Author: Angela

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brave story exposure ladder

Brave stories and exposure ladders for anxiety: a fear of elevators

Photo by Arisa Chattasa on Unsplash

I discussed explanatory stories in my previous post. Now, I will present the more common type of story used for anxiety: brave stories. A brave story is about a situation, person, object, or activity about which a specific child is frightened. I will use the word “situation” in the rest of the post in place of person, object, and activity for simplicity. A brave story is used in combination with an achievable goal that allows the child to better cope with the anxiety or decrease the severity of anxiety associated with the situation. This differs from the explanatory story, which does not have a child-led goal. The explanatory story is about a situation that exists over which a child has little or no control and may be inherently scary (sibling behaviour, COVID-19) but could also be mundane (wedding). The brave story involves the child taking control, taking action and feeling brave and confident, despite feelings of anxiety. The situation is not inherently scary.

Brave stories supplement direct action. The direct action is defined as rungs on an exposure ladder. Exposure ladders are an exercise in cognitive behavioural therapy. Each rung is defined explicitly, and the child is encouraged and supported by caregivers to reach that rung. Rewards may be used after reaching particularly challenging rungs, just as you might reward yourself with drink, food, clothing, or vacations for reaching a goal. Rewarding is not bribing. Bribes are used to convince a child to do something that you want them to do (on your timeline) and may have nothing to do with feelings of anxiety (i.e. a child is tired and does not want to get into their car seat. Offering a treat for getting in the car seat is a bribe). Rewards are for a child doing something (on their timeline) that elicits a sense of pride, despite feelings of fear (i.e. a child is afraid of the car seat and after explicit steps of exposure to the car seat is rewarded with a treat for getting in the car seat, despite feelings of anxiety). The distinction between bribes and rewards can feel fuzzy but it becomes clear when you work through an exposure ladder with your child. I can see the fear written on my child’s face when she does something scary and afterwards, she is beaming and proud of herself and asks for a special treat and is motivated to try again. Alternatively, I can see that there is no fear but just tiredness, hunger, or discomfort about getting in the car seat quickly on my timeline so giving a treat is a bribe.

One of my first brave stories was inspired by my daughter’s increasing hyper-vigilance about the elevator doors closing. Months ago, my daughter, niece, sister and I got trapped in my condo building’s elevator. We were trapped for about 30 minutes while we waited for the fire department to rescue us. My sister and I maintained calm speaking voices, video chatted with grandparents and sang songs. But my daughter was clearly terrified. She reverted into her non-verbal, limp rag-doll state. After the event, we got her running around outside and she seemed okay. She also played “elevator rescue” with my husband for weeks afterwards in our home. A few weeks ago, as I was trying to maneuver a bike into the elevator, the bike fell, and the doors started closing with my daughter inside the elevator and me outside. I was able to press the call button and the doors opened before they completely closed, but I could see my daughter’s terrified face. The following weeks, I noticed that my daughter became hyper-vigilant about making sure everyone got on/off the elevator without the doors starting to close. I thought her anxious behaviour would lesson over time, but it seemed to get worse, so I decided to write a Brave Elevator Story. I also created an Elevator Exposure Ladder that my daughter and I worked on over the following weeks. Before each step, I talked about what we would do.

  1. Read story
  2. Show Lisa how I can get the doors to open by pressing buttons (outside elevator)
  3. Show Lisa how I can get the doors to open by pressing buttons (inside elevator)
  4. Put Rabbit (stuffed animal) on the elevator alone and watch the doors close. Talk about how Rabbit is safe. Mommy pushes call button and we give Rabbit a hug. Repeat.
  5. Mommy goes on elevator alone while Lisa waits outside the elevator. Lisa watches the doors close and Mommy opens the doors again by pushing the buttons (Lisa is praised for bravery and receives a sticker). Repeat.
  6. Mommy goes on elevator alone while Lisa waits outside the elevator and Mommy rides the elevator one floor down. When the doors open, Mommy calls out to Lisa that Mommy is still on the elevator. Mommy rides back up to the floor where Lisa is waiting. (Lisa is praised for bravery and receives a sticker). Repeat.
  7. Lisa goes on the elevator alone and watches the doors close and Mommy pushes the buttons outside to open the doors. (Lisa is praised for bravery and receives a sticker).
  8. Final Goal: Lisa goes on the elevator alone and watches the doors close and Daddy pushes the elevator call button on another floor. Lisa is alone on the elevator when it moves to the next floor. The doors open and Lisa sees Daddy at the new floor. (Lisa is praised for bravery and receives a sticker). Repeat.

