overcoming anxiety information for families
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Overcoming Anxiety Information for Families. Dr. Michael Cheng, Children ’ s Hospital of Eastern Ontario (CHEO). Except where otherwise noted, content is licensed under a Creative Commons Attribution – Non-Commercial License; images are royalty-free stock photos. Contents. - PowerPoint PPT PresentationTRANSCRIPT
Overcoming Anxiety
Information for Families
Dr. Michael Cheng,Dr. Michael Cheng, ChildrenChildren’’s Hospital of Eastern s Hospital of Eastern
Ontario (CHEO) Ontario (CHEO)
Except where otherwise noted, content is licensed under a Creative Commons Attribution – Non-Commercial License; images are royalty-free stock photos
ContentsContents
Overview of anxiety What is it What can we do about it Where can we get help
Case: Britney Identifying data
17-yo female referred for suicidal ideation Living with mother, a busy professional Parents separated since age 5; no contact
with father for years Gr. 12 student
Current resources Individual counselling (1:1 with her and a
counselor) for several weeks with no improvement
HPI Anxiety and depressed for past few months Precipitating stressor
Boyfriend (of past year) broke up with her Doesn’t like discussing emotional issues with her
mother
What is an Anxiety Disorder? What is an Anxiety Disorder?
We all get worried from time to time
But when you have so many worries that it gets in the way of life, we call it an Anxiety Condition (or Anxiety Disorder)
Main types of Anxiety Disorders Main types of Anxiety Disorders
Generalized anxiety disorder Separation anxiety disorder Panic disorder Obsessive compulsive
disorder Phobias Social (phobia) / social
anxiety Anxiety Disorder Not
Otherwise Specified
How common are anxiety How common are anxiety disordersdisorders
The most common emotional/ behavioral problem
6.5% of children/youth at any one time
I.e. in a classroom of 30, there are at least 1-3 people with anxiety conditions!
What Causes Anxiety?What Causes Anxiety?
Why …does my child
have anxiety?…do I have
anxiety?
Many contributing factors…Many contributing factors…
Family history / genetics Some people are wired to be more sensitive to
anxiety, e.g. ‘highly sensitive’ or ‘orchid’ children Stresses in life
Past or current stresses which lead a person to feel that 1) “the world is unsafe”, and/or 2) “I am not competent” E.g. abuse, trauma, bullying, separation/divorce,
relationship stresses, struggles with school, academics, etc…
Stigma and Mental Health Stigma and Mental Health ProblemsProblems
Because anxiety is a brain condition, people with anxiety look ‘normal’
Because they look ‘normal’, its often hard for other people to understand what its like for a person to have anxiety
Realize that anxiety is not the person’s fault; no one causes them to have anxiety, anymore than a person can cause themself to have a seizure disorder, diabetes or cancer
Why Do We Have Why Do We Have Anxiety?Anxiety?
Q. Where do you get your Q. Where do you get your food from?food from?
Where we get our food Where we get our food nowadays!nowadays!
Q. But where did people get Q. But where did people get their food 10,000 years ago?their food 10,000 years ago?
A. Hunting (or Gathering)!A. Hunting (or Gathering)!
To be a good hunter...
You need to be brave... You can’t be too anxious or scared because if you
were too scared, then you’d stay in your cave all day.
Q. But what would happen if you were too brave, with no fear at all?
Having no fear at all can get you into big trouble!
““Just enoughJust enough”” anxiety is good...! anxiety is good...!
Balance is the keyBalance is the key
Having just enough anxiety is the key Too little is not good Too much is not good The key is to have JUST ENOUGH
What happens in the What happens in the body during anxiety / body during anxiety /
stress?stress?
When a caveman is dealing with these dangers, the caveman can either
1) Take flight or 2) Fight
Nature gave human beings an Nature gave human beings an alarm to deal with dangers...alarm to deal with dangers...
Imagine a sabre tooth tiger jumps out at you!
