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Childanixiety
- 1. Childhood Anxiety and Fear University of Rwanda Rebecca L White, MSN, FPMHNP-BC, FNP-BC
- 2. Objectives • Recognize the difference between anxiety & fear in children and adolescents • Identify anxiety levels that are at risk for becoming pathological • Apply Cognitive behavioral therapy basic to children suffering from fear and anxiety • Express a working knowledge and have the ability to educate parents in basic CBT skills with their children
- 3. What is Anxiety • How do I know if a child has anxiety? • Fear of something bad happening • Worrying about the future – “Am I going to get sick” – “Is something going to happen to my parents” – “ Am I going to get a bad grade on this test”
- 4. What is Fear ? • An immediate reaction to an actual or perceived threat • In the moment • A dog barking will I get bitten? • Developmental levels are natures early warning systems to avoid injury
- 5. Normal Developmental Fears • Infancy-strangers, loud noises – Able to differentiate • Early childhood-separation monsters – See normal fears – Separation anxiety • Middle childhood-real-world dangers and new challenges – Attending school – Meeting other kids, going out into world – Earthquake fires, – Worry about school • Adolescence- social status, social group performance. – Peer attention – Social
- 6. Anxiety • Mild fears are common in children • Fears decline with age • Girls report a greater number of fears than boys in general • Problematic anxiety – Similar in girls and boys until puberty then the rate of anxiety in girls is almost double that of boys
- 7. Expression of Anxiety & Depression in Children-Cognitive Development • Emotional & cognitive development - how children express fear and anxiety – Small child clinging, crying , tantrums, stomach aches • Fears change – Concrete fears-monsters, the dark, illness – Abstract “what about my future?” ”what will happen about the world?” “will they like me? “ • Focus changes over time-specific fears decrease over the course of childhood • Social anxiety increases with age – Phobias may be present
- 8. Anxiety • Short term anxiety is common and normal • Related to events Going to a new school • Oral report , teasing at school • Overshadowed by cumulative effect of positive reinforcement
- 9. Normal versus Problematic Anxiety • Intensity of fear – is it within expected limits or out of proportion to the actual threat screaming yelling? • Frequency of fears- – does it continue for longer than normal despite being supported to reassured? • Is fear focused on an inappropriate situation such as fear of dogs but it is a picture of a dog? • Does the fear occur spontaneously ? (no reason)
- 10. Anxiety Disorder • Avoidance – Refuses to do things • Interface – Not facing developmental challenges – Interfering with the child’s life – Goes to school nurse frequently • Distress – Long period of time – Effects all family members • Duration – Lasting for weeks or longer
- 11. Prevalence of Anxiety • 12 to 20 % of children suffer from anxiety – severe enough to interferes with functioning • Most Common 5 % – Generalized Anxiety disorder – Separation Anxiety Disorder – Social Phobia – Specific Phobia
- 12. Prevalence of Anxiety • Less Common (1%) –Obsessive Compulsive Disorders –Agoraphobia • Won’t leave home –Panic –Mutism (selective) • Afraid of refuse to talks
- 13. Separation Anxiety 3 or more of the following : • Distress when separation occurs • Worry about harm may occur to others • Worry something will happen & separation will occur • Refusal to go to school • Fear or reluctance to be alone • Refusal to sleep away from parents • Nightmares • Physical complaints at separation
- 14. Separation Anxiety Symptoms • Ages 5-8- fear of harm befalling attachment figures, nightmares, school refusal • Ages 9-12- excessive distress at separation – Tantrums • Ages 13 -16- somatic complaints & school refusal – Can even occur in adults
- 15. Social Anxiety (Social Phobia) • May be seen as inhibited temperament • Selected Mutism will not talk in public setting • Increases in adolescents • Adults with social anxiety disorder usually identify have onset in adolescence.
