Agenda. Nothing to Fear but Fear Itself*: How to Talk to Kids about Anxiety

Transcription

1 1 Nothing to Fear but Fear Itself*: How to Talk to Kids about Anxiety Dr. Joelle Beecher McGovern Child & Adolescent OCD, Tics, Trich, & Anxiety Group (COTTAGe) University of Pennsylvania, School of Medicine *FDR 2 Agenda Function of anxiety Cycle of maladaptive anxiety Changing anxious patterns Cognitions Emotional and physiological arousal Behavior: Exposure Motivation Support Throughout: Practical suggestions based on developmental levels 3 Normal Developmental Fears Transitory fears and anxieties are part of normal development: First years of life fears of loud noises, strangers, new places, heights preschool age fears of being alone, dark, animals, imaginary creatures school age fears of negative evaluation by others, illness/bodily injury, supernatural phenomena, natural disasters

2 4 When do More? Factors to Consider Typical Development? Frequency and Intensity Interference 5 Anxiety Disorders in Youth What are the different anxiety disorders? Separation Anxiety Disorder Social Anxiety Disorder (Social Phobia) Selective Mutism Generalized Anxiety Disorder (GAD) Specific (Simple) Phobia Panic Disorder Obsessive-Compulsive Disorder (OCD) Posttraumatic Stress Disorder (PTSD) Complicated Greif What do they have in common? Intense/out of proportion anxiety resulting in distress and/or functional impairment 6 Function of Anxiety Anxiety keeps you safe & helps you focus on what is important (REAL ALARM): Car is coming, stay out of road, stay safe Want to do well academically, study, pass Want to make a good impression, follow social norms, have friends Too little anxiety (NO ALARM) Play in road, hit by car, not safe Don t care, don t study, fail test Who cares, violate social norms, limited or no friends Too much anxiety (FALSE ALARM) Don t go out of the house b/c might get hit by car, safe (maybe) but no life Stuck on one question or so worried can t concentrate, fail test Care too much, inadvertently violate social norms, limited or no friends

3 7 The Cycle of Anxiety Nothing learned, still afraid COGNITIVE Automatic negative thoughts: Anxious interpretations Repetitive distressing thoughts Prediction of feared outcomes TEMPORARY RELIEF Distress subsides Temporarily EMOTIONAL & PHYSIOLOGICAL AROUSAL Anxiety, discomfort, fear, disgust Heart racing, can t breathe, stomach ache, etc BEHAVIORAL Escape/Avoidance of feared situation/outcomes Negative Reinforcement: Distress stays in long run 8 The Vicious Cycle of Avoidance A N X I E T Y Avoid Avoid Avoid But anxiety stays high long-term Avoidance temporarily relieves anxiety TIME 9 Changing Anxious Patterns COGNITIVE Automatic negative thoughts False Alarm: Alternative thoughts, Thought truth, boss back positive influence on future cognitions, which will positively affect feelings/arousal, resulting in confidence to approach again EMOTIONAL & PHYSIOLOGICAL AROUSAL Anxiety, discomfort, fear, disgust physiological sensations It s okay to feel anxious Good, my body is working, relaxation HABITUATION Anxiety increases temporarily but decreases over time Learning, feeling of mastery BEHAVIORAL Utilize cognitive and relaxation strategies to help approach & remain in feared situations

4 10 THE OUTCOME OF REPEATED EXPOSURE A N X I E T Y Begin Exposure PANIC PEAK TIME MASTERY OF ANXIETY MASTERY OF ANXIETY Copyright 2000 Aureen P. Wagner, PhD 11 A Simplified Theoretical Approach Blah, blah, blah, do the thing you re afraid of, Blah, blah, blah, the more you do it, the easier it gets. Gwen Franklin, age 6, to her father, Helping Kids Identify & Deal with Anxiety : The Process Connecting thoughts, feelings, and behavior as well as identifying and challenging cognitions and behavioral response to anxiety Storytelling Imaginary play Experiential exercise Child becomes the master Game play Books Movies, TV shows, & youtube clips Dialogue Apps Support team

