcast,  “Your Anxious Child: 5 Minute Solutions”.

Although the experience of anxiety is pervasive in bipolar disorder, the treatment priorities are different from the standard treatment of anxiety. In the standard treatment of anxiety, priority is placed, as in cognitive behavior therapy, on facing the fear and decreasing avoidance. Medication plays a secondary role in treatment of the more standard anxiety disorders, turning down the intensity of anxiety when necessary so that the child can participate in therapy.  In bipolar disorder, medication management of moods is the first priority of treatment, and this is a situation where a child psychiatrist is the key player. Psychological interventions will center more on helping the child maintain contact with reality and creating a sense of safety. These are children who may, while awake or asleep, see scary images that are not there.  Thus, stabilization is often the first priority. This is not to say that we don’t help the child with bipolar disorder learn that he can be upstairs without a parent or talk back to that scary image in the closet or draw that scary dream and potentially change it. But we need a certain stability in moods as a platform to tackle these various worries. These children really benefit from a team approach that can address their diverse needs. They often have pronounced sensory issues which may benefit from sensory-integration therapy. There may be problems in executive functioning that require attention in school. Bipolar disorder is a complex disorder that requires a careful diagnosis, and while anxiety is very prevalent it is not the core feature.

Performance Anxiety

29 Dec

Your aspiring athlete or musician has become increasingly anxious before some competition or performance. If you have an anxious child, this is not necessarily a surprising turn of events. It is the anxious brain at work, always ready to imagine the worst case scenario. And yet, the activities your child is involved in can be so important in developing a sense of competence, learning healthy habits, developing self-discipline, and making friends. So what is the thing to do when your child develops performance anxiety? There are four considerations.

First, there is a question of whether adults have been creating the problem. Parents can be guilty of living vicariously through their children and placing way too much interest in the outcome of an event. Children want to please their parents, so they are especially vulnerable to this pressure. Coaches all too frequently operate under the mistaken belief that being critical and tough fosters competitive excellence. A good coach certainly brings out the best in his or her team, but the prerequisite is creating a climate in which it is safe to make mistakes.  Only when children feel safe to make mistakes can they get the feedback that will enable them to improve and reach their potential.  Unfortunately, many coaches believe that belittling the athlete will motivate him or her, when in fact it only leads to discouragement and anxiety.

Second, for any number of reasons, your child may be overly focused on winning. This is understandable, but counter-productive. In part, one of the benefits in pursuing a sport or musical skill is that it teaches the child focus and concentration skills. Along the way, your child has to learn to tolerate the tension that is inherent in most performance situations. Breathing and visualization skills can be very helpful to children in learning to focus on the here and now of doing their sport, rather than getting ahead of themselves and thinking about winning.

Third, if the performance problem is chronic in nature, consider the possibility that it is the product of an injury, such as falling off a balance beam, or an adverse event such as being criticized by a coach in front of the entire team. A child may have recovered from the physical part of the injury, but psychologically he may still be affected. Trauma occurs when you can’t protect yourself–you fall off the balance beam and you can’t stop your fall, or the coach is berating you and you don’t feel you can say anything. While your child may be able to put this problem into words, she is basically not feeling safe in her performance-related activity. When the more psychological aspects of this injury or trauma is addressed, the problem can be resolved.

Finally, it may be that what appears to be performance anxiety may actually be the manifestation of another problem. A child with separation anxiety might be afraid to participate in a sport because it involves being away from a parent. OCD can also interfere with a performance when obsessions get attached to some aspect of the activity, e.g., “I can’t play golf because my clubs are dirty.” The problem, again, is not the performance, but rather another form of anxiety that gets attached to the activity. Part of the solution in both of these situations is helping the child view these activities as so important and valuable that it is worthwhile to struggle through the discomfort. Having compelling goal is very important in dealing with all forms of anxiety.

The skills learned in dealing with the performance anxiety your child has about participating in a swim meet or a chorus production can be invaluable lessons which will help in all aspects of life.

(For more information on Performance issues see my interview with Dr. Alan Goldberg on my iTunes podcast “Your Anxious Child: 5 minute solutions”)

copyright@Edward H. Plimpton, PhD

Oh she will be fine

20 Dec

“Oh She will be fine”  Edward H. Plimpton, PhD

 

Recently, you expressed a concern about your anxious child to a friend, or perhaps a pediatrician or teacher, and were told “Oh, she will be fine, it is probably just a phase”. Perhaps. A lot of parenting involves learning what to fuss over and what to let go.  Mark Twain once said “I’ve had a lot of worries in my life, most of which never happened”.  A wise statement, implicit in the well-intentioned reassurances from friends and professionals. It is invaluable to draw upon the experience of others who know how certain behaviors and feelings can change and unfold over time. It is not unusual for a child to tearfully and bitterly protest about being dropped off at daycare or school, and then to have the teacher report that she was fully and happily engaged ten minutes later. Experience can teach us not to be too reactive to the present moment, especially since excessive parental reactions foster anxiety and other problems in children.  And children can be incredibly resilient under difficult circumstances in seeking out what they need to prosper and thrive. So there is a lot of truth to the simple statement that “she will be fine”.

