Growing Up Brave: Expert Strategies for Helping Your Child Overcome Fear, Stress

and Anxiety

Donna B. Pincus, Ph.D.

Director and Associate Professor

Child and Adolescent Fear and Anxiety Treatment Program, Center for Anxiety and Related Disorders at

Boston University

Goals for Presentation

1) Why is my child so anxious? Background re: the causes of anxiety in childhood and its disorders

2) How do I know if a child needs treatment? Key assessment strategies for identifying anxiety at home and in schools

3) How are children treated? State of the art cognitive behavioral treatment strategies

4) What are some key techniques that parents and teachers can use to support an anxious child?

5) Where can we refer children for help?

Center for Anxiety and Related Disorders at Boston University 617-353-9610

Center for Anxiety and Related Disorders: Child and Adolescent Program

• Boston University’s Center for Anxiety and Related Disorders Child Program--150 intake assessments per year; children and adolescents aged 4-17

• Most children seen at CARD have primary diagnosis of anxiety or depression

• Children generally seen for 8-16 sessions of cognitive-behavioral skills-focused therapy

• Parent training component to treatment

• Children assessed at pre and post-treatment to determine their progress

CONTACT INFORMATION

• CENTER FOR ANXIETY: Child and Adult Programs: (617) 353-9610

• Websites that contain resources for parents and professionals:

• WWW.CHILDANXIETY.NET–WWW.BU.EDU/ANXIETY–WWW.GROWINGUPBRAVE.COM

Part I: Nature of Anxiety in Children and Adolescents

Images of Fear and Anxiety

Images of Fear and Anxiety

Our fascination with the emotion of fear…

Our fascination with fear, con’t

Images of Bravery

Portraits of Two Children: “Zack”, age 10

• phobia of dark, began age 6• crying at bedtime, anxious• bright lights, needs TV left on• checking door locks and under the

bed• frightened “calling out” to parents• nighttime “battles” with parents• sharing bed with siblings, parents• staying up late hours, tired• fears of dark even during daytime• ashamed of fear of dark

“Emily”, third grader• Had bad day at school• Friend broke her favorite art

project• Worried about math test tomorrow • Afraid that her mother won’t let

her watch her favorite show, “Rugrats” after school

• Gets frightened when she watches scary movies on tv

Normal Fear and Anxiety or an Anxiety Disorder?

• For most children and adolescents, fear and anxiety are experienced without great interference in everyday life

• Natural emotion; enjoyable emotion for many children (e.g., scary movies, stories)

• For some children, fears persist and become interfering in daily functioning or in family functioning and disrupt normal development

Fear, Phobia, and Anxiety• Fear--natural human emotion; intrinsic to

development; a response to a perceived environmental threat involving behavioral avoidance, cognitive distress, and physiological arousal.

• Phobias--exaggerated fears or fears that are more persistent and disturbing and result in maladaptive, avoidant behavior

• Anxiety--distinguished from fear “apprehension without apparent cause”, “future oriented” emotion

Children’s Fears: Normative DataInfants & toddlers: loud noises, strangers, separation

from parents, large objectsPreschoolers: more global, imaginary stimuli, (e.g.,

ghosts, monsters, other supernatural beings, the dark, noises, sleeping alone)

Older children: more realistic fears (e.g., physical injury, health, school performance, death)

--related to cognitive development--predictable developmental sequence (concrete to abstract)--When asked, children will readily identify multiple fears--4.6 fears per child (Jersild & Holmes, 1976)--90% of normal children between ages 2-14 have at least one specific

fear

Etiology• Biological Factors--biologically “prepared” to be

fearful at early age, adaptive, emerge at different points in development

• Environmental Factors--inadvertent reinforcement from siblings, parents

• General and Specific Vulnerabilities--e.g., behaviorally inhibited temperament, early experiences with low levels of control over environment

Children’s Fears, Anxieties, and Phobias

Clinical fears (phobias) occur in 4-8% of the population of latency aged children.

