By Pamela P. Siller, MD

For as long as she could remember, Debbie felt different from her friends. On Shabbos, she always felt that her dresses were too short, or too long, or too casual, or too fancy. She tried very hard to fit in, but nothing seemed to work. The other kids didn't make fun of her…exactly. They just…talked, but Debbie understood what they meant. When she tried to discuss this with her parents, they shrugged it off. They told her to just "ignore the other kids."

Debbie tried really hard to forget about fitting in, but it became all she could think about. When she attempted to fall asleep at night, she just tossed and turned, trying hard not to worry about the next day at school. Would the other kids make fun of her? Would her shoes and jewelry look right? Would she say the wrong thing? If she did not get invited to a party, would her parents be mad? Disappointed? Would her sisters and brothers tease her? She awoke tired and irritable. She could never stop these thoughts from turning around and around in her mind.

Debbie decided to take matters into her own hands. She stopped wearing jewelry, and refused to change her uniform for school. That way she did not need to worry about being made fun of for the way she dressed…she just would not wear clean clothing. By doing so, she would also make sure that she did not get invited anywhere, thereby eliminating her anxiety over rejection.

Nevertheless, this strategy did not work. Her anxiety could not be contained, and her frustrations grew. She became rude, angry, and even began cursing, to the horror and chagrin of her family. She stole things from desks - little things, like colored pens and notebooks. She laughed when their owners became enraged. When called upon by teachers, she did not reply, or purposely gave wrong answers. She tried everything she could to stop the nagging anxiety that would not leave her brain. Nothing helped. She still could not sleep, nor could she stop the merry-go-round of thoughts in her head.

Her parents and teacher noticed this change. First they appeared concerned, but this quickly gave way to anger. This was fine with Debbie. It matched her own anger, and their confusion mirrored her own. The situation quickly spiraled downward.

Eventually, Debbie began hitting other kids and locked herself in her room, refusing to go to school. That was the final straw. Her parents made an appointment for Debbie with a psychiatrist.

During the initial evaluation, both of Debbie's parents were asked to accompany her. Each one was seen separately and then together. Some of the questions asked did not make sense to Debbie's parents, but they came as a relief to Debbie. She had previously been asked why she stole, swore, didn't bathe, and lashed out. She could not answer because she simply did not know.

However, this doctor started at the beginning. "When was the last time that you remember being happy? If you could have anything in the world, what would it be?" At first, Debbie refused to admit her fears or anxieties. But the doctor seemed to understand, to sympathize with her anger, and appreciate her pain.

Initially, the doctor recommended that she come weekly just to talk. She was also asked to take a medication for anxiety and sadness, such as Prozac, an SSRI (Selective Serotonin Reuptake Inhibitor). This came as a surprise to her parents, who were unaware of her underlying anxiety, which led to her sadness and depression.

Debbie is not alone. Often, a person will act out for many different reasons, which they themselves may not understand. Often, an individual will stop performing normally in the hopes that by doing so their worries will be alleviated. They deflect and displace their feelings of anxiety and fear, and build up a figurative wall for protection.

Unfortunately, children, adolescents, and many adults are unable to articulate their feelings of loneliness and inferiority. Obsessive thoughts, which frequently prevent sleep, are often a result of anxiety. These can intensify feelings of emotional isolation, eventually leading to acting out behaviors which can be a cry for help. This often succeeds in obtaining negative attention, but it does not lead to the understanding that is craved. This can eventually result in depression.

If you notice a negative change in a loved one's behavior, it is important not to ignore it, as it may be a sign of distress. Help is obtainable in different forms. Therapy can lead to an increased understanding of a sense of self, as well as teach tools and coping strategies that can be applied in many different situations. However, this is not an immediate fix. A trusting relationship needs to be formed between all parties, and the origin of the pain often needs to be uncovered. Nevertheless, therapy is a priceless investment.

Medications are used when the patient's symptoms are causing impairment in functioning and urgent relief is needed. Medications for anxiety and depression, such as SSRIs (Prozac, Celexa, Lexapro, Paxil, and Zoloft) are generally well tolerated, and lead to fairly consistent relief of symptoms. Some are FDA approved for use in children.

Every person, young and old, goes through stress in life which can cause emotional distress. Sometimes one's coping strategies may not be sufficient, possibly leading to acting out behaviors. At times, these can manifest as aggression, agitation, irritability, or depression. It is important to recognize the pain and the person behind these behaviors and help them to receive help to relieve their anguish, in whatever form it may take.