Anxiety and Selective Mutism in Youth Workshop Dr

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Anxiety and Selective Mutism in Youth Workshop Dr. Alissa Pencer Registered Psychologist A. Pencer

Anxiety and Selective Mutism in Youth Workshop Dr. Alissa Pencer Registered Psychologist A. Pencer October 2012

Outline Part I: Anxiety Disorders in Youth Part II: Selective Mutism l Part I:

Outline Part I: Anxiety Disorders in Youth Part II: Selective Mutism l Part I: Anxiety Disorders in Youth l When is anxiety a problem? l Prevalence and course l Common Anxiety Disorders l Causes l Cognitive Behaviour Therapy for Anxiety Disorders l l l Realistic Thinking Exposure Case Examples and Group Exercises A. Pencer October 2012 2

Fear, Anxiety, and Worry Everyone worries, everyone gets anxious and everyone is afraid of

Fear, Anxiety, and Worry Everyone worries, everyone gets anxious and everyone is afraid of something. l Very young children are often fearful of strangers, the dark, animals and insects. l Older children and adolescents are often fearful of peer rejection and are more selfconscious and strive to fit in with their peers. l Adults often worry about public speaking. l A. Pencer October 2012 3

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A. Pencer October 2012 4

When is Anxiety A Problem? Most children, adolescents and adults use anxiety to help

When is Anxiety A Problem? Most children, adolescents and adults use anxiety to help them make good decisions, e. g. , looking both ways before you cross the street, putting on your seatbelt, setting your alarm so you aren’t late, studying for tests, budgeting time to complete assignments. l Anxiety becomes a problem when it makes the decisions for you, interferes with your life and/or causes significant distress. l A. Pencer October 2012 5

Inverted U-Shaped Relationship Between Arousal and Performance Hebb, D. O. (1955). Psychological Review, 62,

Inverted U-Shaped Relationship Between Arousal and Performance Hebb, D. O. (1955). Psychological Review, 62, 243 -254 A. Pencer October 2012 6

Examples l l l Not being able to join extracurricular activities. Not being able

Examples l l l Not being able to join extracurricular activities. Not being able to speak in front of the class. Not handing an assignment in because “not perfect”. Not being able to go to school because overwhelming. Washing your hands 30 times a day. A. Pencer October 2012 7

How Common are Anxiety Disorders? l Anxiety disorders are the most common psychological problem

How Common are Anxiety Disorders? l Anxiety disorders are the most common psychological problem found in children and adolescents. l Approximately 1 in 10 youth meets the criteria for an anxiety disorder. l Despite this, often mental health centres see more children with aggressive difficulties, attentional problems, eating disorders, or suicidal tendencies. A. Pencer October 2012 8

6 Month Prevalence Rates of Mental or Addictive Disorders in Children 4 -17 §

6 Month Prevalence Rates of Mental or Addictive Disorders in Children 4 -17 § § § Anxiety Disorders ADHD Conduct Disorder Mood Disorders Substance Use Disorders Any Disorder 14 % 7 5 4 4 1 Waddell et al, Can J Psychiatry, 2002 A. Pencer October 2012 9

How Does Anxiety Effect Youth? l Anxious youth tend to have: l l Fewer

How Does Anxiety Effect Youth? l Anxious youth tend to have: l l Fewer friends Difficulty meeting new people, joining clubs and groups Academic problems because they avoid homework, don’t make full use of the resources, and have difficulties concentrating because they worry School avoidance A. Pencer October 2012 10

Long term l In the long term, anxious without treatment have: Restricted choices in

Long term l In the long term, anxious without treatment have: Restricted choices in terms of opportunities for careers l Lower self esteem l Increased likelihood of becoming an anxious and/or depressed adult l A. Pencer October 2012 11

What Does Anxiety in Youth Look Like? l No two anxious youth will behave

What Does Anxiety in Youth Look Like? l No two anxious youth will behave exactly the same way, nor will they worry about the exact same things. l However, there are common anxiety patterns which roughly translate into the anxiety disorders. A. Pencer October 2012 12

