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Anxiety Disorders in Children andAdolescents
Sucheta Connolly M.D.
Director, UIC Pediatric Stress and AnxietyDisorders Clinic
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Normal Fears and Worries
Infants: fear of loud noises, strangers
Toddlers: fear of the dark, monsters, separationfrom parents
School-age: physical injury, storms, school
Teenagers: social evaluation and school
performance
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Common Stressors
Divorce
Family move or friend moves away
oss of pet !reak up with girlfriend"#oyfriend
$oor performance at school"test
Death of relative Transition to middle school"high school
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Signs and Symptoms of
Stress and Anxiety in Youth %ecurrent fears and worries
Difficulty falling asleep or nightmares
&ard to rela' Difficulty separating from parents
Scared a#out going to school
Irrita#ility, crying, tantrums (ncomforta#le in social situations at school,
restaurants, parties
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Anxiety Disorders in Children
and Adolescents )ery common: *-+ of youth have at least one
an'iety disorder %uns in families ./enetics and modeling0
1o-occur with 2D&D in children, and depression and
su#stance a#use in teens 1an persist into adulthood
Treatments are availa#le and effective:
1ognitive-#ehavioral therapy and medication
3arly identification and treatment can reduce severityand impairment in social and academic functioning
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Separation Anxiety Disorder
Excessive fear and distress when separated
fro parents!priary care"ivers or hoe
4orry a#out parents5 health and safety
Difficulty sleeping without parents
Difficulty alone in another part of the house
1omplain of stomachaches and headaches
6ay refuse to go to school or playdates
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Generalized Anxiety Disorder
Excessive, chronic worry related to school,
a#in" friends, health and safety of self and
faily, future events, local and world events
2lso has at least one of these symptoms:
motor"muscle tension, fatigue, difficulty sleeping,
irrita#ility, poor concentration
7ften perfectionists
2n'iety may #e significant, #ut not apparent to others
$hysical complaints are common
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GAD: Additional features
3'cessive self-consciousness, fre8uentreassurance-seeking , worry a#outnegative conse8uences
$erfectionistic, e'cessively critical ofthemselves, persistent worries
1ommon somatic complaints: /Idistress, headaches, fre8uent urination,sweating, tremor
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Social ho!ia
"Social Anxiety Disorder# Excessive fear or discofort in social orperforance situations
3'treme fear of negative evaluation #y others
4orry a#out doing something e$arrassin" in
settings such as classrooms, restaurants, sports,
musical or speech performance
Difficulty participating in class, working in groups,
attending gym, using pu#lic rest rooms, eating in
front of others, starting conversations, making new
friends, talking on the phone, having picture taken
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Social ho!ia
1ommonly feared social situations:
$u#lic performances .reading aloud in front ofclass, music"athletic performances0,
7rdinary social situations .starting or joiningconversations, speaking to adults0
7rdering food at restaurants, attending dancesand parties, takings tests, working or playingwith other children, asking teacher for help.!eidel et al9 +0
Diminished social skills, longer speechlatencies, fewer or no friends, limitedactivities, school refusal .!eidel et al9 +0
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Selecti$e %utism
Una$le to spea# in certain situations %school&despite a$le to spea# in other settin"s %hoe&
Difficulty speaking, laughing, reading aloud, singing
aloud in front of people outside the family or their ;safe
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Selecti$e %utism
Transient mutism during transitionalperiods: first month of school or moveto a new home
%elationship #etween S6 and Social
$ho#ia2ssociated features: e'cessive
shyness, fear of social em#arrassment,
social isolation, clinging, compulsivetraits, negativism, temper tantrums,controlling or oppositional #ehavior,particularly at home
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Specific ho!ia
Excessive fear of a particular o$'ect or situation 6ay avoid the feared o#ject or situation
If a fear is severe enough to impair a child5s
functioning, then it is a pho#ia
Coon pho$ias: animals"insects, heights,
storms, water, darkness, #lood, shots, traveling #y
car"#us"plane, elevators, loud noises, costumed
characters, doctor or dentists, vomiting, choking,
catching a disease
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Specific ho!ia
2n'iety may #e e'pressed through crying,
tantrums, free
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anic Disorder
(ecurrent panic attac#s or intense fear:
racing heart, sweating, shaking, difficulty
#reathing, nausea, di
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anic Disorder
Full panic disorder #est documented in
adolescents
$anic attacks in younger children are
usually cued or triggered #y specific
event of stressor, with out-of-#lueattacks rare
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Differentiating the Specific
Childhood Anxiety Disorders+AD and Social pho$ia
4orries of /2D is pervasive, and not limited to
specific o#ject .Specific pho#ia0 or social situations
.Social pho#ia0
