“Calm Down” and Other Stuff not to Say to your Anxious Child

Phil Ritchie, Ph.D., C.Psych.(the other Dr. Phil)

Who are These Children and Youth and why are they Making

Us Anxious?

Infants and Toddlers

What have we gotten ourselves into? Funny, I thought having a baby would

bring us closer together… Pressure to be perfect – and trouble

accepting when children aren’t. So many experts on their children –

family, friends, strangers, healthcare workers…

China, wood, or concrete?

Preschoolers – So that’s what a tantrum looks like

First asserting their independence and testing parents and caregivers (“I’m in a power struggle with a 2 year old and I’m losing!”).

Parent contests re developmental milestones.

School age children Please don’t turn out like mom/dad. Parent contests continue (sometimes

between mom and dad). Sports, academics, arts, social

pressures, and rehab. Can see some early emergence of

mental illness at this age (e.g., anxiety disorders).

The Tween Years First start presenting their own

beliefs/opinions to peers and parents; can form an opinion based on available evidence

Real fears (war, violence) replace imaginary ones

The Tween Years cont’d Understand delayed gratification Contemplate self-identity,

independence, values Parents remain the principle role

models (exercise, nutrition, problem-solving, managing crises).

Adolescence – This could get scary

The period of life when the child kicks you off the pedestal they put you on only to step up onto it themselves.

That period that immediately follows a child’s first sleeping through the night in which they decide to stay up all night and sleep through the day.

Adolescence – A Series of Crises (with thanks to Dr. Tracy

Vaillancourt)

• Identity – increasingly self-conscious, who do they want to affiliate with, sexuality

• Autonomy – move away from parental influence to that of peers

• Intimacy – relationships no longer based on common activities, now focuses on meeting emotional needs

A Series of Crises cont’d

• Sexuality – biologically driven• Risk-taking – stimulation-seeking• Egocentrism – concerned with how

others perceive them• This is a peak period for the emergence

of mental health issues – 1 in 5 in Ontario

Mental Illness 1 in 5 Canadians will experience

mental illness at some point during their lives.

Some estimates actually have 1 in 5 children and youth experiencing mental illness (e.g., Offord et al., 1989).

70% of mental health problems begin during childhood or adolescence.

Mental Illness cont’d So if mental illness affects 1 in 5, the

remaining 4 in 5 will have a friend, family member, or colleague with mental illness.

In other words, you, a family member, spouse, or friend will likely experience mental illness.

It ain’t “us and them” – it’s all of us!

Stigma and Mental Illness Refers to negative attitudes

(prejudice) and negative behaviour (discrimination) toward people with M.I.

Includes the belief that people with M.I. are not normal or like us; they caused their own problems; they can simply get over their problems if they want to.

Reflects our fear/avoiding of what we don’t understand (CAMH, 2011).

Stigma cont’d Only 50% of Canadians would admit

to having a family member with M.I. Only 49% said they would socialize

with someone who has a M.I. 27% are afraid to be around

someone with M.I. Stigma keeps people with M.I. from

seeking help.

Anxiety Disorders – A Pattern of False Alarms

Anxiety is a good thing – anticipating future danger or misfortune is helpful

Keeps us from diving into unknown waters or walking in a dangerous neighbourhood late at night

False Alarms cont’d When anxiety becomes extreme or

irrational, it goes from adaptive to maladaptive

Most common Mental Illness affecting 12% of population, more than half of which will develop as children or youth

Anxiety Disorders In general, in order to meet criteria

as an anxiety disorder, the associated fear is not just a brief and passing phenomenon, and is interfering with regular development/ normal functioning, and may or may not be recognized as excessive or unreasonable

Anxiety Disorders cont’d Panic Disorder Specific Phobia Social Phobia (Social Anxiety Disorder) OCD (DSM 5 change) Generalized Anxiety Disorder Separation Anxiety Disorder Anxiety Disorder NOS PTSD (DSM 5 change) Selective Mutism (DSM 5 change)

Panic Disorder

Recurrent, unexpected panic attacks With or without agoraphobia Worry about having further attacks

or the implications of having an attack (e.g., losing control, heart attack, etc.)

