anxiety_disorders_in_children_and_adolescents.ppt

8/9/2019 anxiety_disorders_in_children_and_adolescents.ppt

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Anxiety Disorders in Children andAdolescents

Sucheta Connolly M.D.

Director, UIC Pediatric Stress and AnxietyDisorders Clinic


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Normal Fears and Worries

Infants: fear of loud noises, strangers

Toddlers: fear of the dark, monsters, separationfrom parents

School-age: physical injury, storms, school

Teenagers: social evaluation and school

performance


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Common Stressors

Divorce

Family move or friend moves away

oss of pet !reak up with girlfriend"#oyfriend

$oor performance at school"test

Death of relative Transition to middle school"high school


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Signs and Symptoms of

Stress and Anxiety in Youth %ecurrent fears and worries

Difficulty falling asleep or nightmares

&ard to rela' Difficulty separating from parents

Scared a#out going to school

Irrita#ility, crying, tantrums (ncomforta#le in social situations at school,

restaurants, parties


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Anxiety Disorders in Children

and Adolescents )ery common: *-+ of youth have at least one

an'iety disorder %uns in families ./enetics and modeling0

1o-occur with 2D&D in children, and depression and

su#stance a#use in teens 1an persist into adulthood

Treatments are availa#le and effective:

1ognitive-#ehavioral therapy and medication

3arly identification and treatment can reduce severityand impairment in social and academic functioning


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Separation Anxiety Disorder

Excessive fear and distress when separated

fro parents!priary care"ivers or hoe

4orry a#out parents5 health and safety

Difficulty sleeping without parents

Difficulty alone in another part of the house

1omplain of stomachaches and headaches

6ay refuse to go to school or playdates


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Generalized Anxiety Disorder

Excessive, chronic worry related to school,

a#in" friends, health and safety of self and

faily, future events, local and world events

2lso has at least one of these symptoms:

motor"muscle tension, fatigue, difficulty sleeping,

irrita#ility, poor concentration

7ften perfectionists

2n'iety may #e significant, #ut not apparent to others

$hysical complaints are common


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GAD: Additional features

3'cessive self-consciousness, fre8uentreassurance-seeking , worry a#outnegative conse8uences

$erfectionistic, e'cessively critical ofthemselves, persistent worries

1ommon somatic complaints: /Idistress, headaches, fre8uent urination,sweating, tremor


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Social ho!ia

"Social Anxiety Disorder# Excessive fear or discofort in social orperforance situations

3'treme fear of negative evaluation #y others

4orry a#out doing something e$arrassin" in

settings such as classrooms, restaurants, sports,

musical or speech performance

Difficulty participating in class, working in groups,

attending gym, using pu#lic rest rooms, eating in

front of others, starting conversations, making new

friends, talking on the phone, having picture taken


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Social ho!ia

1ommonly feared social situations:

$u#lic performances .reading aloud in front ofclass, music"athletic performances0,

7rdinary social situations .starting or joiningconversations, speaking to adults0

7rdering food at restaurants, attending dancesand parties, takings tests, working or playingwith other children, asking teacher for help.!eidel et al9 +0

Diminished social skills, longer speechlatencies, fewer or no friends, limitedactivities, school refusal .!eidel et al9 +0


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Selecti$e %utism

Una$le to spea# in certain situations %school&despite a$le to spea# in other settin"s %hoe&

Difficulty speaking, laughing, reading aloud, singing

aloud in front of people outside the family or their ;safe


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Selecti$e %utism

Transient mutism during transitionalperiods: first month of school or moveto a new home

%elationship #etween S6 and Social

$ho#ia2ssociated features: e'cessive

shyness, fear of social em#arrassment,

social isolation, clinging, compulsivetraits, negativism, temper tantrums,controlling or oppositional #ehavior,particularly at home


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Specific ho!ia

Excessive fear of a particular o$'ect or situation 6ay avoid the feared o#ject or situation

If a fear is severe enough to impair a child5s

functioning, then it is a pho#ia

Coon pho$ias: animals"insects, heights,

storms, water, darkness, #lood, shots, traveling #y

car"#us"plane, elevators, loud noises, costumed

characters, doctor or dentists, vomiting, choking,

catching a disease


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Specific ho!ia

2n'iety may #e e'pressed through crying,

tantrums, free


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anic Disorder

(ecurrent panic attac#s or intense fear:

racing heart, sweating, shaking, difficulty

#reathing, nausea, di


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anic Disorder

Full panic disorder #est documented in

adolescents

$anic attacks in younger children are

usually cued or triggered #y specific

event of stressor, with out-of-#lueattacks rare


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Differentiating the Specific

