Download Anxiety October 2015 presentation RDCRSD2

Anxiety Disorders in Children and Adolescents
Bonnie Moshenko-Mitchell, Ph.D.
Registered Psychologist
Anxiety Clinic of Central Alberta
ACCA Psychological Assessment Services
October 23, 2015
Anxiety or Anxiety Disorder?
NORMAL ANXIETY
ANXIETY DISORDER
Response to a stressor
Anxious all or almost all of the time
Fleeting
High intensity
Appropriate
Excessive for the situation
Ongoing
Physical symptoms, health issues
Feeling of being detached, disconnected
from reality
Interferes significantly with life
Why is it important to distinguish?
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To have access to appropriate intervention
To build coping
To have a realistic view of what is happening
To foster an individual’s belief in themselves
What can contribute to a student
experiencing anxiety?
• Having a specific anxiety disorder or other mental health
concern
• Temperament issues
• Developmental concerns/Developmental Disorders
• Academic concerns (e.g., learning, classroom environment)
• Sensory Issues
• Health concerns
• Family Issues (e.g., attachment, abuse, neglect, divorce, illness
in family)
• Environmental Issues (e.g., poverty, hunger)
• Substance abuse
Pathway to Anxiety
Misinterpretation of
the danger of the
situation
Physical
symptoms
Feeling that you do not have coping strategies
or are unable to use them
Inappropriate response (anxious response)
Key Ingredients for Developing an Anxiety
Disorder
• Genetic/Biological Predisposition
• Temperament style
• Family mental health history
• Environment
• Stressful life events
• Everyday stress
• Presence or Absence of Coping Strategies
Anxiety and Mental (Cognitive) Shifting
• All day, everyday, individuals are challenged to
make mental shifts:
From one activity/interaction to the next
From a preferred activity/interaction to something nonpreferred
To accept the unexpected
To accept something different than what we wanted
To accept something that someone else wants
To accept something that makes him/her
uncomfortable in some way, which challenges selfbelief
Who has difficulty with mental shifting?
• We all do sometimes, with our abilities to mental
shift being impacted by many things including: the
number of times we are expected to shift, demands
on our brain and our time, food intake, sleep, and
significant life events.
• Other specific issues can impact a student’s ability to
shift. For example, those individuals who have an
inflexible temperament style, including but not
limited to those with Autism Spectrum Disorder,
have difficulties shifting.
What is inflexibility?
• Inflexibility impacts an individual’s ability to
make mental (cognitive) shifts in an adaptive
way:
It takes a long time and great effort to make the shift
The shift results in dysregulation of the emotional
and/or sensory system
The shift results in the display of inappropriate
behaviour towards another person
The shift negatively impacts that person and those
around him/her
Underlying characteristics that are risk
factors for developing anxiety disorders
• Anxiety Sensitivity: Belief that anxiety is
harmful
• Negative Affectivity: Proneness to
experiencing negative emotions
• Behavioural Inhibition: Consistent tendency
to demonstrate fear and withdrawal from
new/unfamiliar situations, people,
environments
How do people with anxiety tend to
think?
Errors in Thinking from “Ten Forms of Twisted Thinking” (Dr.
David Burns) – a.k.a. “Stinkin’ Thinkin’ ”:
• All-or-nothing thinking
• Over-generalization
• Mental Filter
• Jumping to conclusions
• “Should Statements”
• Labeling
• Catastrophizing
• Over-estimating danger
Why do we need to talk about our
thinking?
THOUGHTS
FEELINGS
BEHAVIOURS
Generalized Anxiety Disorder is not
General Worries!
• GAD is excessive worry about a number of events/activities, occurring
more days than not, lasting at least 6 months
• Includes at least three of the following: restlessness, fatigue, difficulty
concentrating, irritability, muscle tension, sleep disturbance
• Pervasive, pronounced, distressing, long in duration, occurs without
precipitants
• Greater range of worries means more likely to meet the criteria for GAD
• Rarely occurs prior to adolescence, and is thought to perhaps be
overdiagnosed in children
• Children/adolescents worry about school and sport performance,
catastrophic events, punctuality. May be perfectionistic and excessively
seek reassurance
What is a Panic Attack?
• Panic attack is different than a sudden attack
of anxiety
• Expected attacks (obvious trigger) versus
unexpected attacks (no obvious trigger)
• Panic attacks can occur with any mental
disorder and some medical conditions
• Uncommon in preadolescent children, with
unexpected ones being rare
Panic Attacks
• An abrupt surge of intense fear that reaches a peak quickly,
and includes 4 or more of the following:
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Rapid heart rate
Sweating
Shaking
Sensation of shortness of breath/feeling of choking
Chest pain
Nausea
Feeling dizzy
Derealization/depersonalization
Fear of going crazy or of dying; sense of doom
Numbness/tingling sensations
Chills/hot flashes
Panic Disorder
• Panic Disorder is recurrent, unexpected (no obvious
trigger) panic attacks
• Persistent worry about having another panic attack
• Behaviour (e.g., avoidance of activities, settings) to
avoid having a panic attack
• Rare in childhood, adolescents seem to be similar to
adults in course, though adolescents perhaps worry
less about subsequent attacks
Anxiety and Autism Spectrum Disorder (ASD)
• Estimates are that children with ASD experience
anxiety 4 times as often as neuro-typically
developing children
• Anxiety greater in children with ASD than in children
with other brain-based concerns
• Individuals with autism have same general thinking
style as non-ASD individuals who have an anxiety
disorder (over-focus issues, black-and-white
thinking)
Why Do Individuals with ASD Experience
Anxiety?
