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Anxiety: Symptoms in Children/PreTeens/Teens

All it takes is a quick Google search to find several articles indicating that anxiety is on the rise in children and teenagers.

An article from the American Psychological Association states:

“Even before the COVID-19 pandemic, growing numbers of young people were experiencing high rates of clinical-level anxiety. About 11.6% of kids had anxiety in 2012, up 20% from 2007. But during the pandemic, those numbers nearly doubled, such that 20.5% of youth worldwide now struggle with anxiety symptoms…”

Children across the nation are experiencing symptoms of anxiety at an increasing, and alarming, rate. Here are some examples of triggers from some of my preteen/teen clients:

  • Anxiety due to bullying at school
  • Anxiety due to parent’s financial troubles
  • Anxiety due to school performance/expections
  • Anxiety due to conflict within their friend group
  • Anxiety due to business/feeling overwhelmed with school, work, extracurriculars
  • Anxiety due to watching news coverage of traumatic events
  • Anxiety due to conflict between their parents
  • Anxiety due to not feeling like they “fit in”
  • Anxiety about body image/weight/clothing size

Because of this increase in anxiety researchers are seeing in children, I thought it prudent to write a series on anxiety in children, pre-teens, and teenagers. Warning: it is always best to consult a medical/mental health provider if you believe your child has anxiety. Leave the diagnosing to the professionals (doctors, psychiatrists, psychologists, therapists, counselors, social workers). I include a post about symptoms not so that you can diagnose your child, but so that you can be aware of what to look for and reach out for help if needed.

To start, here is a list of symptoms for Generalized Anxiety Disorder (GAD) from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition Text Revision (DSM-5-TR):

  • Excessive anxiety and worry occurring more days than not for at least 6 months
  • Restlessness or feeling keyed up or on edge
  • Being easily fatigured
  • Difficulty concentrating or mind going blank
  • Irritability
  • Muscle tension
  • Sleep disturbance

To meet diagnostic criteria according to the DSM-5, individuals must be experiencing the first symptom, plus at least three of the six other symptoms. The symptoms must be causing them distress or impairment in social, occupational, or other important areas of function. Lastly, the symptoms must not be explained by substances or another mental disorder.

If you seek help from a professional, they will use the DSM-5-TR to make a formal anxiety diagnosis. However, there are many other symptoms kids can report that can indicate an anxiety concern. Symptoms I’ve had reported to me by anxious preteens/teens include:

  • Headaches (often caused by muscle tension)
  • Stomachaches
  • Feeling self-conscious or very sensitive to criticism
  • Avoiding situations/places/people
  • Clingy behavior/reassurance seeking
  • Change in appetite
  • Emotional outbursts
  • Hyper-focused on “perfection”/being perfect
  • Anxiety/panic attacks (these can feel different for different people)
  • Racing thoughts
  • Fidgeting

Other symptoms can be experienced, but these are the ones commonly reported to me by my clients.

I’d like to point out that just because your child/preteen/teenager experiences some or a lot of these symptoms doesn’t mean that they have anxiety or could meet diagnostic criteria for an anxiety disorder. I personally experience several of these symptoms, sometimes on a daily basis, but do not meet criteria for an anxiety disorder. This can make diagnosis hard.

The other thing that can make diagnosing tricky is that many of these symptoms overlap with symptoms of other disorders. This is why diagnosing is best left to the professionals. For example, change in appetite, difficulty concentrating, and sleep disturbance are also symptoms of depression (I’m hoping to do a similar series on depression when we’ve wrapped up anxiety, so keep checking back for that!).

So why is this important to know? My personal opinion is that awareness is important because knowing the symptoms means that you can recognize them and get help faster than if you aren’t aware. Generally with anxiety, the sooner you get help for mental health concerns, the faster you progress in treatment. This isn’t always the case, but it’s much easier to treat anxiety in its early stages than it is if someone has been dealing with anxiety for 2-3 years and it’s reached a higher severity.

A point I want to make is that EVERYONE has anxiety. Some anxiety is healthy. If you didn’t have any anxiety, you might cross the road without looking for cars. Anxiety helps us prepare for the future and prevent harm on a daily basis. The catch is that a “normal” level of anxiety does not cause distress. Remember that piece of diagnostic criteria from the DSM-5-TR… the anxiety must be causing distress or impairment in social, academic, work, or other settings.

