Coping with Big Fears Suneeta Monga, MD, FRCPC Psychiatrist, - - PowerPoint PPT Presentation

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
• r 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
• f 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