Stress Management

1. Introduction

• Do you often feel stressed? And do you experience a high level of stress in your family?
• Has it ever happened that your child had become stressed by, in your opinion, small things?
• Do you think that the fact that your child has an Intellectual disability can affect your child’s stress level?
• Do you know how to work with your own and your child's stress levels?

This module focuses on stress management. The module contains three sections that will introduce you to what stress is and how the brain responds in stressful situations. There will be an introduction to what causes stress both for the child with intellectual and developmental disabilities, but also for the child’s family, and at the end a section about stress management.

In every section there will be a list of references.

2. Understanding stress

3. What causes stress

4. Coping with stress

2. Understanding stress

In this section, you will get an introduction to what stress is, how it can be both healthy and unhealthy for us to experience this condition, and how it expresses itself as both physical, cognitive and emotional responses. You will acquire knowledge on how the brain responds to stressful situations, how we get affected by each other's stress and what typical responses are in stressful situations.

Contents of the section:

2.1 Knowledge about stress

2.2 The brain

References

If you would like to know more about stress, we have collected a number of books, articles and links that could be useful. You can find these references below:

• Berk, L. E. (1994). Child development (3. ed. ed.). Boston, Mass.: Allyn and Bacon.
• Dyhr, P. (2017). hjernen introduktionskursus. Retrieved 13.06.2018 https://psyk-ressource.dk/wp-content/uploads/2017/09/hjernen-introduktionskursus.pdf
• Hejlskov, B., & Uhrskov, T. (2007). An adaptation of the stress-vulnerability model in autism. Paper presented at the Meeting of Minds2, Herning, Denmark. http://hejlskov.se/wp-content/uploads/2016/12/StressMeetingOfMinds0207.pdf
• Kabat-Zinn, J. (2005). Full catastrophe living: how to cope with stress, pain and illness using mindfulness meditation (Reissued ed.). London: Piatkus.
• Lazarus, R. S. (1999). Stress and emotion: a new synthesis. London: Free Association.
• Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer. 

• McDonnell, A. (2010). Managing Aggressive Behaviour in Care Settings: Understanding and Applying Low Arousal Approaches (1 ed.): Wiley.
• NHS. Struggling with stress? Retrieved 12.6, 2018, from https://www.nhsinform.scot/healthy-living/mental-wellbeing/stress/struggling-with-stress
• Thybo, P. (2013). Neuropædagogik : hjerne, liv og læring (1. udgave ed.). Kbh.: Hans Reitzel.

2.1. Knowledge about stress

The nature of stress - part 1

In this video we will introduce you to basic knowledge on stress, including two definitions of it, knowledge about how psychological stress can result in physical illness and the concept of ‘appraisal’ – a psychological term used to explain how a situation can be perceived as stressful to some and motivating to others.

Furthermore you will be introduced to stress as a conceptual framework of understanding the challenging behaviour of your child – here it is helpful to distinguish between basic and situational stressors. At the end of the video, we will give you an overview of typical symptoms of increased stress levels. 

(8 min. 58 sec.)

The nature of stress - part 2

(12 min. 42 sec.)

Presentation in PowerPoint:

The nature of stress

Activity

Have you ever experienced a situation that you and your child appraised (see slide 2) differently – one perceived it as being stressful, the other did not?

• Which appraisal / thoughts may have caused you to perceive the situation differently?

2.2. The brain

In this presentation we review the importance of the brain to human development. The brain is a robust and constant part of our development as it has always been "with us". At the same time, it is changeable and under continuous development.

You will be introduced to the concept of stress in relation to the brain and we will focus on the importance of short-term versus prolonged stress.

Prolonged stress will always cause a strain on the organism and thus also on the brain and its function.

The brain

(10 min. 21 sec.)

Presentation in PowerPoint:

The brain

Activity:

Observe your child - or think of a situation with your child:

• Do you recognize any signs of stress in your child?
• What kind of symptoms?
• What is helpful for your child when he / she is stressed?

What about you?

• Do you experience any signs of stress personally? Are they long-term present?
• Consider what is nourishing and helpful to you and your family when You are stressed.

3. What causes stress

In this section, you will get an introduction to the causes of stress, both for children with intellectual and developmental disabilities and the child’s family. You will be presented how a child's developmental profile looks different and the way this impacts the stress that child is potentially experiencing. In addition, you will have the opportunity to listen to two interviews with parents of children with intellectual and developmental disabilities. They will tell their story with a focus on how they have experienced the stress during the first couple of years after their child was diagnosed, and what kind of learning they have had being a parent to a child with special needs . 

