Understanding Anxiety

An in-depth analysis of anxiety. We discuss the latest research on causes, healthy vs unhealthy, various types of anxiety disorders and evidence based treatment. 

We also look at ways families can support someone with an anxiety problem.  

Specific details are described about the use of Cognitive Behaviour Therapy (CBT) to treat anxiety. 

Tips to help parents boost their children's confidence and reduce anxiety are also covered.

For more tips and posts, visit http://www.facebook.com/drannechalfant

Transcript

Justin Kyngdon: Welcome to Episode One of The Annie's Centre Podcast. My name is Justin Kyngdon.

Dr. Anne Chalfant: I'm Dr. Anne Chalfant. In this episode, we'll be discussing understanding anxiety, some initial tips for parents on how to build their children's confidence.

Justin: I will share with you one of our family favorite recipes in the section, "Kids in the kitchen".

[music]

Speaker 3: One mother, one mission, to create a world where families thrive. Dr. Anne Chalfant, internationally acclaimed clinical psychologist, family therapist, author, and mother of four children brings you powerful and practical parenting techniques from her clinical and personal experience. Ladies and gentlemen, the doctor is in the house.

[music]

Justin: The Annie's Centre Podcast is supporting the Buy From the Bush campaign here in Australia by promoting Australian Businesses. Do you know what your friends and family are looking for Anne? They are looking for a fantastic meat. You need to head on over to ourcow.com.au, and by paddock to plate beef boxes direct from the farmer. Who are the farmers? Bianca and David and they I offer one-off bulk beef packages and ongoing subscription boxes so you never run out of meat. The beef is hand-cut by master butchers in the heartland of Australia's premier state New South Wales and sent fresh to you.

We have purchased beef box from Our Cow and we can tell you that the process is seamless. You get text messages to track your delivery. The meat is fresh and delicious and cold, and it all comes conveniently vacuum seal so you can chuck the steaks on the barbie that night or freeze it for when you need it. Don't panic, you are getting a bulk beef box. It's not like you're bringing home the meat tray. Because it's vacuum-sealed, it takes up little room in your fridge or freezer. Know that your hard-earned dollars are going direct into the hands of our hardest working Australians, and Buy From the Bush.

That website again is www.ourcow.com.au. O-U-R-C-O-W.com.au. Go visit the site, check that they deliver to your area, buy a beef box and you too can support Australian farmers doing what they do best, which is make the greatest produce in the world. Our Cow, buy better meat.

Now, on with the show.

Dr. Chalfant: Well, welcome to the first show and it's jam-packed with information for families. We're going to begin with our first topic, our first ever episode of our first-ever podcast, which is understanding anxiety. Since it is our first, we're probably feeling a little anxious ourselves. Aren't we, Justin?

Justin: Yes, absolutely. But it's all-natural, right?

Dr. Chalfant: Absolutely.

Justin: Anxiety seems to be on the rise in Australia. According to the Australian Bureau of Statistics, almost 4.8 million Australians, or one in five had a mental or behavioral condition in 2017 to 18, up from 4 million in 2014 to '15. Anxiety-related conditions have increased and they are the most frequently reported mental health condition in Australia for the last three years. That's some fairly big numbers and quite significant. Clearly.

Dr. Chalfant: Absolutely.

Justin: Clearly. Before we dive into something as big and as serious as this, can you define anxiety?

Dr. Chalfant: Sure. Anxiety is really just a natural feeling that we all experience of being nervous or worried or tense in the face of a threat or a perceived threat, or stress, or some form of danger. It's a natural response that we have in those situations.

Justin: We all have a bit of anxiety.

Dr. Chalfant: We will all at some point experience anxiety, and we all are capable absolutely of experiencing anxiety. The issue is the difference between what we call healthy anxiety and unhealthy anxiety. We're all going to experience healthy anxiety at some point in our life, from probably relative regularly, whenever we might put ourselves under pressure. For example, recording our first podcast, or giving a speech at school if we're talking about kids and teenagers, or meeting someone for the first time in a group situation, those sorts of situations. They're all situations where someone would experience a normal dose or a healthy dose of anxiety or trepidation.

Justin: It seems as though then that there is healthy anxiety, which is just part of if you're active in the world and you're participating in the world, you're not a total couch potato, you're going to have some level of anxiety.

Dr. Chalfant: Yes.

Justin: Then there has to be some movement from being healthy to an unhealthy level of anxiety, to the point which you as a clinician would classify that as a disorder. Based on the fact that you've got specialization in anxiety, can you help me understand when does it move from being a normal part of your life and suddenly you have under stress or under certain occasions, which you would expect it to occur to it then being classified as a disorder in you, and so if is pervasive it's part of your everyday?

Dr. Chalfant: I think before I answer that last part of that question about the unhealthy part of anxiety, I just want to go back a step. In terms of healthy anxiety, it's not just the fact that we will experience it if we're living an active and meaningful life. The other point to make about healthy anxieties is not just healthy, it's helpful. A certain level of anxiety depending on the task that we're undertaking is helpful to us, a certain boost in our adrenaline will add to our performance or enhance our performance in certain situations.

For example, if you're a student, and obviously my specialty is Child and Adolescent Clinical Psychology. If I think about any of my own kids or kids I work with, if there was sitting an exam, then I would expect that they would experience some anxiety in light of the fact that they are under pressure to perform in that situation. A little bit of anxiety is going to help them perform better in that situation than if they cruise on into it with feeling no anxiety at all.

To answer your question or the latter part of your question to come back to the main point, when someone tips over from healthy to unhealthy anxiety, the differences are few things. One factor in terms of difference is that the anxiety is experienced on a much more regular basis, a daily basis. The other is the degree or the intensity of the experience of anxiety. Someone who has unhealthy anxiety or really what we're calling an anxiety disorder is someone who experiences anxiety on a daily basis to the point where it causes them such distress and discomfort that really impacts their daily functioning. They can't complete day to day living tasks. It impacts on their social skills and their ability to form relationships with others, it impacts on their thoughts. It's constantly pervading the way they think and behave. It overtakes their life.

Justin: I understand. Then if I was to observe that in a person, and we took from waking up in the morning and getting out of bed, and the typical functions that a person goes through. Having breakfast, cleaning their teeth, getting dressed, maybe having a shower, and then going out to work or school or whatever it is for that person. What in those different activities we do in the morning would you potentially see anxious behavior or anxious habits?

Dr. Chalfant: When it's an anxiety problem affects us in three main ways. It affects us physiologically, it affects our thinking, and it affects our behavior in terms of avoidance of whatever it is that we are fearful on. Physiologically, thinking, or our cognitions and our behavior through avoidance. Physiological symptoms are the classic symptoms that we think of like sweaty palms, racing hearts, feeling nauseous, needing to go to the toilet, feeling like you need to go to the toilet much more. They are physiological symptoms. Someone could have an anxiety problem and go through that morning routine, being completely overwhelmed by their thoughts and experiencing all of those physiological symptoms without necessarily noticing something different about the way they're conducting that morning routine. You may not necessarily see it in their behavior, but they might be very worried and that might disrupt their concentration. It might make them feel very distressed, even though they're completing those sorts of tasks.

It also depends on what the focus of their anxiety is. There are six main types of anxiety disorders. There is for children separation anxiety, and then there's a social anxiety disorder, so a fear of performing in front of other people because of worries about being negatively evaluated or embarrassing oneself. There's generalized anxiety disorders, so having lots of worries about all aspects of life from health to career, to finances, to family wellbeing. Then there's also specific phobias, so people who are worried about particular objects, or particular situations. Classic examples might be again, in my field, children adolescents, it might be children who are really fearful of dogs, or spiders, or getting needles, or things like that.

