Anxiety in Children and Adolescents: How to Manage those ... · Anxiety in Children and Adolescents: How to Manage those Worries and Fears Isabel Rodriguez-Duncan, LCSW, Ed.S. Clinician,

Anxiety in Children and Adolescents: How to Manage those Worries and Fears

Isabel Rodriguez-Duncan, LCSW, Ed.S.Clinician, CCF

Topics to Cover① Introduction to who we are

② Overview of child anxiety

③ Description of specific anxiety disorders

④ Treatment techniques

⑤ Reinforcing the coping child

⑥ Overview of outcomes

⑦ How to Participate

The CCF

o Provide clinical treatments based in strong evidence for children and adolescents with mental and behavioral health problems

o Conduct top research in all areas of child and adolescent typical development and mental health problems

o Educate upcoming clinicians and researchers in the field

Who We are at the CCF

Who We Are at the CCFTreatment for infants through 17yo◦ ADHD

◦ Aggression

◦ Anxiety, fears, worries

◦ Autism

◦ Mood problems

◦ Learning difficulties

◦ Families in Transition from divorce/Couples Counseling

◦ Based in Behavioral and Cognitive methods

Who We Are at the CCF for AnxietyTreatment for 3-17yo

Use Best Practice Treatments◦ Supported by research◦ 8-16 sessions of Cognitive-Behavioral Therapy (CBT)◦ Attention-Bias Modification Therapy◦ Parent training component to treatment, more for younger children

Clinicians: ◦ Ph.D. level, licensed psychologists, licensed clinicians◦ Highly trained doctoral and masters level graduate students

(supervised)

Overview of Child Anxiety

Normal Fear and Anxiety or an Anxiety Disorder?

For most children and adolescents, fear and anxiety are experienced without great interference in everyday life

Anxiety is:◦ A natural emotion

◦ An enjoyable emotion for many children (e.g., scary movies, stories)

For some children, fears persist and interfere in daily functioning or in family functioning and disrupt normal development

Normal Fears & Worries vs.Anxiety Disorders

o Children’s fears are usually mild, transitory, can be adaptive, and are very common and normal

o HOWEVER, some children experience fears that persist, interfere with daily functioning, and are not age appropriate.

o When these fears become excessive, persistent, and cause psychological distress, and are not associated with an actual threat, treatment is necessary

Prevalence and SignificancePediatric anxiety disorders are common◦ 10-20% of children in the general population report

clinical levels of anxiety

◦ Relatively stable over time

◦ Associated with depressed mood

Pediatric anxiety disorders are impairing◦ Academic and social problems

◦ Predict future emotional health problems (if untreated)

Description of Specific Anxiety Disorders

Anxiety Disorders: Children and Adolescents

o Separation Anxiety Disorder

o Specific Phobias

o Social Phobia

o Selective Mutism

oGeneralized Anxiety Disorder

oObsessive-Compulsive Disorder

o Panic Disorder with or without Agoraphobia

Separation Anxiety DisorderPersistent fear of separation from caregiver

Repeated somatic complaints such as stomachaches, headaches

Reluctance or refusal to go to school, play dates, sleepovers, camp, birthday parties, etc. without a parent present

Symptom trends:◦ Ages 5-8: fears of harm befalling attachment figures,

nightmares, school refusal◦ Ages 9-12:excessive distress at separation◦ Ages 13-16: somatic complaints and school refusal

Specific PhobiaMarked and persistent fear that is excessive or unreasonable

Examples: animals, the dark, heights, thunder/lightening, shots/blood tests, doctors/dentists, vomiting, choking, etc.

Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may provoke a panic attack

Social PhobiaMarked 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

What you might see:◦ Keeps to self in class

◦ Reluctant to answer questions

◦ Shyness around unfamiliar people

◦ Difficulty initiating conversations with peers

◦ Isolation in unstructured settings (lunch, recess)

Age Trends in Social PhobiaoMay begin as inhibited temperament in

preschoolers

oAssociated with selective mutism in young school-aged children

oHigher prevalence in postpubertal adolescents

o Retrospective reports of adults place age of onset in adolescence

Selective Mutismo Consistent failure to speak in social situations where there

is an expectation of speaking

o Failure to speak is not due to lack of knowledge of language

Generalized Anxiety DisorderExcessive anxiety and worry occurring more days than not for at least 6 months, about a number of events or activities

The worrying…◦ Is difficult to control

◦ May be associated with restlessness, fatigue, irritability, muscle aches, and sleep disturbance

What you might see:◦ The “worry-wart” (worry about school, performance, health,

personal safety)

◦ Perfectionism (on-time, need to keep schedule)

◦ Excessive reassurance-seeking and the “What ifs?”

◦ Difficulty with transitions/new situations

Obsessive-Compulsive DisorderObsessions and/or compulsions:◦ Recurrent and persistent thoughts, impulses or images that are

intrusive and cause marked anxiety or distress (obsessions)

◦ Child attempts to suppress such thoughts, or to neutralize them with a thought or action (compulsion)

◦ Distressing and time consuming (at least 1 hour per day)

What you might see:◦ Ordering and arranging of items

◦ Repeated checking (did I lock the front door?)

◦ Erasing and rewriting multiple times

◦ Excessive hand-washing

◦ Counting things over and over or special number of times

Discrete period of intense fear or discomfort

At least 4 symptoms start abruptly and reach a peak within 10 minutes:

Panic Attacks

Palpitations (“I’m having a heart attack”)

Sweating

Trembling or shaking

Shortness of breath

Feeling of choking

Chest pain or discomfort

Feeling dizzy, lightheaded or faint

Derealization or depersonalization

Fear of losing control or going crazy

Fear of dying

Numbness or tingling

Chills or hot flushes

Nausea

Panic DisorderRecurrent, unexpected panic attacks

1 month or more of at least 1 of the following:◦ Persistent concern about additional attacks

◦ Worry about implications of attacks or their consequences (e.g., losing control, going crazy, heart attack)

Rarely occurs in children <12

AgoraphobiaAnxiety about being in places/situations where, if an unexpected panic attack occurs:◦ Escape might be difficult or embarrassing◦ Help may not be available

These situations are:◦ Avoided or endured with marked distress or anxiety about

having an attack◦ Require the presence of a companion

Commonly Avoided Places◦ Classrooms, Crowded hallways, Cafeteria, Movie theater, Malls,

Open spaces

What to Do: Treatment Techniques

Cognitive-Behavioral Treatment

Cognitive-Behavioral Therapy is…oSkills-focused, goal-directive

oPresent and future-focused

oEmpirically supported (12-16 sessions)

Core Treatment ComponentsEducation about anxiety (fear, depression, etc.)

Relaxation (if applicable)

Cognitive Restructuring (“Detective Thinking”)

oExposure!!!

Situational Exposure

Education about Fear and AnxietyFear is…◦ Natural

◦ Necessary

◦ Harmless

Fear is designed to…◦ Draw our attention to an immediate threat

◦ Keep us safe by activating our fight-or-flight system

Child is prompted to face anxious

situation

Child gets (too)

anxious

Child avoids

Adult rescues*

Child’s and adult’s anxiety are lowered*

Negative Reinforcement

Behavioral

Conceptualization

of Anxious

Avoidance

Education about Anxiety: Habituation“Riding the Wave” of Anxiety

Time

Level of Anxiety

Low Anxiety

High Anxiety

3-Component Model of Anxiety

What I Do What I Feel

What I ThinkHelps guide the

selection of

treatment targets and

techniques.


What I FeelWhat I Do

What I Think

Sweaty, hot, shaking

Situation: I have to

give a presentation in

front of the class

I am going to mess up

in front of everyone

Everyone will be

able to see how

scared I am

Try to go last

Feelings intensify,

start feeling

nauseous

Go to nurse for the

duration of class

AVOID



What I Think

Helps guide the

selection of


techniques.

