Big Crowds Anxiety

Excitement and anxiety can sometimes look similar in children before a major event. A child with “excited jitters” may still eagerly talk about the game and respond well to reassurance, while a child experiencing genuine anxiety may become consumed by worry or even try to avoid attending altogether.

Physical symptoms can also appear in anxious children, including headaches, stomachaches and trouble sleeping leading up to the event.

“Excited jitters usually come and go, but anxiety tends to stick around and interfere with daily routines,” said Amanda Jordan, PsyD, psychologist with the Cook Children’s Psychology Department.

Preparing children ahead of time by showing them videos or photos of the stadium, discussing what they can expect and creating a clear game-day plan, can help prevent anxiety symptoms. Parents can also use “first-then” language to help children mentally organize the experience.

For example: “First we’ll find our seats, then we’ll get a snack.”

Families can also benefit from creating a safety plan before arriving at the venue, including identifying meeting spots and teaching children how to find stadium employees for help. Creating a funny family code word for moments when a child feels overwhelmed can also ease stress and remind children it’s okay to ask for a break.

Stadiums Sensory Impact

For many children, sport venues can overload the senses with bright lights, loud music, strong smells and tightly packed crowds. Dr. Jordan says sensory overload can trigger the body’s “fight, flight or freeze” response, making emotional regulation difficult. Children experiencing sensory overload may become irritable, restless or emotional. Others may withdraw, stop talking, cry or struggle to make decisions.

Several sport venues, especially the newest stadiums, now feature dedicated sensory rooms or quiet spaces designed to help guests decompress. Dr. Jordan encourages parents to research venues ahead of time to learn what accommodations are available and where they are located.

Even if a stadium does not offer a formal sensory room, quieter areas such as patios, hallways or less crowded sections may provide children with a chance to reset before returning to the event.

“These spaces can help lower anxiety and give children a place to regulate during stressful moments,” Dr. Jordan said.

Behavioral Challenges

Emotional outbursts during games can happen when children become overstimulated or overwhelmed. In those moments, Dr. Jordan says parents should focus less on discipline and more on helping children feel safe and calm. Getting down to the child’s eye level, speaking in calm tone and validating the child’s feelings can help them decompress and rebalance their emotions.

Parents can also use grounding techniques, such as deep breathing exercise or offering simple choices to help restore a sense of control.

For example: “Would you like to sit with me for a minute, or would you rather go walk around for a little bit?”

Dr. Jordan also encourages families to discuss coping strategies before the event so children know what support may look like if emotions escalate.

The emotional energy inside a stadium can also affect how children interpret social situations. Aggressive reactions from adults or fans may increase a child’s anxiety or sense of insecurity.

“Kids learn how to respond by watching the adults around them,” Dr. Jordan said.

Parents can help by calmly explaining emotional reactions happening around them, such as cheering after a goal or frustration following a penalty call.

Practical Advice

It is recommended to pack a few “mental health essentials” before attending a major sporting event with children.

Some of these items can include:

• Noise-canceling headphones, or earplugs
• Comfort items like a soft blanket or a plush toy
• Sensory or fidget toys
• Snacks

 These items can help children self-regulate and make the big game day more enjoyable.

Parents should also recognize when it might be time to leave early. If a child cannot recover emotionally after taking breaks or using calming strategies, it is time to prioritize the child’s wellbeing and step away from the event.

It’s also important to emphasize that sensory sensitivities are not limited to children with Autism spectrum disorder (ASD). Children with attention deficit hyperactivity disorder (ADHD), anxiety or trauma histories may also struggle in overstimulating environments.

“Sensory overload can affect many different children – and sometimes even parents too,” Dr. Jordan said.

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• Cook Children’s Sports Medicine Physician Heals Young Athletes Through Pickleball Medicine Program

By Linda Puga

As important as a child’s mental health is, it’s equally as important to look at how their journey impacts the people around them -- their caregivers. The ACEs Task Force of Tarrant County developed a video series called The Roadmap for Children’s Mental Health to help families navigate this health issue. These are some tips on how to take care of yourself to ensure you can be the best support system as a caregiver.

