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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

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.

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What to do in those anxious moments: Getting out of your head

12 Jul

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

 

Getting Out of Your Head

 

One effect that anxiety has on your child is that it creates intense self-preoccupation. In those moments, in whatever form his/her anxiety takes, all the child can focus on is the possibility of impending doom. And when your child is in such a state, he/she is not at his/her thinking best. When you find yourself in this position, consider some techniques that help the child get more focused and oriented to the external world. 

 

In a moment of panic, you might say to your child “Look into my eyes and copycat my breathing”.  The idea is to get the child really focused and task oriented on you and your relaxed breathing rather than how he/she is feeling.

 

54321 is a very practical orienting exercise developed by Tom Bunn in his book Soar on overcoming flying fears. This exercise involves noticing five things that you see, then five things that you hear, and then 5 things that feel, not in terms of emotions, but rather sensations. The process is repeated noticing four items in each category, then three, two and one. While doing this exercise, have your child say “I see…”, “I hear…” “I feel…” either to themselves or out loud. The exercise actually requires sustained effort and focus which in turn is helpful in moving the child’s attention away from himself. There are alternatives to this approach, one of which is to ask the child to identify 5 blue objects  in the room and if necessary continue with different colors. Or an even more open ended approach is to ask the child to look around the room and see what catches his/her eye. However, in a moment of high anxiety, most children need more structure and guidance about how to direct their attention. The car drive game of license plate is a game where the parent tries to relieve the discomfort of a long car by helping the child focus on something outside of the car. Yet another variation involves using a snow globe or glitter wand: you can ask your child to shake the wand or globe, pretend the glitter/snowflakes are their upset feelings and watch them settle at the bottom.  And as I mentioned in my essay on Goodnight Moon, in this classic book, the mother bunny is helping relieve the baby’s nighttime anxiety by focusing on what is actually in his/her bedroom. This provides a counterpoint to the growing internal anxiety as bedtime approaches.

 

As a point of clarification, you are not trying to distract your child, in the sense of not thinking about the worry, because we know that does not work. Trying not to think about something or thought suppression only makes the forbidden thought more powerful. To use a computer analogy, we are just trying to divide the child’s attention to multiple browsers or windows rather than have “anxiety” occupy the entire screen. In a manner of speaking, if anxiety does not get full attention, it gets bored and walks away. There are numerous variations on this idea–for example almost any hobby can serve this function. But as with any technique, it requires practice because there is no magic here and it will take some experimentation to find the variation on this idea that works best for your child.

 

 Copyright@Edward H.Plimpton, PhD 2014

Worry Management on the Go-A Simple Technique

12 Jul

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

Worry Management on the Go-A Simple Technique

 In our quest to help anxious children, we are always on the lookout for simple things to help children in those anxious moments.  A very simple and portable technique for dealing with anxiety has appeared in a book for children, Scaredies Away! by Stacy Fiorille and Barry McDonagh, and in another one for adults by Alistair Horscroft called  Beat Anxiety Now. Both involve making a fist.

There are sound ideas operating in the simple technique to be described. The basic idea is that fighting anxious thoughts or trying not to think about them does not work. On some level, you have to accept that you are having an anxious thought or feeling.  So acknowledging them with or without some humor is important. Since anxiety can take the form of thoughts or feelings, noticing where they are in the body can transform the experience by this act of observation. The act of noticing is actually a version of facing your fear or doing an exposure. Anxiety narrows the perspective on the world, so relief involves finding a different frame of reference. One way to change perspective is to imagine transforming anxiety.

In Scaredies Away! the technique is called “The Magic Finger Countdown” and it consists of 4 steps. “Step One: Say ‘hello’ to each and every one of your fears and your body. Step Two: Make a fist and squeeze all of your scaredies out through your arm and into your fist. Step Three: Squeeze your fist tight and tell your fears you have them right where you want them. Step Four: Count down backwards from five while you release one finger at a time. Blow those fears away to make sure they’re gone. Step Five: Say good-by to yours fears. Congratulate yourself on completing the technique! Trust yourself!”

An adult variation on this procedure has been suggested by Alistair Horscroft in his book Beat Anxiety Now, which may also be more acceptable to an older child or adolescent. It is also a five step process.

1. Point with your finger to the place in your head or body where your anxiety, stress or tension is located.
2. Imagine there is a window or door just over that area. Leave the window or door open.
3. Make a light fist with your hand and quietly acknowledge the thought or feeling by saying “yes” to yourself and repeat that several times to yourself.
4. Ask yourself whether you would be willing to let a little of that tension go. Then open your hand and just imagine some of that tension, worry or feeling leaving your body. Don’t try to remove all of the tension, just a manageable bit of it. If you try to remove too much of the tension, it would like the circuits of your brain would get overloaded.
5. Repeat this several times during the day.