Recognizing & Labeling Feelings

Child learns to recognize and label different emotions

Use body language, facial expression, and tone of voice

------------------

Magazines

Feelings Collage

Feelings Charades

Body Reactions to Anxiety

Trembling?

Butterflies?

Sweating?

Stomachache?

Headache?

Pounding Heart?

Coping modeling and role-plays Body Drawing

Fire Alarm and Detective Analogies

RelaxationMuscle Tension

Relaxation Training ◦ Progressive Muscle Relaxation (PMR)

◦ Secret Calming/Deep Breathing

Positive imagery exercises◦ A Peaceful Place



What I Think

Helps guide the

selection of


techniques.

What You Think: Anxious Self-TalkIn situations where we are experiencing strong emotions, like anxiety or fear, thoughts may be unrealistic.

◦ Thoughts about the situation, not the situation itself, are often what scare us.

◦ Consider thoughts to be “fact” and do not question how realistic they are.

◦ Anxious children tend to overestimate the likelihood that something bad will occur, and underestimate their ability to cope with it if it did.

Identifying Anxious Thoughts

If I talk, I’ll say

something stupid

and everyone will

laugh!

What if someone

steals me from

my bed?!?!

I’m not feeling

well! Maybe I have

a disease and I

might die!

I’m scared I’m gonna

do bad on this test

and then I won’t be

able to go to college

and get a good job!

Addressing Anxious ThoughtsThink like a detective! ◦ What trap did I fall into?

◦ Treat thoughts like guesses, not facts

◦ Look for evidence in support and against this thought

◦ Explore alternate interpretations

Three Most CommonThinking Traps

1. Jumping to ConclusionsoLeaping to a specific conclusion without evaluating how realistic

that outcome is.oExample?

2. Thinking the WorstoThinking that the worst possible outcome is going to happen.oExample?

3. Ignoring the PositiveoFocusing on the negative aspects of a situation, while ignoring

the positive.oExample?

Detective Thinking Imagine the worst thing actually happening

Critically evaluate its actual severity:◦ Would it be as bad as first thought?◦ Could you cope with it?◦ Have you handled anything like that before?

Typically, consequences of a situation are:◦ Time-limited◦ Manageable

Say to self: “So what if ‘it’ happens?”

Gather Evidence

# of times feared

outcome occurred

# of times I have been

in this situation

Probability of the feared

outcome happening

**Focus on probability NOT possibility

1.What is the situation? Sitting in the bus

2. What is the anxious thought? I’m going to start shaking and sweating and then I’ll faint. I’ll be so embarrassed, I’ll never be able to ride the bus again.

3. What is the possible thinking trap? Catastrophic Thinking & Probability Overestimation

4. Evidence:What’s happened in the past?

What is the real likelihood?

What is another way it could turn out?

- I’ve never fainted on the bus before - Likelihood (10/100) - If it did happen, I would be embarrassed, but

probably only for a few days- people always find something new to gossip about after a few days.

5. What are some calm thoughts? I probably won’t faint.

6. So what if it does happen? I would feel embarrassed, but it won’t last forever.

Targeting Thoughts: Cognitive Self-Statements

Some kids benefit from single coping self statements (especially if derived from detective thinking):

I am a brave girl (boy).

I can take care of myself when I am alone

There are no monsters under my bed!

I did it the last time, so I can do it again!

*These statements can be made into “coping cards”

*Should always be realistic for the child!*

Five STEPS to Problem Solving

S – Say what the problem is

T – Think of Solutions (even the silly ones)

E – Evaluate each Solutiono What is good about this?o What is bad about this?

P – Pick one and try it out

S – See if it workedo If it worked, great! If it did not, go back to your list of solutions and try another one


What I DoWhat I Feel

What I Think

Helps guide the

selection of


techniques.