“Parents often have a lot of guilt, they have a lot of worries, they have a lot of uncertainty that they’re going through,” said Steve Chennankara, D.O., child psychiatrist at Cook Children's Psychology Clinic - Fort Worth.

First, recognize stress and model appropriate coping skills. Parents need to take care of their own mental health because as a caregiver, they make the medical decisions when it comes to their children, said Dr. Chennankara.

“For their own longevity, when it comes to endurance, they need to know that this is a marathon and not a sprint,” said Dr. Chennankara.

Second, be honest with yourself, your kids, and your peers. Manage stigmas in the ways you see fit.

“I don’t think there’s a one size fits all approach. So, recognizing and being aware of the stigmas that the parents have, or the child has, or a family member has, and bringing that to the light, and processing that, and working through that is important first,” said Dr. Chennankara.

After working through stigmas with yourself and your children, you can extend these practices with your next circle of friends and family, said Dr. Chennankara.

Third, be an advocate. You never know what people are going through, so make sure you’re intentional with the actions you perform and the thoughts you vocalize.

There are different levels of advocacy, depending on where you feel like you’re at right now. Something you can do is share testimonies from your child as a way to reduce the stigma around mental health.

Having these conversations helps kids know that they aren’t alone in struggling with mental illness. 

“One in four kids go through some type of mental distress throughout their developmental period,” said Dr. Chennankara.

Fourth, remember that your best is good enough. Don’t let your opinions get clouded by too many other people.

“There is no such thing as perfect parents. And, a child does not need a perfect parent. They need a present parent,” said Dr. Chennankara.

Remember that asking for help doesn’t make you weak or a failure, it leads to more awareness. Take advantage of all the resources you can.

In order for kids to trust caregivers with the big things, they need to listen to the little things.

Have you ever found yourself stunned or unable to respond to something your child has said or done? If a child or teen tells you they don’t want to be alive anymore, or that they have a plan to harm themselves, what should you do?

Kia Carter, M.D., medical director of Inpatient Psychiatry at Cook Children’s Medical Center, joins us on episode 17 of Raising Joy to answer this question.

Dr. Carter oversees a 15-bed psychiatry unit at the Rees Jones Behavioral Health Center at Cook Children’s. She also supervises consults on the medical floor, assisting children who are admitted for medical reasons, but also have psychiatric concerns.

In this episode of Raising Joy, Dr. Carter explains when you should take your child to the emergency room for mental health concerns, and what admission into the psychiatry unit is like for the patient and their family.

Raising Joy is part of Cook Children’s Health Care System’s Joy Campaign, a communications initiative aimed at preventing youth suicides. For more information about the Joy Campaign, visit cookchildrens.org/joy.

New episodes of the Raising Joy podcast will be available each Tuesday. It is currently available on all major streaming platforms including Apple, Spotify and Google Podcasts.

The news almost seems too much to bear sometimes. Frequently, we are bombarded with horrific stories of children and teens assaulting or even killing other kids in both the U.S. and in other countries.

Bullying, and cyberbullying has reached an all-time high, where bullies often encourage their victims to kill themselves. Depression and anxiety have soared among both children and teens; research states that 1 in 5 youth in the United States meet the criteria for a mental health disorder.

More recently, the Centers for Disease Control and Prevention’s National Center for Health Statistics reported a substantial increase in suicides among teen girls and boys in the U.S. from 1975 to 2015, with the rate among girls hitting a record high.

Every statistic seems more frightening than the next.

Between the years 2007 to 2015, suicide rates doubled among teen girls and increased by more than 30 percent among teen boys. Parents, educators, professionals and even children and teens are left scratching their heads wondering why. Multiple researchers, psychologists and educational experts report there is an empathy crisis among adults and youth. Douglas LaBier, P.D., a business psychologist identified the lack of empathy as the “Empathy Deficit Disorder” and Michele Borba, Ed.D., an educational psychologist calls it the “Selfie Syndrome.”

