104: How to help a child to overcome anxiety

Listeners have been asking me for an episode on supporting anxious children for a loooooong time, but I was really struggling to find anyone who didn't take a behaviorist-based approach (where behaviors are reinforced using the parent's attention (or stickers) or the withdrawal of the parent's attention or other 'privileges.'). Long-time listeners will see that these approaches don't really fit with how we usually view behavior on the show, which is an expression of a need - if you just focus on extinguishing 'undesirable' behavior, you haven't really done anything about the child's need and - even worse - you've sent a message to the child that they can't express their true feelings and needs to you. Listener Jamie sent me a link a book called Beyond Behaviors written by today's guest, Dr. Mona Delahooke, and I immediately knew that Dr. Delahooke was the right person to guide us through this. Listener Jamie comes onto the show for the first time as well to co-interview Dr. Delahooke so we can really deeply understand our children's feelings and support them in meeting their true needs - and overcome their anxiety as well.     Dr. Mona Delahooke's Books

Beyond Behaviors: Using Brain Science and Compassion to Understand and Solve Children's Behavioral Challenges

Beyond Behaviors Flip Chart: A Psychoeducational Tool to Help Therapists & Teachers Understand and Support Children with Behavioral Changes (Affiliate links).

  [accordion] [accordion-item title="Click here to read the full transcript"] Jen: 01:28 Hello and welcome to the Your Parenting Mojo podcast. Today, we're talking about a topic that parents have been asking me about for ages and that is how to support children who are experiencing anxiety. Now, it's not super hard to find research on anxiety and on treatments for anxiety, but the hard part is finding someone who doesn't just see anxiety as an unwanted behavior that we need to extinguish using reinforcements and who actually sees anxiety as a potential cause for behaviors like having a bad attitude or lacking impulse control that we might typically think of as bad behavior rather than being caused by anxiety. So, we have a special guest today who's going to help us move beyond this view of anxiety and that's Dr. Mona Delahooke. Dr. Delahooke is a licensed clinical psychologist with more than 30 years of experience caring for children in their families. She's a member of the American Psychological Association and holds the highest level of endorsement in the field of infant and toddler mental health in California, as a Reflective Practice Mentor. She has dedicated her career to promoting compassionate relationship-based neurodevelopmental interventions for children with developmental, behavioral, emotional and learning difficulties and has written a book called Beyond Behaviors: Using Brain Science and Compassion to Understand and Solve Children's Behavioral Challenges. Welcome Dr. Delahooke.   Dr. Delahooke: 02:43 Thank you so much. I'm so happy to be here.   Jen: 02:45 Thank you. And we have another special guest here today as well. We've heard about her, we've heard her words and now we're going to hear her very own voice. Today, we have with us listener, Jamie. She's not listener Jamie to us. She's Jamie Ramirez in real life and she and her wife are the proud parents of now 11-month-old daughter Elliot. Jamie struggled with anxiety for a good deal of her life and has also read on this topic a lot. And she was the one who suggested that I read Dr. Delahooke’s book and so when Dr. Delahooke agreed to an interview, it was only natural to ask Jamie to join me as a co-interviewer and she enthusiastically agreed. Welcome Jamie.   Jamie: 03:22 Hi.   Jen: 03:23 Yey, you’re here. All right, so let's start kind of at the beginning I guess by talking about how Dr. Delahooke’s thinking about anxiety is different from the way that most researchers and psychologists think about it and treat anxiety and children. So Jamie, I wonder if you could start by reading one of your favorite passages from Dr. Delahooke’s book and then perhaps we can contrast this with the more common view on anxiety. So do you want to go ahead and do that?   Jamie: 03:48 Yeah.   Jen: 03:49 Okay.   Jamie: 03:50 “The truth is that we scrutinized children's behavior from the time that they're born. “She's such a good baby”, we might say of a newborn who is easy to care for, doesn't cry too much, sleeps through the night and whose moods are predictable and easy to read. Without realizing it, we are betraying our cultures understandable bias toward valuing behaviors that we can easily understand and that make our own lives easier as caregivers, teachers, or other providers. As children reach school age, we lavished praise in good grades on those who are good listeners, follow directions and can sit still and perform well on tests. We often reward these good behaviors with positive recognition, not realizing the messages we are sending to children whose natural tendencies fall outside of the easy child profile, particularly in the educational arena e.g. those who can sit still are better than those who cannot. Quiet is better than loud. While these messages may well serve the purposes of group education, they ignore the importance of understanding and appreciating and not judging the range of children's individual differences demonstrated through their behaviors.”   Jen: 04:57 That's such a powerful passage. I can see where it resonated with you. Yeah. And so Dr. Delahooke, I wonder if you can contrast that as sort of the way that you view anxiety with the way most psychologists think about anxiety. What do most psychologists think anxiety is?   Dr. Delahooke: 05:13 Well, the way I was trained and really I think the predominant thought still amongst most psychologists is that anxiety is understood as a disorder. And maybe we can understand that through understanding that the DSM, are you familiar with the DSM?   Jen: 05:35 Yeah. The Diagnostic and Statistical Manual. Just for listeners.   