Preventing Anxiety & Depression in Children

1. Preventing Anxiety & Depression in Children MaritaSchwendler Clinical Psychologist Child, Adolescent & Family Health

2. Childhood Anxiety & Depression ANXIETY • Most common form of psychological distress in childhood • 8% children • 11-20% adolescents • More common in girls • Anxiety often leads to depression DEPRESSION • #1 cause of disability • 0.4 to 2.5 % children • 4.2 to 18.6 % adolescents • Comorbity 15.9 to 61.9%. Tend to be anxious first and older

3. Overview • Normal fears and worries • General signs there is a problem • Types of anxiety and depression • Causes and red flags • Behaviour vs. anxiety/ depression • How to respond in a school setting • When and where to refer

4. Typical Childhood Fears & Worries • Ages Common fearsInfants and toddlers - loud noises- separation, strangersPreschoolers - animals – especially dogs- the dark- ghosts and monstersSchool age - snakes and spiders- fear of failure and rejection- the news and TV shows- blood, injury, and sickness- being home alone- death

5. When should you be concerned? • Ask not what are they worried about but how the worry is impacting on their functioning. • Too much worry/ stress for insignificant circumstances? • Is anxiety/ worry their automatic response? • Are they constantly keyed up? • Is coaxing and/or reassurance ineffective?

6. General Signs of AnxietyWhat to look for? • Difficulty transitioning from home to school or school refusal/ reluctance • Anticipatory anxiety (worrying hours, days, weeks ahead) • Excessive avoidance or withdrawal from activities esp. new situations /people/ activities • Excessive distress to situation e.g. crying, physical symptoms, anger, hopelessness, frustration, embarrassment • Easily distressed, or agitated when in a stressful situation • Worrying excessively about school, friends, sport • Repetitive reassurance questions, "what if" concerns, inconsolable, won't respond to logical arguments • Finding it difficult to relax/sleep • Frequent stomach aches or other physical complaints • Difficulty concentrating (LDs and cognitive problems) • Other conditions ADHD, depression • Overly-responsible, people pleasing, excessive concern that others are upset with him or her, unnecessary apologizing • Perfectionism, self-critical, very high standards that make nothing good enough • Excessive time spent consoling child about distress with ordinary situations, excessive time coaxing child to do normal activities- schoolwork, hygiene, meals

7. Types of Anxiety • Generalised anxiety • Social phobia or social anxiety • Separation anxiety • Specific phobia • Panic disorder • Obsessive-compulsive disorder • Post-traumatic stress disorder

8. Generalised Anxiety Disorder (GAD) Excessive worry and anxiety about a variety of matters • Approx 3-4% children • An inability to stop or explain the worry • Repeatedly seeking of teacher approval • Avoidance of academic & peer activities

9. Social Anxiety Extreme and consistent fear of meeting new people or embarrassing oneself in social situations • Approx 40% of social phobias start before the age of 10 (Montgomery, 1995) • Crying, throwing tantrums, clinging or freezing • Poor eye contact • Speaking very softly and/or saying little or nothing • Appearing anxious when the centre of attention • Constantly alone in the playground, hovering on edge of groups, not joining

10. Separation Anxiety Excessive anxiety of separating from primary caregiver, home or familiar surroundings • Constant thoughts/fears about safety of self/others • School refusal • Becoming panicky, having somatic symptoms or tantrums when separated from parents

11. Specific Phobia Fear of a specific object or situation e.g.. Dogs, spiders, the dark • Fear and avoidance of specific things

12. Panic Disorder Experience recurrent panic attacks and persistent concerns about future attacks • Children tend to report physical symptoms rather than psychological • Repeated sudden interruption to activity • Upset or frightened without any easily identifiable explanation

13. Obsessive Compulsive Disorder Intrusive, obsessive thoughts which are usually alleviated by compulsive actions or checking behaviours • Rare in children • Being preoccupied with certain routines or ideas e.g. cleanliness and hand washing

14. Post-Traumatic Stress Disorder Characterised by the presence of severe anxiety reactions or feelings, following a traumatic event, such as witnessing a death or being involved in a near death experience. • Repetitive play focusing on specific theme or incident • Significant loss or life event

15. Red flags –Contributing factors • Genetics- level of emotionality • Temperament- behaviourial inhibition • Parenting- response, modelling • Cognitive factors-negative attributions & locus of control • Avoidance behaviour • Stressful life events

16. Genetic factors Parental anxiety Parental reaction Anxious vulnerability Arousal & emotionality Processing bias Avoidance Socialisation factors (peers & parents) Non-specific stressors Specific threat experience Anxiety disorder Factors in the Development of Child Anxiety (Rapee, Wignall, Hudson & Schniering,2000)