So if you notice these symptoms, talk to your child and perhaps a coparent. Decide if the symptoms are causing distress or if they are a barrier to your child being successful at home, school, work, or socially. If the answer is yes, I’d recommend reaching out to a mental health professional for an evaluation and to discuss treatment options.

Stay tuned for posts about treatment options for anxiety, how to support your child with anxiety, and coping skills specifically for anxiety.

Disclaimer: I am a licensed mental health therapist, but I am not your therapist. The information in this article is for general informational purposes only. This article does not create a therapist-client relationship. If you need specific recommendations based on your individual circumstances, please consult with a mental health practitioner near you.

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Crash Course on Reinforcement (Positive and Negative)

I’m taking a break from the Social Skills Series to write about Reinforcement. My post Crash Course on the Four Functions of Behavior is one of my most popular. What this tells me, is that people are actually interested in these terms/theories, and looking for more information. So if you are looking for more information on what Reinforcement is, this post is for you.

So what is Reinforcement? Reinforcement is anything that makes it MORE likely for a behavior to happen. Or, if you prefer dictionary definitions, Merriam-Webster says that Reinforcement is, “the action of strengthening or encouraging something.” In the behavior modification world, the “thing” you are trying to strengthen or encourage is positive behaviors. Check out the chart below (AND/OR download it here) – in this post we’re focusing on the top two boxes – positive and negative reinforcement. As you can see, you are either taking something (unpleasant) away or giving something pleasant in order to make the behavior more likely to happen.

There are a multitude of actions/things that can be used as Reinforcement. Reinforcement can be negative OR positive, and this is where it gets a little tricky. “Negative” in “negative reinforcement” doesn’t mean that it’s a punishment. Both negative and positive reinforcement are “good” things that make a behavior more likely to occur. They are both reinforcing. Let me say it again:

Both positive reinforcement AND negative reinforcement are “good” – BOTH make a behavior more likely to occur again.

Positive Reinforcement is usually easier to understand because it’s giving something good to make it likely the good behavior will reoccur. Think praise, rewards, and positive attention. My child does something “good” that I want them to do again (like cleaning up her socks off the floor, so I give her an extra cookie. Or she is kind to a friend, so I tell her what a great job she did. Or she says “okay” with no whining when I say it’s time to turn off the tv, so I give her 5 minutes of tablet time. Or she gets ready for bed without a fuss, so I read an extra book with her before bed. All of these are examples of positive reinforcement. You get something good for doing something good, which makes it more likely you’ll keep doing something good.

So what does the “negative” in Negative Reinforcement mean? It means you’re taking away something considered “bad” or unpleasant to make the positive behavior more likely to occur again. The most popular example of this is the alarm for seatbelts. In cars, it’s pretty common for an alarm to ding if you don’t put your seat belt on. That ding is pretty obnoxious. Once you put your seatbelt on, the dinging stops. This is negative reinforcement. You’re taking away something unpleasant (the dinging) to reinforce positive behavior (putting on the seatbelt). You get something unpleasant removed for doing something good, which makes it more likely you’ll keep doing something good.

Here’s an example of how both negative and positive reinforcement may be used to reinforce a good behavior. Let’s say your child doesn’t like carrots and typically whines about them, but today they ate all their carrots without any whining or fussing.

In this scenario, you have the option of giving something good (positive reinforcement) or taking away something “bad” (negative reinforcement) to make it more likely your child will eat their carrots without a fuss next time.

Unfortunately, I think negative reinforcement may be used to reinforce negative/bad/undesired behavior more often than it is to reinforce positive behavior. If you give your child a food they don’t like, then take it away when they whine/scream/complain/yell… that’s negative reinforcement. You are taking away something unpleasant (the yucky food), which reinforces the negative behavior (whining/screaming/complaining/yelling). If you tell your child it’s time to help with a chore, then change your mind when they throw themselves on the floor kicking and screaming… that’s negative reinforcement. You took away the unpleasant chore, which reinforced the “tantrum” behavior.

