A is for Anxiety

By Penina Pultman, PA-C A IS FOR ANXIETY:

Help for the Back-to-School Jitters

It’s the night before the first day of school. Neatly packed briefcases are lined up at the front door. Tomorrow’s lunches are prepped in the fridge. The house is finally quiet. It’s been a long day. You make one last round of the house, check that the front door is locked, and look in on the kids sleeping peacefully in their beds. You linger at your daughter’s room, smiling at the freshly pressed uniform draped over the chair and the brandnew school shoes lined up under the dresser. She’s so excited to start first grade. You’re about to gently close the door and head to bed yourself when you hear it. The quietest of whimpers. Followed by a sob. And suddenly, you’re on high alert, all tiredness gone. As you murmur words of reassurance and stroke your daughter’s hair, you wonder, are all first graders this anxious about starting school or is your daughter’s fear a sign of something more serious? Everyone experiences anxiety at some point, and that’s not necessarily a bad thing, either. The increased heart rate and breathing an adult feels before an important meeting or a student feels before an exam is the body’s way of entering a 'fight or flight' mode; the resulting heightened awareness can help the individual ace the interview or motivate the student to study for the test. However, when anxiety is intense, excessive, and persistent enough to interfere with one’s daily functioning, it becomes a problem. An anxiety disorder can take the form of generalized anxiety disorder (GAD), panic attacks, social anxiety, selective mutism, separation anxiety, and other fears.

While there is no single factor that causes an anxiety disorder, children who are perfectionists, shy, reluctant to take risks, lack self-esteem or need to feel in control, sometimes develop anxiety during childhood, adolescence or as adults. Anxiety may also develop because of stressful life experiences or health conditions

Approximately 7.1% of school-age children aged 3-17

years have been diagnosed with anxiety; school anxiety, specifically refusing to go to school, affects 2 to 5% of children. This has been exacerbated by the pandemic since remote learning and reduced social interaction has made acclimating to in-person instruction even more challenging for many children. It’s three weeks into the school year, and already you’re worn out by the daily battle to drag your daughter, kicking and screaming, onto the school bus. Some days you relent and let her stay home, but that only seems to fuel her anxiety. Later that day, you tell your husband about the phone call from her teacher. She’s concerned that your daughter isn’t socializing with the other girls during recess. She is also restless and not paying attention in class. Your conversation is interrupted by your four-year-old crying because his big sister shoved him. Your husband points out that your daughter’s behavior at home has also deteriorated.

While both adults and children are affected by anxiety, children find it harder to articulate what they are feeling and to realize that their fears are irrational. Additionally, symptoms of anxiety in children, unlike in adults, often present as frequent nightmares and disturbed sleep, restlessness, falling asleep in school, difficulty concentrating, irritability, crying, and tantrums. Children suffering from anxiety might also be disruptive or act aggressive when they feel overwhelmed by uncomfortable feelings. If you suspect that your child might have difficulty adjusting to school, there are some things you can do to alleviate his or her fears. It’s important, however, to be upbeat and positive about school and avoid projecting your own worries onto the child. For preschool children, visiting the classroom before school starts, role-playing at home, and having playdates with future classmates might be helpful. Older children will appreciate an opportunity to discuss their concerns about school and have their feelings validated. You might want to tell the teacher about your child’s anxiety, so that he or she will be supportive and understanding of your child’s struggles. You read books, seek parenting advice. You try talking her through it, validating her concerns, encouraging her to set small goals. With the teacher’s cooperation, you institute a chart system. But even the promise of a new bike doesn’t seem to hold much allure. She refuses to go on the class trip to the zoo. She stops talking in class. Her fears are spiraling out of control. You meet with the school social worker. The good news is that your daughter does not have a learning disability or ADHD. What she does have, however, is an anxiety disorder. In most cases, school related anxiety will diminish with time and exposure. However, if your child’s anxiety worsens and begins to negatively affects his/her everyday functioning, it’s advisable to have him/her evaluated by a mental health professional. It’s very important to treat anxiety early. If left untreated, a child’s anxiety disorder can have long ranging consequences into adulthood, affecting his/her ability to hold down a job or have healthy relationships. Thankfully, due to increased awareness, seeing a therapist does not carry the same stigma as in the past, yet the shame associated with mental health disorders often causes parents and/or the child to avoid or delay getting the necessary help. Treatment for an anxiety disorder often consists of both psychotherapy (talk therapy) and medication. In psychotherapy, the social worker or psychologist will usually use cognitive behavioral therapy (CBT) to help the child focus on identifying and changing the negative and irrational thought patterns and beliefs that are feeding the anxiety. If the anxiety is severe, the therapist will often recommend the child see a psychiatric provider. On the advice of the social worker, you make an appointment with a psychiatric provider. The doctor is knowledgeable and professional, but you balk at the thought of medicating your child. Isn’t therapy enough? Not always. In life, the doctor explains, we all ride the horses of fear, sadness, and frustration, and for the most part, we’re in control of the ride. But sometimes, inexplicably, the horse runs amok, and the rider is left hanging on for dear life, his runaway emotions wreaking havoc in his life. In this case, the doctor continues, we’d all agree that the rider needs to learn how to control his steed. The analogy is clear. While the therapist is the trainer helping your daughter learn to rein in

