John Piacentini Students Under Pressure: Helping Manage Stress and Anxiety


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Dr. John Piacentini
Professor of Psychiatry and Biobehavioral Sciences in the David Geffen School of Medicine and Director of the Child OCD, Anxiety, and Tic Disorders Program at the Semel Institute for Neuroscience and Human Behavior at UCLA

Recognition and Treatment of Anxiety Disorders in Youth with ADHD and LD
This presentation will review the clinical phenomenology, assessment and treatment of childhood anxiety disorders. Special emphasis will be placed on the recognition and treatment of problematic anxiety in children and adolescents with coexisting ADHD and LD.

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  • Fears in childhood are very normal. In fact, developmentally appropriate fears are crucial to keep children safe from harm, and assist children to make sense of their constantly changing world. Childhood fears become a concern or a problem when the FEAR is outside of the Childs developmental stage – for example, it is normal for a child of 4 or 5 years to be Very afraid of being separated from mum or dad during the first few weeks of going to school. However, it is not developmentally appropriate for a child of 12 to be very afraid of separation from parents, and need to call mum or dada many times during a day to check that they are safe and they won’t forget to come to collect them after school. A normal fear also becomes a problem when the child experiences significant distress – out of proportion to the context, whereby it is extremely difficult to soothe them. DURATION – when the fear is not transitory (for example the first few days or even weeks of school) but rather LINGERS for at least 2 months. And when it interferes with a child’s or family’s life. Anxious kids are great to work with, they are fantastic to have in your classroom , because they do their work quietly, they are often perfectionist o they also do a great job! And they are always eager to please! However, they do cause HUGE amounts of distress to family members and cause massive disruption to family routine.
  • John Piacentini Students Under Pressure: Helping Manage Stress and Anxiety

    1. 1. Anxiety in ADHD and LD John Piacentini, Ph.D., ABPP UCLA Child OCD, Anxiety, and Tic Disorders Program Help Group SUMMIT October 2, 2009
    2. 2. OVERVIEW <ul><li>What is “ anxiety ” ? </li></ul><ul><li>How is anxiety identified? </li></ul><ul><ul><li>In children with ADHD and LD </li></ul></ul><ul><li>How is anxiety treated? </li></ul><ul><ul><li>In children with ADHD and LD </li></ul></ul>
    3. 3. Normal Developmental Fears <ul><ul><li>Infancy – strangers, loud noises </li></ul></ul><ul><ul><li>Early childhood – separation, monsters </li></ul></ul><ul><ul><li>Middle childhood – real-world dangers, new challenges </li></ul></ul><ul><ul><li>Adolescence – social status, social group, performance </li></ul></ul>
    4. 4. What is anxiety…. <ul><li>ANXIETY is a fear response in ABSENCE of real threat </li></ul><ul><ul><li>Affective – fear, panic, agitation, nervousness </li></ul></ul><ul><ul><li>Cognitive – worry, negative thoughts, poor concentration, </li></ul></ul><ul><ul><li>attentional biases </li></ul></ul><ul><ul><li>Physiological – arousal, abdominal, tension, sleep </li></ul></ul><ul><ul><li>Behavioral – flight, fight, freeze, reassurance seeking </li></ul></ul>
    5. 5. Tripartite Model of Anxiety Thoughts Behaviors Feelings
    6. 6. Transient episodes of anxiety <ul><li>Are expected and cause relatively little interference in functioning for the average child or adolescent </li></ul><ul><li>Are associated with circumscribed events (e.g., thunder; new situations; oral report; teasing) </li></ul><ul><li>Are overshadowed by the cumulative effect of positive reinforcement delivered by peers, parents, and teachers (habituation occurs) </li></ul>
    7. 7. What’s the difference between Normal and Problematic Anxiety? <ul><li>INTENSITY of the fear: within expected limits or out of proportion to the actual threat? </li></ul><ul><li>Does the fear reaction occur with increased FREQUENCY and/or remain fixed despite reassurance? </li></ul><ul><li>Is the content of the fear focused on an INNOCUOUS situation? </li></ul><ul><li>Does the fear occur SPONTANEOUSLY ? </li></ul>
    8. 8. When is Anxiety a “Disorder”? <ul><li>Avoidance </li></ul><ul><li>Interference </li></ul><ul><li>(not facing developmental challenges) </li></ul><ul><li>Distress </li></ul><ul><li>Duration </li></ul>
