1. Understanding and Supporting the Anxious Child Allan Donsky MD FRCPC Psychiatry FRCPC Pediatrics Clinical Assistant Professor, Department of Psychiatry, University of Calgary Adjunct Professor, Department of Child and Youth Studies, Mount Royal University Mountain Park November 21, 2013

3. Learning Objectives What is anxiety ? Can Anxiety be “normal” ? How does it arise ? What does Anxiety look like ? What can I do about it ?

4. Birth-6 MonthsLoud noise, loss of physical support, rapid position changes, rapidly moving objects 7-12 MonthsStrangers, looming objects, sudden unexpected objects or unfamiliar people 1-5 YearsStrangers, storms, animals, dark, separation from parents, loud noise, toilet, monsters, ghosts, insects, bodily harm 6-12 YearsSupernatural beings, bodily injury, disease, burglars, staying alone, failure, criticism, punishment Common Age Related Fears

5. What do children have to worry about ?

6. School Related Fears Separation from home Bus Performance anxiety Academics Interacting with peers or teachers Bullied Eating in front of others Using the bathroom Changing for gym

7. 7

8. The most Challenging Decade in life Sex Money Future Identity Academics Independence Sexual Orientation Social Competence

9. General Principles Root word : Anxious, Anger, Anguish = Torment Anxiety can be a Symptom or a Disorder. Synonyms : apprehension, anguish, unease, concern, nervous, misgiving, qualm, disquiet, distress, dread, distraught, threatened, uneasiness, edgy, jittery, trepidation, timid, tense, uneasy, consternation,worry. Anxiety is apprehension, tension, or uneasiness from Anticipated danger. Anxiety has survival value Impairment or distress/suffering makes it a Disorder

10. 10 The Spectrum of Fear and Anxiety in Children Typical, developmentally appropriate Severe anxiety symptoms

11. How common are Mental Health Disorders ? DisorderEstimated Prevalence % Any Anxiety Disorder6.4 ADHD4.8 Conduct Disorder4.2 Any Depressive Disorder3.5 Substance abuse0.8 PDD0.3 OCD0.2 Any Eating Disorder0.1 Tourette Syndrome0.1 Schizophrenia0.1 Bipolar<0.1 Any Disorder14.3 Waddell, Offord et al Can J Psychiatry 2002;47(9):825-832

12. What about temperament ? Arousal Behavioral Inhibition J Am Acad Child Adolesc Psychiatry. 1993 Jul;32(4):814-21.

13. How does Anxiety arise ? Genetics Temperament Environment Family Insecure Attachment Modeling Stress Media School Social Trauma Anxiety +/- Disorder Psychological Splitters and Clumpers

14. Response to Anxiety Fright ( Experience) Freeze ( “ Deer in headlights” ) Flight (Avoidance ) Fight ( Argue, Fuss, Oppositional ) Faint (injury)

15. What might Anxiety look like ? Physiological Cognitive Experiential Behavioral

16. Physiological Somatic symptoms Mild Panic Recognizable as fight or flight Breathing Heart rate Muscle tension Tummy aches Sleep, nightmares Tired

17. Cognitive Worry is a defining feature Attention Concern about adult matters Catastrophic thinking Rigid Hard time letting go Struggle to make choices Unable to see success Negative view of self and others

18. Experiential Dread Sensitive Hyper-vigilant Low self worth Low self esteem

19. Behavioral Fight Flight ( avoidance) Freeze Repetitive actions Nail biting, licking lips, pull hair, chew clothing, pacing Obsessions (repetitive thoughts) or compulsions. Need for reassurance, help seeking, overdependence

20. Why is Anxiety missed ? Awareness Internalizing Silence is seen as absence of problem Tend to normalize shyness Labeled as other things ( very unhelpful !! )

21. Labeled as other things Oppositional Defiant Manipulative Attention seeking Demanding Confrontational Sneaky Pushes buttons Lazy Avoidant Selfish Aggravating Annoying Ignorant Rude Stubborn The real question: “What is going on ?”

