Archive | July, 2013

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.  

Sensory-Intergration

14 Jul

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

Sensory-Integration

Any parent who has more than one child knows,  every child is different from the moment they are born. Sometimes the difference is easy to understand such as when you have one boy and one girl, but that is only the tip of the iceberg.  Did your biceps get buffed when your child was an infant because the only way to calm her was to swing her in a bassinet? Did you find a new use for your washing machine as a way of calming your baby? (Placing the baby on top, not in the washing machine to be perfectly clear). Or did you find yourself driving around endless in your neighborhood so your child could fall asleep? Or perhaps you had one child who just melted into your body when you held him and another who seemed to arch away or squirm when held. What gives?

 These are examples of differences in temperament or variations in how the child experiences the sensory world.  There can be tremendous range in how we experience touch, so that some people hate to be tickled or others find it moderately enjoyable. Some people enjoy the sensation of being on a roller coaster and other experience as one step away from waterboarding.  These differences in how we experience the tactile stimulation of being held or the vestibular sensation of being on a roller coaster reflect variations in how we process or integrate sensory information.  Anxious children can often suffer from problems in sensory-integration, in which they cannot handle and process the incoming stimulation. A child who clings to you when you take her to a birthday party may be overwhelmed by the noise of the party because their ears are super sensitive.  It is not so much a problem being shy as it is of being overwhelmed by the sights, sounds and even the smells of the birthday party.

 What appears to be anxiety in trying something new might be more specifically describes as a problem in sensory-integration. It is all too much. And in such situations you might find child unable to articulate any  reason why they won’t join the birthday party other than she just doesn’t feel right. In contrast,  a child who is anxious in the more traditional sense of the term may be able to articulate some reason why they don’t want to join the party, such as   “I only know the birthday girl”. Admittedly, the distinction may not always be clear cut.  But there are a range of Sensory-Integration interventions, a subspecialty of occupational therapy, that may help your child modulate his sensory experience and consequently be less anxious and overwhelmed. This may involve providing your child with certain sensory experiences which can correct or compensate for her difficulty in processing the information that their senses provide them. If this sounds like your child, a consultation with a Sensory-Integration therapist may be helpful

Story telling for Children

14 Jul

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

Story-Telling for Anxious Children

Nighttime is a favorite time for worries to emerge. In another email, I talked about building a worry motel as a way of containing and labeling worries. But there is also another time-honored way of helping children with worries, which is making up bedtime stories. I have also discussed the value of books in promoting a sense of security and safety, as well as reading books that specifically address anxiety. However, there is nothing like a bedtime story that you have created. It can be tailor-made for your child in a way that no book can ever possibly approximate. And the act of storytelling creates a special moment of intimacy between you and your child in which you let her know that she not alone in feeling scared.

Understandably, when I the mention the idea of bedtime story-telling, parents remind me of how tired they are night and that they don’t have the imagination for it. But it is important to remember that your audience will be appreciative of any efforts you make and the act of engaging in an imaginative activity can actually be relaxing and decrease your stress level. There is a wonderful book for parents by Chase Collins, Tell Me a Story: Creating Bedtime Tales Your Children Will Dream On, which provides many suggestions about how to find the creative story-teller within you. It can be as a simple as picking an event that occurred during the day and providing “feelings” for both the animate and inanimate objects involved. So if a child is afraid of going into the bathroom by herself, there might be a talking toilet or bath towel as part of the story. Bedtimes stories can also be structured around the classic fairy tale plot line that involves a likeable hero, who goes off on a journey, encounters a problem and comes up with a solution and there is a happy ending (Collins, 1992, p73). But there are many variations on how to create a story, including making it much more a joint effort. Here is one example.

A mother had been desperate to help her 8-year-old daughter who had a combination of ADHD and OCD, but nothing was really working.

The answer presented itself at bedtime.  Leah’s vivid imagination has been focused on fairies that could show up at all times of day, but especially at bedtime.  I realized that it might help if I tapped into this playful and imaginative side of her.  One night, while Leah and I were playing together, I asked if she would like the fairies to speak to her through me. She was thrilled with the idea. I would “become” one of the many fairies that I had named, on a nightly basis, and we would talk. At first, it was getting to know the fairies, so we “talked” about such things as what games they like to play and their favorite snacks. But gradually with the fairies doing the talking, her worries and struggles emerged. As with many children with ADHD, Leah sometimes has difficulty falling asleep at night and she had resisted doing any relaxation breathing. That is, until “Goldenmist” arrived on the scene, who has become Leah’s “relaxation” fairy. When Leah has trouble falling asleep, “Goldenmist” will breathe along with her, and she will sometimes ask her to close her eyes, and imagine herself lying in a field full of beautiful flowers. With the help of Goldenmist, Leah is now doing her relaxation breathing …With the help of these “fairies” and our joint story-telling, Leah has become less anxious. It has been interesting to watch how the characters have evolved, in particular how OCD has been morphed productively into “Fluffy.” Leah will readily take advice from “Fluffy” that she would never accept from me. I have made sure that many of the fairies meet a particular need for Leah. Over time, I have come to realize that it is not just the content of the play that Leah has responded to, but it is the story-telling itself.”