17. Depression • 2% children and 5% adolescents will experience a major depressive disorder • Symptoms often masked by other behaviour such as anger or aggression

18. Signs of DepressionWhat to look for? • Lethargy and poor concentration • Frequently seeming cranky, grouchy or irritable • Marked decline in academic interest & performance • Fidgeting or inability to sit still • Loss of interest in activities once enjoyed* • Feelings of worthlessness or hopelessness* • Becoming withdrawn or isolated from others* • Sudden outbursts of anger, aggression and/or crying • Suicidal thoughts • Self-harming or risky behaviour • Constant complaints or emotional outbursts with no apparent cause • Truancy, absenteeism, lateness, school refusal

19. Behaviour vs. Anxiety/ Depression

20. What you can do… • Dealing with emotions- encourage articulation of feelings, anxiety management • Address thinking- challenge thoughts, problem solving • Foster self-esteem- mastery experience, peer relationships, social skills • Predictability and control- routine and involvement • Avoid encouraging avoidance (Anxiety)

21. Dealing with Emotionalitywww.schoolpsychiatry.org • Provide specific steps the student can take to relax, or provide a relaxation ritual • Provide alternative foci to distract the student from somatic symptoms • Have the student identify antecedents/precipitants to anxiety • Help the student address stressors through art activities • Help the student devise and practice problem skills • Design and post visuals for the student to review and use when solving a problem • Identify a hierarchy of safe places for the student to de-escalate emotionality symptoms

22. Addressing Thinking • Have the student practice positive self-talk • Help the student evaluate the evidence for his/her negative conclusions • Challenge the student's negative cognitions • Help the student identify automatic negative thoughts • Help the student examine other perspectives • Provide the student with competing responses to negative thoughts or behaviours • CBT Programs- Get Lost Mr. Scary, Cool Kids, Coping Koala, FRIENDS

23. Detective Thinking (Rapee, Wignall, Hudson & Schniering,2000) • What am I worried about? • What is the evidence? • What happened last time? • What are the facts? • What else could happen? • What is my positive thought? • What will really happen?

24. Dealing with Worry www.schoolpsychiatry.org • Model appropriate behaviour for the student in anxiety-provoking situations • Diminish stress within school situations if possible • Forewarn the student of transitions, and have "tasks" for the student to focus on during transitions • Address student individually, outside of class whenever possible, about fears • Embed desirable, familiar, or safe content in instruction • Add literature (bibliotherapy) that addresses the student's fears, or exemplifies coping strategies • Involve the child in activities as a helper and promote peer interaction through group work (zero bullying policy) • Use visuals to help "pace" the student when he/she is anxious about a parent being away, stressed about completing work, or perservating on a particular upcoming event or activity • Develop a consistent de-escalation procedure familiar to staff

25. Dealing with Depressionwww.schoolpsychiatry.orgwww.learningplace.com.au • Schedule check-ins • Establishing a daily communication mechanism with parents/carers to monitor moods and behaviour • Provide more time & adjust work load • Encourage building links with other students through activities e.g. group work or buddy • Anticipate issues & be aware that some situations may be particularly difficult • Listen to the child’s feelings • Address any comments about suicide

26. Depression cont… • Establishing areas of interest and ability • A desk-top reinforcement schedule to encourage on-task behaviour • Give a job or role which includes positive socialisation and reinforcement • Strategies to manage behaviours out of class- e.g. playground monitoring plan • Whole class sessions on resilience strategies e.g. FRIENDS Program • Access to school counsellor or teacher

27. What to do next… • Consult with other teachers and parents regarding child’s presentation in other settings • Discuss with school counsellor • Encourage parents (or get their permission) to contact the following for an assessment:- • Pediatrician (or G.P) • Local community health or CAMHS service • University clinics (UNSW, USyd, UMacq, UWS) • Australian Psychologist Society on 1800 333 497 or the Find a Psychologist link www.psychology.org.au

28. Anxiety & Depression Websites • www.massgeneral.org/schoolpsychiatry • http://education.qld.gov.au/ • www.panicanxietydisorder.org.au/ Panic disorder association • www.socialanxiety.com.au Social anxiety • www.socialanxietyassist.com.au Social anxiety • www.anxietynetwork.com.au anxiety • www.psy.mq.edu.au/MUARU Macquarie uni anxiety clinic • www.worrywisekids.org anxiety • www.beyondblue.org.au/Depression • www.crufad.com/cru_index.html Research on anxiety and depression • www.friendsinfo.net FRIENDS program