Managing Stress & Anxiety in Teens: - PowerPoint Presentation

1. Managing Stress & Anxiety in Teens: A Cognitive-Behavioral ApproachBonnie Zucker, Psy.D.PsychologistAuthor of Anxiety-Free Kids, Take Controlof OCD, & Parenting Kids with OCDCo-Author of Resilience Builder Program

2. Most common problem in children, adolescents, and adultsEstimated 15-20% of children meet the criteria for an anxiety disorderEstimated 32% of US adolescents (aged 13-18) have an anxiety disorder Many more have stress and stress-related physical conditionsAnxiety Disorders Facts

3. Anxiety Disorders FactsMore common in females than males (ex: 23% vs 15%)50-60% of children with one anxiety meet the criteria for another anxiety disorder or mood disorderStrong relationship between childhood and adulthood anxiety disorder (don’t “outgrow”)

4. Outline of PresentationGiven the high prevalence of anxiety disorders, I will explain how it is treated with CBT. Many of the strategies will be applicable to kids who have intermittent anxiety and those who need stress mgmt.We will discuss parental role in all of this.The focus will then be on what leads to success in adulthood, stress mgmt, and how to think about college and the future.

5. Internalizing vs. Externalizing DisordersInternalizing (ex: anxiety, stress, depression): when the child’s symptoms are “internal” and turned within. Externalizing (ex: anger, oppositionality, impulsivity): when the child’s symptoms are “external” and come out in overt behaviors.While internalizing symptoms can at times be observable & are often responsible for physical complaints (stomachaches), there tends to be a lot going on for the child than is not obvious.

6. Anxiety Disorders TreatmentAnxiety is very treatable; CBT is the most empirically supported approach to treating anxiety disorders in children & adultsCBT is problem-focused, solution-oriented, and teaches coping strategies and techniquesCBT is also beneficial for stress management and offers tools to be more aware of stress and take steps to cope/reduce stress symptoms.

7. Three Parts of AnxietyBodyThoughtsBehavior

8. BodyThoughtsBehavior

9. BodyThoughtsBehaviorSweaty PalmsFast Heart BeatTense MusclesStomachachesWorriesThinking ErrorsNegative Self-TalkAvoidanceNervous Behaviors

10. BodyThoughtsBehaviorSweaty PalmsFast Heart BeatTense MusclesStomachachesWorriesThinking ErrorsNegative Self-TalkAvoidanceNervous BehaviorsLearn Relaxation and Calm Breathing-Guided Imagery/Meditation/YogaFace Your Fears! Get Rid of Nervous Behaviors Conquer Your Worries Identify and Replace Thinking Errors Positive Self-Talk

11. Part 1: Body Relaxation Revolution (H. Benson)Mind-body practices: meditation, yoga, repetitive-worship music/rituals, relaxation techniquesMind-body practices can “switch off” or “switch on” gene activity/expression associated with certain diseasesStudy found: genes in the experienced mind-body practitioners were expressed differently than the same genes in inexperienced practitioners.

12. Relaxation Revolution continuedThe genes that acted differently = associated with stress-related medical issues, including immune responses, inflammation, premature aging, thinning of the cortex, and other conditions that may involve oxidative stress (free radicals causing damage to physical tissue) including cardiovascular disease

13. Part 1: BodyTeach lower diaphragmatic breathing:Slowly breathe in through your nose and breathe out through your mouth, allowing the air to go all the way down to your lower belly (smell the roses, blow out the candles)Demonstrate lower diaphragmatic breathing and have child practice (can use yoga mat and props if needed)One-nostril breathing:breathe in and out through only one nostril (hold other nostril closed and close mouth); need to do this for several minutes to be effective (in for 8, out for 10)** MASTER THIS FIRST when calm/ NOT anxious

14. Part 1: BodyRelaxationAPPS: Calm (calm.com) Insight Timer (Mooji: Nothing here but you; Tom Evans- Be Calm a Little Longer) Headspace

15. Part 1: BodyMindfulnessMindfulness is being aware of your body, your thoughts, and your surroundings; it is tuning into yourself and your experience.Teens who are mindful are more aware when they are feeling stressed and where it is showing up in their body.In high stress states, people are less present in their bodies and somatic symptoms can arise. Being mindful prevents this.

