Helping the Stressed Out Teen

Hey there everybody, and welcome to today's presentation on adolescent anxiety. I'm your host, Dr. Donnellice Snipes. In this presentation, we'll identify the prevalence of anxiety as well as depression in adolescence. We'll explore some triggering issues, discuss how and why adolescents respond differently than adults or even children to stressors in their life, and we'll review a few intervention approaches. Now, it's important to remember that just like children and adults, no one size fits all intervention is going to work for every adolescent. So treatment really needs to be individualized. But my goal in this presentation is just to give you a broader understanding of what may be going on so you can intervene appropriately. All right, so let's start with the first statistic, which I found a little bit shocking but very depressing. And that is that in the 2001 and 2004 survey done by the National Institute of Mental Health, it was found that 31.9%. So basically a third third of adolescents experience clinically significant anxiety. They meet the criteria for an anxiety disorder. Now just let that sink in for a second. That's heartbreaking. When we talk about depression, and that's, you know, any form of depression, we're looking at about 17%, so you know, about 1 in 5, and PTSD, we're looking at about 5%. So all told, adolescents really do have a pretty high rate of mental health diagnoses. Don't get overly obsessed with a particular diagnosis or lack of one. And that's another issue that I struggle with with people because they want a diagnosis and sometimes people. The adolescent doesn't meet all of the criteria for a diagnosis, even if it's sub threshold anxiety or sub threshold depression, that doesn't make it any less problematic for the adolescent. So we really want to focus on what symptoms is the person having that is keeping them from having their highest quality of life and what can we do to help them address that. We want to identify and mitigate those symptoms. It's also important to remember that cognitive behavioral therapy, which is a lot of what we're going to talk about today, doesn't work completely for every diagnosis. It doesn't work at all for certain diagnoses and known events that trigger a strong physiological reaction. So, so a traumatic event may respond well to something called emdr. So being aware that, like I said, there is not one one size fits all treatment that is going to work and what I'm proposing today are just a few things that adolescents can do or parents can help adolescents do to start acknowledging, identifying and coping with their anxiety. So let's talk about the physical triggers first and I'm going to go through this in the PACER format, physical, affective, cognitive, environmental and relational to help you see some of the different triggers that adolescents face. Sleep is a big one and we often don't give enough credit or enough emphasis to the importance of sleep as adults and, but also for our children and our adolescents. Adolescents tend to have more difficulty falling asleep at an early hour, but it doesn't mean that they have any less need for sleep. Adolescents still need at least eight, if not 10 hours of good quality sleep every night in order to allow their brain to rebalance itself, in order to allow their body to repair itself, in order to clear out that chemical called adenosine that creates sleepiness and foggy headedness and it built and it builds up throughout the day. So sleep is really, really, really important. When people don't get enough sleep, they start experiencing difficulty concentrating, they start experiencing reduced immunity, they start experiencing irritability. There's a whole lot of symptoms that can start occurring when people are sleep deprived because their HPA axis, their threat response system is actually more active then because it's trying to help the person stay awake. It can also lead to circadian rhythm disruptions. So they're not really getting the cortisol to help them wake up in the morning and the melatonin to help them go to sleep at night. And that when your circadian rhythms are out of whack, it also monkeys with eating behaviors as well as hormone regulations, those gonadal hormones which we know in adolescence are usually all over the place anyway. So what keeps people from getting adequate sleep? Anxiety. A lot of youth report that when they lay down, when they're still, when they're quiet, their minds are racing. They are anxious about stuff that happened, they're anxious about what they might be missing by sleeping, they're anxious about the next day. So anxiety can keep them from being able to actually relax enough to get good quality sleep where they're sleeping through the night and we're going to talk about thought stopping later in the presentation. Schedules can also keep people from getting adequate quality sleep if they have really intense schedules that keep them busy up until, you know, almost right before bed and then they have to be up way early in the morning. Most adolescents, as I said, tend to have difficulty falling asleep at night. So that 5 o', clock, 6 o' clock time frame when they have to wake up to go to school is actually counterproductive. They've done studies that have found that when school started later, when school started more like 9 o' clock in the morning, that youth were able to focus more and actually did better academically. Homework can keep people from getting adequate quality sleep. And I saw this so much in my kids friends when they were in high school because my children were homeschooled, so it was a little bit different. But the children who were in public school and even private school, a lot of them had literally five and six hours worth of homework to do. And if they had any extracurricular activities after school, then they were often up doing homework until, you know, 10, 11, 12 o' clock at night. So this homework intensity can also prevent them from getting adequate quality sleep. And there are ways to work around. So youth don't have that much out of class work to do. It's all a matter of the approach to teaching, but that's a whole different presentation. And sleep hygiene. Sleep hygiene is really important and I have a lot of videos on the YouTube channel on sleep hygiene that address things like not having caffeine too close to bedtime, not getting too hot, physically too close to bedtime, creating a sleep routine, etc. So sleep hygiene can be really important. And most people, even most adults I work with, have really poor sleep hygiene habits. So it's worth scanning through some of those videos on sleep hygiene to identify what things might be going on. Like for example, one more thing in sleep hygiene is blue light. A lot of youth, especially if they're doing homework or playing video games or whatever, but we'll say homework until right before bed. That blue light is preventing their circadian rhythms from kicking in and helping them to get sleepy. So making sure that they've got a blue light filter that kicks in two hours before bedtime. Now, the bears assessment can be helpful in identifying if the youth has some sort of sleep issues. We want to look at bedtime problems. Do they have difficulty getting to sleep or getting to bed at the right time, you