Microsoft word - anxiety in children - master.doc

Kinder- en Gesinseenheid
Child & Family Unit
B.A. (Hons.), M.A. (Voorligting / Counselling), H.O.D. / H.D.E Voorligtingsielkundige  Counsel ing Psychologist ANXIETY IN CHILDREN
functioning of the child in usual activities, a child is that their parent will be involved in an accident or taken diagnosed as having an "anxiety disorder." ill, or in some other way be“lost” to the child forever. The nature of anxiety
The combined prevalence of the group of disorders Their need to stay close to their parent or home may make it difficult for them to attend school or camp, stay Anxiety is one of many normal human emotions that
known as anxiety disorders is higher than that of virtually at friends’ houses, or be in a room by themselves. Fear can fulfil an very helpful and motivating role. It urges the all other mental disorders of childhood and adolescence. of separation can lead to dizziness, nausea, or individual to strive for the best possible effort and Causes of anxiety
motivates him to produce at his best. When, however, anxiety becomes excessive, it can inhibit the effective Separation anxiety is often associated with symptoms of depression, such as sadness, withdrawal, apathy, or difficulty in concentrating, and such children often fear Although anxiety disorders affect an estimated 13 that they or a family member might die. Young children percent of children and adolescents during any given experience nightmares or fears at bedtime. six-month period, making them the most common class of psychiatric disorders in that age group, the disorders About 4 percent of children and young adolescents are often not recognized, and most who have them do Separation anxiety
suffer from separation anxiety disorder. Among those who seek treatment, separation anxiety disorder is Although separation anxieties are normal among equally distributed between boys and girls. infants and toddlers, they are not appropriate for older Common signs of anxiety disorders in children are children or adolescents. To reach the diagnostic The remission rate with separation anxiety disorder is excessive worrying about ordinary activities. At times,
threshold for this disorder, the anxiety or fear must
high. However, there are periods where the illness is there are physical symptoms such as palpitations,
cause distress or affect social, academic, or job
more severe and other times when it remits. sweating, trembling, stomach ache, or headache. There functioning and must last at least 1 month
Sometimes the condition lasts many years or is a may be avoidance of certain situations that are
precursor to panic disorder with agoraphobia. Older perceived by the child to be sources of anxiety. This Children with separation anxiety may cling to their
individuals with separation anxiety disorder may have avoidance can cause social withdrawal. When these
parent and have difficulty falling asleep by
difficulty moving or getting married and may, in turn, symptoms cause extreme distress and interfere with the themselves at night. When separated, they may fear
worry about separation from their own children and Promed Park, Hibiscusstraat 1A Hibiscus Street,  1792, DURBANVILLE 7551  (021) 975-2230  975-2231  975-2237 Family changes such as birth of a sibling, The child, depending on age, can benefit from play Normal Development of Separation
therapy of cognitive-behavioural therapy (Therapy that Change in caregiver or routine at day care is focused of changing the child’s beliefs and Most common times for separation fears: eight months, associated behaviours in such a way that he can better twelve months and anywhere between 18 months to cope with the anxiety). Relaxation techniques and Parents usually are not the cause of the separation
hypnotherapy is also effective with some children. anxiety, but they can make things worse or better.
