From The Carlat Child Psychiatry Report, March 2018, Anxiety in Children and Adolescents

Issue Links: Learning Objectives | Editorial Information | PDF of Issue

Topics: Anxiety Disorder | Child Psychiatry

CCPR: We see so many kids who are acting out. Can you begin by telling us about how anxiety can be hidden in oppositional or other acting-out behavior?

Dr. Glovinsky: I see that all the time. What you’re bringing up are two groups. One group looks like oppositional behavior with comorbid anxiety underneath. The other is a group of kids who are having difficulty with comprehension and learning, and when teachers ask them to perform, they get flooded with anxiety. A teacher will call me in to observe a kid who is acting out, and what I will see is that the teacher is really having difficulty understanding what’s going on. The teacher is expecting me to focus on aggressive, sometimes destructive behavior, and I’ll bring up the term anxiety, explaining that it is like putting a glass under a faucet, turning it on, and forgetting that you’ve turned on the water. At some point, it floods over. This child is very uncomfortable in the classroom setting.

CCPR: So, how do you help the teacher better understand what’s happening?

Dr. Glovinsky: Teachers often say to me: “The child’s behavior evokes a feeling in me of wanting to punish the child for this behavior.” And that usually ends up with the child being emotionally aroused and behaviorally active, the teacher being reactive to the child’s actions, and the child then escalating further. Many times, that then leads to an emotional explosion by the child. But when I suggest to the teacher that this child is anxious, I want to get into a discussion with the teacher about how—rather than reacting—the teacher can think first about what is troubling this child. I then show the teacher how to respond by providing the support, structure, and scaffolding to decrease the child’s uncomfortable feelings. When we do this, I’ve seen pretty dramatic behavioral changes.

CCPR: That’s really helpful when it comes to having teachers help as part of treatment. But can you also talk about assessing a child in a clinical setting?

Dr. Glovinsky: Assessment requires us to pay attention at multiple levels. The first level is harder to measure. It’s where we pay attention to our own reactions, emotional and physiological, and to the child and the family. We are all busy clinicians, but if we pause and take note of our natural responses and learn how we typically respond to various kinds of kids, we gain a valuable tool that supports our ability to effectively and efficiently assess a child. It may seem less scientific to cultivate intuition, but there is a growing body of research that supports this aspect of assessment (Marsh JK et al, Psychol Assess 2016;28(2):181–193). When a child has anxiety, I have a different reaction than with other behaviors, such as more pure conduct problems. My physiological response to anxiety is different than my response to a child’s aggression or anger. Different emotions in the child trigger different emotions in me. Being aware of my own emotions enables me to respond to the child’s emotional expression in a way that will help support the child. Our challenge is to be attuned to the child’s emotions and to respond supportively and empathically rather than reactively.

CCPR: Many of us learned about countertransference in training. This is a great reminder of a powerful tool. What about other levels of assessment?

Dr. Glovinsky: The second level is interviewing the parents and listening to their story about the frequency of their child’s negative behaviors, and the duration and the intensity of those episodes. It’s important to know, on a scale of 1 to 10, what parents feel are the types of episodes that cause their child the most distress, and where and when these things are happening. Are we talking about pervasive or specific situations? The frequency, duration, and intensity of a child’s episodes provides information that can be translated into an intervention plan. Also, the parent needs to know the triggers that cause the child’s distress—for example, where, when, and why these things are happening. Are we talking about specific situations or a chronic pattern?

CCPR: Then, where do we go with interviewing the child?

Dr. Glovinsky: In interviewing the child, there should be questions about the uncomfortable feelings. Some anxiety, for example, is related to phobias. The child will often lay it right out there: “I’m afraid of this. This is what makes me feel anxious.” You begin to see a pattern. Maybe it happens in math class each day and it doesn’t happen with spelling or reading. This gives you a sense of the triggers. These symptoms are nonspecific. You see them in lots of disorders, and kids can very easily get misdiagnosed.

CCPR: So, what do you do next?

Dr. Glovinsky: I like to do longitudinal evaluations (repeated observations of the same variables) and mood charting, which I then teach the parents how to do over a month. It helps you to learn about the child’s functioning in different settings. I take my time with the parents and tell them that that we are going to figure this out together. So, I’ll do a parent interview, a parent-and-child interview, and a child interview, and have the parents fill out questionnaires to try and pull it all together. It sounds tedious, but it’s hard to know what you’re seeing unless you have the data. Often professionals make recommendations or start treatments without having all the data to know what they are seeing.

CCPR: How about transference experiences? Are these something that people can be aware of early on that might give clues to a diagnosis?

Dr. Glovinsky: We know that our responses to situations are colored by early experiences, particularly with our parents. Selma Fraiberg refers to this as “ghosts in the nursery,” where parents are reacting to their children based on their own experiences with their own parents (Fraiberg S et al, Psychiatr Enfant 1983;26(1):57–98). All parents do this to a degree, even if they are not aware of it. We may react to the child based on our past relationships. So, when I talk to parents, I want to talk to them about all those past parenting influences. This almost invariably leads parents to talk about how their upbringing is affecting how they treat their child—for instance, “My dad yelled at me, and now I coddle my kid too much to make up for it.” It is also a reminder to myself to be aware of how I am reacting to the child and to the parents. Our experiences affect our work with people, and being reflective and self-aware is very necessary in our work.