Childhood Anxiety Disorders+AD and Social pho$ia

4orries of /2D is pervasive, and not limited to

specific o#ject .Specific pho#ia0 or social situations

.Social pho#ia0

/2D an'iety is persistent, Social pho#ia an'iety

dissipates upon avoidance or escape of social

situation

4orries a#out 8uality of relationship with /2Dversus em#arrassment and social evaluation fears

with Social pho#ia


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Differentiating Anxiety

Disorders: Clinical oints 1ued panic attacks can occur with any of the

an'iety disorders in youth, and common among

adolescents

Irrita#ility and angry out#ursts may #e

misunderstood as oppositionality or diso#edience

Tantrums, crying, stomachaches, headaches

common in children with an'iety 1hildren .versus adults0 may not see fear as

unreasona#le


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&!sessi$e Compulsi$e Disorder

$sessions- Scary, $ad, unwanted or upsettin"thou"hts, ipulses, or pictures that #eep

coin" $ac# over and over

3'amples of o#sessions: 2ggressive o#sessions,

contamination, dou#ting, nonsensical thoughts,hoarding"saving, religious, symmetry"e'actness,

violent thoughts"images, thoughts a#out se',

thoughts of death"dying

1hild tries to ignore or suppress the thoughts,impulses, or images


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&!sessi$e Compulsi$e Disorder Copulsions- repetitive $ehaviors or ental acts

%prayin", countin", repeatin" words!nu$ers silently&

that the child feels copelled to do in order to stop

discofort!anxiety of o$sessions

3'amples: 1leaning"washing, checking, counting,

hoarding"collecting, repeating words"num#ers silently,

ordering"arranging, praying, seek reassurance,touching"tapping, ;tell on yourself=, ;just right=

$ersistent o#sessions, compulsions, or #oth that occupy

more than + hour each day

%epetitive and difficult to control


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ostulated 'nfectious(Autoimmune

)tiology $ediatric 2utoimmune >europsychiatric

Disorders 2ssociated with Strep9 ?

$2>D2S $ediatric Infection-Triggered

2utoimmune >europsychiatric

Disorders ? $IT2>Ds


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'nfection "group A !eta*hemolytic strep+#

'mmune ,esponse

"anti!odies produced#

,e$ersi!le "-# .esion of /asal Ganglia

&CD and(or tics

'0ANDs "ANDAS#

athophysiology


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Treatment Planning forChildhood Anxiety Disorders


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Treatment Planning

A"e, severity, ipairent, and coor$idity Mild severity: 1onsider 1!T first

Modsevere: 6edications considered for

acute relief of an'iety, partial response from

other treatment, comor#id disorders that may#enefit from meds and multimodal approach

Severe- 1om#ination intensive treatments

with 1!T and medications may #e necessary 7lder youth, depression, and social

withdrawal often need intensive treatment

Involve child and family in treatment planning


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0reatment lanning Continued

If Parental Anxiety Disorders Present-

Teach parents an'iety reduction skills

1onsider if independent treatment of parental an'iety

disorders needed .meds, therapy0

1onsider additional parental involvement with younger

child

7lder youth - depression, social withdrawal, su#stance

a#use often need intensive focus


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Child*Adolescent Anxiety

%ultimodal Study "CA%S#"Wal1up2 et al+: N )ng 3 %ed2 4556# @** children .A-+Ay0:S2D, /2D, Social $ho#ia +@ sessions of 1!T, sertraline to Bmg"day,

com#ination 1!T and sert, or +B weeks of

place#o9

)ery much or much improved on 1/I-

Improvement scale: *+ com#ination, C

1!T, sertraline, B@ place#o !oth 1!T and sertraline reduced severity of

an'iety in children with an'iety disorders,

com#ination had superior response rate


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CA%S Study

>o increased fre8uency of physical,psychiatric, or harm-related adverse events insertraline vs9 place#o groups

Suicidal or homicidal ideation was uncommon,

no child attempted suicide Eouth with 2D&D were included9 Eouth with

depression or $DD were e'cluded 1om#ination therapy offers #est chance for

positive outcome: consider family preference,cost, treatment availa#ility9

$lace#o for sertraline only group, not forsertraline plus 1!T group9


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C/0 and /eyond

Standard 1!TSocial skills training2ssertiveness skillsSelf-esteem4orking with parents and schools


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thin1

feel

C/0 %odel of Anxiety:

Anxiety7s 0hree Components

1ognitive:

$hysiological:

!ehavioral: do


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Social Phobia

Fears of #eing the focus ofFears of #eing the focus of

attention and em#arrassing selfattention and em#arrassing self

Increased heart rate, shaking,Increased heart rate, shaking,sweating, hyperventilation,sweating, hyperventilation,

di


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CBT Principles for Anxiety.2l#ano Gendall, BB0

Psychoeducation .a#out an'iety and 1!T0 Soatic ana"eent s#ills trainin"

.self-monitor an'iety and learn muscle

rela'ation, diaphragmatic #reathing, imagery0

Co"nitive awareness and restructurin"

