Overcoming Anxiety Information for Families

1
Overcoming Anxiety Information for Families

• Dr. Michael Cheng,
• Childrens Hospital of Eastern Ontario (CHEO)

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2
Contents

• Overview of anxiety
• What is it
• What can we do about it
• Where can we get help

3
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 (11 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
• Doesnt like discussing emotional issues with her
  mother

4
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)

5
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

6
How common are anxiety disorders

• 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!

7
What Causes Anxiety?

• Why
• does my child have anxiety?
• do I have anxiety?

8
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

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Stigma and Mental Health Problems

• 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 persons fault
  no one causes them to have anxiety, anymore than
  a person can cause themself to have a seizure
  disorder, diabetes or cancer

10
Why Do We Have Anxiety?

• Q. Where do you get your food from?

11
Where we get our food nowadays!
12
Q. But where did people get their food 10,000
years ago?
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A. Hunting (or Gathering)!
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To be a good hunter...

• You need to be brave...
• You cant be too anxious or scared because if you
  were too scared, then youd stay in your cave all
  day.

15
Q. But what would happen if you were too brave,
with no fear at all?
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Having no fear at all can get you into big
trouble!
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Just enough anxiety is good...!
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Balance 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

19
What happens in the body during anxiety / stress?
20

• When a caveman is dealing with these dangers, the
  caveman can either
• 1) Take flight or
• 2) Fight

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Nature gave human beings an alarm to deal with
dangers...
22
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 ____?
23
Bodys alarm helps us deal with 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
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Why is anxiety so common nowadays?
25

• Bodys alarm is good with episodic dangers
• E.g. being attacked by a wild animal, followed by
  no stress once the danger is gone
• Bodys alarm is not good with modern dangers,
  which might not be life threatening, but are
  constant and dont go away
• E.g. school pressure
• E.g. social pressure

26
Q. Why are young children so happy and confident
(compared to older children?)
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A. Young children are happy/more confident
because they are deeply connected (attached) to
parents
28
Although children need strong attachments to
parents, unfortunately what often happens to
child-parent attachments as children grow older?
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A. They weaken
30
Q. If a child turns away from parents, who do
they often turn to instead of parents?
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A. Peers
Dalai Lama, 1998 Neufeld, 2005
32
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.
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A. Turning to 1) peers, 2) things
(consumerism), 3) negative behaviours is bad
because

• They can never meet a childs 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

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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

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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)

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Why do so many of todays children/youth detach
from parents?

• Peer oriented culture
• Todays 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

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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
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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/developm
entor/the_impact_of_media_violence_on_children_and
_adolescents_opportunities_for_clinical_interventi
ons
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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

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What to do if you suspect anxiety
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Start by seeing the family 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

42
Attachment Strategies for Anxiety
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43
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

44
How strongly does your child try to attach to you?

• Does your child want to spend 11 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

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How strongly do you try to attach to your child?

• Does your child want to spend 11 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

46
Connecting through Empathy

• Of the various modes that people can attach or
  connect to one another, the deepest mode is
  through empathy and validation

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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

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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

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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

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Listen for feelings, accept and validate
(Connection before Direction)
EMPATHIZE I can see that youre feeling really
sad about this (giving supportive hug)
VALIDATE/ACCEPT Thats okay if youre feeling
sad
SOOTHE Well get through this How can I
support you? Do you want me to listen? Or do
you want some advice?
51
Avoid jumping to advice
Youre feeling sad about that? Come on, theres
a lot worse things than that Youll get over
it You need to just get over this
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If empathy and validation isnt enough, then
dont forget soothing

• Q. What do young children do when overwhelmed?

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If empathy and validation isnt enough, then
dont forget soothing

• Q. What do young children do when overwhelmed?
• A. They cry

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If empathy and validation isnt enough, then
dont forget soothing

• Q. What do we do when we see a young child crying?

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If empathy and validation isnt enough, then
dont 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.

