What’s a Kid to Do? Anxiety and Stress in
Children & Adolescents
Lauren H. Kerstein
2015
With Today’s Presentation, You Will...
• Develop an understanding of what anxiety
looks like in children and adolescents
• Sort out the role that “normal” child
development plays in anxiety
• Explore ways to increase your child’s
capacity for flexible thinking
• Fill your toolbox with strategies that will help
you help your child manage stress
OUR MAIN GOAL IS TO:
BUILD ON STRENGTHS
Lauren H. Kerstein LCSW, P.C. 2012
Anxiety Looks Different in Children
DSM-5 Anxiety Disorders
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Separation Anxiety Disorder (309.21)
Selective Mutism (312.23)
Specific Phobia (Codes based on phobic stimulus)
Social Anxiety Disorder (Social Phobia) (300.23)
Panic Disorder (300.01)
Agoraphobia (300.22)
Generalized Anxiety Disorder (300.02)
Substance/ Medication-Induced Anxiety Disorder
Anxiety Disorder Due to Another Medical Condition (293.84)
Other Specified Anxiety Disorder (300.09)
Unspecified Anxiety Disorder (300.00)
DSM-5 Obsessive-Compulsive and Related
Disorders
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Obsessive- Compulsive Disorder (300.3)
Body Dysmorphic Disorder (300.7)
Hoarding Disorder (300.3)
Trichotillomania (Hair-Pulling Disorder) (312.39)
Excoriation (Skin-Picking Disorder) (698.4)
Substance/Medication-Induced Obsessive-Compulsive and Related
Disorder)
• Obsessive- Compulsive and Related Disorder Due to Another Medical
Condition (294.8)
• Other Specified Obsessive-Compulsive and Related Disorder (300.3)
• Unspecified Obsessive-Compulsive and Related Disorder (300.3)
DSM-5 – Trauma and Stressor Related
Disorders
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Reactive Attachment Disorder (313.89)
Disinhibited Social Engagement Disorder (313.89)
Posttraumatic Stress Disorder (309.81)
Acute Stress Disorder (308.3)
Adjustment Disorders
Other Specified Trauma- and Stressor- Related
Disorder (309.89)
• Unspecified Trauma – and Stressor- Related Disorder
(309.9)
The Wright Family
Anxiety Triggers
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Dark
Separation
Movies
Peer/Social
Nightmares
Tests
Deadlines
Changes in Season
Darkness/ Increased Light
End of School
Anticipation of a new teacher
Anticipation of a special day– holiday, birthday
RED FLAGS: Chansky, 2004
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Excessive distress out of proportion to the situation
Easily agitated, angry or distressed
Repetitive “what if” concerns
Won’t respond to logic
Headaches, stomachaches
Anticipatory anxiety
Sleep disruption
Perfectionist tendencies– nothing is good enough
Overly responsible
Unnecessary apologizing
Concerned that others are upset with them
Avoidance and/or refusal
Excessive time spent consoling/ coaxing in daily activities
Child Development
Child Development and Anxiety
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Anxiety is a normal developmental pattern
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Typically, anxiety first appears at about 7–9 months, when infants demonstrate
stranger anxiety and become upset in the presence of unfamiliar people.
(Developmental Milestone: Discriminate between people)
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A second developmental milestone occurs at about 12–18 months, when toddlers
demonstrate separation anxiety. (Aware parents may not return. Object
permanence, object constancy)
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Separation anxiety is usually resolved by age 2
http://www.nasponline.org/resources/intonline/anxiety_huberty.pdf
Child Development and Anxiety
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Up to about age 8 children tend to become anxious about specific,
identifiable events, such as animals, the dark, imaginary figures (monsters
under their beds), and of larger children and adults.
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After about age 8, anxiety-producing events become more abstract and
less specific, such as concern about grades, peer reactions, coping with a
new school, and having friends.
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Adolescents also may worry more about sexual, religious, and moral
issues, as well how they compare to others and if they fit in with their
peers. Sometimes, these concerns can raise anxiety to high levels.
After the Fight or Flight Response…
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Does anxiety decrease?
Intensity?
Severity?
Duration?
Frequency?
How Do Children and Adolescents
Experience Anxiety?
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Physical Symptoms
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Behavioral Symptoms
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Cognitive Symptoms
Physical Symptoms
Neurological
Body Reactions
Other Physical Symptoms
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Difficulty breathing
Stomachaches
Sleep disruption or trouble falling or staying
asleep
Headaches
Fatigue
Nausea
Dizziness
Unidentified illnesses
Behavioral
Behavioral Symptoms
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New or increased clinginess
Challenges with separation
Extreme shyness (that is out of character)
Refusal or oppositional behavior
Fidgeting
Need for repetition, increased predictability, or
rituals
Increase or emergence of rigidity
Unwillingness to try new things or avoidance
Shutting down
Other Behaviors
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Hair twirling
Hand wringing
Nail biting
Shutting down
Increased motor activity
Repetitive questions
Repetitive behavior
Cognitive Symptoms
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Thought distortions or patterns
Inability to make a decision
Perceptions of interactions, the environment
and events that are inaccurate or skewed
Challenges with concentration
Challenges with learning
Cognitive Symptoms
Perception of Threat (following a
trauma)
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Neurological
Physical
Emotional
Cognitive
Social Perspective
Sensory
State Memory/ Reptilian Brain
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Trauma is stored in State
Memory
Lower limbic system
Not rational– part of
emotional brain
Processes raw data
Fight, flight, freeze/fall
asleep
Stress
State Memory
Triggers all previous
relevant memories
Assumption: This
current situation is
threatening
FEAR DYNAMIC LEADS TO REPETITIVELY NEGATIVE
BEHAVIORS
If you believed that a particular behavior would ensure your
safety, wouldn’t you engage in that behavior?
