Understanding Anxiety in Children and Adolescents for parents and teachers

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Understanding Anxiety in Children and
Adolescentsfor parents and teachers

• L. Read Sulik, MD, FAAP
• Medical Director
• Child and Adolescent Psychiatry
• St. Cloud Hospital
• 320-255-5796
• sulikr_at_centracare.com

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The Spectrum of Fear and Anxiety in Children
Typical, developmentally appropriate
Severe anxiety symptoms
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Developmentally Appropriate Anxiety in Children

• Anxiety and Worry are common in young children
• young children more likely to have anxiety
  symptoms than older children
• girls more commonly than boys (????)
• Range of Anxiety symptoms
• fear of dark, fear of harm to family member, over
  concern about competence, excessive need for
  reassurance, somatic complaints, worries about
  dying and health and worries about social
  contacts

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Anxiety Disorders in Children

• Most common of all mental health disorders, yet
  actual prevalence in children is not clear
• children lack ability to express verbally their
  internal experience of anxiety
• behaviorally express anxiety through clinging,
  freezing, crying, fidgeting
• children lack ability to realize that their
  anxiety is excessive, whereas adults often are
  able to realize this

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Fear

• A primitive, complex, innate neurophysiologically
  -mediated response to some perceived threat of
  harm or danger

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There are 1012 neurons in the brain and each one
has up to 1000 to 10,000 projections!
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Anxiety

• A neurophysiologically-mediated condition of
  hyperarousal of the central nervous system that
  may be acute (panic attack) or chronic and
  sustained

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An individuals intense fear or anxiety may
invoke intense fear in those around him or her
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What scares us?
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I dont have _at__at_ clue what is going on!
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Uncertainty . . .is the most powerful trigger
of anxiety that we confront in our lives
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• When there is a gap in what a child knows or
  understands, they fill in the gap with their own
  interpretation

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Physical Symptoms of Panic Attacks

• Chest pain or discomfort
• chills or hot flashes
• choking sensation (globus hystericus)
• derealization (feeling unreal) or
  depersonalization (feeling detached from self)
• dizzy, light headed, faint or unsteady
• fear of dying
• fear of loss of control
• heart pounding, racing or skipping beats
• nausea or other abdominal discomfort
• numbness or tingling
• sweating
• shortness of breath or smothering sensation
• Trembling
• Uncontrollable feeling of terror

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Physical Symptoms of Anger Attacks

• Chest pain or discomfort
• chills or hot flashes
• choking sensation (globus hystericus)
• derealization (feeling unreal) or
  depersonalization (feeling detached from self)
• dizzy, light headed, faint or unsteady
• fear of dying
• fear of loss of control
• heart pounding, racing or skipping beats
• nausea or other abdominal discomfort
• numbness or tingling
• sweating
• shortness of breath or smothering sensation
• Trembling
• Uncontrollable explosive feeling of rage

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So. . . angry outbursts may be related to
underlying anxiety!
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Fight-or-Flight Response to Fear

• Involves tense muscle tone, increased breathing
  rate, increased pulse rate
• State of hyper arousal and super awareness of
  the brain to all sensory information
• May cause agitation, combative behavior,
  trembling, confusion

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Freeze-and-Withdraw Response to Fear

• Involves shallow breathing, slow pulse rate, pale
  or clammy skin, low blood pressure, and decreased
  responsiveness
• Child may appear stunned, fearful or unemotional
  and unable to respond
• Appear to shut down
• Deer in the headlights look

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Re-experiencing the Fear

• Child experiences severe distress in response to
  internal or external cues that resemble the
  traumatic or fearful event
• May have intrusive and distressing thoughts,
  mental images or dreams
• May experience flashbacks or illusions that cause
  child to act or feel as if event is actually
  happening

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Avoidance Response to Fear

• Child avoids thoughts, feelings, or conversations
  associated with fear
• May feel detached and isolated
• May have restricted range of affect or decreased
  ability to feel strong emotions

