m o d u l e04 Stress Management Stress Management module 04 1 Module 4: Stress Management — a toolkit for health professionals When discussing stress with children and youth, it’s important to remember that experiencing some stress is normal and necessary, and should not be pathologized or feared. This positive stress (or eustress) is healthy and gives one a feeling of fulfillment. It can motivate, increase performance, and provide opportunities for learning. For children and youth, examples include giving a presentation in school or pushing themselves to master a new skill. Children and youth, like adults, will inevitably experience daily hassles or con- cerns (e.g. having too much to do with too little time, negotiating with parents) and unexpected demanding situations or events (e.g. divorce). Children and youth can respond to these situations in a positive or healthy way by employing appropriate stress management or coping strategies, or in a negative way by not employing (or employing unhealthy or risky) stress management or coping strategies. While the demanding situation or event may not be in the child’s control, their response to the situation can be adjusted so that challenges are confronted in a healthy way. Healthy coping and stress management can reduce the negative impact of stress, which can affect both the physical and mental health of children and youth. For instance, negative stress can lead to headaches, abdominal pain, nervousness and sleeping difficulties as well as increased risk-taking behaviour, anxiety or depression.1,2 Chronic stress can contribute to lower immunity, can aggravate autoimmune disorders11, and may play a role in the development of cardiovas- cular disease and metabolic disorders including obesity, insulin resistance, and Type 2 diabetes mellitus.3 Health care professionals can play an important role in identifying and helping children and youth cope with stress. This module provides you with information to promote healthy coping and stress manage- ment for children and youth with mental health challenges. 04 m o d u l e Stress Management Key Messages Discussing Stress with Children and Youth Stress Management Strategies Resources and Handouts S ect i o n 1 : S ect i o n 2: S ect i o n 3 : S ect i o n 4: This module is comprised of the following sections: Healthy coping and stress management can reduce the negative impact of stress, which can affect both the physical and mental health of children and youth Module 4: Stress Management — a toolkit for health professionals 2 Here are some key messages to keep in mind when discussing stress with children, youth and their families: 1. WHAt YoU Do AnD HoW YoU tHinK cHAnGeS tHe WAY StReSS AFFectS YoU Let children and adolescents know that stressful events happen to everyone, and what is important is how they react to these stressful situations – if they react with effective coping and stress management strategies, they will be able to manage the demanding situation in a healthy way. 2. StReSS cAn AFFect HoW YoU FeeL, tHinK, AnD Act All young people will experience stress differently, and their reactions can vary depending on their age. Being able to recognize how they react to stress is important to help build prevention skills so that the next time a stressor occurs, they can use an effective coping strategy before they experience a negative stress reaction. Some ways to help children and youth recognize their reactions to stress can be found in Section 2. 3. StReSS MAnAGeMent iS not ‘one SiZe FitS ALL’ Different strategies will work for different children and youth in different situations. Strategies discussed in Section 3 include appraisal-focused strategies (modifying the way one thinks), problem-focused strategies (dealing with the cause of the problem) and emotion-focused strategies (such as employing relaxation techniques). It’s important to find a strategy that works for the individual child, and is appropriate for the type of stressor they are reacting to. 4. iS it StReSS oR SoMetHinG MoRe SeRioUS? WHen to ReFeR All children and youth will experience some stress in their lives. However, the symptoms of stress may be similar to the symptoms of a more serious mental health concern, and may require a referral to an appropriate health professional. Information to help you make this distinction can be found in Section 2. S e c t i o n 0 1 Key Messages All young people will experience stress differently, and their reactions can be quite different depending on their age 3 Module 4: Stress Management — a toolkit for health professionals S e c t i o n 0 2 Discussing Stress with Children and Youth In this section, key considerations to keep in mind when discussing stress with children and youth are offered. These include tips for bringing up stress, helping a young person identify their reactions to stress, and making the distinction between stress and mental health or substance use concerns. Many children and youth may not understand what the word ‘stress’ means. In order to help them understand what stress is, here are some different ways you could describe it: • Instead of using the word ‘stress’, you could try using other related words such as ‘worry’ • Earl Hipp, in his book Fighting Invisible Tigers: Stress Management for Teens (2008)5, suggests that stress could be described as “the feeling you have when facing many challenges all at the same time”, and that it may be helpful to get youth to imagine all of their worries and problems as separate rubber bands around their heads, and the pressure they feel from the rubber bands as stress • Kenneth Ginsburg, in his book A Parent’s Guide to Building Resilience in Children and Teens (2006)29 suggests describing stress as “the uncomfortable feeling you get when you’re worried, scared, angry, frustrated, or overwhelmed. It is caused by emotions, but it effects your mood and body.” He also suggests relaying to teens that “many adults think that teenagers don’t have stress because they don’t have to work and support a family. They are wrong!” This approach to describing stress can help to normalize and validate the youth’s stress • Some children and youth with mental health challenges have difficulty under standing emotions, including emotional reactions to stress.4 A re- source to help children/youth recognize emotions can be found here: http://www.drcheng.ca/resources/Articles/mood_scales-facesforallages.pdf. When bringing up stress with young people, start by asking the child or youth if anything is worrying them or stressing them out. If the child or youth can’t describe or pinpoint anything, try providing some prompts – for example, Bringing it up Module 4: Stress Management — a toolkit for health professionals 4 QUeStionS to HeLp YoUnG peopLe RecoGniZe tHeiR ReActionS to StReSS: • How does it feel when you’re stressed? • How would you know when you’re stressed? • What sort of thoughts do you have? • How does it affect your behaviour? • How do you act towards others at these times? • How do other people behave towards you? • How would you recognize stress in others?6 you could ask if anything is bothering them at school, at home, or in their relationships. You might also want to start by asking the “three wishes” question: “If you had three wishes and could change any three things in yourself, your life, or your world – what would they be?” The first step in discussing stress with children and youth is helping the young person to recognize their reactions to stress. Discussing current stress helps the young person build prevention skills so that next time, they can use an effective coping strategy before they experience a negative stress reaction. Explain to children and youth that stress can affect how they feel (mentally and physically), how they think, and how they act – questions to help young people recognize their reactions to stress can be found on the left hand side of this page. Some health professionals find it helpful to discuss the biological and evolutionary underpinnings of stress (the ‘fight or flight response’), as this can lead to a more intuitive understanding of how stress affects the mind (mood, emotions, thinking) and the body (cardiovascular, respiratory, immune, etc.). It can also help the child or youth start to identify their own responses to stress. Some ways to describe this to children and youth can be found on the KidsHealth website (kidshealth.org), in the book Fighting Invisible Tigers by Earl Hipp, or in the book A Parent’s Guide to Building Resilience in Children and Teens: Giving Your Child Roots and Wings by Dr. Kenneth Ginsburg (details on how to access these books can be found in the resource section, under ‘Books’). Some ways in which children and youth may react in a negative way to stress include:7 • Acting out • Eating or sleeping difficulties (such as nightmares) • Irritability or crying a lot • Withdrawing from others • Losing interest in school or friends • Physical signs like headaches and stomachaches • Going back to behaviours they outgrew, like wetting the bed S e c T i o n 2 : D i S C u S S i n g S t R e S S W i t H C H i l D R e n A n D Y o u t H discussing Reactions to Stress 5 Module 4: Stress Management — a toolkit for health professionals S e c T i o n 2 : D i S C u S S i n g S t R e S S W i t H C H i l D R e n A n D Y o u t H Pre-teens and teens may also show stress by: • Going against rules or expectations • Showing a lot of anger or distrust • Exhibiting poor self-esteem, like putting themselves down or assuming that others won’t like them • Engaging in risky behaviours such as using drugs or alcohol, engaging in unsafe sex, skipping school, or getting into fights It’s important at this stage to explore what effective and healthy coping skills the child or adolescent already uses, who their supports are, and what they can identify as their strengths and resources. Try asking them: • When you’re stressed out, what do you do to help yourself feel better? • Who can you talk to about it? For more information on helping children and youth identify and build on their strengths and assets, see Section 3 (under ‘Focusing on Strengths and Resources’). Once both current reactions to stress and current coping