It is important to correctly identify and provide appropriate
interventions for the school-aged child with NLD because this child is
particularly inclined toward developing secondary internalizing disorders
such as stress, anxiety and panic, as well as debilitating phobias.
Children's Hospital Oakland has made the study of NLD and related
conditions a specialty in their departments of psychiatry, neurology, and
neuropsychology. Their research to date has revealed that children with
NLD tend to suffer in the emotional realm because these children are not
proficient at interpreting interpersonal interactions -- they lack insight
into the feelings and perceptions of others that the rest of us glean
intuitively.
Dr. Herbert Schreier, Chief of Psychiatry at Children's Hospital
Oakland, states that having NLD "does not preclude having other
conditions such as panic disorder, or anxiety and depression, secondary to
NLD and school organizational issues." According to the National
Institute of Mental Health in Bethesda, Md., anxiety disorders are the
most common of neurobiological disorders. In the United States alone,
twenty-three million people suffer from anxiety disorders. It is not known
how many of these individuals are school-aged children because, child
psychiatrists report, anxiety disorders in children are often overlooked
or misdiagnosed.
Included in the spectrum of anxiety disorders are: panic disorder,
generalized anxiety disorder, social phobia, specific phobia,
obsessive-compulsive disorder and post-traumatic stress disorder. It may
be difficult for parents and teachers to distinguish between normal stress
in a child and conditions of anxiety and panic. Learning to recognize the
difference can help us to better serve those in our care. The students we
work with, even at a very young age, can become seriously afflicted by
anxiety disorders.
It's not hard to imagine how a child who doesn't see the "whole
picture," who is constantly confused by his surroundings and his
interactions with others, and who is unable to anticipate what will happen
next, could experience a disproportionate amount of stress in his everyday
experiences, such as attending school or shopping at a mall. Add to this
the perfectionistic and obsessive/compulsive tendencies of many students
with NLD, and the immense pressure this child faces should be obvious.
It shouldn't surprise anyone that there is a connection between the
excessive stress a student with NLD encounters and her inclination toward
anxiety disorders. Without appropriate intervention, the cumulative effect
of ongoing stress can advance to an unmanageable state of anxiety for a
child already predisposed to internalizing disorders (as Dr. Byron Rourke
of the University of Windsor, and his associates, have found individuals
with NLD to be).
The physical symptoms of anxiety include those of stress (sweaty palms,
racing heart, churning stomach), with the addition of: difficulty
breathing, panicky feelings, chest pain or discomfort, flushed skin,
sweating, trouble sleeping, difficulty concentrating, trembling or
shaking, and headaches.
It is important to note that, while the stress of coping with NLD may
be the trigger for an anxiety disorder, and while excessive stress may
make a child with NLD more susceptible an anxiety disorder, such a
disorder is a biological illness, in and of itself, and will require
concurrent treatment, along with any interventions already in place to
accommodate this child's NLD.
A child with NLD experiences constant confusion and unfamiliarity with
his surroundings and circumstances. Without appropriate intervention, he
will eventually succumb to the cumulative effects of the persistent stress
he encounters in his everyday environment. The student will then become
more vulnerable to the affects of even minor changes in his life, because
of the continual stress which has built up within him. Add to this the
trauma of being in a situation at school where NLD is not well understood
or serviced, and all of these factors together may combine to trigger
panic attacks.
Panic disorder (PD) is one of the anxiety disorders often neglected in
school-aged children. A panic disorder is characterized by recurrent,
spontaneous panic attacks. A panic attack is an acute episode of terror
and discomfort. A barrage of terrifying symptoms take over the body,
usually lasting only a couple of minutes, but sometimes continuing for up
to ten minutes.
During a panic attack, the child experiences extreme fear accompanied
by frightening symptoms such as: difficulty breathing or shortness of
breath; pounding heart; pain or other discomfort in the chest; choking or
smothering sensations; feeling dizzy, unsteady, lightheaded, or faint; a
sense of unreality; tingling in hands or feet; hot or cold flushes;
sweating or chills; trembling or shaking; and feelings of hopelessness,
impending doom, or loss of control. These symptoms gradually fade over the
course of an hour or so, but the individual may feel
"disoriented" for several hours afterward.
To be defined as a "full panic attack," four or more of the
above symptoms should be present. Otherwise, the attack is described as a
"limited symptom attack." Those who experience panic attacks
usually describe them as striking repeatedly "out of the blue"
or "without warning."
To be diagnosed as panic disorder, the initial panic attack is followed
by one month (or more) of one (or more) of the following:
constant worry about having another panic attack between episodes;
constant worry about what caused the attack, or
behavioral changes related to the panic attack (i.e. fear and
avoidance of places or situations).
