7/6/2011
Finding Zen: Anxiety Strategies For the Classroom
Alexa Bagnell, MD, FRCPC IWK Health Centre Dalhousie Department of Psychiatry
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
What is Normal Anxiety? Situation or Trigger: First date Preparing P i ffor an exam Performing at a concert Giving a speech Moving from home Climbing a tall ladder
Transient Anxiety: Apprehension Nervousness Tension Edginess Nausea Sweating Trembling
Does not significantly interfere Does not prevent a person from achieving their goals
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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Anxiety Can Be Adaptive Some anxiety is advantageous Helps in novel situations Anxiety can heighten one’s awareness, prepare a defense to a threatening situation Fear response promotes survival of individual and species Normal developmental stages Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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Normal Fears 190 children in Netherlands- 4-12 years 75% ffearful f l off one stimulus ti l (Muris (M i ett al, l 2000)
Developmental Stages: Infancy- loud noises 9-18 months- stranger and separation 2 4 years 2-4 years- monsters 6-10 years- bodily injury or danger 12-17 years- social Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Anxiety Performance Curve (Yerkes-Dodson Law)
Hebb, D. O. (1955). Psychological Review, 62, 243-254 Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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What Is Anxiety? Brain Registers DANGER!
No Danger
ANXIETY
Ears Nose
Eyes
Sensory Perception
Initiation of Physiologic Cascade Taste
Touch
Heart Rate
Internal Signals Thoughts
Alertness Physical
Perception Tension
Emotions
When is Anxiety A Problem? Most children, adolescents and adults use anxiety to help them make good decisions Anxiety becomes a problem when it makes the decisions for you, interferes with your life and/or causes distress. Two forms: misinterpreting threat or extreme response Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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Anxiety and the Brain
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Sympathetic Nervous System Physiologic Arousal Signal danger Enhance alertness Prepare body for action Fight/flight Fi ht/fli ht response
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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7/6/2011
What is a Panic Attack? 10
Panic Attack: Heart pounding Sweating Trembling Air hunger Smothering Chest pain Stomach pain Nausea Dizziness Tingling/numbness of feet & hands Feeling flushed Feeling chilled
0
TIME
10 minutes
6 Month Prevalence Rates of Mental or Addictive Disorders in Children 4-17 Waddell et al, Can J Psychiatry, 2002
%
Anxiety Disorders
7
ADHD
5
Conduct Disorder
4
Mood Disorders
4
Substance Use Disorders
1
Any Disorder
14
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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7/6/2011
Epidemiology of Anxiety Disorders Approximately 1 in 10 children Most prevalent mental health problem in kids High comorbidity with ADHD, Depression, ODD, substance misuse Functional impairments: school failure and/or dropout, peer/social difficulties, family dysfunction, restricted career opportunities Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
The Acute Stress Response Affects 100% of the Population Affects all domains of brain functioning May impair functioning Resolves without medical treatment
Intensity of Impairing Symptoms
Lasts days - weeks
Emotional Cognitive Physical Behavioral Disturbances & Functional Impairment
DAYS
What to do? Resume usual activities Mobilize emotional supports
WEEKS
MONTHS
Trauma
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What causes anxiety disorders? Genetics Temperament Attachment Parenting/ Modeling Stressor Cognitive differences Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Anxiety Disorders in Children Separation Anxiety Disorder: separation from caregivers,concern bad things will happen to them Selective Mutism: Failure to speak in specific social situation despite speaking in others Generalized Anxiety Disorder: uncontrollable excessive worry about many areas of life functioning (e.g., school work, family, friends, health) Social Phobia: fearful of social or performance situations
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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7/6/2011
Anxiety Disorders in Children Specific Phobia: fear of particular objects or situations Panic Disorder: misinterpret bodily changes and have a fear of losing control Obsessive Compulsive Disorder: the presence of intrusive repetitive thoughts (obsessions) or behaviours (compulsions), >1 hour/day Post traumatic Stress Disorder: Experience traumatic event, reexperiencing, avoidance and numbness, increased arousal, >1 month
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Treatment of Anxiety Disorders in Children 1st Line: Cognitive Behavioural Therapy-CBT 2nd Line: Medication pplus CBT Medications RCT: Anxiety disorders including OCD: sertraline, fluoxetine, fluvoxamine, citalopram, paroxetine Evidence not as strong for venlafaxine Start low and go slow (takes 2 - 4 weeks to start to work) In emergency or extreme distress: benzodiazepines can give temporary relief- potential for addiction Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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7/6/2011
Frewen et al 2008
Harmer et al, 2006
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Three Components of Anxiety
Feeling
Doing
Thinking
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
THOUGHTS
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Thinking Anxious children and teens have unrealistic or extreme thoughts that centre around harm or threat. “My mom is late, she’s been in a car accident.” “I can’t do this presentation because my classmates will think I’m dumb and laugh at me.” “I will get sick in school and throw up, and everyone will know.” “I will get in trouble if my work is not perfect.” Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Feeling Anxious children and teens become more “pumped up” or aroused than situation warrants. Immediate or short-term anxiety is named the flight-fight response. It’s the body’s way of protecting you from danger. The stress response is a longer duration body reaction to threat and change. In anxiety disorders, these responses are activated too easily and excessively or in situations that don’t require it. Example situations: oral presentation, test, separating from parent, substitute teacher, answering question in class.
