Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. I aim to show how contemporary developmental science points us on a path to effective prevention, intervention, and treatment, with the aim of promoting healthy development and wellbeing of all children and families.

Monday, October 27, 2014

Childhood Anxiety: Treating the "What" Rather Than the "Why"

Recently, while studying for my recertification exam as required by the American Board of Pediatrics, using the PREP course offered by the American Academy of Pediatrics, I came across this question:
     A 7-year-old girl is having difficulty establishing relationships with other children despite repeated opportunities to do so. The girl prefers to stay near her mother or her teacher and will avoid other children. She sometimes cries and can be difficult to calm down after being dropped off at school, so her mother frequently remains in the classroom for a few minutes before quietly leaving. On days when morning transitions to school are significantly difficult, her mother will allow her to stay home. Her mother reports that, in preschool, things were worse in that she usually "couldn't" leave her daughter in the classroom. The girl typically speaks little when in public, but she speaks normally when home alone with her mother. She is an only child and the parents are divorced. When the girl spends the weekend at her father’s house, she often expresses worry that something bad is going to happen to her mother. Her mother frequently allows the girl to sleep with her to avoid temper tantrums or nightmares about sleeping alone. Of the following, the BEST next step in this child’s care is  
       A.   Initiate treatment with an SSRI (selective serotonin reuptake inhibitor)
B.   Reassure her mother that her daughter’s problems should resolve without intervention
C.   Refer for neuropsychological evaluation to assess for cognitive impairments
D.   Refer her to a cognitive behavior therapist to work on skills for managing her distress
E.    Refer her to a play therapist to assist the child in recognizing the cause of her distress 
The “correct” answer is D- refer her to a mental health specialist to initiate cognitive behavioral therapy (CBT). Medication is suggested as a second line of intervention if CBT is not effective. In other words change her behavior, but do not offer opportunity to discover the cause. Play therapy, the only alternative form of therapy suggested, leaves it up to the child and therapist to discover the cause.

What might be the cause of her anxiety? Is her mother depressed? Her father? Is there substance abuse in either parent? Did she observe conflict, perhaps even violence, between her parents in the years preceding their divorce? Is there a family history suggesting a genetic vulnerability for anxiety? Does she have sensory processing challenges that cause her to be overwhelmed in the stimulating classroom? Some combination of all of these?

One child I saw with such symptoms had a mother who lay in bed all day in the wake of a pregnancy loss. This child was terrified that something would happen to her mother while she was in school. 

Perhaps this child’s mother had similar struggles with anxiety as a child. But rather than being met with understanding, she received a slap across the face. She may be terrified that her daughter will suffer as she did. If she is flooded with stress in the face of her daughter’s behavior, she might, without thinking, lash out. Or more likely, as her maternal instinct to protect her child overrides a rage response, she might shut down emotionally. Either way, her child will be alone with these difficult feelings. 

I took care of one child who had been diagnosed with anxiety disorder by her previous pediatrician and came to me to get her prescription refilled. After several hour long visits, some with her alone and some with her mother, I learned that every weekend her father drank heavily, leaving her at the age of eight to care for her two younger brothers.  

Where in the treatment plan recommended by the AAP is there opportunity to uncover such a story? Parents may experience terrible shame about their own behavior. Taking a history, in one visit, that reveals "no psychosocial stressors" is inadequate. Parents share this kind of information when they feel safe. Safety comes in the setting of time and space for nonjudgmental listening.  

One much-cited study compared CBT, SSRI, the two in combination, or placebo. No treatment arm existed for listening to the parent, for discovering the meaning of the behavior.

This child’s behavior is a form of communication. Behavior management, and the close second of medication, serves to silence that communication. When we teach a child skills to manage behavior, the story may be buried, emerging years later, sometimes in the form of serious mental illness

When parents can make sense of a child's behavior,  they are in an ideal position to support that child in managing his or her unique vulnerabilities. In a way, parents are best suited to provide a kind of cognitive behavioral therapy. They can help a child to name feelings,  identify provocative situations and develop strategies to manage these experiences.

By bringing in to awareness the way a child's behavior may provoke their own difficult feelings, and in a sense moving these feelings out of the way, parents can be fully emotionally present with a child in a way that supports healthy emotional development.

When a child is young, there is opportunity to offer support for parents and children together and so alter a child’s developmental path. But when, rather than supporting parent-child relationships, we treat the problem as residing exclusively in the child,  such opportunities are missed.


  1. As always, an excellent and thought-provoking post. Thank you.

  2. I'm not sure what the problem is with the answer given. CBT is not simply behavioral management -- that would be behavioral therapy. CBT would examine the young girl's cognitions surrounding her anxiety and withdrawal behaviors and would help her to examine her assumptions about her school environment, social situations, and family life. The therapy would help her to develop more adaptive thoughts about these situations. CBT would address both the "what" and the "why" of her condition. Also, her mother (at least) would likely be involved in the treatment since the girl is so young.

    1. I appreciate that CBT addresses cognition as well as behavior. But as the answer to this question states, CBT is recommended to "work on skills for managing her distress." My concern with this as the primary approach, with medication secondary, is that it does not offer space for curiosity about the cause of her distress, to discover the meaning of behavior in the context of primary caregiving relationships.

    2. O.K. I see your point and was thinking about putting something like it into my previous post. The reason I didn't is that, as a psychiatrist, I did not feel comfortable making assumptions about what a pediatrician should be expected to do. It would be great if all primary care had that kind of curiosity.

  3. The CBT model assumes that the little girl has poor distress tolerance skills rather than also considering the possibility that she may be being subjected to significant stresors that are completely out of her control. Psychologists call that the fundamental attribution error - attributing behavior entirely to the propensities of the individual instead of also looking at the environmental challenges they are dealing with.

    It's a bit like prescribing an opiate to someone who's being followed around by someone continually stabbing them in the shoulder with a pocket knife.

    1. Although some may practice CBT this way, the scope of CBT is much greater than mere poor distress tolerance skills.

    2. I was reacting to the "correct" test answer in the post. Good CBT therapists like Donald Meichenbaum borrow heavily from other therapy paradigms, yet often don't admit that that is what they are doing.

    3. I admit I am not an expert on CBT and am glad to hear that the scope can be broader than indicated in the "correct" response to this question. What is striking to me about this vignette is the early onset of significant symptoms. Exploring the relational/ developmental context is critical to understanding the meaning of her anxiety. Such an understanding will lead the way to what do to manage her symptoms.

  4. Also, the example says: "On days when morning transitions to school are significantly difficult, her mother will allow her to stay home." Without a full evaluation, this suggests that perhaps it's the divorced mother who's really the anxious one when the child is away. The home situation in the example is therefore "WNL." That stands for "we never looked."