Download When is it more than *Just a Phase*?

Anxiety, when is it more than
“Just a Phase”?
Ruth E. Imershein, MD RMOP
US Embassy Lima
Anxiety
A state of being uneasy,
apprehensive, or worried about
what may happen; concern about
a possible future event
In psychiatry, anxiety is an abnormal state, characterized by feeling powerless and
unable to cope with threatening events, typically imaginary, and by physical tension,
as shown by such symptoms as:
sweating
trembling or shaking
palpitations or racing heart rate
feeling dizzy or unsteady
difficulty breathing or the sensation of shortness of breath
fear of losing control or going crazy
Facts
• About 13 out of every 100 children and
adolescents ages 9 to 17 experiencing
some kind of anxiety disorder
• Anxiety disorders affect more than
emotional health -- they are also
associated with many physical illnesses
• If anxiety in children is not detected and
treated early enough, other problems
may develop.
More Facts
• Anxiety disorders frequently co-occur with depressive
disorders or substance abuse.
• Most people with one anxiety disorder also have
another anxiety disorder.
• Many anxiety disorders experienced by adults actually
start in childhood
• Nearly three-quarters of those with an anxiety disorder
will have their first episode by age 21.5
Why?
• A person's genetics,
biochemistry,
environment, history, and
psychological profile all
seem to contribute to the
development of anxiety
disorders.
• Most people with these
disorders seem to have a
biological vulnerability to
stress, making them more
susceptible to
environmental stimuli
than the rest of the
population.
Common Anxiety Disorders in Children
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School Refusal
Generalized Anxiety
Fears and Phobias
Obsessive Compulsive Disorder
Trichotillomania
Selective Mutism
Social Phobia
Acute Stress Disorder
Post Traumatic Stress Disorder
Separation issues or School Avoidance
• Separation difficulties are a normal, healthy part
of a child’s development
• Separation can be difficult if a child is young,
immature or bashful
• If a child has separation difficulties,
he/she may cry, throw a tantrum,
cling to the parent, refuse to enter
the school
• Even though these reactions might
be extreme, they are normal
Common Explanations
• My baby’s too young…a child’s reluctance to attend
school may be a reflection of a parent’s reluctance to
let the child leave.
• My child’s stubborn…is refusing to go to school just
one of many things your child won’t do? If so, then
your child may be difficult or oppositional, not anxious.
• My child doesn’t like school…applies to most
teenagers, but not most young children.
• My child’s too anxious…does the child become anxious
at other time or display distress whenever parents
leave or when left alone in the bedroom at night?
• My child is embarrassed
to go to school…poor
school performance often
contributes to poor
attendance. Children
want to avoid being
teased.
• My child hates school and
claims to have no
friends…shyness or
underlying behavior
problems should be
addressed.
• My child is sick many
mornings…physical
symptoms may be a
manifestation of anxiety,
but a though examination
is in order to determine if
there is a chronic illness.
• My child is too tired…lack
of sleep may be due to
late bedtimes, but
children also should be
checked for physical
illnesses.
What can a parent do?
• Make sure that your child goes to school every day
• Determine the cause of the school avoidance
• If your child is scared, try to make things at school
more familiar
• Decrease separation anxieties for both you and your
child
• Try to eliminate the source of fear (the teasing,
bullying, abuse, etc.)
• Make going to school easier and more fun than staying
home
• Seek professional help
Generalized Anxiety
• My child
– worries too much
– has always been a worrier
– worries about everything, including things that
are beyond his control
– is always nervous and tense
– has frequent headaches, stomachaches,
trouble sleeping
– is constantly seeking reassurance
– is overly sensitive to correction or criticism
– is easily fatigued, irritable, overwhelmed
What to do if it is GAD
– Psychological treatments
• Behavior Therapy
• Cognitive Therapy
• Relaxation Therapy
– Pharmacological treatments
– Clarify normal vs excessive worries
– Establish a stable, predictable support base
– Don’t overprotect your child
– Don’t tease or ridicule your child
If it isn’t Generalized Anxiety Disorder,
then what could it be?
• Normal Childhood
Worries
• Stress Induced Anxiety
• Medical Disorders
• Panic Disorder
• Obsessive Compulsive
Disorder
• Other Anxiety Disorders
Mr. Worry
Fears and Phobias
• Researchers have found certain fears are natural and
arise at specific ages in all children, and these fears
tend to disappear naturally as the child grows older.
