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 pass 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 “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 reassurance that they’re doing things the right way. Even so, assessments 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 class. 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?” 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 classic 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, 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, but they don’t know how the children 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 reassure 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); anxiety related to school may suggest separation anxiety disorder (see Chapter 9); and obsessive attitudes and compulsive behaviors about work may raise suspicions of obsessive compulsive disorder (see Chapter 8). In the case of pathological performance anxiety, the diagnosis can be either GAD or social phobia (see 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, 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 Hancock 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 passive about this treatment; a kid doesn’t just sit around while various medical professionals have their way with him. This treatment is 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 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, which even very young children can master, and visual-imagery. 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 participate 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 assignment 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 class 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 mass 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.
It's Nobody's Fault Page 18