.identify and challenge negative thoughts and

e'pectationsH positive self-talkH 0

Exposure ethods.imaginal and livee'posures with gradual desensiti


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0reatment of Anxiety Disorders

in Children and Adolescents $sychoeducation with the child and parents a#out the

illness and principles of 1!T

$arent training to esta#lish daily structure,

e'pectations, positive reinforcement, monitoring of

symptoms and progress

Involve parents in treatment, especially for children

and when parental an'iety present

1onsider independent treatment of an'iety disorders

in parents

1oordinate treatment with school


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C/0 for Anxiety Disorders in

Children and Adolescents 1onsider age and developmental stage of

child

For younger children using positivereinforcement chart and fre8uent rewards for

efforts is very important9 3'posures increase

an'iety and children need motivation to try9

For younger children use of pictures,cartoons, puppets, and toys to supplement

standard 1!T is helpful9


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Establish Target Symptoms

/earn to identify feelin"s in self 0 others.feelings #arometer0

Esta$lish level of distress

.feelings thermometer0

Develop /adder of stiuli or tri""ers.situations, o#jects, cues, sensations0 withinprimary diagnosis


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Cognitive estr!ct!ring

1hallenge >egative Thoughts

1hallenge >egative 3'pectations

$ositive Self-Talk


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Cognitive Distortions

1outh with anxiety disorders- 2ssume #ad things will happen

!iased attention to threatening words and

criticism

Interpret am#iguous situations as threatening

6ore negative self-talk

(nderestimate their strengths

2ssume they cannot handle stressful

situations

1atastrophic thinking: 2ssume the worst


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Cognitive estr!ct!ring" #oals

Identify negative thoughts that predict #adthings will happen- thinking traps

3valuate negative thoughts to determine ifthey make sense

(se realistic positive self-talk to argue withnegative thoughts and #oss them #ack9

%eplace thinking traps with coping thoughts


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Cognitive estr!ct!ring

(se similar strategies to come up with

alternatives to negative thoughts or

misperceptions that result in angry feelings

!oss #ack aggressive urges

$ractice alternatives to assuming someone will

violate you, hurt you, critici


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)8&S9,)S

Imaginal 3'posures

%ole-playsive 3'posures


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Expos!res /raded so child can e'perience success and

#uild confidence .not flooding0

3'plain that discomfort is part of e'posure

!egin with rela'ation e'ercise to start with

an'iety at low level %eview coping strategies

3sta#lish reward system

6ove from easiest to most challenging itemson Fear adder

Therapist should avoid too much reassurance

during e'posure


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#raded $maginal Expos!re 1hild imagines item or situation from Fear

adder"&ierarchy in detail !egin with easy items to more challenging

1hild notes intensity on Fear Thermometer

!ring an'iety to B or #elow #efore ne't item 2sk: Did anything terri#le happen

$raise often9 %eward for efforts successes

Incorporate rela'ation and self-talk learned toreduce an'iety

2djust fre8uency, intensity of sessions #ased

on success


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&ther Applications for )xposures

Imaginal e'posure and role-plays can #e used

for a range of #ehaviors

This may allow child to identify feelings andthoughts that pop out in certain situations that

make them angry, sad, scared

/ives opportunity to practice new coping

strategies and #ehaviors !e sure to praise for just trying e'posures

.imaginary or real0


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0reatment for Social ho!ia and

anic Disorder Successful treatent of Social Pho$ia and Selective

Mutisre8uires 1!T discussed and additional Social

Skills Training

2reatent of Panic Disorder 7ftenre8uires medications .SS%I5s, other antidepressants first-

line0

C32 for treatent of Panic disorderInteroceptive

e'posure9 %ela'ation training, e'periencing physicalsymptoms in sessions, and overcoming sense of

panic"doom9 Decrease avoidance increase control9

Treatment for Selective M!tism


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Treatment for Selective M!tism

6ost children with S6 have Social pho#ia

7ften need 1!T and social skills training

Severity often warrants medication .SS%Is0

6anagement team with parents and teacher monitoring child5s

communication

$ositive reinforcement for attempts on graded e'posure ladder

Steps to speaking outside ;comfort


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C/0 %odifications for S% Team approach with school involved regularly 1onversational visits )er#al intermediary .parent, friend, doll, toy

puppet, recording device0 that makes morecomforta#le in trying to speak"communicate9

Does not speak for child9 $ositive reinforcement fre8uently %einforce for nonver#al as well as ver#al

responses

S6 child can enlist strong negative responsein adults .la#eled as ;refusing to talk=0

$arents and si#lings need to resist desire tospeak for child


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School ef!sal

Can $e variety of fears %separation,Can $e variety of fears %separation,social anxiety, test anxiety&social anxiety, test anxiety&

4orry, tension, increased heart4orry, tension, increased heartrate, sha#in", sweatin"rate, sha#in", sweatin"

5re6uent a$sence, tardiness, tears,5re6uent a$sence, tardiness, tears,

tantrus, soatic coplaints,tantrus, soatic coplaints,

visits to school nursevisits to school nurse

thin1

feel

do


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School ,efusal(School ho!ia This is a #ehavior cluster, not a diagnosis

