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The common cold of the child’s mental health world

Mary Coffman, Thomas Ollendick and Frank Andrasik August 1, 2013

Tnightmareonight, 5-year-old Jonathan is a fretful, whiney and downright irritable child, and with good reason. He is sneezing, running a low-grade fever and has a runny nose, symptoms so easily recognized that even Jonathan can diagnose himself as having a cold.

Five-year-old Greg is just as fretful, whiney and irritable tonight, but the fever he is running is a psychological one — anxiety. Rather than a runny nose, he is dealing with symptoms related to “runny thoughts,” oozing with images of scary things like monsters hiding under his bed or a masked burglar crawling in through his window. Greg’s “sneezes” come out in the form of fearful statements such as, “Mother, please come back. I’m scared.”

Both children will feel miserable tonight and may wake up tomorrow in a bad mood because they haven’t slept well (the same can be said for their parents). The good news for Jonathan is that within 10-15 days, he will be recovered from his common cold. Greg will not.  Recovery from the psychological equivalent of the common cold is more likely to take months, years or, in some cases, even decades.

‘Common’ doesn’t mean ‘simple’

Nighttime fears, like the common cold, are pervasive among children. One study led by Peter Muris, professor of developmental psychopathology at Maastricht University in the Netherlands, suggests that in Western cultures, nighttime fears occur in many if not the majority of children ages 4-12. Similarly, Jocelynne Gordon of Monash University in Australia, along with other researchers, has pointed out that upward of 30 percent of children display severe fear — or phobia — and related sleep issues at nighttime.

The common cold does not refer to a single virus. More than 200 viruses are associated with the common cold. Similarly, nighttime fears are diverse both in their causes and expression. Children may be afraid of the dark, of unfamiliar sounds, of bad dreams or of imagined burglars, monsters and ghosts. In fact, Virginia Tech’s Child Study Center, where one of this article’s authors, Thomas Ollendick, serves as director, has uncovered more than 30 stimuli for nighttime fears. The center estimates that nighttime fears affect more than 20 million children in the United States. Children who suffer from nighttime fears may demonstrate excessive worry, crying, temper tantrums and overt disobedience.

The Virginia Tech Child Study Center has found that fear of falling asleep in the dark is the most commonly reported problem among children with nighttime fears. The responses of children who are dark-phobic are exaggerated much more than anything we would expect on the basis of any realistic dangers, such as stumbling over objects. One child told us she was afraid the dark would swirl around her and take her away like a tornado. Another child thought he might die if he fell asleep in the dark. Like the common cold, fear of the dark and other nighttime fears can cause a child to feel absolutely miserable.

Although symptoms of the common cold are irritating and uncomfortable, a cold can introduce more serious complications such as ear infections, bronchitis and even pneumonia. Similarly, nighttime fears can lead to complications such as sleep disruption and behavior problems, which in turn may create further problems, including lack of sleep and even missed work for other family members. In such instances, bedtime often becomes a battleground between harried parents and fearful children. One study found that it takes an average of 21 minutes to get nonfearful children to sleep, compared with an average of 76 minutes for fearful children. Moreover, many of these fearful children wake up throughout the night even after they initially fall asleep. Frequently, they go to their parents’ bedroom for comfort and reassurance, resulting in a lack of sleep for both child and parents.

Other “side effects” may occur with fear of the dark. For example, in an earlier study, William Mikulas, professor emeritus at the University of West Florida (UWF), and Mary Coffman, one of this article’s authors, found that 41 percent of children who had a phobia of the dark were also afraid of being alone. Some researchers have suggested that fear of the dark may be predictive of future risk for other anxiety disorders, loneliness and depression. At Virginia Tech, we have shown that about 80 percent of children who are afraid of the dark have other anxiety disorders such as generalized anxiety disorder and separation anxiety disorder. Typically, fear of the dark preceded development of these other disorders.

Also like the common cold, fear of the dark appears to be “contagious” and to run in families. At UWF, we found that 53.6 percent of the children with fear of the dark had either a parent or a sibling who was also afraid of the dark. Children can also “catch” fear of the dark by watching frightening TV shows or movies through a process of learning by observing.

Is treatment really necessary?

For years, researchers considered fear of the dark to be a transitory condition and questioned its clinical significance because it is so common among children. Early on, however, Anthony Graziano and Kevin Mooney found that the average duration of darkness phobia in children was more than five years. In a recent clinical trial, Ollendick and his colleagues confirmed this duration and suggested that in the absence of effective treatments, it was likely to persist even longer. For some individuals, fear of the dark can continue into adulthood.

Five years (or more) is hardly a transitory amount of time for a child. Would we expect a child to suffer the effects of a cold virus on a daily basis for five years without attempting some kind of intervention? The fact that fear of the dark is a common phobia does not make it any less uncomfortable or problematic for a child.

Physiological symptoms often associated with nighttime fear include increased heart rate, elevated blood pressure, shakiness and tears, while psychological symptoms include feeling frightened and anxious and having very unpleasant thoughts and images. Parents spend millions of dollars each year on over-the-counter and prescription medications to assuage their children’s runny noses and sneezes. Unfortunately, many parents do not know where to turn when seeking treatment for their children’s nighttime fears, which are the mental health equivalent of the common cold.