What is an Anxiety Disorder? l Interfering with daily activities l Causing significant distress

What is an Anxiety Disorder? l Interfering with daily activities l Causing significant distress l Reaction is too extreme for the situation l Trigger is not an actual threat A. Pencer October 2012 13

Anxiety Disorders Separation Anxiety Disorder: separation from caregivers and concern bad things will happen

Anxiety Disorders Separation Anxiety Disorder: separation from caregivers and concern bad things will happen to them l Generalized Anxiety Disorder: worry excessively about many areas of life functioning (e. g. , school work, family, friends, health) l Social Phobia: fearful of social or performance situations l A. Pencer October 2012 14

Anxiety Disorders cont’d Specific Phobia: fear of particular objects or situations l Panic Disorder:

Anxiety Disorders cont’d Specific Phobia: fear of particular objects or situations l Panic Disorder: misinterpret bodily changes and have a fear of losing control l Obsessive Compulsive Disorder: the presence of intrusive repetitive thoughts or behaviors l A. Pencer October 2012 15

Causes & Treatment A. Pencer October 2012 16

Causes & Treatment A. Pencer October 2012 16

What Causes Anxiety Disorders? l Genetics Anxiety runs in families l Common for at

What Causes Anxiety Disorders? l Genetics Anxiety runs in families l Common for at least one parent to be somewhat anxious l Research has shown that what is passed on from parent to child is not a specific tendency to be shy or worry but a general personality to be more emotionally sensitive than other people. l A. Pencer October 2012 17

What causes anxiety disorders? l Parent Reaction l l Modeling l l Parent reactions

What causes anxiety disorders? l Parent Reaction l l Modeling l l Parent reactions or the way they handle their child or teen’s anxious behaviour might also play a role (e. g. , being over-protective). Children and adolescents copy their parents coping strategies (e. g. , avoiding fearful situations). Stressors l Bit by a dog, death of a loved one, being bullied, getting sick A. Pencer October 2012 18

Interventions that Help l Psycho education l Treatment: Group CBT for youth and parents

Interventions that Help l Psycho education l Treatment: Group CBT for youth and parents l Individual CBT l Medication l A. Pencer October 2012 19

Evidence for CBT in Anxiety Disorder Treatment l Individual CBT (Kendall, 1994 and 1997)

Evidence for CBT in Anxiety Disorder Treatment l Individual CBT (Kendall, 1994 and 1997) l Study 1: 64% of treatment group no longer with dx l Study 2: 71% of treatment group no longer with dx l Results in both studies maintained at 1 year l At 7 years post-treatment, anxiety disorder no longer primary in 92% of youth l Up to 84% no longer have dx if parent component added (Barrett et al. , 1996) l Individual vs. Group CBT(Manassis et al, 2002; Rapee, 2000) l Group CBT as effective as Individual CBT A. Pencer October 2012 20

Three Components of Anxiety Feeling (Physiological) Cognitive (Thoughts) Doing (Behaviors) A. Pencer October 2012

Three Components of Anxiety Feeling (Physiological) Cognitive (Thoughts) Doing (Behaviors) A. Pencer October 2012 21

Physiological Component A. Pencer October 2012 22

Physiological Component A. Pencer October 2012 22

A. Pencer October 2012 23

A. Pencer October 2012 23

Anxiety and the Brain Limbic System -scans all sensory input, flight/fight response, integrates memory,

Anxiety and the Brain Limbic System -scans all sensory input, flight/fight response, integrates memory, emotion Prefrontal Cortex - decision making, planning, emotion regulation Locus coeruleus -Alarm system: sympathetic nervous system activation A. Pencer October 2012 24

Fight-Flight Response l In fearful situations teens become “pumped up” or aroused. This is

Fight-Flight Response l In fearful situations teens become “pumped up” or aroused. This is the fight-flight response. l l Immediate or short-term anxiety is named the fightflight response. It’s the body’s way of protecting you from danger. The fight-flight response causes you to sweat, increase heart rate, tense muscles, make you breath faster, feel hot or cold, dry mouth, and feel lightheaded or dizzy. A. Pencer October 2012 25

