Catch Them Early

In recent years, there has been increasing emphasis on addressing mental health issues as early as possible.

“Today, we’ve realized that early intervention in mental health sets a positive trajectory for life,” says Tzivy. “Social-emotional skills are a stronger predictor of success than IQ.” In response, she says, many schools have begun giving classes in social-emotional well-being, and the role of teachers has changed as they also assume more responsibility for helping children in these areas.

But that typically happens in middle school or high school, and it’s best to help children as young as possible. “Early childhood is a high-stakes time,” Tzivy says. “But preschool teachers tend to have the least amount of training. The highest rate of expulsion from school is during preschool, since it’s optional and the teachers don’t always know how to handle the challenging children.”

Anxiety is the number one presenting complaint for children at OHEL, but that number can be deceiving. “Sometimes the real issue is depression, but it’s more comfortable for the parent to label it as anxiety,” Tzivy notes. Nevertheless, therapists see plenty of separation anxiety, school phobias, selective mutism, and trauma (which can result from any number of causes, from abuse to divorce, separations, accidents, even dog bites).

While children are most often brought in around age 11, “Often those behaviors began much earlier,” Raizel says. “The anxious behaviors begin at age three or four, and they’re still there at ten. These are the kids who won’t sleep alone, who won’t get on the bus. It’s better to resolve these things early.”

Early intervention is more cost-effective in the long run, and the OHEL programs to help young children generally have a high success rate and short therapy duration.

Those early years, from zero-five, are the years when the parent-child attachment forms. Good attachment is crucial for later mental health, and provides safety for the anxious child. It can be disrupted by many factors, including trauma, chronic or post-partum depression in the mother, and physical illness. When attachment is impaired, the child may react in ways so severe that in rare instances, their behavior may be mistaken for disabilities.

“We had a dramatic situation of a mother with mental illness who would leave her toddler neglected in a highchair for hours upon hours,” Tzivy says. “The child would rock back and forth, completely detached, so you might have suspected autism or another disability. But in the fact, the child was disassociating due to his severe trauma. The child was placed in a healthy environment, received dyadic therapy with his foster mother that helped him process the trauma and develop a healthy attachment to his new caregiver. Over time, those behaviors diminished, and he resumed typical development.”

Sometimes attachment is compromised, such as in cases of acrimonious divorce or domestic abuse, particularly if a child happens to possess similar features or mannerisms to the loathed spouse. In such cases, the mother may withdraw from the child, becoming less nurturing and available. The parent may need to go to therapy in order to repair the attachment to her child. Obviously, an anxious child can only feel safety through a parent if the attachment is secure.

Since young children are so tied to their parents, therapy must be directed towards the parent-child dyad. The Child-Parent Psychotherapy model (CPP) was developed for children suffering from anxiety and other symptoms of trauma. Some of these kids have witnessed domestic abuse in some fashion, which they tend to internalize as being directed toward themselves. Others have been traumatized by medical issues.

“The idea of CPP is that every word spoken is meant to help strengthen the bond between the parent and child,” Tzivy says. “The parent becomes strengthened so she can serve as a protective shield for her child, as a place of safety, as they process the trauma. It’s wonderful, because you see their relationship being repaired in front of your eyes.”

For example, one child was brought in because his behavior had changed, with symptoms that could be considered obsessive-compulsive. When his history was taken, and his mother asked about possible trauma, the only thing she could think of was an incident in which he’d experienced an injury while the family was in a foreign country. The boy didn’t understand the language he was being spoken to in and had to be held down while receiving multiple painful stitches.

“In the treatment, the parent has to say, ‘Sweetheart, you went through a hard hospital visit/scary moment at home/scary moment in school, and that’s why we’re here,’” Raizel explains. “When this boy heard this, he suddenly fell silent — it was an ‘Aha!’ moment.”

Raizel brought in a Playmobil hospital set for the boy, as a “port of entry” into the child’s trauma. As they played, she would make remarks like, “It looks like Shimmy is remembering,” and give Shimmy’s mother the opportunity to validate and step in with comforting, safety-boosting words. Often, as a child recalls and resolves the trauma, the behaviors of concern will typically spike, then resolve.

