Childhood Anxiety: Treating the "What" Rather Than the "Why"

     

Recently, while studying for my recertification exam as required by the American Board of Pediatrics, using the PREP course offered by the American Academy of Pediatrics, I came across this question:

     A 7-year-old girl is having difficulty establishing relationships with other children despite repeated opportunities to do so. The girl prefers to stay near her mother or her teacher and will avoid other children. She sometimes cries and can be difficult to calm down after being dropped off at school, so her mother frequently remains in the classroom for a few minutes before quietly leaving. On days when morning transitions to school are significantly difficult, her mother will allow her to stay home. Her mother reports that, in preschool, things were worse in that she usually "couldn't" leave her daughter in the classroom. The girl typically speaks little when in public, but she speaks normally when home alone with her mother. She is an only child and the parents are divorced. When the girl spends the weekend at her father’s house, she often expresses worry that something bad is going to happen to her mother. Her mother frequently allows the girl to sleep with her to avoid temper tantrums or nightmares about sleeping alone. Of the following, the BEST next step in this child’s care is  

       A.   Initiate treatment with an SSRI (selective serotonin reuptake inhibitor)
B.   Reassure her mother that her daughter’s problems should resolve without intervention
C.   Refer for neuropsychological evaluation to assess for cognitive impairments
D.   Refer her to a cognitive behavior therapist to work on skills for managing her distress
E.    Refer her to a play therapist to assist the child in recognizing the cause of her distress 

The “correct” answer is D- refer her to a mental health specialist to initiate cognitive behavioral therapy (CBT). Medication is suggested as a second line of intervention if CBT is not effective. In other words change her behavior, but do not offer opportunity to discover the cause. Play therapy, the only alternative form of therapy suggested, leaves it up to the child and therapist to discover the cause.

What might be the cause of her anxiety? Is her mother depressed? Her father? Is there substance abuse in either parent? Did she observe conflict, perhaps even violence, between her parents in the years preceding their divorce? Is there a family history suggesting a genetic vulnerability for anxiety? Does she have sensory processing challenges that cause her to be overwhelmed in the stimulating classroom? Some combination of all of these?

One child I saw with such symptoms had a mother who lay in bed all day in the wake of a pregnancy loss. This child was terrified that something would happen to her mother while she was in school. 

Perhaps this child’s mother had similar struggles with anxiety as a child. But rather than being met with understanding, she received a slap across the face. She may be terrified that her daughter will suffer as she did. If she is flooded with stress in the face of her daughter’s behavior, she might, without thinking, lash out. Or more likely, as her maternal instinct to protect her child overrides a rage response, she might shut down emotionally. Either way, her child will be alone with these difficult feelings. 

I took care of one child who had been diagnosed with anxiety disorder by her previous pediatrician and came to me to get her prescription refilled. After several hour long visits, some with her alone and some with her mother, I learned that every weekend her father drank heavily, leaving her at the age of eight to care for her two younger brothers.  

Where in the treatment plan recommended by the AAP is there opportunity to uncover such a story? Parents may experience terrible shame about their own behavior. Taking a history, in one visit, that reveals "no psychosocial stressors" is inadequate. Parents share this kind of information when they feel safe. Safety comes in the setting of time and space for nonjudgmental listening.  

One much-cited study compared CBT, SSRI, the two in combination, or placebo. No treatment arm existed for listening to the parent, for discovering the meaning of the behavior.

This child’s behavior is a form of communication. Behavior management, and the close second of medication, serves to silence that communication. When we teach a child skills to manage behavior, the story may be buried, emerging years later, sometimes in the form of serious mental illness. 

When parents can make sense of a child's behavior,  they are in an ideal position to support that child in managing his or her unique vulnerabilities. In a way, parents are best suited to provide a kind of cognitive behavioral therapy. They can help a child to name feelings,  identify provocative situations and develop strategies to manage these experiences.

By bringing in to awareness the way a child's behavior may provoke their own difficult feelings, and in a sense moving these feelings out of the way, parents can be fully emotionally present with a child in a way that supports healthy emotional development.

When a child is young, there is opportunity to offer support for parents and children together and so alter a child’s developmental path. But when, rather than supporting parent-child relationships, we treat the problem as residing exclusively in the child,  such opportunities are missed.

Investing in early childhood means investing in infants

Why is this so difficult for us to see? The United States has one of the most restrictive parental leave policies in the world, as my fellow blogger Claire McCarthy accurately described in a recent post. We fail to recognize the importance in investing in early relationships. The closest we seem to be able to get is age four. But the abundance of research at the interface of developmental psychology, neuroscience and genetics tells us that 4 years may be too late.