skills/resources have been explored, move to building on the child or youth’s current strengths, and suggesting stress management strategies they could try to prevent negative stress reactions from occurring in the future (see Section 3 for a review of strategies). MAKinG tHe DiStinction BetWeen StReSS AnD MentAL HeALtH oR SUBStAnce USe conceRnS All children and youth will experience some stress in their lives. However, the distinction must be made between stress and more serious mental health or substance use concerns, such as anxiety or depression. If you suspect that the reactions above may actually be a sign of a mental health condition, refer to an appropriate health professional. The Kelty Mental Health Resource Centre (keltymentalhealth.ca) can provide you with information on how to make this distinction, and if necessary provide referral options. Additionally, some major stressors are beyond the ability of children and adolescents to cope without KeY SUppoRtive FActoRS incLUDe: • Family • Peer Supports • Caring Adult Support • Spiritual/Religious Support • Hobbies • Creative outlets • Connection to School discussing Skills and Resources When to Refer Module 4: Stress Management — a toolkit for health professionals 6 S e c T i o n 2 : D i S C u S S i n g S t R e S S W i t H C H i l D R e n A n D Y o u t H professional help, and should be referred to an appropriate professional im- mediately (e.g. sexual abuse, witnessing violence). One mental health condition that has many overlapping symptoms with stress is anxiety – while some signs of stress are also common signs of an anxiety disorder, stress and anxiety disorders are not the same thing. With stress, signs go away as stress lessens. With an anxiety disorder, the signs continue to affect a child’s life long after a stressful situation or event is over.7 If you suspect that the child or youth you are seeing may have an anxiety disorder, visit Anxiety BC for more information on signs, symptoms, and treatment options: www.anxietybc.com. Teenagers sometimes use substances, such as alcohol, tobacco, cannabis, caffeine, or other drugs to cope with stressors in their lives.3 Excessive or inappropriate use of alcohol or other drugs can interfere with daily life and negatively affect school, relationships, and physical and mental health.11 If you suspect the child or youth you are seeing is using substances in an exces- sive or inappropriate way, resources and referral information can be found on the Kelty Mental Health Resource Centre website (keltymentalhealth.ca), the Youth in BC website (www.youthinbc.com/learn-more/drugs-alcohol- addictions), or the Alcohol and Drug Information and Referral Service website (http://bc211.ca/adirs2.html). While some signs of stress are also common signs of an anxiety disorder, stress and anxiety disorders are not the same thing 7 Module 4: Stress Management — a toolkit for health professionals This section details key stress management strategies that health profession- als working with children and youth with mental health challenges may find helpful. Additional strategies suggested by families can be found in the Guide to Healthy Living for Families, available from: keltymentalhealth.ca/toolkits When discussing stress management strategies, work with the child or youth to choose a strategy and help them to develop a small, achievable goal (a SMART goal) using the resources provided in Module 1. StReSS MAnAGeMent StRAteGieS ReLAxAtion tecHniQUeS HeALtHY LiFeStYLe & enviRonMent HeALtHY tHinKinG BeHAvioURAL StRAteGieS S e c t i o n 0 3 Stress Management Strategies Relaxation techniques have been shown to have immediate relaxation effects on children and youth, both physiologically as well as subjectively.12,13,14 Relax- ation techniques are found to be especially effective for situations that are not under the personal control of the child. In addition, relaxation techniques may be particularly beneficial for children who worry a lot, who can’t settle down, who are distractible or hyperactive, who have difficulty falling asleep, or who have depression or anxiety.4,14,15 Some techniques that have been found to be effective with children are detailed below. When choosing a technique, keep in mind the child’s personal prefer- ences and developmental stage. Resources (text, audio and video) of some of the relaxation strategies described below can be found in the resource section. Deep BReAtHinG Deep breathing (‘belly breathing’) is one of the easiest and quickest ways to relax, as it can be done anywhere and at anytime. It allows young people to visit their ‘calm centre’ whenever they start to feel overwhelmed by stress.5 In order to help children and youth understand deep breathing, you can: Relaxation Techniques expLAininG ReLAxAtion to YoUnG peopLe You could try explaining relaxation to young people as “finding your calm centre”, and as a way to relieve tense muscles and relax your brain5 Module 4: Stress Management — a toolkit for health professionals 8 • Describe the difference between how we breathe when we are stressed (fast and shallow) and how we can breathe