Understanding and Supporting Children with Anxiety

Editor’s note: This text-based course is an edited transcript of the webinar, Understanding and Supporting Children with Anxiety, presented by Aimee Kotrba, PhD.

Introduction

I'm pleased to be sharing information with you today about understanding and supporting young children with anxiety. In the clinic where I work, we see a lot of elementary, middle and high school aged children who have anxiety. Increasingly, however, we are seeing children under the age of five who are struggling with anxiety at home, in public, and in the school or daycare setting. It is important that we understand this growing population.

Is Anxiety Normal?

Anxiety is something that we often times discuss as being a problem or an issue that children face. In truth, anxiety is normal. It's adaptive. It keeps us safe in a lot of different situations. Anxiety is our body's way of telling us when we're in danger. There are many situations where children need to be attentive to danger and it's healthy that their bodies are giving them an indication that danger is around. When a strange person pulls up in a van next to a child, we want them to have some indication that this is not right. We want their bodies to react with fear and anxiety so that they run away and let an adult know. The problem is is that sometimes anxiety causes our body to react to danger when there's not really danger present. A parent bringing a child to preschool or a daycare in the morning is not a dangerous situation, and yet for some children, their body and their brain react as if there is a real danger.

We consider anxiety to be a problem when it interferes in a person's life. In children, this interference occurs in three main domains: 

1. Daily functioning (self-care, managing emotions, going to sleep and waking up on time, picking up after themselves, eating properly) 
2. School, daycare, or any school-like activity
3. Social interference (problems interacting with peers in a developmentally-typical way)

Everyone has anxiety. However, the more interference it causes in a child's life, the more likely he or she is to be diagnosed with an anxiety disorder, and the more likely we will need to intervene for that child.

Developmentally Appropriate Fears

There are developmentally appropriate fears for children. At each stage in a child's life, there are certain kinds of fears or anxieties that we expect. For infants, there is a fear of separation and a fear of strangers or novel faces. Separation anxiety typically occurs somewhere between six and 30 months and it peaks at around one year of age. In fact, if children don't go through that fear of separation stage, sometimes that can be concerning because it is a developmentally-typical stage. However, outside of that one to two-year time span, if children still continue to experience separation anxiety (at age three, four or five), that may be considered outside of what is developmentally typical or developmentally appropriate. For toddlers and preschool-age children, they may be afraid of things like being in the dark, dogs or other big animals, imaginary creatures (e.g., monsters, witches, ghosts), and storms or weather-related disasters. Again, that is developmentally typical and expected at that age. If you had a teenager who was still fearful of big animals or monsters, that would be outside of the developmentally typical range.

Red Flags for Young Children

There are some red flags that we look for when we're considering whether or not children are struggling with anxiety. Probably the number one red flag we see is stomach aches or headaches without a medical cause. It's typical that I'll see children coming into my clinic who have already been to their physician because they have regular stomach aches in the mornings before they go to school, or they need to rush to the bathroom over and over again during the day. With headaches, even very young children might complain of having a headache when it's related to anxiety.

Interestingly, there are two main reasons that children get stomach aches when they're anxious. Both reasons are related to the physiological response to anxiety. When we get anxious, our body starts the fight, flight or freeze response, also known as the three Fs. That response prepares us to react to something dangerous. If we encounter a dangerous situation, such as walking out into the middle of a busy street, our body is supposed to do a few things. First, it's supposed to speed up our heart rate. It's also supposed to speed up our breathing or make our breathing shallower so we can breathe more quickly. In addition, our muscles tense, our thoughts start to race quickly, and our body gets ready to either fight, flee, or freeze. If we're out in the middle of a busy road, theoretically, we're going to want to run from the middle of the road. Our body prepares us to flee, which is a healthy response to that dangerous situation. 

In those who experience anxiety when there's no danger present, their body still reacts in the same way. It doesn't know the difference. For children with anxiety disorders, their fight, flight, or freeze response causes all of those physiological things to happen to their body. In children who have frequent stomach aches, it is because their stomach muscles are continually squeezed up and tense. The other thing that happens to our body when we are in the fight, flight, or freeze response is that all of those physiological responses occur but it also stops our body from doing anything that's not absolutely necessary to keep us safe. One of the things that's not absolutely necessary to keep us safe is digestion. For these children, when they get anxious, their stomach muscles tense and squeeze, and digestion stops. As a result, food that is undigested or partially digested is now being squeezed in the stomach muscles, resulting in nausea and stomach aches.

