growing up brave: expert strategies for helping …...growing up brave: expert strategies for...

Growing Up Brave:

Expert Strategies for Helping Children and Adolescents Overcome Fear, Stress and Anxiety

Donna B. Pincus, Ph.D.

Associate Professor, Boston University

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

Donna Pincus, PhD, 2015

Acknowledgements

• Thank you to the MGH Faculty Parents Group

and the Office for Women’s Careers

• NIMH

• Child Program at the Center for Anxiety and Related Disorders


Overview of Presentation

1) Nature of Anxiety in children and adolescents: What is normal, what is not

2) How do I know if a child needs help? Strategies for identifying anxiety at home and in schools

3) What are some practical techniques that parents, grandparents and teachers can use to help prevent maladaptive anxiety and to support an anxious child?

4) Where can we refer children for help?


Child Program: Center for Anxiety and Related Disorders at Boston University

(617) 353-9610


Importance of this topic

• Anxiety disorders are among the most prevalent problems affecting children and adolescents

• These disorders can interfere significantly with adaptive functioning in a wide range of domains

• Fortunately, we now have many effective, non-drug options for helping children overcome fear and anxiety!

• We can help change children’s developmental paths or trajectories


Hopeful prognosis

• Fortunately, we now have many effective, non-drug options for helping children overcome anxiety and

school refusal behavior

• With good assessment and treatment, rate of remission is excellent—recent randomized controlled trial showed that 83% of children with school refusal treated with cognitive behavioral treatments were attending school at one year follow up

• We can help change youth’s developmental paths or trajectories!


Part I: Nature of Anxiety in Children and Adolescents


Wemberly Worried

Wemberly worried about everything. Big things, little things, and things in between.


What do you think kids today worry about?

• Do you think worries differ for school-aged kids versus adolescents?


Images Depicting Fear and Anxiety


Images of Fear and Anxiety


Our fascination with the emotion of fear…


Our fascination with fear


Images of Bravery


Portraits of Two Children: “Zack”, age 10

• phobia of dogs, began age 6

• Cant be around dogs

• Avoids parks, camp, walks

• Has trouble looking at pictures of dogs

• Ashamed of his fear

• Friends make fun of him

• Becomes panicky and has panic attacks when he sees dogs or thinks of them

• Thinks about this fear on a daily basis “will there be dogs there?”

“Anna”, third grader • Gets frightened when she watches

scary movies on TV

• Her sister broke her favorite art project; she had a bad day

• Friend pushed in front of her in line for the bathroom

• Worried about math test tomorrow

• Afraid that her mother won’t let her watch her favorite show, “Arthur” after school

• Hopes she makes a few new friends in her extended day program at school


Normal Fear and Anxiety or an Anxiety Disorder?

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

• 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


How can too much anxiety interfere in children’s functioning?

• Avoidance of developmentally appropriate activities

• Anxiety can have a negative impact on friendships

• Impact on family relationships

• Interferes with teenagers’ desire for independence

• Affects school concentration

• Left untreated, anxiety may lead to additional problems later in life, including behavioral problems, substance use, other anxiety disorders, suicidal ideation, and depression


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 Data Infants & toddlers: loud noises, strangers, separation from parents, large objects Preschoolers: 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


Normal Separation Anxiety


Anxiety: An Adaptive Emotion

• How can physical sensations of anxiety be adaptive? – Sweaty

– Stomachache/nausea

– Dizziness

– Heart Racing

– Shortness of breath

• Anxiety like a “Watchdog”


Culture and Anxiety • Experience of anxiety pervasive across cultures

• Specific fears have been studied and documented in virtually every culture

• Gender differences in pattern and content of fears similar across cultures

• Expression, course, and interpretation of symptoms vary by culture

• Growing literature on differences in anxiety cross culturally Donna Pincus, PhD, 2015

• 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


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 Psychological Vulnerabilities--e.g., behaviorally inhibited temperament, early experiences with low levels of control over environment