I wonder if the answer lies in child development researcher Ed Tronick's  still-face experiment. I remember well when I first learned of his research. I felt a kind of outrage, asking "how did he get this past the IRB( institutional review board for human subjects)?" In his well-known experiment, a mother plays with her infant in a usual way, then presents a still-face for a specified period of time, and then resumes normal interaction.

I now work closely with Dr. Tronick and well recognize the brilliance of his work. He sometimes remarks that it is his students in his Infant Parent Mental Health program at UMass Boston who seem to have the most initial outrage at seeing the experiment. I now understand that as a kind of deep empathy with the experience of both the mother and the baby. With that comes a passion for protecting this relationship, a passion that drives those of us who chose this field.

There is a great poignancy to recognizing the tremendous capacity of the newborn to communicate when we have a system that fails to support stressed early parent-child relationships. The Newborn Behavioral Observation System developed by T. Berry Brazelton and Kevin Nugent beautifully brings out these capacities.

But if a parent is stressed in the setting of such things as emotional distress, her own history of abuse, marital conflict and domestic violence, social isolation and poverty, being available to her infant in the way he needs is difficult. This is where the investment needs to be. Not 4 years, but 4 months, 4 days, 4 hours.

In Sunday's New York Times Nobel prize winning economist James Heckman has an op ed Lifelines for Poor Children where he again speaks to the need to invest in early childhood. He refers to Obama's policy proposal. However in the actual text of Obama's proposal there is relatively little for infants. The emphasis is on the four-year-old.

All we know about the science of early childhood tells us that the brain grows in relationships. The volume of the brain doubles in the first year. The brain makes millions of synaptic connections every minute. It is in infancy that the parts of the brain responsible for emotional regulation have the most rapid development.

 A startling article in the New York Times Can Emotional Intelligence Be Taught? begins with a vignette from a Kindergarten classroom where a child says, "My Mom does not like me," When he describes how his mother screams at him every day, he is taught how to handle the situation in a calm way. Somehow the tables are turned and it is the child's responsibility to manage his out-of control mother. The answer is not to teach this child emotional regulation, but to help this parent-child pair to grow together in a healthy loving way. And this help needs to start in infancy.

This week I will again attend a meeting of Representative Ellen Story's postpartum depression commission at the State House. It is always an uplifting experience as leaders in the field grapple with the question of how best to support parents and young infants. The commission recognizes that this work occurs primarily in the realm of health care, which is where young infants and their parents can most reliably be found.

Sleep and childhood behavior problems: a complex relationship

A study published in the July/August issue of the Journal of Developmental and Behavioral Pediatrics showing a connection between hours of sleep and childhood behavior problems has received a lot of media attention. Children who slept less than 9.4 hours of sleep had more impulsivity, anger, tantrums and annoying behavior. The obvious conclusion-more sleep, better behavior. If only it were that simple.

If one takes the time to look closely, one will discover that what is correctly described as an "association" in the original article is in fact two interlinked phenomena that have a common underlying cause. Sleep problems are behavior problems. To know the cause, one must know the family story.

Sleep is a developmental phenomenon. In infancy a child learns what is commonly called "sleep associations." The breast, a pacifier, a lovey or even a parent's hair may be what a child associates with falling asleep. Frequent night wakings, expected by parents in the early weeks and months, can become a problem if that sleep association requires a parents' physical presence. As the months wear on parents become severely sleep deprived, and often find that this pattern is not so easy to change. In toddlerhood as a child in a normal healthy way begins to assert his independence, he may resist bedtime in the way he says "no" to many things. Further complicating the picture is the fact that sleep represents a major separation. A child who handles the first day of preschool with grace may suddenly refuse to go to bed, or begin waking during the night.

Given the complexity of this process, there are many ways it can get derailed. If parents do not agree about teaching a child to sleep independently, a child in the bed can cause significant marital discord.  When  parents struggle with depression, and this includes both fathers and mothers, they will have aggravation of symptoms, which often includes irritability. in the setting of sleep deprivation. When a parent is quick to lash out at a child, he may become anxious. Sometimes this anxiety leads to "acting out" in the form of oppositional behavior. It seems illogical, but a two-year-old doesn't know how to say "I need you to be with me and I feel sad when you are angry." He may simply see that when he is "difficult" his parents are more engaged with him. Separation anxiety is common in these situations, and sleep is a major separation.  Bedtime refusal and frequent night wakings are common in this setting. This leads to a vicious cycle as both parent and child become increasingly irritable.