Children with anxiety often have difficulty sleeping, especially without their parents. When families come into my clinic, it is a common occurrence that the parents end up sleeping in the child's room, or the child goes into their parent's bedroom to sleep. They may have a difficult time either falling asleep or remaining asleep. In addition, these children may have reoccurring nightmares, causing additional sleeping difficulty.

Anxiety also causes a reluctance to interact with new people or try new things. Children with anxiety tend to be very slow to approach unfamiliar objects, places, or activities. In addition, they're easily overwhelmed. Irritability is common in this population. We see frequent crying and tantrums because a lot of young children (aged zero to five) don't have the verbal skills to describe how they feel when they get anxious. They have a hard time telling their parents, "I'm worried about whether or not you're going to come back to pick me up after school." Instead, that worry manifests as crying and tantrums which might appear as oppositionality or defiance but it is not.

Finally, another red flag is a family history of anxiety. Anxiety runs in families. There is a genetic predisposition towards anxiety. Interestingly, what we see is that if your anxiety "light switch," so to speak, is flipped on, if genetically you have a predisposition towards anxiety, then you might have any kind of the "flavors" of anxiety we're going to talk about in just a few minutes. It could be that Aunt Nancy has panic attacks and Grandma had some social anxiety, or Dad has generalized anxiety and Son has separation anxiety. Genetically, we think it's all very similar. If your genetic light switch is flipped on, you might get any of those presentations. 

Prevalence

Anxiety is concerning to psychologists, adults, and caregivers. This is not just because of the problems that it causes at the moment, but also because if untreated, childhood anxiety can lead to negative outcomes in adulthood. According to the Anxiety and Depression Association of America, about 13% of American children and adolescents will at some point be diagnosed or have a diagnosable level of anxiety. It's the greatest predictor of mood disorders, depression, alcohol and substance abuse in adulthood. We know that it's not something that children typically grow out of. Instead, it tends to get worse and more pervasive and becomes increasingly difficult to intervene with. About 18% of adults in the US have reported disabling anxiety that negatively impacts their lives. In fact, when we look at rates of missed work in adulthood, anxiety tends to be the number one reason why people miss work, not illness. If we look at medication use in adulthood, SSRIs (an anxiety and depression medication like Prozac or Zoloft) tend to be the most used medications in the United States, above and beyond any other kind of medication.

Clearly, anxiety negatively impacts people at all stages of life. The good news is that when we intervene, especially at a young age, anxiety can be managed. We're not going to say that anxiety goes away, because honestly, we wouldn't want anxiety to go away. It keeps us safe. Children can learn ways to cope with their anxiety and caregivers can learn healthy ways to interact with children who have anxiety so that it doesn't interfere in their life.

How Does Anxiety Develop?

How does anxiety develop? It is a combination of both nature and nurture. Parents and caregivers can pass on symptoms of anxiety simply by the behavior they model for their children. Children who are anxious tend to have parents who model anxious behavior vs. healthy coping strategies. In addition, there is a genetic/biological component to anxiety, outside of parental modeling. The brains of children who have diagnosable anxiety are slightly different than the brains of children who do not. Much of the difference in the brain structure occurs in the amygdala. The amygdala is sort of like a guard dog. It's the part of our brain that's meant to keep us safe and give the alarm if it perceives that we might be in a dangerous situation. When it perceives that we're in a dangerous situation, it gives us the fight, flight, or freeze response, as discussed earlier. It causes physiological changes in our body (e.g., racing heart, tense muscles, shallow breathing, racing thoughts) so that we are prepared to protect ourselves.

One problem is that the amygdala is there for our protection only. It's fast-acting and it will overestimate the danger or the potential "bad" things in our environment. It doesn't take other things into consideration. It has no off switch, so to speak. Our amygdala perceives what's going on around us, and if it thinks we're in danger, it sends information down to our body and our body prepares us for that fight, flight, or freeze response. There's no part of our amygdala that thinks, "Wait a second. Mom has always come to pick me up in the past, and she's going to come and pick me up today just like she always has." That reasoning occurs in our frontal lobe. The frontal lobe is not involved in the fight, flight, or freeze response; only the amygdala is involved. There is no communication between our frontal lobe and the amygdala.

The amygdala can learn that it's wrong in two ways: through experience and through the body. Think about a child riding a bike without training wheels for the first time. That child's amygdala takes in the scenario and immediately sends information to their body to go into the fight, flight, or freeze response. But if that child is able to persevere, even though the amygdala is signaling them that it's a scary situation, they will learn how to ride a bike. Going forward, each time the child rides a bike, the amygdala remembers that riding a bike isn't dangerous after all. Through experience, the amygdala has learned not to signal the 3 Fs when riding a bicycle.