Interferes with normal functioning

Specific Phobia

• Exposure to phobic stimulus evokes an immediate anxiety response

• Situation is avoided or endured with intense anxiety/distress

• Interferes with normal functioning

Social Phobia (Social Anxiety Disorder)

Marked fear in social situations, particularly if dealing with unfamiliar people or scrutiny by others

Acutely sensitive to ridicule/humiliation/embarrassment

Social situations either avoided or endured with intense anxiety/distress

Interferes with normal functioning

OCD

• Obsessions – persistent thoughts, impulses, images that are intrusive and inappropriate; not just excessive worries about real life problems

• Compulsions – repetitive behaviours or mental acts the person feels driven to do because of obsessions or “rules”

• Interferes with normal functioning• DSM 5 – Obsessive Compulsive and

related disorders

Post-Traumatic Stress Disorder(DSM5 Trauma and Stressor-

Related Disorders)• Unique - requires a precipitating event

involving actual or threatened death or serious injury, or threat to the physical integrity of self or others

• Response involves intense fear, helplessness, or horror

• Event is re-experienced

PTSD cont’d

Avoidance of stimuli associated with the trauma and numbing of general responsiveness

• Increased arousal, e.g., hyper-vigilance • Interferes with normal functioning • Acute Stress Disorder is essentially PTSD

from 2-28 days post-incident

Generalized Anxiety Disorder

Excessive anxiety and worry the person feels unable to control

May at times be focused on specific situations (e.g., grades, health) but at other times, not directed at anything in particular but still worried

Interferes with normal functioning

Selective Mutism Consistent failure to speak in specific

social situations in which there is an expectation for speaking despite being able to speak elsewhere

The disturbance interferes with educational or occupational achievement or social comm’n

The duration of the disturbance is > 1 month

The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation.

Separation Anxiety Disorder

• Unique in that it is primarily in young children but can be youth as well

• Extreme anxiety about being separated from parents/home

• Developmentally inappropriate anxiety• Interferes with normal functioning

Bullying The effects of bullying on anxiety,

depression, and suicide rates have been consistently demonstrated (e.g., Miller, 2009).

10% of kids who bully are the stereotypical impulsive non-discriminating kid – anywhere, anytime, with anyone.

90% are actually quite popular, sneaky, and powerful (Vaillancourt, 2003).

Bullying cont’d The most popular kids are also the

most abusive of their peers. Very socially skilled (easily fool

parents and teachers), have high but fragile self-esteem, and command fear rather than respect or affection from their peers.

Boys and athleticism; girls and looks.

Resilience in Vulnerable Children and Youth

Who is vulnerable? Those who have experienced abuse, or come from families struggling with mental illness, substance abuse, violence, or other instability.

Protective factors: caring family, connection with school, caring adults, supportive friends with + social values (McCreary Centre Society, 2006).

Protective Factors and Resilience

Family and school connectedness were two of the most strongly protective factors for youth who were abused or came from challenging homes.

Liking school, feeling safe at school, and having a supportive adult in the family to talk to are all protective.

Relationships with friends having pro-social values has a demonstrably + impact.

The Developing Brain Brain develops to mid-20s Children’s brains – its about associations At puberty, pruning process – use it or lose

it Motor and sensory areas are quite

sophisticated in adolescents while decision-making (important for impulse-control and emotional regulation) centres remain underdeveloped

The Developing Brain cont’d When communicating with anyone in

crisis, important to understand how it affects not only their thinking, but also ours (i.e., the adult brain).

Big stress response (HPA Axis) results in blood being diverted from neocortex to lower areas (limbic and reptilian brains)

The Developing Brain cont’d Go into survival mode and the

reptilian brain kicks in Alligators are brilliant survivors,

“living fossils” that have existed 200M years

Alligators are not so good at problem-solving

The Developing Brain cont’d In survival mode, we get “alligator

stupid” (with thanks to Dr. Matthew Sharps)

Reptilian brain is reliable but rigid and compulsive

“Four Fs” – feeding, fleeing, freezing, and mating

The Developing Brain cont’d Survival mode is a vestige of our

hunter/gatherer brain Tunnel vision can be helpful if pursuing a

wild boar looking to turn it into dinner Not so helpful if staring at the hickey on

our teenage daughter’s neck or the crack in the new HDTV after our son invited a “few friends” over c/o Facebook while we were out of town

The Developing Brain cont’d Need our neo-cortex for more

advanced problem-solving (don’t try to fit head in peanut butter jar – get a spoon)

Also need the neo-cortex to manage sub-cortical parts of brain, and to separate affect from problem-solving

The Parent Brain (with thanks to Dr. Matthew Sharps)

When it comes to being a role model, it’s important to understand not only kids’ thinking, but also our own, particularly when stressed.

