2/9/2013
Anxiety:
The Worry Wars:
The Silent Affliction
Equipping our Child Clients to
Effectively Fight Their Fears
Paris Goodyear-Brown, LCSW, RPT-S
397-9480
[Link]
paris@[Link]
How common is it?
1 in 4 people suffer
from an anxiety
disorder over the
course of a lifetime
Females are twice as
likely to have them as
males
1 in 8 children have
diagnosed anxiety
disorders
Factors that influence Anxiety
Anxiety Prevalence Rates
Anxiety is the most
prevalent psychiatric
diagnosis in children
and adolescents
under the age of 16
About 70% of grade
school kids say they
worry every now and
then
How should we view anxiety?
Genetics/temperament
From
Mother/infant
From
attachment pattern
Presence of parental psychopathology
Parenting style
a neurophysiological perspective?
a psychoanalytic perspective?
From a behaviorist perspective?
From a family systems perspective?
From a cognitive perspective?
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What are normal
developmental fears?
Long Term Outcomes
Children
with untreated anxiety disorders
are at greater risk for developing:
Peer
relationship difficulties
Academic failure
Substance abuse
Onset of comorbid diagnoses such as major
depression, eating disorders, and ADHD
90% of children between the ages of 2-14 have
one specific fear
0-2 years
3-6 years
Loud noises, strangers, separation from parents,
large objects
Imaginary figures, supernatural beings, the dark,
noises, sleeping alone, thunder, floods
7-16 years
More realistic fears-physical injury, health, school
performance, death, thunderstorms, earthquakes,
floods
The Anxiety Disorders
Generalized Anxiety Disorder
Obsessive-Compulsive Disorder
ASD/ PTSD
Specific Phobia
Social Phobia
Agoraphobia
Panic Disorder
Selective Mutism
Separation Anxiety Disorder
Anxiety vs. Fear
Fear
is a valid, helpful and immediate
response to a dangerous situation.
Fear occurs when the danger is.
Anxiety occurs when the danger might
be.
-from The Anxiety Cure, pg. 10
4 problems that anxious kids
face
Its harder than other children to self-soothe in stressful
situations
They rarely use their creativity when making plans for
coping with anxiety-although they often have higher than
average creativity
They tend to give up quickly even when they have a
good plan
They dont recognize their success even when they are
making progress
4 General treatment Goals
Helping clients learn and practice self-soothing
strategies
Helping clients use their creativity in developing
useful coping strategies
Helping clients implement the strategies
consistently
Helping clients recognize their successes and
build on them
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Set up the Struggle
Treatment Goal/ Interventions
Copecake Mixer
Copecake Tin
Helpful coping choices
should:
1) Be good for you
2) Be good for others
3) Be easy to do
4) Make you feel better
Cooling Copecakes
Describe six coping
choices that include all
4 ingredients.
Write them in the baking
tin and use each of
them 2-3 times
between sessions.
Gathering a Team
Once youve tried each of the coping
choices, decide which ones
help you the most.
Write these on the copecakes,
decorate them and put them
somewhere as a reminder of
the helpful ways you can cope.
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Physiological Cues
The physiological alarm
Temperamentally anxious or sensitive
children may have physiology that is overly
responsive to our normal survival
mechanisms.
Maraca Madness!!!
When children are experiencing
maraca madness, they cannot
think clearly. Reasoning with
them or threatening them can
make things worse. So what can
you do?
Action Step/ Interventions
SOOTHE!!!
S-soft tone of voice
O-organize
O-offer
T-touch
H-hear
E-end
Keeping Safe Place Safe
Be
sure to specify A place
where nothing bad has ever
happened
Learn to recognize contamination
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Chillin with my iPod
Picture Perfect Postcard
List three songs that help
you feel happy.
List three songs that help
you feel calm.
