Supporting Kids and Teens Who Struggle With Anxiety


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Presented at 2013 Accessibility Summit, McLean Bible Church, McLean, VA, April 20, 2013

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  • Key concept: Many kids (and adults) may struggle…or thrive depending upon the external demands placed upon them by their environment at any given moment. Some might do well in one church and not another, depending upon the specifics of the environment. Some might do well in some activities, but not others.Example…Kid who can attend church weekly and join with peers is unable to go on an overnight retreat, or on a mission trip.“We sit in the first row…he and his brother like to dance to the praise band. When the music’s over, they take the kids out and keep them so busy, he does OK.”
  • How kids with anxiety disorders might struggle with weekend worship, participation in other church activities, spiritual development and in attempts to grow faith at home.
  • Supporting Kids and Teens Who Struggle With Anxiety

    1. 1. Supporting Kids and Teens Who Struggle With Anxiety Stephen Grcevich, MD Chairman, Board of Directors, Key MinistryClinical Assistant Professor of Psychiatry, Northeast Ohio Medical University Senior Clinical Instructor, Child and Adolescent Psychiatry Case Western Reserve University School of Medicine 2013 Accessibility Summit McLean Bible Church, McLean VA April 20, 2013
    2. 2. Learning Objectives: Recognize common signs and symptoms in kids who struggle with anxiety Become familiar with contemporary understanding of the causes of anxiety Examine the impact of anxiety on family functioning and academic, social and spiritual development in children and teens Review strategies for helping kids overcome functional limitations associated with anxiety
    3. 3. “It is our culture that disables.”“When one is disabled, the problem is not reallythat they have impairments and social skilldeficits. The issue at stake is that they live in an„ableist‟ culture that rarely affords them thespace or opportunity to make their uniquecontribution to society and does not lift up thevalue of choosing them as friends.”Ben Conner…Amplifying Our Witness (2012) Can a disability be a disability in some, but not all environments?
    4. 4. Some fears are normal and age-appropriatein children and teens… Infants: loud noises, fear of being startled Toddlers/young children: imaginary creatures, the dark, animals, strangers School-age children: injury, natural events (hurricanes, tornadoes, earthquakes), death Teens: Fears related to school performance, social competence, healthJ Am Acad Child Adolesc Psychiatry 2007;46(2) 267-83.
    5. 5. Common signs of anxiety in children, teens… Avoidance Excessive need for reassurance Excessive physical complaints Sleep disturbances (especially increased sleep latency) Difficulties with concentration, attention Perfectionism “What if” questions Excessive absence from school Easily distressed Lying
    6. 6. Some facts about kids with anxiety… 8% of teens ages 13-18 have anxiety disorders Most experience onset of anxiety by age 6 18% of teens with anxiety disorders have ever received treatment Girls>Boys Severity=persistence Kids often develop new anxiety disorders over time Greater risk of depression, substance abuse Genetics, parent-child interactions, parental modeling, temperament are risk factors Am Acad Child Adolesc Psychiatry, 2007;46(2):267-283
    7. 7. Specific Anxiety Disorders in Children, Adolescents: Note: Kids may experience different manifestations of anxiety as they progress through developmental stages  Separation Anxiety Disorder  Specific Phobia  Generalized Anxiety Disorder  Social Anxiety Disorder  Panic Disorder  Obsessive-Compulsive Disorder  Selective MutismJ Am Acad Child Adolesc Psychiatry, 2007;46(2):267-283
    8. 8. What causes anxiety in children and teens? Genetics…alterations in amygdala circuits involved in emotion processing, disruption in functional connectivity in amygdala-based networks involved in fear-processing The child‟s/teen‟s innate personality style Environment (trauma, illness, life stressors) Overprotective parentsBottom line…Kids with anxiety misinterpret the level of risk in their immediate environment
    9. 9. FIGURE 1Source: Journal of the American Academy of Child and Adolescent Psychiatry 2013; 52:290-299.e2 (DOI:10.1016/j.jaac.2012.12.010 ) Copyright © 2013 American Academy of Child and Adolescent
    10. 10. Functional impairment in kids and teens with anxiety… Child TeenagerSchool: Difficulty separating from parents Test anxiety Difficulty with class participation Difficulty with self-advocacy…getting help Frequent trips to nurse‟s office Avoid extracurricular activities, social events Performances, presentations Fear of failure inhibits class selectionFriends: Challenges in making new friends May depend on small circle of trusted friends Parents often initiate social activity Challenges with group trips/activities Difficulty with sleepovers Dating and breakups more challengingFamily: Often sleep with parents at night Slow to progress toward independence Reluctant to try new activities Frequently reluctant to get driver‟s license Conflict-dependence on electronic communicationCommunity: Less involved with sports, other May have more difficulty applying for jobs extracurricular activities Less likely to docamps, travel experiences
    11. 11. How do our ministry environments create barriers forkids with anxiety and their families?
