Presentation on theme: "Your Anxious Child: What Every Parent Needs to Know!"— Presentation transcript:
1Your Anxious Child: What Every Parent Needs to Know! Anne Marie Albano, PhD, ABPPColumbia University School of MedicineDirector, Columbia University Clinic for Anxiety and Related Disorders February 2014
2Overview ___________________________________________________________ Normal milestones of child and adolescent developmentThe challenges of anxiety along the way……Key skills for youthWhat a parent can do!
3Development is multifactorial and transactional….and so is anxiety! Where do we begin?Development is multifactorial and transactional….and so is anxiety!
4Developmental keys Anxiety is expected and normal Temperament sets the stage….Tasks of development vary with age
5Main Milestones of Childhood Language: ability to speak, communicate, read non-verbal cues, and understand othersCognitive: ability to reason, think, learn, problem-solve, rememberSocial: develop and keep meaningful relationships; respond to others’ feelings
6More 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.
7Developmental 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 responsiblyMake and keep long term relationshipsTake control of personal self care (e.g., sleep, health care, exercise, diet, self-soothing)
8Developmental Progression Common FearsPreschool: Imaginary Objects/situationsGrade School: Health/harm, Scrutiny/CompetenceAdolescence: Social adequacy, PerformanceAnxiety DisordersPreschool: Phobic objects/situations, SADGrade School:OCD, GADAdolescence: Social anxiety, Panic Disorder
9Why does anxiety naturally increase throughout adolescence Complex social cognitive skills developSocial comparison skills are formulatedPeer-group approval becomes importantAcademic demands increaseIndependent social functioning is expected with greater frequencyPuberty x environment interaction
10When does anxiety become problematic? Avoidance/DisruptionInterfers with functioning(not facing developmental challenges)DistressDuration
12Separation Anxiety Disorder Social Phobia Generalized Anxiety Disorder Child Anxiety “Triad”Separation Anxiety DisorderSocial PhobiaGeneralized Anxiety DisorderFrequently occur together, at the same time and respond similarly to treatments
13What are the risks for problematic anxiety? AcademicStressPeerProblemsGenesEarlyExperienceParentingPhysicalhealthTemperamentCognitiveStyle
14Significance of Anxiety Disorders in Childhood Highly prevalent (10% to 20% of youth)Significantly impairs social, academic, family and independent functionMay lead to school refusal behaviorHighly comorbid in childhood with each other; in adolescence with mood and substance abuse disordersCommonly persists into adulthood
15SCHOOL REFUSAL BEHAVIOR: Parameters Complete absence from schoolPartial attendance (e.g., leaving class or school during day)Attendance following intense misbehaviors in the morningUnusual distress during the school day that leads to pleas for future nonattendance
16Treatment of Anxiety in Youth Therapies that have been tested in clinical trials and found effective:Cognitive behavioral psychotherapyMedicationCombined CBT plus Medication
17Gold Standard CBT: The Coping Cat PsychoeducationSomatic ManagementAge-appropriate cognitive restructuringExposure “STIC” TasksAges 8-17; many adaptations of this basic treatment are effectiveKendall (1994); Kendall et al. (1997)
18The CALM Program: Ages 3-8 (Comer, Puliafico & Albano, 2008) C oaching A pproach behavior and L eading by M odelingRationale: 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.
19PCIT/CALMTherapist unobtrusively coaches interactions from behind a 1-way mirror. Parent wears a bluetooth earpiece so that child cannot hear the coachingCourtesy of Jon Comer
20Developmentally-Informed CBT for Adolescents (14-20’s) Goals: Independent functioningEducation for parents and adolescent—togetherDevise hierarchy of situations targeting developmental milestonesWeekly developmental goalsParent-sessions: Letting Go!
22Family EnvironmentParents of children with anxiety are more likely to:Take over for the childProvide negative feedbackAct in more restrictive or controlling mannerThese parental behaviors have been shown to exacerbate anxious and avoidant behavior in childrenOverprotection and overcontrol = increase anxiety risk
23Alfred 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.
24The Role of Modeling in Learning Many behaviors can be observed by watching others (modeling)Fear reactionsAggressionAltruismMoral behaviorAcademic tasksMotor tasksThe list can go on and on……
25Four 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!
26Coercive 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 louderFrom Rex L. Forehand
27And 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.
28Yet another reinforcement trap Parent: (in a louder voice)“I really mean it! Get into your bed!”Child does not complyNO! 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
30Behavioral Theory Antecedent Behavior Consequence Positive consequences increase behaviorNegative consequences decrease behavior“Hidden” consequencesNegative attentionEscape from undesirable taskNot rewarding good behavior
31A B CTen 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.