Empathy is a foundational cornerstone for both emotional and moral intelligence. It is the ability to identify another person’s emotions and imagine what they must be thinking and feeling.

Affective empathy refers to the feelings we experience in response to another person’s emotion, while cognitive empathy is the ability to identify and understand another person’s perspective and emotions. It is what you feel when you step outside of yourself, without abandoning your own perspective, and you can experience that individual’s internal world.

Empathy is the core that makes a society civilized; it is the powerful emotion that stops cruel and/or violent behavior. There is considerable research that supports empathy is hard-wired, children are born with the capacity for empathy; and while empathy will appear early and naturally it has to be nurtured and developed.

In 2010, a research team, led by Sara Konrath of the University of Michigan at Ann Arbor, found that college students self-reported a decline in empathy since 1980, with a significant drop in the last 10 years. Business leaders also report a serious decline in empathy, which is a critical quality required to be a successful leader. Multiple explanations have been offered, and many factors have been identified through research that is negatively impacting the enhancement and development of empathy in our culture.

We place a huge importance on excelling whether that is academics, sports or in the arts. We all want our children to be successful and excel, but our focus has primarily been on making A’s and developing their college resume. Parents and schools no longer value character traits such as citizenship and kindness. Yet, empathy and emotional intelligence make our children more resilient, better leaders and more employable. As parents, we need to shift our focus from grades only to emphasizing acts of kindness and caring for others.

Changes in our culture, parenting styles, social media and technology have contributed to increased self-absorption; our focus is on “me” instead of “we.”

We live in such a polarizing society. I can’t remember another time where people were so open and about their beliefs. With social media and 24 hour news stations, we can’t escape people’s political agendas and opinions. It’s a lot of heat, but not much light out there. Our kids see this and more importantly they hear this from their parents, their peers and every media platform imaginable. They can’t escape it. I think that adds to a culture of meanness. For us to move forward and our children grow up in a better world than what we have now, we have to start respecting other people’s opinions and talk about issues without it becoming literally a life and death issue.

Our youth are bombarded with troubling events, violent, graphic and cruel images; these images are far more graphic and personal today than ever before.

In addition, our children and teens are constantly exposed to television, movies, music, video games and Internet content that is violent, nasty and cruel. The American Academy of Pediatrics has identified over 1,000 studies that astoundingly show violent entertainment can increase aggressive values and behavior in children. Further, viewing violence may desensitize children and teens to empathy. Researchers Drayman and Thomas found that children who have been exposed to violent programming are less likely to help young children in trouble. Generally, behavior is learned by imitating others’ behavior; a number of studies have found children who watch television programs with prosocial messages show increased cooperation and caring. It is critical we monitor what our children and teens are viewing, we need to protect them from viewing violent images and absolutely talk to them about tragic events. We have to model empathy.

So where do we start? I would say by looking in the mirror.

Michele Borba reports that the diminishing emotional availability of parents contributes to lack of empathy in children and teens. Dr. Gottman at the University of Washington found that parents who are the best at developing empathy in their kids are those parents who are both actively involved in their kids’ lives and emotionally available. Emotional availability means face to face conversations, not interacting through technology devices.

Multiple research studies also support that involved dads, in particular, contribute greatly to raising kids who have empathy. These studies specifically note dads who are actively involved in their child’s care, schoolwork and discipline and personal problems have significantly higher levels of empathy.

Another factor identified by Dr. Borba is teaching our boys and now girls as well to mask their feelings. Historically, parents have encouraged their daughters to share their feelings, whereas boys were told to hide or mask their emotions. Children have to be able to understand their feelings in order to understand others’ feelings; without that ability it is hard to develop empathy.

“Abuse in the Cradle” is yet another factor identified by Dr. Borba. Dr. Perry with Baylor College of Medicine notes that the first three years of a child’s life is critical for building empathy or planting seeds of violence. Thus, how a child is treated in those first three years by their primary care givers is profoundly important. A child who experience abuse, neglect or trauma has a difficult time creating critical attachments.

