1. Your Anxious Child: What Every Parent Needs to Know!
Anne Marie Albano, PhD, ABPP
Columbia University School of Medicine
Director, Columbia University Clinic for Anxiety and Related Disorders February 2014

2. Overview ___________________________________________________________
Normal milestones of child and adolescent development
The challenges of anxiety along the way……
Key skills for youth
What a parent can do!

3. Development is multifactorial and transactional….and so is anxiety!
Where do we begin?
Development is multifactorial and transactional….and so is anxiety!

4. Developmental keys Anxiety is expected and normal
Temperament sets the stage….
Tasks of development vary with age

5. Main Milestones of Childhood
Language: ability to speak, communicate, read non-verbal cues, and understand others
Cognitive: ability to reason, think, learn, problem-solve, remember
Social: develop and keep meaningful relationships; respond to others’ feelings

6. More Childhood Milestones
Earlier fears of childhood (the dark, monsters, small animals) decrease.
Your child is capable of greater reasoning and searching for more meaning than simple “Because I said so” statements.
Children become more curious and seek information from many sources.
Right versus wrong is a concept that is now understood, as is truth versus lie.
Children now experience shame and guilt through for their transgressions.

7. Developmental Milestones for Adolescents: Timeline by End of HS?
Emotional independence from parents (solves own interpersonal problems & issues)
Develop self identify (This is who I am)
Behavioral independence from parents (assertiveness, task completion, initiative)
Manage money responsibly
Make and keep long term relationships
Take control of personal self care (e.g., sleep, health care, exercise, diet, self-soothing)

8. Developmental Progression
Common Fears
Preschool: Imaginary Objects/situations
Grade School: Health/harm, Scrutiny/Competence
Adolescence: Social adequacy, Performance
Anxiety Disorders
Preschool: Phobic objects/situations, SAD
Grade School:
OCD, GAD
Adolescence: Social anxiety, Panic Disorder

9. Why does anxiety naturally increase throughout adolescence
Complex social cognitive skills develop
Social comparison skills are formulated
Peer-group approval becomes important
Academic demands increase
Independent social functioning is expected with greater frequency
Puberty x environment interaction

10. When does anxiety become problematic?
Avoidance/Disruption
Interfers with functioning
(not facing developmental challenges)
Distress
Duration

11. DSM Anxiety Disorders Separation Anxiety Disorder Social Phobia
Generalized Anxiety Disorder
Panic Disorder
Agoraphobia
Specific Phobia
Selective Mutism
Closely related:
Post Traumatic Stress Disorder
Obsessive Compulsive Disorder

12. Separation Anxiety Disorder Social Phobia Generalized Anxiety Disorder
Child Anxiety “Triad”
Separation Anxiety Disorder
Social Phobia
Generalized Anxiety Disorder
Frequently occur together, at the same time and respond similarly to treatments

13. What are the risks for problematic anxiety?
Academic
Stress
Peer
Problems
Genes
Early
Experience
Parenting
Physical
health
Temperament
Cognitive
Style

14. Significance of Anxiety Disorders in Childhood
Highly prevalent (10% to 20% of youth)
Significantly impairs social, academic, family and independent function
May lead to school refusal behavior
Highly comorbid in childhood with each other; in adolescence with mood and substance abuse disorders
Commonly persists into adulthood

15. SCHOOL REFUSAL BEHAVIOR: Parameters
Complete absence from school
Partial attendance (e.g., leaving class or school during day)
Attendance following intense misbehaviors in the morning
Unusual distress during the school day that leads to pleas for future nonattendance

16. Treatment of Anxiety in Youth
Therapies that have been tested in clinical trials and found effective:
Cognitive behavioral psychotherapy
Medication
Combined CBT plus Medication

17. Gold Standard CBT: The Coping Cat
Psychoeducation
Somatic Management
Age-appropriate cognitive restructuring
Exposure “STIC” Tasks
Ages 8-17; many adaptations of this basic treatment are effective
Kendall (1994); Kendall et al. (1997)

18. The CALM Program: Ages 3-8 (Comer, Puliafico & Albano, 2008)
C oaching A pproach behavior and L eading by M odeling
Rationale: Targets child’s maladaptive behavior indirectly by modifying parents’ behavior. Focus is on reshaping the primary context of early children development – parent-child interactions. Addresses overprotection and overcontrol, proposed mechanisms in reinforcing and maintaining anxiety.

19. PCIT/CALM
Therapist unobtrusively coaches interactions from behind a 1-way mirror. Parent wears a bluetooth earpiece so that child cannot hear the coaching
Courtesy of Jon Comer

20. Developmentally-Informed CBT for Adolescents (14-20’s)
Goals: Independent functioning
Education for parents and adolescent—together
Devise hierarchy of situations targeting developmental milestones
Weekly developmental goals
Parent-sessions: Letting Go!