• Children may develop fears from a traumatic
experience (e.g. traumatic dog attack), but for some
children, there is no clear precipitating event
• Some children become fearful simply by watching
another child acting scared
• Children's fears are often associated with avoidance,
discomfort, and physical complaints, such as rapid
heart rate, gi distress, sweaty palms, or trembling.
Which fears are normal at what age?
• Most children, when asked, are able to report
having several fears at any given age.
• Some research shows that 90% of children
between the ages of 2-14 have at least one
specific fear.
• If your child’s fear is not interfering with his/her
daily life (e.g., sleep, school performance, social
activities) , or your family’s life, then most likely
your child does not need professional help.
Common fears at specific ages
• INFANTS/TODDLERS (ages 0-2 years) loud
noises, strangers, separation from parents,
large objects
• PRESCHOOLERS (3-6 years) imaginary figures
(e.g., ghosts, monsters, supernatural beings),
the dark, noises, sleeping alone, thunder,
floods
• SCHOOL AGED CHILDREN/ADOLESCENTS (7-16
years) more realistic fears (e.g., physical injury,
health, school performance, death,
thunderstorms, earthquakes, floods.)
Helping a Child Outgrow Fears
• Recognize whether the fears are within
normal range or excessive
• Be sympathetic to the child, not the fear
• Talk about nightmares
• Help confront fears – fears often decrease and sometimes
disappear completely simply when confronted
• Help overcome fears - No more Monsters in the Closet by Dr.
Jeffrey Brown OR What to Do When You're Scared and Worried by James Crist
and/or seek professional help
Phobias
• When children’s fears
persist beyond the age
when they are
appropriate, are
irrational and
excessive and begin to
interfere with their
daily functioning, they
are called phobias.
10 Most Common Phobias
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Acrophobia – fear of heights
Claustrophobia – fear of enclosed spaces
Nyctophobia – fear of dark places
Ophidiophobia - fear of snakes
Arachnophobia – fear of spiders
Trypanophobia - fear of injections
Astraphobia – fear of thunder and lightening
Nosophobia – fear of having a disease
Mysophobia or Germophobia – fear of
germs/contamination
• Triskaidekaphobia – fear of the number 13
Obsessive Compulsive Disorder
• Essential features
– Recurrent obsessions (persistent intrusive
thoughts, impulses or images that are
inappropriate)
– Recurrent compulsions (repeated rituals or
behaviors)
– These are experienced as either time consuming
and / or cause marked anxiety, distress or
significant interference with daily functioning.
– The person attempts to suppress or ignore these
thoughts, impulses, images or behaviors without
success
Does a child have OCD?
• Is the child troubled by excessive worries, particularly about dirt, germs or
other dangers?
• Does the child repeat the same questions over and over again? Or
constantly seek reassurance?
• Does the child seem to have difficulty concentrating?
• Is the child washing excessively? Taking extra showers, longer showers,
changing clothing more frequently?
• Does the child “check” repeated? Reread, erase and rewrite homework
assignments?
• Does the child have to repeat things a certain number of times or until
they are “just right”?
• Does the child arrange things in a certain order or become upset if
something is moved or misplaced?
• Do the symptoms bother the child – make him or her anxious or upset?
• Do the worries or behaviors interfere with relationships and/or activities
at home or school?
Treatments for OCD
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Behavior therapy with exposure
Cognitive therapy and thought blocking
Medications
Parental interventions to assist with professional
treatment
– Recognize the behaviors as symptoms of OCD
– Provide support for the child but don’t come involved
in the rituals
– Use distraction to decrease symptoms
– Help your child to avoid “avoiding”
Trichotillomania
• It can be a habit or a symptom of Obsessive
Compulsive Disorder
• Compulsive hair pulling
– The child feels an overwhelming urge to pull
which increases in intensity until the hair is pulled
– If the child tries to resist the urge, then anxiety
increases
– When the “right” hair is pulled, the child
experiences a sense of relief
Selective Mutism
• Definition - a consistent failure to speak in specific
social situations in which there is an expectation for
speaking.
• Children with selective mutism have the ability to
both speak and understand language, but fail to use
this ability in some situations.
• Selective mutism is not a communications disorder
and is not part of a developmental disorder.
• Most children with selective mutism also have other
anxiety disorders
Does a Child have Selective Mutism?
