behaviorally inhibited temperament behaviour modification brave story exposure ladder fears

My daughter spoke during a birthday party, so why don’t I feel good about it?

My daughter turned 3 years old this past summer. We had virtual “parties” with her paternal relatives and in-person celebrations with her maternal bubble during the pandemic. We sang Happy Birthday and blew out candles many times. She loved it and continues to play “birthday” many months later. Two weeks after her birthday, we were invited to a socially distant outdoor gathering for my friend’s child’s birthday. I thought this would be a good opportunity for my daughter to experience a social gathering with no pressure to play with other kids or do anything at all other than stay by my side to maintain distance from other people. And that is how I should have left it. But…

…I decided to take the opportunity to practice giving something to another child (present) and saying a socially expected phrase “happy birthday, [Friend]”. I did not think she would do these things at the party, but we used the lead up to the party to practice these acts during play in our home. I wrote a story and even conducted a small exposure ladder which included visiting the front yard of the friend’s house the day before the party and stopping to have ice-cream on the sidewalk to increase familiarity with the house (without seeing any people) and provide a positive association with the location (ice cream!). I suspected that the lure of a special treat on the day of the party would be a strong motivator for her to try to speak.

At that time, my daughter only spoke freely to her special bubble of people: parents, maternal grandparents, and little cousin. She spoke with restrictions to a handful of other relatives. She did not choose to speak to anyone else. She would, on occasion, say short statements with my prompting like “hello” and “how are you?” to neighbours that we pass on the sidewalk with the promise of a chocolate chip treat.

If this friend had not had a birthday party, I would not have sought out this opportunity. Even at the time, I felt this was too soon to push social speaking or interacting with another child that we saw infrequently. However, I tried to channel our psychologist, and I think she would have encouraged me to take advantage of the opportunity (especially since I had time to write a story and do a small exposure ladder). When we arrived at the party, my daughter held the present and I encouraged her to pass it to the birthday child. She did so but was clearly nervous. I prompted her to say, “happy birthday” which she was able to blurt out and then we immediately picked a treat from the table. For the rest of the event, my daughter stood beside my chair and watched the proceedings unfold (a bunch of adults sitting at a distance chatting about work and life). At some point I realized she was a bit more frozen than I expected and when I touched her arm, I realized she was slightly shaking. I knew this was too much and reminded her that we were going to see her cousin afterwards and we would leave soon. After a couple of minutes, I told her we were leaving and suddenly she blurted, “I want another cookie!”. The fact that she was able to speak when she was clearly distraught was surprising. Cookies are a powerful motivator, apparently.

At the time, I felt like this event had been a huge success. My daughter completed the socially appropriate act of speaking and giving a birthday gift and was thrilled to have a treat as her reward. I praised her after the event, and she had a big smile on her face. But, deep in my gut, I did not feel good about the experience; something did not sit right. I felt that I had coerced my daughter into playing the role of a puppet. She knew that by performing, she would get treats and praise from Mommy. She may have even felt that my love for her hinged on performing this incredibly difficult and fearful task. How horrible. My love for her is unconditional, but what I know does not matter; what matters is how she interprets my actions.

After much reflection, I realize that this birthday party was me pushing my daughter to do something that she did not want to do and did not need to do. Why did I think this was a good opportunity? Why did I think this was the right thing to do? I have a child who is clearly behaving atypically (not talking to others), and sometimes I feel like I am on the edge of the normal circle looking in and I feel pressure to be making active strides to get into the circle all the time. It was my own feelings of doubt about what I was doing with my daughter, my own feelings of wanting to fit in with the group, my own motivation of making my family appear normal to others, my own interpretation of what my psychologist might have recommended that pushed me to push my daughter. And I regret it.

What makes this situation different from all the other brave stories, exposure ladders, and fear-based activities that we have worked on over the past year? The other stories and ladders and actions were generally motivated by a (fearful) reality that we had to face: COVID-19, I had a doctor’s appointment for a mole removal on my face, our friend’s struggle with a special needs “explosive child” and a toddler, we were trapped in our condo’s elevator which created a phobia, etc. When I reflect on how I have encouraged bravery, it is to face things that we must face even when we are scared. It is about explaining the unknown and making it known. It always felt like we were facing things together and coming away stronger than before. It was never about exposing my daughter to fearful experiences to alleviate my own concerns of being atypical, until this birthday.

Of course, I want my daughter to be able to have good mental health and strategies to cope with feelings of anxiety. I hope that one day social situations and speaking will cause lower levels of anxiety, altogether, but pushing too much too soon will not get us there. My goals for my daughter speaking and engaging in social behaviours are long-term. They do not fit with the traditional age-requirements of our society where all preschools and classes are drop-off by 3 years old. I need to get creative. I need to find or make my own solutions that fit our life. It will be my advocacy and ingenuity that will create the environment my daughter needs to thrive such that we reach those long-term goals without sacrificing our relationship.

In my next post, I will discuss scripts I wrote for my sister to help her toddler make transitions.

behaviorally inhibited temperament behaviour modification

Behaviour Modification: the good, the bad and the balance

Behaviour modification is an oft recommended strategy for extinguishing undesired behaviour and increasing desired behaviour in children. You have probably encountered methods based in behaviour modification psychology like rewards, praise, ignore, time-outs, and consequences. In fact, many health organizations (like the Center for Disease Control in the US and The Child Mind Institute) recommend a basic form of behaviour modification as a general parenting strategy; it sure as hell beats spanking! However, you also may have heard that time-outs are bad, or why too much praise is bad. This is confusing. And research is not necessarily going to help you! There are many randomized control studies to show that behaviour modification works to change behaviours and there are a number of formal methods based on behaviour modification, all with evidence-based research to support them: the Yale ABC Parenting course based on the Kazdin Method (which, paradoxically, does not appear to be based on traditional behaviour modification!), the Triple P Parenting philosophy, and the Parent Management Training program. But there are other psychologists and clinical counsellors that do not recommend traditional behaviour modification strategies (Laura Markham, Gordon Neufeld, Ross Greene, Daniel Siegel (sort of), Vanessa Lapointe, and others). These experts theorize that there are underlying “hidden” consequences of behaviour modification:

  • Loss of connection between parent and child
  • Using parental attention (i.e. love) as a bargaining chip to change behaviour
  • Ignoring the child’s perspective (i.e. being disrespectful).
  • Creating an external locus of motivation (i.e. child will only perform for rewards)

Does the loss of connection between adult and child do long-term damage to the child? For example, administering a time-out for bad behaviour could result in the child experiencing love-withdrawal or humiliation, even while extinguishing the bad behaviour. Drs. Siegel and Kazdin say the problem with time-outs is that most people use them as punishment instead of in a “positive” way; the result is that time-outs, as implemented in the real-world, may be interpreted by the child as punishment, love-withdrawal, and humiliation.