5 13 Cognitions Younger Red /Green Thoughts (Insert) Trick or truth? How likely, examples Immediate effects Externalize anxiety Metaphor Older Anxious/Alternate (Generate) Accurate? Helpful? Probability overestimation Big picture Externalize anixiety Metaphor support adults: validate how real it feels Use caution with cognition work when diagnosis is OCD 14 Externalizing Anxiety Mary was a beautiful Native American girl, but she had a problem, she worried a lot. She named her worry thoughts the goblin because these thoughts made her feel scared all of the time. The goblin thoughts told her to hold on to her mom when she is out, or else a kidnapper might get her; to be afraid of costumed people, clowns, loud noises and fireworks; and to worry about being taken by a kidnapper from her home. 15 Emotional and Physiological Arousal Acceptance of feeling & automatic thoughts Ignore and boss back? Feeling anxious problems Inability to sit with discomfort = problems Physiological: My body is working

6 16 Creative Ways to Learn About Cognitions & Feelings 17 Behavior: How to Encourage Exposure to Feared Thoughts & Situations Support adults got your back? Join and nudge scaffolding Build on success and interest Keep an eye on the larger picture Make it a group effort Do one thing everyday that scares you. - Eleanor Roosevelt 18 Behavior: Connect & Approach via Hierarchy Cougar Costume Looking at cartoon picture 3 Looking at real picture 5 In room costume in closed box 7 In room costume in open box 9 (top shelf, side of desk, on my chair, next to me) Looking at costume in box 10 Touch costume in box 10 Hold costume in hands 10 Wear costume 10 Store Sit in cart, mom stands next to cart and holds my hand (now holds hand or clothes) 5 Walking even in stores with a cart hold mom s hand 7 Hold the cart, not mom 8 Walk next to mom 9 Walk in front of the cart 10

7 19 Working with Exposure Practices: Developmental Considerations Younger : Greater support/directive Age-appropriate language & metaphors Emphasis on behavior More goal-setting & rewards Fun but not too distracting Positive pairing Older: More independence More realistic discussion of risk and values Thoughts plus behavior Big picture rewards More head on Stack the deck Breathing and PMR: helps one pause & stay 20 Exposure to Fear Cues: A Fundamental Truism for Managing Anxiety Across Ages Facing anxiety provoking situations should be: Voluntary Collaborative Emphasis on managing, not avoiding anxiety Hierarchy-driven Designed to promote mastery of anxiety Build on accomplishments, don t dwell on failures 21 Creative Writing Exposure The Cougar looked big and mean He was a scary fiend He bared his teeth and his evil eyes And told Mary he would eat her, like pies Mary, Mary didn t worry Mary, Mary didn t scurry Mary looked that Lion in the eyes and said you can t eat me like pies You can t scare me; you are nothing but a person inside a costume see?!

8 22 Game Exposure: Mother may I 23 Motivation: Tap an Interest 24 What is anxiety taking away? Dr. Seuss I'll stay here, not budging! I can and I will If it makes you and me and the whole world stand still!" Well... Of course the world didn't stand still. The world grew. In a couple of years, the new highway came through And they built it right over those two stubborn Zax And left them there, standing un-budged in their tracks.

9 25 Self Talk: Questions What am I going to take back when I face my fear? What can I think to help me face my fear? What can I do to help me face my fear? What can my team do to help me face my fear? What will happen to my anxiety when I face fears? 26 Self talk: Answers I am willing to tolerate the discomfort because False alarm? Helpful? Accurate? What else? Avoidance strengthens fear, exposure weakens it Anxiety can t last forever My family, school, therapist will help me I can let anxiety chatter in the background Use frustration to motivate to approach 27 Once I was at the rides and I heard a noise and I kept hearing the noise and I started to get used to it. When I first heard the noise, the goblin thought said, it s scary, you should leave. But I said, No way. I don t want to miss out on the rides. I stayed and the goblin thought was hungry, but I didn t feed it. The goblin thought got so weak and it shrunk. I was happy the rest of the night. Soon I didn t even notice the noise anymore and just had fun.

10 28 Mary realized a few things that day: If I am scared, I can face my fear and get closer and closer to what I am scared of until my body gets used to it and doesn t feel scared anymore. My mind makes me think that things are scarier than they really are. Once I really get close to them they are not scary anymore and can be lots of fun! Scary feelings go away as long as I face them. Scary feelings stay if I do not face them and instead avoid things that scare me. It is easier to make friends if I am not scared and crying. 29 Rewarding Efforts Goals: Enhance motivation, address co-morbid problems Internal and external Selecting a reward Concrete and/or social What gets rewarded? Effort, not results Clearly defined behaviors How often? 30 Support Team: Building Alliances Child Anxiety/Avoid Child Anxiety/Avoid Family Not helpful n Not helpful Family School School Child Family School Helpful Anxiety/A voidance