>eed to consider an'iety disorders and

depression

1onsider S2D, /2D, Social pho#ia

>eed to rule out learning disa#ility that canlead to frustrations, poor performance, low

self-esteem9 Increased risk for an'iety and

depression9 Dysle'ia in young children9

6ore common during transitions to a new

school .pre-school, G/, middle school, high

school0

2ssist parents to reduce secondary gains


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'nter$entions for School ,efusal

%ule out D and language impairments

If depression and an'iety present, 1!T and meds

often needed

2ssist parents and school staff to maintain

patient in school9 2void home-#ound school (se li#rary or other area to calm or complete

work part of day, #uild up in class time

/raded e'posures to school situations

2ctive ignoring of unreasona#le somatic

complaints and reward regular attendance

(se rela'ation and coping strategies to reduce

an'iety at school9 1oaches at school too9

h l f l ( dd


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School ,efusal: Fear()xp .adder !e careful not to start e'posures close to

vacations or holidays Initially work on preparing for going to school

.depending on severity of fears0 with live andimaginal e'posures .driving past school,

walking on school grounds, entering school0 Increasing time at school, not necessarily in

classroom Start with most comforta#le setting"activity in

classroom 4ork up to part of day and eventually full day Set up rewards for each step


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0reatment of Youth ith &CD

6ultimodal 2pproach


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0reatment of Youth ith &CD

1ognitive #ehavioral therapy .1!T0 in

conjunction with medications .SS%I5s0

3'posure and %esponse $revention .3"%$0

Develop fear hierarchy, e'pose to pho#icstimuli and repress rituals or avoidance

Family therapy can help decrease the parents5

involvement in the child5s rituals and reinforcing

#ehavior-#ased interventions

Selective serotonin reuptake inhi#itors .SS%I5s0

and 1lomipramine .T12 and SS%I0 are

effective

/oy ith &CD


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/oy ith &CD

++ year #oy with 71D

Intrusive se'ual thoughts"fears9 Dou#ting: %eassurance seeking ;Is this right

2m I 7G= Fears of upsetting and harmingothers9

(nderwear and pants have to fit ;just right=96other has to take in all waists9 >othing can#e loose fitting

$erfectionism: 3rasing, rewriting drawings,work to make it ;right=9 Takes lots of time9

1annot #e rushed to complete things9 Fears of upsetting /od and others:

apologi


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;o ' ,an &CD &ff %y .and "3+

%arch %D2 %;: %arch %anual#

$sychoeducation with 71D as medical illnessand engage child and family in treatment Define 71D as the pro#lem: nasty nickname

with plans to ;#oss #ack= 71D with therapist

Story a#out 71D in child5s life: over timeauthors 71D out of his"her life

6ap child5s 71D: o#sessions, compulsions,triggers, avoidance #ehaviors, conse8uences

2n'iety management training 3'posure and response prevention .3"%$0

using transition


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C/0 for &CD: Adaptations for

Young Child

71D Story#ook .with farm animals and 71 Flea0 $ositive reinforcement program

%eadjust hierarchy to achieve success with little steps

in e'posures if needed9

For young children can do imaginal e'posures usingpuppets, toys, cartoons to practicing ;#ossing #ack=

71D

1an adopt characteristics from superheroes that help

child to defeat 71D 4atch 71D shrink in si


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&CD )xposure(Fear .adder &olding doorkno# .e'posure0 and not washing

hands .response prevention0 6oving items around in room .30 and not

reorgani


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Social Skills"

Meeting and #reeting %e& People

&aving a conversation: taking turns asking,telling, saying something and listening

%ole-play situations with child or teenager

$ractice with a friend and new children

1oordinate with school staff .lunch group0

Involve parents in sessions in younger child


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Social Skills"

%onverbal Comm!nication Importance of nonver#al communication and

improving conversation skills

$ersonal space

3ye contact

Speaking voice .volume0

Involve parents in sessions for younger child

A ti T i i


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Assertiveness Training

Many anxious children wor# hard to always

please others and avoid conflicts 6ay fear something #ad will happen if they upset

others or just discomfort

6ore likely to #e #ullied

1hild works on identifying own needs and negotiating

these with children and adults

%eview assertiveness strategies, role-play in session,

then carry out e'posures

1an use toys, puppets with young children to practice9

Involve parents in sessions9

(se rela'ation, coping strategies and fear ratings

during role-play

A ti T i i E l


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Assertiveness Training" Example

C y9o9 girl with /2D, S2D, Turner5s small stature9

7ften picked up #y other children and girls fight over her not allowingher to play with other peers9 Sometimes children hold her down9 edto school pho#ia9 She fears other children will #e punished if shetells9

$racticed using loud voice, mean face and posture in session9%ole-play with peers who are pushy and demand her to listen9

$racticed turning on ;drama= when child annoying her and will notaccept no to get teacher5s attention