Practice, Practice, Practice!EXPOSURES: “We’ll go places and do things!”

•Anxiety provoking situations

•Aim is not to remove anxiety, but to be able to manage it, so child should experience anxiety.

• Opportunity to practice

• Gradual (step-by-step)

• Repetition is key!

• Reward offered when completed!

Targeting Anxious Behavior: Situational Exposure

Facing Fears◦ Provides basis for more realistic thoughts about

situation◦ Not as scary/dangerous as thought◦ I was able to handle the situation/ feeling

scared

*Do not use relaxation techniques during exposure!*

FEAR

PYRAMID

Example Fear Ladder

ACTIVITY ANXIETY RATING AVOIDANCE RATING

Staying in school for entire day

8 8

Staying in class for entireperiod

7 8

Sitting in classroom for 30 minutes

7 8

Sitting in classroom for 10 minutes

6 6

Sitting outside classroom 5 4

Walking through hallways 5 3

Sitting in counselor’s office 4 3

Reinforcing the Coping Child

Modeling Appropriate BehaviorA child can learn anxious behaviors by observing others

Model brave, calm behavior for the child – self-disclosure

Use appropriate coping skills in the face of anxiety

Reinforcement Techniques

Parents can inadvertently reinforce anxious behaviors◦ Providing excessive reassurance◦ Permitting avoidance

Using Reinforcement◦ Reward/praise non-anxious behavior◦ Active Ignoring of inappropriate behaviors (ex:

reassurance-seeking behaviors, tantrums)

Discouraging Avoidance Learn to support child, but not encourage avoidance

oEncourage child to utilize coping skills

oHelp child break down anxiety-provoking situations into manageable steps. Example: Child is nervous about being alone in the dark.

How would you break this down into manageable steps?

Provide praise when child faces their fears.oLabeled praise is more effective (Example: “Good job”

vs. “You did such a good job staying in your own bed last night.”)

Rewarding ChildrenSetting up a Reward systemoReward should be given immediately after completion of

task, if possible

oNon-monetary

oGive only if see the desired behavior

oSet clear expectations around how rewards can be earned

oBe consistent and follow through!

◦ Can be faded over time

Self-Evaluation and Self-RewardRating performance

Rewarding partial success and effort

Tangible vs. social rewardsExamples:

Toys Game-time with therapist

Stay awake later Choose favorite meal

Praise Movie night

REWARD MENU

5 things a parent or teacher can say to me to make me feel good

1. ___________________________________________________________

2. ___________________________________________________________

3. ___________________________________________________________

4. ___________________________________________________________

5. ___________________________________________________________

5 things I can do with family or friends for fun

1. ___________________________________________________________

2. ___________________________________________________________

3. ___________________________________________________________

4. ___________________________________________________________

5. ___________________________________________________________

5 things that cost less than $5

1. ___________________________________________________________

2. ___________________________________________________________

3. ___________________________________________________________

4. ___________________________________________________________

5. ___________________________________________________________

Overview of Outcomes

Pooled Analysis of CBT for Child Anxiety Disorders

% R

em

issi

on

Dia

gn

osi

s

12 Studies; ITT, p = 0.13, Cochrane Report, 2006

Pharmacological Intervention

RUPP Pediatric Anxiety Study

RUPP Anxiety Study Group. (2001). NEJM, 344, 1279-1285.

