overcoming anxiety information for families

Overcoming Anxiety

Information for Families

Dr. Michael Cheng,Dr. Michael Cheng, ChildrenChildren’’s Hospital of Eastern s Hospital of Eastern

Ontario (CHEO) Ontario (CHEO)

Except where otherwise noted, content is licensed under a Creative Commons Attribution – Non-Commercial License; images are royalty-free stock photos

ContentsContents

Overview of anxiety What is it What can we do about it Where can we get help

Case: Britney Identifying data

17-yo female referred for suicidal ideation Living with mother, a busy professional Parents separated since age 5; no contact

with father for years Gr. 12 student

Current resources Individual counselling (1:1 with her and a

counselor) for several weeks with no improvement

HPI Anxiety and depressed for past few months Precipitating stressor

Boyfriend (of past year) broke up with her Doesn’t like discussing emotional issues with her

mother

What is an Anxiety Disorder? What is an Anxiety Disorder?

We all get worried from time to time

But when you have so many worries that it gets in the way of life, we call it an Anxiety Condition (or Anxiety Disorder)

Main types of Anxiety Disorders Main types of Anxiety Disorders

Generalized anxiety disorder Separation anxiety disorder Panic disorder Obsessive compulsive

disorder Phobias Social (phobia) / social

anxiety Anxiety Disorder Not

Otherwise Specified

How common are anxiety How common are anxiety disordersdisorders

The most common emotional/ behavioral problem

6.5% of children/youth at any one time

I.e. in a classroom of 30, there are at least 1-3 people with anxiety conditions!

What Causes Anxiety?What Causes Anxiety?

Why …does my child

have anxiety?…do I have

anxiety?

Many contributing factors…Many contributing factors…

Family history / genetics Some people are wired to be more sensitive to

anxiety, e.g. ‘highly sensitive’ or ‘orchid’ children Stresses in life

Past or current stresses which lead a person to feel that 1) “the world is unsafe”, and/or 2) “I am not competent” E.g. abuse, trauma, bullying, separation/divorce,

relationship stresses, struggles with school, academics, etc…

Stigma and Mental Health Stigma and Mental Health ProblemsProblems

Because anxiety is a brain condition, people with anxiety look ‘normal’

Because they look ‘normal’, its often hard for other people to understand what its like for a person to have anxiety

Realize that anxiety is not the person’s fault; no one causes them to have anxiety, anymore than a person can cause themself to have a seizure disorder, diabetes or cancer

Why Do We Have Why Do We Have Anxiety?Anxiety?

Q. Where do you get your Q. Where do you get your food from?food from?

Where we get our food Where we get our food nowadays!nowadays!

Q. But where did people get Q. But where did people get their food 10,000 years ago?their food 10,000 years ago?

A. Hunting (or Gathering)!A. Hunting (or Gathering)!

To be a good hunter...

You need to be brave... You can’t be too anxious or scared because if you

were too scared, then you’d stay in your cave all day.

Q. But what would happen if you were too brave, with no fear at all?

Having no fear at all can get you into big trouble!

““Just enoughJust enough”” anxiety is good...! anxiety is good...!

Balance is the keyBalance is the key

Having just enough anxiety is the key Too little is not good Too much is not good The key is to have JUST ENOUGH

What happens in the What happens in the body during anxiety / body during anxiety /

stress?stress?

When a caveman is dealing with these dangers, the caveman can either

1) Take flight or 2) Fight

Nature gave human beings an Nature gave human beings an alarm to deal with dangers...alarm to deal with dangers...

Imagine a sabre tooth tiger jumps out at you!

Q. What are the TWO main choices you have to survive this? You can either ____ or ____?

BodyBody’’s alarm helps us deal with s alarm helps us deal with danger...danger...

Adrenaline (aka norepinephrine) causes: Eyes dilate (to see better) Heart pumps faster (more blood to muscles) Breathing increases (more oxygen) Stomach stops working (more blood for muscles) Sweating (to cool down body when muscles get going)

All this helps the person to either:Fight Take Flight

Why is anxiety so Why is anxiety so common nowadays?common nowadays?

Body’s alarm is good with episodic dangers E.g. being attacked by a wild

animal, followed by no stress once the danger is gone

Body’s alarm is not good with modern “dangers”, which might not be life threatening, but are constant and don’t go away E.g. school pressure E.g. social pressure

Q. Why are young children so happy and confident (compared to older children?)

A. Young children are happy/more confident because they are deeply connected (attached) to parents

ParentChild

Although children need strong attachments to parents, unfortunately what often happens to child-parent attachments as children grow older?

