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Best Practices for Managing Stress and Anxiety During Times of Uncertainty

By Gary Seale, Ph.D., Regional Director, Centre for Neuro Skills

 
The COVID-19 outbreak has produced a great deal of uncertainty and unwelcome anxiety. It’s no wonder we feel distressed when our daily routines have been severely disrupted. Due to social distancing and business closures, most people are not able to visit their favorite restaurant, go shopping, or engage in a work-out routine at the fitness center. When you couple this with concerns about personal health, uncertainty about how long these changes will last, and information and directives that change daily, it’s no wonder that many of us feel diseased or anxious. Several credible sites have recently posted simple but effective strategies to manage stress and remain emotionally healthy during this time of uncertainty. Some of the most frequent suggestions by experts at the American Psychological Association, Forbes, the Harvard Business Review, HealthLine, and others include the following:

Differentiate between what is within your control vs. what is not in your control. Stay focused on the things you can do. Make a list and practice these regularly, and reward yourself for these practices. For example, you can:

  • Wash your hands, cover coughs and sneezes, etc.
  • Limit exposure to news. Manage stress by reducing (or eliminating) the number of times you check in to your favorite media outlet. The American Psychological Association recommends avoiding negative news right before bedtime.
  • Take care of your health (take your vitamins, get enough sleep, hydrate, engage in a daily exercise routine, etc.).
  • Practice your preferred relaxation technique if you feel stressed, such as deep breathing, yoga, mindful meditation, etc. If you don’t have a relaxation practice, now is a great time to develop one.
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    Do the things that help you feel safe, such as:

  • Practice “social distancing” and limit exposure to groups of 10 or more people.
  • Give an “elbow bump” vs. a hug or a handshake.
  • Order out and have food delivered to your home or work; shop on-line and have items delivered to your home vs. going to a store or the mall.
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    Rather than worrying about something that might happen in the future, stay focused on the present; maintain proper perspective.

  • Stay present and in the moment; focus on the task at hand.
  • If you feel yourself “borrowing trouble,” bring yourself back to the present.
  • Use a mindfulness practice (savor a favorite snack or meal; closely observe a pleasing object, such as a flower, etc.). If you don’t have a mindfulness practice, now is a great time to explore/develop one.
  • Put the situation into proper perspective (for example, as of March 24th in Houston/Harris County there are about 206 confirmed/presumed cases of COVID-19 and 2 deaths from this virus. Nineteen have fully recovered. Houston/Harris County has a population of approximately 6+ million. That translates into an infection statistic of 0.003%). Additionally, we live in a time and a nation of great abundance – an abundance of intellectual horsepower (some of the best minds in infectious diseases are here in the U.S. and are working on vaccines for this virus); an abundance of resources (the government has released over a trillion dollars to support research, product development and distribution, and aid to businesses); an abundance of entrepreneurs (companies re-tooling to overproduce cleaning supplies, ventilators, etc.).
  • This situation is temporary. As with other pandemics (MARS, SARS, H1N1, Zika, etc.), this too shall pass.
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    Engage in proven positive psychology practices.

  • Start a gratitude list. Of all the positive emotions, gratitude is one of the most powerful and protective (from depressive symptoms). Simply start a list of all the things you are grateful for, large and small
  • Three Good Things. At the end of the day, list 3 good things that happened during the day. Once you have your list on paper, think about how you made those good things happen and reward yourself
  • Downward comparisons. Rather than thinking or saying to yourself, “I wish I…”, think or say to yourself, “I’m glad I…” For example, “I’m glad I work in the healthcare industry. I have a stable job, and in my work, I am able to help others.”
  • Connect with something larger than yourself. In the example above, you may find yourself feeling compassion for those out of work due to COVID-19, like servers in the restaurant industry. Ordering out from your favorite local restaurant and tipping big may help keep that business open during a time when the restaurant is closed to the public. Or you may want to visit a local blood bank and give blood as most all blood donation activities at large venues, like businesses, churches, etc. have been suspended for the time being.
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    Get outside and enjoy nature.

  • During this time when we are practicing “social distancing”, we may feel “cooped up” which can result in feelings of anxiety. Getting outdoors and enjoying nature can lift your mood and help with managing stress. Walking increases heart rate and respiration, which is good for brain function and overall health. Spending time in the sunlight produces vitamin D, which improves the immune response. Being in “awe” (of nature) is another, very powerful positive emotion that can lift the mood and protect against depressive symptoms.
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    Stay connected and don’t be afraid to ask for help.

