Month: March 2022

Can someone grow out of an anxiety disorder?

I believe in people’s inherent ability to grow and to heal.

Dawn Friedman MSEd

Can someone ‘grow out’ of an anxiety disorder?

I’m going to say never say never. That’s my short answer. My longer answer is, well, a lot longer.

Let’s talk about the word disorder. That’s a clinical term that basically says that your functioning is being harmed or limited by the issue, in this case anxiety and has been for at least six months. Functioning is described as the ability to maintain your day to day activities, work your job or go to school, and manage your relationships. If your anxiety is so bad that you’re not leaving your house or you’re constantly arguing with your partner, that would be poor functioning.

That’s the clinical definition and the clinical definition is one made up by researchers and practitioners and may be subject to change as new research comes to light and we reconsider what functioning means. I mention this because an anxiety disorder is both a clearly defined thing but people are messy and don’t always meet clear definitions.

The other thing is that diagnosing professionals don’t always agree. While we all diagnose under the same defining criteria, that which is put forth in whatever the current DSM model is — and we’re about to come out with a new revision — our judgment is ultimately subjective. We might see functioning differently. Our clients might see functioning differently. There are cultural differences in what healthy relationships look like so we might assume something is dysfunctional and the client may not. And another clinician may not. 

What I’m saying is that getting agreement on what makes for a disorder is more complicated than you’d think. 

That’s kinda taking us into the weeds but I always love a good diagnosis discussion because before I was a therapist I thought the DSM was like a flowchart with clear, obvious answers and it is not that. This is especially true when we talk about diagnosing kids.

To accurately diagnose a child you have to really understand child development, you have to really understand the family culture, you have to a strong sense of whether or not the expectations of the other institutions in which the family lives are realistic. I think often of a child who ended up with a diagnosis that I thought was an extremely poor fit because that child was in a care center that had unrealistic expectations for kids that age. That child went to another center and we saw the issues not exactly disappear but become more like realistic challenges.

I think the person who asked this question is really asking if someone can learn to deal with their anxiety without intervention. And I’d say, yes, sure. Some people can do that. 

Because people with anxiety have brains that are primed to worry. And their brains aren’t going to change. Those of us with anxiety will always have anxious brains and that comes with all kinds of gifts, too. Anxious people tend to be sensitive in other ways. Some have busy and interesting brains who can see all kinds of danger but all kinds of creative and interesting connections, too. Some are super sensitive in relationships, which can make them worry about their impact on other people or how people see them but also make them loving, and compassionate people. Some see all the things that could go wrong first, but that also means that they’re terrific at things like being a surgeon, or a safety monitor, or a white hat hacker. 

Basically an anxious brain has gifts but it also has big challenges and generally we need to learn how to cope with those challenges and learning that is hard, especially if you’re left to do it alone.

I think about my own coping with social anxiety as an older elementary student and later as a teen and I think about how some of the coping mechanisms I came up with were the kinds of coping mechanisms I might have been taught by a therapist. In particular I had a whole visualization I would do at night when I was trying to fall asleep that I use with kids I work with now. But I also see how I came up with some really unhealthy coping mechanisms, too. And I see how my social anxiety curdled into pretty severe depression. So you could say I grew out of it — I mean I did graduate high school, I did end up going to college — I but I could have used the help since the journey was quite messy.

I do believe in people’s inherent ability to grow and to heal. I also think that those people who are really committed to growing and healing will seek out resources and support. They don’t just grow out of their struggles — they face them and they find ways through them including getting help.

And the help is here. There’s help in so many forms. There’s counseling and there are self help books, there are programs like mine. And I think if we really want to support our kids to grow out of anxiety then we should connect them with those resources and we should connect ourselves to those resources because we have such an enormous impact on how our kids function. Especially when it comes to anxiety, how the parents deal with it ultimately decides how the kids deal  — or don’t deal — with it. 

Have a question?

When should I be concerned about my anxious child?

The research shows that the family system needs to shift in order for your child's anxiety to shift.

Dawn Friedman MSEd

This is an interesting question because generally people don’t ask it unless they’re already concerned and they’re wondering if they’re overreacting, which obviously points to some anxiety on the part of the parent.

