Transcript Children and Anxiety

Healthy Strategies to Decrease
Anxiety and Build Resiliency
Barbara J Howard, MD
[email protected]
Definition of Anxiety
“Emotional uneasiness associated with the
anticipation of danger”
Livingston, 1991
Anxiety is Necessary
Survival: fight or flight
 Development of mastery of fears for selfefficacy
 Social purposes
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◦ Acquisition of conscience
◦ Moral conduct
Fears and Phobia
Fear = normal
reaction to real or
imagined danger or
threat
 Phobia= marked
and persistent fear
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Fears in Infancy
Birth: fear of falling ie Moro reflex
6-7mo: change in stimulus level, sudden noises,
loss of support
 8-18mo: separation, strangers, loud events,
physical restraint, large crowds, water
 2yrs: loud sounds, dark colors, large objects,
hats, mittens, going down the drain/toilet, wind
and rain, animals, changes in the location of
physical things
 2 1/2yrs: movement, unexpected events linked
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Fears in Preschool Aged Children
3 yrs: visual fears, masks, old people,
people with scars/deformities, dark,
animals, burglars, parents going out at
night
 4 yrs: auditory fears, dark, imaginary
creatures, recalled past events, aggressive
actions, threats
 5 yrs: fear of injury, falls, dogs
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Fears in School Aged Children
6 yrs: Supernatural events, hidden people, being
left or lost, small bodily injuries, being left alone,
death of a loved one, the elements
 7 yrs: spaces (basements), shadows, ideas
suggested by TV/movies, being late for school,
missing answers in school
 8-9 yrs: school failure, personal failure, disease,
ridicule by peers, unanticipated events
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Fears in Adolescence
10-11 yrs: wild animals, high places,
criminals, older kids, loss of possessions,
parental anger, remote possibilities of
catastrophe, school failure, pollution
 12-17 yrs: physical changes in one’s own
body, isolation, sexual fears, loss of face,
world events
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How Anxiety is Mastered
Imaginative play
 Acquisition of knowledge
 Experience (that is not traumatic)
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Signs of Anxiety Disorders
Avoidance behavior
 Underachieving
 Perfectionism
 Procrastination
 Unable to make decisions
 Somatic complaints
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Anxiety Disorder Signs in School
Frequent visits to the school nurse
 Frequent absences
 Trouble learning
 Trouble with social activities
 Difficulty demonstrating knowledge on
test and classroom participation
 Inattentiveness
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Signs and Symptoms of Anxiety Disorders
Cognitive
Behavioral
Physical
fearful
restless
cardiovascular
nervous
clingy
respiratory
stressed
dependent
skin
fretful
shy
musculoskeletal
self-defeating
withdrawn
GI
poor
concentration
inattention
reluctant
headache
avoidant
dizzy
Epidemiology of Anxiety Disorders
Most common of childhood psychiatric
disorders
 12-20% of children
 Least understood, identified, and treated
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DSM-V Categories
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Separation Anxiety Disorder
Panic Disorder
Agoraphobia
Specific Phobia
Social Anxiety Disorder (Social Phobia)
Generalized Anxiety Disorder
Substance-Induced Anxiety Disorder
Anxiety Disorder attributable to another medical
condition
Anxiety Disorder Not Elsewhere Classified
Panic Attack
Separation Anxiety
Normal Developmental Phenomenon
◦ 6 to 8 months of age with object permanence
◦ Improves after age 3 when children learn that
separation is temporary
 Problem when persists or re-emerges
 Diagnosis therefore should be made with
caution before age 5, never <30 months
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Separation Anxiety Disorder
Developmentally inappropriate and
excessive anxiety concerning separation
from home or from major attachment
figures
 At least 4 weeks, onset before 18 years
 At least 3 symptoms below:
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Separation Anxiety Disorder
 Distress
when separation occurs or
is anticipated
 Worry about loss or harm to major
attachment figure
 Worry than an untoward event will
lead to separation from major
attachment figures
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Reluctance or refusal:
◦ to go to school or elsewhere due to
separation
◦ to be alone without being near a major
attachment figure
◦ to go to sleep without being near a major
attachment figure or to sleep away from home
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Repeated:
◦ nightmares involving themes of separation
◦ complaints of physical symptoms when
separation occurs or is anticipated