The other way that our amygdala learns is through our body. For example, our amygdala may perceive a dangerous situation, and it sends information down to our body to prepare us for the fight, flight, or freeze response. If we know that what's happening isn't really dangerous, we can do things like take deep breaths and relax our body. That's a way of sending information back to our amygdala. Through deep breathing and relaxation techniques, our body can reassure the amygdala that everything is okay, and next time, the amygdala will not be as likely to send the emergency signal.

As stated earlier, our amygdala is like our guard dog. Some of us have an excellent guard dog that only lets us know that we're in danger when we're actually in danger. Some of us have guard dogs that bark all the time when there is no danger present. The good news is that we can teach our amygdala to be a better guard dog.

"Flavors" of Anxiety

There are different types, or "flavors," of anxiety. All of these types of anxiety stem from the same underlying biological indicators in the brain (i.e., an over-reactive amygdala). For the purposes of today's course, we will review the following "flavors" of anxiety as they relate to children:

• Generalized Anxiety Disorder
• Social Anxiety
• Specific Phobias
• Selective Mutism
• Separation Anxiety

Generalized Anxiety Disorder (GAD)

The most common flavor of anxiety for any age group is generalized anxiety disorder (GAD). Generalized anxiety disorder is characterized by excessive and exaggerated anxiety about everyday life events with no real reasons for worry. It can emerge in childhood or adolescence. Children with GAD are constantly worried. They worry about mom coming and picking them up from daycare. They worry about whether or not lunch was packed for them that day. They worry about whether their friends are going to be at school. They worry about monsters at night. They tend to expect disaster or worst-case scenarios. They seek a lot of reassurance from adults. They constantly want adults (parents, teachers, and caregivers) to tell them it's going to be okay. Children with GAD tend to be irritable and restless. Because they have a hard time verbalizing their worries, we tend to see a lot of tantrums, crying, and irritability in young children ages zero to five who have GAD. They'll complain of physical symptoms like stomach aches or headaches. They have to go to the bathroom frequently. They have difficulty concentrating, difficulty falling asleep, or staying asleep at night.

Ordinary worry vs. chronic (GAD) worry. Just because a child has worries doesn't mean that they have generalized anxiety disorder. Ordinary worries lead to planning and problem-solving. They don't tend to interfere with daily functioning, school, or social life. Ordinary worries usually end with choices made and actions taken. They are solution-focused. When a child has ordinary worries, their attention is focused on developmentally important issues.

Conversely, when children have chronic worries, it interferes with planning and problem-solving. They're constantly worried about the same thing over and over again. They tend to focus on unlikely disasters. Their worry does not get solved, and they interfere with daily tasks. The worries are repeated and replaced with other worries and they become the focus of a child's life. No gains are made from this kind of worrying. Psychologists have a name for this kind of chronic worry: rumination. Rumination is an agricultural term that refers to what cows do when they eat. A cow chews its cud and then digests it a little bit, spits it back up, chews it again, digests it a little bit more, spits it back up, and chews it again. Each time a cow ruminates, it loses some of the nutrients and receives less benefit out of the food. Similarly, if a child has chronic worries, they don't get anything out of them. They ruminate on them over and over again, but they are not leading to something good. This type of worry does not lead to problem-solving.

Social Anxiety

Social anxiety is an extreme fear of being judged by others, especially in social or performance situations. Children with social anxiety don't want to be the center of attention. They don't want people looking at them. They fear performing or speaking in front of people. They often don't like positive praise because it gives them a lot of attention. According to the Anxiety and Depression Association of America, the typical age of onset of social anxiety is 13 years old. Increasingly, however, we're seeing that age of onset becoming younger and younger. Children can even have an onset of social anxiety during their preschool years. Children tend to take a long time to seek help when they do have social anxiety. In fact, 36% of people with social anxiety disorder report that they had symptoms for 10 years or more before seeking help. That's why early intervention for any of these diagnoses is so important. This is the only anxiety disorder that's equally common among males and females; all of the rest of types of anxiety tend to be predominantly female-based. When children have social anxiety, it can lead to school refusal, lack of social relationships, and depressive symptoms. In the teenage years especially, it can lead to suicidal ideation or self-harm in children who have social anxiety.

