The Anxious 5 Year Old

13 May

 

Children in preschool and kindergarten are big believers in Santa Claus, the Tooth Fairy and the Easter Bunny. These beliefs are part of what gives this age group its charm and delight. But it requires some modifications in approach when it comes to helping them with anxiety–whether it is separating for school, a scary book, going to sleep or a doctor’s visit. Most books on helping anxious children are focused on elementary school-age children and universally advocate personifying anxiety with names such as the Worry Monster or a suitable name of the child’s invention. However, with kindergarten or preschool children, personifying the problem may backfire because they don’t have the necessary ability to separate themselves from their thoughts and realize that the “Worry Monster” is a convenient therapeutic strategy rather than a new thing to fret about. Children of this age are very concrete in the way they think and can’t categorize their thoughts at this point in their development.

The different ways in which young children view the world can be illustrated by a famous experiment done by the Swiss psychologist Jean Piaget. He presented children with two identical glasses of water and asked if them if the glasses contained the same amount of water or were different. If they agreed that the glasses were the same, then one glass was poured into a thinner but taller glass and the question was repeated. Very often at this age, the child will say that the glasses are different, and the taller one has more water. This is what consistently happens when I do this with the five-year-olds in my practice. They are not able to understand that a change in height is compensated by a change in width. This difficulty in integrating information has relevance for helping your anxious child.

For starters, it suggests focusing more on the immediacy of their experience, their big feelings, with a more descriptive approach. My daughter, Lesley Younis, a kindergarten teacher, gave me the following suggestions. “Rather than talk about anxiety, I would talk about those emergency feelings a child gets in his body. And I would make a simple distinction about anxious feelings between scared-scared and fun-scared. So reading a story about Hansel and Gretel might be fun-scared for most kindergarten children, but for several it would be scared-scared”. The vocabulary to talk about emotions is concrete and tied to the immediacy of their experience.

In this age group, pretend play is the primary way children make sense of their feelings. In pretend play in which, for instance, stuffed animals and toys can become a reflection or a stand- in for the child there are the possibilities for many playful interventions. A stuffed animal might be worried about going to school and then the child can help the bear go to school. For the child who won’t put on a coat to leave the house, a parent can have the coat talk to the child and explain how it wants to go on walks with her. The anxious feelings are more displaced onto another person or object rather than becoming a personified being. The displacement of feeling is more general and less specific than when older children begin talking about the worry monster, and is more useful for this younger age group.

copyright@edward h plimpton

How much to push your anxious child?

7 Apr

How much should I push my anxious child? This is a puzzle all parents face with children, especially those with an anxious bent. The challenge is how to help them face their fears in a way that truly promotes the learning experience of “I can do it”. Push too hard and the child will dig in her heels or melt down. But if the nudging is too gentle or inconsistent nothing will change. To complicate matters, often parents find themselves on opposite sides of this issue, so that one is the tough guy and the other is permissive, with tension resulting between the parents. Additionally, sometimes the parents are pushing out of their frustration rather than out of a thoughtful consideration of what the child needs.

There are three parts to figuring out this problem on how much to push. First, begin with developing a mutual understanding with your child about the nature of the problem and what needs to happen. This is a whole topic by itself, but it merits a brief mention here. There always needs to be a reason for doing something difficult and of course it is better if it is the child’s reason rather than yours. But that isn’t always possible, so that sometimes simply we need to say something  like “children have to go to school”.  Next, there also needs to be some mutual understanding about the nature of the problem, such as “this is anxiety, that is the worry monster talking, that is a false alarm”. These two elements provide a basic foundation from which to proceed.

Second, in thinking about how much to challenge your child, we need to determine at any particular moment where your child is on the arousal/anxiety scale, because this will determine what type of input she will be able to respond to. A child in the middle of a panic attack, or a child coming off the playing field in tears, needs calming down and will not be receptive to advice. So we first need to make note of the anxiety level in your child, which involves not only what she says, but  more importantly any nonverbal behavior suggesting she is in a frozen/inhibited state. In general, we tend to err more on underestimating how anxious children are. At the same time, childhood is a time of big feelings, and there is not always a one to one relationship between the intensity of expression and the capacity to deal with it. Many young children protest mightily at being dropped off to school and then quickly come around once the parent leaves and the school day has started. Sometimes the protest is out of “habit” and does not represent an emotional freeze state. So it is not always easy determining the anxiety level in your child.

