Anxiety, when is it more than “Just a Phase”?

1. Anxiety, when is it more than “Just a Phase”? Ruth E. Imershein, MD RMOP US Embassy Lima

2. Anxiety A state of being uneasy, apprehensive, or worried about what may happen; concern about a possible future event In psychiatry, anxiety is an abnormal state, characterized by feeling powerless and unable to cope with threatening events, typically imaginary, and by physical tension, as shown by such symptoms as: sweating trembling or shaking palpitations or racing heart rate feeling dizzy or unsteady difficulty breathing or the sensation of shortness of breath fear of losing control or going crazy

3. Facts • About 13 out of every 100 children and adolescents ages 9 to 17 experiencing some kind of anxiety disorder • Anxiety disorders affect more than emotional health -- they are also associated with many physical illnesses • If anxiety in children is not detected and treated early enough, other problems may develop.

4. More Facts • Anxiety disorders frequently co-occur with depressive disorders or substance abuse. • Most people with one anxiety disorder also have another anxiety disorder. • Many anxiety disorders experienced by adults actually start in childhood • Nearly three-quarters of those with an anxiety disorder will have their first episode by age 21.5

5. Why? • A person's genetics, biochemistry, environment, history, and psychological profile all seem to contribute to the development of anxiety disorders. • Most people with these disorders seem to have a biological vulnerability to stress, making them more susceptible to environmental stimuli than the rest of the population.

6. Common Anxiety Disorders in Children • School Refusal • Generalized Anxiety • Fears and Phobias • Obsessive Compulsive Disorder • Trichotillomania • Selective Mutism • Social Phobia • Acute Stress Disorder • Post Traumatic Stress Disorder

7. Separation issues or School Avoidance • Separation difficulties are a normal, healthy part of a child’s development • Separation can be difficult if a child is young, immature or bashful • If a child has separation difficulties, he/she may cry, throw a tantrum, cling to the parent, refuse to enter the school • Even though these reactions might be extreme, they are normal

8. Common Explanations • My baby’s too young…a child’s reluctance to attend school may be a reflection of a parent’s reluctance to let the child leave. • My child’s stubborn…is refusing to go to school just one of many things your child won’t do? If so, then your child may be difficult or oppositional, not anxious. • My child doesn’t like school…applies to most teenagers, but not most young children. • My child’s too anxious…does the child become anxious at other time or display distress whenever parents leave or when left alone in the bedroom at night?

9. My child is embarrassed to go to school…poor school performance often contributes to poor attendance. Children want to avoid being teased. • My child hates school and claims to have no friends…shyness or underlying behavior problems should be addressed. • My child is sick many mornings…physical symptoms may be a manifestation of anxiety, but a though examination is in order to determine if there is a chronic illness. • My child is too tired…lack of sleep may be due to late bedtimes, but children also should be checked for physical illnesses.

10. What can a parent do? • Make sure that your child goes to school every day • Determine the cause of the school avoidance • If your child is scared, try to make things at school more familiar • Decrease separation anxieties for both you and your child • Try to eliminate the source of fear (the teasing, bullying, abuse, etc.) • Make going to school easier and more fun than staying home • Seek professional help

11. Generalized Anxiety • My child • worries too much • has always been a worrier • worries about everything, including things that are beyond his control • is always nervous and tense • has frequent headaches, stomachaches, trouble sleeping • is constantly seeking reassurance • is overly sensitive to correction or criticism • is easily fatigued, irritable, overwhelmed

12. What to do if it is GAD • Psychological treatments • Behavior Therapy • Cognitive Therapy • Relaxation Therapy • Pharmacological treatments • Clarify normal vs excessive worries • Establish a stable, predictable support base • Don’t overprotect your child • Don’t tease or ridicule your child

13. If it isn’t Generalized Anxiety Disorder, then what could it be? • Normal Childhood Worries • Stress Induced Anxiety • Medical Disorders • Panic Disorder • Obsessive Compulsive Disorder • Other Anxiety Disorders Mr. Worry

14. Fears and Phobias • Researchers have found certain fears are natural and arise at specific ages in all children, and these fears tend to disappear naturally as the child grows older. • Children may develop fears from a traumatic experience (e.g. traumatic dog attack), but for some children, there is no clear precipitating event • Some children become fearful simply by watching another child acting scared • Children's fears are often associated with avoidance, discomfort, and physical complaints, such as rapid heart rate, gi distress, sweaty palms, or trembling.

