Behavioral therapy works relatively fast. If it doesn’t work right away, it’s probably not going to work, at least not without adding medication. To persist with this type of treatment without adding medicine becomes painful for the parents, the therapist, and, most of all, the child. If a child hasn’t responded to behavioral therapy after about four weeks, it’s probably time to add medication to the treatment. The drugs that have been used to best effect are Tofranil (a tricyclic antidepressant, or TCA), Luvox, Paxil, Prozac, and Zoloft (all selective serotonin reuptake inhibitors, or SSRIs), Xanax (an antianxiety agent), and Nardil and Parnate (monamine oxidase inhibitors, or MAOIs). All of these have been used to excellent effect, sometimes in a matter of days. One mother I know thinks that Prozac worked miracles, and she is not alone.
There can be negative side effects with some of these medications. Tofranil may cause dryness of mouth, constipation, and urinary retention, and there may be some behavioral disinhibition; children can become giddy or oppositional. Tofranil may also affect heart rhythm, so it’s important for a child to have an electrocardiogram at the beginning and with each dose increase. Xanax, which treats anticipatory anxiety as well as separation anxiety, has no effect on the heart rhythm, but it may cause drowsiness and disinhibition in children. MAOIs carry dietary restrictions because the medicine may cause a reaction when taken with foods rich in a chemical called tyramine (aged cheese, red wine, beer, smoked fish, and aged meats). The SSRIs have the fewest side effects. When the dose of an SSRI is started low and increased slowly, there are few side effects. The most common ones are nausea, diarrhea, insomnia, and drowsiness.
Under normal circumstances the medication will take effect within six weeks. A child should continue to take the medicine for at least six months, at which time he should be taken off the medication—gradually, over a period of several weeks—and reevaluated. (I suggest that parents continue the contract policy during this time.) Some children taken off the medicine will redevelop their symptoms, in which case we gradually put them back on medication, enough to make the symptoms disappear; others will continue to be symptom-free without it. It is unlikely that a child will need medicine steadily for a very long period of time—more than a year—but many people diagnosed with SAD require medicine intermittently for many years.
SAD is a serious disorder, but the prognosis for someone with SAD who gets treated is excellent. Left untreated, however, SAD may damage a child permanently over time. If a child can’t separate from his parents, he can’t play with his friends or concentrate at school. If he avoids school, he will fall behind in his studies and lose ground academically, and that in turn will create another group of problems. He may become socially isolated, demoralized, even depressed. (Close to 50 percent of all adolescents who are clinically depressed also have an anxiety disorder. In 85 percent of the cases the anxiety disorder came first.) Twenty-year follow-up studies of children with SAD show that these children are at a higher risk for panic disorder as adults (like Eve, described a few pages back). Parents who don’t take their child’s distress about separation seriously and seek professional help are making a mistake.
PARENTING AND SAD
“Either she’s going into an institution, or I’m going into an institution.”
Those are strong words, especially coming from a mother talking about her intelligent, sweet-faced six-year-old daughter, Melissa. But this, as I soon discovered, was no ordinary six-year-old; this little girl was afraid of just about everything, including loud noises, Hulk Hogan, Big Bird, and the cashier at the local supermarket. She couldn’t look at a newspaper or magazine because she might see a disturbing picture. She became anxious if anything, even a scrap of garbage, was thrown into the trash. At the gas station she was terrified if someone tried to put gas into the car. When she started kindergarten, her mother spent the first two months in the classroom with her. By the time I met Melissa, she refused to leave her mother’s side, even for a moment. She almost never smiled. It’s no wonder her mother was at the end of her rope.
Eight-year-old Matthew was terrorizing his family too. He had been fine in the first and second grades, but starting with third grade he was having difficulty getting up and out in the morning. At the same time he began trailing his mother as she took out the trash, prepared meals, and made the family’s beds. He stood outside the bathroom door until his mother came out, and he crept into his parents’ bed nearly every night. When things were at their worst, Matthew was getting up in the middle of the night with a mirror to make sure his mother was breathing. He couldn’t fall asleep unless his mother was sitting in the room. He always went to school—that’s a firm rule in the family—but he was constantly in the nurse’s office, complaining of headaches and stomachaches. When he got home, he called his dad and stayed on the phone with him for an hour, until Mom got home. Dad has taken to putting Matthew on the speaker phone while he goes about his work.
Another boy with SAD has a mother who is never without her beeper, not because of her work as a real estate broker but because her 13-year-old son must be able to call her a dozen times a day to make sure she hasn’t been in an accident. She and her husband are invited to a variety of business functions and parties at night, but they’ve long since stopped accepting invitations. Too often they were called away after 15 minutes by a baby-sitter unable to cope with their hysterical son.
“We had no life,” yet another mother once told me. “I turned down every invitation. My son couldn’t go to birthday parties. It was too frightening for him. All those people! And what if there was a clown?”