Let’s revisit our carrot scenario to see how positive and negative reinforcement would be used to actually make the negative behavior more likely. This time, let’s say your kiddo sees the carrots on their plate and yells “you know I don’t like carrots, mom! I’m NOT eating these.” Here’s how you might reinforce his yelling with positive and negative reinforcement:

Offer a cookie instead = give something good = positive reinforcement.

Take away carrots = taking away something unpleasant = negative reinforcement.

In this case, both positive reinforcement and negative reinforcement will make it more likely that your child yells at you again – and more likely that they won’t eat their carrots.

The two carrot examples above are also examples of how you can use positive reinforcement AND negative reinforcement at the same time. In the first example, giving a cookie as a reward will be reinforcing. Or letting your child off the hook for cleaning their dishes will be reinforcing. You can use one of these, or you can use both. Using them together will make the behavior even more likely – the reinforcement will be even stronger.

And that’s a wrap on positive and negative reinforcement. The most important thing to remember is this: Both positive reinforcement AND negative reinforcement are “good” – BOTH make a behavior more likely to occur again.

As always, I’d love to read your comments and questions – drop them below!

Disclaimer: I am a licensed mental health therapist, but I am not your therapist. The information in this article is for general informational purposes only. This article does not create a therapist-client relationship. If you need specific recommendations based on your individual circumstances, please consult with a mental health practitioner near you.

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Three Steps (Tell-Show-Do) for Encouraging Compliance with Young Children

Little kids, especially those under 3 years of age, can have a VERY difficult time following directions – which is completely age-appropriate!!  For one, their communication skills are developing, so they may not understand a lot of commands that are said to them.  Secondly, their attention spans are extremely short!  Also, they’re testing their independence and may show a defiant streak!

I do not believe it’s appropriate to give a negative consequence to a child for something that they don’t understand or are unable to do, due to age and development.  BUT you still want to have kiddos of all ages follow through on every task you give them.  So how do you get a child under the age of 3 with limited verbal skills to do this?  You follow 3 steps:

  1. TELL your child what you want them to do.  Keep it short – recommended length of a prompt/direction is one word per age of life (which isn’t always possible, but keep it short)!  Also attempt to be specific.  You might tell your 2-year-old to “pick up toys.”  If she doesn’t…
  2. SHOW your child what you want them to do.  If you told your 2-year-old to “pick up toys” and she looks at you, then keeps playing, get her attention again and show her what you want her to do by picking up a toy and putting it in the box.  Then repeat your prompt (“pick up toys”) and give her the opportunity to pick up.  If she doesn’t, then…
  3. DO the task with your child, hand-over-hand.  Take your daughter’s hand, pick up a toy together, and put it in the toy box.  Once you complete one part together, start over with step one by verbally repeating the prompt.

This is more of a teaching and practicing method – your goal is to help your little one understand what prompts mean, but you’re also teaching them that it’s important to follow through with what mom/dad say!

Disclaimer: I am a licensed independent mental health practitioner and certified professional counselor, but I am not your therapist. The information in this article is for general informational purposes only. This article does not create a therapist-client relationship. If you need specific recommendations based on your individual circumstances, please consult with a mental health practitioner near you.

Posted on by khumbard87

Three Steps (Tell-Show-Do) for Encouraging Compliance with Young Children

Little kids, especially those under 3 years of age, can have a VERY difficult time following directions – which is completely age-appropriate!!  For one, their communication skills are developing, so they may not understand a lot of commands that are said to them.  Secondly, their attention spans are extremely short!  Also, they’re testing their independence and may show a defiant streak!

I do not believe it’s appropriate to give a negative consequence to a child for something that they don’t understand or are unable to do, due to age and development.  BUT you still want to have kiddos of all ages follow through on every task you give them.  So how do you get a child under the age of 3 with limited verbal skills to do this?  You follow 3 steps:

  1. TELL your child what you want them to do.  Keep it short – recommended length of a prompt/direction is one word per age of life (which isn’t always possible, but keep it short)!  Also attempt to be specific.  You might tell your 2-year-old to “pick up toys.”  If she doesn’t…
  2. SHOW your child what you want them to do.  If you told your 2-year-old to “pick up toys” and she looks at you, then keeps playing, get her attention again and show her what you want her to do by picking up a toy and putting it in the box.  Then repeat your prompt (“pick up toys”) and give her the opportunity to pick up.  If she doesn’t, then…
  3. DO the task with your child, hand-over-hand.  Take your daughter’s hand, pick up a toy together, and put it in the toy box.  Once you complete one part together, start over with step one by verbally repeating the prompt.

