Childhood Anxiety Disorders
As a Child Psychiatrist I see a lot of children struggling with different types of anxiety: Separation Anxiety, Generalized Anxiety, Social Anxiety. The symptoms of each above often “travel together” and are persistent into the adult years which can lead to other more serious challenges such as substance abuse and other mood disorders.
Here’s the good news:
We have great treatment options and can provide early intervention so that your child can thrive!
Here is the data to back this up:
The Child/Adolescent Anxiety MultiModel Study (CAMS) (Dr. JT Walkup in 2008) revealed greater than 2/3 of the children with anxiety had two or more types of anxiety listed above. *This is the largest existing anxiety study to date.
The data revealed combination therapy (Cognitive Behavioral Therapy [CBT] and sertraline combined) which showed an 81% response! Therapy alone revealed a 60% response and medication alone a 55% response rate.
Source:Walkup JT,et al, NEJM 359:2753-2766,2008
This is amazing, right?
The bottom line is that you should always start with cognitive behavioral therapy as the first line of treatment for childhood anxiety symptoms. For complex and severe situations medication and cognitive behavior therapy together capture a great response.
What is CBT?
Cognitive behavior therapy is one of the few forms of psychotherapy that has been scientifically tested and found to be effective in hundreds of clinical trials for many different disorders. In contrast to other forms of psychotherapy, cognitive therapy is usually more focused on the present, more time-limited, and more problem solving oriented. In addition, patients learn specific skills that they can use for the rest of their lives. These skills involve identifying distorted thinking, modifying beliefs, relating to others in different ways, and changing behaviors.
How can we as a society have less suffering and more “mental wellness”?
I believe parents, teachers, and pediatricians are on the “front line” to be able to recognize anxiety. If you are a parent reading this ask yourself: “Is there anyone in my family who was a “worrier”? Any relatives with difficulty in social situations?” “Did I have troubles separating from my Mom as a kid?” Many families have a history of anxiety. Usually you see a child psychologist, or a child psychiatrist if there is moderate to severe impairment at school, home, or socially.
If you are a teacher you can give information to the parents at parent-teacher conferences with examples of the ways a student might be shy, socially challenged or perfectionistic. I know that a lot of teachers share their observations, which can prompt a parent to be aware of any need for further help.
I have been very impressed with the pediatricians I work with that are providing early screening for anxiety. I am so happy to see routine questionnaires being given to detect any outlier anxiety or other behavioral issues.
When treating these disorders, I include the importance of nutrition, daily exercise, and daily meditation. It is common sense to limit sugar and teach kids to listen to their bodies to know when they are full or hungry. Kids thrive when they move! A sport, PE, or good old fashioned hide and seek can burn calories and reduce stress.
I am a strong believer in teaching our kids meditation.
I recommend starting with ten minutes a day with the goal of twenty minutes as a lifetime daily habit. I like simple solutions. What if every school in the World included a ten-minute “quiet time” for meditation right after lunch? This is possible and I am committed to implementing these types of important programs into our schools, not only because of the proven research but also the results I’ve seen are life changing.
In summary, childhood anxiety is common and can be treated effectively. Cognitive behavioral therapy is first line treatment. Combined treatment yields 81% response. Prevention of substance abuse and mood disorders can happen if early intervention happens!
ADHD: The Symptoms & What to Do When Diagnosed
I have a confession to make. The word disorder is like nails on a chalkboard to me when discussing the way someone processes or perceives the world. We are all neurodiverse. I value an organized and scientific way about talking about human behavior, I just do not view my patients as “disordered.”
I am not alone in feeling this way. The movement in Western medicine is shifting from illness to patient centered care defined by the Institute of Medicine as “care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.”
I could not start discussing ADHD without making this point. I do not view you or anyone as disordered. We all have our own unique “neurostyle.”
Ok. Let’s discuss ADHD.
The first thought that comes to my mind when I am on the phone with a parent who is making a first appointment about “focus issues” for their child is: “It is going to be ok. No problem. Your kid is going to learn about the way he/she processes information and deals with frustration. School and life in general are about to get a whole lot better.” Before a family walks through the door I have spoken to them on the phone to set the stage for wellness. I let them know that my goal for their child is to spend the least amount of time in my office while gaining the tools to thrive. Kids should be at soccer or out playing with their friends.
The same mindset holds true for the adults I assess. If medications are needed, I prescribe the least amount possible for improved focus and impulse control while preserving an individual’s creativity and spirit. Adults want to thrive too!
The evaluation of a child for ADHD includes a psychiatric interview and collecting and reviewing data from multiple sources. Data gathering includes rating scales from parents, teachers and the child, report cards (from preschool to current age of the child), standardized testing results, and any other psychological or other type of evaluations that have been done. A recent physical exam with a full medical workup is essential to rule out or understand any medical issues that can contribute to focus issues. The clinical interview is approximately two hours as the child and the parents are interviewed separately. Input from any tutors, grandparents, and childcare providers are all taken into account.
