Helping young people cope with stress and anxiety ...€¦ · Generalised anxiety – reassurance seeking, avoiding Obsessions and compulsions – intrusive and distressing PTSD –

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HELPING YOUNG PEOPLE COPE WITH STRESS AND ANXIETY

Dr Melanie WoodfieldClinical [email protected]

WELCOME AND INTRODUCTIONSIntroductionsWhat appealed about this seminar? What do you hope to learn?

HousekeepingToilets, breaks, fire exit

N.B. All cases have been anonymised and are representative only

If material is provocative or unsettling…

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TODAY

Getting to know anxiety and stress – descriptions, function.

Problematic anxiety: Zane and Melanie.

Why and how does anxiety develop?

Ways of understanding and conceptualising anxiety.

Focus on: School Refusal.

Coping strategies – adaptive and maladaptive, including deliberate self-harm.

Treatment – how to help. Including mindfulness and relaxation.

Resources – online, books, and services.

TRUE OR FALSE?1. If something makes you anxious, the best way to cope is to avoid that thing.

2. Simple reassurance (e.g. “It’s OK”) is helpful for very anxious young people.

3. There’s no need for treatment – even severe anxiety will improve on its own eventually.

4. It’s possible to ‘not feel’, and that’s what we should aim for.

5. Anxiety runs in families.

6. Anxiety issues stem from a difficult childhood.

7. Medication is the most effective treatment for adolescent anxiety.

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TRUE OR FALSE?If something makes you anxious, the best way to cope is to avoid that thing. Usually False

Simple reassurance (e.g. “It’s OK”) is helpful for very anxious young people. Usually False

There’s no need for treatment – even severe anxiety will improve on its own eventually. Usually False

It’s possible to ‘not feel’, and that’s what we should aim for. True, and False

Anxiety runs in families. Usually True

Anxiety issues stem from a difficult childhood. Usually False

Medication is the most effective treatment for adolescent anxiety. Usually False

DEFINITIONS

Anxiety involves thoughts of future threat, and a desire to avoid this. It’s a future oriented mood state associated with preparation for possible, upcoming negative events. Anxiety disorders are usually defined by DSM-5 or ICD-10.

Fear involves thoughts of imminent threat, and a desire to escape or flee. It’s an alarm response to present or imminent danger (real or perceived).

from Craske et al. (2009). What is an anxiety disorder? Depression and Anxiety 26: 1066-1085.

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STRESS

A stressor is an environmental condition or external stimulus or an event that causes stress.

Stress is “a condition or feeling experienced when a person perceives that demands exceed the personal and social resources the individual is able to mobilise.“, or an “imbalance between demands and resources” (Lazarus and Folkman, 1984)

HOLMES & RAHE STRESS SCALE (1967)

Two psychiatrists reviewed 5000 medical records, interested in whether stressful life events were linked to illness. Research has subsequently confirmed their findings – stress is closely linked to physical wellbeing.

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COMMON SYMPTOMS OF ANXIETYSleep issues (technology – chicken and egg) and appetite changes

Somatic complaints – nausea, abdominal pain, headaches, sore jaw, muscle tension Irritable Bowel Syndrome

Social withdrawal – fear of negative evaluation by others

Poor school performance, concentration

Irritability, restlessness, fatigue

Panic symptoms – severe fear, hyperventilation, sweating, trembling, dizziness, shortness of breath, heart palpitations. Fear of further attacks, dying, losing control.

Fear of separation – worry that harm will come to loved ones.

Generalised anxiety – reassurance seeking, avoiding

Obsessions and compulsions – intrusive and distressing

PTSD – re-experiencing (dreams, memories), avoid reminders of event, numbness.

FUNCTION/PURPOSE OF ANXIETY

Maintain high levels of vigilance for personal safety

An internal alarm system , preparing us to flee, freeze or fight

Also, connection to others?

But anxious people tend to Selectively attend to threatening information Interpret ambiguous events in a relatively threatening way

Their alarm system / body scanner is set as too sensitive, and needs recalibrating.

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PROBLEMATIC ANXIETY?

Two experiences: Melanie and Zane from One Direction.

I’m not particularly fond of spiders…

And Zane’s not particularly fond of performing…

ZANE (“ONE DIRECTION”)

“Dear Fans

I have been working over the last three months to overcome my extreme anxiety around major live solo performances I feel I am making progress but I have today acknowledged that I do not feel sufficiently confident to move forward with the planned show in Dubai in October.

I am assured that all tickets will be refunded.

I am truly sorry to disappoint you. I hope to see you all soon.

Thank you to all my fans who support me globally.

With love and respect always,

Zayn”

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ABNORMAL FEAR AND ANXIETY

Differs in severity, not in nature.

