9/19/2017. Identifying and Treating Fear and Anxiety in Children IDENTIFYING AND TREATING FEAR AND ANXIETY IN CHILDREN

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1 IDENTIFYING AND TREATING FEAR AND ANXIETY IN CHILDREN Allisn Elledge, PhD Regina Hummel, Ph.D. Pediatric Psychlgists East Tennessee Children s Hspital WHY WE NEED TO IDENTIFY AND TREAT ANXIETY EARLY Anxiety is the mst prevalent mental health disrder in children and teens Anxiety disrders affect 25.1% f children between 13 and 18 years ld. Children ften develp new anxiety disrders ver time (even if the ld nes g away) Anxiety in the 1 st grade has been shwn t predict anxiety and lw academic achievement in reading and math in the 5 th grade. Develpmental prgressin f anxiety disrders in adulthd Untreated childhd anxiety typically cntinues int adulthd Leads t an increased risk f depressive disrders NORMAL VERSUS PATHOLOGICAL ANXIETY Is this smething a child f this age shuld be wrrying abut? Is the degree f distress unrealistic given the child s develpmental stage and the bject/event? Des the anxiety interfere with the child s daily life? Scial functining: i unable t make friends Academic functining: failing classes Family functining: creating cnflicts, limiting family chices Is the child able t recver frm distress when the event is nt present? Tend t wrry abut future ccurrences f bject/event Distress ccurs acrss multiple settings Allisn Elledge, PhD Regina Hummel, Ph.D. 1

2 9/19/2017 COMMON CHILDHOOD WORRIES COMMON ADOLESCENT WORRIES PREVALENCE AND DEMOGRAPHICS Allisn Elledge, PhD Regina Hummel, Ph.D. 2

3 RISK FACTORS FOR DEVELOPING ANXIETY Genetic and envirnmental factrs, frequently in interactin with ne anther, are risk factrs fr anxiety disrders. Specific factrs include: Shyness r behaviral inhibitin in childhd Being female Pverty Expsure t stressful life events Anxiety disrders in clse bilgical relatives Parental histry f mental disrders SEPARATION ANXIETY DISORDER Separatin anxiety is the fear and wrry children experience when they can t be with their parents r guardians. Cmmn in children ages 6 mnth t 2 year. Causes impairment in lder children. Children with separatin anxiety: Prtest, cry r struggle when being separated frm their parents Refuse t g t r stay at day care, preschl r schl by themselves Refuse t sleep at ther peple s hmes withut their parents there t Cmplain f feeling sick when separated. Children with separatin anxiety cmmnly wrry abut bad things happening t their parents r caregivers r may have a vague sense f smething terrible ccurring while they are apart. Average age f nset 4.5 years SELECTIVE MUTISM Refusal t speak in situatins where talking is expected r necessary, t the extent that the refusal interferes with schl and making friends, Children suffering frm selective mutism may stand mtinless and expressinless, turn their heads, chew r twirl hair, avid eye cntact, r withdraw t avid talking. These children can be very talkative and display nrmal behavirs at hme r in anther place where they feel cmfrtable. The average age f diagnsis is arund 5 years ld, r arund the time a child enters schl. Allisn Elledge, PhD Regina Hummel, Ph.D. 3

4 SPECIFIC PHOBIA A specific phbia is the intense, irratinal fear f a specific bject, such as a dg, r a situatin, such as flying. Cmmn childhd phbias include animals, strms, heights, water, bld, the dark, and medical prcedures. Children will avid situatins r things that they fear, r endure them with anxius feelings. Anxiety can manifest as crying, tantrums, clinging, avidance, headaches, and stmachaches. Unlike adults, they d nt usually recgnize that their fear is irratinal. Average age f nset 7 years SOCIAL ANXIETY Scial anxiety is fear and wrry in situatins where children have t interact with ther peple, r be the fcus f attentin. Children with scial anxiety typically: believe that thers will think badly f r laugh at them are shy r withdrawn have difficulty meeting ther children r jining i in grups have a limited number f friends believe everyne is watching them and evaluating them negatively avid scial situatins where they might be the fcus f attentin r stand ut frm thers fr example, talking n the telephne and asking r answering questins in class. Average age f nset is 13 OBSESSIVE COMPULSIVE DISORDER OCD is characterized by unwanted and intrusive thughts (bsessins) and feeling cmpelled t repeatedly perfrm rituals and rutines (cmpulsins) t try and ease anxiety. Cnsume excessive amunts f time (an hur r mre each day Cause significant distress Interfere with daily functining at wrk r schl, r with scial activities, family relatinships and/r nrmal rutines. Bys are mre likely t develp OCD befre puberty, while girls tend t develp it during adlescence. Average age f nset 14 years Allisn Elledge, PhD Regina Hummel, Ph.D. 4

