Anxiety and Selective Mutism in Youth Workshop
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Transcript of Anxiety and Selective Mutism in Youth Workshop
Anxiety and Selective Mutism in
Youth Workshop Dr. Alissa Pencer
Registered Psychologist
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Outline
Part I: Anxiety Disorders in YouthPart II: Selective Mutism
Part I: Anxiety Disorders in Youth When is anxiety a problem? Prevalence and course Common Anxiety Disorders Causes Cognitive Behaviour Therapy for Anxiety Disorders
Realistic Thinking Exposure Case Examples and Group Exercises
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Fear, Anxiety, and Worry
Everyone worries, everyone gets anxious and everyone is afraid of something.
Very young children are often fearful of strangers, the dark, animals and insects.
Older children and adolescents are often fearful of peer rejection and are more self-conscious and strive to fit in with their peers.
Adults often worry about public speaking.
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When is Anxiety A Problem?
Most children, adolescents and adults use anxiety to help them make good decisions, e.g., looking both ways before you cross the street, putting on your seatbelt, setting your alarm so you aren’t late, studying for tests, budgeting time to complete assignments.
Anxiety becomes a problem when it makes the decisions for you, interferes with your life and/or causes significant distress.
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Inverted U-Shaped Relationship Between Arousal and Performance
Hebb, D. O. (1955). Psychological Review, 62, 243-254
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Examples
Not being able to join extracurricular activities. Not being able to speak in front of the class. Not handing an assignment in because “not
perfect”. Not being able to go to school because
overwhelming. Washing your hands 30 times a day.
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How Common are Anxiety Disorders?
Anxiety disorders are the most common psychological problem found in children and adolescents.
Approximately 1 in 10 youth meets the criteria for an anxiety disorder.
Despite this, often mental health centres see more children with aggressive difficulties, attentional problems, eating disorders, or suicidal tendencies.
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6 Month Prevalence Rates of Mental or Addictive 6 Month Prevalence Rates of Mental or Addictive Disorders in Children 4-17Disorders in Children 4-17
%% Anxiety DisordersAnxiety Disorders 77 ADHDADHD 55 Conduct DisorderConduct Disorder 44 Mood Disorders Mood Disorders 44 Substance Use DisordersSubstance Use Disorders 11 Any Disorder Any Disorder 1414
Waddell et al, Can J Psychiatry, 2002Waddell et al, Can J Psychiatry, 2002
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How Does Anxiety Effect Youth?
Anxious youth tend to have: Fewer friends Difficulty meeting new people, joining clubs and
groups Academic problems because they avoid homework,
don’t make full use of the resources, and have difficulties concentrating because they worry
School avoidance
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Long term
In the long term, anxious without treatment have: Restricted choices in terms of opportunities
for careersLower self esteem Increased likelihood of becoming an
anxious and/or depressed adult
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What Does Anxiety in Youth Look Like?
No two anxious youth will behave exactly the same way, nor will they worry about the exact same things.
However, there are common anxiety patterns which roughly translate into the anxiety disorders.
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What is an Anxiety Disorder?
Interfering with daily activitiesCausing significant distressReaction is too extreme for the situationTrigger is not an actual threat
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Anxiety Disorders
Separation Anxiety Disorder: separation from caregivers and concern bad things will happen to them
Generalized Anxiety Disorder: worry excessively about many areas of life functioning (e.g., school work, family, friends, health)
Social Phobia: fearful of social or performance situations
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Anxiety Disorders cont’d
Specific Phobia: fear of particular objects or situations
Panic Disorder: misinterpret bodily changes and have a fear of losing control
Obsessive Compulsive Disorder: the presence of intrusive repetitive thoughts or behaviors
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Causes & Treatment
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What Causes Anxiety Disorders?Genetics
Anxiety runs in familiesCommon for at least one parent to be
somewhat anxious Research has shown that what is passed on
from parent to child is not a specific tendency to be shy or worry but a general personality to be more emotionally sensitive than other people.
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What causes anxiety disorders?
