Brief Therapy for the Treatment of Anxious Children

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1 Importance of Treating Anxiety in Children Brief Therapy for the Treatment of Anxious Children Lynn Lyons, LICSW December 12, 2010 Prevalence Chronicity Co-Morbidity By conservative estimates, 10% of children and teens currently have an anxiety disorder. When left untreated, anxiety generally becomes chronic, and correlates with: Predictors of Anxiety in Children increased rates of depression into adulthood attention and concentration problems impaired peer relationships and social skills conduct problems increased use of medical and psychiatric services an almost 50% retention of the diagnosis 8 years after the initial onset (Keller, et al., 1992) delay in the onset of independent living Temperament Parents/Family Cognitive and Emotional Management McLoone, Hudson, & Rapee, Education and Treatment of Children, 2006; 29(2):

2 What percent of children living with an anxious parent meet the criteria for an anxiety disorder? Lead researcher Golda Ginsburg reports data showing that the children of parents diagnosed with an anxiety disorder are up to seven times more likely to develop an anxiety disorder themselves, and up to 65 percent of children living with an anxious parent meet criteria for an anxiety disorder. Ginsburg, et al., The Child Anxiety Prevention Study: Intervention Model and Primary Outcomes. Journal of Consulting and Clinical Psychology, 77(3), June 2009, Parents of Anxious Children Over-involved, overcritical, overprotective, and anxious are words researchers consistently use to describe the parents of anxious children Mother s behavior more influential than father s A general negative affect/distress in mother, rather than just anxiety-specific symptoms, add to anxiety in children Shamir-Essakow, 2005 An anxious mother, due to her own cognitive bias toward threat and avoidance of threat, may overprotect her children regardless of the child s temperament and become more involved than other, less anxious mothers. Hudson & Rapee, Journal of Clinical Child & Adolescent Psychiatry, Dec. 2002; 31(4): 553 2

3 Stress is contagious From the American Journal of Respiratory and Critical Care Medicine Children whose mothers are chronically stressed during their early years have a higher asthma rate than their peers, regardless of their income, gender or other known asthma risk factors. It is increasingly clear that traditional environmental risk factors do not fully explain the origins of asthma, said lead investigator, Anita Kozyrskyj, Ph.D., Associate Professor in the Faculty of Pharmacy at the University of Manitoba, Canada. Evidence is emerging that exposure to maternal distress in early life plays a causal role in the development of childhood asthma. How do anxious parents and children experience and interpret their world? So what does that mean? Anxious parents and children... Children of anxious parents are more likely to Catastrophize: focus on the worst possible scenario or outcome perceive ambiguous situations as more threatening or dangerous Overgeneralize/Globalize: allow a single negative experience or outcome to predict the same outcome for all future, similar events Personalize: attribute negative outcomes to self, and internalize causes of outcomes have lower estimates of their own competency to cope with such situations engage in all or nothing thinking (perfectionistic) become masters of negative expectancy 3

4 Children of anxious parents are more likely to have more somatic complaints be fearful of physical symptoms have higher levels of anxiety sensitivity Avoidance Barrett, Rapee, Dadds, & Ryan, 1996; Bogels & Zigterman, 2000; Weems, et al., 2001 Avoidance of: social contact new experiences possible failures negative affect physical arousal Families must learn how to: handle discomfort and uncertainty manage emotions demonstrate flexibility make mistakes and manage failure 4

5 The Value of HOW... Beidel and Turner s "Social Effectiveness Training" 12 week program taught social skills to shy kids Kids paired with other kids for public social activities 66% no longer shy or socially frightened after program Number increases to 75% at six month follow-up Beidel, Deborah C.; Turner, Samuel M.; Taylor-Ferreira, Jill C. Behavior Modification. (1999) 23(4) A 2009 study at Johns Hopkins Children s Center on the prevention of anxiety in children: Brief psycho-educational work with parents and children was highly effective Parent traits modified: overprotection, excessive criticism, and excessive expression of fear and anxiety in front of children Child traits modified: worry and avoiding anxiety-provoking situations My Guidelines My Guidelines 90 minute first session I get to work! If there s lots of history to be taken, I meet alone with parents first. A parent needs to be present at ALL appointments. I usually make a CD in the first session. There are homework assignments given at all sessions. I know this feels big and overwhelming to you, but this is not a mystery to me, and I know exactly what to do. Subsequent sessions are 60 minutes, and usually every 2 weeks to start. Contact with the school is very helpful. 5

6 Dear : We are currently working on Peter s worry, particularly the difficulty he has been having staying in class. His pattern has been to complain of a stomach ache, go to visit the nurse, receive a Tums, and then return to class about minutes later. As you know, Peter has been doing this at least twice a day for the last month. Peter, his parents, and I have been working on a new plan, with a goal of helping Peter recognize his worry, manage the physical discomfort he feels, and stay in the classroom if possible. Peter has been taught several tools to do this, and he has been practicing them. He s doing very well, but we need your help. If Peter asks to go to the nurse, please remind Peter of his tools (including ). Cue Peter to use them, and allow him the time and space to do so. It shouldn t take him long, and he knows what to do. Peter does not want other kids to know about this, so please plan with him about how you might cue him privately. A secret word or signal, or a private moment, would be great. Of course, if Peter for some reason is not able to manage his worry, even after prompting and practicing, he may go to the nurse. He won t be there long she has a plan, too! It is important that we all use the same language with Peter, and that we all support his efforts. We are referring to Peter s discomfort as worry, and it is important that we move away from using the term sick, especially when talking about his stomach ache. Key for Peter is the phrase, I feel uncomfortable right now, but I can handle this. Peter knows all about this plan, and is motivated to experiment with it in the classroom. We so appreciate your support along the way. Worry Demands TWO Things: So Managing Worry Requires: Certainty Comfort Tolerating uncertainty Allowing discomfort 6