/2D an'iety is persistent, Social pho#ia an'iety
dissipates upon avoidance or escape of social
situation
4orries a#out 8uality of relationship with /2Dversus em#arrassment and social evaluation fears
with Social pho#ia
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Differentiating Anxiety
Disorders: Clinical oints 1ued panic attacks can occur with any of the
an'iety disorders in youth, and common among
adolescents
Irrita#ility and angry out#ursts may #e
misunderstood as oppositionality or diso#edience
Tantrums, crying, stomachaches, headaches
common in children with an'iety 1hildren .versus adults0 may not see fear as
unreasona#le
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&!sessi$e Compulsi$e Disorder
$sessions- Scary, $ad, unwanted or upsettin"thou"hts, ipulses, or pictures that #eep
coin" $ac# over and over
3'amples of o#sessions: 2ggressive o#sessions,
contamination, dou#ting, nonsensical thoughts,hoarding"saving, religious, symmetry"e'actness,
violent thoughts"images, thoughts a#out se',
thoughts of death"dying
1hild tries to ignore or suppress the thoughts,impulses, or images
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&!sessi$e Compulsi$e Disorder Copulsions- repetitive $ehaviors or ental acts
%prayin", countin", repeatin" words!nu$ers silently&
that the child feels copelled to do in order to stop
discofort!anxiety of o$sessions
3'amples: 1leaning"washing, checking, counting,
hoarding"collecting, repeating words"num#ers silently,
ordering"arranging, praying, seek reassurance,touching"tapping, ;tell on yourself=, ;just right=
$ersistent o#sessions, compulsions, or #oth that occupy
more than + hour each day
%epetitive and difficult to control
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ostulated 'nfectious(Autoimmune
)tiology $ediatric 2utoimmune >europsychiatric
Disorders 2ssociated with Strep9 ?
$2>D2S $ediatric Infection-Triggered
2utoimmune >europsychiatric
Disorders ? $IT2>Ds
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'nfection "group A !eta*hemolytic strep+#
'mmune ,esponse
"anti!odies produced#
,e$ersi!le "-# .esion of /asal Ganglia
&CD and(or tics
'0ANDs "ANDAS#
athophysiology
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Treatment Planning forChildhood Anxiety Disorders
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Treatment Planning
A"e, severity, ipairent, and coor$idity Mild severity: 1onsider 1!T first
Modsevere: 6edications considered for
acute relief of an'iety, partial response from
other treatment, comor#id disorders that may#enefit from meds and multimodal approach
Severe- 1om#ination intensive treatments
with 1!T and medications may #e necessary 7lder youth, depression, and social
withdrawal often need intensive treatment
Involve child and family in treatment planning
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0reatment lanning Continued
If Parental Anxiety Disorders Present-
Teach parents an'iety reduction skills
1onsider if independent treatment of parental an'iety
disorders needed .meds, therapy0
1onsider additional parental involvement with younger
child
7lder youth - depression, social withdrawal, su#stance
a#use often need intensive focus
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Child*Adolescent Anxiety
%ultimodal Study "CA%S#"Wal1up2 et al+: N )ng 3 %ed2 4556# @** children .A-+Ay0:S2D, /2D, Social $ho#ia +@ sessions of 1!T, sertraline to Bmg"day,
com#ination 1!T and sert, or +B weeks of
place#o9
)ery much or much improved on 1/I-
Improvement scale: *+ com#ination, C
1!T, sertraline, B@ place#o !oth 1!T and sertraline reduced severity of
an'iety in children with an'iety disorders,
com#ination had superior response rate
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CA%S Study
>o increased fre8uency of physical,psychiatric, or harm-related adverse events insertraline vs9 place#o groups
Suicidal or homicidal ideation was uncommon,
no child attempted suicide Eouth with 2D&D were included9 Eouth with
depression or $DD were e'cluded 1om#ination therapy offers #est chance for
positive outcome: consider family preference,cost, treatment availa#ility9
$lace#o for sertraline only group, not forsertraline plus 1!T group9
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C/0 and /eyond
Standard 1!TSocial skills training2ssertiveness skillsSelf-esteem4orking with parents and schools
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thin1
feel
C/0 %odel of Anxiety:
Anxiety7s 0hree Components
1ognitive:
$hysiological:
!ehavioral: do
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Social Phobia
Fears of #eing the focus ofFears of #eing the focus of
attention and em#arrassing selfattention and em#arrassing self
Increased heart rate, shaking,Increased heart rate, shaking,sweating, hyperventilation,sweating, hyperventilation,
di
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CBT Principles for Anxiety.2l#ano Gendall, BB0
Psychoeducation .a#out an'iety and 1!T0 Soatic ana"eent s#ills trainin"
.self-monitor an'iety and learn muscle
rela'ation, diaphragmatic #reathing, imagery0
Co"nitive awareness and restructurin"
.identify and challenge negative thoughts and
e'pectationsH positive self-talkH 0
Exposure ethods.imaginal and livee'posures with gradual desensiti
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0reatment of Anxiety Disorders
in Children and Adolescents $sychoeducation with the child and parents a#out the
illness and principles of 1!T
$arent training to esta#lish daily structure,
e'pectations, positive reinforcement, monitoring of
symptoms and progress
Involve parents in treatment, especially for children
and when parental an'iety present
