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With summer fading, anxiety is on the rise for some students anticipating the return of school. But it isn't just the first days of classes that can provoke angst — anxiety in school is seasonal and age dependent, say pediatric psychiatrists.

And, they add, these issues are often predictable and highly treatable. "If parents are aware of the fears that might affect their school-age children at different times of the year, and at certain ages, there is a lot they can do to help," says Dr. John T. Walkup, director of child and adolescent psychiatry at NewYork-Presbyterian Hospital/Weill Cornell Medical Center and vice chair of the Department of Psychiatry at Weill Cornell Medical College.

"It is about knowing when problems occur, anticipating them, and intervening effectively so that children do not suffer academically or socially," he says. "Untreated anxiety and depression lead to coping and adaptation difficulties over time — all of which can be prevented by early recognition and treatment."

Dr. Walkup adds that these anxiety disorders are much more common than parents (and teachers) realize, and while anxiety is a fact of life, many children are impaired enough that they should be assessed and treated. "Behavioral therapy works well for many students," he says. "Others may need medication."

Seasons of Anxiety

Culled from his clinical experience with many children with anxiety disorders, Dr. Walkup outlines what he dubs the "Seasons of Anxiety":

• September: Separation anxiety as school starts. This usually occurs in children under the age of 12 as they anticipate returning to school after a summer spent with their family. With the anticipation of returning to school, these children may have trouble falling asleep, stomach aches in the morning, clingy behavior and apprehension about leaving home and going to school. At school they may go to the nurse with vague symptoms and want to come home.
  
  Although some mild and transient separation anxiety with starting school is common in children ages 4 to 6, separation anxiety in children 7 to 12 is of more concern. Separation anxiety can start abruptly or sharply worsen in this age group. "These kids really worry about separation," Dr. Walkup says. "They worry something bad will happen to their parents or to them. At home, they often don't want to be alone, won't do sleepovers during the school year and often don't want to go to camp in the summertime. Monday morning is more difficult than Friday for these children."
  
  Separation anxiety can be treated with behavioral therapy, such as the well-known "Coping Cat" program, in which a trained professional works with the child and family to identify the fears and develop strategies to manage and overcome them, he says. "It is important that children learn to handle their fears and worries at an early age so that when they are older they don't use avoidance as a coping strategy for routine challenges in living. Kids should be curious about new (safe) situations and experiences, not fearful and avoidant. If they learn they can handle new situations and challenges as an early age they will be more likely to handle challenging situations in adolescence and adulthood. Teens who have had anxiety as children often don't have the kind of complex and supple coping skills in adolescence and often complain of feeling overwhelmed by even routine stresses."


• October - November: General anxiety in the middle of the first term. Slightly older children (9 to 12) with a general anxiety disorder may first appear with symptoms during the first grading period, Dr. Walkup says. "These children tend to be perfectionists who are smart but who may not do well with tests even when they study a lot. When they take a test they blank out, freeze up and underperform; this is especially true with timed tests. And for some reason mathematics is more difficult for these children than language arts.
  
  "Parents may think that their child has a learning disability because they are underperforming, but an assessment for anxiety may be just as important as learning disability assessment," he says.
  
  Children with extreme social anxiety also present with problems during the early school year. "Children with social anxiety are shy, sensitive and extremely self–conscious. These children fear embarrassment in routine classroom activities. They don't like to be called on, won't raise their hand to answer questions, and have trouble asking for help even from safe strangers. They often speak softly and provide short answers, and some rarely speak spontaneously with teachers or other school personnel. Some are so timid that they won't use the school restrooms," Dr. Walkup says. "At younger ages shyness may seem quite endearing, but over time these children get lost in the classroom and can develop issues academically and socially that might become a real problem in their teenage years."
  
  Again, "Coping Cat" skills can help, he says.


• December - March: Wintertime blues. Like adults, adolescents can suffer from seasonal affective disorder (SAD) when days become shorter. "Winter depression like depression at other times of the year is characterized by a depressed mood and an inability to enjoy pleasurable activities. The onset can be subtle, but can lead to social withdrawal, declining academic performance, irritability, restless sleep and changes in appetite. The good news is that it gets better in the spring when the days get longer. Many parents attribute winter depression to the moodiness of teenagers or a simple developmental phase. It is not uncommon for youth to have suffered through three or four winter depressions before parents pick up the seasonal pattern and seek help for their child.
  