• Anxiety can arise due one or more of the following:
• Communication difficulties
• Cognitive differences (e.g., difficulties making mental
shifts)
• Restricted range of interests, adherence to routine,
obsessionality
– Change in routine or schedule (especially if not anticipated)
– Perfectionism (e.g., Need to do things “just so”, difficulty with making
mistakes, wanting to be first in the class)
– Tendency to be “rule-bound”
– Over-focusing on details (can result in “missing” things)
– Inflexibility; need for their own agenda
– persistence
Why Do Individuals with ASD Experience
Anxiety? (cont’d)
• Lack of social understanding/perspective taking
– Unable to read social cues
– Unable to follow a social interaction “at speed”
• Sensory overload (e.g., sensitive to noise, touch, smell,
light)
• Demands of school (e.g., academic, social) or of other
environments
Anxiety and ASD
• How anxiety could be different for people with ASD:
• Responses may be more extreme (disproportionate to
the triggering event)
• Triggers may be more unusual
• May lack awareness of social consequences of
behaviour
• May not see a reason to not be anxious
Anxiety and ASD
• Ways that individuals with ASD avoid experiencing
anxiety:
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Refusing to start or engage in an activity
Rushing a task
Having a tantrum or meltdown
Isolating themselves
Always being on time getting to places
Physical aggression
Bolting
Directing/trying to control others
Engaging in ritualized behaviour
General Comment on Strategies
COGNITIVE SKILLS
Impaired………….…………………………………………………………………………….Intact
DEVELOPMENTAL LEVEL
Immature………………………………………………………………………………………Mature
ADAPTIVE SKILL LEVEL
Low………………………………………………………………………………………………..High
INTERVENTION
Adult Led
Adult Assisted
Positive Behavioural Supports…………………………………… Self-Monitoring
Concrete Approaches
Cognitive techniques
What can be done to prevent anxiety
from progressing to a disorder?
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Teaching problem-solving
Normalizing anxiety (“normal nervous”)
Teaching students to use positive self-talk
Using empowering language and providing positive messages
Reframing “errors in thinking”
Giving students opportunities to build skills (e.g., oral presentations, social
skills)
• Teaching mindfulness
• Talking about good eating, exercise, sleep as being important for mental as
well as physical health
• Looking at your general approach in the classroom (teaching methods,
style, etc)
What general strategies really help
students with anxiety disorders? (cont’d)
• Teacher attitude and consistent approach within a classroom
and across classrooms
• Structure, routine, and predictability in the classroom
• Breaks (Sensory, cognitive)
• Choices
• Helping the student to determine what will work
• Teaching why avoidance is not the best strategy (i.e., When
you avoid something, you give it more power…you can
actually make it seem even worse, avoiding does not give the
brain a chance to gain evidence that the situation is really not
that bad, it decreases confidence about that situation and
others)
What general strategies really help
students with anxiety disorders?
• Use of visual systems to describe anxiety, level of regulation,
etc.
• Staying calm, avoiding over-talking, rationalizing
Resources
• Chansky, T.E. (2014). Freeing your child from anxiety. Chansky,
T.E. (2008). Freeing your child from negative thinking.
• Dalgliesh, C. (2013). The sensory child gets organized. Proven
systems for rigid, anxious, or distracted kids. New York:
Touchstone.
• Greenland, S.K. (2010). The Mindful Child. New York: Atria.
• Harvey, P., & Penzo, J.A. (2009). Parenting a child who has
intense emotions. Oakland, CA: New Harbinger Publications,
Inc.
• MacKenzie, R. J. (2013). Setting Limits with Your StrongWilled Child. New York: Three Rivers Press.
Resources (cont’d)
• McHolm, A.E., Cunningham, C.E., & Vanier, M.K. (2005).
Helping your child with selective mutism. Oakland, CA: New
Harbinger Publications, Inc.
• Pantley, E. (2010). The no-cry separation anxiety solution.
New York: McGraw Hill.
• Rapee, R. M. (2000). Helping your anxious child: A step-bystep guide for parents.
• Shaw, M.A. (1995). Your anxious child. Raising a healthy child
in a frightening world. New York: Carol Publishing Group.
• Wagner, A. P. (2005). Worried no more. Help and hope for
anxious children.
• Wagner, A.P. (2000). Up and down the worry hill. Rochester,
NY: Lighthouse Press.
Resources (cont’d)
Websites: AnxietyBC
OCFoundation.org
Apps:
Mindshift, Breathing Zone,
Meditation Jar, Relax App