Ask Amanda - Dealing with anxiety

Q:
I wanted to put a vote in for the "Ask Amanda" days - this occurred to me last night as I tossed and turned trying to work out how to help my daughter deal with anxiety. She has just started Year 1 and has had a number of wee accidents at school (none over the break) and she wakes up every night and insists on sleeping in our bed - both these behaviours have started with the new term hence I think they may be about her anxiety...would love any advice/tips or simply stories of similar experience...

A:

Imagine this...

You have just been invited to a new friend's home for dinner. It will be the first time you have been there.


Getting there

First, you double check that you have the address right and you are given a description of the place. You might even get someone to drive you past just so you are confident you can get there.

Then you consult Google maps and get a set of written directions, a map and a street view of the place. You are getting even more confident.

On the night you have butterflies in your tummy, but that is expected. Another friend who knows the way offers to come with you. So now you barely worry at all.

With a little anxiety, you get in the car. But because you have someone you trust with you, and you have a written road map, and pictures representing the place, you manage to get there and enjoy the evening - and get home!


A break

But then you don't get invited there for a while. Until one day, a few weeks down the track, you get invited again. Because you have been there before, you don't really worry. You just set off....


Getting there again

But last time you were driving at dusk, so now all the landmarks look different.

And while you thought you could remember all the turns, it turns out that you don't... and you forgot to bring the maps and instructions. And this time you are giving a lift to someone who "sort of" knows the way, but you don't know them well enough to trust them.

You do get there. But by the time you get there you are so anxious it is hard to relax and enjoy the company - all you can think of is having to drive home again.

But you don't really want to tell anyone because you feel like you should know what to do because you know you have done it before.


The analogy

No, this isn't just a random story :). It is an analogy of how a child may feel as they transition back to school after the school holidays...

"Landmarks" change, "supports" are different or fewer. And the expectations are different. For children with developmental disabilities, add to this a difficulty with problem-solving and analysing your environment, and it is no wonder that the transition back to school after the holidays is a very anxious time.


So what can we do?

I will take a little time this month to talk about what can be done. But if anyone reading this blog has a story or some advice to offer, please post a comment here.

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Holidays are over! The challenge for children

Returning to school can be very exciting for children. It can mean re-connecting with friends and all the social fun! It can mean a return to favourite subjects, fun activities....

But settling back into school after the holidays can also be a time of anxiety and tiredness.


Social Challenges

For some children, returning to the social life of school can bring up anxieties and challenges. After the relative freedom of the holidays, they may find it hard to re-adjust back into the routine of the classroom. As discussed in my previous series of posts on the transition to school, children with special needs may need a slow transition back into the learning routine. And there may be some social "bumps" along the way.

Some suggestions for helping children with Autism, Aspergers or developmental disabilities settle back into the social routine include:

1. Using photos of friends and staff to remind the child of who they will be seeing at school.
2. Talking about the photos to remind the child of how they interact with these people. For example, "This is Johnny. You play soccer with Johnny on the playground!"
3. Display a list of the school rules (at home and in class), with illustrations/photos, and revise, review, talk about and practice them.
4. Where possible, arrange small group, supervised activities involving the child's interest at recess and lunch breaks to minimise the sensory and social input. This is a good way to prevent behaviour difficulties that may happen due to the busy, noisy nature of the playground.
5. Establish a home/school reward system so going back to school has its extrinsic (external, "artificial") rewards, even if the child finds it hard to see anything positive about being back at school.
   

Physical Challenges

Returning to school can be a tiring business for everyone. But it is especially important to recognise that children with diverse needs may find it just that bit more tiring.

This may be because of sensory processing difficulties or impairments. For example, children with hearing impairments often have to work much harder to process and interpret sounds. Children with sensory sensitivities may be tired out due to higher levels of stress during the day as they get used to all the sights, smells and sounds of school again.

