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

Some resources to help with sleep

4 Aug

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

Basic Sleep References and Material

Sleep is easily disrupted by anxiety. Without daytime distractions, worry thoughts can fill the child’s bedroom. In addition to the references listed below, consider my essay on making a Worry Motel, it has been an extremely useful intervention for many children. The suggested age ranges are approximate because some children are more indulgent of material that might be geared towards younger children and others have decided intolerance of anything seems babyish. These references are not geared towards the issue of helping your child sleep independently, which is a related issue, but rather providing some alternatives to the “worry channel” that can be playing loud at nighttime.

Dawn Huebner What to Do When You Dread Your Bed: A Kid’s Guide to Overcoming Problems with Sleep
This is good parent child workbook for the elementary school age child (8-12). It has a very child friendly format and discusses some very sound ideas to help with sleep.

CDs

Finding a CD that might be helpful to your child may take some experimenting. We tend to have strong preferences about the type of voice we find calming and the type of music or sounds we enjoy. It is hard to predict what might work for your child. However, I have good luck with the following CDs.

For 5-8 years olds

Jim Weiss Good Night: Enchanting story visualizations with sleeptime music.

Jim Weiss Sweet Dreams: Enchanting story visualizations with sleeptime music

I found the two CDs by Jim Weiss to be very enjoyable for children to listen to.

For 12-18 year olds.

Mark Grant calm and Confident: based on Eye Movement Desensitization Reprocessing

I like Mark Grant because he places no demand on the listening to do anything and consequently removes any performance pressure that can get in the way of sleeping.

Books

The books that have been written to help children ease into sleep are too numerous to list and there are many delightful books in this category. Often it just may be a good book that is engaging and interesting. I suspect each family has their favorite bedtime books.

For 5-8 year olds

Maureen Garth Starbright: Mediations For Children

In order to fall asleep on their own, children need to develop some coping skills. In this book, the parent provides the beginnings of a visualization story to help set the stage and then invites the child to continue the story on his/her own. This helps builds the child’s imaginative capacity to deal with nighttime worries.

Lori Lite A Boy and a Bear: The Children’s Relaxation Book

This is nice book that teaches relaxation skills in which a boy and bear relax on top of the mountain.

Melanie Watt Scaredy Squirrel at night

Melanie Watt has written a series of books on Scaredy Squirrel dealing with fears in a variety of situations.

Sleep problems can be complicated and a professional consultation may be indicated when simple measures don’t work.

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 Deer in the Headlights: Understanding the Anxious Freeze

15 Apr

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

The Deer in the Headlights: Understanding the Anxious Freeze

Perhaps your child will not go to school, or take swim lessons or get that needed shot at the doctor’s office. So you have created a reasonable plan to help her. It involves a series of incremental steps, baby steps or exposures to the source of the fear. But this step by step plan isn’t working. Your child just freezes up and will not budge. What is going on here? The show stopper may be that your child is not engaged in the standard fight or flight response to anxiety but rather a more defensive freeze or immobility response. The importance of the freeze or immobility response has slowly received increasing recognition in the therapy world and it definitely has implications about how you respond to your child.

The freeze or immobility response comes into play when the organism, be it a child, corporate lawyer or zebra, is overwhelmed. But for simplicity’s sake, let’s take the zebra. The lion has caught it, and has the zebra by its throat. Under the circumstances, the poor zebra can’t run away or fight, so it tries to play dead and hopes that this will basically gross the lion out so it will leave her alone. While the circumstance may not be as dramatic, children also can get overwhelmed for all sorts of reasons, and they end up freezing up. So they may stop talking, stop engaging in any eye contact, and become more rigid in their posture. Adults can often get irritated at this lack of responsiveness, and at our worst we assume the child is being manipulative. And that might be part of the picture, but it can also be that the child just feels overwhelmed. And as adults we often discount or minimize events that may be overwhelming to a child because we don’t experience them as such.

So what to do? First, a child in freeze is a child not engaged with people. And we know when someone is highly anxious, their rational or smart brain goes into hiding, so reasons or rational explanations are of little use. Engagement is the thing. You can start with nonverbal engagement when possible, such as tossing a ball or taking the dog for a walk or blowing bubbles, and sometimes simple touch can be effective as well. The child’s body is all revved up and needs some form of physical discharge. The physical activity, in turn, helps the child get out of the freeze response, and then he or she is more available to be engaged with others, such as teachers or parents. Indications that a child is coming out of freeze are smiling, laughter and spontaneous talking.

The freeze or immobility response does not respond to reason and hence requires some special consideration. Failure to recognize freeze responses will lead to a standoff where everyone is just digging in their heels. Think about engaging your child in a more physical manner to help him/her get out of this frozen state.
copyright@edward plimpton