ParentChild

A. They weaken…

ParentChild

Q. If a child turns away from parents, who do they often turn to instead of parents?

ParentChild

A. Peers

Child Parent(s)

Peers

Dalai Lama, 1998; Neufeld, 2005

Negative behaviours

Technology / Consumerism

Who do youth talk to about mental health concerns? Faced with a mental health issue, a female youth is most likely to disclose to:

Friends/peers (46%) No one (31%) Family (11%) Professionals (2%)

Faced with a mental health issue, a male youth is most likely to disclose to: No one (48%) Friends/peers (32%) Family (10%) Professionals (1%)

In other words, youth with mental health issues are even more vulnerable to being disconnected from parents…

Youth Net, personal communication; Davidson, S., & Manion, I. G. (1996). Facing the challenge: Mental health and illness in Canadian youth. Psychology, Health & Medicine, 1(1), 41-56.

A. Turning to 1) peers, 2) things (“consumerism”), 3) negative behaviours is bad because…

They can never meet a child’s emotional/ attachment needs as well as only healthy parents can

Only parents can reliably provide emotional support, acceptance and validation

Especially with peers Friendships come and go Peers are still maturing and changing Your BFF one day can be your worst

enemy the next…

Even if peer orientation works out temporarily…

A child that turns to peers for their needs may be temporarily happy when things are going well with peers

But with peers, the attachment will always be insecure -- there will inevitably be some disappointment Best friend moves away; conflicts,

disagreements with friends Peer-oriented child will be insecure,

stressed, anxious child…

Attachments with peers can be healthy when…

Peers do not replace parents as the primary attachment Friends as secondary

attachments

Peers are mature By adulthood, peers will

hopefully be mature enough to be able to meet the attachment needs (that perhaps parents cannot provide)

Why do so many of today’s children/youth detach from parents?

Peer oriented culture Today’s television, movies, music promotes the view that parents are

incompetent, and that friends (and having things, i.e. consumerism) are the most important goal in life

Modern technology such as internet, cell phones, social media Studies confirm that while our media may help keep us more connected

superficially, for many people they damage deeper, more intimate connections, e.g. “Facebook Depression”

Violence Desensitizing effects of video game, but also internet, television and

movie violence has the effect of reducing empathy for others, but also causes anxiety by directly teaching one that the world is an unsafe place

Video games are bad

Research confirms video games are bad for Behaviour / mood /

relationships Physical health, sleep Empathy

Video games great for Desensitizing people to killing Creating children/youth who

lack empathy and see violence as a way of solving problems

American Academy of Paediatrics, Media Policy Statement

TV Violence Decades of studies confirms that TV

violence contributes to aggression Typical North American child watches 28-

hrs of TV per week, more time than is spent in school

Prior to age 4, young children cannot distinguish between reality and fantasy

Young children imitate aggressive acts Older youth see violent heroes as cool Violence is justified against your

‘opponents/enemies’ Media rarely shows non-violent conflict

resolution

American Academy of Child and Adolescent Psychiatry, http://www.aacap.org/cs/root/developmentor/the_impact_of_media_violence_on_children_and_adolescents_oppor

tunities_for_clinical_interventions

Evidence confirms that adult-child relationships are the key

Key component to preventing depression/suicide is positive social and emotional connections between Teens and supportive adults Teens and school Teens and community

If you have strong connections with adults, then peer connections are not as important (or unnecessary)

Teens with strong connections with adults, even if socially isolated from peers are still resistant to depression/suicide

Keith, 2012

What to do if you What to do if you suspect anxietysuspect anxiety

Start by seeing the family Start by seeing the family physician or paediatrician...physician or paediatrician...

Assessment Questions to learn more

about the problem and whether or not it really is anxiety

Seeing if any medical conditions contribute

Diagnosis Treatment plans

Attachment Strategies for

Anxiety


Ensure strong attachments and relationships with your child

Studies show that the strongest resiliency factor for mental health is strong connections between a parent and child

Humans are a social species Children are dependent on parents for survival The need to connect is hard-wired into all of us, and the

need to connect is important throughout the life span This need for connection or attachment is thus crucial for

Normal physical, cognitive and emotional development Happiness and contentment

How strongly does your child try to attach to you?

Does your child want to spend 1:1 time with you? Does your child want to be like you or have things in

common with you? Does your child try to be loyal to you and take your side? Does your child try to be useful or helpful to you? Does your child express love and affection to you? Does your child talk to you about feelings, and do you

provide 100% unconditional acceptance?Neufeld, 1991

How strongly do you try to attach to your child?

