Anxiety In Children

Anxiety disorders are the most common psychiatric problems of childhood. Parents should be aware of the different kinds of anxiety disorders and the ages at which they occur.

     Fear is a normal and protective reaction. Some forms of anxiety occur in specific age groups and represent normal development. Stranger and separation anxiety are common from 7 months of age to two years of age.  It is easy to see how toddler anxiety developed as an evolutionary advantage – toddlers have the mobility to move away from the protection of their mothers and yet have no awareness of danger, so toddlers who had no fear didn’t stay around for long.

     Preschoolers have “magical thinking”, so they can develop fears about monsters under the bed and bogymen in the closet. The original Grimm fairytales are full of fantastic (and frightening) creatures. Children of this age can also develop an obsession for order and want things done in exactly the “right way”. Parents should recognize that the fears are real, but reassure the child that things will be fine. Parents should not change routines or react as if they also hold the same fear: the night-monsters don’t result in the child sleeping with the parents; if the red socks are in the laundry, wear the blue and you can wear the red tomorrow. We teach our children that fears are normal for all of us but we are in control of how we react to those fears.

     School-aged children often have fears of physical injury to themselves or loved ones. Adolescents have anxiety about social acceptance and success.

     When anxiety impairs normal functioning, becomes obsessive or disrupts the family, it needs attention. Separation anxiety disorder can develop in children in elementary school. They worry about parents being harmed and can refuse to be separated – insisting on sleeping with the parents or refusing to go to school. These children can have significant disruption of their lives with full panic attacks if they are forced to separate from their parents. They can have absolute school refusal, selective mutism where they won’t speak outside the home and they can have physical complaints such as headaches or abdominal pains. A child with this level of impairment may need family counseling, individual therapy and/or medication.

     Adolescents can develop generalized anxiety disorder with continual worries about the future or about past actions. Another aspect of anxiety is obsessive-compulsive behavior where repetitive or ritualistic behavior can interrupt normal daily functioning.

     Any of the anxiety disorders can be related to depression.  A child who suddenly develops anxiety or depression needs to have their family and social situation examined closely for any new disruption. Anxiety and depression are so closely intertwined that the most successful medications used to treat anxiety are antidepressant medications called serotonin reuptake inhibitors or SSRIs.

     Finally, there is a belief among certain physicians that psychological problems, tics and compulsive behaviors that come on suddenly in children can be caused by an infection with streptococcus. In fighting the infection, the body makes antibodies that also attack the brain and nervous system. This diagnosis can be difficult to make and even more difficult to treat. Because some doctors don’t believe it exists, parents may find that their caregiver is reluctant to investigate this possibility.

A Fussy 1 Month-Old Grandson

     A recent 3-day visit from a 1 month-old grandson gave me a good reminder about reasons for infant fussiness.

     Infants in the first 2 months of life don’t need a reason to be fussy. Nothing feels normal for them. They hate it here and want to be put back into the uterus. They get hungry, tired and cold. Things are too loud and too bright. One other new thing they have to deal with is pooping. The sensation is new to them (infants don’t stool in the uterus). When an infant’s colon contracts to push the stool out, the infant can often tighten up and actually hold the stool in. The stool can get large and firm and cause even more discomfort the next time the colon contracts. That happens often because, every time we eat, our stomachs send a message to our colons to contract to make room for more food.

     In general, a fussy infant is either hungry, wet or tired.  Whether he “just ate” 15 minutes ago or “just woke up” or was “just changed”, always go through this list before doing anything else. If he has a clean diaper and he pushes out on the nipple and doesn’t latch on, then hold him for a bit and see if he starts to nod off. If so, he needs to sleep.

     My grandson was dropped off with the message that he had been “very fussy” lately. He had been given a new formula thinking he might be “sensitive” but it didn’t help. He would be falling asleep or happily awake and suddenly get red in the face, strain, pass gas and cry for less than a minute and then settle down again. He was otherwise eating and acting normally.  Through the 3 days he had only one large, very watery stool (common in constipation). After considering allergy, reflux and “gas” (although I’ve never known exactly what “gas” is), grandma and I decided that the problem was constipation. A half of a baby glycerin suppository produced a large, firm stool and a much happier grandson. He will stay on the suppositories about twice a week until he’s back to stooling normally.

"My Tummy Hurts" 2 - Celiac Disease

     The most common cause of recurrent abdominal pain in an otherwise healthy child is constipation. Children can poop everyday and can even have loose, explosive stools and still have constipation (see previous articles on constipation and tummy pain). Sometimes the only way to know is to put the child on a laxative (Miralax), until the child has daily, loose stools without pain or straining. But sometimes this doesn’t work and the child still has recurring abdominal discomfort. That is the time to consider celiac disease.

     Experts don’t consider celiac disease to be an allergy, but the best way for most people to think of it is as “kind-of-an-allergy”. The child’s intestinal wall lining has a reaction to contact with a certain protein and that reaction causes inflammation (like an allergic reaction). However, the child doesn’t develop hives, congestion or itching. There are microscopic finger-like projections on the lining of the gut called villi. These help you to digest your food. The inflammation from celiac disease damages these villi and impairs your gut function.