16. Part 2: Thoughts- Fostering Resilient ThinkingFostering resiliency is helping teens know that they can handle whatever comes their way. No matter what they have to deal with, they can handle it: they can problem-solve and they can tolerate negative/uncomfortable emotions.Ask yourself 2 things:What is the worst thing that could happen?Could I handle it? (answer = always yes)Challenging thinking errors is useful in promoting resilience.

17. Part 2: ThoughtsThinking errors- go through ones most commonly used by teen (see handout)All-or-nothing thinking & Catastrophizing are very common in stressed teenagers. These thinking errors strength anxiety.Parent as model

18. Part 2: ThoughtsThere is a connection between Situations- thoughts- feelings Motto: “I can change the way I think to change the way I feel”

19. Part 2: ThoughtsSituation-Thought-Feeling-Behavior Situation: You have several exams and papers due next week.(Automatic) Thoughts: I can’t get this all done. I’m going to fail. What if I get a bad grade and ruin my GPA? I can’t handle this.Feeling: Anxious, worried, a bit panickedBehavior: Study all night and stay up late. Bite nails. Freak out and spend 2 hours talking about how much work you have (to parent, friend, whoever will listen). OR Procrastinate- put it off because too overwhelmed.

20. Part 2: ThoughtsSituation-Thought-Feeling-BehaviorReplacement Thoughts: I can handle this. It will all get done. Everyone else has this amount of work as well. I will just take one step at a time- focus on one task at a time and it will all get done. Reacting to it won’t make it go away- the only thing that will help is getting started and actually doing the work. Alternative Feelings: More confident, calmerAlternative Behavior: Work at a steady pace, get proper rest, take action and not overreact.

21. Part 2: ThoughtsSelf-Talk Note CardsOn index cards, write:-I must face my fears to overcome them.-I can change the way I think to change the way I feel.-I am okay. Everything will work out.-I can handle this. I am nervous, but I am okay.-I can handle whatever comes my way.-It is my choice to be nervous or I can be calm. Let me do my breathing.-Anxiety is not an accurate predictor of what’s to come. Anxiety is just an unpleasant feeling.-What would someone who wasn’t scared in this situation think and do?

22. Part 2: ThoughtsSelf-Talk Cards-It’s me vs the anxiety. Each time I listen to the anxiety and let it rule my life, it gets stronger. Each time I make decisions based on my values and not the anxiety, I get stronger.-I cannot allow anxiety to make decisions for me.-I cannot allow anxiety to influence my behavior.-I’ve never regretting facing my fears.-I have to “sit with” and tolerate the discomfort.-I will manage my stress by taking one step at a time and only focusing on the task in front of me.-I can take breaks to relax and calm my body. Managing stress is part of being a healthy, successful student.

23. Part 2: Thoughts- Conquer Worry”Worry loop recordings” are a useful way to desensitize to worry thoughts and gain a different perspective. Listening to the recordings externalize the thoughts & allows you to become an observer of (rather than a participant in) the thoughts. With repeated listening, habituation occurs.

24. Part 2: Thoughts- Conquer WorryTeen lists their worries and make an audio recording (include even the scariest thoughts- if they think it, include it).Listen daily 10-15 minutes/day until becomes boring. Usually takes 2-3 weeks.Habituate to the thought, not the content.Can use recorder on phoneListen daily to the recording

25. Part 3: BehaviorMost common behavior associated with anxiety is AVOIDANCEChildren have other anxious behaviors, including:reassurance-seeking 6. asking questionsfidgeting 7. crying picking/pulling 8. meltdownchecking 9. clingingscanning environment 10.rituals

26. Part 3: Behavior continuedFace Your Fears: You must face your fears to overcome themTeach habituation: by staying in a situation, you become used to it (numb out); use example of getting into cold poolTeen will take each step on ladder gradually and with repetition (we don’t just do it once, we do it over and over until it no longer evokes anxiety); This is SYSTEMATIC DESENSITIZATION

27. Part 3: BehaviorHabituation: by staying in a situation long enough, you become used to it. Courage comes after slaying the dragon. You have to face your fears first, before you realize you can do it.For procrastination: action comes first, then motivation, then more action.