I did not think my daughter would reach the goal. This is not the best way to start an exposure ladder. It would be much better to have confidence that your child will succeed. I created the exposure ladder based on my own idea of logical, sequential steps but without a lot of thought of my daughter’s age (2.5 years old) and developmental stage. In hindsight, I should have given this greater consideration and with a different child, I might have stopped the ladder at a lower point. Ultimately, I thought there was so much fear around the elevator that my daughter would never ride the elevator alone (at this age). But isn’t the point to alleviate some of those fears? Anyway, without more thought, I blazed ahead with the plan.

The story intrigued my daughter and we talked about the elevator a few times after reading the story, reinforcing that the elevator was safe and that Mommy can always open the doors (ok, except the freak time when it stalls and you have to wait for the fire department but that’s pretty rare and I decided I was not going to address that in this round of story-exposure-ladder action). I waited for a week or so of reading the story before starting the ladder. Each step was refused by my daughter. I would smile and say, ok, maybe next time we’ll try that. EVERY time, my daughter would wait a couple of seconds and then say, “ok [let’s try it]” and we would try the step. My daughter is one of those kids that loves to please (me). She wants to do what I suggest and has a rule-follower type personality, so this often works to my advantage. I stay enthusiastic, upbeat, and encouraging and eventually my daughter usually complies. Not everyone is so easy (as we will see in another example with my niece in my next post). But her reactions in steps 2-5 gave me more and more confidence that we could achieve the next step. That all stopped at step 7 though. I still hesitated to push her to step 8. Was this step really necessary? Does a 2.5-year-old need to ride the elevator alone? I decided I wasn’t going to push it, but one day I accidentally pressed the wrong floor button. As we were going to the wrong floor, I said, “I could jump out and you could ride the elevator all by yourself to our floor and I’ll meet you up there”. She said, “ok”, without much thought and everything happened too fast to change our minds. Away she went in the elevator while I ran like never before up the stairs to get there before the doors had fully opened. She came out grinning and gave me a hug. She was so proud of herself. She now asks to ride the elevator alone, so I purposely push the wrong floor button and jump out and take the stairs to meet her. Her bravery surprised me! Interestingly, through all the steps, the first few times of each step were clearly causing feelings of anxiety. Her fear was written all over her face as the doors would close, but she would always come out grinning and excited that she had done it “all by myself!”

I learned some valuable lessons from this experience.

  • My daughter is more capable than I thought!
  • When creating exposure ladders, it is important to consider age and developmental stage and to remember that every 2.5-year-old does NOT need to ride the elevator alone. My daughter experienced so many feelings of bravery from steps 4-7 and she stopped being hypervigilant about the elevator doors by step 7, so that is where I should have stopped the ladder. Step 8 was just a bonus.
  • It is okay to take breaks during the exposure ladder and regroup (I took a long break between steps 7 and 8).

Older children can participate in creating the Final Goal and the Rungs (steps) of the ladder, but for very young children, the caregiver will create the goal and ladder. If you have never worked with an exposure ladder for anxiety treatment, try it first on yourself. Pick something that truly gives you feelings of anxiety and fear. If you don’t have an anxious temperament or many fears, this may not be feasible for you. I have done an exposure ladder on my own phobia which helps me understand what my daughter will face at each step. This gives me a sense of empathy that is truly authentic! It is helpful to have an adult describe the feelings and thoughts for their own personal ladder rungs so you know what your child might be going through even though they may not be able to articulate those thoughts and feelings.