 The process of story-telling can communicate to your anxious child that you empathize with him and he is not alone in his struggles. Once you focus on the creative activity, it can actually be a lot of fun. So everyone benefits and that is simply good medicine.

The Worry Motel

14 Jul

The Worry Motel

 

You may have noticed that worries love nighttime, especially bedtime. This is the time when there are no distractions, and worries can have your child’s undivided attention. Fears, darkness, some creepy shadows and some anxiety about tomorrow are the perfect recipe for a restless night, and lots of calling out for Mom and Dad.

 

Here is a serviceable, standby solution that is quite simple and can also be a lot of fun. It draws its value from the idea that fears can be labeled and contained. You and your child need to go into the hospitality business and open a “Worry Motel.” An empty shoe box, decorated with your child’s help and guidance, makes a perfect motel where worries can stay for the night—and hopefully, once they check in, they won’t check out!

 

Here is how to use a Worry Motel. Before bedtime, you and your child should draw or write down any worries that might be lurking around, left over from the day or waiting in ambush for tomorrow. You can model this process by writing down some hypothetical worries that anyone might have. Put the slips of paper in the Worry Motel, and leave them there.

 

Of course, we all know that worries do not cooperate. So ask your child to gather up some action figures, stuffed animals or dolls that would be willing to stand guard overnight and remind the worries to stay in the motel. It is important to emphasize that the worries will need to be taught to stay in the motel, and that this takes a lot of practice—there is no “presto, change-o” magic here. The more you enliven the situation by being playful, the more likely your child is to participate. So you may want to talk to the “guards” and give them special assignments, such as “We really need your help to watch this throw-up worry…he’s a real pest!”

 

When you put the worries in the motel, it can also help to give the child some alternative ideas to absorb him. Have him help you put together a scrapbook with about ten pictures of things he finds interesting or comforting. These might be pictures of a family pet, a summer vacation spot or a favorite sport. If a person is interested or engaged in something, it is hard to be anxious at the same time. So give your child something productive to think about, because trying not to worry does not work.

Anxiety comes in waves

14 Jul

 

 

Anxiety Comes in Waves; Are We There Yet; The Law of Gravity As Applied to Anxiety

Anxiety can exert a vice-like grip on your child’s thinking and feeling that can make it hard for him to believe that anything can change or get better. Getting caught up in an intense pattern of anxious thinking, can make you think that things will always be that way. Moods get supersized. And then all your desperate child wants is relief. But as the often-quoted Greek philosopher Heraclitus stated, you can’t step into the same river twice, that is to say, everything changes. And that is true for feelings as well, even for every intense feelings. Despite what your child may think, worries don’t last forever. Following gravity, what goes up must come down. But children have a different experience of time than adults, as any parent who has taken her child on a long car drive can attest, with the backseat refrain of  “Are we there yet?” This different sense of time can make it harder for children to realize that if they wait, things will get better. Although it makes it easier to distract them and that can be a Godsend, the problem is that if they do not learn from the experience or we don’t help them to learn, ­it will only be temporary relief. Infants begin as creatures of the moment and over the next 20 years become less so, but it is a gradual process. The problem is that combination of out-of-sight out-of-mind, and having difficulty tolerating talking about difficult or unpleasant things.

But for children to be brave and take a leap of faith, they need to have a sense that things will be OK. Either they can become used to things or these things will change. So how do we help children on this front? Experience is obviously the best teacher. Getting back on the bicycle after the nasty fall and seeing that everything is OK is a cliché that works in this instance But with anxious children and especially children with attentional problems, we may need to highlight these experiences and provide a little help so they just don’t slip away.

First, it is important to underline the common everyday axiom that you can get used to things or slightly more technically, you can habituate to things. It is like jumping into a swimming pool. It can be really cold at first, but if the child starts swimming or playing Marco Polo, she gets used to the water and it is not so bad. Consider holding an ice cube in your hand. It is really cold and unpleasant at first, but eventually turns into water. Because we can get used to things, it is important not to give exclusive attention to our first feelings about a subject.