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The most powerful self-regulation strategy

• Q. What do adults do when overwhelmed, e.g. when
  faced with a significant loss?

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The most powerful self-regulation strategy

• Q. What do adults do when overwhelmed, e.g. faced
  with a significant loss?
• We cry.
• Crying research shows
• Crying as attachment behaviour to elicit support
• Recovery theory ? Tears restore bodys
  homeostasis after stress
• Almost everyone feels better after crying
• How crying can make you healthier, The
  Independent, Nov 11, 2008

58
Be safe and validating so that your child is able
to cry with you
Emotions, tears/crying

• Empathy, validation, soothing, reassurance
• Leads to your child processing and integrating
  the stress, so that it is no longer a stress

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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

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Q. Youre 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?

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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

Neufeld, 2005
62
Whenever there is a physical separation, talk
about the next reunion

• Before your child leaves for school
• Parent See you after school Cant wait until
  we go for our walk later after school Ill be
  thinking about you all day
• Text your child during the school day
• Give your child transition objects, e.g. notes in
  your childs lunch box special jewelry or
  possessions
• Before parent leaves for an errand
• Parent See you in half an hour
• Before bedtime
• Youll be in my dreams See you in the morning
  What do you want for breakfast?

Neufeld, 2005
63
Whenever there is an emotional separation, talk
about the next reunion

• Parent
• Im really sorry, but youve been hitting your
  sister.
• Im very disappointed in your behaviour.
• This behaviour is unacceptable. Youre going to
  have to go to your room.
• Bridge the separation
• Ill check on you in a few minutes
• I love you, which is why were going to talk
  about this later and work this out.

Neufeld, 2005
64
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
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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

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Classic Strategies for Anxiety
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67
Get enough sleep!

• Set a regular bedtime routine
• Having a soothing routine
• Reading, relaxation music, etc.
• Remove stimulating things
• Remove televisions from bedrooms!

68
Eat a healthy diet

• Follow Health Canada food guide
• Breakfast
• Snack
• Lunch
• Snack
• Dinner
• In particular
• Having enough carbohydrates
• Limit caffeine or stimulants

69
Exercise

• Exercise has anti-anxiety effects
• Canadian Paediatric Society (CPS) recommends at
  least 1-hr daily

70
Martial 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

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Dealing with Stress/Anxiety
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Life is a balance between coping and stress
Demands / Stresses
Coping Ability
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Life is a balance between coping and stress
Demands / Stresses
Coping Ability
Physical Capacity
Physical Demands
Academic Ability
Academic demands
Social Skills
Social Demands
Emotional Intelligence
Emotional Demands
Etc...
Etc...
74
Q. What happens when demands/stresses gtgt coping?
Demands / Expectations / Stresses
Coping Ability
75
The overwhelmed individual may have

• Physical complaints
• Headaches, stomach aches, etc
• Emotional, behavioural problems
• Stress
• Depression, anxiety, irritability, anger, etc..

76
Reduce Stress / Improve Coping
? Demands / Expectations / Stresses
? Coping Ability
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What the Person with Anxiety Can Do
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78
Tell an Adult that you need their support

• Mom, can we talk sometime?
• Ive been feeling really stressed out.

79
Tell an Adult that you need their support

• Ive been really stressed with
• schoolwork
• people at school
• My friends
• my brother/ sister
• dad!
• I love you, but when you do ______, it stresses
  me out too!
• I need you to listen and support me. Ill let you
  know if I want your advice.

