Children, The Family and Health: What it Takes to Give Children Long Life

The Singapore Workshop: Stress Management

Introduction by Shirley Munyan

Dr. Donnenfeld is a Clinical Child Psychologist in private practice, treating children and adults. She specializes in the area of stress reduction and the treatment of chronic illness and pain disorders. In addition to her private practice, Dr. Donnenfeld is an adjunct Professor to the Clinical Psychology Program at Columbia University and the Health Psychology Program at Yeshiva University. She is a speaker for the Children’s Hope Foundation, an organization benefitting children with AIDs and their families. She is the former Director of Pediatric Consultation / Liaison Service at the Bronx Municipal Hospital, an affiliate of the Albert Einstein College of Medicine.

Penny B. Donnenfeld, Ph D USA

I am a clinical child psychologist who works with children, adults and families. My talk today will cover stress, adults and children. We’re all familiar with inoculations or vaccines for certain diseases such as polio and smallpox. I am here to speak about another type of preventative healthcare practice which has implications not only for the physical health of developing children but also for their psychological well-being. Actually, the more we understand about the workings of our minds and bodies, the more we see how the two are inextricably intertwined.

In order to fully understand stress “inoculation”, certain basic questions will need to be explored. First of all - what indeed is “stress” and why should we be concerned about it? Stress is “physical, mental or emotional strain”. It can come from external events such as school requirements, death in a family, divorce, war, poverty or from internal pressures such as attitudes and expectations. Actually the “stress response” that takes place in our bodies is a series of biochemical changes that prepare an individual to deal with threat, danger or challenge. You may have heard it called the “fight or flight response” During the “stress response”, the thinking part of the brain sends a message which then stimulates the sympathetic nervous system to alert different parts of the body. Heart rate, breathing rate, muscle tension, blood pressure and metabolism all increase. Blood is directed away from hands and feet and the digestive system to the large muscles that can help you fight or run. During the time that this is happening, the adrenal glands start secreting chemicals (like adrenaline) which shut down digestion, growth, tissue repair, and responses of your immune functions. It is a state of emergency. This stress response system was designed to protect humans during primitive times as they survived in the wild and encountered predators who threatened their lives.

Why should we worry about stress at all?

Our world and it’s demands have changed since the days of the cave family. Stresses that occur now often are of a chronic or ongoing type. Stress can occur in response to positive events such as a job promotion or having a baby. Stress can range from things like job demands, or financial pressures to upset over a series of daily tensions such as losing a key or getting a flat tire, being late. Take a moment to think of all the “stresses” or bumps in the road you have encountered in the last week. Stress of an ongoing or chronic type can keep the body in a state of a sustalned emergency. This has dangerous effects on an individual’s physical health. Possible stress-related diseases that can result include: high blood pressure, migralne headaches, ulcers or chronic stomach upset, cardiovascular disease, lowered immune functioning. Stress can exacerbate existing health conditions such as asthma, diabetes and seizure disorders. Psychological problems, such as depression, anxiety and panic disorders, can result. Also, stress can negatively affect conditions such as schizophrenia, depression, manic-depression and more. Often in the attempt to self-treat this chronic level of tension and strain, certain behavioral problems such as alcoholism, drug abuse or chronic over-eating can develop. In children, signs of chronic, unresolved stress can include: poor eating and sleeping, temper tantrums, learning difficulties, failure to grow, apathetic withdrawal, lying, trouble concentrating and more.

Our bodies can reverse the stress response. This is called the relaxation response. Our systems can begin the change from stress to relaxation three minutes after the word goes out in the body that there is no longer a threat. With the relaxation response, your heart rate, breathing, digestion, muscle tension etc. all return to normal.

What can be done to lessen or to stop stress responses or how can the “relaxation response” be stimulated?

First of all, it needs to be recognized that a stress response is either occurring or being maintained in a chronic fashion. This involves checking in with your body, noticing the level of tension in different muscles and evaluating things like your mood, capacity to concentrate and attitude toward the world around you. Once you determine that you ARE feeling stressed, it is important to sort out what may be causing it - whether it is coming from an external demand, internal demand or some combination of the two. Identifying and defining stress is the first step to devising a plan to manage it. This can involve strategies such as setting limits on things that you will agree to do with your time or setting priorities. It may involve purposely lessening the negative impact of the stressor by thinking about more positive ways to look at the situation. People who view stress as a challenge or opportunity for re-evaluation and feel more in control of their lives are less likely to suffer from stress-related illnesses. Such individuals perceive themselves as capable of making choices and influencing events around them. Techniques such as diaphragmatic breathing, using positive imagery, progressive muscle relaxation, step-bystep problem solving with role play and exercise are important tools to use in creating or maintaining a relaxation response.

How can children learn to lessen, reduce or to eliminate some stressful responses?

Well, do parents, teachers and healthcare professionals think of stress reduction or management as a skill to be learned like toilet-training or reading and writing? Do adults purposely model such skills in their behavior?

Picture a parent in the kitchen teaching a young child to cook. Long before that child is actually capable of measuring out ingredients, mixing them together and then monitoring the actual cooking, he or she will watch an adult doing just those things, often speaking aloud about the steps. This type of rehearsal or practice of a skill along the road to competence is exactly what is called for in teaching children about stress management or “inoculating” them against chronic stress-related disorders.

So, the initial step for caretakers of children, is to survey your own stress-management skills and to determine if you are demonstrating attitudes and strategies that you want to pass along. If not, it is not too late to learn and to incorporate new relaxation and stress reduction techniques into your behaviors.

What are the relaxation techniques and when can children do them?

Diaphramatic breathing involves relearning a way of breathing that we did instinctively from birth and throughout infancy and still do while sleeping. It enables you to fully drop your diaphragm when inhaling and thus more fully expand your lungs, getting a more efficient amount of oxygen in your blood. Shallow or chest breathing is used frequently when a person is anxious or tense. This can limit the oxygen in the blood which increases the likelihood of muscle tension and the stress response. Diaphiagmatic breathing or deep belly breathing is something that you can do for a sustained period of relaxation (e.g. 10 minutes in morning or night) or interspersed throughout your day to break the pattern of tension and muscular tightness that we often maintain on an ongoing basis. Thich Nhat Hanh, a Buddhist monk originally from Vietnam, has written about using the sound of a bell or some other cue to remember to take three breaths. In my work with patients, I call it, “transition breathing” and suggest that it be done each time a person changes activities in the course of a day.. Children as young as 2 1/2 or even a bit younger can observe and copy adults’ use of breathing techniques on a regular basis. For example, what does a child in your arms experience in your quality of breathing in reaction to a stressor? Do you tense, breath hold, or breathe in a rapid, shallow anxiety-increasing manner? Older child can be taught game-like breathing strategies e.g. breathing the tightness out of areas of the body, transferring a color, filling the belly like a balloon.

Progressive Muscle Relaxation: This teaches children basic awareness of muscular tension and release. When someone maintains a chronic level of stress response, often the person loses the ability to distinguish between tense and relaxed. This is something we want children to be able to do from very young onward. It is going to be an important part of self-monitoring for the purpose of determining state: relaxed or not. Progressive relaxation involves doing a full body scan, tensing muscle groups and then releasing them. Young children can be directed to squeeze their muscles tight and hard and then to let them get loose and floppy like a rag doll. Older children can learn to do muscle tense and release cycles when they notice their levels of tension rising. Parents or other adults can enhance a child’s learning of these skills by demonstrating them on a regular basis and having younger children, especially, join in.

Positive Imagery: This involves the use of imagination for practicing problem-solving or for creating a relaxing mental vacation from the stresses at hand. In recent research, when athletes were monitored imagining that they were playing their sport, interestingly, activity registered in their muscles and their time to learn a new skill decreased with mental practice. Especially for stress occurring in anticipation of an event, e.g. before a test, a medical procedure etc. adults can talk a child through a visualized positive resolution of the problem - one that can be practical or fanciful For example, you can describe the child looking at the test questions and taking a deep breath and with each breath in finding the answers faster and clearer in his/her mind or you can describe the child sitting by a beautiful waterfall, hearing birds singing and water gurgling and putting his toes in the bubbly water and feeling rested, relaxed comfortable… the possibilities are endless. As soon as a child is verbal, an adult can begin to play imagination games and fully develop the child’s imaging capacities. Older children can be worked with to have certain favorite scripts which they can turn to in their own minds and use when signs of stress arise or they might become interested in some structured use of attention and imagery like that involved in specific meditative processes.

Step-by-step problem solving: This can involve a combination of appraisal, imagery, role play or planning and useful self-talk. Self-talk is the “voice” we hear in our heads that comments on how we are doing things. Negative self-talk and self-criticism can escalate stress responses e.g. you’re stupid and clumsy and will never do anything right. Positive self-talk can help increase relaxation, e.g. you have done things like this before, remember how satisfying it felt to tackle a challenge and sort through what needed to be done, I CAN do this. Appraisal involves putting the issue or task in perspective, considering the range of good and bad outcomes, staying focused, understanding that stress is normal, and thinking of who or what would be helpful in following through. Role playing enables children to rehearse looking at a problem, breaking it down into manageable steps, making efforts to deal with it and reviewing possible outcomes.

Finally, exercise: well, I don’t think I need to ennumerate different types of exercise that can be done. But, it is important to outline the benefits of exercise in managing stress. Exercise improves cardio-vascular functioning, reduces muscle tension, adds oxygen to the body, decreases stress hormones in the blood, teaches the positive benefits of setting a goal and working towards it, improves mood, increases resistance to disease and builds muscular strength and endurance.

This review of stress and stress management skills is really just the beginning of understanding about the impact of stress on you and on children in your life. Hopefully, you have recognized some of the stress signs and stress reduction techniques mentioned in this talk. If not, isn’t it nice to know that they are available for you to learn, practice and pass on.

Question and Answers:

Q - C. Patsawon - Thailand - How can these stress reducing techniques be used in the classroom?

A - Teachers can be trained as a coach. They can teach the techniques and use them when needed by students. A program like this needs to be supported by the school and parents.

Q - L. Kanitta - Thailand - How can you tell a young child is stressed?

A - A child who is stressed may show one or more of the following issues: learning problems, outbursts of temper or be withdrawn and apathetic. Babies without love and adequate comfort show stress in the form of apathy. Children may have a feeling about the stress but lack the words to express the feelings, so behavior is the key.

Q - Dr. Karim - Malaysia - Do you hold sessions with families to teach these stress reduction techniques?

A - My work is with children and parents together. The key is to teach them how to deal with the child on a daily basis in the context of their lives. For parents, they need to get in touch with what they want to achieve, not how it looks to others.

Q - R. Ishak - Malaysia - Children who have limited mental functioning, how would you work with this child?

A - Children with mental deficiencies are approached the same as others except that you find the child’s level and teach as you would to a younger child.

Comment - M. Gard - Australia- If parents are fearful of learning or doing stress management, the form of Artwork or music can be a more acceptable form.

A - Any way stress management can be used to reach children is something I endorse and support.

Comment - Dr. Hashim - Malaysia - As a regular routine, children in nursery schools in Malaysia are taught enjoyable exercises and breathing to music. It is a part of their school day.

A - I’m interested in what is being done in those schools. Let’s talk.

Last Modified: November 29, 2002