Helping Kids with Anxiety

Podcast Transcript

Speaker 4: Welcome to Little Health, a Cleveland Clinic Children's podcast that helps navigate the complexities of child health one chapter at a time.

In each session, we'll explore a specific area of pediatric care and feature a new host with specialized expertise. We'll address parental concerns, answer questions, and offer guidance on raising healthy, happy children. Now here's today's host.

Dr. Ethan Benore: Welcome back to Little Health. I'm your host, Dr. Ethan Benore, chair of Cleveland Clinic Children's Division of Pediatric Behavioral Health.

Anxiety is something that profoundly affects everyone. Today as part of our season on pediatric behavioral health and psychiatry we're discussing anxiety in children and teens and offering you practical support and effective ways to help them manage their worries. Our guests today are Dr. Kristin Eastman.

Dr. Kristen Eastman: Hello, good morning

Dr. Ethan Benore: Good to see you. And Dr. Amy Lee.

Dr. Amy Lee: Good morning.

Dr. Ethan Benore: These are my colleagues. Uh, it's nice that we have East Side, West Side represented here, and so welcome to Little Health.

Dr. Kristen Eastman: Thank you.

Dr. Amy Lee: Thank you.

Dr. Ethan Benore: Do me a favor tell me a little bit about where you are, what you're doing in the world of psychology and Cleveland Clinic.

Dr. Eastman, let's start with you.

Dr. Kristen Eastman: I've been at the Cleveland Clinic now for 25 years, currently working at the Chagrin Falls location. Uh, a large part of what I do is work with anxious young kids and teenagers, specifically generalized anxiety, and also kids with social anxiety and selective mutism. I also work a lot with parents of those kids, helping coach them on how to best support their child.

Dr. Ethan Benore: Excellent. Dr. Lee.

Dr. Amy Lee: I've been with the Cleveland Clinic 32 years and I work at the Avon Point location and I work closely with pediatricians and other behavioral health providers, and I do quite a bit of work with anxious very little kids up through college age kids and their families. I have developed also a group that is to help kids develop coping skills, and we provide that to children throughout the region and their families.

Dr. Ethan Benore: Excellent. I love that we have, uh, the two of you here who have many years of experience at the Clinic, many years of experience with anxiety. Also, we're all parents of children, so we have a lot of perspectives I think, that we can share today. So let's, let's dig into anxiety.

So one of the things that I was hoping to talk about is this idea of what anxiety is. So everybody gets anxious, not everybody gets an anxiety disorder. So what's going on? What, what is anxiety in individuals and when do we determine like, okay, this is this, this is an issue that we need to address in our child?

Dr. Amy Lee: I'm really glad you brought that up because there is a, a lot of talk in the media about

anxiety rates being higher. I think certainly we have a mental health crisis for a lot of youth, but episodes of anxiety disorder are the most common, uh, mental health challenge that people have throughout the lifetime. About a third of individuals will meet criteria at some point in their lives.

Generally anxiety is something that we all experience and it is uh, normal and often appropriate. And so for example, in early childhood, at two and three years old, we might see children begin to have anxiety about brief separations, and we call it stranger anxiety or stranger danger. We may see it before that too, when children just see an unfamiliar face.

So those are typically good signs in development. We would want to see a child be cautious or uncertain when something is different. That means their brain is growing and that's a good thing. So there is a normal type of anxiety or stress related anxiety responses that we want to see throughout childhood.

It's how children learn what's the difference between right and wrong. It's, it's part of our moral compass. So I, I do think there's a sort of good side. There's even information about optimal anxiety, so we can talk about that later. But yeah, I think it's important for folks to realize that anxiety is okay and it's not dangerous in and of itself.

Dr. Ethan Benore: Right, right. I think, you know, it's important to validate anxiety. It's important that to allow kids to express anxiety, that you don't need to always suppress those emotions or expressing those emotions.

