It's Nobody's Fault (23 page)

It doesn’t always go that smoothly, of course. Henry wasn’t a terribly tough case. Children with especially severe social phobia will have to work long and hard before they dazzle the family over the turkey at Thanksgiving. Some never quite get there. It’s not unusual for kids to freeze when the moment of truth arrives. “I knew I was supposed to say something, but I couldn’t remember what,” one little girl said sadly. “It all just went out of my head.” But practice
does
make perfect, and with the right medication combined with good coaching and rehearsal, reasonable assignments, and a lot of parental support, a child will make progress. A change of scenery can make a big difference too. Kids with social phobia may be labeled at school or at camp or even at family gatherings—singled out as that “shy kid” or the one who “never says anything”—and labels are hard for anyone, especially children, to shake.

Not surprisingly, group therapy sessions can be very useful for teaching social skills, since they replicate the social experience more closely than individual sessions do. One of the most interesting groups I know of was assembled by one of my colleagues, a psychologist. She invited three 11-year-old girls with social phobia to her office with the intention of doing some tests. What happened instead is that the girls somehow clicked. One of the girls was carrying a
Baby-Sitters Club
book, and the other two said they liked the series too. The next thing my colleague knew, they were talking among themselves, three preteens with social phobia. After discussion of the
Baby-Sitters Club
had been exhausted
(none of them thought that the TV show was as good as the books), they needed coaching from the therapist. “Why don’t you tell us about what happened when you went horseback riding?” she said to one. “Tell us about the new dress you got for your birthday,” she told another. “What kind of costume will you be wearing for Halloween?” she asked the third. The responses were quite lively, and the session went surprisingly smoothly. The girls really seemed to understand one another.

When social phobia is treated promptly and aggressively, the prognosis is excellent. Left untreated, it may get worse, and it may have a negative impact on all important aspects of a child’s life: school, work, and play. In all likelihood later on it will affect his job choice and performance and will hinder his ability to have a romantic relationship. It will have a lasting effect on self-esteem and may well result in alcohol and drug abuse.

A few years ago I saw Michael, a very bright, handsome 18-year-old boy whose mother had died six months earlier after a long illness. It was a close family, and everyone took the mother’s death very hard. Michael was clearly in terrible pain. Every time his mother’s name up, he would start to cry, sometimes uncontrollably. The reason he finally came to me was that a few nights earlier, at a party with his friends, he got so upset that he went to the bathroom and started smashing his fist against the wall. “I was hitting the wall and crying about how much I miss my mother,” he told me.

Michael had even more reason to miss his mother than his brothers and sisters did. Although it had never been diagnosed, Michael had social phobia—his symptoms were quite obvious even in our first session—and he had always been dependent on her for help in coping with the outside world. Probably without even being aware of it, the mother had coached Michael and rehearsed with him. “I used to talk to my mother about how I was nervous about going to parties, and she would give me ideas about how to act. I could tell her anything,” Michael said tearfully. She made his appointments, chose his classes, and helped him schedule every detail of his life, including what he would wear to any important social occasion. The idea of life without her was devastating.

Behavior modification, with a strong emphasis on social skills training,
calls for the informed assistance of the child’s mother and father—or
trainers
, as I like to think of them. Ideally Mom and Dad will help their child learn social skills by making assignments, coaching, and rehearsing. Parental intervention is not always possible, however. Some parents just aren’t temperamentally suited for the task of trainer. One type of parent who’s likely to have a problem is the kind who’s always asking kids for a progress report. “How did everything go? What did the teacher think of your paper? Did everyone like your new shirt? Did you make a lot of friends?” Those are not the sorts of questions that put a child with social phobia—who’s overly concerned about being scrutinized and evaluated to begin with—at his ease. There’s already far too much anxiety associated with his social performance.

Other parents become too emotionally involved with a child’s social success and consequently apply more pressure than the kid can manage. The unspoken message here is that a child’s inability to handle himself in a social situation is a reflection on the parents. Such mothers and fathers inevitably communicate their disappointment or disapproval, and sometimes even their anger, to their child, and that only increases the poor kid’s anxiety. To be truly helpful, parents must take the matter of social skills training seriously but not so seriously that it makes the child more nervous than he already is. A parent’s goal should be to make a child feel more confident and secure. That may mean putting some emotional distance between parent and child.

“You don’t understand. You have no idea what it’s like to be shy,” one of my patients with social phobia, a 10-year-old girl named Mary Ann, said to her father in my office one day. Mary Ann had a point. Her father, an extremely outgoing family lawyer, didn’t show the remotest signs of social phobia. Not even a cocktail party filled with strangers would scare this man. Of course, he wanted to understand and help his daughter, but trying to relate to a girl for whom the briefest conversation was a trial cannot have been easy for this natural extrovert. It’s not necessarily easy if the parent
does
understand what it’s like to be shy. I treated a little girl with selective mutism whose mother found the child’s disorder completely intolerable. She had no patience with it, and the child knew it. It turned out that Mom was painfully shy herself.

