Tommy, a 6½-year-old boy, was referred by his family physician because of a longstanding pattern of shyness and inhibition that had become dramatically worse on his entering school. He expressed fear that his mother would be harmed or become ill and had several times come home early from school or had tremendous difficulty separating from his mother at the start of school. His mother had a history of anxiety-related difficulties as a child and even at present described herself as rather like Tommy with many worries and concerns about the future.

When left at school, Tommy quickly would begin to complain of headaches or more frequently gastrointestinal upset. He often left the classroom to go to the nurse’s office because he felt nauseous and was afraid he would vomit in the classroom. It was a struggle for his mother to drop him off at school in the morning; he would be reluctant to bring his backpack, would lose his lunch, and would become upset on leaving the car. He had never been willing to take the bus with other children on his street.

His teacher reported that when he was in school and working, his academic abilities appeared to be at age level. She was, however, concerned that his degree of difficulty with separation and his numerous physical complains were taking a toll on his peer relationships and would eventually also impact his academic progress.

His mother noted that Tommy had a long history of anxiety-related difficulties, only falling asleep when one of his parents (usually his mother) was in bed with him. He often woke during the night and would come into his parents’ bed complaining of nightmares. Although his father had tried to interest him in soccer, Tommy was reluctant to have his father leave him.

Although he would play with children in the neighborhood, he wanted his mother around. His parents had difficulty leaving him with a babysitter.

Tommy and his parents engaged in a course of treatment focused both on his anxiety and, for his parents, ways to help him cope more effectively. Issues for the parents included a careful review of ways in which their behavior had frequently supported Tommy’s anxiety and lack of independence. For Tommy, a course of cognitive behavior therapy was helpful combined with the work with his parents. Although Tommy remained a somewhat anxious child, he began to be able to attend school on a regular basis and became more independent at home as well. His sleeping difficulties decreased. After Tommy had completed his treatment, his mother chose to pursue treatment for her own long-standing anxiety difficulties, which had seemed to play some role in Tommy’s problems.

Todd, an 11-year-old boy, was referred for assessment by his primary care provider because of symptoms she suggested might reflect an anxiety disorder. The third and final child and only boy of professional parents, his parents had become concerned about Todd in the fifth grade as his school work had seemed to deteriorate. A successful participant in the martial arts and music, Todd had always been popular at school, although this year, in his private school, the level of work dramatically increased, and the school shifted from what had been narrative reports to an actual report card on which he was getting Bs and Cs. His parents were puzzled because not only his previous narrative reports but periodic achievement testing suggested higher levels of academic ability. His parents initially presented their worry to the pediatrician that he had developed learning problems, but in her discussions with Todd, the pediatrician noted that he complained of many worries and concerns. Although he had a number of physical complaints, the physical examination, including electrocardiography, had been unremarkable.

During the psychiatric assessment and over several sessions, Todd acknowledged being much worried about school this year, partly because he also had begun to feel pressure from his parents about grades and college; in addition, they had suggested he take an additional language in school. Todd had a number of somatic complaints (headaches, recurrent aches and pains), and his parents reported that he was more irritable at home. He indicated that his worries had gradually increased but had been noteworthy over the past 6 months.

Review of the previous year’s psychological testing revealed above-average intelligence and even somewhat higher achievement scores. Todd’s mother, an attorney, reported a history of depression and anxiety and was currently taking a selective serotonin reuptake inhibitor with good effect.

Todd was referred for a course of group cognitive behavior therapy with good results. In addition, his parents and school were encouraged to review his academic load and discontinue the additional course work. There was also an opportunity to discuss with his parents the potential role that increased expectations and premature worries about college might serve as an additional source of anxiety to him. Follow-up in several months revealed that Todd was doing well in school and at home with no apparent recurrence of anxiety-related symptoms.

