This was really hard for me. My daughter struggled with panic on and off for about 4 years. She wanted comfort and reassurance that everything would be okay. I gave her that reassurance. Was that the right thing to do? Maybe, maybe not. Let me explain.
If you are familiar with the treatment for anxiety you probably know or have heard about exposure and response prevention (ERP). If not, here are a few blog posts that will help make sense of it. (It is a crucial part of effective treatment.) It is important because the first response to anxiety is to escape or fix it, anything to make it go away. That avoidance becomes a key element in an anxious cycle that either perpetuates or makes it worse. These avoiding behaviors become ways to “play it safe.” Clinicians call them safety behaviors. Asking a parent for reassurance usually becomes a safety behavior. It takes the edge off the anxiety. Unfortunately, it interferes with exposure. Exposure can permanently and effectively reduce if not eliminate anxiety. From a treatment point of view it is okay to give initial reassurance but then to stop as the exposure process begins.
That is the clinical viewpoint. Now for mom and dad. To not give reassurance is like abdicating parenthood. Let’s be honest, how do you not tell your little one it will be okay or that you are not mad or check their forehead so you can tell them they are not sick, etc. When they are freaking out it is hard-wired that you do anything to help them. I can tell a parent all day long to stop reassuring, and they will say okay, and then cave in. I did. But here is the hard fact. In that moment you comfort them you are, in the long run, perpetuating their anxiety. This is way more than maybe, this is almost a sure thing. Let me offer some possible ways to be a loving parent but not get pulled into the cycle.
First let me clarify what kind of reassurance is a problem and what is just loving comfort. Here are some comparisons:
Comfort: Initiated by the parent. Example: "I know this is hard but we will keep working on this until it is better."
Reassurance: Initiated by child. Example: Constant apologies and asking if parent is upset.
Comfort: It is not necessary to repeat something over and over about things that are not really a problem
Reassurance: Repetitive requests about the same or similar things. Has a ritual feel to it. Sometimes requires exact words or phrases.
Comfort: No sense of pressure from child or feeling you have to stop an escalating cycle.
Reassurance: Sense of pressure that if you don't do this there will be a melt-down. Intensity may increase from child until they get "right" answer.
You may just have to go with your intuition on whether what you are doing is adding to an anxiety loop or not. If you decide it is then consider the following:
Don’t just stop it out of the blue. Explain clearly what you plan to do. Offer some middle ground. For example, at first they can ask two times a day. After several days, reduce it to one. Then every other day, etc.. You can start with more or less but gradually end the pattern. Make it clear and make sure they know it is coming. If you can write out the plan and get agreement that is a really good thing. If you are so tired of this you may want to rush. Don’t move to the next level until your child seems accepting of each step. (By the way, it is not a tidy process. Some days will be pretty easy and some will be horrible.)
Tighten your belt. You have got to get used to seeing your child anxious. It won’t hurt them. You are not being a bad parent. Be kind but firm. Don’t get angry. They will push. Get your guilt in check. If you got an agreement, refer back to that.
Make sure the any other adults agree and follow the plan. Kids know how to work the system.
Consider an anxiety answer book. Your child writes out the question and you write out the answer. (If your child is too young for this you can make an audio recording). When they ask you the same question you can refer them to the book. If they write the same question (or they get tricky and rephrase it) refer them back to the previous answer. This way they can read the answer as often as they want but it breaks the ritual. It is important to treat this book with a degree of seriousness. It isn’t used for anything else and it’s available. You have to give it attention frequently especially at first or it won’t work.
You will mess up. Face it, you will get suckered or you just can’t stand not stepping in. (Remember it is hard-wired.) For example your child says, “Mom, do you love me?” How do you not say, “Yes”, to that? But you know it is part of the ritual. Refer them to the book. Tell them you adore them later when it is not part of the ritual. You can even address this sort of thing when you set up the original plan. Don’t abandon this process. Just acknowledge that you did this and get back on track.
