Spina Bifida, Anxiety, & Anxiety Disorder SBANT Education Day - - PDF document

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Spina Bifida, Anxiety, & Anxiety Disorder SBANT Education Day - - PDF document

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Spina Bifida, Anxiety, & Anxiety Disorder SBANT Education Day February, 23 2019 Plano Conference Center Richard Adams, MD Professor & Director, Division of Developmental Behavioral Pediatrics, UT Southwestern Medical Center Director,

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Spina Bifida, Anxiety, & Anxiety Disorder

SBANT Education Day

February, 23 2019 Plano Conference Center Richard Adams, MD

Professor & Director, Division of Developmental Behavioral Pediatrics, UT Southwestern Medical Center Director, Pediatric Developmental Disabilities, Texas Scottish Rite Hospital

Mary Dryden, MA

Texas Women’s University, Department of Psychology Licensed Psychological Associate (LPA)

UTSW Division of Developmental Behavioral Pediatrics

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Spina Bifida, Anxiety, & Anxiety Disorder

֎ Let’s be clear: there is “anxiety” and there are “anxiety disorders” ֎ Describe the relationship between anxiety and Spina Bifida ֎ Identify core concepts of intervention ֎ Explain how symptoms of anxiety disorders can go unrecognized in children with Spina Bifida. ֎ Approaches to care

SBANT Education Day February 23, 2019

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Adaptive Skills Self-Concept Family Dynamics Autonomic Regulation

Executive Function

Attention Learning Memory

  • Prob. Solving

Organization Cognition

Language

Vocab. Syntax. Pragmatics Inference Social Skills

Myelomeningocele Bio-Psycho-Social Spectrum

Affect Mood Depression Anxiety

Phonologic

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Vachha B, Adams RC, Rollins NK. Limbic Tract anomalies in pediatric myelomeningocele and Chiari II malformation Vachha B, Adams RC. Myelomeningocele, Temperament Patterns, and Parental Perceptions Vachha B, Adams RC. A temperament for learning: limbic system in myelomeningocele Etc. Etc.

Anatomy & Anxiety / Temperament

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5 Spina Bifida and Anxiety Issues

Anxiety

  • “Future‐oriented emotion”
  • Perceptions of lack of control &
  • Unpredictability over potentially aversive

events

  • Rapid shift of attention to the focus of

potentially “dangerous” events

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Anxiety

“What if I …?” “What if it …?” Escaping Avoiding Flight or fight Heart rate Muscle tension

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7 Spina Bifida and Anxiety Issues

Fear

Fear

Anxiety

Threat is felt to be immediate Threat is felt to be future

  • riented

Physiologic arousal is an alarm Physiologic response is excessive apprehension

  • Part of the bodily response system
  • Essential in focusing on escaping immediate

situations / threats

Worry

  • Involves thoughts / images that cause anxiety
  • Content of concern differs from time to time

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Spina Bifida and Anxiety Issues

Anxiety

Disorder Prevalence Age Generalized anxiety 3-12 % > In adolescents Separation anxiety 4-13 % > In children Specific phobia (dog, crowds, clowns) 3 – 9 % Child=Adolescent Social phobia 1- 6 % > In Adolescents OCD 1 -4 % Child~Adolescent Panic Disorder 4 -5 % > In adolescents Post-traumatic stress disorder 1 – 3 % ???

Chorpita, 2007

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9 Spina Bifida and Anxiety Issues

Generalized Anxiety Disorder

  • A. Excessive anxiety / worry more days than not for at

least 6 months about a number of events or activities

  • B. Sense of lack of control
  • C. 1 or more:
  • Restlessness {Keyed up}
  • Easily fatigued • Sleep Disturbance
  • Difficulty concentrating
  • Irritability
  • Muscle Tension

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Spina Bifida and Anxiety Issues

Anxiety

Disorder Prevalence Age

Generalized anxiety 3-12 % > In adolescents

Separation anxiety 4-13 % > In children Specific phobia (dog, crowds, clowns) 3 – 9 % Child=Adolescent Social phobia 1- 6 % > In Adolescents OCD 1 -4 % Child~Adolescent Panic Disorder 4 -5 % > In adolescents Post-traumatic stress disorder 1 – 3 % ???

Spina Bifida

Chorpita, 2007

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11 Spina Bifida and Anxiety Issues

  • Pervasive Dev

Disorders (PDD)

  • Oppositional Defiant

Disorder

  • ADHD
  • “Normal” anxiety

Differential Diagnoses

  • Other anxiety

disorders

  • Depression *
  • Disruptive Behavior

Disorders

  • Tic Disorders

Co‐Existing Conditions

Spina Bifida – specific. Example: Shunt issues

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Anxiety ‐ ‐ ‐ Why Should We Talk About This?