21. NOVEMBER 3, 2003

22. Family Environment
Parents of children with anxiety are more likely to:
Take over for the child
Provide negative feedback
Act in more restrictive or controlling manner
These parental behaviors have been shown to exacerbate anxious and avoidant behavior in children
Overprotection and overcontrol = increase anxiety risk

23. Alfred Adler
“You can love a child all you wish, but you must not make him dependent. You owe it to the child to let him function as an independent being, and you must begin training him from the very beginning to do this. If a child gains the impression that his parents have nothing to do but to be at his beck and call, he gains a false idea of love.”
In The Pattern of Life (1930), page 148.

24. The Role of Modeling in Learning
Many behaviors can be observed by watching others (modeling)
Fear reactions
Aggression
Altruism
Moral behavior
Academic tasks
Motor tasks
The list can go on and on……

25. Four Conditions Necessary for Learning
The child must pay attention to the model.
The child must be able to remember what has been observed. Rehearsal helps.
The child must be able to replicate the behavior (developmentally appropriate).
The child needs to be motivated to learn!

26. Coercive Process/Negative Reinforcement Trap
Parent: “Mike, please sleep in your own room.”
Mike: I don’t want to.
I DON’T WANT TO.
I DON’T WANT TO!
Child begins to cry louder and louder
From Rex L. Forehand

27. And on it goes . . . Parent gives in . . . Outcome:
“Okay, but tomorrow night you have to sleep in your bed, okay?”
Outcome:
Mike’s inappropriate behavior is REINFORCED because his parent gave in and withdrew the request/direction.

28. Yet another reinforcement trap
Parent: (in a louder voice)
“I really mean it! Get into your bed!”
Child does not comply
NO! I won’t! (while spitting and kicking)
Parent intensifies her/his reaction
“That’s it mister! I’ve had it with you!” (while grabbing and make angry faces at child)
Outcome:
Child complies but the parent’s angry and intimidating behavior is reinforced through the child’s compliance.
Also from Rex Forehand

29. How do you undo anxiety?

30. Behavioral Theory Antecedent  Behavior  Consequence
Positive consequences increase behavior
Negative consequences decrease behavior
“Hidden” consequences
Negative attention
Escape from undesirable task
Not rewarding good behavior

31. A  B  C
Ten year-old Jamie is whining that he does not want to go to school. He’s delaying on doing homework and says it’s “too hard!” Jamies’s Mom wants him to get started on his homework and to convince him that school is fun. Jamie begs to stay home tomorrow. Mom tries to comfort Jamie but he cries and pleads with her. Mom eventually tells him that he can have one “mental health day” off from school.

32. A  B  C
Antecedent  Behavior  Consequence A: “Do your math homework, Jamie!” B: Jamie cries and begs to stay home from school C: Mom comforts him and gives him a day off from school.
Use more effective antecedents
Rules
Routines
Good commands
Anticendent example: Baby and poisonous chemicals
Use more effective consequences
Immediate
Salient
Consistent
Short-term

33. #1 Principle to teach parents:
The Premack Principle
High frequency behaviors serve to reinforce low frequency behaviors
Grandma’s Rule: “You can’t get your ice cream until you finish your spinach!”
e.g., School refusal = no computers/tv/gameboy

34. #2 Principle to teach parents: How negative reinforcement works
Parent gives in to tantrum, fear
4th step
1st step
8th step
Impact of rescue:
remembers situation at the height of fear
prevents habituation
no experience of mastery
escape is reinforced
Impact of exposure:
remembers success that allows habituation
learns anxiety passes on its own
willing to approach increasingly challenging situations
feeling of mastery
reinforcement for hanging in
From Chansky (2004)

35. #3 Principle to teach parents: How to use reinforcers
CONTINGENT on performance of the target behavior
CONSISTENTLY applied
Administered IMMEDIATELY after the behavior
Initially on CONTINUOUS schedule, then changed to INTERMITTENT
Kept POTENT
use small amounts and change reinforcers periodically
involve natural reinforcers whenever possible
**The child should be aware that a reinforcer is a consequence of the target behavior**

36. #4 Principle to teach parents: Shaping via reinforcement
Start small, build as you go
Shaping
Components of a target behavior are reinforced in a step-by-step manner

37. Parents taking Action Identify potential role in child’s behavior
Understand the problem
Examine what keeps it going
Use “If-Then”
Parents as “coaches”

38. What is most difficult for parents?
Letting the child struggle
Mistakes promote learning and mastery
Fear that “situation X is too important to fail”
Parental “overprotection trap”
Limits progression through developmental steps 38

39. Anxiety-provoking situations
Interviews (college, work)
Speaking in class/small groups
Dating
Unstructured social situations (e.g., parties)
Meeting unfamiliar people
Initiating or maintaining conversations
Being alone
Boredom
Assertive behavior
Taking to authority figures
Being observed by others
Taking tests (class, SATs)
Making independent decisions
Being wrong
Performance situations
Being the center/focus of attention
Conflict with peers 39

40. Anxiety Fear Hierarchy
Fear Thermometer (SUDS)
Separation Anxiety Fear Hierarchy
Most Anxiety
Situation SUDS
Spending night at friend’s house 10
Spending 2 hours at friend’s– w/o mom 8
Spending 30 mins at friend’s – w/o mom 7
Mom leaving home for 30 minutes 6
Mom leaving home for 15 minutes 5
Mom going out to get mail 3
Mom going in a different room – nighttime 2 10 9 8 7 6 5 4 3 2 1
Least Anxiety

