Anxiety Disorders in Children and Adolescents

Bonnie Moshenko-Mitchell, Ph.D.Registered Psychologist

Anxiety Clinic of Central AlbertaACCA Psychological Assessment Services

October 23, 2015

Anxiety or Anxiety Disorder?

NORMAL ANXIETY ANXIETY DISORDER

Response to a stressor Fleeting Appropriate

Anxious all or almost all of the time High intensity Excessive for the situation Ongoing Physical symptoms, health issues Feeling of being detached, disconnected from reality Interferes significantly with life

Why is it important to distinguish?

• To have access to appropriate intervention• To build coping• To have a realistic view of what is happening• To foster an individual’s belief in themselves

What can contribute to a student experiencing anxiety?

• Having a specific anxiety disorder or other mental health concern

• Temperament issues• Developmental concerns/Developmental Disorders• Academic concerns (e.g., learning, classroom environment)• Sensory Issues• Health concerns• Family Issues (e.g., attachment, abuse, neglect, divorce, illness

in family)• Environmental Issues (e.g., poverty, hunger)• Substance abuse

Pathway to Anxiety

Misinterpretation of Physicalthe danger of the symptomssituation

Feeling that you do not have coping strategies

or are unable to use them

Inappropriate response (anxious response)

Key Ingredients for Developing an Anxiety Disorder

• Genetic/Biological Predisposition• Temperament style• Family mental health history

• Environment• Stressful life events• Everyday stress

• Presence or Absence of Coping Strategies

Anxiety and Mental (Cognitive) Shifting

• All day, everyday, individuals are challenged to make mental shifts:

From one activity/interaction to the nextFrom a preferred activity/interaction to something

non-preferredTo accept the unexpectedTo accept something different than what we wanted To accept something that someone else wantsTo accept something that makes him/her

uncomfortable in some way, which challenges self-belief

Who has difficulty with mental shifting?

• We all do sometimes, with our abilities to mental shift being impacted by many things including: the number of times we are expected to shift, demands on our brain and our time, food intake, sleep, and significant life events.

• Other specific issues can impact a student’s ability to shift. For example, those individuals who have an inflexible temperament style, including but not limited to those with Autism Spectrum Disorder, have difficulties shifting.

What is inflexibility?

• Inflexibility impacts an individual’s ability to make mental (cognitive) shifts in an adaptive way:

It takes a long time and great effort to make the shiftThe shift results in dysregulation of the emotional

and/or sensory systemThe shift results in the display of inappropriate

behaviour towards another personThe shift negatively impacts that person and those

around him/her

Underlying characteristics that are risk factors for developing anxiety disorders

• Anxiety Sensitivity: Belief that anxiety is harmful

• Negative Affectivity: Proneness to experiencing negative emotions

• Behavioural Inhibition: Consistent tendency to demonstrate fear and withdrawal from new/unfamiliar situations, people, environments

How do people with anxiety tend to think?

Errors in Thinking from “Ten Forms of Twisted Thinking” (Dr. David Burns) – a.k.a. “Stinkin’ Thinkin’ ”:

• All-or-nothing thinking• Over-generalization• Mental Filter• Jumping to conclusions• “Should Statements”• Labeling• Catastrophizing• Over-estimating danger

Why do we need to talk about our thinking?

THOUGHTS

FEELINGS BEHAVIOURS

Generalized Anxiety Disorder is not General Worries!

• GAD is excessive worry about a number of events/activities, occurring more days than not, lasting at least 6 months

• Includes at least three of the following: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance

• Pervasive, pronounced, distressing, long in duration, occurs without precipitants

• Greater range of worries means more likely to meet the criteria for GAD• Rarely occurs prior to adolescence, and is thought to perhaps be

overdiagnosed in children• Children/adolescents worry about school and sport performance,

catastrophic events, punctuality. May be perfectionistic and excessively seek reassurance

What is a Panic Attack?

• Panic attack is different than a sudden attack of anxiety

• Expected attacks (obvious trigger) versus unexpected attacks (no obvious trigger)

• Panic attacks can occur with any mental disorder and some medical conditions

• Uncommon in preadolescent children, with unexpected ones being rare

Panic Attacks

• An abrupt surge of intense fear that reaches a peak quickly, and includes 4 or more of the following:– Rapid heart rate – Sweating– Shaking– Sensation of shortness of breath/feeling of choking – Chest pain– Nausea– Feeling dizzy – Derealization/depersonalization– Fear of going crazy or of dying; sense of doom – Numbness/tingling sensations– Chills/hot flashes

Panic Disorder

• Panic Disorder is recurrent, unexpected (no obvious trigger) panic attacks

• Persistent worry about having another panic attack• Behaviour (e.g., avoidance of activities, settings) to

avoid having a panic attack• Rare in childhood, adolescents seem to be similar to

adults in course, though adolescents perhaps worry less about subsequent attacks

Anxiety and Autism Spectrum Disorder (ASD)

• Estimates are that children with ASD experience anxiety 4 times as often as neuro-typically developing children

• Anxiety greater in children with ASD than in children with other brain-based concerns

• Individuals with autism have same general thinking style as non-ASD individuals who have an anxiety disorder (over-focus issues, black-and-white thinking)

Why Do Individuals with ASD Experience Anxiety?