Specific Phobias

Specific phobias are disorders characterized by an excessive or irrational fear of an object or situation that's not normally considered dangerous. Some common phobias include fear of things in the natural environment (e.g., storms, water, heights), fear of animals (e.g., dogs, cats, insects), or a fear of blood injury (e.g., seeing blood, fear of needles or other invasive medical procedures). When adults and adolescents are diagnosed with phobias, they are generally aware that the fear is unwarranted or extreme. There's nothing wrong with being afraid of an angry dog that is growling at you and baring its teeth. However, people with a phobia of dogs may even be afraid of cute little fluffy puppies. That fear would be considered an extreme or unwarranted fear.

Children with specific phobias aren't anxious in general; they only become so when confronted with the particular thing that causes them terror (e.g., dogs, the dark, clowns). This confrontation may be direct (the thing itself) or indirect (a video or picture). Children with specific phobias will anticipate and avoid the thing that triggers their fear, which can interfere with normal activities. Children don't necessarily recognize that their fears are extreme or irrational. 

Selective Mutism

Selective mutism is a specific type of anxiety disorder where children are unable to speak in some situations and to some people but are able to speak fine at home. Typically, these children present with normal speech in the home setting where they are comfortable with parents and siblings. When they're out in public or in a daycare or preschool setting, they don't talk or they talk very little. It may seem like this is a purposeful refusal to speak but most children experience it as an inability to speak. They can't get the words out. There is a lot of evidence to suggest that selective mutism is an extreme form of social anxiety.

In general, parents notice the signs of selective mutism when their child is around three or four years old, however, most children aren't diagnosed until they go to school. It's not that atypical for a three or a four-year-old not to talk in preschool or not to order for themselves at a restaurant, or not to talk when they're in a church daycare. It's only when they get to school and they need to be assessed and there's an expectation that they interact with their peers that it becomes a more obvious problem. Most children are diagnosed somewhere around six and a half to eight years of age. Psychologists indicate that selective mutism becomes much more complicated to treat if the child reaches the age of eight or nine years old. The younger they are at diagnosis, the easier it is to treat. The probability for selective mutism is low at only about 1% of children in elementary school settings. That prevalence seems to be increasing, though, possibly due to the fact that we're getting better at identifying selective mutism.

Separation Anxiety

Separation anxiety is arguably the most common anxiety disorder in very young children, although not the most common if we look across all ages of children. Separation anxiety is when a child has great difficulty separating from parents or caregivers. It's very typical between the ages of one and two years. At about two years of age, if a child is still experiencing a lot of separation anxiety, that is much more atypical and it can inhibit a child's daily functioning. If a child cries the first two days when they go to preschool for the first time, that's completely normal. On the other hand, if they continue to cry day after day and the crying doesn't improve with time or experience, and if the child can't be easily comforted by a familiar caregiver, we would potentially consider that to be separation anxiety.

How Children Develop and Maintain Anxiety

In order to illustrate how children develop and maintain anxiety, it is helpful to look at the graphic in Figure 1. To begin with, let's say a child has a predisposition to anxiety (e.g., they have a genetic component and biological differences that lead them to anxiety, their amygdala is over-reactive, and/or they have parents who may be modeling anxiety). First, they get into a situation that they perceive in some way as being scary or anxiety-provoking. Next, the child does what we all do when something seems frightening or dangerous: they avoid that anxiety. That's not pathological -- that's simply human nature. Then, someone (e.g., a parent, teacher, caregiver, sibling, friend) typically steps in and rescues them from that anxiety, which leads to accidental reinforcement of the anxiety. When someone rescues the child from a scary situation, it makes them feel good. As such, not only is the child more likely to be avoidant next time, but the person is also more likely to rescue again next time. We all tend to be accidental reinforcers or accidental rescuers of anxiety because no one likes to see a child struggle.

Figure 1. How children develop and maintain anxiety.

Example 1. A child has a genetic predisposition towards anxiety. Their amygdala is over-reactive. Every morning, Mom tries to drop off the child at daycare. The child perceives this situation as being scary. Therefore, he tries to avoid Mom leaving. He throws a tantrum, cries, and clings to her. He says things like, "Why don't you love me? I just want to come home with you." Mom feels terrible about this. She doesn't like to see her child struggle, and so she stays for a lot of extra time with the child. Friends of the child might approach and overly comfort him. Teachers might allow Mom to stay all day at school, which accidentally reinforces the behavior. Allowing Mom to stay all day sends the message to the child that they are right: there is something scary and they need protection. Next time the child gets anxious, he's more likely to avoid again, he's more likely to have a temper tantrum and cry and cling to mom again because he found that it works and he was taught that this is an anxiety-provoking situation.