Separation anxiety generally emerges around nine months of age and peaks around 12-24 months. The Warning signals
child's crying and clinging can express two different Medication is needed for a minority of children who messages: they fear that the parent will be gone Child is inconsolable for more than 2 weeks. have persistent symptoms, resistant to behavior forever or they begin to cry when the parent returns. Repeated physical complaints in the morning This reminds the child of how he or she felt when the Separation anxiety continuing into elementary Psychiatrists or other physicians can prescribe school years and interfering with activities that medications for anxiety disorders. These doctors often Separation anxiety generally decreases between 2 and other children do at that particular age. work closely with psychologists, social workers, or 3 years of age. The child often tends to be shy with strangers, but morning separations become easier. The School refusal in an older child or adolescent is degree of separation difficulty may vary from day to Although medications won't cure an anxiety disorder, they can keep the symptoms under control and enable Diagnosis and Symptoms of a Separation Anxiety
For toddlers, those who have had either very few or Disorder
very frequent separations from loved ones experience There have been significant strides in knowledge of Severe, persistent anxiety about being separated
from home or parents. The anxiety must be severe Adults too experience anxiety when separated from enough to interfere with normal activities. The child
Trycyclic Anti-depressants:
loved ones, but it is usually not so overwhelming. The generally shows distress when separated from
Antidepressant medications called tricyclics are started adult has a better concept of time and has had more parents, and worries that the parents may suffer harm
at low doses and gradually increased. Tricyclics have experience dealing successfully with separation. when away from the child. When separated, the child been around longer than SSRIs and have been more may have nightmares and sleep problems. Physical
widely studied for treating anxiety disorders. For Factors that may contribute to separation anxiety
symptoms such as nausea, headaches and abdominal
anxiety disorders other than OCD, they are as effective pain may occur before or during a separation. as the SSRIs, but many physicians and patients prefer the newer drugs because the tricyclics som etimes Treatment – A wholistic approach
cause dizziness, drowsiness, dry mouth, and weight After a stress such as death or illness in the Imipramine (Tofranil) can help separation anxiety Trauma, especially physical or sexual assault; disorder. However, one needs to follow EKGs (heart Parents, child and family may benefit from therapy. tests) and blood tests for safety reasons. Sometimes, Parent education and family therapy are often high doses were necessary for improvem ent. beneficial. Coordination is a key factor. SSRI: (Selective Serotonin Reuptake Inhibitors): In the
Symptoms and Features of OCD
past 10-15 years, a new class of antidepressant diazepines relieve symptoms quickly and have few side effects, although drowsiness can be a problem. In order to meet DSM-4 criteria for OCD, the individual depression and anxiety disorders safer and more Because people can develop a tolerance to them - and must have either obsessions or compulsions. In would have to continue increasing the dosage to get actuality, most children and adolescents have both. the sam e effect - benzodiazepines are generally The SSRIs, Prozac, Zoloft, Paxil etc., when used prescribed for short periods of time. One exception is Obsessions: Recurrent and persistent thoughts,
carefully and monitored closely, can help separation panic disorder, for which they may be used for 6 impulses or images that are experienced, at some time anxiety disorder. At this point, an SSRI would be the months to a year. People who have had problems with during the disturbance, as intrusive and inappropriate medication of choice instead of Imipramine. drug or alcohol abuse are not usually good candidates and that cause marked anxiety or distress. The for these medications because they may become thoughts, impulses, or images are not simply excessive worries about real-life problems. The person attempts If your doctor prescribes an antidepressant, you will to ignore or suppress such thoughts, impulses, or need to take it for several weeks before symptoms start Some people experience withdrawal symptoms when images, or to neutralize them with some other thought to fade. So it is important not to get discouraged and they stop taking benzodiazepines, although reducing or action. The person recognizes that the obsessional stop taking these medications before they've had a the dosage gradu-ally can diminish those symptoms. thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought Buspirone, a member of a class of drugs called
These medications act in the brain on a chemical azipirones, is a newer anti-anxiety medication that is messenger called serotonin. SSRIs tend to have fewer used to treat GAD. Possible side effects include side effects than older antidepressants. People do Compulsions: Repetitive behaviors (e.g. hand