Depending on what the source of anxiety is will determine how that person will act and what they'll avoid. They may really avoid and go to great degrees to keep away from the object of their fear. If it was someone who was afraid of dogs, they may never go to the park, for example, because they may be worried about seeing a dog there. If they have a real problem in terms of anxiety and anxiety disorder, that can be really difficult and interfere with their functioning in terms of socializing.

If you're talking about a child and they can't see their friends at the park, because there might be a dog there, so there's no opportunity to socialize outside the home because they're worried about encountering a dog. That's certainly the case with some of the clients that I've seen. That really impacts on their day-to-day functioning. They might be able to brush their teeth in the morning, but when they get out the door, there might be something that comes up for them then that really disrupts their routine or their life.

Equally, if someone has a generalized anxiety disorder, it may be that they can complete tasks of daily living, as I mentioned earlier, but they're so overwhelmed and overrun by the constant ruminations and going over and over and over again in their mind, all the different things that they're worrying about. The "What if?" thinking style that someone with generalized anxiety disorder has. "What if my health starts to fail? What if I can't meet," if you're an adult, "certain finance repayments?" If it's a child, it might be, "What if my grades in 10 years' time are not good enough that I can get into university?" Really future-based what if [crosstalk].

Justin: Not necessarily "What if I walked out the door-"

Dr. Chalfant: Not necessarily.

Justin: "-and miss the bus and everyone laughs at me?"

Dr. Chalfant: No. It might be that as well, but-

Justin: Then it could be very much.

Dr. Chalfant: -they're often very much orientated to future events that are quite unlikely to occur, but they elevate or believe that the likelihood of those situations is quite high and that the damage or the cost from those situations to themselves is also quite high.

Justin: Have you seen in children, particularly older children, or any, where there is anxiety over the raising or the wellbeing of the younger siblings?

Dr. Chalfant: Yes, absolutely. It depends I think on things like birth order. If the child is the eldest, for example, as opposed to, if they're the middle child and they're still younger siblings. It again depends on the household that they live in. We know that children who are anxious, one of the cause or factors of anxiety is an anxious style of parenting. If parents are, for example very authoritarian in their approach, put a lot of pressure on their children, particularly older children, the firstborn usually is the recipient of a lot of extra parental pressure.

Lots of hopes and wishes for the future laden on the eldest child. They may feel that burden and they can be quite anxious and that may play out in the way they treat younger siblings feeling that they have to be responsible for them and manage them, or you might just see that parenting style played out in the way they respond to their siblings, that they become a third parent in the household or a second parent, if it's a single-parent household.

Justin: Okay. Excellent. We've talked about anxiety on its own. However, what other mental health disorders is anxiety often linked with?

Dr. Chalfant: It's most often linked with depression. That would make sense when we think about the fact that when you have an anxiety disorder, as I said, the characteristics are the physiological experience, the thinking part of anxiety, the "What if?" thinking style and typically negative thinking style, and then the avoidant behavior, so stepping away from fear situations and keeping away from feared situations.

You can imagine if that's impacting on someone's day-to-day living to the point where it disrupts their relationships, their wellbeing, their confidence, then that affects their mood. They will lose self-esteem, they lack confidence, and that lack of confidence and drop in self-esteem is a precursor to something like depression. Most commonly anxiety and depression go together.

Justin: Sounds like they feed each other.

Dr. Chalfant: They can feed each other. Not everyone who experiences anxiety will go on to also develop what we call co-morbid or co-occurring depression, but they are the two that would occur most commonly together. Then of course you can see in terms of children and adolescents, anxiety coexisting with other difficulties. Children who have learning problems, for example, or learning disabilities, may lack confidence and may be very anxious, possibly understandably about their performance at school.

What begins as an understandable fear of performance or worry about performance in a learning environment because they have an actual learning problem, can tip over into extreme and excessive intense levels of fear about attending school, about performing in front of peers in the classroom. Again, that can be quite debilitating and incapacitating.

Justin: If you're a parent with a child with that, although in some form of disability is something to be acutely aware of. Is that the child's trepidation about going into the classroom could be linked to they have learning disabilities self-course, but actually it's the anxiety that needs to be looked at.

Dr. Chalfant: Yes, it's both in that situation. I can certainly think of clients in the past where, for example, that had a reading disability or reading disorder accompanied by severe anxiety mostly related to their school performance and social anxiety. We've had to try and tackle both the anxiety through psychological interventions and treatment. Also, that has improved when we've been tackling their actual reading skills.

We put them on to an intensive reading program like MultiLit for example, which is a very well-regarded intensive literacy intervention program. As they've improved in that program, their anxiety has reduced as well along with learning some coping strategies and confidence-boosting strategies to manage their fears and particularly the physiological symptoms that they've experienced of anxiety.

The other disorder that can co-occur with anxiety for children and adolescents since that's my focus is the developmental or the neurodevelopmental disorders, things like autism spectrum disorder. We know in the scientific literature, that anxiety is four times more common or more prevalent in that population of children versus any other clinical group, or any other group of children that have another type of mental health difficulty, and certainly, four times more common than typically developing or normally developing children if you want to put it that way.

Justin: If we took a for the moment because you could answer this with both, if we looked at a person that was typical, or normally functioning, let's say an adolescent. Let's just pick an adolescent who is normally functioning, who doesn't treat their anxiety. What happens or what can happen? Then if you look at a person, a teenager, again, that has anxiety and they [unintelligible 00:18:40] their anxiety what happens with them? If you want to start with a normally functioning adolescent or the autistic adolescent, I'll leave to you.

Dr. Chalfant: For a non-autistic adolescent, so a typically developing, or one of the words that's used is neurotypical.

Justin: Neurotypical2.

Dr. Chalfant: A neurotypical adolescent [crosstalk].

Justin: Is there any neurotypical adolescent? I don’t think I was a neurotypical adolescent.

Dr. Chalfant: Our children are yet to reach that stage in life so we can reserve our comments for later, maybe not.

Justin: [laughs] Okay.

Dr. Chalfant: If we think about a neurotypical adolescent who has an anxiety problem or an anxiety disorder-

Justin: Yes, and they ignore it.

Dr. Chalfant: -if it's not treated, then we know really by the time someone is an adolescent-- I think a step before that, in terms of an important comment to make, is it's unlikely or uncommon that adolescence is the first time when the anxiety occurs and out of the blue. Usually, by the time someone is an adolescent and is experiencing a significant problem with anxiety, it's at the endpoint, or at the climax of something that has been going on for some time. Possibly since childhood.

The problem with that is, obviously, old habits die hard. If we think about the fact that anxiety has those three main characteristics, the physiological challenges, the cognitive or the thinking part, the worried thinking and ruminations, and the avoidant behavior, then by the time someone is a teenager, and that's left untreated, you can imagine and going into early adulthood and later adult years that they're very entrenched behaviors at that point and really then quite debilitating. We would say then, teenagers moving into early adulthood, who may be avoidant of quite a range of situations depending on again, what the type of anxiety disorder is that they have, but by that stage, certainly if someone has generalized anxiety disorder or social phobia or social anxiety disorder, they may be, as a teenager, avoiding school altogether.

I've certainly treated 15 and 16 year old kids whose anxiety has gone unchecked until that point in time. By the time they come to me, they're no longer attending school, they're refusing school. Along with that, as we discussed, is the comorbidity or the co-occurrence of things like depression, so they won't even get out of bed or can't get out of bed in the morning. Their mood is so low. They're so overrun with fear and worry. Then taking that picture into adulthood, again, you can imagine then how difficult.

