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Feeling stuck with your anxious child? Consider the importance of movement in anxiety

24 May

If your child is anxious, it is natural to ask them what they are afraid of and to encourage them to talk about it. In the normal course of events, these conversations are usually helpful, but words don’t always work, even with very verbal children. The verbal reassurance that seems so natural to provide your anxious child often leads to an endless stream of “but what if…”.  Fortunately, there are strategies for getting out of the reassurance trap, which I have discussed in other essays. Unfortunately, purely verbal solutions can be of limited effectiveness in at least two situations. First, a child in full panic or meltdown mode is not going to be able to listen to reason. That part of their brain has gone off line. Second, often children can’t articulate what they are afraid of, saying “I don’t know, I just am,” and while sometimes it reflects the limitations of being very young, it can also reflect the nonspecific nature of their anxiety as an uncomfortable body sensation. It is more of a “not right feeling” or bodily arousal that doesn’t seemed clearly connected to any particular concern.

The ways in which anxiety can be manifested in movement span quite a range. There is the rapid, shallow breathing of a panic attack. Then there is the frozen or immobilized child who will not get out of the car to go school or the dentist’s office. Or perhaps, he starts hitting the doctor or you because he is about to get a shot. Fun time–right?  More generally, one way of viewing trauma is as an event in which a person cannot perform some self-protective action, either because it happens too quickly or because the person encounters an overwhelming force. Then, to add a layer of complexity, some children have over-sensitivities in which their “fight, flight or freeze” response gets triggered very easily. The sensory input they are receiving from the world is just too much for them.   There is a hypothesis that these sensitivities are the result of the child  not having  integrated some of the primitive reflexes he was born with into the more complex functioning that occurs with development.

Being very helpless creatures at birth, we are fortunately born with a set of reflexes to provide a set of automatic responses to ensure our survival. Commonly known reflexes are the sucking reflex to ensure feeding, the ever endearing palmer grasp where a baby holds onto your finger, and the startle or Moro reflex. There are many more reflexes which in varying time tables should be inhibited as the brain rapidly develops in the first two years of life. Some of these reflexes are essentially emergency self-protective responses to danger, in particular the Moro reflex which provides a way for the infant to hold on to a parent so it doesn’t fall or get dropped. Problems occur when these reflexes do not become integrated or inhibited as the child develops. Suggestive of such problems are children who do not fully crawl before walking, toe walking, excessively slouched noodle-like posture during homework or sitting at the table, and being excessively clumsy or uncoordinated. Essentially, these children are having their “fight, flight freeze” response triggered automatically on a daily basis, so they are constantly on edge or just more reactive to their world.

So if your child is not responding sufficiently to verbally oriented therapy, consider looking at her movement and posture. Sensory-Integration therapy, yoga, and a variety of neurodevelopmental movement programs may lead to some further progess.

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.

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.

About cleaning up: The Sunday Box

14 Jul

Clean Up, Clean Up


It is all too easy for clutter to develop when you have children. Toys and stuffed animals have a way of accumulating despite your best intentions. You are busy and if your suggestions about cleaning up are meet with resistance, then it can seem easier to do it yourself or just to let the matter slide. Perhaps if your child has more than the usual difficulty dealing with transitions, such as from playtime to bedtime, it just doesn’t seem worth the struggle. And then again, perhaps you need to begin with setting a better example yourself. There are also children who can develop unusual emotional attachments to objects, so that they won’t throw away a Lego box because it reminds them of their birthday, or they protest when the old toaster oven has to be thrown away because it has special memories of breakfast. Other children may collect bits of trash because they might be able to find a use for it in some art project; however, the collection continues to grow and grow. Regardless of the reasons, it is important that children learn to organize their belongings and clean up after themselves.