know, because they're up doing homework or they've got away games that kept them out until, you know, the middle of the night, whatever the case may be. So bedtime problems can disrupt the circadian rhythms and make sleep more difficult. Excessive sleepiness gives us an indication that the person's not getting good quality sleep. People should not be, you know, super drowsy all day long, especially adolescents feeling like they need to drink energy drinks or caffeine in order to stay awake. Awakenings throughout the night. If the youth are having awakenings throughout the night, we Want to examine why? What is causing this? Is it anxiety? Is it discomfort for some reason, Is it temperature? Is it they have the dog sleeping in their bed, what's going on? But if they're having these awakenings, that indicates they're not probably not getting the quality of sleep that they need. Regularity and duration of sleep. If the youth is not regularly getting eight to 10 hours of good quality sleep, that's an indication that they may be suffering from some level of sleep deprivation. So, you know, we want to look at not only duration but also quality and you know, how often. So if they get eight hours of sleep on the weekends, but only four hours during the week, that is not very regular. We want to see ideally eight hours every single day. And then sleep apnea. Youth can experience sleep apnea, and that's best identified, I guess, if parents say, yeah, you snore like a freight train. Sleep apnea causes people to wake up multiple times throughout the night. They may not recognize they're waking up, they may not even notice it, but they actually do briefly wake up and then go back to sleep because with sleep apnea they are stopping breathing briefly. So we do want to evaluate those things. If the youth are snoring, that should be evaluated. A sleep study can be helpful. The pediatrician can be really helpful with those things. Nutrition. What we eat provides us the building blocks to keep all of our systems healthy and functioning. What we eat provides the building blocks to help make the neurotransmitters and the hormones that help us feel happy, that help us feel relaxed, like gaba. So nutrition, reasonable nutrition is important. Making sure that people are eating colorfully, they're eating, they're getting enough protein. Especially adolescents need to make sure that they're getting the vitamins, minerals, proteins, you know, macros that they need. Energy drinks can be a problem. A lot of youth drink caffeine or energy drinks. And when we consume stimulants, whether form they are, it triggers that HPA axis. So it's taxing the system. It's kind of like driving a car, you know, really, really hard. So it's causing a lot more stress on their proverbial engine, so to speak. Additionally, caffeine stays in the system for a really long time. So what they are drinking at 2 is probably still in their system at 10 o' clock at night, which is going to make it harder to get to sleep. And it could be a little longer, it could be a little shorter. But it's important to remember that caffeine can stay in your system for 8 to 12 hours. Hormone fluctuations. Now, this unfortunately is part and parcel of being a teenager. But hormone fluctuations can contribute to anxiety. And just like energy drinks, when they ramp people up, when they're, when they're hyped up on caffeine, it can make them more prone to experiencing anxiety because they're already sort of amped. Hormone fluctuations. We know that when hormones get imbalanced for the person, it can contribute to feelings of anxiety or depression. And this is true for people who are biologically male and biologically female. Additionally, people who are taking exogenous hormones, they are taking hormone shots or birth control pills or something, are also altering their hormone levels. And they, there can be an increase in mood symptoms with the alterations of those hormones. And, you know, depending on what's going on with the person, why their hormones are fluctuating, there may be no way to prevent that. So we move into how can we mitigate it? How can we help the person deal with the emotional reactions they're experiencing, a result of these hormones? Gender identity is another thing. And I didn't, I struggled on exactly where to put this. But we know from the research that gender identity is something that is probably innate, and people are determining their gender identity. A lot of people know their gender identity long before their adolescence, but they are starting to explore it more as they come into adolescence, as they reach puberty, as they start exploring feelings of sexuality. So gender identity can be a huge trigger for people when they start experiencing these feelings. They're not exactly sure what they mean for them. And it's important that youth have an avenue where they can explore and express what's going on with them, what they're feeling without fear of judgment. So they can clarify for themselves, you know, how do they feel? What is their gender identity? What is their gender identity? They may have a comparatively hyper responsive HPA axis. The adolescent brain is not fully developed. It does not finish development until about the age of 24. So adolescents tend to be more impulsive, tend to have more difficulty with higher order reasoning, tend to have more extreme physiological responses to stress, as well as substances like addictions. We see a much stronger neurochemical response and neurological response in adolescents to substances. And their brain, just like a clay pot that has yet to go to the kiln, is easy to break, to mar. The adolescent brain is still very malleable. And so when they are exposed to these insults, it can cause more reactivity and even more, if it goes on long term, even more changes. And in the adolescent's Actual brain. I mentioned that they have an immature prefrontal cortex. So they may be hyperactive to stress and they may get stuck in that fight or flight mode, which in dialectical behavior therapy, we call it the emotional mind. But when we are in fight or flee, we are being bathed, if you will, in adrenaline, in norepinephrine, you know, and these excitatory neurochemicals, glutamate, in order to help us evade the threat. So we are not thinking clearly. Even adults, when we are in that full blown fight orf flight state, you are not thinking logically, you're not thinking clearly, you are thinking about what's right in front of you, you are thinking reactively. So adolescents, when they're flooded with so many triggers, when they're feeling this anxiety, and it seems to be pervasive, they may almost get stuck in this fight or flight mode. So when you ask them what is it that's stressing you out, Their legit response is, I don't know, because they are not able to ferret out those things. They are too immersed in the fight or flight. They are too immersed in that anxiety response. So when adolescents say that, a lot of times they're not trying to be evasive, they really are not able to discern what is triggering them at that point. And it's up to us as coaches, as guides, as parents, as teachers, whatever, to help them down regulate, to help them get into their wise mind. And again, we'll talk about that towards the end because until they can get into their wise