There is an old medical proverb that goes: “When you hear hoof beats in the hallway, think horses, not zebras.” The proverb means that we should use common sense and look for the expected cause first, rather than searching out something more exotic. This proverb is valuable to keep in mind if a 
child or teenager develops a problem such as anxiety, depression, or bad behavior.
All too often these days, a child is diagnosed with a “mental disorder” when the actual problem is far less exotic. Like most of us, children are sensitive to their social environment—family, school, and friends. When there is a stressor in one of these areas, a child can develop problem behaviors or anxiety. The key to solving the problem is not to label the child with a “mental disorder” and move toward medication, but rather to make targeted changes in the social environment that will remove the stress from the child.
For example, 11-year-old Cindy was having such severe anxiety attacks that she sometimes vomited. Her parents tried to comfort her, but when Cindy’s anxiety went on for more than six months, her parents took her to the pediatrician. After the pediatrician ruled out medical causes for the anxiety, he suggested family therapy. A few days later, Cindy’s parents brought her to see me.
“She’s always been a nervous child,” Cindy’s mother said. “But now her anxiety has become severe. She sometimes vomits while we’re driving in the car. She is even afraid to go to school at times. Do you think she has an anxiety disorder?”
I don’t think of a child’s anxiety as a “mental disorder.” Instead, I see it as a response to a stressful, anxiety-provoking situation in the child’s life. What could be causing Cindy to be so upset? I wondered.
When I talked with Cindy alone, she told me that her greatest worry was hearing her parents argue about her grandmother (her mother’s mother). “My father hates my grandma,” she confided. Then she broke down in tears. “My parents argue so much that I’m afraid they are going to get divorced.”
Hearing parents argue—whether about in-laws, financial problems, or other matters—can be very frightening to a child and, surprisingly, is a major source of many childhood problems. Children have active imaginations and tend to magnify arguments between parents in their own minds, often making mountains out of molehills.
My strategy to help Cindy get over her anxiety was to meet with her parents alone and help them air out the tension between them that was undoubtedly affecting their daughter.
In the first session with Cindy's parents, her father told me that he felt resentful about his in-laws. He felt that they were too intrusive in the life of his family. "They call all the time, and they come over for dinner at least once a week," he told me. Once her husband was able to express his feelings, Cindy’s mother could begin to create an appropriate boundary with her own parents.
Cindy's mother also was able to voice her own resentments about her husband. He rmain complaints were that he came home from work too late and didn’t back her up about discipline. After a few sessions in which the parents worked out these issues, their arguments at home ceased. Soon their daughter’s anxiety ebbed, and finally it disappeared altogether.
Children tend to become overly worried about parental disagreements (however small). Surprisingly, these magnified worries can lead to symptoms like anxiety, distractibility or bad behavior. Keeping parental arguments away from little ears can have an almost magical effect on a child’s well being.
Other problems in the home environment—trauma, inconsistent discipline, illness or injury of a parent, parental troubles overheard by the child, or even the death of a grandparent or other close relative—are also frequent contributors. Remember, being “honest” with our children does not mean telling them every detail about the family finances or a parent’s stressful work situation.
School, too, is an important influence on a child’s wellbeing. When six-year-old Larry refused to go to Kindergarten day after day, his parents consulted a child psychiatrist. The doctor diagnosed Larry with school phobia and recommended talk therapy and anti-anxiety medication. Larry’s mother was not satisfied with this answer. She decided to take matters into her own hands. She went to Larry’s school and observed in his classroom. There she found that Larry’s teacher sometimes made fun of the students. When she moved her son to a new school, his “school phobia” disappeared as quickly as it had begun.
In the teenage years, friends can become a major source of stress for kids. As a child begins to separate from her family, she becomes more dependent on a peer group of friends to provide emotional support and mirroring. Teenage angst often emerges when the teenager when a friend turns on her and leaves her out of a group. Again, the best solution for the anxiety is not medication (which is at best a temporary fix), but rather finding a therapist for the teen. The therapist can then find the root of the problem. One 13 year old girl started refusing to go to school, pleading nausea as an excuse. Her problem, as it turned out, was not school phobia. It was, instead, that the boy she liked had started going out with another girl.
Once parents start to see the underlying cause of their child’s problem not as a problem in the child but in the child’s social environment, they are on the right track to finding an effective solution. In our culture, we are used to thinking in terms of the disease model to explain human suffering. As parents, we need to get past this way of thinking and reframe emotional problems as responses to situations rather than as reactions to biological pathogens or chemical imnalances. Parents can advocate for their child by asking their pediatrician whether family factors could be contributing to the child’s problem, and by seeking out a professional therapist who is experienced with family therapy.
Early intervention is also critical. Parents should consult a family therapist at the first sign of serious trouble—falling grades, distractibility in the classroom, out-of-control behavior, or unusual moodiness. If a therapist starts talking right off the bat about your child’s “diagnosis,” “disorder,” or “chemical imbalance,” she might not be the best choice. You want a professional who is going to think first of horses, not zebras!
Copyright © Marilyn Wedge, Ph.D.
Marilyn Wedge is the author of the popular book, Pills are not for Preschoolers: A Drug-free approach for Troubled Kids