Justin: I can imagine. It's going to limit your career choices, your educational choices, whether you will go take a trade, which forces you to go into a Technical College, and then also in a worksite or into university, which then forces you to sit at length in lectures and tutorials and laboratories and what have you and mix with other people. That would preclude, if you can't get out of bed, then your earning capacity and capacity to build a life and maybe a family in the future would be significantly hindered if not outright stopped.

Dr. Chalfant: That's right and then the other aspect is some adolescents will turn to, if it's not being treated using evidence based approaches like psychological therapy or certain types of medications that we know have a good scientific basis for use in treating anxiety, those adolescents may self treat, or medicate through other things like substance abuse, for example, as a way of coping and developing their own way of managing really difficult situations. We might see increase in things like alcohol and other drug-related use.

Justin: Right. Okay. There could be a person listening to this in their early 20s, who is like that, and the opportunity for them is to pause and think back through to teenager or maybe early pre-teenager, and consider what occurred in that period of time and help themselves try and join the dots and explain where they're at.

Dr. Chalfant: Absolutely, and or, hopefully use this as a trigger, perhaps to seek some support, whether that's within the family initially, or certainly by the time someone is an adolescent and really debilitated by anxiety, then that really is a need to get access to intensive psychological interventions and possibly what we call anxiolytic or anxiety reducing medications. The thing that's positive about that is we know they work.

Interventions and treatments for anxiety, the evidence-based ones like cognitive behavior therapy or CBT and certain types of medication like we call them SSRIs, those have been shown in the literature over and over again to be very effective in treating anxiety. It's never too late to access support. It's harder when behaviors are more entrenched but certainly the components or the aspects of CBT based intervention, like graded exposure therapy, which is essentially helping someone face their fears in small incremental steps with support of a clinical psychologist to work through those steps, one increment at a time.

Justin: Can you give an example of that?

Dr. Chalfant: Absolutely. If we think of, again, the adolescent as an example, I can think about even adult clients that I've treated. I'll give you a really simple example of a client that I treated who was phobic of spiders that had been going on since she was a child and by the time she came for treatment as an adult, she was really debilitated by her fear of spiders to the point where she wouldn't socialize because she was worried about leaving the house and going to the car and literally the trip from her door to the car and the possibility that a spider might fall down from a tree or be on her car somewhere.

She had difficulty then getting to work for the same reasons, she never dated because she was worried about the possibility that she would be on a date with another person and engage with or see a spider and not be able to cope in that situation.

Justin: Embarrass herself and then therefore-

Dr. Chalfant: Absolutely. Yes.

Justin: That to happen in front of the would be partner.

Dr. Chalfant: Exactly. When she came for treatment, among other things in a cognitive behavior therapy framework, what we did was expose her in a step by step manner to spiders. Starting at the lowest end, or the easiest to manage step, which would-- If you think about a ladder. We talk about with kids a stepladder approach. The first step on the step ladder is the lowest step. It's the one that's the easiest to manage, obviously, because it's the closest to the ground.

Using that analogy with the client, we take the step that is easiest for them to manage. The easiest first step for her was reading about spiders. Nothing to do with actually encountering a spider, but just going online, and reading information about spiders. The next step was reading information about spiders, and also looking at some still life pictures of spiders.

Then the next step was reading information and looking at some video footage of spiders. They're not still life anymore, but actually videos where they're moving, and then the next step was from there, looking at images or saying for example, a dead spider that's been contained and then the next step might have been a dead spider not contained and then the next step might have been a live spider at a distance, et cetera. As the steps go on up the stepladder, they become more and more challenging but the idea being as you conquer each individual step, you're better able to move on to the next run of the ladder.

Justin: At each step, you as the psychologist is discussing what with the patient? What would a patient expect to have in those discussion? They go and do what you suggest and I go and look at the computer and I read it and I sit down in front of you and even just talking about it to you, my palms might be sweating or might be ready just to give up in that first instance.

Dr. Chalfant: It is exactly the case with this client and it is with many clients who are anxious when they start off with graded exposure therapy. For kids and for adults, the treatment approach is exactly the same in terms of principles. It's always about breaking a fear down into individual steps and tackling each step one component at a time. Literally, what you're doing with that person in a therapy session is collaborating or holding their hand.

Not physically on their hands, but being there alongside them as they face that fear and coaching them through, having already taught them in therapy, other skills to use to manage so other coping strategies like, how to use control breathing and relaxation skills so that addresses the physiological symptoms that they may experience when they're facing a fear. Then the cognitive component of cognitive behavior therapy is all about tackling and addressing the negative, unrealistic, often irrational black and white thinking style of someone who's anxious.

Working very hard in therapy, before we expose them to things that they're fearful of, on giving them alternative ways to think about these situations, more realistic ways, challenging their fears, by getting them to really test how likely they are. Look at things like well, how often have you really encountered a spider from the walk, from the house, to the car? How likely is it then to happen this time round? What's happened to other people that you know, when they've walked from their house to the car? Keeping things in perspective.

Justin: You give them all those tools?

Dr. Chalfant: Yes and then we use those tools in the graded exposure session, where they're thinking about maybe for children, we might actually give them a list of helpful thoughts or more realistic thoughts, to challenge their anxious thoughts or their worries and we might get them to read those thoughts and use their deep breathing or their controlled breathing skills and techniques whilst they face the fear situation. We get them to stay in that situation for as long as it takes for their anxiety levels to drop. We rate their anxiety, we get them to rate their anxiety using what we call a SUDS rating which is a subjective unit of distress score which is basically a rating out of 10, where 10 is the most fearful you could experience and zero is nothing.

Justin: Right.

Dr. Chalfant: We're looking for that rating to come down.

Justin: That's over each.

Dr. Chalfant: That's within the session.

Justin: Within the session and then over.

Dr. Chalfant: Then over time so we get them. That would be in a session, but obviously, like any school you learn, you can't just rock up one week and the next week expect that there'll be huge changes if you're not practicing those skills outside of a session. The biggest shifting in someone with something like cognitive behavior therapy and really any psychological intervention is the practice tasks that people do when they're at home and the need for them to do that on a daily basis. Often multiple times a day to keep practicing that. In the case of the spider phobic, it was let's say we were at step one. She's reading about spiders will every day at home, maybe twice a day or three times a day, she might have to get out that book on spiders and keep reading it.

Justin: Parents with children with anxiety, part of their big role in this is that they can't obviously, as you said, literally hold their hand and keep putting their arms around them and saying, "Everything's okay." What they have to do is ensure like doing the child's spelling or their maths or their reading that they're doing this homework as well each and every day and making sure that that space is available for them to do it. That they're following through and not being mollycoddled during the process. They genuinely feel the anxiety and then they have to genuinely use the tools that you're giving them to bring that anxiety down and control it, then mark themselves on a daily basis.

Dr. Chalfant: Absolutely. It's hand-holding in a different way.

Justin: Right. You're making sure they do it to get better.

Dr. Chalfant: Exactly. Exactly right. You're working alongside them, you're partnering up with them, you're forming a team with them in order to support them through the experience rather than find a way around the experience or avoiding the experience. You're trying to encourage them strongly to use the strategies that they're learning in a therapy session and practice them yes at home on a daily basis with the support and in a way, the hand-holding of a parent through that. With kids, we use reward systems. For every time a child faces their fear at home, there would be some reward that's in proportion to the degree of difficulty of what they're faced.

If a ladder for a child is-- Let's talk about a child who's fearful of talking in front of others, who has social anxiety and they're working on a step in their ladder, which is appearing to give news to the class, and maybe they're on a step where they're just practicing news at home with their family, every time they practice that news, they might be rewarded with something like getting to choose what's the dinner the next night, or maybe there's a sticker chart that's being used, or maybe they get dessert the next day or something like that.