Clinically significant anxiety causes marked distress or impairment in important areas (like school, social relationships, family functioning).

Consider: Is the young person’s behaviour and distress clearly excessive, compared with other young people? Is the young person distressed by the anxiety? Or is the family distressed?

Also consider the duration and pervasiveness of the difficulties, and the extent to which they can be controlled or managed.

NORMAL FEAR AND ANXIETY

Normal fears Early childhood - fear of loud noises, strangers and separation. School years – evaluative and social situations, bodily injury, illness. Tends to be a progression from physical threat to less concrete threats.General worry, performance anxiety, shyness around unfamiliar people –common in both adults and children

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TOO MUCH OR TOO LITTLER E T R I E V E D F R O M H T T P S : / / S R 2 L E A R N . W O R D P R E S S . C O M / 2 0 1 1 / 0 7 / 0 4 / C O N Q U E R I N G - T E S T - A N X I E T Y - S T R A T E G Y /

ANXIETY DISORDERS

Very common (most common, but often overlooked).

More common in females than males.

Usually (about 80% of the time) comorbid with other disorders (often another anxiety disorder)

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EXAMPLESSeparation Anxiety Disorder

Panic Attack / Panic Disorder

Generalised Anxiety Disorder

Specific Phobia

Agoraphobia

Social Phobia

Substance-Induced Anxiety Disorder

Obsessive-Compulsive Disorder (OCD)

Acute Stress Disorder

Post-traumatic Stress Disorder (PTSD)

HOW AND WHY DOES PROBLEMATIC ANXIETY DEVELOP?Child factors: Anxious temperament – “behavioural inhibition” BI children withdraw and are frightened when encountering new or unusual events. Prone to tears, clingy

behaviour, less likely to talk, explore or interact with strangers than others their age.

Parent factors: Controlling style, ?rejecting style, overprotection Lab studies suggest parents of anxious children more intrusive, involved, and protective, especially in difficult

times. But, anxious children may elicit certain responses from parents. Particularly if parent is also anxious. Overprotection is unhelpful – maintains anxiety, and kids can’t learn that the world isn’t as dangerous as they

believe.

Cognitive factors: Interpret ambiguous situations in a threatening way. (e.g. group of children laughing).

Avoidance behaviour – more likely to escape or avoid – leads to maintenance of anxiety.

Other factors: Messages from parents through observation and discussion (social modelling). Stressful life events – reduce feelings of safety. General negative life events – anxiety may be worsened by reaction to life events in individuals who are

anxious or emotional temperamentally.

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HOW AND WHYDOES PROBLEMATICANXIETY DEVELOP?

Obtained from p.36 of Rapee et al.’s “Treating Anxious Children and Adolescents” (2000)

THINGS HAVE CHANGED FOR ADOLESCENTS

Nuffield Foundation (UK) research into social trends and mental health

https://www.youtube.com/watch?v=ZuOQuq4NwB4More adolescents reporting anxiety and depressionAdolescent time use and education – the shape of the average day has changed. School experiences have changed – staying at school longer, more focus on assessment, in education/training environments populated by peers (cf. work environments – mixed age). Individual choices about how to spend time, rather than work environment dictating this. More active parenting that continues into early adulthood Parental separation / divorce rates have climbed

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FRAMEWORKS Ways of understanding and conceptualising anxiety

COGNITIVE MODEL

Event

Interpretation of Event

Emotional Response

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COGNITIVE MODEL

Event

Considering asking a partner to the ball

Threat or danger

“I will mix up my words and s/he will reject me”

Anxiety

PROF PAUL SALKOVSKIS

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UNDERSTANDING ANXIETY USING CBT

Anxiety Is future focused, the ‘what ifs’ Involves fears about our ability to cope

Overestimation of the danger of a situation + Underestimation of our ability to cope = Anxiety

AVOIDANCE AS MAINTENANCE

Avoidance of the anxiety producing situation allows the belief to continue because there is no opportunity to prove it wrong. I’m terrible in big group situations

Avoidance stops the uncomfortable sensations of anxiety and acts as negative reinforcement Sore tummy – go home – feel better

Anxiety + Avoidance = Ongoing maintenance of anxiety

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ANXIETY AND THE FIVE-PART-MODEL

Thoughts “I can’t cope”

Physiology Hyperventilation, dizziness, shaking…

EmotionsFear, anxiety

BehaviourAvoid

Context

FIVE PART MODEL INFORMS TREATMENT

Behaviour - avoid doing scary stuff avoid avoiding, foster exposure

Physiology - breathing and adrenalin learn diaphragmatic breathing and relaxation

Thoughts - ‘I can’t cope’ challenge thinking and replace with more balanced thoughts

Emotions – fear, anxiety become aware of anxiety and differentiate it from other mood states –psychoeducation on the function and purpose of fear

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SCHOOL REFUSAL

SCHOOL REFUSAL

The following slides were prepared by Dr David Heyne and Dr Floor Sauter from Leiden University (The Netherlands) and Dr Brandy Maynard from St Louis University (USA) for the World Congress on Behavioural and Cognitive Therapies in Melbourne in June 2016.