Asking and answering research questions is difficult. Some questions are easier to ask and answer than others. It is easy to answer the question, “Do time-outs reduce the frequency of behaviour X”? We randomly assign a group of families to the “treatment” group of receiving instruction on administering time-outs and then we record the before and after frequency of behaviour X (this would be a within subject study design where the subject’s post-treatment behaviour is compared to the same subject’s pre-treatment behaviour) and we can also compare the frequency of behaviour X in the treatment group to a matched control group that didn’t receive treatment. Counting the times behaviour X happens is relatively easy. You can see if it happens. You can record it. However, it’s hard to answer the question, “are time-outs interpreted as love-withdrawal and humiliation by a child and do those experiences affect their self-worth (or other outcome) over the long-term?” or “Do time-outs negatively impact the parent-child relationship over the long-term?” These questions are more interesting, but they are hard to answer. How do you define “long-term”? Is 1 year good enough? 5 years, 20 years? How exactly do you measure humiliation? Is the child asked after a time-out, “did you feel humiliated”? How old is the child? Do they understand this word? Do all cultures define humiliation in the same way? In what language are you asking the question? Do you ask adults to reflect back on time-outs they received as young children? Do you find a surrogate blood marker like cortisol (the stress hormone) and say that a particular increase in cortisol indicates stress and is associated with humiliation? How do you define the parent-child relationship? Is it just based on the theory of attachment as defined by the Strange Situation experiment? Is there a measure of warmth or love and can this be measured in the same way between a 3-year-old and parent and an 18-year-old and parent? These topics are hard to define and a researcher’s definition might not be the same as your definition, making it even more difficult to generalize results. As far as I know, long-term relationship and connection questions have not been adequately answered in the behaviour modification literature, which is exactly why there is debate about behaviour modification strategies!

Ross Greene also has an evidence-based parenting strategy, Collaborative and Pro-Active Solutions that is not based on behaviour modification techniques because he feels those are coercive and disrespectful to the child. A lot of psychology and parenting techniques are based on decades-old philosophies and ideas about children being lesser beings than adults. Children did not deserve respect as true and complete human beings. They needed to be controlled and manipulated into the human we wanted. They were a blank slate and needed to be filled with the “correct” ways of being a human.

For me, the idea of disrespect comes back around to temperament and accepting the child you have. Of course, we cannot accept violent behaviours or behaviours that prevent a child from living a healthy life (with the definition of healthy being subjective to the society in which you live). So, you may find yourself questioning, as I often do, about what strategy is best – behaviour modification because we know it changes behaviour and has a LOT of supporting experts and evidence or a connection-informed approach that appears a little more vague and little more open to interpretation like Dr. Markham’s Peaceful Parent approach (which is anti-consequences, anti-time-out and anti-praise/rewards and uses loving connection and empathic limits to guide children’s behaviour) or Dr. Greene’s approach (generally for older children) to involve them as equals in proposing solutions for daily conflicts (randomized control trial shows the effectiveness of this approach)?

When I met with the child psychologist, she walked me through her course on anxiety and treatment for young children using examples from my experience (the general guidance was very similar to the free course on Anxiety Canada). Over time, the psychologist offered nuanced guidance that alleviated my fears about over-exposing my child to fearful things and “forcing” her to do uncomfortable things. The strategies are based in behaviour modification techniques, specifically differential reinforcement. Briefly, this is a combination of praise/ignore techniques to reinforce desired behaviour and extinguish undesired behaviours. For example, you could use labelled praise to reinforce independent play while you make dinner, “I like how you are using so many colors for your picture” and then ignore the child whining, “Mommy, come play with me.” If you are consistent, and offer more praise than ignoring, your child should eventually play/color without whining while you make dinner. Ignoring should be done less than praise (I think I read somewhere a ratio of 1:10 ignore:praise statements). Ignoring should only be done for minor behaviour issues that do not involve self-harm, harm to others or harm to property. This is an important caveat because if you misinterpret this technique, you may ignore a child hitting another child (or assume two preschoolers should be able to “work it out” on their own).

However, I do not like ignoring because I feel like it breaks my connection with my child. In addition, I am a naturally quiet person and continuously praising my daughter is uncomfortable. I like my daughter to just carry on in her day without me constantly commenting on her behaviour. However, I do see merit to the idea of using praise for specific issues for young children. For example, I am trying to “catch” my daughter and her little cousin sharing/taking turns and praising their behaviour to reinforce my expectation that they take turns and their great accomplishment of successfully taking turns! I use praise as the “rewards” for various steps on exposure ladders as I can see the joy on my daughter’s face that I have acknowledged her effort in a difficult task.

As I am reading Discipline without Damage, by Dr. Jennifer Lapointe, I find myself aligning more and more against traditional behaviour modification. As she argues, the greatest need a child has is connection to their big person. If that big person disconnects (for example, by ignoring the child during a tantrum), the child will eventually do whatever it takes (including changing behaviour) to get that connection back. But, should your love and connection with the child be used as a bargaining chip for desired behaviour? Shouldn’t your love and connection be unconditional? Dr. Lapointe, argues for unconditional connection and, therefore, argues against ignoring “bad behaviour”. In addition, she also views “bad behaviour” as developmentally appropriate behaviour and not necessarily something to change! Just like the phase of diaper wearing will eventually end, so too will the phase of tantrum-throwing, for example.

But, since I was knee-deep in behaviour modification psychology, as guided by my psychologist, I decided to try out the strategies and maybe unsurprisingly had mixed results.