5 COMMON OBSESSIONS AND COMPULSIONS IN CHILDREN AND TEENS Fear f germs r cntaminatin Fear f harm, illness, r death, will happen t themself r thers fear f causing harm t neself r thers, including vilent r aggressive bsessins Fears/feelings/urges related t numbers, e.g., "gd" numbers, "bad" numbers, "magical" numbers. They must repeat actins until gd number is reached hd Fears/feelings/urges related t discarding smething feelings f incmpleteness if smething is discarded Excessive fear f vilating religius r mral rules (in thughts r actins) Fears/feelings/urges related t symmetry r rder Fears/feelings/urges/images related t sexual cntent Fears/feelings/urges related t having smething "just right," "just s" r "perfect GENERALIZED ANXIETY DISORDER Children with generalized anxiety tend t wrry abut many areas f life anything frm friends at playgrup t events in their envirnment. Children with generalized anxiety can wrry abut: health, schlwrk, schl r sprting achievements, mney, safety feel the need t get everything perfect feel scared f asking r answering questins in class find it hard t perfrm n tests are afraid f new r unfamiliar situatins seek cnstant reassurance cmplain abut feeling sick when wrried. Average age f nset 17 years PANIC DISORDER Panic disrder is diagnsed if a child suffers at least tw unexpected panic r anxiety attacks. They cme n suddenly and fr n reasn Cause at least ne mnth f cncern ver having anther attack, lsing cntrl, r "ging crazy. Physical symptms f a panic attack include: increased heart rate and chest pain chking sensatins, difficulty breathing, hyperventilating sweating and trembling gastrintestinal distress bdy temperature changes ht r cld flushes, dizziness, and numbness r tingling in the limbs Cgnitive symptms include: fear f dying r lsing cntrl f ne s mind feeling as if ne is in a dream and events seem unreal Allisn Elledge, PhD Regina Hummel, Ph.D. 5

6 PANIC DISORDER Symptms f panic attacks ften accelerate quickly (within 10 minutes) and peak after several minutes befre diminishing either rapidly r gradually. Very ften, panic attacks are unexpected in nature and feel as if they are cming n ut f the blue. Children and adlescents may start t avid the situatins in which they have experienced a panic attack in the past. In very severe cases, a persn s panic becmes s widespread that he r she requires a safety persn t help, r remains hme fr lng perids f time. Average age f nset 18 POST TRAUMATIC STRESS DISORDER Psttraumatic stress disrder, r PTSD, is diagnsed fllwing the experience f traumatic event r knwledge f a traumatic event. The child must experience symptms fr at least ne mnth. The disrder is characterized by three main types f symptms: Re-experiencing the trauma thrugh intrusive distressing i recllectins f the event, flashbacks, and/r nightmares. Avidance f places, peple, and activities that are reminders f the trauma. Increased arusal such as difficulty sleeping and cncentrating, feeling jumpy, and being easily irritated and angered. POST TRAUMATIC STRESS DISORDER Nt every child wh experiences r hears abut a traumatic event will develp PTSD. It is nrmal t be fearful, sad, r apprehensive after such events, and many children will recver frm these feelings in a shrt time. Children mst at risk fr PTSD are thse wh: Directly witnessed a traumatic event, wh suffered directly (such as injury r the death f a parent), Had mental health prblems befre the event Lack a strng supprt netwrk. Have been expsed t vilence at hme Allisn Elledge, PhD Regina Hummel, Ph.D. 6

