Pediatric-Anxiety-Disorders-PPC-skill-building-7-15-2020-FINAL.ppt

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1. Pediatric Anxiety Disorders and Pediatric Anxiety Disorders and
Associated Disorders Associated Disorders
Andres J. Pumariega, M.D.Andres J. Pumariega, M.D.
Professor and ChiefProfessor and Chief
Division of Child and Adolescent PsychiatryDivision of Child and Adolescent Psychiatry
Department of PsychiatryDepartment of Psychiatry
University of Florida College of Medicine University of Florida College of Medicine
North Central Florida Pediatric
Collaborative Program
July 15
th
, 2020

2. Normative Anxiety in ChildhoodNormative Anxiety in Childhood
Vulnerability as well as adaptive (signal Vulnerability as well as adaptive (signal
anxiety)anxiety)
Stranger anxietyStranger anxiety
Separation anxiety (toddlers, new school)Separation anxiety (toddlers, new school)
Fear of death (8 years old)Fear of death (8 years old)
Performance anxiety (school-related)Performance anxiety (school-related)
Transient social anxiety (latency and Transient social anxiety (latency and
adolescent)adolescent)

3. Anxiety in ChildhoodAnxiety in Childhood
Anxiety both physiological and psychological responseAnxiety both physiological and psychological response
–Prepares for appropriate action/ reactionPrepares for appropriate action/ reaction
–Physiological response: heart rate, BP, muscle tension, Physiological response: heart rate, BP, muscle tension,
sweat, etc. sweat, etc.
–Perceptual response: hyperarousal, hypervigilancePerceptual response: hyperarousal, hypervigilance
–Psychological response: fear, apprehension, mistrust, Psychological response: fear, apprehension, mistrust,
somatizationsomatization
Anxiety disorders are among the most common pediatric
conditions
Anxiety Anxiety disorderdisorder involves excessive response for stimulus involves excessive response for stimulus
and inappropriate for age, context, or stressor; interferes and inappropriate for age, context, or stressor; interferes
with normal functionwith normal function

4. Risk Factors for Anxiety Disorders in Risk Factors for Anxiety Disorders in
ChildrenChildren
Family history/ geneticsFamily history/ genetics
Temperament (“irritable”, “colicky”, “slow to Temperament (“irritable”, “colicky”, “slow to
warm up”)warm up”)
History of trauma (acute/ severe vs. chronic)History of trauma (acute/ severe vs. chronic)
Medical illness (impact as well as pharmacologic Medical illness (impact as well as pharmacologic
effects)effects)
Parental overprotection/ accommodationParental overprotection/ accommodation
Isolation from environmental stimulation, esp. Isolation from environmental stimulation, esp.
peerspeers

5. Anxiety Disorders in Children: DDx and Anxiety Disorders in Children: DDx and
Co-MorbidityCo-Morbidity
Depressive disorders (often comorbid)Depressive disorders (often comorbid)
ADHD (anxiety re performance)ADHD (anxiety re performance)
ODD (anxiety can lead to oppositionality but ODD (anxiety can lead to oppositionality but
Bipolar disorders (often comorbid, mood stability addresses)Bipolar disorders (often comorbid, mood stability addresses)
Substance abuse disorders (anxiety can lead to using Substance abuse disorders (anxiety can lead to using
addictive substances)addictive substances)
Learning disorders (anxiety re performance)Learning disorders (anxiety re performance)
Developmental disorders (esp. ASD) (anxiety re change Developmental disorders (esp. ASD) (anxiety re change
contributes to meltdowns)contributes to meltdowns)
MedicalMedical
–Hyperthyroidism, asthma and its medications, pituitary tumors, Hyperthyroidism, asthma and its medications, pituitary tumors,
Pheochromocytoma, Pheochromocytoma,