Parents who haven’t experienced SAD may find the concessions that these parents make, the way they change their lives to accommodate a child, almost unbelievable. Even parents who see their children suffering can’t always believe there’s something really wrong. Many kids with SAD don’t voluntarily share their fears, so parents find it hard, if not impossible, to understand their child’s behavior. The word “manipulative” is often used—when a child has a stomachache before school but feels fine when his parents suggest a ballgame or when he seems to play one parent against another, shadowing and clinging to Mom but behaving normally around Dad. The latter situation is quite common, and the typical scenario shows an overindulgent mom giving in more easily than a tough dad. Again typically, fathers become furious and blame mothers for coddling their kids; mothers in turn get angry and accuse fathers of not being sufficiently involved.
Parents’ emotions are often tempered by personal experience too, of course. If one of the parents has had SAD, the reaction can go one of two ways. It’s either “Oh, I remember. It was so horrible, and my parents were so strict with me. I would never do that to my own kid. I won’t make my child suffer the way I did” or “I’m not going to give in to this. I won’t let this affect my child the way it did me.” Complicating matters further is the guilt that many parents feel as they see a child asking for nothing more than to be with them. They see a child in pain and are led to think that by being available they can make that pain go away. It’s not surprising that many parents find it difficult to turn away from a needy child.
Family members don’t always help. In fact, I’ve talked to many parents who find it easier to avoid family gatherings altogether than to put up with the disapproving looks or critical comments they receive from friends and relatives when their child misbehaves. One mother said that family gatherings were the occasions she dreaded most: “We hated holidays, but we were expected to attend, even though they all knew that Jon had problems. We would go, but we were so anxious, so on edge about Jon that we never sat down to chat with the family or eat a meal. We had to be with him every minute, or else he’d make a scene and tear the place apart. I think they all thought, ‘That’s why Jon’s crazy. They never leave that poor kid alone.’ I know they blamed us.”
I suspect that this mother is not imagining her relatives’ reactions. The world is full of people eager to express baseless, ill-consider
ed opinions. One faction says, “This kid’s a brat. The mother should be firmer, harder with this kid. What do you mean, he has a stomachache? There’s nothing wrong with his stomach.” The other side’s take is different: “Why are you being so hard on the poor kid? The kid has a stomachache. All he wants is to be with you. That should make you feel wanted. If he doesn’t want to go, he shouldn’t have to.”
Parents sometimes receive less than useful advice from other sources as well. I once saw a four-year-old girl, Kim, who developed SAD when she started nursery school. A lot of mothers stay with their children in nursery school for a couple of weeks, but Kim’s mom stayed for four months. At that point Kim’s father stepped in and said to his wife, “You can’t do this anymore. You’ve got to stop.” The next morning, a snowy February day, the mother told Kim that she would be going to school on her own, and Kim got hysterical. When the car pool pulled up in front of the house, Mom took Kim outside, at which point the little girl took off all her clothes and started screaming. It must have made quite a picture: snow falling, driver honking, and a stark-naked child shrieking loud enough to shatter glass. Not surprisingly, her parents decided to seek professional help.
Unfortunately their problems didn’t end there. The therapist told Kim’s parents that Kim was acting out because of the recent birth of her baby sister and that all Kim really needed to get her through this difficult period was to be babied. “Give her a bottle and some dolls, hug her a lot more,” the therapist said. By the time I saw Kim she could barely let her mother out of her sight without hysterics. After six weeks of behavioral therapy and a low daily dose of Zoloft she was attending school—fully clothed—without a problem.
Some aspects of the treatment of SAD are subject to debate, but everyone agrees on one thing: kids have to go to school. Missing school is one of the few true psychological emergencies for a child, a major danger sign. The longer a child is out of school, the harder it is to get him back. Home tutoring is sometimes recommended, even by some school officials (who should know better), but I’m completely opposed to it. Having a tutor may relieve anxiety over the short term, but in the long term it makes things worse. The sooner a child returns to school the better, and parents who enlist the aid of the school in the process will get the best results.
If a child has been out of school for a long time, it’s unfair to make him go for a whole day right away, so the teacher and principal should be notified that a child is going to need a more flexible schedule for a while. One mother I advised went to the principal and said, “Here’s the deal. I want my kid back in school, but it’s going to take time. The doctor says it’s important to get him back slowly. The first week he’s only going to stay an hour a day. For that hour I’d like him to stay in the library. The next week he’ll stay for two hours a day, maybe with the guidance counselor or the school psychologist. After that I’d like him to go back to his class.” The principal agreed to help.
A child can be reintroduced to school even more gradually than that. Another little boy I treated took two weeks to get back to his regular classroom. The first day all he did was walk in the front door of the building without his mother. Then he turned around and left. Each day he got a little closer. Again, the principal was more than eager to cooperate and made sure that the boy had the work he was missing to take home with him every day. It is the rare school official who takes a hard line about attendance when SAD has been diagnosed, although once in a great while a principal may insist that a child be “in or out.” If that happens and simple reason doesn’t prevail, the child’s doctor should be able to help parents clear any hurdles erected by the school authorities.