1onsider independent treatment of an'iety disorders
in parents
1oordinate treatment with school
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C/0 for Anxiety Disorders in
Children and Adolescents 1onsider age and developmental stage of
child
For younger children using positivereinforcement chart and fre8uent rewards for
efforts is very important9 3'posures increase
an'iety and children need motivation to try9
For younger children use of pictures,cartoons, puppets, and toys to supplement
standard 1!T is helpful9
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Establish Target Symptoms
/earn to identify feelin"s in self 0 others.feelings #arometer0
Esta$lish level of distress
.feelings thermometer0
Develop /adder of stiuli or tri""ers.situations, o#jects, cues, sensations0 withinprimary diagnosis
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Cognitive estr!ct!ring
1hallenge >egative Thoughts
1hallenge >egative 3'pectations
$ositive Self-Talk
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Cognitive Distortions
1outh with anxiety disorders- 2ssume #ad things will happen
!iased attention to threatening words and
criticism
Interpret am#iguous situations as threatening
6ore negative self-talk
(nderestimate their strengths
2ssume they cannot handle stressful
situations
1atastrophic thinking: 2ssume the worst
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Cognitive estr!ct!ring" #oals
Identify negative thoughts that predict #adthings will happen- thinking traps
3valuate negative thoughts to determine ifthey make sense
(se realistic positive self-talk to argue withnegative thoughts and #oss them #ack9
%eplace thinking traps with coping thoughts
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Cognitive estr!ct!ring
(se similar strategies to come up with
alternatives to negative thoughts or
misperceptions that result in angry feelings
!oss #ack aggressive urges
$ractice alternatives to assuming someone will
violate you, hurt you, critici
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)8&S9,)S
Imaginal 3'posures
%ole-playsive 3'posures
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Expos!res /raded so child can e'perience success and
#uild confidence .not flooding0
3'plain that discomfort is part of e'posure
!egin with rela'ation e'ercise to start with
an'iety at low level %eview coping strategies
3sta#lish reward system
6ove from easiest to most challenging itemson Fear adder
Therapist should avoid too much reassurance
during e'posure
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#raded $maginal Expos!re 1hild imagines item or situation from Fear
adder"&ierarchy in detail !egin with easy items to more challenging
1hild notes intensity on Fear Thermometer
!ring an'iety to B or #elow #efore ne't item 2sk: Did anything terri#le happen
$raise often9 %eward for efforts successes
Incorporate rela'ation and self-talk learned toreduce an'iety
2djust fre8uency, intensity of sessions #ased
on success
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&ther Applications for )xposures
Imaginal e'posure and role-plays can #e used
for a range of #ehaviors
This may allow child to identify feelings andthoughts that pop out in certain situations that
make them angry, sad, scared
/ives opportunity to practice new coping
strategies and #ehaviors !e sure to praise for just trying e'posures
.imaginary or real0
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0reatment for Social ho!ia and
anic Disorder Successful treatent of Social Pho$ia and Selective
Mutisre8uires 1!T discussed and additional Social
Skills Training
2reatent of Panic Disorder 7ftenre8uires medications .SS%I5s, other antidepressants first-
line0
C32 for treatent of Panic disorderInteroceptive
e'posure9 %ela'ation training, e'periencing physicalsymptoms in sessions, and overcoming sense of
panic"doom9 Decrease avoidance increase control9
Treatment for Selective M!tism
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Treatment for Selective M!tism
6ost children with S6 have Social pho#ia
7ften need 1!T and social skills training
Severity often warrants medication .SS%Is0
6anagement team with parents and teacher monitoring child5s
communication
$ositive reinforcement for attempts on graded e'posure ladder
Steps to speaking outside ;comfort
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C/0 %odifications for S% Team approach with school involved regularly 1onversational visits )er#al intermediary .parent, friend, doll, toy
puppet, recording device0 that makes morecomforta#le in trying to speak"communicate9
Does not speak for child9 $ositive reinforcement fre8uently %einforce for nonver#al as well as ver#al
responses
S6 child can enlist strong negative responsein adults .la#eled as ;refusing to talk=0
$arents and si#lings need to resist desire tospeak for child
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School ef!sal
Can $e variety of fears %separation,Can $e variety of fears %separation,social anxiety, test anxiety&social anxiety, test anxiety&
4orry, tension, increased heart4orry, tension, increased heartrate, sha#in", sweatin"rate, sha#in", sweatin"
5re6uent a$sence, tardiness, tears,5re6uent a$sence, tardiness, tears,
tantrus, soatic coplaints,tantrus, soatic coplaints,
visits to school nursevisits to school nurse
thin1
feel
do
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School ,efusal(School ho!ia This is a #ehavior cluster, not a diagnosis
>eed to consider an'iety disorders and
depression
1onsider S2D, /2D, Social pho#ia
>eed to rule out learning disa#ility that canlead to frustrations, poor performance, low
self-esteem9 Increased risk for an'iety and