“The greatest factor that is increasing the empathy crisis: we are allowing cruel behaviors to continue! Cruelty is acceptable!” Like Ellen DeGeneres says “Be Kind!”

About the author

Lisa Elliott is a licensed psychologist and clinic manager of Cook Children’s Psychology Clinic, located at 3201 Teasley Lane, Ste. 202, Denton, TX 76210. Cook Children’s Psychology provides care focused on children’s behavior, from ages 3 years through 17.  The Behavioral Health Center brings all services together in an expanded space that will provide a talented, dedicated team of caregivers, physicians and professionals with the facilities, resources, tools and programs they need to ensure that these most vulnerable children receive the high quality treatment they need and deserve. Click to learn more. To make an appointment, call our Intake Department at 682-885-3917.

The American Academy of Pediatrics (AAP) says that while hyperactive behavior can be considered normal for some children, hyperactivity can, but doesn’t have to, be indicative of a neurological-developmental condition, such as ADHD.

ADHD is a diagnosis given when a person shows a persistent pattern of inattention and/or hyperactivity-impulsivity that negatively impacts his or her life.

“A hyperactive child is one who is more physically and/or verbally active than other children his or her age,” said Carolyn Cruse, PsyD, a licensed psychologist at Cook Children’s. “It is important to remember that what qualifies as hyperactivity in one age group may not be called hyperactivity in another.”

In addition, it's crucial for parents to note that having a hyperactive child does not necessarily mean the child has ADHD. When hyperactivity presents as a single symptom, it’s probably incorrect to assume the child has ADHD.

There are different subtypes of ADHD that could be part of a child’s diagnosis:

• Predominantly Inattentive Type - only symptoms of inattention are present and there are no or very few symptoms of hyperactivity.

• ADHD Predominantly Hyperactive-Impulsive Type- mainly symptoms of hyperactivity-impulsivity and a few symptoms of inattention.

• ADHD Combined Type - symptoms of both inattention and hyperactivity-impulsivity.

What Is Hyperactivity?

Hyperactivity shows itself in children as talking excessively, fidgeting or squirming in their seat at school or church, running or wandering when expected to walk or be still and having trouble sitting still for calm leisure activities like coloring or doing puzzles.

Parents sometimes describe their hyperactive children as constantly in motion or always on the go. The overactivity should be more than what is typically seen in other children that age and should negatively impact the child’s ability to function in school, home or other situations in order for it to be considered an indicator of ADHD. Thus, hyperactivity may be the first concern that is noted by parents or teachers.

“Parents should be concerned when their child’s overactivity is negatively affecting his or her ability to learn and behave appropriately in school, complete homework or follow the rules at home and/or participate in extracurricular activities,” Cruse said.

For example, a 5-year-old girl who is starting kindergarten may be observed having trouble sitting still in her seat and constantly wandering the room during “circle time,” but this would generally be seen as age appropriate. However a 7-year-old second grader who moves so much that he falls out of his chair and repeatedly gets out of his seat when he should be completing class work is more likely displaying symptoms of hyperactivity.

Hyperactivity can be seen in very young children or toddlers, but a diagnosis of ADHD should be made cautiously. In very young children, hyperactivity may appear as though the child is having difficulty functioning at home or school. These children are constantly shifting from activity to activity, jumping on furniture, climbing up cabinets and unable to sit still—even briefly—for quiet activities.

Again, the overactivity should be more than what is seen in other children their age. Younger children are also likely to display their hyperactivity and impulsivity as aggressive behavior. These children have not fully learned to respond appropriately to frustration or irritability and may impulsively respond with aggression. Older hyperactive children may also behave aggressively because of their hyperactive/impulsive tendencies.

Hyperactivity is seen in both boys and girls, though boys are more likely to experience hyperactivity at a heightened level that indicates ADHD, according to Cruse.

What Can You Do?

A hyperactive child will benefit from the chance to hand out papers in class, take a note to the teacher in the next room or simply walk to get a drink from the drinking fountain every so often.