Contents of the section:

3.1 Intellectual and other developmental disabilities (IDD)

3.2 Stress in the family

References

If you would like to know more about stress, we have collected a number of books, articles and links that could be useful. You can find these references below:

• APA. (2016). DSM-5® classification. Arlington, VA: American Psychiatric Association.
  
• Beier, H., Elvén, B. H., & Veje, H. K. (2012). Udviklingsforstyrrelser og psykisk sårbarhed (1. udgave ed.). Kbh.: Dansk Psykologisk Forlag.
  
• Bøttcher, L., & Dammeyer, J. (2010). Handicappsykologi : en grundbog om arbejdet med mennesker med funktionsnedsættelse (1. udgave ed.). Frederiksberg: Samfundslitteratur.
  
• Fleischer, A. V. (2009). Set med børns øjne : om menneskeforståelse (1. udgave ed.). Virum: Dansk Psykologisk Forlag.
  
• Fleischer, A. V., & From, K. (2015). Eksekutive funktioner hos børn og unge (1. udgave ed.). Kbh.: Dansk Psykologisk Forlag.
  
• Fleischer, A. V., & Merrild, L. (Eds.). (2005). Indsigt og adfærd i børnehøjde (1. udgave ed.). Virum: Dansk Psykologisk Forlag.
  
• Hejlskov, B., & Uhrskov, T. (2007). An adaptation of the stress-vulnerability model in autism. Paper presented at the Meeting of Minds2, Herning, Denmark. http://hejlskov.se/wp-content/uploads/2016/12/StressMeetingOfMinds0207.pdf
  
• Schopler, E. (1994). Behavioral Priorities for autism and related developmental disorders. In E. Schopler & G. B. Mesibov (Eds.), Behavioral issues in autism (pp. 55-77). New York: Plenum.
  
• Sørensen, K., Eifer, D., & Olsen, M. E. (2018). Udviklingshæmning - en grundbog. Skødstrup: Forlaget Oligo.

3.1. Intellectual and other developmental disabilities (IDD)

In this presentation you will be introduced to typical human development.
You will also be introduced to challenges that may occur when the brain does not develop as expected.
We will review sensory, motoric and cognitive development in detail.
We will touch upon three key concepts no matter what disability your child has; concepts that are invisible to both the child and the family:

• Executive functions
• Central coherence and 
• Theory of Mind

A reduced or atypical development will always have an impact on how you live your life.

A reduced or atypical development always results in an increased risk of stress usually because people with intellectual disabilities often find themselves in situations that are not understandable or too complex for them.

Human development, part 1

(9 min. 33 sec.)

Human development, part 2

(10 min. 7 sec.)

Human development, part 3

(10 min. 18 sec.)

Presentation in PowerPoint:

Human development

Activity:

Observe your child - or think of a situation with your child:

• How do you perceive your child as developed differently than expected?
• Is it easily recognized?
• After watching the presentation, do you recognise developmental issues regarding your child?

Consider these three concepts:

Central coherence, executive functions and Theory of Mind; all of which are invisible.

• Does your child have any disabilities regarding these three key concepts – concepts that might not have been perceivable to you?

What about you?

• As mentioned in the presentation, we are all challenged at our level of functioning - our executive functions in particular - when we are sick, stressed or otherwise.
• Are your executive functions affected by taking care of your child and your family?
• Are you affected by overload on your executive functions?

Consider what type of help/support would suit/benefit you and your family best.
Consider what makes your family prosper and thrive.

3.2. Stress in the family

In the videos below, you will meet two women. Each of them are parents of a child with intellectual disabilities. 

Parent interview 1, part 1

(14 min. 6 sec.)

Parent interview 1, part 2

(8 min. 49 sec.)

Parent interview 2

(13 min 32 sec.)

Stress in the family

In the video we will look at the stress model introduced in 'Nature of stress', but this time from a family perspective. This review of the stress model is based on a family of four who has a child with intellectual disabilities. During the presentation of the family’s stress model, it is clear how the stress of one family member affects another.

(4 min. 13 sec.)

Presentation in PowerPoint:

Stress in the family

Activity		30-60 min (can be divided)
	Should I do the activity alone?	You can do the activity alone. If you are in a two-parent family, try to do the activity together. Invite your child as well. (This will be explained later)
	After completing the activity…	You will have a better overview of the basic and situational stressors of individual family members.
	Before I start, what will I need to do this activity?	A piece of paper and a pencil.
	What do I have to do?	Identify and write down what basic and situational stressors you experience as parents and talk to each other about them. If possible, involve siblings and talk to them about the stress model and focus on how stress affects their everyday lives – both basic and situation-specific. Discuss what potential efforts could be made in your family to decrease basic stressors.
	What to do next?	Choose possible interventions to be taken and agree on who should do what for you to succeed. If possible, do the exercise again after 14 days / 3 weeks to see if the changes have made any difference in the child's level of stress.

