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 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 reassurance 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 associated with GAD involves extended exposure, or 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 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 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 reassure her that her feelings of distress and anxiety will soon pass. 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 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 well liked by their peers. It’s not surprising, really. The symptoms associated with GAD are not likely to make a child the most popular kid in his class. 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 assignments 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 assignment 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 productive.”
Behavioral therapy methods can be made to work on nearly all symptoms associated 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 assignment, as in: “Look, it’s important for you to try to do this. You’ve got some nice rewards coming if you fulfill these tas
ks, 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 class 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.
Six-year-old Victor was having a lot of difficulties in school, academically and socially. His speech hadn’t developed according to the normal guidelines, and he was inattentive, occasionally disruptive, in class. His social skills were similarly undeveloped, and the other kids in school often made fun of him. His parents suspected that Victor had a learning disability, and one of the teachers told them it might be attention deficit hyperactivity disorder; this is what finally brought them to my office. It was only after I had seen Victor a couple of times that I found out that he regularly wet his bed at night and sometimes wet himself during the day. The parents were well and truly disgusted with their son and made no effort to hide their negative feelings. When he came to see me, Victor was so downhearted that he spoke barely above a whisper.
THE BEDWETTING DEBATE
Most children stop wetting their beds at night by the age of three, or five at the latest, but some—estimates put it at five to seven million kids—have trouble with this task. Those children suffer from enuresis, often referred to as bedwetting. According to the textbook, enuresis is the involuntary passage of urine at least twice a week for a period of three months in children over the age of five. It may occur at night or during the day.
The disorder affects twice as many boys as girls. At age five the breakdown is 7 percent male versus 3 percent female. At age 10 it drops to 3 percent boys and 2 percent girls. Enuresis is rare in people older than 18: only 1 percent of all males and about half as many females continue to be bedwetters after age 18.
There are two basic categories of enuresis: primary and secondary. A child who has never been fully trained—that is, a child who has never achieved a six-month period of dryness at night—falls into the primary enuresis group, the more common of the two. A diagnosis of secondary enuresis applies to kids who have been dry for up to a year and then start wetting again. Secondary enuresis usually occurs between the ages of five and eight. (A sub-category of secondary enuresis is transient, or temporary, enuresis. This condition is brought on by trauma or stress, such as a divorce in the family, and may last anywhere from a couple of weeks to several months.)
There’s a high spontaneous recovery rate with enuresis; that is, the problem goes away all by itself. Some sources put it as high as 15 percent, lower with boys than with girls. It’s not difficult to understand, then, why many pediatricians send concerned parents who seek their advice about a child with enuresis away with a cavalier, “Oh, he’ll outgrow it.” There’s a good chance the child will outgrow his problem, but there’s also the distinct possibility that he won’t.
Experts, by whom I mean pediatricians, urologists, psychiatrists, and psychologists, disagree about the age at which a child should be diagnosed with enuresis. The Diagnostic and Statistical Manual of Mental Disorders declares that five years old is the cutoff point, but some pediatricians feel that it’s better to wait until a child is seven or eight before diagnosing enuresis. Why spend time and money, they ask, treating a child who’s going to get better all by himself? There’s a major flaw in that argument, however: a large percentage of the children who are wet at age five will still be wet at age seven, two years later, and the longer a child has this symptom, the more likely he is to experience negative social consequences, including serious family conflict. Furthermore, a child is entitled not to be uncomfortable.
Controversy or no, if a child is five years old and enuresis persists for three months or more, I believe that something should be done about it. Parents should consult as many health professionals as it takes to satisfy themselves that their child is all right. If they don’t, that child could end up with a nickname that will haunt him for a long long time.
THE SYMPTOMS
Most younger children with enuresis, age five and six, aren’t especially bothered by their condition. True, they probably don’t enjoy waking up in wet sheets or seeing their parents get annoyed at them every morning, but the level of distress and dysfunction in these kids is generally quite low. As children get older and become more interested in having an active social life, enuresis begins to interfere more seriously in their lifestyles. Sleepover dates, summer camp, slumber parties—all these things are huge obstacles for the child with enuresis. (I treated a 13-year-old girl who used to stay up all night at pajama parties, even when everyone else was sound asleep. She was terrified that she’d have an accident in front of all her friends. Once, unable to keep her eyes open a moment longer, she spent a few hours dozing in the bathtub behind a locked door.) If a kid has a problem with wetting during the day, even going to school can be a trial. I’ve comforted more than one child who has been brought to tears when his classmates made fun of him because of the telltale odor of his wet pants.
THE DIAGNOSIS
It is estimated that two thirds of all bedwetters never even make it into a pediatrician’s office. Of those who do get to a pediatrician a sizable percentage are sent home with instructions to watch and wait. The kids who are referred to psychologists and psychiatrists are nearly always sent there because they have other behavioral problems, such as ADHD, learning disabilities, or aggression. Kids who have enuresis generally will show signs of other maturational delays, including speech lags and learning difficulties. Enuresis may also be a symptom of a power struggle between a parent and child.
Diane was a 10-year-old girl who was referred to me because of attention deficit disorder (see Chapter 7). There was no hyperactivity associated with Diane’s disorder. In fact, Diane had a kind of dreamy, otherworldly quality, as if she were in some kind of trance. The little girl was an incredibly heavy sleeper, and she wet her bed nearly every night without even waking up.
Her patents told me that some nights Diane would be watching television, and, sitting on the sofa with the rest of the family, she would just urinate. To hear Diane tell it, she knew she needed to go, but she didn’t want to get up. Other times she’d just sort of forget about it until it was too late. Everyone in her family was furious with her, naturally, but Diane really didn’t understand why they were making such a big deal out of it.
Interviews with children who have enuresis are not usually very fruitful. Most children find it hard to explain their behavior.
“I don’t know why I do it,” one child might say. “It just slips out while I’m sleeping. I d
on’t even know it’s happening.”
“I don’t want to wet my bed. Sometimes I try to stay awake all night just to keep from doing it,” says another.
“I think I was dreaming about going to the bathroom,” says a third kid.
“Sometimes I’m too tired to get up and go to the toilet. I’d rather sleep,” says a fourth.
The same few themes run through all the experiences of these children: I was playing with my friends and didn’t notice that I had to go to the bathroom until it was too late; I was sleeping so hard I didn’t even realize I had to go; I knew I had to go, but I couldn’t wake up in time. Each one is a clear indication of enuresis.
THE BRAIN CHEMISTRY
There are many theories about what causes enuresis. The most widely held is that the primary cause of enuresis is a maturational lag. Some of the systems in these kids, including the bladder and the brain, are not maturing as quickly as is to be expected in normal development.
There are experts who put all the blame on a child’s bladder. Many kids with enuresis do, in fact, have a lower functional bladder volume than children without enuresis; this means that a child with enuresis will urinate as much as a normal child over a 24-hour period in terms of volume, but he will need to urinate more frequently in order to put out that same volume. The problem with this theory is that there are many people in the general population who have low functional bladder volume but do not have enuresis.
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