Tiredness may also be due to physical disabilities. For example, sitting for extended periods of time, moving around the school and having limited "rest periods" throughout the day could have an impact on children with Cerebral Palsy.

Concentrating and communicating is also a very tiring activity. For children with ADHD or ADD, who struggle with maintaining attention, re-training themselves back into school can be very tiring. Children with language difficulties, including children with Autism and dyspraxia or apraxia, concentrating and listening gets very tiring by the end of the day.

This may mean that, not just in the first few weeks, a child's "endurance" cracks by the final session of the school day. So having less challenging, less intense activities towards the end of the day, and minimising the amount of homework given is essential.

Children arriving home exhausted are not likely to cope with any further physical or "thinking" demands placed on them. Putting further demands on them does not allow for recovery time, and also can mean an increase in difficult behaviour as the child struggles to cope.


Academic Challenges

This links with the previous points about concentration and language. However, there may be the added factor of a child with special needs "regressing" during the holidays. Words they could read, things they could say and do, may have been "lost" during the holidays. This may simply be due to lack of practice as the words and activities of school are often quite different to those at home.

Be prepared to re-teach some old things before adding too many new concepts and activities. Revision will be important to get the child back into the swing of things.

How is the settling-in period going for you and your children?

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So this is Christmas... and what will we give

Present-giving is such a huge part of Christmas. I remember vividly the excitement that caused sleeplessness on Christmas Eve - then the joy of finding the present at the end of the bed in the morning... Much torn wrapping later, and the day was full of new toys, food and fun.

But present-giving can also cause tension. Trying to please everyone, trying to display pleasure at inappropriate gifts, arguments over money spent, offence at gifts returned.... we all want to avoid these things.


Gift-giving and children with disabilties

I recently listened to parents of children with disabilities discuss the difficulties of presents at Christmas-time. I thought it would be good to use this blog to help build awareness of the issues that we need to consider when giving gifts to children who have special needs.

Some things you need to consider:

• Narrow interests: One thing it is important to realise is that some children with disabilities have quite narrow interests. For example, a child with autism may only use items that have Thomas the Tank engine on them.
  

• Developmental appropriateness: You need to consider the developmental appropriateness of a toy - not just its age appropriateness. For example, some children who have vision impairments use their sense of taste to continue exploring their environment long after their peers have stopped mouthing toys. This means that toys with small detachable parts that might be age appropriate will not be developmentally appropriate for the child as they could be a choking hazard. Other aspects that need to be considered are the child's intellectual, gross motor and fine motor skills. Children with disabilities such as Down Syndrome or Autism may find it more difficult to hold pencils, pick up small items and play with things that involve threading, constructing and significant muscle control in the fingers. Others may find it difficult to balance and use the gross motor skills involved in riding bikes or climbing. And others may find the cognitive challenge of some games such as puzzles, board games, card games and craft activities, beyond their cognitive ability.
  

• Sensory sensitivities: Some children with disabilities are very sensitive to certain textures, sounds and even colours. Toys that do not align with their sensitivities will not be used, and may even cause them some distress.

So how can you make sure you purchase an appropriate gift?

The easiest way is to ask parents. They will be able to tell you about the child's abilities, interests and favourite toys. And don't be offended if they give you a list of specific things or places to shop for their children.


Here are two sites that were recommended by parents:

http://www.specialneedstoys.com.au/shop/

This Australian site provides a range of toys suitable for children with Autism Spectrum Disorders, Communiation and Sensory Processing Disorders, ADHD, Physical Disabilities and Cognitive and Learning Delays. They have toys priced from under $5 to over $100.

The toys include a whole range of things, from puzzles to computer-based games.

http://www.amazon.com

Another parent recommended this Amazon search entitled "Bestsellers in special needs multi-sensory toys."


Spectronicsinoz also has a range of games, though they are more expensive and generally educational. Here are some examples of their games:

Spot on Games
Card Games
Switch-friendly computer games for children with physical disabilities
More computer games called Play with me

All the best for your Christmas shopping :) ... and may your Christmas be full of fun.