depression9 Dysle'ia in young children9
6ore common during transitions to a new
school .pre-school, G/, middle school, high
school0
2ssist parents to reduce secondary gains
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'nter$entions for School ,efusal
%ule out D and language impairments
If depression and an'iety present, 1!T and meds
often needed
2ssist parents and school staff to maintain
patient in school9 2void home-#ound school (se li#rary or other area to calm or complete
work part of day, #uild up in class time
/raded e'posures to school situations
2ctive ignoring of unreasona#le somatic
complaints and reward regular attendance
(se rela'ation and coping strategies to reduce
an'iety at school9 1oaches at school too9
h l f l ( dd
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School ,efusal: Fear()xp .adder !e careful not to start e'posures close to
vacations or holidays Initially work on preparing for going to school
.depending on severity of fears0 with live andimaginal e'posures .driving past school,
walking on school grounds, entering school0 Increasing time at school, not necessarily in
classroom Start with most comforta#le setting"activity in
classroom 4ork up to part of day and eventually full day Set up rewards for each step
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0reatment of Youth ith &CD
6ultimodal 2pproach
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0reatment of Youth ith &CD
1ognitive #ehavioral therapy .1!T0 in
conjunction with medications .SS%I5s0
3'posure and %esponse $revention .3"%$0
Develop fear hierarchy, e'pose to pho#icstimuli and repress rituals or avoidance
Family therapy can help decrease the parents5
involvement in the child5s rituals and reinforcing
#ehavior-#ased interventions
Selective serotonin reuptake inhi#itors .SS%I5s0
and 1lomipramine .T12 and SS%I0 are
effective
/oy ith &CD
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/oy ith &CD
++ year #oy with 71D
Intrusive se'ual thoughts"fears9 Dou#ting: %eassurance seeking ;Is this right
2m I 7G= Fears of upsetting and harmingothers9
(nderwear and pants have to fit ;just right=96other has to take in all waists9 >othing can#e loose fitting
$erfectionism: 3rasing, rewriting drawings,work to make it ;right=9 Takes lots of time9
1annot #e rushed to complete things9 Fears of upsetting /od and others:
apologi
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;o ' ,an &CD &ff %y .and "3+
%arch %D2 %;: %arch %anual#
$sychoeducation with 71D as medical illnessand engage child and family in treatment Define 71D as the pro#lem: nasty nickname
with plans to ;#oss #ack= 71D with therapist
Story a#out 71D in child5s life: over timeauthors 71D out of his"her life
6ap child5s 71D: o#sessions, compulsions,triggers, avoidance #ehaviors, conse8uences
2n'iety management training 3'posure and response prevention .3"%$0
using transition
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C/0 for &CD: Adaptations for
Young Child
71D Story#ook .with farm animals and 71 Flea0 $ositive reinforcement program
%eadjust hierarchy to achieve success with little steps
in e'posures if needed9
For young children can do imaginal e'posures usingpuppets, toys, cartoons to practicing ;#ossing #ack=
71D
1an adopt characteristics from superheroes that help
child to defeat 71D 4atch 71D shrink in si
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&CD )xposure(Fear .adder &olding doorkno# .e'posure0 and not washing
hands .response prevention0 6oving items around in room .30 and not
reorgani
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Social Skills"
Meeting and #reeting %e& People
&aving a conversation: taking turns asking,telling, saying something and listening
%ole-play situations with child or teenager
$ractice with a friend and new children
1oordinate with school staff .lunch group0
Involve parents in sessions in younger child
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Social Skills"
%onverbal Comm!nication Importance of nonver#al communication and
improving conversation skills
$ersonal space
3ye contact
Speaking voice .volume0
Involve parents in sessions for younger child
A ti T i i
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Assertiveness Training
Many anxious children wor# hard to always
please others and avoid conflicts 6ay fear something #ad will happen if they upset
others or just discomfort
6ore likely to #e #ullied
1hild works on identifying own needs and negotiating
these with children and adults
%eview assertiveness strategies, role-play in session,
then carry out e'posures
1an use toys, puppets with young children to practice9
Involve parents in sessions9
(se rela'ation, coping strategies and fear ratings
during role-play
A ti T i i E l
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Assertiveness Training" Example
C y9o9 girl with /2D, S2D, Turner5s small stature9
7ften picked up #y other children and girls fight over her not allowingher to play with other peers9 Sometimes children hold her down9 edto school pho#ia9 She fears other children will #e punished if shetells9
$racticed using loud voice, mean face and posture in session9%ole-play with peers who are pushy and demand her to listen9
$racticed turning on ;drama= when child annoying her and will notaccept no to get teacher5s attention
1oordinated plan with school regarding practicing assertiveness andmonitoring of #ullying #y teacher in classroom and especially atrecess9
$atient has #enefited greatly from 1!T, low dose SS%I9
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Wor1ing ith arents and Schools
Active I"norin"
(ewards
Involvin" Parents in C32 with child4or#in" with Schools