Third, the idea of taking small steps to tackle problems big and small is common sense. The ability to think incrementally, breaking problems down into smaller steps is characteristic of good teaching in any domain. A first step can simply be formulating a sequence of brave steps, a fear ladder, with as much collaboration with the child as possible. We can never really know what the next steps will be for your child; actually we can only make an educated guess. Therefore, it is best to phrase the challenges as experiments and use invitational language. “Would you be willing to pick up the plastic spider or look at a picture of one?”  The next step is guided by the child’s response. Imposing a challenge or exposure on a child generally doesn’t work well, although sometimes  it can’t be avoided. But the best result is obtained when the child is given choices and determines the next step. This process can be slow but if your child is actively making brave challenges you are moving in the right direction.

copyright 2109@Edward H. Plimpton, PhD

The first three things to do when you have an anxious child

5 Nov

Where do you begin when you have an anxious child whose head is filled with thoughts such as, “Am I going to die?” or “Am I going to hurt you? Obviously, the first step is to get a complete picture of what is going on with your child with a professional consultation. But for discussion’s sake, let’s assume that the basic problem is what we might term “an overactive alarm bell.” Be warned: anxiety can be a stubborn creature, so dealing with it can take a lot of work and persistence. Anxious children can become quite negative when you start to do things differently, so it is important that you and your child learn something about how worry operates. Here are the first three things you need to help your anxious child.
First, anxiety narrows our perspective and how we see the world, so we need to get distance by labeling and personifying the problem with names such as “the worry monster,” “brain bug,” or “Mr. Worry.” It is best if your child can come up with his/her own name for worry. It may seem that these names are silly, but doing this is actually an important step for the child in getting some psychological distance from these ever present concerns. The book You’ve Got Dragons by Kathryn Cave can be helpful in conveying this point to elementary school age children.
Second, we need to get out of the reassurance trap. Our natural inclination as parents is to provide reassurance—arguably, it is perhaps what we do best. Unfortunately, all of the reassurance we give our anxious children does not really help, and in fact it actually makes the anxiety worse, since it gives the fears a measure of credibility. Easing away from giving reassurance requires a thoughtful plan, and a way to explain the change to your child. Otherwise, he or she will simply freak out. Simple interventions can involve “putting worry on a diet” by only allowing so many worry questions a day, or making worry wait 10 minutes before answering questions. It is important to emphasize that the child really needs to understand the rational for the intervention, since this way of responding is so different from how parents and children normally communicate.
Third, these initial efforts must be supported by communications that first connect with how the child is feeling, and then redirect him/her. I call these “ two-part sentences.” Examples might be: “This is a scary thought, sounds like a worry monster question,” or “I can see you are worried, let’s play catch for a bit.” And there are many variations of these types of statements which first connect with how the child is feeling and then try to help him/her get off the worry channel.
Remember that anxiety is quite persistent, so it is important to really understand how worry works. Your child is really hoping for some magic cure, and may be quick to say that nothing is working, so you both need to understand that conquering worry does not happen overnight. In addition to my blog and podcast there are a number of helpful books that clarify the process of dealing with anxiety, I like Lawrence Cohen’s The Opposite of Worry, Reid Wilson and Lynn Lyons’ Anxious Parents, Anxious Kids, Dawn Huebner’s What to Do When You Worry too Much or What to Do When Your Brain Gets Stuck, and the online program GoZen.com. So these are first step., Next will be helping your child begin to face his/her fears.
copyright@Edward H. Plimpton

Fear of Throwing Up: Emetophobia-suggestions for school

5 Nov

1. If the child does not feel you understand how hard and scary it is to have this fear, he/she will not listen to anything else you have to say. This fear can be extremely distracting for those children struggling with it and it definitely feels very real to them. So we want to validate the feeling, even if we don’t agree with the child about what to do about it.
2. Unfortunately, answering the constant reassurance seeking questions such as “Do you think I am going to throw up?” provides only momentary relief at best. And likewise, frequent phone calls home are not typically helpful. But to wean the child off this reassurance seeking, incremental steps are needed. Otherwise all you will get is unproductive panic. So in the classroom a manageable first step might be that when the child asks to go the nurse, a teacher could say, “Would you consider waiting 10 minutes to see if this feeling goes away, and pretend to put your worries into this stress ball while you are waiting.” The language needs to clearly communicate to the child that this is a choice. The hope is that by not leaving immediately for the school nurse’s office, the child might give the fears a chance to dissipate. Likewise, if frequent phone calls to home are occurring, it is important to work on cutting them down, perhaps by starting with putting a limit on the amount of phone calls during the school day.
3. A distinction can be made between a “sick stomach” and an “anxious stomach.” A “sick stomach” is an indication of a flu or bad food, whereas an “anxious stomach” is the result of some stress or worry. The problem is that both types of stomachs feel pretty much the same and they certainly grab the child’s attention. The solution is not to focus on the unpleasant sensation, which typically amplifies the discomfort. On a boat or in a car, when you feel nausea, the common suggestion is to look at the horizon. In doing this, turn the focus away from the sensation and onto your surroundings. In a similar manner, we want to enlist the child in thinking about the context in which the stomach discomfort developed. Of course, the school nurse has to make a determination about whether the child might have a “sick stomach.” But if it seems more like an “anxious stomach,” the nurse might ask questions such as “when did your stomach begin to freak out?” or “has there been any point today where you were feeling better?” or “I wonder what was going on when you decided you needed to come see me.” Although it is a challenging endeavor for children, we want to help them see a connection between their reactive stomach and the various stresses that they encounter every day.
4. Basic concepts caregivers need to know to deal with Emetophobia include: problem with reassurance (see Reid Wilson and Lynn Lyons, Anxious Parents, Anxious Kids), what I term a two part sentence or connect and redirect (in Siegel and Bryson, The Whole-Brain Child, personifying worry, covered in all books on anxiety, distinction between anxious stomach and sick stomach, capacity to think in incremental terms, and of course creative ways of facing the fear. And of course these topics are covered in my blog and podcast: edwardplimpton.com and on itunes “Your Anxious Child: 5 minute solutions”.

