How to do it!

Step 1: Teaching your child about anxiety

This is a very important first step, as it helps children and teens understand what is happening to them when they experience anxiety. Let your child know that all the worries and physical feelings he or she is experiencing has a name: Anxiety. Help your child understand the facts about anxiety.

  • Fact 1: Anxiety is normal and adaptive, as it helps us prepare for danger.
  • Fact 2: Anxiety can become a problem when our body tells us that there is danger when there is no real danger.

Step 2: Teaching your child about panic attacks

Help your child understand the facts about panic attacks.

  • Fact 1: Panic attacks are the body’s “flight-freeze-fight” response kicking in. This response prepares our body to defend itself (for instance, our heart beats faster to pump blood to our muscles, so we have the energy to run away or fight off danger). However, sometimes our body reacts when there is no real danger.
  • Fact 2: Panic attacks are harmless, although they can feel very uncomfortable or scary.
  • Fact 3: Panic attacks are brief (typically lasting only 10 to 15 minutes), although they sometimes feel like they go on forever.
  • Fact 4: Others (except those very close to you) cannot tell that you are having a panic attack.

For older children or teens, it can be helpful to discuss anticipatory anxiety, which is the body’s normal response to imagined future threats. Here is one way to explain anticipatory anxiety:

Two hikers are going for a hike in the woods. One hiker runs into the park ranger, who warns her that a bear has been spotted in the woods. The other hiker does not receive this warning and continues on his way enjoying an afternoon hike. The hiker who was alerted to the bear is very cautious and constantly on the lookout for the bear. She becomes sensitive to anything that suggests the bear is near (such as rustling in the woods) and may decide to avoid the woods altogether and not return to the park. This is what happens when you have a panic attack. Because you have been “alerted” to it, you may find yourself always on the lookout for another panic attack. This can make you feel nervous, which may lead to another panic attack. You may even start to avoid things that remind you of the attack.

Helpful Tips

Listen! Make sure you take the time to listen to your child’s thoughts and feelings. Simply feeling heard can be very helpful to your child
Normalize! It is important to let you child know they are not alone. Lots of children have problems with anxiety and experience panic attacks.

Step 3: Building Your Child’s Toolbox

You can help your child by giving them some tools to manage their anxiety and panic attacks. The purpose of these tools is to facilitate the most important step: facing fears. For Panic Disorder, tools in the toolbox include:

Tool #1: Learning to Relax.

This tool involves helping your child learn to relax. Two strategies can be particularly helpful:

  1. Calm Breathing: This is a strategy that your child can use to calm down quickly. Explain to your child that we tend to breathe faster when we are anxious. This can make us feel dizzy and lightheaded, which can make us even more anxious. Calm breathing involves taking slow, regular breaths through your nose.
  2. Muscle Relaxation: Another helpful strategy is to help your child learn to relax his or her body. Have your child tense various muscles and then relax them. You can also have your child use “the flop,” which involves imagining that he or she is a rag doll and relax the whole body at once.
TOOL #2: Realistic Thinking

The next tool is targeted to older children or teens. It involves learning to identify scary thoughts that trigger and fuel physical feelings of panic. First, ask your child what he or she fears will happen during a panic attack. Examples include: “I will pass out,” “It will go on forever,” “I’ll embarrass myself and everyone will laugh,” or “I’ll die.” These thoughts tend to promote panic attacks and can be grouped into two categories:

  1. Overestimating: This happens when we believe that something that is highly unlikely is about to happen. For example, when a child or teen believes he or she will faint or die as a result of a panic attack. This type of thinking is usually related to physical fears (such as fainting and hurting oneself, having a heart attack, going crazy or dying).
  2. Catastrophizing: This is when we imagine the worst possible thing is about to happen and we will be unable to cope. For example: “I’ll embarrass myself and everyone will laugh,” or “I’ll freak out and no one will help.” This type of thinking is often related to social concerns (such as embarrassing oneself).

To help your child determine whether he or she is overestimating or catastrophizing, ask the following questions:

  • What would be so bad about that?
  • What would that lead to?
  • What would happen then?