Does your child want to spend 1:1 time with you? Does your child want to be like you or have things in

common with you? Does your child try to be loyal to you and take your side? Does your child try to be useful or helpful to you? Does your child express love and affection to you? Does your child talk to you about feelings, and do you

provide 100% unconditional acceptance?Neufeld, 1991

Connecting through Empathy

Of the various modes that people can attach or connect to one another, the deepest mode is through empathy and validation…

Your close (female) friend / spouse tells you about the horrible day that she is having…

• Q. Most of the time, what does your (female) friend want you to do? 1) Give brilliant advice, 2) Listen and validate those feelings

Empathy and Validation • A core need that everyone has is to feel loved,

validated, appreciated, respected no matter what• No matter how good/bad you are• No matter how smart/dumb• No matter how pretty/ugly

• Secure, consistent caregivers can meet this need better than (insecure, inconsistent) peers • Empathize• Validate / Accept • Soothe

Listen for feelings, accept and validate (Connection before Direction)

SOOTHE “We’ll get through this…” “How can I support you?” “Do you want me to listen?” “Or do you want some advice?”

EMPATHIZE “I can see that you ’re feeling really sad about this…” (giving supportive hug)

VALIDATE/ACCEPT “That’s okay if you’re feeling sad…”

Avoid jumping to advice

“You’re feeling sad about that? Come on, there’s a lot worse things than that… You’ll get over it…”“You need to just get over this…”

If empathy and validation isn’t enough, then don’t forget soothing…

Q. What do young children do when overwhelmed?


Q. What do young children do when overwhelmed?

A. They cry


Q. What do we do when we see a young child crying?


Q. What do we do when we see a young child crying?

A. We give them a hug, and provide emotional reassurance until they are no longer crying.

Crying is important, but unfortunately, many anxious teens have learned not to cry, or not to turn to adults.

Thus, helping them feel safe enough to cry with a supportive adult is essential.

The most powerful self-regulation strategy…

Q. What do adults do when overwhelmed, e.g. when faced with a significant loss?

The most powerful self-regulation strategy…

Q. What do adults do when overwhelmed, e.g. faced with a significant loss?

A.We cry….

Crying research shows… Crying as attachment behaviour to elicit support“Recovery theory” Tears restore body’s homeostasis after stressAlmost everyone feels better after crying

How crying can make you healthier, The Independent, Nov 11, 2008

Be safe and validating so that your child is able to cry with you…

ParentChild

Emotions, tears/crying…

•Empathy, validation, soothing, reassurance •Leads to your child processing and integrating the stress, so that it is no longer a stress

Bridge all separations

Anxious children/youth, at a very deep level, are often fearful of separations Physical separations, such as when they are physically away

from a parent E.g. going to school, or even bedtime

Emotional separations, such as worrying about parents being upset or overwhelmed

One powerful strategy to help anxious children/youth feel connected is to ‘bridge the separation’

Neufeld, 1991

Q. You’re just had a great date with someone, and you want to see the other person again… What do you say?

–1) “I had a wonderful time. Bye!”, or

–2) “I had a wonderful time. Want to get together on the weekend?”

Whenever there is a separation, talk about the next reunion

• If you as an adult would feel insecure about a lack of bridging, then think how insecure a child would feel...!

• Children naturally feel more insecure because they are still forming their primary attachments with caregivers…

ChildAdult

Neufeld, 2005

Whenever there is a physical separation, talk about the next reunion

– Before your child leaves for school– Parent: “See you after school” “Can’t wait until

we go for our walk later after school” “I’ll be thinking about you all day”

– Text your child during the school day – Give your child transition objects, e.g. notes in

your child’s lunch box; special jewelry or possessions

– Before parent leaves for an errand– Parent: “See you in half an hour”

– Before bedtime: – “You’ll be in my dreams” “See you in the

morning” “What do you want for breakfast?”

Neufeld, 2005

Whenever there is an emotional separation, talk about the next reunion

– Parent: – “I’m really sorry, but you’ve been hitting your

sister.– “I’m very disappointed in your behaviour.”– “ This behaviour is unacceptable. You’re going

to have to go to your room.”– Bridge the separation

– “I’ll check on you in a few minutes”– “I love you, which is why we’re going to

talk about this later and work this out.”

