Slide Presentation from Anxiety in Children and Adolescents by

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Your Anxious Child:
What Every Parent Needs to Know!
Anne Marie Albano, PhD, ABPP
Columbia University School of Medicine
Director, Columbia University Clinic for Anxiety and Related Disorders
February 2014
Overview
___________________________________________________________
• Normal milestones of child and adolescent
development
• The challenges of anxiety along the
way……
• Key skills for youth
• What a parent can do!
Where do we begin?
Development is multifactorial and
transactional….and so is anxiety!
Developmental keys
• Anxiety is expected and normal
• Temperament sets the stage….
• Tasks of development vary with age
Main Milestones of Childhood
• Language: ability to
speak, communicate, read
non-verbal cues, and
understand others
• Cognitive: ability to
reason, think, learn,
problem-solve, remember
• Social: develop and keep
meaningful relationships;
respond to others’ feelings
More Childhood Milestones
• Earlier fears of childhood (the dark, monsters, small
animals) decrease.
• Your child is capable of greater reasoning and searching
for more meaning than simple “Because I said so”
statements.
• Children become more curious and seek information from
many sources.
• Right versus wrong is a concept that is now understood, as
is truth versus lie.
• Children now experience shame and guilt through for their
transgressions.
Developmental Milestones for
Adolescents: Timeline by End of HS?
• Emotional independence from parents (solves own
interpersonal problems & issues)
• Develop self identify (This is who I am)
• Behavioral independence from parents
(assertiveness, task completion, initiative)
• Manage money responsibly
• Make and keep long term relationships
• Take control of personal self care (e.g., sleep,
health care, exercise, diet, self-soothing)
Developmental Progression
Common Fears
Anxiety Disorders
• Preschool: Imaginary
Objects/situations
• Preschool: Phobic
objects/situations, SAD
• Grade School:
Health/harm,
Scrutiny/Competence
• Grade School:
OCD, GAD
• Adolescence: Social
adequacy, Performance
• Adolescence: Social
anxiety, Panic Disorder
Why does anxiety naturally increase
throughout adolescence?
___________________________________________________________
• Complex social cognitive skills develop
• Social comparison skills are formulated
• Peer-group approval becomes important
• Academic demands increase
• Independent social functioning is expected with
greater frequency
• Puberty x environment interaction
When does anxiety become
problematic?
• Avoidance/Disruption
• Interfers with functioning
(not facing developmental challenges)
• Distress
• Duration
DSM Anxiety Disorders
•
•
•
•
•
•
•
Separation Anxiety Disorder
Social Phobia
Generalized Anxiety Disorder
Panic Disorder
Agoraphobia
Specific Phobia
Selective Mutism
• Closely related:
– Post Traumatic Stress Disorder
– Obsessive Compulsive Disorder
Child Anxiety “Triad”
Separation Anxiety Disorder
Social Phobia
Generalized Anxiety Disorder
Frequently occur together, at the same time and
respond similarly to treatments
What are the risks for problematic anxiety?
Peer
Problems
Academic
Stress
Genes
Early
Experience
Parenting
Temperament
Cognitive
Style
Physical
health
Significance of Anxiety Disorders
in Childhood
• Highly prevalent (10% to 20% of youth)
• Significantly impairs social, academic, family and
independent function
•May lead to school refusal behavior
• Highly comorbid in childhood with each other; in
adolescence with mood and substance abuse disorders
• Commonly persists into adulthood
SCHOOL REFUSAL BEHAVIOR:
Parameters
– Complete absence from school
– Partial attendance (e.g., leaving class or
school during day)
– Attendance following intense
misbehaviors in the morning
– Unusual distress during the school day
that leads to pleas for future
nonattendance
Treatment of Anxiety in Youth
• Therapies that have been tested in clinical
trials and found effective:
– Cognitive behavioral psychotherapy
– Medication
– Combined CBT plus Medication
Gold Standard CBT: The Coping Cat
•
•
•
•
Psychoeducation
Somatic Management
Age-appropriate cognitive restructuring
Exposure “STIC” Tasks
Ages 8-17; many
adaptations of this basic
treatment are effective
Kendall (1994); Kendall et al. (1997)
The CALM Program: Ages 3-8
(Comer, Puliafico & Albano, 2008)
C oaching
A pproach behavior and
L eading by
M odeling
Rationale: Targets child’s maladaptive behavior indirectly by
modifying parents’ behavior. Focus is on reshaping the primary
context of early children development – parent-child
interactions. Addresses overprotection and overcontrol,
proposed mechanisms in reinforcing and maintaining anxiety.