The rewards in proportion to the degree of what they're doing, it's not that they're getting a trip to Disneyland simply for practicing news at home.

Justin: All of the things we've discussed about the anxiety and treatment and behavior as it occurs in a neurotypical teenager.

Dr. Chalfant: Yes. That's right. You were asking about someone with autism.

Justin: Autism. Now, we're looking in that world. What needs to be considered in addition to these matters. Maybe a lot of these are the same. Illuminate me on that.

Dr. Chalfant: To be honest, not much is different. We know that now because we've run research that I was certainly involved with my supervisor when I did my clinical doctorate at Macquarie University and subsequently in writing what would the Cool Kids autism program, which I can talk about later with colleagues at Macquarie University. We know through those programs there, again, cognitive behavior therapy-based programs.

They still tackle those same key features of anxiety in kids with autism. They were designed deliberately to use with kids with autism to address the physiological symptoms through teaching them controlled breathing and relaxation skills, the worry thinking parts of anxiety by teaching them more realistic ways to think about things that they're anxious over and the behavioral part, the avoidance part of anxiety by teaching them how to face their fears in a graded or step by step manner.

The main differences really relates more to the fact that individuals with an autism spectrum disorder have a slightly different thinking or learning style to those who don't have an autism spectrum disorder. They tend to be more visual learners that can be more concrete in their thinking style. They're generally even more black and white. For those individuals, what we did when we designed something like the Cool Kid autism program, was we made the resources more visual. We used more scaffolding, more of a recipe style approach. Step one, do this step two, do this, step three, do this.

It was much clearer, I suppose, for them that they had to follow a procedure each time. Making it clearer, more proceduralized, more visual. Simply to tap into their learning style as opposed to the content in terms of therapy being markedly different. That's a good thing because we know that, as I said, CBT or cognitive behavior therapy used with non-autistic individuals as a psychological intervention. I'm talking about not the pharmacological side of things, not the drug or the medicine side of things. Is really the most effective way it's been shown time and time again, as a psychological intervention to treat anxiety in non-autistic individuals.

It's great that we can simply adapt the same principles to individuals with autism, and that we can also find that that's effective for them as well, particularly given how prevalent anxiety is in those individuals.

Justin: When you would consider that in your treatment, it's going to depend on each child, but sometimes do you have to treat the-- What's more often? Do you have to treat the anxiety first in some way before you can really help the child with their autism and developing that, or I guess it depends on their maturity levels and when you get to do that intervention?

Dr. Chalfant: Look, I think that's a really great question. The thing about autism spectrum disorder is there's a saying when you've seen one child with autism, you've seen one child with autism. Every individual with an autism spectrum disorder, actually, although we define individuals on the autism spectrum using a set of diagnostic criteria around their social communication skills and what we call repetitive behaviors, despite that their presentation really varies from person to person. The way they develop is different. Development affects autism.

Some children when they're three and have autism spectrum disorder or ASD, and maybe repetitively lining up-- The classic example is lining up cars over and over again. When they're 10, they may have a very strong interest instead in a certain genre of film, for example, that may be all-encompassing and obsessive and intense. The fact that they've developed and have grown and matured obviously has impacted the content or the nature of their interest in the way they present.

Justin: Autism isn't just this year on one trajectory.

Dr. Chalfant: That's exactly right.

Justin: You're on an evolving trajectory and your autism, if I'm right, is as unique as you are as a person.

Dr. Chalfant: That's true. Yes, that is true, actually, although we know that regardless even as individuals develop, their development is still impacted by the fact that they do have autism. They have these fundamental difficulties with social communication, the social aspects of communication. As we're talking about it, I think this is a great topic for another podcast episode. To come back to your question in terms of the way that in anxiety and the treatment of individuals with autism, with anxiety, because they do differ, really the anxiety treatment is not about treating their autism first because they are so different.

Really, there's not a pill or treatment for autism. It's more about looking at each individual who has autism and looking at what their particular profile of strengths and weaknesses is. That will change from person to person. When you're addressing the fact that they have autism for some individuals the relative weakness might be that they struggle more socially. For others it may be that they have-- Particularly the girls on the autism spectrum, that they've learned some coping strategies to manage better with some of the social aspects of their communication. Particularly nonverbal communication like the use of gestures and facial expressions and things like that. They might be able to get through with those socially to some degree still with a great degree of difficulty, but to survive.

It really differs from person to person. We wouldn't say, "Look, your child has autism so here, do this." There's not a list of go-to things that someone should do just because their child has autism. Particularly we're talking about teenagers. When we're talking about young children, then absolutely we know that there are certain types of early intervention programs that are better than others for them to use.

Coming back into the issue of anxiety and autism. We look at the fact that, as I said, they have a certain learning style and we try and tap into that thinking and learning style when we're managing anxiety in someone with ASD. One other thing that I didn't mention is individuals with autism spectrum disorder and anxiety, we know from the literature what's coming through much more and other scientific literature that is, is that they tend to have this intolerance for uncertainties. That basically a difficulty where they're not clear what's going to happen next, and that is a source of anxiety for them. Which may be a unique feature for an individual with autism versus other non-autistic individuals who also have anxiety.

When we're looking at treatment it would be important to factor that in to our treatment for someone with autism and anxiety. That we address that aspect if that is present for them. Looking at things like dealing and coping with change, deliberately creating change and uncertainty in their environment and teaching them ways to manage and face that and get through that, that we may not necessarily have to do with individuals who are not autistic but still anxious.

Justin: Okay. I'm going to pivot for a minute and then as we look at the diagnosis piece and then we're going to move into treatment and talk about the Cool Kids program in some more detail. What I want to look at is around, how does someone get anxiety so that that can be understood designed in the context of when we move into treatments. Not that I want to put any parent guilt out there but is anxiety genetic, a learned behavior, or can it be a combination of both?

Dr. Chalfant: There's definitely multiple factors when we look at what causes anxiety. The scientific literature tells us that most likely about 40% of anxiety can be explained genetically. Then the other 60% is really from a number of other factors. Things like biological factors, so the parts of the brain that are more stimulated when someone is anxious. Different parts of the brain have been implicated in different studies. The amygdala which is right in, deep in the brain is a center for processing fear and emotions that may be full or overly active in someone who is anxious.

Then there are other scientific studies that talk about a fear network within the brain. Again, different parts of the brain like the hypothalamus, the pituitary gland, the amygdala, that maybe have a network relationship. Again, in that kind of being overstimulated or overly responsive to threat-based stimuli. That's another factor. That's a biological side.

Justin: Brain gets together and gangs up on you?

[laughter]

Dr. Chalfant: Yes. I mean, there are some scientific papers that look at that. They talk about the cognitive brain or the thinking part of the brain and the emotional brain, and suggesting that in a non-anxious individual, those two work in sync. They balance. Whereas in someone who has anxiety, those parts of the brain that's part of that fear network overplay all louder and so it's harder for the frontal lobe and the prefrontal cortex, the parts of the brain that are to do with synthesizing information and planning and analysis and making sense of emotions, they speak louder, if you like. Yes, there is that sense the brain split into two and for individuals who are anxious, that their emotional brain if you like is more in control.

Justin: It sounds like tribal warfare.

Dr. Chalfant: [laughs] That's one factor. We've mentioned already the genetic component. Then there are other factors related to causation. You talked about not wanting parents to feel guilty but certainly we know that style of parenting, we touched on this earlier, can play a role in anxiety.

