What are some unexpected ways that anxiety can manifest - particularly with younger children?

Typical signs of anxiety can include: • Asking lots of repetitive questions about a situation (e.g., Is it going to be okay? What is going to happen?) • Tummy aches • Having trouble getting to sleep • Being perfectionistic • Avoiding situations they are worried about.

Older children can often tell you when they are worried about something but for younger children, who don’t yet have the language, it can be challenging to know if they are worried.

There are other more subtle ways anxiety can present like: being unusually irritable, having repeated/increased temper tantrums, nightmares, headaches, or repetitive behaviours (like lining things up in a particular way). Seeing these behaviours doesn’t necessarily mean they are overly anxious but it might be worth monitoring. If you are worried about your child’s behaviour and you think it is impacting on their life (e.g., they are missing out on things, or impacting on the family life), then I encourage you to seek help. Speak to your doctor. We have also have developed a program for parents of younger children with anxiety, called Cool Little Kids. The program is a brief educational program that reduces anxiety in the short term and the long term: www.coollittlekids.org.au

Anxiety occurs when we think something bad is going to happen and/or we don’t think we can handle the outcome. After this is all over and we have a vaccine for COVID-19 and we go back to ‘normal’ routines, we will all be exposed to situations on a daily basis that reinforce the knowledge that the risk is low. As a result our anxiety will likely decrease. However, if we encourage or unknowingly support children to avoid difficult situations throughout the pandemic (like avoiding talking to their friends, or not joining in on online school activities) then the chances are the anxiety will hang around for longer. To prevent, this it is a good idea to gently encourage your child to face situations they find challenging (as much as possible within the restrictions). Maybe there are some fears you can work on during the restrictions at home (like sleeping on their own, fears of the dark). The best way to do this is by using a stepladder approach by gradually facing fears, starting off with something easy and then gradually working up to something more challenging. I have written some information for another site on this if you want to take a look: https://raisingchildren.net.au/toddlers/health-daily-care/mental-health/anxiety-stepladder-approach

In terms of dealing with anxiety, the strategies that work in preventing and reducing anxiety in school aged children include: • Encouraging your child to use calm, realistic thinking rather than worried, panicked thinking (use this yourself too!) • Facing difficult situations rather than avoiding them. For example, if your child is avoiding situations like sleeping on their own, use a stepladder approach to gradually face their fear. I have written some information for another site on this if you want to take a look: https://raisingchildren.net.au/toddlers/health-daily-care/mental-health/anxiety-stepladder-approach • Encouraging your child to problem solve and develop these skills on their own. Here is a good worksheet from our Cool Kids program (www.mq.edu.au/coolkids) that can help you work through a problem together. • Try not to provide too much reassurance. There is evidence to suggest that reassurance can lead to kids feeling more worried. We think it also prevents the child from thinking through the situation on their own. Your child may only feel like they can cope if you have told them it is okay/safe. Children with high anxiety often get stuck in a cycle of seeking reassurance from parents over and over again (like asking questions like “Is it going to be okay mum?”). In response parents provide a lot of reassurance and the cycle keeps going. Instead of answering the questions, try asking them. Respond to your child’s questions with questions they can answer like: “What do you think?” “What do you think is most likely to happen?” • Not rushing in to help and encouraging your child to handle the situation on their own as much as possible. Communicate to your child that you trust they can handle it. • Using labelled praise and rewards to shape their behaviour by focusing on all the times they are courageous (e.g., “I really liked the way you were able to go into the bathroom on your own and turn the light on”)

I am working on bringing together some resources for parents/carers, teachers/educators, children and young people and also clinicians. Stay tuned (www.mq.edu.au/ceh) but in the meantime, some of my colleagues have also put together a really fabulous evidence-based resource:

https://emergingminds.org.uk/wp-content/uploads/2020/03/COVID19_advice-for-parents-and-carers_20.3_.pdf

At the moment, we do not have enough evidence that mindfulness is an effective strategy to reduce anxiety in children and young people. My team and I have been working on a meta-analysis at the moment (currently under review at a peer-reviewed journal), which actually suggests that mindfulness does not lead to substantial reductions in child anxiety. I would recommend strategies that we know work in reducing anxiety such as realistic thinking and facing your fears.