Parent Reaction Parent reactions or the way they handle their child
or teen’s anxious behaviour might also play a role (e.g., being over-protective).
Modeling Children and adolescents copy their parents coping
strategies (e.g., avoiding fearful situations). Stressors
Bit by a dog, death of a loved one, being bullied, getting sick
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Interventions that Help
Psycho educationTreatment:
Group CBT for youth and parents Individual CBTMedication
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Evidence for CBT in Anxiety Disorder Treatment
Individual CBT (Kendall,1994 and 1997) Study 1: 64% of treatment group no longer with dx Study 2: 71% of treatment group no longer with dx
Results in both studies maintained at 1 year At 7 years post-treatment, anxiety disorder no longer
primary in 92% of youth
Up to 84% no longer have dx if parent component added (Barrett et al., 1996)
Individual vs. Group CBT(Manassis et al, 2002; Rapee, 2000) Group CBT as effective as Individual CBT
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Three Components of Anxiety
Feeling (Physiological)
Cognitive (Thoughts)
Doing (Behaviors)
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Physiological Component
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Anxiety and the Brain
Limbic System-scans all sensory input, flight/fightresponse, integrates memory, emotion
Prefrontal Cortex - decision making, planning, emotion regulationLocus coeruleus-Alarm system:sympathetic nervous system activation
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Fight-Flight Response
In fearful situations teens become “pumped up” or aroused. This is the fight-flight response. Immediate or short-term anxiety is named the fight-
flight response. It’s the body’s way of protecting you from danger.
The fight-flight response causes you to sweat, increase heart rate, tense muscles, make you breath faster, feel hot or cold, dry mouth, and feel lightheaded or dizzy.
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Fight Or Flight?
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In youth with anxiety disorders, the fight-flight response occurs when there is no immediate danger, but instead a perceived danger.
Being in a classroom filled with other studentsUsing a restroom at schoolGoing to the cafeteria Doing a presentationHaving your heart raceParagraph you just wrote is “just not right”
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Cognitive Component
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Examples (Cognitive)
Anxious children and teens have thoughts that center around harm or threat.
“I can’t leave to go to school and be away from my mom or something bad will happen to her.” (Separation)
“I can’t do this presentation because my classmates will think I’m dumb.” (Social)
“If I don’t check the back door lock, someone will break in.” (OCD/GAD)
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Behavioral Component
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Anxious behaviours
Anxious children and teens often behave differently:They pace, fidget, cry, cling, shake.They avoid.
Refusing to go somewhere aloneRefusing to go to school
They seek reassurance. “Am I going to die?” “Am I going to fail?” “Is everyone going to laugh at me?”
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Core Components of CBT
Realistic Thinking/Cognitive RestructuringExposure **Skills Training (e.g., deep breathing and
relaxation, problem solving, social skills, assertiveness, stress management)
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Thinking Errors
Anxious children overestimate how likely it is that an unpleasant event will happen.
They overestimate how bad the consequences will be if the event does happen.
They underestimate their ability to cope with the anxiety and the unpleasant event
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Realistic Thinking
Event Thought/Belief EmotionParent is late there has been a crash
worry,anxietyParent is late stuck in traffic annoyanceParent is late stopped to get pizza happy
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Steps in Realistic/Detective Thinking
1) Identify the situation that is making you worried
2) Identify the worried thought3) Look for “Realistic Evidence” to
challenge your worried thought4) Look for alternative outcomes5) Identify a more realistic thought
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Questions for collecting “evidence”
What is the evidence that this thought is true? What is the evidence that this thought is not true?
What would I tell a friend if he/she had the same thought?
Am I 100% sure that ___________will happen? How many times has __________happened before?
What was the outcome? What is the worst that could happen? What is likely to
happen? If it did happen, what can I do to cope with or handle
it? Am I confusing “possibility” with “certainty”? It may be
possible, but is it likely?
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SituationFeeling 0-10
Anxious Thought
Evidence? Realistic ThoughtFeeling 0-10
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Exposure
By avoiding, children minimize direct and prolonged contact with feared situations.
