April 2022

What can you do with a 4-year-old who might have anxiety?

I love this question because I picture the person who sent it to me kind of throwing their hands up in the air like, “What on earth can you do with a 4-year old who might have anxiety?” But I think that they’re asking a couple of things here, which is how can you tell if they have anxiety — there’s that might there in the question — and what can you do if they do have anxiety.

Now remember on the very first episode we talked about how to tell if a child has anxiety and we talked about looking for behavior that is not developmentally appropriate. That’s a little tougher with a 4-year old because they’re growing out of some toddler/preschool anxieties like being away from caregivers and being afraid of the dark and growing into some bigger kid anxieties like robbers and fires. 

As an aside, I get a lot of calls about 5-year olds because a 4-year old who struggles to leave a parent doesn’t ring quite the same alarm bells as when that child is 5. I mean, it’s not uncommon to have a kindergartener who has trouble leaving mom in the morning but we start seeing that as more of an issue when they hit that age. Even though 5 is a nervous age, generally speaking. As kids start to become more aware of the great big world beyond them, they do tend to get more anxious. 4 and 5 year olds tend to be deep thought ages, when kids start asking about where babies come from and what happens when we die and other big philosophical questions. 

Ok but back to how do we know if a 4-year old is anxious and I guess I’d say that we don’t have to know if a child qualifies for a diagnosis to get better at supporting them. Because anxiety doesn’t have to be at clinical levels to deserve our attention, right? Right.

So let’s talk about that.

This seems like a good time to talk about the slow to warm temperament. Now I have a whole course on temperament in the Child Anxiety Support membership because I think it gives us so much insight not just into our child but into ourselves and the rest of the family. I have a whole activity in there around that and it’s always illuminating. Anyway, back to the slow to warm temperament. This is also called High Withdrawal. Temperament exists on a continuum and this particular continuum goes from High Approach to High Withdrawal.

I’m a Slow to Warm person myself and I have a kid who’s Slow to Warm and I can tell you that it can be frustrating for everyone, including the child themselves.

The Slow to Warm child is not necessarily anxious; they just need to come to things on their own time. They like to stand back on the sidelines and observe what’s going for awhile before they join in. The more you pressure them, the more resistant they become because they need to do things on their own terms. This can look like anxiety but it isn’t. You can tell the difference because an anxious child will never join in — even if they want to — and a slow to warm child will join in eventually if left to themselves. Occasionally I’ll meet with a family who is reporting their child has anxiety but when I sit down to assess the child what I see is a Slow to Warm child in a High Approach family. The family needs to learn how to be more patient, which isn’t easy especially if there are other kids in the family who are raring to go and the slow to warm child is holding everyone up. (This was me in my family and only when I had my own slow to warm kids did I understand why this was frustrating for my parents.)

So the anxious 4-year old may be anxious but they also may be slow to warm so what we need to do in both cases, is continues to offer opportunity to face those uncomfortable things and to stay neutral about how quickly or how deeply they are willing to engage with whatever they’re facing.

Remember the key to anxiety is confronting the things that make us anxious. That’s true for all ages, not just 4-year olds. As parents that means that we validate their feeling without validating their fears. What I mean is we say, “I understand you are scared” and “but I know you can do it.” And then we sit with them while they sit with that.

We’re teaching kids to be brave and you can’t be brave unless you’re scared. There is no brave without fear. 

Because we are fans of brave, we need to also give fear respect but not power. That is to say, all feelings are valid but they don’t necessarily get to drive the bus.

If you’re concerned that your 4-year old is anxious, first I encourage you to check and see if the Slow to Warm Temperament is at play and if so, try to slow things down. Their anxiety might have more to do with feeling pressured or worried that they’ll get left behind. I remember feeling panicked that I would miss out because I wasn’t quite ready. You know, like I want to do the thing but just not quite yet and so I’d meltdown about it. Like I said, that wasn’t easy for my parents.

If it isn’t slow to warm, if it’s a child who is genuinely afraid, that gets more complicated and I’m gonna say maybe check out my membership for the whole spiel and personalized help but generally, find ways to continue to give them opportunity to face those fears with your loving support. 

How can I find a therapist to help my anxious child?

Hey everybody, this week’s question is how can I find a therapist to help my anxious child? The obvious answer to this question is to use a therapist directory like Psychology Today, or use Google like typing in child anxiety therapist near me. Or you can call your insurance and get a list of therapists who are contracted with them.