• CHARACTERISTIC FEATURE OF PHOBIC DISORDERS:– presence of excessive anxiety which leads to avoidance

of a feared object, event, or situation (phobic stimuli) and the experience of extreme levels of fear and anxiety when confronted with the perceived threat

• Children’s fears are usually mild, transitory, can be adaptive, and are very common and normal

• HOWEVER, some children experience fears that persist, interfere with daily functioning, and are not age appropriate.

When these fears become excessive, persistent, and cause psychological distress, and are not associated with an actual threat, they suggest a clinical level of fear and warrant treatment

Gender Differences in Children’s Fears

•Are fears more prevalent in boys or girls?

•Fears more prevalent in girls than boys–May be due to “report bias” : girls more willing to admit

their fears and anxieties–Parents may label behaviors of girls as more fearful–May be genuine gender differences in frequency of fears

and anxieties

Adult’s Phobias vs. Children’s Phobias

• Typically, the same criteria are used to classify phobic disorders in adults and children

• Just like adults, children can develop phobias to an endless array of situations, objects and events

• Relatively little is known about the motoric, cognitive, and physiological aspects of children’s fears when compared to adults

Family Factors Associated with Child/Adolescent Anxiety

Numerous familial variables linked to children’s anxiety disorders

• Parental history of anxiety disorder• Sibling anxiety• Parenting styles:

excessive reassurance, overprotection, aversive parent-child interactions, high levels of parental control and low levels of warmth, less psychological autonomy granting, negative parent-child interactions

Becoming a Scientist Practitioner: Assessing Childhood Fear and Anxiety

• Obtain pre and post-treatment measures(and possibly mid-treatment measures)

• Determine level of interference and distress symptoms have for child and adult

• Look at concordance between parent and child reports; mother and father reports

• Impact of child symptoms on parenting behaviors• Family factors contributing to the maintenance of

childhood anxiety

Assessment Methods for Internalizing Disorders--Children and Adolescents

• Clinical Interviews--most commonly used – Structured format (increased reliability)

• ADIS-R (Anxiety Disorders Interview Schedule for Children)

• Kiddie SADS--Schedule for Affective Disorders and Schizophrenia for School Aged Children

• DICA--Diagnostic Interview for Children and Adolescents

– Unstructured format • Three “system” approach• thoughts, physical symptoms, avoidance behaviors

Self-Report Measures• Fear Survey Schedule for Children (FSSC-R)

• Multidimensional Anxiety Scale for Children (MASC)

• Children’s Depression Inventory (CDI)

• Revised Children’s Manifest Anxiety Scale (RCMAS)

• Child Behavior Checklist, Internalizing Scale (CBCL)

• K-SADS

• Parenting Stress Index (PSI)

• Weekly Record of Anxiety and Depression (WRAD)

“20-20” Video Presentation: Childhood Panic

• Lindsay, age 8• Diagnosis of Separation Anxiety Disorder• Panic Attacks occur in contexts of separation

situations• Distress to parents who feel “trapped” by her fears• Cognitive behavioral treatment duration=12 weeks

Anxiety Disorders: Children and Adolescents

• Separation Anxiety Disorder• Specific Phobias• Social Anxiety Disorder• Generalized Anxiety Disorder• Panic Disorder and Agoraphobia• Obsessive Compulsive Disorder• Post Traumatic Stress Disorder• School Refusal, Test Anxiety

Clinical Presentation of Anxiety Disorders• Separation Anxiety Disorder

– Persistent fear of separation from a caregiver– Repeated physiological complaints such as stomach

distress, headache– Typically diagnosed in childhood– Excessive distress when separation occurs or is anticipated– Reluctance or refusal to go to school– Repeated nightmares involving the theme of separation– Reluctance to be alone or be dropped off at activities

without parent– Worry about harm befalling self or caregiver or major

attachment figure

Specific Phobia

• Marked and persistent fear that is excessive or unreasonable

• Exposure to the phobic stimulus almost invariably provokes and immediate anxiety response, which may provoke a situationally bound panic attack

• In children, anxiety may be expressed by crying, tantrums, freezing, or clinging

• Person recognizes that fear is excessive (in children this feature may be absent)

Social Phobia

• Marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others

• In children, there must be evidence of the capacity for age appropriate social relationships with familiar people, and the anxiety must occur in peer settings as well as with interactions with adults

• Exposure to feared situations provokes anxiety, which may result in a panic attack.