Before I started writing brave stories, I created a Dentist Exposure Ladder with the help of the child psychologist. One of the rungs on the ladder was to read a dentist story. I used Daniel Goes to the Dentist (the book based on the story from Daniel Tiger’s Neighborhood TV show) adapted by Alexandra Schwartz because it was one of the only stories that showed a simple cleaning visit (no x-rays, surgeries, teeth pulling, etc.). I saw how much this story helped my daughter think about the dentist and realized that a personal story (with specific language and images) would have been even better. The combination of Exposure Ladder and personalized Brave Story is more likely to succeed in reducing anxiety, converting an unknown situation into a known situation, and creating positive feelings of bravery in a child than either strategy in isolation.

In my next post, I will describe a Brave Story and Exposure Ladder for a bike trailer fear with a child less eager to please me!

Categories
explanatory story

Coping with a sibling’s unexpected behaviours

Some stories explain a situation that has happened, is currently happening, or is going to happen. An example of an explanatory story is the COVID-19 story. The goals of these stories are to explain in simple, factual language the “who, what, when, where, how” of an event without using judgement or fearful/threatening statements. One of the main goals of an explanatory story is to shift an event from the unknown realm into the known realm. Adults and children tend to fear what is unknown because they don’t know what to expect. Of course, you could expect chocolate, sunshine and rainbows from an unknown event. But, if you have an anxious temperament, the unexpected is always linked to scary thoughts. I don’t know the brain science of why the unknown is more frequently associated with negative emotions and thoughts than positive, but I do know that this is the way it is for people who experience anxiety. In addition, many topics for explanatory stories are inherently scary, such as: COVID-19 (global health problems), war, oppression, -isms (sexism, racism, classism, etc.), fearful/violent religious stories, news stories, illness, aggressive behaviour. These are all topics that tend to occur in real-time (and sometimes over long periods of time) and may or may not have direct impact on your child (from your child’s perspective). These topics may be sources of fear for young children if left in the unknown realm for three main reasons: 1) the topic directly impacts your child and is scary, 2) the environment changes due to the topic (i.e. the topic has indirect impact) or 3) the child is exposed to incomplete or inaccurate information on the topic and their anxious mind catastrophizes the information while shifting the unknown topic into a false known realm.

Besides the COVID-19 story, I wrote explanatory stories for a friend’s 2-year-old child and my almost 3-year-old daughter to acknowledge the unexpected (scary) behaviours exhibited by my friend’s 9-year-old autistic child. I have posted the “sibling” story on the Brave Tools page and changed the original family photos to freely available stock images to protect the identity of the individuals in the story. The words are original. The goals of the story include:

  • State the child is loved
  • State what are the possible behaviours of the autistic child
  • Explain how the child is kept safe
  • Explain who helps the autistic child calm down
  • Explain how the child resumes in family life (i.e. mommy comes back for a snuggle and autistic child cares for child)

After reading the story, you may feel as my husband did: why is there only one page dedicated to describing the scary behaviours? Shouldn’t there be a greater focus on the behaviours since that is what is scary? This will make more sense once you compare an “explanatory” story with a “brave” story, but my answer is, “No”. There should not be additional focus on the scary behaviours. Simple, clear language should be used to describe the behaviours. I write facts about a situation to achieve the goal of changing the unknown into the known by answering who, what, when, where, and how. Focusing on the scary behaviours with multiple pages does not change it more into the known and will likely increase fear because these are situations that are inherently scary. They will never become not scary no matter how many pages you use to describe them. Violence is scary, but you can still use explanatory stories to help make the unknown parts known (Where will I go when the scary behaviours happen? Who will help me? Who will help the violent child? What happens after?), thus alleviating some of the associated fear with a situation [more info].

Alternatively, a popping balloon is not inherently scary which is why you can use a brave story and exposure ladder to help move towards it not being as scary (although you may always have some fear about balloons). I differentiate between two types of stories: explanatory and brave. I will describe brave stories in my next post with an example of the fear of elevators and companion exposure ladder. [Comments are closed on this post. If you have a comment, concern, suggestion or want to tell me your story please contact me.]

