It's Nobody's Fault_ New Hope And Help For Difficult Children And Their Parents Part 6

A child's school should be made aware that he's being treated for social phobia. Many teachers can be very helpful in social skills training and other elements of behavioral therapy. If a teacher knows, for instance, that a child's a.s.signment is to speak out once a day in cla.s.s, he can help the child achieve that goal-by calling on the child early in the cla.s.s to get it over with, for instance, or not calling on him more than once a day until he shows marked improvement. Every little bit helps.

CHAPTER 11.

Generalized Anxiety Disorder When nine-year-old Caitlin and her parents flew in from Chicago to see me, Caitlin had already been through more than her share of experiences with doctors. She'd been suffering from headaches and terrible stomachaches every day for months, and her parents had taken her to several specialists, most recently the neurologist who referred her to me. When I asked Caitlin what kinds of things she worried about, the floodgates opened. She worried about everything everything, she said-that she wasn't playing the piano well enough, that her father was going to run out of money, that her hair didn't look right, that she wouldn't have any friends, that she wouldn't do well in school. The neurologist said that Caitlin's headaches were caused by tension.

Larry, a sweet, serious little first-grader, came home with a handwritten note attached to his first report card. "Larry is a lovely boy. I just wish he would smile more than once a semester," the teacher wrote. Larry's parents knew exactly what the teacher was talking about. At six, their son took his academic life as seriously as a third-year law school student. From the moment he came home, he'd worry about doing his homework a.s.signment, fretting about whether it was complete and correct. One recent morning he and his parents had the following exchange: "Where's my homework?" Larry asked Mom.

"Your homework's in your knapsack. It's all signed," she answered.

"You signed the homework? homework? You're not supposed to sign my homework. You're supposed to sign my homework a.s.signment You're not supposed to sign my homework. You're supposed to sign my homework a.s.signment book!" book!"

"Honey, it's okay. I'm sure it will be fine."

"No, it won't be won't be fine." fine."

"Okay. I'll write a note to the teacher and explain that I didn't know I was supposed to sign the a.s.signment book."

"No, don't write a note. note. You're not supposed to write a You're not supposed to write a note!" note!"

When he finally left for school, little Larry was not not smiling. smiling.

HIGH ANXIETY.

A five-year-old boy on his way to a cla.s.smate's birthday party tells his father he'd really rather not go, thank you very much. When the father questions the child, he discovers that the boy is a little nervous about going to a house he's never visited before. He also fears that the other kids might not want to play with him. The boy finally agrees to go to the party. Dad offers to stay at the party and keep his son company for a little while, but the boy turns the offer down. No, he'll be fine, he says. And after a few minutes at the party, he is.

Another sensitive five-year-old goes to a G-rated movie only to be faced with a PG-rated preview of a coming attraction: a movie with monsters. As soon as the child hears the music of the preview, she turns to her mother and says, "This is going to be scary. I'm closing my eyes." She sits with her eyes shut tight until the ominous background music stops. "I wasn't scared," the little girl said afterward, "but it was good I closed my eyes." eyes."

Both of the youngsters I have just described were experiencing anxiety that falls within normal limits. All kids worry about something at least some of the time. They're afraid of storms, animals, strangers, loud noises, the dark. They fret about wearing the wrong clothes, taking tests, getting invited to parties, and choosing a college. They're scared that other kids won't like them. All of these anxieties are to be expected in a child's normal development.

What is not not part of normal development is the brand of anxiety that Caitlin and Larry exhibit. Both children are suffering from generalized anxiety disorder, or GAD, which is defined in the textbooks as "pathological anxiety characterized by all-consuming worry and excessive or unrealistic anxiety about a number of events or activities occurring more days than not for a period of at least six months." GAD should not be confused with a simple phobia, which is an illogical fear of a particular thing-c.o.c.kroaches, snakes, pigeons, whatever. Until recently GAD had a different name in the textbooks: overanxious disorder. part of normal development is the brand of anxiety that Caitlin and Larry exhibit. Both children are suffering from generalized anxiety disorder, or GAD, which is defined in the textbooks as "pathological anxiety characterized by all-consuming worry and excessive or unrealistic anxiety about a number of events or activities occurring more days than not for a period of at least six months." GAD should not be confused with a simple phobia, which is an illogical fear of a particular thing-c.o.c.kroaches, snakes, pigeons, whatever. Until recently GAD had a different name in the textbooks: overanxious disorder.

