Stephen Grcevich, MD

Chairman, Board of Directors, Key Ministry

Clinical Assistant Professor of Psychiatry, Northeast Ohio Medical University

Senior Clinical Instructor, Child and Adolescent Psychiatry

Case Western Reserve University School of Medicine

2013 Accessibility Summit

McLean Bible Church, McLean VA

April 20, 2013

Supporting Kids and Teens Who Struggle With Anxiety

Learning Objectives:

Recognize common signs and symptoms in kids who struggle with anxietyBecome familiar with contemporary understanding of the causes of anxietyExamine the impact of anxiety on family functioning and academic, social and spiritual development in children and teensReview strategies for helping kids overcome functional limitations associated with anxiety

Can a disability be a disability in some, but not all environments?

“It is our culture that disables.”

“When one is disabled, the problem is not really that they have impairments and social skill deficits. The issue at stake is that they live in an ‘ableist’ culture that rarely affords them the space or opportunity to make their unique contribution to society and does not lift up the value of choosing them as friends.”

Ben Conner…Amplifying Our Witness (2012)

Some fears are normal and age-appropriate in children and teens…

Infants: loud noises, fear of being startled

Toddlers/young children: imaginary creatures, the dark, animals, strangers

School-age children: injury, natural events (hurricanes, tornadoes, earthquakes), death

Teens: Fears related to school performance, social competence, healthJ Am Acad Child Adolesc Psychiatry 2007;46(2) 267-83.

Common signs of anxiety in children, teens…

Avoidance

Excessive need for reassurance

Excessive physical complaints

Sleep disturbances (especially increased sleep latency)

Difficulties with concentration, attention

Perfectionism

“What if” questions

Excessive absence from school

Easily distressed

Lying

Some facts about kids with anxiety…

8% of teens ages 13-18 have anxiety disorders

Most experience onset of anxiety by age 6

18% of teens with anxiety disorders have ever received treatment

Girls>Boys

Severity=persistence

Kids often develop new anxiety disorders over time

Greater risk of depression, substance abuse

Genetics, parent-child interactions, parental modeling, temperament are risk factors

http://www.nimh.nih.gov/health/publications/anxiety-disorders-in-children-and-adolescents/index.shtmlJ Am Acad Child Adolesc Psychiatry, 2007;46(2):267-283

Specific Anxiety Disorders in Children, Adolescents: Note: Kids may experience different manifestations of anxiety as they progress through developmental stages

Separation Anxiety Disorder

Specific Phobia

Generalized Anxiety Disorder

Social Anxiety Disorder

Panic Disorder

Obsessive-Compulsive Disorder

Selective Mutism

J Am Acad Child Adolesc Psychiatry, 2007;46(2):267-283

What causes anxiety in children and teens?

Genetics…alterations in amygdala circuits involved in emotion processing, disruption in functional connectivity in amygdala-based networks involved in fear-processing

The child’s/teen’s innate personality style

Environment (trauma, illness, life stressors)

Overprotective parents

Bottom line…Kids with anxiety misinterpret the level of risk in their immediate environment

FIGURE 1

Source: Journal of the American Academy of Child and Adolescent Psychiatry 2013; 52:290-299.e2 (DOI:10.1016/j.jaac.2012.12.010 )

Copyright © 2013 American Academy of Child and Adolescent

Child Teenager

School: Difficulty separating from parentsDifficulty with class participationFrequent trips to nurse’s officePerformances, presentations

Test anxietyDifficulty with self-advocacy…getting helpAvoid extracurricular activities, social eventsFear of failure inhibits class selection

Friends: Challenges in making new friendsParents often initiate social activity Difficulty with sleepovers

May depend on small circle of trusted friendsChallenges with group trips/activitiesDating and breakups more challenging

Family: Often sleep with parents at nightReluctant to try new activities

Slow to progress toward independenceFrequently reluctant to get driver’s licenseConflict-dependence on electronic communication

Community: Less involved with sports, other extracurricular activities

May have more difficulty applying for jobsLess likely to do camps, travel experiences

Functional impairment in kids and teens with anxiety…

How do our ministry environments create barriers for kids with anxiety and their families?