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How anxious / stressed are you feeling?
How stressed are you?
0 1 2 3 4 5 6 7 8 9
10
Downloadable from www.drcheng.ca
81
If you are feeling too stressed, then focus on
soothing and calming down first
How stressed are you?
0 1 2 3 4 5 6 7 8 9
10
Downloadable from www.drcheng.ca
82
If you are feeling not too stressed, that is a
good time to try to problem-solve any stresses
How stressed are you?
0 1 2 3 4 5 6 7 8 9
10
Downloadable from www.drcheng.ca
83
Dealing with problems and stresses
Problem-Solving

• Whether or not stress caused the anxiety, it
  doesnt help the situation
• Dealing with stresses is always helpful

84
Typical School Stresses

• Teachers / academics / homework
• Friends / other students

85
Typical Home Stresses

• Stress with
• Mom
• Dad
• Brothers
• Sisters
• Other relatives

86
Problem-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!

87
One common stress Disagreements or conflicts
with other people
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Conflict / 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

89
Solving Disagreements

• What does each person want or expect?
• Is it reasonable what each person wants?
• What do people share in common?
• Negotiate and compromise!

90
Negotiation/Compromise
Wishes or Expectations What person A wants? What person B wants?
Common Wishes or Expectations What both person A and B want What both person A and B want
Compromise What person A is willing to do or offer What person B is willing to do or offer
Limits Be assertive Be assertive
Parents may impose Limits and Consequences
91
Distraction and Calming Strategies

• Getting calmed down helps you feel better so that
  you can better deal with the underlying issue

92
Take Deep Breaths (e.g. mindfulness meditation)
93
Move (e.g. go for a walk)
94
Imagine a Relaxing Place
95

• Listen and/or Make Music

96

• Have a Chill Out Zone

97
Changing the Channel (i.e. Just Do Something
Different)
98
Change Your Thoughts, Change Your Feelings CBT
Strategies
99
Introduction to Cognitive Behaviour Therapy (CBT)

• Assuming that one already has good connections
  with the important people in ones life, then CBT
  can be another useful strategy for anxiety

100
You are waiting after school for your parent to
pick you up, but your parent is late! How would
you feel?
? Feelings
__________
Parent is late
__________
__________
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Event
Feelings
Parent is late
102
Q. How come one event can lead to so many
different feelings?
Parent is late
103
Events ? Thoughts ? Feelings
Parent islate...
104
Events ? Thoughts ? Feelings
Something bad has happened!
How dare she be late again!
Parent islate...
Its just bad traffic or shes getting me a
gift...
105
Events ? Thoughts ? Feelings
Negative Thoughts
? Coping Thought
Something bad has happened!
Nothing bad has happened before!
How dare she be late again!
Ill have more time to play with the others.
Its just bad traffic or shes getting me a
gift...
Im sure everythings just fine!
106
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

107
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!
Im just going to chill and have fun with my
friends!
108
Exposure hierarchy in CBT Life is like
weightlifting if there is too much weight, then
do things step-by-step
109
Doing Things Step by Step
Presenting in front of the teacher and the class
Presenting in front of the teacher and a few
classmates
Presenting in front of the teacher
Presenting in front of a parent
Presenting in front of yourself in a mirror
110
Counselling/Therapy for Anxiety
111
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)

112
Medications for Anxiety
113
Medications

• For severe anxiety, or if non-medication
  strategies have not been helpful, then
  medications may be very helpful for anxiety

114
Medications

• Generally affect serotonin in the brain
• Examples
• Fluoxetine (Prozac)
• Sertraline (Zoloft)
• Fluvoxamine (Luvox)
• Citalopram (Celexa)
• Escitalopram (Cipralex)
• Clomipramine (Anafranil)

115
Medications

• 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)

116
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 Childrens 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
• Parents Lifeline of Eastern Ontario (PLEO) (for
  parents of a child/youth with anxiety)

117
Looking for mental health help and information?
eMentalHealth.ca

• Mental health
• Services
• Programs
• Organizations
• Information sheets
• Screening tools
• News
• Events
• Research study directory

118
Summary

• Overview of anxiety
• What is it
• What can we do about it
• Where can we get help

119
Thank you for your attention!

• Any questions?

120
Acknowledgements and License

• Thanks to all the children, youth, families,
  educators, and fellow colleagues who have helped
  give feedback on these handouts!
• You are free to share and distribute as long as
  1) these materials are not used commercially, and
  2) as long as materials are distributed in its
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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
• Knowledge must be shared