Initial panic attacks usually occur when a person is under considerable
stress. Attacks may also follow an illness. Stimulant medications, such as
those used in treating asthma, can also trigger initial panic attacks. A
child may assume that the symptoms of panic he is experiencing are the
same kind of feelings everyone experiences when they are worried or
nervous. He learns to outwardly mask his panic attacks and may show no
overt signs of discomfort.
Panic attacks are largely misunderstood and are not always taken
seriously. A child may be told to "calm down" or
"relax" (the worst possible things to say to someone who is in
the throes of a panic attack). Do not assume she will simply
"outgrow" her panic attacks. If left untreated, a child's panic
disorder can become progressively more and more debilitating, severely
restricting and even dominating her life. School work and friendships will
suffer greatly.
Physicians who see these children often fail to diagnose panic
disorder. And, even when a doctor does recognize the condition, he may
trivialize it, suggesting PD is of no importance or that it is not
treatable.
In the United States, between three and six million people suffer from
panic disorder. Yet, it is believed only one out of three panic disorder
sufferers is correctly diagnosed and treated. The most common age of onset
is the late teens, but much younger children can also be affected. School
phobia and other childhood anxiety disorders are thought to be early forms
of panic disorder. More than half of the people suffering from panic
disorder developed the condition before age twenty-four.
A young adult whose panic disorder progressed to the point where she
was unable to leave her home for eight months states, "Before I knew
I had panic disorder, I just thought I had a problem handling stress . . .
My own battle with stress has been ongoing; I've been fighting it since
kindergarten, at least."
A panic attack is generally proceeded by intense anxiety which,
ironically, can lead to more panic attacks. The child may (consciously or
subconsciously) begin to avoid places and situations where she has
experienced a panic attack or where she fears she may be vulnerable to
another panic attack. This can progress to an extremely disabling
condition known as "agoraphobia," a fear of leaving the home.
Joseph Biederman, et. al, have found that "children meeting the
criteria for panic disorder also frequently met the criteria for
agoraphobia" ["Panic Disorder and Agoraphobia in Consecutively
Referred Children and Adolescents", J. Am. Acad. Child Adolesc.
Psychiatry, 1997, 36(2):214-223].
The exact cause of panic disorder is unknown, but is currently the
subject of intense scientific investigation. Researchers have concluded
that there are physical reasons why people with PD are more sensitive to
stress. One line of research suggests that PD may be associated with
increased activity in the hippocampus and locus ceruleus, areas of the
brain which monitor external and internal stimuli and regulate the brain's
responses to these stimuli.
Current panic disorder research has been focusing on a neurotransmitter
called "cholecystokinin" or CCK. CCK is thought to cause panic
attacks in some people (perhaps in those with a genetic predisposition to
panic disorder). When the body is under stress, it produces endorphins.
When the stressful situation abates, the body produces CCK to counteract
these endorphins. So, the physiological reaction produced by stress is
thought by some to cause panic attacks. Researchers also believe the
neurotransmitter serotonin plays an integral role in the development of
panic disorder.
Other research suggests panic attacks occur when a "suffocation
alarm mechanism" in the brain erroneously fires, falsely conveying
the message to the brain that death is imminent [Klein DF, "False
Suffocation Alarms, Spontaneous Panics, and Related Conditions,"
Arch. Gen. Psychiatry, 50, Apr 1993, p 306-317].
In the case of the child with NLD, everyday occurrences produce an
abundance of stress. Because this child has to "think" about
everything he does, even an "average" day can be overly
demanding and unmanageable. Getting through a day at school takes an
extraordinary amount of determination and perseverance. The stresses of
this student's life may gradually overwhelm him, both physically and
emotionally.
Panic disorder often coexists with other neurocognitive and
neurobiological disorders. Although there seems to be a predisposition to
panic disorder in those with NLD, children with other types of learning
disabilities may also develop PD. In addition, those with PD may also have
a heart condition called "mitral valve prolapse." This condition
involves a defect in the mitral valve, which separates the two chambers of
the heart. People with mitral valve prolapse are thought to be at a higher
risk of developing panic disorder.
It's long been known that cumulative stress can contribute to physical
illnesses, such as ulcers and high blood pressure. Recent advances in
scientific understanding of the brain, such as the CCK research, provide
explanations of how cumulative stress can also lead to neurobiological
conditions, such as anxiety and panic disorders.
The more stress a student with NLD is under, the more likely he is to
experience panic attacks and anticipatory anxiety (both of which can lead
to additional problems of insomnia and agoraphobia). Sleep patterns may be
upset by panic-related anxiety. Sleep is also disturbed when panic attacks
occur at night. This experience can be so traumatic that some sufferers
reach a state where they are afraid to go to sleep and subsequently suffer
from sleep-depravation and exhaustion.