  • 1. Longitudinal studies: association between anxiety

disorders & educational underachievement

  • 2. Occurrence of Anxiety Disorders precede depressive

disorders / substance abuse disorders

  • 3. Anxiety disorders can be related to difficulties in social and

peer relations which can contribute to feelings of loneliness , low self‐esteem  depression.

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13 Spina Bifida and Anxiety Issues

Anxiety ‐‐‐ “Why”

  • 1. Genetics / Temperament
  • 2. Attachment to Caretakers
  • 3. Parenting Styles
  • 4. Life Experiences

Spina Bifida

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Anxiety ‐‐‐ Genetics / Temperament

“behavioral inhibition” – child’s tendency to approach unfamiliar or new situations with distress, restraint, avoidance” Kagan 1999 * “enduring temperament trait”

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PEDIATRICS PEDIATRICS

  • Vol. 115

“Myelomeningocele, Temperament Patterns, and Parental Perceptions”

Richard Adams, MD Behroze Vachha, PhD

Developmental Disabilities, Texas Scottish Rite Hospital for Children Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas

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  • 1
  • 0.5

0.5 1 Persistence Distractibility M

  • od

Intensity Sensory Reaction A daptibility First Reaction Predictability A ctivity

Temperament in children with SB

*gradual * cautious * often

* rare

* less * p < 0.01

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17 Spina Bifida and Anxiety Issues

Anxiety ‐‐‐ “Why”

  • 1. Genetics / Temperament

2.Attachment to Caretakers

  • 3. Parenting Styles
  • 4. Life Experiences

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Anxiety ‐‐‐ Attachment

Warren et. al Longitudinal Study Follow–up at 12 months & through 17 years High‐risk attachment:

* predicted anxiety disorders in adolescence * in scientific analysis – stronger even than maternal anxiety

  • r infant’s temperament

It’s the dynamic interaction

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Anxiety ‐‐‐ “What can impact (up or down)?” 1.Genetics / Temperament

  • 2. Attachment to Caretakers

3.Parenting Styles

  • 4. Life Experiences

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Anxiety ‐‐‐ Parenting Styles

Parental Control

Siqueland et al

Parents of children with anxiety disorders were rated by independent observers as less granting of autonomy than parents of control children {Study among typically developing children }

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Anxiety --- Parenting Styles

Parental Control Observational studies Parents of anxious children were More involved in directing the child’s moment to moment activities More “intrusive” – answering on their behalf, making decisions for them, etc More negative – fearful of potential harm More likely to agree with and encourage the child’s avoidance

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Anxiety ‐‐‐ “Why”

1. Genetics / Temperament 2. Attachment to Caretakers 3. Parenting Styles

4.Life Experiences {Plus: Spina Bifida‐specific}

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Anxiety ‐‐‐ Life Experiences

Anxiety can be related to exposure to negative life events Research reviewed… supports the conclusion that temperament (style of response to stimuli) attachment issues parental clinical anxiety (diagnosed) parenting styles all play a part in the development of anxiety in children

Bernstein & Layne, 2006; etc

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  • 1
  • 0.5

0.5 1 Persistence Distractibility Mood Intensity Sensory Reaction Adaptibility First Reaction Predictability Activity

Temperament profile in Osteogenesis Imperfecti *gradual * cautious * often

* rare

* less

  • Suskauer. Pediatrics.

* less

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Spina Bifida and Anxiety Issues

Anxiety ‐‐‐ What to do?

  • Exposure
  • Modeling
  • Cognitive‐Behavioral Therapy

In review of over 200 investigations, the protocols that consistently demonstrate strongest results in children / adolescents include these 3 components

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Anxiety  Exposure

Strategy: real or imagined confrontation with a feared stimulus Variations in Approach: Intensity Duration Order of stimuli Relaxation Rewards

> 35 RCT’s Exposure shown effective in reducing childhood fears /anxieties

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Anxiety  Modeling

Strategy: Child’s observation of another person interacting successfully with a feared stimulus Variants: Live Model Symbolic Participant Rewards

Modeling has been shown more effective compared to no treatment

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Anxiety  Cognitive‐ Behavioral Therapy (CBT)

EXPOSURE is a central component in CBT

  • C. B. T.

Thought Behavior Emotion

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Spina Bifida and Anxiety Issues

Summary

What Your Spina Bifida Team Can Do To Help

  • 1. Help identify list of fears { Listen }
  • 2. Education about Anxiety
  • 3. Cognitive processing of fears:

ideas & accuracy; coping; control techniques

  • 4. Practice feared situations {real or imagined}
  • 5. Support over time to help new skills
  • 6. Dev Peds: Medications management if needed