All Anxiety Disorders
- Some degree of
- Anxiety disorders are the most common child psychiatric disorder affecting 12-20%
(Costello, E. 1995)
- There is often more than one anxiety disorder present at a time
(Costello, E. 1995)
(Last, C. G 1987)
(Ollendick, T. 1994)
- Avoiding activities is one sign that anxiety has become serious
- Anxiety is associated with significant impairments in ,
and functioning
- The intuitive response of parents is to protect their child from anxiety
resulting in a life of avoiding behaviors
- Physical symptoms of anxiety
Etiology of anxiety
See Clinical Guide Algorithm
Take me to: Separation Anxiety,
General Anxiety,
Specific Phobia,
Social Phobia,
PTSD keypoints,
Panic,
Separation Anxiety Disorder
- Developmentally inappropriate and excessive anxiety concerning separation from
home or from those to whom the individual is attached.
- Normal fear of separation begins with the attainment of object permanence at 6-9 months
- It improves after 3 years when the child understands separations as temporary
- Separation Anxiety Disorder peaks at 7 to 9 years of age
- Prevalence is 3.6%
(Bowen, R. C. 1990)
to 4.1%
(Benjamin, R. S. 1990)
Generalized Anxiety Disorder
Social Phobia
- Fear/worry is limited to social situations where the child would be
exposed to unfamiliar people or to possible scrutiny by others
- Avoidance of the situation leads to impaired functioning.
- School phobia often includes family dynamic issues and a family history of school
refusal and/or anxiety
- Prevalence is 1% (4;13)
-
is an
(Black, B. 1995)
Specific Phobia
Panic Disorder
- Recurrent
panic attacks
- Apprehension and anxiety about the attacks and about future attacks cause
significant impairment.
- Secondary agoraphobia may develop
- Highly familial
- Lifetime Prevalence is 0.6%
(Whitaker, A. 1990)
Post Traumatic Stress Disorder
General
- Characteristic symptoms following exposure to an extreme traumatic
- Response: intense fear, helplessness, avoidance, agitated behavior
- May see re-enactment, repetitive play, generalized nightmares, sense of short
future, physical symptoms
- Use a multimodal treatment plan
- Psycho-education is the first step to helping the parents and child understand anxiety disorders
- Demystification of Anxiety (See: Helping Your Child Understand Anxiety pt)
- Define anxiety as fear in the absence of real danger
- Explain what symptoms the child has and how it affects his/her life
- Explain that this disorder is very common and readily treatable
- Explain that it will take a lot of work on the part of the parent to treat it
- Discuss the importance of getting help for the child (See: Why Overcome Anxiety? pt)
- If the anxiety interferes with the child's ability to engage in age-appropriate
activities then help is needed
- Discuss the of not getting help
- Refer anxious parents for treatment if they are unable to follow through on techniques
due to their own anxiety
General Principles (See: General Principals For Helping Your Child
Cope With Anxiety pt)
- Ensure adequate sleep which helps stabilize mood (See: Sleep DTW)
- Help the parents make the home environment more routine and predictable
(See: Social Development DTW)
- Establish rules of discipline to make the child feel safe and cared
- If there is drug or alcohol abuse in the home, or any violence, seek
professional help for the adults. (See Substance Use DTW,
Domestic Violence DTW)
-
- If the child is aggressive, the behavior needs to be stopped without spanking
- Refer anxious parents for treatment
- Give the child an opportunity to express fears
- Reassure child without criticizing them even if the fear seems trivial
- Reduce
for talking about fears
- Discuss calmly fears which may be realistic
- Supervise the child's exposure to the event, including media coverage
- Invite the child to talk about it, and help the child put it in perspective
- Be honest that scary things can happen
- Emphasize the rarity of the event
- Remind the child that most news is only the bad news, not the good news
- Talk about how the child can decrease the risk of being hurt
- If the event has legal implications, encourage constructive action
Specific Techniques, Behavior Therapy
- For children over 7 years old, give incentives for specific brave behavior
(See: Incentives for Brave Behavior pt)
- Parents will have to encourage the child to face his fears, and may
have to set up opportunities for him to encounter his fear and then provide
positive reinforcement when they are faced.
- Guidelines
- Choose a
- Choose a
that is valued by the child
- Respond consistently and as soon as possible after the child
does what they are supposed to do
- For children younger than 7, use
"Bravery Marks" for brave behavior and for ordinary behavior that could be considered brave for another child (See: Marks for
Behavior Change pt)
- For older children, use incentives for brave behavior
Help the child understand anxiety
(See: Helping Your Child Understand Anxiety pt)
- The goal is for the parent to help the child to eventually function independently in the adult world
- Help the child recognize when they are feeling anxious
- For younger children, have them draw pictures of different emotions, including fear
- For younger and older children, have them read books about characters that worry or feel scared.
- For older children, help them talk their way through the worry by answering questions:
- What am I worried about?
- What is the worst that can happen? What is the best that can happen?
- How likely is the worst to happen? What is most likely to happen?