Dr. Kristen Eastman: You, you know, one thing to piggyback off of what Amy just said, I, I tell families that a lot, especially meeting a family for the first time, who's concerned that everybody wants the anxiety to go away, right?

Which, of course, we want their, we want things to improve, but I try to let them know it's not a bad thing, right? You know, your brain is designed to let you know when something doesn't feel right, and when there's a potential threat or something that's uncomfortable, but we need to take that as a cue.

What do I need to do next to feel comfortable? So we don't need to pull away from it and make it go away. It's a call to action, basically. [Yes, yes. Right.] What do I need to do next so I can feel comfortable in this situation?

And that can be a game changer when you think, you flip around the script and now you're thinking of it as something to lean into and develop a plan for how I can move forward. [Yeah.] Instead of trying to run away from it. Yes.

Dr. Ethan Benore: Love that. Love that. I love the, the concept of, um, I, I talk about threat perception a lot, so understanding that anxiety is trying to tell you something. I love what you said about a call to action, so you need to just listen to those feelings and then determine what the next step is. So, flipping the script is a, a great way of thinking about this.

So, okay. This is great. So, so when you're talking about anxiety with children, this is something that can be healthy if managed appropriately. So how do you guys, as psychologists talk about it with kids and how should a parent try to

educate or discuss anxiety as it's presenting in their child?

Dr. Kristen Eastman: I, I like to sort of talk to kids about their experience, like what they already know. Usually if kids come in and anxiety is the identified concern, they're they're aware because anxiety is uncomfortable and most kids want to make it go away.

It feels like it holds us back, or it feels like it gets in the way of having fun or, you know, so kids will be able to articulate some of those things. So I often ask them about three areas and use that to sort of explain to them, you already know yourself very well. So I'll, I'll ask them about how their body feels when they're feeling this anxiety with whatever label they use.

Um, sometimes kids will say stressed out, sometimes they'll say overwhelmed. Sometimes they'll say anxious. Sometimes they'll say nervous. Um, sometimes they'll say freaked out, you know, whatever words they say. And so usually they can describe the feeling in the body. You know, like, my chest gets tight or my stomach feels weird, or something like that.

Then I ask them kind of, what does your brain think about. So I might help them with some, you know, like sometimes people say, oh no, I can't do it, you know, and then they will very quickly be able to generate some of the, oh yeah, this is what happens, you know, and they can, they can fill that in.

And then I often ask then, what do you do when this is happening? So that's kind of the action part. And typically people do three, one of three things, or a combination of these, you know, the sort of fight back like, no, no, no, I'm not going. Avoidance just kind of all out avoidance or freezing up, just kind of feeling stuck. So then I just explain, okay, well this is how we help kids.

You already know what this is. I may be drawing this or writing it too in front of them and say, you know, this is you. This is how you handle this type of feeling. And then I just talk with them about, you know what I can teach kids and my friends can teach kids is, is how to kind of do the opposite in each one of those areas.

Calm down your body or think a different kind of thought or make an action plan.

Dr. Ethan Benore: I love the idea of following the child's lead and even the tone of your voice as you're talking about it, is more, I wanna help you understand what's going on, but I, I wanna understand what you currently know Yeah. And how you're thinking about this.

I think it's a, a really helpful way. I, I, I sometimes worry that parents can, can talk children, um, to death.

Dr. Kristen Eastman: Right, right.

Dr. Ethan Benore: Or tell them what to feel and how to think.

Dr. Kristen Eastman: Yes. Or how to cope. Right. Use a skill.

Dr. Ethan Benore: So, moving on. Go ahead.

Dr. Kristen Eastman: And then getting parents [Yes] to support that work. Yes. You know, um, and I tell parents, you're, you're, you know, your child best, right?

So the child knows themselves best and can lean into that, but the, the parent also knows their child best. And when something doesn't feel right, um, or feels out of proportion to a situation, usually a good sign that they, you know, getting a little bit of support and a little bit of help would be, would be great.