In any successful treatment of SAD parents must be co-therapists, and that takes commitment, patience, and a structured plan. It’s rarely easy. Checking on a child every 10 minutes in the evening after a full day’s work is no parent’s idea of fun, but the knowledge that next week it will be every 15 minutes and the week after that once every half-hour should provide some comfort. So should the prospect of going out to a movie or not sharing a bed with a five-year-old every night. Efforts made today will pay dividends later, in the form of a healthy, well-rounded, happy child.
CHAPTER 10
Social Phobia/Shyness
The day I first met Rebecca, 16 years old and just coming to the end of her junior year of high school, she had made herself so small that it looked as if she were trying to disappear into the woodwork of my office. I greeted her and asked her how she was feeling. There was no response. I tried again, but she said nothing. Finally, after I asked a third time, I got an answer. “I don’t have any friends,” she said in the softest voice I’ve ever heard, barely a whisper. “I can’t talk to people.” For Rebecca, that statement was practically the Gettysburg Address. As I discovered, she almost never talked to anyone. She didn’t answer her teachers’ questions in class or chat with her classmates. When she used the school bathroom, she had to be alone; her one friend stood guard in the hallway outside the door to assure her complete privacy. She ate by herself in the school cafeteria. If someone joined her, she moved to another table and scattered papers and books around to discourage others. Then she hid behind a notebook while she ate. Rebecca had a number of other anxieties as well, each of which has an element of social concern. She worried that teachers would call on her in class. Any kind of social interaction forced her anxiety level through the roof.
Ten-year-old Eric is in fifth grade. He’s been in therapy since he was five, with three different therapists. The first diagnosis was separation anxiety disorder, because Eric was afraid to leave his house in the morning. Every day since kindergarten his parents had had a battle royal on their hands when they tried to get him ready for school. Extremely bright, Eric did well academically once he got to school, but socially he was having problems. He didn’t have a single friend. If another kid tried to start up a conversation with him, Eric responded in monosyllables and retreated to a corner somewhere. The teachers tried to involve him in activities, but he was having none of it. He would talk to his teacher but only one-on-one, never in a classroom setting. Eric was terrified that he was going to say or do something so stupid that it would make everybody hate him. If he stayed home, he reasoned, that wouldn’t happen. By the time I met Eric, I had to make a house call. When I got there, he was hiding under his bed.
BEYOND SHYNESS
“I was really shy as a kid. I was one of those youngsters who’d hide behind my mother’s leg when my aunts came to visit.”
“I’m okay in most social situations, but I don’t really like them. I really have to push myself to talk to people.”
“I hate parties. I never know what to say. I couldn’t do it at all without a glass of wine.”
Everybody is shy some of the time. Meeting strangers, making a speech, being the guest of honor at a surprise party—those are not situations that most people consider relaxing. Some years ago it was reported that the three greatest fears of the American people are death, heights, and speaking in public. (In fact, speaking in public ranked higher than death!) Of course, some are more shy than others; they’re usually the ones standing behind the potted plant hoping no one will spot them or over by the bar having a third cocktail to loosen their tongue. Many people outgrow their shyness—by the time they’re too big to hide behind Mom’s leg when the aunts come to call, they don’t feel the need to do it anymore—but others continue to be uneasy in specific situations. Shyness is a perfectly natural response to events, especially in children and adolescents. As long as it isn’t excessive, as long as it doesn’t seriously interfere with a child’s ability to function, shyness is nothing to be particularly concerned about.
Obviously, Rebecca and Eric are not functioning very well. Both children are suffering from social phobia, an anxiety disorder characterized by the persistent fear of being scrutinized and judged by others and of doing or saying something that will be humiliating or embarrassing.Some children become so concerne
d that people will be critical of them that they become unable to speak, drink, or eat in front of other people. Others are afraid to use public toilets, not because they worry about hygiene but because they worry about doing something that will make them look bad.
The key to this brain disorder is intense self-consciousness. Children with social phobia are basically afraid that they’re going to do something the wrong way and consequently look foolish to others. They don’t speak in class because they’re afraid they’ll get the answer wrong or say it in a voice that will sound strange. They don’t eat in public because they might spill their food or choke. They have trouble urinating in a public toilet if anyone is around. Children with social phobia believe that all these things (and many more) will make them seem stupid. They’re afraid that people will mock them for their inadequacies.
Children and adolescents with social phobia have not lost touch with reality. When confronted with the force of logic, these kids will readily acknowledge that their fears and anxieties don’t make a whole lot of sense. They know that they’re being “silly,” but they just can’t help themselves.
The numbers on garden-variety shyness are astronomically high, but true social phobia is thought to be uncommon among young people, affecting about 1 percent of the child and adolescent population. (Recent studies have found that social phobia affects as many as 12 percent of all adults.) The symptoms of social phobia are usually noticed in adolescence, especially the mid-teens, but we have good reason to think that adolescence is not when the symptoms actually begin. Teenagers with social phobia often report a long history of painful shyness or social inhibition, but until their teens, they were able to cope. With the increased demands and expectations of adolescence—part-time jobs, interviews for college, dating, and other social pressures—come the distress and dysfunction that bring these kids to psychiatrists’ offices. Even perfectly normal teenagers usually go through a patch of greater-than-average self-consciousness. Teenagers with social phobia go off the charts during these years.
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