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When anxiety strikes early
Children gain freedom from fear at BU center

By Hope Green

Two years ago, Jimmy had an unusual fixation for an active eight-year-old boy: soap and water. An otherwise bright and good-natured child, Jimmy scrubbed his hands at the bathroom sink several times an hour, at home and at school. When he played basketball he kept running into the house to clean off sweat and pavement dust. Sometimes he refused to put on his backpack or coat, petrified of the germs they might carry.

Jimmy's obsessive-compulsive disorder came on subtly at first, but in the fall of 1999, says his mother, "it blew up in our faces." One day, in tears, Jimmy insisted that his toe felt "dirty" after it had accidentally grazed a child he didn't like in a swimming pool. He admitted that he was being irrational, says his mother (a nurse who asked that her son's real name not be used), yet he was unable to tame his fears.

"He had been washing his hands a whole lot to the point where they were red and bleeding," she says. "All I kept thinking to myself was, oh my God, I've got this kid with this problem."

	Donnas Pincus Photo by John Otis

A psychologist referred Jimmy's mother to Donna Pincus, director of the Child and Adolescent Fear and Anxiety Treatment Program at Boston University's Center for Anxiety and Related Disorders (CARD). Pincus worked with Jimmy in 12 sessions, and since then, his mother proudly reports, "he has been totally free of any hand-washing problems and living a completely normal life. He's athletic, well-liked, very smart in school, and he has a good sense of humor. He has little bouts of anxiety, but it's normal anxiety.

"I can't say enough good things about the CARD program," she adds. "These are people who know what they're doing, and they don't make you feel like you have this weirdo kid. They have a plan and a structure, and that's what gives you hope."

Anxiety at an early age
While adult anxiety disorders and phobias are well publicized, particularly the fear of flying, experts estimate that severe anxiety also afflicts 10 percent of children. In addition to its programs for adults, CARD treats patients ages 4 to 17 for general anxiety disorder, panic disorder, phobias, obsessive-compulsive disorder, and separation anxiety disorder.

"We tend to think of childhood as being this carefree time," says Pincus, a CAS research assistant professor of psychology. "It's natural for children to occasionally feel a little anxious or sad, but for some kids, it interferes with their functioning. In the past few years we have gotten to know not only more about the nature of child anxiety, but also what kinds of treatment can be effective. It's really a burgeoning field."

CARD's child and adolescent program has successfully treated about 230 young patients since Pincus arrived at BU in July 1999. Handmade thank-you notes decorated with children's artwork line a shelf of her office; in one letter a former client praises her as "an angel from heaven."

Therapy is short term, usually 8 to 12 sessions, and because CARD is an academic center, research and treatment correspond in a feedback loop: psychologists and doctoral students closely monitor each child's improvement and use the data as a foundation for future study. "Our research helps us make better treatments for kids," Pincus says, "so the two have a nice relationship."

Phobias unlimited
CARD receives many of its referrals from pediatricians, because anxious children often complain of stomachaches or appear to have asthma before their parents understand the true nature of the problem. These children are not necessarily faking their symptoms, says Pincus -- just like adults they can experience a full-blown panic attack, a welling up of irrational terror that causes a rapid heartbeat, dizziness, trembling, shallow breathing, and profuse sweating.

Anxiety often centers on specific situations, so while one child dreads school or birthday parties, another might be morbidly afraid of swimming pools or dogs. Pincus successfully treated an eight-year-old girl for phobias that ranged from fear of eating popcorn (she was convinced she would choke to death on it) to fear of sleep.

"These kids tend to overestimate the likelihood that the worst will happen to them," Pincus says. "What brings parents in here is when their children are either having somatic complaints or their anxiety has started to interfere with some part of their lives or their family's. For example, parents whose kids aren't going to sleep are staying up late and going to work exhausted, and they're feeling less patient with their children so there are more fights within the family. It becomes a vicious cycle, and after a while parents come in here saying, 'We wish our child could just let go and be a child, and not always have the weight of the world on his shoulders.'"

Removing the mystery
For children, as for adults, CARD employs exposure techniques that gradually desensitize patients to anxiety-provoking situations. Children who experience extreme anxiety during electrical storms sit with a therapist and listen to a recording of thunder while a strobe light flashes. Later they might take a field trip to the lightning exhibit at the Museum of Science. "We have an outstanding staff of doctoral students and research assistants who use their creativity to make therapy fun for kids," Pincus says.

To solve Jimmy's hand-washing problem, Pincus developed a step-by-step learning plan with frequent rewards. When he had advanced sufficiently toward his goal of washing only twice daily, Pincus and his mother set up a scavenger hunt where, among other things, he had to root through the trash for clues and clean up after the family dog during a walk.

Such therapy deliberately brings patients to a limited state of anxiety -- with their willing participation and in a safe environment -- while talking them through it. "One of the interesting things about child anxiety treatment is that we're not trying to calm kids down," Pincus says. "What we're really doing is helping them realize that anxiety won't hurt them and that it's a natural part of everyday life."

As an integral part of desensitization, the young patients learn strategies to reverse their anxious thoughts and cope more effectively with their emotions.
"Children here become very educated about the whole cycle of anxiety," Pincus says. "They learn how their thoughts influence their feelings and how feelings influence their behavior. And for many kids, once they get that information, they already feel better. We take the mystery out of this big word anxiety by breaking it down for them."

Parents, too, receive training, and their involvement in child therapy is of growing interest to anxiety researchers. Pincus and her staff teach parents how to guide their children in exposure exercises, and equally important, how to communicate confidence. The result: rather than transmit their own angst, they listen better -- and hover less.

Help for teens
Adolescence is the peak time for the onset of panic disorder, which causes sufferers to avoid situations that might set off a panic attack, such as sitting in a classroom, going to the movies, or taking public transportation. In collaboration with Pincus, Sara Mattis, a CAS assistant research professor of psychology, is directing a research project that provides free treatment for adolescents ages 14 to 17 with panic disorder. Thus far the results are encouraging. One former patient, who had agoraphobia as well as panic disorder, used to have trouble just leaving her house. Now she attends college and travels extensively. Another young woman treated at CARD couldn't sit in restaurants, but now regularly dines out with friends.

Pincus, who received her Ph.D. in clinical psychology at SUNY-Binghamton, was named director of CARD's Child and Adolescent Fear and Anxiety Treatment Program in 1999. Previously she worked at the University of Florida Health Science Center, directing an inpatient counseling program for adolescents with severe diabetes.

She is also the editor and creator of the Child Anxiety Network, an online information resource for parents of anxious children. The Web site, which receives more than 200,000 hits a month, contains a primer on juvenile anxiety disorders, a roster of professional treatment programs and therapists, a newsletter, and lists of recommended picture books and toys.
"For some parents, just knowing how to seek help is important," Pincus says.

This fall she released a CD for children called I Can Relax! In soothing tones she guides children through a series of exercises, such as sitting quietly and envisioning a "worry train" that carts their fears away. The CD also uses a storytelling device to teach children how to progressively relax their muscles.
Under the direction of CAS Psychology Professor David Barlow, CARD has long been a magnet for media attention because of its renowned treatment programs for adults. But lately Pincus has also been in the spotlight: recently her work with youngsters was featured on NBC's Today show and on ABC's 20/20 Downtown.

"We have success stories all the time," Pincus says. "It's gratifying and also very motivating to see that the treatments we have really work."

Visit the Child Anxiety Network at www.childanxiety.net.

11 January 2002
Boston University
Office of University Relations