• Children may not recognize the fear to be excessive

Panic Disorder• Recurrent Panic Attacks

– Discrete period of intense fear or discomfort in which four or more of the following symptoms develop abruptly and reach a peak within 10 minutes• Palpitations, sweating, trembling, shaking, shortness of

breath, feeling of choking, chest pain or discomfort, nausea or abdominal distress, feeling dizzy, unsteady, lightheaded, or faint, feelings of unreality, fear of losing control or going crazy, fear of dying, chills or hot flushes

– At least one month or more of persistent concern about having additional panic attacks; worry about the implications of the attack (e.g., losing control, having a heart attack, going crazy; occur out of the blue)

Panic Disorder with Agoraphobia

• Anxiety about being in places or situations from which escape might be difficult or embarrassing in the event of having an unexpected panic attack

• Common agoraphobic fears in teens: being at school, standing in line, being in a crowd, being on a bridge, traveling in a bus, train, or car, going to a dance, etc.

• These situations are avoided or else are endured by marked distress or with anxiety about having a panic attack or panic like symptoms; patients often want a companion near for help

PANIC DISORDER AND AGORAPHOBIA IN ADOLECENCE

CLINICAL FEATURESaccelerated heart rate

nausea

hot/cold flashes

shaking

shortness of breath

difficulties breathing

depressed mood

SITUATIONS AVOIDEDclassrooms

restaurants

crowds

small and large rooms

elevators

parks

trains

movie theatres

*Adolescents report symptoms that are extremely distressing and commonly interfering in their social, academic, and family functioning.

Generalized Anxiety Disorder

• Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of events or activities

• Person finds it difficult to control the worry• Worry may be associated with restlessness, being

fatigued, irritability, sleep disturbance• The worry causes clinically significant distress or

impairment in functioning• More than one domain

Obsessive-Compulsive Disorder• Either obsessions or compulsions

– recurrent and persistent thoughts, impulses or images that are intrusive and cause marked anxiety or distress

– Person attempts to suppress such thoughts, or to neutralize them with a thought or action (compulsion)

– Compulsions are repetitive behaviors (hand washing, ordering, checking, praying, counting) that a person feels driven to perform in response to an obsession

– These obsessions and compulsions cause marked distress and are time consuming (take more than 1 hour per day)

Post-traumatic Stress Disorder• Person has been exposed to traumatic event; outside the realm

of typical human experience; the person’s response involved fear, helplessness, or horror

• In children, this may be expressed by disorganized or agitated behavior

• The traumatic event is re-experienced, through thoughts or dreams, the patient avoids cues of the trauma, and the patient shows symptoms of increased arousal (difficulty falling asleep, irritability, hypervigilance, exaggerated startle response) ACUTE, CHRONIC, DELAYED ONSET (less than 3 months, more, or 6)

Selective Mutism

• Consistent failure to speak in social situations where there is an expectation of speaking

• The disturbance interferes in educational or occupational achievement or with social communication

• Failure to speak is not due to lack of knowledge of language

School Refusal, Test Anxiety

• Can be due to many factors; not separate clinical diagnoses

• School refusal may be due to panic disorder or social phobia, or to specific phobia of school

• Test anxiety may be due to generalized anxiety disorder, specific phobia of tests, panic disorder

• All are conceptualized through good careful assessment

Cognitive Behavioral Treatment for Child/Adolescent Anxiety: Long Term

Treatment Goals• Reduce overall frequency and intensity of the anxiety response (or depressive symptoms) so daily functioning is not impaired

• Increase the positive activities that reinforce the child’s strengths

• Decrease maladaptive behaviors/thinking

• Help child learn new ways of coping with stressful situations and negative emotions

Three Component Model of Fear and Anxiety

• Teach child about “breaking down anxiety”

• ANXIETY=–What you “feel”–What you “think”–What you “do”–Treatment addresses each of these components–Anxious thought: If I talk to them, they might not

like me

Coming Next… Assessing and Treating Children with Anxiety Disorders: Usable Techniques that Work!