Most kids worry when they have to take a test. Children with GAD worry not just before a test but before, during, and after a test. Normal kids study, get nervous, take the test, and wait to get their grades. Children with GAD study, take the test, and then replay it over and over again in their minds, convinced that their performance wasn't good enough. They're the ones who are always asking in cla.s.s, "What did you put for number 6?" or "I'm sure I failed."

Kids with GAD usually are incapable of evaluating their own performance on a test or anything else; they're just too anxious. Logic has nothing to do with how they feel about themselves. Even when they consistently pa.s.s or they always get straight A's, the worry is always there. I treated a 12-year-old boy who played the violin beautifully but was never satisfied with his performance. Even though his parents, his teachers, and the audiences at his recitals praised him to the skies, he never pleased his toughest critic: himself. He spent hours replaying and second-guessing the performance, saying, "I should have done this. I shouldn't have done that." His performances always went without a hitch, but that didn't matter to him. They were never good enough.

For these kids there's no such thing as "I've gotten 100 percent on every spelling test so far this year, so I'll do okay on this one too" or "I really know the material, so I don't have to study." And even if everything goes perfectly, they derive no real pleasure from an accomplishment. They're already worried about something else.

When a child suffers from GAD, the intensity, frequency, and duration of his anxieties are completely inappropriate to the worry itself. What's more, kids with GAD are always finding new, unexpected things to be anxious about. Here's a conversation a mother had with her six-year-old son, Jerry: "Did the school mail my report card?" asked Jerry.

"I guess they did, honey. I don't know," she answered.

"Shouldn't it be here by now?"

"I'm not sure, honey. Are you worried about it?"

"Yes. I think it should be here by now."

"Are you worried about your grades?"

"No. I just can't remember if I was supposed to bring a report card home or if they're going to send it. Was I supposed to do something so I get a report card? Maybe I didn't do what I'm supposed to do to get my report card."

The poor kid is worried sick about his report card, and he hasn't even seen it yet.

A certain anxiety level in a child is acceptable provided it doesn't interfere with performance or peace of mind; again, distress and dysfunction must be gauged carefully. Having some difficulty falling asleep the night before a big, important event is one thing. Lying sleepless for hours obsessing about a book report that has already been handed in or a test that has been taken is quite another.

Generalized anxiety disorder is relatively uncommon in children and adolescents-and only 3 percent of the general adult population have it, 55 to 60 percent of them female-but I've always felt that there are many more cases out there than we see in our psychiatric clinics or our private practices. After all, GAD can be a productive disorder. Children who are constantly saying, "I have to get my homework done" or "I have to study harder" or harder" or "I have to make sure my clothes are all set for school tomorrow" may not be perceived immediately as having any real problems. They may come across simply as conscientious. "I have to make sure my clothes are all set for school tomorrow" may not be perceived immediately as having any real problems. They may come across simply as conscientious.

Many of the cases of GAD I've encountered involve precocious, bright kids, especially young ones. I recently talked to a six-year-old who said to me, "You know, they have way too many nuclear weapons in Korea now. I'm very concerned about that. I'm also worried about global warming. Did you see how hot it was last week?" I've come across a third-grader who, when told to write a five-page report, turned in twenty pages instead.

Naturally, this kind of "overachiever" behavior is not necessarily alarming to parents; in fact, many parents and teachers welcome and reinforce it. Only when a child's anxieties obviously get out of hand-and they usually do at some point-do parents consider the possibility that something is not as it should be. For one set of parents it came when their daughter Annie was constantly after them to let her take a course to prepare her for the SATs. She wanted to get a high SAT score so that she could be accepted into a good college. Mother and Father said yes, of course, she could take an SAT course, when the time came. Annie kept nagging, asking them daily which course she should choose and when she could start going. Annie was in third grade at the time.

THE SYMPTOMS.

Children with generalized anxiety disorder often make their way to a mental health professional's office because they have physical symptoms-headaches, stomachaches, diarrhea, restlessness, sleep disturbance, fatigue-that cannot be explained. They've had the CAT scans, the barium enemas, and all the rest of the tests, and there are still no answers. It's not that the physical ailments are not real; those pains in the head and the stomach are very real indeed. It's just that they don't have an organic explanation. There's no tumor in the brain or bacteria in the colon. These kids are having a physical reaction to anxiety, and the symptoms may range from very mild to quite severe. The most extreme anxiety symptom I ever witnessed was in a young college student, who was so nervous about her finals that she literally couldn't turn her head; the muscles in her neck had tightened up too much.