Some observations…

God created all of us as unique human beings…more kids in this generation are being diagnosed with autism spectrum disorders and other social disabilities…accident?

Churches are social institutions…we promote fellowship, discipleship…Where does that leave people who struggle with relationships?

Church environments are especially challenging for people with anxiety

“To reach people no one else is reaching, we have to try stuff no one else is trying.”

Common barriers to church participation and spiritual growth in kids with anxiety…

Vulnerability to misinterpret risks in environment

Differences in sensory processing

Cognitive rigidity

Past negative experiences of church

Family stress, isolation

Parents with anxiety

Child Teenager

Weekend Worship:

They prevent the family from attending…Difficulty separating from parentsVisiting new church challenging

They’re reluctant to attendReluctant to attend without friendsUncomfortable with attention of groupTransitions between age-group ministries difficult

Church Activities:

Discomfort reading, praying aloudReluctant to engage unfamiliar kidsDifficulty in unfamiliar environments

Disclosure in small groups challengingUnfamiliar places, experiences may be threatening…retreats, mission trips

Spiritual Disciplines

Prone to misperceive who God is…Prayer, process of confession in some traditions challenging

More prone to ritualismObsessions- doubting salvation, sinning against one’s willGroup disciplines more challenging

Growing in faith at home:

Parents can model faith, practicing disciplines as a positive coping strategy

Parents can sensitively expose teens to new spiritual experiences

Impacts of anxiety on church attendance and spiritual development in children and teens…

What could a church try to welcome kids with anxiety and their families?

Lots of pictures and video letting kids know what to expect on Sundays, during new experiences

Offer to let kids and families tour your campus in advance of their first Sunday

Applications of technology…online church campuses, small groups, Bible studies?

Tips for church staff and volunteers: Kids with anxiety

Don’t call attention to an anxious childKids with anxiety are horrified by interventions that make them feel “different”…buddies, being part of “special needs ministry”Train greeters to observe for problems at “drop-off” Designate a private place for kids/parents in distressLeaders can watch for kids who are aloneOffer to meet with parents when a child’s anxiety appears to interfere with ministry participationRemember…anxiety generally decreases with experience (exposure)Remember potential areas of giftedness: administration, organization, sensitivity to others

Treatment of anxiety disorders in children, adolescents:Cognitive-behavioral therapy (with modifications for specific anxiety disorders)SSRIs, other medications Parent-child, family interventions Classroom-based accommodations, interventions

Evidence-based interventions in orange

J Am Acad Child Adolesc Psychiatry, 2007; 46(2):267-283

CAMS (Child-Adolescent Anxiety Multimodal Study):

NIMH-funded, RCT comparing placebo, sertraline, CBT and combination treatment (CBT+sertraline) for treatment of separation anxiety disorder, social anxiety disorder, generalized anxiety disorder

Children, ages 7-17, N=488

CBT: 14 sessions, using “Coping Cat” curriculum

Sertraline: started at 25 mg/day, increased by fixed-flexible titration (mean dose:133 mg/day)

Walkup JT et al, N Engl J Med, 2008;359:2753-2766

CAMS (Child-Adolescent Anxiety Multimodal Study):

Response rates: COMB: 80.7%, CBT: 59.7%, SER: 54.9%, PBO: 23.7%

COMB>CBT=SER>PBO Effect Sizes: COMB: 0.86,

SER: 0.45, CBT: 0.31 No adverse effects>PBO in

medication groups Beneficial effects of COMB

vs. SER evident after week 8Plac

ebo

Sertra

line

CBT

Combin

ation

0

20

40

60

80

Chart Title

%Responders

Response rates to treatment:

Walkup JT et al, N Engl J Med, 2008;359:2753-2766

A final thought…

“We are all anxious. We all will and do experience anxiety. Anxiety is part of our human condition. With that being said, I believe that God uses our anxiety as a tool to help us grow. It’s a catalyst that keeps us from getting stuck, as it propels us to continually follow God.”

Rhett Smith-author of The Anxious Christian

What have we learned?

The vast majority of kids with anxiety disorders develop symptoms during their grade school years (or earlier) and receive no treatment for their condition.

Anxiety can have a major impact upon a child’s spiritual development and church participation

Churches can take specific steps to making their ministry environments more welcoming to kids with anxiety and their families

Cognitive-Behavioral therapy (CBT) and medication are effective treatments for kids with anxiety…best response when CBT, medication are used together

Additional Resources:Resource page on anxiety and spiritual development:

http://drgrcevich.wordpress.com/resource-page-anxiety-and-spiritual-development/

American Academy of Child and Adolescent Psychiatry:

http://www.aacap.org/cs/AnxietyDisorders.ResourceCenter

National Institute of Mental Health

http://www.nimh.nih.gov/health/publications/anxiety-disorders-in-children-and-adolescents/index.shtml

Anxiety Disorders Association of America

http://www.adaa.org/living-with-anxiety/children

Provides FREE training, consultation, resources and support to help churches serve, welcome and include families of kids with hidden disabilities

Stay in Touch!

Key Ministry Website: http://www.keyministry.org

Church4EveryChild…Steve’s Key Ministry Blog: http://drgrcevich.wordpress.com

Diving For Pearls…Katie Wetherbee’s Blog: http://katiewetherbee.wordpress.com

A Reckless Pursuit…Harmony Hensley’s Blog: http://arecklesspursuit.wordpress.com

http://www.facebook.com/drgrcevichhttp://www.facebook.com/pages/Key-Ministry/116940088329098

http://twitter.com/#!/drgrcevichhttp://twitter.com/#!/KeyMinistry

Questions?

Additional Slides

Cognitive Behavioral Therapy (CBT)

What is CBT?

The goal is to alter cognitive processes by increasing self awareness, facilitate better self-understanding, and improving self control by developing more appropriate cognitive and behavioral skills.

Cognitive Behavioral Therapy (CBT)

Three Components:Cognitive Emotional/PhysiologicalBehavioral

Cognitive Behavioral Therapy (CBT)

Unhealthy Process Healthy Process

Thoughts Distorted thinking: Overly negative, self-critical, selective and biased

More positive, acknowledge success, balanced, and recognized strengths

Feelings Unpleasant, anxious, depressed, angry

Pleasant, relaxed, happy, calm

Behavior Avoid, give-up, inappropriate

Confront, try, appropriate

Cognitive Behavioral Therapy (CBT)

Common Pattern of Anxiety

Child enters difficult situation

Child becomes anxious and fearful

Anxious behavior escalates and child gets stuck

Child avoids the situation or asks others to help

Child continues to think the situation is dangerous and feels helpless

Cognitive Behavioral Therapy (CBT)

Build Confidence Reduce Anxiety

Build stronger relationships Learn to communicate

Take on more responsible roles Develop new skills

Increase independence and self-help skills

Gradually face fears

Cognitive Behavioral Therapy (CBT)

What not to do

Do not try to convince them it will be okay.

Do not minimize their experience.

Do not tell them to fight the anxiety.

Do not physically force them into the situation.

Do not verbally bully them into the situation.

Cognitive Behavioral Therapy (CBT)

What to do

Accept their feelings

Demonstrate understanding

Build competence

Have expectations but alter the process

Parent cooperatively vs. balancing

Respond vs. react

Cognitive Behavioral Therapy (CBT)

Calming Strategy

Catch your breath

Accept negative feelings

Label emotions

Model coping skills

Medications Used in Kids With Anxiety Disorders

SSRIs (Sertraline, Fluvoxamine, Fluoxetine)

Clomipramine

Venlafaxine

Tricyclic antidepressants (imipramine)

Buspirone

Benzodiazepines

J Am Acad Child Adolesc Psychiatry 2007; 46(2) 267-283