    12. 12. Some observations… God created all of us as unique human beings…more kids in this generation are being diagnosed with autism spectrum disorders and other social disabilities…accident? Churches are social institutions…we promote fellowship, discipleship…Where does that leave people who struggle with relationships? Church environments are especially challenging for people with anxiety “To reach people no one else is reaching, we have to try stuff no one else is trying.”
    13. 13. Common barriers to church participation andspiritual growth in kids with anxiety… Vulnerability to misinterpret risks in environment Differences in sensory processing Cognitive rigidity Past negative experiences of church Family stress, isolation Parents with anxiety
    14. 14. Impacts of anxiety on church attendance and spiritual development in children and teens… Child TeenagerWeekend They prevent the family from They‟re reluctant to attendWorship: attending… Reluctant to attend without friends Difficulty separating from parents Uncomfortable with attention of group Visiting new church challenging Transitions between age-group ministries difficultChurch Discomfort reading, praying aloud Disclosure in small groupschallengingActivities: Reluctant to engage unfamiliar kids Unfamiliar places, experiences may be Difficulty in unfamiliar environments threatening…retreats, mission tripsSpiritual Prone to misperceive who God is… More prone to ritualismDisciplines Prayer, process of confession in Obsessions- doubting salvation, sinning against some traditions challenging one‟s will Group disciplines more challengingGrowing in Parents can model faith, practicing Parents can sensitively expose teens to newfaith at home: disciplines as a positive coping spiritual experiences strategy
    15. 15. What could a church try to welcomekids with anxiety and their families? Lots of pictures and video letting kids know what to expect on Sundays, during new experiences Offer to let kids and families tour your campus in advance of their first Sunday Applications of technology…online church campuses, small groups, Bible studies?
    16. 16. Tips for church staff and volunteers:Kids with anxiety Don‟t call attention to an anxious child Kids with anxiety are horrified by interventions that make them feel “different”…buddies, being part of “special needs ministry” Train greeters to observe for problems at “drop-off” Designate a private place for kids/parents in distress Leaders can watch for kids who are alone Offer to meet with parents when a child‟s anxiety appears to interfere with ministry participation Remember…anxiety generally decreases with experience (exposure) Remember potential areas of giftedness: administration, organization, sensitivity to others
    17. 17. Treatment of anxiety disorders inchildren, adolescents: Cognitive-behavioral therapy (with modifications for specific anxiety disorders) SSRIs, other medications Parent-child, family interventions Classroom-based accommodations, interventions Evidence-based interventions in orange J Am Acad Child Adolesc Psychiatry, 2007; 46(2):267-283
    18. 18. CAMS (Child-Adolescent AnxietyMultimodal Study): NIMH-funded, RCT comparing placebo, sertraline, CBT and combination treatment (CBT+sertraline) for treatment of separation anxiety disorder, social anxiety disorder, generalized anxiety disorder Children, ages 7-17, N=488 CBT: 14 sessions, using “Coping Cat” curriculum Sertraline: started at 25 mg/day, increased by fixed- flexible titration (mean dose:133 mg/day) Walkup JT et al, N Engl J Med, 2008;359:2753-2766
    19. 19. CAMS (Child-Adolescent AnxietyMultimodal Study): Response rates to treatment: Response rates: COMB: %Responders 80.7%, CBT: 59.7%, SER: 100 54.9%, PBO: 23.7% 80 COMB>CBT=SER>PBO 60 Effect Sizes: COMB: 0.86, 40 SER: 0.45, CBT: 0.31 20 %Responders 0 No adverse effects>PBO in medication groups Beneficial effects of COMB vs. SER evident after week 8 Walkup JT et al, N Engl J Med, 2008;359:2753-2766
    20. 20. A final thought… Rhett Smith-author of The Anxious Christian “We are all anxious. We all will and do experience anxiety. Anxiety is part of our human condition. With that being said, I believe that God uses our anxiety as a tool to help us grow. It‟s a catalyst that keeps us from getting stuck, as it propels us to continually follow God.”
