Preventing Anxiety & Depression in Children

Preventing Anxiety & Depression in Children

Marita SchwendlerClinical Psychologist

Child, Adolescent & Family Health

2008 1

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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

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Overview

Normal fears and worries

General signs there is a problem Types of anxiety and depression Causes and red flags Behaviour vs. anxiety/ depressionHow to respond in a school settingWhen and where to refer

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Typical Childhood Fears & Worries

Ages Common fears

Infants and toddlers - loud noises- separation, strangers

Preschoolers - animals – especially dogs- the dark- ghosts and monsters

School age - snakes and spiders- fear of failure and rejection- the news and TV shows- blood, injury, and sickness- being home alone- death

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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?

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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

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Types of Anxiety

Generalised anxietySocial phobia or social anxietySeparation anxietySpecific phobiaPanic disorderObsessive-compulsive disorderPost-traumatic stress disorder

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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 approvalAvoidance of academic & peer activities

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Social AnxietyExtreme 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

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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

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Specific Phobia

Fear of a specific object or situation e.g.. Dogs, spiders, the dark

• Fear and avoidance of specific things

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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 activityUpset or frightened without any easily

identifiable explanation

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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

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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

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Red flags –Contributing factors

Genetics- level of emotionalityTemperament- behaviourial inhibitionParenting- response, modellingCognitive factors- negative attributions &

locus of controlAvoidance behaviourStressful life events

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Factors in the Development of Child Anxiety (Rapee, Wignall, Hudson & Schniering,2000)

Genetic factors

Parental anxiety

Anxious vulnerabilityArousal & emotionality

Processing bias

Avoidance

Parental reaction

Socialisation factors (peers & parents)

Specific threat experience

Non-specificstressors

Anxiety disorder

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Depression

2% children and 5% adolescents will experience a major depressive disorder

Symptoms often masked by other behaviour such as anger or aggression

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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

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Behaviour vs. Anxiety/ Depression

Behaviour/oppositional

Anxiety Depression

Avoidance of task

Positive outcome/ payoff

Fear of outcome (injury, humiliation)

Lacks motivation, unable to concentrate

Social isolation

Social skillsProblems- e.g. can’t share

Fear of rejection

Lack of interest, pleasure withdrawal

Absenteeism Defiance, won’t get up

Separation or social anxiety

Lethargy, decreased interest

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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)

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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

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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

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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?

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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

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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

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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

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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

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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