Anxiety and Selective Mutism in Youth Workshop

1. Anxiety and Selective Mutism in Youth Workshop Dr. Alissa Pencer Registered Psychologist

2. Outline Part I: Anxiety Disorders in Youth Part II: Selective Mutism • Part I: Anxiety Disorders in Youth • When is anxiety a problem? • Prevalence and course • Common Anxiety Disorders • Causes • Cognitive Behaviour Therapy for Anxiety Disorders • Realistic Thinking • Exposure • Case Examples and Group Exercises A. Pencer October 2012

3. Fear, Anxiety, and Worry Everyone worries, everyone gets anxious and everyone is afraid of something. Very young children are often fearful of strangers, the dark, animals and insects. Older children and adolescents are often fearful of peer rejection and are more self-conscious and strive to fit in with their peers. Adults often worry about public speaking. A. Pencer October 2012

4. A. Pencer October 2012

5. When is Anxiety A Problem? Most children, adolescents and adults use anxiety to help them make good decisions, e.g., looking both ways before you cross the street, putting on your seatbelt, setting your alarm so you aren’t late, studying for tests, budgeting time to complete assignments. Anxiety becomes a problem when it makes the decisions for you, interferes with your life and/or causes significant distress. A. Pencer October 2012

6. Inverted U-Shaped Relationship Between Arousal and Performance A. Pencer October 2012 Hebb, D. O. (1955). Psychological Review, 62, 243-254

7. Examples Not being able to join extracurricular activities. Not being able to speak in front of the class. Not handing an assignment in because “not perfect”. Not being able to go to school because overwhelming. Washing your hands 30 times a day. A. Pencer October 2012

8. How Common are Anxiety Disorders? Anxiety disorders are the most common psychological problem found in children and adolescents. Approximately 1 in 10 youth meets the criteria for an anxiety disorder. Despite this, often mental health centres see more children with aggressive difficulties, attentional problems, eating disorders, or suicidal tendencies. A. Pencer October 2012

9. 6 Month Prevalence Rates of Mental or Addictive Disorders in Children 4-17 % • Anxiety Disorders 7 • ADHD 5 • Conduct Disorder 4 • Mood Disorders 4 • Substance Use Disorders 1 • Any Disorder 14 Waddell et al, Can J Psychiatry, 2002 A. Pencer October 2012

10. How Does Anxiety Effect Youth? Anxious youth tend to have: Fewer friends Difficulty meeting new people, joining clubs and groups Academic problems because they avoid homework, don’t make full use of the resources, and have difficulties concentrating because they worry School avoidance A. Pencer October 2012

11. Long term In the long term, anxious without treatment have: Restricted choices in terms of opportunities for careers Lower self esteem Increased likelihood of becoming an anxious and/or depressed adult A. Pencer October 2012

12. What Does Anxiety in Youth Look Like? No two anxious youth will behave exactly the same way, nor will they worry about the exact same things. However, there are common anxiety patterns which roughly translate into the anxiety disorders. A. Pencer October 2012

13. What is an Anxiety Disorder? Interfering with daily activities Causing significant distress Reaction is too extreme for the situation Trigger is not an actual threat A. Pencer October 2012

14. Anxiety Disorders Separation Anxiety Disorder: separation from caregivers and concern bad things will happen to them Generalized Anxiety Disorder: worry excessively about many areas of life functioning (e.g., school work, family, friends, health) Social Phobia: fearful of social or performance situations A. Pencer October 2012

15. Anxiety Disorders cont’d Specific Phobia: fear of particular objects or situations Panic Disorder: misinterpret bodily changes and have a fear of losing control Obsessive Compulsive Disorder: the presence of intrusive repetitive thoughts or behaviors A. Pencer October 2012

16. Causes & Treatment A. Pencer October 2012

17. What Causes Anxiety Disorders? Genetics Anxiety runs in families Common for at least one parent to be somewhat anxious Research has shown that what is passed on from parent to child is not a specific tendency to be shy or worry but a general personality to be more emotionally sensitive than other people. A. Pencer October 2012

18. What causes anxiety disorders? Parent Reaction Parent reactions or the way they handle their child or teen’s anxious behaviour might also play a role (e.g., being over-protective). Modeling Children and adolescents copy their parents coping strategies (e.g., avoiding fearful situations). Stressors Bit by a dog, death of a loved one, being bullied, getting sick A. Pencer October 2012

19. Interventions that Help Psycho education Treatment: Group CBT for youth and parents Individual CBT Medication A. Pencer October 2012

20. Evidence for CBT in Anxiety Disorder Treatment Individual CBT (Kendall,1994 and 1997) Study 1: 64% of treatment group no longer with dx Study 2: 71% of treatment group no longer with dx Results in both studies maintained at 1 year At 7 years post-treatment, anxiety disorder no longer primary in 92% of youth Up to 84% no longer have dx if parent component added (Barrett et al., 1996) Individual vs. Group CBT(Manassis et al, 2002; Rapee, 2000) Group CBT as effective as Individual CBT A. Pencer October 2012

21. Three Components of Anxiety Feeling (Physiological) Cognitive (Thoughts) Doing (Behaviors) A. Pencer October 2012

22. Physiological Component A. Pencer October 2012

23. A. Pencer October 2012

24. Anxiety and the Brain Limbic System -scans all sensory input, flight/fight response, integrates memory, emotion Prefrontal Cortex - decision making, planning, emotion regulation • Locus coeruleus • Alarm system: • sympathetic nervous • system activation A. Pencer October 2012