11 What NOT to do: Excessive accommodation Inconsistency across support Excessive reassurance Discord within support Avoidance Lack of communication Punishing anxiety Surprise or forced interventions Being the anxiety police Forgetting child s strengths

12 34 What TO do: Strategies that Help Team effort Join, join, join! Positive: did you catch that? Verbal, non-verbal, get out of the way? Planned vs. unplanned exposures, set up for success Model and approach together Hostage negotiator response model Reduce criticism, promote positive problem solving Reduce accommodation, tolerate child s distress Help child own his/her success 35 Look What I Did! How Great am I? 36 You gain strength, courage, and confidence by every experience in which you really stop to look fear in the face. - Eleanor Roosevelt

13 37 CTSA Child/Adolescent OCD, Tic, Trich, & Anxiety Group (COTTAGe) Our staff has expertise in the treatment of anxiety and related disorders, including: Obsessive-Compulsive Disorder Social Anxiety Disorder Trichotillomania Generalized Anxiety Disorder Tic Disorders Separation Anxiety Disorder Panic Disorder/Agoraphobia Specific Phobias Post Traumatic Stress Disorder We offer Clinical Services: Comprehensive diagnostic evaluations Empirically-supported treatments for youth Research studies on childhood OCD, Tic Disorders, and Trichotillomania Additional Services: Parent Workshops Teacher Workshops School Consultations Clinician Training 38 Contact Us Child & Adolescent OCD, Tic, Trich & Anxiety Group (COTTAGe) Visit us online at: To refer a patient or to schedule an appointment, please call: Thanks to the New Jersey Center for Tourette Syndrome and Associated Disorders (NJCTS) for providing the Wednesday Webinar Series 39 Resources Child and Adolescent OCD, Tic, Trich & Anxiety Group, Philadelphia, PA 19104, Phone: Child and Adolescent Anxiety Disorders Clinic, Temple University (Dr. Philip Kendall), The Anxiety & OCD Treatment Center of Philadelphia,

14 40 Camp Cope-A-Lot: The Coping Cat CD Rom A 12-session computer-assisted CBT for child anxiety 41 Books on Anxiety for Parents & Teachers K. Manassis. Keys to Parenting Your Anxious Child. T. Chansky. Freeing Your Child From Anxiety. Freeing your Child from Obsessive Compulsive Disorer, Freeing your Child from Negativity R. Rapee, S. Spence, V. Cobham, & A. Wignall. Helping Your Anxious Child. J. Dacey & L. Fiore. Your Anxious Child: How Parents and Teachers Can Relieve Anxiety in Children. Aureen Pinto Wagner. Worried No More: Help and Hope for Anxious Children. 42 Books on Anxiety for Parents & Teachers Rapee, Spence, Cobham, Wignall. Helping your Anxious Child: A Step-by-Step Guide for Parents. Kervatt. The Silence Within: A Teacher/Parent Guide to Working with Selectively Mute and Shy Children. Garber, Garber, & Spizman. Monsters Under the Bed and Other Childhood Fears: Helping your Child Overcome Anxieties, Fears, and Phobias. Wilens. Straight Talk about Psychiatric Medications for Kids. Frankel & Wetmore. Good Friends are Hard to Find: Help your Child Find, Make, and Keep Friends.

15 43 Books for Children Danneberg. First Day Jitters. Henkes. Wemberly Worried. Marcus, Marcus, & Jesche. Scary Night Visitors: A Story for Children with Bedtime Fears. Cain & Smith-Moore. I Don t Know Why I Guess I m Shy: A Story About Taming Imaginary Fears. Marcus, Marcus, & Jesche. Into the Great Forest: A Story for Children Away from Parents for the First Time. Melanie Watt. Scardey Squirrel Series. 44 Books for Children Dutro & Boyle. Night Light: A Story for Children Afraid of the Dark. Schaefer & Friedman. Cat s Got Your Tongue? A Story for Children Afraid to Speak. Wagner (OCD). Up and Down the Worry Hill. Hesser (OCD young adult). Kissing Doorknobs. Kant, J. D., with Martin E. Franklin & Linda Wasmer Andrews (2008). The Thought that Counts: A Firsthand Account of One Teenager s Experience with Obsessive- Compulsive Disorder. 45 Internet Resources Anxiety Disorders Association of America: Obsessive Compulsive Foundation: Trichotillomania Learning Center: National Tourette s Syndrome Association: Children's Center for Anxiety: Find a Therapist: