Growing Up Brave

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Introduction

On a warm September evening a couple of years ago, I was scheduled to give a talk to a group of parents and other interested parties on the subject of child anxiety—what causes it and how to prevent it. I hoped for at least a modest turnout. So I was shocked when more than seven hundred people filed into the high school auditorium to hear what I had to say.

Over the course of my two-hour presentation, I provided my audience with information about the nature, proper assessment, and state-of-the-art treatment of childhood anxiety disorders. They asked many questions. I showed video clips of some of my young patients who had successfully overcome their fears and phobias using the techniques I teach children and their parents. What struck me throughout the evening was the surge of emotional responses from parents, caregivers, guidance counselors, school nurses, pediatricians, psychologists, and clergy members. After a round of applause at the end, a line formed in front of my podium. Fifty to sixty people wanted to talk to me about their loved one, their child who suffered from anxiety and who provided the impetus for them to arrive that night in search of answers.

One woman was tearful as she said, "I came here for my granddaughter. She won't go to school. We've had her on medication, but it's not doing much good. Some mornings we have to fight with her just to get her out of bed. It breaks my heart to see her so trapped by her fears and worries." This concerned grandmother said she planned to bring home some of the skills she had learned that evening, and she added, "I only wish I had heard this ten years ago, before things got so bad."

A parent approached to let me know that her daughter was just five years old, but she and her husband arranged for a babysitter so they both could attend and, she hoped, gain some insight into how to encourage her child to "grow up feeling confident and brave." Many family members, this mother said, had what she believed were anxiety disorders and she watched how they had suffered and avoided situations. One refused to fly on airplanes. Another was so timid and fearful that she never seemed to enjoy life. While her young daughter showed no signs of severe anxiety, she stated that she wanted to be "equipped" with ideas and strategies that would help the girl develop coping skills to deal with her emotions as she got older.

One by one, I spoke with people in line. I talked to the father of a preschooler with severe separation anxiety; a mother afraid her children would imitate her own compulsive behaviors; a school nurse who wanted information on what to tell teenagers when they arrived at her office after having a panic attack in the classroom; a teacher wondering how to help her students handle anxiety; a social worker who often saw children she suspected of having underlying anxieties along with behavioral issues; and a pregnant woman who sought help on how not to pass on her vulnerabilities to her yet-to-be-born baby.

Also in line was a young mother who expressed her gratitude for the new skills she had acquired that evening and was determined to put into practice. "I learned so much in just two hours here," she said. "I got some great ideas about how to make some simple changes in our home, so that anxiety never has to become a 'disorder.' It can just be an 'emotion.' You really should write this all in a book!"

The people who came out that September evening, along with the hundreds of other participants in my previous talks and the many families I have worked with directly, provided much of the driving force for my finally sitting down and writing Growing Up Brave. The other huge encouragement came from the success stories of children I have helped or witnessed get better after learning basic skills, children and adolescents whose lives were opened up after receiving treatment.

I am the director of the Child and Adolescent Fear and Anxiety Treatment Program at the Center for Anxiety and Related Disorders at Boston University, one of a handful of highly respected specialty centers in the United States that focus primarily on the treatment and study of anxiety. I have spent more than sixteen years treating children and teens for disorders that wreak havoc in their families, disrupt their lives at school, inhibit their ability to make friends, and put them at risk for substance abuse and depression.

What's exciting right now is new research that has led to the development of specific techniques shown to be extremely successful in reducing or eliminating anxiety disorders within the very short time period of one to sixteen sessions. What's even more exciting is the discovery that parents are essential in countering and even in preventing childhood anxiety. This new knowledge offers mothers and fathers a special opportunity to immediately and positively encourage any child, at any age, toward confident, self-sufficient behavior, using effective techniques that anyone can implement anywhere and at any time.

My message is urgent for several reasons.

First, anxiety is the number one mental health disorder affecting Americans today. More than 18 million adults and perhaps as many as one in five children suffer from a diagnosable anxiety disorder, and many others struggle with lower levels of anxiety that nevertheless interfere with their daily lives. For children with consistently excessive fears or worries, there is much at risk. Unchecked anxiety can become debilitating for anyone, but in children it can interfere with critical social and academic development.