when we are relaxed (slow and deep) • Fast/shallow breathing is breathing that comes from your chest, while deep/ slow breathing comes from your stomach/belly pRoGReSSive MUScLe ReLAxAtion Progressive muscle relaxation (PMR) is a method of systematically tensing and relaxing muscle groups throughout the body. This technique can be done during the day or in the evening to relax or aid sleep. PMR has been found to benefit children experiencing stress2,15 and has been used as one of several techniques to treat a variety of childhood difficulties, including anxiety dis- orders, sleep disturbance, hyperactivity and impulsivity.16 It is important to ensure that the technique used is developmentally appro- priate. For some children, having an adult guide them through the process may be helpful. Additionally, metaphorical PMR scripts (e.g. pretend you are a turtle going into it’s shell) are preferred by some young children to literal PMR scripts (e.g. squeeze your shoulders to your ears).16 A simple PMR script can be found on the Quick Ways to Relax handout, found at the back of this module. MASSAGe tHeRApY Massage therapy may help to reduce stress levels in children and youth with certain mental health conditions. Massage therapy has been shown to be ef- fective in reducing stress levels in child and adolescent psychiatric patients14, S e c T i o n 3 : S t R e S S M A n A g e M e n t S t R At e g i e S • Inhale slowly for 4 seconds through the nose • Ask the child to pretend that he or she is blowing up a balloon in the belly, so the child’s belly should inflate when inhaling • Wait 2 seconds, and then slowly exhale through the mouth. Ask the child to pretend that he or she is emptying the balloon of air, so the tummy should deflate • Wait 2 seconds, and then repeat When belly breathing, make sure the child’s upper body (shoulders and chest area) is fairly relaxed and still.17 BeLLY BReAtHinG FoR cHiLDRen: 9 Module 4: Stress Management — a toolkit for health professionals reducing sleep problems and difficult behaviour in children with autism18,19, and increasing feelings of happiness in adolescents with ADHD.20 If you feel massage therapy may be beneficial for a child or youth you are seeing, refer to a registered massage therapist who has experience with this population. viSUALiZAtion Visualization (or mental imagery) is a potent method of stress management, especially when combined with physical relaxation methods such as deep breathing.21 There are different ways of practicing visualization – some may be more effective for general feelings of stress, while others may be more effective for specific worries. Additional visualization techniques for children can be found in the book Taming Worry Dragons: A Manual for Children, Parents, and other Coaches (4th Ed.). See the resource section under ‘Books’ for details on how families can order this book, free of charge, to anywhere in B.C. Children or youth can be instructed to close their eyes and picture themselves in a calm, peaceful environment. They can then describe to themselves what it looks, sounds, smells and feels like. They can return here when they feel stressed or worried. It may also be helpful for them to find a quiet place in their home or school where they can go to practice visualization. A simple visualization exercise can be found at the back of this module (on the Quick Ways to Relax handout). The worry box is a place to ‘trap’ worries so they’re not running wild in the child’s mind, and the child/youth knows where they are. Creating a worry box involves the child/youth creating a picture in their mind of a place to put their worries for safe keeping, like a drawer, jar or locker. Worries can be put into the worry box and locked up – the box can be opened at a later time to take out a few worries and think about ways to solve them.22 S e c T i o n 3 : S t R e S S M A n A g e M e n t S t R At e g i e S GeneRAL viSUALiZAtion SpeciFic viSUALiZAtion – tHe WoRRY Box Module 4: Stress Management — a toolkit for health professionals 10 Playing with pets has been found to be particularly beneficial at reducing stress levels and increasing emotional well-being25 S e c T i o n 3 : S t R e S S M A n A g e M e n t S t R At e g i e S MAintAininG A HeALtHY LiFeStYLe Being physically active, as well as eating and sleeping well, are some of the best stress-management strategies. Maintaining a healthy lifestyle can help keep the immune system strong and energy levels high, and can help to reduce muscle tension and mental fatigue that accompany stress.3,5,6 For more information on healthy eating, physical activity or sleep please refer to the other modules within this toolkit. contAct WitH nAtURe Contact with nature can reduce feelings of stress and increase well-being.23,24 Try encouraging children and their families to spend time outdoors, and if possible in or near nature. A handout for families at the back of Module 3 provides some ideas for being active outdoors. In addition to actually being in nature (e.g. parks, wilderness, areas with trees or water), studies show that viewing images of nature