Explosive Children

Many families are in crisis, especially during COVID-19 restrictions. An explosive child creates a threatening situation for all people in the household. Many caregivers rely on school to provide some unofficial respite from the child since most families are not receiving official respite care from any health organizations or social programs. You probably know a family coping with an explosive child, but you may not realize that the child is explosive! These parents often suffer in silence and isolation from their families and friends due to shame and embarrassment about their child’s behaviours. No matter how often the parents are reassured that they did not cause these explosions, they feel ashamed because there are still lots of people and professionals who imply that if they only parented the right way, their child would be fixed or cured. Although parenting can affect children, there are a lot of other factors at play (genetics being a big one!). Non-violent, peaceful, non-punitive, responsive parents can still end up with an explosive child. The parents are often sleep-deprived, fear being harmed by their own child, and become anxious and/or depressed. They have tried countless parenting and “expert” philosophies with no long-lasting benefit. They may be silently wading through the world of medication side-effects, dosing, and stigma. These families need a village to raise their most difficult child. Everyone can be part of someone’s village. Take a step back from the news cycles and ask yourself what act can you do today to help someone in crisis? Deliver a meal, clean a toilet, send sweets, offer a sliver of time.

Categories
explanatory story

COVID-19 story for young children

covid-19 virus drawing

A few weeks into isolation recommendations amidst the coronavirus pandemic I noticed some changes in my 2.5-year-old’s behaviour: more tantrums, constantly asking to eat, and more stuttering. I know her behaviourally inhibited (anxious) temperament causes her to have strong reactions to changes in routines, so I was not surprised. However, I thought the routine changes would reduce her social anxiety since she was no longer having to confront situations like music class, forest school or play gyms. I wasn’t too concerned with the changes, but I was having a hard time understanding her through the stutter and my husband was definitely worried. I made a virtual appointment with a child psychologist that specializes in anxiety. I had seen her weekly for a couple of months the previous autumn to get a better handle on behaviourally inhibited temperament, childhood anxiety and treatments. I wanted her to weigh in on whether my daughter’s “new” pandemic behaviours were normal. She made three recommendations: 1) stuttering is out of her wheelhouse and I should get referred to a speech and language pathologist (SLP), 2) make a simple routine chart showing our daily routine and meal times, and 3) talk to my daughter about COVID-19.

I diligently checked off the recommendations. We are on a waitlist for an SLP. I made a simple chart showing our daily activities including meal times and within a few days of posting it, my daughter stopped asking for food constantly. I felt uneasy about recommendation 3. I know it’s important to talk about the pandemic with children to help alleviate anxiety and I had already seen plenty of stories and articles about how to talk to your kids about COVID-19, but I hadn’t seen any stories appropriate for a 2 year old. The stories I read had a detailed description of COVID-19 and viruses and often described school being closed. The stories also seemed to assume the child had already heard words like pandemic, virus, coronavirus, COVID-19, etc. My daughter had never heard the word virus, let alone coronavirus, and did not relate to school closures. We don’t use screens, other than for video chats with extended family, so she wasn’t being exposed to information from the news. My husband was working fulltime from home and I was a busy mom and aunt; he and I did not discuss the pandemic in front of her. I assumed she didn’t have any idea what was going on. I was seriously thinking about ignoring recommendation 3. How could I explain this pandemic in a helpful way to my 2-year-old and how was talking about a virus really going to help with her tantrums? But, as a rule-follower, I find it hard to go against expert advice, so I gave it more thought and decided to write my ideas because I don’t do well trying to speak off the cuff (thank you, INTJ personality and behaviourally inhibited temperament!).

After some brainstorming, I concluded that the best format to deliver COVID-19 information would be a short, personalized story. Prior to this point, I had written a couple of Social Stories for a friend with an autistic child. I had written them in a rush and took some basic pointers from my friend about how they should be written. I decided to write a “social story” for my daughter about COVID-19. But I did not adhere to any specific principles of official Social Stories, per se. I focused on how to address anxiety for a very young child. For content ideas, I read articles from anxietycanada.com and Psychology Today. My goals for the story were as follows:

  1. The story is understandable
    1. Use age-appropriate (simple) language
    1. Use words that I know my child understands
  2. The story is relatable
    1. Use lots of personal pictures
    1. Describe the current unknown situation in relation to known situations
    1. Describe how we help
  3. The story is factual (not fearful)
    1. Highlight both positive and negative changes to my daughter’s routine
    1. Explicitly state positive and negative feelings