• Does the child consistently fail to speak in certain
situation such as in the classroom or in front of
strangers?
• Does the child’s lack of speech interfere with
educational achievements and social
relationships?
• Has the child been mute for at least one months
not including the first month of school?
• Does the child speak normally in at least one
setting, such as at home with family?
• What is the child’s primary language?
Selective Mutism
• The extent to which a child speaks varies greatly
• Punishment or withholding of privileges for not
speaking and communicating effectively in social
settings is inappropriate.
• Treatment should focus on reducing anxieties,
becoming more comfortable and ‘unlearning’ the
silent behavior
• With early diagnosis and the right treatment , the
prognosis is good
Treatment focus for Selective Mutism
• Not on getting a child to speak, but rather
• On decreasing anxiety and teaching coping skills to use
when confronted with anxious situations and should
• Include approaches that gradually desensitize. and
• Use multiple modalities combining, but not be limited
to
– cognitive-behavioral therapy,
– family therapy, play therapy, and school-based and
community-based behavioral interventions
– medications
Social Phobia or Social Anxiety
Disorder
• Diagnosed when people become overwhelmingly anxious and excessively
self-conscious in everyday social situations.
• Children and adults with social phobia have an intense, persistent, and
chronic fear of being watched and judged by others and of doing things
that will embarrass them.
• They can worry for days or weeks before a dreaded situation.
• This fear may become so severe that it interferes with work, school, and
other ordinary activities, and can make it hard to make and keep friends.
• Because these children do not usually display behavioral problems, their
problems tend to go undetected by parents and teachers.
• Earlier onset of the disorder typically means a more severe and chronic
course .
• Untreated this continues to be a lifelong problem. Most adults with social
anxiety disorder indicate that it began in childhood, usually in elementary
school
Age Related Symptoms
• Presentation is related to a child’s age
• If your child is a pre-schooler, some symptoms
to watch for are:
– fear or lack of interest in new things
– cries, whines or appears irritable
– freezes up or clings to parent
– shy around new people
– refuses to participate or speak
School-Aged Children with Social Anxiety
Disorder
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Not always but often…
Don’t read aloud or answer questions in class
Don’t start or join a conversation
Don’t write on the blackboard
Don’t’ speak to adults
Don’t participate in music or athletic performances or after-school activities
Don’t order food in a restaurant
Don’t attend birthday parties
Don’t invite friends over to play
Don’t sit with others at lunch
Don’t want to play with others at recess
Don’t seem able to stop worrying excessively about being evaluated or judged
Don’t like school
Don’t feel comfortable being the center of attention
Don’t speak clearly but rather mumble and avoid eye contact
Teenagers with Social Anxiety Disorder
• Display some or all of the aforementioned plus
• Watch for the following additional symptoms
specific to the teenage years:
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skips school and/or uses drugs or alcohol
fears performance situations such as public speaking
difficulties dating or problems with a job
fear of using public restrooms
fear of signing name in public
Treatment for Social Anxiety Disorder
• Professional help
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Cognitive Behavior therapy
Exposure therapy
Social skills training
Cognitive Restructuring – positive thinking with thought blocking
Symptom Management Skill training to reduce stress and symptoms of
anxiety
• Medications – usually antidepressants
• Parental support
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Recognize “shyness” as social anxiety disorder
Encourage trying new social situations
Don’t ridicule or tease
Seek therapy early
Resources
• Anxiety Disorders Association of America http://www.adaa.org/
• The American Academy of Child and Adolescent Psychiatry –
Facts for Families (http://aacap.org)
• Madison Institute of Medicine – booklets on Social Anxiety,
Panic Disorder, OCD in Children, Depression, Trichotillomania,
etc http://www.miminc.org/
• The OC Foundation - http://www.ocfoundation.org/
More Resources - books
• Is It Just a Phase? by Susan Swedo and
Henrietta Leonard
• What to do when you are scared or worried by
James Crist
• The Boy Who Couldn’t Stop Washing by Judith
Rapaport
• The Boy Who Finally Stopped Washing by
James B
More Resources – online ordering
• Magination Press – self help books for kids and
adults by the American Psychological Association
http://www.apa.org/pubs/magination/
• ChildsWork/ChildsPlay – resources for parents,
teachers and professionals:
http://childswork.com/
• Courage to Change – more resources available
online: http://couragetochange.com/