Some hyperactive children actually function better when allowed to stand at their desk rather than sit. This cuts down on fidgeting and squirming in the chair. Parents may need to let their child have a chance to run and play once he or she get home from school to release pent up energy before starting chores or homework.

Parents can channel their hyperactive child’s energy into positive outlets such as sports, dance or karate. They can also use their child’s energy by making games out of small chores (make putting away toys a beat-the-clock game, putting laundry in the washing machine into a basketball game or sweeping the floor as a dance routine).

“Hyperactive children are often seen as very charismatic and fun-loving,” said Cruse. “They can often find fun in whatever they are doing and tend to be creative. When that hyperactivity is channeled appropriately, these children can grow up to be very high-achieving adults.”

Getting a Diagnosis

If parents believe their children’s hyperactivity is severe enough to be interfering with their daily functioning, and increasing their children’s involvement in appropriate physical activities has not improved the problem, they can contact their pediatrician or Cook Children’s Psychology department regarding a possible evaluation for ADHD.

Once a diagnosis of ADHD has been made, there are various treatment options to help improve a child’s functioning. A therapist/psychologist can help by teaching children to monitor their own behavior and learn to think before acting. They can also help parents learn more effective ways to handle their child’s hyperactivity. Schools can also make accommodations that will help with school performance.

Finally, medication is another treatment option that parents can discuss with their pediatrician or a child psychiatrist.

The documentary describes how Laettner bullied not only the opposition, but his own teammates. And where does the documentary say he learned such behavior? His older brother.

A University of Nebraska-Lincoln study gives a detailed look at bullying from siblings the Journal of Family Violence. The researchers talked to 400 undergraduates and found that students said they were bullied more by their siblings than by other children.

Last year, another study conducted by the University of New Hampshire discovered that 32 percent of children who said they were victimized by a brother or sister reported higher rates of mental-health issues.

Lisa Elliott, Ph.D., clinic manager of Cook Children's Behavioral Health in Denton, Texas, said she has seen several kids lately in her office dealing with problems related to siblings. Elliott, a licensed psychologist, said this goes beyond sibling rivalry or teasing. She is seeing abuse and parents need to be aware of the role they play in this issue. Especially if they are favoring one child over the other. Often times that "favored" child becomes the bully.

“Parents have to be careful that they don’t show favoritism, either directly or indirectly, intentionally or unintentionally,” Elliott said. “The perception of favoritism among siblings is one of the most harmful things parents can do to their children. It’s harmful to the child’s self-esteem, it increases bullying amongst siblings and it often creates very entitled children in the one who is favored.”

A study published in the journal, Pediatrics, showed that kids who had been bullied by their brothers or sisters for a prolonged period of time were twice as likely to report being clinically depressed when they grew up.

"I certainly think in most families there is likely to be some level of conflict or disagreements among siblings at different times," said Joy Crabtree, a licensed psychologist at Cook Children's Southlake Urgent Care and Pediatric Specialties.  "However, I think parents need to be aware of when it may be crossing a line, such as physical altercations, repeated name calling or degrading of a sibling etc. Sometimes it can happen out of ear shot of the parents so it’s important to talk about everyone maintaining respectful communication in the family. If a child feels uncomfortable or targeted, he or she needs to let mom or dad know because it may not be happening in front of the parent. If targeting is occurring, limits and boundaries need to be set so a negative pattern does not continue."

Research conducted by the Universities of Oxford, Warwick, Bristol and University of College London said that bullying among siblings is particularly upsetting because these children have no way out. Bullying includes persistent verbal or physical abuses, as well as just ignoring the other siblings for long periods of time.

“I see children in clinic who are upset about favoritism or jealous of a child or he or she feels an older sibling is being parental or bossy. Sometimes I see feelings of inferiority. But what I hear when it comes to bullying is something very different,” Elliott said. “This is abuse, either physically or verbal. These are siblings and they know each other better than anyone else. That familiarity allows them to say very hurtful comments that the sibling knows is a sensitive or private matter. Sometimes, I see ganging up on a sibling, where multiple brothers or sisters gang up on a child. In those cases, you see extreme physical aggression between siblings that can be every day and makes life miserable for a child.”