6. Childhood Forms of Anxiety Childhood Forms of Anxiety
DisordersDisorders
Generalized Anxiety DisorderGeneralized Anxiety Disorder
–Associated with shyness, perfectionism, sensitive to criticism, excessive worry out Associated with shyness, perfectionism, sensitive to criticism, excessive worry out
of proportion or not relevantof proportion or not relevant
–Somatic symptoms without organic findings (abdominal pain, headache, etc), Somatic symptoms without organic findings (abdominal pain, headache, etc),
ofen with multiple work-upsofen with multiple work-ups
–Avoidance of performance and social demandsAvoidance of performance and social demands
–Rarely incapacitating, associated with low self esteemRarely incapacitating, associated with low self esteem
–Later associated with high degree of co-morbidityLater associated with high degree of co-morbidity
Social Anxiety Disorder Social Anxiety Disorder
–Extreme shyness/ withdrawalExtreme shyness/ withdrawal
–Physiological symptoms of anxiety with strangers or crowdsPhysiological symptoms of anxiety with strangers or crowds
–Good relations with those close to themGood relations with those close to them
–Selective mutism frequent symptomSelective mutism frequent symptom
–Poor social skills and self esteem, seldom incapacitatingPoor social skills and self esteem, seldom incapacitating
–Associated with physical handicaps, speech disorders, shy temperament, losses, Associated with physical handicaps, speech disorders, shy temperament, losses,
parental anxietyparental anxiety

7. Other Anxiety DisordersOther Anxiety Disorders
Panic DisordersPanic Disorders
–Spontaneous panic attacks (2 X per week for dx criterion)Spontaneous panic attacks (2 X per week for dx criterion)
–Hyperventilation, increased HR, sweaty palms, trembling, Hyperventilation, increased HR, sweaty palms, trembling,
feeling of doom)feeling of doom)
–Not related to separation or phobic stimulusNot related to separation or phobic stimulus
–Usually can be co-morbid with GAD, social anxiety disorder, Usually can be co-morbid with GAD, social anxiety disorder,
separation anxiety disorder)separation anxiety disorder)
–Predictive of adult psychopathology (depressive, anxiety)Predictive of adult psychopathology (depressive, anxiety)
Dissociative DisordersDissociative Disorders
–Amnesia, cognitive disconnection, seen with trauma/PTSDAmnesia, cognitive disconnection, seen with trauma/PTSD
Conversion DisordersConversion Disorders
–Non-volitional loss of function (paralysis, vision, anesthesia, Non-volitional loss of function (paralysis, vision, anesthesia,
with acute anxiety or trauma; lacks anatomical correlation with acute anxiety or trauma; lacks anatomical correlation
Unique childhood presentation of anxiety disordersUnique childhood presentation of anxiety disorders
–Tricotillomania: Associated with OCD and other anxiety symptoms Tricotillomania: Associated with OCD and other anxiety symptoms
–Selective mutism: Associated with social anxietySelective mutism: Associated with social anxiety

8. Separation Anxiety Disorder Separation Anxiety Disorder
SymptomsSymptoms
–Intense anxiety/ agitation anticipating separation from primary caretakersIntense anxiety/ agitation anticipating separation from primary caretakers
–Physiological anxiety sx and somatic sxPhysiological anxiety sx and somatic sx
–Persistent fears of danger if separated (self, caretaker)Persistent fears of danger if separated (self, caretaker)
–Fear of attending school or leave caretakers; Fear of attending school or leave caretakers;
–Clinging/ shadowing even within the homeClinging/ shadowing even within the home
–Inability to sleeping alone Inability to sleeping alone
–Nightmares, fears of animals/ monsters, somatic sx. Nightmares, fears of animals/ monsters, somatic sx.
–Untreated can lead to agoraphobia (fear of venturing outside safe space Untreated can lead to agoraphobia (fear of venturing outside safe space
and chronic homebound existence) and chronic homebound existence)
EpidemiologyEpidemiology
–3 percent of children3 percent of children
–Occur either early school age or early teenOccur either early school age or early teen
–90 percent have co-morbid disorders, increased risk of adult MDD and 90 percent have co-morbid disorders, increased risk of adult MDD and
panic disorderpanic disorder
–Maternal anxiety (80 %) and mood disorder (60 %) Maternal anxiety (80 %) and mood disorder (60 %)