Characteristics of Separation
Anxiety Disorder
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Associated psychiatric diagnosis in 4060%
◦ Other Anxiety disorders
◦ Major Depressive Disorder
Prevalence is 2.4-5.4%
 Peak 7-9 years old
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Generalized Anxiety Disorder: DSM IV
 Excessive
and persistent worry
occurs across many of domains more
days than not
 The child finds it difficult to control
the worry
 Causes significant distress or
impairment in functioning
 Associated
with:
◦ Restlessness
◦ Easily fatigued
◦ Difficulty concentrating
◦ Irritability
◦ Muscle tension
◦ Sleep disturbance
Generalized Anxiety Disorder
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Impairment in children tends to take the form
of failure to achieve an expected level of
functioning
Somatic complaints are common
“What if..?” questions
Cognitive distortions-see below
Male=Female until adolescence, then female
predominates
2.7-4.6%
Etiology of Anxiety Disorders
Probable genetic tendency combined with
environmental influences
Temperament
 Genetic
 Neurobiology
 Environment
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Etiology: Behavioral Inhibition
Temperamental bias in 20% of children
 Predisposes to be highly reactive to unfamiliar
situations
 Physiological differences:
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◦ Increased HR, salivary cortisol, tension in larynx and
vocal cords, pupillary dilation during cognitive tasks
EEG differences
 Stability of inherited temperament
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Etiology: Environment
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Difficulties during vulnerable periods
◦ Anxious/avoidant attachment, trust,
separation-individuation
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Trauma
◦ Repetitive events- incl.hospitalization
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Parental/family distress and dysfunction
◦ Anxiety, overcontrol/overprotection
Neighborhood, community, society
 Access to support system
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Physical Conditions that may mimic
Anxiety
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Hypoglycemic episodes
Hyperthyroidism
Cardiac arrhythmia
Caffeinism
Pheochromocytoma
Asthma
Seizures
Migraines
CNS disorders: delirium, brain tumor, lead
Psychiatric Disorders that Mimic or Go along
with Anxiety Disorders
ADHD
 Psychosis
 Autism
 Learning or Language Disabilities
 Bipolar Disorder
 Depression
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Medications that can produce
Anxiety Symptoms
Antihistamines
 Anti-asthmatics
 Sympathomimetics
 Steroids
 Anti-psychotics
 Diet pills
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Anxiety Disorders: Co-morbidity
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Anxiety Disorder
◦ 1/3 of children meet criteria for two or more
Attention Deficit Hyperactivity Disorder
◦ 15-24% of children with SAD or GAD
Depressive Disorders
◦ Major Depression rates from 28%
Medical Conditions
◦ any serious medical condition may be associated
with anxiety
◦ Mitral Valve Prolapse is associated with panic
disorder
Substance Abuse
Eating Disorders (anorexia or bulimia nervosa)
Anxiety Evaluation
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Universal screening is recommended
History from patient and parent
◦ Children: may overlook impairment, limited by
vocabulary
◦ Parents: may underreport internalizing symptoms of
their children
◦ Consider thermometer, smile faces, how much anxiety
has “messed things up”, how many days scared
Developmental history of temperament, separation, fears
◦ Children show anxiety differently (crying, irritability,
tantrums, freezing)
Family assessment
◦ Social and familial context and reinforcers
◦ Family history of anxiety disorders
Physical exam
Natural Course of Anxiety
Disorders
Children who meet criteria for 1 anxiety
disorder: 42% continue to meet criteria
for an anxiety disorder at 21 years
 For 2 disorders, 77% continue to meet
criteria
 Long term: depression, substance abuse
 Early detection and intervention can
prevent these long term problems
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Prevention of Anxiety Disorders
Confident, kind parenting
 Avoid trauma- e.g. intimate partner
violence, intoxication, media
 Avoid bullying by peers or siblings
 Model confidence, problem solving
 Do not rescue too soon
 Regular schedule, healthy meals
 Adequate sleep
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General Advice for Anxious
Children
Routine: have your child use the same routine
every morning to get ready for school and
every evening to get ready for bed
 Predictability: Say the same reassuring phrases
to your anxious child
 Worries: use pat phrases to label them
 Introduce your child to only one new situation
at a time.