This is more of a teaching and practicing method – your goal is to help your little one understand what prompts mean, but you’re also teaching them that it’s important to follow through with what mom/dad say!

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Why You Shouldn’t Use Warnings for Negative Behavior

Negative consequences can be difficult for caregivers to use and follow through with.  Few people actually want to discipline their children, and negative consequences can be inconvenient for caregivers.  These, perhaps, may contribute to a parent using warnings with children.  I’m sure these examples will sound familiar, as most adults have probably used warnings with their own kids, heard other parents use warnings, or heard warnings as a child from their parents.

  • “Do you want a timeout?”
  • “I’ll give you to the count of 3 to stop.”
  • “If you do that ONE more time, you’re going to be in trouble.”

Sure, these “warnings” might sometimes work to change behavior, but using warnings with children have some drawbacks.

  1. Your child may not take the warning seriously, which means they won’t be motivated to change the behavior.  If a parent uses warnings without a lot of follow through, the child won’t take the warnings seriously.  The child sees the warning as an empty threat.  The last time I was pulled over for speeding, all I got was a warning.  Trust me, I’m grateful for that, but it didn’t do much to change my driving speed.
  2. Your child may come to expect a warning each time they choose a negative behavior, so behavior won’t change long-term.  If a parent gives a child one warning every day for the same behavior, the kiddo is basically getting a free pass to behave that way once per day with no negative consequence.  If I knew that I would only get a speeding ticket if I was pulled over twice in one month (and only get a warning for the first time each month), I would only be concerned about speeding if I’d already gotten my warning for the month.  But as soon as the 1st of the month came, I’d be back to speeding again because I knew I’d get a warning first.  If you have a parent who counts to 3 (or higher) before issuing the consequence, you’re essentially giving them a few seconds to do whatever they please, because they don’t have to stop right away, just as long as they stop by the time mom or dad gets to 3!

Instead of using warnings, issue the negative consequence as soon as the behavior happens.  This is called immediacy and is one of the important factors in making consequences effective (see Tips for Making Consequences More Effective).  Nobody is perfect, lots of amazing parents use warnings on occasion, but being aware of the drawbacks may help you to reduce the number of warnings you use (and go straight to issuing a negative consequence)

If you’ve been using lots of warnings and suddenly begin issuing consequences without warnings, be prepared for an angry child who thinks it’s “not fair.”  My opinion is that once your child knows a behavior is unacceptable, earning a consequence is their choice (see Behavior is a Choice (and How Parents Can Use This Knowledge)).  They can choose acceptable behavior or they can choose unacceptable behavior and the consequence that comes with it.  Motivating children to choose acceptable behavior will happen a lot faster if you skip the warnings!

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What To Do When Your Child Is Sent Home From School For Negative Behavior

Most parents think their child would never do anything bad enough at school to get sent home, but it happens.  Kids have rough days too.  You may not be overly concerned if it’s a one-time occurrence, but unfortunately, it can snowball fairly quickly.  Why?  Because most kids would rather be at home than at school!  

I don’t want to bash schools – I know their options are fairly limited, but oftentimes sending a child home for negative behavior can turn a small problem into a big one.  Let’s look at what can (not always!) happen when a child is sent home from school for negative behavior.  The child learns that they can go home as long as they do something “bad” enough at school – being sent home is a reward.  So the child will continue acting up so that he/she can be sent home.  Then, once the school starts developing a behavior plan (IEP) in an attempt to try other interventions and prevent the child from being sent home, it’s too late!  Now the child will do whatever it takes to be sent home, even if it means resorting to behaviors more severe than when they first got sent home (this is called extinction burst).