On the other hand, a child with GAD may have only the mildest physical symptoms; the real telltale signs of GAD are behavioral. Most kids with GAD will be perfectionists, conforming and unsure of themselves. They may appear tense and uptight, but they can also be quiet, compliant, and eager to please. They worry constantly about their competence and the quality of their performance and often require repeated rea.s.surance that they're doing things the right way. Even so, a.s.sessments by others matter hardly at all to these kids; children with GAD worry about their performance regardless of what others think.

Anthony, a second-grader I treated for GAD, would walk to his teacher's desk several times during the day and ask, "Am I doing this right?" "Yes, you are doing it right," she'd reply. Anthony was an outstanding student, and the teacher often told him so. "Okay," answered Anthony. A half-hour later the conversation was inevitably repeated. Anthony didn't want to keep bothering his teacher-he tried to control himself-but his overanxiousness surfaced many times throughout the day. Anthony worried about everything. "I worry about how I'm doing in school, whether people will like me, what college I'll go to, and whether I'll do well in soccer," he told me. It was his teacher who finally noticed that Anthony needed help.

Other kids with GAD react not by demanding their teachers' attention but by being restless and on edge. They often appear (and they often are) tired; sleepless nights can do that to a child. Sometimes they're perceived to be difficult and demanding, because they're never satisfied. These kids are frequently overcautious in social and academic settings and not always very pleasant to be around.

Sometimes a child's GAD symptoms are obvious to everyone but the people closest to him, his parents. It took the grandparents of a little eight-year-old girl, Sally, to get her into my office. Lots of kids want to do well in school, but Sally was more of a perfectionist about her school-work than any child I've ever met. In the morning Sally would announce her study goals and schedule for the day to her mother and father. After school she would come home immediately-she refused all invitations to play with her friends, because they interfered with her plans-play the piano for 40 minutes, and then hit the books. Her dinner conversation was always about her performance: how many goals she got in soccer that day, what test she had the following day, and how she thought she did in art cla.s.s. When she came to see me, Sally had frequent headaches and what her parents called a "nervous stomach."

Her parents knew that Sally's behavior wasn't normal, but it took the no-nonsense older generation, Sally's grandparents, to mobilize them at last. "Are you crazy?" crazy?" Grandma asked delicately. "I love this child, but she acts older than I do. I don't think she knows how to relax. She's such a worrier! If Sally has a spelling test, you have to test her five times even though she got all the words right the first time." Grandpa added his two cents: "She takes more Tylenol than I do for her headaches, and every time I see her she has a stomachache. She needs to see someone." Grandma asked delicately. "I love this child, but she acts older than I do. I don't think she knows how to relax. She's such a worrier! If Sally has a spelling test, you have to test her five times even though she got all the words right the first time." Grandpa added his two cents: "She takes more Tylenol than I do for her headaches, and every time I see her she has a stomachache. She needs to see someone."

THE DIAGNOSIS.

"Gil was always a worrier. That didn't bother us. He was always nervous. That was okay too. But now he's complaining about being sick all the time and missing a lot of school. That's not okay."

When Gil's parents brought him in, they'd done a little research, and they thought that their 10-year-old son had a cla.s.sic case of school phobia. However, after I took his history and did a thorough evaluation-interviewing parents, teachers, and, most usefully, Gil himself-I learned that Gil was afraid of a lot more than just going to school. Here, I discovered, was a kid who was worried seven days a week. He loved sports but avoided joining a team because he thought he was never good enough. He constantly worried about his future, especially his career. Watching television frightened him, especially the news, because he might see something scary or bad. He was especially terrified of nuclear war. He had trouble falling asleep and was tired and jittery much of the time.

