Childhood Anxiety: Signs, Symptoms, and Treatments

1. Always Leading & Inspiring

2. Childhood AnxietyHow can we help?By: Jill McMullen

3. Objectives: The learner will: • Recognize the signs and symptoms of childhood anxiety • Identify treatment options for childhood anxiety • Explore alternative treatments for childhood anxiety

4. What is fear and anxiety? • Fear is the brain’s response to something that has the potential to cause immediate harm • Anxiety is the brain’s response to no immediate danger but an anticipated one

5. Developmental “Normal” Fears • Early infancy: • Within 1st few weeks: fear of loss (physical contact with caregivers) • 0-6 months: Salient sensory stimuli: attention grabbing odors, loud noises, bright lights, ELECTRONICS

6. 0-6 months cont’d • Early exposure to electronics has been shown to increase attentional deficits in adulthood

7. Developmental “Normal” Fears (cont’d) • Late infancy: • 6-8 months: Shyness/anxiety with strangers

8. Developmental “Normal” Fears (cont’d) • Toddlerhood • 12-18 months old: Separation anxiety • 2-3 years: Fears of thunder and lightning, fire, water, darkness, nightmares, animals

9. Developmental “Normal” Fears (cont’d) • Early childhood: • Fear of death or dead people

10. Developmental “Normal” Fears (cont’d) • Primary/elementary school age • 5-7 years old: • Fear of specific objects (animals, ghosts, monsters) • Fear of germs or serious illness • Fear of natural disasters or traumatic events (getting burned or in a car accident) • School anxiety/performance anxiety

11. Developmental “Normal” Fears (cont’d) • Adolescence: • 12-18 years old: rejection from peers

12. Physical symptoms • Fatigue, muscle aches, trouble concentrating, not sleeping well, “not feeling well”, tachycardia, shortness of breath, dizziness, chest pain/tightness, diarrhea, nausea, stomach pain, frequency of urination, trembling, or numbness

13. Anxiety disorders • Severity • Persistence • Dysfunction/impairment

14. Epidemiology • One of the most common psychiatric disorders in children and adolescents • Lifetime prevalence 5-30% • 3 to 5 times more likely if 1 parent hx of anxiety d/o • 6 times more likely if both parents hx of anxiety d/o

15. Why is it important? • Children with anxiety struggle with friendships, family life, and school • Treatment for children can often prevent developing mental health issues or alcohol/substance abuse • Sometimes not recognized by parents as a medical problem to receive treatment • Adults with anxiety often had anxiety beginning in childhood.

16. Informant • Parents: • Often under or over report internal symptoms of anxiety and mood • Often good reporters of external symptoms such as bad behaviors, aggression, and hyperactivity • Child/Adolescent: • Developmental age

17. Past history • Family history • Trauma history • Family dynamic • Other social aspects (sleep, caffeine, diet) • School environment • Surgeries • Medication history • Other therapies currently in or have tried

18. Assessment of dangerousness • Suicide • Homicide • Other risk taking • Alcohol abuse • Drug abuse • Sexual risk taking • Running away

19. Suicide • ASK!! • Intentions/plans • Means • Social support-who will they talk to • Stressors • Reasons to live • Problem solving capability

20. Childhood/Adolescent Anxiety disorders • Separation Anxiety Disorder • Panic Disorder with and without agoraphobia • Social phobia • Obsessive-compulsive Disorder • Acute Stress Disorder • PTSD • Generalized anxiety disorders • Anxiety Disorder NOS

21. DSM V changes • OCD has moved to its own chapter “obsessive compulsive and related disorders” • PTSD has moved to a new chapter “trauma and stressor related disorders” • Anxiety disorders now have 6 month to dx • Panic attacks can occur with all anxiety d/o

22. DSM V changes (cont’d) • Panic disorder and agoraphobia and now unlinked • Separation anxiety can arise in adulthood • Social phobia now called social anxiety disorder • New “performance only” specifier

23. Generalized Anxiety Disorder (GAD) • Excessive worrying and anxiety about a number of different events or activities • Person finds it difficult to control the worry

24. GAD cont’d • Associated with at least 3 or more symptoms from this list: • Restlessness, feeling keyed up, or on edge • Easily fatigued • Difficulty concentrating • Irritability • Muscle tension • Sleep disturbance

25. GAD cont’d • Onset usually before the age of 20 years • Hx of childhood fears and/or social fears • Increase incidence with family hx • Over 80% also have comorbid condition (major depression, dysthymia, social phobia, etc.) • Comorbid substance abuse • Rare complaints of chest pain, tachycardia, or palpitations • Readily admit to excessive worrying over small matters that disrupt life