9. Separation Anxiety Disorder in ChildrenSeparation Anxiety Disorder in Children
Factors in evaluation of school refusal: Factors in evaluation of school refusal:
–Must rule in: Must rule in:
Presence of separation anxiety symptoms outside of Presence of separation anxiety symptoms outside of
attending schoolattending school
Pattern of recurrence year after year at start of schoolPattern of recurrence year after year at start of school
–Must rule out:Must rule out:
Learning disordersLearning disorders
Social pressure (possibly more social anxiety disorder)Social pressure (possibly more social anxiety disorder)
Realistic fears of victimization at school (bullying)Realistic fears of victimization at school (bullying)
Conduct disorder & truancyConduct disorder & truancy
Cultural and family non-support (need for emotional or Cultural and family non-support (need for emotional or
physical companion for parent/ elder, pressure to enter physical companion for parent/ elder, pressure to enter
workforce; cultural expectations)workforce; cultural expectations)

10. Post-Traumatic Stress Disorder in Post-Traumatic Stress Disorder in
Children and AdolescentsChildren and Adolescents
Traumatic stressors: Serious or repetitive abuse (esp. sexual), Traumatic stressors: Serious or repetitive abuse (esp. sexual),
assault, natural disasters, war, accidents, etc.)assault, natural disasters, war, accidents, etc.)
Preceded by Acute Stress Disorder (immediate sx.)Preceded by Acute Stress Disorder (immediate sx.)
Bullying not necessarily trauma (extent of physical/ verbal violence Bullying not necessarily trauma (extent of physical/ verbal violence
or public shaming) or public shaming)
Presentation similar as adults, but including: Presentation similar as adults, but including:
–Different types of anxiety can accompany (generalized, social, panic, phobias)Different types of anxiety can accompany (generalized, social, panic, phobias)
–Non-verbal reliving of trauma in younger children but also older (play, Non-verbal reliving of trauma in younger children but also older (play,
interactional, placing self at risk for repetition of trauma- drive to master); can interactional, placing self at risk for repetition of trauma- drive to master); can
include sexualinclude sexual
–Can be accompanied by disruptive behavioral symptoms (Conduct Disorder Can be accompanied by disruptive behavioral symptoms (Conduct Disorder
can be co-morbid)can be co-morbid)
–Much mood lability and irritability, even self-injurious behaviorsMuch mood lability and irritability, even self-injurious behaviors
–Inattention and hyperactivity Inattention and hyperactivity can mimic ADHD, but HYPER-arousedcan mimic ADHD, but HYPER-aroused (Cuffe, (Cuffe,
McCullough, & Pumariega, McCullough, & Pumariega, J Child & Family StudiesJ Child & Family Studies, 1994); yet , 1994); yet kids with kids with
ADHD have high PTSD prevalenceADHD have high PTSD prevalence

11. Post-Traumatic Stress Disorder in Post-Traumatic Stress Disorder in
Children and Adolescents Children and Adolescents
Chronic PTSD/ PTSD Type 2Chronic PTSD/ PTSD Type 2
–PTSD Type 1 symptoms can subside but also PTSD Type 1 symptoms can subside but also
persist to different degreespersist to different degrees
–Unique sx. include rage episodes, mood swings Unique sx. include rage episodes, mood swings
(confusion with Bipolar), SIB, dissociation, (confusion with Bipolar), SIB, dissociation,
psychotic sx at times psychotic sx at times
–Symptoms typically persist to adulthoodSymptoms typically persist to adulthood
–Associated with serious Axis II disorders in Associated with serious Axis II disorders in
adulthood (esp. Borderline Personality Disorder)adulthood (esp. Borderline Personality Disorder)

12. Obsessive Compulsive Disorder (OCD)Obsessive Compulsive Disorder (OCD)
Common adolescent onset; 2 percent prevalence in Common adolescent onset; 2 percent prevalence in
adolescents; rare younger patients; if so often PANSadolescents; rare younger patients; if so often PANS
SymptomsSymptoms
–Obsessive thoughtsObsessive thoughts: Repetitive thoughts and preoccupations : Repetitive thoughts and preoccupations
(often nonsensical; numbers, words, song tunes) (often nonsensical; numbers, words, song tunes)
–Compulsive behaviorsCompulsive behaviors: Repetitive rituals: Repetitive rituals
–Anxiety disturbance Anxiety disturbance associated; repetitions have goal of reducing associated; repetitions have goal of reducing
anxiety; flares up if interrupted (with irritability and aggression)anxiety; flares up if interrupted (with irritability and aggression)
–Goes beyond normal rituals of school-age childrenGoes beyond normal rituals of school-age children
–Can be comorbid with GAD, social anxiety, separation anxietyCan be comorbid with GAD, social anxiety, separation anxiety
–Co-morbidity with tics/ Tourette’s (also common mechanism)Co-morbidity with tics/ Tourette’s (also common mechanism)
Underlying factorsUnderlying factors
–Midbrain dysfunction Midbrain dysfunction
–Genetic component; usually anxiety disorderGenetic component; usually anxiety disorder
–PANDAS (post-strep) or PANS (other infections) PANDAS (post-strep) or PANS (other infections)
Extremely incapacitating but treatableExtremely incapacitating but treatable

