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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 for 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

Anxiety Can Be Adaptive Some anxiety is advantageous Helps in novel situations Anxiety can heighten one’s awareness, prepare a defense d f to t a threatening th t i 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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7/6/2011

Normal Fears 190 children in Netherlands- 4-12 years 75% fearful of one stimulus (Muris et al, 2000)

Developmental Stages: Infancy- loud noises Infancy 9-18 months- stranger and separation 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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7/6/2011

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

Anxiety and the Brain

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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7/6/2011

Sympathetic Nervous System Physiologic Arousal Signal danger Enhance alertness Prepare body for action Fight/flight response

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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

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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 p g Symptoms

 Lasts days - weeks

Emotional C Cognitive ii Physical Behavioral Disturbances & Functional Impairment

DAYS

 What to do? Resume usual activities Mobilize emotional supports

WEEKS

MONTHS

Trauma

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

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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 G li d Anxiety A i t Disorder: Di d uncontrollable t ll bl 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

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 i t i repetitive intrusive titi th thoughts ht (obsessions) ( b i ) or behaviours b h i (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 plus CBT Medications RCT: Anxiety disorders including OCD: sertraline 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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Frewen et al 2008

Harmer et al, 2006

Three Components of Anxiety

Feeling

Doing

Thinking

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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7/6/2011

THOUGHTS

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 p is a longer g duration body y reaction to threat and change. g response 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 C Complain l i off headache h d h or stomach t h ache h in i stressful situations 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

Anxiety in the Classroom Irritability/ tiredness 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

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7/6/2011

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

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, 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 ill be b if the th eventt does d happen. h They underestimate their ability to cope with the anxiety and the unpleasant event

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 Behavioural Strategies Coping skills- staying on task, deep breathing, muscle relaxation, problem solving Exposure p to anxiety y pprovoking g situations and Response p 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

W orry Scalee

80 70

Exposure Avoidance Anxiety

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

Cognitive Behavioural Therapy 101 Identify what is an anxious behaviour, thought or physical 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

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7/6/2011

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, as soon as it 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

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 E Encourage them th to t take t k little littl steps t toward t d accomplishing the feared task Take the bus to school 2 days a week. Oral presentation alone with teacher 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

QUESTIONS

Academy in School Mental Health Presented by: Sun Life Financial Chair in Adolescent Mental Health

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Dr alexa bagnell 3 slides