mind, until they can get out of that fight or flight mode, they're going to have difficulty identifying exactly what's triggering them at that point in time. Affective and cognitive triggers so emotional and thought triggers. Adolescents, because they are younger, have had fewer experiences to inform their, what we call default schema. Every time we have an experience, we create a file, if you will, in our brain that says, okay, when X happens, then Y happens. And it provides us the ability to predict what's going to happen in the future. So you know an experience of driving, you're driving along and you see a yellow light. Based on your prior experiences, based on your schema about stoplights, you know that if it's yellow, it's probably getting ready to turn red. Unfortunately, a lot of adolescents don't have a lot of schema in order to help them predict what's going to happen and when. You can't predict what's going to happen, or you can't accurately predict what's going to happen, it can feel really scary. A lot of us don't like feeling out of control. So, for example, starting high school or starting college or even starting a new school year, the youth may not have enough schema to inform them that, okay, everything's going to be fine. This is how it's going to go. You know, you can predict this. So they may feel very apprehensive. Starting college, for example, I remember way back when, when I started college, we went up to the university. You know, we visited the dorms when it was time to move in, my parents helped me move in, we toured around the campus. I got my schedule, I went to all of my, where my classes were going to be before classes even started. So I knew where I needed to be, what I needed to be doing. Now, I'd never been in a college class before. I'd only been in high school classes. So I wasn't exactly sure what to expect expect in this new format. But walking through it helped me feel calmer and it gave me some default schema because I knew, okay, this is the way to class, this is how long it's going to take. This is what I can expect. So when youth are getting ready to embark upon something new, helping them walk through it and even if you can't do it in person, helping them walk through it mentally or one of the beauties of Google Earth now is you can actually, you know, virtually go to that town so they can see, you know, do put the little man on the map so you can look around and get street view so they can see what's going on, so they can feel a little less anxious about what they're walking into. Adolescents often have increased learning from less than accurate sources. And it astounds me, it frustrates me how much inaccurate information is out there on the Internet. You know, back in my day, we went to the library, we didn't have Internet. So you trusted that the books that were there were, you know, relatively accurate. But with the Internet, anybody can post on Wikipedia, for example. And it's important to help youth ferret out, you know, what they're reading because a lot of information tends to be polarized. You only get half of the story. So it's important to encourage youth to be informed consumers about what's going on in the world, in their life, in their experiences, so they can make informed decisions. But those inaccurate sources can increase anxiety because a lot of times things that we find in the media on the Internet are designed to persuade us to do something in order to Persuade us the we need to, in order to persuade somebody, we need to increase motivation, we need to increase anxiety, we need to help people see why is this a problem. And a lot of times that is exaggerated for effect to get people motivated. So it's really important to examine, reading this here, how accurate is it? And trusting that somebody else did their due diligence is not a safe thing. We had something happen yesterday, interestingly enough, in the financial world, where a press release went out and a source picked it up and, you know, broadcasted that something was going to happen. And before we knew it, cnbc, msnbc, Fox News, you know, Reuters, all these other places had picked up and run with this story. And we found out an hour later, it wasn't even that long, that the story was completely false. So all of these reputable news outlets had run with a story that was completely inaccurate. So it's important to remember that even those resources that you expect to be accurate make mistakes. We need to help people figure out how to find accurate sources because if they don't know where to find the information, that they have a hard time verifying it. Adolescents also experience increased distress because there's what we call increased emotional salience of distressful triggers when they're anxious or when you're anxious. Think about it. When you're anxious, you tend to notice things that are threatening, that are anxiety provoking. You tend to notice the world threat through a lens of anxiety. You don't notice as much the rainbows and the flowers and the bunny rabbits. You are in that protective mode. So when youth are in that mode, then they're missing all this other stuff. And yes, the unpleasant stuff exists, the stressful stuff exists. That is true. And you know, I'm not dismissing that. However, it's important for all of us to what we call embrace the dialectics and recognize that there's also good stuff. There's good stuff going on, there's positive stuff going on. In addition to this, you know, crappy stuff over here. A lot of adolescents engage in extreme thinking. They put a lot of pressure on themselves for perfection. They have difficulty identifying diminishing returns and talking to other parents as well as, you know, some of the people that I've worked with in, in clinic. It's interesting that even if the parents aren't putting the pressure on the adolescent, a lot of times the adolescents pick that up for themselves and they think, if I'm not perfect, then I'm not going to succeed. And as guides, whatever your role is with adolescents, helping them Understand, sort of the concept of diminishing returns can be important. You know, is it important? You know, how much effort are you going to have to exert to go from an A to an A plus? And is the benefit of all that effort worth it? How much effort are you going to have to exert to go from an A to an A? And all the time and effort that you've got to put into it is being detracted, taken away from all the other things that are important to you. So is getting an A in chemistry more important to you than all these things over here? A lot of adolescents have faulty assumptions about life and what they should know. They get frustrated sometimes. They often think they should know what they think, what they feel, what they're going to do when they graduate, what the future holds. And it's important to help them understand that that's just not realistic. You know, with my kids, you know, helping them recognize, you know, when I went to college, I had a different major and I changed majors along the way. And that's okay. Sometimes you will start something and figure out it's not a good fit for you, and you will, you know, change course. And so it's important to help youth and this kind of, kind of goes along with that perfectionism, recognize that choices they make are often