Chloe McGovern was referred to the pediatric headache clinic at a children’s hospital in a metropolitan area. Chloe was a 13-year-old, eighth-grade student with tension headaches of moderate intensity. The headaches began approximately 18 months ago and have gradually worsened, especially over the past 6 months. These headaches occurred approximately three times per week, with a duration of approximately one to three hours each. Over-the-counter medications (e.g., acetaminophen, ibuprofen) are generally effective in shortening their duration, but Chloe’s parents are worried given the headaches’ increasing frequency and severity.
A neurological examination revealed no apparent structural or functional abnormalities of Chloe’s nervous system. She appeared to be perfect except for her headaches. Consequently, Chloe and her family were referred to a pediatric psychologist at the clinic to explore psychosocial causes for her problem.
The psychologist, Dr. Witten, learned that the onset of Chloe’s headaches coincided with her transition to middle school. Chloe’s mother explained, “Chloe’s always been a perfectionist. She was in accelerated programs throughout elementary school: math, language arts, music. When she started middle school, she tested into the gifted program, meaning that she could skip seventh-grade classes and begin immediately to eighth-grade work for most subjects.” Her father added, “And she’s also a very good musician. They asked her to play for both the seventh- and eighth-grade orchestras. She plays the oboe, which is somewhat rare. Both orchestras needed her.”
Dr. Witten looked up from her notes, “And is all this work hard to manage, Chloe? I mean, you essentially skipped the seventh grade.”
Chloe answered, “Not really.” Then crossed her arms and remained silent.
Chloe’s mother elaborated, “Chloe’s a really hard worker. I drive her to school each morning a little early because she’s on the student council. She tries to do as much homework as possible during study hall. Then, after school, she has orchestra or archery practice. She also takes private oboe lessons twice a week.”
“That seems like a busy schedule,” commented Dr. Witten. Chloe remained silent.
Later, Dr. Witten interviewed Chloe privately. She said, “ Chloe, I know that you’re a good musician. I wonder if you’re a good artist, too. I want you to draw me a picture of yourself just when your headache is about to begin. Draw how you feel.” Reluctantly, Chloe sketched the image of a teenage girl with taut shoulders, stiff neck, bulging forehead and eyes, and a worried expression on her face. Dr. Witten responded, “That’s a really good picture. The girl looks so tense! I wonder what’s going through her mind right now.” Dr. Witten drew a bubble above the image of the girl and then asked, “Write some words that describe what she’s thinking.”
Chloe hesitated, reached for the pencil, paused again and then began writing. The words flowed from her, like water breaking through an old dam that was no longer able to bear the strain: math test, language arts presentation, student council service project, science fair, string ensemble, dad’s cholesterol, mom’s work schedule, friends, another headache, getting enough sleep, grandma’s sick . . .
“Do you think about these things before you have a headache?” asked Dr. Witten.
Chloe looked up from the paper, then answered, “I think about these things all of the time. There’s always something going on in my life, something to worry about. I tell myself, ‘Relax. Nobody else worries about things like you do.’ But it doesn’t do any good. I feel tense all the time. I can’t control it. It’s the worst at night before I fall asleep. All the things I need to do and should have done come to my mind and they don’t stop.”
Dr. Witten responded, “All the things that you’re good at, like school and music?”
“Right,” Chloe sighed. As a tear trickled down her cheek, she added, “That’s just it. I think that if I didn’t worry so much, you know—make sure I’ve planned for everything, I might not get good grades, or do well in my ensembles, or let my parents down.”
Pointing to her head, Dr. Witten replied, “You carry all this pressure up here.” Your problem is not the headaches, though—it’s that you think too much! I’d like to work with you to find a way to stop all that worrying. Would you like that?”
For the first time in a long time, Chloe smiled.
Discussion Questions:
- What DSM-5 anxiety (or associated) disorder best describes Chloe’s behavior?
- How does Chloe meet DSM-5 criteria for this disorder?
- When do problems with worrying tend to emerge? Is Chloe’s age on onset developmentally atypical?
- Chloe seems to worry about mundane things: school, extracurricular activities, family. How does the worrying of children with anxiety disorders differ from the worrying of typically developing children?
- Chloe seems to be a high-achieving girl who is rather mature for her age. Is this typical of children with anxiety disorders?
- Based on the results of longitudinal studies, what disorder is Chloe at particular risk for developing as she enters later adolescence and early adulthood?
- How can cognitive avoidance theory be used to explain Chloe’s problem with chronic worrying?
- If you were Chloe’s clinician, what evidence-based psychotherapies or pharmacological interventions might you recommend? Discuss the Child/Adolescent Anxiety Multimodal Study. Discuss medication management for anxiety in children and adolescents. You must use the Klykylo book to discuss medications. Outside sources not acceptable.
