Some kids can't get to sleep at night. Some can't manage to walk into their classrooms without a prelude of hysteria. Some develop personal relationships with school nurses because their stomachs hurt every day. And some, like Joseph Joyal of North Smithfied, have spent a good portion of their lives making sure cabinet doors are closed properly.
Children suffering from all of the above maladies have anxiety disorders. But Joyal, a 13-year-old who conquered obsessive compulsive disorder (OCD), wants them to know that there's a cure. It's called bravery.
"I had to put full strength into [fighting the OCD] and just stop it," he says. "It was hard."
Joyal beat his demons with cognitive-behavioral therapy, which many experts agree is the best way to bring tranquility to the clinically anxious.
While some anxious kids also benefit from antidepressants or anti-anxiety medication, changing the way they think and behave is most important.
Cognitive-behavioral therapy involves teaching children that they can ignore or fight their fears and giving them the skills to do so.
"The instinctive thing to do is try to help the child, ease their pain and remove the anxiety," says Kathleen Trainor, a child psychologist on the faculty of Harvard Medical School who treated Joyal. "But children have to learn that they can be strong and brave."
THE SURGEON GENERAL estimates that 13 percent of children ages 9 to 17 suffer from anxiety disorders. Psychologist Jennifer Freeman, co-director of the Pediatric Anxiety Research Clinic at the Bradley/Hasbro Research Center, at Rhode Island Hospital, thinks it's more like 18 percent.
"Anxiety is the most common psychiatric disorder in kids," Freeman says.
Kids who tend to worry about everything may have generalized anxiety disorder.
The ones who balk at going to school or to bed by themselves could have separation anxiety.
Those who must constantly wash their hands or shut doors may have OCD, which Freeman says affects 1 to 2 percent of children.
Paralyzing panic attacks characterize panic disorder.
And kids with phobias put enormous amounts of energy into avoiding everything from dogs to school dances to elevators.
Each variety of anxiety can stem from different roots, though experts agree that there is almost always a family history of anxiety.
"There's usually a biological tendency toward anxiety disorders and a psychological component that's a trigger," Trainor says.
Paradoxically, just because a child is biologically wired to be anxious doesn't mean he will develop an anxiety disorder, Freeman says.
"There have to be triggers," she says. "It could be ordinary stress -- just going to junior high or high school, having a grandparent die, getting a new sibling."
Noelle, a ninth grader at Seekonk High School who didn't want her last name used, lost her grandfather when she was in third grade. That same year, her anxiety came to life. She would carry around a wastebasket because she was convinced she was going to throw up, and pinch her throat because she felt as if it were closing up.
"If people around me say they don't feel good, it brings on a panic attack," she says.
A 9-year-old Fall River girl who was treated by Freeman began showing symptoms of anxiety and obsessive-compulsive disorder shortly after her baby sister was born. She didn't want to go to school, she insisted that toilet seats be closed and she couldn't fall asleep unless her stuffed animals were in a certain order, according to the girl's mother, who did not want her daughter identified.
"She thought she was going to die if she did not put that toilet seat down," the mother says.
Anxiety can also be a symptom of a family crisis.
"Oftentimes, a kid who is afraid of leaving home or going to school has some particular fear that something is going to happen at home, or something is going to happen to Mom," says Dr. Gregory Fritz, medical director at Bradley Hospital, in East Providence, and head of child psychiatry at Hasbro Children's Hospital. "Sometimes the kids sense that the parents are having marital problems and that leads to anxiety. They think, if I'm not there to keep tabs on things, it will all fall apart."
Alice Brady, president of the Rhode Island Certified School Nurse Teachers, often finds that kids with unexplained stomachaches or headaches have parents with marital problems.
"In many cases, it's a shift in the family dynamic," says Brady, a school nurse in North Providence. "This is severely stressful to the child and it comes out somatically," or physically.
Adolescence can also trigger anxiety disorders. Gina Bucci, a school nurse at Cumberland Middle School, spends a lot of her time tending to sore heads and bellies.
"The tensions of growing up, puberty, hormones are real big at this age," she says. "There's an increase in academic pressures and a lot of anxiety about that."
Dr. Barbara Gaines, a Providence pediatrician, sees a lot of anxious kids during the holidays, when report cards come out and at the beginning of the school year.
"We're in anxiety season right now," she says.
DESPITE ITS bad reputation, anxiety isn't the worst thing in the world. Dr. James Greer, a child psychiatrist at The Providence Center, likens people to guitar strings when describing normal anxiety.