15. Which fears are normal at what age? • Most children, when asked, are able to report having several fears at any given age. • Some research shows that 90% of children between the ages of 2-14 have at least one specific fear. • If your child’s fear is not interfering with his/her daily life (e.g., sleep, school performance, social activities) , or your family’s life, then most likely your child does not need professional help.

16. Common fears at specific ages • INFANTS/TODDLERS (ages 0-2 years) loud noises, strangers, separation from parents, large objects • PRESCHOOLERS (3-6 years) imaginary figures (e.g., ghosts, monsters, supernatural beings), the dark, noises, sleeping alone, thunder, floods • SCHOOL AGED CHILDREN/ADOLESCENTS (7-16 years) more realistic fears (e.g., physical injury, health, school performance, death, thunderstorms, earthquakes, floods.)

17. Helping a Child Outgrow Fears • Recognize whether the fears are within normal range or excessive • Be sympathetic to the child, not the fear • Talk about nightmares • Help confront fears – fears often decrease and sometimes disappear completely simply when confronted • Help overcome fears - No more Monsters in the Closet by Dr. Jeffrey Brown ORWhat to Do When You're Scared and Worriedby James Cristand/or seek professional help

18. Phobias • When children’s fears persist beyond the age when they are appropriate, are irrational and excessive and begin to interfere with their daily functioning, they are called phobias.

19. 10 Most Common Phobias • Acrophobia – fear of heights • Claustrophobia – fear of enclosed spaces • Nyctophobia– fear of dark places • Ophidiophobia - fear of snakes • Arachnophobia – fear of spiders • Trypanophobia - fear of injections • Astraphobia – fear of thunder and lightening • Nosophobia – fear of having a disease • Mysophobia or Germophobia– fear of germs/contamination • Triskaidekaphobia – fear of the number 13

20. Obsessive Compulsive Disorder • Essential features • Recurrent obsessions (persistent intrusive thoughts, impulses or images that are inappropriate) • Recurrent compulsions (repeated rituals or behaviors) • These are experienced as either time consuming and / or cause marked anxiety, distress or significant interference with daily functioning. • The person attempts to suppress or ignore these thoughts, impulses, images or behaviors without success

21. Does a child have OCD? • Is the child troubled by excessive worries, particularly about dirt, germs or other dangers? • Does the child repeat the same questions over and over again? Or constantly seek reassurance? • Does the child seem to have difficulty concentrating? • Is the child washing excessively? Taking extra showers, longer showers, changing clothing more frequently? • Does the child “check” repeated? Reread, erase and rewrite homework assignments? • Does the child have to repeat things a certain number of times or until they are “just right”? • Does the child arrange things in a certain order or become upset if something is moved or misplaced? • Do the symptoms bother the child – make him or her anxious or upset? • Do the worries or behaviors interfere with relationships and/or activities at home or school?

22. Treatments for OCD • Behavior therapy with exposure • Cognitive therapy and thought blocking • Medications • Parental interventions to assist with professional treatment • Recognize the behaviors as symptoms of OCD • Provide support for the child but don’t come involved in the rituals • Use distraction to decrease symptoms • Help your child to avoid “avoiding”

23. Trichotillomania • It can be a habit or a symptom of Obsessive Compulsive Disorder • Compulsive hair pulling • The child feels an overwhelming urge to pull which increases in intensity until the hair is pulled • If the child tries to resist the urge, then anxiety increases • When the “right” hair is pulled, the child experiences a sense of relief

24. Selective Mutism • Definition - a consistent failure to speak in specific social situations in which there is an expectation for speaking. • Children with selective mutism have the ability to both speak and understand language, but fail to use this ability in some situations. • Selective mutism is not a communications disorder and is not part of a developmental disorder. • Most children with selective mutism also have other anxiety disorders

25. Does a Child have Selective Mutism? • Does the child consistently fail to speak in certain situation such as in the classroom or in front of strangers? • Does the child’s lack of speech interfere with educational achievements and social relationships? • Has the child been mute for at least one months not including the first month of school? • Does the child speak normally in at least one setting, such as at home with family? • What is the child’s primary language?