“She will be fine”, however, can also be an empty and misleading reassurance. Many a parent has sensed that something was not quite right, only to be dismissed with “it is just a phase,” with the underlying message that it is simply the concern of a nervous parent. But life is uncertain, there is no crystal ball, and parenting is definitely an exercise in tolerating uncertainty. Sometimes “she will be fine” is the response of someone who doesn’t have the knowledge to say anything else, or who doesn’t want to share the uncertainty and doubt. It is, after all, quite difficult to tolerate being in a state of uncertainty. But there is good reason not to dismiss your concerns about your child, whom you know better than anyone else. It may seem obvious, but the reason you know your child so well is that you have a sense of her behavior over time, and her daily rhythms, and the way that she is unique. Any one snapshot of your child, say in school or in the doctor’s office, is only a partial view. ADHD, for instance, is not properly diagnosed by just observing a child in a doctor’s office, but rather by looking at her in several different settings.  Anxious children are well known to keep a low profile in school and in other settings outside of the home.  They can keep it together in school, only to fall apart when they are safe with a parent. The disparity in terms of how your child is viewed does not mean that either you or the friendly commentator is incorrect–you just have access to different time samples. And having a sense of a child across time puts a parent in a privileged position.  So your knowledge of your child’s behavior over time is an invaluable piece of information which should not be discounted.

When faced with a strong intuition that something is not right, one thing a parent can do is to keep asking questions and  sharing experience. This may help clarify the nature of your concern and help sort out what is just a phase and what is a roadblock to your child’s development. Parenting can be complicated, and there is a lot of sorting out to be done, which is why we talk about our kids so much. As the famous pediatrician Benjamin Spock said many years ago, “Trust yourself. You know more than you think you do.”

copyright@Edward H. Plimpton, PhD

Why Doesn’t My Child Want to Get Help?

21 Aug

Your home is nice, but sometimes you would like to go out for a change of scenery, perhaps a game of mini-golf or dinner at a family oriented restaurant. Is that really asking too much? Well actually, yes, says your anxious child, home is really better. And realizing how much your child’s anxiety is affecting the entire family, limiting positive family activities, you decide to get help. But there is one problem: your child doesn’t want any help and indicates in no uncertain terms that it is not happening. What to do? The situation is getting urgent and your child won’t budge. Here are three items for your consideration.

First, it may be that you have a child whose first response to anything new is an emphatic “no” or perhaps a dramatic scream of bloody murder–it doesn’t matter whether it is mini-golf or a scheduled visit to a therapist. But given some time, he will come around when he senses you are not going to give up. So time and a clear parental directive is what is needed for the child to wrap his head around this new turn of events. Even though an anxious child’s first reaction to a suggestion to do something different might always be a “no”,  often she can end up going to the birthday party and having fun. But sometimes  that doesn’t happen, so of course, we also want to take the time to see if there are some specific concerns we didn’t know about.

Second, the problem may be that it just feels too hard to talk about those anxious feelings. For some children the concern may be that talking about their fears will make them more real or make them come true. This may be a reflection of the magical thinking that can color children’s mental processes. Saying something out loud, they fear, will somehow make the fear more likely to happen. Even adults will sometimes say “don’t say that,” as if silence offers some protection. Another way in which it may be hard to tolerate talking about worries is that some children are extremely self-conscious and tolerating any attention is rather painful.  Or it may be that your child is just very emotionally reactive for any number of reasons, and tolerating any feelings is very hard. And for this type of child, any new situation needs to be introduced slowly so they can build their tolerance or capacity to deal with it.

Third, if your child shows little motivation to change or to deal with an obvious problem, it may be that you have been too helpful and accommodating. It is only natural as a parent, when your child is in distress, to want to provide comfort and reassurance. And if your child is screaming bloody murder, it may feel a lot easier just to give in to whatever is demanded.  However, if things are too easy and comfortable at home, the anxious avoidance is powerfully reinforced. And then there is little incentive for the child to get out of her comfort zone and challenge herself. Accommodation to anxious behavior can take many forms, from indulging a child’s need for  reassurance,  to buying excessive amounts of soap for a child with germ concerns, or not making them go to school. And because it runs against our natural inclination not to provide comfort to our distressed children, most parents of anxious children have done some reinforcing of anxiety by being overly helpful. However, that does not mean giving free rein to the feelings of impatience or irritation that having an anxious child can create. Yes it is pretty frustrating for your child to have a temper tantrum just because you need to go to a clothing store. But that doesn’t mean that a get tough policy (“we have had enough of your games!”) is appropriate or effective. In fact it will probably make things worse because in the potential power struggle that follows, the real point of mastering anxiety gets lost in the midst of a parent-child battle of wills. Rather, think in incremental terms of how to decrease your accommodating actions, so that the child can adapt slowly, not losing sight of the purpose of this change, which is to help him/her be less limited by anxiety.