  • Take this time to call friends and family and catch up.
  • Talk to a trusted friend about how you are feeling and all the practices you are using to stay healthy, both physically and mentally.
  • If you are feeling particularly distressed, reach out to a counselor or other mental health practitioner.
  • Talk to your supervisor or HR representative about your particular situation and any support you might need.
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    Engage in resilience practices.

  • Think about a time when you faced a challenging situation and overcame it.
  • In your home or office, post some inspirational quotes, for example: “Never, never, never give up.” – Winston Churchill; “Failure is not an option.” – Gene Kranz, NASA Flight Director; “Tough times don’t last, but tough people do.” – Robert Schuller
  • Create a “resilience library” with inspirational books, videos, etc. For example, the book, “Unbroken” by Laura Hillenbrand, or the movie, “Remember the Titans”.
  • When possible, find “positives” (i.e., lower gas prices, safer commutes to work/less drunk drivers on the road, etc.), or lessons learned from the situation.
  • Use humor as appropriate.
  • If you have one, engage in your spiritual practice.
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    Explaining Brain Injury to Your Child

    Chapter Four, The Caregiver’s Journey on tbi.cemmlibrary.org

     

    Having a parent with a TBI can be frightening for a child who looks to them to provide strength and safety.
    A parent with TBI may no longer act the same as they did before the injury. They may be angry, depressed, or uncertain. They may not be able to speak or walk, and they may not be able to do all the same things they did before they were injured (for example, go to work, pick up the kids from school, play on the playground). You can help your children by explaining TBI in a way that they can understand, or you can ask a healthcare provider to talk with your children.

    As a result of the changes caused by the injury, the special parent-child bond that existed previously has probably changed, at least to some degree.

    Children may be confused and upset about what is going on. This could be due to worry about a parent’s condition or concerns about changes in their parents’ relationship. It could also be due to financial strains, or simply adjusting to the new “normal” (in other words, the new way of life following the TBI). Be sure to communicate with your child that they are not to blame for the TBI – many children will assume they somehow contributed to the injury and will carry some sense of responsibility for it. If your child appears to be anxious or depressed for a long time, or they begin taking on risky behaviors, seek professional help.

    It is important to recognize that your children are grieving, just as you are – they are grieving the loss of the parent’s former “self” and the abrupt changes that have taken place. They may withdraw from social activities with peers, have mood swings, become withdrawn or disruptive, do poorly in school, and show other behavioral problems.

    Children also need time and space to be kids. Allow them time to think, play, talk, or just hang out – don’t smother them with too much information or attention over the injury – but be sensitive to their questions and concerns. Build new family routines, and keep an eye out for signs that your child is not coping well.

    Some children may need to take on some caregiving tasks for the parent or for younger children in the family. Children who care for parents or other relatives may experience conflict over the reversal of roles between parent and child. Others will find it helpful for them to play a supportive role.

    Make sure any tasks that your child takes on to help around the house or with caregiving activities – household chores or meal preparation, for example – are suitable for their age. Strive as much as possible to find other adults to help you, rather than relying on your children to play a major caregiving role.


     
    How Can I Tell My Child about TBI?
    
It is difficult to explain TBI to a child. Yet it is vital to tell your child what is going on. Some adults try to protect children from the truth because they think they are too young to understand. Children of almost any age are aware that something is wrong and they want to know what is happening.

    Communicate in an age-appropriate way what has happened to the service member or veteran with TBI. Protecting your children by withholding information may backfire. Children have active imaginations that may create a scenario worse than reality.

    How you tell your child about TBI depends on the age of the child. Here are some suggestions for how to explain TBI to a child:

  • Use Language a Child can Understand: The brain is similar to the command station of a spaceship. If a meteorite hit the command station, the crew would not be able to control what the spaceship does. If the brain is hurt, it may send out the wrong signals to the body or no signals at all. A person with TBI may have a hard time walking, talking, hearing, or seeing.
  • The brain is the body’s computer. When it gets injured, it doesn’t “boot up” properly, runs slower, has less memory, and may not perform all of its normal functions.
  • A cut may take a few days to heal, and a broken bone will usually heal and be as good as new in a few weeks or months. Getting better after a brain injury can take several months or even years, and sometimes the person may not get 100 percent better.
  • Even though the person with the injury may look the same, they may still be injured. These injuries might include having a hard time paying attention or remembering what you told them. They may get tired easily and need to sleep more than usual. They may say or do things that seem strange or embarrassing. They may get angry and shout for no apparent reason.
  • Explaining Anger Changes: Many people with a TBI develop anger as a direct effect of the damage to the brain. In other words, the parts of the brain that normally stop angry flare-ups and feelings have been damaged and don’t do their job as well. The parent with TBI may be mad because they can’t do the things they used to do. Their feelings may be hurt because others treat them differently than before the injury.
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    Brain injury changes people. These changes can be confusing. Try to remember that the changes you see are caused by the brain injury. You can still love and care about the person regardless of the brain injury.
     

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    High school injury reports analyzed by InvestigateWest and Pamplin Media show that girls are twice as likely to get concussions as boys in Oregon. Girls in the 13U age group, pictured above, are the youngest allowed to use headers.
     

    The Concussion Gap: Head injuries in girls soccer are an ‘Unpublicized Epidemic’

    Lee van der Voo, InvestigateWest, photos by David Ball / Pamplin Media Group

     
    When it comes to concussion in sports, all eyes are on football, or so it seems. But it’s not just football that causes a high number of head injuries among young athletes.

    Another culprit? Girls soccer.

    National research has found girls are more likely to suffer a concussion than boys in any sport. In 2017, researchers at Northwestern University generated national headlines when they found concussion rates among young female soccer players were nearly as high as concussion rates for boys playing football — and roughly triple the rate of concussions in boys soccer.

    In Oregon, injury reports from public high schools analyzed by InvestigateWest and Pamplin Media Group mirrored that trend, showing soccer concussions were second to those from football between 2015 and 2017. What’s more, at the schools that included the gender of injured athletes, there were nearly twice as many reports of possible concussions for girls playing soccer than boys in the sport.

    The rate of concussions in girls soccer worries local experts like Jim Chesnutt, a doctor in sports medicine at Oregon Health & Science University, who says those injuries are not widely recognized, even as concussion rates rise for girls playing soccer.

    “In a lot of ways, it’s a growing epidemic for young girls that I think has gone unpublicized,” said Chesnutt, co-director of the Oregon Concussion Awareness and Management Program and a member of the Governor’s Task Force on Traumatic Brain Injury.

    More exposure, more injury

    It’s understandable that much of the youth concussion conversation centers on football, given the physical contact that is visibly — and audibly — evident on every play, as well as the large rosters and the lengthy lists of players who are injured.

    But if you compare girls soccer with football, and only look at the high school participation and injury data, “you’re missing a gigantic part of the picture,” according to Michael Koester, a doctor of sports medicine at the Slocum Center in Eugene. He directs its sports concussion program and serves as the chair of the Sports Medicine Advisory Committee for the National Federation of State High School Associations.

    Koester notes that high school boys play eight to 10 football games per season, and typically play other sports in the off-season.

    Girls, however, play 15 to 20 soccer games in a high school season, but when that season ends, they may play another 80-plus games throughout the winter, spring and summer with club teams, said Koester, who, like Chesnutt, is a medical adviser to the Oregon Schools Activities Association.

    “If we’re looking at injury risk by athletic exposure,” which is one practice or game, a standard in evaluating risk, Koester said, female soccer players probably are playing five if not 10 times more practices and games than football players.

    And Koester doesn’t see the trend ending.

    “The thought used to be that this was all revolving around, ‘Wow! They want to get their kid a scholarship,’ ” he said. “Now it’s kind of gotten to the point where there’s so much single-sport participation that we see kids that are specializing in sport early, just so they’ll be able to make their high school team.”

    Single-sport athletes are more prone to injury in any sport. According to a study by scientists at the University of Wisconsin, high school athletes who specialized in just one sport at an early age were twice as likely to suffer injuries to their lower extremities.

    “We see a lot of overuse injury among girls playing soccer,” Koester said. “We see a lot of ACL injury among girls playing soccer. It’s a well-known problem.”

    Aggressive play

    Another factor is the evolution of sports.

    Angella Bond is an athletic trainer for Tuality Sports Medicine and works on the sidelines with athletes at Hillsboro schools. Anecdotally, she said, all athletes push to be bigger, faster and stronger. Soccer is no exception, nor are girls.