The problem is that none of these answers are very good ones. Not all therapists are on Psychology Today, and there’s no vetting process so people can claim expertise that they may or may not have. Same with Googling plus advertisers tend to clog those results up. And finally many therapists don’t take insurance or your deductible may be so high that you’ll be paying out of pocket anyway. The other thing is a lot of those insurance lists are woefully out of date.

This is all to say that finding a therapist is hard and finding a therapist who works with kids and teens is harder and finding a therapist who works with kids and teens and who has availability and who you and your child like is the hardest thing of all.

I know how to discouraging this can be.

What the research tells us about therapy is that we need to have a great relationship between the therapist and the client to make it successful. That means your child has to like the person that they’re seeing; the relationship itself is what heals. The trust and respect that the clinician and the client have for each other is where the change happens.

Think of it this way. Would you listen to someone you didn’t like? Would you share your biggest concerns, your darkest secrets, your greatest worries with someone you didn’t trust? Well, neither will our kids.

The younger your child is the more you will be involved with their therapy, too. This is especially true of anxiety or behavior issues. (As an aside, 99% of the kids I saw in my practice for behavior issues were dealing with anxiety.)

Anyway, this is especially true because the family system will need to shift and adjust to support the changes we’re asking the child to make. So not only does your child need to like the therapist, you need to, too. That means that you should interview potential therapists — a phone call is probably enough to get a good feel for them.

You want to be able to click with them — to feel like they will listen to you and will appreciate what’s important to you and your child.

Even though the relationship is the defining factor in successful therapy obviously training matters too, especially when it comes to kids.

Again, as I mentioned, people can say they work with children without having any additional training. So ask them about their training and experience. What qualifies them to work with the children, the age your child is?

You can ask about how you’ll be involved and how they will communicate with you. Will you attend some sessions with your child? Without your child? Are they available via email or phone if you need to run something by them?

You might feel shy about asking about this, but therapists understand that you care about your kid and any counselor worth their salt is not going to be put off by a parent who wants to be sure they’re hiring the right person to work with their child or teen.

How do you find people to interview? I encourage you to just ask around. Ask your friends. Ask your child’s teacher. Ask the school counselor. Ask on your local parenting Facebook group. Ask your pediatrician.

And ask them specifics. Is that therapist comfortable crawling around on the floor? If you’ve got a four year old, that’s probably going to matter. Ask about their style. Some kids like a bouncy and colorful therapist, and some wants someone who is calm and quiet.

Because finding a child or teen therapist is difficult. It’s likely that you’re going to have to make some compromises and usually that’s about time. Parents understandably want afterschool or weekend times but these are at a premium. For one thing, many therapists who work with kids have kids. They shape their work schedules the same way the rest of us do, which is to have dinner with their families, take their kids to soccer, be there for bedtime.

Finding an appointment time that doesn’t interfere with school might be difficult. You might have to give on that. With the rise of telehealth, this doesn’t have to be a barrier. Older kids who are comfortable with and do a good job with telehealth may be able to meet with their therapist at school with special arrangement.

When I was working at an agency, there were times I met with kids in an empty office with the school’s happy approval. After all they want kids to do well, too. I remember one particular teen who I used to have lunch with. They were perfectly content to spend their lunch hour with me so we would chat over sandwiches.

If telehealth doesn’t work for your child and you’re worried about them missing school, my experience has been that schools are very understanding about the importance of letting kids come in for counseling. Especially if the schools were the ones who gave the parents a heads up that their child could use some support.

If parents aren’t able to take time off from work to get their kid there I’ve had parents who use babysitters, grandparents, or neighbors to help get their child to their appointments. Again, I know this isn’t ideal and not everyone has that option but if you do that can be something to try.

The other thing to remember, especially when it comes to anxious kids, is that the research shows that parental intervention is just as effective.

If you can’t access therapy for your child right away don’t let that stop you from getting your own help. That can be a therapist for yourself particularly a therapist who understands family systems and child anxiety. And it can also be through a program like mine, which will teach you how to create a personalized program and then support you in seeing it through.

If you have questions about that, please let me know. Meanwhile, while you’re working on those things you can get your child on a waitlist. Many therapists who work with kids do keep a waitlist and you can just ask them to add you to it and let you know when you have openings.

Meanwhile, there’s nothing stopping you from continuing to look around. We therapists understand that if you get into therapy with someone else before our waitlist opens up that of course you’re going to take it.

The other thing is, as long as you’ve got that therapist on the line and you’re talking about wait-lists and wait time, you can ask them if they have any colleagues they’d recommend. Therapist do try to keep track of each other. It’s not like we’re out there battling each other for clients; we want people to be served and if we’re not able to do that, most of us really enjoy connecting people with someone who can.