President Obama is his new budget proposal calls for children to begin school at age 4 but is that the best thing? Recent brain development research shows that children are not ready for school until at least age six. Finland, which consistently scores in the top 3 for high-school math and language scores waits till age seven to start their children. In this interview, Dr. McCarthy discusses this research and other things to consider before starting your child is school. For this link: When To Start School
Anxiety has it’s own unique set of “operating rules.” These are not obvious and sometimes opposite of what one might think. That leads to all kinds of information that is mistaken. Well-meaning but wrong. The Anxiety and Depression Association of America is offering a free webinar on April 17th called Common Myths About Anxiety Disorders. This is a quick preview of some of the common “myths” about anxiety.*
Myth 1: If you have an anxiety problem you should avoid stress or anything that will cause anxiety.
Fact: Avoiding anxiety makes it worse. You get brief relief but long-term grief. If you act like you are vulnerable and that a situation is dangerous, you will feel demoralized. You will have a harder time facing things the next time. You can be anxious and still do what you need to do.
Myth 2: If a panic attack gets too bad you might faint.
Fact: Fainting is caused by a rapid loss of blood pressure. During panic your blood pressure goes up slightly. It is extremely unlikely.
Myth 3: If anxiety gets too bad you might lose it.
Fact: Thoughts and images of losing control do not precede loss of control. You body is in an emergency mode. You are actually physically stronger, able to think fast and have quicker reflexes. This is what happens in real emergencies. The urge to escape can be misunderstood as losing control.** Your physical response is perfectly normal, just at the wrong time.
Myth 4: If you just eat right, exercise, avoid caffeine, take the right vitamins and live a healthy lifestyle then anxiety will go away.
Fact: You might reduce some stress but if you have an anxiety disorder it will not go away. The intensity of your symptoms may vary some due to stress but you need the right information, to face your fears and to make certain changes.
Myth 5: Anxiety Disorders are rooted in the past and treatment should focus on exploring childhood and earlier traumas.
Fact: Whatever the causes, the research is clear: focus on changing and managing one’s current thinking, feeling and behavior is what works with anxiety.
*Adapted from Myth-Conceptions or Common Fabrications, Fibs, and Folklore on the ADAA website.
**Barlow, David H.; Michelle G. Craske (2006-12-14). Mastery of Your Anxiety and Panic: Workbook (Treatments That Work) (Kindle Locations 1063-1071). Oxford University Press - A. Kindle Edition.
Anxiety treatment is stressful. From, “Where are my keys!” all the way to what my friend John would say, “I'm on a balcony 30 floors up with one foot on the rail and the other on a banana peel!” Your child’s anxiety WILL go up if you get them treatment. We often get the question regarding our anxiety program, “Will starting Turnaround cause my child to get more anxious?” and, “Will being exposed to the fears of other kids in the program give my child some new things to worry about?” Our answer: "Yes. It might." Anxiety treatment causes anxiety. If this is the point that you think, “Cause more anxiety? Why would I do that,” then you have just discovered the reason why anxiety is so hard to overcome.
My daughter’s fear started over throwing up. Not actually doing it, mind you, just the possibility of tossing her cookies. Recently, I was talking about that and using it to illustrate facing fears when a parent whose child has a similar fear said, “I’m not doing that because he might throw up.” (I was describing how the video clip, “Who Wants Chowder?” from Family Guy could be a good exposure step.) I’m not pointing fingers; I thought the same thing when my daughter’s fear began. We would avoid the words, sounds, TV shows, jokes, news or anything that might suggest regurgitation.
We made a mistake. A hindsight thing, 20-20 and all that.
You may think what I thought at the time. “I have to keep her from panicking!” I wanted to protect her from those terrible episodes. (It’s hard wired into parent-ness. If she is in pain I need to make it stop!) As I said, we would avoid anything that might bring up “the thing” and cause the panic. If we could keep away the triggers life could go on. We would tell her all the reasons why she didn’t have to worry. “You haven’t done “that” in years, you are not sick, it won’t happen, no need to worry, etc.” (Did you catch the reason this would never work? You can't prove that throwing up will NEVER happen.)
With all due respect to the natural parental urge to protect, trying to talk her into mental avoiding was a mistake. Here was part of our major mistake: We treated the panic like it was dangerous. She thought both vomit and panic were dangerous. By avoiding we acted like they were dangerous. We were all wrong.
