Pediatric Anxiety Disorders - St. Johns County School District

Pediatric Anxiety Disorders - St. Johns County School District

sorders and symptoms in student Easy to implement strategies for parents and caregivers Marlena Jenkins, M.S., BCaBA St. Johns County Public Schools, January 8, 2019 University of FloridaJacksonville FDLRS-MDC UF HEALTH DEVELOPMENTAL PEDIATRIC CENTER Grant-Funded Center for Autism and Related Disabilities (CARD) Dr. Childers Jeannie Potthast Elise Summa Various Providers Works with children and adults with an autism spectrum disorder, dual

sensory impairment or sensory impairment combined with another disabling condition. Parent and teacher consultation and training. Serving families in Duval, Clay, St. Johns, Nassau, Baker and Flagler counties. Florida Diagnostic Learning and Resource System Multidisciplinary Center (FDLRS) Marlena Jenkins Various Providers Psychoeducational, psychological, speech

and/or language, and neurodevelopmental evaluations for children 3 to 22 years, providing they are still in high school, who are struggling in school due to complicated medical, behavioral, developmental and/or social histories. Serving families in Duval, Clay, St. johns, Nassau, Baker and Flagler counties Pay Insurance-Based Developmental Pediatrics Dr. Childers Dr. Dial Neurodevelopmental pediatrician

This division brings together various specialists to work with children at risk for learning, behavioral or developmental delays. They serve children with a variety of disorders, ranging from developmental delays that may be overcome with early care and treatment to lifelong conditions that may be alleviated with ongoing support and Neurology Dr. Tardo

Child Neurology Our child neurology services include Cerebral Palsy; Neurodegenerativ e conditions; Neuromuscular conditions; Hypotonia; Premature followup; Autistic Disorders; Developmental Delays; Headaches and Movement Disorders Self- Pediatric Assessment and Intervention

Program (PAIP) Marlena Jenkins Various Providers Educational Assessment Educational / Behavioral Consultations Food Over-Selectivity Clinic Intensive Academic Intervention Targeted Parent Training Adaptive / Behavior Clinic Study and Organizational Strategies TRAINING AGENDA Defining anxiety

Types of anxiety and related disorders Anxiety related symptoms across childhood and adolescence Making referrals Strategies Questions When you see this image Think deeper about the concept WHAT IS ANXIETY? a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome. desire to do something, typically accompanied by unease. What does the uncertainty of outcomes have to do with anxiety related symptoms If there is a desire to do something why are behavioral manifestations of anxiety labeled

as noncompliance CYCLE OF ANXIETY ANXIETY DISORDERS -THE STATS #1 mental health disorder in America Only 1 in 5 teenagers receive treatment what are the barriers Todays pressures trigger anxiety further are the triggers within our control Must cause clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning to meet diagnosis. The symptoms cannot be better accounted for by another mental disorder or be caused by substances, medications, or medical illness. First Day of Kindergarten

SEPARATION ANXIETY DISORDER -CLINICAL DESCRIPTION Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached. Symptoms last at least 4 weeks in children and adolescents. -symptoms Recurrent excessive distress when separation from home or major attachment figures occurs (or is anticipated) Persistent and excessive worry that something traumatic will lead to separation from a major attachment figure (e.g., being kidnapped) Persistent reluctance or refusal to go to school or other places because of fear of separation Persistent or excessive fear or reluctance to be alone or without major attachment figures at home or in other settings

Persistent reluctance or refusal to go to sleep without being near a near a major attachment figure (or to sleep away from home) Repeated complaints of physical symptoms (e.g. headaches, stomachaches, vomiting) when separated from major attachment figures (or separation is anticipated) GENERALIZED ANXIETY DISORDER -CLINICAL DESCRIPTION Excessive anxiety and worry about a variety of events or activities, even when nothing is wrong or when the worry is disproportionate to actual risk. The worry is difficult to control. Symptoms last at least 6 months. -symptoms The worry is associated with at least three (in adults) or one (in children) of the following physical or cognitive symptoms: Restlessness