Five Count Breathing
Action Step/ Intervention
Personalized Pinwheels
Can of Worms
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COMPONENTS OF FSPT
Flexibly Sequential Play Therapy for
Trauma Treatment
Continuum of
Disclosure
The glimpses that
children show us:
making sense of the
snapshots
Externalizing the Anxiety
Identifying the Worried Talk
Choose
your metaphor
Worried Brain
Dragon Flames
Princess Wand
Octopus with What Ifs
Identify Anxious Thoughts
Identifying the Worried Talk
Choose
your metaphor
Worried Brain
Dragon Flames
Princess Wand
Octopus with What Ifs
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Identifying Anxious Thoughts
Identifying Anxious Thoughts
Creating and Practicing the
Boss Back Talk
Thought Stopping
Choose
your weapon
Boss Back Brain
Sword/Shield/Fire Extinguisher
Wand/Megaphone
Bricks
Crafting Boss Back Talk
Crafting Boss Back Talk
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Exposures
Extinguish the Fear
Draw a picture of the
anxiety producing
stimuli
Talk back to it while
squirting it with the
fire extinguisher
Erase it while using
some chosen power
words
Graduated Exposures-Building
Stepladders by Scenario
An exposure is meant to help the child face the anxiety
producing situation without avoiding it or performing a
ritual to keep the anxiety in check
The child is likely to experience increased anxiety during
the exposure
Following an exposure all the way to a reduction in
anxiety leads to desensitization and habituation
Creating an Exposure
Hierarchy
Help the client make a
hierarchy of fear inducing
stimuli
Help the client rank these in
order of difficulty
Begin with the easiest task first
Make the tasks small enough
so that the client experiences
many successes early on in
treatment
-as adapted from Wolpe as described by Shapiro, 1989
The SUD Scale
SUD Scale activities
A 10 point scale that
helps people quantify the
level of distress or upset
that they feel when
handling an exposure to a
stressful situation or
thought
A useful clinical tool for
measuring alleviation of
intense emotional
reactivity to traumatic
events
-as adapted from Wolpe as described by Shapiro, 1989
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Positive Reinforcement
Treatment Goal/ Interventions
One-A-Day Thermometers
Graduation Celebration
Selective Mutism/Specific
Phobia
Selective Mutism/Specific
Phobia
Case Example 1: Katie
6 year old female born at 30 wks, 4pds,
developmental milestones were all delayed
Slow to warm-up temperament
Fear of choking began after a stomach bug two
months prior to entering tx
Sleeps with parents
Saw a child blue from choking at the beginning of the
school year
Case
Example 1: Katie
1: made tea set, read Cat Got
Your Tongue, drew picture
Session
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Selective Mutism/Specific
Phobia
Case Example 1: Katie
Session 1: made tea set, read Cat Got Your
Tongue, drew picture
Session 2: had tea party, introduced Jerry the
Giraffe, taught him about choking
Session 3: introduced telephones, began
successive approximation tasks with copycat
game
Selective Mutism/Specific
Phobia
Case
Example 1: Katie
4: Albert the alligator, copycatmade several sounds
Session
Selective Mutism/Specific
Phobia
Case
Example 1: Katie
5: Fear flies, marshmallow
game, breakthrough!!!
Session
Selective Mutism/Specific
Phobia
Case Example 1: Katie
Session 6: client made 14 one word
verbalizations during play
Session 7: avoided eye-contact and
verbalizations, was introduced to Talulah the
turtle, played cotton ball war game
Session 8: copycat, made talking book
Selective Mutism/Specific
Phobia
Case Example 1: Katie
Session 9: brought in talking book-had talked
to postal worker, waiter and librarian-much
celebration!
Session 10: Therapist read Who Moved My
Cheese and client drew picture, client spoke
to 19 people in the last 3 weeks and gained 6
pounds
Follow-up check ins
Graduation!!
Separation Anxiety
Disorder
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2/9/2013
What is the Parenting
Response?
The Peacekeeper
may not experience much fall out from the separation
anxiety, because the routines are built around it
The Negotiator
Makes some efforts to help the child with his fears but
backs down if he sees intense distress
The Protector
The Evaluator
Keeps child from situations that might induce anxiety
Varying Safety Signals
Access
to safety signals
Duration of exposure
Distance from home, place or person
Familiarity of person, place or situation
Planning of exposure
Timing
Sees the behavior as manipulative and may become
overly confrontive about anxiety issues
4 types of Safety Signals
Safe
Persons
Safe
Objects
Safe
Actions
Safe
Places
Separation Anxiety Disorder
Separation Anxiety Disorder
Case Example 1: Johnny
Session 1: Externalizing the anxiety, clt.
chose puppet to represent fear, made up
power words/chants for fighting the fear, and
battled the cockroach with fingerpuppets
Session 2: Mountain metaphor, all trials are
seen as successes, did the Big One, two
brains
Case Example 1: Johnny
5 year old Caucasian male with two parent household
Afraid to be away from mom in the house
Wakes up every morning for pre-school saying he
feels sick, cries and begs to stay home
Throws up on the way to school or in the parking lot
every school morning
Wants to stop!