Playing in a busy highway, that is dangerous. So are walking down dark alleys by yourself or feeding the "cute" bears in the forest. Definitely avoid those. Do NOT avoid things that aren’t actually dangerous, like upchucking (My mom’s oblique moniker. I suppose it was better than her saying “barf”) or panic. Neither one is dangerous.
The problem was not vomit or vomiting but the BELIEF about it. Throwing up is unpleasant but NOT dangerous. She believed it was terrible, embarrassing and dangerous. That mistaken belief was the problem.
Anxious beliefs have to be disproved. They have to be put to the test. Will something make me throw up? If it does will it be as bad as I think? Facing means feeling fear first. When you start facing you still believe it enough to activate the fear. You won't go straight to disproving without feeling it first.
“Fight or flight” is the name we give to our bodies activating response to danger. It is what we describe as terror, horror, fear, excitement, rage, etc. It supercharges our bodies to help us deal with danger, challenge and obstacles. It is not an infallible system. Anxiety disorders are mistakes by this defense system. They are false alarms.
“Fight or flight” is an activating response designed for real danger. “Ewww, Yuck!” is the response for puke. A danger reaction like terror doesn't fit. Terror is for looking out of your doublewide at a tornado, treating a major client to an expensive dinner then discovering you don't have your wallet, or riding the Intimidator 305 at King’s Dominion Amusement Park.
Your child has to disobey her "fight or flight" system while it shouts, flashes and shakes its warning. You are going to feel that when you disobey it. It is just a false alarm, a mistake. Noisy and powerful but wrong.
You have to disobey your parental urge to protect her from distress. One of the hardest things you may ever do is see that scared look on your child’s face, “Help me!” and respond, “No, you can do this.”
You can ease into the fear, face it a little at a time, that is fine. But you can’t avoid it. If you run across an anxiety cure that promises a way to skip over the hardship right to peace and bliss don’t waste your money. Treatment causes stress. It has to. Mistakes require correction.
Without question, one of the hardest things to do when you are anxious is to voluntarily face your fear. It is the last thing in the world you want to do. Everything in you wants to do just the opposite. Therapists spend a lot of time in treatment trying to persuade clients to face their fears. As a parent, this is a huge issue. How many hours have we all spent trying to get our kids to not be afraid and do the things they need to do? Here are few things that may help:
Can you break it down into steps? If you are trying to get you child to school and they are melting down or leaving class then drive them to the campus and sit in the parking lot. Start with that. Next have them go into the building. Maybe they can sit in the counselors office. Keep moving forward. If you run into a roadblock, break it down into a smaller step. Keep doing the same step until it gets easier then move to the next. It may take some time arranging with the school or where ever there is the problem. One of my young clients was afraid of the doctor so I got some scrubs and we put them on in my office. Find things like what they fear and start with that. It may take a while, just be patient and persist!
Give them some control. It is better to focus on what someone is willing to do rather than what they won’t do. Start with that. Exposure works better when it is voluntary. However, don’t give the option to NOT do it, just what they can do for now. For example, do you want to focus on the issue now for 15 minutes or after dinner for 25 minutes? Find something they will agree to. One young man was socially anxious. He would flip out about going to church. His parents mapped out what would probably happen and let him pick who he would greet with eye contact. Then they built on that. He had some control but he had to continue to greet people and face his fear.
Remove the option to not do it. If you child is afraid of the dentist then they shouldn’t have the option to not go. They may have the option to go with you and be in the room while you have an exam. They have to do something. If they think there is an option to NOT do something they will make that their life's goal. It is easy just for the sake of peace to give in. Don’t be persuaded by that. If you give in one day, then work on it the next day. Even if there is a setback one day that doesn’t change the overall process.
Don’t freak out when your child gets anxious. A common question we get is whether or not the Turnaround program could give a child more things to fear. The answer sometimes is yes. When you start facing anxiety it gets worse most of the time. I tell people to expect this. You have to keep going and not back away from it. When you have a moment of peace the last thing you want to to stir it up. This is the wrong way to think about it. You are obeying the anxiety! It is hard to see your child in a panic, really hard. Don’t you panic! Anxiety disorders rarely end without a fight. It is hard work. You may lose it and get so angry. There may be shouting and door slamming. I know you may be at your wit’s end. Your heart may be breaking but you must find the strength to keep going. If you are calm, it will help them when they are facing fear.