Successful Ignoring Anecdote

I tried ignoring for a specific instance with success when my daughter was just over 2 years old. My daughter started crying every morning at breakfast about whether her blueberries were hot or cold. Whichever one they were, she seemed to want the opposite. She started jumping out of her bed when I opened her door in the morning, and she would race into the kitchen to monitor the blueberry preparation. She was becoming hypervigilant about blueberries. I relayed this story to the psychologist, and she suggested I try ignoring her and serving the blueberries however I wanted. I am averse to creating power struggles, especially around food and I was not convinced that this was the best solution. My mom suggested I serve both hot and cold blueberries at the same time to try to determine which one my daughter prefers. One afternoon, I did my mom’s suggestion and my daughter happily ate both bowls of blueberries! She did not seem to have a temperature preference. I decided to try out the ignoring. I got my husband on board and we tried the first morning. She cried. I did not speak or look at her and carried on with the rest of breakfast. Eventually, she ate her blueberries. Repeat for about 3 days and I have not had a cold/hot blueberry issue since (it has been over a year)!

Unsuccessful Ignoring Anecdote

Buoyed by my blueberry success, I tried ignoring when she refused to put her shoes on to leave her grandparents’ home, but it escalated into a full tantrum every time. Ignoring did not seem to help that situation and instead her upset continued to escalate. What did help was offering a piggy back ride so that she didn’t have to put on her shoes; I ended up using the piggy back strategy for about two months and then she started wearing her shoes again without being upset.

In hindsight, I think the blueberry issue was my daughter’s anxious brain trying to control the first thing that happened in the morning when she was starving and taking in a lot of visual stimuli and her brain went into hypervigilant overdrive. When the control was removed her brain was relieved and able to relax as her Big Person (me) took control! Whereas the shoes issue seemed more to do with her discomfort with wearing shoes at that time of day and was solved simply by not requiring the wearing of shoes. This brings me to one of the most difficult aspects of parenting anxious (and all) children: finding the root of the problem. I do not like behaviour modification strategies because they focus on solving downstream behaviours when I would much rather focus on addressing the root. But for many children, especially those that do not speak, a parent must be an astute detective to decipher the path back from the behaviour to the root. Hindsight helps and I hope that my hindsight will eventually strengthen my foresight.

As I previously mentioned, Ross Greene, author of The Explosive Child and Raising Human Beings does not use behaviour modification. I love his strategy, although it generally pertains to older, verbal children, and I look forward to using his Collaborative & Proactive Solutions approach as my daughter gains more speech and language ability.

As a scientist, I find it interesting when people emphatically claim that one method (behaviour modification) is the only “correct” parenting method because there is supporting scientific evidence. As far as I can tell, the evidence shows that behaviour modification strategies successfully alter the behaviour for most children (but not all!). However, the studies do not necessarily tell you if the overall long-term effect on the child is positive or negative. For example, time-outs may alter behaviour in most kids (always seemed to work on Nanny 911 and Supernanny!). However, for the minority of children with an inhibited anxious temperament, they may interpret a time-out (or even ignoring!) as punishment, embarrassment and love-withdrawal and come to fear the experience and authority figure (parent). This type of child may stop their negative behaviour but may also resent the parent, which could lead to long-term distrust within the parent-child relationship. I do not know any studies that specifically account for and address temperament with behaviour modification strategies. From everything I have read on inhibited, anxious, sensitive children, it is better to air on the side of caution by favouring loving, warm connections rather than do anything that could be perceived as a punishment by the child. My plan is to continue to use ignoring as minimally as possible and use empathic limits, collaborative solutions, and encouragement for desired behaviour while always looking for the root of a behaviour to meet my daughter’s needs.

I will visit some of the empowering stories from the Brave Tools in my next post and describe how they formed the foundation for taking brave actions.

behaviorally inhibited temperament exposure ladder

My struggle with balancing anxiety treatment and life

Sometimes dealing with anxiety (or a behaviorally inhibited temperament) can feel like a losing battle. You finally address one fear and five more pop up. There are many days when I wonder, “how much fear-facing is too much?” How should I weigh “encouraging bravery and working on fears” with “accepting my child as-is and building a positive, loving relationship”? Experts would say those two goals are the same and do not need to be balanced, especially when you look at the big picture of a person’s life. But every parent of an inhibited child knows that those two goals come into conflict daily. Crying, tantrums, resistance, and abject terror on your child’s face are just some of the possible outcomes of facing fears, even in controlled environments. These behaviours are physically and emotionally exhausting for both the caretaker and the child.

Facing fears is extremely hard. I often wonder how many psychologists and therapists have used cognitive behavioural therapy and exposure therapy to face their own worst fears? I first learned about this treatment when I used both therapies for a medical condition and associated phobia in my twenties. I spent 2 hours per day on meditation, mindfulness and thought records, and then worked on the exposure ladder. I chose each step and set the timeline and rewards. It was incredibly difficult and time-consuming. For the specific phobia, working through the exposure ladder was one of the hardest things I have ever done. I know the physical and emotional toll it takes to face a fear using these methods. This is one of the reasons why I balk at the idea of continuous and constant exposure for inhibited children.

I mentioned my daughter’s tendency to avoid busy play-gyms to the psychologist and she told me, “oh no, you can’t avoid play gyms. You need to go to them.” And I thought, why? I hate them too! They are loud and over-stimulating. Many of the children are poorly behaved with caregivers sitting on the sidelines with their faces in phones ignoring their child who is grabbing toys from anyone within reach. As the gym filled up with more and more children, my daughter stopped moving, looked at the door and walked towards it. I would have had to physically restrain her and have her cry to keep her in the gym (or reward her a lot!). Then, would I have to decide how long before we were “exposed” enough? I could set up an exposure ladder with rewards to achieve a cry-free extended play-gym experience. But is this worth it? I don’t know. I know that I do not like big groups of my peers at busy bars and pubs (the adult equivalent to play-gym?). I do not want to go to a party and make small talk for hours. I am happy and content with my life. I love being a mom and I am a good scientist. I like getting together with close friends. I like being with bigger groups of friends and family on special occasions. I got to “work” my friend’s wedding and I had a blast. I felt useful while still being in the hustle and bustle celebrating my friend’s big day without having to make small talk continuously. I help others and get a lot of joy out of my interests like baking and sewing. So why does my 22-month-old need to survive play gym?

The psychologist would probably agree that there needs to be balance, but when I read information about anxiety, there never seems to be a balance: the recommendation is exposure, exposure, exposure. And the research seems to support this. Researchers have shown that anxious rat pups (baby rats) exposed to novelty early in life became less anxious adult rats compared with control (unexposed) pups. A human child might be less inhibited as an adult with forced, continuous exposure therapy in early life, but at what cost? I do not think science and research has an answer for me. Those mother rats never had to endure tantrums from their exposed pups, and those rat pups did not cry when the researchers picked them up and removed them from their mom (or maybe they did!). And when they were adult rats, we have no idea if they still “loved” their mom and had a positive attachment to their mom. Unlike mother rats, human parents weigh the benefits and consequences to find a solution that works for their family. This might mean exposure, exposure, exposure. But it also might mean some exposure and some avoidance to make space for other non-fear related positive child-parent interactions because there are only so many hours in the day.

