Transcript H382 The Problems Kids have

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https://www.youtube.com/watch?v=dSs
AEWkmBFU
Mild deviation from what’s normal
 Transient
 Part of temperament
 Is it a real problem? How do we even
know it is there?
 Not disruptive
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Untreated anxiety disorders may lead to…
 Short-term: Academic issues (learning,
memory and attention), peer problems,
school attendance issues, low self-esteem
 Long-term: substance abuse, low
academic achievement, depression,
impaired relationships, low social support
(Velting, 2004)
 High co-morbid rate with other anxiety
disorders and depression (70-90%)
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“Scott and I talk about anxiety the way some
brothers talk about money, which is to say
often, and always with an eye on who has
more of it… Our anxieties are different breeds.
Mine is cerebral. It starts with a thought and
metastasizes from there.. Scott’s anxiety is
more physical. It starts with a twinge… and
then rises to his mind, magnifies it which results
in further investigation, creating a feedback
loop resulting in… him being rushed to the
cardiac unit… he’s a hypocondriac.
The product of a multi-complex response system involving
affective, behavioral, physiological and cognitive components
(Barlow, 2002)
 Affective: emotional distress, fear, upset
 Behavioral: avoidance and/or withdrawal
 Physiological: heart racing, dizziness, stomach issues,
shortness of breathe, “state of emergency”
 Cognitive: distorted thinking, “I’m going to die”
Attention/memory/learning issues
 Fear:
The emotional response to real
or perceived imminent threat;
associated with autonomic arousal;
fight or flight reaction; escape
behaviors
 Anxiety: Anticipation of future threat;
associated with muscle tension and
vigilance; prepping for future danger,
avoidant behaviors
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Babies: “unthinkable anxiety” (Winnicott)
Toddlers: toileting, strangers, bodily integrity
Preschool: monsters, imaginary creatures, the dark,
small animals
Elementary school: small animals, the dark,
lightening, personal safety
Middle school: health, dental, fear of evaluation
(academic, social)
Adolescence: social, physical illness, public
speaking, sexual, natural disasters/catastrophes
6-9 years old: children are dealing with issues
of individuation and autonomy
(Separation Anxiety Disorder)
10-13 years old: more aware of mortality and
the wider world (Generalized Anxiety
Disorder)
Adolescence: concerned with social
evaluation and performance (Social
Anxiety Disorder) “Imaginary Audience”
(Elkind, 1979)
Core defining feature: Dysregulation of the
normal response system; May involve
intense and disabling worry or intense fear
reactions in absence of true threat
A. Developmentally inappropriate and excessive
anxiety concerning separation from attachment
fig. (at least 3 of the following)
1. Recurrent excessive distress when separation from
home/attachment fig. occurs or is anticipated
2. Persistent/excessive worry about losing or about
possible harm befalling major att. fig
3. “
“ that an untoward event will lead to
separation from a major attachment fig.
4. Persistent reluctance to go out, to go to
school, to go to work due to separation
5. Persistent fear/reluctance to be alone
without major attachment figure
6. Persistent reluctance/refusal to go to
sleep without being near attach figure
7. Repeated nightmares involving
separation
8. Repeated physical complaints
(headaches, nausea, vomiting)
In clinical samples, boys and girls equal rate;
community samples, girls have higher rates
 Tends to be co-morbid with other anxiety
disorders (79%) (GAD, OCD, Panic),
depression and ADHD/ODD, enuresis, school
refusal (Kendall, 2001)
 May be a precursor to adult anxiety disorder
(Eisen, 2005)
 Needs to be culturally sensitive
 School refusal can be anywhere from 30-75%
(Heyne et al, 2004)
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Reluctance to attend school or stay in
the classroom throughout the day,
associated with emotional distress;
broader than school phobia,
heterogenous in origins (Heyne et al, 2004)
Won’t attend school
 Excessive fearfulness
 Reluctance to get out of bed
 Somatic complaints (headache, stomachache,
nausea)
*****
 Need to differentiate it from truancy
 Need to differentiate it from abiding fear of
school environment: SCHOOL CLIMATE MATTERS
 Most common cause-anxiety disorder (SAD,
Social Anxiety, School Phobia) and depression
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Is it a normal avoidance
reaction to a hostile
environment?
1.
2.
3.
Assess school climate
Assess teacher-child variables
Assess for bullying/relational
aggression
1. Relaxation training
2. Enhancement of social competence
3. Cognitive therapy
4. Exposure to feared stimuli (graduated
exposure)
*Treatment needs to be child specific
*CBT + parent/teaching training most
efficacious (King et al, 1998)
(social skills, coping skills, anxiety
management)
“Can you think of time when you felt safe
and relaxed?
 “Can you imagine where you were?
 Come up with a two syllable work that goes
with that feeling or two one syllable words
that captures that feeling?