32A B CAntecedent 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 antecedentsRulesRoutinesGood commandsAnticendent example: Baby and poisonous chemicalsUse more effective consequencesImmediateSalientConsistentShort-term
33#1 Principle to teach parents: The Premack PrincipleHigh frequency behaviors serve to reinforce low frequency behaviorsGrandma’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, fear4th step1st step8th stepImpact of rescue:remembers situation at the height of fearprevents habituationno experience of masteryescape is reinforcedImpact of exposure:remembers success that allows habituationlearns anxiety passes on its ownwilling to approach increasingly challenging situationsfeeling of masteryreinforcement for hanging inFrom Chansky (2004)
35#3 Principle to teach parents: How to use reinforcers CONTINGENT on performance of the target behaviorCONSISTENTLY appliedAdministered IMMEDIATELY after the behaviorInitially on CONTINUOUS schedule, then changed to INTERMITTENTKept POTENTuse small amounts and change reinforcers periodicallyinvolve 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 goShapingComponents of a target behavior are reinforced in a step-by-step manner
37Parents taking Action Identify potential role in child’s behavior Understand the problemExamine what keeps it goingUse “If-Then”Parents as “coaches”
38What is most difficult for parents? Letting the child struggleMistakes promote learning and masteryFear that “situation X is too important to fail”Parental “overprotection trap”Limits progression through developmental steps38
39Anxiety-provoking situations Interviews (college, work)Speaking in class/small groupsDatingUnstructured social situations (e.g., parties)Meeting unfamiliar peopleInitiating or maintaining conversationsBeing aloneBoredomAssertive behaviorTaking to authority figuresBeing observed by othersTaking tests (class, SATs)Making independent decisionsBeing wrongPerformance situationsBeing the center/focus of attentionConflict with peers39
40Anxiety Fear Hierarchy Fear Thermometer (SUDS)Separation Anxiety Fear HierarchyMost AnxietySituation SUDSSpending night at friend’s house 10Spending 2 hours at friend’s– w/o mom 8Spending 30 mins at friend’s – w/o mom 7Mom leaving home for 30 minutes 6Mom leaving home for 15 minutes 5Mom going out to get mail 3Mom going in a different room – nighttime 210987654321Least Anxiety
41School-based Anxiety Fear Hierarchy Fear Thermometer (SUDS)School Situations Fear HierarchyMost AnxietySituation SUDSGiving an oral report in class 10Not calling mom at all during day 8Taking an exam in the classroom 7Asking the teacher a question in class 6Asking the teacher for help after class 5Having my homework marked up 3Working on a group project 310987654321Least Anxiety
42Understand the Core of Anxiety Anxiety-provoking situations WILL invariably lead to:EmbarrassmentHumiliation/RejectionLoss of controlCatastropheLoss of social statusDeath/Physical Illness
43Keys for Parents Maintenance of anxiety: Know developmental tasks Overprotection, OvercontrolKnow developmental tasksApproach areas of conflictOpenly express your fearsEncourage and listen to your teen’s fears/frustrationsCommunicate and problem solveSet goals and plans
44Basic Childhood Skills Self-soothingCalms self, able to be alone, puts self to sleepIndependenceSleeps alone, entertains self, does homework, seeks information/activityAssertivenessAsks for help, refuse requests, sticks up for selfSocial skillsMakes and keeps friends, interacts with known adults
45Advanced Skills for Adolescents Problem solving skillsHigher-order social skills (e.g., negotiation)Emotion regulation skillsRealistic thinkingPerspectiveAnxiety and stress/time management skillsOpportunities to learn and to mess upFamily support but not overprotection!
46Keeping CalmGoal: Develop tolerance of normal, expected levels of anxietyDeep breathingProgressive Muscle RelaxationMindfulness exercisesYoga
47Typical Cognitive Distortions All or None ThinkingEither I ace this test, or I fail and I’m a loser.CatastrophizingThis is the worst thing that could happen to me!Disqualifying the positiveA B+ on that test just wasn’t very good.Fortune TellingI know that I won’t make friends at that camp.I know something bad will happen to mom.
48OvergeneralizationThat person wasn’t very friendly to me. There just isn’t any nice people around anymore.Mind ReadingI know they think I’m a geek.Shoulds, Can’ts, Won’tsI should’ve said something different . . .I can’t do this, it is impossible!I won’t ever be able toProbability OverestimationI’m absolutely positive that I won’t get into college.
49World 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!”
50Derek 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.”
51Derek 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.”
52Cognitive 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?
53Helpful Coaching Style Focus on effort, not outcomeEvaluate the situation realisticallyThink about what you know and what you’ve done in the pastFocus on coping: How will I handle this?Give opportunities for practiceReward (praise) all efforts, no matter how small
54Exposure: Key to Learning Goals:Provide experience performing in and managing difficult situationsPractice and refine cognitive, social, somatic management, and problem solving skillsRefute anxious thoughtsHabituation to anxietyTolerate anxiety
55Manage parental anxiety…. Transfer to your child?Learn to recognize your own triggersSelf-sootheStick with realitiesProblem solveTake care of your own needs!
56Just 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 identityForm long term romantic relationshipsFormulate long-term vocational goalsComplete educational requirementsEstablish financial independenceLive independently
57Junior to Senior Year Goals Situation Goal Achieved?Going to a college interview out of town on my own NoAsserting myself with a teacher NoPlanning, buying and making my own meals for the month YesGoing to the doctor’s on my own YesArranging for my own transportation to an in-town event YesHandling my own checking account YesCalling to arrange an interview (job, college or internship) YesDoing my own laundry YesTaking driving lessons NoGetting my driver’s permit Yes57
58When 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….