Example 2. A child with social anxiety has a fear of being the center of attention. This child is put into a situation where there's going to be a school play. She doesn't have a speaking part but she plays the role of a tree and has to stand on stage in front of everyone and sway from side to side. This child does what we all do when we get anxious, which is to try to avoid the situation. She says, "No, no, no -- I'm not going to do that. I can't go up on stage. I can't do any of that." Parents and teachers say, "Okay, you don't have to do anything then. We're not going to have you be in the play at all. That's okay. We don't have any expectations of you." This makes the child feel good because she got to avoid that scary situation. Accidentally, what we've said to her is, "You can't handle that scary situation. We don't have any expectation that you're going to do anything that's brave." Next time she gets into another performing situation, she's more likely to avoid. Rescuers tend to create situations for the child where we don't even have an expectation that she faces her fear anymore. When the next school play comes around, the teacher remembers that the child had a hard time last year, and they don't even write her in as a character this time. There's not even an expectation that she's going to do it. The more that this is practiced, the more this becomes the cycle or the way in which a child views and interacts with the world. For children with anxiety, it is clear that the earlier we can intervene, the more effective it will be because it minimizes the number of times that the child is allowed to practice and experience the cycle of avoidance.

Avoidance is the biggest problem when it comes to anxiety. It's not the worries, it's not our overactive amygdala -- it's avoidance. Avoidance keeps children from learning that fear is a warning, not a prediction. They don't learn that just because they think something bad might happen doesn't mean it is going to happen. It becomes their default way of responding to the world. I see teenagers in my practice who started off as preschoolers with anxiety avoiding specific scary situations, being constantly rescued by people. Eventually, they are so used to avoiding and being rescued that now they are worried about everything. They won't go to the dentist office anymore because they don't want to be uncomfortable. They won't go out in public anymore because they don't want to be uncomfortable. These children learn to steer themselves away from any unpredictable or uncomfortable situations, rendering them unable to cope with real life.

How to Communicate Concerns to Parents

If you have a child with anxiety, I want to give you some strategies to help a child learn to be brave. First, it is critical that we communicate our concerns with the child's parents. When children are very young, parents have a lot of ability to intervene. They have many strategies that they can use to change a child's perspective, even more so than teachers or friends do.

Discuss. The first thing you need to do is discuss those specific observations that you have made of the child. For example: "I know that you have discussed how talkative Eva is in the home setting, but at school, I see a slightly different child. I see a child who really struggles to talk to her friends and isn't able to answer her teachers." 

Share. Share your concerns about the effect that their anxiety has on academics, behavior, mood, or socialization. Talk to the parent about the implications of this anxiety, and that it is negatively impacting the child's life. For example: "When Eva has difficulty talking to people, I'm concerned that she's going to have a hard time making good friends. I am fearful that she's not going to be able to participate in all the classroom activities. She's going to miss out on some academics. It makes me sad to see that she's so anxious all day in the school setting." 

Provide. Provide the parents with information about anxiety, or point them toward a psychologist or a therapist who could help. Two of my favorite websites on anxiety for adults are anxietybc.com or childmind.org. They have an abundance of good videos, webinars, and articles about anxiety and what parents could do to help. In your handouts, I have included a slide with information on useful books and websites, both for children and for parents.

Realize. Realize that most parents are already aware of their child's anxiety. This is usually not a surprise to them. It may be that they have been waiting to hear it from someone else, especially someone at school because they're hesitant to act on it if it's not impacting a child's life. It's one thing to deal with your child's anxiety at home if they are having difficulty sleeping or have stomach aches. It's an entirely different thing to hear that they're struggling at school, and that's when most parents will take action. 

Therapeutic Techniques for Anxiety

There are many different techniques that can be used to alleviate anxiety in children. These strategies can be implemented by caregivers, teachers, classroom helpers, or daycare staff.

Our Goal

For children with anxiety, our goal is not to make the anxiety go away. A certain amount of anxiety is good, it's helpful, it's adaptive. Ideally, we want to help children to be comfortable with discomfort. Let children understand that just because they feel anxious doesn't mean that they have to avoid. They can let it pass and still do what's important to them. Think back to the earlier example of riding a bike. If a child feels really uncomfortable about riding a bike and they avoid riding a bike, it never gets better. We can teach children that just because their guard dog is yapping doesn't mean that they can't go ahead and do what they want to do anyway because that's how our guard dog learns.