dizziness, headaches, and nausea. Unlike the sometimes report feeling slightly nauseated or jittery washing, ordering, checking) or mental acts (e.g. benzodiazepines, buspirone must be taken consistently when they first start taking SSRIs, but that usually praying, counting, repeating words silently) that the for at least two weeks to achieve an anti-anxiety effect. disappears with time. Some people also experience person feels driven to perform in response to an sexual dysfunction when taking some of these Other
obsession, or according to rules that must be applied medications. An adjustment in dosage or a switch to propanolol, are often used to treat heart conditions but rigidly. The behaviors or mental acts are aimed at another SSRI will usually correct bothersom e problems. have also been found to be helpful in certain anxiety preventing or reducing distress or preventing some disorders, particularly in social phobia. dreaded event or situation; however, these behaviors Monoamine oxidase inhibitors, or MAOIs, are the oldest or mental acts either are not connected in a realistic class of antidepressant medications. The most Obsessive-compulsive disorder
way with what they are designed to neutralize or commonly prescribed MAOI is phenelzine, which is helpful for people with panic disorder and social phobia. Introduction
Tranylcypromine and isoprocarboxazid are also used to The obsessions or compulsions cause marked distress, treat anxiety disorders. People who take MAOIs are put Community surveys of adolescents have suggested are time consuming (take more than 1 hour per day), or on a restrictive diet because these medications can that at any given time, 1% to over 3% are experiencing significantly interfere with the person's normal routine, interact with some foods and beverages, including symptoms of OCD. Children as young as 5 or 6 can occupational (or academic) functioning, or usual social cheese and red wine, which contain a chemical called show full-blown OCD. Between 30% and 50 % of adults tyramine. MAOIs also interact with some other with OCD reported that their symptoms started during medications, including SSRIs. Interactions between or before mid-adolescence. Fortunately, there are now Consequences of OCD
MAOIs and other substances can cause dangerous elevations in blood pressure or other potentially life- If not treated, OCD tends to be a long-term disorder. Some individuals experience waxing and waning progressive worsening of their OCD until they are anxious feelings, clarifying cognitions in anxiety- prevention. It may have to be done gradually because it housebound and spend much of their days involved in provoking situations,12 developing a plan for coping, can cause the child to experience significant anxiety. obsessions and rituals. Chronic anxiety disorders may and evaluating the success of coping strategies. A The child himself should have an important role in lead to depression. If a child spends a great deal of more recent study in Australia added a parent determining how quickly he wants to move through time obsessing or engaging in mental rituals, he or she component to CBT, which enhanced reduction in post- these steps. The parents can help with this too by may have trouble focusing on the school lessons. treatment anxiety disorder significantly compared with reducing and then eliminating reassurances when a Individuals who need to repeatedly erase and rewrite CBT alone (Barrett et al., 1996). However, none of the child asks obsessive questions. At the same time, they assignments may need to spend hours of time of interventions identified above as well-established or should be supportive and avoid blaming the child if he homework and lose time for friends and family. This probably efficacious has, for the most part, been tested is unable to avoid performing some of the compulsions. same individual may not be able to finish projects because the work is never "just right." Some children The child may benefit from learning relaxation and teens may becom e oppositional if others attempt to In addition, psychodynamic treatment to address techniques and learning mental self-monitoring. interrupt their rituals. For the large number of underlying fears and worries can be helpful, and individuals who m anage to hide their symptoms, the behavior therapy may reduce the child’s fear of Other specific techniques may help individual children cost may simply be years of anxiety and low self- separation or of going to school; however, the tolerate the anxiety engendered by the exposure and experimental support for these approaches is limited. Treatment
Preliminary research suggests that selective serotonin When the symptoms are eliminated or at least reduced reuptake inhibitors may provide effective treatment of to a tolerable level, the therapist should talk to the child separation anxiety disorder and other anxiety disorders and parents about the future. Symptoms may start to Although anxiety disorders are the most common of childhood and adolescence. Two large-scale come back at a later date. They should review the disorder of youth, there is relatively little research on randomized controlled trials are currently being symptoms and discuss how to deal with them. Some the efficacy of psychotherapy (Kendall et al., 1997). For undertaken (Greenhill, 1998a, 1998b). Neither tricyclic individuals come in for intermittent refresher sessions. childhood phobias, contingency management10 was the antidepressants nor benzodiazepines have been only intervention deem ed to be well-established, shown to be more effective than placebo in children Medication
