Archive | July, 2013

PANDAS where strep infection can be a factor

14 Jul

PANDAS

 

Did your child develop anxiety symptoms, motor tics or unusual physical movements quite suddenly? Even if you might be able to point to some change or event that might have triggered the anxiety, are you still left with a feeling that it doesn’t quite make sense?

 

The culprit might be PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection). In this condition, the body marshals its soldiers — the antibodies — to fight infection, but also engages in “friendly fire,” which is what happens in an autoimmune disorder. The antibodies attack the infection, but also attack the basal ganglia, a region of the brain involved in, among other things, movement. As a result, your child may suddenly develop fears, phobias, OCD-type behaviors or motor tics. When talking to your pediatrician about these symptoms, it is important to emphasize the sudden onset, which can differentiate PANDAS from more ongoing anxiety disorders. Ask your pediatrician if it makes sense to have your child tested for Group A strep. This test is useful because strep is a complicated creature, and can be present even when a child shows no obvious symptoms of infection.

 

There are controversies concerning PANDAS, which Lisa Belkin discusses in her article, “Can You Catch Obsessive-Compulsive Disorder?” (New York Times Magazine, May 22, 2005: pages 64-69). But frankly, clinicians who work with children who have OCD have no doubts about PANDAS as a real phenomenon. Beth Alison Maloney, a parent whose son struggled with a severe case of PANDAS, has written a very compelling account in her book, Saving Sammy: Curing the Boy Who Caught OCD. She provides a detailed reference list for those who would like to learn more about PANDAS, which is a very active area of research that generates new information every year. You can also Google Susan Swedo, MD, who is one of the leading authorities on PANDAS.

Asperger’s and Anxiety

14 Jul

Asperger’s and Anxiety
When you have a child who has difficulty making sense of social behavior or reading the nonverbal cues that make up so much of social communication, then that child is more likely to become anxious. It is hard to feel confident or relaxed if you are constantly surprised by the reactions of others. When you have a child who tends to gets overfocused on certain topics and is relatively inflexible in trying any new or any departures from a set routine, this child will have more worries. When a child has pronounced sensory sensitivities or is just more reactive, that child will be more anxious. The sympathetic nervous system, in such children is overactive, while the “keep it calm system,” the parasympathetic system, is underactive. Too much stimulation becomes the straw that breaks the camel’s back. These are some of the symptoms of a child who could receive a diagnosis of Asperger’s, but many children share these features, if not the entire picture. And as a group, a very high percentage of them will end up on medication to help them modulate their intense reactions.
For such children, there is probably no one single intervention that is going to make them less anxious, other than just removing the stress, as when parents decide to homeschool their child because there are so many aspects of going to school that are problematic and overwhelming. But this option isn’t always desirable or practical for most families. So it remains to look at the entire life of the child and see where she is being successful and where she is struggling.
First, anxious children are revved up for an “emergency” but with no place to go with their energy, so having exercise as a part of their lives is important. But for most of these children, with their difficulty reading social cues, team sports are not a viable option. More individually oriented activities such as swimming or martial arts may be better suited to their temperaments. But, it not as simple as just signing them up for swimming classes. These children can often be rather perfectionistic and if something does not come right away, you will get comments such as “this is boring,” the code phrase that should never be accepted at face value. Nevertheless, some form of exercise or activity is critical to prevent the buildup of emotional tension.
Second, children with Asperger’s have trouble identifying their own feelings — and understanding the feelings of others. With regard to themselves, they may not be able to identify when they are anxious, or they may mislabel their feelings as anxiety when it might reflect something else such as a sense of agitation that comes from not being engaged with a preferred activity. Then with regard to their peers, the problem with reading social cues can exert a cumulative effect as interactions get more complex with age, particularly in middle school. Children are becoming more independent from their parents and turning more toward peers at this age. This is a transition that will be hard for children with Asperger’s to keep up with. Perhaps they get made fun of for their socially mistimed overtures or discourses on their favorite topics, or they may just simply be avoided and ignored. As a result, children may become more socially anxious and less inclined to take chances with others. I wish I could say there are some simple solutions, but I am not aware of them. Instead, I think we need to cast our nets widely, collaborating with organizations such as Asperger’s parent groups, and professionals with interests in this area. We just don’t want these struggles to interfere with these children’s unique strengths being nurtured, and having them sidetracked by disabling emotions.