Elliott gives the following tips for parents to watch out for sibling bullying:

• All physical bullying needs to be addressed immediately and not tolerated.
• It is critical to understand the causes for the bullying to address whatever those reasons are –

1. If a child is feeling inferior help, build that child’s self-esteem.
2. If you are inadvertently showing what is perceived to be favoritism by one child, modify your behavior and be sure to praise each child equally with positive behavioral anchors.

• Don’t label your children as the “bright one”, the “musical one” etc.
• Finally, it is critical to teach your children how to problem-solve conflict effectively and how to have empathy for others.

We’ve spent a lot of time recently talking to you grownups out there about all of these conditions in an effort to inform you, but also hopefully to calm your nerves.

But what about your kids? It’s easy to understand why they would panic, especially if they hear of school-aged children being kept home or other kids simply afraid to go to school in fear of Ebola. And it’s all happening in Dallas, so close to where many of them live.

So, what do you say to them?

A lot of it has to do with their age and how much they can comprehend, according to two of our licensed child psychologists at Cook Children’s.

Joy Crabtree, a licensed psychologist for Cook Children’s Behavioral Health in Southlake, said the most important thing parents can do is be there for their children. If your children come to you with questions about anything scary in the news, reassure them that you love them and are there for them. Tell them the chances of them getting a disease such as the Ebola virus is rare. For example, one of the main symptoms of Ebola is fever yet, reassure your child that unless they or someone in their family has travelled to West Africa, or come in contact with anyone from that region, their fever is no more dangerous than any other time they had a fever. We get fever from a lot of things and recover. Answer the questions they ask you, but don’t go off on tangents that will increase their fear. Make sure you know the facts and check them with a reputable source. Don’t drift into other areas that may cause your children discomfort.

Your older children may not want to talk to you about the issues of the day, try to put up a brave front or be blissfully unaware. You know your children better than anyone. If you feel your children are old enough and/or mature enough, and you feel they have heard about it anyway, you might consider bringing up recent events from the news to get their opinion, and to offer reassurance and support.

“For older children, they may have a few initial questions based on what they’ve heard on the news or from friends at school,” Crabtree said. “Make sure that you are giving them accurate information. Make sure to reassure your child, but also let them know that bad things do happen in life. We have to be careful and cautious, but we also can’t live in fear of the unknown. We have to live life to the fullest. You might also let them know that just like there are people (doctors, nurses, etc.) whose job it is to take care of kids, there are people, such as the public health department, whose job it is to take care of communities. They let us know when there is danger and what to do.

Lisa Elliott, a licensed psychologist and clinic manager at the Cook Children’s Psychology clinic in Denton said to keep younger children, elementary age, away from the news and don’t talk to them about something like Ebola unless they ask you. There’s no need to bring up a fearful topic to children, unless it’s for their own good.

For older children, Elliott said ,“There has to be limits to the news and it has to be age appropriate. The older kids can become fixated on bad news sometimes. Help your older children process what they are hearing and make sense of the news. But at the same time, limit them on the amount of news they are watching or reading about. They don’t need to dwell on the issue.”

As for your kids or yourself, Elliott adds it’s a good idea for the entire family to get away from the news and spend some family time together.

After all, the most important thing is to be there for your children.

Related links:

• Ebola in Dallas
• Are you concerned about Ebola?
• 4 reasons not to fear Ebola
• Enterovirus: What we know now
• The flu season
• Whooping cough makes a comeback
• Breaking news: Chikungunya case confirmed in Tarrant County
• Breaking Tarrant County news: Measles alert

For more information

Cook Children's Behavioral Health services provides a broad range of care that focuses on children from 3 years through 17, and their families. We also have some limited services available for children age 2. As part of family-centered care all of our professionals are qualified both through education and experience to work with children who have behavioral and emotional challenges. Our psychiatrists are board certified in child and adolescent psychiatry and our psychologists and therapists are all licensed independently in Texas.