But I think parents really need to be a coach to help facilitate the action plan you know? To help encourage a child who maybe can't remove themself from a situation, to take a breather, calm down, maybe shift their thinking. Um, encouraging them to shift gears, is the way I think of it. Like what can we do to help encourage the child to shift gears so they come out of that fight or flight or freeze state and can move forward?

Dr. Amy Lee: I often also to, to add to that, helping parents not be afraid themselves of the anxious reactions in their kids. Um, because, because sometimes kids, kids' anxiety can be very intimidating, you know? It can, it can be a panic reaction or a very intense tantrum explosive episode.

And so, so parents learning how to kind of scaffold or help their kids approach challenges in, you know, incremental steps or encourage the plan in some way that allows the kid to kind of in toward it and not help the kid avoid or escape the discomfort.

Dr. Kristen Eastman: Which is hard to do when your instinct as a parent,

Dr. Amy Lee: very hard Oh yeah.

Dr. Kristen Eastman: Is to save your child and to help them not feel distressed. Right. So a big part of what. You know, we probably both work on is helping parents know that it's not only necessary, but you're, you're helping them.

Yes. You don't wanna enable [yes] what the, the cycle that's already been going on before they came to see us. [Yes.] We wanna help break that cycle. [Yes].

Dr. Ethan Benore: I talk with parents a lot about managing their, their own arousal, their, their own anxieties. [Yes.] Because how you present yourself, how you show up and, and your word choice has a huge impact on how your child understands anxiety.

So if I think anxiety is something to fear, something that must go away, something that I can't control. Some of that may be because of how my parent is reacting to my anxiety. Again, we talked about everybody has anxiety, so parents have anxiety too. I love that you're talking about, it is distressing as a parent when [distressing] your child suffer.

I don't like to see my child suffer, and I would love to end it as quickly as possible. And so I think we're all pulled to do something in that moment to try to help our child. So what does make it worse? What does make it better for the parent, but but also for thinking about the child themselves?

Everybody wants anxiety to go away. E- even though we talked about it can be a, a healthy thing for us, but, but what can make this worse for a child?

Dr. Amy Lee: So first I ask the kids and the parents, what makes it worse? What makes it better? Because I wanna know where they are. I need to start with them, with what they're already doing.

So I don't try to impose a, okay, first step is X, but if, if there's, mostly just reminding everyone that this is not dangerous. Right. The feeling itself is not dangerous. The discomfort is not dangerous.

Dr. Kristen Eastman: And it will go away.

Dr. Amy Lee: And it will go away. And I also use some like kind of picture descriptions to, to help people see that even if we do nothing and just wait, the feeling will go away.

So encourage people to like, kind of hang in there a little more. Wait a beat for everyone to feel a little calmer before trying to make decisions or discuss what to do. Less talking if is often very helpful. Give kids a chance to recover before trying to figure out what's next.

And collaborate with your child. You know, work together, come up with a, a small action plan, a little problem solution, you know, for the moment. Like, for example, I'll just give like a real life example [yeah] 'cause it's hard, you know, for example, a child has a sports practice and it's the beginning of the season. I'm sure many people are having baseball, softball, soccer practices starting up, you know, this time of year.

And kids may react to meeting new people or you know, going to the practice or the first game by saying, I don't wanna go or resisting once they're in the car. And, and so a parent can do something like, well, yeah, it's uncomfortable. So validate how they feel and it's okay, and let's just get closer to the soccer field and then just take steps at where the child is.

So just kind of move closer to it of success on a given day. Maybe we sat in the parking lot in uniform watching. [Right.] That could be a success for some kids if they have been tantruming about putting the uniform on and getting in the car.

Dr. Ethan Benore: So, so at times the goal is not to play the soccer game. The goal is to manage anxiety in the moment.

Dr. Amy Lee: The, the goal is always to reduce the anxiety with tolerating some discomfort. So it's, the goal is not avoid, so we reduce the anxiety. The goal is do the uncomfortable thing to reduce the anxiety.

