Understanding and Supporting the

Anxious Child

Allan Donsky MD

FRCPC Psychiatry

FRCPC Pediatrics

Clinical Assistant Professor, Department of Psychiatry, University of Calgary

Adjunct Professor, Department of Child and Youth Studies, Mount Royal University

Mountain Park

November 21, 2013

Learning Objectives

• What is anxiety ?

• Can Anxiety be “normal” ?

• How does it arise ?

• What does Anxiety look like ?

• What can I do about it ?

Birth-6 Months Loud noise, loss of physical support, rapid position changes, rapidly moving objects

7-12 Months Strangers, looming objects, sudden unexpected objects or unfamiliar people

1-5 Years Strangers, storms, animals, dark, separation from parents, loud noise, toilet, monsters, ghosts, insects, bodily harm

6-12 Years Supernatural beings, bodily injury, disease, burglars, staying alone, failure, criticism, punishment

Common Age Related Fears

What do children have to worry about ?

School Related Fears

• Separation from home • Bus • Performance anxiety • Academics • Interacting with peers or teachers • Bullied • Eating in front of others • Using the bathroom • Changing for gym

7

The most Challenging Decade in life

• Sex

• Money

• Future

• Identity

• Academics

• Independence

• Sexual Orientation

• Social Competence

General Principles

• Root word : Anxious, Anger, Anguish = Torment

• Anxiety can be a Symptom or a Disorder.

• Synonyms : apprehension, anguish, unease, concern, nervous, misgiving, qualm, disquiet, distress, dread , distraught, threatened, uneasiness, edgy, jittery, trepidation, timid, tense, uneasy, consternation,worry.

• Anxiety is apprehension, tension, or uneasiness from Anticipated danger.

• Anxiety has survival value

• Impairment or distress/suffering makes it a Disorder

10

The Spectrum of Fear and Anxiety in Children

Typical,

developmentally

appropriate

Severe

anxiety

symptoms

How common are Mental Health Disorders ?

Disorder Estimated Prevalence %

Any Anxiety Disorder 6.4

ADHD 4.8

Conduct Disorder 4.2

Any Depressive Disorder 3.5

Substance abuse 0.8

PDD 0.3

OCD 0.2

Any Eating Disorder 0.1

Tourette Syndrome 0.1

Schizophrenia 0.1

Bipolar <0.1

Any Disorder 14.3

Waddell, Offord et al Can J Psychiatry 2002;47(9):825-832

What about temperament ?

Arousal

Behavioral Inhibition

J Am Acad Child Adolesc Psychiatry. 1993 Jul;32(4):814-21.

How does Anxiety arise ?

Genetics

Temperament Environment

Family

•Insecure Attachment

•Modeling

•Stress

Media

School

Social

Trauma

Anxiety +/- Disorder

Psychological

Splitters and Clumpers

Response to Anxiety

• Fright ( Experience)

• Freeze ( “ Deer in headlights” )

• Flight (Avoidance )

• Fight ( Argue, Fuss, Oppositional )

• Faint (injury)

What might Anxiety look like ?

Physiological

Cognitive

Experiential

Behavioral

Physiological

• Somatic symptoms

• Mild Panic

• Recognizable as fight or flight

• Breathing

• Heart rate

• Muscle tension

• Tummy aches

• Sleep, nightmares

• Tired

Cognitive

• Worry is a defining feature

• Attention

• Concern about adult matters

• Catastrophic thinking

• Rigid

• Hard time letting go

• Struggle to make choices

• Unable to see success

• Negative view of self and others

Experiential

• Dread

• Sensitive

• Hyper-vigilant

• Low self worth

• Low self esteem

Behavioral

• Fight

• Flight ( avoidance)

• Freeze

• Repetitive actions

• Nail biting, licking lips, pull hair, chew clothing, pacing

• Obsessions (repetitive thoughts) or compulsions.

• Need for reassurance, help seeking , overdependence

Why is Anxiety missed ?

• Awareness

• Internalizing

• Silence is seen as absence of problem

• Tend to normalize shyness

• Labeled as other things ( very unhelpful !! )

Labeled as other things

• Oppositional

• Defiant

• Manipulative

• Attention

seeking

• Demanding

• Confrontational

• Sneaky

• Pushes buttons

•Lazy

•Avoidant

•Selfish

•Aggravating

•Annoying

•Ignorant

•Rude

•Stubborn

The real question: “What is going on ?”

So what if there is Anxiety?