The similarity between these two techniques is quite apparent.  And the authors both caution that this  procedure isn’t magic and it takes practice. As with any technique, it needs to be introduced and practiced in nonanxious moments. It is hard to learn anything new in a highly anxious state.   I like the simplicity of the technique and its portability. You can pretty much do it anywhere for a wide range of anxiety. One child told me that she quietly made a fist under her desk at school and did this technique and was able to inconspicuously calm herself.  The books will obviously provide a more detailed explanation of this technique.

 

 

 

copyright@Edward H. Plimpton, PhD 2014

The Lessons of Goodnight Moon

30 Dec

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

                                      

When you have a baby, and you live in the United States or some other developed nation, then chances are you have a copy of Goodnight Moon by Margaret Wise Brown. If that book escaped your notice, then  rest assured that it is easily obtained-sometimes even in large grocery stores.   Worries, fear and anxiety have a favorite time of day to make an appearance, which is, of course, bedtime. Hence, the numerous books written about bedtime for young children. In Goodnight Moon, a mother rabbit is helping her bunny to sleep and the dialogue consists of saying goodnight to all of the objects in the room. It begins with:

“In the great green room
there was a telephone
And a red balloon
And a picture of the cow jumping over the moon.
And there were three little bears sitting on chairs…”

So at time when anxiety might be increasing, what does the mommy do? She helps the little bunny get out his/her potentially anxious thoughts by bringing attention to the concrete aspects of their surroundings. What is in the room?  A telephone. What are on the walls? A picture of the cow jumping over the moon. She is helping the little bunny get out of his/her head and focus on reality of where they are. Any thought of monsters under the bed are interrupted by reminders that they are in a very familiar bedroom. So this focus on what is in the room helps keep the little bunny grounded rather than drifting off into an anxious sea of bad thoughts.

But the mother bunny is also doing something else. She is remaining very calm. We know that anxiety is very contagious. An infant or young child has an immature nervous system and consequently relies on adults to help them regulate it. Children are consequently checking in with their parents to see how they appraise what is going on-technically this is referred to as social referencing. And the mommy is indicating to her little bunny that she views the situation as totally safe. In a similar manner, you will help your anxious child by conveying a calm and confident manner that the situation is safe and you will take care of any problem that might develop.

This classic bedtime story illustrates the importance of orienting to the external environment in dealing with anxiety and demonstrates how parents can help children manage their anxiety by providing a calm presence. A similar point is made in another essay on this blog, “Helping Your Anxious Child Get Out of His Head and Out of Worry.”

copyright@Edward H. Plimpton, PhD

Using humor to deal with anxiety

14 Aug

What to do about nightmares

14 Jul

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

 

What to Do About Nightmares

A most unwelcome nighttime visitor is the nightmare. We all get them at some point, and they are usually triggered by a frightening event, or major transition such as starting school or a parental divorce, but also something scary in a movie or television show. Significant trauma can lead to recurrent nightmares, s something our military veterans unfortunately often have to deal with. Nightmares involve very intense emotions, usually fear, and the content is remembered. Recalling our nightmares is in contrast to night terrors, which feature extreme panic but no recollection of the dream. Some common themes of nightmares, to mention a few, involve being chased or attacked, smothered, or falling. The intensity of the nightmare can be traumatizing to your child, and may make him afraid to go to sleep because he might have another one.

What can we do for your child who has had a nightmare? While most nightmares are caused by something scary, it is important to consider whether there might be physical cause (e.g., a fever), a recent illness or a drug reaction. Recurrent nightmares, however, are suggestive of emotional problems that are not being resolved and might merit professional attention. With these cautionary comments noted, there are some things to try

Start by calming your child and providing reassurance. The distinction between reality, fantasy and dreams is not always clear to young children and they may need some help on that front. The intensity of the fear needs to be acknowledged and never laughed at or dismissed. Once you have reassured your child, it is time to find about what happened in the nightmare and to get as much detail as possible. Our general goal with nightmares, as with all scary things, is to create a way where your child can become more active rather than being passively victimized. Nightmares put your child in a defensive position, as in having to run for her life in the dream, and we want help her to take a more active and assertive stance against the images in that dream. Basically, we want to help your child rewrite the nightmare and put herself in a more powerful role.