    9. 9. How Common are Anxiety Disorders in Children and Adolescents? Most common child psychiatric disorder - U.S. Surgeon General’s Report on Mental Health Between 12% to 20% of community youngsters suffer from anxiety severe enough to interfere with their functioning
    10. 10. ADHD Comorbidity – The MTA Study <ul><ul><li>Oppositional Defiant Disorder 39.9 % </li></ul></ul><ul><ul><li>Anxiety Disorder 33.5 </li></ul></ul><ul><ul><li>Conduct Disorder 14.3 </li></ul></ul><ul><ul><li>Tic Disorder 10.9 </li></ul></ul><ul><ul><li>Affective Disorder 3.8 </li></ul></ul><ul><ul><li>Tic Disorder 10.9 </li></ul></ul><ul><ul><li>Mania/Hypomania 2.2 </li></ul></ul><ul><ul><li>Other (eg, Bulimia, Enuresis) 0.2 </li></ul></ul>579 children (age 7.0 to 9.9 yo) with ADHD-combined Type
    11. 11. Anxiety in LD Youngsters <ul><ul><li>Less well studied, but approximately 10-15% of LD youth have been shown to experience clinically significant anxiety </li></ul></ul>
    12. 12. DSM-IV Anxiety Disorders <ul><li>Separation Anxiety Disorder </li></ul><ul><li>Social Anxiety Disorder (Social Phobia) </li></ul><ul><li>Generalized Anxiety Disorder </li></ul><ul><li>Panic Disorder with/without Agoraphobia </li></ul><ul><li>Agoraphobia without history of Panic Disorder </li></ul><ul><li>Obsessive Compulsive Disorder </li></ul><ul><li>Specific Phobia </li></ul><ul><li>Post Traumatic Stress Disorder </li></ul><ul><li>Selective Mutism </li></ul>
    13. 13. Separation Anxiety Disorder Presence of 3 or more of the following <ul><li>distress when separation is anticipated or occurs </li></ul><ul><li>worry about harm befalling others </li></ul><ul><li>worry that an untoward event will result in separation </li></ul><ul><li>refusal to go to school or elsewhere </li></ul><ul><li>fear or reluctance to be alone at home or in other settings </li></ul><ul><li>refusal to sleep away from attachment figures </li></ul><ul><li>nightmares </li></ul><ul><li>physical complaints at separation </li></ul>
    14. 14. SAD: Symptom Age Trends <ul><li>Ages 5-8: fears of harm befalling attachment figures; nightmares, school refusal </li></ul><ul><li>Ages 9-12: excessive distress at separation </li></ul><ul><li>Ages 13-16: somatic complaints and school refusal </li></ul>
    15. 15. SAD: Related Symptoms <ul><li>More likely to report somatic complaints </li></ul><ul><li>Drop from extracurricular activities </li></ul><ul><li>Strained peer-relations </li></ul><ul><li>Compromised academic performance </li></ul><ul><li>Comorbid fears: monsters, animals, insects, the dark, and fear of getting lost </li></ul><ul><li>Comorbid GAD </li></ul><ul><li>Comorbid depression in 1/3 of youth with SAD </li></ul>
    16. 16. Social Phobia <ul><li>Marked and persistent fear of social situations in which the person is exposed to unfamiliar people or possible evaluation; fears embarrassment or humiliation </li></ul><ul><li>The situation provokes anxiety </li></ul><ul><li>The situation is avoided or endured with distress </li></ul><ul><li>Interference in functioning </li></ul><ul><li>Duration of at least 6 months </li></ul>
    17. 17. Associated Features of Social Phobia in Youth <ul><li>Higher levels of depressed mood </li></ul><ul><li>Lower perceptions of cognitive competence </li></ul><ul><li>Higher trait anxiety </li></ul><ul><li>Frequent somatic complaints </li></ul><ul><li>Avoidance of a wide range of situations </li></ul><ul><li>High risk for alcohol abuse (adolescents) </li></ul><ul><li>Heightened risk for suicidality (adolescents) </li></ul>
    18. 18. Generalized Anxiety Disorder <ul><li>Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of activities or events </li></ul><ul><li>The worry is difficult to control </li></ul><ul><li>At least 1 physiologic symptom: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance </li></ul>
    19. 19. Characteristics of Worriers <ul><li>Markedly self-conscious and require frequent reassurance </li></ul><ul><li>“ What if” thinking </li></ul><ul><li>Worry about low frequency events </li></ul><ul><li>Intensity of worry differentiates youth with GAD from those without the disorder </li></ul>
    20. 20. <ul><li>OBSESSION COMPULSION </li></ul><ul><li>Contamination Washing / Cleaning </li></ul><ul><li>Concern about Harm Checking / Others </li></ul><ul><li>Need for Symmetry Arranging / Tapping </li></ul><ul><li>Fear of losing things Hoarding </li></ul><ul><li>Fear of embarrassment Avoidance </li></ul><ul><li>“ Just Right” Phenomenon Repeating </li></ul><ul><li>Moral obsessions Confessing / Telling </li></ul>Obsessive Compulsive Disorder
    21. 21. How to Identify Problematic Anxiety in Children with ADHD and LD?