7 The Worry Stance: I (my child) have to know, or I (my child) can t move forward. This is uncomfortable, so I m going to avoid/prevent it. I (my child) have to be comfortable. I (my child) can t handle this. What we re going for: I (my child) can t know everything, but I (my child) can move forward anyway. This is uncomfortable, but I (my child) can handle it. Moving through discomfort is necessary to learn and grow. I (my child) can handle this. Identifying Parents Anxious Behavior The Importance of Experiential Learning Ruminating Repeating statements of caution (safety chatter) Expressing worst case scenarios Reacting strongly to child s distress Accommodating child, and expecting others to as well Talking (alone) does not change neural pathways Need experience to impact brain s alarm system Experiential learning is more memorable, and needed to create powerful reference experiences More work and creativity is required, but engagement is greater and progress much quicker 7

8 Why I do hypnosis with anxious children: They are already masters at completely absorbing themselves in a narrative. Experimenting and exploring They already know how to use their imaginations to create physiological responses. Self-hypnosis is a tool that promotes mastery both cognitively and physiologically. The use of the yes set in a good hypnosis session is the antidote to their avoidant-driven no set. Observation and information gathering Mastery exercises...it starts at home Steps and sequencing...getting from A to B to C, the antidote to overwhelming Physiological calming and informing Accessing resources Externalizing and personifying Worry Parts Normalizing initial cognitive, physical, and emotional responses Dissociating from or dismissing negative worried thoughts Selectivity and discrimination: the antidote to all or nothing; sometimes it s wise to be cautious, quiet, slow, thoughtful, nervous... Positive anticipation and expectancy: changing the habit of the bad outcome video What could happen? What if? Generating outcomes and managing uncertainty 8

9 PROMOTE WATCH OUT FOR Explore Rigidity Experiment All or Nothing Mastery Always/Never Steps and Sequencing Overwhelmed Reassurance Perfection Selectivity What if? Observation Negative Certainty Expectancy Global Thinking Possibilities Somatizing Experimenting and exploring You can try it, and then you can decide...it s hard to judge with no experience. Observation and information gathering Maybe we could go and watch first, or ask some people about it. I like how you watch and learn. Mastery exercises...it starts at home I m thinking you re ready to do this on your own. Steps and sequencing...getting from A to B to C Let s talk about the first few steps...imagining the end might feel too big right now. Physiological calming and informing My heart goes faster when I m nervous, too. Deep breaths slow a body down. Externalizing and personifying Worry Parts What does your Worry Part look like? Let s figure out how to handle it when it shows up. Normalizing the initial cognitive, physical, and emotional responses It s normal to feel or think like that. All humans and animals react to new things and surprises. How can you respond to those signals? 9

10 Dissociating from or dismissing negative, worried thoughts That Worry Part is so predictable. Maybe we should ignore those boring thoughts. Accessing resources Maybe you remember a time when you...(if not, parent offers memory.) Worry loves you to forget! Selectivity and discrimination: the antidote to all or nothing In certain situations, it s wise to be cautious. OR Some kids like roller coasters and some kids like other kinds of rides. You get to experiment and figure that out. Positive anticipation and expectancy: changing the habit of the bad outcome video I wonder if we can look forward to that turning out better. The 4 B s What could happen? What if? Generating outcomes and managing uncertainty That might happen. We can t know for sure. What else could happen? How can we move ahead and not know everything? The What I Know/What I Don t Know Game Body Brain Bravery Bridge 10

11 Managing Worry (Normal and Problematic) Expect Externalize Experiment (this is Exposure) How to Create an Experiential Intervention (How to DO SOMETHING that works) Know where you re headed, especially the skill(s) you need to teach. Make sure to build the floor with physiological information. Predict discomfort from the start. Tolerating uncertainty is critical. Think sequentially (from less to more). Find a want to. Possible Interventions Possible Interventions Practicing with CD/Heavy Hands What I Know/What I Don t Know Game The Clipboard Interview Expose and Report Technology Drawing, Talking to, Directing the Worry Part Practicing and Role Playing Researching Current Events Finding Books that Support the Skill Worry Kits 11

12 Moving from Less Threatening to More Challenging 1. Indirect( Safe) Contact: books, stories, observing, reporting from a distance 2. Imagining/Planning: story starring self, hypnosis, visualization, recording the plan, reviewing resources 3. Experimenting: giving it a try, gathering data, recording the results The Importance of Contextualization In the treatment setting, at home, or out in the world, there are countless opportunities to introduce these more flexible ways of thinking, planning, and experiencing. The goal is to help the parent and child move from avoidance, to manageable risk, to mastery. Using specified steps, families can connect these themes or concepts to their own world and everyday experiences. Thanks for coming! Lynn Lyons, LICSW (603) lynnlyonsnh.com Specializing in the treatment of anxious families 12