PCIT/CALM
Therapist unobtrusively coaches interactions from behind a 1-way mirror.
Parent wears a bluetooth earpiece so that child cannot hear the coaching
Courtesy of Jon Comer
Developmentally-Informed
CBT for Adolescents (14-20’s)
 Goals: Independent functioning
 Education for parents and adolescent—
together
 Devise hierarchy of situations targeting
developmental milestones
 Weekly developmental goals
 Parent-sessions: Letting Go!
NOVEMBER 3, 2003
Family Environment
Parents of children with anxiety are more likely to:
Take over for the child
Provide negative feedback
Act in more restrictive or controlling manner
These parental behaviors have been shown to exacerbate
anxious and avoidant behavior in children
Overprotection and overcontrol = increase anxiety risk
Alfred Adler
“You can love a child all you wish, but you
must not make him dependent. You owe it
to the child to let him function as an
independent being, and you must begin
training him from the very beginning to do
this. If a child gains the impression that his
parents have nothing to do but to be at his
beck and call, he gains a false idea of love.”
In The Pattern of Life (1930), page 148.
The Role of Modeling in Learning
• Many behaviors can be observed by watching
others (modeling)
–
–
–
–
–
–
Fear reactions
Aggression
Altruism
Moral behavior
Academic tasks
Motor tasks
• The list can go on and on……
Four Conditions Necessary for
Learning
1. The child must pay attention to the model.
2. The child must be able to remember what has
been observed. Rehearsal helps.
3. The child must be able to replicate the behavior
(developmentally appropriate).
4. The child needs to be motivated to learn!
Coercive Process/Negative
Reinforcement Trap
Parent:
“Mike, please sleep in your own room.”
Mike:
I don’t want to.
I DON’T WANT TO.
I DON’T WANT TO!
Child begins to cry louder and louder . . . .
• From Rex L. Forehand
And on it goes . . .
• Parent gives in . . .
– “Okay, but tomorrow night you have to sleep in
your bed, okay?”
• Outcome:
– Mike’s inappropriate behavior is
REINFORCED because his parent gave in and
withdrew the request/direction.
Yet another reinforcement trap
• Parent: (in a louder voice)
– “I really mean it! Get into your bed!”
• Child does not comply
– NO! I won’t! (while spitting and kicking)
• Parent intensifies her/his reaction
– “That’s it mister! I’ve had it with you!” (while
grabbing and make angry faces at child)
• Outcome:
– Child complies but the parent’s angry and intimidating
behavior is reinforced through the child’s compliance.
• Also from Rex Forehand
How do you undo
anxiety?
Behavioral Theory
Antecedent  Behavior  Consequence
• Positive consequences increase behavior
• Negative consequences decrease behavior
• “Hidden” consequences
– Negative attention
– Escape from undesirable task
– Not rewarding good behavior
ABC
• Ten year-old Jamie is whining that he does
not want to go to school. He’s delaying on
doing homework and says it’s “too hard!”
Jamies’s Mom wants him to get started on
his homework and to convince him that
school is fun. Jamie begs to stay home
tomorrow. Mom tries to comfort Jamie but
he cries and pleads with her. Mom
eventually tells him that he can have one
“mental health day” off from school.
ABC
Antecedent  Behavior  Consequence
A: “Do your math homework, Jamie!”
B: Jamie cries and begs to stay home from
school
C: Mom comforts him and gives him a day off
from school.
#1 Principle to teach parents:
• The Premack Principle
– High frequency behaviors serve to
reinforce low frequency behaviors
• Grandma’s Rule: “You can’t get your ice
cream until you finish your spinach!”