In a typical school day, classroom activities are often broken up with a variety of different types of activities so children are not typically sitting in one place for long periods of time. Teachers are working hard to make sure children’s learning is not interrupted during this pandemic. But it does mean that there are longer than usual periods of sitting in one place – which can be really difficult for some children. As this is a new way of learning, it will take some time for everyone to adjust to the new routines. Encourage your son to take breaks away from school work during the day. Encourage exercise breaks. Try and stick to regular bedtimes and develop a good sleep/bedtime routine.

If your son usually doesn’t have difficulties attending to classroom, and you think his lack of settling is because he is worrying, it might be useful for him to learn some strategies to manage his worry. There are some suggestions about managing anxiety in several of the other questions, with suggested resources that you might find useful.

It might also be helpful to set him some goals about focusing on his school work. Set up a challenge for him about being able to attend to his work and put in an appropriate reward if he is able to attend for the specific class day. For example, if you find he can only sit still for 10 minutes at his desk, then set him a challenge to stay there for 10 minutes (with a reward if this is successfully completed) and then gradually increase the time, so he is able to sit in with the rest of the class. I recommend also reaching out to his teacher and let the teacher know you are concerned. The teacher would usually be able to monitor this issue in the classroom and adjust accordingly.

Importantly try not to reward the lack of focus. The tendency might be to let him watch something else on TV or do something fun instead of schoolwork. This could set up some unhealthy patterns. You want to reward him for staying focused on his schoolwork. If you are concerned I encourage you to speak to your doctor.

To a pre-schooler, I would simply say something like “Right now, to keep us safe, to keep grandma safe, from the virus, we can’t visit her house at the moment. This is not forever - just for now.” I would encourage your child to think about other ways you could still see grandma or stay connected. See if they can suggest an idea or maybe you can suggest some ideas like drawing her a picture, seeing her on a videocall, putting a picture up of her on the wall. If s/he is upset about not seeing grandma, acknowledge this, like “It is hard not being able to see her. You love her very much. You like seeing her.” And then, you can work together to find some ways you can stay connected.

There are some great online services that you could try. I am not sure where you are located but here are some you could try: www.mq.edu.au/coolkids (AUS) www.copingcatparents.com/Products (US) www.brave-online.com/ (AUS)

In terms of dealing with anxiety, the strategies that work in preventing and reducing anxiety include: • Encouraging your child to use calm, realistic thinking rather than worried, panicked thinking (use this yourself too!) • Facing difficult situations rather than avoiding them. For example, if your child is avoiding situations like sleeping on their own, use a stepladder approach to gradually face their fear. I have written some information for another site on this if you want to take a look: https://raisingchildren.net.au/toddlers/health-daily-care/mental-health/anxiety-stepladder-approach • Encouraging your child to problem solve and develop these skills on their own. Here is a good worksheet from our Cool Kids program (www.mq.edu.au/coolkids) that can help you work through a problem together. • Try not to provide too much reassurance. There is evidence to suggest that reassurance can lead to kids feeling more worried. We think it also prevents the child from thinking through the situation on their own. Your child may only feel like they can cope if you have told them it is okay/safe. Children with high anxiety often get stuck in a cycle of seeking reassurance from parents over and over again (like asking questions like “Is it going to be okay mum?”). In response parents provide a lot of reassurance and the cycle keeps going. Instead of answering the questions, try asking them. Respond to your child’s questions with questions they can answer like: “What do you think?” “What do you think is most likely to happen?” • Not rushing in to help and encouraging your child to handle the situation on their own as much as possible. Communicate to your child that you trust they can handle it. • Using labelled praise and rewards to shape their behaviour by focusing on all the times they are courageous (e.g., “I really liked the way you were able to go into the bathroom on your own and turn the light on”)