The bias underlying anxiety treatment (and the associated research) is that uninhibited, social traits are preferred over all other personality traits [more info]. As an introverted, inhibited, shy person, that slant feels wrong to me. Our strange existence in the pandemic has given me pause to reflect on anxiety treatment and exposure and I am still working towards finding a balance for my daughter and me. I found great success with the elevator exposure ladder, but would I want to do this every day for every fear? No. I am taking a page from Ross Greene’s book Raising Human Beings, and prioritizing my daughter’s fears. I do not need to tackle them all. She does not need to tackle them all.

In my next post I discuss behaviour modification and my mostly hate relationship with this ubiquitous parenting strategy.

The Good in Inhibited Children

After I wrote this post, I started reading an evidence-based book, The Orchid and the Dandelion by W. Thomas Boyce. The author weaves his personal family history with research findings related to inhibited (orchid) and uninhibited (dandelion) children. He creates a story that describes the challenges of having an inhibited temperament and the unique opportunities to nurture great beauty in the child. It is the first writing that I have come across that explicitly states research-backed positive traits of an “orchid” child. I will provide an update when I finish the book.

behaviorally inhibited temperament play-it-out re-enactment


In my previous post, I discussed some of the strategies that my partner and I used to help our daughter with specific aspects of her anxiety that were exhibited before 2 years of age. Most of those strategies were developed in response to her actions and were not based on any treatment or specific anxiety knowledge – just our best guess of how to cope in the moment! In this post, I will discuss one of our earliest “informed” strategies that is broadly applicable to general anxieties from the past, present and future and continues to have great impact in our daily life. I titled this strategy “play-it-out” and it is the manifestation of my husband’s and my interpretation of a few sections from the book The Whole Brain Child by Daniel Siegel and Tina Bryson.

The Whole Brain Child has wonderful information. The brain science is fascinating, and the “comic” descriptions of the various strategies were very useful. Of interest to my husband were the sections on storytelling to integrate the left and right sides of the brain (Chapter 2, Strategy 2) and on memory integration with events (Chapter 4, Strategies 6 and 7). Integrating the left and right sides of the brain works to link facts and details (left) with feelings and emotions (right). Through storytelling, the child names the event and is then better able to move towards taming the feelings for future related events. This strategy conveniently involves memory integration, in which we remember the event and associated feelings such that the feelings are explicitly connected to the event instead of floating around disconnected. Floating feelings can become attached to unrelated events, causing phobias and fears that, from an outsider’s perspective, appear to have no origin.

For example, a young child is bitten by a dog. The child cries and eventually recovers and the days and weeks (maybe months) pass. Eventually, the child fears cats, birds, dogs, and various animals. You might reassure her that the animals are friendly, safe, and more afraid of her than she is of them, but nothing you say seems to change her fear. What happened? The dog-biting event created a feeling of fear in the child. By effectively ignoring the event (i.e. allowing “time to heal all wounds” and “memory to fade”), the disconnected, floating fearful feelings attached themselves more broadly to many animals. No reassurances will fix the problem because the reassurance does not address the original dog-biting event. At this stage, a brave story and exposure ladder could be used to help the child face the fear. What could the parent have done differently to possibly prevent this phobia from developing in the first place? After the dog-biting event, the parent can talk to the child by describing the event and naming her feelings and experience. In the days and weeks that follow, the parent can help the child tell the story (if the child is verbal) and even re-enact it with stuffed animals. This creates a connection between the fear and hurt with that specific dog-biting event. If the dog was unfamiliar, then your child will probably never see the dog again and that will be that. If the dog was familiar, the child will still probably have some lingering fear about that dog in future situations because that dog really did bite her! She will need many positive interactions before she can “trust” the dog again. And of course, she may need more explicit instruction on how to safely interact with that dog (and all dogs). That is normal. But, hopefully, she will not develop a phobia of all dogs from the single dog-biting incident.

As you probably guessed, my daughter was that child that was bitten by a strange dog (without teeth!) when she was 12 months old. After the bite, she did not cry, there was no blood or cut and I did not think it hurt. I ignored the situation since she appeared to be fine and thought, “oh well, her memory will fade”. But I was wrong! She was terrified of dogs for the next 8 months and at 3 years old rarely pets a dog and has a look of terror on her face if a dog comes towards her. As soon as I read The Whole Brain Child, I knew I hadn’t handled the dog-biting event well! The problem is that I did wait long enough for the memory to fade so now I am not sure if there is any point in describing the original event as it would be completely unknown to my daughter. Just as predicted in the book, the feelings attached themselves to all dogs (luckily, they did not attach themselves to cats or birds – look out Goose, my daughter is coming for you!). Now I am faced with a phobia treatment with a story and exposure ladder. However, her dog fear is low on my fear-conquering priorities, so it is on the back burner for now.

After discussing the left-right brain integration and memory integration, my husband implemented our new “play-it-out” strategy to link our daughter’s emotion with an event. For example, our very active daughter liked to spin in our small living room with hardwood flooring and various pieces of furniture. Inevitably, she would fall and impact something and burst into hysterical crying. I held her and witnessed the tears and provided words for the experience, “ouch, you had a tumble. That hurt. You are sad. It’s ok to be sad and cry.” Eventually, she stopped crying and my husband used her large stuffed penguin (which was about her size!) to re-enact the event. He showed her with the penguin how she fell (trip, face-plant, etc.), what she hit (foot stool) and where on her body she hit (head). He repeated the process as many times as she asked. She was enthralled after the first time! Often, my husband re-enacted the event himself and then our daughter re-enacted the re-enactment at slow speed, complete with a fake fall! We did this repeatedly. Sometimes, we did not see the event and could not re-enact it accurately. Instead, we first asked her what part on her body hurt. She might point to her knee and then we guessed what she impacted “might this have happened? Or maybe you hit this?” She might grunt (which was her sound for yes). And then we re-enacted what we thought happened. Now that she is 3, she often points or describes which part on her body is hurt and then she will sob into my chest and mumble “show [me] what happened”. The re-enactment is now part of her healing process! She stops crying almost immediately when Daddy re-enacts the event. Not only are we integrating events, feelings, facts and memories, we are also changing the unknown into the known, the exact root fear of people with anxiety! So much of what is scary about falling is not knowing how or why it happened and then not knowing how to prevent it in the future!