changeable. You can change careers, you can change majors in school. So there are ways to mitigate. If you realize it's a bad situation and that's what's really important, you're not forever tied to this. Yes, it may be difficult to get out of it. You may have to do some extra work, but it's not something that can't be addressed. Adolescents these days have so much stimulation that distracts from their mindfulness. Back in the 80s, before we had computers, we had time, we. Well, we had three television channels, and that was it to begin with. But we also had times where we would go out, we would sit, we would be quiet. We didn't have all of the input from constant binging and buzzing and vibrating and what have you. We didn't have, you know, 3,000 channels to choose from or all the video games. So it was a different time. And adolescents these days, and I'm not knocking it, I'm just saying it is a different culture now. Adolescents these days have so much constant input that there is very little downtime unless they willfully extract themselves and turn off their phone, turn off the tv. When we are regularly being bombarded with all of that stuff, it's hard to notice what's going on inside of ourselves, what we need, what we think. Because as soon as we start to check in with ourselves, all of a sudden the mobile device dings or something else goes off and we lose focus. Mindfulness can be huge for adolescents and, well, for everybody. It's really important that we help them start learning how to unplug. Even if it's just for two minutes in the morning, two minutes at lunch and two minutes before bed, and literally two minutes to check in with themselves and see what's going on can help them and help us identify what's going on and mitigate anything that may be starting to become a problem before it becomes a big deal. Cognitively, adolescents are going through mental changes. And you know, if you want to go back and look at Piaget's theories on cognitive development, up until the age of 11, they tend to think very concretely. They have difficulty abstracting, hypothesizing, seeing other options. You know, if somebody is rude to them, for example, they have difficulty thinking, well, what are three other reasons why this person might have been rude? Because they are in the moment, they have difficulty getting outside of that. They also tend to think very dichotomously. It's either good or bad. And when they're experiencing life, those schema that they're forming are being formed on what's right in front of them. Dichotomous. It's either a good experience or a bad experience. So their schema that inform how they anticipate the world going into adolescence are often not 100% accurate. They are good. Oftentimes they're good, but they're not necessarily 100% accurate. When people are in concrete reasoning or concrete level of cognitive development, they use inductive reasoning. So they go from an observation to an idea. They generalize. So green traffic lights always turn yellow. That is a generalization that they make. Alright, well most of the time that's true. But what happens if you come to a stoplight that is changed manually because an emergency services vehicle is coming through? Because they have the ability to control the intersection lights now? Well then a green traffic light may suddenly turn red. Oh my gosh. So that doesn't fit with that schema. And it's not that their original schema was wrong, it just was too narrow. It didn't take into consideration the exceptions to the rule. When people get about age 11 and up, they start developing abstract thinking. And this isn't something that happens. They just wake up on their 11th birthday, they and think differently. Bada bing. This is something that develops over time, but they start being able to use deductive reasoning. So taking a general concept and extrapolating down. So deductive reasoning basically says if A, then B, and if B then C, therefore A equals C. So if any of the premises are incorrect, then the solution will also be incorrect. So if somebody uses premises, you know, uses assumptions that they got off, you know, sweeping generalizations that they got off the Internet or from a friend or wherever, and those statements are not 100% correct, then it means that their ultimate reasoning is not necessarily going to be 100% correct. So I want you to think about how much incorrect or only partially correct information is out there, you know, in the news, on the Internet, even among people that you talk to. Most of us don't have the whole picture about everything. We have some information, but we don't know everything about a particular topic. Based on their years of experience, how many of the generalizations that they made during childhood, those dichotomous Generalizations are still 100% accurate. And again, they were accurate at that time, they were accurate in that context. But they often don't take into consideration all of the permutations of what could happen. So it may lead to faulty reasoning. And adolescents are often not taught to challenge their existing generalizations. To be curious. You know, when I come to a stoplight, is it always going to turn from green to yellow? That's not a question that a lot of people ask, but the answer is no because of the situation that we talked about earlier. So, you know, what else might be going on. And that's where context really becomes very important. In prior situations, this happened, this situation is similar. So I may know what's going to happen, but what is different, what might change the outcome now? So we want to help people explore. Relationships are a perfect example. You know, if you were in a relationship last year with somebody and it ended and now you're in a relationship with somebody else, you may. The person may expect certain things to happen based on prior relationships, but the current person may not have that information. The current person may act completely differently. So it's important to include the context and evaluate what's going on in the present based on prior knowledge as well as present context. Context, there can also be a lot of environmental triggers, and these can be agonizing for people and, and I see it in adults, too, but definitely for adolescents who are trying to figure out who they are, they're developing their identity, they are going through a lot of things, and they don't have nearly as many experiences as their adult counterparts. So lack of safety is a big one. And lack of safety leads to stress, leads to anxiety, kicks off that fight or flight response. So what are we talking about with lack of safety? Well, I termed it virtual safety. I don't know what you want to call it. When the Internet is in your house, it brings all of that stress from school, from the outer world into your house. Back in the day, you know, we would leave school and if we had a fight with somebody at school or something bad happened, okay, we left it at school and people, you know, went and did their own things and they weren't still perseverating on that. In today's world, the things that happen continue to occur. And when you log on to the Internet, it's right there. So your home is in some ways less safe because your home now starts to serve as a trigger, as a reminder of the bad thing that happened. You can't