    21. 21. What have we learned? The vast majority of kids with anxiety disorders develop symptoms during their grade school years (or earlier) and receive no treatment for their condition. Anxiety can have a major impact upon a child‟s spiritual development and church participation Churches can take specific steps to making their ministry environments more welcoming to kids with anxiety and their families Cognitive-Behavioral therapy (CBT) and medication are effective treatments for kids with anxiety…best response when CBT, medication are used together
    22. 22. Additional Resources:Resource page on anxiety and spiritual development: development/American Academy of Child and Adolescent Psychiatry: Institute of Mental Health adolescents/index.shtmlAnxiety Disorders Association of America
    23. 23. Provides FREE training,consultation, resources andsupport to help churches serve,welcome and include families ofkids with hidden disabilities
    24. 24. Stay in Touch!Key Ministry Website: http://www.keyministry.orgChurch4EveryChild…Steve‟s Key Ministry Blog: http://drgrcevich.wordpress.comDiving For Pearls…Katie Wetherbee‟s Blog: http://katiewetherbee.wordpress.comA Reckless Pursuit…Harmony Hensley‟s Blog:!/drgrcevich!/KeyMinistry
    25. 25. Questions?
    26. 26. Additional Slides
    27. 27. Cognitive Behavioral Therapy (CBT) What is CBT?The goal is to alter cognitive processes by increasing self awareness, facilitate better self- understanding, and improving self control by developing more appropriate cognitive and behavioral skills.
    28. 28. Cognitive Behavioral Therapy (CBT) ThoughtsThree Components: Cognitive Emotional/Physiological Behavioral Behavior Feelings
    29. 29. Cognitive Behavioral Therapy (CBT) Unhealthy Process Healthy Process Thoughts Distorted thinking: Overly More positive, acknowledge negative, self-critical, success, balanced, and selective and biased recognized strengths Feelings Unpleasant, anxious, Pleasant, relaxed, happy, depressed, angry calm Behavior Avoid, give-up, Confront, try, appropriate inappropriate
    30. 30. Cognitive Behavioral Therapy (CBT) Common Pattern of Anxiety Child enters difficult situation Child becomes anxious and fearfulAnxious behavior escalates and child gets stuckChild avoids the situation or asks others to help Child continues to think the situation is dangerous and feels helpless
    31. 31. Cognitive Behavioral Therapy (CBT) Build Confidence Reduce Anxiety Build stronger relationships Learn to communicate Take on more responsible roles Develop new skills Increase independence and self- Gradually face fears help skills
    32. 32. Cognitive Behavioral Therapy (CBT) What not to do Do not try to convince them it will be okay. Do not minimize their experience. Do not tell them to fight the anxiety. Do not physically force them into the situation. Do not verbally bully them into the situation.
    33. 33. Cognitive Behavioral Therapy (CBT) What to do Accept their feelings Demonstrate understanding Build competence Have expectations but alter the process Parent cooperatively vs. balancing Respond vs. react
    34. 34. Cognitive Behavioral Therapy (CBT) Calming Strategy  Catch your breath  Accept negative feelings  Label emotions  Model coping skills
    35. 35. Medications Used in Kids WithAnxiety Disorders SSRIs (Sertraline, Fluvoxamine, Fluoxetine) Clomipramine Venlafaxine Tricyclic antidepressants (imipramine) Buspirone Benzodiazepines J Am Acad Child Adolesc Psychiatry 2007; 46(2) 267-283