5aily treatent
'orking &ith Parents and
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'orking &ith Parents and
Teachers" Active $gnoring
Active reinforceent of positive $ehaviors
Active i"norin" of unwanted $ehaviorto
e'tinguish .complaining, reassurance-seeking,
crying, whining, somatic complaints0
%ole-play with parents, discuss with teachers
Temporary increase in pro#lem #ehavior, does not
mean they should give in
%educes children depending on adults rather thantrying new coping skills
'orking &ith Parents and
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'orking &ith Parents and
Teachers" e&ards
1hild chooses meaningful rewards Small, ine'pensive, or preferred activity %einforcement after desired #ehavior .trying
not just successes0
Short list of desired #ehaviors .fear ladder0 Su#stitute new #ehaviors as mastered Timely, consistent rewarding 1oordinate reward system #etween home
school $ost in visi#le location at homeH teacher
keeps in desk at school Child learns selfpraise over tie
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$nvolving Parents in Treatment
Parents with anxiety disorders can $enefitfro anxiety ana"eent s#ills!treatent
and can iprove effectiveness of C32 in
child
$arents may #e overprotective, controlling, or
facilitate avoidant responses
$arents included in child5s treatment as
;coaches= to assist child in coping with current
and future an'iety issues
P $ l
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Parent $nvolvement
earn how to handle child5s an'iety earn graduated e'posure and how to use it
6odify view of child as vulnera#le and in need
of protection or control
See child as resilient and capa#le of coping
&elp parent to feel knowledgea#le and skilled
enough to help the child cope with future
challenges Involve all relevant caregivers to increase
consistency of response to an'iety
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Parent (Teacher) $nvolvement
$arents .teachers0 can odel calmness and
pro#lem-solving approaches
Find middle ground: encourage the child toapproach feared situations and give child
control over pace that is tolera#le
/ive prompts, #ut resist need to ;rescue=
Focus on small, positive steps, #uild courage,
competence, and autonomy for child
S h l $ t ti f A i t
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School $nterventions for Anxiety
School personnel who child can meet with
regularly and #e availa#le to help child calm
Discourage leaving school .fever or vomiting0
3ncourage self-monitoring with Feelings
Thermometer 1oping #ag availa#le if needed
%einforce attempts to use rela'ation"coping
skills as well as successful coping Desensiti
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School $nterventions for
St!dents &ith Anxiety
Modified assi"nents Coprehension chec#s
Identify adult at schooloutside classroom who can
meet with child and engage in pro#lem-solving or
an'iety management strategies School staff prompt child to use coping strategies prior
to school triggers .tests, recess, starting assignment0
2estin" in private, 8uiet place to reduce an'iety
Educate teachera#out child5s an'iety and suggeststrategies to facilitate child5s coping .reframe0
1hildren with an'iety disorders might 8ualify for a
Section789 plan or special education if significant
impact on school functioning .handout0
*amily $nterventions
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*amily $nterventions
$arental emotional overinvolvement
$arental criticism and control
Family communication
Impact of child an'iety on parent #ehavior
Integrative models .Dadds %oth, B+0
Interaction #etween attachment and
parent-child learning process,
#ehavioral and temperamental characteristics
of child and parent
1onsider impact on si#lings
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Family 'nter$entions Canicholas BC0
SS,' i Y Child
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SS,'s in Young Children
Start very low in young children and goslow to reduce side effects and increasetolerance to initial and temporary side
effects Fluo'etine li8uid Bmg"ml can start at
9-B9 mg"day Sertraline li8uid Bmg"+ml can start at
B9-mg"day 6onitor for activation, #ehavioral
disinhi#ition along with other side effects
SS,'s for Selecti$e %utism
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SS,'s for Selecti$e %utism +B week place#o- controlled study for Fluo'etine mean dose
of 9Cmg"kg .!lack and (hde, +@0C children, ages C-+@, with S6 and Social $ho#ia
Improved significantly on parent and teacher rating relative
to place#o #ut still with S6 symptoms .with minimal side
effects0
7pen trial of B+ children ages to +@ with S6 supports
Fluo'etine in graduated doses9 AC improved in an'iety and
speech, inversely correlated with age .Dummit et al9, +A0
Sertraline in children with S6 with low side effects, general
#enefits .1arlson et al9, +0 onger trials with more individual dosing needed
&ther Antidepressants
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pTricyclic antidepressants .S2D, Social pho#ia0
1onflicting results e'c 1lomipramine for 71D
Cloipraine.T12 non-selective S%I0 1an augmentat low doses with SS%I9 %e8uires cardiac monitoring,
3G/, #lood levels9 Side effects can #e significant:
sedation, di
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&ther %edications for Anxiety
3uspirone./2D0
>o pu#lished controlled studies92dverse side effects: lightheadedness,
headache, dyspepsia9
&igher peak plasma levels in children vsadolescents9 6ay #e tolerated at -Jmgin teens and -A9mg in children, twicedaily
6ay #e an alternative to SS%Is for /2Din youth9 1ontrolled studies needed9
6ay augment SS%Is9