• e.g., School refusal = no
computers/tv/gameboy
#2 Principle to teach parents: How
negative reinforcement works
Parent gives in to tantrum,
fear
4th step
1st step
8th step
Impact of rescue:
Impact of exposure:
• remembers situation at the
height of fear
• remembers success that allows
habituation
• prevents habituation
• learns anxiety passes on its
own
• no experience of mastery
• escape is reinforced
• willing to approach increasingly
challenging situations
• feeling of mastery
From Chansky (2004)
• reinforcement for hanging in
#3 Principle to teach parents: How
to use reinforcers
• CONTINGENT on performance of the target
behavior
• CONSISTENTLY applied
• Administered IMMEDIATELY after the behavior
• Initially on CONTINUOUS schedule, then changed
to INTERMITTENT
• Kept POTENT
– use small amounts and change reinforcers periodically
– involve natural reinforcers whenever possible
**The child should be aware that a reinforcer is a
consequence of the target behavior**
#4 Principle to teach parents:
Shaping via reinforcement
• Start small, build as you go
• Shaping
– Components of a target behavior are
reinforced in a step-by-step manner
Parents taking Action
•
•
•
•
•
Identify potential role in child’s behavior
Understand the problem
Examine what keeps it going
Use “If-Then”
Parents as “coaches”
What is most difficult
for parents?
 Letting the child
struggle
 Mistakes promote
learning and mastery
 Fear that “situation X
is too important to
fail”
 Parental
“overprotection trap”
 Limits progression
through developmental
steps
Anxiety-provoking situations
• Interviews (college, work)
• Speaking in class/small
groups
• Dating
• Unstructured social
situations (e.g., parties)
• Meeting unfamiliar people
• Initiating or maintaining
conversations
• Being alone
• Boredom
•
•
•
•
•
•
•
•
•
Assertive behavior
Taking to authority figures
Being observed by others
Taking tests (class, SATs)
Making independent
decisions
Being wrong
Performance situations
Being the center/focus of
attention
Conflict with peers
Anxiety Fear Hierarchy
Fear Thermometer (SUDS)
Separation Anxiety Fear Hierarchy
Most Anxiety
1
0
Situation
SUDS
9
8
Spending night at friend’s house
7
Spending 2 hours at friend’s– w/o mom
6
Spending 30 mins at friend’s – w/o mom 7
10
8
5
Mom leaving home for 30 minutes
6
3
Mom leaving home for 15 minutes
5
2
Mom going out to get mail
3
4
1
0 Least
Anxiety
Mom going in a different room –
nighttime
2
School-based Anxiety Fear
Hierarchy
Fear Thermometer (SUDS)
School Situations Fear Hierarchy
Most Anxiety
1
0
Situation
SUDS
9
8
Giving an oral report in class
10
7
Not calling mom at all during day
8
6
Taking an exam in the classroom
7
Asking the teacher a question in class
6
3
Asking the teacher for help after class
5
2
Having my homework marked up
3
Working on a group project
3
5
4
1
0 Least
Anxiety
Understand the Core of Anxiety
• Anxiety-provoking situations WILL invariably
lead to:
– Embarrassment
– Humiliation/Rejection
– Loss of control
– Catastrophe
– Loss of social status
– Death/Physical Illness
Keys for Parents
• Maintenance of anxiety:
– Overprotection, Overcontrol
•
•
•
•
Know developmental tasks
Approach areas of conflict
Openly express your fears
Encourage and listen to your teen’s
fears/frustrations
• Communicate and problem solve
• Set goals and plans
Basic Childhood Skills
• Self-soothing
– Calms self, able to be alone, puts self to sleep
• Independence
– Sleeps alone, entertains self, does homework,
seeks information/activity
• Assertiveness
– Asks for help, refuse requests, sticks up for self
• Social skills
– Makes and keeps friends, interacts with known
adults
Advanced Skills for Adolescents
•
•
•
•
•
•
•
•
Problem solving skills
Higher-order social skills (e.g., negotiation)
Emotion regulation skills
Realistic thinking
Perspective
Anxiety and stress/time management skills
Opportunities to learn and to mess up
Family support but not overprotection!
