When a child’s anxieties take over

Giulia Cacciatore has personality, the kind that makes you want to be 13 again.

An honor roll student, she peppers her conversations with superlatives and wears her long blonde hair in a pony tail that sways when she moves. Giulia loves mashed potatoes, music — Coldplay, Bruno Mars and One Direction — and riding horses is her “favorite thing in the whole wide world.”

Listening to her, one would never imagine that just two years ago, she suffered from debilitating anxiety. Her fear of vomit and of becoming ill had resulted in extreme weight loss and weeks of missed school days. Her behaviors — including excessive hand washing that left her hands cracked and bleeding, refusing to eat food without checking an expiration date and hours of distress after the sight of vomit — frightened her parents.

Her mother, Micheline Cacciatore, had sought help from a psychologist with little change in Giulia’s behavior. Desperate, she did some research, and found the Child and Adolescent Mood and Anxiety Treatment (CAMAT) program, part of the University of Miami’s Department of Psychology. Against the advice of the psychologist who thought the program was too aggressive, she pursued treatment for Giulia.

The program, which focuses on groundbreaking research and treatment of anxiety and depression disorders in children and adolescents, uses intensive cognitive behavioral therapy (CBT), in which patients are gradually exposed to what they fear and overcome the fear in the process.

“Their whole lives are changed by being in contact with something they’ve been afraid of, and we’ve seen that repeatedly,’’ said Jill Ehrenreich May, Ph.D., director of CAMAT.

Like many parents who deal with a child’s anxiety, Cacciatore and her husband, Fabrizio, felt alone. They struggled to help Giulia, maintain a family life and raise their other child, son Luca, now 5.

“It sounds silly when you tell somebody, ‘My kid’s afraid of vomit and my life is completely upside down because of it.’ It sounds ridiculous, but it’s really real,” Micheline Cacciatore said.

While Giulia’s case was extreme, anxiety disorders are not only real, they are common, Ehrenreich May said.

“Anxiety disorders are pretty much the common cold of childhood mental illness,” she said. “They don’t get as much press as things like ADHD or autism, but they’re more common if you consider all anxiety disorders as a group.’’

Fear and anxiety are normal and instinctual in everyone, allowing us to protect ourselves from threats, she said. However, some children, including Giulia, are more prone to anxiety and anxiety disorders. Anxiety can turn into depression if left untreated, she said. In addition, compared with previous generations, Ehrenreich May said, “threat information” now follows kids everywhere, from computers and social media to cellphones and television.

“You have easy access to the idea that bad things can happen,” she said.

According to the National Institutes of Mental Health, a large national survey of adolescent health found that about 8 percent of teens 13-18 have an anxiety disorder, with symptoms appearing at around 6 years old. Of these teens, only 18 percent received mental health care. Brain imaging shows that children with anxiety disorders have atypical activity in specific areas of the brain, compared with people without the disorder.

Nevertheless, Ehrenreich May said, the types of anxiety therapists see hasn’t changed much.

The most common type of anxiety seen at CAMAT is generalized anxiety disorder — a high level of worry about specific issues — school, the future, performance, hurricanes, the state of the world and illness, among them. The second most common disorder therapists see is social anxiety disorder, which is often seen in children with ADHD, Asperger’s Syndrome and high-functioning autism.

“Kids who have ADHD … oftentimes get negative feedback from their social and academic environment and over time they become overly vigilant as a way of coping,” she said.

Many children with ADHD also have poor frustration tolerance, which can result in avoidance of situations, activities, anything that causes them anxiety, she said. Children on the autism spectrum are also prone to generalized anxiety and particularly social anxiety.

“They feel like they’re getting negative feedback, and they don’t understand why.”

While parents may first opt for traditional psychotherapy, experts including those from the National Institutes of Mental Health, say that in order to decrease symptoms, parents should seek treatment from psychotherapists trained in cognitive behavior therapy, who can also prescribe medication.