Recent Genetic Research on Child

Anxiety Disorders

Children with a specific genetic marker are more responsive to cognitive behavioral therapy than those

without the marker (Hudson & Eley, 2012)

http://www.youtube.com/watch?v=4Tx10lTWU8E


http://www.youtube.com/watch?v=q8WDjrmhtF0

Gender Differences in Children’s Fears

•Are fears more prevalent in boys or girls? • By age 6 anxiety disorders are twice as prevalent in

girls than boys

•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

–Female vulnerability to anxiety may be related to genetic influences, social roles, experiences


Factors that May Predispose or Protect Against Anxiety Disorders

• Parental responses that increase child anxiety: – modeling of anxious behavior – overprotection of the child – over-reassurance of safety – inadvertent reinforcement of anxious behavior/avoidance. – high levels of parental control and low levels of warmth – less psychological autonomy granting

• By providing appropriate structure and expectations and encouraging approach of new experiences, parents may help protect their child against developing an anxiety disorder


What Causes Anxiety Disorders to Persist?

• Maintained and intensified by a variety of influences (including characteristics of the child, and the environmental context)

• Cognitive/behavioral avoidant coping responses

• Difficulty with social, or emotion regulation skills

• Cognitive biases/distorted beliefs

• Behaviors that serve to protect child from anxiety/ reward anxious behaviors


Growing Up Brave

Pincus, D. (August, 2012). Growing Up Brave: Expert Strategies for Helping Your Child Overcome Fear, Stress, and Anxiety. New York: Little, Brown. Part 1: Understanding the Nature of Childhood Anxiety Part 2: Anxiety Disorder Prevention Strategies Part 3: Strategies to lessen anxiety and promote bravery Part 4: Growing Up Brave through the years Donna Pincus, PhD, 2015

Sleep and anxiety

• Presence of sleep related problems may increase a child’s vulnerability to experience an anxiety disorder

• Sleep disorders and anxiety disorders have a reciprocal relationship

• Poor sleep quality can interfere with a child’s attention and emotion regulation during the day, which can in turn increase a child’s anxiety about falling asleep

• Conducting research currently on sleep and anxiety disorders in youth; 90% of children in our Child Program also suffer from a sleep-related problem


Good Sleep Predicts Good Emotional Regulation, Good Academic

Functioning • Bedtime consistency

• Soothing/relaxing bedtime environment

• Consistent/brief bedtime ritual

• Relaxation exercises can help

• Praise for brave behaviors

• Brave Nights Calendar


“Brave Nights”

__I went to bed promptly, within 15 minutes after

being told

__ I went to bed without complaining, arguing, or

crying

__ I slept in my own bed with all sources of light

and noise turned off

__ I slept through the night without calling out.

__ I fell asleep by myself.


Extra Parental Attention = Powerful Reinforcement!


-unwillingness or inability to go to bed within reasonable time (15 min) -unwillingness or inability to sleep alone in bed with all sources of light and noise turned off -unwillingness or inability to go to bed without arguing, complaining, crying, delaying, asking for water, pleading to stay up -inability to sleep through the night without calling out, wandering or leaving the bed

Fear of the Dark Program


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Identifying child anxiety in schools

• Over-utilization of school nurses’ office

• Inattention, behavioral issues

• Difficulties with Separation

• Worry about school performance or peer interactions

• Unhelpful School Based “Accommodations” – allowing youth “passes” to take frequent breaks from class

– Sitting in library

– Lying down in nurses’ office

– Going to “partial” days of school

• These measures often inadvertently reinforce the “cycle” of anxiety, and further exacerbate youth’s problems.


Anxiety Disorders: Children and Adolescents

• Separation Anxiety Disorder

• Specific Phobias

• Social Anxiety Disorder

• Generalized Anxiety Disorder

• Panic Disorder and Agoraphobia

• Post Traumatic Stress Disorder

• (School Refusal, Test Anxiety, OCD)


Cognitive Behavioral Treatment for Child 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 – See cycle of anxiety handout demonstration – Anxious thought: If I talk to them, they might not

like me Donna Pincus, PhD, 2015

Making Anxiety Understandable: The Three Component Model or “Cycle of Anxiety”

Thoughts

Physical Sensations

Behavior


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

• Cognitive Restructuring Handout • Write down anxious thought, evidence for and against thought,

and new positive coping thought; come up with one more anxious thought and restructure!