Fatigue Impaired concentration or feeling that mind is going blank Irritability Increased muscle aches or soreness Difficulty sleeping (trouble falling asleep or staying asleep) Sometimes associated with other physical symptoms such as nausea or diarrhea. SPECIFIC PHOBIAS -CLINICAL DESCRIPTION Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation. The phobic object/situation is actively avoided or endured with intense fear or distress. Will almost always provoke an immediate anxiety response Fear is recognized as being excessive or unreasonable.

Symptoms last at least 6 months. SPECIFIC PHOBIAS -GENDER DIFFERENCES Boys Fears Free Option Girls Fears Free Option Predators Being kidnapped Being hit by a car Parents dying Snakes The dark Burglar

Frightening movies Frightening movies Thunderstorms The dark Being teased Being teased Bats Frightening dreams Bats/ghosts/spooky things Medical operations Sleeping in the dark/Making a

Spiders Spiders mistake Source: Muris, P., Merckelbach, H., & Collaris, R. (1997). Common childhood fears and their origins. Behavior Research and Therapy, 35(10), 929-937 OBSESSIVE-COMPULSIVE DISORDER Characterized by obsessive, intrusive thoughts (e.g. constantly worrying about staying clean, or about one's body size) that trigger related, compulsive behaviors (e.g. repeated hand-washing, or excessive exercise). These behaviors are performed to alleviate the anxiety associated with the obsessive thoughts.

Obsessions/compulsions interfere with social or work interactions. The symptoms are not triggered by a) the physiological effects of a substance (i.e. drugs or alcohol) or b) another medical condition (e.g., excoriation or hoarding). OBSESSIONS AND COMPULSIONS Obsessions: Recurrent & persistent thoughts/urges/images that are experienced as intrusive & unwanted Individual attempts to ignore or suppress thoughts/urges/images, or tries to neutralize them with some other thought or action (i.e., performing a compulsion) Compulsions: Repetitive behaviors (e.g., hand washing, ordering, checking) or

mental acts (e.g., counting, repeating words silently) that individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. Behaviors or mental acts are aimed at preventing/reducing anxiety/distress, or preventing some dreaded event/situation. Obsessions or compulsions are time-consuming (e.g., take >1 hour/day) or cause distress/impairment in functioning PANIC DISORDER Recurrent expected or unexpected panic attacks AND one or more of the following symptoms for at least one month: Pounding heart Sweatiness Feeling of weakness Faintness Dizziness Tingling or numbness in hands Feeling flushed Sense of unreality

Feeling of loss of control or losing one's mind Fear of dying or something physically wrong (e.g., heart attack, stroke) At least 1 of the attacks has been followed by 1 month (or more) of one or both of the following: Persistent concern or worry about future/additional panic attacks or their consequences A significant change in behavior related to the attacks (e.g., behaviors designed to avoid panic attacks) SOCIAL ANXIETY DISORDER -CLINICAL DEFINITION Marked fear or anxiety about 1 or more social situations in which the individual is exposed to possible scrutiny (embarrassment or criticism) by others. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated.

The social situations almost always provoke fear or anxiety. Symptoms last at least 6 months in children and adolescents. Generalized fear is present across any social situations Specific eating in public, public speaking, talking with certain roles SOCIAL ANXIETY DISORDER -SYMPTOMS Significant and persistent fear of one (or more) social or performance situations in which the individual is exposed to unfamiliar people, or to possible scrutiny by others due to fear of humiliation or embarrassment. Note: In children, the anxiety must be present in peer situations and not only in interactions with adults. Exposure to the feared social or performance situation provokes significant anxiety.