I do sometimes hear from parents who are concerned about their child’s anxiety and then a thorough assessment shows that their child doesn’t have anxiety or at least not clinical levels of anxiety. Because of course we all have anxiety or at least we should, because anxiety is part of being a healthy functioning, human.

Think about it, it’s normal to get anxious before a big exam or before a big presentation or before you’re going to run your first 5k or before your first date with someone new. Anxiety is just part of life.

Clinical anxiety is when that anxiety is interfering with life. So if you’re throwing up before a big exam, or if you’re having panic attacks before your big presentation.

Or if you want to run a 5k, but you never sign up because you’re so sure you’re going to fail.

Or if you want to go out on dates and you never do because you’re too nervous.

Now those would be clinical levels. But back to that worried parent who is maybe worried even though their child isn’t showing clinical levels. Well, I think that worry needs attention too. And again, it’s not uncommon.

Let me break this question down a little more. Instead of asking when you should be concerned, let’s change it to two different questions.

The first would be when should I get help for my anxious child? And the second would be, what do I need to do to take care of my own concern, unrelated to whether or not the child meets clinical levels?

So the first question, when should I get help for my anxious child, that down and dirty answer is if your child is stuck or you are stuck.

If their anxiety is limiting their life or your life, then it’s time to get help. If they’re missing out on social or educational opportunities; if they seem unhappy or frustrated with themselves; if their self esteem is tanking because of what they can’t do then it’s time to get help.

And if you are missing out on social or educational or work opportunities; if you can’t go have coffee with friends because your child melts down; or if you are having to miss work because the school is calling about your child’s anxiety; or if you are just so nervous about them that you’re losing sleep then it’s time to get help.

But what if your child is managing pretty well and you’re still worried about them? What if they’re able to do the things, all those things I listed, but you see them struggle and the struggle is upsetting to you or scares you?

Well, then we’re talking about your anxiety and it’s time to get help.

One of the things that we know about anxiety is that anxiety occurs when people have a more negative outlook or look at a neutral situation and interpret it in negative ways and sometimes this is happening with parents. So again, they’ll tell me that they’re concerned about their child’s anxiety and we do an assessment and the child is not actually anxious.

But it’s clear that the parent is experiencing them as anxious because the parent has anxiety. So they’re reporting things more negatively.

When we look at the child from an objective clinical point of view, we see the kid’s functioning is fine, but they are struggling because to struggle is part of being human.

The child might be anxious before they have to speak in front of the class and they maybe get a tummy ache and they’re worried about it and they fret a little bit but they’re able to do it. However the parent is seeing them fret and struggle and it’s upsetting the parent and that’s the parent’s anxiety. That doesn’t mean it’s not real because of course it’s real it’s just real for the parent and that deserves attention

Happily anxiety treatment is a family affair. So if you’re concerned it makes sense that you should get help. As I’ve said in previous posts, research shows that when you get help, it will help your child. So I’d say the first step is for you to get help and then in the context of you getting help, you can start to figure out if your child needs their own individualized support.

I’ll talk about finding a counselor for your child in a future post. But let’s focus on what you getting help can mean for your family.

This is the wonderful thing about a parent getting help for their child’s anxiety: Your child is part of the family system. The research shows that the family system needs to shift in order for your child’s anxiety to shift. The shifts we recommend in anxiety treatment really come down to helpful boundaries that support instead of accommodate anxiety. I know in order to set up and hold those boundaries parents need to work on their own coping skills because setting boundaries with anyone — let alone our kids — is hard. At first we’re sure to feel anxious about it but feeling anxious is how we overcome anxiety.

I’m simplifying things a lot here, but I hope you catch my drift. When the parent changes, the family system changes. And when the family system changes, the other family members change. It’s just how it works. In short, if the child’s anxiety is an issue the parent getting help will help. And if the child’s anxiety is not an issue, if it’s the parent’s anxiety, that is an issue the parent getting help will help. Which is all to say, when should you be concerned about your child’s anxiety? The answer is when you’re concerned. Then it’s a concern.

It’s either a clinical level of concern for your child, or it’s a concern for you because if you’re worried that worried, deserves attention.

I think it’s really important that we acknowledge that when it comes to family systems, that parents are part of the system, the child is part of the system. And any time we introduce more supports and information and interventions into one part of the family system, the whole system shifts.