So perhaps we can begin by having your child draw the nightmare or the scariest image in it. A monster drawn on paper can’t move. But if that is too scary, your child might have to begin by drawing a jail for the monster or some special guards against it. The next move depends upon the nature of the beast, the nightmare images, so to speak, but there are a range of options. Let’s try to avoid the most violent options, such as killing the monster. Because we are in the world of dreams, we can’t count on such actions carrying any finality. The monster may come right back the next night with greater intensity just like the sequel to the horror movie playing at the local movie theater. Perhaps your child could render the monster harmless by drawing something silly onto his monster picture, such as diaper, or give it a lollipop. We may also transform the nightmare monster by helping your child ask it questions, such as “What are you doing in my dream?” or “Why are you chasing me?” Anne Wiseman, in Nightmare Help: a Guide for Parents and Teachers, provides a variety of questions you can ask your child to help him with his nightmare. A very basic question she suggests is asking your child what he would need to feel safe or less scared. In general, asking questions to help your child rewrite and transform the dream into something where he is more in control is the goal. Even though dreams take place in your head when you are asleep, there is emerging evidence that is possible during your waking hours to transform your dreams by rewriting them, and thus lessen this nighttime annoyance.

Get out of your head

14 Jul

 

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

Helping Your Anxious Child Get Out of His Head and Out of Worry

 

When an anxious thought or image takes hold in your child, it hijacks his attention. In children’s intense preoccupation, a narrowly focused tunnel vision takes hold in which the worry is the only thing in sight. This narrowing of vision makes sense if there were a realistic danger that had to be dealt with. Hitting the reset button involves helping the child get out of her head and refocused onto the world around her. For example, one girl struggled watching movies with her friends because she was much more easily frightened by what she saw compared with her friends. On her own, she came up with the idea that when she was frightened by something she saw, she would look around the room and start naming what things. She would say to herself, “There is the lamp, there is the cat, there is my popcorn…” and this listing would help her reorient and gain some distance from the frightening image.

A slightly different example is provided by a 10-year-old boy who had been anxious about going to school for a long time. There were frequent trips to the school nurse and guidance counselor with complaints about stomach pains. Merely talking about his feelings and providing reassurance didn’t help with his anxiety. Partly in desperation, the guidance counselor started having the child write down his schedule in her office as soon as he got into school. By the time he was finished writing down his schedule for the day in great detail, his anxiety had diminished to the degree that he was able to go to his class without difficulty. This simple exercise did a couple of things. First, the act of writing his schedule down moved him away from his anxious thoughts because he had to think about his schedule, which was not the same every day.  Second, since he was filled with nervous anticipation about what was going to happen during the day, writing his schedule moved him away from the anxious anticipation to visualizing what would really happen during the day. This focus on the external reality of the day seemed to help calm him down. Third, the anxious child is usually operating at high speed, but writing something down can really slow things down so he can challenge some of his anxious thoughts or they can just dissipate on their own.

So helping your child focus on the environment outside of his head can often be an important step in helping him deal with anxious thoughts.

Effort versus Performance

14 Jul

Effort Versus Performance

 

Whether it is an upcoming swim meet or a spelling bee on Friday, children can often suffer from performance anxiety, some of which is perfectly normal and appropriate. However, when the anxiety clearly begins interfering with the child’s participation in the event, then the issue of performance anxiety needs to be considered. Some children who are rather perfectionistic by nature can put a lot of pressure on themselves.

 

Adults, however, provide added pressure depending upon whether they focus on the child’s effort or performance. It turns out that how we praise children can have a big effect on how they perform depending upon whether you focus on their effort or intelligence.  This insight comes from research by Carol Dweck, who discovered an interesting effect on children’s school performance depending upon whether parents comment on the children’s effort and hard work, or their intelligence and talent. She proposes that we tend to understand success as either the result of innate ability and talent, or the result of hard work and effort.

 

However well-intentioned, telling your child that he/she is smart and brilliant can inadvertently put pressure on him as when he encounters a problem in his homework that he has difficulty solving. This child may feel that because he could not solve the problem easily, this is an indication that he is not as smart as he thought he was because it required effort. So he gives up. Anything that requires effort is to be avoided and challenges are not welcome.

 

In contrast, comments that focus on the child’s effort tend to promote greater persistence and a more positive attitude. This has been confirmed in studies on children’s performance on math tests where the feedback in one classroom was on how smart they were and in the other classroom, the feedback focused on their persistence and effort. When given achievement test, the “persistence” group did substantially better.