14. Lifetime Prevalence of Anxiety Lifetime Prevalence of Anxiety
DisordersDisorders
(National Comorbidity Survey; Kessler et al, 1999)(National Comorbidity Survey; Kessler et al, 1999)
–GAD- 4.1 to 6.6 %GAD- 4.1 to 6.6 %
–Social Anxiety Disorder- 2.6 to 13.3 %Social Anxiety Disorder- 2.6 to 13.3 %
–OCD- 2.3 to 2.6 %OCD- 2.3 to 2.6 %
–PTSD-1 to 9.3 %PTSD-1 to 9.3 %
–Panic Disorder- 2.3 to 2.7 %Panic Disorder- 2.3 to 2.7 %
–Agoraphobia- 6.7 %Agoraphobia- 6.7 %
–Simple Phobia- 11.3 %Simple Phobia- 11.3 %

16. PANS or PANDAS PANS or PANDAS
Pediatric Autoimmune Neuropsychiatric Syndrome (PANS)/ Disorder Pediatric Autoimmune Neuropsychiatric Syndrome (PANS)/ Disorder
Associated with Strep (PANDAS)Associated with Strep (PANDAS)
Prevalence- estimated at 1 in 200Prevalence- estimated at 1 in 200
MechanismMechanism
–Infection burrows into midbrain centers associated with repetitive movement Infection burrows into midbrain centers associated with repetitive movement
circuitrycircuitry
–Immune response attacks neural cells and create inflammation and erratic Immune response attacks neural cells and create inflammation and erratic
stimulation of these circuitsstimulation of these circuits
DiagnosisDiagnosis
–OCD sx onset or flareups after strep infectionsOCD sx onset or flareups after strep infections
–Impulsivity, irritability, tic symptoms, attentional sx.Impulsivity, irritability, tic symptoms, attentional sx.
–Elevated ASO and anti DNAase B titersElevated ASO and anti DNAase B titers
TreatmentTreatment
–Treat OCD plus 14 day course of PNC; usually resolves episodeTreat OCD plus 14 day course of PNC; usually resolves episode
–Rarely: IVIG (mixed recent evidence), plasmapheresis (similar to NMDA Rarely: IVIG (mixed recent evidence), plasmapheresis (similar to NMDA
encephalitis) encephalitis)

18. Cultural Factors in the Diagnosis of Cultural Factors in the Diagnosis of
AnxietyAnxiety
Often under diagnosed in minority populations in spite of Often under diagnosed in minority populations in spite of
greater prevalencegreater prevalence
Often mixed anxiety and depressive symptomsOften mixed anxiety and depressive symptoms
Culture-bound syndromes: e.g. Susto, Ataques de Culture-bound syndromes: e.g. Susto, Ataques de
Nervios (Hispanics), Koro (Japanese), etc.Nervios (Hispanics), Koro (Japanese), etc.
Often experienced as somatic symptomsOften experienced as somatic symptoms
Attribution to spiritual, interpersonal, religious causationAttribution to spiritual, interpersonal, religious causation
Often associated with dissociative symptoms Often associated with dissociative symptoms
Ritual interventions acceptable and often effective Ritual interventions acceptable and often effective