- What can I do if the worst happens?
- What can I do to prevent the worst from happening?
- Will worrying prevent the worst from happening?
Relaxation
: (See: Relaxation training pt)
Relieving Physical Pain
- Abdominal Breathing
- Relaxation Tapes
- Physical versus psychological pain
- Acknowledge that it is real pain and not just "in their head"
Relaxation: Relaxing the Mind
- Begin with body relaxation exercises
- Visualization of a "calm place"
Other Techniques
Pharmacotherapy
(See Child Psychopharmacology DTW)
When to Consider Medication:
- The child's anxiety is significantly interfering with function in home,
school, or the social setting
- Facing fear causes the child great distress
Take me to: Separation Anxiety,
General Anxiety,
Specific Phobia,
Social Phobia,
School Phobia,
PTSD,
Panic
Treatments for Specific Disorders:
Separation Anxiety
- Refer to Management of Anxiety and General Principles
- Reward for brave behavior (See: Incentives for brave behavior pt)
- Relaxation techniques (See: Relaxation training pt)
- Practice Separation (See: Separation Anxiety pt)
- Systematic desensitization (2)
-
- A may make separation easier
- Determine if parental ambivalence will get in the way of techniques
- Pharmacology
Generalized Anxiety Disorder
(See GAD pt)
- Refer to Management of Anxiety and General Principles
- Teach the child about anxiety (See: Helping Your Child
Understand Anxiety pt)
- Relaxation Techniques (See: Relaxation Training pt)
- Pharmacotherapy
Specific Phobias
(See: Specific Phobia pt)
- Refer to Management of Anxiety and General Principles
- Teach the parent and child:
- Fear = a strong physical, mental, and emotional reaction to a truly dangerous event
- Anxiety = fearful reaction to events that are not dangerous, or significantly less dangerous than the person imagines
- Phobia = extreme avoidance of anxiety-provoking fear interfering with daily activities
- Desensitization therapy:
- A series of small steps starting with the easiest and working up to the most difficult using encouragement, praise, and incentives
- Increases child's sense of control, reducing fear, and increasing chances of success
- The sooner the child faces the feared situation, the less opportunity exists for anticipatory anxiety to develop
- Use daily exposure- may have to be planned (bare minimum is once a week for desensitization to occur
- Don't allow early escape from a feared situation while anxiety is still high: on average it takes about 20 minutes for anxiety to subside in a feared situation
- Make sure exposures are the same the same every time, without variations
- Pharmacology
Social Phobia/School Phobia
(See: Social Phobia pt)
- Refer to Management of Anxiety and General Principles
- Teach the parent about the cycle of avoidance
- Shy children tend to avoid social situations to the point where
avoidance interferes with normal activities such as making friends
or playing in the school yard
- The longer social situations are avoided, the less opportunity these
children have to develop social skills
- Eventually, these children look different to their peers because of
this lack of social skills
- Because they are perceived as being different, others interact
differently with them
- Further avoidance occurs as a result, creating a vicious cycle
- Help them face the social situations they fear
- Start with what the child is already able to do
- Encourage them to invite another child over
- Gradually increase
- Social Skills therapy if needed through a mental health agency or school
- Pharmacotherapy
School Phobia
- After Short Absences
- Return the child to school, expect them to stay there with lots of praise
at the end of the day for being brave
- After long absence
- Create a to the class.
- Combine an incentive for facing the feared situation with a for not facing it.
- May need or the bus
- Evaluate and discuss family dynamics contributing. Involve all family members
in the plan.
-
- Expect setbacks after weekends and holidays
- Discuss condition and treatment plan with school authorities as well, developing a plan
for a return to school as soon as possible
- Social Skills therapy if needed
- Family therapy if needed
- Make a for illness symptoms
- Pharmacotherapy - SSRIs (See Child Psychopharmacology DTW)
Post-Traumatic Stress Disorder
- Refer to Management of Anxiety and General Principles
- Inform the parents that their reaction is the biggest determinant of how the child will cope
- For minor events:
- Early stages: let the child express his fears. If he is having difficulty
doing this with a parent, a referral for individual therapy may be needed
- Watch for feelings of blame and desires for revenge to disembue
- For a minor event, do not let the child continue to talk about the event for
a prolonged period of time.
- The goal is to not have the child see himself as a victim
-
- Role-play. Have the child practice a different ending to the witnessed trauma
- Relaxation exercises with breathing techniques or cassette tapes
- Parents may have been exposed to the same trauma and have symptoms needing treatment
themselves
- For long term stress:
- Refer for Cognitive Behavioral Therapy to help the child deal with disturbing memories
of abuse and feelings of associated anxiety
- Professional counseling for repeated traumas, serious trauma
Panic Disorder
(See: Panic Disorder pt)
- Refer to Management of Anxiety and General Principles
- Relaxation Exercises (See: Relaxation pt)
- Teach the child about what is happening during a panic attack
- Pharmacotherapy (See Child Psychopharmacology DTW)
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