Treatment Response CGI-I = 1 or 2 ITT, LOCF

ResponderN (%)

Non-ResponderN (%)

Total

COMB 113 (80.7) 27 (19.3) 140

CBT 83 (59.7) 56 (40.3) 139

SRT 73 (54.9) 60 (45.1) 133

PBO 18 (23.7) 58 (76.3) 76

Total 287 (58.8) 201 (41.2) 488

Walkup et al., 2008

In Summaryo Ignore inappropriate or anxious behavior where possible, attend to

positive or “brave” behavior

o Facilitate at-home exposure practice

o Model confidence during exposure practice

o Remind child to use skills if anxiety expressed “ride the wave,” do “quick calming,” or use detective thinking

o Don’t solve the problem for your child

o Implement Reward System

For the younger ones…Use more concrete vs. abstract methods to engage

Create character for their anxiety

Simple relaxation strategies

More family-based coaching and parent training

CBT for Other Disorders

Obsessive-Compulsive Disorder

◦ Exposure and Response Prevention

◦ Bossing back OCD

Panic Disorder

◦ Interoceptive exposures

Tic Disorders, Tourettes, Trichotillomania

◦ Habit Reversal

Depression

- Focus on cognitions

- Interpersonal Therapy for Adolescents (IPT-A)

- Family-focused treatments

Intensive TreatmentsPanic Disorder with or without Agoraphobia

Specific Phobias

o One-session treatment (Ollendick, Ost, et al., 2009)

Separation Anxiety Disorder

Obsessive Compulsive Disorder

Selective Mutism-

A Clinically Significant Outcome

How to Participate

Clinical ServicesIndividual and group therapy offered for children ages 3-17◦ MINT

◦ CAPP

◦ General CCF

CALL 305-348-0477

Research ProgramsCHILD ANXIETY AND PHOBIA PROGRAM (CAPP)

Attention Bias Modification Training

Purpose: Evaluate a computer administered attention training program as a brief, low intensity intervention

Eligibility: ages 6-17, mild to moderate levels of anxiety, and do not meet criteria for anxiety disorder

Research ProgramsCHILD ANXIETY AND PHOBIA PROGRAM (CAPP)

“Brain training”◦ Research study of mild brain stimulation during an

attention training program for teenagers

(ages 13-17) with anxiety disorders

◦ Safe, noninvasive procedures used in over 1,000 published studies

◦ 4 weekly sessions

◦ Compensation provided for participation

◦ Call 305-348-1937 for more information!

Research ProgramsMENTAL HEALTH INTERVENTIONS AND TECHNOLOGY

PROGRAM (MINT)

Coaching program for young children with anxiety ages 3-7Trial for internet-based version of CBT for children ages 7-17

Saturday Treatment Program (SatTP)o If your child is ages 5-11 and struggling with behavior problems or

ADHD

o 8 Weeks

o Children participate in therapeutic recreational activities focused on social and sports skills

o Promotes positive peer relationships

Parenting Strategies Groupo If your child is ages 5-11 and struggling with behavior

problems or ADHDo 8 Weekly parenting classes o Provide interactive support for parents o Homework help available (extra cost)o School consultations available (extra cost)

T POWER Group – Teens Pursuing Opportunities with Evolving Relationships12-17 years old with interests in building social skills. Presenting socially awkward.

No formal diagnosis required – preliminary screening provided.

12 Sessions

6:00 PM - 7:30 PM Thursday Evenings.

Contact Information

Center for Children and Families

FIU, AHC 1 Room 140

11200 SW 8th St., Miami, FL 33199

(305) 348-0477

Email: [email protected]

Web: www.ccf.fiu.edu

Effectivechildtherapy.fiu.edu

mailto:[email protected]

http://www.ccf.fiu.edu

Helpful Resources

Growing up Brave, Pincus

You and Your Anxious Child: Free Your Child from Fears and Worries and Create a Joyful Family Life, Albano

Helping your anxious child: A step-by-step guide for parents, Rapee, Spence, Cobhan & Wignall

Keys to parenting your anxious child, Manassis

Freeing your child from anxiety, Chansky

www.childanxiety.net

http://www.childanxiety.net

Anxiety in Children and Adolescents: How to Manage those ... · Anxiety in Children and Adolescents: How to Manage those Worries and Fears Isabel Rodriguez-Duncan, LCSW, Ed.S. Clinician,

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