Download Treatment of Young Children with Separation Anxiety

Growing Up Brave: Expert Strategies for
Helping Your Child Overcome Fear, Stress
and Anxiety
Donna B. Pincus, Ph.D.
Director and Associate Professor
Child and Adolescent Fear and Anxiety Treatment
Program, Center for Anxiety and Related Disorders at
Boston University
Goals for Presentation
1) Why is my child so anxious? Background re: the causes of
anxiety in childhood and its disorders
2) How do I know if a child needs treatment? Key assessment
strategies for identifying anxiety at home and in schools
3) How are children treated? State of the art cognitive behavioral
treatment strategies
4) What are some key techniques that parents and teachers can
use to support an anxious child?
5) Where can we refer children for help?
Center for Anxiety and Related Disorders
at Boston University 617-353-9610
Center for Anxiety and Related Disorders:
Child and Adolescent Program
• Boston University’s Center for Anxiety and Related Disorders
Child Program--150 intake assessments per year; children and
adolescents aged 4-17
• Most children seen at CARD have primary diagnosis of anxiety
or depression
• Children generally seen for 8-16 sessions of cognitivebehavioral skills-focused therapy
• Parent training component to treatment
• Children assessed at pre and post-treatment to determine their
progress
CONTACT INFORMATION
• CENTER FOR ANXIETY: Child and Adult
Programs: (617) 353-9610
• Websites that contain resources for parents and
professionals:
• WWW.CHILDANXIETY.NET
– WWW.BU.EDU/ANXIETY
– WWW.GROWINGUPBRAVE.COM
Part I: Nature of Anxiety in
Children and Adolescents
Images of Fear and Anxiety
Images of Fear and Anxiety
Our fascination with the emotion of
fear…
Our fascination with fear, con’t
Images of Bravery
Portraits of Two Children:
“Zack”, age 10
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phobia of dark, began age 6
crying at bedtime, anxious
bright lights, needs TV left on
checking door locks and under the
bed
frightened “calling out” to parents
nighttime “battles” with parents
sharing bed with siblings, parents
staying up late hours, tired
fears of dark even during daytime
ashamed of fear of dark
“Emily”, third grader
• Had bad day at school
• Friend broke her favorite art
project
• Worried about math test tomorrow
• Afraid that her mother won’t let
her watch her favorite show,
“Rugrats” after school
• Gets frightened when she watches
scary movies on tv
Normal Fear and Anxiety
or an Anxiety Disorder?
• For most children and adolescents, fear and
anxiety are experienced without great
interference in everyday life
• Natural emotion; enjoyable emotion for
many children (e.g., scary movies, stories)
• For some children, fears persist and become
interfering in daily functioning or in family
functioning and disrupt normal development
Fear, Phobia, and Anxiety
• Fear--natural human emotion; intrinsic to
development; a response to a perceived
environmental threat involving behavioral
avoidance, cognitive distress, and
physiological arousal.
• Phobias--exaggerated fears or fears that are more
persistent and disturbing and result in maladaptive,
avoidant behavior
• Anxiety--distinguished from fear “apprehension without
apparent cause”, “future oriented” emotion
Children’s Fears: Normative Data
Infants & toddlers:
loud noises, strangers, separation
from parents, large objects
Preschoolers:
more global, imaginary stimuli, (e.g.,
ghosts, monsters, other supernatural
beings, the dark, noises, sleeping
alone)
Older children:
more realistic fears (e.g., physical
injury, health, school performance,
death)
--related to cognitive development
--predictable developmental sequence (concrete to abstract)
--When asked, children will readily identify multiple fears
--4.6 fears per child (Jersild & Holmes, 1976)
--90% of normal children between ages 2-14 have at least one specific
fear
Etiology
• Biological Factors--biologically “prepared” to be
fearful at early age, adaptive, emerge at different
points in development
• Environmental Factors--inadvertent reinforcement from
siblings, parents
• General and Specific Vulnerabilities--e.g., behaviorally
inhibited temperament, early experiences with low levels
of control over environment
Children’s Fears, Anxieties, and Phobias
Clinical fears (phobias) occur in 4-8% of the
population of latency aged children.