Separation Anxiety Disorder
Case Example 1: Johnny
Session 3: Read Wemberly Worried and
made Fear glasses and Courage glasses
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2/9/2013
Separation Anxiety Disorder
Case Example 1: Johnny
Session 4: Chain of courage to work on over
the holidays
Separation Anxiety Disorder
Separation Anxiety Disorder
Case Example 1: Harry
Session 7: Dad came, talked about problems
with morning routine, introduced morning
scavenger hunt and Brave Behavior chart
for morning routine
Session 8: client mastered Brave Behavior
chart
Separation Anxiety Disorder
Case Example 1: Harry
Session 15: client started book entitled
Getting Over Your Fear
Session 16: another crisis session for mom
Session 17: graduation party
Case Example 1: Harry
Session 5: mom was excited that client went
back after 3 week absence without gagginghe cried but used his new skills, celebrated
his chain of courage
Session 6: Client punched holes in fear while
making positive statements and did a set of
dot paintings representing the fear getting
smaller
Separation Anxiety Disorder
Case Example 1: Harry
Session 9: termination phase, started Memory book
Session 10: courage has grown sandtray, 1/2 tray for
before and now
Session 11: 6 week old baby of close family member
dies in her sleep, talked about breathing, death and
dying
Session 12: session with mom for her grief issues,
encouraged closure rituals for the client
Session 13 & 14: grief work
Trauma induced Separation
Anxiety
Case
example 2: Betsy
11
year old girl who lived with mom and dad
up until a year and a half ago when mom and
dad separated
Dad first attempted suicide, then assaulted
mom
Client is terrified to be away from her mom at
night-even in the other room
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2/9/2013
Treatment highlights
Case
OCD is not about the inability
to think rationally; its about
the anxiety that results from
the inability to believe what
you know to be true in a given
situation.
example 2: Betsy
Sandtray
about dad
Safe place sandtray
Exposure/response prevention work
-from Freeing Your Child From Obsessive-Compulsive Disorder, by Tamar
Chansky (pg. 20)
Letting the Kid Off the Hook
Psychoeducation
Neurophysiology
A
Bobbys Story
Problems That You Have
is paramount:
= a hiccup in the brain
stuck doorbell
How I found out I had OCD
We were watching TV
and on Dr. Phil this girl
had OCD. Some of the
things that she had to
do were wash your
hands many times and
flicker on and off the
lights 42 times-she was
12 or so. What I was
doing was counting and
thought that that would
be the same thing.
How I found out I had OCD
So I went to my mom
and dad and I said I
think I have OCD. I
started saying two
pages full of what I had
to do. Mom wrote them
down. Then we came to
see Ms. Paris.
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2/9/2013
My symptoms
Count shoes and parts of
shoes
Right foot day
Left foot day
Counting windows
Counting everything
Blinking a certain number
of times
Not able to get shoes right
Soccer cleets
Jumping rope
When I met Ms. Paris
What is OCD?
It is a time waster. After the
walk with my dad talking
about it, I went home and my
shoes were so
uncomfortable that I threw
them down on the floor. I
pulled out most of my shoes
and socks (because socks
feel different) and tried them
all on. It wasted an hour and
thirty minutes. That time I
didnt fight back. I hardly
even thought about fighting
back.
What is OCD
When I started to learn how to
fight back
I learned that OCD is like a kid
knocking on your door so
many times and he runs
away. At first you go and
open it again and again, then
you just say O.K. Stop it.
just like you would say to
OCD Stop bothering me.
When you learn to fight back
what I did was very cool. I
made a picture and wrote
OCD on it and scribbled all
over it and I burned it in the
fire and flushed it down the
toilet. You can make up your
own consequence for OCD.
When I met Ms. Paris I
was nervous. How she
talks to you about OCD
is nice and she
understands. She
doesnt yell at you and
she even lets you play
with toys for activities.
So there was really no
reason to be nervous.