The next aspect of the play-it-out method is performing oral stories and plays to address previous anxiety-inducing incidents (like a dog-biting event!). After nap time, I used her stuffed animals to ask her about her morning. Usually, she did not describe anything, so the animals asked me, and I provided a few details. The animals continued to probe but, unfortunately, my daughter’s language is a little delayed and she just did not have the words, so I typically recounted the incident in as factual language as possible. The animals asked questions and expressed feelings and concerns. For the first storytelling, the animals acted as an interested audience to the story and then transitioned into play. For retellings of the story, the animals acted out an analogous story and showed the expected/desired behaviour with possible ideas and solutions that my daughter could use the next time she found herself in that situation.

For example, during one of our first days at a parent and tot forest school when my daughter was 2 years old, another child walked up to my daughter and pushed her over. It happened fast. My daughter and I were both shocked. I was so busy trying to assess the group of kids and help my daughter stand near the group without freezing that I was not anticipating a direct knock-out! My daughter burst into tears and I provided comfort and eventually we carried on with the class. That day after nap, I began my storytelling. My daughter was visibly upset about the situation. We talked about how the other child was having a hard time that day and she was feeling mad. It was wrong of her to push. It was surprising and unexpected. We moved on to play as I did not want her to dwell on the event and I hadn’t actually thought of what the best strategy was moving forward! Even Mommies need time to think. In subsequent retellings, the animals suggested that my daughter say, “no” or “ouch! That hurt! Don’t push!” (I would have been lucky to have her make any sound directed towards another child, so it was a bit of stretch to suggest speaking. I was hoping for the “no”). For my part, I decided that I needed to be more upfront with the other child. A week later, we attended the next class and as the other child made another beeline to my daughter, I stepped forward and said (in the most enthusiastic, cheerful voice I could muster), “Hello, Jill, I like your whistle.” This preemptive invitation to a friendly interaction paid off. The child stopped moving towards us and looked at her whistle. Then I pointed out my daughter’s whistle. Then, the teacher started talking and we avoided a negative interaction. After a few more classes with forced Mommy-induced positive interactions, the other child had settled into forest school and I no longer needed to head her off at the pass! We retold the pushing story almost daily for weeks (usually from my daughter’s prompt). But by the end of forest school, my daughter talked about this other child in a positive way and included her in our “forest school play” at home. The other child was now referred to as a friend who rolled down hills and was a highlight of our forest school experience. The play-it-out method not only integrated her memory and feelings with the single pushing event but eventually, allowed my daughter to think more fondly of this child as we talked about her many positive attributes in our stories.

Another example is when my daughter was afraid of her little cousin who had learned to crawl! From an adult’s perspective, it was a funny scene: my 18 month old 80th percentile-size toddler slowly backing away and saying “no” with a sheer look of terror on her face from an army-crawling 10 month old 10th percentile-size baby. The little Crawler was desperate to get closer and touch my daughter and my daughter would repeatedly say “no” and fall into my lap and scramble up my body to get away from the little Crawler. My daughter could not focus on any activity if the Crawler was in the room. The only time she appeared to feel safe was in the highchair where the Crawler could not reach her. I used the animals to re-create the situation, and the animals came up with different ideas to cope with the little Crawler, like climbing onto the couch, giving the Crawler a toy, or having a snuggle with Mommy. After performing this play many times, my daughter started giving the Crawler toys, unprompted! It was amazing. My daughter still had great fears and concern about her little cousin. But, as we talked about more ideas (like Mommy will make sure everyone has food, since my daughter would be in a panic that the Crawler would eat all her food) and helped each of them have positive interactions, their relationship has grown to have more and more positive interactions. Now that they are 3 and 2.25 years old, they both speak in their own limited language (which does not overlap that much!) and “argue” about everything like whether it is raining. Whatever choice one makes the other makes the opposite, regardless of the weather or the truth. The little cousin always offers help when my daughter is upset and although my daughter still refuses that help, she occasionally offers hugs to her cousin when she is hurt!

In my next post I will discuss my struggle with balancing anxiety treatment and fears with life enjoyment.

behaviorally inhibited temperament

Seven strategies to use with young fearful children

As I witnessed the various atypical behaviours from my daughter (a selection of which are listed in the previous post), my partner and I started developing solutions. We fine-tuned our strategies as we read more articles and books. Here are some of the most successful solutions that we used from when our daughter was 7 months to the present time. 

