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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.

“Just scared but can’t say why”

9 Aug

It is generally easier to help your child when he/she can clearly identify what is scary. A monster under the bed is an easier problem to contend with than a nonspecific “I am afraid”.  But there are occasions when children can’t identify why they are scared, or if they do, it may feel like they are making up an explanation. Sometimes we haven’t asked the right question or the child doesn’t feel safe enough to spill the beans. But there is another layer to this problem: the experiences of anxiety and fear are products of the brain’s alarm system, designed to keep us safe and alert to danger. When we consider how the alarm system can malfunction in two different ways, we may get a clue as why your child can’t pinpoint the reason for his/her concern.

The first way is that there may be a problem in the wiring and software of the alarm system, so that it generates too many false alarms or overstates the magnitude of the threat. OCD, for instance, is a problem with the junk mail filter or “anti-virus” program in the brain. The junk mail filter isn’t doing its job and is letting anxious thoughts clutter the mind. Educating children about junk mail or “not believing everything you think” can be an extremely helpful first step.

The second way the alarm system can malfunction is by getting overloaded. Just like any other system, our alarm system has a limit to what it can process, and this is what happens with trauma. When the alarm system can successfully implement a self-protective response of fight or flight, no trauma results because it has done its job. But there are a variety of circumstances in which the alarm system gets overloaded and the system shuts down. It can’t run away or put up a fight so it just  freezes.  What comes out are all the symptoms we associate with PTSD: flashbacks, avoiding any reminders of the trauma, and increased anxiety and emotional arousal. Traumatic stressors can include war, natural disasters, car crashes, medical procedures, and interpersonal violence, to name a few.   When it comes to children,  this type of stress actively interferes with nervous system development, which is actually a 25- year construction process, according to contemporary neuroscientists.

A central brain structure in anxiety and fear is the amygdala. It can form nonverbal, essentially unconscious memories of frightening events and it is operational at birth. The part of our brain that helps make conscious recollection, the hippocampus, is a work in progress during the first two years of life, which is why we don’t have clear memories of being babies. However, the amygdala can encode traumatic events on a nonverbal level: in one study, boys who were circumcised without anesthesia were shown to be more reactive to vaccination shots at 4-6months compared to boys who received this procedure with anesthesia. Although there is no conscious recollection, the reactivity of the infants who did not receive the anesthesia suggests that their bodies  had learned something from the experience and that the sensations wer remembered. While the research is clear that chronic stress and trauma can make the nervous system more reactive and anxious, on a more practical level, it is a hard thing to prove. Sometimes, a parent can say that their child was never the same after a particular incident, such as illness or accident, or that the mother knows she went through a horrific experience while pregnant or giving birth, and it certainly affected her. But the science is clear that nonverbal memories can be formed. So we are making some informed speculation based on neuroscience, trauma research and the clear inability to come up with an alternative explanation.  It may be that when your child can’t say why he or she is afraid, what you are seeing is the long shadow of something frightening that happened long ago to a tiny brain that got overwhelmed. Therapeutic interventions that are more based in becoming aware of body sensation, such as Somatic Experiencing Therapy, EMDR and Sensori-Motor Psychotherapy, can be very helpful with this kind of trauma.

copyright@edward plimpton

The Kid Figures It Out

24 Sep

Edward H. Plimpton, PhD Your Anxious Child: Emails to Parents

The Kid Figures it Out

Amid the despair and discouragement concerning whether your anxious child will actually get better, there is the potential for something amazing to be overlooked. At all levels of our body we have the capacity and tendency to self-heal. A Band-Aid after all only supports the body healing from a cut or scrape; the immune system does the job. And well-known artists such as Steven Spielberg have said that their art is a way that they master the fear they had as a child. But guess what? If we are not watching we can miss a child inventing their own cure for anxiety all on their own.

A three-year-old boy enters a daycare full of enthusiasm only to discover that one of  the popular books in the classroom is Going on a Bear Hunt. This is a rhyming, interactive book in which a family goes on a “bear hunt” only to run away quickly at the first hint of the bear.  He had overheard his older sister’s enjoyment of this book at home, but at his two-plus years it was just too scary for him. But there was that dreaded  book again, and the problem was that all of the other children were enjoying it and he didn’t want to be left out. Over the next several months, in small steps, he gradually got over his fear without any direct help from adults.  At first, whenever the book was being read, he would leave the room in a hurry. This lasted for several weeks. Then he began peeking around the corner and listening until the family got close to the bear. Another month or two. Then he began he nuzzle up to the adult who was reading the book and then exit when it got to the scary part. Another month or so. Then he requested a blanket so he could hear about the bear hiding in his cave. Then he pretended to be the bear and chased the other children in the classroom at the end of the book. And his pleasure at mastering his fear was evident, a process that unfolded gently and gradually over several months, guided by his own internal psychological “immune” system. A therapist could not have devised a better plan.

