Your anxious child

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.

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

Tics

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

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
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.

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.

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.