Jason (not his real name) was a charismatic seven year old child – except when it came time to go to school. "Then the fights would begin" his mother remembers.

Jason would hide when the school bus was about to arrive, or be dragged out screaming – his mother was sure the whole neighborhood thought she was beating the boy.

This was school refusal, a manifestation of "separation anxiety" – a common form of anxiety in children, "especially if school is traumatic for the child, or they are suffering academic frustration" notes Scott Young, MD, child psychiatrist with the Rappahannock Area Community Services Board in Fredericksburg . "But it's a mistake to let them stay home," he added.

Anxieties That Mature With the Child

All children are anxious to some extent, "especially the 'milestone years' of kindergarten and 9th grade," said Dr Young. This may manifest as simple fears in toddlers and young kids. Like fear of the dark, the bogey man, a fear that they or their parents will get sick, or not wanting to be left alone to go to sleep. "Back to school" time, the focus changes – it starts to become anxiety about "social acceptance" notes Carol LeMon Houchin, Director of Council ling at North Stafford High School. "What their peers think", their social status, their clothes, how they perform in sports, etc. all become points of anxiousness. Houchon points out, "Boys and girls manifest differently. Girls "melt down" and are demonstrative...Boys "pack it down" and work it out with sports, endless computer games or drugs."

One modern stressor is texting - or even sometimes "sexting," (sending provocative picture texts). "There are rules against the kids having cell phones," Houchin notes, "but they still manage to send messages that promote anxiety." As kids advance through school, academic pressures about school work tend to be exacerbated with exams. A daughter of friends of the family manifested anorexia nervosa (an actual form phobia) at SAT time.

If the child has any kind of Learning Disability or reading deficit, this may manifest as anxiety as the child struggles to keep up. College age students find, in addition to the step up in academic pressure, anxiety in leaving home and breaking those close and supportive friendships of childhood.

We're All Anxious

Children and adults alike experience anxiety. We all have built in the "flight or fight" reaction where our pulse, blood pressure and respiration increase, our muscles tense, we get knots in our stomach or even diarrhea, and become tense. All the manifestations we see with anxiety, which are all part of our personal "homeland security" – would be more appropriate while hunting Wooly Mammoths or running away from Saber Toothed tigers than modern day threats of taking exams or arguing with your parents.

As I explain to my patients, every "illness" or "characteristic" is a spectrum of traits we all possess. Everyone is a bit anxious/depressed/phobic/ paranoid/ADD (attention deficit disorder)/OCD (obsessive compulsive disorder) to some extent. This can sometimes be a good thing – obsessive compulsive and anxious people tend to be careful and conscientious. How are along the spectrum we range, and the particular circumstances of our lives, determine whether or not the degree of metal "illness" we manifest is a problem.

When normal anxiety becomes pathological is "when it interferes with function." "When you can't get the kid to school or grades are falling off," noted Dr Young, "That's when it is time to get help – from the school councilor, a therapist or even a child psychiatrist."

Where to Take Our Children?

There are variations on anxiety (see Nov/Dec for continuation on this Anxiety in Children series). The variety, or the circumstances, will determine what form of help is appropriate.

In some cases it is situational; parents are getting divorced, a parent is in the military and is being deployed, or there's a death in the family. Other "situational" influences include parent anxiety or very strict or controlling parenting. This will tend to make things worse. Perversely, sometimes the affluent family may experience an adverse effect according to British psychologist Oliver James and his book, "Afflenza" (he terms a "virus infection" of affluence that is sweeping the English speaking world and creating a dangerous "obsessive, envious keeping-up-with-the-Jonses" materialism). "Controlling parents put kids at high risk of both anxiety and depression," he notes. And parents of 'Affluenza' inflicted families tend to be very status conscious; pressurizing their kids to be perfect. Studies show "the children used high marks and outstanding performance as a way to ensure acceptance," he notes. James claims that as our physical discomforts are dispelled by our society becoming more affluent and materialistic, our neuroses, like anxiety and depression, increase. We were less neurotic when life was simpler and less materialistic.

If anxiety is situational, treatment may vary from the child who has an inbuilt, anxious nature. "Or if it is something more of a neurological manifestation, like ADD," said Dr Young, " These kinds of conditions may be more amenable to medicines," he noted.

Often there are physical manifestations such as; headache, rashes, nausea, stomach pains, and diarrhea which often land the family in the primary care doctor's office and these symptoms may be hard to diagnose. One may also experience more traditional, emotional symptoms like tantrums, being clingy, nightmares, and school refusal.

The anxious child may be out and out defiant and present like 'Oppositional Defiant Disorder' (ODD - an ongoing pattern of disobedient, hostile, defiant behavior toward authority figures).

Incidentally these "D" disorders seem to be getting out of control. Most people know about ADD (attention deficit disorder). Maybe you have heard of ODD before, and David Walsh, of the 'National Institute on Media and the Family' in Minneapolis and author of 'NO: Why Kids — of All Ages — Need to Hear It and Ways Parents Can Say It," has come up with a new diagnosis: 'DDD' or "Discipline Deficit Disorder" = A Parent Disorder!

Situational anxieties are more likely to be temporary - and are more amenable to techniques such as Cognitive Behavioral Therapy where the child is taught to examine, and then control thoughts and bodily reactions to stressful circumstances. But the first line of defense is, of course, the parents. "Are parents good at picking up anxiety?" I asked Dr Young. "If they were anxious children themselves, they're liable to be attuned," he said. "But if they are still anxious now, the child is liable to pick up on it, and it may make things worse."

Very quiet, shy children, and those anxious to please, may be harder to spot. Also, children may "hold it in" at school and be worse behaved at home, as was the case with Michael who, as soon as he got home, "would spend hours in the bathroom washing his hands because he was so obsessed with germs."

"Often all is needed is acceptance, listening, patience, and encouragement from the parents," notes the website WorryWiseKids.org. "If that is not enough, your child may need counseling." (Continued in October Issue)

Dr. Patrick Neustatter is retired from Pratt Family Physicians. He now manages the Moss Free Clinic in Fredericksburg and serves as our On Call columnist.