25. Fight-Flight Response In fearful situations teens become “pumped up” or aroused. This is the fight-flight response. Immediate or short-term anxiety is named the fight-flight response. It’s the body’s way of protecting you from danger. The fight-flight response causes you to sweat, increase heart rate, tense muscles, make you breath faster, feel hot or cold, dry mouth, and feel lightheaded or dizzy. A. Pencer October 2012

26. Fight Or Flight? A. Pencer October 2012

27. In youth with anxiety disorders, the fight-flight response occurs when there is no immediate danger, but instead a perceived danger. Being in a classroom filled with other students Using a restroom at school Going to the cafeteria Doing a presentation Having your heart race Paragraph you just wrote is “just not right” A. Pencer October 2012

28. Cognitive Component A. Pencer October 2012

29. Examples (Cognitive) Anxious children and teens have thoughts that center around harm or threat. “I can’t leave to go to school and be away from my mom or something bad will happen to her.” (Separation) “I can’t do this presentation because my classmates will think I’m dumb.” (Social) “If I don’t check the back door lock, someone will break in.” (OCD/GAD) A. Pencer October 2012

30. Behavioral Component A. Pencer October 2012

31. Anxious behaviours Anxious children and teens often behave differently: They pace, fidget, cry, cling, shake. They avoid. Refusing to go somewhere alone Refusing to go to school They seek reassurance. “Am I going to die?” “Am I going to fail?” “Is everyone going to laugh at me?” A. Pencer October 2012

32. Core Components of CBT Realistic Thinking/Cognitive Restructuring Exposure ** Skills Training (e.g., deep breathing and relaxation, problem solving, social skills, assertiveness, stress management) A. Pencer October 2012

33. Thinking Errors Anxious children overestimate how likely it is that an unpleasant event will happen. They overestimate how bad the consequences will be if the event does happen. They underestimate their ability to cope with the anxiety and the unpleasant event A. Pencer October 2012

34. Realistic Thinking EventThought/BeliefEmotion Parent is late there has been a crash worry,anxiety Parent is late stuck in traffic annoyance Parent is late stopped to get pizza happy A. Pencer October 2012

35. Steps in Realistic/Detective Thinking 1) Identify the situation that is making you worried 2) Identify the worried thought 3) Look for “Realistic Evidence” to challenge your worried thought 4) Look for alternative outcomes 5) Identify a more realistic thought A. Pencer October 2012

36. Questions for collecting “evidence” • What is the evidence that this thought is true? What is the evidence that this thought is not true? • What would I tell a friend if he/she had the same thought? • Am I 100% sure that ___________will happen? • How many times has __________happened before? What was the outcome? • What is the worst that could happen? What is likely to happen? • If it did happen, what can I do to cope with or handle it? • Am I confusing “possibility” with “certainty”? It may be possible, but is it likely? A. Pencer October 2012

37. A. Pencer October 2012

38. Exposure By avoiding, children minimize direct and prolonged contact with feared situations. Anxious children have no opportunity to learn that the situation is harmless. A. Pencer October 2012

39. High First time Second time if removed at point B Second time if taken out of situation Anxiety A B Low Time A. Pencer October 2012

40. Fighting Fear by Facing Fear • The Keys to Stepladders: • gradual (start low on anxiety thermometer) • stay in step “long enough” (until anxiety decreases) • use coping strategies • need to repeat steps • importance of rewards A. Pencer October 2012

41. Creating Stepladders • Write a practical goal • Brainstorm all possible steps to reach the goal • Child/Teen should give each step a worry rating • Choose steps that cover the entire range of ratings • Write chosen steps in order • Negotiate rewards for each step and ultimate reward for achieving the goal A. Pencer October 2012

42. Common Problems Step too hard Not enough repetition Speeding through Look out for subtle avoidance (e.g. lucky charms) A. Pencer October 2012

43. School Based Version of “Cool Kids” Cool Kids Anxiety Program School Kit This package is an adaptation of the Cool Kids program for use within a school setting. It is designed tobe run by school therapists and related mental health professionals.The therapist's manual describes in detail how to conduct each session of the program including exercises and comments to assistsuccessful implementation. http://centreforemotionalhealth.com.au/pages/resources-products.aspx A. Pencer October 2012

44. CASE EXAMPLE(S) and GROUP EXERCISES A. Pencer October 2012

45. Case example #1 Ten year old boy with separation anxiety who was recently bullied. Now needs parents to drive him to school, won’t go into school without parent present, won’t attend class unless parent remains in the school. Defiant if confronted about attending. A. Pencer October 2012

46. Case Example #2 Thirteen year old girl, diagnosed with Generalized Anxiety Disorder (GAD). Perfectionist qualities. Very concerned that people will think she is “stupid”. Spends an inordinate amount of time on homework checking for errors. A. Pencer October 2012

47. Case Example #3 15 year-old male with social anxiety disorder. • Will not talk to people at school. • Cannot do presentations at school. • Will avoid any social gatherings with more than 3 people and rarely goes to friend’s houses. • Will not eat in the cafeteria. • Misses school very often. A. Pencer October 2012

48. Questions ? ? A. Pencer October 2012

49. Helping Children with Selective Mutism Acknowledgment to Dr. Melanie Vanier A. Pencer October 2012

50. Outline • Part II: Selective Mutism • Common characteristics • Prevalence and course • Contributing factors • Assessment • Intervention approach • Case example/group exercise • General discussion A. Pencer October 2012