Fight Or Flight? A. Pencer October 2012 26

Fight Or Flight? A. Pencer October 2012 26

l In youth with anxiety disorders, the fightflight response occurs when there is no

l In youth with anxiety disorders, the fightflight response occurs when there is no immediate danger, but instead a perceived danger. Being in a classroom filled with other students l Using a restroom at school l Going to the cafeteria l Doing a presentation l Having your heart race l Paragraph you just wrote is “just not right” l A. Pencer October 2012 27

Cognitive Component A. Pencer October 2012 28

Cognitive Component A. Pencer October 2012 28

Examples (Cognitive) l Anxious children and teens have thoughts that center around harm or

Examples (Cognitive) l Anxious children and teens have thoughts that center around harm or threat. “I can’t leave to go to school and be away from my mom or something bad will happen to her. ” (Separation) l “I can’t do this presentation because my classmates will think I’m dumb. ” (Social) l “If I don’t check the back door lock, someone will break in. ” (OCD/GAD) l A. Pencer October 2012 29

Behavioral Component A. Pencer October 2012 30

Behavioral Component A. Pencer October 2012 30

Anxious behaviours l Anxious children and teens often behave differently: They pace, fidget, cry,

Anxious behaviours l Anxious children and teens often behave differently: They pace, fidget, cry, cling, shake. l They avoid. l Refusing to go somewhere alone l Refusing to go to school l l They seek reassurance. “Am I going to die? ” l “Am I going to fail? ” l “Is everyone going to laugh at me? ” l A. Pencer October 2012 31

Core Components of CBT l Realistic Thinking/Cognitive Restructuring l Exposure ** l Skills Training

Core Components of CBT l Realistic Thinking/Cognitive Restructuring l Exposure ** l Skills Training (e. g. , deep breathing and relaxation, problem solving, social skills, assertiveness, stress management) A. Pencer October 2012 32

Thinking Errors Anxious children overestimate how likely it is that an unpleasant event will

Thinking Errors Anxious children overestimate how likely it is that an unpleasant event will happen. l They overestimate how bad the consequences will be if the event does happen. l They underestimate their ability to cope with the anxiety and the unpleasant event l A. Pencer October 2012 33

Realistic Thinking Event Thought/Belief Emotion Parent is late there has been a crash stuck

Realistic Thinking Event Thought/Belief Emotion Parent is late there has been a crash stuck in traffic stopped to get pizza worry, anxiety annoyance happy A. Pencer October 2012 34

Steps in Realistic/Detective Thinking 1) Identify the situation that is making you worried 2)

Steps in Realistic/Detective Thinking 1) Identify the situation that is making you worried 2) Identify the worried thought 3) Look for “Realistic Evidence” to challenge your worried thought 4) Look for alternative outcomes 5) Identify a more realistic thought A. Pencer October 2012 35

Questions for collecting “evidence” l l l l What is the evidence that this

Questions for collecting “evidence” l l l l What is the evidence that this thought is true? What is the evidence that this thought is not true? What would I tell a friend if he/she had the same thought? Am I 100% sure that ______will happen? How many times has _____happened before? What was the outcome? What is the worst that could happen? What is likely to happen? If it did happen, what can I do to cope with or handle it? Am I confusing “possibility” with “certainty”? It may be possible, but is it likely? A. Pencer October 2012 36

Situation Feeling 0 -10 Anxious Thought Evidence? A. Pencer October 2012 Realistic Thought Feeling

Situation Feeling 0 -10 Anxious Thought Evidence? A. Pencer October 2012 Realistic Thought Feeling 0 -10 37

Exposure l By avoiding, children minimize direct and prolonged contact with feared situations. l

Exposure l By avoiding, children minimize direct and prolonged contact with feared situations. l Anxious children have no opportunity to learn that the situation is harmless. A. Pencer October 2012 38

High First time Anxiety Second time if removed at point B Second time if

High First time Anxiety Second time if removed at point B Second time if taken out of situation A B Low Time A. Pencer October 2012 39