     The protein that causes the reaction is called gliadin. This is in grains such as wheat, barley and rye. These grains are called “gluten”, so celiac disease is called “gluten intolerance”. It is thought that celiac disease affects up to 1% of the population, which makes it a very common problem. It can start as early as 6 month of age when foods containing gluten are introduced into the diet but it often goes into adulthood without being diagnosed especially when there are only subtle symptoms such as anemia, infertility or slow growth. The intestinal symptoms of celiac disease are abdominal pain, diarrhea, bloating, gas, and vomiting. The child may loose his appetite, become fussy and have poor weight gain.

     There are several blood tests that can be done to make the diagnosis of celiac disease but parents have to be very certain what test was used because the tests have a wide variance of accuracy. It is even harder to get an accurate test in a child under 2 years of age.  A biopsy of the intestinal wall to see the damage to the villi is accurate, but is more difficult than just drawing blood.  

   The only treatment for celiac disease is to avoid glutens for life. This is very difficult, expensive and imposes a real burden on the whole family. It is important that a child (or adult) not be put on a gluten-free diet until after a firm diagnosis of celiac disease has been made because removing gluten from the diet can cause the diagnostic tests to be negative. There are many sources for information about gluten-free diets on-line and in local support groups. After being placed on a gluten-free diet, a child with celiac disease should be followed routinely be a health care professional who is comfortable dealing with the disease.

Living On The Farm Protects Against Asthma

     For decades, the rate of asthma and allergies in children has been increasing. One reason for this increase is the “antibacterial” mood of our society. Products from laundry soaps to hand cleaners are designed to kill bacteria and we strive to make our environment more “clean”. It has long been suspected that our “anti-germ” mentality has actually caused our children to have more allergies and asthma. When most of our population lived on farms, children were exposed to many forms of bacteria and fungus that today’s urban children don’t encounter. There have now been many studies, including a recent one in the New England Journal, that show that the exposure to these germs gives children who live on farms protection from developing allergy and asthma.

     This most recent study compared children in Germany who lived on farms to those who lived in cities. Dust from the children’s rooms and mattresses were examined for bacteria and fungus particles and it was clear that the farm children were exposed to more germs and also different types of germs. The farm children also had less allergy and asthma than the city children. In fact, the more they were exposed to different types of germs, the lower their risk for asthma!  

     This brings up interesting possibilities of how we might now try to expose modern city children to more germs. Once again, maybe Grandma was right when she said, “ You have to eat some dirt to be healthy.”

Is It ADHD?

     There are medical problems that can occur along with ADHD and there are medical conditions that can be mistaken for ADHD. When parents and physicians are evaluating whether a child or adolescent has ADHD, these other problems should be considered.

     Two important questions that are asked when making the diagnosis of ADHD are: “Were the symptoms present before 7 years of age?” and  “Have the symptoms been present for more than 6 months?” True ADHD symptoms develop early in life and are part of the child’s makeup. As the child gets older, the symptoms cause more and more difficulty for the child. If a child has been previously been doing well but then has a rapid decrease in grades or school performance, ADHD is not the cause. ADHD symptoms of inattention or hyperactivity can be caused by disease, seizures, drug use, depression, sleep disorders or family stresses such as divorce or sexual abuse. A careful investigation of the child’s physical health and social situation needs to be done when ADHD symptoms develop in a child who has not had them before.

     There are also problems that are commonly associated with ADHD. If not recognized, the treatment for the child’s ADHD can be less successful. The most common complications in children who have ADHD are conduct disorders and oppositional defiant disorder. These behavior disorders cause the child to have “repetitive behavior in which social norms and rules are violated” and “defiant, disobedient and hostile behavior”.   Almost 1/3 of children diagnosed as having ADHD have behavior problems. Another problem that limits a child’s response to ADHD therapy is learning disability. It is thought that up to 60% of children with ADHD also have a learning disability. It needs to be considered in any child who is being evaluated for ADHD. Finally, children with ADHD frequently have emotional problems – both anxiety and depression. In order for the ADHD therapy to be successful, these problems need to be treated, too.

K2, Spice and Bath Salts - New Recreational Drugs For Teens

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     Adolescents have begun using 2 different kinds of man-made drugs to get high. Both are legal, easily obtained in tobacco stores and gas stations and over the Internet, and both are dangerous.

     The first are synthetic forms of the active ingredient in marijuana – THC. THC is the compound that causes the high that marijuana gives and it is in a class of drugs called cannabinoids.. The synthetic forms of cannabinoids were developed for medical use and scientific research. They are stronger than the compounds found naturally in plants and animals. These drugs are marketed to adolescents as being a “safe” high and have over 100 names with the most common being “K2” and “Spice”.  They have the same “high” effects of marijuana including the less common effects of marijuana such as paranoia, sadness and sedation. Because they have a stronger effect on the nervous system, all of these effects can be magnified along with more serious panic attacks, headaches and hallucinations. These drugs are similar to THC but they are not THC, therefore they do not show up on a routine drug screen.

