Anxiety Disorders in Children and Adolescents · may develop new anxiety disorders over time. • The more severe the anxiety disorder and the greater the impairment in functioning,

Anxiety Disorders in Children and Adolescents

Roberto Sassi MD PhDTackling Depression and Anxiety: Focus on Strategies across the LifespanHamilton, ONOctober 22nd 2010

Image: Michelle Meiklejohn / FreeDigitalPhotos.net

Thursday, February 10, 2011

AACAP Practice Parameters for Anxiety. J. Am. Acad. Child Adolesc. Psychiatry, 2007;46(2):267-283.

Anxiety in Children and Adolescents

• One of the most common forms of mental problems among children and adolescents: Prevalence rates for having at least one childhood anxiety disorder vary from 6% to 20% over several large epidemiological studies

• Often go undetected or untreated.

• Girls somewhat more likely to present with anxiety.

• Effective and early treatment may reduce the impact of anxiety on academic and social functioning in youths and may reduce the persistence of anxiety disorders into adulthood.


Long Term Trajectory of Anxiety in Children

• Despite remission of some initial anxiety disorders, children may develop new anxiety disorders over time.

• The more severe the anxiety disorder and the greater the impairment in functioning, the more likely it is to persist

• Children and adolescents with anxiety disorders are also at risk of developing depression, substance abuse, educational underachievement.


Anxiety disorders disrupt the normal psychosocial development of the child:

‣ children with severe social phobia may not socialize with other children

‣ children with separation anxiety may not have the opportunity to develop independence from adults

‣ social problems include poor problem-solving skills and low self-esteem

‣ anxious children interpret ambiguous situations in a negative way and may underestimate their competencies


Risk and Protective Factors


‣ Temperamental style and attachment: “high reactive” at 4 months, “behavioral inhibition” at 18 months

‣ Parental anxiety disorder: increased risk of anxiety disorder in children, and greater functional impairment in children already affected.

‣ Anxious parents can model fear and anxiety, reinforce anxious coping behavior, and unwittingly maintain avoidance, despite their desire to be of help to their child.

‣ Overprotective, overcontrolling, and overly critical parenting styles that limit the development of autonomy and mastery may also contribute to the development of anxiety disorders in children with temperamental vulnerability

‣ Learning to use active coping strategies, distraction strategies, and problem-focused rather than avoidant-focused coping can protect youth from anxiety.

Interplay of Genetics and Environment:



Normal versus Pathological Anxiety

• All children experience anxiety: Fear and worry are common in normal children.

‣ Infants: fear of loud noises, fear of being startled, and later a fear of strangers.

‣ Toddlers: fears of imaginary creatures, fears of darkness, and normative separation anxiety.

‣ School-age children: worries about injury and natural events (e.g., storms).

‣ Older children and adolescents: worries and fears related to school performance, social competence, and health issues.

• Anxiety becomes a medical issues when is persistent and more functionally impairing than normal fears and worries


Body

Stomachache

Fatigue

Shortness of breath

Insomnia

Sweating

Restlessness

Palpitations

Poor concentration

Diarrhea

Headache

Mind

Many worries about things before they happen.

Constant worries or concerns about family,

school, friends, or activities.

Repetitive, unwanted thoughts (obsessions) or actions (compulsions).

Fears of embarrassment or making mistakes.

Low self esteem and lack of self-confidence.

May seek a lot of reassurance.

Crying, irritability, and angry outbursts.

May also be quiet, compliant and eager to please, so their

difficulties may be missed


Selective Mutism

• Children who persistently fail to speak, read aloud, or sing in specific situations (e.g., school) despite speaking in other situations (e.g., with family and in the home environment).

• The duration of the disturbance is at least 6 months (not including the first month of school).

• May whisper or communicate nonverbally with select individuals such as peers or teachers in some situations.

• Most of these children also have symptoms of social phobia, and selective mutism may be a subtype or earlier developmental manifestation of social phobia

• Rule out a communication disorder, neurological disorder, or pervasive developmental disorder.

Girls 2-5:1Boys7 of 1000 children

Preschool-teenager


Selective Mutism

• Treatment

‣ Stimulus Fading with slide-in technique

‣ Desensitization, using indirect means (IM, email, voice recorders).

‣ Shaping, starting with non-verbal communication, then certain sounds, whispering, then talking.

Forceful attempts to make child talk are not helpful.Without treatment, may lead to depression, other anxiety disorders.


Separation Anxiety Disorder

• Excessive anxiety beyond that expected for the child's developmental level related to separation or impending separation from the attachment figure. Symptoms of separation anxiety include:

‣ constant thoughts and intense fears about the safety of parents and caretakers

‣ refusing to go to school

‣ frequent stomachaches and other physical complaints

‣ extreme worries about sleeping away from home, or without parents in the room

‣ being overly clingy, homesick

‣ panic or tantrums at times of separation from parents.