Fighting Fear by Facing Fear l. The Keys to Stepladders: l gradual (start low

Fighting Fear by Facing Fear l. The Keys to Stepladders: l gradual (start low on anxiety thermometer) l stay in step “long enough” (until anxiety decreases) l use coping strategies l need to repeat steps l importance of rewards A. Pencer October 2012 40

Creating Stepladders 1. 2. 3. 4. 5. 6. Write a practical goal Brainstorm all

Creating Stepladders 1. 2. 3. 4. 5. 6. Write a practical goal Brainstorm all possible steps to reach the goal Child/Teen should give each step a worry rating Choose steps that cover the entire range of ratings Write chosen steps in order Negotiate rewards for each step and ultimate reward for achieving the goal A. Pencer October 2012 41

Common Problems l l Step too hard Not enough repetition Speeding through Look out

Common Problems l l Step too hard Not enough repetition Speeding through Look out for subtle avoidance (e. g. lucky charms) A. Pencer October 2012 42

School Based Version of “Cool Kids” l § Cool Kids Anxiety Program School Kit

School Based Version of “Cool Kids” l § Cool Kids Anxiety Program School Kit This package is an adaptation of the Cool Kids program for use within a school setting. It is designed to be run by school therapists and related mental health professionals. The therapist's manual describes in detail how to conduct each session of the program including exercises and comments to assist successful implementation. http: //centreforemotionalhealth. com. au/pages /resources-products. aspx A. Pencer October 2012 43

CASE EXAMPLE(S) and GROUP EXERCISES A. Pencer October 2012 44

CASE EXAMPLE(S) and GROUP EXERCISES A. Pencer October 2012 44

Case example #1 Ten year old boy with separation anxiety who was recently bullied.

Case example #1 Ten year old boy with separation anxiety who was recently bullied. Now needs parents to drive him to school, won’t go into school without parent present, won’t attend class unless parent remains in the school. Defiant if confronted about attending. A. Pencer October 2012 45

Case Example #2 Thirteen year old girl, diagnosed with Generalized Anxiety Disorder (GAD). Perfectionist

Case Example #2 Thirteen year old girl, diagnosed with Generalized Anxiety Disorder (GAD). Perfectionist qualities. Very concerned that people will think she is “stupid”. Spends an inordinate amount of time on homework checking for errors. A. Pencer October 2012 46

Case Example #3 15 year-old male with social anxiety disorder. a) b) c) d)

Case Example #3 15 year-old male with social anxiety disorder. a) b) c) d) e) Will not talk to people at school. Cannot do presentations at school. Will avoid any social gatherings with more than 3 people and rarely goes to friend’s houses. Will not eat in the cafeteria. Misses school very often. A. Pencer October 2012 47

A. Pencer October 2012 48

A. Pencer October 2012 48

 Helping Children with Selective Mutism Acknowledgment to Dr. Melanie Vanier A. Pencer October

Helping Children with Selective Mutism Acknowledgment to Dr. Melanie Vanier A. Pencer October 2012 49

Outline l Part II: Selective Mutism Common characteristics l Prevalence and course l Contributing

Outline l Part II: Selective Mutism Common characteristics l Prevalence and course l Contributing factors l Assessment l Intervention approach l Case example/group exercise l General discussion l A. Pencer October 2012 50

Common Characteristics • Fearful of being seen or heard speaking in certain situations (at

Common Characteristics • Fearful of being seen or heard speaking in certain situations (at school) • Visibly anxious when expected to speak • May communicate nonverbally • Social phobia symptoms A. Pencer October 2012 51

Influenced by Situational Factors People Activity Location A. Pencer October 2012 52

Influenced by Situational Factors People Activity Location A. Pencer October 2012 52

Prevalence and Course • ~1% of young children • Seems more common in girls

Prevalence and Course • ~1% of young children • Seems more common in girls • Onset in preschool years • Little known about the course • Without effective intervention, may persist for many years A. Pencer October 2012 53

Possible Contributing Factors • Shy or anxious temperament • Family history of shyness or