41. School-based Anxiety Fear Hierarchy
Fear Thermometer (SUDS)
School Situations Fear Hierarchy
Most Anxiety
Situation SUDS
Giving an oral report in class 10
Not calling mom at all during day 8
Taking an exam in the classroom 7
Asking the teacher a question in class 6
Asking the teacher for help after class 5
Having my homework marked up 3
Working on a group project 3 10 9 8 7 6 5 4 3 2 1
Least Anxiety

42. Understand the Core of Anxiety
Anxiety-provoking situations WILL invariably lead to:
Embarrassment
Humiliation/Rejection
Loss of control
Catastrophe
Loss of social status
Death/Physical Illness

43. Keys for Parents Maintenance of anxiety: Know developmental tasks
Overprotection, Overcontrol
Know developmental tasks
Approach areas of conflict
Openly express your fears
Encourage and listen to your teen’s fears/frustrations
Communicate and problem solve
Set goals and plans

44. Basic Childhood Skills
Self-soothing
Calms self, able to be alone, puts self to sleep
Independence
Sleeps alone, entertains self, does homework, seeks information/activity
Assertiveness
Asks for help, refuse requests, sticks up for self
Social skills
Makes and keeps friends, interacts with known adults

45. Advanced Skills for Adolescents
Problem solving skills
Higher-order social skills (e.g., negotiation)
Emotion regulation skills
Realistic thinking
Perspective
Anxiety and stress/time management skills
Opportunities to learn and to mess up
Family support but not overprotection!

46. Keeping Calm
Goal: Develop tolerance of normal, expected levels of anxiety
Deep breathing
Progressive Muscle Relaxation
Mindfulness exercises
Yoga

47. Typical Cognitive Distortions
All or None Thinking
Either I ace this test, or I fail and I’m a loser.
Catastrophizing
This is the worst thing that could happen to me!
Disqualifying the positive
A B+ on that test just wasn’t very good.
Fortune Telling
I know that I won’t make friends at that camp.
I know something bad will happen to mom.

48. Overgeneralization
That person wasn’t very friendly to me. There just isn’t any nice people around anymore.
Mind Reading
I know they think I’m a geek.
Shoulds, Can’ts, Won’ts
I should’ve said something different . . .
I can’t do this, it is impossible!
I won’t ever be able to
Probability Overestimation
I’m absolutely positive that I won’t get into college.

49. World Series, 9th inning, 7th game, 2 outs, the score is tied
What is Derek thinking when he gets up to bat?
“Oh no, I can’t do this.”
“My stomach hurts.”
“I want to go home.”
“If I strike out, I can never play baseball again.”
“I’m afraid of that pitcher, he’s mean!”

50. Derek takes a swing . . . and misses!
“I knew I was a loser!”
“I’m so embarrassed!”
“I’m gonna get fired.”
“Now Mr. Torre will really be mad at me.”
“The guys hate me, I just know it.”

51. Derek Jeter’s REAL Thoughts
“Okay, so, he’s throwing me a slider.”
“I’ve been here before, I know what to do.”
“This is what I practice for and I’m ready.”
“I’m going to send this ball straight into the left field bleachers.”

52. Cognitive Challengers for Older Children/Teens
How would an objective observer view this situation?
What alternative explanations are there for this situation?
What if you saw a friend struggling What would you think or do?

53. Helpful Coaching Style
Focus on effort, not outcome
Evaluate the situation realistically
Think about what you know and what you’ve done in the past
Focus on coping: How will I handle this?
Give opportunities for practice
Reward (praise) all efforts, no matter how small

54. Exposure: Key to Learning
Goals:
Provide experience performing in and managing difficult situations
Practice and refine cognitive, social, somatic management, and problem solving skills
Refute anxious thoughts
Habituation to anxiety
Tolerate anxiety

55. Manage parental anxiety….
Transfer to your child?
Learn to recognize your own triggers
Self-soothe
Stick with realities
Problem solve
Take care of your own needs!

56. Just when you thought you were done
Just when you thought you were done! Milestones for Adolescence through Emerging Adulthood: Timeline: Late 20’s?
Accept sexual identity
Form long term romantic relationships
Formulate long-term vocational goals
Complete educational requirements
Establish financial independence
Live independently

57. Junior to Senior Year Goals
Situation Goal Achieved?
Going to a college interview out of town on my own No
Asserting myself with a teacher No
Planning, buying and making my own meals for the month Yes
Going to the doctor’s on my own Yes
Arranging for my own transportation to an in-town event Yes
Handling my own checking account Yes
Calling to arrange an interview (job, college or internship) Yes
Doing my own laundry Yes
Taking driving lessons No
Getting my driver’s permit Yes 57

58. When to seek help? The anxiety does not go away….
Your child is increasingly unhappy….
Family routines and functioning are affected….
You and your spouse are at each other….
No matter what you try, nothing works….

59. For a little more help…

60. Helpful Websites www.effectivechildtherapy.com www.anxietybc.com
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