19. Family Accommodation (FA)Family Accommodation (FA)
Seen across different types of anxiety disordersSeen across different types of anxiety disorders
Patterns: Patterns:
–Over-protection and fostering of avoidanceOver-protection and fostering of avoidance
–Accommodation of fears, rituals, preoccupationsAccommodation of fears, rituals, preoccupations
–Minimizing competing demands for functionMinimizing competing demands for function
–Stated goal is to reduce distress and conflictStated goal is to reduce distress and conflict
–At times parent has anxiety or depressive disorder, engage also for At times parent has anxiety or depressive disorder, engage also for
self-reliefself-relief
Family Accommodation aggravates symptoms Family Accommodation aggravates symptoms
–Interferes with exposure and desensitizationInterferes with exposure and desensitization
–Major psychological and neurobiological mechanisms for recovery Major psychological and neurobiological mechanisms for recovery
(note role in natural fear reduction)(note role in natural fear reduction)
–Home schooling with no medical indication major form of excessive Home schooling with no medical indication major form of excessive
accommodation, very deleteriousaccommodation, very deleterious

20. Recognizing Anxiety Disorders Recognizing Anxiety Disorders ESES
Parents/ teachers most reliable about externalizing disorders
but child best reporter for internalizing disorders (anxiety,
depression).
Important to obtain parent rating but if possible child rated
screener
Private conversation may be needed (parent and child).
Interested and accepting attitude from health care provider
is essential for child to share concerns.
Examine within a context of impairment
–Some symptoms are transient or in response to acute stressor
–Does the shy child warm up?
–Prolonged response to a normative stressor may indicate a need for
treatment

21. Assessment Considerations Assessment Considerations ESES
Family dysfunction/ parental psychopathology can influence
reliability of symptoms.
–What is the lens of the parent?
–Parents may either not recognize level of distress- or over-
interpret severity
Family and social history is often not volunteered but may be a key
to understanding.
Teacher or other reliable adult input may be useful- especially
important to understand if symptoms are present in all settings.
How is school going? How does he/she sleep? These
recommended for each visit by TFOMH of AAP.
Children with chronic disease are twice as likely to have a
psychiatric disorder, most often anxiety and/or depression

22. Screening and Diagnostic ToolsScreening and Diagnostic Tools
PSC-17 (internalizing sub-scale)PSC-17 (internalizing sub-scale)
GAD-7GAD-7
SCAREDSCARED
Child PTSD Symptom scale and othersChild PTSD Symptom scale and others
Y-BOCS-C and others (OCD)Y-BOCS-C and others (OCD)

23. Anxiety Disorders and COVID Anxiety Disorders and COVID
Pandemic and mitigation can have Pandemic and mitigation can have
significant impact on anxiety disordersignificant impact on anxiety disorder
–Aggravation of illness anxietyAggravation of illness anxiety
GAD (xcs worry re risk for self, others, to paralysis)GAD (xcs worry re risk for self, others, to paralysis)
OCD (aggravation of compulsi ons, esp germ phobia)OCD (aggravation of compulsi ons, esp germ phobia)
–Aggravation of separation anxietyAggravation of separation anxiety
–Artificial alleviation of social anxiety disordersArtificial alleviation of social anxiety disorders
–Potential aggravation of FA (has to consider Potential aggravation of FA (has to consider
reality factors)reality factors)

24. Treatment of Pediatric Anxiety Treatment of Pediatric Anxiety
Disorders Disorders
Pharmacotherapy Pharmacotherapy
–SSRI's SSRI's
Efficacy with GAD, social anxiety disorder, social Efficacy with GAD, social anxiety disorder, social
phobia/selective mutism, tricitillomania, phobia/selective mutism, tricitillomania,
Efficacy with OCD (Zoloft, Prozac, Luvox) Efficacy with OCD (Zoloft, Prozac, Luvox)
Efficacy with PTSD (to reduce comorbid anxiety, Zoloft) Efficacy with PTSD (to reduce comorbid anxiety, Zoloft)
Promise with panic disorder and separation anxiety disorderPromise with panic disorder and separation anxiety disorder
–Buspirone: promising adjunct, short term relief Buspirone: promising adjunct, short term relief
Non-addictive serotonin agonistNon-addictive serotonin agonist
–Benzodiazepines Benzodiazepines
Some efficacy demonstrated; use only short term acute Some efficacy demonstrated; use only short term acute
(panic, agitation)(panic, agitation)
Caution due to high addiction potentialCaution due to high addiction potential
Side effects: sedation, disinhibition, overdose Side effects: sedation, disinhibition, overdose