  1. Our basic “discipline” guidelines and strategies came from reading Peaceful Parent, Happy Kids by Dr. Laura Markham. This positive parenting method has nothing to do with anxiety, but we found it a useful approach for coping with the regular trials of parenting (conflicts!). Markham describes an approach to discipline called “Empathic Limits”. In brief, discipline starts from a place of connection or attachment between parent and child [more info]. Then, the parent sets and enforces empathic limits using these steps:
    • Get down to the child’s level (with eye contact or physical touch)
    • Join with the child, “It looks like you’re having fun throwing sand”
    • State your concern, “I’m concerned someone is going to get hurt”
    • Use calm, kind, empathetic words as you set the limit, “I do not want other people getting hurt with sand, so let’s find a different way for you to use the sand now.”
    • Acknowledge her point of view as you set the limit, “It’s hard to stop what you are doing. But it’s time to find something else to do.”
    • Whenever possible, offer a choice, “Do you want to drive the truck through the sand or play on the slide now?”
    • If needed, calmly enforce an action, “I see you’re having difficulty safely playing in the sand where our friends are playing too. We are leaving the park now. We can try again tomorrow.” (aka “bring on the crying!”)
  2. For the long period of time when my daughter would “freeze” on the sidewalk and stare at another person until she burst out crying, I tried to “catch” her before the freeze by touching, talking and picking her up to comfort. Some people might think that this is rescuing behaviour which can actually make anxiety worse in the long run, but I thought it was more important to prevent the “freeze” response. My goal was to stop her brain from entering the freeze/fight/flight state, in which her brain and body would be overwhelmed by stress. I wanted my touch, words and voice to still have some influence before her automatic primitive brain took control. In hindsight, this “catching before the freeze” could be an early rung of an exposure ladder for an eventual goal of greeting our neighbours. Each step of an exposure ladder requires the anxious person to control their behaviour and commit to the step. If their brain is overwhelmed by stress and in a fight/flight/freeze, they are not in control. At 3 years old (and under pandemic conditions), my daughter rarely enters the freeze/fight/flight response. She will say, “no” and be resistant to novelty but she typically will not become paralyzed with fear anymore.
  3. A second strategy we employed for passing people on the sidewalk was to hold my daughter’s hand while we passed someone and label the person as a “kind neighbour out for a walk like us”. Usually, she did not like holding hands but when passing another person, holding my hand gave her the safety and comfort she needed to keep moving forward. The more times she walked by people without stopping (and freezing), the more times she experienced nothing bad happening! Although holding her hand does not directly address her fear of other people, the act of walking past people reinforces the tangential idea that there is no threat on the sidewalk. In addition, by labeling the person as a kind neighbour out for a walk, I created a familiar connection of someone being kind. This was a concept we had already celebrated when we first met a “kind doctor” when my daughter had a potential UTI. As well, it was a commonality between my daughter and the neighbour: they both like walking! At 3 years old, we still talk about neighbours walking in the neighbourhood and we practice brave talking.
  4. Bring a comfort toy (lovey) to all outings. I used this strategy based on our sleep consultant’s suggestion to provide an object that can be used to self-sooth for independent sleep and I was trying to create an attachment between my daughter and the object. It was so successful for sleep, comfort and soothing that I kept using it for general comfort for anxiety behaviours that typically occurred in social settings. Many people envision Charlie Brown’s Linus and his seemingly disgusting blanket being dragged around in perpetuity when they think of a child and her “lovey”. And in some respect, that’s true! (It’s good to have multiple loveys so they can be washed!) The lovey was one of the only things that allowed my daughter to calm when she escalated to fearful crying after freezing. Due to her sensory processing differences, my daughter dislikes being held, touched, hugged, etc., except on her terms, so having a lovey gave her comfort when hugging an adult was not helpful. At 3 years old, she brings a favourite toy outside and rarely uses it for comfort, but it is there if she wants it. She has loveys inside that still provide lots of comfort and joy. Maybe she will always have something soft to snuggle as she gets older. She may always need a lucky “rabbit’s foot” for comfort and I would rather she have a comfort object than to seek out food, cigarettes, drugs and alcohol to fill that need. Is Linus really so bad?
  5. Use a “brave” phrase to encourage my daughter to physically move forward: “1, 2, 3, go”. She would say this phrase at the top of a slide and then push herself forward, at the edge of a field to start running, and to continuing walking on the sidewalk before entering a “freeze” state. This was surprisingly successful. My partner and I would say the phrase and smile and encourage her to come forward and eventually she started saying it. I would even hear her whisper it and I could see her using it as a self-motivation tool. We have just recently returned to using mostly empty playgrounds since the pandemic and for the first few slides, I heard her counting to herself before pushing off! She no longer uses it for walking or running – she just walks and runs!
    • Note: Many inhibited children are also physically timid. When I described my daughter at almost 3 years old to the public health nurse, the nurse was shocked that she jumps, climbs, runs, rides a scooter, and rides a push bike. She was surprised my daughter was so physical. Since she was 7 months old, I have spent a lot of time at local parks and playgrounds every day. We were often the only ones there in the morning rain or shine. This allowed me to encourage physical bravery and physical movement without the inhibiting social factors of other children in busy playgrounds. She built confidence and had a natural interest in going fast, moving her body, and getting from one place to another. When we would go to busy playgrounds, she moved less, observed more and I had to “hover” much more because if she froze, she might suddenly let go of a ladder or swing or walk off a platform. But, as time went on and her confidence built, she was able to physically move past other people because she had enough muscle memory and confidence to keep her body moving even when her mind was in a state of stress.
  6. Lisa went through a few phases of being afraid of various slides and of sliding too fast. We showed her strategies of slowing herself down by using her hands and feet or by sliding on her tummy. As she went down the slide with a strategy, we would describe what she was doing and how she was controlling her speed. This gave her confidence that she was in control and she was safe. Eventually, she started sailing down the slides at full speed again!
  7. Modelling expected behaviour for child-to-child interactions. At busy play gyms or play spaces, I try to intervene with other children just prior to a physical altercation (which would then put my daughter in freeze mode). I spoke the words for my daughter saying things like, “No, my turn” or “I want to get out”, and I would describe to the other child what was happening, “She is using this toy. She is having a turn. You can have a turn when she is finished” or, “She is trying to get out of the house”. My daughter still has trouble speaking to others, but she is able to say these types of phrases to her cousin and she started turning her back to show kids at play gym that she was still using a toy. It’s not the ultimate behaviour I want, but they are steps in the right direction: remaining in control of her brain (staying out of the freeze state), using her body in a coordinated manner to express possession/turn-taking through body language, and starting to use appropriate phrases with another child in a low-anxiety setting.

You might notice that the outcome from some of these strategies does not meet your expectations for your child. You may feel strongly that they should not carry a stuffed animal when they are school-aged. And I completely understand why! Kids who are different are more likely to be teased and bullied at school. Unfortunately, your kid is who they are. You can try to change them into something else, but somewhere along the line that will probably backfire through rebellion or a poor parent-child relationship. However, you could prioritize weaning from a lovey at social settings like school and develop a story to help your child willingly leave the lovey at home. There are a few ideas to keep in mind when you think about your child’s behaviour and your expectations: are your expectations reasonable for your child’s age and developmental stage (i.e. make sure you are expecting typical or normal behaviour at the most, not advanced behaviour)? Are your expectations reasonable for your child’s inherent personality (given you may have an inhibited child, should you adjust your expectations)? If your child is not meeting many expectations, what are the priorities? Answering these questions may help you decide which goals are important and which ones you will let go of, for now.

In my next post, I will describe our play-it-out strategy that has evolved into a useful multi-purpose tool to help us process past events and prepare for the future.

Secure attachment and attachment parenting

Secure attachment between child and parent is now recognized as one of the most (if not the most) powerful and important influencing factor on a child’s wellbeing. Attachment has been tested by researchers using the “Strange Situation” experiment. The results of the experiment indicate whether the child is attached and how they are attached to the parent. In fact, the first thing our child psychologist did when she met my daughter and me was to conduct a version of the “Strange Situation” to confirm that we were attached. The psychologist said that there was no intervention for anxiety or any other problems that could be administered without attachment. Attachment appears to be generated through responsive parenting during infancy and babyhood. It is not simple to define exactly what behaviours the parent needs to exhibit to create attachment. There are many roads to having an attached child.