Tzivy and Raizel give a quick tour of the clinic, which includes cheerful offices with colorful wall murals and toy bins. Since children are most familiar with home settings, and need to convey what happens there, the toys include homey items like play kitchens, dollhouses, and a selection of dress-up costumes.

There are puppets for acting out scenarios, and big hide-and-seek blocks which allow children to hide themselves while acting out their fears. There’s even a sand therapy table, used by specialized therapists, particularly in cases of abuse. Therapists put away their badges when clients come to make the atmosphere feel less official, doing their best to minimize the power differential between professional and client.

It Takes Two

When a child is very young, he has few verbal skills or agency, and treatment necessarily involves the parents. “We have parents who don’t understand this,” Raizel says with a laugh. “They think they can drop their child off for therapy and pick him up later, all fixed. We have to explain that they’re part of the solution. No three-year-old is capable of walking into a session and explaining, ‘Hi, I’m Sruli, and I’m here for anxiety!’

“But we never want to make parents feel shame for what’s going on. We understand that they’re doing the best they can for their child. We try to empower them, and make it clear we believe they’re the experts on their child and the cure will come from them.”

Cognitive behavioral therapy has been the treatment of choice for anxious school-age children, often combined with exposure therapy. As Susannah Meadows describes in The Other Side of Impossible, “CBT doesn’t cure anxiety; it helps a person be aware of worries when they start to infiltrate his mind, and take a critical look at them… Anxiety is a haunted house you sometimes can’t avoid entering. Once you’re inside, it helps to know the ghosts are fake… CBT trains a person to recognize the white sheets are costumes.”

Dr. Mona Potter, director of the McLean Anxiety Mastery Program, suggests in a Harvard Health newsletter that children can be encouraged to practice “detective thinking, to catch, check, and change anxious thoughts… we also encourage them to approach, rather than avoid, anxiety-provoking triggers.”

This sort of approach characterizes a new model called Coping Cat, a cognitive-behavioral treatment approach developed by Dr. Philip Kendall. It’s a 16-session treatment that uses a mnemonic called FEAR (“Feeling Frightened” — somatic reactions like breathing rapidly, “Expecting Bad Things to Happen”— identifying anxious cognitions, “Attitudes and Actions that can help,” and “Results and Rewards.”) Designed for kids ages 6–13, it includes a workbook that teaches children to distinguish between thoughts, feelings, and behaviors, and rewards them as they work through and face their fears.

They’re taught to identify anxious thoughts and come up with coping thoughts, to relax themselves physically when confronting anxiety, and to practice approaching scary situations little by little.

Approaching frightening situations includes receiving exposure therapy to gain confidence in their ability to cope with their fears. “Therapists start with something small, something the child can be successful with, and build from there,” Raizel says. “The parent is involved as well.” Dr. Kendall came to OHEL and trained over 30 OHEL therapists in his method.

“Coping Cat is about 65 percent effective, and 80 percent effective when combined with medication,” she says. “When it’s not effective, there may be other things going on, such as a comorbid condition such as depression. Sometimes the parents may be unconsciously accommodating the child’s anxiety.”

The Apple Doesn’t Fall Far

Today, Raizel explains, parents are very invested in protecting their children, sometimes to a fault. But helicopter parenting, facilitated by technology that allows parents to constantly monitor them, can backfire, because children don’t get a chance to face their fears. “Too much protectiveness doesn’t allow the child to develop coping skills,” she says.

For example, a child may be afraid of speaking in front of other people, so his mother steps in and speaks for him each time. One mother in the clinic couldn’t seem to hold back from intervening when her child responded to questions. The therapists asked her to stay in the room when they worked on helping the child open up and answer questions, but the mother couldn’t resist interrupting when the child gave the wrong answer. “The mother was also anxious,” Raizel says.

It’s often the case that anxiety begins with the parents. “Anxiety cases have become more prevalent and more complicated everywhere in the past few years,” says Dr. David Rosmarin, a Harvard professor and the director of three anxiety clinics in the New York area. Of his roughly 500 patients, he estimates that 25–40 percent are frum, with 100–200 new cases coming in each year. A UCLA survey found that while 18 percent of teens in 1985 felt “overwhelmed by all they had to do,” by 2016, that figure was 41 percent.