&ther %edications for Anxiety
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&ther %edications for Anxiety!en
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&ther %edications for Anxiety+uanfacine orClonidine
>o controlled studies for an'iety disorders 1onsider w" SS%I when an'iety w" significant autonomic
arousal and"or restlessness
!aseline 3G/, !$ and pulse monitoring
Severe re#ound hypertension with a#rupt discontinuation
Tourette5s, 2D&D, Trichotillomania, other impulse-control
disorders, !ipolar, $TSD
33loc#ers
1onsider for focused performance an'iety .>o trials in youth0
%edications for Comor!idity
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%edications for Comor!idity
Depression: Impairment, SS%I, monitor suicidal
risk, 1!T .Fluo'etine recommended0 AD=D: First choice stimulants and #eh t'9 If
stimulants e'acer#ate insomnia or an'iety,
2tamo'etine second line, also !uproprion and
)enlafa'ine9 /uanfacine or clonidine .get 3G/0 forhyperactivity" impulsivity and sleep struggles9
Alcohol a$use: 1aution against #en
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0reatment of 0SD: %edicationsN Treat significant depression and anxiety
N SS$+s "Antidepressants#
For anxiety2 depression2 core symptoms
N #!anfacine or Clonidine
For hyperarousal2 impulsi$ity2 startleN Antipsychotics "such as ,isperidone#
For dissociation2 !rief psychosis2 se$ere
aggression"monitor A'%S or D'SC9S2 glucose2 eight#
N Meds can red!ce severity of symptoms so
child can engage in therapy and expos!res
% di ti f C !id
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%edications for Comor!id
Autism Spectrum Disorders
1onsider SS%I5s when o#sessive features,
perseveration, rituals, an'iety, depression,
irrita#ility prominent
/uanfacine or 1lonidine may assist with
impulsivity, e'plosiveness, restlessness
7ther meds such as antipsychotics and mood
sta#ili
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Case )xample: %ary
/2D, Depession, $hysical
Trauma
Case )xample: %ary
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Case )xample: %ary +C y9o9 4F with recent #ack surgery due to lum#ar fracture that
did not heal, chronic /2D9
6ajor depression since surgery with high irrita#ility, decreased
appetite, sleep distur#ance, anhedonia, hopelessness
/2D never identified #efore with perfectionism regarding
grades, sports, cannot rela', very goal-focused, over
organi
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y
2gitated depression acutely increasing over B weeks
and emerging suicidal ideation: Started Loloft and
increased over one month to +mg
Initiated rela'ation with deep #reathing and imagery
with 6ary and father
!etween sessions received a call from mother 6ary
not practicing rela'ation and more irrita#le with mother
Session: /2D severe9 6ary feels she is failing therapy
homework and mother does not understand an'iety
Discussed chronic communication issues #etween
6ary and mother who does not have an'iety #ut is veryorgani
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%ary:lan /2D severity now more apparent9 6ary afraid to
rela' for even a moment9 $raise 6ary for identifying her an'iety symptoms and
frustrations with mother
Slow down pace of 1!T rela'ation module and"or
e'amine thoughts first Take time to focus 6ary5s understanding of her severe
/2D and impact of #ack pro#lems, /2D, decreased
social life on her functioning over several years
4ork on communication #etween mother and 6ary,and pursue further family treatment
1ontinue medication until ma'imi
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%ary: ;ighlights
1onsider severity in starting with 1!T or 1!T
and meds
$ace of 1!T depends on what patient can
tolerate: emphasi
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Case )xample: Clarence
/2D, S2D, Social $ho#ia
2D&D, DSocial skills deficit
Case )xample: Clarence "history# * year old #oy with 2D&D referred for severe ;sleep
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* year old #oy with 2D&D, referred for severe sleep
an'iety= and meets criteria for /2D, S2D, Social $ho#ia,
71D traits9
2n'iety #ecame significant after ro##ery of family property Byears ago: credit cards stolen9 Some $TSD features9
Father travels often with jo#9 Father with possi#le 71D
traits, low frustration tolerance for Thomas9 Thomas overly
dependent on mother9
2n'iety at night sometimes makes it hard to even sleep well
in mother5s room .no one resting in family0
2D&D, severe and D impacting academic and social at
school .irritating to other children0
2n'iety limits social activities: fearful of #eing away frommother, assertiveness skills and social skills poor .#ullied #y
students at school0
)xample: Clarence "0reatment#
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)xample: Clarence "0reatment#
2D&D com#ined type interfered with 1!T9 %e8uired
numerous med trials responded to com#ination ofStrattera, 2dderall .M% and regular0 and /uanfacine
.appetite suppression, increased irrita#ility, increased
an'iety on various 2D&D meds0
)arious SS%I5s tried: tended to get hyperarousal,irrita#le on several with good results on 1ele'a9
$ositive reinforcement chart set up with clear rewards
and conse8uences9
4orked on power struggles and active ignoring9 3sta#lished team with mother, school, and therapist9
)xample: Clarence "0reatment#
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)xample: Clarence "0reatment# %ela'ation: deep #reathing, muscle rela'ation, and
imagery .light #lue, #each scene0 $ositive self-talk: fears other children think he is
stupid, do not want him as a friend, want him to feel#ad9
Fears of ro##ers #reaking into house at night and