Big stress response (HPA Axis) results in blood being diverted from neocortex to lower areas (limbic and reptilian brains).

The Adult Brain cont’d

In survival mode, the reptilian brain kicks in (we get “alligator stupid”).

Reptilian brain is reliable but rigid and compulsive.

“Four Fs” – feeding, fleeing, freezing, and mating.

Not so helpful when navigating conflict with a child/youth.

The Adult Brain cont’d

While dealing with a crisis, important to get out/stay out of “alligator stupid” mode, and have the higher centres (better problem-solving) of the brain remain active.

Chronic stress, a bad night’s sleep, too many skinny pumpkin spice lattés (they were on sale), or a history of early trauma can make this more challenging.

Coping with Anxiety:Ours and Theirs

When appropriate, taking a few slow, big breaths can help (longer breaks if necessary).

Become the surrogate neo-cortex – get the child to slow down, help her/him see that there are other solutions.

PARAVERBALS – It’s not what you say but how you say it

As anxiety increases, people stop processing content.

Paraverbals refer to tone, volume, and cadence.

Woman without her man is nothing. Woman: without her, man is nothing.

ACTIVE LISTENING Two distinguishing characteristics:

• Listener grasps both the facts and feelings.

• Conveys that the other’s point of view is understood.

ACTIVE LISTENING When dealing with someone anxious or

agitated, recognizing and validating their feelings can help diffuse any anger: “you seem angry, what’s gone on?”

You can empathize/validate without agreeing with them: “I think I’d feel angry too if I thought someone had treated me like I was stupid.”

“Just calm down” is the fastest, surest way to achieve the opposite result (if not sure - ask your spouse).

ACTIVE LISTENING Offer your undivided attention and

sufficient time to address the concern. Use eye contact, other non-verbal cues to

convey that there is no more important way for you to spend your time at this moment.

Check the facts before countering with a rebuttal (you’ll get there) – “If I understand correctly…”

Take turns – get them to check their facts.

Classroom Accommodations for the Anxious Student

Check in with student on arrival Don’t penalize for being late

(symptoms at home often interfere with getting out the door)

Assist with peer interactions Anticipate difficulty with transitions Give notice re. changes in routine

Classroom Accommodations cont’d

Extra time for tests and assignments Safe place Use of nonverbal cues so as not to

centre out the student Model appropriate coping behaviours

Supporting the Anxious Child

Worry• Answer the “what ifs” and take away

anxiety associated with the unknown• Track improvements with feedback to

your child/youth• Have them rate their fear and then track

it

Support cont’d Emotional Outbursts

• Identify triggers with the child/youth• Encourage them to problem-solve (e.g.,

CPS)• Develop a hierarchy of safe places

(home and school) in which to de-escalate from a meltdown

Support cont’d Separation Anxiety (typically younger

children with school)• Begin classroom session with something

enjoyable to warm up the student• Parent can send a note congratulating

student on success• Allow a 30 second phone call from

student to parents (scripted and parents prompted not to respond to tears)

Support cont’d Social Fears

• Begin any group activity with one or two peers then gradually increase the numbers (i.e., don’t overwhelm them)

• Role play social interactions that could be difficult (e.g., going to restaurant and ordering food)

• Alternatives to oral presentations at school (e.g., record presentation)

Support cont’d OCD

• Encourage child to get unstuck using a countdown

• Snap rubber band on wrist• Challenge faulty logic (did you get sick

last time you used the washroom?)• Less intrusive rituals• Adjusted homework load• Recorded homework

Support cont’d PTSD - Hyper-vigilance is the most

common problematic symptom at home and school• Use a calm voice at all times• Help identify triggers• Work with child/youth to learn how to

interrupt the shutting down process

Support cont’d Selective mutism is not about power

and control – do not turn this into a power struggle

Complex communication difficulties require thorough assessment often with a multidisciplinary team (e.g., SLP, psychologist, physician), examine contributing factors