Girls 2:1Boys4 of 100 children6-10 years old



Separation Anxiety Disorder

• Different than normal “separation anxiety” at ages 1-4.

• 75% children who present with separation anxiety disorder will develop school refusal, usually starting after a period when child is closer to parent (summer vacation, brief illness, etc).

• Cognitive-Behavioural Therapy, school modifications are first line of treatment and very effective

• Medications only rarely indicated.

Parents frequently reinforce separation anxiety symptoms: when the child who refuses to leave is given extra attention or when the child who

refuses to attend school is excused by the parent

Homeschooling is contraindicated.


Specific Phobias

• Extreme fear about a specific thing or situation, causing significant distress and interfering with usual activities.

• In younger children, fears usually involve immediate, concrete threats:

‣ spiders

‣ darkness

‣ loud noises

‣ animals (e.g. dogs)

‣ costumed characters

• As children get older, they can develop other fears:

‣ injections, needles

‣ going to the dentist

‣ natural events (e.g. weather, earthquakes)

‣ heights

‣ enclosed spaces (e.g. elevator, tunnels)


www.anxietybc.com


http://www.anxietybc.com


Specific Phobias

• Treatment: CBT with exposure

‣ Exposure to feared stimuli on step-by-step basis

‣ Observation of other people dealing with fearful stimuli

‣ Relaxation

Fear Hierarchy:(1) seeing pictures of dogs in magazines;

(2) going to a pet shop and looking at a dog through the window; (3) going to a pet shop and petting a small puppy that is being held by somebody;

(4) petting a larger size dog that is on a leash; and (5) petting yet a larger dog that is running loose

Silverman & Moreno. Child Adolesc Psychiatric Clin N Am 14 (2005) 819–843


Generalized Anxiety Disorder

• Chronic (>6 months), excessive worry in a number of areas such as schoolwork, social interactions, family, health/safety, world events, and natural disasters with at least one associated somatic symptom.

• Children with GAD have trouble controlling their worries. These children are often perfectionistic, show high reassurance seeking, and may struggle with more internal distress than is evident to parents or teachers.

• The worries of GAD are not limited to a specific object or situation, and worry is present most of the time.





• They are often described as "little adults", since they sometimes spend hours worrying about adult concerns (for example, the family budget, or whether grandma is taking her medication).

They try to relieve their worry by doing some of the following behaviors:• Seeking excessive reassurance (e.g., asking a parent to review homework several

times, to make sure that it is perfect).• Checking (e.g., calling parents' cell phone several times, to ensure they are okay).• Information-seeking or list-making (e.g., reading every book on a subject before

completing homework or making a decision).• Withdrawal from groups (e.g., in an attempt to avoid worrying about their friends, a

child with GAD might just avoid having close friends; "what if my friend got angry with me?")

• Avoidance/procrastination (avoid going to school because of worries about parents being harmed while they are away; procrastinating homework so that they don't have a lot of time to worry about whether it was well done)

www.anxietybc.com





• Treatment: psychoeducation, CBT and in severe cases medication.

What Parents Can Do:• Teach your child about anxiety (e.g., anxiety can become a problem

when our body tells us that there is danger when there is no real danger).

• Teach your child about GAD (e.g., how uncertainty is a trigger for anxiety).

• Encourage your child to stop seeking reassurance (e.g.,tell your child to ask only once, or “Well, if you aren’t 100% sure, what is so bad about that?”).

• Teach your child relaxation exercises (e.g., breathing, muscle relaxation)

• Teach your child to be more comfortable with uncertainty (e.g., by doing things he/she was avoiding to do)

• Reward/Praise your child’s progress.

www.anxietybc.com




Social Anxiety Disorder

• Social phobia is characterized by feeling scared or uncomfortable in one or more social settings (discomfort with unfamiliar peers and not just unfamiliar adults) or performance situations (e.g., music, sports).

• Associated with social scrutiny and fear of doing something embarrassing in social settings such as classrooms, restaurants, and extracurricular activities.

• May have difficulty answering questions in class, reading aloud, initiating conversations, talking with unfamiliar people, and attending parties and social events.




Social Anxiety Disorder

• Treatment is CBT with exposure, and medications in some cases.

What Parents Can Do:

• Teach your child about SAD (e.g., how social anxiety is common but that there are better ways to deal with it than avoidance).

• Help your child with realistic thinking (e.g.,confront the automatic negative thoughts and challenge their worries).

• Teach your child relaxation exercises (e.g., breathing, muscle relaxation)

• Teach your child to face his/her fears (e.g., by systematically exposing him/her to social situations)

• Help your child to develop social skills (e.g., body language, voice quality, conversation skills, assertiveness)

• Reward/Praise your child’s progress.

www.anxietybc.com




Panic Disorder

• Recurrent episodes of intense fear that occur unexpectedly: pounding heart, sweating, shaking, difficulty breathing, chest pressure/pain, feeling of choking, nausea, chills, or dizziness.