Related to the value of taking incremental steps in dealing with anxiety is developing the capacity to tolerate tension. A high school girl had struggled with separation anxiety all of her life, and it had interfered with her having adventures during the summer as well getting together with her friends. But she explained that she has begun to really enjoy the tension and suspense of Alfred Hitchcock movies. She made it clear that she did not like the  horror movies or gory movies  that some of her peers are drawn to, but the Hitchock films involved her in the feeling of suspense.  On her own, she has devised a program to increase her capacity to tolerate tension and anxiety. This improvised movie therapy exposed her to emotional tension and anxiety in a way which she could manage and feel empowered by. She was learning to face her fear.

An eighth grader who was voracious reader explained that she had seen a Disney movie when she was in second grade and it gave her nightmares. But she found as her parents were reading to her at night, her interest in the story made the anxiety disappear. She quickly became an avid reader. Now her top ten  favorite books would easily match that of any adult. She had found a way, again on her own, to focus her attention in an extremely productive manner.

These children invented a cure for their anxiety. They did need a safe and supportive environment for this natural capacity to emerge. But given some minimal support, a natural healing process took place. Perhaps, you can catch your child inventing his/her own solutions to mastering those worries.

copyright@Edward H. Plimpton, PhD

Obsessive-Compulsive Disorder

27 Aug

    From Your Anxious Child: Emails to Parents by Edward H. Plimpton, PhD                                    

                                              Obsessive-Compulsive Disorder

The condition commonly called OCD is not the same as being “obsessed” with football, gardening or “Dancing with the Stars”. To have a strong, consuming interest is not the same as having OCD. In OCD there is an intense preoccupation, which causes considerable distress, and which the individual seeks to get rid of through a series of actions which are known as rituals.  Because of the excessive and often time consuming nature of these rituals, or compulsions, and the emotional distress involved, they begin to interfere with everyday life. Perhaps the most well-known OCD ritual is hand washing, which can be carried out to such an extreme that the hands become red and chafed. But rituals can also take on the form of questions which are repetitive such as, “Are you sure you know the way home?” or, “Are you sure I don’t have cancer?” in which no amount of reassurance seems to put the matter to rest. And with some rituals there is a clear superstitious or magical element, as when a child might tap his foot a certain number of times.  Some rituals do not involve an overt behavior but rather consist of having to have a “good thought”  in order to undo a” bad thought.”  There are several sources for the distress that this condition causes. First, the awareness that the rituals do not make sense and that other people don’t share their concerns. Second, with intrusive thoughts, the child might feel, “If  I am having these bad thoughts I must be a bad person.” Third, the intense discomfort that occurs from the obsessions and consequently the difficulty in not acting on them. The rituals really do provide some momentary relief and consequently become quite compelling. The unfortunate problem is that the rituals begin to act like an addiction so that the more you do them the more you have to do them.

There are a number of good books for parents on this topic: Tamar Chansky  Freeing Your Child From Obsessive-Compulsive Disorder, John March with Christine Benton Talking Back to OCD, and Dawn Huebner What To Do When Your Brain Gets Stuck: A Kid’s Guide to Overcoming OCD,  to name just a few.  And don’t get discouraged if your child appears to be dealing with OCD. It is actually one of the more treatable anxiety disorders providing the therapist is trained in cognitive behavior therapy using exposure and response prevention.  There is some emerging evidence that children who receive treatment for OCD may not necessarily retain their symptoms into adulthood, or at least the severity will be greatly diminished.  The reason to take action is simple: we don’t want the child to accumulate the hours of practicing the OCD habits that will then create an entrenched way of doing business, and early intervention can interrupt the development of this habit.  Additionally, don’t be surprised to discover that some of your best intentioned efforts to help your child, while they may have provided short term relief, actually made the problem worse over time. Our default reaction as parents is to provide comfort and reassurance when there is distress, but in the landscape of OCD such reassurance is not helpful. This is not to say that you should stop being empathic and caring with your child, but rather that there are skills that need to be learned. It is not straight forward, but then again neither is OCD.

First Aid for Panic

27 Aug

From Your Anxious Child: Emails to Parents by Edward H. Plimpton, PhD

First Aid for Panic

A child in the grip of panic, or perhaps even terror, is not a sight that a parent easily forgets. The circumstances can range from a trip to the dentist, the prospect of a thunderstorm  observing  something frightening, or just getting out of the car to go to school. But there is your child hyperventilating, and either huddled in a ball or pacing back and forth and feeling desperate.  And what can you do? Well, actually the first aid advice tends to be very similar, even when it comes from professionals who have every different orientations. The basic elements in bringing a panic attack under control involve the following:

  1. The hyperventilating needs to be replaced by slow, deep “belly breathing.”
  2. The disorientation and dizziness produced by the panic need  to be counteracted by having the child “ground” herself by feeling her feet on the ground.
  3. The child needs help to get “out of their heads” by orienting to the immediate physical environment.
  4. Challenging the self-talk that sustains the panic, as in, “I can’t handle this.”