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Adjusting to the new physical environment

As mentioned in the previous post, one of the key changes in any transition is the change in the physical environment. The one thing that may cause the greatest concern for us as parents or teachers in this respect is the safety of the child, especially on the playground where fences are not always “child-proof” and the out-of-bounds areas are defined by rules rather than physical boundaries.

Handley (2006) discusses some great strategies to help children learn where they can and can’t go in the physical environment at school. This is called boundary training. Some of the steps she suggests include the following:

Design visual supports

Depending on the age of your child, Handley suggests using photos, line drawings or maps of the school. These should have clearly marked boundaries.

Young children or children with more significant developmental delays are likely to better respond to photos – especially photos of themselves standing in the areas being photographed. This means that they can relate the photo to a real experience, rather than trying to use imagination to put themselves into the picture.

Colour code or sort photos of the child in different areas

To help the child understand where they can and can’t go, sort the photos accordingly. That is, take photos of the child in places they can go, and photos without the child of places where they can’t go.

Make charts with appropriate symbols to cue the child into where they can/can’t go

Handley suggests making two charts – a “I can play here” and an “I cannot play here” chart. She encourages the use of universal colour codes (red for stop, green for go) and signs (see below).

For example, your chart may look like this:

Colour-code spaces

For inside spaces, mark areas with the same symbols and colour-coding. Or, for older children, use maps of rooms and colour-code them. Different areas of a classroom may be “off-limits” at different times of the day. For example, children must stay on the mat during group time, at their desks during work time and outside during play time. Symbols on doors or on the floor can help your child identify these physical boundaries.

Make a video

This would work in a similar way as your photographs. Take videos of the child playing in different areas. Handley (2006) suggests that you say something like “This is John in the playground. This is safe” when filming in safe areas. Alternately, film the unsafe areas without the child and state “John is not allowed to play here. This is not safe.”

Laminate the “no” symbol to attach to “no go” zones. Or carry it around to help prompt the child to stay within the boundaries.

Go on orientation walks

Frequent walks around the boundaries can help the child understand and identify where they can and can’t go. Repetition and familiarity is essential. Only stop these walks when the child can identify the boundaries without any prompting.

Reward successes

Use visual rewards when the child successfully stays within the boundaries. Make sure you get to know what the child responds to – some children love stickers, others don’t. Most children have a specific interest area – use that as a basis for your rewards.

Use frequent reminders

Children can be reminded by parents as they walk in the school gates about where it is appropriate and inappropriate to go - using the symbols, photos and chart where possible. Teachers, before they send children out of the class into the playground, can remind children of the boundaries. Use the visual charts and symbols to reinforce these reminders.

But rather than always reminding the child, get them to remind you sometimes.

At home, before the school year starts:

Start familiarising your child with the symbols and colour-coding. Use the colour-coded charts to identify the areas of your home where your child cannot go. Get them involved in creating and using these so that they are used to it before they actually go to school (or high school). Colour code different spaces according to your routine to get your child used to the fact that some parts of the physical environment are only off-limits at certain times (eg. outside is off-limits after dark).

Once you have decided on what school you are going to you should have the opportunity to visit that school in the school year before starting at the school. With the school’s permission, have family outings to take photos in the school grounds, start making the colour chart at home. You could do this during the day when students are in their classrooms, then try going when the other children are on the playground – gradually getting your child used to the playground atmosphere.

Wherever possible, don’t wait until the school year starts to familiarise your child with the school’s physical environment….get in as early as you can.


Reference

Handley. E. (2006). Making Change Easier: Helping Students with an Autism Spectrum disorder prepare for change during the school day, from day to day or transition from school to school. A Guide for Parents and Schools. Autism South Australia: South Australia.

If you want more information, you might want to search for publications or books on Autism SA’s site at http://www.autismsa.org.au/html/resource/resource_intro.html. Your local library may be able to help you get hold of these.

