How Parents Can Help Anxious Children.
Anita Iacaruso’s 4-year-old daughter, Ashley, struggled with serious anxiety. When Ms Iacaruso dropped her off at school, Ashley would cry and cling to her. “Someone would have to peel her off of me,” says Ms Iacaruso, who herself was once voted “shyest” in high school. “It was so painful to watch your child be in that kind of pain and look so fearful. I usually came to work and sat at my desk and cried.” When the family went to church on Sunday, Ashley refused to play with other children during the social hour unless her father joined her. And when the Iacarusos went to restaurants, Ashley refused to speak to the waiters. Ms Iacaruso, who works in communications at a government agency in Washington, D.C., says that she initially tried to push Ashley to play with the other children on her own at church and order her own food at restaurants. But Ashley “would cry and then usually we would give up,” Ms Iacaruso says. “We would get so frustrated.” Anxiety is a normal human emotion, of course, and a typical part of childhood. Various fears—of the dark in toddlers, of monsters in 5-year-olds and of being shunned by friends during the teenage years—are developmentally appropriate. Children should be a bit nervous before a big test: It can motivate them to study.
Anxiety becomes a disorder, however, when it impairs a child’s basic functioning—preventing her from going to school or making friends, for example—or causes serious distress. Anxious kids also tend to have physical symptoms, such as headaches and stomachaches, which don’t have a medical cause. Anxiety disorders are remarkably common among children in the U.S.: Nearly one-third of them will have an anxiety disorder by age 18, according to a 2010 study in the Journal of the American Academy of Child and Adolescent Psychiatry—and girls are more at risk.
Many parents naturally want to comfort and protect their distressed children and shield them from whatever is causing the pain. But this is often the exact opposite of what they should do, say experts in the field. Today, psychologists and treatment programs are increasingly focusing on how parents can alter their own behaviour to best help their anxious children. Some parents, for example, may be inclined to let their son skip a birthday party that he’s dreading, or order for him at a restaurant if he is afraid to talk to the waiter. But giving anxious kids an out sends the message that these ordinary situations really are dangerous and that the child can’t cope. Though the immediate upset may recede, the result can be an even more anxious child—and overwhelmed and stressed-out parents. “Letting those kids escape those situations, there is short-term gain and long-term pain,” says Andrea Chronis-Tuscano, a professor of psychology at the University of Maryland. Allowing children to avoid stressful encounters means that they lose opportunities to develop important skills and to build confidence for handling new challenges. “Other kids are learning how to navigate those social situations, but the kids who are avoiding them are also lagging behind. That is going to make them even less comfortable in the future,” she says.
Some anxiety disorders can emerge as early as the preschool years, but the median age of onset is 11, according to a 2005 study published in the Archives of General Psychiatry. By contrast, the median age for mood disorders such as depression is 30. The most common disorders in youngsters are separation anxiety, social anxiety and generalized anxiety disorder. Children with separation anxiety are terrified of being away from their parents and often worry that something terrible will befall them. Socially anxious children are afraid of interacting with peers and may be miserable during playdates and birthday parties. Those with generalized anxiety are consumed with worries and may need constant reassurance about everything from homework and soccer games to taxes and terrorism. There are effective treatments, including therapy, medication or a combination of the two. In cognitive behavioural therapy (CBT), children gradually face the situations that cause them anxiety and learn to tolerate uncomfortable feelings. Studies have found that about half to 70% of children treated with CBT see a decrease in their symptoms and a significant improvement in their functioning. Antidepressants such as Prozac and Zoloft have also been shown to alleviate anxiety symptoms in children, though they have come under fire because of some evidence showing an increase in suicidal thoughts among those who take the drugs.
Researchers say that the parents of anxious children can make things better—or worse—with their own behaviour. They generally believe, however, that parenting itself is just one of the many factors that contribute to anxiety. In a 2007 review of the scientific literature on the subject, published in Clinical Psychology Review, researchers found that parenting, on average, explained only about 4% of the variation in anxiety issues among children (though some parental behaviours, like overcontrol and failing to grant autonomy, had a greater impact). Genetics play a stronger role. Studies of twins have found that genes are responsible for 30% to 40% of the variation in the individual risk for anxiety disorders. Instead, many scientists believe that anxious kids elicit an overprotective response from parents. Parents think that they “are damaging my child by letting them be anxious and crying,” says Anne Marie Albano, director of the Columbia University Clinic for Anxiety and Related Disorders in New York. “The second thing they fear is ‘my child is going to hate me’” if a parent doesn’t rescue them. Psychologists take pains to say that they aren’t blaming parents for their children’s anxiety. The field has a dark legacy of falsely indicting parents—particularly mothers—for the psychiatric illnesses of their children. In the 1950s, cold, callous “refrigerator” mothers were blamed for causing autism and schizophrenia in their children. Even now, it is tough to measure the impact of parenting on the development or maintenance of childhood anxiety. Most of the research is observational, and scientists can’t assign children randomly to receive certain types of parenting that could be detrimental, notes Daniel Pine, chief of the section on development and affective neuroscience in the Intramural Research Program at the National Institute of Mental Health.