Second, to help the child learn from experience, it may to helpful to ask him questions geared toward helping him notice his experience, rather than leading him to the answer you already know. For example, if a child is anxious in the morning before school, afraid she might throw up, when she comes home, you might ask her, “So what happened to those worries about throwing up today?” This question will hopefully help her see and reflect on the fact that once she got involved in her school work, the feeling went away.

Having faith that things can change is a lesson not restricted to childhood. We continue to learn and remember this throughout over lives.

Get out of your head

14 Jul

 

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

Helping Your Anxious Child Get Out of His Head and Out of Worry

 

When an anxious thought or image takes hold in your child, it hijacks his attention. In children’s intense preoccupation, a narrowly focused tunnel vision takes hold in which the worry is the only thing in sight. This narrowing of vision makes sense if there were a realistic danger that had to be dealt with. Hitting the reset button involves helping the child get out of her head and refocused onto the world around her. For example, one girl struggled watching movies with her friends because she was much more easily frightened by what she saw compared with her friends. On her own, she came up with the idea that when she was frightened by something she saw, she would look around the room and start naming what things. She would say to herself, “There is the lamp, there is the cat, there is my popcorn…” and this listing would help her reorient and gain some distance from the frightening image.

A slightly different example is provided by a 10-year-old boy who had been anxious about going to school for a long time. There were frequent trips to the school nurse and guidance counselor with complaints about stomach pains. Merely talking about his feelings and providing reassurance didn’t help with his anxiety. Partly in desperation, the guidance counselor started having the child write down his schedule in her office as soon as he got into school. By the time he was finished writing down his schedule for the day in great detail, his anxiety had diminished to the degree that he was able to go to his class without difficulty. This simple exercise did a couple of things. First, the act of writing his schedule down moved him away from his anxious thoughts because he had to think about his schedule, which was not the same every day.  Second, since he was filled with nervous anticipation about what was going to happen during the day, writing his schedule moved him away from the anxious anticipation to visualizing what would really happen during the day. This focus on the external reality of the day seemed to help calm him down. Third, the anxious child is usually operating at high speed, but writing something down can really slow things down so he can challenge some of his anxious thoughts or they can just dissipate on their own.

So helping your child focus on the environment outside of his head can often be an important step in helping him deal with anxious thoughts.

Effort versus Performance

14 Jul

Effort Versus Performance

 

Whether it is an upcoming swim meet or a spelling bee on Friday, children can often suffer from performance anxiety, some of which is perfectly normal and appropriate. However, when the anxiety clearly begins interfering with the child’s participation in the event, then the issue of performance anxiety needs to be considered. Some children who are rather perfectionistic by nature can put a lot of pressure on themselves.

 

Adults, however, provide added pressure depending upon whether they focus on the child’s effort or performance. It turns out that how we praise children can have a big effect on how they perform depending upon whether you focus on their effort or intelligence.  This insight comes from research by Carol Dweck, who discovered an interesting effect on children’s school performance depending upon whether parents comment on the children’s effort and hard work, or their intelligence and talent. She proposes that we tend to understand success as either the result of innate ability and talent, or the result of hard work and effort.

 

However well-intentioned, telling your child that he/she is smart and brilliant can inadvertently put pressure on him as when he encounters a problem in his homework that he has difficulty solving. This child may feel that because he could not solve the problem easily, this is an indication that he is not as smart as he thought he was because it required effort. So he gives up. Anything that requires effort is to be avoided and challenges are not welcome.

 

In contrast, comments that focus on the child’s effort tend to promote greater persistence and a more positive attitude. This has been confirmed in studies on children’s performance on math tests where the feedback in one classroom was on how smart they were and in the other classroom, the feedback focused on their persistence and effort. When given achievement test, the “persistence” group did substantially better.

This point was recognized a long time ago in the book How to Talk So Children Will Listen and Listen So Children Will Talk, by Adele Faber and Elaine Mazlish, who recommended simply describing what you see rather than lavishing praise on your child. Rather than saying to your kindergarten child’s quickly drawn picture, “Oh that is so beautiful,” instead comment, “Wow, there are so many colors in this picture and the house has four windows.” The latter does communicate that the child’s effort was worthy of detailed attention and it brings her attention to what she did that helped make the picture interesting.

 

So when it comes to providing encouragement for your child, try to focus more on describing the way in which you see him displaying effort and persistence rather than praising him for being talented or smart.

copyright@Edward H Pllimpton, PhD