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Some things I frequently hear from my child patients and parents alike are “I [my kid] is having panic attacks all the time.” After I ask what symptoms they are experiencing, usually only around 2/10 are experiencing actual clinical panic attacks. In order to really start reducing this confusion, let’s begin by defining a panic attack (not an “anxiety attack,” which is a layman’s term). According to the Diagnostic and Statistical Manual of Mental Disorders (5^th edition), also known as the DSM-5, a panic attack is “an abrupt surge of fear or intense discomfort that reaches a peak within a few minutes, and during which four or more of the following symptoms occur”:

1. Palpitations, pounding heart, or accelerated heart rate
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering
5. Feeling of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, lightheaded, or faint
9. Chills or heat sensations
10. Paresthesias (numbness or tingling sensations)
11. Derealization (feelings of unreality) or depersonalization (being detached from oneself)
12. Fear of losing control or going crazy
13. Fear of dying

The presence of panic attacks are not a diagnosis in and of itself. However, depending on how frequently they occur, and in what context they appear (e.g., do they appear “out of the blue” or do they occur only in social situations), this clinical information can determine a more serious diagnosis (e.g., Panic Disorder vs. Social Anxiety Disorder).

I frequently hear “my child is stressing out, crying all the time, and is nonsensical when they speak.” While these symptoms can accompany panic attack symptoms, they alone do not count for panic symptoms. If you do think your child is experiencing panic symptoms, they should be getting a proper clinical evaluation by a mental health professional to determine the duration, type, and clinical presentation of the symptoms. This way, they can be properly diagnosed and then treated.

With recent events in Brussels, Paris and the Ivory Coast, and current threats in my home area of Washington, D.C., I find this topic is coming up quite a bit in sessions with my patients. So, I thought I would address it to my readers.

Colloquially, I hear a lot of parents saying “talking about terrorism is not appropriate for a child to learn about” and they take the stance of “hear no evil, see no evil.” The problem is, as much as I would love (and I mean LOVE) for that to be reality, whether we discuss it or not with our children, they may hear about it in some form or another from friends, extended family, teachers, news broadcasts, or a random stranger on the street.

So, the question is, if we know that our children may get some exposure to this harsh reality, do we avoid talking about or do we not? If we do talk about, how do we do so? Some questions I hear frequently from my parents with anxious children is: “I don’t want to make them more scared of the world, I don’t want them to be frightened to leave the house, I want them to know the world out there is safe.” These are very legitimate concerns I hope to address.

Terrorism causes fear of an unpredictable nature, or more technically, our ability to “tolerate uncertainty.” When I meet with patients, especially those with pre-existing anxiety, I ask them to look at 7 days of their life, a week, and assess how much control they have over their life throughout the week (i.e., how much time to do you spend making deliberate decisions that are thought out, and decide how you will react emotionally to an event, situation, or another person). In the office, I initially get a response of 70-90%. However, when looking at the actual recorded data over a real-time period of 7 days, the percentage dramatically and consistently drops to 5-15%. This example demonstrates that we believe we have much more control over our life than we actually do. We can also overestimate our belief that we can control bad things from happening AND that if we hear more about an event happening, it is likely to increase the possibility of that event actually happening.

Did you know that your chances of getting hit by lightning is 1 in 700,000 (and in your lifetime is 1 in 3,000), whereas your chances of dying from a terrorist attack is 1 in 20 million? Because we hear more about these awful terrorist situations on the news or from friends, we can have what is a called a “thought-action” fusion. It feels as though the mere thought of dying in a terrorist attack somehow increases our actual chances. Logically, we all know this just is not true, but our emotions tell us something different altogether. It is hard for parents to tolerate the discomfort of knowing the majority of our own lives and our children’s lives are not within our conscious control. However, if we can teach our child to begin to tolerate circumstances such as these, it can have generalizing effects for being able to tolerate uncertainty and distressing situations in the future.

If you decide as a parent to speak with your child about current events, it can be done in several ways. A younger child, ages 3-7, may or may not have been introduced to the concept of terrorism. A way to gage whether they have been already exposed is to ask them, “do you ever hear about bad guys?” Keep it general and more elusive, and let them take the helm of the conversation. They may say, “yes, kids at school are talking about scary things in Paris” OR they may say, “you mean like Ursula from Little Mermaid?” There really is no reason to bring up unnecessary horrors of terrorism to young children if you can be relatively sure they are not thinking about it. However, it DOES NOT mean that you can’t give them skills in place in case they do hear about it in the future. A younger child, ages 3-7, has likely already been introduced to “bad guys” in movies or books. It’s a relatively effective way to frame people who want to hurt others. However, letting them know that you are there to protect them and the world still remains a safe place is important for them to know.