• CHARACTERISTIC FEATURE OF PHOBIC
DISORDERS:
– presence of excessive anxiety which leads to avoidance
of a feared object, event, or situation (phobic stimuli)
and the experience of extreme levels of fear and anxiety
when confronted with the perceived threat
• Children’s fears are usually mild, transitory, can
be adaptive, and are very common and normal
• HOWEVER, some children experience fears that
persist, interfere with daily functioning, and are
not age appropriate.
When these fears become excessive, persistent, and
cause psychological distress, and are not
associated with an actual threat, they suggest a
clinical level of fear and warrant treatment
Gender Differences in
Children’s Fears
•Are fears more prevalent in boys or girls?
•Fears more prevalent in girls than boys
–May be due to “report bias” : girls more willing to
admit their fears and anxieties
–Parents may label behaviors of girls as more fearful
–May be genuine gender differences in frequency of
fears and anxieties
Adult’s Phobias vs. Children’s Phobias
• Typically, the same criteria are used to classify
phobic disorders in adults and children
• Just like adults, children can develop phobias to an
endless array of situations, objects and events
• Relatively little is known about the motoric,
cognitive, and physiological aspects of children’s
fears when compared to adults
Family Factors Associated with
Child/Adolescent Anxiety
Numerous familial variables linked to
children’s anxiety disorders
• Parental history of anxiety disorder
• Sibling anxiety
• Parenting styles:
excessive reassurance, overprotection, aversive parentchild interactions, high levels of parental control and
low levels of warmth, less psychological autonomy
granting, negative parent-child interactions
Becoming a Scientist Practitioner:
Assessing Childhood Fear and Anxiety
• Obtain pre and post-treatment measures
(and possibly mid-treatment measures)
• Determine level of interference and distress
symptoms have for child and adult
• Look at concordance between parent and child
reports; mother and father reports
• Impact of child symptoms on parenting behaviors
• Family factors contributing to the maintenance of
childhood anxiety
Assessment Methods for Internalizing
Disorders--Children and Adolescents
• Clinical Interviews--most commonly used
– Structured format (increased reliability)
• ADIS-R (Anxiety Disorders Interview Schedule for
Children)
• Kiddie SADS--Schedule for Affective Disorders and
Schizophrenia for School Aged Children
• DICA--Diagnostic Interview for Children and Adolescents
– Unstructured format
• Three “system” approach
• thoughts, physical symptoms, avoidance behaviors
Self-Report Measures
• Fear Survey Schedule for Children (FSSC-R)
• Multidimensional Anxiety Scale for Children (MASC)
• Children’s Depression Inventory (CDI)
• Revised Children’s Manifest Anxiety Scale (RCMAS)
• Child Behavior Checklist, Internalizing Scale (CBCL)
• K-SADS
• Parenting Stress Index (PSI)
• Weekly Record of Anxiety and Depression (WRAD)
“20-20” Video Presentation:
Childhood Panic
• Lindsay, age 8
• Diagnosis of Separation Anxiety Disorder
• Panic Attacks occur in contexts of separation
situations
• Distress to parents who feel “trapped” by her fears
• Cognitive behavioral treatment duration=12 weeks
Anxiety Disorders: Children and
Adolescents
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Separation Anxiety Disorder
Specific Phobias
Social Anxiety Disorder
Generalized Anxiety Disorder
Panic Disorder and Agoraphobia
Obsessive Compulsive Disorder
Post Traumatic Stress Disorder
School Refusal, Test Anxiety
Clinical Presentation of Anxiety Disorders
• Separation Anxiety Disorder
– Persistent fear of separation from a caregiver
– Repeated physiological complaints such as stomach
distress, headache
– Typically diagnosed in childhood
– Excessive distress when separation occurs or is anticipated
– Reluctance or refusal to go to school
– Repeated nightmares involving the theme of separation
– Reluctance to be alone or be dropped off at activities
without parent
– Worry about harm befalling self or caregiver or major
attachment figure
Specific Phobia
• Marked and persistent fear that is excessive or
unreasonable
• Exposure to the phobic stimulus almost invariably
provokes and immediate anxiety response, which
may provoke a situationally bound panic attack
• In children, anxiety may be expressed by crying,
tantrums, freezing, or clinging
• Person recognizes that fear is excessive (in
children this feature may be absent)
Social Phobia
• Marked and persistent fear of one or more social or
performance situations in which the person is exposed to
unfamiliar people or to possible scrutiny by others
• In children, there must be evidence of the capacity for age
appropriate social relationships with familiar people, and
the anxiety must occur in peer settings as well as with
interactions with adults
• Exposure to feared situations provokes anxiety, which
may result in a panic attack.