"If it's really slack, it can't function," Greer says. "It needs a certain level of tension to work."
Anxiety becomes a problem, Greer says, "if people's coping skills are inadequate or they're feeling overwhelmed."
"It's really normal for kids to have fears and anxiety," Freeman says. "But if it's so intense or so distressful that it's interfering with life, then it's not normal."
Parents will be able to tell that anxiety is not being kind to their children if they start to exhibit telltale behaviors.
"Physical symptoms are a big part of anxiety," Freeman says. "If [parents] start seeing those things -- my stomach hurts, my head hurts, my back and legs hurt -- that would be a clue that they're anxious."
Gaines often sees children who claim they can't breathe. Though their parents may suspect asthma, Gaines discovers that the kids are actually hyperventilating from anxiety.
"They might say, 'I feel like there's not enough air in the room,' " she says.
Gaines begins treating anxious kids by talking to them and teaching them breathing and other relaxation techniques. If she feels they need more help, she'll refer them to the Hasbro/Bradley anxiety center.
Psychiatrist Charles Staunton, associate medical director of child and adolescent services at Butler Hospital, encourages parents to talk to their kids before turning to professionals. He says if a student who liked school suddenly seems unhappy there, or a child is suddenly worried about germs, for example, parents could say, "You seem kind of nervous. Is something bothering you?"
"You're detectives to their mental health the same way you're detectives for their physical health," Staunton says.
He adds that if parental sleuthing doesn't yield results, then it's time to see a doctor.
"It's always fair game, if you think something's not right and you've given it your best shot," Staunton says.
Before sending children to medical professionals, Christopher Willis, a psychologist at three schools in Portsmouth, tries to find out if there's a simpler solution. He asks kids if they're having trouble with bullies, teachers or the kids on the school bus. He may recommend family counseling.
"If it gets to be where the anxiety is crippling or the kid can't get on the bus or is having panic attacks, those are the cases where kids need professional help," Willis says.
COGNITIVE-BEHAVIORAL therapy gives kids control over their recovery, but they must be willing to put up a good fight for it to work. "I tell them to boss back or take charge of their [anxiety]," Freeman says.
"Kids who have anxiety often don't know they can fight it, so they give in," says Trainor, the Harvard Medical School psychologist who also practices at Massachusetts General Hospital and in Framingham, Mass. "When they conquer it, it raises their self-esteem."
Typical of cognitive-behavioral therapists, Trainor teaches youngsters to identify, understand and diffuse their "silly thoughts." She also coaches kids to distract themselves during anxiety attacks.
"I call it changing the channel in their head," she says.
"Avoidance is the worst thing," Freeman says. "A lot of [cognitive-behavioral therapy] is teaching them to do the opposite of what the anxiety is telling them to do."
As children gradually face their fears, they earn points that can be exchanged for non-material rewards, such as extra family time or favorite dinners.
Donna Pincus, director of the Child and Adolescent Fear and Anxiety Program at Boston University's Center for Anxiety and Related Disorders, tells patients not to fear the physical sensations that come with anxiety.
"Our job is not to take away kids' anxiety, but to help them manage it and be more accepting of this as an emotion," Pincus says.
Parents are a vital part of the process, and not just because they dole out the rewards for bravery.
"Anxious kids often come with anxious parents," Pincus says. "We help the parents with skills, too. Instead of saying to the child, 'You'll be fine,' they need to encourage the child to use their skills and praise them."
NOELLE, the Seekonk freshman, finally found relief from her panic attacks last year after participating in cognitive-behavioral therapy at Boston University's anxiety center. Now when she feels a panic attack coming on, she forces herself to stay in the situation and uses her "brave behaviors."
She tells herself: "It's just a panic attack. It's going to go away."
Cognitive-behavioral therapy was so successful for the Fall River girl who developed crippling anxiety after her mom had a baby that she never needed medication, as some children do. And she was fine after a third sibling arrived.
And Joseph Joyal, who at one time had to tap his spoon four times between each bite of food, set all the clocks to the same time every morning, touch the entire car before walking away from it and switch his pencil from hand to hand before using it, no longer has any obsessive-compulsive behaviors.
"Sometimes I have cravings, but I tell myself, I've got a bigger willpower now to say forget it, I'm not gonna do it. It's not worth it."
Susan Kushner Resnick can be reached at sresnick@projo.com.