Justin: What style of parenting is going to lead to-- not always but has a higher chance of leading to an anxious child?

Dr. Chalfant: Okay. Definitely a parenting style where parents are overprotective and/or quite authoritarian in their approach can be a vulnerability factor or a predisposing factor for anxiety in kids and adolescents. Certainly in kids. Parents who themselves run anxious and therefore model anxiety or worry and are sensitive to fear and show poor coping. Then they are parents where the children will pick up on that modeling.

Justin: If I have a phobia to spiders then it's likely that I could transfer that same phobia to my children through my behavior if maybe constantly-

Dr. Chalfant: If you're constantly avoiding spiders.

Justin: -or spraying. If I spray everywhere.

Dr. Chalfant: For example, yes, and articulating fears about spiders and checking the house constantly for the first sign of a spider. Then children would be observing that and picking up on that. Not necessarily that that would transfer to them as a phobia of spiders. It's more about the general style of coping that children pick up on. The need to be checking for things and showing lack of resourcefulness and lack of resilience and transferring that or modeling that for children, and children learning that that is the right way to cope when obviously it's not the best way to cope.

Justin. You could say that if a parent has a spider phobia and a child can't cope so well when their maths homework comes on.

Dr. Chalfant: For example. If they're learning that one way to cope in light of fear or threats is to be avoidant and to crumble or to worry and become distressed, then in the child's own world where things come up that they are fearful of or potentially threatening, they may have learned that that's the way to cope in that situation. Parenting is another aspect. Then there's just other factors like temperament. Some children just have a more sensitive style or personality, if you like. That can be a factor.

Then there are just other environmental stressors. We know that children who experienced loss, whether it's loss of a parent or who lived through parental separation and divorce, certainly children who've lived in any kind of adversity, whether there's been neglect or abuse, they're all groups of kids that can be particularly vulnerable to experiencing a mental health difficulty including anxiety.

Justin: For parents and caregivers out there right now who might be suddenly looking at their children or the children they look after, maybe it's grandparents listening, uncles, aunts, so on and so forth, we don't want to then end up creating a, my child did this and suddenly rush out the door and get them tested for anxiety disorder. To help, and obviously this is direct clinical advice, what are the telltale signs that a child's anxiety is now moving from what we discussed at the top of the program, normal and occurs under those typical circumstances where we'd expect it to occur, to it actually developing now into an anxiety disorder? What would they be looking for?

Dr. Chalfant: The main signs are that the frequency of the experience of anxiety, so it's becoming much more frequent. As I said earlier on, a day basis. You will see the child is becoming anxious and/or distressed when they're facing the situation that they're fearful of.

It's the tendency for the child to, again, articulate fears with their overestimating how likely their feared event is to actually occur even when that event may be quite neutral or ambiguous even. Using the example of the dog phobia earlier that they fundamentally articulate beliefs that they are going to see a dog when they leave the house to walk to the bus stop even though the possibility of that may be potentially low. It's the tendency for children to overestimate how bad that would be if they did see a dog, for example.

Justin: Traumatizing it.

Dr. Chalfant: Yes, catastrophizing, is probably the word that we would use. They think really it's end of the world stuff. It's really terrible for them, if that were to happen. The other thing is just that the anxiety is really out of sync or in congruent with what the fear is. For example a child who has to give news in school, who has a social anxiety problem, moving from a healthy anxiety where they feel a little bit nervous about giving news to the class to a child who has an anxiety problem where they are ruminating on a daily basis in the weeks leading up to the new or even the week leading up to the news because they fundamentally believe that they are absolutely going to make a mistake, embarrass themself, that the class will laugh at the them.

The thought of that causes significant distress, are the sorts of signs of when anxiety's tipping over into a problem. It's about the frequency, the intensity, the type of thinking, and the fact that that thinking is really far beyond what the situation really requires. It's really incongruent with the situation. The situation sounds quite neutral to any other person, but for that individual, it's seen as very threatening and harmful.

Then the other factor is just as we were saying earlier the degree to which they're avoiding that situation is another telltale sign. That they are deliberately putting themself out of the possibility of facing a fear. If they're refusing to go to school on the day when it's news, then that starts to impact on their day to day coping.

Justin: They suddenly get a stomach bug and they don't feel well.

Dr. Chalfant: Yes, for example. Yes.

Justin: The two words that parents would be wanting to keep in mind if they're seeing behavior that's catastrophizing and behavior that's avoiding a given situation or situations, whatever they may be. It more than just, "Well, I don't want to do whatever .I just don't want", and then you have to push them a little and then I'll do it. It's actually more extreme in that.

Dr. Chalfant: It's about the extreme response. It's the intensity and it's the frequency of that behavior occurring. For someone who is not experiencing anxiety as a problem that response would be far less frequent. We're really talking about on a daily basis is quite extreme, intense responses, distress, et cetera.

Again, we think about the difference between the appropriateness of the responses in terms of the content. It's appropriate for a three-year-old to be potentially fearful of separating from their parents when they go to preschool, but it's really inappropriate for an eight-year-old to be experiencing that same degree of distress when they're kissing their parents goodbye and attending grade two. We look at that as well.

Justin: Excellent. Moving now into the treatment aspect for autism and we mentioned the Cool Kids Program earlier and you offered the autism version of the Cool Kids Program and anxiety treatment program for children in conjunction with Macquarie University. Can you give us a brief overview of the Cool Kids Program?

Dr. Chalfant: The Cool Kids Program is a world-renowned cognitive behavior therapy-based intervention program that was manualized. Basically put into a guide for therapists to use with anxious kids and subsequently anxious adolescents and their families. It essentially made CBT, Cognitive Behavior Therapy, into a form that families and kids with the guide of a therapist could understand. It translated those things skills or brought those skills to life.

We talked about challenging unrealistic fears and using graded exposure of stepladder approaches. What the Cool Kids Program did was essentially capture those approaches to treatment and put them into a program that was very user friendly to kids and their parents. That is now a world regarded world-renowned program. It was developed by Macquarie University by Professor Ron Rapee and colleagues there and has now been disseminated across the globe and translated into other languages and extensions from that program have been developed for adolescents and different types of anxiety disorders et cetera.

Justin: It's had an enormous impact.

Dr. Chalfant: It's had a phenomenal impact worldwide. I'm really proud as an Australian to say that that is something that's come from Australian academics and researchers and clinicians. It's a highly regarded program and one of the first of its kind. That's the Cool Kids programming, the original.

Justin: I think we should be proud of it as Australians in Australia where sometimes that people do wonder what are we making anymore here and what are we doing anymore here to understand better that there is a program that is being developed in this country. That's now positively impacting the lives of children, adolescents, and families around the world. It should be a sense of pride for all of us. I found stands a personal sense of pride but that more broadly is something quite significant.

Dr. Chalfant: The Cool Kids original program was nothing that I can claim.

Justin: I understand. Yes, of course.

Dr. Chalfant: What I did as a part of my doctoral thesis, my clinical doctorate, I was very lucky to be supervised by Professor Ron Rapee who is really one of the foremost figures in terms of anxiety research in the world. He and another colleague Heidi Lyneham and myself in conjunction with Aspect which is Autism Spectrum Australia where I at the time was working, we developed the autism spectrum disorder version of the Cool Kids Program.

We did that because as I said earlier, we know that children with autism prevalence rates are much higher in kids with autism spectrum disorder than they are in non-autistic individuals. We were trying to see if we could adapt that program for kids on the autism spectrum and still provide the same benefits in terms of treatment that we know exist for individuals who are anxious when we use a CBT-based approach.