Academic

Attendance , Avoidance , Underachievement

Behavioral

Avoidance , oppositional

Cognitive

No risks, confidence, image

Developmental

Image, success, confidence,

Emotional

Stunted

Family

Power struggles, tired

Physical

Gym avoidance

Social

Loneliness, tobacco & alcohol use

Common Beliefs About Worries: All untrue

Worrying:

• Motivates me

• Helps find solutions to problems

• Prevents negative outcomes

• Protects me from negative emotions

• Is a positive personality trait …it means I care

Francis, K. & Dugas, M. J. (2004). Assessing positive beliefs about worry: Validation of a structured interview. Personality and Individual Differences, 37, 405-415.

Pedal , Steer and Brake

What can I do to help ?

• Treat own Anxieties

• Get Educated

• Stop

• Criticism

• Rescuing” – Makes it worse

• Dismissing their experience

• Reassuring the wrong way ( “ Don’t worry”)

• Start

• Reassuring the right way ( “ You can handle this “)

• Bravery = Support activities in spite of Anxiety

• Encourage facing new situations

Are Feelings Real ?

“My feelings are real but they don’t always tell me the truth”

Relationship is everything

• Establish trust

• People don’t care how much you know till they know how much you care

• Be authentic …let them see your weaknesses

• Stay calm….even if you do not know what to do !

• Act as a coach, not solver

• Recognize patterns so they can be:

• Explored

• Explained

• Expanded

• Have proactive conversations

• Use student’s ideas first and then yours

How much do I push ?

Stress

Perf

orm

ance

Breaking point

Rage Lose it Meltdown Freak out Over-react

Peak

Push Back off

Life is Simple, not easy

Moments

Feelings

Actions

Helpful

Unhelpful ( F words)

Avoidance

Relief

“Pop ups”

Anxiety

•Education •Relaxation •Emotional vocabulary

•Coaching •Reality check •Evidence •Realistic & Constructive •Worry Thermometer •Mastery & Pleasure •Internal praise •Modeling •Social engineering •Exposure •Experiments •Problem Solving

Thoughts

Perfectionism

Excellence and “ Good Enough”

• Perfectionism is unattainable = set up for failure = never feel good enough = give up or burn out trying

• Need to be real

• Effort is most important

• Honor roll is 80 %

• No such thing as a mistake

• what is worst thing that can happen ?

• Celebrate “Not knowing”

• “Own it ,fix it , Show some learning “

• Self worth is not tied to achievement

Balancing Act for Adults

Gentle

Firm limits

Refrain from Criticism

Exposure

Courage/Bravery

Treat Parental Anxiety

Unified &

Consistent

Goldilocks

Educational

• Learning Disabilities

• Attentional issues can be secondary

• School Modifications

• Teacher/ Resource and Admin support

• Time out/Quiet place

• Bullying

• Academic load

• Homework issues

• Tutoring.

• Attendance

But I don’t have time to do this ?

Definition of Insanity……… Until you stop doing what is not working there is no space to do something different

Online Resources

American Academy of Child and Adolescent Psychiatry. Aacap.org Anxiety Disorders Association of America adaa.org AnxietyBC™. Anxietybc.com Canadian Paediatric Society. caringforkids.cps.ca/behaviour/fears.htm Chansky, T. (2004). Freeing your child from anxiety: Powerful, practical solutions to

overcome your child’s fears, worries, and phobias. New York: Broadway Books. Cheng, M. (2006). Selective mutism: A guide for teachers.

www.drcheng.ca/resources/Articles/selective_mutism-for_school.doc Cheng, Mi. (2009). Overcoming anxiety: A guide for families.

www.drcheng.ca/resources/Articles/anxiety_info_for_families.doc Garland, E.J. & Clark, S.L. (2000). Taming worry dragons: A manual for children, parents,,

and other coaches. Vancouver, BC: Children’s and Women’s Health Centre of British Columbia.

“What to do when you worry too much; A kids guide to overcoming Anxiety” Dawn Huebner

Counselling Recommendations

When Dr. Donsky presented to our staff, he recommended the following people for counselling services:

• Julie Brock – 220, 7370 Sierra Morena Blvd. SW 403-686-8379

• Dan Drybrough – Learning Solution 102, 7370 Sierra Morena Blvd. SW 403-685-0880

• Julie Robinson – Bonavista Medical Clinic 739 Lake Bonavista Drive SE 403-278-2434

• Leona Doig - 403–540-8773

• Doug Murdoch - 403–440-8536

** Dan Drybrough and Julie Robinson have come with high recommendations from our parents.