External stressors

In the following video we will discuss the fact that in most cases a lot of different people/professionals are involved when you have a child with an intellectual disability and that this is often a major source of stress for the family.

(2 min. 3 sec.)

Presentation in PowerPoint:

External stressors

Activity		30 min.
	Should I do the activity alone?	You can do the activity alone. If you are in a two-parent family, try to do the activity together.
	After completing the activity…	You will have a better understanding of how many people your family is in contact with and whether it is possible to reduce the number.
	Before I start, what will I need to do this activity?	A piece of paper and a pencil.
	What do I have to do?	You and your partner must make a list of all the people you are in contact with regards to your child with intellectual disability. Consider the possibility of reducing the number of people involved by reducing the number of meetings, reduce the amount of contact or getting someone to help you coordinate.
	What to do next?	Consider whether the social worker should be contacted to help you coordinate.

4. Coping with stress

In this section, we will look at how it is possible to cope with the stress we have discussed in previous sections. For instance, you can focus on becoming aware of what coping strategies are useful for you in stressful situations.

We present two analysis tools, the Iceberg Model and a stress reduction program. These will help you to get a better understanding of your children's reactions, behaviour and needs. Using links in this section, you can print worksheets that you can use.

You will also get knowledge about mindfulness as a tool to cope with stressful situations as well as a more general way of being present in the moment. There will be an interview with a parent who has participated in a mindfulness program and you will hear what difference it has made for her.

Contents of the section:  

4.1 Coping

4.2 Mindfulness

4.3 Stress reductive programme 

4.4 The Iceberg Model

References

If you would like to know more about stress, we have collected a number of books, articles and links which could be useful. You can find these references below:

4.1. Coping

Adaptive coping 

In this video we will introduce you to the notion of “coping with stress” – how to manage stress. There is no right or wrong way to cope with stress. However, there are healthy and unhealthy ways of coping – ways that reduce stress or ways that maintain or induce more stress.

Basically, there are two ways of coping; problem-focused and emotion-focused coping. Problem-focused coping is ’fixing’ the problem – so to speak. It’s a healthy way of coping with stress if you perceive a high degree of control over a situation or person that you perceive as stressful. Emotion-focused coping means managing the emotional influences of the stressor. Emotion-focused coping is a healthy way of coping with stress if you perceive a low degree of control over a situation or person that you perceive as stressful.

As one does not perceive high or low degree of control over all things, the goal is, through increased awareness on how much control one perceives, “adaptive coping” – the ability to move between problem-focused and emotion-focused coping. 

(6 min. 33 sec.)

Presentation in PowerPoint:

Coping with stress

Activity

Make a list of your problem-focused coping strategies and your emotion-focused coping strategies.

• Which list is longer? 
• Does it tell you anything about how you manage stress in general?

Consider the degree of control you perceive in different stressful situations.

• How does the degree of perceived control relate to coping strategies you employ?
• Would it be healthier for you to use other coping strategies more?
• Emotion-focused coping?
• Problem-focused coping?

4.2. Mindfulness

What is mindfulness?

Mindfulness is  defines as an ability to be fully present from moment to moment, without judging or evaluating what is happening - with a friendly and curious attitude towards yourself and others. 

Mindfulness is an inherent quality of human consciousness and it means that everyone is able to meditate, consciously focusing on something. Paradoxically, this is both very simple and time-consuming as we are often distracted by our thoughts and emotions and therefore struggle to be present. By brain training methods like mindfulness you can increase your ability to be mindful. This will allow you to look at your life in a different and more creative way, and have better access to your own strengths and wisdom.

At CSB, we use Mindfulness-Based Stress Reduction (MBSR) as a starting point for mindfulness training. This program was developed by Jon Kabat-Zinn, Professor of Massachusetts University, USA in 1979. It is a method with a scientific basis developed for coping with stress, depression, pain and other stress-related symptoms. Since then, numerous scientific studies have shown that the MBSR program has a positive effect on different physical and mental disorders, such as stress, depression, anxiety, pain, sleep disorder, headache, overweight, etc.

However, everyone can benefit from meditation exercises. For example, training mindfulness strengthens the immune system and thus prevents diseases. Through an MBSR course you can learn to take better care of yourself and regain a meaningful connection between your body, thoughts and emotions.