You are the most powerful person in the system (although I know sometimes when we’re dealing with child anxiety, we can feel pretty powerless) and you’ve got the power to shift things in your family. You just need the information. So you know how to shift things and the support so that you’re able to shift things and I promise you that things will change.

Have a question?

How can I make my anxious child feel heard and understood?

Now the tricky part is trusting the hard work we’ve done and in the resiliency of the relationship. What I’m saying here is that we need to be prepared to disappoint and even anger our kids.

Dawn Friedman MSEd

This week’s question comes from Facebook. 

“How can I make my anxious child feel heard and understood when she feels anxious about going to schooL. I know that skipping school will actually increase the anxiety AND Exposure to school lessons it but it kills me to nudge her to go when it’s so scary for her.”`

I really appreciate that what we have here is a parent who understands that helping anxious kids means helping them face their fears, which is NOT easy. 

I’ve talked in previous episodes about the difficulty in shifting things in the moment when the child is actively afraid. In those moments we’re helping them cope with that feeling so they will learn that this feeling — as terrible as it is — won’t kill them and it will get better. So much of that work is done when they are NOT anxious. We exercise those coping tools, those calm down tools, when we don’t need them so we have access to them when we do need them.

It’s the same with feeling heard and understood. We help our children feel that way by practicing respectful, thoughtful, compassionate parenting throughout the rest of our days together. We don’t have to do this perfectly, of course, we just need to do it. 

When you ask your child how their day was and really listen, you’re helping them feel heard and understood.

When you remember to get them the kind of squeezie yogurt they like for lunch, you’re helping them feel heard and understood.

In our everyday parenting we are establishing a relationship where heard and understood is a given. It’s just part of the day to day give and take of being with them. 

Now the tricky part is trusting the hard work we’ve done and in the resiliency of the relationship. What I’m saying here is that we need to be prepared to disappoint and even anger our kids.

This is extremely important with anxiety work because our children are tuning into us to get a better picture of what’s safe and what isn’t safe and — importantly — what they’re capable of doing. 

Here’s a story to illustrate this. It’s a version of something I’ve seen in my clinical practice. 

A parent is driving their child to a birthday party. The parent knows that the child is nervous about going because they only know the birthday kid; they don’t know anyone else there. The family has talked about it and the child wants to attend and has been gearing themselves up for it. Perhaps this is what we were working on in therapy, making plans to deal with the discomfort, figuring out how to get out of the car and walk into the party in spite of their fear.

Anyway, the parent pulls up to the venue with the child and the child is sitting there taking deep breaths, preparing to go in. Then the parent says, “Do you want me to walk you up there?”

Boom!  Child melts down. Why? Because without intending to, the parent has just undermined the child. They meant to convey support but the child heard, “I don’t think you can do this.”

It feels sometimes like we can’t win for losing with the anxious child. They want our help but they may also resent our help. That’s just how it is. We help too much and they don’t feel capable. We don’t help and they’re angry that we’re leaving them alone. So let’s give up on the idea that we can parent an anxious child without bumps and bruises to the relationship.  

When we do push them to face their fears, we are saying, “You can do this.” Our children may not like to hear it but they need to hear it. And we need to have faith in them before they are able to have faith in themselves. We are the training wheels on their facing anxiety bicycle.

That doesn’t mean that kids like the nudging; Anxious children like the accommodations because they think they need them. The child’s goal is to avoid the things that make them anxious and accommodations allow them to do that. When we remove the accommodations they aren’t going to like it. They may feel like we’re not hearing them and we’re not understanding them. They may feel that if we WERE hearing and understanding, we would be accommodating. They may even feel betrayed in that moment. 

But we don’t stop accommodating out of the blue. We don’t just launch our children into an exposure without talking to them first. There is a process and a preparation for it. We create a plan not just how we’re going to move forward but how we’re going to come back together afterwards. 

The reason accommodations happen are complicated but generally we may believe our children can’t handle what’s making them anxious without our help or we’re concerned about the damage to the relationship since most anxious kids are pretty free about telling us the many ways they’re disappointed in us when we stop accommodating. They may say things like, “You don’t care, you don’t love me.” Right? That’s hard to hear and it can be scary to hear. Are we doing real damage to the relationship?

I wanted to talk a little about rupture, which is what we’re really describing here. Rupture is what the literature calls the inevitable conflicts between parent and child. 