26. Selective Mutism • The extent to which a child speaks varies greatly • Punishment or withholding of privileges for not speaking and communicating effectively in social settings is inappropriate. • Treatment should focus on reducing anxieties, becoming more comfortable and ‘unlearning’ the silent behavior • With early diagnosis and the right treatment , the prognosis is good

27. Treatment focus for Selective Mutism • Not on getting a child to speak, but rather • On decreasing anxiety and teaching coping skills to use when confronted with anxious situations and should • Include approaches that gradually desensitize. and • Use multiple modalities combining, but not be limited to • cognitive-behavioral therapy, • family therapy, play therapy, and school-based and community-based behavioral interventions • medications

28. Social Phobia or Social Anxiety Disorder • Diagnosed when people become overwhelmingly anxious and excessively self-conscious in everyday social situations. • Children and adults with social phobia have an intense, persistent, and chronic fear of being watched and judged by others and of doing things that will embarrass them. • They can worry for days or weeks before a dreaded situation. • This fear may become so severe that it interferes with work, school, and other ordinary activities, and can make it hard to make and keep friends. • Because these children do not usually display behavioral problems, their problems tend to go undetected by parents and teachers. • Earlier onset of the disorder typically means a more severe and chronic course . • Untreated this continues to be a lifelong problem. Most adults with social anxiety disorder indicate that it began in childhood, usually in elementary school

29. Age Related Symptoms • Presentation is related to a child’s age • If your child is a pre-schooler, some symptoms to watch for are: • fear or lack of interest in new things • cries, whines or appears irritable • freezes up or clings to parent • shy around new people • refuses to participate or speak

30. School-Aged Children with Social Anxiety Disorder • Not always but often… • Don’t read aloud or answer questions in class • Don’t start or join a conversation • Don’t write on the blackboard • Don’t’ speak to adults • Don’t participate in music or athletic performances or after-school activities • Don’t order food in a restaurant • Don’t attend birthday parties • Don’t invite friends over to play • Don’t sit with others at lunch • Don’t want to play with others at recess • Don’t seem able to stop worrying excessively about being evaluated or judged • Don’t like school • Don’t feel comfortable being the center of attention • Don’t speak clearly but rather mumble and avoid eye contact

31. Teenagers with Social Anxiety Disorder • Display some or all of the aforementioned plus • Watch for the following additional symptoms specific to the teenage years: • skips school and/or uses drugs or alcohol • fears performance situations such as public speaking • difficulties dating or problems with a job • fear of using public restrooms • fear of signing name in public

32. Treatment for Social Anxiety Disorder • Professional help • Cognitive Behavior therapy • Exposure therapy • Social skills training • Cognitive Restructuring – positive thinking with thought blocking • Symptom Management Skill training to reduce stress and symptoms of anxiety • Medications – usually antidepressants • Parental support • Recognize “shyness” as social anxiety disorder • Encourage trying new social situations • Don’t ridicule or tease • Seek therapy early

33. Resources • Anxiety Disorders Association of America - http://www.adaa.org/ • The American Academy of Child and Adolescent Psychiatry – Facts for Families (http://aacap.org) • Madison Institute of Medicine – booklets on Social Anxiety, Panic Disorder, OCD in Children, Depression, Trichotillomania, etc http://www.miminc.org/ • The OC Foundation - http://www.ocfoundation.org/

34. More Resources - books • Is It Just a Phase? by Susan Swedoand Henrietta Leonard • What to do when you are scared or worried by James Crist • The Boy Who Couldn’t Stop Washing by Judith Rapaport • The Boy Who Finally Stopped Washingby James B

35. More Resources – online ordering • Magination Press – self help books for kids and adults by the American Psychological Association http://www.apa.org/pubs/magination/ • ChildsWork/ChildsPlay – resources for parents, teachers and professionals: http://childswork.com/ • Courage to Change – more resources available online: http://couragetochange.com/