Here are some examples of how to help your child recognize whether he or she is overestimating or catastrophizing:

Parent: What were you afraid would happen when you had the panic attack?
Child: I wouldn’t be able to breathe.
Parent: What would happen then?
Child: I would die. (Example of overestimating)

Parent: What were you afraid would happen when you had the panic attack?
Child: I would be scared.
Parent: What would be so bad about feeling scared?
Child: I would get so scared that I would pass out.
Parent: What would happen if you passed out?
Child: Other kids might notice.
Parent: What would happen if they noticed?
Child: They would point and laugh. (Example of catastrophizing)

Challenging overestimating:

Encourage your child to think about scary thoughts as a question, not a fact. Then, have your child evaluate the evidence for or against the thought. Children and teens with Panic Disorder often confuse possibility with probability. For example, just because it can happen, doesn’t mean that it likely will happen. Here are some questions to ask your child:

  • How many times have you had this thought during a panic attack?
  • How many times has it actually happened?
  • Next time you have that thought, how likely is it that it will really happen?

Help your child understand that some of the things he or she fears are very unlikely. Even though your child has had the thought many times, it has not come true. Here’s an example of how to help your child challenge overestimating.

Parent: So it sounds like you are afraid that you will die when you have a panic attack?
Child: Yeah.
Parent: Do you know what overestimating is?
Child: Um…I’m not totally sure.
Parent: Overestimating is when we take something that is very unlikely to happen, and we believe that it will actually happen. Does that sound familiar to you?
Child: Yeah, I guess so.
Parent: Can you think of something you might be overestimating when you are having a panic attack?
Child: Um…I guess thinking I won’t be able to breathe or that I’ll die. I know it’s unlikely, but when I’m having a panic attack, it just feels like it will happen!
Parent: Well how many times have you had this thought when you are having a panic attack?
Child: A lot!
Parent: Has your fear ever come true?
Child: No, but it sure feels like it might.
Parent: But even when it feels like you are going to die, nothing bad happens. The chances of something bad happen are extremely small. It’s important to remind yourself of that when you are having a panic attack!

Challenging catastrophizing: To challenge catastrophic thinking, ask your child to imagine the worst, and then help him or her figure out how to cope. Here are some questions to ask your child:

  • How bad is it really?
  • Is it just annoying or is it terrible?
  • Will it make a difference in your life a week or year from now?
  • What could you do to cope if it did happen?

Help your child understand that some of the things he or she fears are more of a hassle than a horror, and that there are things your child can do to cope with the situation. Here’s an example of how to help you child challenge catastrophizing.

Parent: So it sounds like you are worrying about having a panic attack at school. What would be so terrible about having a panic attack at school?
Child: I might pass out and other kids would see.
Parent: What’s the worst that could happen?
Child: Everyone would be looking at me and laughing, and I would be so embarrassed I would just freeze.
Parent: Sometimes when we feel anxious we tend to catastrophize. This means that we automatically imagine the worst will happen, and we believe that we won’t be able to handle it! Do you think that you might be catastrophizing?
Child: I don’t know. Maybe.
Parent: It sounds like you are picturing that you would make a huge scene if you had a panic attack, but the last panic attack you had at school was nothing like that. You left the school and went outside to get fresh air. Besides, does it really matter what everyone thinks?
Child: Well, it would be very embarrassing.
Parent: Have you ever been embarrassed before?
Child: Um…yeah, once I tripped down the stairs at school.
Parent: Were you able to handle being embarrassed?
Child: Ugh, A few people laughed – I thought I would just die… But I guess after a while it was okay – no one seems to remember now.
Parent: I wonder if you could handle being embarrassed if you had a panic attack?
Child: Well…I guess it wouldn’t be that bad.
Parent: What could you do to cope if you did have a panic attack in class?
Child: Um…I would probably want to leave, and be alone. I guess I could excuse myself and go to the bathroom.

Tip: Younger children may have a more difficult time identifying exactly what they fear. However, they can benefit from coming up with some coping statements that they can say to themselves to help them deal with a panic attack. For example, “It won’t go on forever, it will end,” “My stomach is upset, but I’ll be okay” or “If I have to take a break, I can leave class and come back after.”

Tool #3: Making Coping Cards

It’s not easy facing fears, so it’s a good idea to develop “coping cards” that your child can carry with him or her during the day to help manage anxiety.

