The anxiety that Jenny and Ernie feel is, of course, more serious than my Sunday Night Blues. On Sunday nights Jenny is anxious not because she hasn’t done her homework for the next day but because she knows she is about to lose access to her mother. Ernie is not fretting over a forthcoming spelling test. He’s worried that something terrible is going to happen to his parents. My diagnosis was the same for both kids: separation anxiety disorder, or SAD.
THE SYMPTOMS
There is an important difference between separation anxiety and separation anxiety disorder. Children between seven months and 11 months experience stranger anxiety: when they see somebody unfamiliar—not Mom, Dad, a relative, or a regular caregiver—they become alarmed. Most children have separation anxiety between 18 months and three years. For instance, a normal two-year-old whose father goes outside for a few minutes, leaving the child with a family friend, will probably have some separation anxiety. As he leaves, the father might say, “I’ll be right back, Sam. I’m going to the car to get something. Talk to Carol.” Almost immediately, Sam will start to get anxious, thinking, “Wait. I don’t know this person. Where’s my father?” That reaction is normal, provided that Carol is able to console or distract Sam so that the anxiety doesn’t last more than a few minutes. Another two-year-old playing comfortably outside might well take a break, touch base with Mom, and then resume playing after a few minutes. That’s normal too. So is some weepiness in the early days of nursery school.
However, by the age of four, a child should be able to leave his parents or his home without distress or anxiety, and about 96 percent of all children can do so without a problem. (The fact that many children start nursery school at age four is no accident.) It is estimated that 4 percent of all children have SAD.
Every once in a while SAD makes its first appearance not in the early days of nursery school or in first or second grade but later, during adolescence. The disorder seems almost to “spring up,” with no earlier evidence that there was a problem. Often what brings on the symptoms of SAD is a change or a loss. That was the case with two young people I treated for late-onset SAD. Amelia, 15 years old, showed the first signs of SAD when she and her family moved to a new state in the middle of her sophomore year of high school. Amelia had always loved school, but she just couldn’t adjust to the new setting. Every day there were tearful phone calls home, in which Amelia would beg her mother to come and get her. By the time I met Amelia, she had stopped going to school. In fact, she was refusing to leave her front yard. Her parents were completely baffled by the change in their daughter.
Another “late bloomer” with SAD was 13-year-old Rafael, whose SAD came on after he missed a few weeks of school because of a case of mononucleosis. When he was finally well enough to go back to class, Rafael didn’t feel comfortable being there any more. He told his parents he was tired and light-headed, and he insisted on staying home, where he would spend the day watching TV and sleeping. When I saw Rafael for the first time, it had been nine weeks since he’d been to school and almost that long since he’d left the house. Before the mono he had seemed perfectly normal, with no symptoms of SAD.
Children suffering from SAD are preoccupied with thoughts that harm is going to come to them or their parents. They feel distress when they have to leave their parents, to go to bed at night or to school in the morning. At school during the day or if they have to go away overnight, they’re terribly homesick. Sometimes they experience physical symptoms. Younger children often get stomachaches and diarrhea; older kids may experience dizziness and rapid heartbeat. Their nightmares have a recurring theme: something bad is happening to their family. The house burns down; Mom gets sick and has to go to the hospital; someone evil is chasing the child. Children with SAD don’t like to be alone in the house and may shadow their parents, following them from attic to basement. One mother I spoke to said she literally could not go anywhere in the house without having her six-year-old daughter tag along. Children with SAD can have worries that aren’t obviously associated with the disorder; an eight-year-old boy named Eddie told me he was worried that someone was going to break into his apartment and steal the silver. Why the silver? The family always used the good silver for their special Sunday night suppers.
Kids with SAD can have extremely high IQs. John was one of the smartest children I’ve ever met. At the age of 10 he had verbal skills way above the norm. He was also one of the best-natured, sweetest kids I have come across. Dressed in his school uniform with his blond Dutch boy haircut, he looked like a youngster right out of a Norman Rockwell illustration. A few minutes into our meeting it became obvious that something wasn’t quite right. Increasingly fidgety, John kept looking toward the door, behind which his mother was waiting. Suddenly he ran to the door and opened it to make sure Mom was still there, an act he repeated many times during the visit. I soon learned that John was preoccupied with the thought that his mom and dad were going to die. When he was in school, the idea sometimes upset him so much that he would get down on his knees and pray that nothing bad would happen to his parents.
THE DIAGNOSIS
The morning nine-year-old Elizabeth stepped into my office, the first thing I noticed were large patches missing from her curly red hair. My first thought was that she was being treated for cancer. I soon learned that her hair loss had nothing to do with chemotherapy. Every night, after she went to bed and was left alone in her room, she would pull out clumps of her own hair. There was nothing compulsive or ritualistic about the hair-pulling; she didn’t pull three strands on one side and then three on the other, for instance. She pulled her hair out because she was worried. Elizabeth was convinced that as she slept, someone was going to break into her apartment and do something terrible to her mother and father. Lately her fears had been getting worse, and she’d been refusing to go to school. She was afraid of what would happen if she left her parents at home alone.