Justin: While you were writing this program, did you have any aha moments so to speak or eureka moments that made you rethink or better inform your approach to treating children with anxiety?

Dr. Chalfant: I think there were probably two things I would say about that. The first, not so much an aha moment, as opposed to a moment of confirmation of-- That science, is about a testing hypothesis. What our view was that these kids with ASD. We were testing the hypothesis that we'd be able to apply, what is a mainstream CBT-based program to this special population.

It was our hope and our view that we would be able to do that. That they would have the thinking abilities and the ability to what work through the cognitive challenging aspects or the changing unhelpful and unrealistic thoughts and to helpful and more realistic thoughts which can be quite challenging even for an adult who's not autistic. Let alone a child who is autistic.

We were to view that we would see success in doing that and that we would be able to use things like graded exposure hierarchies, and stepladder approaches with these kids and get positive outcomes in terms of reduction in their anxiety. One of the great things about that experience and running that research which underpins the Cool Kids, ASD version was saying that that was the case. That those results rang true.

Then I think the second aspect was what we know again, in the mainstream, scientifically torture for kids who are anxious and their families. Is the importance of families being involved in the child's therapy. Parents having a role in treatment and parents attending treatment with their kids when we're treating anxiety disorders. Not dropping a child off for therapy and picking them up and getting the child-- Expecting that the responsibility is on the child to manage their disorder but parents playing a part in things like creating the stepladders and managing the graded exposure hierarchies at home and supporting the child through that. Really involving them very actively in that process. Educating parents about anxiety, giving parents skills to even manage their own anxiety. As we said earlier in this podcast, we know that there's a role in terms of modelling parental, the way parents model coping or lack of coping and the impact that has on anxious kids.

What we saw, again, in the ASD version of the Cool Kids program, when we developed it and ran it through my doctoral research, what was that again there was that benefit. It really made a big difference, a significant difference to have parents involved in that process to get them to come along to the treatment sessions and to have separate education section to the parents, separate to the kids while the kids were going through their own therapy or coping strategies and learning their strategies.

Also, moments in sessions where they were working together as a family unit and setting up hierarchies and homework practice tasks, and then coming back the following week and looking at how they'd gone with those and adjusting from there. It was just as beneficial to have parents involved with those kids on the autism spectrum as it was, and as we saw in other research.

Justin: Okay, excellent. What if a person or parent wants to address the anxiety that they see in their child, what would be the first step or best first step that they should take? Is it go access the Cool Kids' program directly, or do you need to go speak to your GP first? Then you can go into that program? What are your recommendations?

Dr. Chalfant: I think it depends again on this idea of the balance between healthy and unhealthy anxiety. There is certainly skills that parents can develop and work on in terms of modelling confidence to kids who have healthy anxiety, but just need to be perhaps a little bit more resilient. Things like boosting children's confidence, having a can-do attitude, supporting children to face these more generally, rather than avoid them. Those are general things that parents can do.

Justin: Talking about where they've had to face a fear during their Workday when they come home to help the child understand that it's a normal part of life. You have to do it as an adult as much as you have to do as a child.

Dr. Chalfant: Absolutely. Yes, that's a really good example, actually. Modelling that in terms of how they face their own day, but also talking through with their child, "Okay, I can see that this is something that you're fearful of. Let's problem-solve some ways that we might face that fear." The child might say, "Well, I don't want to." For example, let's say, it's a separation worry. "I don't want mom, dad to go out tonight. I want you to stay home with me."

As the parent trying to problem-solve with the child ways that they could cope by making it clear that, in fact, mom and dad are going out tonight, so let's think about what you could do, knowing that we're going out. One thing that the child come up with is, "Well, just don't go." Yes. Okay. Well, yes, that's one possibility. Is that they're validating what the child is saying. Saying, "It's okay, we'll accept that for now. We'll talk about that as well, but what other ways could we problem-solve this situation? Is it that we could maybe have someone that you can call if you're feeling nervous. You've got obviously the babysitter here, you can talk to them about it. Maybe we could put a movie on that will take your mind off it", those sorts of things.

Having a can-do approach and approach where you're ultimately going to come to a point where you say that we are going to go but you've got some strategies to managing this situation. You will be able to cope, you've coped before, nothing terrible is going to come of this and we're all going to manage and get through it. We're really boosting resilience and confidence and encouraging kids to work through that.

That's something that parents can do more generally with children at any time whether they have healthy or unhealthy anxiety and mostly when they have healthy anxiety. When a child has unhealthy anxiety, when a child has an anxiety disorder, then really we know that treatment, as we discussed, is really required. Some children can recover from that with intensive parental support, but more often than not children are better placed by accessing some sort of psychological intervention.

The process to get to that or the way to go about the pathway to that these days with things like Medicare rebates for mental health support, et cetera. The first protocol might be the GP in order to look at whether the child seem to present with an anxiety difficulty, and then the GP referring them to a clinical psychologist, for example-

Justin: Can you go direct to a clinical psychologist?

Dr. Chalfant: Yes, definitely parents can go directly to the clinical psychologist to try and start off supporting and using a CBT-based approach and that really use the expertise of a clinical psychologist. The other thing is and or sometimes psychiatrist might be involved, sometimes the GP and the clinical psychologist work together, or the psychiatrist and the clinical psychologist work together if the anxiety is so severe that it needs a combination of treatments like medication and other psychological strategies.

Usually, the role of medication is to reduce very, very severe anxiety to a point where the child or the adolescent is able to function in a therapeutic intervention. It allows them to then be in a position where they can start to help themselves.

Justin: Just to help define that there, am I right in saying that the psychiatrist is the only one of the psychiatrist and clinical psychologist, the psychiatrist is the only one that can prescribe the medication, your clinical psychologists cannot.

Dr. Chalfant: That's correct.

Justin: That's why they have to work together. In that very specific scenario where the patient has to have medical intervention before they can really get value and benefit from the therapeutic intervention that the clinical psychologist, that's where their expertise lies.

Dr. Chalfant: Yes. Sadly that doesn't always happen. In fact, frequently that doesn't happen. They don't necessarily work together like many aspects of our health system. It could be quite disjointed, and families can doctor shop and clinician shop trying to find the next person that will give them instant results. Usually, that's out of desperation and concerned because, by the time you're looking at medication to treat anxiety, the anxiety is quite severe and debilitating, but it is important that they do.

Justin: For those parents, the rock-solid advice for them, because they are obviously under a lot of stress and I can empathize enormously with them because you only want your loved ones to have a normal life or as normal as possible life. What you're looking for is a psychiatrist and a clinical psychologist that will work in lockstep to the total benefit of your loved one.

Dr. Chalfant: That's exactly right. In Sydney, which is where we are, there are definitely clinics where there are psychiatrists and clinical psychologists, for example, who work within the same practice. Then that's much more advantageous for those families.

Justin: One visit and you can coordinate to go one visit, see one, and then see the other potentially.

Dr. Chalfant: Exactly. Or there are places like the Centre for Emotional Health again, which is at Macquarie university, but it's a centre of excellence in terms of research, but also the application of that research. It's a centre where there are scientists and academic professionals who are researching best practice treatment for anxiety and other aspects. The theories around anxiety, causation, all the things that we've discussed. There's a clinic attached to that, which we mentioned Heidi Lyneham and Ron Rapee earlier.

Ron is the founding director of that centre and Heidi is the clinic director at the centre. That is the centre where they have actual clinical psychologists, professionals who are fully registered and working, but they also have students who are completing their clinical psychology registration. They're supervised by more senior clinicians. Families can access support there and it will be good because it's in a university institution, might be with some subsidized cost from the universities, and that's another potential option.