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No such thing as evil

“There is no such thing as evil. Youth behaviour that challenges the common expectations and values of society is not the result of inherent wickedness, but is a multifaceted problem emerging from a complex network of factors.” (Leaman 2005 p1)

I don’t think there is anything I want to add to that… I just thought it was a great, thought-provoking statement. It draws attention to what is not always in the forefront of our minds when we are dealing with the most difficult behaviour: that behaviour is very complex and there are many factors both seen and unseen that influence that behaviour.

But, like Leaman, I also want to make that point that this is not excusing behaviour. Rather, it is an attempt to understand it so we can effectively change it.

Leaman also talks about three hidden contributors to aggressive or other disruptive or difficult behaviours.

Low self-esteem

There are many reasons for low self-esteem, but one that children with differing abilities may face more frequently than others is failure. Failure in the classroom. Failure in social relationships. Failure in achieving their potential in other areas.

A child who experiences what they see as failure can be at risk of spiralling into disempowerment and/or depression. For some children this can be seen in bullying behaviour as the child tries to empower themselves. For others it can be seen in both passive and active defiance, or refusals to complete tasks.

For example, it is recognised that children diagnosed with Oppositional Defiance Disorder often have low self-esteem (Better health Channel, 2007). Their refusals to obey rules, swearing, blaming or needling others can be linked to (though they are not exclusively a product of) low self-esteem and the need for power and control. Refusals to obey rules and swearing or bullying others swing the balance of power back in their favour. Blaming others for their mistakes or errors, or simply refusing to attempt tasks, can be a protection mechanism to avoid being seen as weak or having failed in a task. By doing these things they are controlling their environment through intimidation or defiance.

Egocentricity

Acting impulsively or acting without first considering the effect of their actions on others can also be a contributor to aggressive behaviour. For more on this see the previous posts on executive function and the development of empathy.

Internalised anger

Children with Down Syndrome can also be seen as stubborn or defiant. However, the issue is more that, due to their intellectual disability/developmental delay, it is more likely that they do not understand what is required of them (Feeley & Jones, 2006). The difficulty is that they may find it very hard to put into words as their developmental delay and physical difficulties can influence their ability to communicate complex, abstract concepts like emotions. This may be exacerbated by low self-esteem from experiences of “failure”, and thus increase the risk of the child acting aggressively or defiantly in order to express their feelings or protect themselves from embarrassment.

It is important, in this case, to recognise that children with Down Syndrome have been shown to be at increased risk of depression and other anxiety disorders (Pollack, 2009). So responding to the needs of the child rather than focusing on the behaviour is important.


Leaman has some great suggestions of strategies to deal with difficult and aggressive behaviour. If you can get your hands on this book, whether you are a teacher or a parent dealing with challenging behaviour, I am sure you will find it very helpful.


References:

Better Health Channel/Victorian Government. (2007). Oppositional Defiance Disorder. Retrieved 26th August 2009 from http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Oppositional_defiant_disorder

Feeley, K. and Jones, E. (2006). Strategies to Address Challenging Behaviour in Young Children with Down Syndrome. Retrieved 26th August 2009 from http://www.down-syndrome.org/case-studies/2008/

Leaman, L. (2005) Managing Very Challenging Behaviour. London: Continuum

Pollack, S.D. (2009) Waisman Center. Retrieved 26th August 2009 from http://www.waisman.wisc.edu/faculty/pollak.html

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Helping children make good choices

The final four steps in the problem-solving process involve being able to identify your choices, analyse the consequences of these choices before you act, then being able to make the best choice in the circumstances.

Life isn’t black and white

We have probably thought at some point in our lives how much easier things would be if there was a clear, black and white, right or wrong answer to a problem. But life is not like that. It is full of shades of grey.

There may be many different solutions to a problem, each with its own positives and negatives. And the best solution may differ according to the context you are in.