More than one researcher has concluded that panic disorder is a chronic
condition. The chronic nature of PD emphasizes the need for varied
treatment methods. The National Institute of Mental Health (NIMH) has
found that a combination of medication and cognitive-behavioral therapy
seems to work the best for most panic disorder sufferers. For a child with
PD, medication is usually not the first course of treatment. An
intervention plan should be developed according to the child's individual
needs.
"Insight-oriented" psychodynamic therapy ("talk
therapy") or other forms of psychotherapy which focus on the client's
past have proven to be counterproductive as a model of intervention for
individuals with NLD, and also for those suffering from PD. Psychodynamic
approaches to therapy do not help people overcome panic disorder or
agoraphobia.
Therapy should focus on practical, directive-type therapy,
concentrating on the difficulties and successes the person is experiencing
at the present time, and on directly teaching skills which will help this
individual to cope more effectively in the future. The therapist should
assume a positive coaching role.
At a conference held at the National Institutes of Mental Health (NIH)
under the sponsorship of the National Institute of Mental Health (NIMH)
and the Office of Medical Applications of Research, conferees concluded
that "any treatment which fails to produce an effect within six to
eight weeks should be reassessed."
What is a Panic Attack?
The three basic components of panic disorder: the panic attack, the
anticipatory anxiety, and agoraphobia, are each associated a distinct area
of the brain. These three areas are: the brain stem, limbic system, and
frontal cortex, respectively. Panic attacks are believed to occur when the
brain's normal mechanism for reacting to a threat - the so-called
"fight or flight" response - becomes inappropriately aroused.
They are triggered by stimulation of areas in the brain stem that control
the release of adrenalin. Stimulation of the locus ceruleus produces most
of the physical symptoms of panic.
When confronted with a real or perceived threat, our central nervous
system's "fight or flight" response is automatically triggered
to prepare our bodies for immediate action. A similar response activates
in most living organisms when facing danger, for the purpose of survival
and protection. It becomes a panic attack when this emergency response
presents itself in a situation where it is not warranted. The physical
symptoms of a panic attack are extremely uncomfortable and intensely
frightening for the person experiencing them.
The brain rouses the sympathetic nervous system, inducing the release
of adrenaline from the adrenal glands. This release of adrenaline, in
turn, causes the individual to experience a hot flush sensation. The rate
and strength of his heartbeat will increase to supply more oxygen to the
his tissues, preparing his body for "fight or flight." Blood
vessels contract or expand to divert blood from the skin, fingers, and
toes to the large muscles. This diversion of blood is accomplished for the
purpose of reducing bleeding, in case of an "attack," and may
cause a feeling of coldness or numbness in the hands or feet of the
individual.
Breathing will increase in rate and depth, in order to provide more
oxygen for the anticipated exertion. Breathlessness, dizziness, and pain
or tightness in the chest may be experienced. Sweat glands are also
stimulated, to prevent overheating. The pupils of this individual's eyes
may dilate, to admit more light and augment peripheral vision, allowing
the individual to scan a wider area for danger. Sensitivity to bright
light, and visual disturbances may occur, as a result of his dilated
pupils. The digestive system shuts down to conserve blood for his muscles.
A dry mouth or nausea may follow.
All the muscles of his body tense to prepare for escape. This muscle
tautness may cause spasms and trembling, when the anticipatory action is
not fulfilled. All of the individual's thoughts are focused on the pursuit
to discover the imminent threat, maintaining an heightened state of
alertness and vigilance. Even if there is no plausible explanation for
this emergency response, the individual is unable to concentrate on
anything else while it is occurring.
The "fight or flight" response is time limited because the
adrenaline is metabolized by the body. When the perceived danger has
passed, the parasympathetic nervous system counteracts the activation of
the sympathetic nervous system. The symptoms gradually fade, over the
course of about an hour.
Stress and Anxiety Intervention for the Child with NLD
It should come as no surprise to anyone that there is a connection
between stress and panic. With this in mind, it is imperative that parents
and teachers do everything possible to lessen the stress a student with
NLD experiences in his daily activities.
Significant life events involving a real or perceived threat can
contribute to the development of panic disorder. A student with NLD who
feels threatened by his peers or teachers at school is at risk.
A high-school senior with NLD and PD was served with a subpoena at
school (after being betrayed and deceived by school officials) and
suffered a major panic attack, on the spot. He had to leave the school
grounds in order to recover. This type of ignorant behavior on the part of
school officials is unconscionable and cannot be tolerated.
CAMS aimed at previewing, preparing and supporting the student will
help decrease the amount of stress she encounters. As a parent or teacher,
you will not be able to eliminate all sources of stress, so aim to defuse
as many as you can. Forget archaic notions of "responsibility."
It is important to recognize that the goal for this student is to
eliminate stressors, which may mean reducing expectations of
accountability and responsibility. It is important for the adults in this
child’s life to understand his disorder and to make appropriate
adjustments in their behavior and communication, so they can help the
student cope better with the stress he encounters. In addition to careful
planning and monitoring, the following ten pointers can help, at home and
at school.