22. So what if there is Anxiety? Academic Attendance, Avoidance, Underachievement Behavioral Avoidance, oppositional Cognitive No risks, confidence, image Developmental Image, success, confidence, Emotional Stunted Family Power struggles, tired Physical Gym avoidance Social Loneliness, tobacco & alcohol use

24. Common Beliefs About Worries: All untrue Worrying: Motivates me Helps find solutions to problems Prevents negative outcomes Protects me from negative emotions Is a positive personality trait …it means I care Francis, K. & Dugas, M. J. (2004). Assessing positive beliefs about worry: Validation of a structured interview. Personality and Individual Differences, 37, 405-415.

25. Pedal, Steer and Brake

26. What can I do to help ? Treat own Anxieties Get Educated Stop Criticism Rescuing” – Makes it worse Dismissing their experience Reassuring the wrong way ( “ Don’t worry”) Start Reassuring the right way ( “ You can handle this “) Bravery = Support activities in spite of Anxiety Encourage facing new situations

27. Are Feelings Real ? “My feelings are real but they don’t always tell me the truth”

28. Relationship is everything Establish trust People don’t care how much you know till they know how much you care Be authentic …let them see your weaknesses Stay calm….even if you do not know what to do ! Act as a coach, not solver Recognize patterns so they can be: Explored Explained Expanded Have proactive conversations Use student’s ideas first and then yours

29. How much do I push ? Stress Performance Breaking point Rage Lose it Meltdown Freak out Over-react Peak PushBack off

30. Life is Simple, not easy Moments Feelings Actions Helpful Unhelpful ( F words) Avoidance Relief “Pop ups” Anxiety Education Relaxation Emotional vocabulary Coaching Reality check Evidence Realistic & Constructive Worry Thermometer Mastery & Pleasure Internal praise Modeling Social engineering Exposure Experiments Problem Solving Thoughts

31. Perfectionism

32. Excellence and “ Good Enough” Perfectionism is unattainable = set up for failure = never feel good enough = give up or burn out trying Need to be real Effort is most important Honor roll is 80 % No such thing as a mistake what is worst thing that can happen ? Celebrate “Not knowing” “Own it,fix it, Show some learning “ Self worth is not tied to achievement

33. Balancing Act for Adults Gentle Firm limits Refrain from Criticism Exposure Courage/Bravery Treat Parental Anxiety Unified & Consistent Goldilocks

34. Educational Learning Disabilities Attentional issues can be secondary School Modifications Teacher/ Resource and Admin support Time out/Quiet place Bullying Academic load Homework issues Tutoring. Attendance

35. But I don’t have time to do this ? Definition of Insanity……… Until you stop doing what is not working there is no space to do something different

36. Online Resources American Academy of Child and Adolescent Psychiatry. Aacap.org Anxiety Disorders Association of America adaa.org AnxietyBC™. Anxietybc.com Canadian Paediatric Society. caringforkids.cps.ca/behaviour/fears.htmcaringforkids.cps.ca/behaviour/fears.htm Chansky, T. (2004). Freeing your child from anxiety: Powerful, practical solutions to overcome your child’s fears, worries, and phobias. New York: Broadway Books. Cheng, M. (2006). Selective mutism: A guide for teachers. www.drcheng.ca/resources/Articles/selective_mutism-for_school.doc Cheng, Mi. (2009). Overcoming anxiety: A guide for families. www.drcheng.ca/resources/Articles/anxiety_info_for_families.doc Garland, E.J. & Clark, S.L. (2000). Taming worry dragons: A manual for children, parents,, and other coaches. Vancouver, BC: Children’s and Women’s Health Centre of British Columbia. “ What to do when you worry too much; A kids guide to overcoming Anxiety” Dawn Huebner

37. Counselling Recommendations When Dr. Donsky presented to our staff, he recommended the following people for counselling services: Julie Brock – 220, 7370 Sierra Morena Blvd. SW 403-686-8379 Dan Drybrough – Learning Solution 102, 7370 Sierra Morena Blvd. SW 403-685-0880 Julie Robinson – Bonavista Medical Clinic 739 Lake Bonavista Drive SE 403-278-2434 Leona Doig - 403–540-8773 Doug Murdoch - 403–440-8536 ** Dan Drybrough and Julie Robinson have come with high recommendations from our parents.