“Just scared but can’t say why”

9 Aug

It is generally easier to help your child when he/she can clearly identify what is scary. A monster under the bed is an easier problem to contend with than a nonspecific “I am afraid”.  But there are occasions when children can’t identify why they are scared, or if they do, it may feel like they are making up an explanation. Sometimes we haven’t asked the right question or the child doesn’t feel safe enough to spill the beans. But there is another layer to this problem: the experiences of anxiety and fear are products of the brain’s alarm system, designed to keep us safe and alert to danger. When we consider how the alarm system can malfunction in two different ways, we may get a clue as why your child can’t pinpoint the reason for his/her concern.

The first way is that there may be a problem in the wiring and software of the alarm system, so that it generates too many false alarms or overstates the magnitude of the threat. OCD, for instance, is a problem with the junk mail filter or “anti-virus” program in the brain. The junk mail filter isn’t doing its job and is letting anxious thoughts clutter the mind. Educating children about junk mail or “not believing everything you think” can be an extremely helpful first step.

The second way the alarm system can malfunction is by getting overloaded. Just like any other system, our alarm system has a limit to what it can process, and this is what happens with trauma. When the alarm system can successfully implement a self-protective response of fight or flight, no trauma results because it has done its job. But there are a variety of circumstances in which the alarm system gets overloaded and the system shuts down. It can’t run away or put up a fight so it just  freezes.  What comes out are all the symptoms we associate with PTSD: flashbacks, avoiding any reminders of the trauma, and increased anxiety and emotional arousal. Traumatic stressors can include war, natural disasters, car crashes, medical procedures, and interpersonal violence, to name a few.   When it comes to children,  this type of stress actively interferes with nervous system development, which is actually a 25- year construction process, according to contemporary neuroscientists.

A central brain structure in anxiety and fear is the amygdala. It can form nonverbal, essentially unconscious memories of frightening events and it is operational at birth. The part of our brain that helps make conscious recollection, the hippocampus, is a work in progress during the first two years of life, which is why we don’t have clear memories of being babies. However, the amygdala can encode traumatic events on a nonverbal level: in one study, boys who were circumcised without anesthesia were shown to be more reactive to vaccination shots at 4-6months compared to boys who received this procedure with anesthesia. Although there is no conscious recollection, the reactivity of the infants who did not receive the anesthesia suggests that their bodies  had learned something from the experience and that the sensations wer remembered. While the research is clear that chronic stress and trauma can make the nervous system more reactive and anxious, on a more practical level, it is a hard thing to prove. Sometimes, a parent can say that their child was never the same after a particular incident, such as illness or accident, or that the mother knows she went through a horrific experience while pregnant or giving birth, and it certainly affected her. But the science is clear that nonverbal memories can be formed. So we are making some informed speculation based on neuroscience, trauma research and the clear inability to come up with an alternative explanation.  It may be that when your child can’t say why he or she is afraid, what you are seeing is the long shadow of something frightening that happened long ago to a tiny brain that got overwhelmed. Therapeutic interventions that are more based in becoming aware of body sensation, such as Somatic Experiencing Therapy, EMDR and Sensori-Motor Psychotherapy, can be very helpful with this kind of trauma.

copyright@edward plimpton

The Kid Figures It Out

24 Sep

Edward H. Plimpton, PhD Your Anxious Child: Emails to Parents

The Kid Figures it Out

Amid the despair and discouragement concerning whether your anxious child will actually get better, there is the potential for something amazing to be overlooked. At all levels of our body we have the capacity and tendency to self-heal. A Band-Aid after all only supports the body healing from a cut or scrape; the immune system does the job. And well-known artists such as Steven Spielberg have said that their art is a way that they master the fear they had as a child. But guess what? If we are not watching we can miss a child inventing their own cure for anxiety all on their own.

