Overcoming
Anxiety
Information for Families
Dr. Michael Cheng,
Children’s Hospital of Eastern
Ontario (CHEO)
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Attribution – Non-Commercial License; images are royalty-free stock photos
Contents




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?


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







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
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 13 people with anxiety
conditions!
What Causes Anxiety?
 Why
…does my child
have anxiety?
 …do I have
anxiety?

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
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 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
Anxiety?
Q. Where do you get your
food from?
Where we get our food
nowadays!
Q. But where did people get
their food 10,000 years ago?
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 enough” anxiety is good...!
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
What happens in the
body during anxiety /
stress?



When a caveman is dealing with
these dangers, the caveman can
either
1) Take flight or
2) Fight
Nature gave human beings an
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 ____?
Body’s 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
Why is anxiety so
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
Child
Parent
Although children need strong attachments to
parents, unfortunately what often happens to
child-parent attachments as children grow
older?
Child
Parent
A. They weaken…
Child
Parent
Q. If a child turns away from
parents, who do they often turn
to instead of parents?
Child
Parent
A. Peers
Negative
behaviours
Peers
Technology /
Consumerism
Child
Parent(s)
Dalai Lama, 1998; Neufeld, 2005
Who do youth talk to about
mental health concerns?

Faced with a mental health issue, a female youth is most likely to disclose to:


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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:

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

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

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
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


Modern technology such as internet, cell phones, social
media


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
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

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Typical North American child watches 28hrs 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_m
edia_violence_on_children_and_adolescents_opportunities_for_
clinical_interventions
Evidence confirms that adultchild relationships are the key

Key component to preventing depression/suicide is
positive social and emotional connections between

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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
suspect anxiety
Start by seeing the family
physician or paediatrician...

Assessment

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
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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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Attribution – Non-Commercial License; images are royalty-free stock photos
Ensure strong attachments and
relationships with your child

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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?
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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?

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



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)
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…”
SOOTHE “We’ll get through
this…” “How can I support
you?” “Do you want me to
listen?” “Or do you want some
advice?”
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 selfregulation strategy…
Q. What do adults do
when overwhelmed,
e.g. when faced with a
significant loss?
The most powerful selfregulation 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 stress
Almost 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…
Emotions, tears/crying…
Child
Parent
•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?
“I had a wonderful
time. Bye!”, or
–1)
“I had a wonderful
time. Want to get
together on the
weekend?”
–2)
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…
Adult
Child
Neufeld, 2005
Whenever there is a physical separation,
talk about the next reunion
–
Before your child leaves for school
–
–
–
–
Before parent leaves for an errand
–
–
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
Parent: “See you in half an hour”
Before bedtime:
–
Neufeld, 2005
“You’ll be in my dreams” “See you in the morning”
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!


Set a regular bedtime
routine
Having a soothing
routine


Reading, relaxation music,
etc.
Remove stimulating things

Remove televisions from
bedrooms!
Eat a healthy diet

Follow Health Canada food
guide






Breakfast
Snack
Lunch
Snack
Dinner
In particular


Having enough carbohydrates
Limit caffeine or stimulants
Exercise

Exercise has antianxiety effects

* Canadian Paediatric Society (CPS)
recommends at least 1-hr daily
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
Dealing with
Stress/Anxiety
Life is a balance between coping
and stress
Coping Ability
Demands / Stresses
Life is a balance between coping
and stress
Coping Ability
Demands / Stresses
Physical Capacity
Physical Demands
Academic Ability
Academic demands
Social Skills
Social Demands
Emotional Intelligence
Emotional Demands
Etc...
Etc...
Q. What happens when
demands/stresses >> coping?
Coping Ability
Demands /
Expectations /
Stresses
The overwhelmed individual may have:

Physical complaints


Headaches, stomach
aches, etc…
Emotional, behavioural
problems


“Stress”
Depression, anxiety,
irritability, anger, etc..
Reduce Stress / Improve Coping
 Coping Ability
 Demands /
Expectations /
Stresses
What the Person
with Anxiety Can
Do
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Attribution – Non-Commercial License; images are royalty-free stock photos
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) schoolwork
2) people at school
3) My friends
4) 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.
How anxious / stressed are
How
stressed
are
you?
you feeling?
0
1
2
3 4 5 6 7 8 9 10
Downloadable from www.drcheng.ca
If you
are
feeling
too
stressed,
How
stressed
are
you?
then focus on soothing and
calming down first…
0
1
2
3 4 5 6 7 8 9 10
Downloadable from www.drcheng.ca
If you are feeling not too
How stressed
are
you?
stressed,
that is a good
time
to
try to problem-solve any
stresses…
0
1
2
3 4 5 6 7 8 9 10
Downloadable from www.drcheng.ca
Dealing with problems and
stresses: Problem-Solving


Whether or not stress
caused the anxiety, it
doesn’t help the situation
Dealing with stresses is
always helpful
Typical School Stresses


Teachers / academics / homework
Friends / other students
Typical Home Stresses

Stress with





Mom
Dad
Brothers
Sisters
Other relatives…
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!
One common stress:
Disagreements or conflicts
with other people
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
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!
Negotiation/Compromise
Wishes or
Expectations
Common Wishes or
Expectations
What person A
wants?
What person B
wants?
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
Distraction and
Calming 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 Feelings:
CBT Strategies
Introduction to Cognitive
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
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
__________
__________
Event
Parent is late
Feelings
Q. How come one event can lead to so
many different feelings?
Parent is late
Events  Thoughts  Feelings
Parent is
late...
Events  Thoughts  Feelings
Something
bad has
happened!
Parent is
late...
How dare
she be
late
again!
Its just bad
traffic – or
she’s getting
me a gift...
Events  Thoughts  Feelings
Negative Thoughts
Something
bad has
happened!
How dare
she be
late
again!
Its just bad
traffic – or
she’s
getting me a
gift...
? Coping Thought
Nothing bad
has
happened
before!
I’ll have more
time to play
with the
others.
I’m sure
everything’s
just fine!
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...

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
Life is like weightlifting – if there
is too much weight, then do
things step-by-step
Doing Things Step by Step
Presenting in
front of the
teacher
Presenting in
front of a parent
Presenting in
front of yourself
in a mirror
Presenting in
front of the
teacher and a
few
classmates
Presenting in
front of the
teacher and
the class
Counselling/Therapy
for Anxiety
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
Anxiety
Medications

For severe anxiety, or if non-medication
strategies have not been helpful, then
medications may be very helpful for anxiety
Medications


Generally affect serotonin
in the brain
Examples
 Fluoxetine (Prozac)
 Sertraline (Zoloft)
 Fluvoxamine (Luvox)
 Citalopram (Celexa)
 Escitalopram (Cipralex)
 Clomipramine (Anafranil)
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)
Getting Help in Ottawa for
anxiety

In a crisis


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


Child, Youth and Family Crisis Line of Eastern Ontario,
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
Summary

Overview of anxiety
What is it
What can we do about it

Where can we get help


Thank you for
your attention!
Any questions?
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
entirety
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
Except where otherwise noted, content is licensed under a
Creative Commons Attribution – Non-Commercial License