I am working on bringing together some resources for parents/carers, teachers/educators, children and young people and also clinicians. Stay tuned (www.mq.edu.au/ceh) but in the meantime, some of my colleagues have also put together a really fabulous evidence-based resource:

https://emergingminds.org.uk/wp-content/uploads/2020/03/COVID19_advice-for-parents-and-carers_20.3_.pdf

I think a little bit of anxiety at the moment is totally normal. There is increased threat at the moment and that little bit of anxiety helps us to take action when we need it. If we weren’t anxious at all then there would be no motivation to physically distance ourselves from others or wash our hands more than usual. I would say the difference between anxiety that is appropriate at the moment versus what might warrant seeking help would be based on the amount of distress it is causing and how much it is impacting on the child’s life. Are they unable to sleep, leave the parent’s side, be in a room on their own? Are they spending all their time searching online for information about the virus or are they spending a lot of time asking repetitive questions about whether they are going to be okay? If these things are happening on a daily, or almost daily basis, then I would recommend getting help. Services are still being provided (mostly using telehealth). Seek help from your local doctor as a first step or try some online programs: www.mq.edu.au/coolkids (AUS) www.coollittlekids.org.au (AUS) www.copingcatparents.com/Products (US) www.brave-online.com/ (AUS)

Great question. It is so hard at times like this when we are dealing with our own worries to not want to talk about it all the time, even when the children are around. I would recommend however, unloading your worries on a friend or a partner instead. The COVID-19 pandemic provides a really great opportunity to teach your child how to deal with stressful situations – as this will not be the only time in their life they experience a highly stressful situation. Think about what you want your child to learn from you.

I think it is okay to talk about your worries with children, when you are at the point you can model a helpful response. Best to not to discuss your worries if what is going to come out of your mouth are things like’: “This is such a dreadful situation. I don’t know how we are ever going to cope. I hope we don’t all catch it and die…(fill in all your worried worst-case scenario thoughts here). ….” Showing your children how you handle your worry can be really useful (talking to a friend, problem-solving the situation, thinking realistically, developing helpful habits like exercising, eating healthily, using good sleep hygiene). Take some time to work on your worried thoughts before you talk to your children about it.

I agree that it is important for us to have good balanced knowledge about what is happening at the moment. But this kind of continually searching can become an unhelpful strategy, that will keep the anxiety going. I would ask a question that might get to your client’s worried thoughts about why it is important. Is it a thought like “I need to have all the information so I can protect myself against catching COVID-19” ? Would it cause him/her distress if s/he can’t search? I would be encouraging the client to gradually to reduce the amount of time she is searching. Use a stepladder approach to reduce the number of hours she is searching with a goal of being able to just check once a day and only a reputable source (such as government health website): https://www.mq.edu.au/about/campus-services-and-facilities/hospital-and-clinics/centre-for-emotional-health-clinic/cool-kids-anxiety-program-for-professionals/chilled2ed-Stepladder.pdf

I think a little bit of anxiety at the moment is totally normal. There is an increased threat to our health at the moment and that little bit of anxiety helps us to take action when we need it. If we weren’t anxious at all then there would be no motivation to physically distance ourselves from others or wash our hands more than usual. Not knowing can be difficult to manage. It is hard not knowing when the situation will end or whether we will catch COVID-19 or whether a recent sneeze is an early sign of the virus. We do however have the capacity to deal with uncertainty. Even before COVID-19, there were never any guarantees about our health. Encourage your child (school aged) to use calm, realistic thinking rather than worried, panicked thinking. Encourage them to think in a balanced way about the virus. How many people in the world have recovered from the virus? Based on the numbers, how likely is it? What else might happen? This is not positive thinking, because there is still an increased chance compared to usual and we need to be real about this. We want to encourage a more balanced approach to thinking about the situation.

In addition to helping your child think realistically, there are some other things you can do that can keep the anxiety from being out of proportion to the situation.
• Facing difficult situations rather than avoiding them. For example, if your child is avoiding situations like sleeping on their own, use a stepladder approach to gradually face their fear. I have written some information for another site on this if you want to take a look: https://raisingchildren.net.au/toddlers/health-daily-care/mental-health/anxiety-stepladder-approach • Encouraging your child to problem solve and develop these skills on their own. Here is a good worksheet from our Cool Kids program (www.mq.edu.au/coolkids) that can help you work through a problem together. • Try not to provide too much reassurance. There is evidence to suggest that reassurance can lead to kids feeling more worried. We think it also prevents the child from thinking through the situation on their own. Your child may only feel like they can cope if you have told them it is okay/safe. Children with high anxiety often get stuck in a cycle of seeking reassurance from parents over and over again (like asking questions like “Is it going to be okay mum?”). In response parents provide a lot of reassurance and the cycle keeps going. Instead of answering the questions, try asking them. Respond to your child’s questions with questions they can answer like: “What do you think?” “What do you think is most likely to happen?” • Not rushing in to help and encouraging your child to handle the situation on their own as much as possible. Communicate to your child that you trust they can handle it. • Using labelled praise and rewards to shape their behaviour by focusing on all the times they are courageous (e.g., “I really liked the way you were able to go into the bathroom on your own and turn the light on”)

I am working on bringing together some resources for parents/carers, teachers/educators, children and young people and also clinicians. Stay tuned (www.mq.edu.au/ceh) but in the meantime, some of my colleagues have also put together a really fabulous evidence-based resource:

https://emergingminds.org.uk/wp-content/uploads/2020/03/COVID19_advice-for-parents-and-carers_20.3_.pdf

To a pre-schooler, I would simply say something like “Right now, to keep us safe, to keep grandma and grandpa safe, from the virus, we need to walk/stand like this (demonstrate the recommended safe distance). This is not forever - just for now.” You could make it into a game if they are struggling with it, set it up as a challenge if you have to go out.

I prefer the term physical distancing because we can still be social in so many other ways through video and phone calls, drawing pictures for their grandparents and friends. We need to create physical distance but still stay connected socially. Of course, none of these words actually will be appropriate for pre-schoolers. But you can still communicate the idea that there are other ways we can stay close. Your child will likely be able to come up with some great ideas of how they can still stay close in other ways.

As you know, we feel anxious when we think i) something bad is going to happen and ii)we won’t be able to handle the outcome. If a young person has the tendency to be anxious, then they may also be more likely to look for ‘bad things’ or overestimate the likelihood that the bad things will happen and underestimate their ability to cope. We call this ‘worried thinking.’ This kind of thinking is reinforced by the media, because media often focuses our attention on the negative outcomes and doesn’t talk about the high percentage of tests that come back negative for COVID-19 and also the number of people who contract COVID-19 and recover. Strategies that we know help to reduce anxiety include learning to think realistically. But this takes practice and is hard to do when the young person is very worried. Here is a worksheet from our Cool Kids treatment program, that you can use to take your client through a situation they are worried about. https://www.mq.edu.au/about/campus-services-and-facilities/hospital-and-clinics/centre-for-emotional-health-clinic/cool-kids-anxiety-program-for-professionals/chilled2ed-Realistic-Thinking.pdf

You can ask your client to work through this and come up with evidence, kind of like if they were a detective, or a lawyer or a scientist. Ask them to find the facts of the situation. Ask questions like: What are the facts?; What else could happen? What happened when you worried before? What is likely to happen? These questions might help your client think about the situation from a more balanced perspective, rather than always thinking the worst. I would also encourage your client to turn to reliable sources of information: Government data and fact sheets from your country’s health department. New information is being learned about the virus and this is where accurate information will be displayed.