Dr. Delahooke: 05:38 Yes. For listeners, it's kind of the dictionary, so to speak, for labeling and diagnosing individuals along a set of criteria. So one shift that's happened in the last kind of less than a decade starting in 2013 was that the DSM that Tom Insel, who was the head of the National Institutes of Mental Health announced that the national institutes were going to be diverting funding away from straight DSM criteria and more towards looking at underlying causality. So the short answer to your question, the way many of my colleagues, I believe view anxiety is as a DSM disorder and the American Psychological Association defines anxiety as an emotion characterized by feelings of tension, worried thoughts and physical changes like increased blood pressure. So anxiety is defined kind of loosely in a way as something that if you have a certain amount of characteristics or symptoms, then you have anxiety.   Dr. Delahooke: 06:51 And that's kind of how it's viewed now as a thing, as an actual like, oh, your child has anxiety. Well, there is no blood test for anxiety. Right? So it's not exactly like your child has diabetes, you know, your child's blood sugar level is above 105 or whatever. Anxiety, the way I was trained, I was really in my education in the 80s was that it seemed like anxiety was this thing that you treat with a certain protocol such as cognitive behavioral therapy and medication if needed. And that was what would help it go away. But what I wasn't taught was what's underlying all sorts of anxiety. Well, there's all these different subtypes and so it's really exciting to me that the shift is now not just looking at a symptom checklist, but looking at the brain circuitry and the domains, the dimensions of functions rather than these categories. And it's a really exciting shift.   Jen: 08:04 Yeah. And I just want to delve a little deeper into a couple of things you mentioned, you mentioned medication and cognitive behavioral therapy, and from the research that I've done, it seems as though each of those are effective in about half of the children that are treated. Is that right?   Dr. Delahooke: 08:19 Well this, yeah, generally speaking with the research you might find different percentages, but some percentages are about a third. Some go up to a half.   Jen: 08:29 Okay.   Dr. Delahooke: 08:31 But you think about half, that still leaves another half.   Jen: 08:35 Yes, it does. Yeah. And so what are some of the challenges of treating this anxiety in children?   Dr. Delahooke: 08:42 Well, now that I have a different protocol, I'm finding much way fewer challenges that I think that early in my career when I was using the standard protocols is that I found that for example, cognitive behavioral therapy, trying to talk to a child and help a child actively change their thoughts and their cognitions come up with the ways that their brain can help them shift their thinking and feel better. Right? Which are great ideas, super great ideas. But I've found that for many children that fall fell flat on its face. And that's when I went to look for answers as to why. Why would some children be able to shift their thoughts? And why would others just not have that capacity, especially in the heat of the moment? And that became one of my biggest clinical questions.   Jen: 09:39 Okay. And so just before we get to that, I want to briefly mention the study that came out of the Yale Child Study Center that got a lot of press, I think it was about within the last year or so and it found that a new program that teaches parents how to use reinforcements to treat their child's anxiety was as effective as traditional cognitive behavioral therapy. So again, it's working for about the third to a half of the people who are being studied. And so I'm just curious about what you make of that particular approach just because it's something that parents have probably heard of recently.   Dr. Delahooke: 10:10 Right. Well, first of all, parent involvement is fantastic. We know that parent involvement, parent-based treatment is really makes most sense from a neurodevelopmental perspective because the way human beings regulate their emotions and eventually their behaviors is through co-regulation, meaning other human beings who attuned to them and we develop our emotional capacities in our ability to self-regulate emotions through relationships. So, parent involvement is great. Now, I glanced at this study yesterday, but I think you said Jen, that it uses a behavioral paradigm.   Jen: 10:54 Yup. Yup.   Dr. Delahooke: 10:56 Okay. Okay, so here's where I think the research coming out of the lab of Jonathan Green is way more impactful and will have more efficacious results and that is because it's not based on the paradigm of behavioral reinforcement essentially. Now the idea of reinforcing behaviors we want to see and ignoring or punishing behaviors we don't want to see is a paradigm that was developed in the last century.   Dr. Delahooke: 11:28 And it started with studying animals, you know, in the lab. And it was exciting back then because you could figure out how to alter rats and dogs behaviors through reinforcement schedules. This was picked up to work with humans. And specifically one population that it was picked up on was for individuals, children and teens who are self-injuring at the University of Washington and later on at UCLA with Ivar Løvaas. So the science then was to protect and to try to of course try to help children improve their behaviors. But what is missing in my opinion and perhaps why the Yale study didn't get more than a 50% improvement rate so it equaled cognitive behavioral, is that it involved the paradigm, the older paradigm of reinforcing surface behaviors. And we now know that behaviors aren't the tip of the iceberg. So once you locate what is happening underneath the child's behavior, then you have a pathway to really helping them gain behavioral control and deal with their anxiety or their worries or their, whatever concerns they have that is much more natural and much more sympathetic with brain development. So essentially what this study apparently did not, it had--okay, the good part was that it was parent-based, but it was still along the lines of cognitive behavioral therapy because it involved the assumption that children's behaviors are deliberate and purposeful. We might think of that as willful and we can talk to them about it or put them on a reinforcement schedule for it. But to me that's the problem because not all behaviors are due to reinforcement.   