Support cont’d We need children/youth to learn to

identify what makes them fearful and then label it as external to them (i.e., it doesn’t define them)

Move towards “bossing back” the fear

If it interferes with activities of daily living, get professional help

Support cont’d Exposure/Response Prevention

• Not your job as parent • Vicious cycle of fear – avoidance –

increased fear has to be interrupted• Teach the anxious youth how to re-wire

their brain through E/RP• Annie and the slug• Same for elevators, public speaking,

counting by 3s

Connection/Attachment (with Thanks to Dr. Michael Cheng)

Attachment starts from Day 1 (essential for survival), but must continue to be nurtured throughout the lifespan.

Must balance child’s attachment needs with support from parent(s), family, community.

Connection/Attachment cont’d Tweens/teens may begin to turn

away from parents to meet attachment needs.

Peers more likely to be “fair weather” attachment figures, fickle, prone to abandon others, and reluctant to set limits, brains not geared towards mature decision-making.

Connection/Attachment cont’d Media portrayal of family has

devolved over time. In TV, from Cosby Show or Family

Ties to The Simpsons or Friends. In movies from Swiss Family

Robinson to Harry Potter. The message - parents are dweebs,

to be mocked or scorned; happiness comes from friends.

Connection/Attachment cont’d Other modern technologies similarly

interfere with attachment. Reinforces notion of parental

incompetence. Decreases likelihood that parents will

be seen as authorities on a subject. Divides attention (e.g., texting). Increases need for immediate peer

feedback (again, texting).

Connection/Attachment cont’d Impact of modern technologies:

• 30 years ago, a child is doing homework and needs to find the capital of Australia – how does he/she do this?

• Today, how would a child find out this information?

Connect – A Parent’s Attachment “To Do” List

Take an interest Cooperate/collaborate in their care –

with them, parents, other healthcare professionals, etc.

Catch them being good, but still okay to have consequences

Give them a voice (but not a democracy)

Model coping

Connect - More Attachment Stuff

Talk – about drugs, bisexuality, cyber-bullying, chronic physical illness, mental illness, self-harm, suicide (there’s no evidence that asking the question ever put the thought into someone’s mind)

Begin by answering questions – it’s never too soon to start

Connect - More Attachment Stuff

Competence, not competition (think of dating).

Express affection (say it, show it). Limit box time (TV, computer, video

games) and keep it out of bedroom (including cell phones).

Eat meals together. Really! Play games (no, not video games).

Connect - More Attachment Stuff

Spend time together unplugged (e.g., car rides).

Enlist their help (shared chores, cooking, baking).

Open-ended questions (e.g., “what was the hardest/best part of your day,” not “what did you learn in school today?”)

Connect - More Attachment Stuff

Model healthy imperfection – admit your flaws and when necessary, apologize.

Don’t assume that just because you’ve told them something, they will accept it –challenges to your values can provide an opportunity for discussion.

Welcome their friends in your home. Model self-care.

The (New) Three Rs Routine

• Bedtime stories, teeth-brushing, and getting clothes out for the next day may be outgrown, but not the need for structure/predictability

Ritual• Collective identity/part of a continuum

Ridiculous• Laugh

Remember Alligator stupid leaves us reverting to

old patterns of behaviour when stressed

Behooves all of us to model a calm approach to conflict and crisis resolution

Self-Care for Caregivers - Keeping Our Alligators at Bay

Deal with our demons Exercise, nutrition, water, sleep,

relaxation, and communication Balance Set a goal of one meaningful

conversation each day

And when necessary…

Sea Kelp

(Seek Help)

And Finally… An optimist will be wrong just as

often as a pessimist, but will have a whole lot more fun doing so.

Community Resources Youth Services Bureau (including

crisis beds, mobile crisis team, SHAG), Crossroads Children’s Centre, Children’s Aid Society, Dave Smith / Rideauwood/ Sandy Hill Addictions Services, YouthNet, Pink Triangle, Community Health Centres, Family Physicians.

Web-Based Resources www.cheo.on.ca www.ementalhealth.ca http://www.kidsmentalhealth.ca/child

ren_youth/learn_more.php http://www.centretownchc.org/media/

53436/glbttq_youth_resource_list.pdf