Stress, Anxiety, Panic and Phobias: Secondary to NLD

by Sue Thompson, MA, CET

It is important to correctly identify and provide appropriate interventions for the school-aged child with NLD because this child is particularly inclined toward developing secondary internalizing disorders such as stress, anxiety and panic, as well as debilitating phobias. Children's Hospital Oakland has made the study of NLD and related conditions a specialty in their departments of psychiatry, neurology, and neuropsychology. Their research to date has revealed that children with NLD tend to suffer in the emotional realm because these children are not proficient at interpreting interpersonal interactions -- they lack insight into the feelings and perceptions of others that the rest of us glean intuitively.

Dr. Herbert Schreier, Chief of Psychiatry at Children's Hospital Oakland, states that having NLD "does not preclude having other conditions such as panic disorder, or anxiety and depression, secondary to NLD and school organizational issues." According to the National Institute of Mental Health in Bethesda, Md., anxiety disorders are the most common of neurobiological disorders. In the United States alone, twenty-three million people suffer from anxiety disorders. It is not known how many of these individuals are school-aged children because, child psychiatrists report, anxiety disorders in children are often overlooked or misdiagnosed.

Included in the spectrum of anxiety disorders are: panic disorder, generalized anxiety disorder, social phobia, specific phobia, obsessive-compulsive disorder and post-traumatic stress disorder. It may be difficult for parents and teachers to distinguish between normal stress in a child and conditions of anxiety and panic. Learning to recognize the difference can help us to better serve those in our care. The students we work with, even at a very young age, can become seriously afflicted by anxiety disorders.

It's not hard to imagine how a child who doesn't see the "whole picture," who is constantly confused by his surroundings and his interactions with others, and who is unable to anticipate what will happen next, could experience a disproportionate amount of stress in his everyday experiences, such as attending school or shopping at a mall. Add to this the perfectionistic and obsessive/compulsive tendencies of many students with NLD, and the immense pressure this child faces should be obvious.

It shouldn't surprise anyone that there is a connection between the excessive stress a student with NLD encounters and her inclination toward anxiety disorders. Without appropriate intervention, the cumulative effect of ongoing stress can advance to an unmanageable state of anxiety for a child already predisposed to internalizing disorders (as Dr. Byron Rourke of the University of Windsor, and his associates, have found individuals with NLD to be).

The physical symptoms of anxiety include those of stress (sweaty palms, racing heart, churning stomach), with the addition of: difficulty breathing, panicky feelings, chest pain or discomfort, flushed skin, sweating, trouble sleeping, difficulty concentrating, trembling or shaking, and headaches.

It is important to note that, while the stress of coping with NLD may be the trigger for an anxiety disorder, and while excessive stress may make a child with NLD more susceptible an anxiety disorder, such a disorder is a biological illness, in and of itself, and will require concurrent treatment, along with any interventions already in place to accommodate this child's NLD.

A child with NLD experiences constant confusion and unfamiliarity with his surroundings and circumstances. Without appropriate intervention, he will eventually succumb to the cumulative effects of the persistent stress he encounters in his everyday environment. The student will then become more vulnerable to the affects of even minor changes in his life, because of the continual stress which has built up within him. Add to this the trauma of being in a situation at school where NLD is not well understood or serviced, and all of these factors together may combine to trigger panic attacks.

Panic disorder (PD) is one of the anxiety disorders often neglected in school-aged children. A panic disorder is characterized by recurrent, spontaneous panic attacks. A panic attack is an acute episode of terror and discomfort. A barrage of terrifying symptoms take over the body, usually lasting only a couple of minutes, but sometimes continuing for up to ten minutes.

During a panic attack, the child experiences extreme fear accompanied by frightening symptoms such as: difficulty breathing or shortness of breath; pounding heart; pain or other discomfort in the chest; choking or smothering sensations; feeling dizzy, unsteady, lightheaded, or faint; a sense of unreality; tingling in hands or feet; hot or cold flushes; sweating or chills; trembling or shaking; and feelings of hopelessness, impending doom, or loss of control. These symptoms gradually fade over the course of an hour or so, but the individual may feel "disoriented" for several hours afterward.

To be defined as a "full panic attack," four or more of the above symptoms should be present. Otherwise, the attack is described as a "limited symptom attack." Those who experience panic attacks usually describe them as striking repeatedly "out of the blue" or "without warning."

To be diagnosed as panic disorder, the initial panic attack is followed by one month (or more) of one (or more) of the following: (1) constant worry about having another panic attack between episodes; (2) constant worry about what caused the attack, or (3) behavioral changes related to the panic attack (i.e. fear and avoidance of places or situations).