Dr. Kristen Eastman: Even if it's only a small part. Or

Dr. Amy Lee: even if it's only a small part or

Dr. Kristen Eastman: she part said observing. Mm-hmm.

Dr. Amy Lee: You know, or some kids it may be like we can walk up to the edge and we're uncomfortable playing that first time, but we watch right there with the team, that's fine too.

And what I often encourage parents to do is really praise what your child did, you know, versus talk about what they need to do next time or what they didn't do or what we have to do. Um, so we just focus on the successes and build on that.

Dr. Kristen Eastman: And, and parents giving them a job to do too. Yes. Also can help in those situations.

Um, maybe, you know, collecting equipment or handing things out as opposed to jumping in and playing. [Right.] You know, at least it's, and again, inching them closer towards what the end goal is to participate.

Dr. Amy Lee: Anything that sort of increases this, we use this word exposure. Anything that sort of increases the exposure, it's a little bit of new territory, a little uncomfortable, but it's not gonna overwhelm.

Dr. Ethan Benore: I love this because you know, in my head I'm thinking about the parent that just is shaking their child, telling them to, you need to calm down so then I can calm down and, and what you guys are saying is there, there's an active role parents need to play play

Dr. Amy Lee: Oh, absolutely.

Dr. Ethan Benore: In this coaching their child through those moments. [Yes.] Helping them develop, practice the skills, experience, discomfort, and then praising them [yes] for getting through that. That's what sets 'em up for success the next time.

Dr. Amy Lee: Yes.

Dr. Ethan Benore: Okay.

Dr. Amy Lee: Like I always think of these kind of anxious spots that kids have as, okay, this is a project. You're gonna work on this project, you know, for the next month or two. Right? It's not a a one day solution and we fix it.

Also we'll sometimes see things generalize, you know, if families start to see, oh, okay, I understand how this works. We do a little bit until we get more comfortable, they'll start to, on their own approach challenges with smaller steps. I don't know if you see that.

Dr. Kristen Eastman: Agreed. Yeah.

Dr. Amy Lee: Kristen. Yeah.

Dr. Ethan Benore: So. I wanted to think about or talk about, is there a, like a core set of skills or things to do? And I, I'm asking because the, the word CBT or cognitive behavioral therapy gets thrown around a lot. And when I talk about it with parents and with kids, I don't think that they, they know what they're talking about.

I think other individuals may say that they do CBT, but it's, it's not. And so if someone is doing, um, appropriate evidence-based treatment for anxiety. What, what are the, the, the key components that should be there? What does the, the science say or you guys who have been doing this for decades, what, what do you say it should be there?

Dr. Amy Lee: So really the, the little orientation I provided earlier is, is the outline for the CBT orientation. It's, it's identifying physiologic distress or arousal. And then skills for calming, like people have heard about breathing, like abdominal breathing or body movement, things like that that can settle the, the body's automatic responses.

And then also, uh, there's this concept of changing thoughts, kind of what Kristen was talking about with kind of taking an opposite approach, flipping the narrative. So I can't do it. I can sometimes do this, right? You know, it would be a flip.

Or mindfulness, which is just kind of go to the present moment. Don't think, just go to the present moment, what's happening around me. And then the other area of of intervention is exposure. And that is what we were just talking about, like needing to be uncomfortable to get more comfortable. It's kind of those three areas, body, mind, and action that CBT interventions should focus on.

And so parents can ask you know, what is your plan treatment provider for helping my child develop skills in these three areas?

Dr. Ethan Benore: You know, for better or for worse, sometimes we treat the therapy room as a sacred space that whatever happens in there we can't talk about. And I, I always, I, I get worried when a child comes from therapy and can't explain what they did, can't explain some skills.

And I, I think it's okay for parents to ask their child generally, what are the things that you're doing in there? What are the things that you're learning? And to your point, going directly to the therapist to be like, walk me through this. There, there are some clear actions that should be happening in therapy and I need to know as a parent where my child's at so I can support them in applying the skills in the real world.