Establish a regular exercise routine: Stress is a reaction to
change. It is an internal physical reaction triggered by external
factors (i.e. pressures at home or school). Exercise can help release
pent-up stress. The child with NLD probably does not exercise as much or
as often as his peer group, owing to balance and coordination problems.
Discover a noncompetitive form of exercise he can participate in
regularly (i.e. walking the dog or swimming laps).
Learn to Relax: A student with NLD probably has no idea what
it feels like to be totally relaxed. She lives in a constant state of
tension: wondering what will happen next, trying to remain balanced in
her chair, worrying about being teased or ridiculed, trying to keep
herself organized, etc. This child may need to be directly taught
(through verbal instruction) the difference between being tense and
being relaxed.
Establish a regular sleep schedule: Lack of quality sleep
makes the body extremely vulnerable to stress. A child with NLD often
has difficulty getting to sleep at night and/or staying asleep.
Transitioning from a wakeful state to a sleeping state presents the same
difficulties as other transitions in this child's life. If at all
possible, establish a schedule where this child goes to bed at the same
time every night -- including weekends and vacations -- and gets up at
the same time each morning.
Laughter is good medicine: Laughter helps release stress. All
too often the child with NLD is described as "the serious little
professor" type. Because this child tends to be very literal, he
may miss out on a lot of the humor in everyday situations. Point out
amusing incidents and silly situations to him (verbally). You may not
approve of your child spending time on school nights watching shows like
"The Simpsons" or "Friends" every week, but if
they're making him laugh, you should consider it therapeutic!
Schedule Time Out for Fun: Organization of time and place
often pose a major problem for students with NLD during high school and
college years (and beyond). Since this student is unable to visualize,
she will have difficulty setting realistic goals and priorities. Such a
student can get so bogged down with school work, she "forgets"
to pursue other avenues of her life. It is important to help her seek a
healthy balance between academic and social pursuits. Find an activity
-- preferably something that can be done with others (playing a musical
instrument, singing in a choir, attending sports events) -- which gives
this child pleasure. Help her schedule time to participate in this
activity regularly, without worrying about other things which may not
get done.
Improve Dietary Choices: Dietary changes can actually help a
child cope better with the stress he encounters. Eating a healthy diet
(high in fiber, low in fat, with lots of fruits and vegetables) will
make him stronger and more resilient! Junk food should be kept to a
minimum. Also, consider eliminating caffeine (Mountain Dew, Coke,
chocolate) from this child's diet. Caffeine is a stimulant and can
actually cause sensitivity to stress. Caffeine consumption is known to
cause panic attacks in some people.
Create a Support Network: Assign one case manager at school
who will oversee this child's progress and assure that all of the school
staff are implementing the necessary accommodations and modifications.
Inservice training and orientation for all school staff, promoting
patience, tolerance and acceptance, is a vital part of the overall plan
for success. Everyone at school must be familiar with, and supportive
of, this child's academic and social needs.
Change Self-Critical Thought Patterns: The child with NLD
tends to put herself down a lot, to think of herself as worthless or
ineffectual, to have trouble being assertive, to dislike herself or her
life, and to generally criticize herself. These types of self-critical
thought patterns can make it difficult to handle stress. Cognitive
therapy can teach a child to reverse some of these thought patterns.
Parents and teachers must encourage more positive thought patterns. Find
something positive in every experience.
Learn Time Management and Organization Techniques: Stress
accumulates when a child feels rushed and overwhelmed. Remember: He
processes information slowly. Be sure you allow enough time for him to
do the things you ask of him. This will help him better cope with the
stress he encounters. Because this student lacks an internal structure
for organization, it is important to provide him with an external
structure for organization. Stress results from change. Strive to create
predictable cycles in his life.
Curb Perfectionistic Tendencies: Probably because this child
hones in on infinitesimal details, while failing to see the "whole
picture," perfectionism is common among students with NLD. Because
perfection in all endeavors of one's life is absolutely impossible,
trying to be perfect can cause incredible anxiety for this child. Two
techniques for decreasing perfectionistic tendencies are: 1) continually
point out to this child the difference between "doing your
best" and "being perfect," and 2) praise this child for
every incremental accomplishment, everyday of the year, no matter how
small it may be. If she is only able to progress partway toward a
particular goal, consider it an achievement rather than a failure.
A number of organizations can help in finding information about, or a
specialist to treat, anxiety disorders in your child. They include:
The National Institute of Mental Health
(800) 64-PANIC - Pamphlets on anxiety disorders.
The American Academy of Child and Adolescent Psychiatry
(800) 333-7636. Ask for Lisa Doucette.
Anxiety Disorders Association of America
(301)231-9350 email: anxdis@aol.com - List of anxiety disorders
specialists and support groups.
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