Anxious children have no opportunity to learn that the situation is harmless.
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A
B
Time
High
Low
Anxiet
y
First time
Second time if removed at point B
Second time if taken out of situation
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Fighting Fear by Facing Fear
The Keys to Stepladders: gradual (start low on anxiety thermometer)stay in step “long enough” (until anxiety
decreases) use coping strategiesneed to repeat steps importance of rewards
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Creating Stepladders
1. Write a practical goal2. Brainstorm all possible steps to reach the
goal3. Child/Teen should give each step a worry
rating4. Choose steps that cover the entire range of
ratings5. Write chosen steps in order6. Negotiate rewards for each step and ultimate
reward for achieving the goal
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Common Problems
Step too hard Not enough repetition Speeding through Look out for subtle avoidance (e.g.
lucky charms)
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School Based Version of “Cool Kids”
Cool Kids Anxiety Program School Kit This package is an adaptation of the Cool Kids program for use within a school setting. It is designed to be run by school therapists and related mental health professionals. The therapist's manual describes in detail how to conduct each session of the program including exercises and comments to assist successful implementation.
http://centreforemotionalhealth.com.au/pages/resources-products.aspx
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CASE EXAMPLE(S) and
GROUP EXERCISES
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Case example #1
Ten year old boy with separation anxiety who was recently bullied. Now needs parents to drive him to school, won’t go into school without parent present, won’t attend class unless parent remains in the school. Defiant if confronted about attending.
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Case Example #2
Thirteen year old girl, diagnosed with Generalized Anxiety Disorder (GAD). Perfectionist qualities. Very concerned that people will think she is “stupid”. Spends an inordinate amount of time on homework checking for errors.
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Case Example #3
15 year-old male with social anxiety disorder.
a) Will not talk to people at school.b) Cannot do presentations at school.c) Will avoid any social gatherings with more
than 3 people and rarely goes to friend’s houses.
d) Will not eat in the cafeteria.e) Misses school very often.
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Helping Children with Selective Mutism
Acknowledgment to Dr. Melanie Vanier
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Outline
Part II: Selective MutismCommon characteristicsPrevalence and courseContributing factorsAssessment Intervention approachCase example/group exerciseGeneral discussion
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Common Characteristics
• Fearful of being seen or heard speaking in certain situations (at school)
• Visibly anxious when expected to speak
• May communicate nonverbally • Social phobia symptoms
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Influenced by Situational Factors
People
Activity
Location
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Prevalence and Course
• ~1% of young children
• Seems more common in girls
• Onset in preschool years
• Little known about the course
• Without effective intervention, may persist for many years
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Possible Contributing Factors
• Shy or anxious temperament
• Family history of shyness or anxiety
• Speech - language difficulties
• New culture
• Limited socializing with school peers
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No Evidence SM Caused By:
• Trauma
• Family Dysfunction
• Manipulation
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APA Diagnostic Criteria
• Consistent failure to speak in specific situations
• Speaking in other situations• Interferes with: educational achievement
or social communication• At least one month duration• Not due to: communication disorder or
unfamiliarity with the language
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Initial Assessment Considerations
• Speech – language difficulties • Autistic spectrum disorder• Hearing impairment • Cognitive/ learning difficulties• Co-occurring anxiety disorders• Shyness
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Initial Assessment Process
• Parent interview/ detailed history • Parent and teacher reports: - norm-referenced behaviour
questionnaires (e.g., CBCL) - selective mutism questionnaires• Direct observation (classroom, office)
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Intervention Approaches
• Most approaches have not been systematically evaluated
• Approaches useful in treating anxiety have been applied to selective mutism:
behavioural therapy cognitive-behavioural therapy (CBT) medication
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Behavioural Approach
● Most evidence based approach (Cohan, Chavira, & Stein, 2006)
● Emphasis on modifying the environment
● Stimulus fading/ graduated exposure is key
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Intervention: First Steps
● Establish “management team”● Provide psychoeducation ● Reduce pressure to speak ● Encourage nonverbal participation ● Begin regular monitoring
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Key Intervention Goals