Possible Contributing Factors • Shy or anxious temperament • Family history of shyness or anxiety • Speech - language difficulties • New culture • Limited socializing with school peers A. Pencer October 2012 54

No Evidence SM Caused By: • Trauma • Family Dysfunction • Manipulation A. Pencer

No Evidence SM Caused By: • Trauma • Family Dysfunction • Manipulation A. Pencer October 2012 55

APA Diagnostic Criteria • Consistent failure to speak in specific situations • Speaking in

APA Diagnostic Criteria • Consistent failure to speak in specific situations • Speaking in other situations • Interferes with: educational achievement or social communication • At least one month duration • Not due to: communication disorder or unfamiliarity with the language A. Pencer October 2012 56

Initial Assessment Considerations • Speech – language difficulties • Autistic spectrum disorder • Hearing

Initial Assessment Considerations • Speech – language difficulties • Autistic spectrum disorder • Hearing impairment • Cognitive/ learning difficulties • Co-occurring anxiety disorders • Shyness A. Pencer October 2012 57

Initial Assessment Process • Parent interview/ detailed history • Parent and teacher reports: -

Initial Assessment Process • Parent interview/ detailed history • Parent and teacher reports: - norm-referenced behaviour questionnaires (e. g. , CBCL) - selective mutism questionnaires • Direct observation (classroom, office) A. Pencer October 2012 58

Intervention Approaches • Most approaches have not been systematically evaluated • Approaches useful in

Intervention Approaches • Most approaches have not been systematically evaluated • Approaches useful in treating anxiety have been applied to selective mutism: behavioural therapy cognitive-behavioural therapy (CBT) medication A. Pencer October 2012 59

Behavioural Approach ● Most evidence based approach (Cohan, Chavira, & Stein, 2006) ● Emphasis

Behavioural Approach ● Most evidence based approach (Cohan, Chavira, & Stein, 2006) ● Emphasis on modifying the environment ● Stimulus fading/ graduated exposure is key A. Pencer October 2012 60

Intervention: First Steps ● Establish “management team” ● Provide psychoeducation ● Reduce pressure to

Intervention: First Steps ● Establish “management team” ● Provide psychoeducation ● Reduce pressure to speak ● Encourage nonverbal participation ● Begin regular monitoring A. Pencer October 2012 61

Key Intervention Goals ● To develop an exposure hierarchy involving gradual steps ● To

Key Intervention Goals ● To develop an exposure hierarchy involving gradual steps ● To learn and implement strategies to move child along hierarchy, to transfer comfortable speaking from one situation to others A. Pencer October 2012 62

Creating the Exposure Hierarchy ● Develop separate hierarchies for people, activities, and locations •

Creating the Exposure Hierarchy ● Develop separate hierarchies for people, activities, and locations • Then combine into one integrated hierarchy A. Pencer October 2012 63

Exposure Hierarchy: People Dimension ● Consider people in terms of potential “conversational partner” ●

Exposure Hierarchy: People Dimension ● Consider people in terms of potential “conversational partner” ● Generally, children with selective mutism are most likely to speak to parents at school first ● List people the child: speaks to in any setting, speaks to selectively, will interact nonverbally, tends to avoid A. Pencer October 2012 64

Exposure Hierarchy: Activity Dimension ● Consider activities in terms of speaking demands and the

Exposure Hierarchy: Activity Dimension ● Consider activities in terms of speaking demands and the child’s comfort level ● Generally, children with selective mutism are more likely to speak during activities that are familiar and fun, and least likely to speak during academic activities ● List activities from ones child is already comfortable doing to those that would be increasingly anxiety-provoking A. Pencer October 2012 65

Exposure Hierarchy: Location Dimension ● Consider school locations in terms of comfort level, privacy,

Exposure Hierarchy: Location Dimension ● Consider school locations in terms of comfort level, privacy, and novelty ● Generally, children with selective mutism are more likely to speak at school in locations that are unlike the classroom and have not been associated with a pressure to speak (e. g. , playground, unfamiliar room) ● List school locations from ones that are quieter, private, and novel, to those that would be increasingly anxiety-provoking A. Pencer October 2012 66