Very often, a child’s anxiety is simply a reflection of the parent’s anxiety, or is exacerbated by the parent’s desire to ease his child’s anxiety by accommodating it. “It can be a vicious cycle,” Tzivy says. “Take separation anxiety, when a child is dropped off at play group. The child is anxious at being left by the mother. If the mother allows him to cling and cry, she only makes things worse. The child picks up on her nonverbal cues. She wants to comfort him, but she’s showing him that she’s also having a hard time separating, so his anxiety may increase.”

It’s a natural reflex for parents to want to make their children more comfortable: think the mother who repeatedly takes a hypochondriac child to the doctor, or who asks the teacher to allow her test-anxious child to take tests in the office rather than the classroom.

“You have to think about whether or not you’re reinforcing a problem behavior,” Tzivy says. “Is this helping the behavior to stop, or reinforcing it? Children need to experience discomfort sometimes. We can’t always spare them from that, nor should we. It’s through this process that they develop coping skills and they grow.”

Not every parent is accommodating; there are those who tell their children to buck up and keep a stiff upper lip, or tell them, “Big boys don’t cry.” Some shy away from sharing their own emotions, occasionally asking if it’s a problem to cry in front of their children. The answer is yes, as long as the crying is not uncontrolled, and the parent is generally coping with their everyday responsibilities. Research on children who lost fathers in the Yom Kippur War revealed that those whose mothers grieved with them fared better than those whose mothers grieved in private.

“When parents openly identify and label their feelings, while modeling coping, the child gets the message, ‘This is hard for me, I’m upset, but I’m managing.’ Children then learn that they can be sad and upset and still be okay too,” Tzivy says.

During the current pandemic, parents’ ability to cope and deal with anxiety has had a tremendous impact on how their children processed the situation. As the pandemic eases, children who experienced losses — economic, familial, even the loss of teachers and other school personnel — will be particularly at risk for increased anxiety and complicated grief reactions.

Tzivy mentions a child whose mother contracted COVID and was out of commission for a month. The child developed nightmares and thoughts of scary people and animals coming to get her.

“A lot of the work was with the mom, helping her manage her own anxiety and impart messages to her child that she was healthy and safe,” Tzviy says. “We helped her create structure and routine in the house, managing bedtime routines and separation at bedtime.

“The therapist did some dyadic work with the child and mom through play, in which the child learned to label her scary feelings and to vanquish the scary animals in the play sessions. The mom learned to recognize the child’s cues and provide safety and reassurance.”

In order to help parents reduce their participation in maintaining their children’s anxiety, Dr. Eli Lebowitz, the associate director of the Anxiety and Mood Disorders Program at the Yale Child Study Center, developed a 12-session counseling program called SPACE (Supportive Parenting for Anxious Childhood Emotions). Lebowitz believes that while it’s natural for parents to give in to anxious children — allowing them to stay home from school, sleep in the parents’ beds — in the long run, it only increases anxiety.

Parents are coached in ways to modify their voices, language, and body language to create an ambiance of confidence and calm. They might cut back on the number of text messages sent to their children, from dozens to just a few. If the parent is allowing the child to stay home from school because of anxiety-related stomachaches, the parent might say instead, “I know you’re feeling upset right now, but I’m sure you will be okay,” and send the child to school. In a study of 124 children ages 7–14, SPACE was found to be as effective as cognitive behavioral therapy, the usual treatment of choice.

Even when children have been successfully treated, Tzivy says, parents still have to keep their expectations realistic. Kids are kids, and even the healthiest ones will occasionally balk, talk back, or throw tantrums. “We try to give parents the realistic version of what to expect,” Raizel says.

The COVID pandemic has forced OHEL therapists to do more of their therapy via Zoom sessions, and quarantine brought both clouds and silver linings. One family’s oldest child, a four-year-old, displayed many disruptive behaviors and aggression toward her younger siblings. Her parents often fought about her behaviors and weren’t consistent in their approaches to managing her, but the father wasn’t involved in treatment.

