It's Nobody's Fault (19 page)

SAD can be and often is mistaken for other disorders. SAD is often called school phobia, but that’s a misnomer. A child with SAD may not want to go to school, but he isn’t afraid of it. Being in school—without Mom and Dad—is what he’s afraid of. SAD is sometimes confused with depression. The child may look and act depressed—SAD may result in loss of concentration, sleep and appetite disturbance, and a demoralized state, all symptoms of major depressive disorder (see
Chapter 14
)—but, it’s crucial to note, those symptoms nearly always disappear when Mom and Dad are around. A child who has no appetite for his lunch at school may eat perfectly well at dinner, when he’s at home with his parents. By contrast, the loss of appetite associated with clinical depression doesn’t come and go. A youngster with SAD may be perceived as defiant, especially when he has to be dragged kicking and screaming onto a school bus. Attention deficit hyperactivity disorder (see
Chapter 7
) may also be suspected, since children with SAD are so worried that they often appear inattentive and distracted in school. One mother whose daughter I treated received a succinct but less than helpful diagnosis from her neighbor: “spoiled brat.”

Jenny, Ernie, John, and Elizabeth demonstrate a wide variety of anxiety symptoms, but at the core of each is the most important factor in SAD: a threat to the integrity of the family. That’s what we look for when we examine a troubled child. And we look for it the old-fashioned way: by taking a detailed developmental history from the parents and interviewing the child. Here’s how an interview with a child might go.

The child doesn’t always directly acknowledge worrying about his parents. He might talk about kidnappers or burglars or voice concerns about the security of his house. But it doesn’t take too long to get to the real fear.

Here’s another line of questioning I might try.

A child need not have all of the symptoms of SAD to qualify for a diagnosis; if a child is suffering, even one or two symptoms are sufficient. As is the case with all brain disorders, SAD is a spectrum disorder, ranging from mild to severe, so along with any diagnosis should come an evaluation of
distress
and
dysfunction.
There is a critical difference between a child who is a little uncomfortable sleeping with the lights off and one who is so pained to leave his home and family that he avoids going outside, refuses to accept sleepover dates with friends, or, worst of all, won’t go to school. It’s not enough for a child to have a rewarding, secure home life. Like a healthy adult, a healthy child should have an active social and “work” life as well.

Stephen, 10 years old, had one of the most severe cases of SAD I’ve seen. I’ll never forget the day he first came to my office; rather, I should say
they
came to my office. When I opened the door, three generations were sitting in my waiting room, staring up at me: Grandma, Mom, and little Stephen. Stephen was refusing to go to school by himself. He agreed to attend school if his mother would drive him and then sit in the car right
outside his classroom so that he could see the car through the window. The mother had been doing just that, and the school was remarkably cooperative; the staff agreed to the unusual parking setup and even let Stephen make calls (on the cellular phone he carried) to his mother on the car phone. This strategy had been going on for six months when I met Stephen, but now there was a crisis: Stephen’s mother was finding the arrangement more difficult all the time. When she told Stephen that she couldn’t take him to school any longer, he threatened to kill himself. When it was time to go to school, he cried hysterically, saying: “I’m going to die. You’re going to die.”

Stephen had SAD, and it doesn’t take a world-class diagnostician to see where it came from. As I soon discovered, both Grandma and Mom had it as well. They lived a block away from each other and were inseparable. They had never spent a day apart and went everywhere together, including my waiting room. Obviously, the DNA Roulette wheel had spun, and Stephen had an unlucky number. Stephen had inherited his brain chemistry from his mother.

What is it about the chemical composition of that family’s brains that results in SAD? What causes SAD? As always, it’s difficult to answer precisely, but the most likely answer is an imbalance of serotonin and norepinephrine.

Eve, a 30-year old computer programmer, was waiting for the bus that would take her to work. It was a cool autumn day, but Eve felt hot and clammy. Her heart was racing, and the street seemed to be spinning. She felt dizzy and lightheaded. She was sure she was having a heart attack, so she sat down on the sidewalk. When her fellow commuters asked her what was wrong, she couldn’t speak. In fact, she was having trouble breathing. Someone took out a cellular phone and called 911. Moments later Eve was evaluated in the emergency room of a nearby hospital. Her cardiogram was normal, and so, it seemed, was everything else. Eve’s symptoms had subsided by then, and more than anything else she was embarrassed. This was the second time that Eve had gone through this, and it looked as if “nothing” was wrong. But the emergency room doctor told her that something was indeed wrong. Eve had had a panic attack. The psychiatrist on call confirmed the diagnosis and took it a step further; she told Eve that she had panic disorder: an adult psychiatric disorder (seen occasionally in adolescents) consisting of panic attacks and worry about future attacks.

SAD seems to be the childhood version of panic disorder. There are all sorts of data to support this theory: landmark studies (conducted by Donald Klein) show that 50 percent of patients with panic disorder had separation anxiety disorder as children; moreover, other studies indicate that the children of adults with panic disorder have separation anxiety disorder more than three times as often as the children of depressed or normal adults; and finally, the same medicines are effective in the treatment of both disorders.

Studying the causes of panic disorder has added immeasurably to our knowledge of what causes SAD. We know that both disorders are caused by a defect in the way the brain recognizes and responds to danger. It all happens in the
locus ceruleus
, the part of the brain that alerts the body when there is danger by producing norepinephrine. In people who have panic disorder and, more to the point, children with SAD, the locus ceruleus basically gives the “Danger!” signal when there is no danger, thereby upsetting the balance of norepinephrine and serotonin.

If a child diagnosed with SAD is in extraordinary distress, it may be advisable to medicate him right away, but behavioral therapy without medicine is usually the first line of attack against SAD. Sometimes behavioral therapy is all that’s necessary; in a recent study 40 percent of the kids diagnosed with SAD were determined to be functioning quite well (although only about half were symptom-free) after four weeks of behavioral psychotherapy.

In behavioral therapy we concentrate on modifying the way a child acts under various circumstances, addressing both the child’s separation anxiety and his
anticipatory anxiety
—the worries he has about something that is going to happen. The goals are quite specific: for example, a child must sleep in his own bed, play with his friends, and, most important, go to school. He must not follow his mother from room to room or cry when he can’t see her. He must allow a baby-sitter to care for him once in a while.

Therapists have tried many different ways of working with children to achieve these goals, but the one with which I have had the most success is the contract. This is a formal written agreement signed by the parents
and the child and witnessed by me. To make it even more official, everyone gets a typed copy. (I’ve never gone so far as to get the documents notarized, but I’d gladly do so if I thought I’d get better results.) To my way of thinking the contract offers a perfect way to let a child know what is expected of him, to reassure a child that there are things he can count on from his parents, and to reward him for positive behavior. What’s more, if the child doesn’t live up to his part of the bargain, we don’t have to blame him. We can blame the contract.

Here are a few contracts I’ve drawn up.

“Jennifer agrees to go to bed by eight o’clock. She will stay in bed with the light on for 15 minutes. During this 15 minutes Mom will come three times to check on her. Jennifer will not leave the bed. At the end of 15 minutes Mom will turn off the light and Mom will continue to check on her every five minutes until Jennifer is asleep and twice after she’s asleep. For every night that Jennifer does this, she gets a star. If she gets three stars, she gets a prize. If she gets five stars, she gets a prize and a half. With seven stars she gets two prizes.” Jennifer traded in her stars for TV shows.

“Sara agrees to go to school every day. Sara will not cry during school or when Mom leaves. Sara will go to sleep without Mom or Dad in the room. Mom promises to take Sara to school and pick her up each day. Dad promises to tell Sara one five-minute story and will check on her every five minutes before she falls asleep and twice after she’s asleep.” Sara asked for tickets instead of stars. When she earned five tickets, she got a package of stickers.

