The Impact of Anxiety

October 31, 2016

Anxiety is a big, diverse topic that I will address over time in multiple posts. Here and now I want to introduce the subject in general, and provide some examples of how anxiety impacts our young people. We all have a measure of anxiety that has been wired into us by evolution which can be activated by some level of threat. It is easy to imagine that evolution favored prehistoric people who had some degree of anxiety by allowing them to maintain a high enough level of alert to avoid predators and other natural dangers. Given that in most of the industrialized world such immediate perils are not nearly so omnipresent, to a great extent higher levels of anxiety are now much more likely to present ourselves, and our children, with difficulties as opposed to advantages. I am often asked if anxiety is more common now in children than in the past. It certainly seems to be, as the 24 hour everything cycle that most of exist within makes it difficult to have time for rest and reflection, and serves to push those who would be anxious but able to compensate over the edge into a state of dysfunction.

An anxiety disorder is diagnosed when worries and fears are severe and persistent enough to create impaired function and/or reduced quality of life. Anxiety disorders are the most common form of behavioral illness in children and adolescents, with studies showing that in a given year in the United States over ten percent of the pediatric population meets diagnostic criteria for an anxiety disorder. Anxiety disorders commonly make it difficult to do well in school or in peer interactions, and often precede or exist together with other mental and behavioral illness, including depression.

We all have known or interacted with young people, knowingly or not, whose behavior has been negatively altered by anxiety in a manner that was a problem either for them or those around them, often both. Generalized Anxiety Disorder in a young child can lead to a chronic state of feeling afraid and overwhelmed by simple, daily activities and stimuli, causing them to act difficult, oppositional and irritable. Their parents often live in dread of family, friends, teachers and casual contacts concluding that their child is ill-behaved due to a parenting deficiency instead of understanding that the behavior is the result of complex genetic and environmental forces, and that both parent and child wish it could be different.

School can be a painful experience for a teenager with Social Anxiety Disorder, who have outsized concerns over what others think of them even in the most trivial of ways, and have continual fear that they will do or say something that will cause them embarrassment. The developmental difficulties that young people typically encounter during adolescence are magnified many times over by social anxiety as they make their way through increasing autonomy, emerging sexuality, and looming life choices.

Given the increased vulnerability and risk anxiety disorders create, awareness by parents, doctors and educators of the existence, signs and symptoms of this type of illness in young people is essential. Continuing to increase this awareness will facilitate the diagnosis, treatment and accommodations that affected children and teenagers need in order to be their best selves.


Medicine: An Important Component

October 31, 2016

Medicine is an important component of the treatment plan for many children with behavioral illness, just as is for many other illnesses. It is much more common for families to resist the idea of using medicine for their child's ADHD, anxiety or depression than it is for other chronic illnesses such as asthma or diabetes. It is easy to oversimplify the reasons for this reluctance and say that it is due to the stigma often attached to behavioral illness, or negative experiences of a friend or family member with treatment, or denial, when in actuality the reasons are often complex and not easily articulated. For many parents, the bottom line is a concern that medicine will be harmful to their child. Many state that they are worried that medicine will change their child's personality, or "turn them into a zombie."

Medicines always come with the risk of side effects, and those that are used to treat behavioral disorders sometimes cause behavioral side effects. Medicines that treat severe, life-threatening mental illnesses that involve psychosis or high risk of suicide often do have meaningful side effects, both physical and behavioral. Doctors often have no choice but to ask patients to tolerate these toxicities as the risks of the untreated illness are greater than the severity of the problems the medicines can cause.

For the vast majority of patients who need treatment for ADHD it is possible to develop a treatment plan which involves a medicine that is effective without side effects that are difficult to tolerate. ADHD causes children affected by it a significant amount of dysfunction, and left untreated it increases the risk of school failure, anxiety, depression and substance abuse. Stimulants have been used to safely treat ADHD since the 1960's, and in the decades they have been used have been proven effective and shown no evidence of long term toxicity when used appropriately under careful observation.

Anxiety and depression are a somewhat different story as the evidence is muddier, but it is clear that many young people derive great benefit from treatment of these disorders with a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine. Level of function and quality of life is often markedly improved, and serious side effects are extremely rare.

Medicine for behavioral illness is not a panacea, but it is often an essential component of a carefully constructed and monitored care plan which helps some of our children to be their best selves.


Behavioral Illness

May 17, 2016

So many times I hear a young child who is having trouble learning in elementary school described as lazy. I also hear the words stubborn, or difficult, used to describe young children with certain behavior problems. Whenever a parent uses these or similar words to describe their children, either based on their own observations or what they have been told by teachers, it prompts me to start a conversation about how to interpret children's behavior in light of what is developmentally appropriate for children of elementary school age.

Children in this age group are wired to want to please to adults in their lives, so if they are not doing so, our first thought should be that they can't, not that they won't. If we approach the problem with the premise that, for example, our third grader does not seem like she is trying to learn to read because she cannot pay attention well enough, or cannot grasp the basic skills, we are more likely to offer help rather than express disappointment. Similarly, if we understand that our kindergartener's tantrums in transition are due to anxiety, we are more likely to go out of our way to help prepare him for upcoming change rather than punish him when the difficult behavior surfaces.

In contrast, adolescent development creates behaviors that increase their sense of autonomy, often by creating distance from their parents and other adults, but that is its own topic for another day. When young children's behavior is consistently a problem we need to look for a possible underlying disorder as opposed to dealing with the behavior at face value. In doing so we will help these children be their best selves.


Can't vs. Won't.

April 22, 2016

We all want the best for our children, in health, happiness, family life, friendships, work satisfaction, prosperity, financial security and many other variables that impact their sense of well being. I think of the combination of all these factors as the desire that each of us has for our children to be able to be their best selves.

For so many children, behavioral illness blocks the path toward achieving their full potential, and imposes problems that complicate their lives. Think of the child with ADHD who is unable to pay attention well enough to learn in school, or the anxious child who is too much on edge to be able to tolerate even small transitions, or the depressed adolescent who feels too badly to maintain basic routines. We all know children and teenagers with problems not unlike these.

Our health systems do a reasonable job at providing care for children with most chronic illnesses, allowing children with asthma to breathe comfortably and children with diabetes to control their blood sugar, for example. Too many children with behavioral illnesses do not receive effective care, or even any care, much more often than we should tolerate. The reasons are complex, relating to the ways our doctors are trained, the ways they are paid, and basic societal concepts about what is health and what is illness.

My goal is to help close the gap, to help make it more routine for the quality and availability of care of behavioral illness to be on par with the care of other medical problems, and in doing so to help more of our children have the chance to be their best selves.