• Anxiety can arise due one or more of the following:• Communication difficulties• Cognitive differences (e.g., difficulties making mental

shifts)• Restricted range of interests, adherence to routine,

obsessionality– Change in routine or schedule (especially if not anticipated) – Perfectionism (e.g., Need to do things “just so”, difficulty with

making mistakes, wanting to be first in the class)– Tendency to be “rule-bound”– Over-focusing on details (can result in “missing” things)– Inflexibility; need for their own agenda– persistence

Why Do Individuals with ASD Experience Anxiety? (cont’d)

• Lack of social understanding/perspective taking– Unable to read social cues– Unable to follow a social interaction “at speed”

• Sensory overload (e.g., sensitive to noise, touch, smell, light)• Demands of school (e.g., academic, social) or of other

environments

Anxiety and ASD

• How anxiety could be different for people with ASD:• Responses may be more extreme (disproportionate to

the triggering event)• Triggers may be more unusual• May lack awareness of social consequences of

behaviour• May not see a reason to not be anxious

Anxiety and ASD

• Ways that individuals with ASD avoid experiencing anxiety:

• Refusing to start or engage in an activity• Rushing a task• Having a tantrum or meltdown• Isolating themselves• Always being on time getting to places• Physical aggression• Bolting• Directing/trying to control others• Engaging in ritualized behaviour

General Comment on Strategies

COGNITIVE SKILLSImpaired………….…………………………………………………………………………….Intact

DEVELOPMENTAL LEVELImmature………………………………………………………………………………………Mature

ADAPTIVE SKILL LEVELLow………………………………………………………………………………………………..High

INTERVENTIONAdult Led Adult Assisted Positive Behavioural Supports…………………………………… Self-MonitoringConcrete Approaches Cognitive

techniques

What can be done to prevent anxiety from progressing to a disorder?

• Teaching problem-solving• Normalizing anxiety (“normal nervous”)• Teaching students to use positive self-talk• Using empowering language and providing positive messages• Reframing “errors in thinking”• Giving students opportunities to build skills (e.g., oral presentations, social

skills)• Teaching mindfulness• Talking about good eating, exercise, sleep as being important for mental

as well as physical health• Looking at your general approach in the classroom (teaching methods,

style, etc)

What general strategies really help students with anxiety disorders? (cont’d)• Teacher attitude and consistent approach within a classroom

and across classrooms• Structure, routine, and predictability in the classroom• Breaks (Sensory, cognitive)• Choices• Helping the student to determine what will work • Teaching why avoidance is not the best strategy (i.e., When

you avoid something, you give it more power…you can actually make it seem even worse, avoiding does not give the brain a chance to gain evidence that the situation is really not that bad, it decreases confidence about that situation and others)

What general strategies really help students with anxiety disorders?

• Use of visual systems to describe anxiety, level of regulation, etc.

• Staying calm, avoiding over-talking, rationalizing

Resources

• Chansky, T.E. (2014). Freeing your child from anxiety. Chansky, T.E. (2008). Freeing your child from negative thinking.

• Dalgliesh, C. (2013). The sensory child gets organized. Proven systems for rigid, anxious, or distracted kids. New York: Touchstone.

• Greenland, S.K. (2010). The Mindful Child. New York: Atria.• Harvey, P., & Penzo, J.A. (2009). Parenting a child who has

intense emotions. Oakland, CA: New Harbinger Publications, Inc.

• MacKenzie, R. J. (2013). Setting Limits with Your Strong-Willed Child. New York: Three Rivers Press.

Resources (cont’d)

• McHolm, A.E., Cunningham, C.E., & Vanier, M.K. (2005). Helping your child with selective mutism. Oakland, CA: New Harbinger Publications, Inc.

• Pantley, E. (2010). The no-cry separation anxiety solution. New York: McGraw Hill.

• Rapee, R. M. (2000). Helping your anxious child: A step-by-step guide for parents.

• Shaw, M.A. (1995). Your anxious child. Raising a healthy child in a frightening world. New York: Carol Publishing Group.

• Wagner, A. P. (2005). Worried no more. Help and hope for anxious children.

• Wagner, A.P. (2000). Up and down the worry hill. Rochester, NY: Lighthouse Press.

Resources (cont’d)

Websites: AnxietyBCOCFoundation.org

Apps: Mindshift, Breathing Zone, Meditation Jar, Relax App