escape it. The home feels less safe. Disinhibition, and you can consider this emotional abuse or neglect sometimes, because disinhibition is a phenomenon that occurs on the Internet when people say things online that they would never say to a person face to face. And those comments are often very unpleasant and border on abuse or neglectful. Additionally, people who are on the Internet can become so involved in the Internet that they are not attuned. Parents are not attuned to what's going on with their child. They can be so involved in their own online drama or video games or whatever it is that they may be unaware of what's going on with their adolescent. So we do see the Internet not only bombarding the adolescent, but also potentially causing the parents, causing the caregivers to be less responsive. Deep fakes are another thing, and I don't know how common they they are in for the average person. But deep fakes are when somebody modifies a video to make it look like somebody else. So modifying a video to make it look like Sally did something, then Sally sees it online, and everybody sees it online and thinks it's really Sally. That can be devastating. Identity theft. And I'm not talking about financial identity theft like a lot of people think, but creating a Instagram account, creating a Tinder account, creating some sort of account using someone else's photos in order to either pose as them or in order to harm their reputation. And it's really difficult because in this culture we're expected almost to be to have an online presence. However, our online presence makes us vulnerable because people can capture our images and steal our identity and sully our reputation a whole lot easier than before. Catfishing somebody posing as something that they're not can also create a lack of a sense of safety. If people are engaging in an online discussion, developing a friendship, a relationship online and intimate or platonic, it doesn't matter if they start to really trust this person and then all of a sudden they realize, you know, the person they're talking to is not a 16 year old male, it's actually a 47 year old male. Well, that can be shocking, unsettling, terrifying, and can leave the person feeling very, very vulnerable. And that can be a problem out of context posts or lifelong posts negatively impacting school acceptance or jobs. We have to be so careful now because what's on the Internet tends to stay on the Internet and we're seeing evidence of employers and significant others and whomever going back in social media years even to look to see if somebody ever said anything that they deem offensive. And it could be the person didn't mean it that way, or it could be the person did mean it and, and back then, but now they have become more enlightened, more accepting, and they wouldn't ever dream of saying that. But it's important to recognize that people change. I would hope people improve. So things that somebody said when they were in middle school or high school may not even be reflective of their thoughts, their feelings, or their behaviors as late adolescents or early adults. Another issue that is interesting that I've seen over the years is this. Since we don't have to leave our house as much we can communicate online, a lot of adolescents are having fewer experiences in real life face to face and, and out there, leaving the safety of their own home, as safe as it is, feels terrifying. There are a lot of adolescents who really have no desire to learn how to drive. They are terrified to be on the road. There are a lot who still turn 16 and they're at the driver's license office, you know, the morning of their birthday. But I am seeing a lot more youth who are not interested in going out and doing things in a face to face sort of setting. And that's even been compounded more now by the pandemic where online communication, watch parties, discord servers, all those things have become even more ubiquitous. And home delivery keeps it so people really, if they don't want to leave their home, don't have to. So there is a lot of anxiety in some adolescents when they have to get outside of their comfort zone if they're in face to face school. If they're in public or private school, that is less true. But for people who are in online school or homeschooled, then that can become more of a problem. And then what I call the Instagram facade. And it's not just Instagram, it's a lot of the Internet itself. People don't take pictures of themselves looking, you know, like they haven't had a bath in three days and post it on the Internet. They don't take a picture of themselves in the middle of a house that looks like a tornado hit it and say, hey, this is my day. They post their very best pictures. And I've talked to people before who do a lot of posting of selfies and stuff, and most of them say that, you know, for every picture I post, I have to take, you know, 15, 20, 30 pictures to find one that I like. But most of us assume that everything we see on the Internet, you just picked up your. Picked up your phone, took a picture of yourself, and it just looked that perfect. So it's important again to challenge that schema, challenge that belief that what you're seeing is representative of 100% of that person's life. They may be showing you a really awesome event in their life. They've got other stuff over here that's kind of crappy. The adolescents are also undergoing something called identity versus role confusion. And you can look up Erik Erikson's stages of psychosocial development, but basically during this period, the youth is defining or answering the question, who am I? What do I stand for? Identity involves the experiences, relationships, and values that make up a person's sense of self. So up until now, they've had experiences, relationships, and developed some values. A lot of them have been communicated by their family, by their culture, by their community. And during adolescence, youth are starting to question some of this and say, do I really believe this? People who are not allowed to explore and test out different identities might end up developing something called role confusion. They are unsure of who they are and where they fit in, if anywhere. And unfortunately, this is really very prominent right now because of cancel culture. A lot of people feel very unsafe expressing their thoughts. And if it doesn't fit with a certain narrative, they feel scared to even talk, even in real life, even face to face talk to people about their thoughts and what, especially if they differ from that narrative, so they're not allowed to explain, explore it, which leads a lot of people to feeling like their thoughts and their values and that sort of thing may not be Acceptable, ergo they may not be acceptable. So it's really challenging for a lot of youth right now because they, they aren't given that opportunity to try on those different hats to explore what does it mean to believe this. People who develop a role identity based on one or more canceled principles often fear abandonment if people knew the real them. So we have a lot of people that are silent about what they believe because they're afraid of rejection. Parental distress is another issue that is causes, and it's not just now that causes adolescents stress. If they perceive that their parents