OCD is a liar. It keeps
coming up all day
everyday. It makes you
physically exhausted at
the end of the day. It
tells you you cant do
that but you really can.
Hes telling you that
youll be uncomfortable
or that something bad
will happen.
Turning the Tide
OCD is not the real you.
When you first have it, you
dont even know what it is.
You just think its part of
you-like its normal. Ms.
Paris told me that OCD is a
liar and that I can talk back
to it. I drew a picture of a
boxing ring. It was me and
OCD fighting and OCD
seemed so much bigger at
the time because before I
knew Ms. Paris I didnt know
to fight back.
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2/9/2013
Getting There
Before I met Ms. Paris OCD
was in charge all the time.
When I saw Ms. Paris, I
started to get bigger and
bigger and he started to get
smaller and smaller. Im not
as exhausted and I have
more time for fun. I will
remember it when I am an
adult, but I hope it will be
completely gone. If OCD tries
to creep up on me again, Ill
be ready for it.
Bossing It Back
Websites
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Books for Kids
Books for Kids
Mr. Worry: A Story about OCD by Holly L. Niner
Shadow Moves by Caroline H. Sheppard
Starbright: Meditations for Children by Maureen Garth
The Worrywarts by Pamela Duncan Edwards
The Kissing Hand
Understanding Katie by Elisa Shipon-Blum
Up and Down the Worry Hill: A Childrens Book about
Obsessive-Compulsive Disorder and its Treatment by
Aureen Pinto Wagner Wemberly Worried by Kevin
Henkes
Who Moved My Cheese? For Kids by Spencer Johnson
Youve Got Dragons by Kathryn Cave
You have to do the
uncomfortable thing, no
matter what. It will keep
talking to you but one by
one, itll eventually go away.
It doesnt matter that it keeps
talking to you, it matters that
you have fun. If you do the
uncomfortable thing anyway,
you can consider it a win.
A Terrible Thing Happened by Margaret Holmes
Babars Yoga for Elephants by Laurent de Brunhoff
Brave Bart: A Story for Traumatized and Grieving
Children by Caroline Sheppard
Cats Got Your Tongue?: A Story for Children Aftraid to
Speak by Charles Schaefer
Jessica and the Wolf: A Story for Children Who Have
Bad Dreams by Ted Lobby
Just in Case by Judith Viorst
Llama Drama by
Maybe Days: A Book for Children in Foster Care by
Jennifer Wilgocki
References
Barrett, P. & Shortt, A. (2003). Parental Involvement in the
Treatment of Anxious Children. in Evidence-Based
Psychotherapies for Children and Adolescents (eds. Kazdin, A. &
Weisz, J.)
Christophersen, Edward & Mortweet, Susan. (2001). Treatments
That Work With Children: Empirically Supported Strategies for
Managing Childhood Problems.
Dacey, John S. & Fiore, Lisa B. (2000). Your Anxious Child: How
Parents and Teachers Can Relieve Anxiety in Children. JosseyBass: San Fransisco.
Eisen, Andrew R. & Engler, Linda B. (2006). Helping Your Child
Overcome Separation Anxiety or School Refusal. New Harbinger
Publications: Oakland.
Kendall, Philip et al. (2003). Child-Focused Treatment of Anxiety
in Evidence-Based Psychotherapies for Children and Adolescents
(eds. Kazdin, A. & Weisz, J.)
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2/9/2013
References
March, J. & Albano, A.M. (2002). Anxiety Disorders in Children and
Adolescents.
March, J. & Mulle, K. (1998). OCD in Children and Adolescents: A
Cognitive-Behavioral Treatment Manual. New York: The Guilford
Press.
McHolm, A. et al. 2005(). Helping Your Child With Selective
Mutism: Steps to Overcome a Fear of Speaking. Oakland: New
Harbinger Publications.
Shipon-Blum, Elisa. (2003). The Ideal Classroom Setting for the
Selectively Mute Child. Philadelphia: SMART Center.
Spencer, Elizabeth D. et al. (2003). The Anxiety Cure for Kids: A
Guide for Parents. John Wiley & Sons: New Jersey.
The Worry Wars:
Equipping our Child Clients to
Effectively Fight Their Fears
Paris Goodyear-Brown, LCSW, RPT-S
397-9480
[Link]
paris@[Link]
16