also helps to relieve stress and improve well-being.26 SociAL SUppoRt A healthy social environment, most importantly social support, has been found to be one of the most important factors in lowering feelings of stress.8 For teens, this social support – especially from peers – is particularly important. This seems to be especially true for teenage girls, as they are most likely to go to their friends for support when they are feelings stressed.1,3,6 A website developed specifically for teenage girls dealing with stress is: www.howtochill.ca Ask young people to think about those who can give them support when they need it, and encourage them to talk to trusted friends and family members or other trusted adults about their worries. Learning to think in a healthy way is a powerful stress management tool. It allows children and adolescents to control the way situations affect them and how (or if) other people affect them. Healthy Thinking Healthy lifestyle & environment 11 Module 4: Stress Management — a toolkit for health professionals coMMon tHinKinG tRApS • overgeneralizing (using words like ‘never’ or ‘always’) • Black and white thinking • Jumping to unfounded conclusions • taking things personally • exaggerating the conse- quences of a situation • Predicting something bad will happen, without any evidence • Focusing on the negative in a situation and ignoring the good • telling yourself how you “should” act 11 S e c T i o n 3 : S t R e S S M A n A g e M e n t S t R At e g i e S AvoiDinG tHinKinG tRApS Talking to young people about the link between their feelings and thoughts can show them how managing difficult thoughts can help to minimize feelings of stress: while external circumstances can’t always be changed, their reaction to these situations can. Research has shown that people who reinterpret a stressful situation in a more balanced way have a less intense response to the stressor.6 One of the most common thinking traps is engaging in negative self-talk. Encourage children and youth to think about what their negative self-talk is, and how they can re-frame it. The new script might include things such as: 22 • “I can handle it” • “I will try my best and not worry about it” • “Just because ____ is nasty to me doesn’t mean everybody dislikes me” Changing their method of self-talk may take some practice, and writing down both their negative and positive (or ‘red’ and ‘green’) thoughts can be helpful. Resources for managing self-talk can be found in the resource section (under ‘Anxiety BC’ and ‘Here to Help’) as well as in the Guide to Healthy Living for Families. FocUSinG on StRenGtHS AnD ReSoURceS Stress can be seen as a badly tipped scale, with more demands on one side than personal coping resources to deal with them. Stress management can look at decreasing the demands, but it can also look at boosting the personal resources to cope.8,9,10 When discussing stress with children or youth, it is important to help them identify their internal and external resources for coping with stress. For instance, internal resources could include believing they can handle stress, or having high self-esteem or a sense of humor. External resources could include support from friends, family or teachers. Try asking children or youth to think about a time when they did something well or accomplished a task to get them thinking about their strengths and resources. You could also encourage them to think about and write down the positive things in their lives, such as people, things or talents – this simple technique has been shown to be effective at helping youth to not dwell on the negatives.5 Another technique is getting the child or youth to keep a gratitude journal, in which they write down what they are grateful for each day. This can be done individually by the child, or as a family. Module 4: Stress Management — a toolkit for health professionals 12 Mindful behaviour involves an individual being fully in contact with what is taking place in the present moment S e c T i o n 3 : S t R e S S M A n A g e M e n t S t R At e g i e S Behavioural Strategies MinDFULneSS Mindfulness is the practice of “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally”.34 Thus, if a child/youth was walking to school ‘mindfully’, they would practice maintaining a continuous awareness of their breathing, pay attention to the feeling of their bag on their shoulder, and perhaps the mild tension associated with approaching the school.31 A growing body of research suggests that mindfulness-based psychosocial interventions are effective for a wide range of mental health and physical health disorders in adult populations.32 For example, research in adults has shown that mindfulness-based stress reduction (MBSR), an evidence-based group training program for managing stress, can significantly reduce anxiety and panic symptoms, depressive relapse, and psychological distress in both clinical and healthy, stressed populations.32 Preliminary research on mindfulness-based interventions with children and adolescents is emerging, with promising results.30,31,32,36 For example, in a number of