are experiencing a lot of distress, whether it's because of finances or relationships or what's going on in the world or whatever, that stress perceptible, that stress is sometimes oppressive to the adolescent and it often creates stress in the adolescent themselves because they're like, well, if, you know, caregivers are stressed, then maybe I should be stressed about this. I don't really understand it, but it's stressing me out now. Likewise, when parents get too stressed about life, they can become disengaged. So they're so caught up in their own stuff that they have a hard time recognizing what's going on with the adolescent. Some adolescents are having difficulty with in real life or face to face relationships because they spend so much time texting and not as much time talking. And texts can be taken out of context, not as much as talking, less so, even though sometimes you can misunderstand what somebody's trying to say. So communication can be a challenge. The cancel culture. And I know I've already mentioned that, but it seems to have a constantly changing landscape. So what is okay to say and think and believe Today may not be a month from now or two months from now. And it can feel terrifying to wonder, did I miss something? Did I miss the memo? FOMO fear of missing out often equates to no time for relaxation. Youth are so worried about missing out on the next trend or whatever else that they may not be able to relax back in. I know I keep going back in back in the day, but in the 80s, you know, we would have our magazines that we would look at to see fashion trends or whatever. But then once you read through the magazine, that was it, there was nothing else to look at. Now you can scroll through fashion websites for, for literally days and see more and more stuff. So it can be very overwhelming if you're afraid that, okay, if I don't go to this one more site, maybe I'm going to miss something in today's day and Time. There's also what I call a larger fishbowl before the Internet. And I keep referencing that because a lot of us who are engaging with adolescents grew up before the Internet or in the early days of the Internet. But before the Internet, the people that we had the option of getting to know went to our school. They were in our communities. We didn't get to know somebody who lived on another continent. Today you can get to know anybody, anywhere. And that is really exciting. But it can also have some detrimental effects because people feel like they've got so many more options that they may not exert the same amount of effort into maintaining those relationships. So when something starts to get challenging, difficult, boring, unpleasant, they may just say, you know, there's somebody else out there. Whereas before that, before there were so many options, there used to be a lot of effort on trying to make sure to do what you could to enhance a relationship, improve a relationship, etc. So I am seeing in clinical practice, as well as, you know, talking to people that, you know, there, there does seem to be less stick to itiveness, if you will. In, in relationships there's also the whole concept of ghosting and that it can be detrimental to somebody's self esteem. If they're trying to connect with somebody, they feel like they've got a connection going and then all of a sudden the person feels, just disappears. It can be very unsettling. Now, were they getting catfished maybe? Or did the person find somebody else? Maybe. Was it about them? Maybe, but maybe not. We don't know the answers. And that ambiguity, that not understanding why did this person suddenly disappear can haunt people. And a lot of times, in order to come to acceptance of it, people try to make up their own rationale for why it happened. And they may be right, but a lot of times they may be wrong. And sexuality and relationships are another area of stress. We talked about gender identity earlier and that's not something that people decide. That's not a choice. What I'm talking about with sexuality is when to have sex. And you know, the different options that are out there for sexuality, the sexually transmitted diseases, all of the stuff that comes along with developing one's sexuality is overwhelming. And it only seems to be getting more so now that there are all kinds of different relationship structures out there, like non monogamy, polyamory, relationship anarchy. There are a lot of different permutations and people need to be able to figure out, you know, how do they feel, feel about these different structures and again, sexuality itself. So what are Some tips, and I know the text on this is really small, but I wanted to get it all on one slide. Create a vision board for a rich and meaningful life. And you can have the youth do it, you can have the adolescent do it. You can also do it also as a family. So this is your vision as an individual, as you. And let's look at our family vision as well. A vision board helps people figure out what is important for me to use my energy on. So I have people go through and identify four words that they want people to use to describe them. And each of those four words goes. If you're doing a poster, one goes on the top, one goes on the bottom, one goes on the left, one goes on the right. So they kind of frame the vision board, or you can put it like I did, at the roots of the tree, however you want to do it. But those values are going to feed, they're going to shape, they're going to nurture everything else. So what do you want to be known for? Relationships. What relationships are important in your life? Thinking about family, friends, mentors, your higher power, Whoever those relationships are with. Put a picture of each of them on the tree. On the back of the picture, write why they're important and ways you can use your energy to nurture your relationship with them. And then attach another piece of paper to the back of that. Identify any possible barriers to having a fulfilling relationship and what you can do to address it. And then we're going to do the same thing, basically for things and experiences. What things and experiences are important? Your health, your hobbies, things on your bucket list. Place a picture of each of them on your tree. On the back of the picture, write why they're important and ways you can use your energy to nurture those things. And attach another piece of paper to each one and identify any possible barriers to developing that and ways to address them. So in this example, the hobbies were golf and fishing. And then health was really important. I put that at the heart of the tree. And then the person's job over here is important to them as well as their pets. And I don't know if you want to consider pets, things or relationships, but we got the pets and then their higher power, their grandparents, their friends. You know, you see where we're, where we're going with this. But it gives people a visual representation of what is it that I really want to spend my energy on, what is worth my time. Purposeful action means choosing to use your energy to do those things instead of just Spinning your wheels, you want to get that traction to move forward. So traction is knowing what you want to spend your energy on instead of getting caught up. Being angry about something somebody said on Instagram, you