    As athletes develop, they take bigger hits at higher speeds, and competitive games build on their momentum. As competition grows in girls soccer, the sport is trending to be more aggressive, she said.

    “Unfortunately, I think that happens with girls sports,” she said. “Arms fly a little bit more.”

    Chesnutt agreed. “I think over the years, soccer has become more physical,” he said. “And I think the physical contact and the aggressive nature of that physical contact is more associated with concussions.”

    According to the American Academy of Pediatrics, soccer — unlike football, ice hockey and lacrosse — is not a “collision sport.” But it is a “contact sport” because athletes “routinely make contact with each other or inanimate objects.”

    Header balls, though often singled out as a source of concussions, are not necessarily to blame.

    The force created when a soccer ball meets a head can rattle a brain, but data increasingly points to other factors when competitors vie for a ball in the air.

    According to a study by The Research Institute at Nationwide Children’s Hospital, while headers accounted for 27 percent of concussions, it was knocks with other players on aerial play — including head-to-head contact and arms and elbows to the head — and contact with the ground that accounted for 70 percent of those concussions in girls soccer, suggesting aggressive play is a factor in most concussions involving headers.

    Why girls?

    But why are girls more prone to concussions than boys while playing soccer? The prevailing theories focus on their weaker neck-muscle development, weaker body strength (needed to stabilize the neck and head during aerial play), and more frequent contact with the ground. A year ago, a study in the Journal of the American Osteopathic Association found that female high school soccer players took twice as long as male players to recover.

    It’s also possible that girls don’t benefit as much from early treatment. A recent study published by the American Academy of Pediatrics found that girls are five times more likely than boys to stay on the pitch and play through a head injury.

    And the soccer community has been slow to recognize the hard hits its girls are taking. Instead, soccer is at the forefront of the cultural empowerment of girls.

    Local experts concerned about concussion risk note that sports, including girls soccer, have plenty of benefits. Just being physically active is good for kids, and sports like soccer help establish lifelong fitness habits, teach team-building skills, and promote character development and assertiveness.

    “The worry is that the take-home message is that (girls soccer) is healthy and fantastic and nothing can be bad about it,” said Koester, who says an opposite negative message, equally extreme, is more often associated with boys playing football.

    Greater awareness needed

    Concussion education and awareness in girls soccer is paramount, according to local experts such as Chesnutt.

    “I think the way to decrease it is to really analyze how we can modify the amount of body contact that goes on in soccer to limit the dangerous aggressive behavior that is associated with concussion,” he said.

    Unlike youth football, a sport that’s adjusting to new information about concussions all the time, soccer has largely failed to address new information about concussions, Chesnutt said.

    Football, for example, has reduced head-to-head helmet play, limited full-contact practices and games, and zeroed in on the specialty teams with the highest concussion rates.

    “Football has really done, I think, an exceptional job of identifying some areas where there have been some definite higher incidents and some problems,” said Chesnutt, who lectures nationally about youth concussions. “As a group of coaches, leagues, parents and referees, they’ve all looked at it and come up with some solutions that have decreased concussion rates. And I think it’s time for soccer to do the same thing.”

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    New Rules to Protect Your Kid’s Noggin

    May 25, 2019, Parents Magazine

     
    Children bonk their head all the time when they’re wrestling with siblings, playing soccer, and just being clumsy-and it’s easy to worry that a bump could turn into something bigger. After all, more than 800,000 kids in the U.S. get a concussion every year. For the first time, the Centers for Disease Control and Prevention has released specific “return to learn” and “return to play” guidelines for head injuries, based on 25 years of research. One doctor shares the big takeaways.

    ALWAYS take any injury beyond a light head bump seiously. A concussion occurs when a bump, blow, or jolt to the head or a hit to the body makes the brain bounce or twist in the skull. This creates chemical changes and can sometimes damage brain cells. “If your child complains of a headache or dizziness, is nauseous or vomiting, appears dazed, or sleeps more or less than usual, it’s time to get a doctor’s evaluation,” says Dennis Cardone, D.O., associate professor of orthopedic surgery and pediatrics and co-director of the NYU Langone Concussion Center. Even toddlers can get a concussion from a tumble, so look for changes in their behavior such as not wanting to nurse or eat or losing interest in toys.

