«Sally Patton UNITARIAN UNIVERSALIST ASSOCIATION BOSTON Copyright © 2004 by the Unitarian Universalist Association of Congregations. All rights ...»
Specific Phobias. According to the Anxiety Disorders Association of America (ADAA), a specific phobia is diagnosed when a fear becomes a central part of an individual’s life after six months and starts to interfere with his or her daily activities.1 In more general 142 Welcoming Children terms, a specific phobia is an intense reaction to or irrational fear of a specific object that is generally not considered dangerous and avoidance of that object. For example, a small child may fear large dogs. Even if a specific dog is friendly, the child will avoid that dog and then all large dogs and eventually all dogs. When adults struggle with phobias, they usually realize that their fears are irrational.
However, most children have difficulty articulating their fears and do not realize when those fears are irrational or out of proportion to the situation. Thus, common childhood phobias include animals, storms, heights, water, blood, the dark, and medical procedures. Specific phobias in children are most common between the ages of six and nine years old and are not usually debilitating. They generally disappear as children grow older.
Agoraphobia. This anxiety disorder is sometimes defined as an anxiety disorder distinct from specific phobia. It affects one in twenty in the general population.2 Agoraphobia is an allencompassing anxiety that renders people unable to participate in most social situations. According to John S. Dacey and Lisa B.
Fiore in Your Anxious Child, agoraphobia is actually about the fear of losing control in public places.3 People with this condition feel so anxious about being vulnerable in unfamiliar surroundings that they are reluctant to leave their own homes. Agoraphobia is uncommon in early childhood and usually begins to appear in adolescence or young adulthood. Most children and adolescents with agoraphobia experience panic attacks.
Social Anxiety Disorder (SAD). Sometimes called social phobia, SAD is characterized by persistent anxiety in social situations, usually because of the threat of embarrassment, scrutiny, or humiliation. Individuals with this anxiety disorder are intensely selfconscious and concerned about what other people think of them.
And even though they may realize that these feelings are exaggerated, they cannot control them. Among children, SAD is most common in middle childhood and adolescence, although it can be 143 Anxiety Disorders found in preschool and grade school children who are excessively shy. If left unresolved, SAD can lead to isolation, depression, and substance abuse.
Selective Mutism. This condition is considered a symptom of SAD or a severe form of SAD. Some younger children avoid certain social situations by shutting themselves out verbally; thus, they will speak in some social situations but not others. The onset of selective mutism usually occurs before age five but is not considered serious until a child enters school. Although children are generally diagnosed between the ages of four and eight, they were probably extremely shy previously. Selective mutism can also be a symptom of posttraumatic stress disorder (PTSD) resulting from sexual abuse. Maya Angelou’s book I Know Why the Caged Bird Sings is a classic story of selective mutism due to sexual abuse.4 School Phobia. Children who refuse to go to school may have one or more anxiety disorders. Sometimes refusal to go to school is considered a single anxiety disorder referred to as school phobia.
Some professionals place school refusal in the SAD category. It can also be a response to agoraphobia or part of separation anxiety disorder, obsessive-compulsive disorder, or generalized anxiety disorder. In general, most professionals view school refusal as a symptom or behavioral response to anxiety, rather than a single anxiety disorder.
Anxiety-based school refusal affects 2 to 5 percent of the school-age population. If left untreated, it can lead to serious consequences in socialization skills, self-esteem, and school performance. The most common stressors leading to school refusal are separation anxiety, concerns about academic performance, anxieties about making friends, and fear of a teacher or a bully. Common school fears include being separated from caregivers; riding on the bus; eating in the cafeteria; using the school bathroom; being called on in class; changing for gym; interacting with other children or teachers; and being picked on by peers or older children. 5 144 Welcoming Children Separation Anxiety Disorder. It is normal for very young children to feel anxious when separated from their parents or caregivers.
Usually by the age of four, children can cope with this anxiety or be distracted from it. When children over the age of four are unable to or exhibit excessive anxiety about leaving their parents over a period of at least four weeks, they are probably experiencing separation anxiety disorder. In younger children, this disorder exhibits itself as crying, clinging, and/or panic. In older children and adolescents, the signs of separation anxiety disorder include unrealistic worry about potential harm to loved ones or fear that they will not return home; reluctance to sleep alone; refusal to attend school; and physical symptoms such as stomachache or headache.
These children and youth may refuse to sleep over at a friend’s house or show reluctance to go anywhere by themselves.
Generalized Anxiety Disorder (GAD). The characteristics of GAD are excessive or unrealistic anxiety about a variety of situations.
People with GAD cannot handle anxiety; therefore, they develop anticipatory anxiety when they’re even thinking about being put in an uncomfortable situation. Dacey and Fiore describe the person with GAD as someone who “worries about worrying.”6 In many cases, people with this disorder are perfectionists, who constantly repeat tasks until they think they have done them just right.
GAD usually begins to affect children between the ages of six and eleven and can continue into adolescence and adulthood if left untreated. These children are often easy to identify because anxiety dominates their lives. Their physical symptoms may include restlessness, tiredness, difficulty concentrating, irritability, unusual muscle tension, and sleep disturbance. For a specific diagnosis of GAD, one of these physical symptoms must occur regularly over the course of six months. Many children and adolescents with GAD also experience panic attacks. GAD is a frustrating condition because children generally do not know the source of their anxiety; they just feel overly anxious. If they have a panic attack, they do not know why.
145 Anxiety Disorders Panic Disorder. This anxiety disorder is rare in young children, with the onset usually occurring in the midtwenties. However, it does occur more often among older children and adolescents. A diagnosis of panic disorder is made when an individual experiences at least two unexpected panic attacks followed by at least one month of worrying about having another panic attack. A panic attack is a short episode of intense fear or discomfort that lasts approximately twenty to thirty minutes and peaks after about ten minutes. In order to be classified as a panic attack, four or more of the following symptoms must develop abruptly and peak within
• a feeling of imminent danger or doom
• the need to escape
• shortness of breath or a smothering feeling
• a feeling of choking
• chest pain or discomfort
• nausea or abdominal discomfort
• dizziness or lightheadedness
• a sense of things being unreal, depersonalization
• a fear of losing control or “going crazy”
• a fear of dying
• tingling sensations chills or hot flashes7 • About half of adults with panic disorder had SAD as children, which has prompted some researchers to propose that SAD is an early manifestation of panic disorder.8 Agoraphobia can result from panic disorder when a child starts to avoid places in which she or he has experienced or might experience a panic attack.
Posttraumatic Stress Disorder (PTSD). Many people associate posttraumatic stress disorder with military conflict, but in fact, this disorder can occur in the aftermath of any trauma, such as a 146 Welcoming Children serious accident or natural disaster. In particular, individuals who have experienced an event that involved a threat of death or serious injury to themselves or others are at risk for developing PTSD.
PTSD can result if the person felt such intense horror, fear, or helplessness that the trauma is imprinted in such a way that he or she continuously relives the trauma in his or her mind.
Identifying PTSD in children and adolescents can be difficult because they often do not know how to effectively communicate their feelings and emotions. With children who have experienced trauma, it is important to watch for the signs that might indicate PTSD, such as frequent headaches and stomachaches and extreme agitation. Other symptoms and behaviors that may indicate that children and adolescents are re-experiencing the trauma include
• dramatic play behaviors that act out the traumatic events
• repeated bad dreams
• thoughts or recollections
• avoidance of the activities, situations, or people associated with the trauma
• detachment from others or numbness and loss of interest in surroundings
• difficulty remembering the details of the trauma
• inability to sleep and irritability difficulties in focus and concentration9 • Children who have experienced sexual abuse are at particular risk for developing PTSD. According to the National Center for Post-Traumatic Stress Disorder (NCPTSD), 10 percent of boys and 25 percent of girls will be sexually abused by the time they are eighteen years old, and 90 percent of these children will experience some symptoms of PTSD. Early warning signs that a child has been sexually abused can resemble the symptoms of anxiety disorders as well as depression and behavior disorders. Whatever the cause of the trauma, Dacey and Fiore strongly recommend that children receive professional intervention immediately, as the consequences of letting this disorder go untreated can be dangerous.10 147 Anxiety Disorders Obsessive-Compulsive Disorder (OCD). OCD is a complex psychoneurophysiological disorder characterized by fearful and repetitive thoughts that drive individuals to perform senseless rituals in order to reduce the fearful thoughts. Obsessions are recurrent, persistent thoughts, images, and impulses that are frightening in nature; they generally revolve around the fear of hurting oneself or others. The most common obsessions are about contamination, such as fear of dirt or germs, and persistent doubts about having performed some necessary act, like turning off an appliance. Obsessions can also take the form of extreme discomfort when things are out of order or horrific impulses such as thinking about hurting someone. Compulsions are repeated behaviors or mental acts that are used to decrease the fear and anxiety
caused by obsessions. Common compulsions include:
• Cleaning: Individuals concerned with contamination and germs will constantly clean their hands or their homes. Many avoid touching things they think are dirty, such as shoes, doorknobs, chalk, and other people.
• Checking: Checking several times to make sure that doors and windows are locked or that the stove and other appliances are turned off or unplugged.
• Symmetry: Doing things the same way every time, such as making sure eating utensils are lined up, exiting a room the same way one entered it, and making sure all the pictures on the wall are lined up perfectly.
• Hoarding: The inability to throw anything away—even useless items. People with this compulsion often spend hours sorting items.
• Repeating: Repeating a name, phrase, or action over and over again, such as turning the lights on and off or rewriting a school assignment over and over until it is perfect.
• Praying: Praying constantly, confessing every bad thought, and praying for everyone so they will not come to any harm.
The cycle that characterizes obsessive-compulsive disorder works like this: Obsessions, or fearful and repetitive thoughts, 148 Welcoming Children cause a high level of anxiety, which leads the individual to act out compulsions, or repetitive behaviors, in an effort to neutralize the anxiety. And while the individual may feel immediate relief, he or she will eventually feel worse, at which point the anxiety will return and the cycle will begin again. Thus, the person with OCD never learns what most of us know—that the anxiety will go away on its own. Obsessive-compulsive disorder is particularly prevalent among children, affecting one out of every hundred American children, or over one million in all. This makes OCD more prevalent than diabetes, although it is rarely discussed. Children as young as age four can develop OCD. Today, through cognitive behavior therapy (CBT) and medication, children and adolescents can learn to successfully treat and manage their OCD.11 OCD Spectrum Disorders. The term OCD spectrum disorders was first used in the 1990s by psychiatrist Eric Hollander, who posited that there were other disorders that presented characteristics similar to those of OCD—for instance, trichotillomania, or compulsive hair pulling; body dysmorphic disorder (BDD), or preoccupation with an imagined body defect; hypochondriasis, or the belief that one has a serious physical illness despite medical advice to the contrary; kleptomania, or compulsive stealing; severe nailbiting; compulsive gambling; and compulsive buying or spending.
The difference between OCD and the OCD spectrum disorders is the feeling associated with the behavior. People with OCD may feel some fleeting relief upon completing a compulsion but no pleasure. Someone with an OCD spectrum disorder, on the other hand, often feels both pleasure and relief while performing the compulsive behavior, followed by distress when he or she sees the damage that the compulsion caused.12