ask yourself, is this worth my energy or is it stealing energy from things that are important to me? Motivation is also important. People need to be motivated to make changes, to look at their schema, to do things a little bit differently. But in order for people to even think about changing, even if you think it's going to make them feel better, the person has to feel competent. They have to feel like, okay, if I do this, I'm actually going to be able to affect a change. They need to feel safe. You know, making changes means getting outside of our comfort zone. So they need to feel like they're safe and supported at doing that. They need to feel empowered and capable of making that change. They need to feel like they've got enough energy, enough knowledge, and enough support. Support in terms of motivation in order to enhance it, we can help people examine different aspects. How is making this change going to make you feel better? Physically? How is it going to make you happier? How is making this change going to help you think more clearly? Or how does making this change make logical sense? Looking around the environment, what can you do in the environment? What sights or sounds can you add to remind you to make this change? So, like mindfulness meditations, putting a push notification on your mobile device, or putting a note up somewhere to remind you, putting pictures of the people that are important in your life around your, around your room, those sorts of things can remind people why making the change is important. And relationally, how will making this change improve your relationships and of your relationships? Who is supportive of this change? Who is there to support you and encourage you and help you stay safe? Once people are motivated to make a change, then we can start looking at mindfulness. And remember I said two minutes. Mindful morning, noon and night is helpful, super helpful. If you can do more, great. But basically during that two minutes, the person evaluates what's going on with them. Physically, how do they feel? Do they feel tired, sick, hungry, in pain? Anything that helps them identify, anything they need to do to, anything they need to mitigate, what do I need to address? But when they do that scan, they also may identify good things. Physically, I feel energetic, I'm full. I feel healthy. Well, great. You know, that's awesome. So let's keep on keeping on. Affectively, how do I feel emotionally? If I feel anxious about something, what's going on what can I do about it? If I'm feeling safe and empowered and happy, well, great. Nothing to see here. Let's keep doing what we're doing. Cognitively, am I thinking clearly? Am I, you know, able to remember things? Am I having any problems? Is my attitude a good one? Or is my attitude negative and pessimistic? Environmentally, does anything need to change? Is it too hot? Is it too cold? Are there things in my environment that are contributing to my stress, like stuff all over flat surfaces? And relationally, what is going on? How do I feel about myself? What's my self esteem like? How am I feeling with myself and with other people? You know, what's going on in my relationships? Do I have some tension going on over here in this relationship with this person who's really important? If so, what do I need to do? Do I have some happy things that I'm expecting to happen? You know, maybe you and your friends are going to go out this afternoon after school or something, you know, so focusing on that, I've got some things I'm looking forward to relationally. So we're looking for both strengths and vulnerabilities. Not just trying to find all the negative, but looking for what's positive that's going on too. If people do that three times a day, they're much more likely to catch things early and address them before they become big festering wounds, so to speak. Distress tolerance activities. Think of unpleasant emotions like bees. We need bees to pollinate and do all kinds of other things. They're important. Just like we need emotions to help us stay safe. Anger, anxiety. Those feelings tell us, hey, there might be a threat, you better get up and check it out. So we don't want to completely eliminate them, but we want to learn how to deal with them. So just like a bee that lands on your arm, if you swat at it or resist it, a lot of times you're going to end up getting stung. If you observe it with curiosity, you say, hey, what does this be want? Hey, what is this feeling trying to tell me? And then let them leave when they're ready, it's a lot less painful. The bee eventually flies off our emotions. If there's no if we feel anxious or angry and we say, hey, there really a threat? And we determine, no, there's really no threat, then that feeling of anxiety will go away. Two ways for urge surfing. If you don't want to think about the bee, think about a wave that comes in. And it comes in, it gathers energy, it crests, it hits the sand, and then it recedes. And that's really what our urges, what our cravings, what our emotions do. A lot of the time, if we don't continue to feed it and add energy, it's going to dissipate. Another example that you can use if you don't like the waves is clouds. If you've ever just laid on your back and watched the clouds in the sky, they're there and then they float away. You know, all on their own, they just float away. So distressful emotions are like clouds in the sky that on their own will float away. Now, the mnemonic for distress tolerance is tags, thoughts, and remember I said on the very first slide. A lot of adolescents have difficulty with racing thoughts, keeping them from getting enough sleep, or when they start thinking about something, they get caught up in it, they start to spiral. So thought stopping is really important. And you can do this by telling yourself, no, I'm not going to think about it right now. Some people find it's helpful when they start having those thoughts to write them down, get them out, and then put them in a box or a jar and knowing that I will get back to that later. And then skip scheduling worry time where they can go over those things. So writing them down, telling yourself to stop or doing something to help stop those thoughts, and that can be, you know, singing, singing's a good one. Distress tolerant thoughts also can be used to replace those, because once you stop the unpleasant thoughts, your mind is likely not going to be a void. You know, it's hard to just clear our mind. That is a very difficult task. So instead of stopping it and expecting silence, replace it with empowering thoughts. So replace it with thoughts that, you know, this is unpleasant, but I can deal with it. Or whatever you want to tell yourself to help yourself move through the unpleasant moment. Activities can help you tolerate distress, to help you get into that wise mind. Activities that either distract you or produce pleasure, like watching a comedian or talking to a friend, anything that can help you tolerate that distress until the adrenaline bleeds off and you can get into your wise mind and think logically about what's going on. Guided imagery can be really helpful. And you can either see whatever this issue is that you're distressed about successfully resolving, you can envision that, or you can envision your distress, your anger, your