Childhood Anxiety Dr John Callary Child & Adolescent Psychiatrist Father of 4

Case vignettes

Books: The Panic Book & The Secret Problem

Books: Living with Fear & The Hidden Gifts of The Introverted Child

Childhood Anxiety Phenomena – healthy vs unhealthy Developmental and systemic considerations Sensitization & Desensitization Childhood Anxiety Disorders - prev 8-10% Management

Anxiety Perceived threat > Perceived capacity to cope Fight or Flight response

Normal age-related fears Everyone has worries and fears. They are part of living. Children of all ages have fears and their typical fears differ at different ages: Infants and toddlers - loud noises, separation, strangers Preschoolers - animals, especially dogs, the dark, ghosts and monsters School age - snakes and spiders, fear of failure and rejection, the news and TV shows, blood, injury, and sickness, being home alone, robbers, death, parent’s well-being Most children will grow out of these fears.

So why are some children more anxious So why are some children more anxious? Why does their anxiety persist/worsen? Genetic factors - Anxiety seems to run in families Parents remark their child is like they were at that age... Anxious children are often temperamentally intense and sensitive children. Modelling - Anxious parents can unknowingly model anxious behaviours communicates to children that there is something to be scared about. Parental reaction to the child’s anxiety - to reassure Sometimes reassuring children can accidentally reinforce anxious behaviours Children may gain a lot of attention or may escape from a feared event by continuing to be anxious.

So when is anxiety a problem? Degree of distress Disruption to participating in everyday activities and routines

Anxiety-Response

Imagined Anxiety

Avoidance - Sensitization

Face the Fear – Graded Desensitization

Dynamic and Diagnostic Formulation Why this child in this way @ this point in time? Bio Psycho Social Cultural Predisposing Precipitating Perpetuating Protective

Systemic Aspects Family School – peers, teachers, studies Community

Family of 6 = 15 relationships!

What does an Anxiety Disorder look like? Unrealistic /excessive worries Physiological Constitutional Avoidance (Social) Behavioural

Anxiety Disorders - DSM Separation Anxiety Over-anxiety Disorder of Childhood Social Phobia Selective Mutism Obsessive Compulsive Disorder Panic Disorder +/- Agoraphobia

Comorbidity Attachment Disorder Learning difficulties Depression ADHD Intellectual Disability Asperger’s Syndrome

Management Psycho-education Intervention vs No intervention Address co-morbidities & systemic Parental anxiety CBT, Relaxation therapy, Hypnotherapy, Social skills, Other therapies or activities Medication

What can parents/carers do to help? 1. Find out what the problem is. Listening to how they feel in a sympathetic but calm way. 2. Teach them calming techniques, such as slowing their breathing, and relaxation techniques. 3. Encourage your child to generate suggestions on how they can cope with the anxiety; what your child can do to make themselves feel better. It is an important step for them to try to reduce their anxiety. 4. Summarise the options your child has in the situation. They can continue to feel upset and anxious and behave in an anxious manner or they can choose to do something that reduces their anxiety and lets them feel better. (e.g. relaxation techniques, realistic thinking) ....

What can parents/carers do to help? 5. Go through the options with your child and ask, “What would happen if you did this?” Don’t allow them to use avoidance as a solution. 6. Resist the temptation to use excessive reassurance (e.g “its fine I am here, I will deal with it”). Some children then only feel safe if they are with their parents. 7. If you are an anxious parent it is important to not project/transfer your own feelings/fears to your child – (e.g. how scary/dangerous is that spider?) 8. Encourage your child to use realistic thinking. Ask your child “challenge” questions whenever your child expresses worries or fears by reminding them to examine the evidence… “What is it that you are worried about? Has that ever happened before? Are there any other ways of looking at it?”

Cognitive Behavioural Therapy Very effective for anxiety and depression Hierarchy of tasks Graded desensitization Habituation and reinforcement “think positive” “act positive” “feel positive”

Medication Symptomatic relief Never the whole answer Shallow evidence for efficacy; side effects SSRI Start low and go slow