We can help children create coping strategies. We can teach them to act brave and therefore be in charge of that scary feeling. We can teach others to react appropriately to anxiety so that we're not accidentally reinforcing it, we're not rescuers. The child can learn how to build "brave muscles." We tell children that even though they are afraid, the braver they act, the more brave muscles that they will build, and the easier things will become later. 

Caregiver Behaviors Associated with Anxiety

There are some caregiver behaviors associated with anxiety. When you're a caregiver of a child with anxiety or when you're trying to help parents be supportive of a child with anxiety, be mindful of these behaviors that may contribute to a child's anxiety:

• Parental/Caregiver overcontrol: Intrusive parenting, exerting control in conversation, limiting of authority and independence.
• Overprotection: Excessive caution and protective/rescue behaviors without cause; never exposing the child to situations that are anxiety provoking, always ensuring that the child wins or succeeds. This teaches the child that they are not capable of doing things that are scary. A certain amount of discomfort and failure is necessary to teach the child that they can be brave and they are going to be okay.
• Modeling of anxious interpretation: Agreeing with child’s anxious assessment of a situation, reinforcing the idea that normal things in the world are too scary to approach. For example, if you tell the child how much you hate going to the dentist because it always hurts -- that is going to lead to more anxiety.
• Tolerance or encouragement of avoidance behaviors: Suggesting or agreeing with not trying something difficult. Also, giving a lot of attention when the child is anxious can reinforce anxiety. For example, I see a lot of parents who layer on the affection and love when their child gets anxious. They hug them, they hold them when they cry, they give them a lot of reassurance. That kind of intense affection in times of anxiety can be reinforcing or can be rewarding to a child. Instead, parents are encouraged to remain calm and model resilience and try not to give a lot of additional affection when children are overly anxious.
• Rejection or criticism: Disapproving judgment, dismissive, or critical behavior. Or, the other way that parents tend to swing is, "Why don't you just go ahead and do it, everything's fine, it's not a big deal." That mentality is also problematic. 
• Conflict: Fighting, arguing, and disharmony in a family associated with higher levels of anxiety.

Caregiver Behaviors that Buffer Stress

In contrast to caregiver behaviors that reinforce anxiety, there are positive caregiver behaviors that buffer stress, including:

• Reward coping behavior: Focus on the means, not the end. Reward taking on challenges and recognize partial successes. Encourage and reward the use of coping strategies. We can't all control our own anxiety. There are times when a child is going to cry and they might not be able to control that. I can't always control when I worry or when I'm anxious. What I do have control over is whether or not I engage in some of those coping behaviors.
• Extinguish excessive anxious behavior: Reduce anxious behavior by not responding to it excessively, either with concern or anger. Try to be calm.
• Manage own anxiety: Limit displays of distress; don’t introduce their worries into the mix.
• Authoritative/Democratic caregiving style: Caregivers direct children’s behavior while valuing independence. This is associated with lower levels of anxiety and higher self-confidence. Allow children to fail or to struggle sometimes. This tells the child, "I believe in you in so much that I'm willing to let you do it alone even though it might be scary and even though you might not do it right. I trust that you're going to figure it out."

Building Blocks for Managing Anxiety

Identifying emotions. The first step in managing anxiety is being able to identify your own emotions. We can help children recognize their emotions in the following ways:

• Modeling. For young children (ages zero to two years), start to name feelings for them. For example: "It looks like you're feeling sad right now. I can tell by your face and what your body looks like." For children ages three to five years, you can start helping them name their own feelings.
• Feeling chart. You might want to use charts that show common feelings: happy, sad, mad, scared, guilty. Encourage them to start observing and naming their own feelings. Model and name your own feelings and demonstrate good self-control. You could say things like, "I'm feeling really frustrated right now. I'm going to take a calm breath." Then, children can not only see your emotion but also how you're handling that emotion.
• Zones of regulation. Zones of regulation is an intervention tool that is often used by therapists but also can be used by caregivers, and in preschools and day care centers. Zones of regulation teach children how to identify their emotional states, as well as simple coping strategies that they can use to deal with those different emotional states. The emotional states are coded with different colors (e.g., angry/frustrated = red; yellow = distraught; green = calm).