CCPR: How does a busy clinician do this while working with the child or family?

Dr. Glovinsky: In the moment, I will often remark, “Let me take a second to think about that,” modeling that kind of reflective stance. When somebody is telling me a story, I might ask a gentle open-ended question, such as, “What’s that like?” Then, as I listen, I try to put myself in the shoes of the other person. It is very powerful and enlightening. It’s what Atticus Finch told Scout to do in To Kill a Mockingbird. But we often forget the importance of doing this and instead become judgmental about the child’s behavior or the parents’ style of parenting, which obscures our ability to really understand and help them.

CCPR: Can you talk a little about the constitutional factors that might be contributing to anxiety in children—things that we as child psychiatrists should be mindful of?

Dr. Glovinsky: A lot of the work that I do with parents ends up being psychoeducational. I have a whiteboard in my office where I’ll draw things first to talk about differences in reactivity. I relate to parents that there’s a stimulus, and it can be external or internal, and we all react to stimuli. So, that’s a physiological experience, and I’ll talk to them about differences in reactivity, and then I’ll talk to them about differences in what I call “rise time.”

CCPR: Rise time? Please tell us more.

Dr. Glovinsky: Rise time is the rate at which a person reacts and how intense that reaction is. For some of us, we go from 0 to 60—full throttle! But others are very slow to respond to situations. Some of this is physiological: the speed and intensity of sensory processing. Chess and Thomas talk of 9 variables of temperament that describe a person’s general reactivity: mood quality, biological rhythmicity of sleeping and eating, and other bodily functions, including approach/withdrawal, persistence, adaptability, activity level, attention, emotional reactivity, and sensory reactivity (Thomas CS. Temperament in Clinical Practice. New York, NY: The Guilford Press; 1986). Just think about mood. If we are already anxious, we may be quicker to react and may do so more intensely. When we are depressed, we may be sluggish in our responses. I find it very helpful to talk with parents about their child’s individual profile. So, instead of concluding that a child is being oppositional, we understand that this is an active child, who is quite reactive to emotions in others. This gives us a more rational, less judgmental map for parenting and for treatment.

CCPR: That’s very helpful. Are there other pearls you might share along these lines?

Dr. Glovinsky: Sure. I also like to use the metaphor of a staircase, for which the first step is physiological. If that step is unsteady, then it is hard for the child to get to the next step, which is paying attention. And if she can’t pay attention, then she can’t manage the third step, which is emotional regulation. Without emotional regulation, she can’t reach the next step and make rational cognitive decisions. We tend to focus on the top step, judging her poor behavioral decisions rather than looking at the steps below, particularly those first-step biological aspects.

CCPR: That’s a helpful metaphor. Got any more?

Dr. Glovinsky: Yes. Different people respond to different analogies, and one of my favorites to talk with parents about are the autonomic nervous systems of animals. I note that herbivores developed alarm systems way back in time to sense danger, and even as omnivores we carry similar systems with us to this day. Just to be careful, sometimes that system goes off in a child when it doesn’t need to, and how we respond to that can make a difference in whether the child becomes even more sensitive or learns to adjust his alarm system.

CCPR: Interesting. Can you give us an example?

Dr. Glovinsky: Sure. Often, when a child says that there are monsters under the bed, the parent checks and says to the child, “See? There are no monsters.” But the very fact that the parent is checking is giving the child a message that monsters could be there. That then makes the child’s “alarm system” more sensitive. I then tell the parents, “We’re going to explain to you how to do something different. We’re going to teach your child a word for anxiety.” I have one little girl who uses a “lion” feeling for anger and a “bunny rabbit” feeling for anxiety. When I talk to her about being anxious, she doesn’t have a clue what I’m talking about. But if I talk about that bunny feeling, she’s got it. So I’ll talk to the parents about finding a word to tap into. That way, if the child says, “There’s a monster in my closet,” the parent can respond with, “Oh boy, there goes that bunny rabbit feeling. We have to get that bunny rabbit calm.”

CCPR: There’s one final question that I have, and it always comes up for psychiatrists: What do you see as the role of medication in the treatment plan for children suffering from anxiety? What are your thoughts?

Dr. Glovinsky: I see medication to be extraordinarily helpful. In that, I think we should also look at frequency, duration, and intensity. Anxiety is a little different than mood disorders. Lots of times, because the child is doing chaotic things that could be life-threatening, mood disorders are extreme cases that need to be dealt with as an emergency. I don’t see that with anxiety, so my tendency is to try and work with it, and to use different techniques, such as meditation and mindfulness. And then, if those don’t seem to be working, we certainly use medication. In my clinical experiences, medication has been very helpful. But at other times, I think people jump in too quickly and don’t give themselves the chance to observe, to ask the question about how anxiety has been dealt with by other clinicians.

CCPR: Thank you for your time, Dr. Glovinsky.