Keeping Calm
 Goal: Develop tolerance of normal,
expected levels of anxiety
 Deep breathing
 Progressive Muscle Relaxation
 Mindfulness exercises
 Yoga
Typical Cognitive Distortions
• All or None Thinking
– Either I ace this test, or I fail and I’m a loser.
• Catastrophizing
– This is the worst thing that could happen to me!
• Disqualifying the positive
– A B+ on that test just wasn’t very good.
• Fortune Telling
– I know that I won’t make friends at that camp.
– I know something bad will happen to mom.
• Overgeneralization
– That person wasn’t very friendly to me. There
just isn’t any nice people around anymore.
• Mind Reading
– I know they think I’m a geek.
• Shoulds, Can’ts, Won’ts
– I should’ve said something different . . .
– I can’t do this, it is impossible!
– I won’t ever be able to . . . .
• Probability Overestimation
– I’m absolutely positive that I won’t get into
college.
World Series, 9th inning, 7th
game, 2 outs, the score is tied
• What is Derek
thinking when he gets
up to bat?
– “Oh no, I can’t do
this.”
– “My stomach hurts.”
– “I want to go home.”
– “If I strike out, I can
never play baseball
again.”
– “I’m afraid of that
pitcher, he’s mean!”
Derek takes a swing . . . and
misses!
•
•
•
•
“I knew I was a loser!”
“I’m so embarrassed!”
“I’m gonna get fired.”
“Now Mr. Torre will
really be mad at me.”
• “The guys hate me, I
just know it.”
Derek Jeter’s REAL Thoughts
• “Okay, so, he’s
throwing me a slider.”
• “I’ve been here before,
I know what to do.”
• “This is what I
practice for and I’m
ready.”
• “I’m going to send this
ball straight into the
left field bleachers.”
Cognitive Challengers for Older
Children/Teens
• How would an objective observer view this
situation?
• What alternative explanations are there for this
situation?
• What if you saw a friend struggling . . . What
would you think or do?
Helpful Coaching Style
• Focus on effort, not outcome
• Evaluate the situation realistically
• Think about what you know and what
you’ve done in the past
• Focus on coping: How will I handle
this?
• Give opportunities for practice
• Reward (praise) all efforts, no matter
how small
Exposure: Key to Learning
 Goals:
 Provide experience performing in and
managing difficult situations
 Practice and refine cognitive, social,
somatic management, and problem
solving skills
 Refute anxious thoughts
 Habituation to anxiety
 Tolerate anxiety
Manage parental anxiety….
 Transfer to your child?
 Learn to recognize
your own triggers
 Self-soothe
 Stick with realities
 Problem solve
 Take care of your own
needs!
Just when you thought you were done!
Milestones for Adolescence through Emerging
Adulthood: Timeline: Late 20’s?
•
•
•
•
•
•
Accept sexual identity
Form long term romantic relationships
Formulate long-term vocational goals
Complete educational requirements
Establish financial independence
Live independently
Junior to Senior Year Goals
Situation
Goal Achieved?
Going to a college interview out of town on my own
No
Asserting myself with a teacher
No
Planning, buying and making my own meals for the month
Yes
Going to the doctor’s on my own
Yes
Arranging for my own transportation to an in-town event
Yes
Handling my own checking account
Yes
Calling to arrange an interview (job, college or internship)
Yes
Doing my own laundry
Yes
Taking driving lessons
No
Getting my driver’s permit
Yes
When to seek help?
• The anxiety does not go away….
• Your child is increasingly unhappy….
• Family routines and functioning are
affected….
• You and your spouse are at each other….
• No matter what you try, nothing works….
For a little more help…
Helpful Websites
•
•
•
•
www.effectivechildtherapy.com
www.anxietybc.com
www.adaa.org
www.abct.org
• Follow me on twitter!
– @AnneMarieAlbano
• Website: www.annemariealbano.com

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