4 Tips to Help Your Anxious Preschooler Adjust to School

anxious preschooler

The first day of preschool can lead to anxiety for a variety of reasons. They’re new to school, they’re not sure what to do, or they’re just excited about being in a new environment. No matter why they’re anxious, these 4 tips will help your anxious preschooler feel more comfortable and confident during their first year of preschool.

1: Validate your anxious preschooler’s feelings

Talk openly about being worried and explain that it’s a typical experience when we start new things. Anxiety is a normal and common feeling, but sometimes it can be hard for kids to understand why they’re feeling anxious. Let them know that it’s normal to feel a little nervous at first and that there are plenty of people here who will help them feel comfortable and safe.

2: Help your anxious preschooler get their bearings

Make sure the know how the classroom works. Where is their cubby? Do they know where to hang their jacket? Do they start their day — on the playground? In circle time? Is it time for free play at the sensory table? A big part of feeling comfortable during their first year is having space to relax and get settled in.

3: Help your anxious preschooler connect with others

One of the best ways to help anxious preschoolers connect with others is by role modeling that connection. Introduce yourself to other children in the class and then introduce your child. Don’t answer for your child, give them room to do their own talking. Step away if needed to give the kids space to begin navigating their own relationship.

4: Celebrate together at the end of the first day

Since anxiety can lead to low self-esteem, it is important for parents to help their children build self-esteem through positive reinforcement and encouragement. Praising your child for hanging in there even though they felt afraid. Help them connect with their success — they made it through the first day! It’s all easier from here on out! 

I hope that these tips will help your anxious child  feel more comfortable and confident during on their first of preschool.

What can teachers do to help students with anxiety?

"When I look over 504s I am impressed by the creativity and compassion I see in so many of them."

Dawn Friedman MSEd

“What can teachers do to help students with anxiety?

Teachers can do a lot. A lot. Namely they can recommend that their anxious students get on a 504 plan. This requires collaboration between the teachers and the administrators and the parents, which is a great way to get eyes on the child and everyone on board to helping that child be successful. 

Let’s talk a little bit about 504s.

If a child has anxiety or OCD then they may qualify for a 504 plan. A 504 plan refers to Section 504 of the Rehabilitation Act of 1973, which is the civil rights legislation that protects individuals with a disability from discrimination in programs that receive federal funds from the Department of Education. What this means is that students with anxiety severe enough that quote limits one or more major life activities end quote qualify for support. A 504 may require a formal diagnosis — that would be their doctor or a counselor, clinical social worker or psychologist — but some school will offer supports on the recommendation of a school counselor alone. The anxiety must cause “substantial limitation.” The specifics on how this will play out will depend on the school but generally refers to how well the child is functioning in comparison to their peers and who better to know that than the teacher who is seeing the whole classroom. If a child’s anxiety is getting in the way of their functioning, if they are melting down, missing class, or having trouble finishing their work due to their anxiety then they would qualify. Note: that federal funding part may mean that a child may not get a 504 if they go to a private school that does nor receive federal funding. But that doesn’t mean that teachers there can use a 504 model to support their students. Oh and charter school do use 504s. 

Ok back to the question.

Teachers can refer a child to a 504 plan as can counselors and other support staff and parents can request a referral, too. 

A 504 plan is different than an IEP or individualized education program. An IEP addresses 13 specific diagnoses, which includes ADHD or autism. I mention these because anxiety is often a feature of those diagnoses and if your child has ADHD or autism, you may want to pursue an IEP. IEPs provides special education. A 504 plan is more broad and provides services and supports to remove educational barriers. A 504 plan also tends to be but isn’t always less formal. School receive additional funding for children on an IEP but not so for a 504. 

An example of the difference might be a child on an IEP might receive help from an aide or pull out services while a child with a 504 would not. 

On rare occasions a child with OCD or anxiety as a stand alone diagnosis might meet criteria for an IEP but again, if they can stick with their peers with accommodation and don’t need special services, then an 504 is the way to go.

I know it’s confusing but most of the time, kids with anxiety will qualify for 504s not IEPs.

There are not standard accommodations for anxiety and its presentation is different in different kids. But some common accommodations include:

  • getting a heads up about a pop quiz, so no surprise testing
  • a reduction in homework or more time to finish
  • the ability to leave the classroom to see the school counselor, get a drink of water, or otherwise get a break
  • fidgets or comfort items at their desk
  • Classroom seating to help the child feel safe in some way (such as near a window or near the teacher or near a friend)
  • Allowing the child to listen to music or wear headphones to block out noise

Ok, I wanted to stop here for just a minute to talk about the word “accommodation.” In the anxiety and OCD literature when we’re talking about accommodations, we’re talking about the things that keep kids stuck in anxiety. But when we’re talking about 504s, we’re using the word to address policies that remove barriers to the child’s success in the academic setting.