Targeting Thoughts: Detective Thinking

• How do you know if your thoughts are realistic? – Think like a detective, look for evidence

• Detective Thinking involves: – Identifying your thought – Looking for evidence to support or deny this thought – Coming up with a realistic interpretation/thought – Figuring out if you could cope with that?


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.”



• 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


http://images.google.com/imgres?imgurl=ceinfo.unh.edu/counties/coos/jog.jpg&imgrefurl=http://ceinfo.unh.edu/counties/coos/helthtom.htm&h=270&w=184&sz=26&tbnid=g4isS2wurUIJ:&tbnh=107&tbnw=73&prev=/images%3Fq%3Djog%26hl%3Den%26lr%3D%26ie%3DUTF-8%26oe%3DUTF-8

Changing Behavior: “Situational Exposure”

• Learn to experience fear/anxiety without avoiding

• “Bravery Ladder”/Fear Hierarchy – Breaking fears into smaller steps – Building in Rewards – Practice in vivo (classrooms, trains, elevators,

malls, etc.) – No relaxation techniques during exposure


Exposure Therapy: Riding the Wave of Anxiety

• Sample Bravery Ladders: – Fear of Dogs

– Fear of Vomiting

– Separation fears

– Panic fears


Sample Contingency Management: “Brave Kid Chart”



• 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.


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


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! Donna Pincus, PhD, 2015

Parenting Skills Training Component

• Differential reinforcement of child behaviors and fears • Strategies for dealing appropriately with misbehavior • Increase positive parent-child interactions • Teach appropriate ways to give commands • Limit setting • Education about the cycle of anxiety • Anxiety as a natural emotion • Non avoidance! • Praise (Example: Brave night! Brave night!)


Average Fear & Avoidance Hierarchy Ratings F

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Parent Quote

“There are no words to express our gratitude. After watching her suffer for almost 3 years, it is

nothing short of miraculous to have her living the life of an average 12 year old after a week of

treatment…know that we couldn't be happier with the results of our visit to Boston”


A Clinically Significant Outcome


Current Research and Programs

• Creative ways to bring anxiety treatments to youth in schools and other community settings – Internet based treatments

– Current grant: Transporting panic disorder treatments to youth in public schools

– “Camp” formats of treatment: Boston Brave Buddies

– Integration of preventive anxiety treatments into primary care settings


Take these new skills home!


Questions and Ideas

Websites of interest www.childanxiety.net

www.growingupbrave.com www.bu.edu/anxiety


http://www.childanxiety.net/

http://www.growingupbrave.com/

http://www.bu.edu/anxiety

Center for Anxiety and Related Disorders at Boston University

Contact Information

• Center for Anxiety and Related Disorders – (617)-353-9610

– 648 Beacon Street, 6th Floor, Boston, MA 02215

• Child Programs, Adult Programs


Case Descriptions Across the Developmental Spectrum: “Samantha” • age 12 • Afraid to speak with other people 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– 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 • Family is very supportive of her • She is lonely and feels left out


Case Description: Conor • Age 15

• If he has a thought that he thinks is negative, he has to “spit” to get the thought out of his mind

• Friends started to notice that he spits all the time

• Sailing instructor, straight A student

• Wants life to go well for him, doesn’t want to “jinx” himself so he has developed compulsive behaviors like not stepping on cracks, counting, and mantras, 15 wipes of deodorant

• Having a hard time stopping his thoughts/rituals Donna Pincus, PhD, 2015

“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 Donna Pincus, PhD, 2015

“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


Case Description: Marisa • Age 14

• Developed fear of pigeons

• Doesn’t know how it started

• Avoiding going abroad with her family due to pigeons

• Shrieks when she sees pigeons and tries to move away

• Feels this fear is ruling her life


growing up brave: expert strategies for helping …...growing up brave: expert strategies for...

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