Home remedies and therapeutic interventions

For most parents, the first course of treatment is a home remedy — the “chicken soup” approach. Some parents suggest using “monster spray,” a bottle of plain water that they tell their children will destroy monsters. Other parents employ nightly “reassurance routines,” which might include looking under the bed with the child or staying in the room until the child falls asleep. At Virginia Tech’s Child Study Center, we had one parent who provided his son a knife to attack the monsters should they appear, while another placed sidings on the bed to prevent a monster from getting under the bed. The “treatments” seem endless and speak to the ingenuity of well-meaning parents.

Experts have developed a wide array of therapeutic techniques for nighttime fears, including components such as relaxation, self-control, parent training, positive reinforcement and graduated exposure. According to the Association for Behavioral and Cognitive Therapies (abct.org), exposure is the evidence-based treatment of choice for phobias. During exposure therapy, the child is exposed to his or her fear through repeated contact with the feared object or situation in a controlled, graduated and safe manner. Exposure and other treatment procedures have been provided through individual therapy, parent training, groups, the Internet, and even stories and books.

Many parents turn to children’s books, or bibliotherapy, to help their child understand and overcome nighttime fears. Many of the stories are short, cute, enjoyable and, like the effects of chicken soup on the common cold, may actually have some beneficial effects. This is particularly true for those children with mild fears of the dark — the kind associated with transitional phases in the child’s life. It is unclear, however, whether these stories are helpful with children who are phobic. Uncle Lightfoot, Flip That Switch, written by Coffman and illustrated by D.C. Dusevitch, is a fictional book on fear of the dark for ages 5-8. During its development, the book was tested in a series of studies supervised by Mikulas at UWF. The book incorporates elements of cognitive behavioral interventions such as exposure games, cognitive restructuring and parent instructions in a humorous, playful way so that children can actually have fun overcoming their fear of the dark. In addition to studies conducted at UWF, an earlier version of Uncle Lightfoot was field-tested by Isabel Santucruz and colleagues at the University of Murcia in Spain and found to be effective in treating fear of the dark.

During the development of Uncle Lightfoot, the children themselves taught us about the improvements that needed to be made. Six-year-old Emily was one of those teachers. Emily was afraid of the dark for three years before her family sought help. Emily may have “caught” her fear from her 9-year-old sister, Sarah, who was also afraid of the dark. Emily was so terrified that she was unwilling to stay alone in her dark room for even five seconds. After her parents read Uncle Lightfoot to her several times over a period of five weeks, Emily was frequently able to sleep in her bedroom all night with the lights off. Emily’s mother said she observed her daughter’s growing confidence while listening to the story and playing the games. Emily made comments such as, “I’m getting braver” or “I can do that. It’s easy!” Bravery, like fear, is contagious.

When a therapist is needed

Although at-home treatments may work for many families, professional help may be necessary in other situations. At the Child Study Center at Virginia Tech, we have been working on a form of intensive therapy called “one-session treatment,” a variant of cognitive behavior therapy, in studies funded by the National Institute of Mental Health. Following an in-depth interview with the parent and child, the clinician spends up to three hours in an extended session with the child. In this session, the child is asked to perform tasks that require greater and greater contact with the feared object or situation in a graduated and controlled manner. Weekly telephone follow-up sessions for one month help the child and the child’s parents to apply the techniques in their homes and communities.

One-session treatment has been evaluated in several studies involving hundreds of children in the United States and Sweden, and as many as two-thirds of the children in those studies are no longer fearful of the nighttime. On average, the study participants had experienced a fear of the dark for longer than five years. Follow-up over a four-year period revealed that 85 percent were free of all symptoms; the remaining 15 percent were improved but still needed additional treatment.

At Virginia Tech, we recently completed a small pilot program on a “stepped-care” approach that combines the best of home remedies and professional care. In the study, the phobic child’s family was initially provided an exposure-based fictional children’s book and consulted on how to implement the book. If this approach alone was not successful or only partially successful, therapists then provided more intensive services to the family using one-session treatment. Results from this study look very promising, with about half of the families responding to the children’s book alone and not requiring additional treatment.

Parents and children have numerous options for treating the common cold. Similarly, parents and children need effective tools for treating nighttime fears. Whether through bibliotherapy, evidence-based interventions or a combined approach, a “cure” to the common cold of the mental health world may be right around the corner.

 

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Mary Coffman is a nationally certified counselor with licensure in South Carolina and Florida. Her career has included counseling, teaching parenting classes, administration, writing, adjunct college teaching and research. Contact her at maryfcoffman@yahoo.com.

Thomas Ollendick is director of the Child Study Center at Virginia Tech and a university distinguished professor of clinical child psychology. He is the author or coauthor of more than 300 research publications, 75 book chapters and 25 books. Much of his research has centered on childhood anxiety and phobias.

Frank Andrasik is distinguished professor and chair of the Department of Psychology at the University of Memphis. He currently serves as director of the university’s Center for Behavioral Medicine. The primary focus of his research has been in the area of stress and behavioral medicine.

Letters to the editor: ct@counseling.org

 

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