Recent advances in Anxiety Disorders and Coping Skills - Erin D. Berman, Ph.D. National Institute of Mental Health

Recent advances in Anxiety
Disorders and Coping Skills

        Erin D. Berman, Ph.D.
   National Institute of Mental Health

    http://patientinfo.nimh.nih.gov

How do we help children with
             anxiety?
   Understand the anxiety FIRST! First step to any
    intervention.
       Ever be misunderstood?

   Nervous, scared, worried

   Panic, Fight vs. Flight
     Vs. problem solving!
     How to deal with panic

Evolutionary picture of Anxiety
   Anxiety is Adaptive

   Amygdala
       hub between the parts of
        the brain that process
        incoming sensory signals
        and the parts that interpret
        these signals

Physical Symptoms of Anxiety
   Stomachaches/ headaches
   Nausea
   Frequent trips to the bathroom
   Tightness or pain in the chest
   Sweating
   Dizziness or light headedness
   Heart racing
   Feeling faint
   Response (you can’t stop it)
        Listen
        Be a calming influence (panic
         spreads)
        Remind that this ends

AMYGDALA

The circuitry of attention bias in pediatric GAD

Novel Interventions

                                        12

                                        10

                                        8

                        Anxiety Score
                                        6

                                        4

                                        2

                                        0
                                               Train to Neutral              Train to Angry

                                        Altered Response to Stress

Training of Attention
                                                      Eldara, Ricona, & Bar-Haim in press

Therapist-free therapy
Economist, March 2011

When does anxiety become a
                “disorder”?
   Avoidance

   Interference

   Distress

   Transient vs. Persistent
       Lifetime prevalence of 25% (Kessler,
        2005) and children 3-27% prevalence.

Anxiety Disorders

   Separation Anxiety Disorder
   Generalized Anxiety Disorder
   Social Phobia
   Specific Phobia
   Panic Disorder
   Posttraumatic Stress Disorder

Anxious Youth In Schools
   Problems may be less apparent than youth with
    behavioral disorders
   Children may appear perfectionist; “good kids”;
    but can perform poorly in school (Mychailyszyn et al., 2010).
   Somatic complaints often frequent
       Especially in minority youth (Canino, 2004; Gee, 2004; Pina &
        Silverman, 2004)

   Anxiety can also present as oppositional
    behavior, such as through avoidance of tasks or
    school refusal

High Comorbidity
   A large, national survey of adolescent mental health
    reported that about 8 percent of teens ages 13–18 have an
    anxiety disorder
       symptoms commonly emerging around age 6
       However, of these teens, only 18 percent received mental health care.

   Anxiety is a highly comorbid disorder 65-84% in
    epidemiological and clinical samples (Bird, Gould, &
    Staghezza, 1993; Albano, Chorpita, Barlow, 2003) .
      behavioral disorders

      depression

      substance abuse and

      other anxiety disorders

Separation Anxiety Disorder
    Developmentally inappropriate and excessive
        anxiety about separation from caregiver
   More common in younger children
   More common in girls
   Persistent for 3 months
   Fears of harm to either:
     Themselves or family
     Themes of monsters, illness,

    natural disasters, driving safety.

Separation Anxiety
   Behavioral Intervention: Establish check-
    ins on arrival to facilitate transition into school
   Accommodations: Accommodate late
    arrival due to difficulty with transitions.
         Because transitions may be particularly difficult for these
         children, allow extra time for moving to another
         activity or location .
        When a child with anxiety refuses to follow directions, for
         example, the reason may be symptoms of anxiety rather
         than intentional oppositionality.