killing him and family9 2ny sounds would trigger this9&ow likely 4hat else could sounds #e Safety ofcommunity 2lternative thoughts
Sytematic desensiti
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C e ce " e e #
Social skills training and assertiveness training to
address response to #ullying along with coordinationwith school to monitor9
earning meeting and greeting, how to treat play date,
tolerating small frustrations with peers
Ignoring ver#al #ullying, responding with humor,monitoring reactions on face and #ody to potential
#ullies9 /etting help from adults when needed9
Family treatment to address need for acceptance
from father9 4ork on gaining competence versusdependence on mother9
>ew social and interpersonal challenges of
adolescence
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Clarence: ;ighlights
Treat predominant or most impairing
symptoms first: comor#idity
isten to family5s major concerns: ;sleepan'iety=
1onsider social functioning as an important
outcome
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Case example: 3immy
Selective 6utism
Social 2n'iety Disorder
)xpanding Safety zone
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p g y From clinic to school
K Select transition agent.s0 - parent,therapist, si#s, even classroom teacher
K Select strategies
K Select se8uence of e'posures From home to school
K Select transition agent.s0 - parent, si#s,
classmates, teacher
K Select strategies
K Select se8uence of e'posures
=> Stages in Speech )mergence in
S h l "l #
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School "least to most#
19 1unningham5s workH adapted #y Genny,Fung, 6endlowit Stages in Speech )mergence
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=> Stages in Speech )mergence
in School "cont7d#*: Speaks to one peer w" normal volume
: Speaks softly or whispers to several peers
+: Speaks in normal voice to several peers++: Speaks softly or whispers to teacher
+B: Speaks in normal voice to teacher
+J: >7%62 S$331& I> S1&77
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Case example: 3immy
@ +"B yo male, living with parents,#ilingual Spanish-3nglish
>ormal pregnancy, development Shy temperament: S6 since age B9 1omor#idities: Social $ho#ia, Speech
2rticulation disorder Family history of: /2D, Social $ho#ia,
Depression, 2lcohol 2#use, Speechtherapy in father
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3immy "cont7d#
%egular pre-school
Stage +-B for speech emergence
2ccepted #y a few classmates, afraid ofteacher
School felt he would ;grow out of it=
Conversational ,isits
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Peopleto visit .family, neigh#or, friend0 2ies of dayto visit .#efore school, recess,
lunch, after school, evening0
Places to visit.private setting to classroom0
2ypes of activitiesto stimulate speech
.games from home, computer, art, reading0
6ake a ta#le of a#ove and rate the amount ofcomforta#le speaking encouraged #y each
activity
3immy * )xpanding Safety ?one
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from ;ome to Clinic 1!T approach, adapted for young child
$ositive sticker chart
6edication
P 1!T emphasis on #ehavioral .due to young age0 with
some use of superhero themes
P 2n'iety shrunk as super Qimmy grew strongerP (sed play, drawings, and nature walks as medium of
engagement
P Deep #reathing, #each imagery, petting stuffed animal,
sound of shell to help with rela'ation
P %ewarded regularly, often for his efforts at home and in
session9 %ewarded for practicing and success with
e'posures9
3immy* )xpanding Safety ?one to
Cli i C ti d
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Clinic Continued $t relieved that an'iety had a name and that he could
con8uer it .worry monster- #ig green #lo#09 2ttacked itin drawings on dry-erase #oard and puppet play
Individual to parallel play to cooperative play $arents, #rother, cousin in session
Descri#ed aloud Qimmy5s activities during play Initiated Loloft li8uid at mg and eventually up to
Jmg with significant improvement in nonver#alcommunication, initiating social interactions,
whispering, and then speaking 4orked on eye contact, volume of speech, greetingskills, assertiveness skills9 2ngry e'pression hardest9
$racticed social skills with visits to office ;neigh#ors=in the clinic
3immy* )xpanding Safety ?one
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3immy )xpanding Safety ?one
to School
%eviewed various school environments for#est ;fit=9 Decided to change schools #ased onstructured social opportunities availa#le
$sychoeducation with school team and parents
Set up #rief, fre8uent play dates at home with
peers from school with parents utili
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School Continued
First: parent and Qimmy visit schoolplayground
Then, parent and Q visited classroom alone Then, parent and Q visited with cousin in
classroom Then parent, Q, cousin, and teacher $t talking to cousin in classroom 3ventually speaking with teacher and
classmates 1urrently: Stage +J
>ew focus: Initiating social interactions incrowded places
3i ;i hli h
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3immy: ;ighlights
$sychoeducation for parents and educators very
important
Treating parental an'iety and assisting with
reactions of relatives, parents5 frustrations (tili
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,)S&9,C)S AND,)F),)NC)S
1linician
$arent1hild
+
eferences for Parents -Teachers H l i Y A i Child (R
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Helping Your Anxious Child (Rapee,
Wignall, Spence, Cobham, 2008)
e!s "o #aren"ing Your Anxious Child
($anassis, 2008)
%reeing Your Child &rom Anxie"!