    22. 22. Accurate Diagnosis of Anxiety Disorders in Youth <ul><li>Young children tend to think in the moment and hence misrepresent symptoms or severity </li></ul><ul><li>Adolescents may under-report their anxious symptoms (especially boys) </li></ul><ul><li>The nature of certain anxiety disorders (e.g., social anxiety) lends itself to being misdiagnosed or missed completely </li></ul><ul><li>Accurate diagnosis in youth is dependent upon both child/adolescent AND parent report </li></ul>
    23. 23. Assessment of Anxiety Disorders <ul><li>Diagnostic Interview Schedules </li></ul><ul><ul><li>Anxiety Disorders Interview Schedule for Children (ADIS) </li></ul></ul><ul><li>Questionnaires </li></ul><ul><ul><li>Child, Parent, Teacher </li></ul></ul><ul><ul><li>Multidimensional Anxiety Scale for Children (MASC) </li></ul></ul><ul><ul><li>Screen for Child Anxiety and Related Disorders (SCARED) </li></ul></ul><ul><li>Behavioral Assessment Techniques </li></ul><ul><ul><li>Observation </li></ul></ul><ul><ul><li>Behavioral Avoidance Tasks </li></ul></ul>
    24. 24. Identifying Anxiety Potential RED flags? <ul><li>Extreme shyness </li></ul><ul><li>Isolation </li></ul><ul><li>Avoids social situations </li></ul><ul><li>Extreme discomfort when the center of attention </li></ul><ul><li>Avoids schoolwork for fear of making a mistake </li></ul>
    25. 25. Identifying Anxiety Potential RED flags? <ul><li>Expects bad things to happen </li></ul><ul><li>Excessive worry about upsetting others </li></ul><ul><li>Asks questions (or asks for reassurance) too frequently </li></ul><ul><li>Perfectionism </li></ul><ul><li>Excessive worry about failure </li></ul><ul><li>Wiggles, is jittery, shaky, high strung, tense and unable to relax </li></ul><ul><li>Lacks self-confidence </li></ul>
    26. 26. Physical red flags <ul><li>Trouble catching breath </li></ul><ul><li>Stomachaches/ headaches </li></ul><ul><li>Complains of nausea </li></ul><ul><li>Sweating </li></ul><ul><li>Dizzy, faint, or light headed </li></ul><ul><li>Increased heart rate </li></ul><ul><li>Shaking or feeling jittery </li></ul><ul><li>NOTE: Potential functional role </li></ul><ul><li>of physical complains </li></ul>
    27. 27. Four Key Questions <ul><li>To screen quickly for one or more anxiety disorders in children, four questions are often useful </li></ul><ul><li>Does the child worry or ask for parental reassurance almost every day? </li></ul><ul><li>Does the child consistently avoid certain age-appropriate situations or activities, or avoid doing them without a parent? </li></ul><ul><li>Does the child frequently have stomachaches, headaches, or episodes of hyperventilation? </li></ul><ul><li>Does the child have daily repetitive rituals? </li></ul>Manassis (2004)
    28. 28. Differentiating Anxiety from ADHD / LD <ul><li>ADHD/LD ANXIETY </li></ul><ul><li>Overactivity Agitation </li></ul><ul><li>Inattention Anxious Preoccupation </li></ul><ul><li>Realistic worry Unrealistic worry </li></ul><ul><li>Social Skills Deficits Social Anxiety </li></ul>
    29. 29. School Refusal <ul><li>Important to identify the reason underlying school refusal: </li></ul><ul><li>Separation fears Boredom, demoralization </li></ul><ul><li>Social anxiety Bullying, teasing </li></ul><ul><li>Test anxiety Learning problems </li></ul>
    30. 30. Treatment of Anxiety in Children with ADHD and LD
    31. 31. Treating Complex Cases “Lumpers vs Splitters” <ul><li>Careful evaluation of all problems </li></ul><ul><li>Problem list - rank ordered by severity </li></ul><ul><li>Typically treat most severely impairing problem first </li></ul><ul><ul><li>school, social, family, self-esteem, distress </li></ul></ul><ul><li>Also consider impact of comorbidity on treatment </li></ul><ul><ul><li>for example, inattention impairs ability to participate in CBT </li></ul></ul><ul><li>Select best treatment for each problem </li></ul>
