MANAGING ANXIETY, A Conversation with Dr. Joanna Stern and Dr. Laurie Freeman
April 13, 2022
By Melanie Wells
On April 13, NYC-Parents in Action’s Spring Lunchtime Webinar presented a sensitive, substantive conversation between two experts, Dr. Joanna Stern, Senior Director of the Mood Disorder Center at the Child Mind Institute, and Dr. Laurie Freeman, psychologist in private practice, NYC-PIA Facilitation Chair and NYC-PIA Board member.
Dr. Freeman noted NYC-PIA’s good fortune in welcoming Dr. Stern to “help us learn best ways parents can understand and support their children’s mental health,” adding that Dr. Stern provides children, adolescents and parents “with excellent treatment to provide support and tools to make meaningful changes in their lives.”
The audience was doubly fortunate in having Dr. Freeman, head of NYC-PIA’s Parent Talk Program, as moderator. Parent Talks, explained Dr. Freeman, bring parents together “to connect with each other and have a village.” She then turned the floor over to Dr. Stern for a presentation on “Managing Anxiety.”
Dr. Stern offered some context on the work of the Child Mind Institute (an independent national nonprofit, dedicated to “transforming the lives of children and families struggling with mental health and learning disorders”) citing its evidence-based clinical practice, research, and public educational outreach.
Framing anxiety using a strong example that parents could quickly recognize, Dr. Stern referenced a recent shooting at a subway station in Sunset Park, Brooklyn. The incident served as a striking, recurring backdrop throughout the discussion.
Anxiety can lead to a sense of vulnerability, Dr. Stern began, noting that we all experience emotions and vulnerability, but not everyone experiences them at the same level of intensity. She listed three elements that can affect vulnerability levels:
Biological Predisposition – We contribute this through genetics and biology we pass on to our kids, which can shape the way they experience emotions.
Psychological Characteristics – A person prone to view the world through a lens that sees things as frightening, is more likely to feel depressed more often.
Social Environment – Growing up in NYC (particularly in the contained private school world) creates a unique social environment. In this “sub-sphere” of NYC, cultural factors may influence “how strongly our kids experience their emotions.” Unlike schools outside NYC, where the competitive level is lower, our kids may feel “unique levels of pressures” stemming from cultural factors.
Thoughts, feelings and behaviors are part of a “model of emotion,” where each element has impact on another. Dr. Stern’s example: If a parent hears of an event like the subway shooting, there’s a strong reaction (Panic? Avoid all subways?) and if we follow that reaction (“it’s not safe!”) we may avoid the subway system, which can set up a cycle that can enhance anxiety.
Anxiety, Dr. Stern said, is a normal reaction bodies and brains have to signal danger to us. For example, crossing a busy midtown street can “turn on” an anxious reaction if an express bus is barreling down toward you, prompting a step back. That’s logical. Sometimes, however, “our bodies and brains deliver a false alarm” when there is NO actual danger present. Dr. Stern said an alarm may be adaptive and helpful (jumping back from a speeding bus) but some are “out of control” and not helpful. To know when a reaction is out of control, it helps to consider FREQUENCY, DURATION AND IMPAIRMENT:
FREQUENCY: How often does the person experience the reaction? How often does the anxious thought “pop up?”
DURATION: How long does it last? Does it pop in and depart, or does the “pounding heart and alarm” last for hours? How long has this pattern been going on? She offered an example from the subway shooting: “Once the shooter in the subway is arrested, if I’m still having this fear reaction, we’d discuss it in terms of duration.”
IMPAIRMENT: How much does it interfere with daily functioning/jobs? As parents, one of our jobs is to care for the kids; for kids, the big job is to go to school and complete all homework. If anxiety reactions interfere with the ability to perform jobs, it’s an impairment problem.
ANXIETY CAN PRESENT IN MANY WAYS, e.g., nail biting; struggle to focus; stomach aches and headaches; crying, or difficulty managing emotions; sleep problems; avoiding school or extracurricular activities, especially those formerly enjoyed.
The “gold standard” for treatment involves incremental levels of exposure in a controlled way. The patient can eventually conclude that the fear “isn’t actually going to hurt me” and over time, can even be “tolerated.” Referencing the subway example, Dr. Stern offered a scenario: “I can say, ‘I can put myself on the subway,’ so I walk to the train stop but during the walk, my anxiety may rise. I may be shaky, breathing fast, heart pounding, but I go down the subway steps. As I draw closer, anxiety levels rise and reach the ‘panic peak.’” Here, Dr. Stern said, the temptation is to flee and escape. If we do flee, anxiety may dissipate quickly, but then we will not, over time, “habituate” (learn that “I CAN survive this”).
