Hurricane Sandy did a lot of damage in my area (Long Island). A lot of damage. Indeed, my office was closed for about two weeks. I couldn’t call my patients and they couldn’t reach me. Next time, I’ll make sure I have a better backup plan, although even cell phones weren’t working for the first few days as the cell towers also got damaged.
But all my young patients have returned to therapy, and it’s been interesting to hear how they and their families managed to cope with being without power and having their lives disrupted.
Now you might think that kids with a lot of OCD or anxiety problems would get even more anxious under unplanned and unpredictable circumstances, right? Well, you’d be wrong. As I saw after 9/11, kids with anxiety disorders actually did really well – as well as their non-anxious peers, anyway. Most of the adults in my practice also reported no exacerbations in anxiety during the long power outage, although they reported more frustration and anger, as one might expect, since the adults were dealing with the power company and the children weren’t.
One of the things we also learned was that being without internet and electronics turned out to be a Very Good Thing. Kids and teens in my practice reported that at first, they felt somewhat disconcerted or at a loss without their usual activities and online interactions, but after a while, they realized they were actually less stressed and more relaxed without all the internet and electronics. Some found other ways to amuse themselves, like reading or going out more to play on the street during daylight hours when they might otherwise have been indoors on the computer.
Of course, having no school may well have contributed to their less anxious state, but it’s interesting that they uniformly reported feeling better without so much internet and electronics.
Now the trick is for us to capitalize on that awareness.
Carousel image credit: NOAA
Some premonitory urges are experienced as an urge to action. Such urges have been described in a number of clinical conditions including Tourette syndrome and Obsessive-Compulsive Disorder (OCD). An interesting article in the September 2011 issue of Cognitive Neuroscience looks at their functional underpinnings. Here’s the abstract:
Several common neuropsychiatric disorders (e.g., obsessive-compulsive disorder, Tourette syndrome (TS), autistic spectrum disorder) are associated with unpleasant bodily sensations that are perceived as an urge for action. Similarly, many of our everyday behaviors are also characterized by bodily sensations that we experience as urges for action. Where do these urges originate? In this paper, we consider the nature and the functional anatomy of “urges-for-action,” both in the context of everyday behaviors such as yawning, swallowing, and micturition, and in relation to clinical disorders in which the urge-for-action is considered pathological and substantially interferes with activities of daily living (e.g., TS). We review previous frameworks for thinking about behavioral urges and demonstrate that there is considerable overlap between the functional anatomy of urges associated with everyday behaviors such as swallowing, yawning, and micturition, and those urges associated with the generation of tics in TS. Specifically, we show that the limbic sensory and motor regions-insula and mid-cingulate cortex-are common to all of these behaviors, and we argue that this “motivation-for-action” network should be considered distinct from an “intentional action” network, associated with regions of premotor and parietal cortex, which may be responsible for the perception of “willed intention” during the execution of goal-directed actions.
Jackson SR, Parkinson A, Kim SY, Schüermann M, Eickhoff SB. On the functional anatomy of the urge-for-action. Cogn Neurosci. 2011 Sep;2(3-4):227-243.
A computer-based training method that teaches a person with anxiety to shift attention away from threatening images reduced symptoms of anxiety in a small clinical trial in children with the condition. The results of this first randomized clinical trial of the therapy in children with anxiety suggest that the approach warrants more extensive testing as a promising therapy.
As many as a quarter of 13- to 18-year-olds have met the criteria for an anxiety disorder at some point. Currently available treatments—including cognitive behavioral therapy and medication—relieve symptoms of anxiety in about 70 percent of children treated. Most children with clinical anxiety do not receive treatment, partly because of difficulties in access to care, including distance and financial resources. Scientists are searching for additional approaches, including therapies that do not involve medication with its associated side effects.
A treatment called attention bias modification (ABM) has emerged from the observation that people with anxiety unconsciously pay more attention than others to anything that seems threatening. One way of detecting such a bias is a dot probe test. In the test, people view a computer screen on which angry and neutral faces are flashed briefly, adjacent to each other. After the faces disappear, a test image of dots appears where either one or the other face was, and the person has to respond by pushing a button. People with anxiety consistently respond more quickly to dots that appear where the angry face was located.
ABM presents patients with an exercise similar to the dot probe test, but the dots always appear where the neutral face was, and thus consistently draw the attention of the participant to this non-threatening image. A recent meta-analyses of ABM in adults by some of the same investigators who carried out this work suggested its potential as a treatment.