Diagnosing GAD can be a tricky business. First of all, it's an internalized disorder internalized disorder, which means that its key symptoms have to do with thoughts and feelings. Teachers and parents are not always useful in giving a history when it comes to GAD. They usually know what the kids in their care do do, but they don't know how the children feel. feel. Parents are wonderful at rationalizing too. Seven-year-old Megan came home from school crying and told her parents that the other kids were making fun of her all the time. "They don't like me. They say, 'All you talk about is school. Why do you always talk about school?'" Megan told Mom and Dad tearfully. Megan's parents were quick to rea.s.sure their daughter. "Oh, those other kids are just jealous because they're not as smart as you are," they told Megan. "You're fine just the way you are." Parents are wonderful at rationalizing too. Seven-year-old Megan came home from school crying and told her parents that the other kids were making fun of her all the time. "They don't like me. They say, 'All you talk about is school. Why do you always talk about school?'" Megan told Mom and Dad tearfully. Megan's parents were quick to rea.s.sure their daughter. "Oh, those other kids are just jealous because they're not as smart as you are," they told Megan. "You're fine just the way you are."

Cindy's parents likewise were fooled about their daughter. "Cindy is a wonderful student," they told me. "She comes home from school and she immediately does her homework and then she always practices the violin. Before dinner she gets her clothes ready for the next day. She's absolutely perfect." What they neglected to mention is that Cindy's social life is a lot less than perfect-she spends almost no time playing with her peers-or that even though her music teacher has recommended Cindy for a special program, the child is convinced she has no musical talent. Although her parents seem to have missed the signs, an objective observer can see quite easily that there's an overanxious quality about Cindy, even when she is supposedly relaxed. She is never truly loose or at ease. The diagnosis: GAD.

GAD has symptoms that are similar to several other disorders. Restlessness and difficulty in concentrating are symptoms of attention deficit hyperactivity disorder (see Chapter 7 Chapter 7); anxiety related to school may suggest separation anxiety disorder (see Chapter 9 Chapter 9); and obsessive att.i.tudes and compulsive behaviors about work may raise suspicions of obsessive compulsive disorder (see Chapter 8 Chapter 8). In the case of pathological performance anxiety, the diagnosis can be either GAD or social phobia (see Chapter 10 Chapter 10). Severe performance anxiety is a symptom of social phobia if the performer is worried about what people are thinking about him. However, if the feeling is, "I haven't prepared enough for this recital" and then, after a standing ovation, "I should have played the piece louder and faster and better," then it's more likely to be GAD. Of course, there is also the distinct possibility that a child has more than one disorder. In adults GAD co-occurs with depression about 80 percent of the time, with the anxiety disorder developing first.

One case of GAD I treated, a six-year-old girl in first grade, started with what seemed to be acrophobia acrophobia, a fear of high places. Her parents told me that their daughter, Elena, who was usually quite obedient, had refused to go out for recess on the school's third-floor rooftop playground. Elena loved the playground in the park and played there often, but she wouldn't set foot on the rooftop despite the efforts of her parents and teacher. When I interviewed Elena, she told me how much she had enjoyed visits to the Empire State Building in Manhattan and the Hanc.o.c.k Building in Chicago, so I knew in short order that she wasn't afraid of heights. After much discussion, Elena explained her fear of going on the roof; a gust of wind might demolish the fence, she told me, and she would be blown off the roof. We treated her for GAD.

THE BRAIN CHEMISTRY.

The most recent studies related to GAD-all done on adults rather than children and adolescents, unfortunately-indicate that this disorder is related to a regulation problem in the brain of the neurotransmitter norepinephrine, the brain chemical that affects concentration and attention. Specifically, people with GAD tend to have too much norepinephrine. This theory is supported by the fact that an increase in norepinephrine has several physical consequences, among them increased heart rate, increased sweating, and decreased ability to concentrate. Obviously all three areas have an impact on a person's cognitive abilities and his ability to perform so far. Studies of whether or not GAD runs in families have been inconclusive.

THE TREATMENT.

The recommended treatment for GAD is behavioral therapy combined with medication. Behavior-oriented psychotherapy is effective in the treatment of GAD, but the results are even more dramatic when medication is prescribed along with it. In many cases we suggest that a child be given a small dose of antianxiety medication as he begins behavioral therapy. The medicine takes the edge off the symptoms, making it easier for the child to work on changing his behavior. Once the child is functioning and the therapy is underway, we might well take him off the antianxiety medicine or decrease the dosage.