Anxiety can have a deep developmental impact. In a study published in 2007 in the journal BMC Public Health involving 478 school-age children, anxiety was linked to poorer grades in school. In another study of 140 children age 8 to 14, published in 2011 in the Journal of Anxiety Disorders, subjects with an anxiety disorder were more likely to have been bullied recently than those who did not. Other research shows that these children generally have fewer friends and feel less well-liked than their peers. Having an anxiety disorder as a child also raises the risk of other problems, including depression, substance abuse and even suicide. Because of this constellation of problems, there is a growing push to identify anxious children and treat them early.
As for how parenting can help, or hurt, Eli R. Lebowitz, associate director of the Anxiety and Mood Disorders program at the Yale Child Study Center in New Haven, Conn., has been focusing on what professionals call “family accommodation,” that is, as he puts it, “changes to the parents’ behavior that are aimed at reducing the child’s anxiety or avoiding it.” This could include sleeping next to a child with separation anxiety or answering countless questions for a child with generalized anxiety. This kind of behaviour is extraordinarily common in families with anxious kids. In a 2013 study in the journal Depression and Anxiety, involving 75 parents of anxious children, more than 97% reported resorting to accommodations. About 70% of parents said that this distressed them. When parents didn’t accommodate the children’s anxiety, however, more than half of kids, 56%, became angry or abusive. The study found that children whose parents do more accommodating had more severe anxiety symptoms (but without concluding whether the accommodations were a cause or an effect). In studies of childhood obsessive-compulsive disorder, a greater family accommodation has been linked to less improvement after treatment.
Dr. Lebowitz and his colleagues at Yale have developed a new treatment called Supportive Parenting for Anxious Childhood Emotions (SPACE). In it, the only ones who get the therapy are the parents themselves. Therapists teach them to identify the ways in which they accommodate their child’s anxiety and coach them on how to convey support by acknowledging these feelings. Parents are taught to express confidence that their children can face fear-inducing situations and deal with uncomfortable feelings. Finally, they are instructed in how to gradually take away accommodations. In a small pilot study of SPACE with the parents of 10 anxious children who had refused direct treatment, the children’s symptoms were significantly reduced after the program. Yale researchers are in the midst of a larger clinical trial involving 120 families comparing the SPACE program to cognitive behavioural therapy, which treats the children directly. Studies that have added a parenting component to CBT for children have shown mixed results.
When Kelley Smith brought her 9-year-old daughter, Pearl, to the Yale Child Study Center in May 2017, she didn’t think that she accommodated her daughter’s anxiety at all. Pearl had a lot of difficulties trying new things, such as camp or Sunday school, and speaking to adults. She would often complain of stomachaches and headaches. “I would have said I’m very strict with her and I make her do difficult things, and her anxiety is her deal,” says Ms Smith, a teacher from Woodbridge, Conn. Through the SPACE program, Ms Smith realized that she was spending a lot of time, sometimes hours, answering Pearl’s anxiety-induced questions and providing reassurance about the family’s schedule. Eventually, she would run out of patience and get angry. “I would get frustrated and say I’m not answering any more questions, and then she would get upset and cry,” Ms Smith says. She was also speaking for Pearl at restaurants and the library, partly because her child’s silence and the ensuing awkwardness sparked her own anxiety, something for which she herself got treatment in her 30s. Pearl “was getting old enough that this was getting weird, but I didn’t know how to stop it,” Ms Smith says. The Yale therapists coached Ms Smith to express support for Pearl, acknowledging how difficult facing scary situations was for her, and then helped her to set up a plan to limit the accommodations. The family told Pearl that she could only ask questions about the family’s schedule for five minutes in the morning and the evening. Pearl would also be expected to order for herself at restaurants and check out books on her own at the library. At first, Pearl used every second of the five-minute blocks for her questions. But gradually she needed less time, and soon she was able to order her own grilled cheese. “I started to get used to it,” Pearl says. “I just was confident.” Ms Smith says Pearl’s anxiety is greatly reduced, though she still has some issues with big tests and parties.
Dr Albano says that Columbia is introducing a new component to its cognitive behavioural therapy program to specifically address parents’ own anxious thoughts about their children’s anxiety. Parents are being taught mindfulness and relaxation techniques and “cognitive restructuring,” basically a method of reinterpreting catastrophic thoughts in a more realistic way. Jill Ehrenreich-May, an associate professor of psychology at the University of Miami, has developed treatments for childhood anxiety that teach parents about a range of “problematic parenting behaviours” which, she says, reinforce children’s anxiety. Besides overprotection and overcontrol, she also includes criticism and inconsistency, which can end up reinforcing a child’s avoidance of scary situations. Children may keep asking their parents to get out of an anxiety-causing event, treating their parents like a slot machine, she says, because they know “if I keep pressing on it, eventually I’m going to win.” The consistency turned out to be important for Ms Iacaruso and Ashley. Ms Iacaruso enrolled her daughter in a program at the University of Maryland for children who are at a high risk of developing social anxiety. The program had Ms Iacaruso break her goals into smaller steps and use rewards for Ashley—like a sticker or a stamp on the arm—to show progress. To tackle the goal of ordering her own food at restaurants, Ashley was first expected to simply look at the waiter while her mother ordered for her. Then Ashley had to point to the item she wanted on the menu. Breaking up the goal into smaller increments made it much easier for Ashley to be able to accomplish each step—and for Ms Iacaruso to stick to the plan and not give up. Eventually, Ashley could order her favourites, macaroni and pizza. “I say ‘thank you,’” she says proudly
Credit: Andrea Petersen for The Wall Street Journal, 8 December