26. Selective mutism • Large number of individuals with selective mutism are anxious. • Diagnosed in children.

28. Separation anxiety disorder • Marked fear of being separated from home or attachment figure • Substantial number of individuals recognized in adulthood as having disorder • >6 months • Nightmares, physical symptoms, excessive distress with separation from attachment figure or fearfulness of separation

29. Social anxiety disorder • Excessive fear of being perceived negatively in social or performance situations • Also known as social phobia • >6 months • Crying, freezing, tantrums

30. Panic disorder and agoraphobia • DSM-V: 2 separate diagnoses • Large number of agoraphobia do not contain panic attacks • Can co-occur and then diagnosed as 2 separate diagnoses, each with specific criteria

31. Panic disorder • Unexpected panic attacks with intense fear and somatic and/or cognitive complaints • Heart pounding, sweating, dizziness, trouble breathing, uncontrollable crying, impending doom thoughts

32. Agoraphobia • 2 or more agoraphobia situations in order to distinguish agoraphobia from specific phobias • Fears being out of proportion to actual situation • >6 months

33. Specific phobias • Marked or persistent fear of a specific thing • Animals, weather, shots, etc. • >6 months to minimize over diagnosis of transient fears • Crying, tantrums, clinging, freezing

34. Obsessive-compulsive disorder (OCD) • Recurrent obsessions and/or compulsions that cause significant distress and/or impairment in daily functioning

35. Post traumatic stress disorder (PTSD) • Persistently reexperiencing traumatic events • Avoidance of trauma reminders • Increased arousal

36. GAD vs. ODD Nordahl, H. et al., 2010 • Generalized anxiety disorder (GAD): • Parental psychopathology • Disruption of attachment between the child and parents • Acute life events • Abuse • Overprotective parenting • Loss • Parental avoidance and modeling of anxious behaviors

37. GAD vs. ODD (cont’d) • Oppositional defiance disorder: • Parent psychopathology • Poor disciplinary practices • Marital discord • Strict/coercive parenting

38. GAD vs. ODD (cont’d) • Findings: • ODD most commonly associated with abusive child-parent relationships and discordant relationships with teacher/school and/or peers • GAD most commonly associated with overprotective parents, parental pressures, acute threats, and inadequate supervision/control

39. Anxiety vs. Attention • Does the attention disorder cause anxiety of not completing tasks? • Does the anxiety disorder cause difficulty paying attention so tasks aren’t completed?

40. Treatment • Various combinations of therapies • Psychoeducation, cognitive therapy, behavioral shaping, school consultation, and pharmacotherapy • First line: psychoeducation for patients and family • CBT for patients • Moderate to severe cases consider medication in combination or medication sooner if psychotherapy is ineffective or based on degree of impairment

41. How do we help? • Educating parents • Educating Children • Using medications when appropriate • Individualizing care

42. Child-Parent Interventions • Getting parents involved with therapy can increase effectiveness of methods employed by clinician so it extends into the home environment

43. Family cognitive behavioral therapy • Using the family setting to change child’s irrational thoughts • Helps parents with: • Control • Acceptance • Modeling

44. Parent-Child Interaction therapy (PCIT) • Play therapy integrated with developmental, social learning, and behavioral theories • Used with preschoolers, children in foster homes, victims of physical abuse, children with developmental delays, and children with separation anxiety

45. PCIT (cont’d) • 2 phases: • Child directed phase • Parent directed phase • Each phase teaches parents how to modify their actions thus modifying reactions of the child • Increase of relationship to form: • Healthy attachments • Reinforcement contingencies • Reducing anxiety-provoking responses

46. Child-parent psychotherapy • Modeling play therapy • Using the parent to actively play with child • Enhances emotional harmony

47. Theraplay • Ann Jernberg (1960) • Structuring, challenging, engagement, nurturing, and play • Increase a therapeutic relationship of bonding, attunement, and playfulness with their child

48. Children • Teaching children how to • Recognize anxiety symptoms or “where they are at” • Learning individual tools that are helpful to them to use to activate the parasympathetic nervous system to calm themselves

49. Medications • SSRIs/SNRIs • Hydroxyzine • Buspirone • 2nd generation neuroleptics In comorbid cases: Stimulants, 2nd gen neuroleptics, anticonvulsants, sleep medications

50. Key points • Solid history of client and key symptoms • Involve families but educate children, also • Individualize care