• Children may not recognize the fear to be excessive
Panic Disorder
• Recurrent Panic Attacks
– Discrete period of intense fear or discomfort in which four or
more of the following symptoms develop abruptly and reach
a peak within 10 minutes
• Palpitations, sweating, trembling, shaking, shortness of
breath, feeling of choking, chest pain or discomfort,
nausea or abdominal distress, feeling dizzy, unsteady,
lightheaded, or faint, feelings of unreality, fear of losing
control or going crazy, fear of dying, chills or hot flushes
– At least one month or more of persistent concern about
having additional panic attacks; worry about the implications
of the attack (e.g., losing control, having a heart attack, going
crazy; occur out of the blue)
Panic Disorder with
Agoraphobia
• Anxiety about being in places or situations from which
escape might be difficult or embarrassing in the event
of having an unexpected panic attack
• Common agoraphobic fears in teens: being at school,
standing in line, being in a crowd, being on a bridge,
traveling in a bus, train, or car, going to a dance, etc.
• These situations are avoided or else are endured by
marked distress or with anxiety about having a panic
attack or panic like symptoms; patients often want a
companion near for help
PANIC DISORDER AND
AGORAPHOBIA IN ADOLECENCE
CLINICAL FEATURES
SITUATIONS AVOIDED
accelerated heart rate
nausea
hot/cold flashes
shaking
shortness of breath
difficulties breathing
depressed mood
classrooms
restaurants
crowds
small and large rooms
elevators
parks
trains
movie theatres
*Adolescents report symptoms that are extremely distressing and commonly
interfering in their social, academic, and family functioning.
Generalized Anxiety
Disorder
• Excessive anxiety and worry occurring more days than
not for at least 6 months, about a number of events or
activities
• Person finds it difficult to control the worry
• Worry may be associated with restlessness, being
fatigued, irritability, sleep disturbance
• The worry causes clinically significant distress or
impairment in functioning
• More than one domain
Obsessive-Compulsive Disorder
• Either obsessions or compulsions
– recurrent and persistent thoughts, impulses or images that
are intrusive and cause marked anxiety or distress
– Person attempts to suppress such thoughts, or to neutralize
them with a thought or action (compulsion)
– Compulsions are repetitive behaviors (hand washing,
ordering, checking, praying, counting) that a person feels
driven to perform in response to an obsession
– These obsessions and compulsions cause marked distress
and are time consuming (take more than 1 hour per day)
Post-traumatic Stress Disorder
• Person has been exposed to traumatic event; outside the realm
of typical human experience; the person’s response involved
fear, helplessness, or horror
• In children, this may be expressed by disorganized or agitated
behavior
• The traumatic event is re-experienced, through thoughts or
dreams, the patient avoids cues of the trauma, and the patient
shows symptoms of increased arousal (difficulty falling asleep,
irritability, hypervigilance, exaggerated startle response)
ACUTE, CHRONIC, DELAYED ONSET (less than 3 months,
more, or 6)
Selective Mutism
• Consistent failure to speak in social situations
where there is an expectation of speaking
• The disturbance interferes in educational or
occupational achievement or with social
communication
• Failure to speak is not due to lack of knowledge
of language
School Refusal, Test Anxiety
• Can be due to many factors; not separate clinical
diagnoses
• School refusal may be due to panic disorder or
social phobia, or to specific phobia of school
• Test anxiety may be due to generalized anxiety
disorder, specific phobia of tests, panic disorder
• All are conceptualized through good careful
assessment
Cognitive Behavioral Treatment for
Child/Adolescent Anxiety: Long Term
Treatment Goals
• Reduce overall frequency and intensity of the
anxiety response (or depressive symptoms) so
daily functioning is not impaired
• Increase the positive activities that reinforce the
child’s strengths
• Decrease maladaptive behaviors/thinking
• Help child learn new ways of coping with
stressful situations and negative emotions
Three Component Model of Fear and
Anxiety
• Teach child about “breaking down anxiety”
• ANXIETY=
– What you “feel”
– What you “think”
– What you “do”
– Treatment addresses each of these components
– Anxious thought: If I talk to them, they might not
like me
Coming Next… Assessing and Treating
Children with Anxiety Disorders:
Usable Techniques that Work!
