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Coping with ‘Big Fears’
Suneeta Monga, MD, FRCPC
Psychiatrist, Anxiety Disorders Clinic, Hospital for Sick Children
Assistant Professor of Psychiatry, University of Toronto
Helping Kids Cope with Anxiety and Depression April 5th, 2014
LEARNING OBJECTIVES:
1. Recognize anxiety disorders in children and adolescents.
2. Understand the role of “talk therapy” in the treatment of
child and adolescent anxiety disorders.
3. Appreciate the role of medications in the treatment of youth anxiety disorders.
WHAT IS AN ANXIETY DISORDER?
Anxiety disorders are common, treatable medical conditions that affect one in eight children
They are the most common psychiatric disorder in children and adolescents
Anxiety disorders are characterized by persistent, irrational and overwhelming worry, fear and anxiety that interferes with daily activities
They are real disorders that affect how the brain functions
STRESS VERSUS ANXIETY DISORDER Stress does not cause an Anxiety Disorder!
Some anxiety can actually be beneficial!
Anxiety is a normal part of childhood and every child goes through phases of ‘normative anxiety’
e.g. fear of the dark, fear of monsters Definition of an Anxiety Disorder is when anxiety
causes interference in day to day functioning
Increased recognition and awareness of childhood anxiety in the past 10 years
WHAT CAUSES AN ANXIETY DISORDER ?
GENETICS
TEMPERAMENT Behavioral inhibition
ANXIETY DISORDER
Significant interference in daily functioning
Inability to get to school
Inability to make friends
Inability to speak at school
Inability to demonstrate knowledge at school
Combination of biological and environment factors similar to allergies and diabetes
MODELING
STRESS
RECOGNIZING ANXIETY IN YOUNG CHILDREN Shy, quiet, hesitant
Difficulty trying new things Perfectionistic
Preference for routine or predictability Difficulty with change
Somatic Complaints Headaches, stomachaches
Inflexible, rigid, things have to be” just so”
Poor, picky eaters
RECOGNIZING THE ANXIOUS CHILD AT HOME
Temper tantrums / behavioural difficulties
Moody, irritable Easily ‘fly off’ the handle
Difficulty with sleep Can’t fall asleep, nightmares
Sensitivity (emotional or
sensory) Can be highly sensitive to
criticism Easily moved to tears
BLURRED LINES
The distinction between normative anxiety and an anxiety disorder is a “grey area”
How much distress does your child have compared with his/her peers?
Check in with teachers – do they have concerns socially or academically?
Ensure there is no bullying, learning issues, or other home / school stressors
Think about family history – is there a strong family history for anxiety or mood disorders?
HELPFUL STRATEGIES FOR ALL ANXIOUS CHILDREN Recognize feelings and label anxiety symptoms
Avoid avoidance using gentle but firm reassurance and encouragement
Facilitate structure and routine
Identify conflicts within the home and work on them
Positive Reframing / Modeling effective coping
Facilitate socialization – e.g. play dates
Reward attempts and approximations and complement process not product
Set the expectation for speech for quiet, anxious children – e.g. “even shy children have a voice”
ASSESSMENT OF ANXIETY DISORDERS
Full assessment by a mental health professional is required to provide a diagnosis
Core elements of the assessment typically include:
Speaking with the family together and then with child alone and parents alone
Process of an assessment looks at: Is this normative anxiety?
What is driving the anxiety?
Is the anxiety primary or other issues causing the anxiety?
Are there other psychiatric disorders present?
TYPES OF ANXIETY DISORDERS:
1. Specific Phobias - fear of specific objects
2. Separation Anxiety Disorder - worry about separation
3. Generalized Anxiety Disorder - “worry warts”
4. Social Anxiety Disorder - worry about embarrassment or humiliation
5. Selective Mutism - anxiety prevents child from speaking
6. Panic Attacks & Panic Disorder - overwhelming anxiety ‘out of the blue’
7. Obsessive Compulsive Disorder - repetitive worry and ritualistic behavior to prevent the worry
SCHOOL REFUSAL
Not a clinical diagnosis
Can be related to a variety of issues, and not necessarily related to a psychiatric disorder
Need an understanding of why the child is missing school in order to come up with a management plan
Bullying or other peer problems Learning issues/challenges (LD?) Stressors in child’s life/family Parenting problems Teacher-Child difficulties (poor fit) Psychiatric disorder – often
anxiety but could be any anxiety disorder
EXTERNAL DRIVERS OF ANXIETY
Learning Issues
Speech Language Issues
Parental/Family Issues eg., Divorce
These, issues need to be Identified and Treated
Social Issues eg., Autism
Exacerbate Anxiety
Anxiety Exacerbates these Issues
Treatment using standard Anxiety Management is
not Beneficial
EXAMPLES OF NORMATIVE ANXIETY: 1.Child is anxious about parents who are arguing a lot
Parental education about effect of constant arguing Marital therapy may be of benefit.
2.Child is anxious about parents dying after loss of grandparent/relative
May be normative part of grief reaction and likely won’t need intervention unless extreme or sustained
3.Child is anxious about bullying that is occurring Speak to school about addressing bullying issue
TREATMENT PLAN An accurate diagnosis and understanding of patient and
family drives the treatment plan Biological / psychological / social perspectives considered
in developing treatment plan taking into consideration the circumstances, needs and wishes of patient and their family
Often a three-step treatment plan is utilized: 1. Psycho-education to youth and family about anxiety
disorders 2. Talk Therapy – most commonly Cognitive Behavioural
Therapy 3. Use of Medications
PSYCHOEDUCATION:
Usually begins at the assessment
Everyone need to be on the same page Parents and families need to “Avoid Avoidance” and
facilitate coping
Parents and families need to model effective coping
Helpful books to read include: Keys to Parenting Your Anxious Child by Katharina Manassis
Raising Your Spirited Child by Mary Sheedy Kurcinka
What to Do When You Worry Too Much: A Kid’s Guide to Overcoming Anxiety by Dawn Huebner
COGNITIVE BEHAVIORAL THERAPY (CBT)
A type of talk therapy that addresses the connection between our feelings, thoughts and behaviors
Teaches children to recognize and identify their feeling states
Teaches children various relaxation strategies
Teaches children simple cognitive strategies Identifying their worry thought and determining how realistic, or
appropriate it is
Helping children utilize more adaptive or “BRAVE” thoughts
At Sick Kids – we offer a specific variety of CBT programs for anxious children and their parents
USE OF MEDICATIONS
Although CBT is effective for most mild to moderate cases of childhood anxiety disorders occasionally medications are required for more severe cases of anxiety
Use of antidepressant medications such as the Serotonin Selective Re-uptake Inhibitors (SSRIs) A large research study (CAAMS) found that the combination of
CBT and medications worked better in children aged 7 to 17 than either treatment alone