“Roger agrees to go to bed quickly without complaining. Roger will stay in his own bed and not go to Mom and Dad’s bed or his brother’s bed during the night. Mom and Dad promise to let Roger keep his bedside light on. Roger can play or read quietly in bed.” Roger used his stars to play video games.

“Cynthia agrees to stay in school from the beginning to the end of lunch. Two stars. She will not cry when she gets on the bus. One star. She agrees to stay with the baby-sitter on a weekend night, without Mom and Dad, for three hours. One star. Without crying, two stars. Going to bed before the parents come home, three stars.” With 11 stars Cynthia may rent the video of her choice.

Obviously no one wants a child to fail—the last thing he needs is to feel worse about himself than he already does—so some contracts have
to be especially easy and very specific, like the one I drew up for little eight-year-old Karen: “Karen agrees to brush her teeth, wash her face, and prepare for bed by eight o’clock. Karen will get into bed by 8:30 and turn off the lights by 8:45. Mom and Dad promise to let Karen watch TV until 8:30, tuck Karen in at 8:45, check on her every ten minutes till she’s asleep. If Karen wakes up, she can call Mom. Mom promises to go to her room and sit in a chair for a few minutes.” Once Karen has mastered these simple tasks, we’ll draw up a more ambitious contract for her.

A few of my colleagues oppose the idea of attaching rewards to behavior with these contracts, but I’m in favor of them, provided they’re not too lavish. Books, videos, baseball cards, doll clothes, or any other relatively small items that a child values make these kinds of contracts that much more effective. Rewards do a lot to increase a child’s motivation, and children enjoy looking at their “trophies,” tangible evidence of their accomplishments.

Behavioral therapy works relatively fast. If it doesn’t work right away, it’s probably not going to work, at least not without adding medication. To persist with this type of treatment without adding medicine becomes painful for the parents, the therapist, and, most of all, the child. If a child hasn’t responded to behavioral therapy after about four weeks, it’s probably time to add medication to the treatment. The drugs that have been used to best effect are Tofranil (a tricyclic antidepressant, or TCA), Luvox, Paxil, Prozac, and Zoloft (all selective serotonin reuptake inhibitors, or SSRIs), Xanax (an antianxiety agent), and Nardil and Parnate (monamine oxidase inhibitors, or MAOIs). All of these have been used to excellent effect, sometimes in a matter of days. One mother I know thinks that Prozac worked miracles, and she is not alone.

There can be negative side effects with some of these medications. Tofranil may cause dryness of mouth, constipation, and urinary retention, and there may be some behavioral disinhibition; children can become giddy or oppositional. Tofranil may also affect heart rhythm, so it’s important for a child to have an electrocardiogram at the beginning and with each dose increase. Xanax, which treats anticipatory anxiety as well as separation anxiety, has no effect on the heart rhythm, but it may cause drowsiness and disinhibition in children. MAOIs carry dietary restrictions because the medicine may cause a reaction when taken with foods rich in a chemical called
tyramine
(aged cheese, red wine, beer,
smoked fish, and aged meats). The SSRIs have the fewest side effects. When the dose of an SSRI is started low and increased slowly, there are few side effects. The most common ones are nausea, diarrhea, insomnia, and drowsiness.

Under normal circumstances the medication will take effect within six weeks. A child should continue to take the medicine for at least six months, at which time he should be taken off the medication—gradually, over a period of several weeks—and reevaluated. (I suggest that parents continue the contract policy during this time.) Some children taken off the medicine will redevelop their symptoms, in which case we gradually put them back on medication, enough to make the symptoms disappear; others will continue to be symptom-free without it. It is unlikely that a child will need medicine steadily for a very long period of time—more than a year—but many people diagnosed with SAD require medicine intermittently for many years.