   The Sunday Box is a simple and highly effective way to get your children to clean up after themselves. It has the hallmark features of a good behavioral intervention in that it involves very little talking and lets the consequences make the point. The Sunday Box involves picking a certain time each evening, perhaps right after dinner, when your children need to have finished putting away their belongings. At that designated time, you walk around with a large box or trash bag, “the Sunday Box” and put into the box anything that has not been put away. You repeat this patrol with the Sunday Box every night until the clean-up habit is well established. The Sunday Box is securely put away so the children cannot get to it. Some parents have resorted to putting it in the truck of their car, and then bringing it out on Sundays, when any items can be retrieved by the child. Any item that the child does not take out of the Sunday Box remains in the box and if it stays in there for more than two weeks, perhaps this is an indication that the item in question has outlived its usefulness and should be donated to charity or “disappear” for a while — to reappear at a later date when it may be more appreciated.


Before starting with the Sunday Box, explain to your child what the Box will involve. It is also important to develop an organizational strategy with your child about where things go, so that at clean-up time he doesn’t have try to figure out where to put things. Thus, there is a box for Legos, crayons, action figures/dolls, and everything has its designated place. One reason that clutter develops is that there is not a system for filing and putting belongings, so things get piled and not filed. Do not threaten your child with the Sunday Box. Just simply announce “Oh it is 7 o’clock, time for the Sunday Box,” and let the actions speak. When your child complains that he doesn’t have a particular item, listen compassionately and remind him that the item will be available on Sunday. If it is an item such as a winter coat, you can substitute a less desirable item until Sunday. But the learning is in the experiencing of the consequences and not with a lot of discussion and reminding by the parents and that is why this is a very effective intervention.




14 Jul

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



The landscape of the anxious child can include learning disabilities, sensory sensitivities, and other problems such as ADHD and, sometimes, tics. In a tic, a part of the body suddenly makes a repetitive and stereotyped movement. Tics tend to be fast movements without any purpose. Common tics involve eye blinking, shoulder twitches and the neck jerking. Tics are categorized medically in terms of the length of time they have been present and the range of tics displayed — Tourette’s syndrome representing the extreme. Medical evaluations are important here so that certain diseases can be excluded from consideration. In various manifestations, tics have been estimated to occur in 12% to 18% of all school-aged children. Tics often first manifest themselves at ages 5-7, and are most intense around 12-14 years of age. After that, for many, they gradually decrease over time. So while early adolescence isn’t a great time to stand out and be different, for most children tics decrease in severity over their childhood. Another commonly noted feature of tics is that they tend to wax and wane over time and can change in form and appearance. Because they can’t take their body as a given to behave itself, a consequence is that these children often develop a precocious self-awareness. The presence of tics forces them to become more aware of themselves in a way that other children are not forced to do.

For many parents and children, the tics are an annoyance but the least of their concerns. Other problems such as OCD, ADHD and various learning problems may exert a more disruptive effect on the child’s life.

What can be done about tics? First, it is important to note that for many children, as mentioned above, the tics get less severe and pronounced over time. So the thing to do is nothing and not to make a big deal about it. Second, for some children medication may offer some help in decreasing tic severity, but unfortunately there is no panacea right now. Third, tics can draw attention to a child and consequently the potential to be ridiculed or bullied by peers is a possibility.  What is helpful here is educating other people about tics. School-based educational interventions around Tourette’s can be helpful in decreasing the ignorance and fear that is often behind bullying. Fourth, the intensity of the tics may be also managed by a behavioral training program involving habit reversal or developing a competing response. For many children, the tics are preceded by a feeling that has been variously described as “an inside itch” “inner tension” or “not right feeling” and performing the tic provides momentary relief from this feeling. The treatment involves performing a response that is incompatible with the tic until the urge for it goes away. Finally, identifying the situations in which the tics occur in can provide valuable clues about how to either reduce the stress or manage the boredom that triggers the tic.

For the child and the family, it can be extremely annoying to have your body take on a life of its own, but fortunately for many it is a problem that decreases in severity over time.

PANDAS where strep infection can be a factor

14 Jul



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.


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.




14 Jul

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


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