Dr. Kristen Eastman: I think it's critical to work with parents. Yes. I mean,

Dr. Amy Lee: I feel like I too.

Dr. Kristen Eastman: Sometimes I feel like I work with parent, depending on the age, work with the parents more than the child themselves. Again, they're spending the most time with the child. They're with them across the settings where they function well and the settings where they struggle.

Um, so they need to be able to put, put homework into action. And again, to help coach the child, like I said before, to be a cheerleader to help them [Yes] move forward.

Dr. Amy Lee: I, and I find parents are often desperate for guidance.

Dr. Kristen Eastman: They absolutely are.

Dr. Amy Lee: And so when you said. Concerned when kids can't tell you what they learned in any previous treatment. I'm concerned when parents don't know. They didn't receive any guidance or something. So it is appropriate to ask for guidance and separate sessions.

Um, you know, child's confidentiality can be preserved by just having a parenting session. Or, you know what I, I'm sure Kristen does this too, you know, divided sessions. So part of the time there's some parent guidance and part of the time there's work with a child. Yeah.

Dr. Ethan Benore: So, okay. I have, I have two more questions. I'm interested in the, the first is this, again, parents wanting to alleviate their child's suffering, but sometimes we may over accommodate, we want to rescue the child.

So, and you, we talked about experiencing anxiety and getting through those moments. What do you tell parents who are drawn too much to over accommodate or rescue their child in the moment. What, what does that, to you guys what does that look like and how do you help a parent who just feels obligated or, or has their own anxiety about, I need to remove this for my child?

Dr. Kristen Eastman: One, one thing I find myself saying a lot, I guess, is it's okay to be uncomfortable. It's okay for your child to be uncomfortable, and in fact being uncomfortable is how we grow. Is how the brain, you know, grows and, and repetition and practice of doing something differently is how new pathways in the brain are created.

So if we want change, which they do because they, they're coming and seeking support. Just giving parents, I think reassurance that, again, coaching them and cheerleading while they practice something new. Their, parents are critical, I think, to the whole equation working.

Dr. Amy Lee: There's a lot of pressure on parents these days I think too, you know, to prepare their kids for success and for the world and um, and I think parents are hungry for guidance and support themselves.

I will often going back to that idea of like, where are they in the present. I'll often ask them about experiences that their child has overcome already and what worked. And most people can recognize, oh, they didn't want to do this thing. Or you know, even if it was a toddler developmental skill, you know, so there can be times where people can recognize, oh, I was okay with them being uncomfortable with that.

Like, I'll search for experiences they've already had in parenting where, where it's acceptable to let your child be uncom- or with discipline, right. Sometimes people are comfortable with, well, I knew they needed to learn right from wrong, so I was okay with them being upset with me when I, you know, took that toy away.

Or I was okay with them being upset when I didn't let them run in the street. So we, we try to you know, identify what are some experiences you've already had and encourage folks to go. So that is how we teach.

Dr. Ethan Benore: This last question I'm thinking of is, I, I do think that sometimes parents and, and kids may be a little avoidant about entering in for treatment care or education for anxiety, because in their mind, if I'm anxious, I'm gonna be anxious forever.

And so I don't want to be a, a lifelong anxiety patient. And so how do you know when you're done with treatment? We're done with learning? How, how do you know that I've got this?

Dr. Kristen Eastman: Well, I think at the onset we're, we're looking for, you know, what are, what are your goals? What are, what are the problem areas, and what are we hoping to achieve and accomplish?

Right? So it might be um, being more independent with going to soccer practice, for example, or getting from watching and observing on the sidelines to actually getting into the game and, and having fun. Um, so I think a big part of what we do, of course, is talk about what that looks like to make progress.

And we ask in the beginning do we wanna understand, of course, where the opportunities are to not get stuck. I talk about being stuck a lot. Where are we getting stuck and we're not moving forward and getting involved and doing the things that we want and need to do.