1oordinated plan with school regarding practicing assertiveness andmonitoring of #ullying #y teacher in classroom and especially atrecess9

$atient has #enefited greatly from 1!T, low dose SS%I9


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Wor1ing ith arents and Schools

Active I"norin"

(ewards

Involvin" Parents in C32 with child4or#in" with Schools

5aily treatent

'orking &ith Parents and


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Teachers" Active $gnoring

Active reinforceent of positive $ehaviors

Active i"norin" of unwanted $ehaviorto

e'tinguish .complaining, reassurance-seeking,

crying, whining, somatic complaints0

%ole-play with parents, discuss with teachers

Temporary increase in pro#lem #ehavior, does not

mean they should give in

%educes children depending on adults rather thantrying new coping skills



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Teachers" e&ards

1hild chooses meaningful rewards Small, ine'pensive, or preferred activity %einforcement after desired #ehavior .trying

not just successes0

Short list of desired #ehaviors .fear ladder0 Su#stitute new #ehaviors as mastered Timely, consistent rewarding 1oordinate reward system #etween home

school $ost in visi#le location at homeH teacher

keeps in desk at school Child learns selfpraise over tie


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$nvolving Parents in Treatment

Parents with anxiety disorders can $enefitfro anxiety ana"eent s#ills!treatent

and can iprove effectiveness of C32 in

child

$arents may #e overprotective, controlling, or

facilitate avoidant responses

$arents included in child5s treatment as

;coaches= to assist child in coping with current

and future an'iety issues

P $ l


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Parent $nvolvement

earn how to handle child5s an'iety earn graduated e'posure and how to use it

6odify view of child as vulnera#le and in need

of protection or control

See child as resilient and capa#le of coping

&elp parent to feel knowledgea#le and skilled

enough to help the child cope with future

challenges Involve all relevant caregivers to increase

consistency of response to an'iety


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Parent (Teacher) $nvolvement

$arents .teachers0 can odel calmness and

pro#lem-solving approaches

Find middle ground: encourage the child toapproach feared situations and give child

control over pace that is tolera#le

/ive prompts, #ut resist need to ;rescue=

Focus on small, positive steps, #uild courage,

competence, and autonomy for child

S h l $ t ti f A i t


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School $nterventions for Anxiety

School personnel who child can meet with

regularly and #e availa#le to help child calm

Discourage leaving school .fever or vomiting0

3ncourage self-monitoring with Feelings

Thermometer 1oping #ag availa#le if needed

%einforce attempts to use rela'ation"coping

skills as well as successful coping Desensiti


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School $nterventions for

St!dents &ith Anxiety

Modified assi"nents Coprehension chec#s

Identify adult at schooloutside classroom who can

meet with child and engage in pro#lem-solving or

an'iety management strategies School staff prompt child to use coping strategies prior

to school triggers .tests, recess, starting assignment0

2estin" in private, 8uiet place to reduce an'iety

Educate teachera#out child5s an'iety and suggeststrategies to facilitate child5s coping .reframe0

1hildren with an'iety disorders might 8ualify for a

Section789 plan or special education if significant

impact on school functioning .handout0

*amily $nterventions


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*amily $nterventions

$arental emotional overinvolvement

$arental criticism and control

Family communication

Impact of child an'iety on parent #ehavior

Integrative models .Dadds %oth, B+0

Interaction #etween attachment and

parent-child learning process,

#ehavioral and temperamental characteristics

of child and parent

1onsider impact on si#lings


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Family 'nter$entions Canicholas BC0

SS,' i Y Child


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SS,'s in Young Children

Start very low in young children and goslow to reduce side effects and increasetolerance to initial and temporary side

effects Fluo'etine li8uid Bmg"ml can start at

9-B9 mg"day Sertraline li8uid Bmg"+ml can start at

B9-mg"day 6onitor for activation, #ehavioral

disinhi#ition along with other side effects

SS,'s for Selecti$e %utism


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SS,'s for Selecti$e %utism +B week place#o- controlled study for Fluo'etine mean dose

of 9Cmg"kg .!lack and (hde, +@0C children, ages C-+@, with S6 and Social $ho#ia

Improved significantly on parent and teacher rating relative

to place#o #ut still with S6 symptoms .with minimal side

effects0

7pen trial of B+ children ages to +@ with S6 supports

Fluo'etine in graduated doses9 AC improved in an'iety and

speech, inversely correlated with age .Dummit et al9, +A0

Sertraline in children with S6 with low side effects, general

#enefits .1arlson et al9, +0 onger trials with more individual dosing needed

&ther Antidepressants


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pTricyclic antidepressants .S2D, Social pho#ia0

1onflicting results e'c 1lomipramine for 71D

Cloipraine.T12 non-selective S%I0 1an augmentat low doses with SS%I9 %e8uires cardiac monitoring,

3G/, #lood levels9 Side effects can #e significant:

sedation, di


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&ther %edications for Anxiety