There is a lot of misinformation available. It might be worth having a conversation together about how easy it is to spread misinformation. Encourage your client to discover this on his/her own by asking questions like: That is an interesting piece of information. Tell me more. Where did you hear about that? Take an inquisitive approach to model how you would determine if something is true. Is it from a reputable source? Has it been reported in more than one place?

The way a child responds to the current situation depends partly on the way the parent responds (it is also dependent on a lot of other things as well, such as the unique qualities the child brings to the situation, other environmental factors). It can be really tough, as you have alluded to, if you - the parent - are also struggling. Ideally, being calm provides a strong role model and can help your child stay calm. The COVID-19 pandemic provides a really great opportunity (as strange as that sounds) to teach your child how to deal with stressful situations – as this will not be the only time in their life they experience a highly stressful situation. Think about what you want your child to learn from you. In terms of dealing with anxiety, the strategies that work in preventing and reducing anxiety include: • Encouraging your child to use calm, realistic thinking rather than worried, panicked thinking (use this yourself too!) • Facing difficult situations rather than avoiding them. For example, if your child is avoiding situations like sleeping on their own, use a stepladder approach to gradually face their fear. I have written some information for another site on this if you want to take a look: https://raisingchildren.net.au/toddlers/health-daily-care/mental-health/anxiety-stepladder-approach • Encouraging your child to problem solve and develop these skills on their own. Here is a good worksheet from our Cool Kids program (www.mq.edu.au/coolkids) that can help you work through a problem together. • Try not to provide too much reassurance. There is evidence to suggest that reassurance can lead to kids feeling more worried. We think it also prevents the child from thinking through the situation on their own. Your child may only feel like they can cope if you have told them it is okay/safe. Children with high anxiety often get stuck in a cycle of seeking reassurance from parents over and over again (like asking questions like “Is it going to be okay mum?”). In response parents provide a lot of reassurance and the cycle keeps going. Instead of answering the questions, try asking them. Respond to your child’s questions with questions they can answer like: “What do you think?” “What do you think is most likely to happen?” • Not rushing in to help and encouraging your child to handle the situation on their own as much as possible. Communicate to your child that you trust they can handle it. • Using labelled praise and rewards to shape their behaviour by focusing on all the times they are courageous (e.g., “I really liked the way you were able to go into the bathroom on your own and turn the light on”)

I am working on bringing together some resources for parents/carers, teachers/educators, children and young people and also clinicians. Stay tuned (www.mq.edu.au/ceh) but in the meantime, some of my colleagues have also put together a really fabulous evidence-based resource:

https://emergingminds.org.uk/wp-content/uploads/2020/03/COVID19_advice-for-parents-and-carers_20.3_.pdf

Nightmares in young children are common; between 10 to 50% of 3- to 5-year-olds experience nightmares. In fact, most adults (around 75%) will be able to recall a nightmare they experienced as a child. We also know that nightmares are increased when a child is exposed to highly stressful events, like the current COVID-19 pandemic. There are a number of things you can do that might help if your child is experiencing repeated nightmares: • Reduce exposure to media (not entirely cutting our media but I recommend not having media on in the background 24/7); • Develop good sleep hygiene (sticking to a bedtime routine, using bed for sleeping only, including a relaxation exercise in the bedtime routine) • When they wake from the nightmare, tell them it was a bad dream and it was not real. You can tell them in a quiet reassuring voice they are safe and that you are there. Stay with them until they are calm but encourage them to go back to sleep on their own if they can. You could also repeat the relaxation exercise or part of their bedtime routine. • Seek help from a psychologist if the nightmares are creating a lot of distress or are interfering with your child’s (or your own) sleep, for example, if they won’t go to sleep because of a fear of having another nightmare or if they have a great deal of trouble getting back to sleep on a regular basis. • For more strategies, I recommend this site for information on pre-schoolers. https://raisingchildren.net.au/preschoolers/sleep/nightmares-night-terrors-sleepwalking/nightmares