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SYSTEMS WORKFamily workFacilitating exposureReducing conflict, including around school attendance – instead promoting positive interaction to reduce stress (Heyne et al., 2008).Allowing time for skills practice, communication, and family problem-solving.

School staffLowering the hurdles as much as possible

N.B.

Efficacy of treatment is greater for children, poorer for adolescents.

Also note – absence from school reduces the quality and number of opportunities to increase social interactions, so a cycle can develop: socially anxious YP are more likely to refuse school, and refusing school can worsen social anxiety.

For some, a decrease in anxiety leads to an increase in school attendance, but not for others.

CBT-type interventions are the most widely supported by the literature. Medication does not seem to improve the effects of CBT-type treatments for school refusal.

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COPING STRATEGIES Adaptive and maladaptive

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HOW YOUNG PEOPLE COPE

Often they cope well – talking with supportive peers or parents, seeking help when necessary, noticing own ‘warning signs’ and responding to these.

Or they may cope using unhelpful strategies, such asBy avoiding what causes unpleasant stress and anxiety Short term gain, but long term pain…

Distraction

Compulsions

Using alcohol and other drugs

Over- or under-eating

Deliberate self harm

DELIBERATE SELF HARM

• Deliberate self-harm is a term used when someone injures themselves intentionally. Can refer to a one-off incident, or a regular and ongoing pattern.

• Prevalence is hard to gauge as most people keep self-harm private. Estimates vary from 0.4% to more than 10% of the general population. Women generally self-harm more than men. Deliberate self-harm is rare in children under 12.

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Thoughts of death and dying, and thoughts of suicide are surprisingly common in adolescence. The thoughts may or may not be associated with any intent to act.

Self-harm may be a coping or survival strategy (maladaptive). Or it may represent suicidal behaviour. Self-harm and suicide have an intimate relationship but are different in intent. Assumptions can be dangerous.

It is important to note that people who self-injure are statistically at greater risk of going on to commit suicide.

Risk (to self, to others, and from others) changes constantly, and risk assessment is notoriously tricky.

A common myth (not true) is that asking directly gives young people ideas.

Beware of “you won’t tell anyone, will you?”, or “I’ll only tell you if you promise not to tell my Mum”.

“You seem really down, and that makes sense given what’s been happening. Sometimes when people feel really down they have thoughts of ending their life. Is that true for you?”“Are you having thoughts of ending your life (suicide)?”Parent or caregiver may need to be informed, even if young person does not want this to happen. Particularly if you’re involving other services, e.g. CAMHS.

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INTERVENTION - DSH

Deliberate self-harm is often a strategy (unhelpful) that a young person is using to cope with an associated difficulty, such as a mood or anxiety disorder, or emotion regulation difficulties.

Important to identify the function of the behaviour. Can work with young person to substitute behaviour that results in a similar outcome, but is less harmful. DBT-type strategies can be helpful, e.g. T – temperature

I – intense exercise

P – paced breathing

P – progressive muscle relaxation

Important to address the underlying difficulties.

TREATMENT How to be helpful

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WHERE TO START

Comprehensive assessment first.

Formulation / conceptualisation – why anxiety, why now?

Use this information to determine what’s needed Nothing?

Psycho-education and support

Skill-building – teaching specific strategies

Working with parents

Manualised intervention

Referral to specialised services

PROF PAUL SALKOVSKIS

How psychological treatments work: People suffer from anxiety because they think situations are more dangerous than they really are.

Treatment helps the person to consider alternative, less threatening explanations of their problem

If the alternative explanation is to be helpful It has to fit with your past experience

It has to work when you test it out

Good therapy is about two (or more) people working together to find out how the world really works

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TREATING STRESS, OR MILD ANXIETY

Validate and reflect emotions.

Problem solve if possible.

Identify values (compass points metaphor, passengers on the bus metaphor)

Look for exceptions to the young person’s “rules”, and highlight these. Often black/white, and grey can be helpful E.g. “I have no self-control at all”

Look for examples of the young person doing something which mattered, despite their doubts or fears, and highlight these.

