Karen Wang, a Parent of a child with special needs and Dr. Sarah Baker a child Psychologist present about important topics relating to children with special needs Including: Child Anxiety Anxiety in childhood: What’s typical, and what’s not? What to do (and not do) when children are anxious Behavioral treatment for kids with anxiety Handling tantrums and meltdowns How to support siblings in special needs families

1. Helping Your Anxious Child
Evidence-Based Strategies to Help Your Child Overcome
Fear, Worry & Panic
SARAH E. BAKER, PH.D.
KAREN WANG, M.A.

2. Alex & Evie
@ 20 months

3. Child Anxiety: An Overview
 Anxiety disorders are the most prevalent psychiatric condition among children
 10-20% of children will suffer from a diagnosable anxiety disorder
 1 in 4 children will experience significant anxiety at some point in their lives
 Rates of anxiety in children with developmental disabilities are even higher (e.g., about
40% of children with ASD)
 Anxiety does not go away without treatment (and usually worsens with time)
 The good news: Anxiety disorders are the most treatable psychiatric condition
 More good news: YOU can learn how to help your child manage anxiety!

4. What is Anxiety?

5. What is Anxiety?
 An adaptive emotion that readies children both physically and psychologically to
cope with danger
 We are hard-wired with an “early warning” system that alerts us to potential
dangers so that we can react quickly
 “Fight or Flight” response
 Physical: Pupils dilate, heart rate increases, breathing quickens, palms sweat
 For some, the body’s “alarm” system is naturally set at a sensitive level or
programmed via experience to respond when no real danger is present
 “False Alarms”

6. Anxiety and Performance:
Yerkes-Dodson Law

7. Fear vs. Anxiety
 Fear tends to be associated with events in the present moment
 Anxiety is associated with the anticipation danger or discomfort (i.e., it hasn’t
happened yet)
 Anxiety is complex
 Involves internal experiences: thoughts, feelings, memories, physical sensations
 Thinking about a frightening event can evoke physical sensations that trigger
judgmental thoughts, which invite more intense feelings, etc.
 Anxiety is contagious
 When a child is anxious, parents are more vulnerable to their own fear/worry

8. Why is My Child Anxious?
 Multiple Factors Contribute to Anxiety
1. Genetics and Brain Physiology
2. Temperament and Behavioral Inhibition (BI)
3. Parenting Style – Result, or Cause?
4. Environmental Factors (including trauma)
 The Anxiety “Formula”:
 Overestimation of Threat + Underestimation of Ability to Cope = Anxious Response

9. Parenting Behaviors Associated with
Anxiety in Children (in Chansky, 2004)
 Parental Overcontrol: intrusive parenting, exerting control in conversation, limiting
autonomy and independence in conversation
 Overprotection: excessive caution and protective behaviors without cause
 Modeling of Anxious Interpretation: agreeing with child’s distortion of risk,
reinforcing the idea that things in the world are too scary to approach
 Tolerance or Encouragement of Avoidance: suggesting or agreeing with not trying
something difficult
 Rejection or Criticism: disapproving, judgmental, dismissive or critical behavior
 Conflict (weak factor): family disharmony

10. Positive Parenting Behaviors that
Buffer Stress (in Chansky, 2004)
 Reward Coping Behavior: focus on means, not ends; reward taking on challenges;
recognize partial successes
 Extinguish Excessive Anxious Behavior: reduce anxious behavior by not responding
to it excessively (either with concern or anger)
 Manage Own Anxiety: limit displays of distress; don’t introduce parent’s worries
into the mix
 Develop Family Communication and Problem Solving Skills: open-house policy for
positive communication and problem solving opportunities
 Authoritative Parenting Style: direct child’s behavior while valuing independence
and warm interactions

11. Typical Fears & Anxieties of Childhood
 Infancy through Preschool
 Stranger anxiety, separation anxiety, unfamiliar and over-arousing objects and events
(big dogs, insects, thunderstorms, loud noises)
 Elementary School Years
 Dangers in the world (fires, earthquakes, car crashes, burglars, terrorist attacks), the
dark, being alone, illness, social rejection, academic failure, disruption of the family (e.g.,
divorce), death
 Middle and High School Years
 Humiliation, loss of popularity or athletic or academic standing, sex and intimacy, the
future