SAD can be and often is mistaken for other disorders. SAD is often called school phobia, but that’s a misnomer. A child with SAD may not want to go to school, but he isn’t afraid of it. Being in school—without Mom and Dad—is what he’s afraid of. SAD is sometimes confused with depression. The child may look and act depressed—SAD may result in loss of concentration, sleep and appetite disturbance, and a demoralized state, all symptoms of major depressive disorder (see Chapter 14)—but, it’s crucial to note, those symptoms nearly always disappear when Mom and Dad are around. A child who has no appetite for his lunch at school may eat perfectly well at dinner, when he’s at home with his parents. By contrast, the loss of appetite associated with clinical depression doesn’t come and go. A youngster with SAD may be perceived as defiant, especially when he has to be dragged kicking and screaming onto a school bus. Attention deficit hyperactivity disorder (see Chapter 7) may also be suspected, since children with SAD are so worried that they often appear inattentive and distracted in school. One mother whose daughter I treated received a succinct but less than helpful diagnosis from her neighbor: “spoiled brat.”
Jenny, Ernie, John, and Elizabeth demonstrate a wide variety of anxiety symptoms, but at the core of each is the most important factor in SAD: a threat to the integrity of the family. That’s what we look for when we examine a troubled child. And we look for it the old-fashioned way: by taking a detailed developmental history from the parents and interviewing the child. Here’s how an interview with a child might go.
DOCTOR: “Everyone worries about something. What do you worry about?”
CHILD: “I don’t know.”
DOCTOR: “Some kids worry about tests in school. Do you worry about them?”
CHILD: “No.”
DOCTOR: “Some kids worry about their parents not having enough money. Do you worry about that?”
CHILD: “No.”
DOCTOR: “Some kids worry about their parents’ health.”
CHILD: “Yeah, I kind of worry about that.”
The child doesn’t always directly acknowledge worrying
about his parents. He might talk about kidnappers or burglars or voice concerns about the security of his house. But it doesn’t take too long to get to the real fear.
Here’s another line of questioning I might try.
DR. K: “When you’re at school, tell me what it feels like.”
CHILD: “I don’t know.”
DR. K: “What does it feel like when you see your mother when you come home from school?”
CHILD: “Sometimes I feel like I could cry.”
DR. K: “You feel sad?”
CHILD: “No, I feel happy.”
DR. K: “Do you ever feel as if there’s something pushing on your chest?”
CHILD: “Yes, but it goes away after school.”
A child need not have all of the symptoms of SAD to qualify for a diagnosis; if a child is suffering, even one or two symptoms are sufficient. As is the case with all brain disorders, SAD is a spectrum disorder, ranging from mild to severe, so along with any diagnosis should come an evaluation of distress and dysfunction. There is a critical difference between a child who is a little uncomfortable sleeping with the lights off and one who is so pained to leave his home and family that he avoids going outside, refuses to accept sleepover dates with friends, or, worst of all, won’t go to school. It’s not enough for a child to have a rewarding, secure home life. Like a healthy adult, a healthy child should have an active social and “work” life as well.
THE BRAIN CHEMISTRY
Stephen, 10 years old, had one of the most severe cases of SAD I’ve seen. I’ll never forget the day he first came to my office; rather, I should say they came to my office. When I opened the door, three generations were sitting in my waiting room, staring up at me: Grandma, Mom, and little Stephen. Stephen was refusing to go to school by himself. He agreed to attend school if his mother would drive him and then sit in the car right outside his classroom so that he could see the car through the window. The mother had been doing just that, and the school was remarkably cooperative; the staff agreed to the unusual parking setup and even let Stephen make calls (on the cellular phone he carried) to his mother on the car phone. This strategy had been going on for six months when I met Stephen, but now there was a crisis: Stephen’s mother was finding the arrangement more difficult all the time. When she told Stephen that she couldn’t take him to school any longer, he threatened to kill himself. When it was time to go to school, he cried hysterically, saying: “I’m going to die. You’re going to die.”
Stephen had SAD, and it doesn’t take a world-class diagnostician to see where it came from. As I soon discovered, both Grandma and Mom had it as well. They lived a block away from each other and were inseparable. They had never spent a day apart and went everywhere together, including my waiting room. Obviously, the DNA Roulette wheel had spun, and Stephen had an unlucky number. Stephen had inherited his brain chemistry from his mother.
What is it about the chemical composition of that family’s brains that results in SAD? What causes SAD? As always, it’s difficult to answer precisely, but the most likely answer is an imbalance of serotonin and norepinephrine.
Eve, a 30-year old computer programmer, was waiting for the bus that would take her to work. It was a cool autumn day, but Eve felt hot and clammy. Her heart was racing, and the street seemed to be spinning. She felt dizzy and lightheaded. She was sure she was having a heart attack, so she sat down on the sidewalk. When her fellow commuters asked her what was wrong, she couldn’t speak. In fact, she was having trouble breathing. Someone took out a cellular phone and called 911. Moments later Eve was evaluated in the emergency room of a nearby hospital. Her cardiogram was normal, and so, it seemed, was everything else. Eve’s symptoms had subsided by then, and more than anything else she was embarrassed. This was the second time that Eve had gone through this, and it looked as if “nothing” was wrong. But the emergency room doctor told her that something was indeed wrong. Eve had had a panic attack. The psychiatrist on call confirmed the diagnosis and took it a step further; she told Eve that she had panic disorder: an adult psychiatric disorder (seen occasionally in adolescents) consisting of panic attacks and worry about future attacks.