An evaluation of an Adult for ADHD includes a clinical interview, a review of rating scales and input from someone close to them about their behavior as well as any other evaluations and a medical workup. If adults have access to their childhood report cards they are reviewed as well. All forms of data are important.
The initial connection to the patient and their family is the most important step. If someone trusts you they will be able to give you “the bottom line” as to why they are there and leave the shame at the door.
In making the diagnosis of ADHD you need six or more symptoms for children and five or more for age 17 or over:
ADHD – Predominantly Inattentive Presentation
- Fails to give close attention to details or makes careless mistakes.
- Has difficulty sustaining attention.
- Does not appear to listen.
- Struggles to follow through on instructions.
- Has difficulty with organization.
- Avoids or dislikes tasks requiring sustained mental effort.
- Loses things.
- Is easily distracted.
- Is forgetful in daily activities.
ADHD – Predominantly Hyperactive/Impulsive Presentation
- Fidgets with hands or feet or squirms in chair.
- Has difficulty remaining seated.
- Runs about or climbs excessively in children; extreme restlessness in adults. Difficulty engaging in activities quietly.
- Acts as if driven by a motor; adults will often feel internally as if they were driven by a motor.
- Talks excessively.
- Blurts out answers before questions have been completed.
- Difficulty waiting or taking turns.
- Interrupts or intrudes upon others.
ADHD – Combined Presentation
- Individual meets both sets of inattention and hyperactive/impulsive criteria.
As an Integrative Psychiatrist I embrace Western Medicine coupled with all paths to wellness. The biopsychosocial treatment plan is coupled with a Spirit/Mind/Body approach that focuses on mental wellness, not mental illness. The severity of symptoms and a multidimensional understanding of the patient determine whether or not medication will be recommended in adjunct to behavioral therapy and other modalities of treatment.
Did you know? It is speculated that some of the most creative, intuitive and brilliant entrepreneurs and scientists had ADHD. Just google it. I am not saying that everyone with ADHD is brilliant. I am saying that the ability to access “non-linear” information is essential for creativity and invention. This is why it is important to be properly assessed and not overmedicated. We all want to be the best version of ourselves!
Be empowered. Be educated. Know all of your options for thriving with any focus or behavioral challenges. Find someone who will embrace your neurostyle – no matter what!
You know what I love? Kids and Adults who reach their fullest potential. Do you know how cool it is when I get a card around the holidays with someone’s report card with high marks due to high effort? Or a top realtor has tripled their sales due to improved focus?
That is the reward and honor of helping to facilitate your “A” game!
How To Thrive During a Crisis
Child Psychiatry Crisis’ come in many flavors. I am going to list some of the most common chief complaints I experience from the parents of my patients:
“My son’s grades went from B’s to D’s & F’s. We have done everything. Tutors. Therapy. Help!”
“My daughter is complaining of stomach aches. She has missed almost a month of school. The pediatrician has ruled everything out. I tend to have some anxiety and it is heartbreaking to see her suffer like this.”
“My son is just not able to keep up in school or socially. He also is having trouble making friends. Therapy is helping a bit yet we need to figure this out.”
“My daughter was always a good eater until she took this nutrition class. She always likes to be perfect and she followed the nutrition tips to the point now where she is counting calories, has lost 15 lbs, and will not eat at the dinner table with us.”
“My kid was bullied last year. We were hoping a break from that group would help. It started again. He is sad. He wants to change schools now.”
Do you know how hard it is for someone to call a Child Psychiatrist for his or her child? Really, really hard. Parents often tell me that they waited three to six months to make the call. They report: “I was just hoping it would be a phase.” They also mention that they think calling me means: “I have to put my child on meds.”
I make it very clear that is always done based on clinical presentation (severity and true indication) and that I would choose all other modalities of wellness before going the medicine route.
By the time someone calls me they have already tried therapy, tutors, nutrition changes. You name it. Parents want their child to thrive. So do I. You can see that a Child Psychiatrist is usually the last line of defense.
When the call comes in a child is usually in crisis. I educate parents about the process of the evaluation and clearly state: “My goal is to prescribe the least amount of doctors appointments and the least amount of medications. The end point is for your child to move out of crisis, feel empowered and thrive.”
My patients thrive. Bottom line. It does happen.
I spend time on the phone before a family comes into my practice so patient education and therapeutic intention is known. My patient, their parents and myself are going to all be working towards thriving and mental wellness. I set that expectation and hold them accountable for engaging in their life and treatment. I am a Doctor and a Facilitator of Wellness. I believe that everyone needs to realize how powerful and important their thoughts, actions and behavior are.