25. Treatment of Pediatric Anxiety Treatment of Pediatric Anxiety
DisordersDisorders
Other Agents Other Agents
–Alpha 2 agonists blockers (Clonidine, Guanfacine, Alpha 2 agonists blockers (Clonidine, Guanfacine,
Intuniv), useful with PTSD (reduce over-arousal)Intuniv), useful with PTSD (reduce over-arousal)
–Prazosin (alpha blocker): significant use in PTSD Prazosin (alpha blocker): significant use in PTSD
–Antihistamines (Benadryl, Vistaril): Both for Antihistamines (Benadryl, Vistaril): Both for
agitation and sleep; non-addictive) agitation and sleep; non-addictive)
–Beta blockers (Propanalol): Blocks adrenaline, Beta blockers (Propanalol): Blocks adrenaline,
reduce over-arousalreduce over-arousal
–Risperidone: Useful for PTSD Type 2 (chronic Risperidone: Useful for PTSD Type 2 (chronic
traumatization; associated with dissociative traumatization; associated with dissociative
symptoms, agitation, rage episodes, psychotic symptoms, agitation, rage episodes, psychotic
episodes)episodes)

26. Treatment of Pediatric Anxiety Treatment of Pediatric Anxiety
DisordersDisorders
PsychotherapyPsychotherapy
–Effective as solo modality for mild anxiety; combo with Effective as solo modality for mild anxiety; combo with
meds for moderate to severe anxiety or OCDmeds for moderate to severe anxiety or OCD
–Cognitive-behavioral therapyCognitive-behavioral therapy
Anxiety reduction techniques: relaxation, desensitization, Anxiety reduction techniques: relaxation, desensitization,
imagery/ reframingimagery/ reframing
Social skills training for social anxietySocial skills training for social anxiety
OCD techniques: response preventionOCD techniques: response prevention
PTSD: Trauma-focused CBT (narrative, response prevention) PTSD: Trauma-focused CBT (narrative, response prevention)
–Family therapyFamily therapy
Psychoeducation and similar CBT techniquesPsychoeducation and similar CBT techniques
Address Address family accommodation, anxiety, and traumatizationfamily accommodation, anxiety, and traumatization
–Group therapyGroup therapy
Mutual support, social skills, and fear reduction techniques Mutual support, social skills, and fear reduction techniques

27. Ways to Strengthen Child ResilienceWays to Strengthen Child Resilience
Resilience: the ability to endure a significant
stress and still thrive
–Comes more naturally for some kids than others
–Is a skill caregivers can help child build
–Has both internal and external elements
Strong, stable, and supportive relationship w/ caregiver
(external support)
Skills we teach children (internal supports)

28. ExternalExternal Support for Child ResilienceSupport for Child Resilience
Help child recognize their feelings
–Let child know you’re listening to what they’re saying and
you recognize how they’re feeling
–It’s okay to let children experience some anxiety-they need
to know that anxiety is not dangerous but something they
can cope with
Help child learn or practice anxiety reduction skills
–Work together on problem-solving, asking your child what
they think should happen and how they’d like to handle the
situation
Help child break down big tasks into smaller steps they can
accomplish
Help role-play or act out possible ways your child could handle a
difficult situation
–Identify any negative self talk and replace with balanced
thoughts
–Schedule time for relaxation and rest

29. ExternalExternal Support for Child ResilienceSupport for Child Resilience
Model healthy emotion regulation
–Be willing to share the basics about your feelings
(there will be times when your child is aware that you
are upset, angry or sad, whether you try to hide it or
not) and let them know you will not always feel this
way
–Take care of your own mental, emotional and physical
health
When children see you taking time for yourself, it reinforces
the importance of self-care in handling stressors in life
–The more you can show your child that you’re rolling
with the punches, the more likely they’ll learn that they
can too

30. ExternalExternal Support for Child ResilienceSupport for Child Resilience
Build child’s personal strength
–Encourage self-efficacy
Do not take over or do it for your child
–This might help child feel better in the moment, but it sends the
message that you don't believe your child can do it, and they may start
to think the same way about themself
Limit providing reassurance
–Teach your child to answer their own questions and manage their
feelings in the moment
–Recognize and praise your child for facing challenges,
trying something new, or brave behavior
–Don’t punish mistakes or slow progress, let them
know that mistakes and disappointments are OK and
part of learning and growing