3uspirone./2D0

>o pu#lished controlled studies92dverse side effects: lightheadedness,

headache, dyspepsia9

&igher peak plasma levels in children vsadolescents9 6ay #e tolerated at -Jmgin teens and -A9mg in children, twicedaily

6ay #e an alternative to SS%Is for /2Din youth9 1ontrolled studies needed9

6ay augment SS%Is9

&ther %edications for Anxiety


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&ther %edications for Anxiety!en


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&ther %edications for Anxiety+uanfacine orClonidine

>o controlled studies for an'iety disorders 1onsider w" SS%I when an'iety w" significant autonomic

arousal and"or restlessness

!aseline 3G/, !$ and pulse monitoring

Severe re#ound hypertension with a#rupt discontinuation

Tourette5s, 2D&D, Trichotillomania, other impulse-control

disorders, !ipolar, $TSD

33loc#ers

1onsider for focused performance an'iety .>o trials in youth0

%edications for Comor!idity


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%edications for Comor!idity

Depression: Impairment, SS%I, monitor suicidal

risk, 1!T .Fluo'etine recommended0 AD=D: First choice stimulants and #eh t'9 If

stimulants e'acer#ate insomnia or an'iety,

2tamo'etine second line, also !uproprion and

)enlafa'ine9 /uanfacine or clonidine .get 3G/0 forhyperactivity" impulsivity and sleep struggles9

Alcohol a$use: 1aution against #en


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0reatment of 0SD: %edicationsN Treat significant depression and anxiety

N SS$+s "Antidepressants#

For anxiety2 depression2 core symptoms

N #!anfacine or Clonidine

For hyperarousal2 impulsi$ity2 startleN Antipsychotics "such as ,isperidone#

For dissociation2 !rief psychosis2 se$ere

aggression"monitor A'%S or D'SC9S2 glucose2 eight#

N Meds can red!ce severity of symptoms so

child can engage in therapy and expos!res

% di ti f C !id


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%edications for Comor!id

Autism Spectrum Disorders

1onsider SS%I5s when o#sessive features,

perseveration, rituals, an'iety, depression,

irrita#ility prominent

/uanfacine or 1lonidine may assist with

impulsivity, e'plosiveness, restlessness

7ther meds such as antipsychotics and mood

sta#ili


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Case )xample: %ary

/2D, Depession, $hysical

Trauma

Case )xample: %ary


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Case )xample: %ary +C y9o9 4F with recent #ack surgery due to lum#ar fracture that

did not heal, chronic /2D9

6ajor depression since surgery with high irrita#ility, decreased

appetite, sleep distur#ance, anhedonia, hopelessness

/2D never identified #efore with perfectionism regarding

grades, sports, cannot rela', very goal-focused, over

organi


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y

2gitated depression acutely increasing over B weeks

and emerging suicidal ideation: Started Loloft and

increased over one month to +mg

Initiated rela'ation with deep #reathing and imagery

with 6ary and father

!etween sessions received a call from mother 6ary

not practicing rela'ation and more irrita#le with mother

Session: /2D severe9 6ary feels she is failing therapy

homework and mother does not understand an'iety

Discussed chronic communication issues #etween

6ary and mother who does not have an'iety #ut is veryorgani


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%ary:lan /2D severity now more apparent9 6ary afraid to

rela' for even a moment9 $raise 6ary for identifying her an'iety symptoms and

frustrations with mother

Slow down pace of 1!T rela'ation module and"or

e'amine thoughts first Take time to focus 6ary5s understanding of her severe

/2D and impact of #ack pro#lems, /2D, decreased

social life on her functioning over several years

4ork on communication #etween mother and 6ary,and pursue further family treatment

1ontinue medication until ma'imi


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%ary: ;ighlights

1onsider severity in starting with 1!T or 1!T

and meds

$ace of 1!T depends on what patient can

tolerate: emphasi


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Case )xample: Clarence

/2D, S2D, Social $ho#ia

2D&D, DSocial skills deficit

Case )xample: Clarence "history# * year old #oy with 2D&D referred for severe ;sleep


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* year old #oy with 2D&D, referred for severe sleep

an'iety= and meets criteria for /2D, S2D, Social $ho#ia,

71D traits9

2n'iety #ecame significant after ro##ery of family property Byears ago: credit cards stolen9 Some $TSD features9

Father travels often with jo#9 Father with possi#le 71D

traits, low frustration tolerance for Thomas9 Thomas overly

dependent on mother9

2n'iety at night sometimes makes it hard to even sleep well

in mother5s room .no one resting in family0

2D&D, severe and D impacting academic and social at

school .irritating to other children0

2n'iety limits social activities: fearful of #eing away frommother, assertiveness skills and social skills poor .#ullied #y

students at school0

)xample: Clarence "0reatment#


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2D&D com#ined type interfered with 1!T9 %e8uired

numerous med trials responded to com#ination ofStrattera, 2dderall .M% and regular0 and /uanfacine