Feeling stuck with your anxious child? Consider the importance of movement in anxiety

24 May

If your child is anxious, it is natural to ask them what they are afraid of and to encourage them to talk about it. In the normal course of events, these conversations are usually helpful, but words don’t always work, even with very verbal children. The verbal reassurance that seems so natural to provide your anxious child often leads to an endless stream of “but what if…”.  Fortunately, there are strategies for getting out of the reassurance trap, which I have discussed in other essays. Unfortunately, purely verbal solutions can be of limited effectiveness in at least two situations. First, a child in full panic or meltdown mode is not going to be able to listen to reason. That part of their brain has gone off line. Second, often children can’t articulate what they are afraid of, saying “I don’t know, I just am,” and while sometimes it reflects the limitations of being very young, it can also reflect the nonspecific nature of their anxiety as an uncomfortable body sensation. It is more of a “not right feeling” or bodily arousal that doesn’t seemed clearly connected to any particular concern.

The ways in which anxiety can be manifested in movement span quite a range. There is the rapid, shallow breathing of a panic attack. Then there is the frozen or immobilized child who will not get out of the car to go school or the dentist’s office. Or perhaps, he starts hitting the doctor or you because he is about to get a shot. Fun time–right?  More generally, one way of viewing trauma is as an event in which a person cannot perform some self-protective action, either because it happens too quickly or because the person encounters an overwhelming force. Then, to add a layer of complexity, some children have over-sensitivities in which their “fight, flight or freeze” response gets triggered very easily. The sensory input they are receiving from the world is just too much for them.   There is a hypothesis that these sensitivities are the result of the child  not having  integrated some of the primitive reflexes he was born with into the more complex functioning that occurs with development.

Being very helpless creatures at birth, we are fortunately born with a set of reflexes to provide a set of automatic responses to ensure our survival. Commonly known reflexes are the sucking reflex to ensure feeding, the ever endearing palmer grasp where a baby holds onto your finger, and the startle or Moro reflex. There are many more reflexes which in varying time tables should be inhibited as the brain rapidly develops in the first two years of life. Some of these reflexes are essentially emergency self-protective responses to danger, in particular the Moro reflex which provides a way for the infant to hold on to a parent so it doesn’t fall or get dropped. Problems occur when these reflexes do not become integrated or inhibited as the child develops. Suggestive of such problems are children who do not fully crawl before walking, toe walking, excessively slouched noodle-like posture during homework or sitting at the table, and being excessively clumsy or uncoordinated. Essentially, these children are having their “fight, flight freeze” response triggered automatically on a daily basis, so they are constantly on edge or just more reactive to their world.

So if your child is not responding sufficiently to verbally oriented therapy, consider looking at her movement and posture. Sensory-Integration therapy, yoga, and a variety of neurodevelopmental movement programs may lead to some further progess.

The Bipolar Child and Anxiety

27 Mar

 

Anxiety is often the first symptom that is clearly identified in children who have bipolar illness. It might be intense separation anxiety, OCD type behaviors, or frightening dreams, to name a few possible symptoms.  But in bipolar disorder the mood instability adds an additional layer of complexity and intensity. This is not an easy diagnosis to make.  There is controversy surrounding this diagnosis, which keeps company with other disorders, to add to the confusion. The term bipolar refers to a disruption in the regulation of moods, so that rather than maintaining a relative steady state, the child swings between periods of depression and periods of mania or elation. And sometimes children are in a mixed state that contains elements of depression and mania, where a pronounced irritability might be seen. Suicidal ideation and hypersexuality can also be part of the picture.  This condition is viewed as primarily a biologically based disorder with a strong genetic component.