TREATING ANXIETY – CORE COMPONENTS

Education / information

Cognitive restructuring

Exposure in some form: • Graded exposure - ‘approach and retreat’• Exposure and response prevention - ‘feel the fear and do it anyway’• Mindfulness of emotion - ‘I can cope with this emotion’

Relaxation

Problem solving, social skills training, assertiveness

Parent workAll link back to the overall model of how anxiety develops and is maintained

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TREATMENT

Reflect or validate

Avoid ‘empty’ reassurance, like “it’ll be OK”, “they like you – you’re imagining it”

Provide information / education around the effects of stress and anxiety on the body

Problem solve if possible

Reduce demands

Introduce/enhance supports

Behavioural activation, pleasurable activity scheduling, exercise

THINKING ERRORS

If not possible to problem solve, check thinking, and come up with adaptive alternatives “If …. were true, what would that mean about you?” Is the thought true? What’s the evidence for/against? If not… If it is true, is it helpful? Or what is the effect this thought is having on my feelings and behaviour? What could be the effect of changing my thinking? What should I do about it? What is the worst that could happen? (Could you live through that)? What’s the best that could happen? What’s the most realistic outcome? What would I tell (a friend) if s/he were in the same situation?

I haven’t chosen a university course – I should have chosen by now – I’m letting people down – I’m inadequate, I’m a failure.

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MANUALISED TREATMENTS

Cool Kids programmes - Ron Rapee and colleagues (Centre for Emotional Health at Macquarie University)

“Helping your Anxious Child: A Step-by-Step Guide for Parents”

“Treating Anxious Children and Adolescents: An Evidence-Based Approach”

Coping Cat – Phillip Kendall

MATCH-ADTC (Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems) – Chorpita and Weisz

“Think Good, Feel Good” – Paul Stallard

Centre for Clinical Interventions - http://www.cci.health.wa.gov.au/

MINDFULNESS

“Life is what happens to you while you’re busy making other plans”

Our mind often takes us to the past, or the future.

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MINDFULNESS - RESOURCES

The Mental Health Foundation’s website, including information about their mindfulness courses and “Pause, Breathe, Smile” programme for children. www.mindfulaotearoa.nz

CALM – Computer Assisted Learning for the Mind – University of Auckland: “A motivational tool for students struggling with depression, anxiety, stress, relationships and other factors that can contribute to poor study practices”. www.calm.auckland.ac.nz

Search phrases like “mindfulness of the breath script” or “guided mindfulness exercises” online.

DROPPING ANCHOR

Russ Harris www.ACTmadesimple.com

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RELAXATION STRATEGIESThere is no one way of relaxing. Find what works for you.

Progressive muscle relaxation (PMR) and autogenic training Guided calming imagery Meditation Controlled breathing Pilates and yoga Physical exercise, nature, sunlight Relaxing activities – books, music, watching a comedy

Parental involvement (children)

Start with developing an awareness of how child/YP feels when they are tense versus how they feel when relaxed.

PRACTICE

Progressive Muscle Relaxationp. 88-89, Rapee et al. (2000)

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RESOURCES

ONLINE RESOURCES

The Lowdown: www.thelowdown.co.nz

SPARX: www.sparx.org.nz (https://www.youtube.com/watch?v=Y9cj-rRrH94 )

Werry Centre www.werrycentre.org.nz

Centre for Emotional Health at MacQuarie University – factsheets www.centreforemotionalhealth.com.au

MoodGYM (CBT, depression): www.moodgym.anu.edu.au

Mental Health Foundation’s list, including apps: https://www.mentalhealth.org.nz/get-help/a-z/apps-e-therapy-and-guided-self-help/

Anna Freud Centre podcasts (UK) http://www.annafreud.org/about-us/news/2016/08/ground-breaking-podcast-series-launched/

Psychology Tools website psychology.tools

Skylight online store (St Luke’s Innovative Resources): www.skylight.org.nz

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WRITTEN RESOURCES

Rapee’s books, and other manualised interventions (mentioned earlier)

Edmund Bourne’s “The Anxiety & Phobia Workbook”

Roz Shafran and colleagues’ “Overcoming Perfectionism”

Forsyth and Eifert’s “The Mindfulness and Acceptance Workbook for Anxiety”

Paul Stallard’s “Think Good, Feel Good” (adolescent version in press)

SERVICES

SGCs

GP – PHO-funded sessions (e.g. Procare, East Tamaki Healthcare)

Youthline counselling

Family Works, Home and Family, etc.

Therapists or Psychologists in private practice, including Anxiety NZ Trust (formerly Phobic Trust)

Child and Adolescent Mental Health Services (CAMHS) Kari Centre (ADHB) Marinoto North and Marinoto West (WDHB) Whirinaki (CMDHB) Out-of-Auckland CAMHS, and contact details for all, see www.werrycentre.org.nz

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THANK YOU [email protected]