“Good Morning America” Video Presentation: Childhood Panic

• “Lindsay”, age 16• Diagnosis of Panic Disorder with Agoraphobia• Panic Attacks occur in range of situations• Distress to parents who feel “trapped” by her fears• Cognitive behavioral treatment duration=8 days

Treatment Techniques Used with Children and Adolescents

• Cognitive Therapy Techniques - teaching ways that thoughts affect feelings and behaviors. Teach common cognitive errors as well as new ways to think about situations “detective training”

» Anxious thought

• Write down anxious thought, evidence for and against thought, and new positive coping thought

Challenges to Utilizing Cognitive Restructuring with Children and

Adolescents• Need good motivation• Child/adolescent is assigned homework and compliance

may be an issue• Developmental considerations• Cognitive ability of child• Need meta-cognitive abilities to access one’s own thoughts• Works well as an effective tool with most

children/adolescents

Treatment Techniques Used with Children and Adolescents

• Interoceptive Exposure - learning not to let physical sensations of anxiety scare you

• Utilized to treat Panic Disorder and Agoraphobia

• Series of exercises, conducted repeatedly to teach child not to fear the physical sensations brought on by the fear response

• Physical sensations are not harmful, they are natural

• Conduct exercises in session to “bring on” panic

Treatment Techniques Used with Children and Adolescents

• Exposure Therapy /Fear Avoidance Hierarchy - calls for child to confront feared stimulus and remain in its presence for progressively longer periods of time; child is rewarded for each success

• Fear of Dogs– break down into smaller steps• Fear of Shots, Bugs using “Bravery Ladder”• “Reward Store” for each success, typically special

time with mom or dad• Do not use relaxation techniques during exposure!

Relaxation Training Script

• Progressive muscle relaxation with imagery

“Pretend you are a furry, lazy cat. You want to stretch. Stretch your arms out in front of you. Stretch them way out. Feel them pull from your shoulders. Good! Now let them drop quickly…Notice how good it feels to be relaxed…it feels good and warm and lazy.”

Treatment Techniques Used with Children and Adolescents

Exposure/Response Prevention• Used with children with obsessive compulsive disorder• Expose child to anxiety by having him or her “wait”

progressively longer time periods before performing compulsion

• Eventually, eliminate compulsion entirely• Replace and substitute with more appropriate,

functional behaviors (e.g., hair pulling is replaced with keeping hands occupied in a less harmful way)

Treatment Techniques Used with Children and Adolescents

• Shaping - rewarding successive approximations to a desired behavior

• Contingency Management -- rewards for brave behaviors. Typically designed by therapist but implemented by parents. Sticker charts.

• Modeling Treatments -- having a frightened child observe another child interacting adaptively with the feared stimulus; can be live or filmed.

Cognitive Self-Statements

I am a brave girl (boy).

I can take care of myself when I am alone.

I can take care of myself when I am in the dark.

I am brave and can take care of myself.

Social Skills Training

• Learning and practicing skills that facilitate social interactions

• Practicing skills in real life settings• Examples: eye contact, smiling, keeping

appropriate voice levels, asking questions, keeping conversations flowing, ways to increase positive reinforcement from the environment

Parenting Skills Training Component• Increase parental warmth, attention, and praise to child

• Strategies for knowing when something is misbehavior and when it is anxiety and how to handle each

• Increase positive parent-child interactions

• Teach appropriate ways to give commands and set limits

• Education about the cycle of anxiety

• Non avoidance!

• Praise (Example: Brave night! Brave night!)