.appetite suppression, increased irrita#ility, increased

an'iety on various 2D&D meds0

)arious SS%I5s tried: tended to get hyperarousal,irrita#le on several with good results on 1ele'a9

$ositive reinforcement chart set up with clear rewards

and conse8uences9

4orked on power struggles and active ignoring9 3sta#lished team with mother, school, and therapist9



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)xample: Clarence "0reatment# %ela'ation: deep #reathing, muscle rela'ation, and

imagery .light #lue, #each scene0 $ositive self-talk: fears other children think he is

stupid, do not want him as a friend, want him to feel#ad9

Fears of ro##ers #reaking into house at night and

killing him and family9 2ny sounds would trigger this9&ow likely 4hat else could sounds #e Safety ofcommunity 2lternative thoughts

Sytematic desensiti


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C e ce " e e #

Social skills training and assertiveness training to

address response to #ullying along with coordinationwith school to monitor9

earning meeting and greeting, how to treat play date,

tolerating small frustrations with peers

Ignoring ver#al #ullying, responding with humor,monitoring reactions on face and #ody to potential

#ullies9 /etting help from adults when needed9

Family treatment to address need for acceptance

from father9 4ork on gaining competence versusdependence on mother9

>ew social and interpersonal challenges of

adolescence


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Clarence: ;ighlights

Treat predominant or most impairing

symptoms first: comor#idity

isten to family5s major concerns: ;sleepan'iety=

1onsider social functioning as an important

outcome


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Case example: 3immy

Selective 6utism

Social 2n'iety Disorder

)xpanding Safety zone


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p g y From clinic to school

K Select transition agent.s0 - parent,therapist, si#s, even classroom teacher

K Select strategies

K Select se8uence of e'posures From home to school

K Select transition agent.s0 - parent, si#s,

classmates, teacher

K Select strategies

K Select se8uence of e'posures

=> Stages in Speech )mergence in

S h l "l #


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School "least to most#

19 1unningham5s workH adapted #y Genny,Fung, 6endlowit Stages in Speech )mergence


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=> Stages in Speech )mergence

in School "cont7d#*: Speaks to one peer w" normal volume

: Speaks softly or whispers to several peers

+: Speaks in normal voice to several peers++: Speaks softly or whispers to teacher

+B: Speaks in normal voice to teacher

+J: >7%62 S$331& I> S1&77


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Case example: 3immy

@ +"B yo male, living with parents,#ilingual Spanish-3nglish

>ormal pregnancy, development Shy temperament: S6 since age B9 1omor#idities: Social $ho#ia, Speech

2rticulation disorder Family history of: /2D, Social $ho#ia,

Depression, 2lcohol 2#use, Speechtherapy in father


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3immy "cont7d#

%egular pre-school

Stage +-B for speech emergence

2ccepted #y a few classmates, afraid ofteacher

School felt he would ;grow out of it=

Conversational ,isits


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Peopleto visit .family, neigh#or, friend0 2ies of dayto visit .#efore school, recess,

lunch, after school, evening0

Places to visit.private setting to classroom0

2ypes of activitiesto stimulate speech

.games from home, computer, art, reading0

6ake a ta#le of a#ove and rate the amount ofcomforta#le speaking encouraged #y each

activity

3immy * )xpanding Safety ?one


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from ;ome to Clinic 1!T approach, adapted for young child

$ositive sticker chart

6edication

P 1!T emphasis on #ehavioral .due to young age0 with

some use of superhero themes

P 2n'iety shrunk as super Qimmy grew strongerP (sed play, drawings, and nature walks as medium of

engagement

P Deep #reathing, #each imagery, petting stuffed animal,

sound of shell to help with rela'ation

P %ewarded regularly, often for his efforts at home and in

session9 %ewarded for practicing and success with

e'posures9

3immy* )xpanding Safety ?one to

Cli i C ti d


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Clinic Continued $t relieved that an'iety had a name and that he could

con8uer it .worry monster- #ig green #lo#09 2ttacked itin drawings on dry-erase #oard and puppet play

Individual to parallel play to cooperative play $arents, #rother, cousin in session

Descri#ed aloud Qimmy5s activities during play Initiated Loloft li8uid at mg and eventually up to

Jmg with significant improvement in nonver#alcommunication, initiating social interactions,

whispering, and then speaking 4orked on eye contact, volume of speech, greetingskills, assertiveness skills9 2ngry e'pression hardest9

$racticed social skills with visits to office ;neigh#ors=in the clinic

3immy* )xpanding Safety ?one


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3immy )xpanding Safety ?one

to School

%eviewed various school environments for#est ;fit=9 Decided to change schools #ased onstructured social opportunities availa#le