(Chans'!, 200) %reeing Your Child &rom C*
(Chans'!, 200+)
Helping Your Child i"h Selec"i-e$u"ism ($cHolm e" al, 200.)
When Children Re&use School/ #aren"
Wor'boo' (earne! Albano, 2001)++
,eferences for Children 4h t T D 4h E 4 T 6 h
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+++
4hat To Do 4hen Eou 4orry Too 6uch.&ue#ner, B0
2 !oy and a !ear: The 1hildren5s %ela'ation!ook .ori ite, +C0
!link, !link, 1lop, 1lop: 4hy Do 4e DoThings 4e 1anRt Stop 2n 71D Story#ook
.6orit< Qa#lonsky, B+0
Talking !ack to 71D .Qohn 6arch, BC0 For children, teens and parents 4hat To Do 4hen Eour !rain /ets Stuck: 2
Gid5s /uide to 71D .&ue#ner, BA0
,esources for Adolescents
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++B
My Anxious Mind- A 2een;s +uide toMana"in" Anxiety and Panic %2op#ins 0Martine:, >88?&
(idin" the 4ave 4or#$oo# %Pincus,
Ehrenreich 0 Spie"el, >88@& foradolescents with panic disorder
Anxiety Disorders %Connolly, Sipson 0
Petty, >887& for iddle 0 hi"h schoolstudents to help the understand anxietydisorders and reduce sti"a with storiesand drawin"s fro youth with anxiety.
eferences for Clinicians
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2reatin" Anxious Children and Adolescents
%(apee, 4i"nall, =udson0 Schnierin", >888&
Co"nitive 3ehavioral 2herapy with Children-A +uide for the Counity Practitioner%Manassis, >88?&
Master of Anxiety and Panic for Adolescents(idin" the 4ave, 2herapist +uide %Pincus,Ehrenreich, Mattis %>88@&
Practice Paraeter for the Assessent and2reatent of Children and Adolescents withAnxiety Disorders %AACAP >88B&
++J
CBT Anxiety Therapy Man!als
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Coping Cat.$hillip Gendall0
and CAT %for adolescents&
How I Ran OCD Off My Land .Qohn 6arch0
Meeky Mouse Therapy Manual: CBT
rogra! for "ele#ti$e Mutis!.D9 Fung, 29
Genny S9 6endlowit
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reschool C/0 %anual for 0SD
2vaila#le from Dr9 6ichael Scheeringa
mscheertulane9edu
6anual authors: 69 Scheeringa 6D,
Q9 1ohen 6D and 9 2maya-Qackson 6D
++
,)S&9,C)S>ational 1hild Traumatic Stress >etwork
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>ational 1hild Traumatic Stress >etwork
www9musc9edu"tfc#tH www9nctsnet9org2merican 2cademy of 1hild 2dolescent$sychiatry .2212$0 www9aacap9org2n'iety Disorders 2ssociation of 2merica
.2D220 www9adaa9orgS6 /roup- 1hild 2n'iety >etworkwww9selectivemutism9org2ssociation for !ehavioral and 1ognitive
Therapies www9a#ct9org7#sessive 1ompulsive Foundation
www9ocfoundation9org!oston (niversity an'iety clinic
www9childan'iety9net ++C
%&,) ,)S&9,C)S
http://www.musc.edu/tfcbthttp://www.nctsnet.org/http://www.aacap.org/http://www.adaa.org/http://www.selectivemutism.org/http://www.abct.org/http://www.ocfoundation.org/http://www.childanxiety.net/http://www.childanxiety.net/http://www.ocfoundation.org/http://www.abct.org/http://www.selectivemutism.org/http://www.adaa.org/http://www.aacap.org/http://www.nctsnet.org/http://www.musc.edu/tfcbt -
8/9/2019 anxiety_disorders_in_children_and_adolescents.ppt
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%&,) ,)S&9,C)S
www9chadd9org for adhd in children and
adults
www9#pkids9org for 1hild and adolescent
#ipolar foundation
4e#site for $6D1 at (I1 .pediatric mood
disorders clinic0 and %2I>!74 program
through www9uic9eduat J+B"C-AABJ ocfoundation
http://www.uic.edu/http://www.uic.edu/