If you can make yourself tolerate the panic peak, then over time you’ll learn “I can tolerate this” and anxiety can lessen. -Dr. Joanna Stern
If we don’t learn to “tolerate” the panic, anxiety will return during later exposures. But, said Dr. Stern, “If you can make yourself tolerate the panic peak, then over time you’ll learn ‘I can tolerate this’” and anxiety can lessen. Avoidance, though, paves the way to the next panic.
Dr. Stern then segued to the question on every parent’s mind: What can I do to help?
What can I do to help? Model your own anxiety and how you think through your own behaviors rationally and calmly. -Dr. Joanna Stern
Model your own anxiety and how you think through your own behaviors rationally and calmly.
Be honest: Explain your own fear. A parent could honestly say, ‘I’m so afraid by what happened on the subway I’m tempted not to go back in the subway until they get this guy.’ Dr. Stern advised not to stop there but to continue modeling, by saying, “But, no. I’m going to face my fear and give myself credit for doing it.’ If your child follows this formula, praise him.
Praise anxiety-fighting behaviors. Say, “I know how scared you are and how tough it is for you to go in and give your school presentation, but good for you, you got out of bed!”
Establish reward systems: Maybe an ice cream after getting on the subway? Or after giving the school presentation? Dr. Stern noted it’s important to “establish these ahead of time.” Then there is the other side of the coin, what happens if your child DOESN’T do the required task?
Establish reasonable consequences: Say, ‘”If you don’t go to school and give your presentation, I won’t be able to let you go to the party this weekend.” Set consequences ahead of time.
Be a Cheerleader: Encourage your child (and yourself!) to face fears.
Next, Dr. Stern addressed DEPRESSION, noting that “it’s more than a bad mood” and not anything you can “just get over.”
Signs of depression may include:
Frequent feelings of sadness; increasing Irritability and anger; changes in sleeping or eating habits; frequent crying; feelings of worthlessness, guilt, or shame; helplessness and hopelessness; physical pains with no explanation; chronic fatigue that doesn’t improve with sleep; stomach aches and headaches for no reason; social withdrawal; loss of interest in favorite activities; difficulty concentrating; lowered academic performance; suicidal thoughts.
Specific school-related signs include: Difficulty concentrating, or planning and organizing; forgetfulness; (parents may pin these on ADHD, but they can stem from depression); social isolation or withdrawal from friends; increased irritability or hostility.
Depression is a serious disorder than can impact the brain development of adolescents…Suicide is the third leading cause of death in adolescents and young adults. – Dr. Joanna Stern
Depression, said Dr. Stern, is a “serious disorder than can impact the brain development of adolescents.” One in five adolescents experience depression, said Dr. Stern, and suicide is the “third leading cause of death in adolescents and young adults.” Treatment of depression can be very effective at mitigating the “duration, the severity and how much it interferes in daily life.” When seeking treatment parents should assess how long the signs/symptoms have been present, how intense they are, and how different the child seems from her “typical self.”
Factors that may lead to depression include:
Genetics – (most notably, if a close relative has suffered it);
Differences in the brain – (level of neurotransmitters in the brain);
Traumatic events – (including in early life)
Learned patterns of negative thinking – (can be learned from parents, at school or from peers).
Ineffective coping strategies – (Kids are not born with strategies; they must be learned and some kids learn them more easily than others).
HOW CAN YOU HELP? Start with VALIDATION.
Validation needs to make sense. Don’t just say “I agree with you.” Rather, find “a kernel of truth” and build on that. Say, “Yes, I understand, it makes sense to me that you’re afraid of getting back on the subway” and don’t just shut the subject down (“What do you mean? Look at all the police around! Nothing will happen!”)
Look for small ways to get active. If your child says, I can’t go to school, start SMALL. Suggest getting up, getting dressed, moving from bed to couch. Manageable chunks work best.
Dr. Freeman thanked Dr. Stern and opened the Q and A, with questions from the audience:
Q: After the validation step, how does a parent proceed to next steps?