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Persistent Hyperarousal

• Child has difficulty sleeping and thinking
  clearly
• May be excessively vigilant and startle easily
• May appear angry, irritable or rageful

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Post Traumatic Stress Disorder

• Individual has experienced or witnessed an
  unusually traumatic event
• that threatened death or serious physical injury
• individual responded with intense fear, horror,
  or helplessness
• or with agitated and disorganized behavior

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Define witnessed . . .
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The hormone Corticotropin-Releasing Factor (CRF)
is released in the brain in response to
stress CRF travels to the pituitary gland where a
second hormone ACTH is released ACTH travels in
the blood to the adrenal gland which releases a
third hormone Cortisol
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Cortisol provides feedback to the brain to turn
off the production of catecholamines (i.e.
norepinephrine) in response to stress In chronic
stress this system malfunctions and the
catecholamine response is not turned off and
maintains a state of hyperarousal Persistent
hyperarousal often leads to exhaustion of
neurotransmitters which can lead to depression
Demonstration
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Stress, Fear, Anxiety, Depression and Meaning
Behaviors
MEANING
Interpersonal Relationships
Performance
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The Chronically Stressed Child

• Pearls
• Child who is in a persistent state of
  hyperarousal appears hyperactive
• Child who is numbed emotionally with a restricted
  range of affect will dissociate to triggers of
  the traumatic event and appear inattentive
• Child who has mood lability associated with
  persistent hyperarousal will appear impulsive

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The Chronically Stressed Child

• Children are most comfortable when their
  surroundings appear predictable and safe
• They like to feel that the adults around them are
  in control
• Maintaining a calm, reassuring manner

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The Chronically Stressed Child

• Experience stronger stress reactions
• Anger may be due to hyperarousal
• May appear hyperactive due to hyperarousal and
  anxiety
• Remember chronic traumatic stress responses

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Treatment of Anxiety Disorders

• Multi-modal Treatment
• Education of signs and symptoms and course of
  anxiety disorder to child and his or her parents
• Behavioral Interventions
• Psychotherapy
• Pharmacotherapy
• Relaxation

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Treatment of Anxiety Disorders

• Cognitive Behavioral Therapy
• highly structured and focusing on changing
  maladaptive thoughts and assumptions and learning
  new ways to change behavior
• Psychotherapy
• traditional supportive therapy and
  psycho-education are as effective as CBT
• Alternative Therapies
• Relaxation
• Biofeedback

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Pharmacotherapy for Anxiety Disorders in Children

• Goals of pharmacotherapy in anxiety disorders
• Decrease state of hyperarousal, suppress overly
  exaggerated fight and flight response
• Reduce worried, ruminating thinking
• Reduce rigidity in thinking
• Target Anxiety-related Sleep Dysfunction

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Take Home Messages
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Anxiety Begets Anxiety

• Anxiety in a child will often invoke anxiety in
  you and you may feel irritable
• Your anxiety may invoke anxiety in a child you
  are working or living with
• Pay attention to your own internal responses

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Children Fill in the Gaps

• Remember that uncertainty is one of the most
  powerful triggers of anxiety that we experience
• When there is a gap in what a child knows or
  understands, they fill in the gap with their own
  interpretation
• With anxious children dont assume they know or
  understand, ask questions, be clear with your
  responses

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Children Lack Self-Soothing

• Anxious children need a safe, nurturing
  environment and relationships in order to develop
  self-soothing skills
• Self-soothing skills are needed to help the child
  tolerate distress at some level
• Your words and your behavior communicate
  understanding to the anxious child and helps
  foster soothing

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Lifestyle Management of Depression

• Sleep
• Diet and Nutrition
• Exercise
• Relaxation
• Support System

• Chemically Free
• Medications
• Therapy
• Fun and Recreation
• Personal Growth

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Questions