Initial panic attacks usually occur when a person is under considerable stress. Attacks may also follow an illness. Stimulant medications, such as those used in treating asthma, can also trigger initial panic attacks. A child may assume that the symptoms of panic he is experiencing are the same kind of feelings everyone experiences when they are worried or nervous. He learns to outwardly mask his panic attacks and may show no overt signs of discomfort.

Panic attacks are largely misunderstood and are not always taken seriously. A child may be told to "calm down" or "relax" (the worst possible things to say to someone who is in the throes of a panic attack). Do not assume she will simply "outgrow" her panic attacks. If left untreated, a child's panic disorder can become progressively more and more debilitating, severely restricting and even dominating her life. School work and friendships will suffer greatly.

Physicians who see these children often fail to diagnose panic disorder. And, even when a doctor does recognize the condition, he may trivialize it, suggesting PD is of no importance or that it is not treatable.

In the United States, between three and six million people suffer from panic disorder. Yet, it is believed only one out of three panic disorder sufferers is correctly diagnosed and treated. The most common age of onset is the late teens, but much younger children can also be affected. School phobia and other childhood anxiety disorders are thought to be early forms of panic disorder. More than half of the people suffering from panic disorder developed the condition before age twenty-four.

A young adult whose panic disorder progressed to the point where she was unable to leave her home for eight months states, "Before I knew I had panic disorder, I just thought I had a problem handling stress . . . My own battle with stress has been ongoing; I've been fighting it since kindergarten, at least."

A panic attack is generally proceeded by intense anxiety which, ironically, can lead to more panic attacks. The child may (consciously or subconsciously) begin to avoid places and situations where she has experienced a panic attack or where she fears she may be vulnerable to another panic attack. This can progress to an extremely disabling condition known as "agoraphobia," a fear of leaving the home.

Joseph Biederman, et. al, have found that "children meeting the criteria for panic disorder also frequently met the criteria for agoraphobia" ["Panic Disorder and Agoraphobia in Consecutively Referred Children and Adolescents", J. Am. Acad. Child Adolesc. Psychiatry, 1997, 36(2):214-223].

The exact cause of panic disorder is unknown, but is currently the subject of intense scientific investigation. Researchers have concluded that there are physical reasons why people with PD are more sensitive to stress. One line of research suggests that PD may be associated with increased activity in the hippocampus and locus ceruleus, areas of the brain which monitor external and internal stimuli and regulate the brain's responses to these stimuli.

Current panic disorder research has been focusing on a neurotransmitter called "cholecystokinin" or CCK. CCK is thought to cause panic attacks in some people (perhaps in those with a genetic predisposition to panic disorder). When the body is under stress, it produces endorphins. When the stressful situation abates, the body produces CCK to counteract these endorphins. So, the physiological reaction produced by stress is thought by some to cause panic attacks.

Researchers also believe the neurotransmitter serotonin plays an integral role in the development of panic disorder.

Other research suggests panic attacks occur when a "suffocation alarm mechanism" in the brain erroneously fires, falsely conveying the message to the brain that death is imminent [Klein DF, "False Suffocation Alarms, Spontaneous Panics, and Related Conditions," Arch. Gen. Psychiatry, 50, Apr 1993, p 306-317].

In the case of the child with NLD, everyday occurrences produce an abundance of stress. Because this child has to "think" about everything he does, even an   "average" day can be overly demanding and unmanageable. Getting through a day at school takes an extraordinary amount of determination and perseverance. The stresses of this student's life may gradually overwhelm him, both physically and emotionally.

Panic disorder often coexists with other neurocognitive and neurobiological disorders. Although there seems to be a predisposition to panic disorder in those with NLD, children with other types of learning disabilities may also develop PD. In addition, those with PD may also have a heart condition called "mitral valve prolapse." This condition involves a defect in the mitral valve, which separates the two chambers of the heart. People with mitral valve prolapse are thought to be at a higher risk of developing panic disorder.

It's long been known that cumulative stress can contribute to physical illnesses, such as ulcers and high blood pressure. Recent advances in scientific understanding of the brain, such as the CCK research, provide explanations of how cumulative stress can also lead to neurobiological conditions, such as anxiety and panic disorders.

The more stress a student with NLD is under, the more likely he is to experience panic attacks and anticipatory anxiety (both of which can lead to additional problems of insomnia and agoraphobia). Sleep patterns may be upset by panic-related anxiety. Sleep is also disturbed when panic attacks occur at night. This experience can be so traumatic that some sufferers reach a state where they are afraid to go to sleep and subsequently suffer from sleep-depravation and exhaustion.