Fear of Throwing Up

14 Jul

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

 

The Fear of Throwing Up

 

Vomiting has got to make the list of one of the most unpleasant experiences that can happen. Your body is momentarily out of your control and what comes out is just disgusting. Seeing someone else throw up, which happens to children in school, is equally unpleasant and can induce a nauseous feeling that can make you wonder whether you are going to throw up. A fear of throwing up is not uncommon. The folk singer Joan Baez from the 60’s described in her autobiography and more recently, Sara Blakely, the inventor of Spanx, has stated that she has had a fear of throwing up.  For some children, either throwing up or seeing someone throw up can have a traumatizing effect and they will go to great lengths to avoid anything that might give them germs. This fear can be part of many worries a child has or can be a stand alone fear.

 The fact that most people vomit infrequency is not actually a very helpful fact for those struggling with this fear. It certainly deserves to be mentioned, but that fact by itself does little to dislodge the fear. Likewise, the fact that vomiting is relatively unusual also makes it harder to allow experience teach the child that they can survive such an occurrence, however unpleasant it may be. The sense of not being in control and the violent aspect of vomiting all create that dramatic memory of the event that is a feature of psychological trauma. But there is also another powerful factor having to do with the experience of disgust, an emotion has not always been sufficiently appreciated. Disgust is an important self-protective emotion, wired into us from years of evolutions, that protects us from food poisoning and getting too close to something that could make us sick.

So what to do? First, in the moment and aftermath of a vomiting incident, the child needs big time reassurance and comfort. Later, providing some information about the facts of vomiting to your child is important because in the absence clear information, the child will invent their own explanations about what is happening and that will most likely make the situation worse.  However, “the facts” by themselves will not dislodge this powerful fear.  Practical nauseous prevention strategies should be reviewed, so in the car looking down will more likely lead to nausea than picking a spot of the horizon to focus on.  Then look for ways to desensitize this topic by activities such as making fake vomit at home. Just getting used to seeing fake vomit around that you either make or buy from a joke/novelty store can help desensitize this issue.  The two-part sentence referred to elsewhere can help as in “yes it is awful to barf, but you survived” “yes it is disgusting, but your stomach just had to do it”. Because of the very wired in nature of this fear, it can require some patience to deal with it effectively.

 

Medication

14 Jul

Recalculating Part II: Considering Medication

 

The suggestion to put your child on medication may bring an automatic “No way!” to your mind. After all, haven’t we all sat through TV ads about drugs that, judging by the actor’s beatific expression, seem to be miracle cures? And then haven’t we all felt the skepticism creep in as the announcer’s voice speeds up and reels off a series of unpleasant, and even life-threatening, side effects?

 

Most parents are very hesitant to put a child on medication, but there are some factors that might combine to make it a useful option. For instance, in some cases a child’s anxiety limits his ability to go to school, participate in sports or other activities, or participate in therapy that is designed to help him learn to tolerate anxious feelings. Sometimes, the child’s behavior can be seriously disruptive to family life, or even threaten the child’s health, such as when a fear of choking makes him reluctant to eat. I have been involved in cases, such as ones dealing with a child with school anxiety, in which there has been very good collaboration between the school, home and treatment professionals , and it is still not enough because the child is just too distressed and anxious to participate on her own behalf. In these cases, and in others, such as obsessive compulsive disorder, medication has often been quite helpful. Medication can help turn down the volume or intensity of the anxiety so that the hard work of learning coping skills becomes more obtainable.  So yes, medication can be helpful. And we need to stop and ask ourselves whether we have made a good faith effort to explore behavioral intervention, pausing to make sure that the treatment has been appropriate to the problem,  and then  can honestly say to ourselves “These reasonable efforts aren’t enough”.  Of course defining “enough” involves calculating a number of factors that are not always easy to define.  

