Sherri McClurg, Psy.D.

Managing Director, Family Center by the Falls

Stephen Grcevich, MD

President and Founder, Family Center by the Falls

Presented at Lake Ridge Academy

October 6, 2011

Anxiety Disorders in KidsAn Overview for Parents and Teachers

Some fears are normal and age-appropriate in children:

Infants: Fear of loud noises, fear of being startled Toddlers/Young Children: Fear of imaginary creatures, fear of the dark, animals, strangersSchool-age children: Worry about injury, natural events (storms), deathOlder children, teens: Fears related to school performance, social competence, health issues

J Am Acad Child Adolesc Psychiatry 2007;46(2) 267-83.

How are kids with anxiety disorders different from their peers?

They misperceive the level of threat, danger in their environmentThey think too much…eventually to the point that academic performance, family functioning, friendships, extracurricular activities are compromised…rumination, perseveration, indecisiveness, perfectionismDecision to treat is grounded in the degree to which anxiety interferes with daily functioning

Epidemiology of Anxiety Disorders:

8% of teens ages 13-18 have anxiety disorders, most with onset around age 6 (only 18% have received treatment)Girls>Boys (especially phobias, panic disorder, agoraphobia, separation anxiety)Severity=persistenceKids often develop new anxiety disorders over timeGreater risk of depression, substance abuseGenetics, parent-child interactions, parental modeling, temperament are risk factorsCoping skills may be considered as protective factors

http://www.nimh.nih.gov/health/publications/anxiety-disorders-in-children-and-adolescents/index.shtmlJ Am Acad Child Adolesc Psychiatry, 2007;46(2):267-283

Warning signs of significant anxiety in children and teens:“What if” questions

Avoidance

Excessive need for reassurance

Excessive physical complaints

Sleep disturbances (especially increased sleep latency)

Difficulties with concentration, attention

Perfectionism

Excessive absence from school

Easily distressed

Lying

Specific Anxiety Disorders in Children, Adolescents:

Note: Kids may experience different manifestations of anxiety as they progress through developmental stages

Separation Anxiety Disorder

Specific Phobia

Generalized Anxiety Disorder

Social Anxiety Disorder

Panic Disorder

Obsessive-Compulsive Disorder

Selective Mutism

J Am Acad Child Adolesc Psychiatry, 2007;46(2):267-283

Conditions associated with or mistaken for anxiety disorders in children, teens:

ADHD (treatment may exacerbate anxiety)

Asperger’s Disorder

Learning Disabilities

Depression

Psychotic Disorders

Medication-induced anxiety

Treatment of anxiety disorders in children, adolescents:Cognitive-behavioral therapy (with modifications for specific anxiety disorders)SSRIs, other medications Parent-child, family interventions Classroom-based accommodations, interventions

Evidence-based interventions in red

J Am Acad Child Adolesc Psychiatry, 2007; 46(2):267-283

Medications Used in Kids With Anxiety Disorders

SSRIs (Sertraline, Fluvoxamine, Fluoxetine)

Clomipramine

Venlafaxine

Tricyclic antidepressants (imipramine)

Buspirone

Benzodiazepines

J Am Acad Child Adolesc Psychiatry 2007; 46(2) 267-283

CAMS (Child-Adolescent Anxiety Multimodal Study):

NIMH-funded, RCT comparing placebo, sertraline, CBT and combination treatment (CBT+sertraline) for treatment of separation anxiety disorder, social anxiety disorder, generalized anxiety disorder

Children, ages 7-17, N=488

CBT: 14 sessions, using “Coping Cat” curriculum

Sertraline: started at 25 mg/day, increased by fixed-flexible titration (mean dose:133 mg/day)

Walkup JT et al, N Engl J Med, 2008;359:2753-2766

CAMS (Child-Adolescent Anxiety Multimodal Study):

Response rates: COMB: 80.7%, CBT: 59.7%, SER: 54.9%, PBO: 23.7%

COMB>CBT=SER>PBO

Effect Sizes: COMB: 0.86, SER: 0.45, CBT: 0.31

No adverse effects>PBO in medication groups

Beneficial effects of COMB vs. SER evident after week 8

Walkup JT et al, N Engl J Med, 2008;359:2753-2766

CAMS (Child-Adolescent Anxiety Multimodal Study):

Response rates: COMB: 80.7%, CBT: 59.7%, SER: 54.9%, PBO: 23.7%

COMB>CBT=SER>PBO Effect Sizes: COMB: 0.86,

SER: 0.45, CBT: 0.31 No adverse effects>PBO in

medication groups Beneficial effects of COMB

vs. SER evident after week 8Plac

ebo

Sertra

line

CBT

Combin

ation

0

20

40

60

80

Chart Title

%Responders

Walkup JT et al, N Engl J Med, 2008;359:2753-2766

Cognitive Behavioral Therapy (CBT)

What is CBT?

The goal is to alter cognitive processes by increasing self awareness, facilitate better self-understanding, and improving self control by developing more appropriate cognitive and behavioral skills.

Cognitive Behavioral Therapy (CBT)

Three Components:Cognitive Emotional/PhysiologicalBehavioral

Cognitive Behavioral Therapy (CBT)

Unhealthy Process Healthy Process

Thoughts Distorted thinking: Overly negative, self-critical, selective and biased

More positive, acknowledge success, balanced, and recognized strengths

Feelings Unpleasant, anxious, depressed, angry

Pleasant, relaxed, happy, calm

Behavior Avoid, give-up, inappropriate

Confront, try, appropriate

Cognitive Behavioral Therapy (CBT)

Common Pattern of Anxiety

Child enters difficult situation

Child becomes anxious and fearful

Anxious behavior escalates and child gets stuck

Child avoids the situation or asks others to help

Child continues to think the situation is dangerous and feels helpless

Cognitive Behavioral Therapy (CBT)

Build Confidence Reduce Anxiety

Build stronger relationships Learn to communicate

Take on more responsible roles Develop new skills

Increase independence and self-help skills

Gradually face fears

Cognitive Behavioral Therapy (CBT)

What not to do

Do not try to convince them it will be okay.

Do not minimize their experience.

Do not tell them to fight the anxiety.

Do not physically force them into the situation.

Do not verbally bully them into the situation.

Cognitive Behavioral Therapy (CBT)

What to do

Accept their feelings

Demonstrate understanding

Build competence

Have expectations but alter the process

Parent cooperatively vs. balancing

Respond vs. react

Cognitive Behavioral Therapy (CBT)

Calming Strategy

Catch your breath

Accept negative feelings

Label emotions

Model coping skills

Conclusions:

Anxiety is one of the two most common mental health disorders among children and teens in the U.S.

The vast majority of kids with significant anxiety develop symptoms during their grade school years (or earlier) and receive no treatment for their condition.

Kids with anxiety may be overrepresented among the student body at independent schools

Cognitive-Behavioral therapy (CBT) and medication are effective treatments for kids with anxiety…best response when CBT, medication used together

Questions?

Stay in Touch!

Family Center by the Falls: http://www.fcbtf.com

Phone: (440) 543-3400

E-mail: drgrcevich@fcbtf.com, drsherri@fcbtf.com

https://www.facebook.com/StephenGrcevichMD

@drgrcevich

Additional Resources:American Academy of Child and Adolescent Psychiatry:

http://www.aacap.org/cs/AnxietyDisorders.ResourceCenter

National Institute of Mental Health

http://www.nimh.nih.gov/health/publications/anxiety-disorders-in-children-and-adolescents/index.shtml

Anxiety Disorders Association of America

http://www.adaa.org/living-with-anxiety/children