Q. What are the TWO main choices you have to survive this? You can either ____ or ____?
BodyBody’’s alarm helps us deal with s alarm helps us deal with danger...danger...
Adrenaline (aka norepinephrine) causes: Eyes dilate (to see better) Heart pumps faster (more blood to muscles) Breathing increases (more oxygen) Stomach stops working (more blood for muscles) Sweating (to cool down body when muscles get going)
All this helps the person to either:Fight Take Flight
Why is anxiety so Why is anxiety so common nowadays?common nowadays?
Body’s alarm is good with episodic dangers E.g. being attacked by a wild
animal, followed by no stress once the danger is gone
Body’s alarm is not good with modern “dangers”, which might not be life threatening, but are constant and don’t go away E.g. school pressure E.g. social pressure
Q. Why are young children so happy and confident (compared to older children?)
A. Young children are happy/more confident because they are deeply connected (attached) to parents
ParentChild
Although children need strong attachments to parents, unfortunately what often happens to child-parent attachments as children grow older?
ParentChild
A. They weaken…
ParentChild
Q. If a child turns away from parents, who do they often turn to instead of parents?
ParentChild
A. Peers
Child Parent(s)
Peers
Dalai Lama, 1998; Neufeld, 2005
Negative behaviours
Technology / Consumerism
Who do youth talk to about mental health concerns? Faced with a mental health issue, a female youth is most likely to disclose to:
Friends/peers (46%) No one (31%) Family (11%) Professionals (2%)
Faced with a mental health issue, a male youth is most likely to disclose to: No one (48%) Friends/peers (32%) Family (10%) Professionals (1%)
In other words, youth with mental health issues are even more vulnerable to being disconnected from parents…
Youth Net, personal communication; Davidson, S., & Manion, I. G. (1996). Facing the challenge: Mental health and illness in Canadian youth. Psychology, Health & Medicine, 1(1), 41-56.
A. Turning to 1) peers, 2) things (“consumerism”), 3) negative behaviours is bad because…
They can never meet a child’s emotional/ attachment needs as well as only healthy parents can
Only parents can reliably provide emotional support, acceptance and validation
Especially with peers Friendships come and go Peers are still maturing and changing Your BFF one day can be your worst
enemy the next…
Even if peer orientation works out temporarily…
A child that turns to peers for their needs may be temporarily happy when things are going well with peers
But with peers, the attachment will always be insecure -- there will inevitably be some disappointment Best friend moves away; conflicts,
disagreements with friends Peer-oriented child will be insecure,
stressed, anxious child…
Attachments with peers can be healthy when…
Peers do not replace parents as the primary attachment Friends as secondary
attachments
Peers are mature By adulthood, peers will
hopefully be mature enough to be able to meet the attachment needs (that perhaps parents cannot provide)
Why do so many of today’s children/youth detach from parents?
Peer oriented culture Today’s television, movies, music promotes the view that parents are
incompetent, and that friends (and having things, i.e. consumerism) are the most important goal in life
Modern technology such as internet, cell phones, social media Studies confirm that while our media may help keep us more connected
superficially, for many people they damage deeper, more intimate connections, e.g. “Facebook Depression”
Violence Desensitizing effects of video game, but also internet, television and
movie violence has the effect of reducing empathy for others, but also causes anxiety by directly teaching one that the world is an unsafe place
Video games are bad
Research confirms video games are bad for Behaviour / mood /
relationships Physical health, sleep Empathy
Video games great for Desensitizing people to killing Creating children/youth who
lack empathy and see violence as a way of solving problems
American Academy of Paediatrics, Media Policy Statement
TV Violence Decades of studies confirms that TV
violence contributes to aggression Typical North American child watches 28-
hrs of TV per week, more time than is spent in school
Prior to age 4, young children cannot distinguish between reality and fantasy
Young children imitate aggressive acts Older youth see violent heroes as cool Violence is justified against your
‘opponents/enemies’ Media rarely shows non-violent conflict
resolution
American Academy of Child and Adolescent Psychiatry, http://www.aacap.org/cs/root/developmentor/the_impact_of_media_violence_on_children_and_adolescents_oppor
tunities_for_clinical_interventions
Evidence confirms that adult-child relationships are the key
Key component to preventing depression/suicide is positive social and emotional connections between Teens and supportive adults Teens and school Teens and community
If you have strong connections with adults, then peer connections are not as important (or unnecessary)
Teens with strong connections with adults, even if socially isolated from peers are still resistant to depression/suicide
Keith, 2012
What to do if you What to do if you suspect anxietysuspect anxiety
Start by seeing the family Start by seeing the family physician or paediatrician...physician or paediatrician...