“The behaviors worsened during COVID, due to everyone being home together all the time with no outlets,” Tzivy says. “But since the father had more flexibility from the quarantine, and telehealth became available, both parents started participating in treatment. They’re now gaining insight into the needs behind the child’s behaviors, and developing more consistent approaches to managing the behavior. Both the child’s behavior and parents’ relationships have improved.”

Currently, OHEL has been developing a tool kit for schools with recommendations, tips, and lessons for each grade level to help children ease back into school this fall after COVID. The tool kit provides psychoeducation about stress and language to help them process, clear safety measures, a focus on gratitude, starting school with last year’s teachers, promoting mastery and perspective, and easing gradually into school routines.

Life is challenging, and anxiety will always arise in times of stress. But if we can develop the skills to deal with it — preferably as young as possible — we all stand a better chance of handling our challenges with cool heads and a positive attitude.

Does My Child Need Treatment?

When is a child simply a little worried or scared? When has he crossed the line into troublesome anxiety? Here’s how to judge it.

A basic guideline is to think of Intensity, Frequency, Interference, and Duration:

1. Intensity: How intense is the anxiety or stress your child is experiencing? Does it seem more intense than what you might expect for someone that age in the same situation? Or is it in the range of what you might expect, but given that there are stressful things going on lately, the child has just been more anxious than usual?
2. Frequency: Is anxiety too frequent? Almost every day, more often than not? Does the anxiety come up almost every time the child is faced with the situation or object that disturbs them?
3. Interference: Is it interfering with his daily life? Think of how the anxiety might be getting in the way at school — not just how well your child is doing academically but also how much he enjoys going to school, what he’s getting out of the experience, and how he’s functioning while there.

• Is the anxiety getting in the way of your child’s day-to-day activities or school functioning?
• Is it difficult to make new friends, keep friends, or enjoy time with friends?
• What about family relationships? Is anxiety making things tense at home — family members getting into arguments or feeling like they have to “work around” the anxiety?
• Finally, how much is it bothering your child? Does he seem very distressed because the anxiety is intense? Is your child noticing how difficult things are in different situations? Is it hard for your child to stop feeling anxious or to distract once it starts?
• 4) Duration: Has it been going on longer than a few months? Does it last or cause problems even over the summer break?

Source: The Coping Cats Parents website

Lessen the Stress

Here are ways parents can help children learn to manage anxiety:

• Personalize and externalize: Ask your child to give anxiety a name. Your child can draw pictures of anxiety, too. Then, help your child acknowledge anxiety when it rears up: “Is that spiky-toothed, purple Bobo telling you no one wants to play with you?” Labeling and distancing anxiety can help your child learn to control it.
• Preview anxiety-provoking situations: Consider touring new places, like a new school, ahead of time.
• Model confidence: Children are emotional Geiger counters. They register anxiety radiating from parents. Try to be mindful of what you model through words and body language. Work on tempering overanxious reactions when appropriate.
• Narrate their world: “Children are coding the world. Particularly through early childhood their brains are just sponges, taking everything in,” says Dr. Potter. “We can help them with the narrative they’re constructing: ‘Is the world a safe place or a dangerous place where I have to be on guard all the time?’”
• Allow distress: Avoiding distressing situations invites anxiety to ease temporarily, only to pop up elsewhere. Rational explanations won’t work, either. The whirring emotional center of the brain known as the limbic system requires time and tools to calm down enough to let the thinking (cognitive) center of the brain come back online. Instead, try distress tolerance tools: one child might splash her face with cold water, another might charge up and down stairs to blow off anxious energy, tense and relax her muscles, or distract herself by looking around to find every color in the rainbow.
• Practice exposure: Gradual exposure helps rewire an anxious brain and shows a child he can survive anxious moments. Let’s say your child is anxious about talking in public, ducking his head and squirming if addressed. Pick a pleasant, slow-paced restaurant for a fun weekly date. Then coach your child to take charge of ordering foods he likes in small steps. At first, he might whisper the order to you and you’ll relay it to the waitress. Next, he might order just his drink or dessert, and finally a full meal as distress tolerance and confidence grows.

Adapted from Harvard Health Publishing

(Originally featured in Family First, Issue 707)