Integrated Hierarchy: The “Conversational Ladder” ● Combine the separate dimension lists to form a

Integrated Hierarchy: The “Conversational Ladder” ● Combine the separate dimension lists to form a series of increasingly anxietyprovoking, school-based speaking situations ● Child should continue speaking at each new step ● Be prepared to insert an intermediate step if the child stops speaking A. Pencer October 2012 67

Integrated Hierarchy: The “Conversational Ladder” ● Repeated exposure (practice) at each step until child

Integrated Hierarchy: The “Conversational Ladder” ● Repeated exposure (practice) at each step until child becomes confident ● Initial steps should involve changes in activity and location, then practice similar steps with a new person ● Track progress to identify next step(s) A. Pencer October 2012 68

Ways to Promote School Participation • Encourage nonverbal participation (e. g. , jobs in

Ways to Promote School Participation • Encourage nonverbal participation (e. g. , jobs in the classroom; nonverbal communication with teacher) • Playdates at home with classmates • Re-arrange classroom seating to increase comfort • Alternative evaluation methods A. Pencer October 2012 69

Conversational Visits • Opportunities for child to practice comfortable speaking at school with conversational

Conversational Visits • Opportunities for child to practice comfortable speaking at school with conversational partner(s) • Very important if child is not speaking at all or very little at school • Short-term strategy A. Pencer October 2012 70

Conversational Visits • Begin with a person child speaks comfortably to (often parent) in

Conversational Visits • Begin with a person child speaks comfortably to (often parent) in a private space at school • Comfortable speaking transferred to new activities and locations, then to other conversational partners A. Pencer October 2012 71

The Use of Positive Reinforcement (Praise, Rewards) ● Positive reinforcement creates positive memories of

The Use of Positive Reinforcement (Praise, Rewards) ● Positive reinforcement creates positive memories of approaching, not avoiding. ● Praise the child’s bravery (emphasis on effort, not outcome). Low key praise is best. ● Incentives (rewards) can be helpful in some circumstances. A. Pencer October 2012 72

General Strategies: Building Social Skills ● Practice social skills at home (role playing with

General Strategies: Building Social Skills ● Practice social skills at home (role playing with puppets; conversations with older children) ● Help the child develop strategies to solve problems ● Gently provide direct instruction and feedback as needed ● Arrange real-life opportunities for practice (find activities that play to the child’s strengths) A. Pencer October 2012 73

General Strategies: Anxiety Management • Psychoeducation re: anxiety • Help the child learn relaxation

General Strategies: Anxiety Management • Psychoeducation re: anxiety • Help the child learn relaxation strategies (so they can tolerate discomfort) • Use other anxiety management strategies as appropriate A. Pencer October 2012 74

CASE EXAMPLE and GROUP EXERCISES A. Pencer October 2012 75

CASE EXAMPLE and GROUP EXERCISES A. Pencer October 2012 75

Case Example Sarah is a 6 -year-old girl who has been diagnosed with selective

Case Example Sarah is a 6 -year-old girl who has been diagnosed with selective mutism. l Sarah attends first grade at a small, rural school. l Sarah is described as quite talkative at home, and loves spending time playing “school” with her younger sister and chatting with her grandmother. She has a younger, close friend (Michelle) who goes to her school and lives down the street and they both enjoy doing crafts and playing board games. l Her parents recall that she has always been a quiet girl who needs time to warm up to new people or new situations. A. Pencer October 2012 76

l She does not speak to any of the children at school, although the

l She does not speak to any of the children at school, although the classroom teacher thinks she may have seen Sarah speak to another little girl (Lisa) from her class on the playground once. l Sarah has not spoken to her teacher, and blushes and looks away when her teacher asks her a question. l The teacher is not concerned at all about Sarah’s learning, and has told her parents that Sarah seems to be taking everything in and follows classroom routines well. A. Pencer October 2012 77

QUESTIONS/ GENERAL DISCUSSION A. Pencer October 2012 78

QUESTIONS/ GENERAL DISCUSSION A. Pencer October 2012 78