Jen: 13:31 Yeah. I love this ‘cause it's a bridge from where we've been to where we're going. So what I'm hearing you say is that the reason the study was as successful as it was was because of the involvement of parents. And maybe this helped parents to attune to their children a little better than they were before, which helped them to better support their child. And the reason it didn't work better is because we were using reinforcement.   Dr. Delahooke: 13:54 That's a yes. Again, I'm not a researcher, but I'm going to go back and read that study. Yeah, I think that's a good guess because once you involve parents and especially if the parents have a gentle way with the child and look how were the parents doing the reinforcement, right? Was it gentle? Was it soothing? Was it calming the autonomic nervous system? Likely the artifacts of the study and the variables that they didn't measure may have been just as important as the reinforcements.   Jen: 14:27 Yeah. Okay. All right, so now I understand a bit about where we've been. Jamie, do you want to kind of take us forward from here and delve into some of Dr. Delahooke’s ideas a little bit?   Jamie: 14:35 Yeah, sure. I wanted to spend a good chunk of time drawing out your thinking on the idea that when we see behavior that is problematic or confusing, the first question we should ask isn't how do we get rid of it, but rather what is this telling us about the child? And I'd like to do this using a case study from your book of a child named Matthew.   Jamie: 14:54 So to summarize, Matthew was late to start speaking and was diagnosed with autism. You observed him in a session in school when he was trying to get the attention of his aide who was next to him. When she didn't respond, he touched her arm and then she followed his IEP or individualized educational plan, which says she wasn't supposed to respond to non-preferred behaviors. So she moved away from him. He continued to try to get her attention. So she moved behind him and when he leaned back in his chair to see her, he fell over. So then the aide took Matthew to the calm down room, which was a small closet with a padded floor and you watched him through the one way window looking really flattened sad with his aide ignoring any interaction with him. So let's talk about what's going on here. What do you think that the teacher and the aide are seeing in this situation? And do you think that they see Matthew as being in conscious, volitional control of his actions?   Dr. Delahooke: 15:48 Thank you for reading that Jamie. And it just brings, every time I hear it or listen to it, it brings me back to that moment to that classroom where I was sitting in the back of the room and using the lens that I now use. It felt like I was watching a slow moving car crash. So the answer to your question, did I think that they saw Matthew as being conscious and having volitional control of his actions? Absolutely. And let me just say that I have so much compassion for the teachers. I did and I do. And if anyone's listening today and you've heard me talk before, you know that this is a no blame, no shame space for me. I don't intend to have anyone feel bad about what they have done or the ways they approach children because it's in our cultural DNA to view behaviors on the surface.   Dr. Delahooke: 16:47 So I'll just say that out front I don't mean to offend anybody with what I'm saying. I just need to add a layer of understanding to our current approaches. So when I looked around the room, when I saw that Matthew, his initial bid for attention, which was to try to grab the arm of his aide, that was viewed as a bad behavior because she was wanting him to listen to the teacher who was giving the lesson. But this was a child who had individual differences that compromised his ability to easily ask for things he did not have the words to do that and his motor system was also kind of roughly connected to his intention system, so the very best he could do was swat at his aide. And I saw that as a brilliant adaptation to him letting her know he needed something.   Dr. Delahooke: 17:47 He either needed help or he was feeling uncomfortable or he needed to move. And when she moved away so that he couldn't touch her, I just thought, Oh wow, there we go, the behavior is being viewed as bad because it's noncompliant or because it's poorly understood. And what I wanted to do with that moment is say, let's celebrate that behavior. He needs you. Let's find out what this child needs at this moment. Anyway, as you read, when he started to increase his ability to grab her, then he's trying to grab her, which meant to me that his nervous system, his fight or flight system was engaged and he was actively trying to seek social engagement to feel better. She moved where he could not see her or touch her and he fell over and then they brought him to, it was called the calm down room, but it was really a timeout room.   Dr. Delahooke: 18:45 There was nothing soothing about that room. So when I looked around the room I expected to see, or I guess I hoped to see adults in distress going, Oh my gosh, this poor child who can take him out and see what he needs. And instead what I saw was everybody ignoring the situation, which was how they were trained. It was on the child's IEP to ignore non-preferred behaviors. And so I believe they absolutely saw Matthew’s behaviors as volitional and that he had control over them. And what I saw was a stress response that started off slow, what I call the light green zone like he was still in social engagement. He was looking at her, he was trying to touch her and the aide was trained to understand that as a noncompliant behavior and it went south very fast and he ended up being punished for trying to reach out and that's why I put that story in the book.   Jamie: 20:01 So, you wanna...