 Examples:
Re-lax
Be Strong
Be Calm
I Can
Feel Good
Peace-ful
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Savoring: slowly and patiently dissolve in
your mouth a piece of candy, dried fruit or
something chewy. Focus on the texture,
flavor and other sensations- savor it fully
(Foxman, 2013)
“The last one there is the winner.”
 How many sounds can you hear around
you? Focus on one, what do you think it is?
Where is it coming from? What does it
sound like?
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Still Quiet Place by Amy Salzman, MD
http://www.youtube.com/watch?v=GIJn5XhqPN8
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https://www.youtube.com/watch?v=FUJs0fXTWTE
https://www.youtube.com/watch?v=QNmMH6tqi
Mc
A. Excessive worry and anxiety occurring
more days than not for at least 6 mos.
about a number of events or activities
B. The person finds it difficult to control the
worry
C. Anxiety and worry are associated with 3 of
the following (one for children)
Restlessness, easily fatigued, difficulty
concentrating, irritability, muscle tension,
sleep disturbance
D. Has to cause significant impairment
Hard working
 Conforming
 Perfectionistic
 Concerned about evaluation
 Highly punctual
 Hard on self
 Lack of self-confidence
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Reframe the harmless: What if…? To What
might…?
Shelve the shoulds… “I could choose…”
Reality test the tragic
Prescribe the symptom: pick a time to
worry…
“Don’t believe everything you think”/all or
nothing thinking
Externalize worries: Guatemalan Worry Dolls
Worry box
Essential feature: Marked and persistent fear of social
situations in which possible scrutiny may occur
 Afraid of showing anxiety symptoms that will be negatively
evaluated
 Social situations almost always provoke fear or anxiety
 In children, anxiety may be expressed by crying, tantrums,
freezing, shrinking from social situations (must be with peers
too)
 Feared social/performance situation avoided or endured
with dread
 Interferes with normal routine/functioning
 Typically lasts 6 months or more
** Performance specifier
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 Highly
sensitive to criticism
 Fear of rejection
 Difficulty with self-assertion
 Poor Social skills
 May be shy or typically withdrawn
 Self-esteem issue
Genetics: 30-40% attributed to genetics
 Temperament: Behavioral inhibition as
infants, greater vulnerability; activation of
the right pre-frontal cortex on EEG
 Family contribution: “Top down”- kids of
anxious parents are 5 times more likely to
have an anxiety disorder than controls
(Beidel & Turner, 1997)
 “Bottom up”- 80% of kids with SAD/GAD
had moms with anxiety disorders (Last,
1987)
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1. Parenting characteristics: overprotective,
overcontrolled, rejecting, disapproving, critical,
judgmental and hostile (Ginsburg et al, 1995; Leib
et al, 2000)
2. Parenting styles: Authoritarian- high control, low
warmth
Permissive- low control, high
warmth
Authoritative- high control, high
warmth
3. Parent’s temperament: highly anxious, doesn’t
scaffold well; anxiety-enhancing behaviors
4. Parent’s attachment style
Emotional brain & thinking brain
 Local lane vs. Express lane
 Caveman (amygdala) vs. Teacher
(cortex)
 Change the channel:
 Learning and lecturing: amygdala
doesn’t care!
 Both “brains” need to be addressed
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1. Screening (formal and informal)
2. Classification using DSM-5
(assess onset, duration and course)
3. Comorbidities***
4. Assess alternative causes (r/o medical
problems)
5. Treatment considerations
1. Psychoeducation
2. Somatic management skills training
3. Cognitive restructuring
4. Exposure methods: graduated,
systematic, controlled
5. Relapse prevention
 Symptoms
Mood, behavior, somatic
 Sources
Family, school, friends, media
 Solutions
Reasonable goals, cure “nature deficit disorder”, limit
media, SLEEP, nutrition, discover FLOW activities
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FEAR: Feeling frightened?
Expect the worst?
Attitudes/actions that can help
Results and rewards
14-18 sessions (60 mins.)
1st 6-8 sessions teach skills
STIC activities- “show-that-i-can”
Remaining sessions: practice new skills,
exposure (modeling, role-playing, relaxation
training); homework assigned
8-13 years old, 14-17 years old
Psychoeducation
 Contingency management
 Reducing parental anxiety
 Cognitive restructuring
 Improving parent-child relationship
 Relapse prevention
** 10-16 weeks, flexible format
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http://www.youtube.com/watch?v=yH2
AFoQJrQQ
Co-morbidity of anxiety disorders: primary
anxiety disorder gone, what about the comorbid disorders?
 Heterotypic Continuity: the prediction of a
disorder by another disorder (Costello et al,
2003)
 Does CBT get to the underlying issue(s) that
may have caused the vulnerability in the
first place?
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