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

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

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

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

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

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.

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)

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

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

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

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

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

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

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

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

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

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)

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.

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

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!

NOVEMBER 3, 2003

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

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.

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……

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!

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

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.

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

How do you undo anxiety?

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

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.

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

#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

#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)

#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**

#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

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

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

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

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

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

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

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

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

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!

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

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.

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.

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!”

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.”

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.”

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?

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

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

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!

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

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

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….

For a little more help…

Helpful Websites www.effectivechildtherapy.com www.anxietybc.com www.adaa.org www.abct.org Follow me on twitter! @AnneMarieAlbano Website: www.annemariealbano.com