- 16. Name some commonly avoided situations • Birthday parties • Meeting new people • Talking to adults • Entering a group of peers • Talking one on one • Being assertive • Performances • Class participation • Public speaking • Public or shared Restrooms • Playing sports • Dating
- 17. Generalized Anxiety Disorder • Excessive worry & anxiety occurring more days than not for at least 6 months • Worry is difficult to control – At least 1 physical symptom: fatigue, restlessness, difficulty concentrating , irritability, muscle tension, sleep disturbances
- 18. Generalized Anxiety Disorder • Self conscious and require frequent reassurance – “What if ????” • Worry about low frequency events – Intensity of worry differentiates youth with Generalized Anxiety Disorder from those without the disorder
- 19. Anxiety Issues at School • Generalized Anxiety Disorder – Excessive worry about school work, friendships – Needs for reassurance – May ask repeated questions • Social Phobia – Avoidance or extreme discomfort – R/T doing or performing in groups or in front of others • Separation Anxiety Disorder – Worries about something happening to parent – Wants to call parent, wants to go home
- 20. Refusal to Attend School • Identify underlying reason for refusal to go to school – Separation fears – Social anxiety – Test anxiety – Boredom – Bullying or being teased – Learning problems or disability
- 21. Warning Signs for Anxiety • Shyness (extreme) • Isolation • Avoidance of social situations • Extreme discomfort when the center of attention • Avoids schoolwork for fear of making a mistake
- 22. Warning Signs for Anxiety • Expecting bad things to happen • Excessive worries about upsetting others • Frequent questions • Perfectionism • Excessive worries about failure • High strung, shaky, unable to relax • Lacking self-confidence
- 23. Somatic Physical Symptoms • Shortness of breath • Stomach aches • Headaches • Nausea • Sweating • Dizziness, fainting, light headed • Increased heart rate • Shaking or jittery – + reinforcement
- 24. Screening for Anxiety • Does your child worry or ask for parental reassurance almost every day? • Does your child consistently avoid certain age-appropriate situations or activities, or avoid doing them without a parent? • Does your child frequently complain of a stomach ache, headache or have times or episodes of hyperventilating ? • Does your child have daily repetitive rituals?
- 25. Anxiety Channels • Thoughts worries, negative thought, poor concentration • Feelings Psychical symptoms- headaches, stomachaches, heart racing • Behaviors Avoidance, clinging, excessive crying
- 26. Three Parts of Anxiety Break the Connections Thoughts BehaviorsFeelings
- 27. Cognitive Behavioral Therapy (CBT) • Change the thoughts and feelings first – Then behavior change becomes easier • CBT in children starts with changing physical symptoms first • Easiest to identify and then move to thoughts and behaviors • Deep Breathing Exercises
- 28. Performing for your class “The class will think I am stupid” Avoid, Freeze Sweat heart races , flushed
- 29. Anxiety Cycle Time to get up for school Separation worries, stomach ache Tantrum, gets to stay homeSymptoms Resolve Negative Reinforcement
- 30. Negative Reinforcement • The more you give your child the worse the anxiety gets. • Break the cycle in treatment
- 31. Parenting Strategy • Reward courageous behaviors – Avoid giving in to your child's fear behavior • Don’t give in to the child’s attempts to avoid things they should be doing – like school or activities • Teach your child to communicate, cope and problem solve • Control your anxiety as a parent
- 32. How To Win the Avoidance Battle • Disengage or ignore – at the earliest possible point • Do not engage in back and forth arguing • Maintain a calm emotional reaction – Avoid punishment – Calmest person wins !!! • As soon as child calms down even briefly, engage in a different activities – Positive reinforcement of appropriate behaviors – This can include discussion of the event
- 33. References • Cohen, J. A., Berliner, L., & Mannarino, A. (2010). Trauma focused CBT for children with co-occurring trauma and behavior problems. Child abu • Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., Cloitre, M., ... & Mallah, K. (2017). Complex trauma in children and adolescents. Psychiatric annals, 35(5), 390-398. • Stallard, P. (2005). A clinician's guide to think good-feel good: Using CBT with children and young people. John Wiley & Sons.se & neglect, 34(4), 215-224. • Vigerland, S., Ljótsson, B., Thulin, U., Öst, L. G., Andersson, G., & Serlachius, E. (2016). Internet-delivered cognitive behavioural therapy for children with anxiety disorders: a randomised controlled trial. Behaviour Research and Therapy, 76, 47-56.