At the moment, the Centre for Emotional Health at Macquarie University is working towards a solution for therapists to be able to work with their clients using online versions of our program, including Cool Kids Chilled. This would enable therapists to provide clinical support for their clients engaged in the online program. This is especially important to allow international clients the opportunity to access the program. At the moment, in Australia, families can access the program, supported by a therapist in our clinic (www.mq.edu.au/coolkids). In our clinic, we have also been delivering services to the clients (who prior to COVID-19 were face to face clients) via secure videoconferencing platforms (with share screen capabilities). We have been using electronic versions of our worksheets from the second edition of Cool Kids. Here is a link to these worksheets:

https://www.mq.edu.au/about/campus-services-and-facilities/hospital-and-clinics/centre-for-emotional-health-clinic/cool-kids-anxiety-program-for-professionals

A good place to start is to have a conversation with your child about what they already know. This will help you to hear the kinds of words your child is using and help you to know your child’s existing level of understanding and perhaps uncover some misconceptions. It is often the misconceptions that are creating unnecessary anxiety. Asking the child what they already know is a good place to start. It is important to talk to children about what is going on and to listen and acknowledge their worries and concerns. The level of detail and explanation can vary a great deal, based on age and development. It is always helpful to provide an explanation, even for younger children, about why you are asking them to do something, even for pre-schoolers. I think for children of all ages it is important to reinforce that this is a temporary situation. I have written this piece on talking to children about coronavirus that you might find useful:

https://lighthouse.mq.edu.au/article/march/how-to-talk-to-your-children-about-coronavirus-top-10-questions-answered

Here is a really great resource as well that has information for different age groups:

https://emergingminds.com.au/resources/communicating-with-your-child-about-covid-19/

It is a worrying time, particularly if your child already has a propensity to worry. Sounds like you already have a good sense of your daughter’s anxiety and what is helping to maintain it. As you pointed out, reinforcing anxiety does help it to grow.

Anxiety plays an important role in our survival. It is there to help us respond to threat. It makes us take action. Like at the moment, anxiety is driving us to take wash more often and to physically distance ourselves from others. This will help keep us and others safe. For some young people, like your daughter, this process switches on more often than it needs to, even without the COVID-19 pandemic. She is more likely to think something is threatening.

It might be helpful for your daughter to think about the current changes in our behaviour as a temporary thing. The temporary behaviours are appropriately matched to the level of threat. When the threat is no longer there, we won’t need to engage in these behaviours.

I would also be encouraging her to develop strategies to challenge her worried thoughts about the world being unsafe. I have an example in another question that goes through an example of how to support her to challenge her thoughts and think in a more realistic way. This takes a lot of practice. Encourage her to be open to alternative interpretations of situations, rather than always expecting something bad could happen, encourage her to think about what else might happen.

I would also be on the look for out for subtle ways she might be avoiding situations or seeking reassurance, or doing lots of checking. Is she avoiding talking to her friends? Exercising? Asking lots of “what if?” questions. Because of the lockdowns, it is so much easier for young people (and people of all ages for that matter), to avoid situations they find challenging. Provide some gentle encouragement to face situations she might be avoiding, even if they are small acts of courage. This will help to prepare for when things go back to ‘normal’. When the restrictions are no longer in place, think about how you can help her to work with you to gradually get back to the world. Here is a stepladder sheet that we use in our Cool Kids program that can be very helpful in breaking down a situation and gradually facing situations. You want her to learn more accurate information about the world. We want her to learn that her worried thoughts about what might happen are not as likely to come true as she thinks. You also want her to learn new information that she handle the situation. This requires testing out her fears. Start with low or easy steps (these would be steps that are only a little bit anxiety provoking) and gradually build up to more challenging situations:

https://www.mq.edu.au/about/campus-services-and-facilities/hospital-and-clinics/centre-for-emotional-health-clinic/cool-kids-anxiety-program-for-professionals/chilled2ed-Stepladder.pdf