  "When depression is severe, such as when children have an obvious problem with eating or energy levels, medication may help to shorten the duration of these episodes. Once the pattern is recognized, teens shouldn't have to suffer from these episodes or face the risk problems with academic and social functioning."
  
  Although some adults with SAD may do well with light therapy, studies of light therapy for adolescents are limited, he says.


• April - June: Manic spring. Spring is commonly the season when teens with bipolar disorder present with manic behavior. Teens with mania have a marked change in their usual mood state, with decreased need for sleep, boundless energy, over-the-top ideas and plans, and willingness to engage in risky behaviors that they wouldn't have dreamed of doing even a couple of months earlier, Dr. Walkup says.


• July - August: Out-of-control summer. Once school is over, some youth who were able to maintain behavior control because of the structure and daily routine of school find themselves with too much time on their hands and with too little supervision. These youth can get into problems with rule breaking, delinquency, substance abuse, and premature sexual activity. Planning for structured summer activities with adequate adult supervision will go a long way to prevent children from engaging maladaptive behaviors in the summer. "More hands-on parenting can help," Dr. Walkup says.

Alongside seasonal issues, Dr. Walkup notes that parents can look for certain conditions based on the child's age. Children under age 5 are rarely depressed, but this is the time that early symptoms of anxiety may show up, as well as attention deficit hyperactivity disorder (ADHD). School-age children exhibit ADHD, anxiety and misbehavior. Depression can become an issue during the period right before puberty, but mostly shows up in the early to mid-teenage years, he says. The later teenager years are when bipolar disorder typically begins. "Being alert to the age and season that mental health problems first begin to present themselves can help children get the help they need sooner and minimize the burden of unrecognized and untreated mental health problems," Dr. Walkup says.

After 20 years at Johns Hopkins University School of Medicine, Dr. Walkup joined NewYork-Presbyterian/Weill Cornell in November 2009. He has been involved in a number of the large definitive clinical treatment trials for childhood psychiatric disorders including adolescent depression, childhood anxiety, early-age mania and suicidal behavior in teens.

Dr. Walkup's other interests include Tourette syndrome, psychopharmacology, and community–based participatory research with American Indian communities. He has been funded for large projects working with American Indian tribes in the Southwest United States. He is the chair of the medical advisory board of the USA Tourette Syndrome Association and serves on the scientific advisory boards of the Trichotillomania Learning Center and the Anxiety Disorder Association of America.

For more information, patients may call 866-NYP-NEWS.

NewYork-Presbyterian Hospital/Weill Cornell Medical Center

NewYork-Presbyterian Hospital/Weill Cornell Medical Center, located in New York City, is one of the leading academic medical centers in the world, comprising the teaching hospital NewYork-Presbyterian and Weill Cornell Medical College, the medical school of Cornell University. NewYork-Presbyterian/Weill Cornell provides state-of-the-art inpatient, ambulatory and preventive care in all areas of medicine, and is committed to excellence in patient care, education, research and community service. Weill Cornell physician-scientists have been responsible for many medical advances — including the development of the Pap test for cervical cancer; the synthesis of penicillin; the first successful embryo-biopsy pregnancy and birth in the U.S.; the first clinical trial for gene therapy for Parkinson's disease; the first indication of bone marrow's critical role in tumor growth; and, most recently, the world's first successful use of deep brain stimulation to treat a minimally conscious brain-injured patient. NewYork-Presbyterian Hospital also comprises NewYork-Presbyterian Hospital/Columbia University Medical Center, NewYork-Presbyterian/Morgan Stanley Children's Hospital, NewYork-Presbyterian Hospital/Westchester Division and NewYork-Presbyterian/The Allen Hospital. NewYork-Presbyterian is the #1 hospital in the New York metropolitan area and is consistently ranked among the best academic medical institutions in the nation, according to U.S.News & World Report. Weill Cornell Medical College is the first U.S. medical college to offer a medical degree overseas and maintains a strong global presence in Austria, Brazil, Haiti, Tanzania, Turkey and Qatar. For more information, visit www.nyp.org and www.med.cornell.edu.