A: Dr. Stern: It’s important HOW you say it. Timing matters, so, pause. Give that validation a second to “sink in” and let your child absorb it before you ask anything. Then, after the pause comes the “ask.” Be sure to “ask in the right way,” Dr. Stern said, so even when “saying the right words,” parents should also be careful with delivery. She advocated pausing between thoughts, and not just delivering a rapid stream of words “without any sense of empathy.” Remember, “connection matters,” so try to “connect to the emotion” the child is feeling.
So, said Dr. Freeman, recapping for parents: “Give it a pause, take care how you say it, then ask what you need to ask.”
Give it a pause, take care of how you say it, then ask what you need to ask. – Dr. Laurie Freeman
Dr. Stern added, “validation is acceptance” and the “opposite of acceptance is change,” but “we need both to go together.” She explained that validation “greases the gears” because people “need to feel understood” when they must make “difficult changes.” Assure your child “I get it,” but then deliver the ask, explaining that “we have to do the hard thing anyway (I have to go to my office; you have to go to school.)”
Q: How should a parent respond to children having stomachaches, hiding, showing oppositional behavior? If we know it’s anxiety, does that change how we respond?
A: For a child hiding, the “temptation is to go drag them out.” Instead, start with validation.
if your child cannot verbalize what’s prompting hiding, you can say, “Here’s what I noticed” (no judgment just observation): “every night at bath time you run and hide from me so I wonder if something’s going on? Are you worried about something?” The reaction might be denial, so be willing to take “no” for an answer, but still hold your theory while accepting the child’s answer, at least for the moment. Don’t argue (“No, it’s what I said, not what you said”) but “keep an ear open” for what might develop, because your suggestion may “open the door” to a later, more honest conversation.
Q: For older children, what about anxiety around academics, tests, grades?
A: Again, find the kernel of truth. Don’t say “I have it way harder” at work. Acknowledge it can be hard to be a kid too. Try to connect to your child’s struggle with geometry by finding something that feels hard for YOU, then connect to the emotion behind it. You can say, it makes sense to be worried about this, I get it. Let go of attachment to outcomes, advised Dr. Stern. Instead, praise the process. Say, “I love what you did when you focused and studied for an hour and a half” or “I loved when I asked you to put it away and you stopped, and were able to take a break for dinner.” These are behaviors we master as well-functioning adults, so they deserve praise, just as do good grades.
Q: Negative self-talk: Can parents help here?
A: I’m a big fan of modeling. Kids are like “sponges” in the way they pick up on and repeat what we say and do. Model “self-talk.” Say, “Here’s what I want to do differently” and model how you’d “try to do better next time.” Show acceptance, saying, “This is how I feel right now but I hope I’ll be more positive about it next week.”
Q: How about the interaction of anxiety with motivation in teens?
A: “Anxiety can be de-motivating” and can trigger “fight or flight” reactions. When “flight” kicks in it may “look like the child is avoiding responsibility.” The teen may try to hide from a task that scares her. Use the “I notice” strategy: Say, “I noticed you didn’t meet with your teacher, so I wonder if you’re worried about what you’ll find out when you meet with her.” Then, pause, and wait for the answer. If there’s denial, you can still model, saying, “When I’m anxious about a meeting, I ask myself what’s the tip of the iceberg, the smallest piece that’s doable?” Suggest to your teen: “Could you email the teacher, from here, right now?” The key is to stop the cycle of avoidance, via some small, doable step.
Q: Advice on responding to rage that seems out of control?
A: Note where/when it shows up. If your child is stressed when asked to do something that brings anxiety, try pairing the request with validation. Say, “I’m about to ask you something I imagine you won’t want to do and I understand why you’re not going to want to.” Say that you understand why they get upset, and then see if you can make the request.
Dr. Stern added a warning regarding rage: “If you’re afraid for your own, or your child’s, or another family’s safety, be prepared to take your child to the ER to get treatment.”
Dr. Freeman thanked Dr. Stern for her wealth of information, and summed up the takeaways:
1) Model a realistic, hopeful view by slowing down, empathizing, validating, and still asking that kids do what they need to do.
2) Use incremental steps that, even if scary are manageable, so we help kids achieve a result.
3) Praise effort, not just outcomes.
Finally, Dr. Freeman noted, today’s terrific advice perfectly reinforces our NYC-PIA motto:
Be involved, Be informed, Be connected.