Here is what is tricky. Sometimes academic accommodations in a 504 plan are supportive and helpful and sometimes they are accommodations in the clinical sense, that is to say they keep kids stuck. 

For example one support often listed in 504 plans is allowing the child to record a presentation instead of standing on front of the class to read it. Now we could argue that keeps the child stuck in their anxiety about public speaking. And yes, frankly, it does. But if we’re working on social anxiety there is likely better places to put our efforts and meanwhile that child needs to not be falling behind in school. So as a support, I’d say that one’s ok especially if we have plans to work on social anxiety in other ways. That can be part of a 504, too, like helping a child connect with peers by having the child attend a lunch bunch group. Or helping create connections by assigning work groups or dyads.

By the same token, if we’re working with a child who has separation anxiety who often goes to the nurses’s office to get a ride home because their stomach hurts, that might be a great place for the school and parents to work together to interrupt that behavior. It may be in the 504 that instead of sending the child home, the school will give them a break from the classroom with the expectation that they will return. So maybe the child gets a pass to spend 15 or 20 minutes practicing some breathing exercises with the nurse or the school counselor before heading back to class.

Again, 504s are individualized and parents and teachers can be thinking about which supports make long-term sense (like being able to take an exam in the library where it’s quiet) and which should be short-term with a plan to move the child away from them and toward greater independence (like having the child sit near the teacher for now while the school actively works on helping them connect to other kids socially).

I’ll tell you one thing, when I look over 504s I am impressed by the creativity and compassion I see in so many of them. And I have found that many teachers when they work with a family to create a 504 plan for one student end up discovering that the whole class benefits. 504s give us a chance to look at some policies and procedures critically. For example, lots of kids do better when they can check out a fidget to take to their desk. And lots of kids do better when they can wear listen to music during study time. 

If you are interested in talking to your child’s school about creating a 504 plan, I encourage you to reach out to your child’s teacher and the school counselor to get it started. They’ll help you figure out next steps. And even if your child doesn’t qualify for a 504, you can still talk about better ways to meet your child’s needs. 

Have a question?

How is OCD different from generalized anxiety?

Unlike generalized anxiety, in OCD our children get trapped in obsessions (the uninvited, upsetting, intrusive thoughts) and stuck in the compulsions.

Dawn Friedman MSEd

How is OCD different from generalized anxiety?

Let’s do a quick overview about what obsessive compulsive disorder (OCD) actually is. It’s one of those terms that we use in an off-hand way like, “Ugh, I’m so OCD, I just have to have everything super clean.” Or, “Wait a second, I have to straighten that crooked picture because I’m super OCD.”

That’s not actually OCD.

OCD is fueled first by obsessive, intrusive thoughts. We all have these — every person on the planet has intrusive thoughts — but in OCD these thoughts get stuck.

For example, you likely have had the experience of driving when all of a sudden the thought, “What if I spun the wheel and drove off the road” shows up in your brain. These thoughts are unwanted and show up uninvited. They are often contrary to what we really want or are upsetting. Like, “What if I got out of bed and when I put my feet down someone under the bed grabbed me.” 

If we don’t have OCD those thoughts can be annoying or give us a little shiver or surprise us. They may even embarrass us but they pass quickly. We think, “Huh, that’s weird” and we move on. 

If we have OCD we give those thoughts meaning. We think, “Oh my gosh, do I have a death wish? What’s wrong with me?” Or we think, “Maybe I had that thought about someone under my bed because it’s a premonition.” 

Then we have to do something to address the thought and that’s the compulsion.

Perhaps we have to pull over and take deep breaths until we’re sure we’re not going to drive off the road. Or we need to check under the bed before we can go to sleep. As you can see, there’s a lot of magical thinking present in OCD.

Again, that may happen with someone who doesn’t have OCD, too. If you’ve ever had to go back and make sure you locked your front door behind you then you know about compulsions, too.

We have a thought, “What if I left the door unlocked?” And then it nags at us until we go check.

The difference with OCD is that we get trapped in those obsessions (the uninvited, upsetting, intrusive thoughts) and stuck in the compulsions. Eventually going back and checking once doesn’t help. We have to go twice. We have to go back and try the door, them check if the keys are in our pocket, take two steps and turn around and check again. 

Now as you’re thinking about this, about how OCD works, you may recognize signs of it in yourself or your child but again, I want to reiterate that we all have intrusive thoughts and we all occasionally get stuck in them a little bit.