Training mindfulness can help people to cope with life’s minor or major challenges, such as worries, a racing mind or tiredness in often hectic everyday life. A high number of our problems are linked to our thoughts and emotions. We spend a lot of time and make an enormous effort to be in the past or in the future, for example, when we worry about, contemplate on or plan major or minor chores. Thoughts and emotions can easily escalate and create a negative spiral of stress, anxiety and depression. By systematic training in mindfulness, it is possible to learn to stop that and choose a beneficial way of acting in pressured situations instead of reacting automatically and perhaps inappropriately.

By mindful attention it is possible to train the ability to be more present and gain greater mental / bodily calm and balance in life - even when life is difficult;  it is a way to generally create higher levels of well-being and greater joy in life.

From MBSR parenting course:

Interview: In this video, you will meet a woman, who was a participant at a MBSR parenting course.

(14 min. 38 sec.)

Evaluation report from the MBSR parenting course:

Evaluation of a mindfulness course January – March 2018

Guided meditations:

Guided body scan, Jon Kabat-Zinn (YouTube) (29 min. 2 sec.):

Guided sitting meditation with Jon Kabat-Zinn (YouTube) (39 min. 54 sec.):

Guided mountain meditation with Jon Kabat-Zinn (YouTube) (10 min. 2 sec.):

Activity

Try out the guided meditation methods listed above - hopefully they will give you a sense of peace and well-being.

Links to other videos:

What is mindfulness? (YouTube) (5 min. 17 sec.):

Life is right now (YouTube) (7 min. 13 sec.):

A new pair of glasses (YouTube) (4 min. 4 sec.):

4.3. Stress reductive programme

Stress profile and stress reduction program 

In the video you are presented with a tool called 'Stress Profile'. The tool is divided into two sections. The first section called 'stress profile' is where you should focus on what stresses your child. The second section called 'stress reductive program' is where you should look at what you can do to reduce the child's stress level.

In the section 'Stress profile', you are asked to fill the form on what the child's basic stress factors and situational stress factors are, and how it is expressed in both warning signs and chaos signs. Then, the focus is on how the child and their caregivers cope with the child's stressors as well as what is seen as protective factors in relation to the child and its stress level. Lastly, you are asked to fill the form on whether your child has sensory desires and needs, how much physical activity your child performs and whether your child implements any activities to distress mentally.

Then the section on stress reduction begins. Based on the topics mentioned above, we now focus on clarifying how we can work with the child’s stress level. Additionally, we will point out what kind of thoughts and challenges might occur in relation to this stress reduction plan.

(10 min. 29 sec.)

Presentation in PowerPoint:

Stress profile and stress reduction programme, empty

Stress profile and stress reduction programme, example

Activity		60 minutes
	Should I do the activity alone?	You can do the activity alone. If you are in a two-parent family, try to do the activity together.
	After completing the activity…	You will understand what initiatives can be taken focusing on stress reduction.
	Before I start, what will I need to do this activity?	A piece of paper, a pencil and a printed version of the (empty) stress profile.
	What do I have to do?	Use the written guide and watch the video as a guide to fill the stress profile. Start out by filling the first section ’stress profile’.  Fill one slide at a time and include examples that can help you understand what is at stake for your child. Go to the next section that focus on stress reduction.  Use the section on Sensory desires & needs to fill in what is realistic for your family.
	What to do next?	Review what you have listed in the section ‘stress reductive programme’ and put it into practice.

4.4. The iceberg model

In this video we will introduce you to the ‘Iceberg Model’. We will explain how the iceberg is used as a metaphor for understanding children with intellectual disabilities, where the top of the iceberg represents behaviour, and the submerged portion represents the reasons behind. The video also includes a step by step review of how to use the iceberg model for analysis as well as a review of a specific example.

The Iceberg Model

(9 min. 5 sec.)

Presentation in PowerPoint:

The iceberg model

Activity		30 minutes
	Should I do the activity alone?	You can do the activity alone. If you are in a two-parent family, try to do the activity together.
	After completing the activity…	You should be able to analyse the behaviour of your child so that the interventions you take are more targeted to the actual reasons of problems.
	Before I start, what will I need to do this activity?	A piece of paper and a pencil. You can draw a simple iceberg on your paper.
	What do I have to do?	Find a problem that you want to analyse. The problem should be as specific as possible.  Use the written guide and watch the video while filling in the Iceberg Model specific to the current issue. Write down as many details as possible: how it happened, when, with whom and where before you begin to talk about the reasons why. Then write down 5 reasons why the problem has arisen based on your knowledge of children with intellectual disabilities. Then, when the latter is completed, help each other to find possible solutions based on the hypotheses you have made about why the problem had arisen.
	What to do next?	Choose what solution you want to start testing and agree on how to get started.