Assessment Questions to learn more
about the problem and whether or not it really is anxiety
Seeing if any medical conditions contribute
Diagnosis Treatment plans
Attachment Strategies for
Anxiety
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Ensure strong attachments and relationships with your child
Studies show that the strongest resiliency factor for mental health is strong connections between a parent and child
Humans are a social species Children are dependent on parents for survival The need to connect is hard-wired into all of us, and the
need to connect is important throughout the life span This need for connection or attachment is thus crucial for
Normal physical, cognitive and emotional development Happiness and contentment
How strongly does your child try to attach to you?
Does your child want to spend 1:1 time with you? Does your child want to be like you or have things in
common with you? Does your child try to be loyal to you and take your side? Does your child try to be useful or helpful to you? Does your child express love and affection to you? Does your child talk to you about feelings, and do you
provide 100% unconditional acceptance?Neufeld, 1991
How strongly do you try to attach to your child?
Does your child want to spend 1:1 time with you? Does your child want to be like you or have things in
common with you? Does your child try to be loyal to you and take your side? Does your child try to be useful or helpful to you? Does your child express love and affection to you? Does your child talk to you about feelings, and do you
provide 100% unconditional acceptance?Neufeld, 1991
Connecting through Empathy
Of the various modes that people can attach or connect to one another, the deepest mode is through empathy and validation…
Your close (female) friend / spouse tells you about the horrible day that she is having…
• Q. Most of the time, what does your (female) friend want you to do? 1) Give brilliant advice, 2) Listen and validate those feelings
Your close (female) friend / spouse tells you about the horrible day that she is having…
• Q. Most of the time, what does your (female) friend want you to do? 1) Give brilliant advice, 2) Listen and validate those feelings
Empathy and Validation • A core need that everyone has is to feel loved,
validated, appreciated, respected no matter what• No matter how good/bad you are• No matter how smart/dumb• No matter how pretty/ugly
• Secure, consistent caregivers can meet this need better than (insecure, inconsistent) peers • Empathize• Validate / Accept • Soothe
Listen for feelings, accept and validate (Connection before Direction)
SOOTHE “We’ll get through this…” “How can I support you?” “Do you want me to listen?” “Or do you want some advice?”
EMPATHIZE “I can see that you ’re feeling really sad about this…” (giving supportive hug)
VALIDATE/ACCEPT “That’s okay if you’re feeling sad…”
Avoid jumping to advice
“You’re feeling sad about that? Come on, there’s a lot worse things than that… You’ll get over it…”“You need to just get over this…”
If empathy and validation isn’t enough, then don’t forget soothing…
Q. What do young children do when overwhelmed?
If empathy and validation isn’t enough, then don’t forget soothing…
Q. What do young children do when overwhelmed?
A. They cry
If empathy and validation isn’t enough, then don’t forget soothing…
Q. What do we do when we see a young child crying?
If empathy and validation isn’t enough, then don’t forget soothing…
Q. What do we do when we see a young child crying?
A. We give them a hug, and provide emotional reassurance until they are no longer crying.
Crying is important, but unfortunately, many anxious teens have learned not to cry, or not to turn to adults.
Thus, helping them feel safe enough to cry with a supportive adult is essential.