 

Deciding to use medication is similar to the decision-making process for any intervention: It involves sorting out the “risk-benefit ratio.” In other words, are the potential benefits worth the potential risks? Additional, we need to ask of the possible interventions which ones are likely to be effective for the problem at hand. For your own thinking and also to get the best possible advice from any professional you may consult, it is important to clearly describe the problem and it’s history.   A behavior checksheet can assist in this process but it cannot replace your own observations. . A concisely summarized, one-page report from a parent can help a professional give more effective help — and of course, the parent must feel that the professional is trustworthy. A good professional has the attitude of Jerome Groopman in his book, How Doctors Think. In his conclusion, he states, “But after writing this book, I realized that I can have another vital partner who helps my thinking, a partner who may, with a few pertinent and focused questions, protect me from the cascade of cognitive pitfalls that cause misguided care” (p 268-269).  I would hope that you have a physician for your child with such a perspective. In the best of circumstances a decision to consider using medication involves a careful weighing of options and creation of collaborative relationship with the professionals involved.

More Fight than Flight

14 Jul

The Middle School Child

 

You are just trying to help and you get comments such as “you’re retarded”, “no, not all the time” or “I don’t’ want to talk about it”. Is there a new way in which you are feeling ineffectual as a parent? Perhaps you have a tween or middle school child. In order to help your middle schooler with an anxiety problem, we must first acknowledge that he or she is at a very particular stage of life that is characterized by the physical transformation of puberty and an increased awareness of himself and the world around him. And of course there is a great deal of variability in how children respond to these changes. But, accommodating these changes throws his emotional equilibrium out of balance for a while. Julie Ross has described this age in her book How to Hug a Porcupine: Negotiating the Prickly Points of the Tween Years, as follows:

 

The essence of our children remains, but they are drawn inward for a period in order to develop properly. Similar to the caterpillar who spins a chrysalis to

protect itself while it changes into a butterfly, our children ‘protect’ themselves with anger, sensitivity, tears, defiance and disorganization. These behaviors are the human chrysalis, the outer shell that protects the delicate, unformed butterfly while it is most vulnerable (P. 5).

This a time in the life of your child where the words “tolerance” “patience” and “forbearance” will be needed in your vocabulary but will be perhaps hibernating in your child’s. Your best efforts to help and engage in a discussion may be met with a very off-putting “Leave me alone!” or “Nothing will help” And this reflects not so much disrespect, but rather the fragile nature of her psyche at this phase of growing up.

 

 While something different is happening to their bodies which cannot be denied, there a counter pressure to not feel that they different in thoughts and feelings from their peers. As a rule, they don’t like anything that makes them feel singled out and imagining that they get anxious in ways that their peers don’t get the alarm bells ringing. This problem is made more acute because the definition of what is normal shrinks during this time period to what they imagine is typical for their peers. But the operative phrase here is “imagine,” since they often do not have any solid evidence of what their peers may be thinking or feeling. This is an age when having a fear or anxious preoccupation can be terrifyingly embarrassing because it potentially signifies that they are different.

 

This is also the age where the development of social phobia is frequently reported to begin. As a parent, you will naturally feel some urgency to help, but any help must begin with the understanding that your child is on the doorstep of adolescence, and that this is even more important than the anxiety. The latter will be easier to address if the common pitfalls of communicating with this age group are minimized —and as Julie Ross points out in her book, there are many ways to miscommunicate with tweens. So maintaining, and even reinventing, your relationship with your middle school child is the necessary first step before other issues can be addressed.

 

 

The Middle School Child

14 Jul

The Middle School Child

 

You are just trying to help and you get comments such as “you’re retarded”, “no, not all the time” or “I don’t’ want to talk about it”. Is there a new way in which you are feeling ineffectual as a parent? Perhaps you have a tween or middle school child. In order to help your middle schooler with an anxiety problem, we must first acknowledge that he or she is at a very particular stage of life that is characterized by the physical transformation of puberty and an increased awareness of himself and the world around him. And of course there is a great deal of variability in how children respond to these changes. But, accommodating these changes throws his emotional equilibrium out of balance for a while. Julie Ross has described this age in her book How to Hug a Porcupine: Negotiating the Prickly Points of the Tween Years, as follows:

 

The essence of our children remains, but they are drawn inward for a period in order to develop properly. Similar to the caterpillar who spins a chrysalis to

protect itself while it changes into a butterfly, our children ‘protect’ themselves with anger, sensitivity, tears, defiance and disorganization. These behaviors are the human chrysalis, the outer shell that protects the delicate, unformed butterfly while it is most vulnerable (P. 5).

