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TRANSCRIPT
Strategies for helping children
to understand and manage their
anxiety.
Maria Ivanka Milić Clinical Psychologists
Psychstuff4kids
Westmead + Chatswood
Ph: 0411 36 11 26
1
“ANXIETY”
• What is anxiety?
• What does it looks like?
• Strategies:
psychoeducation/understanding
structural,
behavioural &
cognitive tools.
2
What is anxiety?
• Normal emotion which is adaptive and important to our lives.
• Triggered by “threat”.
• Everyone gets anxious.
• Real and perceived threat.
• Three aspects to anxiety : physiological, cognitive, & behavioural.
© Maria Ivanka Milic, Clinical Psychologists, Psychstuff4kids 3
ANXIETY: When is it helpful?
Very poor
PERFORMANCE
Very good
Average
ANXIETY LEVEL
Very calm aroused panic
4
ANXIETY: The Psychological model
Trigger
situation
thought
bodily sensation
© Maria Ivanka Milic, Clinical Psychologists, Psychstuff4kids Westmead and Chatswood 5
Words in my
mind.
If I…..then…
What if…..
F
e
e
l
i
n
g
s
Actions:
Avoidance of
feared trigger Bo
dy
cl
ue
s
What may trigger anxiety feelings?
• Everyday events.
• Temperament.
• “Normal” fears and anxieties at a particular
developmental stage.
• Expected and unexpected changes.
• Acute and/or ongoing stresses for child, family,
community.
• Individual life challenges (eg. learning, friendships).
© Maria Ivanka Milic, Clinical Psychologists, Psychstuff4kids 6
Flight - fight response • The body reacts to real and perceived threats in the same way.
• The body prepares to run, freeze or fight the threat.
• Perceived threats are not the sorts of threats that you can easily run,
freeze or fight so there is no corrective response that would remove
the FFF symptoms.
• Over-breathing (and possibly hyperventilation) causes the carbon
dioxide levels to change and any of the following bodily changes:
– light headedness - difficulties concentrating
– dizziness - tingling sensations in hands
– weakness in the legs - pain in the chest
– increased heart beat - irregular heart beat
– tightness in the chest
– feeling you cannot breathe
CONCLUSION: the physical symptoms are real, not imagined
© Maria Ivanka Milic, Clinical Psychologists, Psychstuff4kids
Primary Anxiety
© Maria Ivanka Milic, Clinical Psychologists, Psychstuff4kids Westmead and Chatswood 8
My primary anxiety(ies)
Primary + Secondary Anxiety
© Maria Ivanka Milic, Clinical Psychologists, Psychstuff4kids Westmead and Chatswood 9
Anxiety about my anxiety
My primary
anxiety(ies)
Levels of anxiety.
© Maria Ivanka Milic, Clinical Psychologists, Psychstuff4kids Westmead and Chatswood 10
Anxiety about how you will respond
to my anxious behaviour
Anxiety about my anxiety
My primary
anxiety(ies)
ANXIETY: What does it look like?
Different for different children:
• slower in starting & completing tasks
• avoidant (“stubborn” & “defiant”)
• irritable and snappy out the door
• confused quiet, reserved
• over plan/organise meltdowns/tears
• very compliant very very helpful
© Maria Ivanka Milic, Clinical Psychologists, Psychstuff4kids Westmead and Chatswood
11
Impact of anxiety:
• Executive functioning skills.
• Cognitive tiredness.
• Missed opportunities for learning • classwork,
• “I can do it!”
• can cope with the feeling and it does go away,
• anxiety bigger than it needs to be,
• new skills
© Maria Ivanka Milic, Clinical Psychologists, Psychstuff4kids 12
Executive Functioning Cooper-Kahn & Laurie Dietzel (2008). Late Lost and Unprepared: A
Parent’s Guide to Helping Children with Executive Functioning.
List of executive functions:
1. Inhibition: “Stopping myself!”
2. Shift: “Can I move my thinking around?”
3. Emotional Control: “ Stop and think when feeling”.
4. Initiation: “getting started and thinking about how to start”
5. Working Memory: “how much can I hold in my thinking” “my
RAM”
6. Planning/Organisation: “of what I have to do now and in the
future”
7. Organisation of Materials: “where are my things”
8. Self-Monitoring: “how am I going?”
13
When is anxiety “clinical”?
• Children who met criteria for a diagnosis of anxiety disorder
become anxious more easily, more often, and more intensely.
• The anxiety significantly interfers with functioning : school,
social, family.
• Disproportionate anxiety present for 6 months of more.
• These children are not different.
• Most common disorder occurring in children and adolescence.
• Under diagnosed and yery treatable.
• If Anxiety in children and adolescence is left untreated ->
increased risk of depression, adult mental health disorder.
© Maria Ivanka Milic, Clinical Psychologists, Psychstuff4kids Westmead and Chatswood 14
Clinical Anxiety Diagnoses
DSM-V anxiety disorders in children and adolescents :
– Separation Anxiety Disorder
– Selective Mutism
– Specific Phobia
– Social Anxiety Disorder
– Panic Disorder
– Agoraphobia
– Generalised Anxiety Disorder
– Unspecified Anxiety Disorder
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Anxiety Management :
Practical Strategies
• Adult and situation considerations.
• Talking feelings.
• Educating children about anxiety.
• Helping children manage physical symptoms
• Detective thinking
• Fighting Fears by Facing Fears’ (exposure)
© Maria Ivanka Milic, Clinical Psychologists, Psychstuff4kids Westmead and Chatswood 16
In the classroom: • Use strategies to compliment executive functioning/learning eg.
break down tasks into stages, regular breaks.
