Anxiety

Worry, Anxiety, and Stress

Interventions must address worried thoughts and anxious feelings as well as the physiological and behavioral response.

Physiological

Breathing Strategies

Teaching a child to use his or her breath to reduce anxiety starts by example. Kids naturally mimic what they see, and illustrating how you adapt your own breathing pattern to relax is a great place to start. You can expand on the lessons by engaging the child in several exercises to help normalize and regulate her breath.

Kindergraten - grade 1

Conscious Discipline has a number of visuals and activities that assist kindergarten to second graders in learning breathing techniques.  They even have a suggestion to have each student make their own breathing star booklet consciousdiscipline.com

Grades 2-3

For most of my students in grades 2-3 I teach the 4 Square Breathing mindfulness technique.  I sometimes give them a copy of this diagram and have them trace the square as we practice breathing.  With a very active student (or group) we might draw the square with one arm in front of our bodies as we do the slow breath 4 times.  This technique can be explained simply and it must be done at least 4 times correctly to make a difference.  Many parents have shared with me that their child came home and taught them 4 Square Breathing!

Abdominal breathing can be combined with counting to keep mind from returning to thoughts that fuel anxiety (If only... or What if...).  It can also be combined with imagery or mindful movement.  For example, picture a relaxing spot and take 5 deep slow breaths. Do a mindfulness walk taking one step with each breath, focusing on the present moment.

Grades 4-5

This breathing and counting pattern has been around for a long time, based on meditation practices. A Harvard researcher made it the "go to" technique for anxiety and help getting to sleep. Parents can also use this one themselves.

Psychological

It is important to help students who are anxious understand that anxiety if a trick - the brain is sending a false alarm.  Even though the anxious person feels a sense of dread, there is no real danger.
Children need help to develop a connection to how their body feels (sensations) and their thoughts and feelings. Just because their heart is racing does not mean they are in danger, it may mean they need to get up and move.

Behavior

Avoidance of the source of anxiety makes it stronger.  Students need support to confront the source of their anxiety, not avoid it.

Other anxiety-driven behavior can include:

Making excuses to avoid going out or doing things.
Hurrying out of places or situations where we feel anxious.
Only going to quiet places where there aren't many people.
Not saying anything in front of others.
Sitting near doors and exits or at the back.
Walking to avoid buses; crossing the street to avoid people.
Drinking or taking a pill before doing something stressful.

Counseling Strategies

1 Calm the body and senses first

      2 Understand feelings and scale intensity

      3 Apply cognitive strategies


Externalize Worry and Anxiety

It sometimes helps to have a child give their worrying a name like "my worry brain" or "scaredy cat" then it does not feel like something that will always be part of them or a part they cannot control. Drawing a picture of the "worry monster" or creating it out of clay or other materials makes it easier for a young child to see that as the problem not who they are as a person.

 Traumatic Stress Disorder

Fears and Worries List This is a simple worksheet that divides worries into groups by level.  Try to get the client to identify at least 1 worry at each level (These things make me a little worried, These things are hard to do, and These things are really hard to do.  Writing down fears can make them seem more manageable.  This activity is adapted from Helping Your Anxious Child: A Step-by-Step Guide for Parents by Ronald M. Rapee and 4 other authors.  I highly recommend the book for parents.

 My Pocket Plan Most children like paper folding activities.  This activity makes creating a plan to talk back to worry more engaging and likely to be referred to between sessions.  This is adapted from a goal setting activity from Second Step.  After discussing what helps decrease anxiety the student picks 3 and decides on the order they will use the coping strategies.  For example, 1) slowly count 5 belly breaths in and out; 2) positive statement "even though I am worried, I can come to school and have a good day;" 3) think about playing my favorite game at recess with a friend.  Writing down a coping plan helps cement it in memory and having it in a pocket makes it accessible to practice and share with parent/guardian.

Grounding Techniques 
Grounding is a technique that helps someone stay in the present moment.  Grounding skills fall into two categories or approaches, sensory awareness and cognitive awareness.
Sensory Awareness -
5 Senses Exercise
Trace hand on paper and label each finger with one of the senses. Add a picture to represent the sense(ring finger lavender). Post it in several places, like the car if driving is a trigger. When anxiety starts to increase breathe deeply and stare at your hand. Go through the 5 senses exercise from memory.
5-4-3-2-1 Exercise
Name 5 things you can see
Name 4 things you can feel
Name 3 things you can hear
Name 2 things you can smell or like to smell
Name 1 thing you like about yourself
My Favorite Things
Make a list of some favorite things that make you feel really good like baking cookies with your family or taking a walk on the beach. When anxiety is triggered, take 3 deep breaths and imagine feeling more relaxed with each breath. Try to see one of your favorite things in you mind's eye. Try to hear the sounds. Can you smell the smells? How do you feel in that place? Then return to a focus on your breathing.
Cognitive Awareness
Re-orient yourself to the present moment and place by asking questions:
1 Where an I?
2 What is today?
3 What is the date?
4 What is the month?
5 What is the year?
6 How old am I?
7 What season is it?

Children's Literature

Anxious Annie by Bobula & Bobula

This book is a great resource for OCD children and anxious thinkers. 

See Children's Book page for additional suggestions.

Consultation

Helping students with anxiety requires collaboration with staff and parents.  Generally an anxious child will have a negative impact on the family and they will be looking for help.  Teachers sometimes think the child just needs to "grow up" or blames the parents.  For detailed suggestions go to Anxiety in Children Some suggestions include:

Routines and Structure

Help Children Identify Feelings

Provide Opportunities for Communicating About Feelings (but postpone and limit)

Provide Soothing and Comforting Strategies

Respect Child's Fears

Model Brave Behavior

Encourage Brave Behavior

Teach Relaxation Skills

Role-play social situations ahead of time

Encourage "Feeling Good" Activities

Use Children's Literature (read together and discuss)

Teach Problem Solving Strategies

Challenge Unhelpful Thoughts (Worry Brain)

Don't offer more reassurance than needed

Don't allow excessive checking in

Coping Cards

Students with anxiety need several strategies to talk back to their "worry brain" when anxiety levels are high.  Some students respond to making their own coping cards on a small index card they can carry in their pocket.  I have not had luck with the pre-made versions, but when we work on a coping statement and the client writes it his or herself it can sometimes help with the initial exposure to the activity the student would like to avoid.  The coping card target the thinking part of anxiety (in the cortex of the brain).  Here is an example of a third grade boy's card who was extremely afraid of storms.  

"I am feeling sick to my stomach because my worry brain is thinking about a storm coming.

I am safe in school during a storm.

I can stay in my classroom.

I can do belly breathing and remind myself that storms are not dangerous when I am inside."

A girl transitioning to middle school who felt real panic at drop-off used:

"I am safe

I am calm

I can handle coming to school."

I usually make a copy on the copier of what the client wrote so a back-up is available if the original is lost. 

I have also used coping cards with some success for anger management. With anger I usually have them write one side for school and the other for home.  Often the problem and strategies change by location.