There are other university clinics, not just in Australia, but worldwide that are teaching institutions for clinical psychologists, and for psychiatry, et cetera, where families usually can go to a clinic within the university institution and access support there as well, and see that more connected model of care.

Justin: Families cannot be overwhelmed by this, but they can literally go to the source. The university, in this case, say Macquarie, or as you said, any in the world, don't be overwhelmed by that fact. Don't think that you're not of that level, or you have to be some special case before you go in there. That you can really cut to the chase and go see these people and you will get potentially, in the case of, definitely, Macquarie University, as the premier or the number one health care for this in all of Australia.

Dr. Chalfant: Without a doubt. I think the other thing to say is sometimes families think that or can just understand that we'd be reactive. Typically you don't want to be taking your child off to a clinician when it seems like the child's anxiety may potentially be borderline like something sub-threshold or subclinical, not super distressing, not causing lots of difficulty in terms of their day to day functioning. They don't want to be too alarmist and create a problem-

Justin: That could be-

Dr. Chalfant: -that's isn't going to be there.

Justin: Going into their final years of high school-

Dr. Chalfant: For example.

Justin: -and you could be like, "Well, I don't want to make this worse-"

Dr. Chalfant: By drawing attention to it and everything is messed up.

Justin: Correct. "I'm not going to march you into an enormous university surrounded by lots of people and then go see someone to talk about this."

Dr. Chalfant: Make your child second guess themselves and go, "Well, actually, maybe I really do have a problem." Having said that, there is nothing wrong with at any stage learning, good coping strategies. I've certainly seen clients over the years who don't have a child, even who has an anxiety problem but maybe has a child that could be vulnerable, have that sort of temperament.

Justin: Tendencies.

Dr. Chalfant: Yes or tendencies that we talked about and want to simply learn good strategies and approaches to help their child proactively to manage anxiety [crosstalk] with them.

Justin: Sorry. It's interesting you say that because, typically, what you think about is that if you're struggling in maths or history or English or whatever, then you go see a tutor, right? You go see a tutor to improve. Maybe that isn't the case for your child. Maybe seeing the tutor is important but maybe seeing, as you said, someone that's going to also tutor you or help you with the coping mechanisms to bring those anxiety levels down, getting guider control where you're going to begin solving more in the classroom and learning more. Maybe yes, you need tutoring, that's completely fine, it's up to you. That could actually be, we'll go treat that before you then load up more on the extra-curricula training, for example.

Dr. Chalfant: That's correct. Coming back to your question about treatment options, that brings me to another point and that is that there are lots of great books and resources out there for families who don't necessarily need to or feel ready to directly access treatment in a clinic or with a therapist. Whether they're in an institution like a university or whether they're a private practicing clinical psychologist or psychiatrist or therapist. There are self-help guides if you like for parents to work with and support kids who have a tendency to be anxious.

Again, I suppose to highlight the work of Ron and Heidi and their colleagues. That is because they really are leaders in this field. There is a book called Helping Your Anxious Child and that is a guide for parents or a book that parents can purchase on Amazon or through Booktopia and simply read about strategies that would work at home to build confidence in kids and work through situations that children fear. Just to help level off tendencies to be anxious.

Justin: We've got some other resources that we want to mention. Before we do that, quite specifically, there could be teenagers listening to this and that they observe in their friends at high school. It could be young adults that they're observing and friends that they've made at university. They're concerned about that person's level of anxiety. What are some ways that you could give to young adults and some ideas of how they could approach their peer to discuss their anxiety? Maybe to encourage them to think about it, if not go and get treatment. It's not going to then result in maybe a breakdown in that friendship or cause more anxiety, which the friend wouldn't want to see. How could be ways and tips that they could approach that friend that's going to help improve the situation, not make it worse?

Dr. Chalfant: It's a really excellent question because for me personally, I can think of an interaction I had with one of my own patients who is a teenager in therapy recently. She said to me, what she wanted from her friends were people who were supporters not enablers. What she meant by that was she wanted people to support her in trying to learn to cope with things that made her anxious by encouraging her. Again, having that can-do approach for her. "You've got this, I know you can manage it, give it a go", those sorts of things. As opposed to enabling her to avoid the things that made her anxious and giving her encouragement around showing lack of confidence.

More broadly speaking, I suppose, giving attention and praise and encouragement to brave behavior in their friends would be something that they could do just as parents could do that for their kids. Certainly, adolescents can do that for other adolescents to be supportive rather than helping a friend avoid something that makes them anxious because really that's the worst thing that you can do.

Justin: If they've got a friend who doesn't really like coming out, don't invite them to a party where there's going to be 60 people. Maybe go to their place for a coffee or have them to your place for a coffee one-on-one and then praise that behavior.

Dr. Chalfant: It could be absolutely that or if they can get to the party, maybe only stay for the first time 5 or 10 minutes and then plan to go off somewhere afterwards to celebrate that small win with like a coffee or a movie or whatever it is. I think the other thing is just to let the friend know that it's normal. That it is okay to have these experiences. Sometimes adolescents feel like they're the only ones going through these emotions and they feel, or they isolate themselves because of those worries. Trying to encourage them and explain to them that really and we know from just the stats that really up to 20% of the population will experience anxiety problem at some point.

For 3 to 17-year-olds, that's as highest 10%. It's not as uncommon as we might think. Taking the stigma out of it, making them feel it is a reasonable emotion to have and that it can be a normal experience, but maybe it's just that they are having that experience, as we said, too frequently or too intensely. All of this is a matter of just getting some help to bring that back and putting it into some perspective like that would be a good way. I think that would be more palatable for a teenager rather than feeling like they really have a big problem and making them feel like there's a stigma or something that they should isolate themselves from others because they are on their own in this.

Justin: Excellent. Let's just list those resources. Again, we will put links to all of the resources in our different social media posts and podcasts, YouTube, et cetera. I'll have you step through those.

Dr. Chalfant: The clinic that I was talking about, it's the Centre for Emotional Health. That, as I said, is at Macquarie University, which is, again, a center for excellence in terms of scientific research around anxiety. Whether that's adolescent, adult, child, parents, or the interaction of parent and child anxiety and a clinical center as well, where anxiety can be treated either individually or through group programs. There's a number of resources that families can access on that website. There are articles and scientific articles and papers that not just families, but other clinicians might want to read in terms of upskilling themselves and their own professional development.

There were so many different aspects to that center in terms of the sorts of services they can offer in managing anxiety. Beyond the Centre for Emotional Health, the Cool Kids Program, which can be accessed at the Centre for Emotional Health, we talked about already.

Justin: That's worldwide, so, if you Google-

Dr. Chalfant: It's been translated into Spanish, Danish, Korean, all sorts of other languages as well.

Justin: You could just Google Cool Kids. Cool as in C-O-O-L. Not any funky spelling. Is Cool Kids Program. You could just Google that and see if it's offered in your area, your region.

Dr. Chalfant: You could see if the program is being offered but again, you can purchase the language translation of that program at the Centre for Emotional Health, that is the center where it was ultimately developed or through the researchers who are now at that center or who founded that center. If people access the Centre for Emotional Health, they'll be able to access a number of products and resources, including the Cool Kids program and the languages in which it's been translated.

Justin: For example, just to clarify that, if I am in Korea and I am a Korean I can go online and purchase the Korean translation and have that shipped across to me.