The trick with children who are in a panic state is to translate those ideas into a format or language that helps them grab hold of the lifeline you are offering.  It may be that the best medicine you can offer at first is to be a calm, reassuring presence while you are waiting for this wave of anxiety to subside.  You don’t resolve the problem by being reactive, and in fact by being calm you create a sense of safety.  But of course we want to do more than just wait the panic attack out, we want to teach your child some skills to deal with these intense feelings.   Children of course depend upon their parents to help them regulate and manage their emotions  because their nervous systems are still under construction.  So the parent’s job is to help the child build a bridge to the basic first aid strategies for panic.  There are several elements in this bridge building:

  1. The parent is actively modeling belly breathing, grounding techniques and orienting to the external world.
  2. When possible, using pleasing imagery that will capture the child’s imagination. I like the image of breathing like a frog, but there are many possibilities: blowing up a balloon, blowing out birthday candles, or smelling a beautiful flower.
  3. The immediate relief provided by avoiding the panic-inducing situation is powerful, which can lead to children avoiding participating in school or other activities. So the parent has to find a way to set some limits to help the child learn how to manage these feelings. Sometimes, “just do it” is appropriate to the situation. But that requires some judgment and sensitivity, not just getting tough, so the child is not just overwhelmed but can learn to deal with the problematic situation. A studied balance between being very firm and very flexible is optimal, and this rests on having a sense of how overwhelmed the child is.
  4. The first aid is going to work better if the parent and child have practiced those techniques outside of the panic moments. In  the heat of the moment it is almost impossible to learn anything new.

The Importance of Breathing in Dealing with Anxiety

6 Aug

From Your Anxious Child: Emails to Parents by Edward H. Plimpton

 

The Importance of Breathing in Dealing with Anxiety

 

Got a panic stricken, hyperventilating youngster in front of you? One basic first aid  measure will involve convincing the child to take calm, deep relaxing breaths.  Perhaps you will ask them to blow into a paper bag and fill it up, or just look into your eyes and copy-cat your breathing or just imagine that they are blowing bubbles. This calm, deep belly breathing in which you can see the belly or diaphragm move, helps counteract the overactive alarm system that characterizes many anxious children. It also helps to get them physically active to burn off all that anxious energy.

 

But the benefits of practicing this type of belly breathing go beyond temporary first aid. When we breathe, there is a difference in our heart rate between inhaling and exhaling. Our heart rates increase when we breathe in and slow down when we breathe out. This is known as heart rate variability and it correlates with anxiety. About 10-15% of children are biologically more on the shy and anxious side, and as psychologist Jerome Kagan discovered, these children have lower heart rate variability than their less anxious peers. Fortunately, practicing calm breathing can do wonders. In one study, on the power of breathing, adults were given artificial blister wounds on their arms, one group was taught breathing skills and the control group was left alone. The group that was taught breathing skills found that their blister wounds healed much more quickly than those of  the control group. In other words, breathing helps support the body’s natural capacity to heal itself. We know that the emergency response system, the sympathetic nervous system, the part involved in the fight or flight responses, gets a “regular exercise” from all the anxious things your child does. However, the calming and repairing system has been typically sitting on the sidelines and does not have a chance to get into the ball game. Engaging in calm breathing actually helps build up the muscles in the calming and repairing system, or the parasympathetic system. As a result, the child has some calm down “muscles” that can help tame the overactive alarm “muscles” or help set the foundation so that the child can access his/her smart brain.

 

There are many child friendly ways to teach calm breathing and here are some to get you started.

  1. “Make Lemonade”. Get some newspaper and crumple it up. Put one newspaper ball in your hand. Now pretend the ball is a lemon, and squeeze out as much lemon juice as possible. Do one hand at a time, squeeze as hard as possible, and then relax.
  2. Pretend you are blowing out birthday candles
  3. In more tense situations, ask the child to look into your eyes and copy-cat your breathing.
  4.   http://youtu.be/OaVB7j4BJn    This Ytube video also contains some nice suggestions for children.
  5. Consider also the following books: Lori Lite A Boy and a Bear: The Children’s Relaxation Book, Michael Chissick and Sarah Peacock Frog’s Breathtaking Speech: How Children (and Frogs) Can Use the Breath to Deal with Anxiety, Anger and Tension.

 

Anxious children often want instant results and can be quick to dismiss suggestions. Parental modeling of calm breathing helps as well as  incorporating it into the bedtime routine or other transitional moments. It is a skill that needs to be practiced in nonanxious moments for it to have a chance to be helpful in more high intensity situations.

 

copyright@Edward H. Plimpton 2014