Avoidance and Anxiety in Childhood Anxiety Disorders
Managing a child’s anxiety can be quite difficult for parents. Sometimes parents know that the teen has an irrational fear so they try to convince the child through logical argument that they are safe. This can feel like running on a rat-wheel, however, as rational argument doesn’t have any lasting impact on the child. They may feel somewhat comforted today, but be just as afraid tomorrow. Other times, the child’s distress is so intense that the parent gives up on trying to convince them and allows the child to miss important activities. Watching your own child suffer can be so painful, that many parents prefer to let the child avoid the pain. Often there is a disagreement between parents regarding how much a child should be pushed to face their fears. This can result in marital discord as one partner becomes identified as “permissive” or “weak” parent while the other becomes labeled as the “uncaring enforcer.” Making matters worse, the child can begin pitting the parents against each other; they may think, “Mom say’s I have to go, but I’ll tell Dad how scared I am and he’ll tell me I don’t.” This kind of thinking inevitably leads to more conflict as each parent feels the other isn’t supporting him or her. The question I’m often asked is: “Whose right and whose wrong? Am I wrong to let him stay home, or are they wrong to push him to go?”
This depends largely on the context; neither individual is wrong or right in all cases. If a child has been terrified of dogs and there is a party at a local dog park, then perhaps it makes sense to allow them to skip it. Going might be so terrifying that the child will have a miserable experience and is unlikely to get over his fear from this kind of exposure. On the other hand, if there is a party at a person’s house who owns a dog, and the parents agree to keep the dog in the basement for the entire party, then it might be a wise choice to push the child to attend. This might cause increased anxiety in the short-term but result in a decreased fear of dogs in the long-term.
Let’s use what we know about anxiety disorders to look at these situations more carefully. The initial cause of a child’s anxiety may not be well understood. It is likely a combination of biological and environmental factors and while a dog bite might cause a fear of dogs in one child, another could be fine. What we do know is that once a fear is developed, it is maintained and strengthened through a process known as negative reinforcement.
Negative reinforcement refers to the strengthening of a behavior as a result of the removal of an unpleasant experience. For instance, if an adult feels anxiety before a party and drinks alcohol, their anxiety is temporarily decreased. As a result of the removal of an unpleasant experience (anxiety), the person is more likely (strengthening of behavior) to drink again the next time a party occurs. Likewise, when you start driving your car, there is an annoying beeping sound that occurs if the driver doesn’t have their seat belt on. Because you can remove this unpleasant beeping by putting your seatbelt on, you are more likely to put it on today and again in the future. That is another instance of negative reinforcement.
Applying this to a child with a fear of dogs. What happens if he has a friend’s birthday party coming up and there might be a dog there? The child feels anxious about going to the party and deciding not to go results in a short-term elimination of this anxiety. By eliminating the unpleasant experience of anxiety, avoiding the party has been negatively reinforced. As a result, he feels less anxious today, but he is missing out on the experience of the party and is more likely to skip future parties.
This is a critical point and I encourage you to re-read the sections above if it doesn’t make sense. Many parents believe that by their child is not ready to face these anxiety-provoking situations right now but they will be in the future. Negative reinforcement reveals that this logic is incorrect. By allowing them to avoid these situations today, they will be more likely, not less, to avoid them in the future.
So if you’re child is struggling with anxiety, I invite you and your partner to sit down and identify all the responsibilities or events that your child is not participating in. Are they getting excused from social gatherings? Being alone? Household chores? Identify as many possible activities/situations/people/responsibilities that your child might be avoiding or is avoiding due to anxiety. To help identify the avoidance patterns, consider roles/responsibilities in family, social life, school/work, chores, and health. Then with your partner, pick one or two that you want to get him to stop avoiding and consider what a good first step might be.
Consider Jane and Steve’s example below regarding their son Jon who fears dogs.
Persons/activities/people/responsibilities that Jon avoids due to anxiety about dogs
Not playing baseball outside (Social, health)
Not running or exercising outside (health)
Won’t go on walks with the family (health, family)
Misses friend’s birthday parties who own dogs (social life)
Won’t go out to dinner because we might encounter a dog on the way (family, social life)
Won’t play at friends’ houses who own dogs, only will have them over to ours (family, social life)
We can’t have a dog event though we both grew up in dog households (family)
Won’t take out the trash because there could be a dog outside (chores)
Skips school field trips (school, social)
1-2 things we want him to stop avoiding
Going out to dinner with family
Going on walks with the family
From here, Jane and Steve will have to plan a dinner excursion with the family and prepare their son for it. Rather than thinking, “Can Jon go?” Ask the question “How can Jon go?” Perhaps they can let Jon pick the first restaurant. If Pizza is his favorite food, then maybe we can entice him to come out for pizza. Or, maybe our first restaurant will be a place that isn’t in an area where there are lots of dogs. Or maybe the first restaurant will be only a 2-3 minute walk from the car.
After completing this first experience, then they can try a place with a slightly longer walk to the car, or where there might be more dogs. Each time, the goal is to make it slightly more challenging then the time before. The first few times are often the hardest because there is such a strong desire to avoid as a result of previous negative reinforcement for avoiding. Pushing past this desire, rather than allowing it to determine the outcome, will eventually (and sometimes fairly quickly) result in an elimination of the fear.
Some things to be aware of:
Avoid promising the child that they won’t encounter the feared object. If they fear dogs, don’t promise that we won’t see any dogs on our way to dinner. You can’t guarantee this, and the point of the exercise is to try going out to dinner even knowing that we might encounter a dog.
Fight the urge to distract the child during the activity. Parents often want to help their child avoid the fear and feel better; unfortunately, this leads to more avoidance. Instead of learning that they can tolerate it if they do encounter a dog, they learn that they can only tolerate it by distracting themselves. Encourage them beforehand and you can walk with them for the first few outings and help calm them down afterwards. But while they are actually in the anxiety-provoking situation, notice your desire to protect them and just try to help them be aware of their experience. You can ask them:
What thoughts they you having?
What feelings or physical sensations are you having?
What do you feel like doing?
If a dog (or some other fears object) comes along, encourage them to look at it rather than away from it.
If at first you don’t succeed, try, try again. Even trained professionals sometimes over- or under-estimate how difficult a given situation will be for a child. Some of these experiences go amazingly well and the fear is largely eliminated in the first experience. Other times, it takes trial and error to figure out exactly what the child is afraid of so that you can help them face that situation. While facing anxiety-provoking situations does lead to a short-term increase in anxiety, the long-term rewards are far greater. There is also an implicit lesson here that most parents want their kids to learn: life can be very hard at times, but you can keep going even when it’s hard. If you do keep moving forward, you can have the kind of life that you want for yourself. It may help to remind yourself of this lesson as you gently push your child to face different fears.
By Jonah Lakin Psy.D.