I wrote the story and was amazed at how much my daughter enjoyed it. Weeks after reading it she still talks about the “new cold” in relation to activities in our lives. If I say, “no” about something she will ask, “because of the new cold?” I was able to refer to the story when she resisted washing her hands after coming inside and avoided a few (not all!) meltdowns. The story provided us with a platform to talk about the changes we continue to notice when we go out for walks. It also provides my husband and I (and my parents and sister) the same language to consistently reinforce the story concepts.

Now that you have read the story, you might feel that it is not right for your family. That’s good! A story like this should not be right for anyone else’s family. It is critical to personalize these stories when you are using them for very young children. As children age, they gain life experience such that there is a greater chance that a generalized story is applicable to that child. However, for young children with very short memories and limited experience, it is important to adjust the story to fit the child such that it is understandable, relatable, and factual, from that specific child’s perspective.

I will review a few aspects of the story and how they relate to the three goals. Then, I will analyze some statements from a generalized COVID-19 Social Story to see why those statements are not useful in a story for my child and probably most 2-year-olds.

  • I call the coronavirus (COVID-19) the “New Cold” and people who have the new cold are referred to as “Sickly Sues”. This might seem like strange language to you, but I considered exactly what words I had used since my daughter’s birth to describe when we got sick (with anything – common cold, flu, food poisoning, headache, roseola, etc.). I most commonly used the words “cold” and “Sickly Sue” (That is a family thing – thanks, Mom!). Your family might use “Sniffles” or illness. The point is that I knew my daughter had feelings associated with those words. She used those words to describe herself when she was sick. Using this vocabulary supports goals one and two: understandable (language) and relatable (feeling of sickness).
  • I explain that some people wear masks like dentists and Mommy makes masks for our family and I have a photo of my daughter wearing her mask. Luckily, we had talked about masks prior to COVID-19 because of the dentist. We had already started our anxiety exposure ladder leading up to visiting the dentist and covered our faces with scarves while playing dentist. If you have not talked about the dentist in your family, try to think of another positive mask association that your child has. Maybe you have seen people cover their faces in the winter when skiing or playing in the snow. Maybe your child likes construction and they have seen a welder’s mask. Doctors, nurses, welders, carpenters, etc. The discussion of masks supports goals two and three: relatable (dentists wear masks) and factual (stating that masks are being worn without adding judgement or fear like relating the masks to robbers or “bad guys”).
  • I talk about “helpers” (i.e. doctors help, [Name] helps) because toddlers and young children love to be helpers! My daughter turns on the washing machine and dishwasher and we have talked about how to help someone who is hurt (ask if they are okay, get an adult). Being a helper is something she understands from other activities in life. So, instead of being burdened by having to wash hands, use sanitizer and give others space, it is empowering that this little person is helping with the “new cold”. Describing “helpers” supports goal two: relatable (helpers existed before the pandemic, exist during the pandemic and will exist after the pandemic).

Here are a few statements from a typical COVID-19 social story and why they don’t work for my daughter. Although I am reprinting statements from this story, most other stories had these same kinds of statements:

  1. The Coronavirus is a virus that can make people feel unwell. The coronavirus can also be called COVID-19. My daughter doesn’t know the word virus, Coronavirus or COVID-19. It’s too much detail and would have been superfluous to include a statement with synonyms of coronavirus.
  2. People who have the coronavirus may have fever, sore throat/dry cough, shortness of breath. This is too much detail for a young child; they likely won’t stay engaged for a long list of symptoms. I chose a single symptom (cough) in my story; I also selected a symptom that I knew my daughter understood (cough, not dry cough). I like the symptom “cough” because it is something we can easily play/pretend and she can see it (body tensing, hand/elbow covering face) and hear it.
  3. I know that I will be safe… I like the idea of stating that a child is safe, although I didn’t include that message in my story since there was no focus on the danger/threat/safety aspect of the pandemic; I didn’t discuss family members getting sick or dying because it was low risk for us. If I lived in a different place, that might be more relevant. Instead, I included a phrase from Daniel Tiger’s Neighborhood that we learned about in our Daniel Tiger Goes to the Dentist book, “When we do something new, let’s talk about what we’ll do.” I sing this phrase constantly for anything we do that is “new” and scary. Although the phrase is not correct for this situation, the feelings behind it are empowering to my daughter. This is one more personalized aspect of the story to keep my daughter engaged and feeling confident. I also included the phrase, “mommy, daddy and [Name] will always be a family.” This phrase is more powerful than the “safety” concept because even if mommy or daddy die, we are still a family. Relationships and family transcend death.
  4. …and I don’t have to feel afraid. I would not include this kind of statement in any story. No one has to feel afraid, but they do! I prefer to phrase feelings as simple statements like “I feel sad. I feel scared. I feel happy.” Negative commands are confusing and try to control how a child feels. Statements such as “I don’t have to feel happy. I don’t have to feel sad. I shouldn’t feel mad” may be confusing for a young child if they are experiencing a feeling that the story has told them not to feel. If you incorrectly guess a child’s feeling by writing, “I feel happy” when they actually feel sad, the child can say, “no” and then you can correct it. But if you write, “I don’t have to feel sad”, the child cannot easily respond “yes/no” because a statement written in the negative is more confusing for a young child to understand and then relate it back to what they are actually feeling.

It is June now and the city is starting to open up again, but I am resisting diving back into old patterns, as I expect a second wave of the virus and I’d rather try to hold steady instead of implementing more routine changes, suddenly. The story and routine chart helped to reduce some anxiety. In addition, enough time has passed such that our new isolation routine has now become our routine, and my daughter is surrounded by people with whom she feels comfortable and she isn’t having to confront anxiety-producing social situations. I believe my daughter’s stutter is caused by anxiety and her temperament and not by a developmental issue. Therefore, my hypothesis is that if we address the anxiety, improvement in stutter will follow. COVID-19 caused the elimination of most of my daughter’s anxiety sources. I’m not saying elimination (avoidance) is the best way to deal with anxiety (more info) and without COVID-19 I wouldn’t have self-selected this isolation just to see what happens, but now that it has happened, it’s amazing to see my daughter flourish! The stutter (more info) has improved to better than pre-COVID levels and tantrums are down. I hope that in this state of low anxiety, my daughter will be able to practice and solidify stutter-free speaking patterns. I am curious if, by eliminating most social situations and allowing her language to develop in a low anxiety COVID-19 isolation bubble, she will maintain that language and speech pattern when we eventually face new social situations. We may still need to employ exposure ladders for those social situations, but will her speech patterns be affected? Only time will tell! (And we have the SLP waitlist in our back pocket.)

Anxiety

Avoidance is precisely the wrong way to deal with anxiety because it does not help a person learn skills to cope with anxiety. It just pushes it out of the way until later. A person who avoids the fearful event/object will still experience anxiety when confronted with it in the future. Find out more about anxiety at anxietycanada.com. However, for extremely young children, there is also a developmental component to consider. Separation anxiety is normal in babies and toddlers and there is a large “normal” range of behaviour. As a scientist, I like to follow evidence-based parenting practices, which support non-avoidance exposure ladders for treating anxiety in children. However, most research is based on older children (school-age+) and adults with diagnosed anxiety disorders and it is often just assumed to work for young children (when it is still thought of as a temperament and not a disorder).

Stutter

My daughter has stuttered since she started talking at 2 years old. Usually I understood what she was saying through context and I even thought her stuttering was improving before the isolation rules came into effect. Prior to the pandemic, she exhibited whole word stuttering (5-20 times repetition of a word); for example, during snack time after music class she said, “got got got got got got got got got got got got… JAM!” which was an exclamation about the sandwich containing real jam instead of apple butter. During isolation, whole word stuttering continued as well as being “stuck” (no sound comes out and she was stuck on a word with her mouth open and muscles visibly straining to get the sound out) and sound holding, like “I want to go hoooooooooooooome”.

In the next post I will further discuss explanatory stories for young children with an example of coping with an autistic sibling.