• Youths with panic disorder fear recurrent panic attacks and their consequences, and they may develop avoidance of particular settings where attacks have occurred (agoraphobia).

• Cued panic attacks can occur with any of the anxiety disorders, are common among adolescents, and need to be distinguished from panic disorder, which occurs at a much lower rate.

• The uncued attacks of panic disorder are not limited to separation, a feared object/situation, social situations/evaluation, or other environmental cues.





What Else Parents Can Do:

•Help with realistic thinking: challenging overestimating and catastrophizing.

•Help child to face fearful situations: both by helping child to avoid places and feared body sensations. Exposure to exercise, spinning chairs, rapid breathing, etc.

•Reward/Praise progress

Panic Disorder

• Treatment is CBT with exposure, and medications in some cases.

What Parents Can Tell Their Children About Panic Attacks:

• Fact 1: Panic attacks are the body’s “flight-freeze-fight” response kicking in when there is no real danger.

• Fact 2: Panic attacks are harmless, although they can feel very uncomfortable or scary.

• Fact 3: Panic attacks are brief (typically lasting only 10 to 15 minutes), although they sometimes feel like they go on forever.

• Fact 4: Others (except those very close to you) cannot tell that you are having a panic attack.

www.anxietybc.com




Treatment

• Multi-Modal Treatment

‣ education of the parents and the child about the anxiety disorder,

‣ consultation with school personnel and primary care physicians,

‣ cognitive-behavioral interventions,

‣ psychodynamic psychotherapy,

‣ family therapy, and

‣ pharmacotherapy.

Image: Francesco Marino / FreeDigitalPhotos.net


Cognitive Behavioural Therapy

• Exposure-based CBT has the most empirical support

• Five components of CBT for childhood anxiety disorders:

‣ psychoeducation with child and parents about the illness and CBT,

‣ somatic management skills training (e.g., relaxation, diaphragmatic breathing, self-monitoring),

‣ cognitive restructuring (e.g., challenging negative expectations and modifying negative self-talk),

‣ exposure methods (e.g., imaginal and in vivo exposure with gradual desensitization to feared stimuli), and

‣ relapse prevention plans (e.g., booster sessions and coordination with parents and school)




Parent and School Interventions

• Parent Intervention:

‣ Parental anxiety, parenting styles, insecure attachment, and parent-child interactions are risk factors that may not be addressed by child-focused interventions.

‣ Interventions that improve parent-child relationships, strengthen family problem solving, reduce parental anxiety, and foster parenting skills that differentially reinforce adaptive coping and appropriate autonomy in the child are important.

• School Intervention.

‣ length of homework assignments

‣ teacher’s aide for problem-solving or anxiety management strategies.

‣ testing in a quiet, private environment

‣ educate the classroom teacher about the nature of the child’s anxiety and suggest strategies that facilitate the student’s coping.

‣ Individualized Educational Plan.




How Parents Can Help

http://www.heretohelp.bc.ca

AssessmentHave a child's general health checked by the doctor: untreated allergies, anemia, ear infections or other problems make it harder for anxious children to cope.

Look after the BasicsNo one copes well when they are tired or hungry. Anxious children don’t eat well or get enough sleep. Offer frequent nutritious snacks. Establish bedtime routine.

Establish RoutinesRoutines reduce anxiety. But anxiety tends to disrupt routines. So you need to work hard to build regular patterns so life is more predictable. Have the child help plan the routine. Plan time for homework and projects.

Firm and Consistent ParentingAnxious children feel calmer when life is predictable, when they know what is expected of them, and what the consequences will be.




How Parents Can Help


Tools to RelaxTeach the child a way of relaxing by mental imagery and progressive muscular relaxation.

Tools to Cope with Worrying"Locking up" worries in an imaginary box or setting a scheduled "worry" time are some tools to control the amount of energy worry takes up.

Taking RisksAnxious children need to try some experiments like making phone calls, talking to a new friend, and encouraging themselves through positive "self-talk" instead of imagining the worst. Parents can model these tools.

Physical ExerciseThis is helpful not only in relieving stress, but also in triggering a physical "relaxation response." Exercise will improve energy and reduce worry. Try to find something fun to do together rather than making this a chore.




Thank you.

Roberto Sassi MD PhDAssistant Professor

Department of Psychiatry and Behavioural NeurosciencesMcMaster [email protected]


mailto:[email protected]

mailto:[email protected]

Documents

Anxiety Disorders in Children and Adolescents · may develop new anxiety disorders over time. • The more severe the anxiety disorder and the greater the impairment in functioning,