    If diagnosed with a concussion, your child will need menlal rest, says Dr. Cardone. That means taking a break from all activities for two to three days, and after that, starting with light aerobic activity. He may need to attend school for only half the day or do little to no homework (he won’t mind this rule!). However, he shouldn’t return to any sports or strenuous activities that have a high risk of falling or contact (think: field hockey, gymnastics, climbing a tree) until he’s been cleared by his doctor, which should be within a few weeks.

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    UCSF Researchers Advocate Prioritizing Teens for Education and Prevention

    by Scott Maier (August 17, 2016) — The number of Americans diagnosed with concussions is growing, most significantly in adolescents, according to researchers at UC San Francisco. They recommend that adolescents be prioritized for ongoing work in concussion education, diagnosis, treatment and prevention.

    The findings appear online August 16, 2016, in the Orthopaedic Journal of Sports Medicine.

    “Our study evaluated a large cross-section of the U.S. population,” said lead author Alan Zhang, MD, UCSF Health orthopaedic surgeon. “We were surprised to see that the increase in concussion cases over the past few years mainly were from adolescent patients aged 10 to 19.”

    Concussions are a form of mild traumatic brain injury resulting in transient functional and biochemical changes in the brain. They can lead to time lost from sports, work and school, as well as significant medical costs.

    Though symptoms resolve in most concussion patients within weeks, some patients’ symptoms last for months, including depression, headache, dizziness and fogginess. Neuroimaging and neuropathological studies also suggest there may be chronic structural abnormalities in the brain following multiple concussions.

    Recent studies have shown an increase in traumatic brain injuries diagnosed in many U.S. emergency departments. Smaller cohort studies of pediatric and high school athletes also have indicated a rise in concussions for certain sports, such as football and girls’ soccer. However, this is the first study to assess trends in concussion diagnoses across the general U.S. population in various age groups.

    In this study, Zhang and his colleagues evaluated the health records of 8,828,248 members of Humana Inc., a large private payer insurance group. Patients under age 65 who were diagnosed with a concussion between 2007-2014 were categorized by year of diagnosis, age group, sex, concussion classification, and health care setting of diagnosis (emergency department or physician’s office).

    Overall, 43,884 patients were diagnosed with a concussion, with 55 percent being male. The highest incidence was in the 15-19 age group at 16.5 concussions per 1,000 patients, followed by ages 10-14 at 10.5, 20-24 at 5.2 and 5-9 at 3.5.

    The study found that 56 percent of concussions were diagnosed in the emergency department, 29 percent in a physician’s office, and the remainder in urgent care or inpatient settings. As such, outpatient clinicians should have the same confidence and competence to manage concussion cases as emergency physicians, Zhang said.

    A 60 percent increase in concussions occurred from 2007 to 2014 (3,529 to 8,217), with the largest growth in ages 10-14 at 143 percent and 15-19 at 87 percent. Based on classification, 29 percent of concussions were associated with some loss of consciousness.

    A possible explanation for the significant number of adolescent concussions is increased participation in sports, said Zhang, MD, who is also assistant professor of orthopaedic surgery at UCSF. It also may be reflective of an improved awareness for the injury by patients, parents, coaches, sports medical staff and treating physicians.

    For example, the U.S. Centers for Disease Control and Prevention “HEADS UP” initiative has caused numerous states such as California to alter guidelines for youth concussion treatment.

    Many medical centers also are establishing specialty clinics to address this, which could be contributing to the increased awareness. At UCSF, the Sports Concussion Program evaluates and treats athletes who have suffered a sports-related concussion. The team includes experts from sports medicine, physical medicine and rehabilitation, neuropsychology and neurology. Their combined expertise allows for evaluation, diagnosis and management of athletes with sports concussions, helping them safely recover and return to sports.

    Other UCSF orthopaedic surgery contributors to the Orthopaedic Journal of Sports Medicine study were senior author Carlin Senter, MD, associate professor; Brian Feeley, MD, associate professor; Caitlin Rugg, MD, resident; and David Sing, clinical research associate.

    UC San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy; a graduate division with nationally renowned programs in basic, biomedical, translational and population sciences; and a preeminent biomedical research enterprise. It also includes UCSF Health, which comprises two top-ranked hospitals, UCSF Medical Center and UCSF Benioff Children’s Hospital San Francisco, and other partner and affiliated hospitals and healthcare providers throughout the Bay Area.

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