Unfortunately, there aren’t a lot of things that parents can do about school behavior and the school’s response.  Parents can use rewards and negative consequence (click here for tips on how to do so).  Parents can also do their part to reduce the likelihood that being sent home is reinforcing for a child.  So what do you need to do in order to make sure going home isn’t like a reward?

  1. Make sure your child doesn’t get a free pass to have fun the rest of the day.  Don’t let them spend the whole day in their room playing with their favorite toys.  Don’t take them on fun errands or to the park.  Make sure that they’re doing something that they don’t necessarily like during the time they’re supposed to be in school.  Let me be clear… I don’t mean stick your kiddo in a corner for 5 hours.  But consider having your child do some chores or do school work (or print out some academic worksheets).
  2. Make sure you’re not giving your child an excessive amount of attention for what happened (remember that bad attention can still be reinforcing).  Sure, you’re probably going to talk to your child about what happened and what a better choice would’ve been.  Here’s what you don’t want to happen… your child gets attention from you as you discuss the situation the entire way home, then more attention when you call his grandparent and tell them what happened, then even more attention while hearing you talk to your spouse when they get home from work, and then they get even more attention when their other parent comes to talk to them about what happened.  Cut that attention down as much as you can if you have a child who thrives on being the center of attention (give them that attention when they do something well instead!).
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Problem Solving Flower Worksheet

Due to the way kids’ brains develop, they’re not always great at problem-solving.  It can be difficult for them to think about all the choices they have in a situation, think about the outcomes of those situations, then make a decision based on that information.  BUT with some help from an adult, they’re usually capable of doing so… they just need some help going through the steps.  Also, a visual representation usually helps make the process more entertaining for the child.  Below, you’ll find a problem-solving worksheet that can be used to help guide a child through the problem-solving process (printable copy here).

Screen Shot 2018-01-21 at 8.09.21 PM

Start by having your child write (or write for them) the “problem” in the center of the flower.  Then, have them come up with 5 different choices they could make to try to solve their problem.  If it’s a not-so-great choice (or a TERRIBLE) one, go ahead and let them write it down.  After each choice they come up with, have them identify what the outcome might be and talk about it.  So, if their “problem” is that their brother is calling them names and the “choice” is to kick him, talk about how his/her brother might get hurt, and that your kiddo will get in trouble for kicking his/her brother.

If you need more than 5 spaces, fill up the back.  Once you and your kiddo have all the choices you can think of, sum up each choice and the outcomes, then help your kiddo pick the best option and follow through on it.

Note: this worksheet can also be used if your kiddo has ALREADY acted (and made a not-so-great choice).  Just have them write out all the choices and outcomes, pick which one would have been a better choice, then practice it.  We can’t go back in time and change what they did, but going through this will make it more likely that they’ll make a better choice if/when the same situation (or a similar one) comes up in the future.

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Should You Let Your Child “Earn Back” a Privilege?

I recently was asked if it’s “Ok” to let a child earn back electronic time that was taken away as a negative consequence due to behavior.  My opinion on the subject is that it’s appropriate, but only sometimes (like, once in a blue moon!).  Here’s my stipulations:

  • Don’t get into a habit of letting them “earn back” a privilege.

You took that privilege away for a reason!  Regularly letting a child earn back a privilege will make that consequence seem less severe for them.  Why be upset about losing a privilege if you know you’re probably going to earn it back?  This then decreases motivation to choose positive and pro-social behaviors.  It all comes down to follow through.  Let’s look at an example for adults: If my boss tells me that I have to stay late every time I hand in a report late, but almost every time he lets me leave early anyways…?  Guess what, I’m not going to be all that motivated to hand in my report on time… because I’ve learned that there’s no follow through on the consequence.

  • Don’t undo the entire consequence.

When using negative consequences, the best (fastest) way to decrease negative behavior is to use a negative consequence every single time it happens.  So if a parent does decide to let a child “earn back” something, don’t let them earn ALL of it back.  For example, if your child lost 15 minutes of electronic time, give them maybe 10 or 5 back.  Or it they lost ALL electronic privileges (computer, phone, Xbox, etc.), pick ONE device that they can use.

  • IF you are going to let them earn back a privilege, make sure they’ve gone above and beyond to earn it.

