Growing up in West Virginia, I have little memory of anyone talking about anxiety. It was never a hot topic at school. No one on the news seemed to discuss it (although I am not sure I ever really paid attention to the news growing up). I have no recollection of my parents or other adults trying to talk to me about it. It wasn’t until college that I really started to grasp the concept of anxiety. I am not saying that people around me were not affected by it. I simply was not aware of the signs.

We are seeing more and more cases of anxiety in kids as technology and our world progresses. Major contributors are social media, cell phone use, video game involvement, and the cliques of like-minded peers at school. I typically see at least one patient a day in clinic that is either struggling with or is currently being managed for anxiety. Conditions range from minor anxieties all the way to life-inhibiting symptoms. Our current climate with SARS-CoV-2 has only propagated the amplitude of this psychological condition.

When we dig deep into the topic, we truly have to ask ourselves: What is anxiety? Why do we experience it? What is its purpose in life? Can it actually help me? Can I control it? These are all topics patients who struggle with anxiety or their loved ones ask about frequently. We use things like medications or various coping mechanisms to help manage anxiety. Sometimes these tactics work, but other times we see little to no improvement. Failure to truly understand the root of our anxieties results in little hope of fully managing the issues.

Anxiety is usually derived from a simple calculation in the brain: a situation leads to a feeling that then leads to action. Our ancestors used their anxieties to survive. If a predator approached, their fight-or-flight response kicked in and that thought process led to an action (running away or defending the tribe). The same can be said about food scarcity, preparing for weather changes, or other life-altering events.

This act – although apparently innate – is mainly a learned response. For our brains to create this pathway of action, a person must first learn it either through teaching or observation. From a young age, kids are learning from their surroundings. The anxiety of the flight-or-fight response is most likely imprinted in early childhood. We also know that children placed in high-stress situations on a frequent basis (also known as toxic stress) can develop changes to the brain’s structure and neurological pathways. This may alter their ability to understand right from wrong or risky behaviors. The big question is this: Can we change this learned response?

I listen to a podcast frequently on my drive to work produced by Brooke Castillo called “The Life Coach School Podcast.” The program is the first time I heard the acronym CTFAR. This simple structured concept can be used in many of life’s varying situations: self identity, over eating, exercise, job fulfillment, and even anxiety. Let’s break it down and see how we can use this to manage our children’s anxiety.

C – Circumstance. We are constantly bombarded with varying stimuli in our environment. This can vary from a light turning red on our way to work all the way to someone screaming obscenities at us from across the street. These are things we have no control over. Just like you can’t make the rain stop with the clap of your hands, you also can not change how others may act toward you.

T – Thoughts. When we are placed in a circumstance, a thought instantly comes to mind. In may be positive, neutral, or negative in nature. Typically, this thought comes quicker and quicker the more we are exposed to the same circumstance. Have you noticed how easy it is to get frustrated with your kid yelling about not wanting to eat their peas again? This is most likely due to a thought that occurs in your mind right as the circumstance occurred.

F – Feelings. Boy, do we have a lot of those. Feelings heavily influence our daily lives. When our day starts out happy, it seems like the rest of our plans go a lot smoother compared to those mornings we awaken to arguing kids and stubbing our toe in the shower. Our feelings are a direct representation of our thoughts. A thought of pure joy can bring calm and comfort to our bodies, whereas negative thoughts can easily lead to feelings of rage and frustration.

A – Actions. Our minds and bodies are programmable machines, following carefully learned patterns developed over our lifetimes. When our feelings respond in one way, our bodies act. Feelings of anger or rage can trigger the action of the release of stress hormones in our body, resulting in unwanted consequences. Joyful moments may lead to dopamine surges, oxytocin release, or other “happy hormones” that bring more desirable outcomes.

R – Response. This is how our body reacts to the original circumstance. The Actions that were triggered from the Feelings that were driven by our Thoughts lead to this specific preprogrammed Response by the body. Feeling stressed about your child hitting their brother again? You may start to notice your hands shaking. Your breaths are more shallow. Your headache is throbbing. These are all neurological responses secondary to the actions of the brain as a result to the thoughts you had about your kids. Kind of similar to an anxiety attack, right?

The ability to understand this pathway can greatly aid in the management of a person’s anxiety. Let’s use a recent patient of mine as an example. Their anxiety was not life limiting, but they were one of those people whose mind never “shut off” at night. It had begun to rain one evening; while they were in bed, they imagined the house flooding. This led to thoughts of drowning and dying. Did this all actually happen? No. But in the patient’s mind, it did. The result was the patient laying in their bed shaking, sweating, and eventually needing to go to their parents’ room. Let’s further examine this situation using the CTFAR method.

The CIRCUMSTANCE was the rain. The THOUGHT was “what if my house floods?” This thought led to a FEELING of fear, which then led to the brain taking the ACTION of releasing stress hormones related to the flight-or-fight response. These chemicals in the body created the RESPONSE of sweating, shaking, and the need to go the parents’ room. See how that works? In this scenario, the important concept is to determine where we can control the anxiety before we feel it. We can’t control the rain. That is obvious. But we CAN control the THOUGHT that initiated the cascade of events.

I instruct my patients to write out CTFAR on paper. Next, I have them pick a recent event that led to an anxiety response. In this case, we used the rain with thoughts of flooding, fear, and anxiety symptoms.

The next step is to make a new column of CTFAR, write out the circumstance, and then stop. Ask yourself, “How do I want to feel when this situation occurs?” Perhaps it is calm. Perhaps it is understanding. Whatever it may be, write that in the RESPONSE column. Now work backward. In the above example, the patient wanted to be calm. So the ACTION would be the release of “happy chemicals.” The FEELINGS to get to this action may be happiness or joy. Now, one must ask themself what THOUGHT can get me to that feeling. Maybe it is the thought of the rain feeding the flowers in the garden. Maybe it is the thought of running through the sprinklers. Maybe it is as easy as “Oh, how nice. It is raining.” Whatever that thought is, make it simple and reproducible. Now, review your new CTFAR pathway. Read it out loud. Make the conscious effort to repeat this new mantra.

Just as everything in life is a learned routine, these CTFAR pathways are learned as well. The act to unlearn a pathway in the brain and learn a new one is not easy, but it is doable with enough repetition. I recommend that the parents run through these routines with the patient in a role-playing fashion. As they are sitting at home together, calmly say, “Oh look, it is raining outside.” The conversation should occur when it obviously is NOT raining. This will help the child understand they are running through the training program of CTFAR. Encourage them to THINK the calming thought they wrote down. Practice recognizing how this makes them FEEL. Register the ACTIONS and RESPONSE of the body. This training can help the brain restructure the early-coded pathway to a more desirable one, helping manage situational anxieties.

This is not a fool-proof method to manage everything anxiety related. However, one of the advantages with this method is that it can be used for several other situations not related to anxiety. Always yell at your kids when they don’t brush their teeth? You can try structuring a thought to make it a calmer or more successful experience. Always get upset with your husband on how he loads the dishes in the dishwasher? (ahem) I bet we can work on that.

What are some recent situations where you can use the CTFAR method to improve your life and the life of your child? We are all conditioned to respond to stimuli in certain ways. Make sure your brain responds in the way you desire.

We are all imperfect creatures, created to strive for perfection but never fully reach it. Embrace your imperfection. Grow every day.

Imperfect Dad, MD

Disclaimer: Although this is posted on the main blog page, I felt this topic warrants a repeat of my site’s disclaimer. This is not meant as medical advice. It is meant for your education and entertainment alone. If you or someone you know struggles with anxiety, depression, or suicidal ideation, contact your primary care physician immediately for medical help.