The most powerful self-regulation strategy…
Q. What do adults do when overwhelmed, e.g. when faced with a significant loss?
The most powerful self-regulation strategy…
Q. What do adults do when overwhelmed, e.g. faced with a significant loss?
A.We cry….
Crying research shows… Crying as attachment behaviour to elicit support“Recovery theory” Tears restore body’s homeostasis after stressAlmost everyone feels better after crying
How crying can make you healthier, The Independent, Nov 11, 2008
Be safe and validating so that your child is able to cry with you…
ParentChild
Emotions, tears/crying…
•Empathy, validation, soothing, reassurance •Leads to your child processing and integrating the stress, so that it is no longer a stress
Bridge all separations
Anxious children/youth, at a very deep level, are often fearful of separations Physical separations, such as when they are physically away
from a parent E.g. going to school, or even bedtime
Emotional separations, such as worrying about parents being upset or overwhelmed
One powerful strategy to help anxious children/youth feel connected is to ‘bridge the separation’
Neufeld, 1991
Q. You’re just had a great date with someone, and you want to see the other person again… What do you say?
–1) “I had a wonderful time. Bye!”, or
–2) “I had a wonderful time. Want to get together on the weekend?”
Whenever there is a separation, talk about the next reunion
• If you as an adult would feel insecure about a lack of bridging, then think how insecure a child would feel...!
• Children naturally feel more insecure because they are still forming their primary attachments with caregivers…
ChildAdult
Neufeld, 2005
Whenever there is a physical separation, talk about the next reunion
– Before your child leaves for school– Parent: “See you after school” “Can’t wait until
we go for our walk later after school” “I’ll be thinking about you all day”
– Text your child during the school day – Give your child transition objects, e.g. notes in
your child’s lunch box; special jewelry or possessions
– Before parent leaves for an errand– Parent: “See you in half an hour”
– Before bedtime: – “You’ll be in my dreams” “See you in the
morning” “What do you want for breakfast?”
Neufeld, 2005
Whenever there is an emotional separation, talk about the next reunion
– Parent: – “I’m really sorry, but you’ve been hitting your
sister.– “I’m very disappointed in your behaviour.”– “ This behaviour is unacceptable. You’re going
to have to go to your room.”– Bridge the separation
– “I’ll check on you in a few minutes”– “I love you, which is why we’re going to
talk about this later and work this out.”
Neufeld, 2005
When there is a reunion, ensure there is a greeting– When the child wakes up in the morning
– “Good morning!”– When child comes home after school
– “Hello!”– “I was thinking about you when I was at work
today”– When parent sees child after a longer than usual
absence– “I missed you so much” “I was thinking about
you”
Neufeld, 2005
The Power of Attachment Strategies
Many times, attachment strategies will be sufficient
But sometimes, it will not be enough… Nonetheless, having a good attachment
between parent-child will always make it easier for other treatment interventions to take place…
Classic Strategies for Anxiety
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Get enough sleep!Get enough sleep!
Set a regular bedtime routine
Having a soothing routine Reading, relaxation music,
etc.
Remove stimulating things Remove televisions from
bedrooms!
Eat a healthy dietEat a healthy diet
Follow Health Canada food guide Breakfast Snack Lunch Snack Dinner
In particular Having enough carbohydrates Limit caffeine or stimulants
ExerciseExercise
Exercise has anti-anxiety effects
* Canadian Paediatric Society (CPS) recommends at least 1-hr daily
Martial Arts and YogaMartial Arts and Yoga
It is believed that yoga may be helpful for anxiety
Martial arts has been shown helpful for confidence / self-esteem
Ideally family classes to help with family bonding
Dealing with Dealing with Stress/AnxietyStress/Anxiety
Life is a balance between coping Life is a balance between coping and stress and stress
Demands / Stresses
Coping Ability
Life is a balance between coping Life is a balance between coping and stress and stress
Demands / Stresses
Coping Ability
Etc...