7 WHEN ANXIETY LOOKS LIKE SOMETHING ELSE Anxiety can ften present with a primarily medical symptms. It is cmmn fr children t reprt smatic issues that stem frm anxiety. These include: GI Issues nausea, diarrhea, cnstipatin, functinal abdminal pain, lss f appetite Headaches Shrtness f breath Chest Pain Heart palpitatins Cmmn Psychiatric C-Mrbidity 8.2 times mre likely t meet criteria fr Depressin 3.0 times mre likely t meet criteria fr ADHD 3.1 times mre likely t meet criteria fr ODD COGNITIVE BEHAVIORAL THERAPY Structured, time-limited, present-fcused, skillsbased apprach t psychtherapy Helps patients develp strategies t mdify: dysfunctinal thinking patterns r cgnitins (i.e., the C in CBT) maladaptive behavirs (i.e., the B in CBT) Basic underlying thery Emtinal experiences are influenced by ur thughts and behavirs Mental health prblems arise when peple exhibit maladaptive and extreme patterns f thinking and behavir CBT FOR CHILDREN RCTs have shwn CBT t be effective fr a range f child emtinal prblems including : Depressin Generalized anxiety OCD OCD Specific phbias Scial anxiety Schl refusal Trauma Chrnic illness/pain cping Allisn Elledge, PhD Regina Hummel, Ph.D. 7

8 COGNITIVE BEHAVIORAL THERAPY 1. Psycheducatin WITH CHILDREN & TEENS 2. Implement individual behaviral techniques 3. Implement cgnitive techniques 4. Develp cntingency management system with parents 5. Practice 1. Cgnitive techniques 2. Expsure tasks What cmpnents f CBT can be intrduced r implemented by the primary care prvider? PSYCHOEDUCATION Essential fr bth children & parents Start with: Anxiety is a gd thing! Functinally, anxiety serves t prtect us frm danger Alerts us t when we need t be mre cautius Evlutinarily beneficial (saber tth tiger example) Our brains use sensatins in ur bdy like an alarm that t alerts us and prepares us t act ( fight r flight ) Fast heart Fast breathing Tense muscles Sweaty palms/cld hands/ pinpricks n ur skin Anxiety becmes a prblem when ur bdy has physilgic respnse t benign, nn-threatening stimuli OR when the level f physilgic respnse is much greater than the threat TALKING ABOUT ANXIETY MONSTERS Speak in terms f Anxiety Mnsters (r Anxiety Brains) Helps children/teens separate anxiety frm themselves Gives them smething t battle r bss back Physilgical Respnse ( False alarms ) Anxiety mnsters use ur bdy s natural anxiety respnse t cnvince us that what he/she tells us is right Why is anxiety s painful? S we will listen! This is a gd thing, but ur mnster uses it against us. Makes it hard t think clearly, s it is hard t fight r bss the anxiety mnster Avidance ( Mnster fd ) Aviding surce f anxiety is highly reinfrcing Believing the anxiety mnster is what keeps it arund Fr teens: educate n why avidance wrsens anxiety ver time and hw extinctin wrks Hw d we beat it? We take away it s fd (i.e., stp aviding, face yur fears) Fr teens: speak abut facing fears in terms f re-teaching ur bdy hw it shuld behave Allisn Elledge, PhD Regina Hummel, Ph.D. 8