More than one researcher has concluded that panic disorder is a chronic condition. The chronic nature of PD emphasizes the need for varied treatment methods. The National Institute of Mental Health (NIMH) has found that a combination of medication and cognitive-behavioral therapy seems to work the best for most panic disorder sufferers. For a child with PD, medication is usually not the first course of treatment. An intervention plan should be developed according to the child's individual needs.

"Insight-oriented" psychodynamic therapy ("talk therapy") or other forms of psychotherapy which focus on the client's past have proven to be counterproductive as a model of intervention for individuals with NLD, and also for those suffering from PD. Psychodynamic approaches to therapy do not help people overcome panic disorder or agoraphobia.

Therapy should focus on practical, directive-type therapy, concentrating on the difficulties and successes the person is experiencing at the present time, and on directly teaching skills which will help this individual to cope more effectively in the future. The therapist should assume a positive coaching role.

At a conference held at the National Institutes of Mental Health (NIH) under the sponsorship of the National Institute of Mental Health (NIMH) and the Office of Medical Applications of Research, conferees concluded that "any treatment which fails to produce an effect within six to eight weeks should be reassessed."


The three basic components of panic disorder: the panic attack, the anticipatory anxiety, and agoraphobia, are each associated a distinct area of the brain. These three areas are: the brain stem, limbic system, and frontal cortex, respectively. Panic attacks are believed to occur when the brain's normal mechanism for reacting to a threat - the so-called "fight or flight" response - becomes inappropriately aroused. They are triggered by stimulation of areas in the brain stem that control the release of adrenalin. Stimulation of the locus ceruleus produces most of the physical symptoms of panic.

When confronted with a real or perceived threat, our central nervous system's "fight or flight" response is automatically triggered to prepare our bodies for immediate action. A similar response activates in most living organisms when facing danger, for the purpose of survival and protection. It becomes a panic attack when this emergency response presents itself in a situation where it is not warranted. The physical symptoms of a panic attack are extremely uncomfortable and intensely frightening for the person experiencing them.

The brain rouses the sympathetic nervous system, inducing the release of adrenaline from the adrenal glands. This release of adrenaline, in turn, causes the individual to experience a hot flush sensation. The rate and strength of his heartbeat will increase to supply more oxygen to the his tissues, preparing his body for "fight or flight." Blood vessels contract or expand to divert blood from the skin, fingers, and toes to the large muscles. This diversion of blood is accomplished for the purpose of reducing bleeding, in case of an "attack," and may cause a feeling of coldness or numbness in the hands or feet of the individual.

Breathing will increase in rate and depth, in order to provide more oxygen for the anticipated exertion. Breathlessness, dizziness, and pain or tightness in the chest may be experienced. Sweat glands are also stimulated, to prevent overheating. The pupils of this individual's eyes may dilate, to admit more light and augment peripheral vision, allowing the individual to scan a wider area for danger. Sensitivity to bright light, and visual disturbances may occur, as a result of his dilated pupils. The digestive system shuts down to conserve blood for his muscles. A dry mouth or nausea may follow.

All the muscles of his body tense to prepare for escape. This muscle tautness may cause spasms and trembling, when the anticipatory action is not fulfilled. All of the individual's thoughts are focused on the pursuit to discover the imminent threat, maintaining an heightened state of alertness and vigilance. Even if there is no plausible explanation for this emergency response, the individual is unable to concentrate on anything else while it is occurring.

The "fight or flight" response is time limited because the adrenaline is metabolized by the body. When the perceived danger has passed, the parasympathetic nervous system counteracts the activation of the sympathetic nervous system. The symptoms gradually fade, over the course of about an hour.


It should come as no surprise to anyone that there is a connection between stress and panic. With this in mind, it is imperative that parents and teachers do everything possible to lessen the stress a student with NLD experiences in his daily activities

Significant life events involving a real or perceived threat can contribute to the development of panic disorder. A student with NLD who feels threatened by his peers or teachers at school is at risk.

A high-school senior with NLD and PD was served with a subpoena at school (after being betrayed and deceived by school officials) and suffered a major panic attack, on the spot. He had to leave the school grounds in order to recover. This type of ignorant behavior on the part of school officials is unconscionable and cannot be tolerated.

CAMS aimed at previewing, preparing and supporting the student will help decrease the amount of stress she encounters. As a parent or teacher, you will not be able to eliminate all sources of stress, so aim to defuse as many as you can. Forget archaic notions of "responsibility." It is important to recognize that the goal for this student is to eliminate stressors, which may mean reducing expectations of accountability and responsibility. It is important for the adults in this child’s life to understand his disorder and to make appropriate adjustments in their behavior and communication, so they can help the student cope better with the stress he encounters. In addition to careful planning and monitoring, the following ten pointers can help, at home and at school.

