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