Tarnow Articles

Anxiety in Children and Adolescents 

As child psychiatrists, we are frequently called on to evaluate children who are having difficulties at school. Symptoms ranging from sporadic grades, poor test performance, attentional problems, or decreased enjoyment at school, to outright school refusal may precipitate an evaluation. The combination of difficulty concentrating and a discrepancy between the child's ability and the child's actual performance often brings teachers and parents to suspect Attention Deficit Hyperactivity Disorder (ADHD), since the public has become educated to both the "hyperactive" and "inattentive" forms of ADHD.

It has been an exciting development that children who are struggling in school are more frequently referred for an evaluation early in their schooling. No assumptions are made during an evaluation. It is the job of the psychiatrist to consider all etiologies of poor attention and decreased school functioning as well as comorbid or contributing factors. Through our work, we have found that anxiety is often the sole etiology or primary contributing factor in decreased school performance.

Anxiety in childhood is problematic in many arenas. Social anxiety, once thought of as simply "shyness", does more than cause a child or adolescent to have difficulty with peer relations. For example, anxiety has been proven to decrease memory ability as well as the ability to focus and concentrate. On this level, more than self-esteem is on the line as grades begin to fall. When anxiety becomes overwhelming, a person will naturally avoid an anxiety-producing stimulus. Hence, school refusal may begin.

Many of the assessments we perform for school refusal reveal a child or adolescent that has panic attacks or other overwhelming anxiety symptoms in the classroom. A typical day at school provides endless potential stressors. From the peer interactions on the morning bus ride to the timed test situation to a low grade that may halt a season of sports or other school activity, a child has many opportunities to test the "fight or flight" response. The "fight or flight" response is controlled by the adrenalin system. When this system is on, one feels stress or anxiety. In school, this anxiety is typically experienced as distraction. Therefore, the teacher may send home frequent notes regarding the child's inattention to tasks. Parents and teachers may begin to suspect ADHD.

Anxiety is helpful in "normal" doses. Anxiety aids in motivating someone to study for a test, or avoid a situation that may be dangerous. The trick is that "normal" anxiety decreases once the danger is gone or once the material has been studied. In an anxiety disorder, the anxious state persists when no danger is present. The child will often tell us he/she knows it does not make sense, but he/she cannot stop worrying about an event such as a test even though the child is well prepared. This is the student that insists "I know I knew it!", but was unable to recall the information during the exam. We often hear "My mind went blank." Add several of these bad experiences, which we call "freeze responses", together and the test situation becomes a stimulus for a panic attack. In a panic attack, the child commonly experiences an intense sense of doom and feels he/she may soon die. A simple pop quiz can now be experienced as a life-threatening stressor. Logically, the child knows this is not true, but the anxiety can still be experienced as if it were. School avoidance or refusal results.

As mentioned above, another school performance anxiety is the "freeze response". This is the scenario in which the student is prepared but the mind goes blank at test time. The child may feel immobilized by stress and stare off, appearing glazed over or "not with it". Teachers often believe the child was unprepared or "lazy". The child will insist he/she knew the material during the review the night before the exam. Parents are often baffled as they helped their child review and agree that the information seemed well learned. Nevertheless, at test time, his or her mind "went blank". This particular type of academic anxiety is often confused with the inattentive type of ADHD.

In addition, children with anxiety at school may act out with disruptive behaviors. The disruptive behavior is typically an action that helps the child avoid the anxiety-producing stimulus. This can include talking, skipping class, "forgetting" assignments, fighting, and even substance abuse to produce an altered state of mind. Obviously, the disruptive behavior is not helpful in solving the problem, but at the moment it can be an acceptable alternative to that dreadful anxious feeling. Teaching the child appropriate tools to decrease the anxiety becomes paramount.

Knowing that severe anxiety decreases school performance and may lead to behavior difficulties, it comes as no surprise that family conflicts often arise. The level at which parents should set and maintain limits is commonly questioned. Many parents may not recognize that their parental limits/ expectations may exacerbate the symptoms. Parents who do not understand that avoidance is behind the disruptive behaviors are left baffled and often quite angry. Either way, support and education to the parents is crucial. Changing communication patterns in a family can help decrease family friction. This friction may certainly serve as fuel to an anxiety disorder. Support to the child is also critical as the anxiety and resulting problems may lead to depressed mood, lowered self-esteem, and impaired teacher / family / peer relationships.

Treatment of anxiety disorders in children and adolescents needs to be individualized and multi-faceted. It must include education for the child, family, and teachers, as well as arm the child with new strategies to combat the anxiety. These strategies include individual biofeedback, self-hypnosis, and family therapy. Supportive, insight-oriented, and cognitive behavior therapies can also be important tools to decrease the intensity of the adrenalin response to stress. School-based therapies may also play large roles.

Finally, medication has long been an important component in the treatment of anxiety disorders. More and more studies are being performed in children and adolescents. This has been exciting in that the evidence consistently reveals that the SSRI medications are effective in lowering anxiety levels. In many cases, the anxiety is so intense that the medications are necessary to lower the adrenalin system's response so that therapy can begin.

The Medication Corner, provided by the Tarnow Center for Self-Managementsm, is a featured article in each of the ADDA Newsletters. The article will provide you with the latest information and research about the medications that are being used to treat Attention Deficit Disorder. Debra C. Stokan, M.D., and Jay Tarnow, M.D. will keep you abreast of all the latest happenings in the medical community. In order for us to address your needs, we would like to encourage you to "ask the professionals" your questions. Write the Tarnow Center for Self-Managementsm with your questions and we will see that they are answered in each edition of the newsletter. You may contact us at: Tarnow Center for Self-Managementsm: The Medication Corner, 1001 West Loop South #215, Houston, Texas 77027, or fax: (713) 621-7015, or call: (713) 621-9515, or visit www.tarnowcenter.com.