“Good Morning America” Video
Presentation: Childhood Panic
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“Lindsay”, age 16
Diagnosis of Panic Disorder with Agoraphobia
Panic Attacks occur in range of situations
Distress to parents who feel “trapped” by her fears
Cognitive behavioral treatment duration=8 days
Treatment Techniques Used with Children and
Adolescents
• Cognitive Therapy Techniques - teaching ways that thoughts
affect feelings and behaviors. Teach common cognitive errors
as well as new ways to think about situations “detective
training”
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Anxious thought
• Write down anxious thought, evidence for and against thought,
and new positive coping thought
Challenges to Utilizing Cognitive
Restructuring with Children and
Adolescents
• Need good motivation
• Child/adolescent is assigned homework and compliance
may be an issue
• Developmental considerations
• Cognitive ability of child
• Need meta-cognitive abilities to access one’s own thoughts
• Works well as an effective tool with most
children/adolescents
Treatment Techniques Used with Children
and Adolescents
• Interoceptive Exposure - learning not to let
physical sensations of anxiety scare you
• Utilized to treat Panic Disorder and Agoraphobia
• Series of exercises, conducted repeatedly to teach
child not to fear the physical sensations brought on by
the fear response
• Physical sensations are not harmful, they are natural
• Conduct exercises in session to “bring on” panic
Treatment Techniques Used with
Children and Adolescents
• Exposure Therapy /Fear Avoidance Hierarchy calls for child to confront feared stimulus and remain
in its presence for progressively longer periods of
time; child is rewarded for each success
• Fear of Dogs– break down into smaller steps
• Fear of Shots, Bugs using “Bravery Ladder”
• “Reward Store” for each success, typically special
time with mom or dad
• Do not use relaxation techniques during exposure!
Relaxation Training Script
• Progressive muscle relaxation with imagery
“Pretend you are a furry, lazy cat. You want to stretch.
Stretch your arms out in front of you. Stretch them way
out. Feel them pull from your shoulders. Good! Now
let them drop quickly…Notice how good it feels to be
relaxed…it feels good and warm and lazy.”
Treatment Techniques Used with
Children and Adolescents
Exposure/Response Prevention
• Used with children with obsessive compulsive disorder
• Expose child to anxiety by having him or her “wait”
progressively longer time periods before performing
compulsion
• Eventually, eliminate compulsion entirely
• Replace and substitute with more appropriate, functional
behaviors (e.g., hair pulling is replaced with keeping
hands occupied in a less harmful way)
Treatment Techniques Used with
Children and Adolescents
• Shaping - rewarding successive approximations
to a desired behavior
• Contingency Management -- rewards for brave
behaviors. Typically designed by therapist but
implemented by parents. Sticker charts.
• Modeling Treatments -- having a frightened
child observe another child interacting adaptively
with the feared stimulus; can be live or filmed.
Cognitive Self-Statements
I am a brave girl (boy).
I can take care of myself when I am alone.
I can take care of myself when I am in the dark.
I am brave and can take care of myself.
Social Skills Training
• Learning and practicing skills that facilitate social
interactions
• Practicing skills in real life settings
• Examples: eye contact, smiling, keeping
appropriate voice levels, asking questions,
keeping conversations flowing, ways to increase
positive reinforcement from the environment
Parenting Skills Training Component
• Increase parental warmth, attention, and praise to child
• Strategies for knowing when something is misbehavior and
when it is anxiety and how to handle each
• Increase positive parent-child interactions
• Teach appropriate ways to give commands and set limits
• Education about the cycle of anxiety
• Non avoidance!
• Praise (Example: Brave night! Brave night!)