anxiety, your pain, whatever it is, like a knob, like a volume knob, and turn down the volume. Some people, instead of seeing the volume and turning that down, see it as a color. So if it is red, you know, just glare Glowing bright red. They see the color fading and getting darker and more, more, more transparent as their emotions tune down, tone down. So there are a lot of different images but basically you want to help the brain recognize that this is going to turn out okay. We can turn down that threat response. And sensations can help kind of jar somebody out of distress. If they start focusing on a different sensation. It can be something they see see that makes them happy or that create attracts their focus. It can be something they smell that helps them relax. Lots of studies have shown that essential oils can be really helpful for improving relaxation. Just inhaling them, not anything else. And sounds, some people find that sounds like music can help distract them again until they can down regulate so they can process what's going on a little bit more effectively. Now distress tolerant thoughts can be really helpful for helping people recognize that they can sit with an emotion and it can be unpleasant, but they can tolerate it, the sensations. Another sensation, and I don't have it on here, is touch. Holding ice cubes is another sensation that is potent enough that it's going to attract somebody's attention a lot. So it often distracts them from those distressing thoughts which gives their brain a chance to down regulate, to tone down so they can get into their wise mind. Exercise and stretching can also be really helpful. Adolescents are growing rapidly. Exercise and stretching can help with feelings of coordination as well as reduce those growing pains. Mild exercise has been shown to help reduce cortisol levels while moderate to intense exercise can almost help reset the stress response. When we're anxious, we may be sitting still still, but we're breathing faster and our heart rate is going like this and we may even be sweating. Well, if you start doing something physical and your physical activity starts to match the rest of that, then when you stop doing that physical thing, a lot of times your heart rate and respiration will come down accordingly. So you're almost like re syncing the mind and the body. Beta testing can be another strategy that people use. Breathe. When you breathe slowly, breathe in for four, hold for four, exhale for four, do that a couple of times. When you slow your breathing, it triggers the relaxation response. So that helps you get into your wise mind. Then examine the facts in context. If you find that your mind reading or jumping to conclusions, look at what are the actual facts. What do I know for certain? Not what am I guessing or assuming, but what do I know? If you're using all or nothing thinking, look for exceptions like this person always does this and it's always a bad thing. Well, look for exceptions. Magnification can mean making a mountain out of a molehill. So look at the first facts in the situation. Is this really that catastrophic? It may feel like it, but in the big scheme of things, is getting an F on this test, you know, going to keep you from getting into college and then whatever else, is it really going to spiral? What are some other examples of situations where something like this has happened, that it didn't turn out badly? And what's the probability that your worst case scenario is actually going to come true? Personalization is another cognitive error that we make a lot. And so it's important if you're personalizing things, if you think that it's about you stepping back and saying, what are three other explanations why this may have happened that didn't have to do with me or didn't have to do 100% with me? I remember when I was in college, I was in what was called a weed out class and we would take these tests and I would get my test back and I'd have a D on it and it would be shocking and terrifying to me and I would start thinking, oh, I must, I must not be able to do this. Started personalizing it. In reality, everybody in the class, literally everybody in the class was getting similar grades because the teacher was making the test that hard. And you know, ultimately at the end of the semester, the entire class's grades were curved in order to meet that bell curve. So it's important to step back and say, is it 100% about me? T stands to talk to others and think about alternatives. What can I do to handle this situation? Once I know the facts and context, what should I do about it? Once you've processed that, either by thinking about it or talking about it or both, then act, take action steps, start trying to improve the next moment and, and then assess your outcomes. Other interventions, Physical, you know, as I said, sleep, nutrition and stretching can be really important. And minimizing that stimulants affectively or emotionally. Add positive things to your life. Don't just eliminate the distress. Enhance coping skills. Practice radical acceptance. That means saying it is what it is. You know, it may suck, it may be great, but there's nothing I can do about it. I'm accepting the moment as it is. It is what it is, and I can choose to improve the next moment, but this moment is what it is. Urge surfing and distress tolerance. We already talked about to help people tolerate the distress until they can get into their wise mind and figure out what to do. Next, Cognitively, three minute thoughts is one of my favorite activities. I have people sit down and sometimes they may not know what they're thinking, but they spend three minutes just writing down whatever pops into their head. And then they go back and evaluate those thoughts for which ones were positive, which ones were negative, which ones were accurate, and which ones were inaccurate or based on assumptions. Tragic optimism means being able to accept life as it is in the moment and have hope that things can get better. Beta testing we just talked about breathing, evaluating the facts in context, thinking about options, and talking to people about what your options are and then taking action. Setting aside worry time where things that you're stressed about you put in a box or in a jar or table, however you want to say it, and then you have a certain time each day where you allow yourself to explore those things. That way you're not trying to juggle it with everything else throughout the day. Environmentally Create space safety by asking yourself what adds distress in my different environments and how can I create safety in order to feel less anxious all the time? And it really depends on what causes stress for different people and relationally enhance interpersonal skills. Learn about setting healthy boundaries Effective communication Empathy Biologically, adolescents are going through a lot of changes. Physical health and wellness behaviors can help reduce some of the vulnerabilities so they're not as amped up so they're not as prone to reacting with extreme anxiety. Mindfulness and other cognitive strategies can help modify outdated or immature schema to help adolescents better cope with situations and interpret situations. And a strong support system that reminds the adolescent they are safe can also be a huge assist.