anxiety and selective mutism in youth workshop dr. alissa pencer registered psychologist

Anxiety and Selective Mutism in

Youth Workshop Dr. Alissa Pencer

Registered Psychologist

A. Pencer October 2012 2

Outline

Part I: Anxiety Disorders in YouthPart II: Selective Mutism

Part I: Anxiety Disorders in Youth When is anxiety a problem? Prevalence and course Common Anxiety Disorders Causes Cognitive Behaviour Therapy for Anxiety Disorders

Realistic Thinking Exposure Case Examples and Group Exercises


Fear, Anxiety, and Worry

Everyone worries, everyone gets anxious and everyone is afraid of something.

Very young children are often fearful of strangers, the dark, animals and insects.

Older children and adolescents are often fearful of peer rejection and are more self-conscious and strive to fit in with their peers.

Adults often worry about public speaking.


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.

Anxiety becomes a problem when it makes the decisions for you, interferes with your life and/or causes significant distress.


Inverted U-Shaped Relationship Between Arousal and Performance

Hebb, D. O. (1955). Psychological Review, 62, 243-254


Examples

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.


How Common are Anxiety Disorders?

Anxiety disorders are the most common psychological problem found in children and adolescents.

Approximately 1 in 10 youth meets the criteria for an anxiety disorder.

Despite this, often mental health centres see more children with aggressive difficulties, attentional problems, eating disorders, or suicidal tendencies.


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

%% Anxiety DisordersAnxiety Disorders 77 ADHDADHD 55 Conduct DisorderConduct Disorder 44 Mood Disorders Mood Disorders 44 Substance Use DisordersSubstance Use Disorders 11 Any Disorder Any Disorder 1414

Waddell et al, Can J Psychiatry, 2002Waddell et al, Can J Psychiatry, 2002


How Does Anxiety Effect Youth?

Anxious youth tend to have: 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


Long term

In the long term, anxious without treatment have: Restricted choices in terms of opportunities

for careersLower self esteem Increased likelihood of becoming an

anxious and/or depressed adult


What Does Anxiety in Youth Look Like?

No two anxious youth will behave exactly the same way, nor will they worry about the exact same things.

However, there are common anxiety patterns which roughly translate into the anxiety disorders.


What is an Anxiety Disorder?

Interfering with daily activitiesCausing significant distressReaction is too extreme for the situationTrigger is not an actual threat


Anxiety Disorders

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

Generalized Anxiety Disorder: worry excessively about many areas of life functioning (e.g., school work, family, friends, health)

Social Phobia: fearful of social or performance situations


Anxiety Disorders cont’d

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 or behaviors


Causes & Treatment


What Causes Anxiety Disorders?

GeneticsAnxiety runs in familiesCommon for at least one parent to be

somewhat anxious 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.


What causes anxiety disorders?

Parent Reaction Parent reactions or the way they handle their child

or teen’s anxious behaviour might also play a role (e.g., being over-protective).

Modeling Children and adolescents copy their parents coping

strategies (e.g., avoiding fearful situations). Stressors

Bit by a dog, death of a loved one, being bullied, getting sick


Interventions that Help

Psycho educationTreatment:

Group CBT for youth and parents Individual CBTMedication


Evidence for CBT in Anxiety Disorder Treatment

Individual CBT (Kendall,1994 and 1997) Study 1: 64% of treatment group no longer with dx Study 2: 71% of treatment group no longer with dx

Results in both studies maintained at 1 year At 7 years post-treatment, anxiety disorder no longer

primary in 92% of youth

Up to 84% no longer have dx if parent component added (Barrett et al., 1996)

Individual vs. Group CBT(Manassis et al, 2002; Rapee, 2000) Group CBT as effective as Individual CBT


Three Components of Anxiety

Feeling (Physiological)

Cognitive (Thoughts)

Doing (Behaviors)


Physiological Component


Anxiety and the Brain

Limbic System-scans all sensory input, flight/fightresponse, integrates memory, emotion

Prefrontal Cortex - decision making, planning, emotion regulation

Locus coeruleus-Alarm system:sympathetic nervous system activation


Fight-Flight Response

In fearful situations teens become “pumped up” or aroused. This is the fight-flight response. Immediate or short-term anxiety is named the fight-

flight 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.


Fight Or Flight?


In youth with anxiety disorders, the fight-flight response occurs when there is no immediate danger, but instead a perceived danger.