This a time in the life of your child where the words “tolerance” “patience” and “forbearance” will be needed in your vocabulary but will be perhaps hibernating in your child’s. Your best efforts to help and engage in a discussion may be met with a very off-putting “Leave me alone!” or “Nothing will help” And this reflects not so much disrespect, but rather the fragile nature of her psyche at this phase of growing up.

 

 While something different is happening to their bodies which cannot be denied, there a counter pressure to not feel that they different in thoughts and feelings from their peers. As a rule, they don’t like anything that makes them feel singled out and imagining that they get anxious in ways that their peers don’t get the alarm bells ringing. This problem is made more acute because the definition of what is normal shrinks during this time period to what they imagine is typical for their peers. But the operative phrase here is “imagine,” since they often do not have any solid evidence of what their peers may be thinking or feeling. This is an age when having a fear or anxious preoccupation can be terrifyingly embarrassing because it potentially signifies that they are different.

 

This is also the age where the development of social phobia is frequently reported to begin. As a parent, you will naturally feel some urgency to help, but any help must begin with the understanding that your child is on the doorstep of adolescence, and that this is even more important than the anxiety. The latter will be easier to address if the common pitfalls of communicating with this age group are minimized —and as Julie Ross points out in her book, there are many ways to miscommunicate with tweens. So maintaining, and even reinventing, your relationship with your middle school child is the necessary first step before other issues can be addressed.

 

 

Halloween

14 Jul

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

Halloween

 

Halloween is a bonus opportunity to acquire a treasure trove of candy, and have fun dressing up, but it is also a holiday about fear. At its best, Halloween offers a playful opportunity to encounter  imaginary fears —  ghosts, zombies and the like. By dressing up, a child can assume another persona such as a powerful superhero, or momentarily go over to the dark side by becoming Darth Vader or a zombie-ghost. In this way, the holiday retains some of its relationship to its Celtic origins, where it was believed that in this seasonal transition between fall and winter, ghosts and other roaming spirits would be out and about. By putting on masks and costumes, you could fool the spirits into thinking you were one of them, and thus, they would leave you alone. It is even possible that your mask might frighten the spirits away. And besides, dressing up is just fun by itself.   

But for this holiday to be fun and not a “Nightmare on Elm Street,” a parent needs to know whether a child can make the distinction between what is pretend and what is real. Otherwise, the child may not be able to understand that changes in appearance do not alter a person’s underlying identity. Preschool children are the most vulnerable in this regard. They are often confused by transformations in appearances, and it makes them uneasy and sometimes quite frightened. When a parent dresses in a costume or puts on a mask, the preschool child may be anxiously uncertain as to whether mommy has actually changed into a witch. This difficulty in dealing with transformations and alterations in appearances also explains why preschoolers and even some older children can be frightened by movies such as Spirited Away , an animated  film in which the parents get turned into pigs.   

The exaggeration or distortions in appearance that are part of many masks can create frightening sticky images for the child. The exaggerated smiles and eyes of clowns are often a source of distress and discomfort for children rather than a source of amusement. The vivid exaggeration of appearance, just like a frightening scene in a movie, can get stuck in the imagination and be hard to dislodge, especially at nighttime.

So for Halloween to be fun and not traumatizing, adults need to be thoughtful about how easy it is for  children to tolerate changes in appearances or to erase sticky images from their minds. As an age group, preschool children are most challenged by these issues, but school-age children are also vulnerable. Parents may need to restrain themselves in the costumes they put on and think twice about greeting trick-or-treaters with scary costumes. Remember, too, that children can be reluctant to verbalize their fears because they don’t want to be considered “ scaredy-cats,” so be alert for nonverbal signs of anxiety, and remember things that may have scared your child in the past. Rather than tell your children not to be afraid, use the occasion to help them articulate what they are afraid of. An anxious child may seem eager to go into the haunted house, only to have nightmares that night. With the knowledge that the child tends to get anxious, the parent may need to exert some authority and say no to the haunted house. The goal is to have Halloween be exciting and fun, not frightening. It helps to remember that the children themselves are not always the best judges of what they are up for.