28. Part 3: Behavior continuedExample of Ladders

29. Parenting RoleIn helping your teen thinking positively about themselves, school, and the future, parents have a HUGE influence.Sometimes, a teen is stressed/anxious due to internal pressures (e.g., perfectionism),Other times, the pressure is coming from external pressures (e.g., competitive environment) or the family system.

30. Parental RoleFor internal pressure/ anxiety, the goal is to not reinforce or worsen the anxiety by accommodating it or providing reassurance.Instead of trying to alleviate their discomfort, we need to encourage children to be brave, face their fears, and tolerate the discomfort. We do this gradually and by guiding them to externalize the anxiety and not give into it. Authoritative parenting!

31. Parental RoleSample Parental Responses (that encourage challenging the anxiety):“I see how hard this is for you. I know you can talk back to the anxiety.”“If you are scared, this is your chance to practice being brave. You can only practice being brave when you are scared.”“It‘s only the anxiety talking. What can you say back?”“I know that you want me to answer your questions, but I can’t talk to anxiety. I can talk to you, but not the anxiety.”“What can you do to calm down and relax?”“I see you are having a hard time calming down right now. Let’s do your breathing and read your cards to help.”“Even though it may not feel like it, you can handle this.”

32. Parental RoleParents can vicariously experience their own stress (e.g., during college admission process). Common worries about where your child will get into college, etc. Parents can manage their stress by using same techniques and also reframing their role, seeing the big picture, etc.

33. Parental RoleWhen the pressure is coming from the environment (competitive academic, friends focused on grades, etc.):Parents need to be the source of reason.Parents need to support a balanced view of the self, others and the world.Parents need to encourage a healthy lifestyle and school-life balance.Encourage “relative comparisons”

34. Parental RoleWhen parents are the ones to pressure:Creates stress in the child Disrupts parent-child relationshipSupports an externally-driven mindsetInterrupts the child’s development of self-drive, inner motivation, self-efficacy, and self-esteemHigher risk of depressionHigher risk of anxiety disorders

35. Parental RoleQuestions we need to ask ourselves as parents:-What is the role of a parent?-What is our parenting goal (can ask this situation-specific and larger scale)?-How is our parenting supporting or hindering our child’s confidence?

36. Success in AdulthoodSelf-esteem is related to the greatest amount of happiness in adulthood (and success at work, in relationships)Grit is highly predictive of success in life.Resilience is highly related to well-being and lower mental health issues.Internal locus of control= essential for success and well-being

37. Success in AdulthoodParenting goals need to be aligned with:-fostering/maintaining self-confidence-promoting grit-helping children cope with failure and obstacles to develop resilience-developing an internal (vs external) locus of control

38. Success in AdulthoodSelf-confidence both allows one to stand up for themselves/their rights, and is developed by doing so (sticking up for yourself leads to confidence).Believing in our child and supporting our child (on their team) and not shaming or blaming is essential for developing confidence.

39. Success in AdulthoodGrit is “stick with it-ness,” not giving up, not quitting. By having our children stick with commitments, keep working at it, “growth mindset” comes in here, they develop grit. Resilience comes from dealing with failure and not letting obstacles stand in the way of a goal. Grit is often involved, but the characteristic of being resilience has a lot to do with lower anxiety/depression.

40. Success in AdulthoodInternal locus of control is when you see that you have some control regarding how things are going to play out. You believe there is something you can do to effect a situation, or at minimum, your experience of a situation.External locus of control is when you feel that no matter what you do, the situation can’t change and the outcome is out of your control.