A three-year-old boy enters a daycare full of enthusiasm only to discover that one of  the popular books in the classroom is Going on a Bear Hunt. This is a rhyming, interactive book in which a family goes on a “bear hunt” only to run away quickly at the first hint of the bear.  He had overheard his older sister’s enjoyment of this book at home, but at his two-plus years it was just too scary for him. But there was that dreaded  book again, and the problem was that all of the other children were enjoying it and he didn’t want to be left out. Over the next several months, in small steps, he gradually got over his fear without any direct help from adults.  At first, whenever the book was being read, he would leave the room in a hurry. This lasted for several weeks. Then he began peeking around the corner and listening until the family got close to the bear. Another month or two. Then he began he nuzzle up to the adult who was reading the book and then exit when it got to the scary part. Another month or so. Then he requested a blanket so he could hear about the bear hiding in his cave. Then he pretended to be the bear and chased the other children in the classroom at the end of the book. And his pleasure at mastering his fear was evident, a process that unfolded gently and gradually over several months, guided by his own internal psychological “immune” system. A therapist could not have devised a better plan.

Related to the value of taking incremental steps in dealing with anxiety is developing the capacity to tolerate tension. A high school girl had struggled with separation anxiety all of her life, and it had interfered with her having adventures during the summer as well getting together with her friends. But she explained that she has begun to really enjoy the tension and suspense of Alfred Hitchcock movies. She made it clear that she did not like the  horror movies or gory movies  that some of her peers are drawn to, but the Hitchock films involved her in the feeling of suspense.  On her own, she has devised a program to increase her capacity to tolerate tension and anxiety. This improvised movie therapy exposed her to emotional tension and anxiety in a way which she could manage and feel empowered by. She was learning to face her fear.

An eighth grader who was voracious reader explained that she had seen a Disney movie when she was in second grade and it gave her nightmares. But she found as her parents were reading to her at night, her interest in the story made the anxiety disappear. She quickly became an avid reader. Now her top ten  favorite books would easily match that of any adult. She had found a way, again on her own, to focus her attention in an extremely productive manner.

These children invented a cure for their anxiety. They did need a safe and supportive environment for this natural capacity to emerge. But given some minimal support, a natural healing process took place. Perhaps, you can catch your child inventing his/her own solutions to mastering those worries.

copyright@Edward H. Plimpton, PhD

Obsessive-Compulsive Disorder

27 Aug

    From Your Anxious Child: Emails to Parents by Edward H. Plimpton, PhD                                    

                                              Obsessive-Compulsive Disorder

The condition commonly called OCD is not the same as being “obsessed” with football, gardening or “Dancing with the Stars”. To have a strong, consuming interest is not the same as having OCD. In OCD there is an intense preoccupation, which causes considerable distress, and which the individual seeks to get rid of through a series of actions which are known as rituals.  Because of the excessive and often time consuming nature of these rituals, or compulsions, and the emotional distress involved, they begin to interfere with everyday life. Perhaps the most well-known OCD ritual is hand washing, which can be carried out to such an extreme that the hands become red and chafed. But rituals can also take on the form of questions which are repetitive such as, “Are you sure you know the way home?” or, “Are you sure I don’t have cancer?” in which no amount of reassurance seems to put the matter to rest. And with some rituals there is a clear superstitious or magical element, as when a child might tap his foot a certain number of times.  Some rituals do not involve an overt behavior but rather consist of having to have a “good thought”  in order to undo a” bad thought.”  There are several sources for the distress that this condition causes. First, the awareness that the rituals do not make sense and that other people don’t share their concerns. Second, with intrusive thoughts, the child might feel, “If  I am having these bad thoughts I must be a bad person.” Third, the intense discomfort that occurs from the obsessions and consequently the difficulty in not acting on them. The rituals really do provide some momentary relief and consequently become quite compelling. The unfortunate problem is that the rituals begin to act like an addiction so that the more you do them the more you have to do them.

There are a number of good books for parents on this topic: Tamar Chansky  Freeing Your Child From Obsessive-Compulsive Disorder, John March with Christine Benton Talking Back to OCD, and Dawn Huebner What To Do When Your Brain Gets Stuck: A Kid’s Guide to Overcoming OCD,  to name just a few.  And don’t get discouraged if your child appears to be dealing with OCD. It is actually one of the more treatable anxiety disorders providing the therapist is trained in cognitive behavior therapy using exposure and response prevention.  There is some emerging evidence that children who receive treatment for OCD may not necessarily retain their symptoms into adulthood, or at least the severity will be greatly diminished.  The reason to take action is simple: we don’t want the child to accumulate the hours of practicing the OCD habits that will then create an entrenched way of doing business, and early intervention can interrupt the development of this habit.  Additionally, don’t be surprised to discover that some of your best intentioned efforts to help your child, while they may have provided short term relief, actually made the problem worse over time. Our default reaction as parents is to provide comfort and reassurance when there is distress, but in the landscape of OCD such reassurance is not helpful. This is not to say that you should stop being empathic and caring with your child, but rather that there are skills that need to be learned. It is not straight forward, but then again neither is OCD.

Follow

Get every new post delivered to your Inbox.

Join 132 other followers