     The second group of drugs currently being abused by adolescents is called cathinones. These drugs are called “bath salts” but I don’t know why because they have nothing to do with the powders you add to your bath. The canthinones are stimulants – basically synthetic amphetamines. They have names like “Rave” and “Ecstasy”. Cathinones are more dangerous than the cannabinoids. They can have the same effects as “Meth” and cocaine – heart attacks, seizures strokes and death. They can cause the adolescent to harm himself or others and, like all amphetamines, they are addictive. They cannot be detected by routine drug testing.

     Parents need to be aware of the signs of adolescent drug use: sudden lack of interest in school, dropping grades, quitting previously enjoyed activities, acquiring a new group of friends who don’t seem to be interested in school or sports and dramatic changes in schedules or routines. If you think your adolescent is doing drugs, don’t let the teen’s excuses keep you from talking to the child’s caregiver. Because the drugs cannot be detected, the parent’s only recourse is straight talk.

    

Vaccines, Influenza and Autism

     In the wake of a new study about influenza and autism, I wanted to give a brief summary of what this new report may mean.

     In 1998 a small study by a British surgeon named Wakefield was published in the British Medical Journal Lancet. The study claimed that the MMR vaccine caused autism. This spread around the world like wildfire and the rate of MMR vaccination declined. After reviewing studies of hundreds of thousands of children, in 2010 the British General Medical Council found Wakefield guilty of 4 counts of dishonesty in his study and described his research as “irresponsible”. The next year the British Medical Journal labeled Wakefield’s study as an “elaborate fraud” and gave an apology for publishing it. Dr. Wakefield is currently barred from practicing medicine in the United Kingdom.

   But the damage was done and parents still express concerns about vaccines causing autism even though there has never been a scientific study that has even suggested a connection. Many viral illnesses, however, can infect the brain and cause a disease caused encephalitis. Encephalitis can lead to permanent brain damage, blindness, deafness and other neurologic problems. The damage done by these infections is not officially autism, but the symptoms can be confusing especially when a child gets infected early in life or in the uterus. Many vaccines protect children and adults against those kinds of viral illnesses.

     A recently released study suggests that if a mother gets influenza while she is pregnant, her child may have an increased risk of autism. We know for a fact that any viral infection in the mother’s bloodstream can be transmitted to a baby in the uterus, so, if the baby’s brain were to become infected, brain damage and autism could be a possible result. It was recommended that any woman of child-bearing years should get an influenza vaccine early in the flu season and see her doctor if she develops flu symptoms. Certainly, more investigation will be done on this subject.

     Most vaccines are “killed” vaccines. That means that the vaccine contains virus particles but no live virus. The vaccine cannot cause the infection. People commonly say “I got flu from the flu shot”, but it can’t happen from a killed vaccine. Another type of vaccine called a “live” vaccine has live virus particles in it and can give the patient a very mild infection, but a more serious infection can potentially occur. This is why it was easy for some physicians to believe Wakefield’s report of the measles vaccine (in MMR) causing autism because it is a “live” vaccine. Those doctors felt that a child could get encephalitis from the vaccine and that infection could cause autism. It was only after reviewing hundreds of studies from many sources involving thousands of children that the MMR connection to autism was proven to be completely false. 

     The nasal spray vaccine for influenza is also a live vaccine. Doctors already do not recommend the nasal flu vaccine for patients with asthma for fear that they could get the disease and, until we learn more about the possible connection between influenza and autism, it might be prudent for pregnant woman to get the killed influenza injection rather than the nasal spray. However, it is definitely recommended that all women of childbearing age get an influenza vaccine.

Children At Risk Of Death From Influenza

     Now that influenza season is upon us, parents need to be aware of a study done during the 2011-12 flu season that was published in Pediatrics.

     There are many children who are at a greater risk of death if they catch influenza. Children with chronic respiratory problems such as asthma are at risk as are children who have other medical problems such as heart conditions and children who have immune system problems.

     But what this study pointed out is that children who have neurologic problems also have almost a five time greater risk of dying from influenza than do healthy children. The neurologic problems studies ranged from cerebral palsy to moderate developmental delay to epilepsy. It was thought that the increased risk of death in these children may have resulted from a decreased ability to cough.

     What these kinds of studies show is that influenza is not just a cold. It should be taken seriously by all parents but especially by parents of children with medical problems. That means getting your child vaccinated against influenza – “the flu shot”. Of the children mentioned in the study who died from influenza, only 23% had been vaccinated and only 3% had been vaccinated with the H1N1 – the second strain of flu that went around in 2011. Every child over the age of 6 months should be vaccinated and children with other medical problems or neurologic problems should definitely be vaccinated. Even if your child is vaccinated, a child with a medical problem who develops flu-like symptoms should be seen by their caregiver to determine whether they should receive antiviral medication. The decision of whether or not to start a child on medication should not be solely based on the rapid influenza test because, early in the disease, it may not yet have turned positive.

     Finally, this Fall brought us a new influenza strain - H3N2 – which is associated with pigs and is not covered by the regular flu vaccine. Any child who is in contact with pigs should wash their hands thoroughly after the contact, should never eat while in contact with pigs and should start antiviral medications at the first sign of any flu symptoms.