41. Success in AdulthoodHaving an External locus of control sets one up for depression (learned helplessness, Seligman).This is where strategies, techniques, and the right attitude come in: we want the orientation to be “what can I do differently, what I can change, how can I think differently or approach this situation differently?”

42. Success in AdulthoodRelated to internal locus of control: seeing that you have choices, options. Flexibility is key here (also part of resilience)Having control is also related to lower level of stress (there is a lot on this in Self-Driven Child – Stixrud & Johnson). Lower levels of stress allow our prefrontal cortex to work well (better reasoning, clearer thinking, organized thinking, etc.)

43. Parental InvolvementBabies are externally-motivated (they do things to elicit a response from parents)Adults are (or at least should be) internally-motivated.The goal of parenting is slowly pull back and let children make their own decisions, (even if they fail), give children responsibility, and give them the chance to figure it out on their own (e.g., not do it for them ).

44. Parental InvolvementIf your child has a low grade or is socially rejected, this is your opportunity to teach how to cope with failure, disappointment, and pain. This is your opportunity to teach them how to problem-solve (talk to teacher) and be assertive (stick up for themselves with peers).Maintaining a connection with them through the tough times supports the development of resilience!

45. Parental InvolvementHandling failure: it is essential that children are able to deal with failure. Failure is a natural part of life, not something to be avoided or feared. We only learn from mistakes, from failures. Both academic and social failures allow us to become better and successful.PS: You can’t handle failure without failing!

46. Parental InvolvementBill Stixrud & Ned Johnson’s The Self-Driven Child: the parent as “consultant”Benefits of being a consultant: it supports the teen’s goals, makes his or her goals more clear, affirms that it is their goal, not yours.If hesitant, try it out for a period of time (3-4 months).

47. Stress ManagementWork/life balance. Time for fun/play; needed for creativity.Sleep!!!Clean eating (80/20)Exercise (150 minutes/week minimum).Relaxation/meditationGratitudePositive “Can Do” attitude

48. Stress/Worries about CollegeHave your child read Where you go is not who you’ll be by Frank BruniEmphasize that it’s not required to go to a top college to a have great success in your career and in life. College is a stepping stone for your future, and what you do it college, and how you develop as a person, are arguably more important factors that where you attend.

49. Worries about CollegeReassure your child that they will go to college. Emphasize what is in their control and what is not.We make the best decisions based on our options. Emphasize internal locus of control.

50. Relative vs Normative ComparisonsCompare yourself to yourself, not to others.Also, being happy for others brings you more happiness in your life, vs competing which causes your energy to leak.

51. PublicationsAnxiety-Free Kids: An Interactive Guide for Parents & ChildrenTake Control of OCD: The Ultimate Guide for Kids with OCDParenting Kids with OCD: A Guide to Understanding and Supporting your Child with OCDSomething Very Sad Happened: A Toddler’s Guide to Understanding DeathResilience Builder Program for Children & Adolescents: Enhancing Social Competence & Self-Regulation (A cognitive-behavioral group approach)- Co-Authors: Mary Alvord & GradosRelaxation & Self-Regulation Techniques for Children & Teens: Mastering the Mind-Body Connection (Audio CD)- Co-Authors: Mary Alvord & Bryce AlvordRelaxation & Wellness Techniques: Mastering the Mind-Body Connection (Audio CD)- Co-Authors: Mary Alvord & Bryce Alvord

52. Recommended BooksRelaxation revolution. By Herbert Benson & William ProctorWhere you go is not who you’ll be: The antidote to the college admissions mania. By Frank BruniMindset: The new psychology of success. By Carol Dweck.The worry cure: 7 steps to stop worry from stopping you. By Robert LeahySelf-driven child: The science and sense of giving your kids more control over their lives. By William Stixrud & Ned JohnsonParenting by heart: How to stay connected to your child in a disconnected world. By Ron TaffelWhy we sleep: Unlocking the power of sleep and dreams. By Matthew WalkerAnxious kids, anxious parents: 7 steps to stop the worry cycle and raise courageous and independent children. By Reid Wilson & Lynn Lyons