This point was recognized a long time ago in the book How to Talk So Children Will Listen and Listen So Children Will Talk, by Adele Faber and Elaine Mazlish, who recommended simply describing what you see rather than lavishing praise on your child. Rather than saying to your kindergarten child’s quickly drawn picture, “Oh that is so beautiful,” instead comment, “Wow, there are so many colors in this picture and the house has four windows.” The latter does communicate that the child’s effort was worthy of detailed attention and it brings her attention to what she did that helped make the picture interesting.

 

So when it comes to providing encouragement for your child, try to focus more on describing the way in which you see him displaying effort and persistence rather than praising him for being talented or smart.

copyright@Edward H Pllimpton, PhD

 

 

 

My child won’t get out of the car!

14 Jul

Won’t get out the car!! What to do?

Suggestion from Edward H. Plimpton, PhD

 

Parents dealing with a child who is anxious may find themselves in a situation where their child seems physically frozen with fear.   It might be that they won’t get into the dentist chair, get out of the car to go to school or join the other children at a birthday party. When it happens more than once, a plan of action is needed. As with all problems, it is important to consider a range of factors that may be at play here. But there is also the practical problem of what to do and there some interventions that may be helpful regardless of the underlying reason.   For sake of discussion, let’s consider the child who won’t get out of the car.

  1. We should begin by recognizing that this can be very stressful for the parent. You may be trying to get to work on time, having already been late a number of times because of your child’s struggles, and you are feeling the pressure. In addition, we need to remember how contagious feelings are, which adds to your and your child’s distress. As you are driving to school you are left wondering how you are going to get your child out of the car and into school. So just as in airplanes, when the oxygen mask drops down from the ceiling-first attend to yourself and then you can help someone else. First, try to notice any physical tension in your body.  This is a simple request, but can be surprisingly helpful. Try to slow down and breathe in a calm, relaxed manner. You will more effective dealing with your child if you start from a position of being relatively calm. After all, it is a two-way street: Your child’s anxiety affects you, and your mood affects your child. You have to be calm in order for your child to be calm.
  2. If a child is curled up in the far corner of your van or is holding onto the car door for dear life, he or she is clearly overwhelmed by his or her feelings. It may feel like you have a stubborn or manipulative child, but that does not mean that is the child’s motive. It is more a reflection of how overwhelmed they feel rather than manipulation. It may be that just getting into the car was a major accomplishment.              Conceptually, we think of anxiety as reflecting our biological defensive system of fight or flight. But there is a more primitive defensive response that occurs when we can’t engage in fight or flight—we become immobilized or freeze. It is similar to the way in which animals play dead when caught by a predator. And your child in the car may be in a frozen state.  

If you can engage your child in some activity in the car, whether it is playing some version of license plate, listening to a song, or having a conversation,-any activity that helps him/her get out of his/her head and the anxious preoccupation is good. Likewise, if we can get the child to do some relaxation breathing, rather than hyperventilating, that would certainly help the cause.  But I understand that this may not be possible.

  1. Don’t pull your child out of the car. It will only make the situation worse and could result in tug of war in which someone gets hurt.
  2. Approach your child in a calm manner. Empathize with how overwhelmed he/she must feel. “I can see you shaking and huddled up, I  am guessing you are feeling  pretty scared”, or “I am guessing you are pretty scared, and if I felt that scared, I would hold onto back seat for dear life as well”   Trying to understand how your child feels isn’t the same as giving him permission to miss another day of school. But rather if you child feels understood, then she may become more flexible. It would not be unusual in such a situation for your child not to give any indication of whether you said something useful or it was just stupid. Don’t despair; it is hard to feel eloquent when you are talking to someone huddled in a ball.
  3. This really may be the best they can do in the moment. Try to get the child to look at you. Try to see if your child will tolerate any physical contact from you, whether-a hand on the shoulder-or a hug. We are trying to make the child feel safe and calm down her nervous system.  
  4. One yardstick to keep in mind is that many panic attacks resolve themselves in about 15 minutes, so stay calm and hang in there. You may just need to give the situation some time.
  5. You might say, “Being upset is hard work, let me know if you need something to drink or eat.”
  6. It is always helpful if there is a compelling reason for the child to get out of the car that can help override his current feelings. Sometimes schools can give children special assignments such as helping the gym teacher or feeding and caring for a school pet.
  7. Although no one wants to jump to put their child on medication, and it shouldn’t be the first intervention,  there is a place for medication in helping children get control of themselves so that they can participate more fully in solution of this problem.  Medication won’t solve any problems, but it may turn down the anxiety dial so that the child can be more available to solve this problem.
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