Specific Techniques for Supporting an Anxious Child for Teachers and Parents

• Specific praise and small rewards of brave behaviors• Model brave coping behavior• Help child to face fears, even gradually!• Give child control/choices around

age appropriate decisions• Don’t be overly reassuring; be gently encouraging• Help child use appropriate coping skills to manage

high emotions; communicate openly!• Anxiety is a natural emotion and sometimes can help!

Implementing evidence based treatments in practice: Advantages and Challenges• Advantages

– evidence supports treatment efficacy– evidence that gains are maintained– “makes sense” to patients, good acceptability;

parents like the idea of skills vs. meds– empirically based; ongoing assessment allows for

measurement of progress– concrete CBT strategies work well with children

and adolescents– parents gain guidance and skills that often

translate to other siblings

Implementing evidence based treatments in practice: Advantages and Challenges• Challenges

– complex cases with comorbid diagnoses often require additional sessions

– need for referral sources/providers specifically trained in CBT techniques

– patient motivation– patients/parents need to be actively involved in therapy

A Clinically Significant Outcome

Case Descriptions Across the Developmental Spectrum: “Sally”

• “Sally”, age 14• Afraid to speak with other girls at school• Fears sitting in lunchroom with people she doesn’t know• Gets along well with siblings, gets straight A’s in school• Behavioral Observations– Sarah speaks softly, can barely hear

her, seems very shy yet can smile and engage appropriately• Wants to develop peer group at school yet avoids contact with

peers for fear of rejection or embarrassment• Has friends at her summer home with whom she is very

comfortable• Family is very supportive of her

“Jake”, age 7• Worries about everything all day long• Constantly asking parents “worry questions”• Parents repeatedly answer questions but are sick of them• Jake worries about grades in school, whether a terrorist

will come to their town, whether parents have adequate finances, what time parents will be home; worries ahead of time about family vacation (what if it rains, what will we do? What if someone gets sick?); constantly asking questions about family’s whereabouts

• Parents describe him as the “policeman” of the house• Wish he would just “let go” and relax• Jake has good friends, appropriate interests, often

distracted by his worry

“Adam”, age 17• Fear of elevators since age 10 when he witnessed his mom

telling story of how she got stuck in an elevator• Avoids cities and restaurants that are in tall buildings• Excellent student, loves science, would love to go to top notch

university but choosing college based on building heights on the campus; choosing small college that doesn’t fit with his interests but has low buildings due to fears

• Embarrassed to share fear with buddies; refuses to go out with people to the city, says he has plans already

• Feels he can’t go to the prom and has missed other activities through the years due to fears

• Coming to treatment to get help; wants to get rid of these fears

Discussion Questions• How would you go about doing a more complete

assessment of this child/adolescent?

• In being a scientist/practitioner, you decide to give some measures at pre and post treatment to measure your patient’s progress. Which measures do you choose?

• How would you diagnose patient?

• What cognitive-behavioral treatment techniques that you learned today would you be likely to use with this patient in treatment?

Discussion Questions, con’t• Provide two concrete, measurable goals that could be tracked

throughout treatment

• Would you include the parents/family in any part of treatment? If so, what type of parent component do you think would be helpful?

• Conceptualize your case by tailoring the 3 component model to your patients’ concerns- how might you present this to your patient in session one?

• What might a Fear and Avoidance Hierarchy look like for your patient?

Conclusions• Cognitive behavioral treatments work well

• Great need for more controlled trials

• Can utilize these assessment and treatment techniques in clinical practice

• Patients like “hands on” techniques, concrete strategies work well with children and adolescents

• Can measure change and progress and chart your patients’ successes!

IT DOESN’T TAKE A WIZARD!• Brains - skills, tools for being a good therapist• Heart - ability to connect with child and care

about helping family • Courage - Teaching child that there is “no place” he

or she can’t go • Home - Teaching child to feel at “home” with all of

our natural, human emotions

Take these new skills home!

Questions and Ideas

Websites of interestwww.childanxiety.netwww.bu.edu/anxiety