Building self-control. Helping a child build self-control is another building block for managing anxiety. You have to have some self-control in order to use coping strategies. Some ideas for building self-control include:

• The bubble game. To begin, have the child seated with their bottom on the floor. The first step of the bubble game is to blow as many bubbles as you can and pop as many as you can. The second step is to blow bubbles but not to pop any, even if they land on your nose, even if they land right on your foot. By refraining from popping the bubbles, children are learning how to use some self-control.
• Losing at a game. It's okay to allow children to lose at a game and to encourage self-control in that time. Let them know that it may not be fun to lose, but that's part of life and we need to learn how to be self-controlled when we lose a game.
• The marshmallow task. If you haven't seen this, go online and Google "marshmallow task" and you will find YouTube videos. The idea behind this task is that children learn how to develop self-control by putting off receiving the desired reward. You place marshmallows in front of the child. You tell the child that if they wait a certain period of time, they can have two marshmallows, or they can eat one right now. This encourages delayed gratification, and that children can control their own behavior in order to have better rewards in the end.

Calming strategies. Some calming strategies that you can use with children include:

• Belly breathing with a breathing buddy (we will discuss in further detail later in the presentation). 
• Blowing out the candle. We usually tell children to blow out like they are blowing out a candle.
• A calming corner. A dedicated place in the classroom or in a daycare where there are calming items, like a beanbag chair, a weighted blanket, soft toys, coloring books, and crayons. It is a place where children can modulate their own emotions.
• Calming glitter jar/bottle. If you look online, you can find directions on how to make a calming glitter jar. It allows children to focus on something that's calming and slow-moving. 
• Externalizing anxiety/worry. We often use something we call a Worry Monster (Figure 2). Children can learn that their worries aren't necessarily true and that their worries are something outside of themselves. We'll say, "Is that the Worry Monster again?" Then, you could have children tell you their worry, you could write it down or they could draw a picture of their worry. This particular monster has a zippered mouth so that you can fold up their worry and have the Worry Monster eat it. You can teach children that this is something that they can externalize or make separate from themselves. They can even learn to boss back the Worry Monster. They can learn that their worry is, to some degree, within their control.

Figure 2. Example of a worry monster.

Relaxation. There are many strategies we can teach to promote relaxation. These include:

• Progressive muscle relaxation. Muscle relaxation is one of the ways that our amygdala learns. If we can calm our body down, it tells our amygdala that we're okay. Lori Lite has some nice tracks online that you can use, like the Angry Octopus, a Boy and a Bear. These encourage progressive muscle relaxation, teaching children how to relax their body (Lite).
• Diaphragmatic breathing (also called belly breathing). We teach little children how to breathe in through their belly, expand their belly like a balloon, and then breathe out, sort of like the balloon is losing all of its air. All of this should happen through their mouth, not through their nose. That's a good strategy for teaching children how to breathe and calm themselves.
• Visualization. There's also a program called Ready...Set...R.E.L.A.X. that caregivers can use with children (Allen & Klein).

Size of the problem. Another strategy for teaching building blocks for managing anxiety is teaching them that the size of the problem depends on how they're going to react to it. Little children don't comprehend the size of a problem. They tend to experience all problems as bigger than they really are. We can start teaching them that problems come in little, medium, or big sizes. The way that we react to those problems should depend on the size of the problem. First, you might start off by giving them examples of problems and talking about how big they are.

• A little problem might be someone is playing with a toy that you want to play with.
• A medium problem might be you want to be on the tire swing but a friend pushes you off the tire swing and you hurt your knee.
• A big problem might be that you feel like you're going to throw up.

Depending on the size of the problem, that's how you react to it.

• For a small problem, you might want to stay calm, take a deep breath, and use your words.
• For a medium problem, that might be a good time for belly breathing and asking an adult for help.
• For a big problem, you're supposed to get help from a teacher or a parent right away.

Preschoolers are just learning to problem solve but they need our help. You can teach children some steps for solving problems. For instance, maybe the first step is just saying or identifying what the problem is. The second step might be thinking about two to three solutions to the problem. The third step is choosing a solution. The fourth step is trying out the solution. You can practice problem-solving with children over and over again so that they can become skilled problem solvers, and hopefully carry this skill into adolescence and adulthood. 

What Can Teachers Do to Help?

What can teachers do to help children with anxiety?