Establish a regular exercise routine: Stress is a reaction to change. It is an internal physical reaction triggered by external factors (i.e. pressures at home or school). Exercise can help release pent-up stress. The child with NLD probably does not exercise as much or as often as his peer group, owing to balance and coordination problems. Discover a noncompetitive form of exercise he can participate in regularly (i.e. walking the dog or swimming laps).

Learn to Relax: A student with NLD probably has no idea what it feels like to be totally relaxed. She lives in a constant state of tension: wondering what will happen next, trying to remain balanced in her chair, worrying about being teased or ridiculed, trying to keep herself organized, etc. This child may need to be directly taught (through verbal instruction) the difference between being tense and being relaxed.

Establish a regular sleep schedule: Lack of quality sleep makes the body extremely vulnerable to stress. A child with NLD often has difficulty getting to sleep at night and/or staying asleep. Transitioning from a wakeful state to a sleeping state presents the same difficulties as other transitions in this child's life. If at all possible, establish a schedule where this child goes to bed at the same time every night -- including weekends and vacations -- and gets up at the same time each morning.

Laughter is good medicine: Laughter helps release stress. All too often the child with NLD is described as "the serious little professor" type. Because this child tends to be very literal, he may miss out on a lot of the humor in everyday situations. Point out amusing incidents and silly situations to him (verbally). You may not approve of your child spending time on school nights watching shows like "The Simpsons" or "Friends" every week, but if they're making him laugh, you should consider it therapeutic!

Schedule Time Out for Fun: Organization of time and place often pose a major problem for students with NLD during high school and college years (and beyond). Since this student is unable to visualize, she will have difficulty setting realistic goals and priorities. Such a student can get so bogged down with school work, she "forgets" to pursue other avenues of her life. It is important to help her seek a healthy balance between academic and social pursuits. Find an activity -- preferably something that can be done with others (playing a musical instrument, singing in a choir, attending sports events) -- which gives this child pleasure. Help her schedule time to participate in this activity regularly, without worrying about other things which may not get done.

Improve Dietary Choices: Dietary changes can actually help a child cope better with the stress he encounters. Eating a healthy diet (high in fiber, low in fat, with lots of fruits and vegetables) will make him stronger and more resilient! Junk food should be kept to a minimum. Also, consider eliminating caffeine (Mountain Dew, Coke, chocolate) from this child's diet. Caffeine is a stimulant and can actually cause sensitivity to stress. Caffeine consumption is known to cause panic attacks in some people.

Create a Support Network: Assign one case manager at school who will oversee this child's progress and assure that all of the school staff are implementing the necessary accommodations and modifications. Inservice training and orientation for all school staff, promoting patience, tolerance and acceptance, is a vital part of the overall plan for success. Everyone at school must be familiar with, and supportive of, this child's academic and social needs.

Change Self-Critical Thought Patterns: The child with NLD tends to put herself down a lot, to think of herself as worthless or ineffectual, to have trouble being assertive, to dislike herself or her life, and to generally criticize herself. These types of self-critical thought patterns can make it difficult to handle stress. Cognitive therapy can teach a child to reverse some of these thought patterns. Parents and teachers must encourage more positive thought patterns. Find something positive in every experience.

Learn Time Management and Organization Techniques: Stress accumulates when a child feels rushed and overwhelmed. Remember: He processes information slowly. Be sure you allow enough time for him to do the things you ask of him. This will help him better cope with the stress he encounters. Because this student lacks an internal structure for organization, it is important to provide him with an external structure for organization. Stress results from change. Strive to create predictable cycles in his life.

Curb Perfectionistic Tendencies: Probably because this child hones in on infinitesimal details, while failing to see the "whole picture," perfectionism is common among students with NLD. Because perfection in all endeavors of one's life is absolutely impossible, trying to be perfect can cause incredible anxiety for this child. Two techniques for decreasing perfectionistic tendencies are: 1) continually point out to this child the difference between "doing your best" and "being perfect," and 2) praise this child for every incremental accomplishment, everyday of the year, no matter how small it may be. If she is only able to progress partway toward a particular goal, consider it an achievement rather than a failure.

A number of organizations can help in finding information about, or a specialist to treat, anxiety disorders in your child. They include:

Copyright 1998 by Sue Thompson. The author retains all rights. Reproduction of this material is prohibited, other than for individual educational purposes, without the express written permission of the author. Distribution or sale of this material is strictly prohibited. If you wish to inquire about availability or arrange for a workshop, keynote presentation, or staff inservice training with Sue Thompson, please call (925) 944- 9765 and leave a message.

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