Second, in our culture of aggressive medical treatment plans, more children than ever are being prescribed psychotropic drugs to manage behavior. While these medications may be effective in reducing symptoms, they can also cause troubling side effects, and the rush to medicate is in most cases unnecessary.

Third, we want our kids to enjoy carefree childhoods, yet today's academic, social, and cultural pressures have sent anxiety levels soaring, and child psychologists, teachers, pediatricians, and parents are becoming increasingly concerned about the proven significant and negative outcomes for our children and families.

So I am happy to present in this book the good news on how we can approach childhood anxiety. My own research and the work of my colleagues from specialized anxiety centers in the United States and other countries demonstrate that the family environment significantly affects how and if anxiety manifests in children. We begin at such early ages teaching kids to read or to use math concepts, but teaching them how to deal with negative emotions is not usually at the head of the school lesson plan. It is in the interaction between parent and child that kids first and most powerfully learn those critical lessons about life—that it's safe to try new things, that frustration and fear and sadness can be overcome, that situations that make us afraid can be mastered.

Growing Up Brave is divided into several parts. In part I, I will outline the nature of child anxiety disorders, including which fears are absolutely normal and predictable, and which might be a cause for concern. Much of what kids go through is developmentally appropriate, and it is always striking for parents to learn that almost all children can identify at least one fear at each point in their childhood. You will also learn why parenting skills—or parental styles of interaction—can be so crucial in easing high levels of anxiety.

In part II, you'll learn how to set up home and daily routines to include activities that will help your child feel more secure and confident. From learning how to foster a warm attachment to your child through play to establishing a consistent bedtime and sleep procedure, some simple strategies can go a long way toward preventing anxious behaviors from creeping up in the first place.

In part III, you will see how to interrupt spiraling anxiety by helping your child change maladaptive or negative and worrisome thoughts, excessive fearfulness about physical feelings, and avoidant behaviors. Each chapter walks you through the tools you need to bring a child's better coping skills into action. Throughout, you'll read the real-life stories of kids I have worked with in treatment (their identities and case details have been changed), children from preschool age through adolescence who faced crippling anxieties over social situations, difficulty separating from mom or dad, irrational worries about impending disasters, trouble sleeping, and other problems—and you will see how, step by step, they learned to be brave.

Finally, in part IV, I provide some advice to parents whose children might benefit from professional help or medications, and how to go about finding a good therapist.

I am tremendously excited to be able to translate for you years of research executed by myself and my colleagues in the field. And as a mother, I'm aware that parenting is truly one of the hardest jobs, and knowing how to deal with problems as they arise can be difficult without the right information. That's what you will find here.

Let's get started!

CHAPTER 1

The Brave Child

Learning to Cope with the Range of Human Emotions

We all want our children to enjoy a happy, carefree childhood. But that goal can be hard to achieve. From packed schedules and demanding jobs to family complications, economic pressures, illnesses, and on and on, parents today live under a barrage of stressors. So do our kids. Cable television and the Internet deliver a relentless stream of anxiety-provoking news and images into our homes, where impressionable children struggle to make sense of reports about wars, terrorism, violent crimes, environmental disasters.

Then there are the everyday, personal worries and tensions of childhood. Your son has a bossy peer whom he has to sit next to. Your daughter wasn't invited to a birthday party. The first day of kindergarten is looming. A math test is coming up.

Anxiety is real. It's not all bad; in fact, this completely normal human emotion is not only unavoidable, but it's a necessary and useful part of life. Most children figure out how not to let their fears get the better of them. Others have a harder time. And for some, persistent, uncontrolled anxieties make them feel miserable, interfere with age-appropriate development, and cause their parents endless worry and frustration.

In Growing Up Brave, I want to share with you this good and hopeful message:

In my years as a clinical psychologist working with hundreds of children and families, and in league with other professionals at the forefront of advances in treating anxiety disorders in young people, I have seen again and again the truly life-changing results when parents and children put into practice some relatively simple skills.