according to an evaluation by Ollendick and King (Klein et al., 1992; Bernstein et al., 1998). (1998), which applied the American Psychological Recent advances in medication have added to our Association Task Force criteria (noted earlier). Several treatment options. In the past few years there have psychotherapies are probably efficacious for treating Moderate to severe OCD may merit starting with a phobias: systematic desensitization11 ; modeling, based combined approach of psychotherapy and medication. on research by Bandura and colleagues, which capitalizes on an observational learning technique Cognitive-Behavioral Psychotherapy
Clomipramine, (Anafranil) ages 10 and up (Bandura, 1971; see also Chapter 2); and several cognitive-behavioral therapy (CBT) approaches Near the beginning of this type of therapy, the child and family are educated about the biological basis of OCD. The symptoms are the fault of the disease, not the Fluoxetine, (Prozac) approved for adults, but may soon Paroxetine (brand nam e Paxil) approved for adults. CBT, as pioneered by Kendall and colleagues (Kendall As the therapy progresses, the child should begin to et al., 1992; Kendall, 1994), is deemed by the Am erican expose himself to the anxiety-provoking object or The main medications used for OCD are Clomipramine Psychological Association Task Force as probably situation and then try to avoid performing the usual (brand name Anafranil) and the Selective Serotonin efficacious. It has four major components: recognizing compulsion. This is called exposure and response medications that may be added if those medications important for them to continue the education process. A Generalised Anxiety disorder
good understanding of the disorder can help the child and family feel a greater sense of mastery and control. Children with generalized anxiety disorder (or Clomipramine is chemically similar to the older tricyclic overanxious disorder of childhood) worry excessively antidepressants. Its efficacy in OCD seems to be The process of education should extend on after the related to its ability to decrease serotonin reuptake. It end of the therapy. It can occur through reading age- occurrences. They worry unduly about their academic used to be the only effective drug for OCD. At this appropriate books, attending support groups or having performance or sporting activities, about being on point, it is usually not the first line drug for children with group therapy with peers. I have listed some time, or even about natural disasters such as OCD. This is because of several potential side effects. recommended books and support groups at the end of earthquakes. The worry persists even when the child It can be sedating. It can also cause dry mouth and the article. Secrecy and shame are common in is not being judged and has always performed well in eyes. It has been associated with som e changes in individuals with OCD. Education and the support of the past. Because of their anxiety, children may be EKGs. (A measure of the heart rate and the electrical others can help the individual keep the disorder in overly conforming, perfectionist, or unsure of conduction within the heart.) Because children may be themselves. They tend to redo tasks if there are any more sensitive to this cardiac effect, we usually monitor imperfections. They tend to seek approval and need EKGs and heart rate in children on Clomipramine. Children and families should be aware that OCD can constant reassurance about their performance and Despite this, when used carefully, it has helped many be chronic and that symptoms may return months or their anxieties (DSM-IV). The 1-year prevalence rat e years later. Some children will schedule "check up" for all generalized anxiety disorder sufferers of all sessions every six months or each year. If symptoms ages is approximately 3 percent. The lifetime There are now several SSRI medications. They include reoccur, they may return to therapy for a shortened prevalence rate is about 5 percent (DSM-IV). Fluoxetine (brand name Prozac) Fluvoxamine (brand name Luvox) Paroxetine (brand name Paxil) and About half of all adults seeking treatment for this Sertraline (brand name Zoloft). All seem to be effective disorder report that it began in childhood or Associated disorders
at reducing the symptoms of OCD, but different ones adolescence, but the proportion of children with this may be best for individual patients. Fluoxetine has the disorder who retain the problem into adulthood is advantage of being available in liquid form. Using the Tourette's Disorder is more likely to be present in unknown. The remission rate is not thought to be as liquid, one can start at very small doses and titrate the boys and in children who develop OCD at a younger high as that of separation anxiety disorder. age. It is important to identify this disorder because Social Phobia