Rupture is inevitable and it is also necessary. Ruptures in the parent-child relationship are more frequent in times of tremendous growth on the part of the child, which is to say sparring with your toddler is built into your child’s developmental trajectory. You can expect more ruptures whenever your child is growing in complex ways so adolescence or when you’re working on helping your child overcome their anxiety. 

The flip side of rupture is repair. Rupture is when the relationship is torn or damaged in some way and repair is how we come back from that. Every close and meaningful relationship will have rupture as disagreements and conflicts are simply part of intimacy. In the paper Repairing the bond in important relationships published in The American Journal of Psychiatry, the author writes ‘Growth is facilitated when a strong affective bond is established with an important other and the inevitable disruptions of this bond are repaired’ 

Did you hear that first part? Growth is facilitated. What this means is that ruptures are not bad; they are neutral and part of parenting. Repair happens before the rupture in the ways that we establish a base of respect, compassion, empathy and presence and it happens after the rupture, too, in the way we process the conflict.

Back to the original question. Let’s reread it. “How can I make my anxious child feel heard and understood when she feels anxious about going to schooL. I know that skipping school will actually increase the anxiety AND Exposure to school lessons it but it kills me to nudge her to go when it’s so scary for her.”

I feel like what the questioner is yearning for is a way to avoid rupture or to repair in the midst of rupture. Instead let’s shift our goal to creating a culture of repair that can tolerate the inevitable ruptures. Let’s shift our thinking so that we see ruptures as necessary catalysts for growth and know that our relationship with our child can and will withstand the strain and can even grow stronger through it. 

Have a question?

Can children have panic attacks?

Intervening early is always a good idea when it comes to kids. They don’t need a full blow anxiety diagnosis to benefit from the skill building that comes with recognizing their worries and helping them shift their thinking in ways that empower them to face those fears.

Dawn Friedman MSEd

Can children have panic attacks? Short answer YES. 

But first let’s define panic attacks.

Diagnostic Criteria for a panic attack per the  DSM-V requires that the person experience at least four of the following symptoms:

  • recurrent heart palpitations or increased heart rate;
  • sweating;
  • trembling;
  • shortness of breath;
  • chest pain;
  • feeling as if their choking;
  • nausea or stomachache;
  • dizziness;
  • chills or feeling hot;
  • numbness or tingling;
  • derealization or depersonalization (feelings of unreality, feeling outside of oneself);
  • fear of “going crazy” or losing control;
  • fear of dying.

Understandably panic attacks can add to anxiety, meaning they can become an anxious event unto themselves. For example, a child with a social anxiety disorder who then has a panic attack at a social event, may now worry about having a panic attack along with their worry about the social event. Panic attacks complicate matters for sure.

That said sometimes panic attacks can seem to come out of the blue and not have a connected or predictable trigger. Sometimes they just happen and for many children and adults, those are scariest of all. For one, it really can feel like you’re going crazy. It’s one thing to have a panic attack because an angry dog leaps out at you barking but it’s entirely different to have one for no discernible reason at all. 

There is some discussion about panic attacks and children arguing that they are very uncommon in young children. Some experts argue that children cannot be diagnosed with panic disorder. The DSM itself reports that they rarely occur in children under 14. I’d say that doesn’t reflect my observation. I hear reports of panic attacks in younger children often enough that I think they may have been previously under reported.

I recently read some research about that and there was an argument made — an argument I agree with by the way — that children may be experiencing panic attacks and just not have the language to describe them. They may know that their tummy hurts but they may not have words to describe feeling shaky or sweaty. They are very unlikely to be able to describe feelings of depersonalization or derealization. And then there’s a whole argument about what a child is capable of developmentally. In other words, if a child is too young to have a strong sense of self, are they capable of experiencing depersonalization? Can a preschooler who is still learning the difference between fantasy and reality experience derealization? 

My guess is that a panic attack in a very young child may look like a meltdown. It may look like fear. And isn’t that ultimately what a panic attack is? Would we view a panic attack differently if we thought of it as a fear attack?

That said, generally panic attacks in children and adolescents are less likely to be related to panic disorder — panic attacks that come out of the blue, seemingly unrelated to another anxiety diagnosis — but they do exist in kids.

Children who describe more somatic symptoms — those tummy aches, headaches, dizziness, etc. that we talked about at the beginning of this episode — seem to be at higher risk to develop full blown panic attacks. This may have something to do with perceived sensitivity to bodily changes. 

What this means is that a child who is highly sensitive to feeling heart palpitations, or noticing sweatiness may be more likely to interpret that as rising anxiety. This may also explain why there is a strong genetic component to panic disorder, speaking to brain differences. Also — and this certainly makes a lot of sense — asthma is associated with panic disorder not just that children with asthma are more likely to experience panic attacks but children with a family history of asthma are, too. Again, this might be traced to a family sensitivity to subtle differences in breathing.

This leads me to something interesting that I read in the DSM under their discussion of cultural issues related to diagnosing panic disorder. There is a Vietnamese concept of “hit by the wind,” which describes having a panic attack after walking out into the wind and having it take your breath away. I’ve had so many parents tell me that their children get anxious or meltdown on windy days. They perhaps also feel “hit by the wind.” 

Children who report panic symptoms are also more likely to have separation anxiety. There’s been some research that shows that parents who have a panic disorder or who have panic attacks are more likely to have children with separation anxiety disorder. What’s the connection there? Well, we don’t know but I think it points to a need to acknowledge that anxiety disorders are complicated and that it makes sense to consider the presentation and the needs of the entire family.

Treatment for panic attacks is the same as treatment for other forms of anxiety, which is cognitive behavioral therapy and sometimes medication. The particulars for that treatment will depend on the presentation and age of the child or teen. But in general we work on helping the child to calm their body and increase their distress tolerance and limit their avoidance of the things that scare them. 

This discussion we’re having today about panic attacks, panic disorder and diagnosis I think is useful because it helps us see the limits of our understanding of individual experiences. We can’t climb inside a 6-year old’s brain to see what they’re experiencing and their ability to tell us is limited. Looking at the criteria can help us know what questions to ask, what diagnosis to consider, and how to case conceptualize in order to create the most effective intervention. But people — including children — are complicated and rarely fit neatly into any prescribed categories. I think it makes the most sense to look at the research but always be open to tweaking what we know if the individual in front of us is a little bit outside of the guidelines. So if a child is telling us that they have three symptoms of a panic attack, why refuse to label what’s happening to them if acknowledge their feelings of fear and their bodily sensations with the words “panic attack” will help us help them. 

Intervening early is always a good idea when it comes to kids. They don’t need a full blow anxiety diagnosis to benefit from the skill building that comes with recognizing their worries and helping them shift their thinking in ways that empower them to face those fears.

Have a question?

Should I homeschool my child because of their social anxiety?

Pulling a child who is socially anxious out of school or letting them stay home because they’re afraid to be away from us may make them feel better in the short term but we need to consider how that’s going to benefit them in the long term.

Dawn Friedman MSEd

The question this week is a big one and it’s specific. Should I homeschool my child because of their social anxiety?  I have also heard this question as should I homeschool my child because of their separation anxiety and these are the same question. Separation anxiety in young children if left untreated tends to turn into social anxiety in older children and teens. In either case, my answer is going to be the same. 

Before I give you my answer, I want you to know that that my husband and I homeschooled both our kids. Our son, who is now an adult, went all the way through as a homeschooler until graduation. And our daughter, who is going to graduate this spring, decided to drop into school starting in 7th grade. In other words, I am a fan of homeschooling. We loved homeschooling and I know that it can be a great fit for some families.

That said, people should homeschool because they want to homeschool. If you want to homeschool your kids, go for it! But if you are considering it because your child is struggling in school and you’re feeling trapped, then let’s stop a minute and consider your situation.

If you are thinking about homeschooling because your child is struggling with social anxiety or separation anxiety let me tell you that homeschooling is NOT going to cure that. In fact, it might make it worse. At least you’re going to have to plan ways for them to confront their social anxiety and separate from you in other ways. 

Anxiety drives avoidance and anxiety disorders are diagnosed when the avoidance gets so bad that the child is missing out or struggling to function. A child who is homeschooling to avoid social interaction or separating from caregivers is by definition suffering from an anxiety disorder. That that anxiety disorder is not going to get better unless the family is committed to creating ways for that child to get social and separate.