With older children, ages 8-14, you can be more specific (and increasingly complex with older teenagers) when discussing world events. This is an age group that will likely have gotten some exposure to current events. Frame the events in a way that they can understand there are some unpredictable events in the world, but the chances of something happening to you is still extremely small (you can even use the example above). You want to model for them that you do not avoid harsh topics, because when we as parents avoid, it reinforces to the child that there is something legitimate to be concerned over. Sometimes it also helps to develop a specific plan of action in case there is anything that the family ever encounters. Worrying is non-productive if there is no end date in mind, but it can be productive if it leads to problem-solving techniques.

In these strategies, we can help our children tolerate the harsh realities of the world, build their resiliency to stressful events, and their abilities to tolerate distress and uncertainty. Let me know your thoughts on this very difficult, personal, and challenging family topic.

 

 

 

 

 

 

Going back to my second blog, “Emotional Vocabulary..,” I wanted to update my readers on the “talk” I gave to a group of 4-year-old children and their teachers. I think it is important to mention more about the “process” of interacting with them in effective, positive ways, compared to the content (at least in this particular blog entry). When I met all twelve (yes 12!) 4-year olds, I asked them to sit down in a circle. For parents and clinicians alike, this particular age group poses difficulties in the attention and hyperactivity department. Have you ever witnessed how much food a 4-year-old throughout the day consumes? It is a true testament to how much energy they are expelling. Young children are in constant “move mode” and when they are asked to sit and be still, this is akin to asking Mexican jumping beans to stay still and not fall off the counter. It just won’t happen.

So, if I have to work with young children with lots of energy, it was important that I engage them in different activities every five minutes (give or take a minute). They need constant reinforcement, whether that is a small present (e.g., plastic animals, stickers) or verbal praise. Young children are soooooo responsive to this reinforcement when learning new skills. They also love to be the “teacher” when given the opportunity. I had one child stand up and act out all different emotions (joy, sadness, disgust, fear, anger) and had the other children guess which emotions she was expressing (on a more complicated level, this enables the children to really start practicing emotion recognition, a more developmentally advanced skill). The other children were rewarded for raising their hands AND giving the correct answer. One boy ended up with 3 small plastic animals as a reward after answering all the questions correctly AND raising his hand. Other children were asking why they did not have a small toy, and I responded by saying it was because he demonstrated the proper behavior AND answers. In a small microenvironment, they were learning that positive behaviors could have a positive result. On a side note, this is where parents sometimes can go awry and feel that ALL kids need a toy no matter what (usually this is because they feel bad if the children feel bad). In small doses, not rewarding behavior that does not warrant a reward can have long-term benefits in terms of tolerating distress, increasing motivation, and reducing overall levels of anxiety. All the kids in the class were so responsive and at the end, I told them all that if they all practiced diaphragmatic breathing and problem-solving techniques with me, they could each earn a small toy. Each child was individually singled out for their positive engaged behavior and given verbal praise, followed by a toy (however, this was CONTINGENT upon the prior behaviors).

You may ask, how is this all relevant to me, as a parent? It definitely is! When teaching your child a new skill (e.g., making their bed, or placing clothes in the laundry, not being mean to their sibling, etc.), it is important you first teach the skills step by step, then model the behavior for them (use your acting skills, and then have them practice with you without laughing), then have them re-teach you the skill, all the while loading on the positive, genuine verbal reinforcement. I would recommend that if they can demonstrate this behavior for a longer time frame (e.g., 2-3 days or a week), you consider a small tangible reward. Kids need stimulation and to be engaged. You will get more positive behaviors from them with these skills. If you try it this week, give me a shout and let me know how it goes!

