1. Anxiety Disorders in Children Diagnostic and Educational Implications John P. Frampton, Psy.D. Licensed Psychologist, Comprehensive Psychological Services

2. Foundations of Anxiety Disorders Neurobiology Behavioral Inhibition Social Development Genetics

3. Problematic Parenting Style ANXIOUS Overly Responsive Overly Controlling

4. Amy’s Answering Machine

5. “Normal” Worry in Children 70% of children report worry 2 to 3 times per week The worry is moderately intense, moderately interfering Thoughts feel out of control Like adults, the worry is predominantly self-referent Type of worry varies by age Most children do not recognize the benefits of worry

6. CASE EXAMPLES Michael 12-year old, 6th grade, classified ED with GAD High average verbal IQ, average non-verbal IQ, weak WM Difficulty with work production, math computation, divided att. Significant behavioral outbursts CBT effective Peter 7th grade boy in therapeutic day placement with severe outbursts Significant learning disability, school refusal, work refusal Relabeled tantrums, paradoxical interventions Modified expectations to build momentum

7. Diagnostic Criteria for Generalized Anxiety Disorder A.Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). B.The person finds it difficult to control the worry.

8. Diagnostic Criteria for GAD Cont’d C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). NOTE: Only one item is required in children. 1. Restlessness or feeling keyed up or on edge 2. Difficulty concentrating or mind going blank 3. Irritability 4. Muscle tension 5. Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

9. Diagnostic Criteria for GAD cont’d D.The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a Panic Attack (as in a Panic Disorder), being embarrassed in public (Social Phobia), being contaminated (as in OCD), being away from home or close relatives (Sep. Anxiety Disorder), gaining weight (Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder.

10. Diagnostic Criteria for GAD Cont’d E.The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. F.The disturbance is not due to the physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.

11. Cognitive-Behavioral Therapy Research proven Focuses on the here and now Solution-focused Practical for parents, teachers, and particularly children Lends itself to objective goal-setting Structured, often with homework and parent involvement

12. Relaxation Systematic Desensitization Social Skills Self-Instruction

13. Treatment 1.Develop Self-Awareness Observing physiological reactions Discussing the purpose of worry Improve labeling feelings Recording “worry” thoughts Counting “worry” thoughts Beginning to question the worry by asking 1. What’s the evidence 2. What’s another way of looking at it 3. So what if it happens?

14. Treatment Cont’d 2. Modifying Imagery Turn off Technique using role play, puppet play, etc. Repetition of thoughts Time projection Substituting positive imagery Exaggeration 3. Modifying Emotions Normalize anxiety and strategies Active acceptance - “oh, it’s you again” Positive self-instruction Graphs and diaries Concentration/Distraction Relaxation methods Emotional Review

15. Treatment Cont’d 4.Modifying Behavior Motivation- explaining the approach and benefits Educational devices Graded changes, shaping behavior Role-Play Surprise yourself Choice framework Modifying environment

16. Classroom Considerations Based on Cognitive Behavioral Model Consider cognitive profile Behavior modification to encourage and reinforce self- monitoring Predictable schedule Consistency in approach by school staff Accommodations for working memory deficits Work systems Coping thoughts on desk Preview/Review

17. Classroom Considerations Cont’d Assess need to modify discipline Daily home communication Written expression and note-taking accommodations Extra time Modified work load Model “think aloud”

18. Parent and Family Intervention Approach with respect and compassion Collaborate with to fully understand what their child is “up against” Help family to recognize the affect of the anxiety on the family Begin to disengage family from the anxiety –Cheerleader, supportive –Co-therapist Behavior modification not enough Later, remap how anxiety influences the family Frequent and proactive communication with family, recognizing miscommunications anxiety can create Prescribe experiences/feelings

19. Anxiety and Attention Deficit Disorder CBT continues to be effective in improving anxiety management Comorbid impulse control issues may change course of treatment Appear to be more responsive to social skill training in general Increased rate of mood disorders in parents Increased need for more than one medication

20. References Anxiety Disorders in Children and Adolescents 2nd Edition. Written by Tracy Morris and John March. Guilford Press 2004. Clinical Practice of Cognitive Therapy with Children and Adolescents: The Nuts and Bolts. Written by Robert Friedberg and Jessica McClure. Guilford Press 2002. Worry in Normal Children. Written by Peter Muris et al. Journal of the American Academy of Child and Adolescent Psychiatry 37:7, July 1998. Center for Cognitive Therapy (www.padesky.com) Anxiety Disorders Association of America (www.adaa.org) The Coping Cat Workbook 2nd Edition. Written by Philip C. Kendall, Ph.D. and Kristina A. Hedtke. Temple University Children and Adolescents Anxiety Disorder Clinic. A Parent-Only Group Intervention for Children With Anxiety Disorders: Pilot Study. Written by Margo Thienemann, Phoebe Moore, and Kim Tompkins. Journal of the American Academy of Child and Adolescent Psychiatry 45:1, January 2006.