Physical Capacity
Academic Ability
Social Skills
Emotional Intelligence
Etc...
Physical Demands
Academic demands
Social Demands
Emotional Demands
Q. What happens when Q. What happens when demands/stresses >> coping? demands/stresses >> coping?
Demands / Expectations /Stresses
Coping Ability
The overwhelmed individual may have:The overwhelmed individual may have:
Physical complaints Headaches, stomach
aches, etc… Emotional, behavioural
problems “Stress” Depression, anxiety,
irritability, anger, etc..
Reduce Stress / Improve CopingReduce Stress / Improve Coping
Demands / Expectations /Stresses
Coping Ability
What the Person with Anxiety Can
Do
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Tell an Adult that you need their support
Mom, can we talk sometime?
I’ve been feeling really stressed out.
Tell an Adult that you need their support
I’ve been really stressed with:
1) schoolwork2) people at school
3) My friends4) my brother/ sister
5) dad!
I love you, but when you do ______, it stresses
me out too!
I need you to listen and support me. I’ll let you know if I want
your advice.
0 1 2 3 4 5 6 7 8 9 10
How stressed are you?
Downloadable from www.drcheng.ca
How anxious / stressed are How anxious / stressed are you feeling?you feeling?
0 1 2 3 4 5 6 7 8 9 10
How stressed are you?
Downloadable from www.drcheng.ca
If you are feeling too stressed, If you are feeling too stressed, then focus on soothing and then focus on soothing and calming down first…calming down first…
0 1 2 3 4 5 6 7 8 9 10
How stressed are you?
Downloadable from www.drcheng.ca
If you are feeling not too If you are feeling not too stressed, that is a good time to stressed, that is a good time to try to problem-solve any try to problem-solve any stresses…stresses…
Dealing with problems and Dealing with problems and stresses: Problem-Solvingstresses: Problem-Solving
Whether or not stress caused the anxiety, it doesn’t help the situation
Dealing with stresses is always helpful
Typical School StressesTypical School Stresses
Teachers / academics / homework Friends / other students
Typical Home StressesTypical Home Stresses
Stress with Mom Dad Brothers Sisters Other relatives…
Problem-solving each stressProblem-solving each stress
Stress or stressful situation: _____________
What I want to see different (my goal) _____________
Things I can try to deal with this stress 1. _____________
2. _____________
3. _____________
Finally -- try out a strategy until you find one that works!
One common stress: One common stress: Disagreements or conflicts Disagreements or conflicts
with other peoplewith other people
Conflict / DisagreementsConflict / Disagreements
A situation where One person(s) wants and expects one set of things The other person(s) wants and expects a different set
of things Common Issues
Rules at home Friends Control Life values Money
Solving DisagreementsSolving Disagreements
What does each person want or expect? Is it reasonable what each person wants? What do people share in common? Negotiate and compromise!
Negotiation/CompromiseNegotiation/Compromise
Wishes or Expectations
What person A wants?
What person B wants?
Common Wishes or Expectations
What both person A and B want
CompromiseWhat person A is
willing to do or offerWhat person B is
willing to do or offer
Limits Be assertive* Be assertive*
*Parents may impose Limits and Consequences
Distraction and Distraction and Calming StrategiesCalming Strategies
Getting calmed down helps you feel better so that you can better
deal with the underlying issue
Take Deep Breaths(e.g. mindfulness meditation)
Move (e.g. go for a walk)
Imagine a Relaxing Place
Listen and/or Make Music
Have a Chill Out Zone
‘Changing the Channel’(i.e. Just Do Something
Different)
Change Your Thoughts, Change Your Thoughts, Change Your Feelings: Change Your Feelings:
CBT Strategies CBT Strategies
Introduction to Cognitive Introduction to Cognitive Behaviour Therapy (CBT)Behaviour Therapy (CBT)
Assuming that one already has good connections with the important people in one’s life, then CBT can be another useful strategy for anxiety
Parent is late
? Feelings
__________
__________
__________
You are waiting after school for your You are waiting after school for your parent to pick you up, but your parent is parent to pick you up, but your parent is late! How would you feel?late! How would you feel?