Dr. Chalfant: Correct and you could use it as a Korean therapist with your own clients in Korean, or you could be a Korean family and look at the parent workbook of that program and work through some of the strategies with your child. Either of those options. We mentioned Helping Your Anxious Child, which is the book that Professor Ron Rapee and colleagues wrote and that's available through Booktopia and Amazon. I highly recommend that book for families and then there are fact sheets, again, that can be accessed. Again, an example is at Macquarie University and then of course the book that I wrote, which relates to individuals with autism and anxiety, which is Managing Anxiety in People with Autism: A Treatment Guide for Parents, Teachers & Mental Health Professionals and that again is accessible online through Amazon.

Justin: As we said, links to all of those resources will be on our social media and on the podcast and YouTube channel. Fantastic, thank you very much for an excellent session on our main topic, understanding anxiety. Now in that frame, you've been putting a lot of posts on Facebook with different information, and one recent post on Facebook and LinkedIn was entitled Managing Anxiety in Kids and Building Confidence. You wrote in that post children are presenting more and more with anxiety and worries. What can parents do to help them? Dr. Chalfant, what can parents do?

Dr. Chalfant: This was coming from, as you said, a post that I'm writing for LinkedIn and Facebook almost on a daily basis, but I've taken the Thursdays each week and focused on anxiety each Thursday.

Justin: How many have there been so far?

Dr. Chalfant: I think there's been four Thursdays now. This was the first of those Thursday anxiety posts and tips. It was starting with the lower level or easiest steps and we've been building each Thursday on this first tip.

The first tip was around building confidence and then we've looked at a can-do attitude and then in subsequent weeks we've talked about teaching some simple relaxation skills. In fact, the fourth one was around perspective-taking, and we were talking earlier in the podcast around trying to transform unhealthy worries and unhelpful thinking styles into more realistic perspectives and problem-solving. That's what that one was about. This was the first one and it was simply around the idea of just getting parents to shift their attention from worries to bravery.

Trying to change their focus from cajoling kids or teenagers when they are feeling worried and nervous and hand-holding them through that too much to giving their attention instead to when children and adolescents are being brave. That being a first step at building confidence because we know that depending on where attention is given, we will see more of those behaviors. That's just simply behavioral science at its simplest.

The more attention we give to a behavior, the more likely we are to see that behavior occurs. If we give more attention to brave behavior, then children are more likely to show brave behavior more often and if we reward brave behavior, then they'll be more motivated to show that. It was just simple tips, like finding opportunities at home to encourage and praise up your child for doing something on their own. For being brave in anything like maybe you go out to dinner and the child is the one to order something off the menu when they normally wouldn't. That might be worthy of praise and making a big fuss about how brave that child was in that situation and really trying to encourage parents in that post. I was talking a lot about the specific language that they use.

It's really important to be very specific when you're praising children in order to really target exactly what the behavior is that you want to see more of. Using words like, "You were so brave, you did that on your own, you did that without my help." Those catchphrases are really critical in highlighting to the child in a really obvious way exactly what it is they're doing that is so great and then that's what motivates them to continue with that or keep showing more of that behavior or perpetuating that behavior. It was about trying to encourage bravery and kids using those catchphrases and trying to be, I suppose, like a detective and catch kids out at any simple opportunity when they are being bright. Whatever that might be.

Justin: We often catch kids whenever they are doing something wrong. This is catching kids when they are doing something right.

Dr. Chalfant: Yes and then finding opportunities maybe to deliberately create situations where a child can show independence. In that way, we've manipulated things so that we then have an opportunity to praise them for bravery. For example, maybe parents can give their kids little responsibilities or extra jobs around the house. Then use that as an opportunity to highlight back to the child, how the child did that on their own or did that without the parents help or did that independently, or did that really bravely? Exactly.

Justin: Excellent. Fantastic. It's on the Facebook page. It's at Dr. Chalfant, search for yourself and Annie's Centre and they can get that post and many, many others.

Dr. Chalfant: That was the first anxiety post and there have been others since then it build on that initial skill. All right, I think we're up to our last segment, which is kids in the kitchen. Justin, over to you.

Justin: The first recipe rather than I thought we would kick off with is one that was actually found on one of those grocer's cards that you get at the local greengrocer or even a local supermarket. It's called roast garlic and lemon chicken and I love that this recipe specifically is because it's all basically cooked and then served in the one tray. You can scale it up and down. You can increase the amount of ingredients. If you've got more mouths to feed, or you can reduce it down for a smaller size-

Dr. Chalfant: This recipe is amazing. Every time we make it for guests, friends, kids-

Justin: Oh, it's a great one for guests because it can be done not quite last minute, but it doesn't have-- you're not spending hours and then waiting for the soufflé to rise and if the soufflé doesn't rise you can't be out there crying in the corner and ordering pizza and people love it. It's pretty-

Dr. Chalfant: Delicious.

Justin: -delicious and it's fairly foolproof. Six ingredients; chicken pieces, legs and thighs, garlic, thyme, lemon, olive oil, and salt, and pepper. That's it. You can combine all of those in a large dish. You line a foil tray with baking paper and then place one layer onto that tray of all of those ingredients. You roast in the barbecue or oven and serve it sprinkled with feta cheese straight from the tray. Drop trays down put the tomes on feta cheese and you're done. it may be a salad on the side and a bit of mashed potato and you're on your way. On Facebook, we will post the pictures of the recipe card. You can get all the details of that. The photographs of a version of it that I cooked very recently on the barbecue and you can see that there were several trays because we were cooking for guests-

Dr. Chalfant: We had no leftovers at all because everyone wanted seconds.

Justin: It's a real shame and when we cook with garlic with this, you might be concerned that you're going to be there forever, crushing garlic cloves, or slicing garlic into thin slivers rather of garlic. You don't have to worry about that. You literally take the entire garlic head and chop it in half and throw it on the dish. It's only as hard as doing that. It's fantastic. Highly recommend that one and details will be in the Facebook post.

Dr. Chalfant: We'll have other kids in the kitchen and recipes in other episodes.

Justin: Absolutely. There are loads and many, many more and we would obviously love to hear back from people and see pictures of people in the kitchen with their children.

Dr. Chalfant: I think that's it for this episode of our very first podcast, hopefully, everyone has found something that they can take with them moving forward on anxiety or confidence building in their kids or their adolescents. We're always open to in either through Facebook or other ways of contacting us ideas for what people would like us to do podcasts on. Just to finish up I have a joke. I like to finish sometimes on a joke. Patients often ask me to tell them a joke in sessions, not necessarily because I'm the world's best joke teller, but nonetheless, they seem to keep coming back. Here's my joke. What did the left eye say to the right eye?

Justin: I do not know. What did the left eye say to the right eye?

Dr. Chalfant: Between us there's something that smells.

Justin: [laughs] Okay. Good, I like that one. Well, as you said, that's a wrap for this episode of the Annie's Centre Podcast. I'm Justin Kyngdon.

Dr. Chalfant: And I am Dr. Anne Chalfant.

Justin: Our mission is to help families thrive and we hope this episode has done just that. Let us know by visiting the Annie's Centre Facebook page and leaving a comment. You'll find Anne on Instagram, Facebook, LinkedIn and Twitter. Search the hashtag, #DrAnneChalfant or #Anniescentre. That centre spelled the English way, which is C-E-N-T-R-E, so hashtag A, double N, I-E-S-C-E-N-T-R-E or @ D-R, A, double N, I-E-C-H-A-L-F-A-N-T or #DrAnneChalfant or #anniescentre. Don't forget to leave a rating and a review on the podcast app where you found us. Tell you family and friends to listen and do the same.

[music]

Speaker 3: The Annie's Centre Podcast was brought to you by Annie's Centre proprietary limited. Please visit anniescentre.com and subscribe to receive the latest updates and digital downloads from Dr. Anne Chalfant.

[music]

[01:31:40] [END OF AUDIO]