Cognitive behavioral therapy differs from traditional psychotherapy or “talk therapy’’ in that the focus is on the present, and is action-oriented in educating patients and parents about the disorder and ultimately exposing patients to what they fear.

Ehrenreich May said that whether medication or CBT is used, an essential part of treating anxiety is to stop the avoidance. Without addressing avoidance, a behavior may lessen or go away only to morph into other anxiety behaviors. Cognitive behavioral therapy helps kids develop coping skills that transfer later on, she said.

Despite the need for treating children, she said, a relatively small number of programs exist nationwide, primarily as part of research programs on college campuses. CAMAT, which opened in 2008, conducts research, and every child who receives treatment becomes part of that research, Ehrenreich May said.

There are also clinics at Florida International University, University of South Florida and University of Central Florida.

Micheline Cacciatore said she was fortunate to find help, and she and Giulia hope they can help others by sharing their story.

“Without them [CAMAT], I have no idea where we would be now,’’ Cacciatore said. “Not only did they give me back my daughter, but the parenting skills that I learned also helped us get our whole family back on track.’’

Giulia was always an anxious child, her mother said. Add to that a move to Miami from Massachusetts, bullying at a school she eventually left and food poisoning at a restaurant, and Giulia’s anxiety increased.

Her therapist at CAMAT, Erin Girio-Herrera, Ph.D, said Giulia’s case was tough, not just because of the particular phobia, but because she had become “highly avoidant,’’ vehemently refusing and resisting treatment.

“Initially when they told me what the treatment was going to be, I just felt like I was throwing her in a lion’s cage and she was either going to get eaten alive or come out of it. I knew we had to do it because nothing else was working,” Micheline Cacciatore said. “She was losing weight daily, and it was becoming dangerous.”

At 11, Giulia weighed 56 pounds. According to the Centers for Disease Control and Prevention, the median weight for an 11-year-old girl is 108 pounds. Now she weighs 85 pounds, a healthy weight for her height and size.

Micheline Cacciatore said Giulia’s previous psychologist had also used cognitive behavioral therapy. However, “she wasn’t doing it to the extent they do it at UM. They have patients every hour. They don’t have time for that. The symptoms never went away.”

Still, she said, “It was really hard to put all my trust in them, and we did almost drop out a couple of times.” Giulia’s pained reactions, crying for hours, were hard to bear. Some therapy sessions lasted all day.

“A lot of the parents of kids we work with are exhausted because they’re providing reassurance 24 hours a day,” Ehrenreich May said.

Micheline Cacciatore said she was one of them. “It was the only way we could get her out of the house or get to sleep. She would make us promise her over and over that she wouldn’t get sick.

“It was the hardest promise to make, because we knew it was an empty promise if she got sick. We learned the second day of therapy from Dr. Girio. No more [promises that she would not get sick].”

“What kids get a lot of is, ‘It's OK, you don’t need to worry. That’s never going to happen.’ If that was curative, I wouldn’t have a job,’’ Ehrenreich May said.

Girio-Herrera said the process begins relatively slowly, with psycho education “so she had some understanding of what’s happening in her body.” Then she began to trigger Giulia’s reactions.

Girio-Herrera had a staff person cough outside the door to the office. She “choked” on a sip of water, and coughed, then rolled a colorful pen across the table. Giulia caught it without thinking. Giulia had to touch surfaces in the bathrooms at CAMAT. She saw pictures and video of people gagging and vomiting.

Finally came exposure to the smelly vomitous mass. She and Girio-Herrera ultimately came up with a name for the object of her fear — Voldemort.

“At times when it was hard for her, I would say things like, ‘So are you going to let Voldemort win?’ ’’ Girio-Herrera said. “ ‘Can you be stronger and braver than Voldemort right now?’ Those kinds of things were helpful to her.”

“I remember the day I killed Voldemort. It was good,” said Giulia, now enjoying being a seventh-grader at Riviera School. She is considering becoming a therapist like Girio-Herrera.

“I keep telling her ‘You saved me,’ ” Giulia said of Girio-Herrera, “and she says ‘No, you did it.’ ”