Praise, praise, praise. Encourage, encourage, encourage. They may have to borrow hope from you. We would say to our daughter, “It is just anxiety.” “You may make headway today or another day but you WILL make headway.” “This is a stage of life to work through, not your whole life.” “You will grow up and have a fine life.” “Maybe you will have anxiety at times but that won’t keep you from a good life.” “You will get educated.” “It takes as long as it takes.” “We will figure this out.” Give your child a hopeful future and the solid commitment to do what has to be done. Each step give real encouragement. Be honest and don’t ignore the present hardship by minimizing. There is a big difference between saying, “It isn’t that bad,” and “It feels really bad right now but it will get better.” You may not feel hopeful at moments but step back and get your bearings. Maybe you have battled anxiety yourself. Speak out of your own experience. Maybe you have not done as well as you would like coping. Use this hard time to say let’s both work on it.
Anxiety was an intense and often overwhelming issue for 4 to 5 years of our life. There were moments that I wasn’t sure I could continue to take it...and I'm the adult (at least sometimes). I’m sure my child felt the same if not worse. She couldn't always describe her feelings and thoughts but I still remember the fear in her eyes. If you are in middle of struggling with one or more of your kids who are anxious you may wonder how long will this go on? Will this take years? Will it be a lifelong battle? What if it ruins their life? Here are a few thoughts that I have come to realize that might be helpful.
1. The built-in need and ability to be anxious never goes away.
It is necessary for life. It is the message that there is a big problem. We all have to learn how to deal with hardships, problems and dangers. Life is hard. We need an alarm system. That is permanent. Thank God for that. An anxiety disorder is just the normal system giving off false alarms. I tell my patients that nothing is wrong with the alarm system itself, only that it is going off at the wrong time. There will always be anxiety. That is good. Healing is coping with and getting control of false alarms. Bottom line: It is just a false alarm.
2. Crippling anxiety with correct treatment gets better. Better is better, not perfect. It is not either/or. Doing better is success. Don’t predict the future based on where your child is on any given day. It may take a while. Your life may get really messed up. This is a hard word but it will almost certainly take longer than you hoped for things to improve. It will be up and down. Bottom line: Don’t give up. Keep working on it, it takes as long as it takes.
3. People will give lots of advice. They mean well. Bottom line: If someone hasn’t been through this then they probably don’t know what they are talking about. Thank them but don’t take their "well-meaning" critique to heart.
4. Life is not ruined if you or your child struggles with anxiety. A lot of people (in their hard moments) feel like if they have to continue with anxiety their life just gets ruined. Frankly, that type of thinking will make a person feel really bad. Be careful to not compound the problem with catastrophic thoughts. An anxiety disorder is an incredibly hard thing for a kid and parent(s). Really hard. Life can still be good. Even in the worst case anxiety is only part of a persons life. Bottom line: Part of life doesn’t ruin all of life. Discipline your mind to find the good, hopeful and wonderful part of life.
I think I will add a few more thoughts to this list. I would love for you to contribute any principles that have been helpful for you. Email them to me and I’ll add them in another blog. (Let me know if I can use your name). email@example.com
We join the nation in grieving the loss of those fallen in Newtown, CT.
Parenting an anxious child is incredibly difficult. If the anxiety interferes with school then it is even harder! Talk about a bind! School is mandatory in most places and if your child is resisting because of anxiety that it is a perfect storm for escalating panic. The more they miss, the more pressure to go and as pressure increases so does the panic. I've been there. It is a nightmare.
If the school resistance lasts more than a few days and seems to be increasing you should start the process of getting help. It might pass but it doesn't take long for anxiety to build steam. It might take a while to get an appointment or find the right kind of help. Start with the school counselor if there is one.
Here is the first principle that you must treat as foundational. Avoidance is not a good solution for anxiety. It is so tempting because it gives immediate relief but it truly makes the anxiety worse in the long run. When this is just beginning many parents will give their child some relief by letting them stay out a day or so. I mean everyone can use a break now and then, right? However, this little bit of relief becomes amazingly reinforced. Think of it from a child's point of view. Panic or stay home with mom or dad? Once this is an option it will become very desirable. As panic builds the need for relief gets desperate. Developmentally kids really don't get the long term effect of not going to school. They just want relief now.