recent pilot studies, child and youth participants in MBSR training reported increased relaxation, improved sleep and concentration, greater self-awareness, and less emotional and behavioural reactivity.32,33,36 Mindfulness-based interven- tions with children and adolescents in school- and community-based settings have also shown promise.30,31 If you feel that a mindfulness-based intervention may be useful to the child or youth you see in your practice, you may want to explore opportunities in your community. Additional information on mindfulness can be found in the resource section of this module. tiMe MAnAGeMent Stress can be caused by not having enough time to get everything done. For children and youth with some mental health conditions, managing time can be especially challenging – for instance, children with ADHD may have difficulty organizing tasks or activities, and can be easily distracted.27,35 13 Module 4: Stress Management — a toolkit for health professionals SettinG pRioRitieS: tHe ABc MetHoD • Write out all of the things that need to get done in the near future • Mark the very important ones as ‘A’, pretty important ones as ‘B’, and things that would be nice to do but not essential as ‘C’ • order these by letter • Within each letter priori- tize again by number (i.e. A-1, A-2, A-3, etc.)5 S e c T i o n 3 : S t R e S S M A n A g e M e n t S t R At e g i e S Five StepS to pRoBLeM SoLvinG Step 1: Choose the problem Step 2: understand the problem Step 3: Come up with different solutions Step 4: Compare the solutions Step 5: Find the best solution and put it into action28 Some top time management tips include: • Writing out a weekly schedule and looking for ways to make it more balanced • Practicing the ‘ABC Method’ of time management (see text on the left hand side of this page) • Practicing saying no to tasks that are unimportant or that there simply isn’t enough time for • Getting enough sleep – this ensures you have enough energy to get all necessary tasks done (see Module 5 for more information on getting a good night’s sleep) Links to child- and youth-focused websites that discuss time-management skills can be found in the resource section. pRoBLeM SoLvinG Problem solving is a skill that can be applied to many situations. It can help to decrease stress once it has occurred, and can help to prevent stress from occurring in the first place. While the steps for solving problems are fairly straightforward, many children and youth have not learned these steps.6 Five simple steps to problem solving can be found on the left hand side of this page. Some questions that can be asked to help the child/youth understand the problem include: 28 • Have you had this problem before? How did you handle it? • Is there anything more you need to know about this problem before you can solve it? • Are there people who can help support you in solving this problem? An important component of problem solving is knowing the difference between problems that can be solved and problems that can’t. For problems that can’t be solved, coping techniques such as healthy thinking or relaxation may be more beneficial. A problem solving worksheet for younger children can be found as a handout at the back of this module and resources for youth can be found in the resource section (under ‘MindCheck’ and ‘Here to Help’). Module 4: Stress Management — a toolkit for health professionals 14 GeneRAL StReSS organization details Web Address Adolescent Health Working group • Adolescent provider toolkits; stress management section in the Behavioral Health toolkit www.ahwg.net/knowledgebase/ nodates.php?pid=79&tpid=2 Anxiety BC • Resource on stress management and anxiety specifically for youth and young adults http://youth.anxietybc.com/ Child & Youth Health • information on stress written for younger children, including relaxation exercises www.cyh.com (type in ‘kids and stress’ in the search bar) Kelty Mental Health Resource Centre • information on stress management, including a healthy thinking interactive activity, for children, youth and families http://keltymentalhealth.ca/ healthy-living/stress KidsHealth • Web page for parents with info on recognizing signs of stress in children and helping them cope kidshealth.org/parent/emotions/ feelings/stress.html • information for teens on recognizing and dealing with stress; includes an audio breathing exercise kidshealth.org/teen/your_mind/ emotions/stress.html# Here to Help • Handouts on stress, problem solving, healthy thinking and more www.heretohelp.bc.ca mindcheck.ca • Stress management resources for young people, as well as mental health screening tools http://mindcheck.ca/mood-stress online Resources Resources and Handouts S e c t i o n 0 4 In this section, you will find resources that may be helpful to both yourself as well as to the families you see in your daily practice. At the end of this section, you will find some tools and handouts. Some of these tools will be useful for you to use with the children and youth you see (e.g. assessment tools), while others can be given to children, youth or parents/caregivers as a handout.