$sychoeducation with school team and parents

Set up #rief, fre8uent play dates at home with

peers from school with parents utili


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School Continued

First: parent and Qimmy visit schoolplayground

Then, parent and Q visited classroom alone Then, parent and Q visited with cousin in

classroom Then parent, Q, cousin, and teacher $t talking to cousin in classroom 3ventually speaking with teacher and

classmates 1urrently: Stage +J

>ew focus: Initiating social interactions incrowded places

3i ;i hli h


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3immy: ;ighlights

$sychoeducation for parents and educators very

important

Treating parental an'iety and assisting with

reactions of relatives, parents5 frustrations (tili


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,)S&9,C)S AND,)F),)NC)S

1linician

$arent1hild

+

eferences for Parents -Teachers H l i Y A i Child (R


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Helping Your Anxious Child (Rapee,

Wignall, Spence, Cobham, 2008)

e!s "o #aren"ing Your Anxious Child

($anassis, 2008)

%reeing Your Child &rom Anxie"!

(Chans'!, 200) %reeing Your Child &rom C*

(Chans'!, 200+)

Helping Your Child i"h Selec"i-e$u"ism ($cHolm e" al, 200.)

When Children Re&use School/ #aren"

Wor'boo' (earne! Albano, 2001)++

,eferences for Children 4h t T D 4h E 4 T 6 h


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+++

4hat To Do 4hen Eou 4orry Too 6uch.&ue#ner, B0

2 !oy and a !ear: The 1hildren5s %ela'ation!ook .ori ite, +C0

!link, !link, 1lop, 1lop: 4hy Do 4e DoThings 4e 1anRt Stop 2n 71D Story#ook

.6orit< Qa#lonsky, B+0

Talking !ack to 71D .Qohn 6arch, BC0 For children, teens and parents 4hat To Do 4hen Eour !rain /ets Stuck: 2

Gid5s /uide to 71D .&ue#ner, BA0

,esources for Adolescents


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++B

My Anxious Mind- A 2een;s +uide toMana"in" Anxiety and Panic %2op#ins 0Martine:, >88?&

(idin" the 4ave 4or#$oo# %Pincus,

Ehrenreich 0 Spie"el, >88@& foradolescents with panic disorder

Anxiety Disorders %Connolly, Sipson 0

Petty, >887& for iddle 0 hi"h schoolstudents to help the understand anxietydisorders and reduce sti"a with storiesand drawin"s fro youth with anxiety.

eferences for Clinicians


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2reatin" Anxious Children and Adolescents

%(apee, 4i"nall, =udson0 Schnierin", >888&

Co"nitive 3ehavioral 2herapy with Children-A +uide for the Counity Practitioner%Manassis, >88?&

Master of Anxiety and Panic for Adolescents(idin" the 4ave, 2herapist +uide %Pincus,Ehrenreich, Mattis %>88@&

Practice Paraeter for the Assessent and2reatent of Children and Adolescents withAnxiety Disorders %AACAP >88B&

++J

CBT Anxiety Therapy Man!als


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Coping Cat.$hillip Gendall0

and CAT %for adolescents&

How I Ran OCD Off My Land .Qohn 6arch0

Meeky Mouse Therapy Manual: CBT

rogra! for "ele#ti$e Mutis!.D9 Fung, 29

Genny S9 6endlowit


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reschool C/0 %anual for 0SD

2vaila#le from Dr9 6ichael Scheeringa

mscheertulane9edu

6anual authors: 69 Scheeringa 6D,

Q9 1ohen 6D and 9 2maya-Qackson 6D

++

,)S&9,C)S>ational 1hild Traumatic Stress >etwork


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>ational 1hild Traumatic Stress >etwork

www9musc9edu"tfc#tH www9nctsnet9org2merican 2cademy of 1hild 2dolescent$sychiatry .2212$0 www9aacap9org2n'iety Disorders 2ssociation of 2merica

.2D220 www9adaa9orgS6 /roup- 1hild 2n'iety >etworkwww9selectivemutism9org2ssociation for !ehavioral and 1ognitive

Therapies www9a#ct9org7#sessive 1ompulsive Foundation

www9ocfoundation9org!oston (niversity an'iety clinic

www9childan'iety9net ++C

%&,) ,)S&9,C)S
http://www.musc.edu/tfcbthttp://www.nctsnet.org/http://www.aacap.org/http://www.adaa.org/http://www.selectivemutism.org/http://www.abct.org/http://www.ocfoundation.org/http://www.childanxiety.net/http://www.childanxiety.net/http://www.ocfoundation.org/http://www.abct.org/http://www.selectivemutism.org/http://www.adaa.org/http://www.aacap.org/http://www.nctsnet.org/http://www.musc.edu/tfcbt


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%&,) ,)S&9,C)S

www9chadd9org for adhd in children and

adults

www9#pkids9org for 1hild and adolescent

#ipolar foundation

4e#site for $6D1 at (I1 .pediatric mood

disorders clinic0 and %2I>!74 program

through www9uic9eduat J+B"C-AABJ ocfoundation
http://www.uic.edu/http://www.uic.edu/

anxiety_disorders_in_children_and_adolescents.ppt

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