● To develop an exposure hierarchy involving gradual steps
● To learn and implement strategies to move child along hierarchy, to transfer comfortable speaking from one situation to others
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Creating the Exposure Hierarchy
● Develop separate hierarchies for people, activities, and locations
• Then combine into one integrated hierarchy
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Exposure Hierarchy: People Dimension
● Consider people in terms of potential “conversational partner”
● Generally, children with selective mutism are most likely to speak to parents at school first
● List people the child: speaks to in any setting, speaks to selectively, will interact nonverbally, tends to avoid
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Exposure Hierarchy: Activity Dimension
● Consider activities in terms of speaking demands and the child’s comfort level
● Generally, children with selective mutism are more likely to speak during activities that are familiar and fun, and least likely to speak during academic activities
● List activities from ones child is already comfortable doing
to those that would be increasingly anxiety-provoking
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Exposure Hierarchy: Location Dimension
● Consider school locations in terms of comfort level, privacy, and novelty
● Generally, children with selective mutism are more likely to speak at school in locations that are unlike the classroom and have not been associated with a pressure to speak (e.g., playground, unfamiliar room)
● List school locations from ones that are quieter, private, and novel, to those that would be increasingly anxiety-provoking
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Integrated Hierarchy: The “Conversational Ladder”
● Combine the separate dimension lists to form a series of increasingly anxiety-provoking, school-based speaking situations
● Child should continue speaking at each new step
● Be prepared to insert an intermediate step if the child stops speaking
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Integrated Hierarchy: The “Conversational Ladder”
● Repeated exposure (practice) at each step until child becomes confident
● Initial steps should involve changes in activity and location, then practice similar steps with a new person
● Track progress to identify next step(s)
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Ways to Promote School Participation
• Encourage nonverbal participation (e.g., jobs in the classroom; nonverbal communication with teacher)
• Playdates at home with classmates
• Re-arrange classroom seating to increase comfort
• Alternative evaluation methods
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Conversational Visits
• Opportunities for child to practice comfortable speaking at school with conversational partner(s)
• Very important if child is not speaking at all or very little at school
• Short-term strategy
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Conversational Visits
• Begin with a person child speaks comfortably to (often parent) in a private space at school
• Comfortable speaking transferred to new activities and locations, then to other conversational partners
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The Use of Positive Reinforcement (Praise, Rewards)
● Positive reinforcement creates positive memories of approaching, not avoiding.
● Praise the child’s bravery (emphasis on effort, not outcome). Low key praise is best.
● Incentives (rewards) can be helpful in some circumstances.
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General Strategies: Building Social Skills
● Practice social skills at home (role playing with puppets; conversations with older children)
● Help the child develop strategies to solve problems
● Gently provide direct instruction and feedback as needed
● Arrange real-life opportunities for practice (find activities that play to the child’s strengths)
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General Strategies: Anxiety Management
• Psychoeducation re: anxiety • Help the child learn relaxation
strategies (so they can tolerate discomfort)
• Use other anxiety management strategies as appropriate
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CASE EXAMPLE and
GROUP EXERCISES
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Case Example
Sarah is a 6-year-old girl who has been diagnosed with selective mutism.
Sarah attends first grade at a small, rural school.
Sarah is described as quite talkative at home, and loves spending time playing “school” with her younger sister and chatting with her grandmother. She has a younger, close friend (Michelle) who goes to her school and lives down the street and they both enjoy doing crafts and playing board games.
Her parents recall that she has always been a quiet girl who needs time to warm up to new people or new situations.
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She does not speak to any of the children at school, although the classroom teacher thinks she may have seen Sarah speak to another little girl (Lisa) from her class on the playground once.
Sarah has not spoken to her teacher, and blushes and looks away when her teacher asks her a question.
The teacher is not concerned at all about Sarah’s learning, and has told her parents that Sarah seems to be taking everything in and follows classroom routines well.
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QUESTIONS/
GENERAL DISCUSSION