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 5 th , 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 ? Combination of biological and environment factors similar to allergies and diabetes MODELING GENETICS ANXIETY DISORDER  Significant interference in daily functioning TEMPERAMENT  Inability to get to school Behavioral inhibition  Inability to make friends  Inability to speak at school STRESS  Inability to demonstrate knowledge at school

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 Exacerbate Anxiety  Social Issues eg., Autism  Parental/Family Issues eg., Divorce Anxiety Exacerbates these Issues Treatment using standard These, issues need to be Anxiety Management is Identified and Treated 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