While being anxious can be helpful in getting things done, a child can be paralysed by too much fear, writes SHEILA WAYMAN.
SIXTEEN-YEAR-old Carla is preparing to play a major series of tennis tournaments in the US. Yet she has suddenly lost not only her serving technique but also all confidence in it.
Anxiety is crippling her abilities. She is thinking: “This is an important match; everybody is going to be watching me; whether I get a college scholarship depends on how well I do; I don’t want to disappoint my coach and parents; I am going to look bad.”
It is athletes like her who go to clinical psychologist Dr Robert Friedberg in Pennsylvania, a specialist in anxiety disorders in children and adolescents. He has pioneered therapy to help youngsters cope with performance, academic or social anxiety that is blighting their lives and holding them back.
Carla is preoccupied with “catastrophic-type beliefs”, says Friedberg. Anxious athletes like her “are getting too far ahead of themselves. We have them break it down.
“They are thinking of the outcome of the match. You focus their attention on individual strokes within a point, so that their concentration becomes doing the things they need to do just at the moment, not thinking points, games, matches.
“Another thing we work with them on is to get rid of outcome goals – winning or losing,” he says. Instead, they are encouraged to put all their efforts into improving their game. “If her first serve percentages are 48 per cent, and she improves to 62 per cent of her first serves in a match, it is a victory, regardless of the outcome.
“She is also comparing herself to others, rather than to herself: ‘This person is moving up the rankings and improving and I’m not’. She needs to be comparing herself to her own goals, her own baseline,” says Friedberg, who is associate professor at the Department of Psychiatry in Penn State Milton Hershey Medical Center.
He will be in Dublin next month to address an information evening for parents/carers on anxiety disorders, as well as to brief fellow professionals on his work.
Anxiety is the most prevalent mental disorder in young children and adolescents, and it is on the increase. About 13 of every 100 children and adolescents aged nine to 17 experience some kind of anxiety disorder, according to a 1999 report from the US Department of Health and Human services.
Friedberg attributes the rise to the greater academic, economic and social pressures on kids today.
“There are limited spots in competitive colleges,” he points out. “They want to get a good education and get a good job because they want to make money.
“They engage in a lot of comparisons with their peers. A lot of cliques are formed: who is most popular, who is most athletic, and who is smartest. They want to be in those cliques.”
However, a little anxiety is no bad thing. It can motivate children to work harder, to concentrate more, to behave better and to avoid dangerous situations. It is over-anxious children who have a problem.
Diagnosis of an anxiety disorder often starts when a child is brought to a doctor with “unfounded bodily complaints”, such as stomach aches, headaches, poor sleep, he explains in a phone interview with The Irish Times ahead of his visit.
But if anxiety is a common and, indeed, natural human emotion, how do you tell if your child has an anxiety disorder?
The big deciding factor is the frequency, intensity and duration of the symptom, he says. “If it happens a lot, lasts a long time and it’s strong.”
Another crucial consideration is how much it impairs the typical activities of a child or adolescent. “Does it affect their school performance? Does it affect their social relationships? Does it affect them going out to play? Does it affect their eating, their sleeping? What typical areas or routines does it impair?”
A child could be frequently anxious but if it doesn’t last long and it doesn’t impair his or her functioning, then he or she is just anxious. There is nothing too much to worry about.
“Usually high achievers have some anxiety, that’s the positive part of the anxiety,” he points out. “The negative part is if it becomes too much and impairing.”
Take separation anxiety, which is a normal phenomenon for babies from about six months, who become upset when a parent leaves the room. But Friedberg sees much older children at his clinic for whom separation anxiety persists.
“In an infant, it is an achievement to have separation anxiety,” he says. “It is a really nice, developmental achievement because it shows the child is able to see when the caregiver is present and not present and experience the stress at the absence of a care-giver.”
A three month old does not know the difference between the mother and another nice woman and is equally soothed by both, he suggests.
By the time children are seven, eight or nine years old, they should no longer be worried by the temporary absence of their parents.
“At this age, separation anxiety is seen as a normal developmental process gone awry; it has passed the normal timetable.”
So it is classed as a disorder and parents are advised to seek professional help.
“One of the interesting things about separation anxiety is that it is something of a culturally constructed diagnosis,” notes Friedberg. “In Western cultures we really value autonomy. We try to get the kid more independent at an earlier age. In other cultures it is not a big deal.”
It is all relative, he stresses. “Again you go back to frequency, intensity and duration and the level of impairment. If a kid is afraid to go to school at age eight and has some anxiety, but it is not frequent, intense or long in duration and he still goes to school, that’s fine. I’m not sure he’s separation anxious – he just doesn’t like to leave home.”
We all know parents who seem to spend their entire lives uptight and stressed out about something, so we’d be hardly surprised if their children took after them. But Friedberg says anxious parents do not cause anxiety disorders in their off-spring, but they may contribute to them, to a lesser or greater degree.
There is an interesting psychological process referred to as the FEAR effect, which stands for: Family Enhancement of Avoidance Responses, he explains. “What happens is the child may feel anxious and then the parent sees the anxiety as bad, when in fact anxiety is very normal.”
So in that family context, what is a normal, natural response to any perceived threat is seen as being undesirable. The parents feel they have to get rid of this anxiety, that the child shouldn’t be anxious.
“The child begins to interpret that there is something bad about being anxious and then the parents also get activated and say the child shouldn’t get anxious and they start to over-protect and over-control. The more they over-protect and over-control, it kind of undermines the kid’s confidence and they think ‘I can’t do it myself’ – that is the cycle.”
For parents dealing with an anxious child, the first rule is to “listen, listen, listen and respond”, says Friedberg. “To really get the whole story, don’t pre-empt it. Once you have heard them, then come up with some sort of strategy.”
The second rule is do not let them avoid the source of the anxiety. “A child may be riding his bicycle and fall off and skin his knee and cry and then be afraid to get back on the bike. But, as any parent knows, you have to get them back on the bike as soon as possible.”
In summary, first you listen and validate their anxiety; then you help them face the fear.
Friedberg is an acknowledged leader in making cognitive therapy accessible to children and he has co-authored several books on the topic. It is an approach which teaches people to confront their negative thoughts, develop new, positive thoughts, and to practise alternative behaviour.
This kind of therapy was initially developed for adults and was too verbally demanding for children. Friedberg describes his work in applying it to children as “dumbing it down; making it more accessible, engaging, simple and fun for kids, through play, experiments, exercises, that sort of thing”.
Essentially he is teaching youngsters to tolerate anxiety, he explains, rather than totally get rid of it. “What you want them to do is to be able to have anxiety and have the anxiety work for them, rather than work on them. That anxiety can be motivating and also anxiety tells you there’s danger there.”
There could be objective danger and there could be subjective danger, and what they do in therapy is teach children to know the difference.
“Where there is objective danger, we teach them problem-solving skills and escape mechanisms to circumvent or stay away from the objective danger. If it is just irrational or subjective danger, then you teach them different ways to evaluate a relatively safe situation so it is not so threatening.”
Depending on the severity of the case, Friedberg would expect to work with a young client for 16-20 sessions.
Having specialised in treating anxiety disorders among children and adolescents for more than 20 years, what attracted him to this area of practice?
“Because anxiety is so prevalent and it is also very treatable,” he says. When he was starting out, he thinks people were not so aware of the importance of early intervention for children and adolescents suffering anxiety.
A particular time for parents to watch out is around the age of seven and eight. At this stage, children become more aware of expectations of them, from parents, teachers and peers, and can start worrying that they are not meeting them.
Entering and leaving secondary school are also vulnerable times in a child’s life. Parents should make sure their children are coping with the big changes involved and not becoming excessively anxious. Generally, boys tend to get referred for anxiety earlier than girls because it is seen as so abnormal in a boy, he says. “With a girl, it’s ‘she’s just a worrier’.
“By adolescence, it’s probably girls who are seen more often. I think when they get to adolescence, boys don’t show the anxiety. They’ve gotten socialised out of it.”
Friedberg’s talk at the Lucena Clinic in Rathgar on June 2nd will be on the eve of the Leaving Cert and Junior Cert exams, when many households will be in a state of high anxiety. What advice does he have for parents in the countdown to the State exams?
Be reassuring and help your children talk through their fears, but also manage your own “catastrophising”, he suggests (see panel).
“You always have to remember that parenting is for the long term,” he adds. “Looking at it as if this is your defining moment is too much of a short-term goal. There are many defining moments in a kid’s life, not just the big exam.”
The anxious exam student
Zoe (17) is preparing for her college exams and she’s experiencing a lot of physical complaints and has problems sleeping. When she takes exams, she gets nauseous and has to leave the room, which means often she cannot finish the exam.
She has beliefs such as “I need to be absolutely perfect in my answers”. This slows her down in her written work.
She feels she has to achieve at an exceptionally excellent level. If she does moderately well, that is a failure in her eyes. Not surprisingly, any exam is very threatening for her and makes her very anxious.
“Firstly, she has what we call all-or-none thinking,” explains Dr Robert Friedberg. “She is either perfect or a dismal, complete failure – there is nothing in the middle.
“What we do is work with her essentially to find that middle ground. It’s okay to get a B, 86 per cent, you don’t have to get a 99. So you work with her to be able to change that belief pattern.
“Then she has another major thinking error, which is catastrophising: ‘If I mess up this test, it is going to be disastrous. There is no recovery; nothing can happen that will make it better.’
“It is another way in which she is overly focusing on the situation.
“What we have her do is to put things in perspective, which is ‘how important is one test?’. We help her see this is a snapshot of her life, not the total end piece.
“Then she also has the sense, ‘because I’m anxious, there is something really wrong with me’. The anxiety of itself is horrible. ‘Because I’m anxious it means something bad is going to happen.’ We help her see that anxiety has nothing predictive; it just means you’re anxious.”
Dr Robert Friedberg will address an information evening for parents and carers on Anxiety Disorders in Children and Adolescents at the Lucena Clinic, Orwell Road, Rathgar, Dublin on June 2nd at 7pm.
Admission is free but places must be booked in advance. To register, e-mail: Marie.mccourt@sjog.ie or tel: 01-492 3596.