GAD can be treated with benzodiazepines, a group of antianxiety drugs. The ones most often prescribed are Klonopin, Valium, and Xanax. These medicines may occasionally cause lack of inhibition (giddiness, impulsivity, and agitation) in children, but the side effects disappear when the dose is lowered or the drug discontinued. These medicines work fast and need to be stopped slowly; as the child gradually discontinues the medicine, he should be watched carefully for a return of the anxiety symptoms. BuSpar, a new type of antianxiety medicine, has had a positive effect on children and adolescents with GAD. BuSpar takes one to two weeks to be fully effective, and the side effects are mild and transient. When youngsters with GAD don't respond to BuSpar or the benzodiazepines, we often look to Luvox or Prozac, which can take almost six weeks to get a positive effect. Controlled studies of Luvox are ongoing with children and teenagers with Generalized Anxiety Disorder. Luvox is the first SSRI to receive FDA approval for use in children under the age of twelve.

The behavioral approach to treating GAD is target-oriented: quite simply, the goal is to identify the problem-find out what's bothering the child-and work with the child to make the worry go away. There's nothing pa.s.sive about this treatment; a kid doesn't just sit around while various medical professionals have their way with him. This treatment is active. active. A child needs to be very much involved. He has to think about his fears, confront them, and work on ways to make them disappear. None of these things comes easily to a child, let alone an overanxious one. A child needs to be very much involved. He has to think about his fears, confront them, and work on ways to make them disappear. None of these things comes easily to a child, let alone an overanxious one.

A behavioral therapist treating GAD will teach kids techniques that help them to relax and settle down. The techniques are simple, but they can have a profound impact on a child's behavior, especially his ability to calm his nerves. An overanxious child, who can't "just relax," is helped immeasurably by being able to call upon these techniques when he needs them. The two relaxation techniques most often relied upon are deep breathing exercises deep breathing exercises, which even very young children can master, and visual-imagery. visual-imagery. The two techniques are almost always used together. The two techniques are almost always used together.

For example, in helping a girl who's afraid to sleep because of excessive anxiety, the therapist would first teach relaxation, have the child practice it, and then use visual imagery to maintain and reinforce the child's relaxed state. For example, the therapist would paint a verbal picture of the setting as a little girl prepares for sleep. The child would be asked for details of the bedroom, until the scene is completely set: wallpaper, pictures on the wall, dolls on the shelf, everything. Then the therapist would ask the child to picture going to sleep in a dark room. Again there would be many details, and the girl would partic.i.p.ate actively. She would "practice" this behavior in the comfort of the therapist's office a few times, and then she'd be sent home to try the real thing. Sleeping alone in a dark room would be the little girl's a.s.signment for the week.

Setting goals is critical to the successful treatment of GAD, and the more specific the goal, the better. A seven-year-old boy with GAD was terrified of taking tests in school. The therapist took him through a series of relaxation techniques and then actually went with him to school, to the very room where he took the tests he feared so much. The therapist got the child to relax again and then to focus on the room. Together they picked a spot on the wall that he would stare at if he became anxious. It was agreed that whenever he looked at that spot, he would stop worrying.

Another child fretted about taking a field trip with his cla.s.s and used visual imagery to help himself through it. At the suggestion of the therapist, he and his parents got out a map and traced the journey every evening for a week before the trip, talking about the trip in detail. The boy was especially worried about the bridges he would have to cross-he was afraid they'd collapse-so they worked out in advance what he would do when he got to a bridge. His parents suggested he take out his crossword puzzle book and work on a puzzle while crossing the first bridge. When he got to the second bridge, he would talk to his friend.

Kids really need their parents' help in working through the symptoms of GAD. For parents, that sometimes means going against their own natural instincts. That was certainly true in the case of Ryan, a 10-year-old boy with a clear case of GAD. An excellent student, good at sports, and popular with his peers, Ryan was a ma.s.s of worries. He didn't think he could do anything right. When I first saw him, he was suffering from severe headaches and stomachaches. Ryan's parents had always taken a healthy interest in his activities, deriving satisfaction from his accomplishments and supporting all of his efforts. They applauded him for his good grades and celebrated with him when his team won. I made them change their ways.