Researchers at Tel Aviv University (TAU) in Israel carried out a clinical trial on ABM as an outcome of a three-year collaboration with scientists at the National Institute of Mental Health and the University of Maryland, College Park, Maryland. Yair Bar-Haim of TAU led the study, which appears in the American Journal of Psychiatry. The study enrolled 40 children, 8 to 14 years old, who had sought help for anxiety. For children receiving ABM, after faces appeared on a screen, two dots appeared on the screen; children had to determine whether the dots were side by side, or one above the other. In every case, dots appeared only where the neutral face had been. There were also two control groups: in the first, dots appeared equally frequently where angry and neutral faces appeared; in the second, the only faces that appeared throughout were neutral, so the dots always appeared in the location of a neutral face. The object of the second control group was to help confirm that any therapeutic effect was from the ABM training, and not from desensitizing the children to threatening faces. Children in the study were randomly assigned to receive treatment, or to be in one of two control groups. All children had four training sessions over 4 weeks, with 480 dot-probe trials per session.
Although the trial was small, there was a “reasonably robust” decrease in the severity of anxiety, according to the authors. Following ABM, both the number and severity of symptoms were reduced.
An important feature of ABM, says NIMH author Daniel Pine, is that it addresses the fundamental neurological function underlying anxiety: attention. Changes in attention happen very quickly—in milliseconds. “We know from neuroscience that if you want to change behaviors that happen very quickly, you have to practice. You can’t just tell someone how to drive, or throw a ball. You have to practice,” says Pine.
Longitudinal studies that follow children into adulthood suggest that most chronic mood and anxiety disorders in adults begin as high levels of anxiety in children. In fact, childhood anxiety is as important in predicting adult depression as it is for adult anxiety. The ability to influence attention biases early in development might provide a powerful means of prevention for both of these disorders later in life. The approach requires no medication and in practical terms, the computer-based nature of ABM lends itself to large-scale dissemination, in a medium children are comfortable with. Larger-scale trials will be able to provide more information on the efficacy of the treatment in children and how it works to reduce symptoms of anxiety.
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Eldar, S., Apter, A., Lotan, D., Perez-Edgar, K., Naim, R, Fox, N.A., Pine, D.S., and Bar-Haim, Y. American Journal of Psychiatry. 2012 Feb 1;169(2):213-30.
Source: National Institute of Mental Health Science Update
Trying to understand the impact of one condition can be a challenge, but some conditions tend to have a lot of other problems that “go with them.” ADHD is a disorder that has a tremendous amount of comorbidity. To help teachers understand that they need to be aware of “what else” the student with ADHD may have, I often use the following overhead:
Overwhelming, isn’t it?
With so much going on, it is somewhat understandable that teachers – and even parents – often overlook the presence of an anxiety disorder. And yet anxiety may contribute to some of the worrisome behavior that they have been attributing to ADHD. If a student becomes disruptive due to heightened levels of anxiety but their behavior is misunderstood as ADHD-related impulsivity or disinhibition, parents may think their child needs (more) medication for ADHD, when what they might really need is treatment for anxiety. And increasing a stimulant medication to treat ADHD may make anxiety worse.
I came across an article online that may open some parents’ and teachers’ eyes about the relationship between ADHD and anxiety:
It’s not uncommon for individuals with attention deficit hyperactivity disorder (ADHD) to struggle with anxiety, whether it’s several symptoms or a full-blown disorder.
In fact, about 30 to 40 percent of people with ADHD have an anxiety disorder, which includes “obsessive-compulsive disorder, generalized anxiety disorder, phobias, social anxiety and panic disorder,” according to Roberto Olivardia, Ph.D, a clinical psychologist and clinical instructor at Harvard Medical School. The Anxiety Disorders Association of America even estimates the figure to be almost 50 percent.
Read more of this article on PsychCentral.
I’ll be conducting an all-day workshop for educators on Monday, December 5, 2011 at the Grappone Conference Center in Concord, New Hampshire. The event is sponsored by the University of New Hampshire Institute on Disability and is geared to regular and special education teachers, school psychologists and social workers, behavior specialists, occupational therapists, administrators, and parents.
Neurological disorders that emerge in childhood often have significant impact on students’ academic, behavioral, and social-emotional functioning. Participants will learn about the cardinal features of Tourette’s Syndrome, Obsessive-Compulsive Disorder, Attention Deficit Hyperactivity Disorder, Executive Dysfunction, Mood Disorders such as Depression and Bipolar Disorder, and the memory deficits, sensory issues and “storms” that sometimes accompany them. Strategies and assistive technology to accommodate symptom interference in activities such as handwriting, homework, math calculation, and written expression and big projects will be described. Pitfalls in behavioral interventions, and simple social skills and problem-solving interventions will also be identified.
Hope to see you there!