Parent is late
Event Feelings
Q. How come one event can lead to so Q. How come one event can lead to so many different feelings?many different feelings?
Parent is late
Events Events Thoughts Thoughts Feelings Feelings
Parent islate...
Events Events Thoughts Thoughts Feelings Feelings
Parent islate...
Something bad has
happened!
How dare she be
late again!
Its just bad traffic – or
she’s getting me a gift...
Events Events Thoughts Thoughts Feelings Feelings
Something bad has
happened!
How dare she be
late again!
Its just bad traffic – or
she’s getting me a gift...
Nothing bad has
happened before!
I’ll have more time to play
with the others.
I’m sure everything’s
just fine!
? Coping ThoughtNegative Thoughts
Events Thoughts Feelings
Events lead to Thoughts Thoughts lead to feelings
Worry thoughts lead to feeling worried Happy thoughts lead to feeling happy Angry thoughts lead to anger Coping thoughts / realistic thoughts lead to better
coping
Thus...Thus...
In order to feel good and cope Figure out what negative, or worry thoughts you
are having Replace those with more positive, helping or
coping thoughts
I know something bad has
happened!
I’m just going to chill and have fun with my friends!
Exposure hierarchy in CBT Exposure hierarchy in CBT
Life is like weightlifting – if there Life is like weightlifting – if there is too much weight, then do is too much weight, then do things step-by-stepthings step-by-step
Doing Things Step by Step Doing Things Step by Step
Presenting in front of yourself in a mirror
Presenting in front of a parent
Presenting in front of the teacher
Presenting in front of the teacher and a few classmates
Presenting in front of the teacher and the class
Counselling/Therapy Counselling/Therapy for Anxietyfor Anxiety
Therapy and Counseling Therapy and Counseling
Various types of therapy/counseling CBT Interpersonal Psychotherapy Attachment-based
approaches Types of therapists/counselors
Psychologists Social workers Certified counselors Physicians (psychiatrists,
family physicians with psychotherapy training)
Medications for Medications for Anxiety Anxiety
MedicationsMedications
For severe anxiety, or if non-medication strategies have not been helpful, then medications may be very helpful for anxiety
MedicationsMedications
Generally affect serotonin in the brain
Examples Fluoxetine (Prozac) Sertraline (Zoloft) Fluvoxamine (Luvox) Citalopram (Celexa) Escitalopram (Cipralex) Clomipramine (Anafranil)
MedicationsMedications
Although there were concerns about medications such as SSRIs being unsafe in children and youth, newer research confirms that they are safe and effective when used appropriately (Bridge, JAMA, 2007)
Getting Help in Ottawa for anxiety In a crisis
Child, Youth and Family Crisis Line of Eastern Ontario, Agencies offering counselling
Youth Services Bureau (age 12-18) Crossroads Children’s Centre (age 4-12) Family Services Centre / Catholic Family Services / Jewish Family Services
Therapists in Private Practice Psychologists (to find one, visit College of Psychologists Ontario or Ottawa
Academy of Psychology) Self-Help, Mutual Aid
Anxiety Disorders Association of Ontario Parent’s Lifeline of Eastern Ontario (PLEO) (for parents of a child/youth with
anxiety)
Looking for mental health help and information? eMentalHealth.ca
Mental health Services Programs Organizations Information sheets Screening tools News Events Research study
directory
SummarySummary
Overview of anxiety What is it What can we do about it Where can we get help
Thank you for Thank you for your attention!your attention!
Any questions?
Acknowledgements and Acknowledgements and LicenseLicense Thanks to all the children, youth, families, educators, and fellow
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If you are a non-profit organization / health professional, feel free to contact use about adapting these for your own use
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