For the six months we treated Ryan for GAD his folks were asked not to discuss performance with him. If they talked about his soccer game, it was not to inquire, "Who won?" but to ask, "Did you have fun?" There was to be no talk about winning or losing, good grades or bad. Ryan's teachers were asked to hold on to his test papers until the end of the week, so that Ryan got his grades only on Friday. If he tried to talk to his parents about his test grades, all they'd say is that they were sure he did his best. It wasn't always easy, for Ryan or his parents-in the early stages of the treatment Mom and Dad actually used cue cards to remind themselves of what they were supposed to say-but in six months Ryan's headaches and stomachaches had disappeared.

In virtually any behavioral therapy for GAD there almost always comes a time when the child is made anxious, sometimes very very anxious. It's part of the basic process: before a child can be desensitized, he must usually be made to feel discomfort. With children the therapeutic process is usually gradual; kids confront their fears slowly, with lots of positive reinforcement (in the form of rewards and praise) and rea.s.surance from parents and therapist. At times, mild negative consequences, such as loss of TV or play time or other privileges, are also used to "punish" a child's opposition to reasonable expectations. Both rewards and punishments are meted out for effort, not achievement. anxious. It's part of the basic process: before a child can be desensitized, he must usually be made to feel discomfort. With children the therapeutic process is usually gradual; kids confront their fears slowly, with lots of positive reinforcement (in the form of rewards and praise) and rea.s.surance from parents and therapist. At times, mild negative consequences, such as loss of TV or play time or other privileges, are also used to "punish" a child's opposition to reasonable expectations. Both rewards and punishments are meted out for effort, not achievement.

One of the most effective techniques of getting a child over the fears and anxieties a.s.sociated with GAD involves extended exposure extended exposure, or flooding flooding, in which a child is put in the very situation-either in reality or in his imagination-that causes distress for an extended period of time. He is then made to understand that the fear is irrational. This method relies upon a biological fact: the body can't maintain a high level of anxiety for more than about 90 minutes; the anxiety "burns itself out." When a child sees sees that what he fears has not happened, the anxiety will dissipate. If the child is to alter his thoughts as well as his behavior-the that what he fears has not happened, the anxiety will dissipate. If the child is to alter his thoughts as well as his behavior-the cognitive cognitive component of the therapy-it's essential that he know what is going on every step of the way. Children must describe their fears and then become aware that those fears are groundless. component of the therapy-it's essential that he know what is going on every step of the way. Children must describe their fears and then become aware that those fears are groundless.

In the case of Sally, the little girl with the impatient grandparents and the intense worries about her performance at school, here's how a flooding might go.

"Sally, I want you to imagine that you're getting ready for school," the therapist might say. "All your homework is done. But just as you're packing your bookbag, you notice that your math paper is crinkled and smudged. Just then the bus pulls up outside, and the driver beeps her horn twice. You have to rush to get on the bus, and the driver doesn't smile at you. You're afraid that you did something to make her mad. You can't stop thinking about your math paper. Your stomach starts to hurt, and you feel sick, as if you have to go to the bathroom. When the teacher asks you to hand in your math homework, you feel even sicker. You think maybe she'll tell your parents. Maybe you'll get an F."

After the flooding, the therapist would guide the child through her deep breathing exercises and rea.s.sure her that her feelings of distress and anxiety will soon pa.s.s. Once the child has made it safely through the scene, it's time to help her learn from the experience.

"So you heard the story of a really terrible day and you got through it?" the therapist might ask.

"Right," Sally would say.

"How do you feel?"

"Okay, I guess."

"Did anything bad happen?"

"I guess not.

"You were worried, right?" asks the therapist.

"Yeah."

"Did anything bad happen to you? Did your toes fall off?"

"No." Sally starts to smile.

"Are you sure your toes didn't fall off? Maybe we'd better check to make sure. Why don't you take off your shoes so we can have a look?"

At this point Sally is at ease. The crisis, or at least this this crisis, is over. crisis, is over.

As productive a disorder as GAD may sometimes appear to be, it is critical that a child with GAD symptoms be treated promptly. Left untreated, GAD may result in stress-related physical ailments, even something as serious as heart disease, as well as other psychological disorders, especially depression. The disorder may also interfere with a child's ability to reach his academic potential and prevent him from making friends. These children are so anxious all the time, so fearful about their competence and performance, so worried about not being liked, that they're often not very not very well liked by their peers. It's not surprising, really. The symptoms a.s.sociated with GAD are not likely to make a child the most popular kid in his cla.s.s. Of course, not being liked then leads to loss of self-esteem, not to mention a whole list of new things for a child to worry about. well liked by their peers. It's not surprising, really. The symptoms a.s.sociated with GAD are not likely to make a child the most popular kid in his cla.s.s. Of course, not being liked then leads to loss of self-esteem, not to mention a whole list of new things for a child to worry about.