Jimmy, age 9 years, was the oldest of three children. His parents had become worried about him in preschool when he had major difficulties in peer interaction despite being academically gifted. A diagnosis of Asperger disorder was eventually made. Jimmy had multiple and long-standing special interests, including cars, the stock market, and dogs. Interestingly, Jimmy had been bitten by a dog at age 3 years, having, according to his mother, lunged on top of the dog from behind in an attempt to ride it. Since that time, he had been acquiring considerable information on dogs and knew a tremendous amount about dog breeds. However, over time, he had become more and more anxious about seeing or being near actual dogs. At first, his parents noticed that he became anxious and fearful even if seeing a dog from some distance. Over time, he became so upset that his parents would have to cross the street with him if a person was walking a dog on the sidewalk. At other times, he might have a tantrum or cling to them for safely. The family could not visit friends with dogs, and even travel in the car with Jimmy had become a burden because he would become very agitated at even seeing a dog in a yard or behind a fence. Somewhat paradoxically, his long interest in dogs was not particularly helpful because his knowledge was highly academic rather than practical, and it had become a sore point in the family because both his younger siblings highly desired having a pet dog. Various attempts to “reason” with him had been unsuccessful because he was convinced that every dog would bite him.

Jimmy was referred for a course of cognitive behavior therapy (CBT), which included a focus on explicit teaching about ways to monitor his anxiety, a graduated desensitization program with eventual exposure to a large but profoundly placid dog, and training in ways to approach dogs successfully. The family was also put in touch with a special agency that provided dogs for children with autism and similar social disabilities, and although Jimmy remained wary of other dogs, he came to be very close to this one. His parents noted that his ability to ably verbalize specific rules from the CBT (e.g., “The first rule is to ask the owner if the dog is friendly. The second rule is to ask if I can pet the dog. The third rule is to … ”) also encouraged them to seek additional treatment over time, which helped him cope with other problem situations.

Comment: At times, the special interests of children with Asperger disorder (see Chapter 4) revolve about something they were, or initially were, afraid of. This may partly be a coping mechanism but can have, as in this case, varying degrees of success because the knowledge acquired is of a very factual rather than social-interaction or practical nature. For a diagnosis of phobic disorder to be made in children, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) makes two modifications in its diagnostic guidelines: (1) children do not have to recognize that their fear is unreasonable, and (1) children may express anxiety through crying, freezing, and tantrums rather than through panic attacks.

In this condition, an individual, usually a child, is unable to speak in specific situations (e.g., in school). Although originally thought of as a communication disorder, the condition has been more recently viewed as an anxiety-related disorder given the frequency with which it is associated with anxiety. The original term for the condition, elective mutism, also implied that the problem was one of deliberate choice rather than reflecting significant emotional difficulties.

Typically, the child functions normally in many ways but because of his or her shyness and inhibition may be unable to participate with peers. The child may, for example, be highly verbal at home or when he or she is comfortable but is largely nonverbal in school. Girls are more likely to exhibit the condition. Various gradations are noted, with some children speaking to adults but not peers or vice versa. Although there is some potential for confusion with autism, children with this condition can and usually do speak in situations when they are comfortable. The unusual motor mannerisms seen in autism are not observed in selective mutism, and when the child does talk, his or her language is not unusual, as it is in autism. It is important to establish that the situation is not better explained by another condition (e.g., psychosis or concern over a speech impediment).

Children with selective mutism often have a history of behavioral inhibition and anxiety difficulties. Potential risk factors include underlying speech or language problems. Unfortunately, the condition tends to be self-reinforcing and rather persistent. Early intervention is important and should include a speech-language assessment (to clarify any potential underlying vulnerabilities) as well as a psychiatric assessment with special attention to anxiety-related issues. Treatment approaches vary with the age of the child and other relevant features. Unfortunately, well-meaning but poorly informed treatments that attempt to “force” speech often only make the child more anxious. Behavioral approaches have been used to encourage the gradual generalization of speech to other settings; the child might, for example, be initially encouraged to whisper and then gradually speak more forcefully.

Family members often have a history of anxiety disorders, particularly social anxiety disorder. It is important to note that transiently, many children are rather quiet and shy on entering school, and selective mutism should not be diagnosed in this initial period because many children go on to communicate normally.