Problem-solver’s block (as opposed to writer’s block)

Problem solving involves a lot of what we call higher-order-thinking processes (Queensland government, 2004; Thomas, nd). That is, we have to be able to look at the situation and analyse it. We need to be able to predict how our actions may affect others or ourselves. We then need to make decisions about what consequences we can live with, and which ones we want to avoid.

These complex processes can become very difficult for some children. For example, most of us when under extreme stress or emotion just let ourselves go with what our body and feelings want us to do.

For example, when confronted with a live cockroach I am likely to utter a genteel (or not) scream and take flight to the nearest elevated surface. If I was reasonable, I would know that a cockroach cannot hurt me.

Alternately, when I was faced with a crisis when teaching I surprised myself with the ability to go through required steps to ensure the safety of those in my care… and when everyone had gone home, dissolved into uncontrollable tears.

In these situations I acted without thinking because the strength of the emotion interfered with the rational problem-solving process. The practiced, routine or natural response takes over.

In the same way, children living with anxiety disorders or depression may find it difficult to problem-solve as negative thoughts, tiredness and fluctuating emotions may make it hard to concentrate, organise their thoughts, and analyse the situation effectively (Crundwell & Killu, 2007).

So in the face of teasing or exams, they may become frozen or speechless or unable to work through the problem. Alternately, they may have a “melt-down” or demonstrate their emotion through verbal or physical aggression against others or themselves.

Taking things literally

For children with intellectual disabilities/developmental delays, the ability to use higher-order thinking skills is impaired. For the most part they will need to be taught, step-by-step, how to respond to difficult situations. The difficulty with this is that they may implement these steps rigidly, not adapting them to the required context (Raymond, 2004) .

For example, we met Jo in the previous post. Jo was taught to offer an exchange and take turns if a child has taken something of hers or something she wants. So at “fruit break”, when another child took the slice of orange that she wanted, she offered an apple in exchange. When this was refused, she suggested they “take turns” eating the orange. The difficulty with this is that, a school, there is a clear rule about not touching or sharing others’ food.

This is called a difficulty in adaptive behaviour, which is usually used as a key measure of intellectual or developmental delays.

Impulsivity

As mentioned in previous posts, acting without thinking about consequences is a key characteristic of ADD or ADHD. For more on this, follow this link and also follow up the references to the Stop, Think, Do program by Lindy Petersen.

Think Good, Feel Good by Paul Stallard

This table could be a great tool to help children work through an issue. It comes from Chapter 12 in Stallard’s book. I would highly recommend that you access this book if your child is having difficulties with problem-solving due to confidence, anxiety or other issues.

You could adapt this table to help children with developmental delays in the problem-solving process. Using Boardmaker or other picture languages to complete this table, or creating social stories are some alternatives.


References

Crundwell, M.R., and Killu, K. (2007). Understanding AND Accommodating Students with Depression in the Classroom. Teaching Exceptional Children, 40(1), pg. 48

Queensland Government. (2004). Higher order thinking. Retrieved 28/08/2009 from: http://education.qld.gov.au/corporate/newbasics/html/pedagogies/intellect/int1a.html

Raymond, E.B. (2004). Learners with Mild Disabilities: A Characteristics Approach. New York: Pearson Education.

Stallard, P. (2002). Think Good- Feel Good. John Wiley & Sons: Australia

Thomas, A. (nd). Higher order thinking – it’s HOT! Retrieved 28/7/2009 from: http://www.cdl.org/resource-library/articles/highorderthinking.php

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Resilience....

“Resilience is the ability to manage and learn from difficulties and to bounce back after diversity.” (Department of Education and Children’s Services, 2007 p1)

Each of us has a different definition of what is a “disastrous” event, an event that makes us lose control of our emotions.

For some it can take something as little as the inability to find one’s keys, for others it takes significant life events like the passing of a loved one. That is because we each have differing levels of resilience.

There is some debate over just what makes one person more resilient than another, but personality, life experiences, emotional intelligence and self-perception will all influence how well we bounce back.