Tool #4: Facing Fears

The most important step in helping your child manage anxiety and panic is to face what he or she fears. This includes:

  1. Unpleasant body sensations that feel similar to a panic attack.Avoided situations or places.

1. Facing feared body sensations:

Children and teens with panic disorder are typically sensitive to physical sensations, such as increased heart rate, stomachache, or chest pain. In order to overcome panic, they need to repeatedly bring on the sensations they fear, so that over time those sensations no longer make them anxious. This also gives them a chance to discover that their fears do not come true (for example, they don’t pass out). Here’s a list of exercises you can try with your child to trigger physical sensations.

Exposure exercises:
  • Running on the spot for 30 – 60 seconds (racing heart, breathlessness, chest discomfort).
  • Running up and down stairs for 30 – 60 seconds (racing heart, breathlessness, chest discomfort).
  • Rapid breathing. Agree ahead of time on a length of time that your child can repeatedly perform it with minimal anxiety. Then, try increasing it by 15 seconds, up to a maximum of two minutes for teens and one minute for children (dizziness, breathlessness, racing heart, numbness and tingling).
  • Breathe in and out through a small straw for 30 – 60 seconds while pinching nostrils (choking sensations, breathlessness, racing heart).
  • Shaking head from side to side, or moving head around by drawing a circle in front of you with your nose for 30 seconds (dizziness).
  • Spinning around in place or spinning in a chair for 30 seconds (dizziness, nausea).Hold breath for 15 to 30 seconds (breathlessness, dizziness).
  • Stare at your hand for two to three minute (feelings of unreality – things looking and seeming weird).
  • Stare at a light on the ceiling for one minute and then try and read something (blurred vision).
  • Wear a tight turtleneck or scarf around your neck for a few minutes (tightness in the throat).

Model each exercise first and tell your child what you felt after doing it (For example: “Running on the spot makes me feel out of breath”). Then, have your child try each one, and rate his or her anxiety level from 0 (no fear/anxiety at all) to 10 (very severe anxiety/fear). Use the Fear Thermometer to help with the ratings. Identify the exercises that cause the most anxiety and bring on sensations that feel very similar to what your child experiences during a panic attack.

How to do exposure to feared sensations! Once you and your child have created a list of exercises, start with the exercise that is the least scary and build up to the exercise that is the most scary. The exercises can be broken up into smaller steps if necessary (e.g., start with running on the spot for 30 seconds, then 45 seconds, and finally, one minute). Have your child continue the exercise until he or she starts to feel the feared sensations, and encourage him or her to use the calm breathing technique and realistic thinking/coping statements. While doing the exercises, have your child rate his or her anxiety level, from 0 (no fear/anxiety at all) to 10 (very severe anxiety/fear). Use the Fear Thermometer to help with the ratings. Have your child repeat the exercise until his or her anxiety drops by about half (for example, if your child’s rating is a 6, have your child repeat the exercise until he or she experiences a 3). Focus on one exercise at a time. Once your child experiences very little anxiety when completing that exercise on several different occasions, move onto the next one.

Tip #1: Practices should be planned in advance and you should aim to have at least one practice session a day. The more your child practices the faster his or her fear will decrease!
Tip #2: Have the whole family try the exercises. Everyone can say what feelings they have after the exercise, and how anxious they feel.

2. Facing feared places or situations:

It is important for your child to start entering situations that he or she has been avoiding due to fears of having panic attacks. Help your child identify feared situations or places, such as going places alone, entering crowded stores, or riding the bus. Then, arrange the list from the least to the most scary. Starting with the situation that causes the least anxiety, encourage your child to repeatedly enter the situation and remain there until his or her anxiety decreases. Once your child can enter that situation without experiencing much anxiety, move on to the next item on the list. Let your child know that he or she will experience anxiety when facing fears – this is normal.

Step 4: Building on Bravery

Learning to manage anxiety takes hard work. If your child is doing better, then you both deserve lots of credit! In a way, learning to manage anxiety is like exercise – your child needs to “keep in shape” and practice his or her skills regularly. Make them a habit! This is true even after your child is feeling better and has reached his or her goals.

Don’t be discouraged if your child reverts to using old behaviors. This can happen during stressful times or during transitions, such as going back to school or moving, and it is normal. It just means that your child needs to start practicing using the tools. Remember, coping with anxiety is a lifelong process.