For the first time, Generation Y, aka the Millenials, are outnumbering both Generation X and the Baby Boomers. Young adults in this generation are considered those who are currently 17-34 years of age. Approximately 31.5% of these individuals are living with their parents in the United States and of those, 40% have a clinical anxiety or depressive disorder. Many young adults in this group are considered to be “regrouping,” a term coined by David Sachs, where a young adult goes home with the intention of moving forward within a self-initiated short-term timeline (e.g., saving money for a few months or years and applying to graduate school or jobs). However, for some young adults, they become stagnant in a “Floundering” or “Meandering” stage, where they have no self-initiated goals and are not motivated to change their current circumstances.

When I work with these young adults I first determine if there is a clinical anxiety or depressive disorder that has not been diagnosed and therefore treated. However, if a clinical disorder is not applicable after thorough assessment, it is essential that the family structure and the individual’s current skills be evaluated. These are just some of the questions I ask my young adult and their parents: “What are your responsibilities at home? How are your finances handled? Are you expected to do chores at home? What are your short and long-term goals? Do you have any plans to achieve them?” If a young adult is not experiencing any natural real-world consequences for their actions, then their behaviors will likely maintain and/or increase. We have to decrease behavior by not reinforcing it, or rewarding it. This is a tough task, especially for parents who see their role as providers and have difficulty setting limits.

It is important that the contingencies within the family are examined. For example, if a young adult refuses to get a job and make a financial contribution towards the household, are the parents financially compensating them? A frequent comment I hear from parents is “I just don’t understand why they [young adult] aren’t motivated to move on with their life.” This is an interesting comment because their lack of launching can be due to pre-existing contingencies within the family and/or a deficiency in skills. Sometimes, we as parents expect that our child should know something. I made this mistake the other day when I admittedly became frustrated with my 4-year-old child for not making their bed. The 4-year-old was expressing frustration in the form of a behavioral tantrum. I questioned myself and asked, “Wait, have I ever taught them to make their bed?” The answer was “no.” The lack of their behavior initiation was not due to motivation, but rather lack of skills. We want to be careful that we do not assume a lack of launching is because of motivation, because it could be do to a lack of skills. For example, does your young adult want to get a job, but does not know how to interview? Do they not know how to write a resume or CV. Ask them where they feel deficient in their ability to achieve their goals, and if they are able to identify their goals. This process is really one step at a time, but be patient, and be like a sleuth who is there to assist but not to overcompensate.

 

I will be giving a presentation on this topic at the Anxiety and Depression Association of America’s conference in Philadelphia in late March 2016. Make sure to post a question about this topic.

 

 

I rarely bring up personal information in my clinical sessions, mostly because I want my patients’ time to be 100 percent their own. If I do bring in personal information, it is because it is very relevant to the process or their experience. Today, I had an experience I would like to share with you all.

I brought my daughter back to my elementary school to meet my 6^th grade teacher, a very kind, and generous woman. When we met again, after quiet a number of years, it was more like old friends talking to one another. However, being at my old school, lots of memories flooded back and I began to understand and truly appreciate her role in my life. As a 12 year-old child, you are desperate to be independent, have freedoms and you dream of the day of going to high school, and eventually an adult. What would it be like to pick out the food I want at the grocery store? What would it be like to have my own money? What you don’t understand, at least at the time, is how formative each and every day is as a child. You don’t think that a negative experience with a peer or a teacher will affect you, but it can and does. I know this because the kindness my 6^th grade teacher taught me has stayed with me my entire life. On her white board, she STILL has written “MISTAKES (spelled incorrectly with letters that are backwards) ALLOWED HERE.” What a wonderful lesson to learn as a child. That lesson taught me that I am not perfect and nor should I be, that making a mistake and finding a way to right that mistake can be so much more rewarding than never making a mistake in the first place, to be patient with my family and friends and with my own patients, and to accept that we are all imperfect on this journey of life. It is a message I share with almost every patient I see in practice, though most do not know the origin of the statement.

Seeing my teacher today reminded me that just like a teacher, parents have the power to build up or tear down their children. Why do we call childhood the “formative” years? It’s because so much of our personality as adults and our memories are formed/based in these years. Your children will remember their younger years more than their 20s or 30s.

Remember that when you teach your child how to problem-solve and persevere through a mistake instead of protecting them from it, you are building them up. Remember that when you want to scream at your child because you are feeling frustrated or they are misbehaving, those experiences can be some lasting memories that your child will not only remember, but will help their personality form as an adult. As parent you have the power to build up your child and make them into a strong, resilient adult, and you also have the power to tear them down. The power is overwhelming and scary, but it can also be the most rewarding.