How facing risk can build resilience

A list of school safety rules as seen in the BBC news http://news.bbc.co.uk/2/hi/uk_news/education/8107858.stm

SAFETY RULES
Wearing goggles to put up posters
Five-page briefing on the dangers of glue sticks
Ban on running in the playground
Wet grass stopping PE lessons
Ban on playing with conkers
One person at a time in staff kitchen
Ban on sweets because of choking risk
Buoyancy aids for capable year 11 swimmers on a school trip to France

It may be suggested that some of these are a little over-the-top. But we want to protect our children. Isn’t that a good thing?

Like for most things, we need to do it in moderation. There is research that suggests that children who face either low or high levels of risk through their lives, whether it be physical or emotional risk, are likely to be less resilient than those children who have faced a moderate level of risk (Fergus and Zimmerman, 2005; Gill, 2007). If a child has not had to face and deal with any risk before, they are more likely to be anxious and unsure of how to deal with problems or challenging situations in their lives. They may not be familiar with the feelings associated with a healthy adrenaline rush and may not be able to cope with or use that emotion to their advantage.

On the other side, children who face high levels of risk in their lives are likely to be worn down by unhealthy levels of fear and anxiety. Every person has a breaking point, and there is a point at which fear and anxiety can limit our ability to problem-solve or manage our emotions.

But it is more complicated than that…

We cannot simply push children to face “moderately risky” situations and hope they will develop resilience. As mentioned before, we don't always know what can be defined as a "moderately risky" situation for a person. And we also need to think about what will help children learn good coping strategies.

Research suggests that children are more likely to be resilient if they have good role models, adequate supervision and good social/emotional supports (Fergus & Zimmerman, 2005). They also need to be educated on risks and problem-solving.

Let’s take the simple example of the glue sticks. We probably don’t need a five-page briefing on the topic. However, you will need to choose child-friendly glue sticks, supervise young children closely whilst using them and occasionally remind them that the glue is for the paper not for their mouths.

Coping skills

How we deal with every-day problems tells us a lot about resilience. What do our children or students do when they are faced with problems?
· Are they curious or do they show signs of anxiety or fear?
· Are they confident enough to make mistakes – and learn from them?
· Can they change their minds or ways of doing things when things don’t go the way they planned?
· Can they honestly express their feelings, or do they withdraw or hide behind humour or acting out?
· Can they defend themselves?
· Can they see the positives that come out of any situation?

Children with disabilities

For children with disabilities there is a number of factors that can influence their resilience.

For example, children with developmental delays or literacy difficulties might have frequently experienced failure in classroom settings if their needs have not been accommodated adequately. This is likely to influence their sense of self-efficacy. And this, in turn, can lead to refusal to attempt work they perceive as too difficult.

Children who have difficulty with higher order thinking skills such as reasoning, problem-solving, analysing will struggle to cope with every-day problems. For these children you may see frequent and sometimes violent outbursts. These could be due to anger, frustration, fear and other strong emotions they are not able to manage.

Children with language delays will find it difficult to use conventional problem-solving methods such as communication of feelings or negotiation.

Children with sensory sensitivities may be so overwhelmed by noise, sound, movement or touch that they are not able to control their response.

Education and emotional literacy

To build resilience, we need to think about specifically teaching our children or students the following:
- self-esteem and self-belief
- coping and problem-solving skills
- recognising and managing emotions
- self-defence mechanisms (preferably not of the violent kind)
- communication skills

In my posts this month I will try to share a few strategies, resources and programs that may be helpful.


References

Department of Education and Children’s Services (2007). Resilience. Issues in Society, 260, p 1-3.

Fergus, S, & Zimmerman, M.A. (2005). Adolescent Resilience: A Framework for Understanding Healthy Development in the Face of Risk. Annual Review of Public Health, 26, p399-419.

Gill, T. (2007). No Fear: Growing up in a risk averse society. London: Calouste Gulbenkian Foundation.

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