It's Nobody's Fault (25 page)

The behavioral approach to treating GAD is target-oriented: quite simply, the goal is to identify the problem—find out what’s bothering the child—and work with the child to make the worry go away. There’s nothing passive about this treatment; a kid doesn’t just sit around while various medical professionals have their way with him. This treatment is
active.
A child needs to be very much involved. He has to think about his fears, confront them, and work on ways to make them disappear. None of these things comes easily to a child, let alone an overanxious one.

A behavioral therapist treating GAD will teach kids techniques that help them to relax and settle down. The techniques are simple, but they can have a profound impact on a child’s behavior, especially his ability to calm his nerves. An overanxious child, who can’t “just relax,” is helped immeasurably by being able to call upon these techniques when he needs them. The two relaxation techniques most often relied upon are
deep breathing exercises
, which even very young children can master, and
visual-imagery.
The two techniques are almost always used together.

For example, in helping a girl who’s afraid to sleep because of excessive anxiety, the therapist would first teach relaxation, have the child practice it, and then use visual imagery to maintain and reinforce the child’s relaxed state. For example, the therapist would paint a verbal picture of the setting as a little girl prepares for sleep. The child would be asked for details of the bedroom, until the scene is completely set: wallpaper, pictures on the wall, dolls on the shelf, everything. Then the therapist would ask the child to picture going to sleep in a dark room. Again there would be many details, and the girl would participate actively. She would “practice” this behavior in the comfort of the therapist’s office a few times, and then she’d be sent home to try the real thing. Sleeping alone in a dark room would be the little girl’s assignment for the week.

Setting goals is critical to the successful treatment of GAD, and the more specific the goal, the better. A seven-year-old boy with GAD was terrified of taking tests in school. The therapist took him through a series of relaxation techniques and then actually went with him to school, to the very room where he took the tests he feared so much. The therapist got the child to relax again and then to focus on the room. Together they picked a spot on the wall that he would stare at if he became anxious. It was agreed that whenever he looked at that spot, he would stop worrying.

Another child fretted about taking a field trip with his class and used visual imagery to help himself through it. At the suggestion of the therapist, he and his parents got out a map and traced the journey every evening for a week before the trip, talking about the trip in detail. The boy was especially worried about the bridges he would have to cross—he was afraid they’d collapse—so they worked out in advance what he would do when he got to a bridge. His parents suggested he take out his crossword puzzle book and work on a puzzle while crossing the first bridge. When he got to the second bridge, he would talk to his friend.

Kids really need their parents’ help in working through the symptoms of GAD. For parents, that sometimes means going against their own natural instincts. That was certainly true in the case of Ryan, a 10-year-old boy with a clear case of GAD. An excellent student, good at sports, and popular with his peers, Ryan was a mass of worries. He didn’t think he could do anything right. When I first saw him, he was suffering from severe headaches and stomachaches. Ryan’s parents had always taken a healthy interest in his activities, deriving satisfaction from his accomplishments and supporting all of his efforts. They applauded him for his
good grades and celebrated with him when his team won. I made them change their ways.

For the six months we treated Ryan for GAD his folks were asked not to discuss performance with him. If they talked about his soccer game, it was not to inquire, “Who won?” but to ask, “Did you have fun?” There was to be no talk about winning or losing, good grades or bad. Ryan’s teachers were asked to hold on to his test papers until the end of the week, so that Ryan got his grades only on Friday. If he tried to talk to his parents about his test grades, all they’d say is that they were sure he did his best. It wasn’t always easy, for Ryan or his parents—in the early stages of the treatment Mom and Dad actually used cue cards to remind themselves of what they were supposed to say—but in six months Ryan’s headaches and stomachaches had disappeared.

In virtually any behavioral therapy for GAD there almost always comes a time when the child is made anxious, sometimes
very
anxious. It’s part of the basic process: before a child can be desensitized, he must usually be made to feel discomfort. With children the therapeutic process is usually gradual; kids confront their fears slowly, with lots of positive reinforcement (in the form of rewards and praise) and reassurance from parents and therapist. At times, mild negative consequences, such as loss of TV or play time or other privileges, are also used to “punish” a child’s opposition to reasonable expectations. Both rewards and punishments are meted out for effort, not achievement.

One of the most effective techniques of getting a child over the fears and anxieties associated with GAD involves
extended exposure
, or
flooding
, in which a child is put in the very situation—either in reality or in his imagination—that causes distress for an extended period of time. He is then made to understand that the fear is irrational. This method relies upon a biological fact: the body can’t maintain a high level of anxiety for more than about 90 minutes; the anxiety “burns itself out.” When a child
sees
that what he fears has not happened, the anxiety will dissipate. If the child is to alter his thoughts as well as his behavior—the
cognitive
component of the therapy—it’s essential that he know what is going on every step of the way. Children must describe their fears and then become aware that those fears are groundless.

In the case of Sally, the little girl with the impatient grandparents and the intense worries about her performance at school, here’s how a flooding might go.

“Sally, I want you to imagine that you’re getting ready for school,”
the therapist might say. “All your homework is done. But just as you’re packing your bookbag, you notice that your math paper is crinkled and smudged. Just then the bus pulls up outside, and the driver beeps her horn twice. You have to rush to get on the bus, and the driver doesn’t smile at you. You’re afraid that you did something to make her mad. You can’t stop thinking about your math paper. Your stomach starts to hurt, and you feel sick, as if you have to go to the bathroom. When the teacher asks you to hand in your math homework, you feel even sicker. You think maybe she’ll tell your parents. Maybe you’ll get an F.”