Neufeld, 2005

When there is a reunion, ensure there is a greeting– When the child wakes up in the morning

– “Good morning!”– When child comes home after school

– “Hello!”– “I was thinking about you when I was at work

today”– When parent sees child after a longer than usual

absence– “I missed you so much” “I was thinking about

you”

Neufeld, 2005

The Power of Attachment Strategies

Many times, attachment strategies will be sufficient

But sometimes, it will not be enough… Nonetheless, having a good attachment

between parent-child will always make it easier for other treatment interventions to take place…

Classic Strategies for Anxiety


Get enough sleep!Get enough sleep!

Set a regular bedtime routine

Having a soothing routine Reading, relaxation music,

etc.

Remove stimulating things Remove televisions from

bedrooms!

Eat a healthy dietEat a healthy diet

Follow Health Canada food guide Breakfast Snack Lunch Snack Dinner

In particular Having enough carbohydrates Limit caffeine or stimulants

ExerciseExercise

Exercise has anti-anxiety effects

* Canadian Paediatric Society (CPS) recommends at least 1-hr daily

Martial Arts and YogaMartial Arts and Yoga

It is believed that yoga may be helpful for anxiety

Martial arts has been shown helpful for confidence / self-esteem

Ideally family classes to help with family bonding

Dealing with Dealing with Stress/AnxietyStress/Anxiety

Life is a balance between coping Life is a balance between coping and stress and stress

Demands / Stresses

Coping Ability

Life is a balance between coping Life is a balance between coping and stress and stress

Demands / Stresses

Coping Ability

Etc...

Physical Capacity

Academic Ability

Social Skills

Emotional Intelligence

Etc...

Physical Demands

Academic demands

Social Demands

Emotional Demands

Q. What happens when Q. What happens when demands/stresses >> coping? demands/stresses >> coping?

Demands / Expectations /Stresses

Coping Ability

The overwhelmed individual may have:The overwhelmed individual may have:

Physical complaints Headaches, stomach

aches, etc… Emotional, behavioural

problems “Stress” Depression, anxiety,

irritability, anger, etc..

Reduce Stress / Improve CopingReduce Stress / Improve Coping

Demands / Expectations /Stresses

Coping Ability

What the Person with Anxiety Can

Do


Tell an Adult that you need their support

Mom, can we talk sometime?

I’ve been feeling really stressed out.

Tell an Adult that you need their support

I’ve been really stressed with:

1) schoolwork2) people at school

3) My friends4) my brother/ sister

5) dad!

I love you, but when you do ______, it stresses

me out too!

I need you to listen and support me. I’ll let you know if I want

your advice.

0 1 2 3 4 5 6 7 8 9 10

How stressed are you?

Downloadable from www.drcheng.ca

How anxious / stressed are How anxious / stressed are you feeling?you feeling?

0 1 2 3 4 5 6 7 8 9 10



If you are feeling too stressed, If you are feeling too stressed, then focus on soothing and then focus on soothing and calming down first…calming down first…

0 1 2 3 4 5 6 7 8 9 10



If you are feeling not too If you are feeling not too stressed, that is a good time to stressed, that is a good time to try to problem-solve any try to problem-solve any stresses…stresses…

Dealing with problems and Dealing with problems and stresses: Problem-Solvingstresses: Problem-Solving

Whether or not stress caused the anxiety, it doesn’t help the situation

Dealing with stresses is always helpful

Typical School StressesTypical School Stresses

Teachers / academics / homework Friends / other students

Typical Home StressesTypical Home Stresses

Stress with Mom Dad Brothers Sisters Other relatives…

Problem-solving each stressProblem-solving each stress

Stress or stressful situation: _____________

What I want to see different (my goal) _____________

Things I can try to deal with this stress 1. _____________

2. _____________

3. _____________

Finally -- try out a strategy until you find one that works!

One common stress: One common stress: Disagreements or conflicts Disagreements or conflicts

with other peoplewith other people

Conflict / DisagreementsConflict / Disagreements

A situation where One person(s) wants and expects one set of things The other person(s) wants and expects a different set

of things Common Issues

Rules at home Friends Control Life values Money

Solving DisagreementsSolving Disagreements

What does each person want or expect? Is it reasonable what each person wants? What do people share in common? Negotiate and compromise!

Negotiation/CompromiseNegotiation/Compromise

Wishes or Expectations

What person A wants?

What person B wants?