No matter how empathetic parents are—and no matter how skilled at advising and coaching their kids—there are plenty of children who simply won’t
let
their parents be their trainers. They’ll take advice from
a therapist or a teacher or a family friend, but not from their folks. There’s not a great deal parents can do when they meet this kind of resistance, except to insist that the child work with
someone
who knows what he’s doing. “Okay, if you don’t want to rehearse with Daddy and me, you have to talk to Aunt Laurie about it,” a mother might say. The child needs training, regardless of who the trainer is.

A child’s school should be made aware that he’s being treated for social phobia. Many teachers can be very helpful in social skills training and other elements of behavioral therapy. If a teacher knows, for instance, that a child’s assignment is to speak out once a day in class, he can help the child achieve that goal—by calling on the child early in the class to get it over with, for instance, or not calling on him more than once a day until he shows marked improvement. Every little bit helps.

W
hen nine-year-old Caitlin and her parents flew in from Chicago to see me, Caitlin had already been through more than her share of experiences with doctors. She’d been suffering from headaches and terrible stomachaches every day for months, and her parents had taken her to several specialists, most recently the neurologist who referred her to me. When I asked Caitlin what kinds of things she worried about, the floodgates opened. She worried about
everything
, she said—that she wasn’t playing the piano well enough, that her father was going to run out of money, that her hair didn’t look right, that she wouldn’t have any friends, that she wouldn’t do well in school. The neurologist said that Caitlin’s headaches were caused by tension.

Larry, a sweet, serious little first-grader, came home with a handwritten note attached to his first report card. “Larry is a lovely boy. I just wish he would smile more than once a semester,” the teacher wrote. Larry’s parents knew exactly what the teacher was talking about. At six, their son took his academic life as seriously as a third-year law school student. From the moment he came home, he’d worry about doing his homework assignment, fretting about whether it was complete and correct. One recent morning he and his parents had the following exchange:

“Where’s my homework?” Larry asked Mom.

“Your homework’s in your knapsack. It’s all signed,” she answered.

“You signed the
homework?
You’re not supposed to sign my homework. You’re supposed to sign my homework assignment
book!”

“Honey, it’s okay. I’m sure it will be fine.”

“No, it
won’t be
fine.”

“Okay. I’ll write a note to the teacher and explain that I didn’t know I was supposed to sign the assignment book.”

“No, don’t write a
note.
You’re not supposed to write a
note!”

When he finally left for school, little Larry was
not
smiling.

A five-year-old boy on his way to a classmate’s birthday party tells his father he’d really rather not go, thank you very much. When the father questions the child, he discovers that the boy is a little nervous about going to a house he’s never visited before. He also fears that the other kids might not want to play with him. The boy finally agrees to go to the party. Dad offers to stay at the party and keep his son company for a little while, but the boy turns the offer down. No, he’ll be fine, he says. And after a few minutes at the party, he is.

Another sensitive five-year-old goes to a G-rated movie only to be faced with a PG-rated preview of a coming attraction: a movie with monsters. As soon as the child hears the music of the preview, she turns to her mother and says, “This is going to be scary. I’m closing my eyes.” She sits with her eyes shut tight until the ominous background music stops. “I wasn’t scared,” the little girl said afterward, “but it was good I closed my
eyes.”

Both of the youngsters I have just described were experiencing anxiety that falls within normal limits. All kids worry about something at least some of the time. They’re afraid of storms, animals, strangers, loud noises, the dark. They fret about wearing the wrong clothes, taking tests, getting invited to parties, and choosing a college. They’re scared that other kids won’t like them. All of these anxieties are to be expected in a child’s normal development.

What is
not
part of normal development is the brand of anxiety that Caitlin and Larry exhibit. Both children are suffering from generalized anxiety disorder, or GAD, which is defined in the textbooks as “pathological anxiety characterized by all-consuming worry and excessive or unrealistic anxiety about a number of events or activities occurring more days than not for a period of at least six months.” GAD should not be confused with a simple phobia, which is an illogical fear of a particular
thing—cockroaches, snakes, pigeons, whatever. Until recently GAD had a different name in the textbooks: overanxious disorder.

Most kids worry when they have to take a test. Children with GAD worry not just before a test but before, during, and after a test. Normal kids study, get nervous, take the test, and wait to get their grades. Children with GAD study, take the test, and then replay it over and over again in their minds, convinced that their performance wasn’t good enough. They’re the ones who are always asking in class, “What did you put for number 6?” or “I’m sure I failed.”

Kids with GAD usually are incapable of evaluating their own performance on a test or anything else; they’re just too anxious. Logic has nothing to do with how they feel about themselves. Even when they consistently pass or they always get straight A’s, the worry is always there. I treated a 12-year-old boy who played the violin beautifully but was never satisfied with his performance. Even though his parents, his teachers, and the audiences at his recitals praised him to the skies, he never pleased his toughest critic: himself. He spent hours replaying and second-guessing the performance, saying, “I should have done this. I shouldn’t have done that.” His performances always went without a hitch, but that didn’t matter to him. They were never good enough.