PARENTING AND GAD.

At a dinner party recently I overheard two women talking about the new teacher that their third-grade sons have in school this year. From what I was able to make out, the new guy doesn't believe in taking it easy on the kids when it comes to homework.

"What do you think about the homework a.s.signments this year?" asked one mother.

"They're pretty heavy," said the other. "I feel sorry for Hugh sometimes."

"Chris comes home every day, and he's a wreck," said the first. "He throws himself on the bed and screams, 'How am I going to do this? It's too much. What am I going to do?' I mean, he's hysterical about it."

At this point I was convinced that this kid needed some help. However, as I continued to eavesdrop, I realized that his mother was handling her son's anxiety effectively in her own way.

"What I do is I go in there, and I say, 'Chris, let's look at the a.s.signment and break it down into 20-minute segments. Why don't you take 20 minutes and do one part?' Then we go on to the next segment. He always gets the homework done, and the tears don't usually last very long."

What Chris's mother is doing is basically a behavioral intervention, and I don't think a therapist could have done it any better. My guess is that Chris has generalized anxiety disorder, but his is a mild case. At the moment, at least, his distress and dysfunction are modified by having the right mom.

Alas, not every child, diagnosed with GAD or not, has the right mom or dad. I have seen many parents, particularly high-powered, successful professionals, unwittingly put pressure on their overanxious kids. "I manage a large firm, and I pride myself on getting the most out of my staff," the father of a 10-year-old boy with GAD told me. "But my son practically falls apart if I put any pressure on him or make suggestions. If I criticize him, there are bound to be tears. I'm only trying to help him, but I seem to make him less less productive." productive."

Behavioral therapy methods can be made to work on nearly all symptoms a.s.sociated with GAD, but it isn't always easy for parents to put their children through the discomfort that is involved. Some parents aren't comfortable doing what's necessary to help a child with GAD get his life in order. When a child throws a temper tantrum, these parents will say, "I can't put him through this." They might think, "I'm harming my child. I'm doing something bad to my child. Look at the distress he or she is going through." I don't blame parents who have a hard time dealing with the symptoms of GAD; after all, it's a parent's natural instinct to reduce a child's pain, not add to it, even temporarily.

While they are perfectly understandable, such feelings are counterproductive in treating an overanxious child. Parents have to be able to say, "You've got to stick it out. You've got to take that math exam" or "We have to take a plane to visit Aunt Judy. It won't be easy, but you have to get over this. We're going to help you."

While it's important for parents to be supportive, mothers and fathers should try to remain unemotional and detached to the greatest extent possible. Sometimes it helps to regard the new behavior being reinforced as an a.s.signment, as in: "Look, it's important for you to try to do this. You've got some nice rewards coming if you fulfill these tasks, but if you don't try, there will be consequences. You're going to lose some television."

It's also a parent's job to make sure that the school is part of the solution when it comes to treating a child with GAD. Teachers need to be educated about GAD. In particular, they have to be made to understand that they need to tread lightly when they lay down the law to these children. A policy of "Absences other than for illness will not be excused" will greatly upset a child with GAD whose parents keep him out of school for a special family event. Most kids who hear the standard motivational speeches-"How you do in middle school is very important. It will predict your high school and college performance"-don't give the warning much thought, but children with GAD take the message, and all messages, very much to heart.

These kids have enough worries without being given new ones at school, so finding the right teacher for a child with GAD is critical. If there's a choice between a tough teacher and one who's more nurturing, parents would do well to place a child with GAD in the cla.s.s of the nurturer. A good teacher-student match can make life a lot easier for these youngsters.

CHAPTER 12.

Enuresis/Bedwetting Glen was a terrific kid-smart, confident, personable, a good athlete. He was about to go into the sixth grade. When I met him, his parents had just brought him home from summer camp, and he was desperately unhappy. His fellow campers had come up with a new nickname for him there: "Diapers." At 12 years of age Glen still wet his bed almost every night, and despite his best efforts and those of the camp counselors to keep his bedwetting a secret all summer, the other boys had found out. The last week of camp had been sheer torture.