12. Problematic vs. Transitory Anxiety:
When To Be Concerned
 Anxiety is problematic when (The Four Ds):
 It is disproportionate to the situation
 Excessive time spent consoling child about ordinary situations or coaxing him/her to perform
normal activities (homework, hygiene, etc.)
 It disrupts or interferes with day-to-day life
 Difficulty attending school, playdates, family gatherings, etc.
 It is distressing to your child
 As evidenced by crying, physical symptoms, feelings of embarrassment or hopelessness
 The duration suggests that it is an ongoing problem (> 6 months)
 No improvement is seen with time, or the situation worsens despite your efforts

13. Child Anxiety Subtypes (DSM-5)
 Separation Anxiety Disorder
 Specific Phobia
 Social Anxiety Disorder (Social Phobia)
 Selective Mutism
 Panic Disorder and Agoraphobia
 Generalized Anxiety Disorder
 Obsessive-Compulsive Disorder (and related disorders)
 Post-Traumatic Stress Disorder

14. So…How Do I Help My Child?
 Therapeutic Interventions
 Cognitive Behavioral Therapy (CBT)
 Play Therapy + CBT
 Acceptance and Commitment Therapy (ACT)
 Medication

15. What is Cognitive Behavioral Therapy
(CBT)?
 An evidence-based approach and “gold standard” for treating anxiety
 Based on the idea that how we think and act affects how we feel
 Includes the following components (adjusted for child’s developmental level):
1. Psychoeducation
2. Somatic (body) Management Skills
3. Cognitive Restructuring
4. Exposure (aka “bravery practice”)
5. Relapse Prevention

16. Three Parts of Anxiety
 Anxious Body
 A constellation of physical symptoms experienced as distressing
 E.g., Racing heart, rapid/shallow breathing, sweating, stomachache, tense muscles
 Anxious Thoughts
 “What if I fail my math test?”
 “What if my parents never come to pick me up?”
 “This is scary and I can’t do it!”
 Anxious Actions
 AVOIDANCE or escape
 Freezing
 Attempts to get help ( parent rescue)

17. Worry Wheel
Anxious
Body
Anxious
Actions
Anxious
Thoughts

18. Worry Wheel: Example
Body: Shaking,
sweating, racing
heartbeat,
stomachache
Actions: Refuse visit to
park, cling to mom, cry
Thoughts: “Dogs are
scary and dangerous!”
“What if the dog tries
to bite me?”

19. Step 1: Empathize
Listen and understand before attempting to “fix it”
 Resist the temptation to tell your child to stop worrying, or to reassure her that
there’s nothing to worry about!
 Acknowledge that this is difficult for her, with words and gestures
 Hug her, rub her back, hold her hand (if she will accept this)
 “I know this is really hard for you.”
 “I can see that this is making you really upset.”
 “I know you really want to [go to the birthday party], but you feel like you can’t.”

20. Step 2: Calm the Anxious Body
You can’t be anxious and relaxed at the same time!
 “We’re going to calm things down and relax, when you feel ready.”
 Diaphragmatic breathing
 “Balloon breaths” or “Bubble breaths”
 Blow on a pinwheel to make it spin
 Progressive Muscle Relaxation
 Guided relaxation of muscle groups to release tension
 Visualization/Relaxing Imagery
 Using all 5 senses to imagine a soothing place, situation, or memory
 Other strategies: Music, Cuddling, Calm Down Jars, etc.

21. Breathing to Relax – Videos
 For young children (and lovers of Sesame Street):
 “Belly Breathe” with Elmo
 https://youtu.be/_mZbzDOpylA
 For elementary-aged children:
 “Just Breathe”
 https://www.youtube.com/watch?v=RVA2N6tX2cg

22. CBT Strategies At Home
 Become a “Stress Detective”
 Play therapy
 Physical activity, especially games like “Red Light,
Green Light” or “Simon Says”
 Creative expression
 Visualization (see sample script)
 Breathing exercises
 Be silly!
 Recommended books:
The Relaxation &Stress Reduction Workbook for Kids by
Lawrence Shapiro and Robin Sprague
Generation Stressed by Michele Kambolis
Engaging Autism by Stanley Greenspan

23. Step 3: Calm the Anxious Thoughts
Challenge and change the internal worry script
 Identify unhelpful/negative thoughts and beliefs (“thinking traps”)
 All-or-Nothing Thinking (“The day is ruined!”)
 Doomsday Thinking (“What if Daddy is in a car accident?”)
 Exaggerated Thinking (“I’m the worst at math!”)
 Should/Shouldn’t Thinking (“I shouldn’t feel so nervous all the time”)
 Mind Reading (“My best friend doesn’t like me anymore”)
 etc.
 Replace thinking traps with more helpful and realistic thoughts