Attachment parenting is a parenting philosophy first proposed by Dr. William Sears with basic advice about how to parent with the goal of creating a secure attachment between parent and child. The problem is that the specific strategies are not all supported by research as necessarily creating secure attachment. Unfortunately, much of the advice can end up creating unnecessary stress on the parent-child relationship when the parent, for any reason, doesn’t follow the advice (i.e. vaginal delivery, breastfeeding, baby-wearing) and instead feels guilt, shame, and anxiety about not doing what Dr. Sears recommends. For some reason, this parenting philosophy seems to have created a militant following, such that there can be associated parent- (usually mother-) shaming if you don’t do attachment parenting. If you strongly support Dr. Sears’ attachment parenting philosophy and it has worked for you, that’s wonderful, but it is not the only way of creating a secure attachment with a child and for many parents and children, other strategies are more successful at creating a secure attachment and maintaining the parent’s mental health.

This article is a great summary of the differences between secure attachment and Attachment Parenting by developmental psychologist Dr. Divecha. This article is a summary of how a parent can create a secure attachment with their child and provides an interesting comparison between “secure attachment” and “bonding” (terms that are often incorrectly used interchangeably).

behaviorally inhibited temperament

Behaviours associated with an inhibited temperament

Now that we’ve seen a few tools in action (explanatory stories, brave stories, exposure ladders, routine chart), I am going to circle back around to talk about what motivated me to start investigating temperament and anxiety: my daughter’s behaviours in infancy. This ultimately led me to the brave tools that I am currently using.

From my daughter’s 3rd month of life, I knew her reactions to the environment were atypical. As time went on, I also knew she was not meeting social expectations/milestones for age-matched peers. There are plenty of books that advise parents not to worry about meeting milestones. Child development varies widely across children and a child who does not speak at two years might speak in full sentences by three without any intervention. On the other hand, delays in achieving milestones can indicate developmental issues that are best treated early or at least monitored by a healthcare professional. But how does a parent know when to wait and see and when to act? I started making a list of behaviours that were “different” when my daughter was around 18 months. There are too many behaviours to list all of them, but this is a representative sample. Each behaviour is not necessarily remarkable but taken together they paint a picture of a fearful child.

  • At 3 months Lisa was held by my friend. One week later, the same friend came over and upon seeing her, Lisa burst into tears; from that point forward, Lisa exhibited fear (crying) for all people other than mom and dad.
  • Lisa tracks/monitors every person in the room and is clearly concerned if someone “disappears” from view. Once she could make sounds, she called a person back when they left the room.
  • If a “stranger” (friend/acquaintance with child) comes into our house, Lisa sits in my lap, unable to do any activity.
  • At 5 months, Dad went on a five-day work trip. When he returned, Lisa cried and would not go to him. It took approximately 24-48 hours for her to warm to him again.
  • From 11-16 months, when we would walk down the street Lisa would fixedly stare at a stranger. After a couple minutes, she would burst into tears. She seemed paralyzed prior to crying.
  • At play gym if another child approaches or takes her toy, Lisa appears stunned and does not respond. If another child blocks her way out of an enclosed space or end of a tunnel, she will become afraid, panicky and eventually burst into tears.
  • Around 13-14 months, Lisa ran into the bathroom and saw the bathmat moved off the floor. She ran out of the room crying.
  • By 18 months, Lisa “freezes” and then bursts into tears if I talk to another mom at play gym or the park.
  • When Lisa is alone at the park, she makes sounds, sings, says words, and smiles; if another child approaches, she stops moving and making sounds. Her facial expression is blank. She stares at the child and is unable to continue with her activities.
  • Lisa stands off the sidewalk if she sees another person or dog walking, up to a block away (in either direction – behind or ahead of us). She waits for them to pass us (or turn a corner) before continuing.
  • By 21 months, Lisa smiles when she sees someone she likes arrive at a park (Grandpa, Gammie, Daddy), but when the person approaches, she shies away and hides behind my legs or indicates she wants to be held.
  • Lisa cried and hid when she observed Auntie letting out her hair from a ponytail.
  • At 2 years old, Lisa refused to get into the swimming pool when the music for aquacise was playing (although she was already in her bathing suit and showered). She said “no, stop” when the announcements played over the PA system at Science World and wanted to leave the Aquarium.
  • Lisa asks to sing songs outside music class and seems to express interest in going to class, but she will not participate in the class and “melts” into me if the teacher tries to touch her or speak to her directly.
  • Lisa is unable to go down the slide when another child is near the bottom or the side or is looking in her direction.
  • When staying at other places (grandparents’ house), Lisa reduces her food and liquid intake and appears distracted and unable to be calm.
  • Most recently, at almost 3 years old, Lisa reacted negatively upon seeing Daddy after he had trimmed his beard (no eye contact, avoidance). The next time Daddy trimmed his beard, we asked her to watch. After she watched and received a brave sticker, she was almost in tears and wanted to snuggle with Mommy.

If you met my 3-year-old daughter today, you would probably label her as shy and quiet. You might think she is timid and sedentary, and she may even seem a little dull! She probably wouldn’t speak to you and she might try to pull me away from you and eventually she might start crying from a seemingly miniscule event like falling down or eye contact! But she is a completely different child in her comfort zones at home, with select family members or outside alone. She sings, dances, runs, jumps, talks, builds, tells stories and moves constantly. This dual personality is typical of children with behaviorally inhibited temperaments [more info] and often only their parents and a few chosen people are privy to all the amazing parts of their personality. When my daughter was just under 2-years-old, I tried to record her different behaviours but unfortunately, she is also influenced by the camera such that she becomes more inhibited. I was not coordinated enough nor had the forethought to set up the camera unobtrusively. As a result, the differences that I captured are minimized on camera: the inhibited behaviour is more mild than typical because I couldn’t step back and film during extreme inhibition behaviours and she altered her behaviours, due to the camera, for the comfortable/uninhibited situations! Nevertheless, these videos provide a small glimpse into the range of behaviours exhibited by my behaviourally inhibited child.