Common Wishes or Expectations

What both person A and B want

CompromiseWhat person A is

willing to do or offerWhat person B is

willing to do or offer

Limits Be assertive* Be assertive*

*Parents may impose Limits and Consequences

Distraction and Distraction and Calming StrategiesCalming Strategies

Getting calmed down helps you feel better so that you can better

deal with the underlying issue

Take Deep Breaths(e.g. mindfulness meditation)

Move (e.g. go for a walk)

Imagine a Relaxing Place

Listen and/or Make Music

Have a Chill Out Zone

‘Changing the Channel’(i.e. Just Do Something

Different)

Change Your Thoughts, Change Your Thoughts, Change Your Feelings: Change Your Feelings:

CBT Strategies CBT Strategies

Introduction to Cognitive Introduction to Cognitive Behaviour Therapy (CBT)Behaviour Therapy (CBT)

Assuming that one already has good connections with the important people in one’s life, then CBT can be another useful strategy for anxiety

Parent is late

? Feelings

__________

__________

__________

You are waiting after school for your You are waiting after school for your parent to pick you up, but your parent is parent to pick you up, but your parent is late! How would you feel?late! How would you feel?

Parent is late

Event Feelings

Q. How come one event can lead to so Q. How come one event can lead to so many different feelings?many different feelings?

Parent is late

Events Events Thoughts Thoughts Feelings Feelings

Parent islate...


Parent islate...

Something bad has

happened!

How dare she be

late again!

Its just bad traffic – or

she’s getting me a gift...


Something bad has

happened!

How dare she be

late again!

Its just bad traffic – or

she’s getting me a gift...

Nothing bad has

happened before!

I’ll have more time to play

with the others.

I’m sure everything’s

just fine!

? Coping ThoughtNegative Thoughts

Events Thoughts Feelings

Events lead to Thoughts Thoughts lead to feelings

Worry thoughts lead to feeling worried Happy thoughts lead to feeling happy Angry thoughts lead to anger Coping thoughts / realistic thoughts lead to better

coping

Thus...Thus...

In order to feel good and cope Figure out what negative, or worry thoughts you

are having Replace those with more positive, helping or

coping thoughts

I know something bad has

happened!

I’m just going to chill and have fun with my friends!

Exposure hierarchy in CBT Exposure hierarchy in CBT

Life is like weightlifting – if there Life is like weightlifting – if there is too much weight, then do is too much weight, then do things step-by-stepthings step-by-step

Doing Things Step by Step Doing Things Step by Step

Presenting in front of yourself in a mirror

Presenting in front of a parent

Presenting in front of the teacher

Presenting in front of the teacher and a few classmates

Presenting in front of the teacher and the class

Counselling/Therapy Counselling/Therapy for Anxietyfor Anxiety

Therapy and Counseling Therapy and Counseling

Various types of therapy/counseling CBT Interpersonal Psychotherapy Attachment-based

approaches Types of therapists/counselors

Psychologists Social workers Certified counselors Physicians (psychiatrists,

family physicians with psychotherapy training)

Medications for Medications for Anxiety Anxiety

MedicationsMedications

For severe anxiety, or if non-medication strategies have not been helpful, then medications may be very helpful for anxiety


Generally affect serotonin in the brain

Examples Fluoxetine (Prozac) Sertraline (Zoloft) Fluvoxamine (Luvox) Citalopram (Celexa) Escitalopram (Cipralex) Clomipramine (Anafranil)


Although there were concerns about medications such as SSRIs being unsafe in children and youth, newer research confirms that they are safe and effective when used appropriately (Bridge, JAMA, 2007)

Getting Help in Ottawa for anxiety In a crisis

Child, Youth and Family Crisis Line of Eastern Ontario, Agencies offering counselling

Youth Services Bureau (age 12-18) Crossroads Children’s Centre (age 4-12) Family Services Centre / Catholic Family Services / Jewish Family Services

Therapists in Private Practice Psychologists (to find one, visit College of Psychologists Ontario or Ottawa

Academy of Psychology) Self-Help, Mutual Aid

Anxiety Disorders Association of Ontario Parent’s Lifeline of Eastern Ontario (PLEO) (for parents of a child/youth with

anxiety)

Looking for mental health help and information? eMentalHealth.ca

Mental health Services Programs Organizations Information sheets Screening tools News Events Research study

directory

SummarySummary

Overview of anxiety What is it What can we do about it Where can we get help

Thank you for Thank you for your attention!your attention!

Any questions?

Acknowledgements and Acknowledgements and LicenseLicense Thanks to all the children, youth, families, educators, and fellow

colleagues who have helped give feedback on these handouts! You are free to share and distribute as long as 1) these materials are

not used commercially, and 2) as long as materials are distributed in its entirety

If you are a non-profit organization / health professional, feel free to contact use about adapting these for your own use

Knowledge must be shared

Except where otherwise noted, content is licensed under a Creative Commons Attribution – Non-Commercial License

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