24. Taming Worry and Anxious Thinking
 Ask Yourself Two Things
1. What is the worst thing that could (actually) happen?
2. Could I handle it?  The answer is always YES! There is nothing in life you cannot
handle.
 (Follow up with: What is most likely to happen?)
 Confidence Booster
 Brainstorm all the ways you might handle the bad thing if it were to happen
 Now, what do you think? Do you feel a little more confident that you can do it?
 Summarize your plan and repeat it to yourself when needed

25. Taming Worry and Anxious Thinking
 Big Picture Perspective
 At the end of my very, very long and very, very wonderful life, will it really matter if
__________________? Will this really matter in the big picture?
 Time Machine
 Have your child ask herself:
 How important is this event/thought at this moment? (rate on scale of 1-10)
 How important will this event/thought be in an hour? In a day? Week? Month? Year? Five
Years? Ten Years?
 New script: “Although this is really scary/embarrassing/upsetting to me right now, in a
day it will seem a little better, and in a week I probably won’t even remember it
happened!”

26. Taming Worry and Anxious Thinking
 Schedule Worry Time
 Set aside a specified amount of time each day (15 minutes or so) during which your
child intentionally worries
 Benefits
 Helps child to externalize worry in a structured way
 Teaches child to control worry by delaying it until a specific time
 Shows child that worry tends to be repetitive and useless
 Verbalize worries, record them and listen to them, and/or write them down

27. Taming Worry and Anxious Thinking
 Positive Self-Talk
 Change the “script,” and eventually (with practice) he will start to believe it
 Create “self-talk coping cards” that he can carry with him when needed
 Examples:
 “I can handle this”
 “I am worried, but I am okay”
 “I am scared, but I am safe”
 “I can help myself relax”
 “I know I have to face my fears to overcome them”

28. Taming Worry and Anxious Thinking
 Talk Back to Anxiety!
 Allows your child to see the anxiety as something separate from her, and feel more in
control
 Examples:
 You aren’t the boss of me! I decide what to think!
 Be quiet, [Worry Bug]! I’m going to smush you!
 If this were really important, my parents would be helping me worry, not helping me stop!
 I don’t have to listen to you! I’m going to change the channel.
 My parents wouldn’t let me be in danger, so this must be safe.
 My friend don’t worry about this, so I won’t either.

29. Step 4: Change Anxious Actions
Help your child gradually and safely face his fears
 Anxious actions include:
 Avoidance, reassurance seeking, clinging, crying, fidgeting, freezing up, having a
tantrum, picking (hair, nails, lips), rituals
 Avoidance
 Most common anxious behavior
 Prevents child from facing fears and learning he can handle them
 Perpetuates anxiety cycle
 Learning to face fears via exposure is the most potent “ingredient” in CBT

30. “Bravery Ladder”
 Make a list of your child’s worries
 Rate intensity of each worry (1-10, or big-medium-small)
 Draw a ladder on a posterboard and place the lowest-ranked worry on the bottom
rung, with other worries written in ascending order (so the hardest/scariest one is on
the top)
 Review “Coping Toolbox” and which strategies your child will use
 Start with the easiest task and calmly support your child in facing each fear until it no
longer elicits an anxious response (he “habituates” to it)
 Have child use a “Fear-mometer” to rate fear and watch it drop
 Don’t give up! If the task is too hard/scary, break it down or return to the previous
“rung” to end on a positive note

31. Bravery Ladder: Example
Separation Anxiety
My Bravery Ladder
(10) Mom goes out of town without me
(10) Go on a sleepover at a friend’s house
(9) Mom goes out of town for the day without me
(8) Go on a playdate at a friend’s house
(8) Mom goes out for 1 hour, then 2 hours without me
(7) Mom goes out for 15 minutes, then 30 minutes without me
(7) Sleep in my bed alone for one night this week (then 2, 4, 5, and 7 nights)
(6) Use a public restroom on my own (without Mom)
(4) Mom takes out the trash and I stay focused on the TV
(4) Mom stays upstairs while I stay downstairs (for 5, 10, 15, and 30 minutes, then 1 hour)
(3) Mom goes into other rooms without singing to me
(2) I stay in the living room while Mom is in kitchen (for 5, 10, 15, 20, and 30 minutes)