31. ExternalExternal Support for Child ResilienceSupport for Child Resilience
Have appropriate expectations
–It's important that you have the same expectations of
your anxious child that you would of another child
–Understand that pace may be slower and you may
need to plan for transitions (e.g, allow extra time in
the morning if getting to school is difficult)
–Have clear and consistent limits and consequences
for inappropriate behavior
All caregivers need to be on same page w/ how to handle
child’s anxiety

32. InternalInternal Support for Child ResilienceSupport for Child Resilience
Deep BreathingDeep Breathing
–Inhale through the noseInhale through the nose
–Exhale through the mouthExhale through the mouth
–Conscious and ControlledConscious and Controlled
Practice while standing
–Have child place one hand on stomach and one hand on chest
–Ask child to take deep breaths that move just their belly, not their chest
Practice while laying down
–If needed, have child lay on the exam table and place a pen on their
belly
–Ask them to take your pen “for a ride” on their breath
–Have them practice breathing standing up

33. Internal Support for Child ResilienceInternal Support for Child Resilience
ABC BreathsABC Breaths
–AlligatorAlligator
Ask child to pretend they’re an alligator using their arms
They should stretch their arms wide to open the alligator’s
mouth while they simultaneously take a deep breath in
Then snap their arms together to shut the alligator’s mouth
while pushing their breath out
–ButterflyButterfly
Ask child to pretend they’re a butterfly using their arms as
wings
They should reach their wings behind them while taking a
breath in, then bring their wings forward as they breathe out
–CandlesCandles
Ask child to pretend they’re blowing out birthday candles
They should take a deep breath in and then push the breath
out as if they are extinguishing the fire on their candles

34. Internal Support for Child ResilienceInternal Support for Child Resilience
54321 Senses Scavenger Hunt54321 Senses Scavenger Hunt
–5 things they can see right now
Ask them to describe each item and what they like about it
–4 objects they can feel or touch right now
Have them touch
 each item and describe what each feels like
Examples: their hair, clothing, chair, floor, clipboard, etc.
–3 things they can hear right now
Examples: clock ticking, A/C, talking, phone ringing, etc.
Can have them do this w/ eyes closed to better focus
–2 things they can smell right now
Tell them they may need to get up and walk around and to tell
you if they like or dislike each smell
Examples: someone’s perfume, their armpits, paper, etc.
–1 thing they can taste right now
If you don’t have a piece of candy or mint to give them, ask
them to describe the taste of the inside of their mouth

35. Internal Support for Child ResilienceInternal Support for Child Resilience
Progressive Muscle RelaxationProgressive Muscle Relaxation
–Start w/ head, then move to feet
–Tense muscles for 5 seconds, exhale and relax for 10
seconds
Tighten your face muscles by raising your eyebrows as high
as you can and smiling as big as you can…hold for 5
seconds…and exhale and release those muscles letting your
eyebrows and cheeks relax and become soft
Wrinkle up your nose/lips, like you ate something sour
Lift your shoulders to your ears like a turtle going into its shell
Show me your strong arm muscles by flexing your biceps
Squeeze all the juice out of the orange with your fists
Try to make your shoulder blades touch each other
Suck your tummy in as far as you can
Press your knees together like you’re holding a penny in
between them
Flex your feet and spread your toes
Curl your toes like you’re digging them into the sand

36. Anxiety Resources for CaregiversAnxiety Resources for Caregivers
WebsitesWebsites
–AAnxiety Disorders Association of America www.adaa.org
–Children’s Center for OCD and Anxiety www.worrywisekids.org
–Child Anxiety Network
www.childanxiety.net/Anxiety_Disorders.htm
–American Academy of Child and Adolescent Psychiatry
www.aacap.org/aacap/families_and_youth/resource_centers/An
xiety_Disorder_Resource_Center/Home.aspx

Books Books
–Freeing your Child from Anxiety, Revised and Updated Edition:
Practical Strategies to Overcome Fears, Worries, and Phobias
and Be Prepared for Life-From Toddlers to Teens (2014), by
Chansky
–Helping Your Anxious Child: A Step by Step Guide for Parents
(2008), by Rapee, Psych, Spence, Cobham, and Lyneham
–Worried No More: Help and Hope for Anxious Children (2005),
by Wagner