There are some distinctive features in the experience of anxiety for a child who has to struggle with a mood disorder. What powers the child’s   experience of anxiety is the sheer intensity with which they experience their moods; they seem to have no serviceable “ brakes”, or feel that there is any control over mood. It is the internal experience of intensely fluctuating moods that produces the feeling of danger and lack of safety. But there is more. This intensity also comes with disturbing images. Many children with bipolar illness have truly horrendous nightmares. While all children will have a nightmare on occasion, they usually wake up before the robber enters the room.  For a bipolar child, however, it doesn’t stop there. The dream unfolds in the worst graphic detail. And the vividness of the dream may continue to preoccupy the child during the day, and then he/she may dread going to bed lest another similar dream occurs. The intensity of moods can create hallucinations and other impairments in reality testing.   A good description of having bipolar disorder as a child can be found in Intense Minds: Through the Eyes of Young People with Bipolar Disorder by Tracy Anglada, whom I also interviewed for my iTunes podcast,  “Your Anxious Child: 5 Minute Solutions”.

Although the experience of anxiety is pervasive in bipolar disorder, the treatment priorities are different from the standard treatment of anxiety. In the standard treatment of anxiety, priority is placed, as in cognitive behavior therapy, on facing the fear and decreasing avoidance. Medication plays a secondary role in treatment of the more standard anxiety disorders, turning down the intensity of anxiety when necessary so that the child can participate in therapy.  In bipolar disorder, medication management of moods is the first priority of treatment, and this is a situation where a child psychiatrist is the key player. Psychological interventions will center more on helping the child maintain contact with reality and creating a sense of safety. These are children who may, while awake or asleep, see scary images that are not there.  Thus, stabilization is often the first priority. This is not to say that we don’t help the child with bipolar disorder learn that he can be upstairs without a parent or talk back to that scary image in the closet or draw that scary dream and potentially change it. But we need a certain stability in moods as a platform to tackle these various worries. These children really benefit from a team approach that can address their diverse needs. They often have pronounced sensory issues which may benefit from sensory-integration therapy. There may be problems in executive functioning that require attention in school. Bipolar disorder is a complex disorder that requires a careful diagnosis, and while anxiety is very prevalent it is not the core feature.

Performance Anxiety

29 Dec

Your aspiring athlete or musician has become increasingly anxious before some competition or performance. If you have an anxious child, this is not necessarily a surprising turn of events. It is the anxious brain at work, always ready to imagine the worst case scenario. And yet, the activities your child is involved in can be so important in developing a sense of competence, learning healthy habits, developing self-discipline, and making friends. So what is the thing to do when your child develops performance anxiety? There are four considerations.

First, there is a question of whether adults have been creating the problem. Parents can be guilty of living vicariously through their children and placing way too much interest in the outcome of an event. Children want to please their parents, so they are especially vulnerable to this pressure. Coaches all too frequently operate under the mistaken belief that being critical and tough fosters competitive excellence. A good coach certainly brings out the best in his or her team, but the prerequisite is creating a climate in which it is safe to make mistakes.  Only when children feel safe to make mistakes can they get the feedback that will enable them to improve and reach their potential.  Unfortunately, many coaches believe that belittling the athlete will motivate him or her, when in fact it only leads to discouragement and anxiety.

Second, for any number of reasons, your child may be overly focused on winning. This is understandable, but counter-productive. In part, one of the benefits in pursuing a sport or musical skill is that it teaches the child focus and concentration skills. Along the way, your child has to learn to tolerate the tension that is inherent in most performance situations. Breathing and visualization skills can be very helpful to children in learning to focus on the here and now of doing their sport, rather than getting ahead of themselves and thinking about winning.

Third, if the performance problem is chronic in nature, consider the possibility that it is the product of an injury, such as falling off a balance beam, or an adverse event such as being criticized by a coach in front of the entire team. A child may have recovered from the physical part of the injury, but psychologically he may still be affected. Trauma occurs when you can’t protect yourself–you fall off the balance beam and you can’t stop your fall, or the coach is berating you and you don’t feel you can say anything. While your child may be able to put this problem into words, she is basically not feeling safe in her performance-related activity. When the more psychological aspects of this injury or trauma is addressed, the problem can be resolved.

Finally, it may be that what appears to be performance anxiety may actually be the manifestation of another problem. A child with separation anxiety might be afraid to participate in a sport because it involves being away from a parent. OCD can also interfere with a performance when obsessions get attached to some aspect of the activity, e.g., “I can’t play golf because my clubs are dirty.” The problem, again, is not the performance, but rather another form of anxiety that gets attached to the activity. Part of the solution in both of these situations is helping the child view these activities as so important and valuable that it is worthwhile to struggle through the discomfort. Having compelling goal is very important in dealing with all forms of anxiety.

The skills learned in dealing with the performance anxiety your child has about participating in a swim meet or a chorus production can be invaluable lessons which will help in all aspects of life.

(For more information on Performance issues see my interview with Dr. Alan Goldberg on my iTunes podcast “Your Anxious Child: 5 minute solutions”)

copyright@Edward H. Plimpton, PhD