These are some examples, and there are as many different stories as there are families. By the time parents come to see me at the Early Childhood Social Emotional Health Program with behavior problems, which in my experience always include sleep problems, they may be hard pressed to describe moments of joy with their children.

I feel for the parent who reads an article with the title More Sleep Might Help Tots' Tantrums, with its recommendation to have a child get more sleep to improve behavior, and is unable to change the situation because the underlying cause is not addressed. This is where our culture of advice and quick fixes can lead parents to be overwhelmed by feelings of inadequacy and guilt.

The key to treating these complex problems is to give parents space and time to tell the full story. When parents themselves feel heard and understood, they are in a better position to be curious about the meaning of their child's behavior.

This study is important because it calls attention to the need to address sleep in the setting of behavior problems. However, when a child and family are struggling, simple recommendations have a child get more sleep are not only not helpful, but may make parents feel worse. A downward spiral of sleep deprivation and behavior problems will likely persist.

If a family and clinician has the time, then it is possible to make sense of the situation and take steps to set the whole family on a better path; to bring joy back in to relationships.  The younger the child, the easier this is to do.

Childhood trauma: stories that must be told

My 51st birthday is approaching. My father is 87 years old. Yet it was not until this spring that I learned details of the story of his childhood in Nazi Germany, his escape to America as a teenager, and his dramatic rescue of his parents from the concentration camp Theresienstadt when he returned to Germany as a soldier with the United States army.  It took his grandson, my 13-year-old son, to get him to break this silence, when my son requested that his grandfather speak to his 8th grade class following their visit to the Holocaust museum in Washington, DC.

My father's story is one of not only survival, but of triumph in the midst of unimaginable horror. He would never use the word "trauma" to describe his experience.  Bits of the story had emerged at times, in part around my daughter's bat-mitzvah 4 years earlier. But in general he ascribed to Elie Weisel's notion that it was a horror so great it could not be spoken of.

French psychoanalysts Francoise Davoine and Jean-Max Gaudilliere have a different adage on the cover of their book, History Beyond Trauma; "Whereof one cannot speak, thereof one cannot stay silent." They argue that personal stories of war and societal trauma, if not told in words, emerge as symptoms, sometimes as mental illness, sometimes in subsequent generations.

Davoine offers a wonderful example in a story of her own family. She and her husband were on a trip with their young children when she discovered a growth in her abdomen. Despite a fear of cancer, they decided to say nothing to their children and finish the month-long trip. Shortly after the discovery, her son developed severe anxiety around bedtime and refused to go to sleep. It emerged that, being highly sensitive to his parents emotions, as children can be, he was worried, but didn't know what to be afraid of. When his parents explained about the lump, his sleep problem resolved. They write:

Let us imagine, for a moment, the following catastrophic scenario: continuing to play the admirable mother, Francoise keeps the secret. The child would find himself burdened by the cut out truth of the story. Rushing into a hyperactive exploration, or barricaded in a hyperpassive withdrawal, nowadays he might have been quickly diagnosed and chemically brought back to reason.

In my behavioral pediatrics practice, I often hear stories like this from parents, both of major trauma in the form of such things as abuse or death of a sibling, or subtler trauma of having an emotionally troubled parent. At first parents focus on the child's "behavior problem." But in a non-judgmental atmosphere where sufficient time is given,  parents are usually eager talk about their own history, and become curious about the effects of their experience on themselves as parents, and on their child.

For example, a 4-year-old girl  had severe separation anxiety. It emerged that her mother had a miscarriage when she was three, and had never had the opportunity to mourn the loss. Her daughter was worried about her, and so did not want to leave her either to go to school or go to sleep.  A father of another boy with "defiant behavior." had been abused by his own father, and found himself full of explosive rage that came out, against his will, in his relationship with his young son.

In recent posts I have been focusing on qualities a child brings to the relationship with his parents. In our quest to understand a child's experience, this is an essential piece. But equally important is to understand what parents bring to the relationship, in particular in terms of their own unique history. Parent-child relationships are a complex, intricate dance. At times they can be clumsy and full of stepped on toes. But with work and careful attention, they can be transformed back into a dance of joy and grace.

I am blessed by the fact that my father is alive and in good health. I am hopeful that we now have the opportunity to write a book together telling of both his remarkable life, and also how his experience came to be known by me and my children. It will serve as a dramatic example of a story that needs to be told.