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Floor Time

14 Jul


Floor Time


A recent Nielsen Company survey reports that the average American is spending an average of 4 hours 49 minutes watching TV a day — and that is those ages 2 years on up. Yikes. But then again, your TV time is probably after the children are in bed, unless your anxious child just won’t bite the pillow. TV is a problem inasmuch as it is a regular source of scary images for children that will keep them up at night and you from your late-night show. It is a lean, efficient anxiety-producing electronic machine. But also there is the issue of whether it is being used too much as a substitute babysitter and keeping you and your child from more productive activities.


It sometimes can take some time to figure out why your child is anxious or having a hard time in school. Does your child have a short attention span because he/she is anxious or because of attention deficit disorder or both? Or, does your child have some learning disabilities that need to be clearly identified? Whatever the reason, you know that you have a stressed-out child on your hands and the answers to these questions may take some time. When all else fails, consider going back to the basics. A lot of undesirable behavior in children is inappropriate attention-seeking. Children crave attention. The most basic mental health intervention you can give your child is 20 minutes of undivided attention everyday. In a way, it may not sound like much, but actually it can really do a lot to take the edge off things. The activity can take many forms, but please try something more interactive than video games. Sometimes you have to try out a few ideas to find ones that are a good match between you and your child. It will probably be more fun if you engage your child in an activity that you find interesting than one for which you have no aptitude. But then again, being a parent is a way to expand your horizons and develop some new interests.


Time spent with your child is important because children often do not respond promptly and efficiently to such well-meaning inquiries as, “How was your day at school?” The response often suggests that you don’t have security clearance to have access to such information. However, given some time, often children will spontaneously blurt out a concern or share an experience. The time you spend with your child also communicates to her that you consider her important and worthy of your time and that of, course, will help her feel that she is worthwhile. It is one instance where quantity of time is as important as the quality of time.

Two Types of Anxiety

14 Jul


Two Types of Anxiety

I would like to follow up on my previous email concerning the importance of trying to be specific about the anxious expressions in your child. For the sake of discussion, I think it is helpful to draw a distinction between classic expressions of anxiety and what I would call more derivative expressions. In the more classic forms of anxiety, it is usually easier to identify what the child is anxious about with statements along the lines of, “I am scared” or “I am afraid that …” accompanied by an apprehensive facial expression or tense posture. The more classic forms of anxiety can be thought of as an overactive alarm system, in which there are either a high number of false alarms or simply too many alarms altogether. Treatment will involve helping the child face his fear and in doing so reprograming the “alarm system” to more appropriate settings.


But anxiety can manifest itself in a more general form where it is not so much a problem of an overactive alarm system as it is a by-product of a system that has trouble regulating itself. This is what I mean by a derivative expression of anxiety. Some part of the system is not working efficiently and the anxiety is a reflection of this problem. The engine isn’t running efficiently, the machinery used to deal with unexpected/changes in plans is not working efficiently. The glitches will show up when there are transitions. This is different from just an overactive alarm system. This is more like negotiating a dark passageway with a flashlight and never knowing what might jump out at you. If the world is filled with a lot of unwanted surprises, you will be more anxious. Some examples:


  1. A      10-year-old girl with ADHD gets anxious at her summer camp because there      are a lot of field trips pertaining to their nature studies. She has      always had trouble with directions and even as a young adult can get      confused about right versus left. She is anxious because she does not      really understand where she is going and she wonders to herself, “What if      I get lost?”
  2. A boy      with very significant ADHD and dyslexia is very athletic but reluctant to      try new activities. In part he is sensitive to the noise that occurs with      indoor sports and is also unsure of what to expect. He is impulsive and      often gets corrected in school and since he is nonresponsive, voices get      raised.
  3. Children      who struggle with unstable moods will be vulnerable to anxiety. They can’t      count on how they will feel from one moment to the next and this creates a      baseline state of ongoing tension. Not being able to count on some      internal stability will lead to anxiety. So you will see children who are      afraid to be upstairs by themselves or go outside by themselves. Tracy      Anglada has written a book on children with bipolar disorder and she      quotes one child as follows “I      remember being quite anxious as a child. I would describe it as an      unexpected event, where something normal would cause me to panic, my chest      would tighten, my heart would beat rapidly and I would sometimes just      break down and cry” (p 87). And certainly nighttime is a time of      heightened anxieties and with someone with bipolar these fears can be      especially intense where dreams can be quite vivid and disturbing.
  4. Perhaps      it is not as common in children, but the experience of having a major      depression where you can’t focus or concentrate on anything can be a      frightening experience.
  5. A high      school student has experienced significant help from being diagnosed with      ADHD and receiving medication, but complains about being socially isolated      and would like to make more friends. In talking with her, one can see that      maintaining eye contact is a struggle and she does not understand jokes or      any nuances in conversation. She seems to be someone with difficulties in      processing nonverbal information.
  6. Children      with Aspergers or other conditions in which there is a strong detail      orientation and corresponding difficulty in seeing the big picture are      going to be more vulnerable to surprises.
  7. If you      are someone with pronounced sensory sensitivities, you depend on a certain      continuity in order to maintain a sense of well-being. Anything that      upsets that precarious balance will lead to more avoidance behavior. So      one of those children whom the parents had a impossible time calming down      as an infant and had a variety of sensory sensitivities is going to have a      much harder time adjusting to the school environment and may show a lot of      separation anxiety.


Although the distinctions between classic anxiety and derivative expressions in real life may be fuzzy, it is important in making a plan of action to determine whether the primary problem at the moment is the “overactive alarm system” or a larger problem in self-regulation.

So it is just “anxiety”

14 Jul


\Just Anxiety’


I often hear parents explain to me that their child is “just anxious” or that they have been told that their child is anxious. As in, “Johnny is not doing well in school because he is anxious.” By giving him the label of “being anxious,” it may appear that we now understand his behavior. It would certainly be better than suggesting he is just trying to make life difficult. But I don’t think that by itself, saying your child is anxious is very helpful. Too often it can be a catch-all phrase, like “stress,” that doesn’t really say anything. There is a good chance you already know that on some level, and the problem is just being redescribed. To be helpful, a label or description must be specific enough to point in some direction or suggest a course of action. In the most general sense, to be anxious is to anticipate some danger. But we need be more specific about what, how and why your child has anxious symptoms. Some questions that need to be pursued include the following:

  1. What      situations trigger your child’s concern?
  2. While      the situation might be anxiety-provoking for many children, such as the      beginning of the school year, does the passage of time or experience help      the fears diminish?
  3. Alternatively,      is the anxiety more a manifestation that the child has “too much on her      plate” or has too many things to deal with?
  4. Turning      more specifically to your child, what is it about her that makes her view      a situation as more dangerous than the situation seems to merit? Some      possibilities to consider include:
    1. The       child has always been apprehensive, shy or had difficulty maintaining a       steady state.
    2. The       child may have an undiagnosed medical problem.
    3. The       child may have a learning disability that makes it hard to keep up with       his classmates.
    4. The       child may have a condition such as ADHD, which in some ways makes the       world less predictable. As a result, the child feels more ambushed by       surprises on a daily basis.
    5. Finally,       it may be that your child is just “wired” with an overactive alarm       system, but it will still be important to specify the things that seem to       set it off.


It is important to try to be specific about your child’s anxiety. Conversely, you may also want to think about the situations and ways in which your child is not anxious.

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.