Growing Up Brave: What Does It Mean?

A common quick-to-come-to-mind notion is that bravery means not being afraid. "You're afraid of the water? Just jump right in. Get over it. There's nothing to be afraid of! Go ahead. Do it."

Of course, there are things to be afraid of. Parents know that, children know that. And some things it's right to be afraid of. But kids who are prone to anxiety fear too much, including situations and objects that will bring them no harm.

When I talk about a child growing up brave, I mean one who over time develops a solid sense of self-efficacy. The psychologist Albert Bandura, sometimes called the father of self-efficacy, writes: "People with high assurance in their capabilities approach difficult tasks as challenges to be mastered rather than as threats to be avoided."¹

A brave child navigates tough situations, even if he worries that every other kid he knows seems to have no problem with them. He learns to cope with his emotions, no matter what they are or how uncomfortable they make him. He confronts what he's most afraid of, and does not let what's stressful in the world stop him from taking steps, moving forward, and participating in his life. He knows that some things are hard, but even when his brain is saying, You can't do this, he develops the personal resources to deal with stress, with daily hassles, and with what frightens him. He learns to be accepting of himself; he feels good about his accomplishments.

That is what you hope to see in your child, the conviction that he can manage whatever comes his way. You play an active role in helping him get there. Part of any parent's job is to encourage a child to feel there's nowhere he can't go—within the context, of course, of teaching what's truly not safe or not appropriate. It's not safe to go off with strangers, but it is safe to walk into the kindergarten classroom even though mom won't be staying with you and you don't know the other kids. You feel worried about going on a playdate, but being a little worried doesn't have to stop you from doing it. You're afraid of the dark and bedtime, but you can sleep and you'll wake up in the morning feeling just fine.

That's what anxious kids want to know. When I work with children, I sometimes ask them what it means to be brave. We talk about who they consider brave people, even among the characters they've met in books and movies. I ask, "What is it about that person that you admire?" Usually, the brave one is identified as being strong. Children tell me, "He can do anything, he's strong, he has a lot of confidence." They say they wish they were more that way themselves.

In gaining self-confidence, with parents' help, children realize that their emotions and sensitivities don't have to derail them from activities that may be a required part of growing up or may just be a lot of fun. And parents can help children learn to go through life without having one eye constantly on what's around the corner or what's ahead. Bravery speaks to the idea of being in the present moment. Anxiety, after all, is a future-oriented emotion. The anxious child is always anticipating, mentally putting himself in an expected situation that he is sure will make him feel just terrible. When you help your child become brave, he discovers that even if you're not around, he has the ability to calm himself, to notice situations and avoid the ones that are not safe and approach the ones that are okay, even if it's difficult.

All this is kind of a tall order, or at least a challenge, for us parents. We're protective. It hurts to see your daughter sitting tearfully next to you at the birthday party while all the other little guests are playing musical chairs. It's painful—and maddening or frightening—to watch your son obsessing over routine activities and engaging in compulsive behaviors that may make him seem strange and isolate him from his peers.

The first step in helping your child get control of his emotions is to deal with yours, by appreciating the role of anxiety in life.

Anxiety: A Normal Human Emotion

Anxiety or excessive fearfulness in a child is difficult for parents to confront. We have a hard time with it. We tend to yank our kids back from the situations or objects that are causing them fear, yet we don't react that way with other emotions. If a child is sad, we feel comfortable telling him it's all right, everybody feels sad sometimes, it's okay to cry. If he's angry, well, everybody gets mad sometimes, being angry doesn't mean he's bad or naughty, we just don't hit people.

When a child says he's afraid, our instinct is to wave it off: "There's nothing to be afraid of, don't worry, relax." He talks about having a frightening dream: "It's not real, come on, we'll make some cocoa." He says dogs are scary: "That's all right, you don't have to meet any dogs."

Besides having a tendency to just shoo them away, parents often misinterpret signs of anxiety—the behaviors that worried kids use as coping mechanisms, such as avoidance, physical complaints, crying, tantrums, withdrawal, and clinging—as intrinsic characteristics, "just his personality." Family members, teachers, too, will describe a child as "shy" or say he's "always been a fussy kid" or is "going through a phase."

But fear is normal. In fact, our society has somewhat of a fascination with this emotion. The feelings that are associated with anxiety can be exhilarating. Many children become really excited about Halloween, for example, about all the neat, spooky, ghosty, witchy creatures, and how much fun they are. Kids are intrigued by the anglerfish with the gigantic, scary teeth in the movie Finding Nemo. They're thrilled by a roller-coaster ride. Many of us adults actively seek out the sensation of fear. We'll go mountain climbing, skydiving.

So fear and anxiety are natural, part of being human. Sometimes they're actually enjoyable. Sometimes they can be helpful. When I first work with a child, we often start off talking about "emotion identification" (and many children, even older ones, to their detriment, don't possess a "feeling vocabulary"; they don't understand the full range of human emotions). I ask the child to describe the different emotions she experiences. What do they feel like? With older kids, I might say, "Why would I not want to take away all your anxiety?"

We discuss the idea that if all her anxiety were eliminated, she wouldn't be safe anymore. She wouldn't know to stop and lurch back when a car came rushing at her. Being afraid of getting hit by a car is obviously what helps her move out of the way. That's what we know as the "fight-or-flight response," which prepares her body to confront the threat and deal with it or to leave the scene as quickly as possible. A little anxiety also enables people to perform better; she can run a bit faster in a competitive race, do a bit better on a test. It can put us on heightened alert in a good way.

The fact that we know certain fears are developmentally appropriate and are experienced across all cultures makes us understand that they are almost hard-wired, or part of the chemistry of the brain. It's adaptive to become afraid of some things; it's how we're supposed to be.

When fears persist, are not age-appropriate, or interfere with daily functioning, however, and when they are undetected, untreated, or misunderstood, a child is at risk in several ways. One teenager's story demonstrates that risk.

When Anxious Feelings Take Over

When 15-year-old Leah came to our clinic for treatment for panic disorder, the girl had just been released from a two-week inpatient program after her parents discovered she'd been skipping school to hang out in the park drinking and smoking pot. In the program, Leah had admitted that she used drugs and alcohol to "numb out" the stress she felt about school and social situations. She told her parents and therapist that simply walking into a classroom would make her heart start to race, and she'd feel so nauseated that she thought she might throw up. She was always afraid of having a panic attack.

Smoking a joint before the day began became a ritual that allowed her to get herself into the school building. At parties, she'd drink heavily in order to lessen her fear that no one would talk to her. She was associating with a group of kids who were making similarly bad choices because she was convinced no one wanted to be friends with her. Leah avoided many social situations out of terror that she'd panic and embarrass herself.

Her mom and dad were shocked to learn how Leah felt. They thought she was just "testing the waters," playing at being an indifferent and rebellious teen. They never considered that their daughter was desperately trying to manage the high levels of anxiety that made her everyday life unbearably stressful.

But in my office that day, Leah told all three of us she couldn't remember ever feeling any other way.

Anxiety and Social Development

Childhood social anxiety tends to become apparent when children first enter social situations. By age three, they are moving away from parallel play (alongside other children with minimal interaction) to social play with peers. They're hard at work developing the skills that allow them to separate psychologically from the caregivers they depend on, growing in autonomy and self-esteem.

Observe in any preschool or playgroup on any day, and you will likely see kids gather in the dress-up areas, assigning roles and costumes: "You be the mom and I'll be the dad and Rachel can be the kitty." They fully inhabit imaginary worlds, learning to adapt to one another's personalities and styles. There is often also a child or two who are reluctant to enter the fantasy play. They hang back, or seek out the teacher for special attention, or hide in a corner with a picture book.

Such behavior is not always cause for alarm. Some children do hesitate to engage in social play, and there are plenty of boys and girls who feel shy in new situations, or are overwhelmed by kids whose play-style differs from their own. The child who simply has a shy temperament, however, will usually eventually warm to social situations if given time and encouragement.

Leah's mother remembered how her daughter would cling to her when she was a young child, insisting that mom stay during playdates. Although she was chatty and playful at home, Leah refused to go to friends' houses. When she did have friends over to her home, she was sometimes reluctant to play with them unless her mother made an effort to engage both little girls by participating in make-believe games. "Leah loved to be the princess," her mother recalled. "But only if I would join in and be the dragon, or the queen, or whatever extra character she needed." On the rare occasions when mom was successful in initiating shared play between Leah and a friend, and was able to leave the room, it wouldn't be long before the friend came looking for her with the complaint that "Leah won't play unless you do."

If her parents had brought Leah to see me when she was a preschooler, I would have asked them whether Leah found other situations difficult. I would also have asked about the family's nighttime routine. It would not have surprised me to hear that the child insisted on mom or dad sitting with her or even climbing into bed with her until she was asleep. They might have noted that Leah worried excessively that something bad would happen to her or her parents if they weren't all together. And it's likely that during our interview, her mother would have mentioned difficulties with drop-off at school or daily requests to stay home from activities.

These are typical behaviors demonstrated by children with separation anxiety. In our work with adolescents who are diagnosed with panic disorder, we will sometimes hear the teen report having had problems with just these issues as a child.

Leah's parents characterized their young daughter as "a little shy," and they assumed she'd become more outgoing as she got older. They often allowed her to evade situations that distressed her, letting her stay home from birthday parties, for example. The truth was that Leah's anxiety back then was already interfering with her ability to engage with others. Over time, she internalized her parents' message that she was shy, and the more she avoided social encounters and separation situations, the less chance she had to experience success and develop confidence.

Socially anxious children find personal interactions nerve-wracking, whether it's meeting new school classmates or trying to join a group on the playground. Paralyzed by a fear of saying or doing the wrong thing and worried about being disliked, they turn away from the peer interactions necessary to developing a healthy sense of social identity. Consequently, they often fall behind their age-mates in peer relationship skills.

It's understandable that parents might question whether social deficits caused by childhood fears or worries should be of concern during the early years. The fact is, by the time a child begins elementary school, they can emerge as real liabilities.

Anxiety and Academics

If a child carries debilitating anxiety into the school years, she may also face challenges in the classroom.

Studies show that children learn best when they are alert and relaxed, but have trouble storing and retrieving information when excessively stressed. For optimal learning to take place, kids need to be focused and feel safe, and for some anxious kids those two conditions can be impossible to achieve in the classroom environment.

In elementary school, Leah said, she was always terrified that she'd be called on by the teacher, because this meant that the other kids would shift their attention to her. She was afraid to make a mistake, or ask for extra time to figure out an answer. As a result, her earliest classroom memories were of trying to be as unobtrusive as possible. Because all her mental energy was directed at staying invisible, she couldn't concentrate well on anything that was taught.

Teachers recognized that Leah was a bright child from an educated, middle-class family that wanted her to succeed. Despite her anxiety, her work was fine. She was not disruptive, and because she rarely interacted with the other children she was never a source of social drama. Throughout her grade school years, teachers attributed Leah's lack of participation to the fact that she was just quiet.

Next to parents, teachers are on the front lines for identifying troubles. But, quite understandably, they are inclined to focus on children who upset the classroom by being oppositional. They also watch for indications of learning disabilities—delays in communication skills; slow language development; difficulty in forming words, writing, or understanding others; or trouble with spelling, math, and grammar. Students who consistently lose materials, or who do the work but forget to hand it in, may also be on a teacher's radar.

In a busy classroom, with perhaps a couple dozen children to monitor, a teacher might not connect certain behaviors, such as asking to leave the room (by making requests for frequent bathroom passes, for example) or refusing to read aloud, to anxiety. But in fact, the actions of an anxious child can mimic many characteristics associated with learning disorders. She may be so stressed about getting the right answer on a math problem that she attempts to avoid the question altogether, telling the teacher, "I can't do this" or "I don't know." Fears about reading aloud can cause a confident reader to stumble over words or even freeze to the point of being unable to speak. A child who is afraid to go to school may be so distracted in the hours before it begins that she can't organize the materials she needs for the day and consistently leaves homework or notebooks behind.