After the flooding, the therapist would guide the child through her deep breathing exercises and reassure her that her feelings of distress and anxiety will soon pass. Once the child has made it safely through the scene, it’s time to help her learn from the experience.

“So you heard the story of a really terrible day and you got through it?” the therapist might ask.

“Right,” Sally would say.

“How do you feel?”

“Okay, I guess.”

“Did anything bad happen?”

“I guess not.

“You were worried, right?” asks the therapist.

“Yeah.”

“Did anything bad happen to you? Did your toes fall off?”

“No.” Sally starts to smile.

“Are you sure your toes didn’t fall off? Maybe we’d better check to make sure. Why don’t you take off your shoes so we can have a look?”

At this point Sally is at ease. The crisis, or at least
this
crisis, is over.

As productive a disorder as GAD may sometimes appear to be, it is critical that a child with GAD symptoms be treated promptly. Left untreated, GAD may result in stress-related physical ailments, even something as serious as heart disease, as well as other psychological disorders, especially depression. The disorder may also interfere with a child’s ability to reach his academic potential and prevent him from making friends. These children are so anxious all the time, so fearful about their competence and performance, so worried about not being liked, that they’re often
not very
well liked by their peers. It’s not surprising, really. The symptoms associated with GAD are not likely to make a child the most popular kid in his class. Of course, not being liked then
leads to loss of self-esteem, not to mention a whole list of new things for a child to worry about.

At a dinner party recently I overheard two women talking about the new teacher that their third-grade sons have in school this year. From what I was able to make out, the new guy doesn’t believe in taking it easy on the kids when it comes to homework.

“What do you think about the homework assignments this year?” asked one mother.

“They’re pretty heavy,” said the other. “I feel sorry for Hugh sometimes.”

“Chris comes home every day, and he’s a wreck,” said the first. “He throws himself on the bed and screams, ’How am I going to do this? It’s too much. What am I going to do?’ I mean, he’s hysterical about it.”

At this point I was convinced that this kid needed some help. However, as I continued to eavesdrop, I realized that his mother was handling her son’s anxiety effectively in her own way.

“What I do is I go in there, and I say, ‘Chris, let’s look at the assignment and break it down into 20-minute segments. Why don’t you take 20 minutes and do one part?’ Then we go on to the next segment. He always gets the homework done, and the tears don’t usually last very long.”

What Chris’s mother is doing is basically a behavioral intervention, and I don’t think a therapist could have done it any better. My guess is that Chris has generalized anxiety disorder, but his is a mild case. At the moment, at least, his distress and dysfunction are modified by having the right mom.

Alas, not every child, diagnosed with GAD or not, has the right mom or dad. I have seen many parents, particularly high-powered, successful professionals, unwittingly put pressure on their overanxious kids. “I manage a large firm, and I pride myself on getting the most out of my staff,” the father of a 10-year-old boy with GAD told me. “But my son practically falls apart if I put any pressure on him or make suggestions. If I criticize him, there are bound to be tears. I’m only trying to help him, but I seem to make him
less
productive.”

Behavioral therapy methods can be made to work on nearly all symptoms associated with GAD, but it isn’t always easy for parents to put their children through the discomfort that is involved. Some parents aren’t comfortable doing what’s necessary to help a child with GAD get his life in order. When a child throws a temper tantrum, these parents will say, “I can’t put him through this.” They might think, “I’m harming my child. I’m doing something bad to my child. Look at the distress he or she is going through.” I don’t blame parents who have a hard time dealing with the symptoms of GAD; after all, it’s a parent’s natural instinct to reduce a child’s pain, not add to it, even temporarily.

While they are perfectly understandable, such feelings are counterproductive in treating an overanxious child. Parents have to be able to say, “You’ve got to stick it out. You’ve got to take that math exam” or “We have to take a plane to visit Aunt Judy. It won’t be easy, but you have to get over this. We’re going to help you.”

While it’s important for parents to be supportive, mothers and fathers should try to remain unemotional and detached to the greatest extent possible. Sometimes it helps to regard the new behavior being reinforced as an assignment, as in: “Look, it’s important for you to try to do this. You’ve got some nice rewards coming if you fulfill these tasks, but if you don’t try, there will be consequences. You’re going to lose some television.”

It’s also a parent’s job to make sure that the school is part of the solution when it comes to treating a child with GAD. Teachers need to be educated about GAD. In particular, they have to be made to understand that they need to tread lightly when they lay down the law to these children. A policy of “Absences other than for illness will not be excused” will greatly upset a child with GAD whose parents keep him out of school for a special family event. Most kids who hear the standard motivational speeches—“How you do in middle school is very important. It will predict your high school and college performance”—don’t give the warning much thought, but children with GAD take the message, and all messages, very much to heart.

These kids have enough worries without being given new ones at school, so finding the right teacher for a child with GAD is critical. If there’s a choice between a tough teacher and one who’s more nurturing, parents would do well to place a child with GAD in the class of the nurturer. A good teacher-student match can make life a lot easier for these youngsters.