Our goal as parents needs to be to push for our children’s lives to get bigger and more expansive as they grow. We want them to become more independent and better able to function without our help. Our decision making needs to remember that. It’s not just about coping in the here and now. Pulling a child who is socially anxious out of school or letting them stay home because they’re afraid to be away from us may make them feel better in the short term but we need to consider how that’s going to benefit them in the long term.

Again, I’m a big fan of homeschooling and if a family decides it will be easier to handle the anxiety by homeschooling and creating different kinds of opportunities then that’s fine. But if the plan is that the child will come home and not have to deal with peers, or friends, or other adults then that’s not going to serve them well. I have met families who have decided to homeschool temporarily, hoping their child will grow out of their anxiety, but without a plan to confront the anxiety, this doesn’t work. And in fact, the anxiety gets worse or starts showing up in other areas of their lives. 

If the anxiety is severe enough that you are thinking about homeschooling, then I encourage you to reach out to a therapist. You’ll want a therapist who understands the value of homeschooling and isn’t going to just knee-jerk tell you it’s bad for a kid because that’s not necessarily true. But you also need one who can help you figure out if what you’re offering is an accommodation or a support. An accommodation is something that sinks your children more deeply in their anxiety and a support is something that’s meant to help them grow out of it. But it’s not always easy to tell the difference especially when we’re in it with our kids. Oftentimes we need an outsider who understands anxiety and anxiety treatment to help us come up with ways to lift the child out of their anxiety. 

The right therapist can also help you figure out whether or not your child’s anxiety is caused by a poor fit educational environment that can be changed in ways to make it more appropriate for your child. Anxiety often shows up with other diagnoses like ADHD, learning disabilities, giftedness and autism spectrum disorders. Those things need to be appropriately diagnosed and addressed. If they’re not then of course that’s not going to be a good environment for your child and we shouldn’t be surprised if the result is school refusal.

If you are in the United States, and your child has a formal anxiety diagnosis or one of these other diagnoses then they may be eligible for a 504 plan or IEP or individualized education plan. 504s are a plan for how schools will support children with a diagnosed disability. IEPs focus on special education so, for example, a pull-out program or an aid. How these might look depend on the needs of the child and the policies of the school district. Getting an IEP or 504 can be challenging and if that’s something you’re interested in exploring, I encourage you to reach out to your child’s school counselor and again a therapist may be able to help you navigate that. Although most likely you will need a thorough assessment by a neuropsychologist. Sometimes masters level counselors or social workers are trained to do this work but most often it’s a doctoral level psychologist. 

I’ll be doing a future episode about working with your child’s school that will go into this in more detail. But for now I want you to know that there may be options that can keep your child in school even if they have a social anxiety disorder, separation anxiety disorder or school refusal.

But back to homeschooling. it may be that the anxiety is not the primary issue or not the only issue that’s leading you to consider home education, which may mean it is the right choice for your family. Maybe the issue is not avoidance but creating a better experience for your child. That’s certainly possible. It may be that your school options just aren’t a good fit for other reasons. You may not like the culture of the school, or want to travel during the school year, or feel that your child would be better served with a different kind of educational experience. Those things might be what is bringing you to homeschooling and your child’s anxiety may just be part of it. 

In that case I encourage you to consider what your child might need in order to support them in learning to manage and grow through their anxiety.

Remember anxiety is about avoidance so anxiety treatment is about confrontation. That doesn’t mean you’re going to take your socially anxious child and enroll them in toastmasters, the program for public speaking. But you do need to look for social opportunities and opportunities for them to separate from you and learn to be around other people. 

Fortunately many communities have options and resources for homeschooling families. Rec centers and libraries may offer classes. There are group tutoring programs. Churches, mosques and synagogues have activities for young children and teens. Or you might look for a social skills group through an occupational therapist or counseling practice. You can also look locally for homeschool co-ops. Connecting with local homeschool families on Facebook or on other social media may help you find these resources. Also programs like 4H, Girl Scouts, or Junior Achievement may be open to homeschool students. 

Homeschooling is a lot of work for parents and while it can be a wonderful gift for kids, there may be other more appropriate answers for the children who’s struggling to stay in school because of anxiety. 

I welcome your thoughts and questions on this topic. Reach out if you have something to share or something to ask! See you next week!

Have a question?

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