Specific Techniques for Supporting an
Anxious Child for Teachers and Parents
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Specific praise and small rewards of brave behaviors
Model brave coping behavior
Help child to face fears, even gradually!
Give child control/choices around
age appropriate decisions
• Don’t be overly reassuring; be gently encouraging
• Help child use appropriate coping skills to manage
high emotions; communicate openly!
• Anxiety is a natural emotion and sometimes can help!
Implementing evidence based treatments
in practice: Advantages and Challenges
• Advantages
– evidence supports treatment efficacy
– evidence that gains are maintained
– “makes sense” to patients, good acceptability; parents
like the idea of skills vs. meds
– empirically based; ongoing assessment allows for
measurement of progress
– concrete CBT strategies work well with children and
adolescents
– parents gain guidance and skills that often translate
to other siblings
Implementing evidence based treatments
in practice: Advantages and Challenges
• Challenges
– complex cases with comorbid diagnoses often
require additional sessions
– need for referral sources/providers specifically
trained in CBT techniques
– patient motivation– patients/parents need to be
actively involved in therapy
A Clinically Significant Outcome
Case Descriptions Across the
Developmental Spectrum: “Sally”
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“Sally”, age 14
Afraid to speak with other girls at school
Fears sitting in lunchroom with people she doesn’t know
Gets along well with siblings, gets straight A’s in school
Behavioral Observations– Sarah speaks softly, can barely hear
her, seems very shy yet can smile and engage appropriately
• Wants to develop peer group at school yet avoids contact with
peers for fear of rejection or embarrassment
• Has friends at her summer home with whom she is very
comfortable
• Family is very supportive of her
“Jake”, age 7
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Worries about everything all day long
Constantly asking parents “worry questions”
Parents repeatedly answer questions but are sick of them
Jake worries about grades in school, whether a terrorist
will come to their town, whether parents have adequate
finances, what time parents will be home; worries ahead of
time about family vacation (what if it rains, what will we
do? What if someone gets sick?); constantly asking
questions about family’s whereabouts
• Parents describe him as the “policeman” of the house
• Wish he would just “let go” and relax
• Jake has good friends, appropriate interests, often
distracted by his worry
“Adam”, age 17
• Fear of elevators since age 10 when he witnessed his mom
telling story of how she got stuck in an elevator
• Avoids cities and restaurants that are in tall buildings
• Excellent student, loves science, would love to go to top notch
university but choosing college based on building heights on
the campus; choosing small college that doesn’t fit with his
interests but has low buildings due to fears
• Embarrassed to share fear with buddies; refuses to go out with
people to the city, says he has plans already
• Feels he can’t go to the prom and has missed other activities
through the years due to fears
• Coming to treatment to get help; wants to get rid of these fears
Discussion Questions
• How would you go about doing a more complete
assessment of this child/adolescent?
• In being a scientist/practitioner, you decide to give some
measures at pre and post treatment to measure your
patient’s progress. Which measures do you choose?
• How would you diagnose patient?
• What cognitive-behavioral treatment techniques that you
learned today would you be likely to use with this patient in
treatment?
Discussion Questions, con’t
• Provide two concrete, measurable goals that could be tracked
throughout treatment
• Would you include the parents/family in any part of
treatment? If so, what type of parent component do you think
would be helpful?
• Conceptualize your case by tailoring the 3 component model
to your patients’ concerns- how might you present this to
your patient in session one?
• What might a Fear and Avoidance Hierarchy look like for
your patient?
Conclusions
• Cognitive behavioral treatments work well
• Great need for more controlled trials
• Can utilize these assessment and treatment techniques in
clinical practice
• Patients like “hands on” techniques, concrete strategies
work well with children and adolescents
• Can measure change and progress and chart your patients’
successes!
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IT DOESN’T TAKE A WIZARD!
Brains - skills, tools for being a good therapist
Heart - ability to connect with child and care
about helping family
Courage - Teaching child that there is “no place” he
or she can’t go
Home - Teaching child to feel at “home” with all of
our natural, human emotions
Take these new skills home!
Questions and Ideas
Websites of interest
www.childanxiety.net
www.bu.edu/anxiety