• Support children with anxiety. Talk to parents about what they see so that the parents can get support of their own.
• Try to be matter-of-fact with information, and be careful not to reassure too much. We want children to face their fear instead of being reassured or rescued from their fear.
• Remove attention from anxious whining or complaining.
• Be careful not to accidentally reinforce avoidance. You don't want that child to be rescued over and over again. For instance, if a child has separation anxiety, you don't want the parent to attend the full day of class with them every day because that never asks them to face their fear. Instead, have the parent come in and attend the first 20 minutes for one week, gradually reducing the time down to five minutes per day just to get the child settled. After a while, the parent should be able to drop off the child at the door of the classroom, or eventually in the hallway where they can see the teacher. There's always a strategy to help children take the next step in being brave, even if that's scary for them.
• Be consistent with expectations and rules.
• Model your own resilience and grit and bravery.
• Provide positive attention to brave behavior. The more children are coping, the more they're being brave, that should be getting the reinforcement and the reward.
• Give parents information about anxiety. If anxiety is severe, outside treatment is recommended. For very young children, we talk more about behavioral therapy than cognitive behavioral therapy, but you could look for either. Behavioral therapy and cognitive behavioral therapy are both the gold standard for treating anxiety disorders at any age, especially in childhood. The idea of behavioral therapy or cognitive behavioral therapy is to give children coping strategies for dealing with anxiety and teaching parents and caregivers how not to step in and accidentally reinforce or overprotect that child from anxiety. When we're doing behavioral or cognitive behavioral therapy, we're asking children to face their fears at a slow and reasonable pace. Maybe some verbiage that you can use is, "I'm concerned about your child and research shows that treatment can be helpful. I've heard through the grapevine about a few clinics that families seem to really appreciate." I know that some teachers in public school systems can't give direct recommendations for intervention, but most of the time, teachers are able to indicate that perhaps the child needs more help than what the school can provide.
• Help build grit! We talk a lot in schools about grit or growth mindsets, the idea of staying with something even when it's hard or experiencing something that's challenging and going ahead and doing it anyway. Encouraging parents to allow their child to struggle or fail sometimes is the way we build grit. Grit is highly associated with positive outcomes later on in adulthood. In fact, when psychologists have studied the most successful adults, they find that the common thread between those people is not IQ, it's not educational attainment, it's not money -- it is grit. Grit is the ability to hang with it and continue on even when things are uncomfortable or aren't going as you had planned. Grit is the opposite of anxiety or the opposite of avoidance. Grit helps you continue on even when a situation is anxiety provoking and that helps to reduce anxiety.

Resources for Children and Adults

Some books for children that encourage bravery and the growth mindset include the following:

• Chester the Brave (Audrey Penn)
• You Are Brave (Todd Snow)
• The Girl Who Never Made Mistakes (Mart Pett)
• I Can Handle It! (Laurie Wright)
• I Am Brave (Jen Porter)
• Beautiful Oops (Barney Saltzberg)
• Rosie Revere, Engineer (Andrea Beaty)
• The Dot (Peter Reynolds)
• Louder, Lili (Gennifer Choldenko)
• Courage (Bernard Waber)
• Too Shy for Show and Tell (Beth Bracken)
• Daredevil Duck (Charlie Alder)
• Wilma Jean the Worry Machine (Julia Cook)

I also recommend the following books and websites for parents and teachers:

• Freeing Your Child from Anxiety (Chansky)
• Raising Resilient Children (Brooks & Goldstein)
• How to Parent Your Anxious Toddler (Daniels)
• How Children Succeed (Tough)
• Anxious Kids, Anxious Parents (Wilson)
• Anxiety British Columbia Canada (AnxietyBC) website: youth.anxietybc.com
• http://www.mindfulschools.org/resources/explore-mindful-resources/
• www.childmind.org
• My personal favorite is called Anxious Kids, Anxious Parents by Reid Wilson. I'm not crazy about the title because it suggests that parents created the anxiety in their children, but that's not the author's intention. The idea is that when your child is anxious, you, as a parent, become anxious, because we don't like to see our children struggle. The good news is that there are things that parents and caregivers can do to help moderate or teach children good coping strategies, thereby reducing their anxiety.

Thank you all so much for your participation today. I hope that this presentation was helpful for you. I would encourage you all to intervene as early as possible with childhood anxiety disorders because there are truly positive outcomes for children who learn these coping strategies early.

References

Allen. J.S., & Klein, R.J. (1997). Ready...Set...R.E.L.A.X.: A Research-Based Program of Relaxation, Learning, and Self-Esteem for Children. Watertown, WI: Inner Coaching.

Anxiety and Depression Association of America - facts and statistics (n.d.).  Retrieved from www.adaa.org 

Lite, L. (1996). A Boy and a Bear:  The Children's Relaxation Book. Marietta, Georgia: Stress Free Kids.

Lite, L. (2011). Angry Octopus. Marietta, Georgia:  Stress Free Kids.

Wilson, R. (2013). Anxious Kids, Anxious Parents. Deerfield Beach, FL: Health Communications, Inc.