Heading childhood anxiety off at the pass

Untreated anxiety in children is associated with all sorts of bad things later in life. The good news is, if you do treat it, it can usually clear up.

Untreated anxiety in children is associated with all sorts of bad things later in life–mood disorders, alcohol and drug abuse, suicidality, underachievement in school, and low earning potential. The good news is, if you do treat it, it can usually clear up.

It’s usually easier to prevent something than it is to treat it, so it would be great if we could predict which kids are likely to develop chronic problems with anxiety, and head it off at the pass. That might actually be plausible, since anxiety has a trajectory of development. As Strawn et al. put it, “…the adolescent with panic and generalized anxiety disorders was once a boy with separation anxiety disorder and…a toddler with extreme shyness…”

But, how would one do that prediction?

(If you’re mainly here to improve your English, you will find an explanation of head it off at the pass in the English notes at the end of this post.)

I am a happy practitioner of the write-about-what-you-don’t-know approach to scribbling. Right at this moment I am realizing that I don’t know very much about the development of anxiety in children and adolescents. So, I am reading the paper Research Review: Pediatric anxiety disorders–what have we learnt in the last 10 years?, by Jeffrey Strawn, John Walkup, and a bunch of other folks. It describes a number of risk factors for the development of a variety of anxiety disorders. The risk factors fall into categories of cognitive bias, behavioral tendencies, family environment, parental disorders, substance abuse, and environmental exposure.

When I’m trying to understand a new disease, I sometimes play this game: walk into a restaurant, look around, and pick out the person most likely to suffer from it. (At my advanced age, that is often me, but that’s another story.) For the kinds of risk factors that are related to pediatric and adolescent anxiety disorders, that’s not really an option, so instead, I’m trying something different: I’m writing about some kids who I would expect (based on my limited knowledge) to develop anxiety–or not. So, here’s what we’re gonna do today: we’ll look at my little vignettes, say for each one whether we think the kid is at high risk or low risk of developing an anxiety disorder, and then explain why. I have written these vignettes in the style of the notes that a physician (doctor) writes when they examine a patient. That’s why it sounds odd. (We’ll talk about some of those oddities in the English notes.) Ready? C’est parti.

John is a 5y3m-old male with an uneventful medical history. He is referred to the psychiatry clinic because of bursts of tears and screaming when dropped off at school, persisting into the third week of the school year. He is in his third foster home since his mother was hospitalized for anxiety and depression six months ago.

Reminder: this is not the story of a real child. I have made it up myself for educational purposes.

Likely outcome? John is at high risk of developing an anxiety disorder. His behavior at school–not wanting to be dropped off even after three weeks from the beginning of the academic year–is a kind of behavioral inhibition, and behavioral inhibition is a risk factor for later development of anxiety disorders. Childhood separation events are, too, and John has experienced these multiple times–first with the long and continuing hospitalization of his mother, and then due to repeated changes of foster care placements. Having a parent with an anxiety disorder or depression also increases a child’s risk of developing an anxiety disorder, and John’s mother has both of those–that’s why she’s been hospitalized for so long.

Mary is an 8 year old healthy-appearing female. She is referred to the environmental health clinic after routine screening at her school suggested a high probability of lead and mercury exposure.

Mary lives with her paternal grandmother since her mother was imprisoned for sale of controlled substances and child endangerment and her father died in an automobile accident soon after. The grandmother seems quite controlling, but reports that she has changed household routines in response to Mary’s fear of sleeping alone.

Reminder: this is not the story of a real child. I have made it up myself for educational purposes.

Probable outcome? Mary is at high risk of developing an anxiety disorder. Exposure to environmental contaminants increase a child’s likelihood of developing subsequent problems with anxiety. Like John, she has experienced multiple separation events, with her mother being sent to prison and her father dying soon after. Over-controlling parenting, such as she is getting from her grandmother, also increases the risk of developing an anxiety disorder. “Family accommodation,” or changes made to group behavior in response to a child’s early anxiety symptoms, also increase the likelihood of developing an anxiety disorder, so despite the use of “but” in the example, this is not a good thing for this kid.

Harry is a cheerful, outgoing adolescent who presents in the Emergency Department with exquisite point tenderness in the right femoral area after a fall experienced while practicing his newly-discovered passion for rock-climbing. His father died in Iraq when John was six months old. His mother remarried two years later, and she reports that John has been close to his stepfather ever since. He denies alcohol, drug, or tobacco use.

Reminder: this is not the story of a real child. I have made it up myself for educational purposes.

What does the future hold? Harry is at low risk of developing an anxiety disorder. He clearly does not have a fear of trying new things, and is not shy. Although he lost his father, it happened so early in his life that he probably did not experience it as a separation event–recall that his father was deployed to Iraq–and he has always had a close relationship with his stepfather. The lack of alcohol, drug, or tobacco use is relevant in that these kinds of substance abuse (and I say that as someone who cheerfully enjoys fine American tobacco products) are often associated with anxiety disorders.


English notes

To head something off at the pass: to take action in order to prevent something from happening. This is a cowboy thing: a pass is a narrow path at a low point in a mountain range that lets you get through the mountains without having to climb them. You can prevent someone from getting somewhere that they’re trying to go if they have to go through a pass to get there–they’re narrow, and therefore easy to block. Some examples of the use of this expression:

  • Dilbert tries to head off criticism of Trump at the pass by defining it as coming from some “other side.” (Source: Twitter)
  • The apologists for Trump & Trumpies sure managed to tone down his rhetoric & head off his bigotry at the pass, didn’t they. (Source: Twitter)

How I used it in the post: It’s usually easier to prevent something than it is to treat it, so it would be great if we could predict which kids are likely to develop chronic problems with anxiety, and head it off at the pass.

Now let’s look at some of the odd aspects of medical English:

to refer to: in this sense, to refer someone to a treatment facility is to send them to that facility for consultation by a specialist. Your insurance company will usually require you to have a referral from your primary care provider for this kind of thing. How I used it in the post:

  • He is referred to the psychiatry clinic because of bursts of tears and screaming when dropped off at school
  • She is referred to the environmental health clinic after routine screening at her school

to present with something: this expression is used to describe a patient’s state when first meeting with a health care provider. How I used it in the post:

Harry is a cheerful, outgoing adolescent who presents in the Emergency Department with exquisite point tenderness in the right femoral area after a fall experienced while practicing his newly-discovered passion for rock-climbing.

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