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Help your child to plan ahead as a way of
coping with change = active coping rather
than avoidant
 When big changes are inevitable:
◦ Break down the big event into several
little changes with the child and think of
coping strategies for each
◦ Explore with the child which ones are
most worrisome and then put them into
perspective
◦ If possible, practice
◦ Reward bits of success with
points/marks
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Marks
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Make a mark on child’s hand for appropriate
behaviors
Use marks for brief period up to all day
Aim for 6-10 marks per hour
Give marks for “bravery” a little more than usual
Reward number of marks
Give bonus numbers for outstanding behavior
Phase out when behavior has improved and
parent is practiced at other acknowledgement
Treatment
Fewer than 20% of children receive the
necessary treatment for their anxiety
disorder
 Broad Goals:
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◦ reduce symptoms and relieve distress
◦ prevent complications
◦ minimize any disability associated with this
disorder
Treatment
Demystification
 Exposure based Cognitive Behavioral Therapy
(Coping Cat, Kendall, 1990)
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Relaxation
Desensitization
Self talk
Exposure
Relapse prevention
Parent involvement/ family therapy esp if anxious
 School accommodations -504 Plan
 Pharmacotherapy
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Anxiety
Coping skills
Stressor
Innate
vulnerability
Anxiety
Support
Learn the Signs of Anxiety (Ginsburg)
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Knowing the signs of anxiety helps you know when to take action. A little
anxiety is helpful (motivates you to study; keeps you safe) but too much
anxiety feels bad and causes problems.
Anxiety shows itself in 3 ways:
◦ Bodily reactions (e.g., headaches, sweating, shaking, heart beating fast,
stomach aches)
◦ Negative thoughts of getting hurt or being embarrassed (e.g., "I might
get hurt," “people will make fun of me”)
◦ Actions or behaviors (e.g., running away, freezing, nail biting, crying,
hitting)
The best thing to do:
Keep a diary to track each of the above signs; learn how your anxiety
shows itself, learn what situations trigger your anxiety signs; look for
patterns (e.g. always before gym class; always at night).
Face Your Fears (Ginsburg)
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The best way to reduce anxiety is to reduce avoidance by facing your
fears (instead of running away).
Avoidance keeps fear/anxiety around because you never learn that
your worst fears are not true, and you never develop the skills you
need to cope with the situation.
The best thing to do:
 Face your fears gradually rather than jumping into the scariest
situation all at once. Take it one step at a time like you are climbing a
ladder.
 Create a list of all the situations that you avoid and put a number (010) next to each situation (0 = not at all scary to 10 = the most
scary).
 Break down each step into smaller steps if needed.
 Take at least one step on the ladder each day and practice the same
step over and over until it gets easy and no longer makes you feel
nervous or scared.
Calm Your Body (Ginsburg)
Learning how to relax and calm the tension in your body will reduce your
anxiety and help you face your fears. Just as you can make your body tense,
you can make it relax.
The best thing to do:
 Learn and practice Deep Breathing:
◦ Pretend you are a balloon that expands when it fills with air and deflates
when the air is let out.
◦ Inhale through your nose slowly, blowing up like a balloon. Hold your
breath for three seconds, and exhale through your mouth--pushing out all
the anxious feelings out your body.
◦ Tell yourself "relax" as you blow all the air out.