The person recognizes that the fear is excessive or unreasonable. why does development matter The feared social or performance situations are avoided or else are endured with intense anxiety or distress SELECTIVE MUTISM -CLINICAL DEFINITION Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation. The duration is at least 1 month. Symptoms cannot be better accounted for by another mental disorder or be caused by substances, medications, or medical illness.

ANXIETY ACROSS THE AGES -CHILDHOOD- ANXIETY ACROSS THE AGES -CHILDHOOD & ADOLESCENCE- IS IT TIME TO BE CONCERNED? Worry that lasts for months Worry that causes physical distress Refuses to go to school or participate in activities Trouble concentrating in class Seems unusually gloomy/pessimistic Asks for a lot of reassurances Becomes upset if reassurances are considered inadequate Seems irritable & angry Sleep deprivation Is excessively self-critical Suicidal ideation Self-harm

Fears are significantly interfering with your family, educational, work, daily life RESTRUCTURING THOUGHTS Anxious Thought Evidence that thought is TRUE Evidence that thought is FALSE New Thought The storm might cause lightning to strike our school and hurt me.

Lightning can strike buildings. Chances are lightning wont strike our school. Even if lightning strikes the building, I will remain safe. Lightning can strike people who are not under shelter. The school is built to handle storms and keep people safe. If lightning strikes the school, the roof will protect

me. IF the roof catches on fire, I will evacuate *I have an emergency plan. * I will follow the emergency plan. QUESTIONS TO ASK -FALSE THOUGHTS Do I know for sure that ______ will happen? What evidence do I have that _______ will happen? How likely is it really? Has _______ ever happened before? Even if _______ happens, can I live through it? What is the worst possible outcome? (Rate how bad it is) Could I cope? Do I have the coping mechanisms or do I need help? Do I know anyone else who has been in this situation? What

did they do? Have I been able to cope with ______ in the past? SONOW WHAT DO WE DO? Define the behavioral manifestation and Collect data Step 1 if the effects of anxiety related symptoms are impacting the students learning and school based relationships Observable and Measureable Peer Modeling (select a peer that is similar to the target child/teen) Arrange for frequent learning opportunities and taper off over time Use pivoting technique in the natural environment Maintain open lines of communication

Develop a plan and stick to the script Practice, practice, practice Never use the child/teens fear during times of discipline TARGETING PHYSICAL FEELINGS Slow breathing Deep abdominal breathing Body scan Imagery breathing Quick 5-4-3-2-1 Grounding Activity 4-7-8 BREATHING BRAVERY LADDER Hardest behavior at top, easiest behavior at bottom

Take (emotional, physiological) temperature along way Earn Bravery Dollars Use labeled praise IN SCHOOL -SOCIAL SITUATIONS1. [Hardest] I went to the lunchroom and sat at a table with some kids I know and joined a conversation. 2. I went to the lunchroom and sat at a table with some kids I know. 3. I started a conversation with somebody in my class.

4. I said hi to a kid in my class who I usually dont talk to, even though he didnt say hi first. 5. I tried to speak up more loudly when I answered a question in class. 6. I answered a question in class when the teacher called on me. It was a question that she did not prepare me for answering ahead of time. 7. I answered a question in class when the teacher called on me. It was a question she prepared me for answering ahead of time.

8. I remembered to face somebody I was talking to and not turn GOING TO SCHOOL 1. [Hardest] I left for school on time, had no reminders, and I entered the school building all by myself with no fussing. I changed my worry thoughts and noticed that I can still go to school even when I am anxious about it. 2. I did number 3 on ladder and got to school on time. 3. I did number 4, but this time I walked into school by myself, not with my parents. 4.