headache, GI complaints, tremor, agitation, drowsiness treatment may need to be modified. Children and and insomnia. These medications may affect how other adolescents with OCD are more likely to have Children with social phobia (also called social anxiety drugs are broken down in the liver. One must use caution when mixing medications. If a child taking an oppositional behavior, separation anxiety disorder SSRI, it is a good idea to consult one’s physician or and other anxiety disorders. Some of the anxiety performance, or if they have to speak in class or in pharmacist before taking other prescription or even disorders have similarities to OCD and are called public, get into conversation with others, or eat, drink, non-prescription medications. Many children take a obsessive-compulsive spectrum disorders. These or write in public. Feelings of anxiety in these long time to achieve a good response to medication. 10 include tricotillomania, (compulsive hair pulling and situations produce physical reactions: palpitations, to 12 weeks is not uncommon. Som e children will twirling, ) body dysmorphic disorder (the obsession respond to one medication but not to another. that part of one's body is unattractive or misshapen) tension, etc. Sometimes a full-blown panic attack and habit disorders such as nail biting and scab ensues; som etimes the reaction is much more mild. Dealing with Recurrences
picking. The exact relationship between these two Adolescents and adults are able to recognize that spectrum disorders and true OCD is not yet entirely their fear is unreasonable or excessive, although this Education about OCD often an early part of the recognition does not prevent the fear. Children, therapy. Both parents and child are included. It is however, might not recognize that their reaction is Kindergarten or First grade for the first few excessive, although they may be afraid that others will notice their anxiety and consider them odd or When leaving, give a quick kiss and hug and Positive experiences with caregivers, short Don't prolong your departure or come back Young children do not articulate their fears, but may cry, have tantrums, freeze, cling, appear extrem ely timid in strange social settings, shrink from contact surroundings and people before actually leaving Even if you feel that a strict teacher or a bully with others, stay on the side during social events, and might be part of the problem, keep your child try to stay close to familiar adults. They may fall going to school while these problems are being behind in school, avoid school completely, or avoid "Lovie" or "Cuddly" Represents closeness to social activities am ong children their age. The parents. If possible, allow the child to take the If your child does stay home, do not make it an avoidance of the fearful situations or worry preceding the feared event may last for weeks and interferes Do not give in. Let the child know that he or she with the individual’s daily routine, social life, job, or school. They may find it impossible to speak in social Remind the child of previous brave things he or situations or in the presence of unfamiliar people (for she has done. Talk about how a fictional review of social phobia, see DSM-IV; Black et al., Start occasionally using a babysitter by six m onths understand that you appreciate how distressing of age. This helps the child tolerate short periods Social phobia is common, the lifetime prevalence it must be to be separated from loved ones. away from the parent and encourages him or her to ranging from 3 to 13 percent, depending on how great the fear is and on how many different situations Even though children of this age do not engage in induce the anxiety (DSM-IV; Black et al., 1997). In Never make fun of a child's separation distress. cooperative play, start contact with peers by 12 survey studies, the majority of those with the disorder months. By age three, the child should be were found to be female (DSM-IV). Often the illness Do not bribe child to m ask the distress. If you is lifelong, although it may becom e less severe or plan a special activity after you pick the child up, Some form of preschool may be helpful by age 3 or completely remit. Life events may reassure the 4. This is especially important for children who individual or exacerbate the anxiety and disorder. Focus on the positive things that happened in A model for supporting children with anxiety
daycare. Don't let them dwell on fears or Affirming the child’s capacity to take charge of the Taking stock of our own model of thinking and actions Minimize fears by limiting scary TV shows If it is an older child, consider introducing him or her to some of the children who are to be in the class and arranging play dates in advance. Suggested Books
Preparing the child--reading books about going The Good-bye Book by Judith Viorst Willingness to bear and manage discomfort Into the Great Forest: A story for children away from their Make shopping for school supplies a special parents for the first time by Irene Marcus problem-focussed approach whilst retaining Expect a child to be more tired and possibly more irritable than usual when he or she starts Brain Lock: Free Yourself from Obsessive-Compulsive Behavior by Jeffrey M. Schwartz 1996, Regan Books. Blink, Blink, Clop, Clop: Why Do We Do Things We Can't Stop? by Moritz and Jablonsky, ChildsWork, ChildsPlay OCD in Children and Adolescents: A Cognitive-Behavioral Manual by John March and Karen Mulle1998, The Guilford


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