I can't emphasize this enough, If there is any way you can do it, keep your child going to school. Ok but let's face it, if your child is freaking out what parent won't be tempted to give their child relief? I mean you are probably freaking out as well. A natural reaction is to pull back and get your bearings. Plus, who wants to send a crying child to school? Can they even learn if they are continually anxious? It just looks like a no-win situation. What if you are a single parent? Is there even anyone who can stay with your kid? Everything can change in just a couple weeks.
You are not being a bad parent if this happened. Being compassionate is not being a wimp. Who would of guessed it would have gotten to the place your kid can't go to school? Sometimes it isn't clear the problem is anxiety until well into it. By the way, a frequent complaint is nausea or stomach pain. While it is probably anxiety you should pay a visit to the pediatrician anyway.
Schools don’t like kids to miss too many days for obvious reasons. They will likely get pretty intense as late and missed days pile up. Some schools have an "enforcer" who hears all kinds of excuses and treats this as one of those situations. They may even begin to talk about failing the grade or other consequences depending on the local laws. You must become your child’s advocate. You may have to educated some of the staff. You may have to stand up to the staff. Many schools will work with an anxious child but you will need a plan. Parent's often worry that if they disclose this problem their child will get judged. That is possible but engage anyway. This is more important for their life than their 3rd grade teachers opinion. Work with the school counselor or your child’s therapist to create a gradual plan to get your child fully attending school. See if the school will work with that.
If it looks like it full attendance is not going to happen within a reasonable amount of time look into a 504 plan. This is a section of the Americans with Disabilities Act and it applies to students. You can look online for information about this. This will keep your child on track academically while you work on the anxiety. Once they are back at school the plan will be dropped and everyone moves on. Many parents are reluctant to go this direction because they are concerned their child will be “labeled” or that the school administrators or teachers will be upset about having to do this. That may happen but consider giving the school the benefit of the doubt. Most of the people there chose this career because they care about kids. Even the "enforcer" may be an ally once the problem is understood. Also, they have to try to treat all the students equally and this plan will give the school permission to go above and beyond for you child. And it they don’t like it, too bad, your child may need the help and that's their job.
Keeping your child in school is obviously the best thing but in the real world sometimes you just can’t get your child in school or they are just missing too many days to make it up. What then?
Not everything I am about to mention is even an option in many situations. If you end up considering one of these options, keep the goal of fully returning to school for the future. These are from most desirable to least.
1. Change to a school that is similar in size, requirements, demographics, etc. For example, one of my clients moved from a large private school to a similar size public school. He was having panic nearly every day in the first school and last I talked with him he hasn’t had any anxiety since going to the new school.
2. A school that is smaller, more flexible, has more resources for kids with difficulties. These are usually private schools but some places have specialty schools that are part of the public school system. In our area we have magnet (specialty) schools and some Montessori schools. This may be less stressful overall and they may be able to be flexible enough to reduce the overall anxiety. The staff may have more time since there are fewer kids.
3. Home School. I am not saying home school is negative at all or the least desirable educational option. It may be first choice for many families. I am saying avoiding is negative. Depending on the situation home school can be a major avoidance. In some areas, home school parents form groups for their students to have classes together. Join that if possible. If this isn’t available find ways for your child to go into other situations that require some risk. This can be private classes, sports activities, volunteer situations, etc. The key is to face the fear in any way you can.
If you have to pull your child out of a situation that has become unworkable you still need to keep them facing their fears. Do what they can do. Then gradually increase the challenge of their exposure. This can be a long process. It might not be the “plan.” It might be embarrassing. But it is what it is. What you can do is keep working on it. Your child will get educated, they will get through this, they can have a great life.
I have already written about the first two reasons that can keep someone stuck in their anxiety in Part 1 of this blog. You can read that here.
Continuing on, the third reason anxiety may persist is that you are not putting the fear to the test. Say you want to walk to the other side of busy highway. Imagine the fear being something like, “I will distract drivers, cause an accident and get arrested.” In your mind, you rehearse the danger and think of all the things that could go wrong. How do you disprove the fear?