Being in a classroom filled with other studentsUsing a restroom at schoolGoing to the cafeteria Doing a presentationHaving your heart raceParagraph you just wrote is “just not right”


Cognitive Component


Examples (Cognitive)

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)

“I can’t do this presentation because my classmates will think I’m dumb.” (Social)

“If I don’t check the back door lock, someone will break in.” (OCD/GAD)


Behavioral Component


Anxious behaviours

Anxious children and teens often behave differently:They pace, fidget, cry, cling, shake.They avoid.

Refusing to go somewhere aloneRefusing to go to school

They seek reassurance. “Am I going to die?” “Am I going to fail?” “Is everyone going to laugh at me?”


Core Components of CBT

Realistic Thinking/Cognitive RestructuringExposure **Skills Training (e.g., deep breathing and

relaxation, problem solving, social skills, assertiveness, stress management)


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.

They underestimate their ability to cope with the anxiety and the unpleasant event


Realistic Thinking

Event Thought/Belief EmotionParent is late there has been a crash

worry,anxiety

Parent is late stuck in traffic annoyance

Parent is late stopped to get pizza happy


Steps in Realistic/Detective Thinking

1) Identify the situation that is making you worried

2) Identify the worried thought3) Look for “Realistic Evidence” to

challenge your worried thought4) Look for alternative outcomes5) Identify a more realistic thought


Questions for collecting “evidence”

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?


Situation

Feeling 0-10

Anxious Thought

Evidence? Realistic Thought

Feeling 0-10


Exposure

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

Anxious children have no opportunity to learn that the situation is harmless.


A

B

Time

High

Low

Anxiet

y

First time

Second time if removed at point B

Second time if taken out of situation


Fighting Fear by Facing Fear

The Keys to Stepladders: gradual (start low on anxiety thermometer)stay in step “long enough” (until anxiety

decreases) use coping strategiesneed to repeat steps importance of rewards


Creating Stepladders

1. Write a practical goal2. Brainstorm all possible steps to reach the

goal3. Child/Teen should give each step a worry

rating4. Choose steps that cover the entire range of

ratings5. Write chosen steps in order6. Negotiate rewards for each step and ultimate

reward for achieving the goal


Common Problems

Step too hard Not enough repetition Speeding through Look out for subtle avoidance (e.g.

lucky charms)


School Based Version of “Cool Kids”

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


CASE EXAMPLE(S)

and

GROUP EXERCISES


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.


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.


Case Example #3

15 year-old male with social anxiety disorder.

a) Will not talk to people at school.b) Cannot do presentations at school.c) Will avoid any social gatherings with more

than 3 people and rarely goes to friend’s houses.

d) Will not eat in the cafeteria.e) Misses school very often.


Helping Children with Selective Mutism

Acknowledgment to Dr. Melanie Vanier


Outline

Part II: Selective MutismCommon characteristicsPrevalence and courseContributing factorsAssessment Intervention approachCase example/group exerciseGeneral discussion


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


Influenced by Situational Factors

People

Activity

Location


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


Possible Contributing Factors

• Shy or anxious temperament

• Family history of shyness or anxiety

• Speech - language difficulties

• New culture

• Limited socializing with school peers


No Evidence SM Caused By:

• Trauma

• Family Dysfunction

• Manipulation


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


Initial Assessment Considerations

• Speech – language difficulties

• Autistic spectrum disorder

• Hearing impairment

• Cognitive/ learning difficulties

• Co-occurring anxiety disorders

• Shyness


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)


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


Behavioural Approach

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

● Emphasis on modifying the environment

● Stimulus fading/ graduated exposure is key


Intervention: First Steps

● Establish “management team”● Provide psychoeducation ● Reduce pressure to speak ● Encourage nonverbal participation ● Begin regular monitoring


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


Creating the Exposure Hierarchy

● Develop separate hierarchies for people, activities, and locations

• Then combine into one integrated hierarchy


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


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


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


Integrated Hierarchy: The “Conversational Ladder”

● Combine the separate dimension lists to form a series of increasingly anxiety-provoking, school-based speaking situations

● Child should continue speaking at each new step

● Be prepared to insert an intermediate step if the child stops speaking


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)


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


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


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


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.


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)


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


CASE EXAMPLE

and

GROUP EXERCISES


Case Example

Sarah is a 6-year-old girl who has been diagnosed with selective mutism.

Sarah attends first grade at a small, rural school.

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.

Her parents recall that she has always been a quiet girl who needs time to warm up to new people or new situations.


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.

Sarah has not spoken to her teacher, and blushes and looks away when her teacher asks her a question.

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.


QUESTIONS/

GENERAL DISCUSSION

anxiety and selective mutism in youth workshop dr. alissa pencer registered psychologist

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