Vicious Cycle
FEAR
“BEHAVIORAL” RESPONSE
PERPETUATION OF BELIEF
SYSTEM (IF I DO THIS, I STAY SAFE)
MAINTENANCE OF MALADAPTIVE
BEHAVIOR
ANXIETY in the Classroom or At Home
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Many people look at the child’s fear response as “behavior”
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Irritability
Fatigue
Frequent Somatic Complaints
Decline in Grades
Anger
Aggression
Defiance
Dishonesty
Refusal
Rigid
Withdrawal
Poor coping skills with everyday stressors
Need for reassurance
Suicidal ideation
Lauren H. Kerstein LCSW, P.C. 2012
A PERSPECTIVE SHIFT - SKILL FILTER
DEVELOP A BETTER
UNDERSTANDING OF ANXIETY,
AND THEN BUILD A TOOLBOX
OF STRATEGIES
Develop a More Concrete Understanding
of Feelings
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What are feelings
What do they look like
What do they feel like
Background Information/ Context
Triggers
Intensity
Decision Making/Control
Strategies
Lauren H. Kerstein LCSW (2010)
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SOCIAL/ EMOTIONAL CONTEXT
Lauren H. Kerstein LCSW, PC 2013
Kerstein, L. (2008). My Sensory Book: Working Together to
Explore Sensory Issues and the Big Feelings They Can Cause: A
Workbook for Parents, Professionals, and Children. Shawnee
Mission, KS: Autism Asperger Publishing Company.
Feeling Intensity and Decision Making
Lauren H. Kerstein LCSW (2010)
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SELF CHECK THERMOMETER
10
Things that Cause Me Stress
Relaxation Strategies
HIGH STRESS
HIGH STRESS
MEDIUM STRESS
MEDIUM STRESS
LOW STRESS
LOW STRESS
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Lauren H. Kerstein LCSW, PC 2010
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Interventions
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Identify anxiety symptoms
Make the anxiety concrete
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Worry bug
Lizard
Draw it
Name it
Describe it
SPECIFIC INTERVENTIONS
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Dialectical Behavior Therapy
Cognitive Behavior Therapy
Thought Distortions
Cognitive Restructuring
Wizard/ Lizard
Worry Bug/ Fly Swatter
Flip it
Negative thinking charts
Develop an understanding of feelings
Develop an understanding of triggers
Role Plays
Progressive Relaxation
Self-monitoring
Help the individual recognize strengths
Reward system for conquering fears
Children’s Automatic Thoughts Scale
Lauren H. Kerstein LCSW,
P.C. 2011
BREAKING THE CYCLE (STRATEGIES)
Trigger
Neg Thought
Neg Feeling
Strategy
Lauren H. Kerstein LCSW, PC 2010
Strategies
Know your triggers
• Reward… Reward… Reward
• Model It, Demonstrate It
• Giraffes Can’t Dance
• Scaredy Squirrel
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Flexible Thinking
MODEL IT
• Rock brain, “brainpoline”
• Flexi brain
(Michelle Garcia Winner)
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You want
me to do
what?
Find Your Brainpoline
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Switch seats
Drive a different way
Clay brain versus rock brain
Wizard/ Lizard
Breakfast for Dinner
Change your language/ talk about
flexibility/ model it!
Problem Solving Grid
Problem
Feelings
Outcome 1
Outcome 3
Solution 2
Lauren H. Kerstein LCSW, PC 2010
Solution 1
Solution 3
Outcome 2
Lauren H. Kerstein LCSW, P.C.
OPTIONS AND CONSEQUENCES
Situation
Feelings
Option 2/ Plan
Outcome/Consequence
Option 3/ Plan
Outcome/Consequence
Lauren H. Kerstein LCSW, PC 1/2006 as adapted from Myles, Brenda Smith and Diane Adreon. (2001). Asperger Syndrome and Adolescence –
Practical Solutions for School Success. Kansas: Asperger Autism Publishing Company.
Lauren H. Kerstein LCSW, PC 2010
Option 1/ Plan
Outcome/Consequence
POWER CARD (Lauren H. Kerstein 2006, Adapted from Brenda Smith Myles
and Richard L. Simpson)
In order to stay in control of my body in class, keep my voice low and get
my work done, I need to:
Listen and follow the rules that keep me,
other kids, other adults, my mom, dad and
teachers happy and safe
Keep my body in control - try to think of a
solution to solve the problems instead of
yelling – stay calm
Lauren H. Kerstein LCSW, PC 2010
Use a break ticket when my thoughts
begin to race in my head.
Experiential Strategies
It’s the Smallest Interventions that Make all
the Difference
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Corrina Corrina
Lauren H. Kerstein LCSW, P.C.
www.LaurenKerstein.com
www.LaurenKerstein.net