2/9/2016. Anxiety. Early Intervention for childhood Mental Health issues. ANXIETY DISORDERS in Children and Adolescents.

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1 ANXIETY DISORDERS in Children and Adolescents. Joy Lauerer DNP PMHCNS BC Discussion Points Anxiety Early Intervention for childhood Mental Health issues Why? Important to long term health outcomes! What happens when no intervention? 1

2 Review of Anxiety Disorders Case 1- Matt, OCD,trichotillomania Case 2 Casey, bullying,anxiety substance use Diagnosis Evidence based treatment Family Support Anxiety Most common symptom, affects almost all at some point over life Prevalence in childhood 10-20% More girls than boys Age varies - panic disorder mid teen years Genetic, biological disorder, stressors, diet,caffeine, sleep In children can be development Anxiety Children and adolescents with anxiety are at much greater risk for increased risk of anxiety and depression in adulthood Importance of early intervention Build resilience and coping skill! Mindfulness practices, early introduction of resilience practices 2

3 The numbers are growing- 1 in 4 children experience some form of trauma trauma often presents with anxiety or worry Greater numbers of families struggling financially Families with more stress Technology? TYPES OF ANXIETY DISORDERS GENERALIZED ANXIETY DISORDER PANIC DISORDER OBSESSIVE COMPULSIVE DISORDER SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA) POST-TRAUMATIC STRESS DISORDER SPECIFIC PHOBIAS Remember to tease out other important differential diagnosis Trauma ADHD ODD Substance use Depression Family dynamics 3

4 Screening-Anxiety Review physical health, family history Somatic symptoms are common Mental Health assessment severity and impairment Child s temperament Questions -parents and child Review for any trauma Scared Tool - one for child and one for parent GAD -7 adolescents Questions from SCARED tool When I feel frightened, it is hard to breathe I don t like to be with people I don t know well. I get scared if I sleep away from home. I worry about other people liking me. Common Symptoms Restlessness Social withdrawal Persistent worries about school,peers Poor sleep Somatic complaints Fears Restlessness Difficulty with concentration 4

5 Coping mechanisms Ego defense mechanisms When anxiety increases we use coping mechanisms to try and relieve it Children don t often have well developed coping mechanisms- opportunities to increase positive coping skills Ego focused coping- protect feelings GENERALIZED ANXIETY DISORDER Characterized by constant, chronic, unfounded worry every day, possibly all day Physical symptoms Muscle tension Fatigue Restlessness Difficulty sleeping Irritability Edginess Gastrointestinal discomfort or diarrhea PANIC DISORDER Frequent spontaneous panic attacks- pre teen or teen Live in fear of having another attack Can result in agoraphobia-fear of public places; in this case due to fear of having an attack in these places 5

OBSESSIVE COMPULSIVE DISORDER Characterized by: Obsessions-unwanted intrusive thoughts Compulsions-ritualistic, repetitive behaviors/routines aimed at reducing anxiety Matt age 7 OCD with hair

6 OBSESSIVE COMPULSIVE DISORDER Characterized by: Obsessions-unwanted intrusive thoughts Compulsions-ritualistic, repetitive behaviors/routines aimed at reducing anxiety Matt age 7 OCD with hair pulling Matt age 6 Anxiety and Comorbidities- The lego obsession ODD no, not going to do it! Anxiety at school, poor social skills No hx of trauma Began hair pulling- lost all hair Excellent parent Meds & Therapy 6

7 SOCIAL ANXIETY DISORDER Extreme fear of being scrutinized or judged by others in social or performance situations Few or no social/romantic relationships Fear based thinking Bullying risk frequently presents in adolescents. The issue of school refusal & anxiety Options Slippery slope? How realistic is it for children to not learn too adjust to being with others? Home alone online School changes / adjustments Bullying Still major issue The case of Casey Suicide is often related to bullying Cyber bullying and after school site Fear, devastating to self esteem- suicidal ideation often develops No tolerance Encourage early reporting 7

8 POST-TRAUMATIC STRESS DISORDER Occurs following a traumatic event Characterized by flashbacks of the event, emotional numbness, avoidance of anything associated with the trauma, and heightened arousal Symptoms must persist for one month following the event for a PTSD diagnosis Can have a delayed onset months or years after event. Trauma PTSD Increase in PTSD over the last 20 years as culture has become more violent. Many clients who come for TX have preexisting trauma. Sometimes not previously disclosed or at conscious awareness. Trauma can manifest as physical symptom. Without treatment clients suffer for years with psychiatric symptoms. PTSD in children Trauma much more common Must ask carefully Brain is believed to have changed following trauma. Must use bottom up reorganization to help children- Teach how to re- experience the body as safe, regulate emotional states, organize experience. 8

9 PTSD continued Talking isn t the most affective intervention Trust,establish safety, EMDR neuro-feedback, somatic releasing, dance, Turn the experience into smaller part of self-have some sense of how to manage triggers and periods of activation. Van Der Kolk s work : Change in Brain left /right causes memory to store deactivation in left hemisphere causes loss of parts of experience. When something reminds traumatized person of experience their right brain acts as if it was happening now. Activate alarm system. Sooner or later most clients come up with what they call there cover story offers some explanation for public conversation. PTG- post traumatic growth PTG How resilience can be fostered to help patients recover, grow in spite of trauma. A new person can emerge with new awareness, meaning, grace. Support systems,corrective experiences,coping skills. 9

10 SPECIFIC PHOBIAS Irrational, debilitating fear of something in particular Avoidance behavior Spiders,dark Can help child develop sense of mastery TREATMENT Medication-FDA approved SSRI s, ( Fluoxetine, Sertraline, nonbenzo s Psychotherapy- Cognitive Behavioral Therapy is the most popular for these disorders- The importance of therapy! Cognitive-restructuring thought patterns that propagate anxiety- self soothing. Behavioral- changing the behavioral responses to anxiety-provoking situations. Non traditional breath, meditation, yoga Coping Cat Coping Cats is a CBT based program to teach children how to identify symptoms of anxiety, methods to cope, ways to challenge fearful thinking Have at least 2 therapists you feel comfortable with to refer children with anxiety. Ask for progress reports! 10

11 Nursing Care With obsessional ritualistic behavior allow for some behavior. ( female client 5min in shower). SSRI monitoring Anxiety? PTSD PET, CBT, EMDR Education Parent, family support PTSD treatment Slow, first must re- organize self and ego Trauma is pre verbal- without words- When engaged in trusting relationship begin to disclose trauma. Bessel Van Der Kolk MD - pioneer Symptom management,realize repetitive behaviors,make connections between internal states and actions emotional regulation skills. Numbing, hyper stimulation. Body regulation skills. ( yoga, EMDR, somatic regulation. Nursing Interventions Safety what will help? Modify environment decrease stimulation. Breathing Encourage activity if helpful. When anxiety has reduced can then work on insight and coping. Psycho- education. Insight, move clients away from fear based thinking. 11

12 Questions 12

Loud noises, loss of support, heights, strangers, separation (in the present) Animals, the dark, storms, imaginary creatures, anticipatory anxiety

Loud noises, loss of support, heights, strangers, separation (in the present) Animals, the dark, storms, imaginary creatures, anticipatory anxiety Anxiety is normal, adaptive, and protective Anxiety varies in intensity from person to person High levels of anxiety are problematic Lowering the volume, not changing the station Developmental Stage Infancy