◦ You can also imagine your favorite place where you feel comfortable and
relaxed.You can do this whenever you feel anxiety in your body.
 Learn and practice Progressive Muscle Relaxation
◦ One way to get your muscles to relax is to do the opposite first. Sit or lie
down and squeeze each muscle group one at a time, holding it for 3
seconds, and then relaxing.
◦ Start with your face, then do your neck and shoulders, arms and hands,
chest and stomach, legs and buttocks, and feet. Then tense and relax your
whole body—all body parts at once.
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Change Your Thoughts (Ginsburg)
People talk to themselves all the time (even if they are not aware of it).
 Thinking that something bad or dangerous will happen increases and keeps
anxiety going.
 Because we can have different thoughts in the same situation, we can learn to
change thoughts so that they help reduce rather than increase anxiety.
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The best thing to do: Use the diary to track your thoughts so you know what your
anxious thoughts are. Remember you can have different thoughts in the same
situation and that what we say to ourselves will affect how we feel and what we do.
 To “change” your thoughts do the following:
 Do a reality check: List the evidence for and against the thought (e.g., “be a
detective”)
 Ask what others you look up to might think in the same situation
 Ask yourself the following questions to help develop coping thoughts: Do I know
for sure that this is going to happen? What else might happen? Has this ever
actually happened before? How likely is it to happen? Has this happened to anyone I
know? What is the worst that could happen and is that really so bad? Is it going to
matter a day, week, month, or year from now?
 Write your new helpful, thoughts down on a coping card to use when you are
facing your fears
Problem “SOLVE” It (Ginsburg)
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Too much anxiety often causes problems and too many problems can cause
anxiety. Use this problem-solving method to prevent problems from building up,
solve existing problems more quickly and efficiently, and reduce and/or prevent
anxiety. It can also help you get along better at home by reducing conflicts.
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The best thing to do: Use the SOLVE Method. Each letter of the word SOLVE
is a step in a method to solve problems
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Settle down- don’t try to solve problems when upset. Think about what helps
you settle down and relax. Note what emotions got in the way of solving
problems--usually it is anxiety or worry. Use your relaxation exercises.
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Own the problem- what part of the problem is yours? Don’t take on others’
problems. Be sure the problem is defined in concrete and specific terms (e.g., “I
can’t find my favorite shirt to wear to the party” instead of “I have nothing to
wear!”).
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List solutions: write down all of your ideas - even if silly and do not evaluate yet.
Brainstorm! Sometimes you may want to get another person to help you.
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Vote for one solution by examining short and long-term consequences; think
about the pros and cons of each solution.
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Engage in the one solution that seems best. Evaluate outcomes and repeat steps
if needed.
When to use medication
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Making it easier for the child to face what is
feared
Blocking the most distressing physical symptom of
anxiety
Reducing a child’s anxiety level in order to reduce
its interference with day-to-day activities
Reducing the consequences of prolonged,
untreated anxiety problems
Treating those types of anxiety that respond
particularly well to medication eg OCD
In children SSRIs, esp. prozac.
Beware of suicidal ideation at dose changes
Summary
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Anxiety disorders are very common, yet
frequently under-diagnosed
Can cause impairment in many domains with a
high incidence of co-morbidity
Think of balance:coping
Multimodal treatment necessary
SSRI and newer antidepressants are first line of
pharmacotherapy
Selected References- Anxiety
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Eifert, G, Forsyth, J. Acceptance and Commitment
Therapy for Anxiety Disorders: A Practitioner's Treatment
Guide to Using Mindfulness, Acceptance, and ValuesBased Behavior Change Strategies. New Harbinger
Pub. 2005
Hayes, S and Spencer, S. Get out of your mind and
into your life, New Harbinger Pub. 2005
Kendall 1990 Coping Cat
Manassis, Katherina (1996). Keys to Parenting your
Anxious Child.
Walkup, John T., Ginsburg, Golda S. (2004). Anxiety
Disorders in Children and Adolescents.