• Model coping talk out loud in class.
• Allow and coach flexibility in tasks.
• Make things predictable and familiar when eg.
– Changing activities
– Starting a new activities
– Doing an unfamiliar activity
– Giving a more complex task
• Make clear expectations of how you want the task completed
• When disciplining the class, be aware of who you are disciplining.
• Watch for tiredness and overload.
© Maria Ivanka Milic, Clinical Psychologists, Psychstuff4kids Westmead and
Chatswood
17
Can I detect and talk feelings?
The child:
© Maria Ivanka Milic, Clinical
Psychologists, Psychstuff4kids 18
How do I talk about and to anxiety?
• It is OK to feel anxious. Eliminating or avoiding anxiety is not the
solution. One builds resilience by learning “I can feel anxious and I
can manage this feeling. I am OK.””I can ask for help if I need to.”
• Be aware of one’s own emotional response (eg. your tone of voice,
body language, words).
• Your role is to support not to “take away” the child’s anxiety.
• Modelling a positive way of talking about your own feelings helps.
• Think about the now for a few minutes. Once acknowledged, think
about what they can do now to return to task. Plan for how the anxiety
can be managed in more detail later (Who? When? Where?).
© Maria Ivanka Milic, Clinical Psychologists, Psychstuff4kids Westmead and Chatswood 19
Can I detect and talk feelings?
• Labeling emotions
• Younger children (e.g., under 6) – may need to
do this for them ‘looks like you might be feeling
anxious right now, I can tell because you are
tensing your face and looking scared’
• Older children (e.g., > 6 years) – ask ‘how are
you feeling right now?’ May still need to guess
and label emotion for them
© Psychstuff4kids Westmead and Chatswood 20
How BIG are my feelings of
anxiety?
© Maria Ivanka Milic, Clinical Psychologists, Psychstuff4kids Westmead and Chatswood 21
Ways to decrease the physical symptoms
• Explain physical symptoms (“psychoeducation”) about the flight-
fight response.
• Help them to monitor their own body and learn which symptoms they
get.
• Strategies:
– Slow breathing exercise.
– Relaxation/mindfulness techniques.
– Distraction techniques.
– Exercise
• Repetition is critical.
• Progress is not smooth.
• Adults in the environment need to remain calm.
• Reward the child for their efforts.
© Maria Ivanka Milic, Clinical Psychologists, Psychstuff4kids Westmead and Chatswood 22
Thinking
Like a detective, look for the evidence….
© Maria Ivanka Milic, Clinical Psychologists, Psychstuff4kids Westmead and Chatswood 23
Anxiety makes us think:
-Something bad will
happen,
-Overestimate likelihood,
-Overestimate how “bad”
it will be,
-Underestimate our ability
to cope.
Like a detective ask questions:
Acknowledge the fear though then wonder with the child aloud:
- Has it ever happened? What happened? How often?
- Has it ever happened to their friend or classmate? What happened?
How often?
- If it has happened or less happened, what have they noticed actually
happened?
- Is Mr Worry playing tricks and telling you lies?
- Is it only a little problem or not a problem, and Mrs Naughty is making it
sound really really big and bad?
Chat out loud, your own unhelpful thoughts and helpful coping
thoughts in a situation you were scared.
Reflect on what you have learnt about anxiety
- “Mr Scared shrinks if I ignore his words and keep trying”.
© Maria Ivanka Milic, Clinical Psychologists, Psychstuff4kids 24
Facing the fear - Graded Exposure
• Fears are faced gradually, working from lesser fears through to
greater fears.
• The child should stay in the feared situation “long enough” for their
anxiety/fear to drop so that they learn “nothing bad will happen”.
So, the longer they stay the better.
• Repetition is critical.
• Progress is not smooth.
• Monitor for subtle avoidance and distraction.
• Excessive reassurance must be avoided.
• Adults in the environment present as calm.
• Reward the child for their efforts.
© Maria Ivanka Milic, Clinical Psychologists, Psychstuff4kids 25
As the support person it is important to:
• Encourage and support the child to practice facing their fears.
• When the child is facing their fears:
– Ask the child to rate their level of anxiety before the exposure.
– Monitor for subtle avoidance and distraction, and if you notice any, remind
them they need to focus back on the task.
– Avoid giving (excessive) reassurance. Ok to give them some helpful self-
talk if they are young
– If the child refuses to do the task, physically forcing them to do so is not
effective and could be detrimental.
– Reward the child for their efforts.
© Maria Ivanka Milic, Clinical Psychologists, Psychstuff4kids Westmead and Chatswood 26
Some helpful resources: Rapee, Wignall, Spence, Cobham, Lyneham (2008) Helping Your Anxious Child:
A Step-by-Step Guide for Parents (2nd Edition)
Gottman (1997) Raising and Emotionally Intelligent Child: The Heart of
Parenting.
For the parent or teacher to read with the child:
• Morgan & Cartlidge (2004) Brave Mouse
• Zelinger & Zelinger (2011) Please Explain “Anxiety” to Me! Simple Biology and
Solutions for Children and Parents.
• Ironside (2011) The Huge Bag of Worries.
• Cook (2012) Wilma Jean the Worry Machine
• Al-Ghani (2013) The Panicosaurus: Managing Anxiety in Children Including Those
with Asperger’s Syndrome.
• Huebner (2006) What to Do When You Worry Too Much: A Kid’s Guide to
Overcoming Anxiety
©Maria Ivanka Milic, Clinical Psychologist, Psychstuff4kids Westmead 27