I validate the “illness” part of suffering yet explain that our thoughts and word choice are an essential part of the “fast track to wellness.” I use language that is appropriate for each age group. I embrace Western medicine coupled with all paths to wellness. I practice with an open mind and heart and this leads to the best outcome for my patients.
If you are seeking a doctor for you or your child it is important to know if they are well trained, compassionate and empathic.
How do you figure this out? You get to spend time with them. You listen carefully to not only the facts they educate you with but how they deliver the information. Do you feel like they want you to be well? Are they treating you like a person and not like you are a “walking target symptom”? Do they make eye contact when they are talking to you? Do they listen to your viewpoint?
The key to going from crisis to thriving is the belief in your ability to get well, the belief in your doctor’s expertise and empathy, and your determination to follow the outlined path to wellness and “engage” in your health.
We as Child Psychiatrists have the data to utilize medication, cognitive behavior therapy and other indicated treatment modalities thanks to our “Academic Mental Health Warriors.” I want to express gratitude to my colleagues at UCLA and Emory University and all of the “Pioneers of Child Mental Health” that have been doing the clinical trials to gain the knowledge and data we have at this point in history.
When you or your loved one is going through a crisis, remind yourself or them that on the other side of that is stabilization and that everyone has the ability to maintain a place of thriving.
We all want what is best for our children. I want to take it a step further and push the envelope of wellness. As a society we need to embrace mental health and wellness in every environment. We need to be proactive not reactive. We all thrive when individuals thrive.
Focus on the end point of THRIVING – not just the current crisis. Take that first step and look at the areas in your life that make you feel energized. Ask yourself, how can I create my best life? Make a list and begin to focus on those things. With the right support, the right plan, you will begin to turn your life around and thrive.
Create The Best Version of Yourself with Meditation & Mindfulness
Meditation and mindfulness are not considered “fads” in the medical and science community anymore. I recommend twenty minutes or longer a day for your mental wellness. As you practice everyday, it will become second nature to you – just like brushing your teeth. It is good for you. It can be done anywhere. Studies show it reduces stress, a depressed mood, anxiety, pain, and helps with focus. You can do a “moving meditation” with exercise, a traditional chant, engage in yoga, or just focus on your breath.
Usually when someone comes to see me they have tried everything to be well. I always incorporate the recommendation to practice meditation and/or mindfulness daily. An example of mindfulness that I share with my clients is a phrase I use throughout the day: “Be kind. Be loving.” These phrases are helpful in staying “present”.
Develop a practice that works for you. Define what your mode of relaxation is and incorporate that into your daily practice as a meditation. Think positive thoughts, visualize the best version of yourself, and send loving thoughts to yourself, your loved ones and the world. As you incorporate this daily, you will begin to see the positive difference it will make in your life.
I have gratitude for the research of Neuroscientist Sara Lazar of Harvard University. She is a “Meditation Scientist Super Star” in my mind! She was so inspired after taking a yoga class, that she switched her Ph.D. studies from molecular biology to the neuroscience of meditation. She is one of the first scientists to test the benefits of meditation and mindfulness with brain scans.
Her interview by the Washington Post on 5/26/15 discussed her group’s neuroimaging studies. Her first study looked at long-term meditators. A 50-year-old meditator’s brain had the same amount of gray matter in the prefrontal cortex as a 25 year old. The frontal cortex is associated with working memory and executive decision-making.
When you are mindful you are paying attention to your breathing, sounds and present moment and shutting cognition down. This allows you to still and quiet your mind, which allows you to relax.
Her second study looked at people in an eight-week mindfulness stress reduction program who had never meditated before and had a non-participating control group called “non-meditators”.
I was pleasantly surprised by Sara Lazar’s study results. Here is what she found:
The meditators showed thickening in areas of the brain that correlate with an improvement in self-relevance, learning, cognition, memory, emotional regulation, perspective taking, empathy and compassion.
Does this sound too good to be true? There is more…
The amygdala, “the fight or flight part of the brain” which is important for anxiety, fear and stress got smaller in the group that went through the mindfulness-based stress reduction program. The change in the amygdala was also correlated with less stress!
Her group’s study showed changes in the brain after just eight weeks. The participants took a weekly class and were told to meditate 40 minutes a day. In her study they averaged 27 minutes a day.
Her Harvard group continues to do studies to work on the functional significance, quantity, and quality of practicing meditation and mindfulness. Thank you Sara!
I know what I want our children to do right after the pledge of allegiance…
Meditate at school.
I would love to see this “be the norm.”
Dr. Denise’s Wellness Tips:
- Meditation and Mindfulness are considered a natural mind medicine.
- Be flexible with yourself. Start with 5-20 minutes a day.
- Find a word, phrase, or thought that honors your mindfulness style and repeat it throughout the day.
- Parents, teachers, doctors: start your children as young as possible with this essential wellness tool.