I would like to thank you, Mrs. McPhaul, for being a teacher who always believed in me, who worked tirelessly with me and all your students over the past 28 years to “build us up.” She is a person who never sees weaknesses as a “weakness,” but only as opportunities to grow and build a future happy and healthy adult. Remember adults (parents or teachers alike); we have the power to change our children’s lives. Will we tear them down or will be build them up? Will we help our children to become resilient adults, who can face adversity effectively? The decision is up to you.

When children and even teenagers are asked how they are feeling, they frequently have difficulties expressing themselves (you may hear the “I dunno” response frequently). Parents I work with can see their children “act out,” whether in temper tantrums or by outright disobeying them. There can be a multitude of reasons as to the causes of these behaviors, but one I make sure to address is identifying and developing an emotional vocabulary. An emotional vocabulary means being able to identify the internal experience you are feeling and being able to express yourself in an effective manner.

Around ages 3-5, pre-school age children are first exposed to the meaning of rudimentary, basic emotions (happiness, sadness, fear, and anger). Typically, they learn from their environment and their peers that there are “good” emotions (happiness) and “bad” emotions (sadness, fear, anger). Therefore, any time they experience fear (or anxiety) or sadness and anger, they make the association that what they are feeling is wrong or “bad.” If a child’s emotional vocabulary does not develop beyond these basic types of understanding, as they get older you may see behavioral problems develop as they are not properly able to express themselves, and therefore work through their problems (internal or external) effectively.

I gave a talk recently at a local elementary school and discussed this issue with parents. The parents I speak with continually are surprised by the importance, but also direct simplicity of this issue. They frequently ask, “What can I do to start expanding my child’s emotional vocabulary?” Well, I like to de-label the basic emotions to start. First, I challenge my patients to think about times in their lives when it would be GOOD to feel sad, or when it would be BAD to feel happy.

A particularly effective example I like to use:

Imagine your dog gets sick from eating a sock. Why would it be BAD to be happy in this situation?”

 

What’s the answer here? Well, because you love your dog and it would mean you did not care about them if they are in pain. These types of examples challenge a child’s basic understanding of emotion and begin their education in the true complexity of emotions.

As children develop their emotional vocabulary it is important that parents begin to observe their behaviors to assist them in expressing themselves more effectively. For example, if your child is throwing a temper tantrum on the floor, it is probable they are feeling frustrated because something they want or something they want to do is not happening. Temper tantrums are the behavioral manifestation of their emotion. However, wouldn’t it be more effective to say, “Mom/Dad, I am feeling frustrated with XY and Z and I need help problem-solving.” You may be thinking, there is no way my 3 year-old child can implement this strategy, but I am here to say, yes they can and I have witnessed it first hand. I am not promising this will work every time, but it is a definitive step in the right direction and can ease stress and increase communication all at once. Try developing your emotional vocabulary this week and let me know how it goes!

When I teach my undergraduate classes in Abnormal Psychology or when I first meet with my kids, parents and families, I discuss with them the important of balance. When I have a patient that comes in and they are experiencing too much anxiety or depression, I commonly hear, “How can I no longer feel any anxiety or sadness?” This is an interesting question because is it actually good to feel no/zero amounts of anxiety or sadness? The answer–it’s not! For example, anxiety in moderate and manageable doses leads us to feel motivated to get our work done, to get up in the morning and brush our teeth, to get out of bed even when our kids have kept us up the night before. We need anxiety to function, but it is all about what is your “normal.” I always put this word into quotations, even with my patients in session because everyone has their own normal. More anxiety may work for one person (i.e., more productive at work, more attentive to their spouses or childrens’ needs), but for another it may be too much. This leads me to discuss when is the anxiety or depression your child is experiencing too much? Because children have a limited emotional vocabulary (something I will address in my next blog post), it is important as parents to look for the overt behavioral signs of anxiety and depression. These can include but are not limited to avoiding school work, friends, activities during or out of school, low tolerance for stressful situations and wanting to escape, spending copious amounts of time in bed, not engaging in conversations, and other behaviors like crying or having tantrum behaviors. These can be “normal” in the context of them happening every now and then, but we know that we have reached a clinical level where professional intervention may be necessary when they are happening with increased intensity and frequency. If your child is not functioning in their life as they were previously, it is important to recognize that your child may be out of balance and may be in need of a professional evaluation.