9 BEHAVIORAL METHODS Brief educatin fr parents n hw t help their child manage their anxius bdies may be helpful The case f ppsites If ur false alarms are painful and make it hard t think, we must first turn ff the alarm Oppsite f fast breathing? Slw breathing! Oppsite f tense muscles? Relaxed muscles! Diaphragmatic Breathing Belly Breathing r Balln Breathing Fr yunger children: blwing bubbles, pinwheel, etc Muscle Relaxatin Get flppy Rag dll vs. Barbie/GI Je; Cked vs. raw spaghetti GRADUAL EXPOSURE TO FEARS Cnsider creating a simple fear hierarchy with patient and/r parent Pyramid is like a set f stairs: Easy t get up a stry using the stairs But, if 2 r 3 steps were missing it wuld feel a lt harder It wuld be even harder t just jump frm the first flr t the secnd flr with n stairs! Fear hierarchy lets kids tackle fears in tlerable dses It is essential that children & parents understand hw facing their fear starves the anxiety mnster Feeling uncmfrtable means it s wrking! The mnster is thrwing a fit because yu aren t feeding it BEHAVIOR MANAGEMENT BY PARENTS Children will struggle t remember t use what is discussed when ut in the real wrld. Essential t talk t parents abut Prmpting child t breathe/relax Limiting avidance f feared subject** Limiting gain fr anxius behavirs Including excessive attentin ti Parents may need sme cnvincing it s hard t see yur child in pain & nt swp in t rescue them Children must experience sme discmfrt t vercme the anxiety Facing yur fears a skill-- parents cannt always be there t rescue their child, they must learn hw t (and that they can) tlerate distress Allisn Elledge, PhD Regina Hummel, Ph.D. 9

10 BEHAVIOR MANAGEMENT BY PARENTS Prmpt Gentle verbal prmpts t breathe/relax when anxiety creeps up Setting up calm dwn spts in the hme Reward Set up simple tken ecnmy t reward child using skills and/r facing their fears Set limits n anxiety Discuss active ignring f undesirable behavirs Even anxius nes! Cntinual reassurance nt likely t help and might even cmmunicate that this is a tpic that the child shuld be wrried abut Discuss limiting child s avidance f fears Example a child wanting t leave the park because f fear f pssible strm, d nt leave immediately in respnse t child s fear if n strm in near future TIPS FOR PARENTS It can be hard fr parents t ignre and/r limit a child s avidance Sensitive implementatin f active ignring May include a warning frm parent befre ignring Ex: I knw that yu are wrried abut this, but we are nt ging t discuss it anymre. Then ignre Ignring nly when child nt attempting t use calm dwn skills Ex: It lks like yur anxiety mnster is setting ff a false alarm. I will be happy t help yu with yur belly breathing, just tell me when yu are ready. Then ignre Delay delivery f cnsequence Handing ut cnsequence during an anxiety episde nly likely t escalate anxiety Mre helpful t determine cnsequence after situatin has deescalated Ex: I knw that it made yu nervus when. But, yu hit yur sister because yu were s upset. Because yu hit, yu must. A NOTE ON MEDICATION Large, multi-site, placeb cntrlled studies generally cnclude that cmbinatin SSRI and psychtherapy is superir t either alne -Treatment f Adlescents with Depressin Study -Pediatric Obsessive Cmpulsive Disrder Treatment Study -Child/Adlescent Anxiety Multimdal Study A psychlgist s cncerns with medicatins Medicatins d nt build lng-term skills Smetimes a quick fix can decrease mtivatin fr cntinuing therapy -- therapy is lnger term & hard wrk We have little data n lng-term effects f psychiatric meds given t children Better t try behaviral ptins first? Medicatins shuld be seen as ne part f a larger interventin, nt the main interventin Can be helpful in decreasing anxiety s that behaviral gals can be reached Meds are ideally shrt-term aids t behavir therapy Allisn Elledge, PhD Regina Hummel, Ph.D. 10

11 WHEN TO REFER Has yur initial educatin been helpful? If first-line, basic anxiety educatin was given and has been fllwed, but patient is still struggling -- cnsider referral Is the issue causing interference in patient s daily life? Schl, family, sleep, diet, extracurricular activities Hw capable d yu think the family is t handle the child s anxiety? Hw anxius (and/r frustrated) are the parents themselves? Are they receptive t yur initial educatin? Resurces in ur area fr children are scarce and wait lists are lng never a bad idea t refer early & get a family n a waitlist while yu are mnitring whether r nt first-line educatin (and/r time) is helpful in reslving the prblem CASE EXAMPLES 11 y/ female with general anxiety and vmit phbia 13 y/ female with Crhn s Disease & chking phbia 16 y/ female with chrnic migraines and scial anxiety 5 y/ male with typical weather fears 4 y/ male with nightmares after watching Ztpia Any f yurs? Allisn Elledge, PhD Regina Hummel, Ph.D. 11