You have to cross the street. It may take crossing a lot depending on how scary it seems. Is there some risk? Yes, but it is safe enough. Each time you test the fear it is increasingly disproven. We do this all the time. I remember the first time I drove some friends out of town. I just got my license. We took a two-lane country road. Every truck that passed in the other lane evoked serious anxiety in me. Now I hardly give driving a second thought. It is still risky and I still have some level of vigilance but I am used to it.
Fourth, you may only be partially putting the fear to the test. Continuing with the previous example, what if you will only cross the street certain times of day when the traffic is light or only with a crowd of people? If you only cross then you will be “playing it safe”. You still have not fully disproven the fear. This is where you have to live with uncertainty and risk. You have fully put the fear to the test. In this case crossing would include high traffic and by yourself. The purpose of testing is to dis-confirm the fear – all of it.
Finally, maybe you need to make a decision. This is actually a type of avoiding. You may be avoiding dealing with something that requires a decision. Maybe you are worrying about a report for example. “What should I include in the report? How well will I do on the report? When will I write the report because I’m not sure what to write? What if I do poorly and there is a bad consequence so I have to make sure I write something great and so forth.” What is being avoided in this example? Writing the report. You are postponing writing. Sometimes people will add other things to the list of problems and then it gets so complicated and elaborate this strengthens the belief that a decision can’t be made. Sometimes it is wise to wait to decide but sometimes it can just be avoiding something that requires a choice. Avoiding that decision will keep someone anxious.
We get anxious and/or feel fear frequently in the normal course of life. Most of the time we don’t even remember it. It comes, it goes, it is just part of life. But when it gets stuck or cranks up to a critical mass what has happened?
Think of the function of fear. It is a warning system. There is a problem so it commands, “Do something! Solve it!” If you can solve the problem or it goes away then the anxiety ends. So what is happening when the anxiety stubbornly persists?
To put it simply, if you are still anxious then you have not solved the problem. You may be very committed to solving it. You may even to go extraordinary lengths. But if you are stuck, then your attempted solutions are malfunctioning in some way. If I may, I would like to suggest some possible reasons your real and earnest attempts might be unsuccessful.
First of all, if you are worried or anxious about something you may want to know with 100% certainty that the problem is fixed and things are safe. This urge for certainty is usually specific to the problem. Most of the time that is just not possible. In the rest of life we all settle for close enough. We live with risk every day. No matter how hard you try you can’t know with 100% certainty that something bad won’t happen. If you are worried you might pick up a virus and if you want certainty you may go through daily life captivated by everything you have to avoid touching. But you still are not sure, not matter how hard you try. If you want to be free of fear you have to touch those things. The uncertainty is making you anxious and you try to solve the problem by achieving 100% uncertainty. Unfortunately, you just can’t know you are safe with 100% certainty. If you want to overcome an anxiety problem the first step is agree to live with uncertainty. You do anyway. We all do. You just have to accept the risk. Not accepting uncertainty will keep you anxious. Is the burden of fear really worth it since you can't achieve certainty?
Second, a core fear may not be addressed. For example, if you feel panic at school that is a problem you have to solve. The most obvious solution that comes to mind is not go to school. Shouldn’t that stop the panic and fix the problem? You will get quick relief but you have not solved the problem. First, it causes other big problems. Second, the problem is still present - it is just at the school. Having a panic attack at school is not the core fear. The core fear will be something like, “I will have a panic attack when I don’t want one and be completely embarrassed in front of my class. That will be awful, terrible, humiliating and I can’t live with it.” One aspect of the core fear is humiliation. If you try to solve it by avoiding school you don’t address this core fear. You have to disprove the fear that you will be humiliated and that you can’t live with it. You still fear humiliation, just at home. In fact, not going might also cause humiliation. The truth is that you can live with it. You may not like it but you can bear it. But you have to deal with it to know that. In fact, by avoiding it you make it stronger because you are acting in support of the core fear. You are making the case to yourself that you can’t bear it. To stop being afraid you have to face the core fear.
Here are a few common core fears:
Fear of harm to self or others
Fear of losing control or going crazy
Fear of being responsible for something terrible
Fear of embarrassment
Fear of being judged
Fear of being imperfect
Check back for Part 2 in the near future.