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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7/6/2011
BEHAVIOURS
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Doing- Anxious Behaviours Pace, fidget, cry, cling, shake Avoid Refusing to go to school or class Refusing to go somewhere alone Complain of headache or stomach ache in stressful situations g Reassurance seeking. “Am I going to die?” “Are you sure ________ won’t happen?” Repetitive behaviours to prevent event Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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Anxiety in the Classroom Irritability/ tiredness Ab t i Absenteeism Frequent somatic complaints Decline in grades Withdrawal from peer group Use of alcohol/drugs Poor coping with everyday stress Calling home frequently/reassurance seeking Angry outbursts/ suicidal ideation Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Core Components of CBT Exposure ** Realistic Thinking/Cognitive Restructuring Skills Training (e.g., relaxation, problem solving, social skills, assertiveness, stress management)
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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7/6/2011
Cognitive Behavioural Therapy 101 Cognitive Strategies:
Psychoeducation: physical basis of anxiety symptoms and misinterpretation of situations Problem-Solving: recognizing symptoms and how to cope when feeling anxious and “stuck” Realistic Thinking: “I am going to fail”challenge the thought, thought collect evidence
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Thinking Errors Anxious children overestimate how likely it is that an unpleasant event will happen. They overestimate how bad the consequences will be if the event does happen. y underestimate their ability y to cope p with the They anxiety and the unpleasant event
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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Cognitive Behavioural Therapy 101 Behavioural Strategies Coping skillsskills staying on task task, deep breathing, breathing muscle relaxation, problem solving Exposure to anxiety provoking situations and Response Prevention Encourage and reward all positive steps in fighting anxiety Modeling and parent education
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Avoidance Behaviour- Anxiety Curve Anxiety Exposure Curve 100 90
Wo orry Scale
80 70
Exposure Avoidance Anxietyy
60 50 40 30 20 10 0 Time 0
Time 1
Time 2
Time 3
Time 4
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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7/6/2011
Cognitive Behavioural Therapy 101 Identify what is an anxious behaviour, thought or them physical feeling feeling. Label it for them. “Do you think your stomach ache is really because you are anxious about the test” “Your heart is racing because of worry.” Once a behaviour is identified, help the child think of ways to cope on their own: Take a deep breath. Coping self talk (e.g., “Its just my worry, I am not going to forget everything. I can do this.”) Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Anxiety Behaviour Management 101 Acting as a team- parents and school Remove attention from anxious behaviours Decrease reassurance seeking, increase positive coping Identify when ignoring the behaviour “I have already answered that question, go to the next one” Praise the positive behaviour behaviour, as soon as it occurs occurs. “Nice job continuing on with your work” **comments given to individual- not whole class
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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7/6/2011
Prevent Avoidance By avoiding feared situations, or seeking reassurance, children learn they are not able to cope with the situation or their worry Model being brave and problem solving Encourage them to take little steps toward accomplishing the feared task Take the bus to school 2 days a week. Oral with O l presentation t ti alone l ith teacher t h Go to first class
Safe place to go in school when anxious Reward effort! Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Consultation Example 10 year old girl not attending school for past 4 weeks. Stomachaches every morning and thinks she is going to be sick. Mom informs school she is not able to force her to go.
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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7/6/2011
Cognitive Behavioural Strategies Graded Exposures: n+1 rule (what is step up from current situation?)
Desensitization: visit school after school hours, arrive early when school is quieter
Flooding: force full time return (usually only works for absences of 2-3 weeks or less)
Remove incentives: for staying home Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
Anxiety Treatment at IWK TAG (Treatment for Anxiety Group): Across all IWK Outpatient Mental Health Clinics Psycho education session for parents CBT Group Treatment- manualized Groups: Parenting Your Anxious Child (< 7-8 y) Cool Kids (7-12 y) Chilled (13-18 y) ACCESS: IWK Central Referral 464-4110 Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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7/6/2011
QUESTIONS
Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health
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