be healthy

Anxiety can be an inherited condition, and is not as uncommon as some may think. According to the DSM-IV-TR – the diagnostic reference manual published by the American Psychiatric Society – as many as four percent of children and adolescents suffer from separation anxiety, and as many as five percent of all Americans suffer generalized anxiety at some point in their lifetimes.

It is important to recognize and treat anxiety in children, since children with anxiety can often develop symptoms in adulthood, such as adult generalized anxiety, panic disorder, phobias, as well as one of a number of somatoform disorders-problems in which there are physical complaints but no physical or laboratory findings that reflect the symptoms.

Jimmy T's Struggle

The following is a description of Jimmy T., a boy struggling with anxiety.

The symptoms
Jimmy T. is a nine-year-old child who is having a tough time at school. He pays many visits to his school counselor, principal, and the infamous detention hall. Jimmy cannot concentrate, focus or pay attention in class. He seems to be too restless and fidgety, even hyperactive. He wanders around in the classroom and cannot sit still. His work is messy and disorganized and he does not keep up with his assignments. He has had to stay in after school and at recess because he is too disruptive and does not demonstrate the proper cooperative attitude in the classroom. Play therapy with Jimmy's outpatient therapist is difficult because he is in constant motion and cannot focus. Moreover, he is consistently late to school because of various complaints about his hurting head and stomach. He does not have an explanation for his behaviors; he just knows that something is "not quite right."

His mother complains that getting him ready for school each morning is a tedious and stressful ordeal because he constantly screams and is uncooperative. He cries intensely and does not want to leave the house. She sometimes has to play tug of war, pulling him into the car in order to get him to school on time.

A misdiagnosis
Jimmy's pediatrician diagnosed him with attention deficit hyperactivity disorder because of his ongoing issues and symptoms; however, stimulant medications such as Ritalin did not seem to help. In fact, they made him more irritable, moody, and hyperactive. His counselors did not know what to do or how to proceed with his therapy time and asked that he be seen by a child psychiatrist.

Indeed, anxiety in childhood may look like attention deficit hyperactivity disorder; a careful psychiatric medical history and mental status exam is vital.

ADHD vs. Anxiety

Jimmy was suffering from two forms of anxiety: separation anxiety and generalized anxiety-both were confusing his parents, teachers, pediatrician, and therapist. On the surface, his symptoms seemed to match those of conduct problems and attention deficit hyperactivity disorder, but there were important clues pointing to a different diagnosis. Children with attention deficit hyperactivity disorder cannot pay attention and focus, appear or are reported to be impulsive, and may also be hyperactive. The anxious child may appear to have the same issues but is also preoccupied by excessive worry, tension, and nervousness. Anxious children may complain that their bodies hurt and that they suffer daytime fatigue as well as lack of sleep at night. The following illustrates Jimmy's symptoms that differ from ADHD:

• Jimmy was severely stressed on most days when he had to separate from his mother and go to school. This intense distress and worry (and the focus on losing his mother) caused him to appear distracted and inattentive in school. In addition, his intense anxiety and worry often fueled his refusal to go to school on time and participate in class. This appeared to be misbehavior, when indeed he was expressing his inner turmoil.
• He would consistently complain of stomachache, headache and nausea before and during school. This was part of his anxiety disorder, but was interpreted as manipulation by his teachers and parents.
• After a careful psychiatric history, psychological testing, and observation in play therapy, it was noted that Jimmy's severe inattentiveness, restlessness, and difficulty concentrating were more a result of nervousness and excessive worry than hyperactivity. And the intensity of Jimmy's anxiety greatly affected his ability to participate and perform well academically in his third grade class.
• His experience of stress, nervousness, and worry was not expressed only at times of separation from his mother. The anxiety occupied his whole day, and affected his ability to play with friends, finish his homework, do household chores, and participate in his school routine. He was always irritable, easily fatigued, and complained often that his neck and shoulder muscles were tense and tight. He had trouble settling and experienced restless, unsatisfying sleep.

Children with anxiety can be treated with therapy and medications.

Individual play therapy
Individual play therapy with a child psychiatrist or psychologist explores conflicts and unconscious themes that interfere with a child's world of play, family interaction, and school life.

After regular visits with a child psychiatrist, it became clear that Jimmy's anxiety was, at least in part, a result of his parents' divorce when he was five years old. His drawings reflected intense anxiety about his father's absence. His playtime with the therapist also gradually revealed that he felt responsible for his mother's anxiety and feelings of abandonment that persisted after the divorce. Although she had the best intentions, her feelings and insecurities were transferred to Jimmy. She did not give him requisite space to create his own friends and play more independently. His mother was not able to contain her own expression of loss, so Jimmy felt responsible for her pain. The absence of his father only worsened his insecurity. It was therefore hard for Jimmy to separate from her and go to school without arousing his own worry about losing his parents.

Behavioral therapy
Jimmy also received behavioral therapy. His therapist would identify those times that produced the most anxiety in Jimmy, such as getting dressed, being in the car, and actually entering the school building. At first, this was discussed in play and through drawings. Then, these scenarios were play acted in the therapist's room. Jimmy and his therapist would pretend to visit school so that Jimmy could learn to extinguish the anxious reactions he had to normal daily childhood tasks.

Medications
Medications have helped Jimmy with his nervousness, restlessness, and worry. The newer class of antidepressant medications, or serotonergic agents (such as Prozac, Paxil, Celexa, Zoloft, and Luvox) have proven effective in helping Jimmy with his symptoms. These drugs are still being studied in children and adolescents, however, and more data is needed before we can conclude they are beneficial. Such medications affect neurotransmitters in the brain (in this case, chemicals partially responsible for production of anxiety) so that patients can shed excessive anxiety and worry, and experience a more relaxed state. For Jimmy, these medications also help him contain his intense feelings of separation and worry when he has to be in school or away from the family for other reasons.

Conclusion

Jimmy's school and family now recognize that symptoms of inattention, distraction, fidgetiness, and restlessness do not automatically spell attention deficit hyperactivity disorder. These symptoms can point instead to anxiety in children, and it is critical that parents and teachers understand the difference between these conditions. Effective treatment depends first and foremost on a proper diagnosis.