My daughter exhibits inhibited behaviour. She is trying to tummy swing but focuses almost exclusively on another child and her mother playing on neighbouring equipment. The other child moves to the neighbouring swing and Lisa tracks the movement. Interestingly, at the time, I celebrated this behaviour because she was still able to push her feet against the ground. Typically, she would leave the swing and “melt” into me or hang completely limp on the swing. We were making progress!
My daughter is uninhibited while playing with the swings. She makes noises and is active. Daddy arrives and she starts tummy swinging and “cawing” like a crow, then says “sit” to indicate she wants help to sit on the swing. This video was recorded just 10 minutes after the “inhibited” video! Notice that she immediately changes tasks when she notices Daddy arrive. She does this even now. When someone arrives, she does not go to them nor hug them, and she barely acknowledges them. Instead, she will switch to a very active task. It is as if she gets a surge of adrenaline and needs to release it (my hypothesis is that this is the start of a “flight” response, but she is able to control it before completely succumbing to her amygdala).

As I tracked my daughter’s behaviours, I came across the description of a childhood anxiety disorder called selective mutism [more info]. When I read about the behaviours associated with selective mutism, it described my daughter perfectly. She was too young for us to determine if she was “mute” around other people, but everything else aligned well. I found a child psychologist in the city that specialized in childhood anxiety, selective mutism, and worked with very young children. While on the wait list, the psychologist recommended I start reading about the behaviourally inhibited temperament, since a 2-year-old would never be diagnosed with an anxiety disorder like selective mutism.

From what I have read, the behaviours of a child with either an anxiety disorder like selective mutism or a behaviourally inhibited temperament can be identical. Researchers have found that a behaviourally inhibited temperament in infancy is predictive of future social anxiety disorders, but not all people with an inhibited temperament will end up with an anxiety diagnosis (Kagan et al., 1992 and Degnan and Fox, 2007). Most children with anxiety disorders are diagnosed during school years, while temperaments can be detected by 3 months of age in infants. As I was writing this blog, I came across this article that proposes exactly what I have wondered: is an inhibited temperament different than an anxiety disorder or is it just an anxiety disorder that is observable in infants? The article does not answer the question as the research is not there yet. Ultimately, does it matter if your very young child (less than 3 years old) has an inhibited temperament or an anxiety disorder? If you’re looking at ways to help your child with behaviours and fears, then probably not; if you’re looking at how to understand your child and how to describe your child to other people, then it might make a big difference.

Mental health has a stigma associated with it. When someone hears that a young child has an anxiety disorder, they may have unhelpful thoughts:

  • the parent caused that (judgement)
  • the child is damaged (hopelessness)
  • the child should be fixed (judgement and power)
  • we need to make that child behave like this other “normal” child (control)

But if a person hears that a child has an inhibited temperament that is a stable part of personality, they will likely have different thoughts:

  • What is an inhibited temperament? (curiosity and learning)
  • I wonder what temperament I have and what I was like as a baby (curiosity and learning and possible recognition of genetic influence)
  • I guess that’s just who the child is (acceptance)
  • So that’s why that child is different than this one (understanding)
  • It looks like that child needs extra help with that task (empathy)

Many parents do not consider temperament when they have babies (and why should they? Not many people talk about it!), nor do they know how temperament is defined. Medical professionals do not educate new parents on this topic. Instead, they say the baby has “colic”, the toddler is “shy” or “slow to warm” (aka cold). Other parents can provide unhelpful advice such as expose the child and “socialize” them to fix their behaviours (aka cure them), leave the child to cry because this is the “real world” and the kid needs to adapt. But these words and ideas do not define temperament, they do not encourage respect of the child, nor do they validate that temperament is normal and stable. Children with different temperaments behave differently and that is okay.

One of my concerns as I read about behavioural inhibition, anxiety and treatments and prepared for my first appointment with the psychologist was that she would try to make me convert or change my daughter into the opposite of who she is. However, I was relieved when the psychologist confirmed that:

  1. Inhibited temperaments are stable through life.
  2. There is no cure for anxiety since the brain (amygdala) is designed to experience anxiety with fight/flight/freeze responses to threats.
  3. Bravery is not about eliminating fear but about accomplishing things that have meaning to us to lead a healthy and happy life, despite fear.

I often consider these points as I reflect on my daughter’s latest fears or most severe ongoing fears (talking and interacting socially). She is who she is. My job is to facilitate her interests and support her in finding contentment in her life. Hopefully, I will achieve this by providing a secure, loving foundation with tools she can wield to meet and overcome challenges. I want her to know that she can feel fear and still be brave and move forward towards her goals. She does not need to reach my potential or achieve my goals or become the person I am. Parents often talk about wanting their child to reach their full potential, but that is almost always code for wanting the child to reach the parent’s idea of potential. Ross Greene has a wonderful discussion in his book Raising Human Beings about accepting the cards you are dealt in life and moving forward together: parent and child. Will my daughter ever be the charismatic life of the party type? Probably not. Will she find a creative way to make her mark on the world? I think that is a very real possibility.

In my next post, I will describe seven useful strategies that we used to help our anxious daughter when she was less than 2 years old.

behaviorally inhibited temperament

The developmental psychologist Jerome Kagan studied temperament in infants and defined two temperaments: inhibited and uninhibited. Kagan described these temperament profiles as shy, timid, and fearful for the inhibited child and bold, sociable, and outgoing for the uninhibited child. Inhibited infants reacted more strongly to novel objects compared to uninhibited infants. Kagan and others also found that inhibited temperaments in infancy are associated with anxiety disorders in adolescence and adulthood. Researchers have suggested that parenting styles and cognitive behavioral strategies can positively affect an inhibited child’s response to novel stimuli, especially social situations, and reduce their fear response to prevent the onset of future anxiety disorders.

selective mutism

Selective Mutism is a childhood anxiety disorder characterized by a child’s fear of speaking in specific social situations (typically school). Children with selective mutism often have a genetic predisposition to anxiety and exhibit extremely inhibited temperaments as infants and toddlers. Like any anxiety disorder, the person’s brain has an over-active amygdala that is triggered into fight/flight/freeze by typically non-threatening events (like social situations). Many children with selective mutism also have sensory processing difficulties such that their brain may be over-reacting to smell, sight, touch, sound and/or taste stimuli causing inflexibility, frustration, and feelings of anxiety. A few typical behaviours include inability to speak in select social settings, blank facial expressions, lack of smiling, awkward body language, physical symptoms and negative behaviours prior to social activities.