    32. 32. Treating Complex Cases <ul><li>Possible to address multiple problems simultaneously </li></ul><ul><ul><li>SSRI medication for anxiety and depression </li></ul></ul><ul><ul><li>Parent training/behavioral reward system for ADHD and anxiety </li></ul></ul><ul><li>But this must be done carefully </li></ul><ul><ul><li>burden on child and family </li></ul></ul><ul><ul><li>less therapy time available for each problem </li></ul></ul><ul><ul><li>confusing to child </li></ul></ul><ul><ul><li>may lessen efficacy of one or both interventions </li></ul></ul>
    33. 33. Helping Children Manage their Anxiety <ul><li>Okay To Do </li></ul><ul><li>Be sensitive </li></ul><ul><li>Provide positive feedback </li></ul><ul><li>Provide realistic encouragement </li></ul><ul><li>Be consistent </li></ul><ul><li>Seek additional resources </li></ul><ul><li>Not Recommended </li></ul><ul><li>Accommodate the anxiety </li></ul><ul><li>Single the child out </li></ul>
    34. 34. Two Effective Treatments for Anxiety <ul><ul><li> Cognitive Behavior Therapy </li></ul></ul><ul><ul><li> SSRI Medication </li></ul></ul>
    35. 35. Cognitive Behavior Therapy From Kendall, 1992
    36. 36. Cognitive Behavior Therapy <ul><li>Education about Anxiety </li></ul><ul><li>Recognizing Emotions and Bodily Feelings </li></ul><ul><li>Recognizing Anxious Thoughts </li></ul><ul><li>Change Negative Thoughts </li></ul><ul><li>Change Avoidant Behaviors </li></ul>
    37. 37. Impact of ADHD and LD on CBT <ul><li>Difficulty self-monitoring and accurately reporting symptoms, distress and internal states </li></ul><ul><li>Can’t attend to therapist </li></ul><ul><li>Difficulty staying seated </li></ul><ul><li>Difficulty comprehending therapy concepts, exercises, and expecations </li></ul><ul><li>Poor frustration tolerance/need immediate gratification </li></ul><ul><li>Family environmental factors </li></ul>
    38. 38. Accommodations for ADHD and LD <ul><li>Greater emphasis on behavioral vs cognitive factors </li></ul><ul><li>More concrete exercises and examples </li></ul><ul><li>Slower pace </li></ul><ul><li>More repetitions </li></ul><ul><li>More frequent rewards </li></ul><ul><li>Greater parental involvement </li></ul>
    39. 39. Early Caveman Game: Ethological Perspective: Anxiety as an adaptive advantage Kiss the Mammoth and Run
    40. 40. Recognizing Emotions Easy
    41. 41. Recognizing Emotions Harder
    42. 42. Identifying Anxious Feelings Start with less threatening exercises (magazine pictures, stories about others) and then move to more personal material Hardest
    43. 43. Monitoring Anxious Feelings
    44. 44. Somatic Exercises <ul><ul><li>To address somatic symptoms </li></ul></ul><ul><ul><ul><li>Progressive Muscle Relaxation </li></ul></ul></ul><ul><ul><ul><li>Deep Breathing </li></ul></ul></ul><ul><ul><ul><li>Visual Imagery (Spaceship Rides) </li></ul></ul></ul><ul><ul><ul><li>Develop tolerance of normal, expected </li></ul></ul></ul><ul><ul><ul><li>levels of anxiety </li></ul></ul></ul><ul><ul><ul><li>Practice at home </li></ul></ul></ul>
    45. 45. Dossick & Shea, 1988 Identifying Anxious Thoughts
    46. 46. Changing Anxious Thoughts
    47. 47. Anxiety Fear Hierarchy <ul><li>Situation SUDS </li></ul><ul><li>Riding an elevator alone 10 </li></ul><ul><li>Riding an elevator with parent 8 </li></ul><ul><li>Riding a glass elevator 6 </li></ul><ul><li>Bathroom alone with door closed 6 </li></ul><ul><li>Bathroom with parent with door closed 5 </li></ul><ul><li>Small room alone with door closed 5 </li></ul><ul><li>Small room with someone with door closed 4 </li></ul><ul><li>Small room alone with door slightly ajar 2 </li></ul>Least Anxiety Most Anxiety 10 9 8 7 6 5 4 3 2 1 Separation Anxiety Fear Hierarchy Fear Thermometer (SUDS)