SAD seems to be the childhood version of panic disorder. There are all sorts of data to support this theory: landmark studies (conducted by Donald Klein) show that 50 percent of patients with panic disorder had separation anxiety disorder as children; moreover, other studies indicate that the children of adults with panic disorder have separation anxiety disorder more than three times as often as the children of depressed or normal adults; and finally, the same medicines are effective in the treatment of both disorders.
Studying the causes of panic disorder has added immeasurably to our knowledge of what causes SAD. We know that both disorders are caused by a defect in the way the brain recognizes and responds to danger. It all happens in the locus ceruleus, the part of the brain that alerts the body when there is danger by producing norepinephrine. In people who have panic disorder and, more to the point, children with SAD, the locus ceruleus basically gives the “Danger!” signal when there is no danger, thereby upsetting the balance of norepinephrine and serotonin.
THE TREATMENT
If a child diagnosed with SAD is in extraordinary distress, it may be advisable to medicate him right away, but behavioral therapy without medicine is usually the first line of attack against SAD. Sometimes behavioral therapy is all that’s necessary; in a recent study 40 percent of the kids diagnosed with SAD were determined to be functioning quite well (although only about half were symptom-free) after four weeks of behavioral psychotherapy.
In behavioral therapy we concentrate on modifying the way a child acts under various circumstances, addressing both the child’s separation anxiety and his anticipatory anxiety—the worries he has about something that is going to happen. The goals are quite specific: for example, a child must sleep in his own bed, play with his friends, and, most important, go to school. He must not follow his mother from room to room or cry when he can’t see her. He must allow a baby-sitter to care for him once in a while.
Therapists have tried many different ways of working with children to achieve these goals, but the one with which I have had the most success is the contract. This is a formal written agreement signed by the parents and the child and witnessed by me. To make it even more official, everyone gets a typed copy. (I’ve never gone so far as to get the documents notarized, but I’d gladly do so if I thought I’d get better results.) To my way of thinking the contract offers a perfect way to let a child know what is expected of him, to reassure a child that there are things he can count on from his parents, and to reward him for positive behavior. What’s more, if the child doesn’t live up to his part of the bargain, we don’t have to blame him. We can blame the contract.
Here are a few contracts I’ve drawn up.
“Jennifer agrees to go to bed by eight o’clock. She will stay in bed with the light on for 15 minutes. During this 15 minutes Mom will come three times to check on her. Jennifer will not leave the bed. At the end of 15 minutes Mom will turn off the light and Mom will continue to check on her every five minutes until Jennifer is asleep and twice after she’s asleep. For every night that Jennifer does this, she gets a star. If she gets three stars, she gets a prize. If she gets five stars, she gets a prize and a half. With seven stars she gets two prizes.” Jennifer traded in her stars for TV shows.
“Sara agrees to go to school every day. Sara will not cry during school or when Mom leaves. Sara will go to sleep without Mom or Dad in the room. Mom promises to take Sara to school and pick her up each day. Dad promises to tell Sara one five-minute story and will check on her every five minutes before she falls asleep and twice after she’s asleep.” Sara asked for tickets instead of stars. When she earned five tickets, she got a package of stickers.
“Roger agrees to go to bed quickly without complaining. Roger will stay in his own bed and not go to Mom and Dad’s bed or his brother’s bed during the night. Mom and D
ad promise to let Roger keep his bedside light on. Roger can play or read quietly in bed.” Roger used his stars to play video games.
“Cynthia agrees to stay in school from the beginning to the end of lunch. Two stars. She will not cry when she gets on the bus. One star. She agrees to stay with the baby-sitter on a weekend night, without Mom and Dad, for three hours. One star. Without crying, two stars. Going to bed before the parents come home, three stars.” With 11 stars Cynthia may rent the video of her choice.
Obviously no one wants a child to fail—the last thing he needs is to feel worse about himself than he already does—so some contracts have to be especially easy and very specific, like the one I drew up for little eight-year-old Karen: “Karen agrees to brush her teeth, wash her face, and prepare for bed by eight o’clock. Karen will get into bed by 8:30 and turn off the lights by 8:45. Mom and Dad promise to let Karen watch TV until 8:30, tuck Karen in at 8:45, check on her every ten minutes till she’s asleep. If Karen wakes up, she can call Mom. Mom promises to go to her room and sit in a chair for a few minutes.” Once Karen has mastered these simple tasks, we’ll draw up a more ambitious contract for her.
A few of my colleagues oppose the idea of attaching rewards to behavior with these contracts, but I’m in favor of them, provided they’re not too lavish. Books, videos, baseball cards, doll clothes, or any other relatively small items that a child values make these kinds of contracts that much more effective. Rewards do a lot to increase a child’s motivation, and children enjoy looking at their “trophies,” tangible evidence of their accomplishments.
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