her anxiety, the psychiatric provider offers the saddle, the medication, that will make the ride tolerable.

Psychiatric providers, like psychologists and therapists, also specialize in the diagnosis and treatment of emotional, mental, behavioral, and developmental issues; however, unlike therapists and psychologists, the psychiatric provider is a medical doctor who will focus on chemical imbalances in the brain and can assess both the mental and physical effects of a disorder. A psychiatric provider can prescribe medication, and while they may provide some counseling, a collaboration between the therapist and psychiatric provider is usually the best way to ensure the patient’s needs are met.

When looking for a psychiatric provider, referrals from your pediatrician, therapist, or community-based mental health referral service are a good place to start. Aside from practicalities such as insurance and area of expertise, it’s important that the psychiatric provider be someone who can relate to and understand your perspective, and that you and your child feel comfortable talking to him/her. It may be beneficial to find a psychiatric provider who has worked with other people with a background similar to your own. The ideal psychiatric provider is a team player, who works together with the family and therapist, and who individualizes treatment by welcoming feedback and making appropriate adjustments. The initial visit is an opportunity for the psychiatric provider and your child to get acquainted. The doctor will want to know about your concerns. They will also ask you about the symptoms your child is exhibiting, your child’s medical history, family history, and if there are any previous mental health issues. The psychiatric provider will probably also want to meet with your child separately. At the end of the visit, the psychiatric provider will evaluate the case and make recommendations such as prescribing a natural regimen of diet, exercise, vitamins, and supplements. If these are not entirely successful, low dose, light, and short-term medication may be added for additional relief.

A follow-up visit will probably be scheduled for 1 week, at which point the efficacy of the treatment will be assessed. Additional visits are usually scheduled at the 3-week and 6-week marks, and generally every 3 months thereafter as long as the patient is stable and doing well. Depending on the complexity of the case, a patient might need see a doctor for as little as a few weeks or for as long as several years. If medication is prescribed for your child’s anxiety, note that most anxiety medications require a few weeks for the full effect to be experienced. However, there are faster acting medications that can be prescribed short-term for the interim period, if necessary. You should, however, see some signs of improvement within two to six weeks. Most anxiety drugs used to treat childhood anxiety are considered safe and typically have mild side effects. If the medication isn’t effective or well-tolerated, the psychiatric provider will tweak the dosage or find an alternative medication.

Starting a child on anxiety medication is not a life sentence. The best outcome, however, happens when medication is used in conjunction with therapy. Anxiety medication takes the edge off the symptoms so that the child, is able to engage in therapy and gain the tools to manage the anxiety on his/her own. Generally, the treatment for a childhood anxiety disorder will continues for about one year, and, with a supportive environment, many times the medication can be tapered off and discontinued.

As you wait with your daughter at the bus stop, you reflect on the past few months. Dealing with a child’s anxiety disorder has been a difficult and overwhelming journey for all of you. Baruch Hashem, she’s made tremendous progress since that fateful first day of school. The school bus pulls up to the curb, and your daughter bounces up the steps and waves goodbye. As the doors close behind her, you wave back and don’t stop even as the bus recedes into the distance. You are so proud of your little girl who conquered her fears, and you are forever grateful to the wonderful team of mental health professionals who helped her break free of the anxiety that held her captive.

Penina Pultman is a psychiatric physician associate with a private practice in Brooklyn, NY. She is affiliated with Weill Cornell psychiatry professor Rabbi Richard Louis Price, M.D. To schedule a consultation, call 917 275 7878 or email info@ healthsjourney.com.