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One step at a time-thinking incrementally

14 Jul

The Incremental Mindset


I share with you the desire to help your child overcome the anxiety that is so much interfering with his or her life. It is hard to be patient when you can see your child in the grip of something that really does not make sense. Understandably, most parents respond to their child’s discomfort with reassurance. It is a natural parental response. Unfortunately, when you are in the “land of anxiety,” no amount of reassurance seems to work, and your child seems like a bottomless pit. So we need some different medicine, and this takes the form of finding a way to face the fear.


There is a delicate balance between pushing your child to confront her fears versus letting her do things at her own pace. Because avoidance behaviors are so reinforcing—they really do provide some short-term relief–chances are that things will get worse, not better, if a child is consistently allowed to avoid anxiety. Avoidance, in fact, actually makes people more afraid in the long run, and becomes a sort of addiction.


As I said, the cure for the anxiety is going to involve finding a way to face the fear, rather than avoid it. However, this needs to be approached carefully. We want your child to master his fears, not be overwhelmed by the interventions that are designed to help him. In most cases, what we need to do is to start with very modest projects and build from there. A very common mistake is to forget to start small. Thinking in incremental steps sounds simple but “impatience” and “frustration” gets in the way potentially for both parent and child. That is in the eagerness to resolve the problem we can get impatient and ask the child to do more than he is ready for or the child may similarily gets impatient . There is also a tendency to devalue the importance of incremental steps by either adults or the child with a comment along the lines of “…but he (I) still can’t…” But that is obviously a mistake for it takes the spotlight away the small successes that can provide hope and encouragement.


At this point, we need to clearly identify the building blocks that each child needs in order to be able to confront fear. Typically it is helpful to make a hierarchical list of the steps it will take to confront a fear or a “fear ladder”. A fear of dogs might begin with looking at pictures or movies of dogs, then observing them outside at a distance and then gradually move closer.  In addition, having a  “feeling thermeter” is important tool in adjusting the pace.   It takes some thought and patience to break a problem down into manageable incremental steps. It is bit like the game of pick-up sticks where you are looking for next stick to take that won’t rattle the pile.  The range of possibilities can vary dramatically from child to child. For some children, just having a clear rationale of what we are doing and why is sufficient. But if we can clearly outline the steps to take, then the journey becomes more tolerable and we can focus on the child’s small victories along the way.

Child meeting therapist for first time-or actually doing anything new

14 Jul

First Session

I am looking forward to meeting your child next week, but don’t be surprised if the reaction you get from your child is, “No way, I am not going!” As I said in our meeting, I think it is important to remember that for any anxious child, any new situation can be especially challenging and that include seeing a doctor who specializes in worries. I think it is helpful to view their brains as having an overactive alarm system that just sends out a lot of false alarms. So I do not think we should be surprised if he does not want to speak, appears to be velcroed to your side and puts his mouth on your ear to whisper. Going anywhere new and meeting anyone new can be scary. The older child may simply hide behind impossibly vague statements or feign a vaguely coma-like state, or get irritable and ask when he is going home. These are simply the ways in which the child shows the new situations get the alarms bells ringing or more technically activate the sympathetic nervous system. However, an informal rule of thumb is that anxiety waves typically last 15-20 minutes. So I do not have expectations that your child will participate in the session for the first 15-20 minutes, but if she does, that is great. I will direct a lot of questions to you (remember I am not going to meet alone with your child at first) and I might do something like toss a ball around, or give you and your child some pipe cleaners, or some other way of discharging some physical tension.


A problem with anxiety is that your body gets all revved up thinking that there is some wicked danger nearby like a sabre-tooth tiger, but it has no place to go, so all that tension gets translated into something like an upset stomach, headache or feeling that you are going to faint. It really helpful to have some way of getting rid of that anxious tension. So that is why you may find me tossing a ball around, giving you pipe cleaners or excitedly showing you how my remote control spider works (as long this isn’t one of the worries). Please don’t ask say to your child “Would you like to tell Dr. Ted about …. (your soccer game or whatever)?” Have you noticed that this never works? If we give your child some time, she will start talking in her own way.

Give Worry a Name

14 Jul


Give Worry a Name



It is common for adults who struggle with anxiety to make a comment such as, “I know it is weird but…” with reference to their anxious habit. They know on some level that it doesn’t make sense, if for no other reason than knowing that others don’t share their concerns. The more entrenched the anxious habit, the harder it is to hold on to this insight. And for children, the ability to recognize that their anxious habits do not make sense is one that develops over time as they grow out of the magical thinking of childhood and develop more realistic thinking. But this discrepancy probably also reflects the underlying neurobiology of anxiety in that one part of the brain that can analyze the situation and see it doesn’t make sense, but another part of overrides it with the intense fear and dread it produces. Personifying anxiety, giving anxiety a name, can be an extremely useful tool in capturing this reality and providing a tool to get some distance from the problem.