I accomplished all of the things on my morning routine with 1 or no reminders and got into the car without any fussing or fighting. 5. I was able to change my worry thoughts when I felt anxious this morning and then did 2 of the things on my morning routine with only 1 reminder. 6. I woke up on time and also did 1 of the things on my morning routine with only 1 reminder from my parents. 7. [Easiest] I woke up on time this morning. COPING CARDS Palm-sized, colorful cards that have pre-printed positive "self-statements" that have been designed specifically for

children. Children can read the statements on the cards anytime, and can store them easily in a backpack or pocket for quick, easy reminders of their ability to cope with whatever comes their way. Coping Cards include several blank cards in addition to the pre-printed cards for your child to personally tailor specific cards to his or her fears or concerns. Appropriate for children between the ages of approximately 5-14 years, Coping Cards are a great tool for boosting youngsters' confidence in their ability to cope with stress and anxiety. Donna Pincus, Ph.D., The Child Anxiety Network, 2001 TALKING MAP BEHAVIORAL APPROACH -WHAT IS THE FUNCTION Any technique or process that is meant to alter a dimension or the

effects of behavior. Examples of behavioral strategies are planned ignoring, redirection, reinforcement, and punishment, etc. Function based Escape/Avoidance: to get away from or eliminate contact with something, some place, or someone Access: to gain initial or more access to something, some place, or someone Automatic: internally driven desire to fulfill a need (measured by the student himself)

Attention Maintained: meant to gain initial or continued access to attention from something in the environment Power/Control: desire to have things my way or to overpower something in the environment CHANGING BEHAVIOR Reinforcement Punishment Positive and Negative Positive and Negative Increases the likelihood Decreases the likelihood

that the behavior will occur again that the behavior will occur again BEHAVIORAL APPROACH Although you have a functionally equivalent replacement behavior you may have missed the anxiety provoking trigger. SHAPE up the target behavior Reinforcement small steps moving toward the larger goal/ behavior POST - CRISIS Reflective journaling Written, drawing or audio recording Buddy check time (using peer model)

Self evaluation (rating scale) How well did I use the rehearsed coping skills? Was I more or less independent than the last time? Gratitude journal Puts negative thoughts in perspective A nap Some panic attacks can be so physically and mentally exhausting that a little rest is needed Monitor for escape or avoidance based behaviors DO Its okay to allow your student to experience anxiety-provoking situations DONT Bend over backwards to avoid anxiety-provoking

situations Minimize your students Validate your students feelings or tell them feelings how they should feel instead Overly reassure your Encourage your student student or try to to BE BRAVE! and/or remove your student to BEAT THE WORRY from the anxious MONSTER! situation IT TAKES A VILLAGE -BUT LETS START WITH YOU Select an accountability partner. Someone the child/teen is comfortable talking with in an open fashion.

Discuss strengths and weaknesses Assist with advocating on behalf of the child/teen Available to talk through ideas, trouble shoot and provide feedback on progress/regression Responsible for helping to redirect the child/teen back to the task at hand. Responsible for verbally and tangibly reinforcing the child/teen. Someone who is easily accessible. SEEKING PROFESSIONAL HELP Cognitive-Behavioral Therapy (CBT) Consult with your childs/adolescents PCP Society of Clinical Child and Adolescent Psychology (online presentations by psychologists) Anxiety and Depression Association

of America Child Anxiety Network REFERENCES & RECOMMENDED READING Pincus, D. B. (2012). Growing Up Brave: Expert Strategies for Helping Your Child Overcome Fear, Stress, and Anxiety. Little, Brown, and Company, New York, NY. Resources and exercises/toolkits for home and school: Anxiety BC: WayAhead: Mental Health Association NSW: Rethinking Thinking Trevor Maber (TED ED): Childrens Fears: Developmental or Disorder?: What Educators Should Know Sacha N. Matthews University of Pittsburgh, School of Educational, 2010 Gratitude Journal: various religious and non-religious themed journals

What are your final questions, deeper take away thoughts and things to continue working through in the days or months ahead? Feel free to contact our UF JAX FDLRS-MDC for continued conversation or to schedule consultative support! Marlena Jenkins, M.S., BCaBA [email protected] 904-633-4332

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