32. Bravery Ladder:
Example
Specific Phobia
Level Fear:
Dogs
Boss to be Defeated Strategies to
Level Up
LEVEL 1
Things that worry me a
little
Seeing a dog from a
distance
Master Worry
1) Watch dog on TV or
YouTube
2) Go to a pet store and
look at the dogs in cages
3) Go to an on-leash park
and look at dogs from a
distance
LEVEL UP!
Level 1 Complete!
LEVEL 2
Things that are difficult
for me
Being close to a dog
Anxiety Invader
4) Go to an on-leash park
and move close to a dog
5) Move a bit closer
6) Stand next to a dog
LEVEL UP!
Level 2 Complete!
LEVEL 3
Things that are VERY
difficult for me
Petting a dog
The Great Fearful
7) Hold a dog’s leash
8) Let a dog smell the
back of my hand
9) Pet a dog
GAME OVER!
Level 3 Complete!
From:
www.michelekambolis.com

33. A Note about (Over)reassurance
 Reassurance temporarily makes a child feel more safe and secure, but can actually
strengthen her overall anxiety
 Child learns to rely on it, instead of learning ways to tolerate distress and self-soothe
 Confirms to the child that the situation/object must be pretty scary, if it’s worthy of this much
of mom’s or dad’s time and attention!
 Often leads to parent-sanctioned avoidance
 Instead of reassuring for the umpteenth time, try:
 “You sound nervous about going to school, but you have to go. What can you do to calm
down? How can I help make it better for you?”
 Chart progress (absence of begging, asking, or other nervous behavior) on a calendar and
reward

34. Step 5: Practice, Practice, Practice!
 Celebrate your child’s achievements (and your own hard work)…but don’t stop
there!
 Encourage your child to continue to face any fears that arise to “Stay In Shape”!
 Arrange opportunities for your child to step out of his comfort zone
 Review the coping tools in his “toolbox”
 Provide encouragement and support, but don’t do the work for him!

35. Managing & Preventing Panic Attacks
Symptoms
 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. Numbness or tingling sensations
 11. Feelings of unreality or detachment from oneself
 12. Fear of losing control or going crazy
 13. Fear of dying
Treatment
 Learn how to calm the
nervous system
 Create an imaginative
plan:
Safe location
Remove trigger
Use toolbox
Breathing or chanting
 Don’t give up!
 Evaluate and adjust your
planFight or Flight Response

36. What About Medication for Anxiety?
 Some children’s symptoms are so severe and/or debilitating that they have difficulty
engaging in behavioral treatment
 Rule of thumb: Begin with CBT and consider adding medication if the child does not
show some response in 4 to 6 weeks
 Think of medication as part of your toolkit, not as an instant fix
 “Dial down” the volume of symptoms
 SSRIs: Prozac, Zoloft, Paxil, Celexa
 Slow acting, few side effects, not addictive
 Benzodiazepines: Xanax, Klonopin, Ativan
 Sedating effect, quick acting, can be habit forming

37. Supporting Siblings
 When a child has special needs, sibling reactions can vary greatly
 Some become helpers or “fixers”
 Some seek attention by acting out
 Some get angry or resentful
 Some try to stay out of the way and take care of themselves
 Support siblings by speaking honestly with them about their brother or sister’s
challenges
 Speaking in terms of strengths and weaknesses can help them understand, and doesn’t
target or blame the child with special needs

38. Supporting Siblings At Home
 Safety first
 Separate activities?
 Develop interests
 Friendships & family relationships
 Special time with Mom or Dad
 Family fun
 Validation: recognize strength

39. For Parents:
Freeing Your Child From Anxiety:
Powerful, Practical Solutions to
Overcome Your Child’s Fears,
Worries, and Phobias
by Tamar E. Chansky, Ph.D.

40. For Parents:
Generation Stressed: Play-Based
Tools to Help Your Child
Overcome Anxiety
by Michele Kambolis

41. For Parents:
Parenting Your Anxious Child
with Mindfulness and Acceptance
By Christopher McCurry, Ph.D.

42. For Teens:
My Anxious Mind: A Teen’s Guide
to Managing Anxiety and Panic
by Michael A. Tompkins, Ph.D.
and Katherine Martinez, Psy.D.

43. For Parents and
Children:
Anxiety-Free Kids: An Interactive
Guide for Parents and Children
by Bonnie Zucker, Psy.D.

44. For Parents and
Children:
Don’t Feed the WorryBug!
By Andi Green
Helping Young Worriers Beat the
Worry WorryBug
by Dr. John Irvine

45. Picture Books
I Used To Be Afraid
by Laura Vaccaro Seeger
When I Feel Afraid
By Cheri Meiners

46. THANK YOU!
Questions?