So with your child,  a  basic starting point may be  to give the anxiety a name such as “The worry monster,” “Mr. Perfect”, “Mr. What If, or “Brain Bug,” but it is preferable if possible that the child come up with his own name. This helps separate the child from the problem and taps into a natural tendency of children to personify things. But it is also a helpful way of talking about a problem, that the “worry center of their brain,” something outside of conscious awareness, is sending a lot of “junk mail.” It is sending a lot of false alarms and tricking the child into thinking there is problem. It is good to embellish this idea as much as possible by drawing a picture of it. Then rather than just responding to your child’s anxious questions, you can respond compassionately with, “That sounds like another brain bug question, this guy just doesn’t stop, how annoying is that?” Then later we can begin to make the “Brain Bug” wait for an answer rather than responding to it right away. “Brain Bugs” tends to be very impatient creatures that love a great deal of attention and if not responded to right away, they will often get bored and walk away.


Some children, particularly as they move into the middle-school years, may feel that giving anxiety a name is silly and immature. There are also children with hoarding tendencies who tend to overpersonify objects and consequently this strategy would be more complicated. So perhaps for those children, a more matter-of-fact label would be more appropriate. “OCD” or “Anxiety” might be more acceptable along with a more adult-level discussion of the problem. The goal of personifying is have a tool that will have the child not immediately act on her anxious impulse, but rather activating a pause button so that a more thoughtful response can occur. Overall, giving anxiety a name has proven to be an extremely useful and also fun first step in dealing your child’s worries.

The GPS Says “Recalculating”

14 Jul


The GPS Says “Recalculating”



When you have an anxious child, not one who is momentarily anxious because it is the start of a new school year or a first sleep-over, but a child whose worries seem to pervade the home or prevent him from just being a kid, then you are in a new land of parenting. For most parents, the advice of the famous pediatrician, Benjamin Spock, to trust your intuition —“You know more than you think you do”— holds true. However, when your child enters the land of anxiety, you may need to, as the GPS device in my car often says, “recalculate.” As parents, when our child shows distress, our default reaction is to provide comfort, and it is really what most of us do best. However, with an anxious child if your primary response is to provide reassurance, you may actually be making the situation worse without intending it. The reason is that just as we tend to repeat things that give us good rewards, we also tend to repeat actions that take away an unpleasant feeling. Thus, an anxious child may look to a parent for reassurance and feel a momentary sense of relief upon hearing the answer. However, an informal indication that you have an anxious child on your hands is that your efforts at reassurance do not seem to work, and the child keeps on asking the same or similar questions over and over again. You have a bottomless pit on your hands and if you are going to help your child, an adjustment in your default setting will be needed. Of course if you lapse into an impatient diatribe, insisting that your child’s fears do not make sense, which is hard to avoid, you only make things worse.


This adjustment in parenting has to be thoughtful because we need to present your child with a challenge that will help him grow, but not overwhelm him with something that he is not ready for or has the skills to deal with. As Dupont et al explain, the worry dragon is always saying, “better safe than sorry.” In general, it is the quest to be absolutely certain that everything is going to be alright that puts a child in the restrictive prison built by worry. Learning to tolerate some uncertainty and discomfort is a big “key” to getting out of this prison cell. . The challenge in dealing with children is make this process workable when the general capacity for dealing with intense emotions, whether it is losing a board game or at a swim meet, is quite fragile. However, these are important skills to develop. There is a famous psychology experiment by Walter Mischel who presented 4-year-olds with a choice in which they could have one marshmallow immediately, or wait 15 minutes and have two marshmallows. He found that the children who were able to wait and not eat the marshmallow right away did better 15 years later on a variety of academic and social dimensions. So if we can help our children make the “worry monster” wait, rather than responding to him right away, we will be teaching them something quite important.


14 Jul



Do you have a child who clings to you like Velcro when you go out to a new place? When you are in the bathroom, does he pace outside the door? Is she reluctant to go upstairs by herself, or to go outside to play? Does he need endless reassurance — that he doesn’t have cancer, that his food isn’t poisoned, or that it is impossible for a shark to get into the bathtub?


If you recognize any of these behaviors, you may have an anxious child. Anxious children are often plagued by fears and beliefs that make no sense to their friends or parents, but are only too real to them. Without some special handling, these fears can turn into major barriers that spoil an anxious child’s fun and sap his confidence.


In this book, I have collected some e-mails that I have sent to parents of anxious children on topics that come up frequently in our work together. These messages may give parents some ideas about how to handle a child’s anxiety, or point them in the right direction to get more help or useful information. Professionals, too, may find these e-mails useful as handouts to their clients.


For those who would like to read more about anxious children and how to help them, I have attached a bibliography that includes some books that consistently get good feedback from the parents in my practice.