    48. 48. Behavioral Exposure
    49. 49. Charting Anxiety during Exposure
    50. 50. Examples of Exposures Social Anxiety <ul><li>Conversations (initiating, joining in) </li></ul><ul><li>Giving an oral report </li></ul><ul><li>Asking someone for a date </li></ul><ul><li>Interviewing for college or a job </li></ul><ul><li>Meeting someone for the first time </li></ul><ul><li>Dealing with teasing </li></ul>
    51. 51. Reward Program
    52. 52. Cognitive Behavior Therapy FEAR PLAN F eeling Frightened E xpecting Bad Things to Happen A ttitudes & Actions that will Help R esults & Rewards From COPING CAT (Kendall et al., 1992)
    53. 53. CONSULTANT provide information CHEERLEADER provide encouragement COACH supervise/administer treatment components CLIENT target of specific aspects of intervention Level of Parental Involvement
    54. 54. Family Techniques Teach parents to: Reward child’s courageous behaviors Extinguish child’s fear behaviors Communicate, cope, and problem-solve Control their own (parent’s) anxiety
    55. 55. Relapse Prevention <ul><li>Transfer of responsibility for treatment </li></ul><ul><li>Development of relapse prevention plan: </li></ul><ul><ul><li>Monitoring symptoms </li></ul></ul><ul><ul><li>Reinstitute exposure </li></ul></ul><ul><li>Fading sessions </li></ul><ul><li>Booster groups/planned sessions at times of high stress </li></ul>
    56. 56. CBT for Child Anxiety (ITT Outcomes) Cochrane Report, 2006 CBT N=498 Control N=311
    57. 57. Impact of Comorbidity on CBT Response Kendall et al., 2001 Comorbidity does not lead to worse CBT response
    58. 58. Medication for Child Anxiety Fluvoxamine Placebo RUPP Anxiety Study Group. (2001). NEJM, 344 , 1279-1285.
    59. 59. The C hild/Adolescent A nxiety M ultimodal S tudy (CAMS) Walkup, Albano, Piacentini et al., (2008). New England Journal of Medicine
    60. 60. CAMS Study Design <ul><li>488 7-17 year old with a primary diagnosis of </li></ul><ul><ul><li>Separation, Social, or Generalized Anxiety Disorder </li></ul></ul><ul><li>Four Treatment Arms </li></ul><ul><ul><li>CBT </li></ul></ul><ul><ul><li>Sertraline </li></ul></ul><ul><ul><li>Combination (CBT+Sertraline) </li></ul></ul><ul><ul><li>Pill Placebo </li></ul></ul><ul><ul><li>Which Treatment Works Best for Which Children? </li></ul></ul>
    61. 61. CAMS Sample Characteristics <ul><li>Externalizing Comorbidity </li></ul><ul><ul><li>11.9% ADHD-Inattentive (stable meds) </li></ul></ul><ul><ul><li>9.4% Oppositional-defiant or Conduct Disorder </li></ul></ul>
    62. 62. Treatment Response COMB > CBT = SRT > PBO
    63. 63. Pediatric Anxiety Rating Scale
    64. 64. Impact of Anxiety on ADHD Treatment Response MTA Study <ul><li>ADHD children with comorbid anxiety responded just as well to stimulant medication as children with ADHD and Anxiety </li></ul><ul><li>However, children with comorbid anxiety disorder responded better to CBT than those without an anxiety disorder </li></ul>
    65. 65. Meds for ADHD+Anx Abikoff et al., 2005 <ul><li>32 children with ADHD+Anxiety first treated with methylphenidate for ADHD. Responders then randomized to fluvoxamine or placebo for anxiety symptoms </li></ul><ul><li>ADHD symptoms showed similar response to stimulant regardless of treatment group </li></ul><ul><li>There was no difference between fluvoxamine and placebo in reducing anxiety symptoms </li></ul>