Kids especially go through developmental stages when we would expect some OCD-like behaviors. Preschoolers who are hung up on things being just right don’t necessarily have OCD. I think we can all relate to standing over a sobbing child who wants the other shoes or needs them retied so they are the same tightness on each side or who won’t wear that shirt but will only wear a “soft shirt” or can only drink out of a green cup. Right? Right. That’s developmentally appropriate. Annoying but not a mental health issue.

So how do you tell the difference?

The picky preschooler should grow out of their demands. These things are preferences and may upend the day but the child eventually learns to be more flexible. The child with OCD will remain well and truly stuck and their rituals may become more elaborate.

The child with developmentally appropriate preferences can learn to be flexible with support. They will eventually run out of steam and move on. The child with OCD becomes increasingly upset. They may want to move on but are unable to. 

The other thing is that in OCD the compulsions may seem more bizarre or disconnected from what’s happening. Like that example of checking the door, it may need to happen in a particular pattern. Check the door by turning the knob twice, step away, turn back, turn it twice again. This is because in OCD the person is chasing that “just right” feeling and it gets harder to reach the longer they stay trapped in the compulsion.

Children who have OCD need their parents assistance in some of their compulsions and parents may not realize this. This often comes in the form of reassurances, which are also common in general anxiety, but may also show up in needing the parent to do things in a certain order. Such as say good night in a particular way. The child will meltdown if the parent says, “Good night, sleep tight. Sweet dreams.” Instead of, “Sweet dreams, good night sleep tight.” The child will demand that the parent does it over and over until it’s exactly the way the child needs to hear it. The parent may not realize that the obsessive thought has to do with, “What if a robber breaks in” and needs the parent to say good night exactly right to neutralize that obsessive, intrusive thought.

Other common ways that OCD shows up is washing hands and concerns about contamination. A child may not be able to eat off a particular fork or needs to rinse already clean dishes. Checking is common, checking for homework or checking that no one’s hiding in the closet. Children may need to enact particular rituals like repeating words to themselves or doing things in a particular order.

Children may also need to confess their intrusive thoughts. Those thoughts are upsetting and remember they’re assigning meaning to them. A child might think about going on a forbidden web site and then need to come and tell you that they thought about it. Or they may have an intrusive thought about hitting the dog and will need to confess it to you. Again, we all have intrusive thoughts. We might board the bus and randomly think, “What if I kissed the bus driver” and we forget about it almost as soon as we think it. The child with OCD will worry it means they want to kiss the bus driver. That might make them feel ashamed and they’ll need to tell you about it or say hello to the bus driver in a particular way or squeeze their eyes shut repeatedly to try to neutralize that upsetting thought.

This is another way that OCD gets diagnosed, is when a child has to blink or sniff or click their tongue or do some other repetitive motion that adults notice. These kinds of tics are not uncommon in childhood even for children who don’t have OCD, but they tend to disappear after a few months. This is super common in younger children, like kids who get that chapped rash around their mouth because they can’t stop licking their lips. Parents should consider getting their child evaluated for OCD if those tics continue for more than six months or start getting more complex like if A child who shrugs their shoulders after every question starts shrugging their shoulders then blinking or yawning, for example.

In the latest version of the DSM, which is the DSM-5, OCD got moved out of anxiety disorders and into its own categorization. This is because the current theory is that OCD in itself isn’t fueled by anxiety but that the obsessions CAUSE anxiety. Also it allowed them to move other disorders like hoarding and body-focused repetitive behaviors such as skin picking or hair pulling into the OCD category since this seems to be a more accurate way to case conceptualize. These, too, are marked by an intrusive thought or feeling of not-quite-rightness. Hoarding is about a worry of losing something important and everything might be important and body-focused repetitive behaviors are driven by an intrusive need to pull hair or skin pick, that feeling that things won’t feel right until they do.

Treatment for OCD is about helping the child to tolerate that uncomfortable feeling brought on by the intrusive thought and preventing them from doing the exposure. This is called Exposure Response Prevention and is an arm of CBT or cognitive behavioral therapy. Some children may also benefit from medication to help them calm their anxiety enough to work on the CBT piece. Because parents are usually part of a child’s compulsions and because parents are such an important support, they should be part of the treatment. In fact most of the research around anxiety and parent involvement has focused on parents of children with OCD and it’s clear that they are central to treatment success. In other words, the child won’t get better if parents don’t do their own work to support their child. My program, Child Anxiety Support, addresses the kinds of things that parents can do to support a child with OCD.

Have a question?

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