Generalized Anxiety Disorder
                (GAD)
   Worrier
   Excessive worrying: not linked to any ONE
    event/situation.
   The child is distressed over any number of
    things—from the health of family members to
    tests at school, performance and future events.
   Self critical
   Perfectionism

Recognize the Sound of Worry
   Let the thought come in          No thought, no
    and go out like any other         matter how horrible,
    thought- don't try to stop        changes what is going
    it, don't push the pause
    button, don't try and
                                      on in front of me
    force it out, play out the       Just because I have
    movie                             the thought, doesn't
   Relabel- It's not me - it's       mean it is true
    worry, I am not weird/in
    danger/insert your own-
    XXX is a false alarm

Instructional Intervention:
    Challenge Negative Thoughts
   “NO ONE likes me”, “I messed up during
    class, now it is over”

       Empathize FIRST vs. don’t just fix it right away
            Empower your child to come up with ideas

       Define “HELPUL” vs. “UNHELPFUL” thinking

Social Anxiety Disorder

   More common in
    adolescents
   Excessive Fear of
    social evaluation
    and/or embarrassment

Typical Social Anxiety Problem
                Solving
   Devise a desensitization approach agreeable to
    the student

    Example:
    If the student fears speaking in front of the class, allow the
    student to: have the speech read by a peer; read the speech into a
    recorder outside class; introduce other students doing speeches;
    do the speech with a peer reading some part. Finally, have the
    student read his/her own speech.

Behavioral Intervention Planning
   Develop a consistent de-escalation procedure
    familiar to staff
    Example:
    When worried, the student will:
   1) take 10 breaths
   2) identify how a preferred "hero" would handle the situation (for the tiny
    ones)
   3) access designated staff
   4) do alternative, less stressful work
   5) do reading for five minutes in an alternative area (corner of room, library),
    then answer questions.

Provide alternative foci to distract the
        student from somatic
 symptoms(Behavioral Intervention)

 Recurrent    headache, stomachache, nausea,
 dizzy ect..
   provide   the student a phrase to think of or
   activity (doing three problems then standing up,
    10 problems then walking to the fountain)
   Breathing

   With all of above need to be practiced ahead of
    time

Managing Anxiety in the School
        Setting (BALANCE!)
            Do                           Don’t
   Be sensitive                 Accommodate the
   Educate                       anxiety too much
   Give positive feedback       Let the child avoid too
                                  much
   Be calm
   Be consistent                Single the child
                                  out/ridicule
   Slowly face their fears
                                 Excessive reassurance
   Seek additional
    resources                    Being too directive
                                  (“taking over”)
                                 Over control the child

Basic Stress Reduction Tools
   Exercise (essential for               Drawing
    treating depression)
                                          Meditation
   Talking to friends
       (essential coping skills for      Cooking/baking
        depression)

                                          Deep breathing
   Playing (GET OUT of the
    House!!)
                                          Progressive Muscle
                                           Relaxation (yoga)
   Reading

Balance

                                               Problem Solving
         Validation
                                   Focuses on change, commitment to
The acceptance of the person
                                   change, and making things different,
for who they are at this moment.
                                   hopefully better

Problem Solving Skills

Face your fears: Baby STEPS
   Small steps

   Model first, if you can
       Or find a “model” (other kids, cartoon characters) to
        watch

   Gently encourage trying new things or new
    behaviors.

Emotion Thermometer
             10___________
             9 ___________
             8 ___________
             7 ___________
             6 ___________
             5 ___________
             4 ___________
             3 ___________
             2 ___________
             1 ___________

Face your Fears

Treating Anxiety
                      Beyond the Home
Medication                                Therapy
   SSRI’s                                 Examining thinking and
       help regulate neurotransmitters     feelings
       Generally well-tolerated
                                           Education

                                           Involving parents and
                                            schools
                                           Homework

                                           Facing fears

                                           Therapist as a coach

NIMH Current Studies
   Thorough evaluation & Participation provided
    free of charge. Travel reimbursement available.
   Children Ages 8-17
   Participation Includes:
     Medical evaluations
     Psychotherapy or treatment medication
      (Outpatient visits over 8 weeks)
     Participants must:
         Be medically healthy
         Not be taking any psychiatric medications

NIMH Contact Information
http://patientinfo.nimh.nih.gov
                OR
          301-402-8225
                OR
          301-496-6642

Resources
   http://patientinfo.nimh.nih.gov
   www.abct.org (therapists)
   http://www.aboutourkids.org/families
   http://csefel.vanderbilt.edu/
   Helping Your Anxious Child: A Step-By-Step Guide for Parents
    Written by Sue Spence , Vanessa Cobham, Ann Wignall, Ronald
    M. Rapee
   www.adaa.org