Dr. Amy Lee: Yeah, and, and I think, so the, starting with the original goal. You know, have we met the original goal? Review that. And then I will like, kind of wean people out of therapy. Like, you know, I think you're, you've got this, now you understand what do you do in those conditions. And begin to prepare people for parents and kids for, okay, now you know, new things come up, you're gonna apply the same skills.

And, and then, you know, we might move to monthly visits, then quarterly visits, you know. And then, and then kind of check in about is it coming up in any new way that you didn't expect?

And then help folks to recognize that some of the things that are working are the same skills. So kind of just applying and generalizing is sort of, I think, how we, we would try to encourage folks to, you know, and with the, you know, you can come back. Right, right. You know, if you need to, but like, I want you to keep practicing these things.

And also the idea of anxiety as a trait. There were two things you said versus, uh, temporary. You know, we all can have it.

Dr. Ethan Benore: Wait, can I say one thing?

Dr. Kristen Eastman: Yeah, yeah.

Dr. Ethan Benore: About, about treatment and then.

Dr. Kristen Eastman: Yeah. Yeah.

Dr. Ethan Benore: Which to school i, I like, I like this. I, I think about, um, something that you guys said at the beginning, um, which is we all have anxiety.

And so when I'm thinking about goals, um, with kids, it's, it's, I either don't get as anxious anymore. I still have anxiety.

Dr. Kristen Eastman: Yes, exactly.

Dr. Ethan Benore: But I, but anxiety doesn't have me, it doesn't get the better of me. Yes. Or when I do get anxious, I feel competent. [Yes.] I have the skills to manage it. [Yes.] So I don't stay anxious.

[Yes.] Um, but I love the idea of talking about with the families, the, the, the clear goals that you have so that you feel that you have made the accomplishments and knowing that there's always help that you can come back. Okay. So, so switching to school, tell me,

Dr. Amy Lee: but also, so on that,

Dr. Ethan Benore: yes.

Dr. Amy Lee: Um, the idea that, you know, it's sort of helping folks with like identity.

Like let's not think of anxiety as a thing you have forever. Yes. Let's think of it as something that you're, you're a sensitive person and you might tend to feel anxious with new experiences, new situations, or at unexpected times and so you know what to do. You know, so like that kind of casting.

And so with that in mind, I do think it's very appropriate for kids to have accommodations in school when they're in the midst of an anxiety flare up, not necessarily forever.

So I do my best to educate parents and kids about that. And again, the idea is we just wanna build challenges that are appropriate so we can be a little uncomfortable, but not overwhelmed and we gradually increase the challenge even in the school setting. Yeah.

Yeah. So sometimes it's an issue of staying in school and sometimes it's related to just testing.

And in those conditions, you know, many times kids just need a little more time or a chance to take breaks, so they need a less standardized approach to testing, and I think that's appropriate as well. Uh, but again, I, I always encourage folks to be aware of when you don't need it anymore, you know, and, and see if you can manage without it.

Dr. Ethan Benore: I always love that moment when I am working with kids, the, the look on their face that I, I've got this. I, I know I know what to do. Yes, I know that I will feel anxious, but I'm not scared about feeling anxious [yes] anymore.

As we know, anxiety is a challenge. It is a challenge that we all face, but there are wonderful skills and wonderful people who can help you and your child manage anxiety.

Cleveland Clinic's Children's provides comprehensive mental health support for children's, teens and their families during these challenging times. And, uh, if you would like to schedule an appointment with one of our providers, you are welcome to call us at two one six four four four kids. That's 216.444.5437.

Thank you so much, Dr. Lee. Thank you so much Dr. Eastman. Thank you both for being here.

Dr. Amy Lee: Thank you.

Dr. Kristen Eastman: Thank you.

Speaker 4: Thanks for listening to Little Health. We hope you enjoyed this episode. To keep the little health tips coming, subscribe wherever you get your podcasts or visit Cleveland Clinic Children's/Little Health.