 Your child should do something EXTRA special and out of the ordinary in order to earn that privilege back.  Maybe your kiddo didn’t do their chores and lost TV time for the day, but later did their normal chores AND extra chores to.  Maybe your child hit their sibling and lost phone and computer privileges, but apologized (without being prompted) to their sibling and helped them with a task.

One last hint: if your child comes to expect to earn their privileges back (i.e., by asking “so do I get my time back since I apologized to my sister?”), then you’re likely letting them earn back privileges too often.  Also… the answer to that question should be “no.”  Don’t give in if your kiddo asks for their negative consequence to be undone!

 

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Tips for Making Negative Consequences More Effective

Just like praise (see my blog post Tips for Making Praise More Effective), there are some things to consider when deciding on a consequence.  Consequences can be both positive (rewards) and negative (read more on that here).  Some of the tips below are relevant for both positive and negative consequences, but this blog post will focus on tips for making negative consequences more effective.  Components to consider include:

Immediacy: the consequence will be more effective if it immediately follows the behavior.

Limit verbals: this is where a lot of parents go wrong.  It can be easy to fall into the habit of “lecturing” and re-hashing the behavior with your kiddo.  However, this can actually be reinforcing, as you’re giving the child lots of attention and one-on-one time during those fun talks.  Therefore, it is typically recommended that you limit verbal interaction – label the behavior and what you’d like your child to do differently, then let the consequence do the “talking.”

Neutral facial expression/voice: I’ve mentioned before that some children are reinforced by parental reactions… there are some kiddos who think it is hilarious when they can get other people worked up.  Therefore, try to use a neutral facial expression and neutral voice tone when giving a consequence.

Consistency: this one is SO important.  If you decide that a behavior is undesirable, then you have to do something about it every time your child chooses to act that way.  If they think they can get away with it sometimes, then they’re going to keep doing it.  This is why adults speed while driving.

Size: make sure that the size of the consequence fits what the negative behavior is.  Losing electronic privileges for a week might not be appropriate for forgetting one daily chore, but might be appropriate if your kiddo gets in a fight at school.

Follow through: Once you hand out a consequence, you must be able to follow through with it.  If you tell your child that they’ve lost television time, then let them watch television with you that night, that consequence means nothing.  Therefore, before you decide on a consequence, think about if it’s realistic and something you’re able to follow through on.

 

I have created the following handout for caregivers.  It might be beneficial to print it out and pin it up somewhere as a reminder.  A printable file can be found here.

Screen Shot 2017-12-20 at 12.42.56 PM

Disclaimer: I am a licensed mental health therapist, but I am not your therapist. The information in this article is for general informational purposes only. This article does not create a therapist-client relationship. If you need specific recommendations based on your individual circumstances, please consult with a mental health practitioner near you.

Posted on by khumbard87 · 4 Comments

Crash Course on the Four Functions of Behavior

There is a purpose behind all behavior; sometimes the purpose is fairly obvious and other times it can be hard to tell why someone is behaving a certain way.  There are 4 general functions of behavior and they are Tangibles, Escape/Avoidance, Attention, and Sensory.  I have created a (very colorful!) informational handout that summarizes the four functions of behavior.  This can be very helpful for therapists, teachers, and parents.

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You can find the file to print here.

Tangibles is when someone exhibits behavior in order to get something. Escape is when someone exhibits behavior in order to get OUT of something. Attention is when someone exhibits behavior to get attention (NOTE: to many kids, negative attention is better than no attention, so they may act up to get the attention from getting into trouble). Lastly, Sensory is when someone exhibits a behavior because it helps them cope with an uncomfortable feeling.

Sometimes it’s easy to determine the function of behavior. Sometimes it’s not. For tips on how to identify the function of behavior, read the blog post Tips for Identifying what “Function” is Fueling Your Child’s Behavior. Remember that this can be tricky stuff, and seek the help of a professional if you need it!

Disclaimer: I am a licensed mental health therapist, but I am not your therapist. The information in this article is for general informational purposes only. This article does not create a therapist-client relationship. If you need specific recommendations based on your individual circumstances, please consult with a mental health practitioner near you.