IDEAS on Anxiety Child and Parent Resource Institute

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1 Child and Parent Resource Institute: Mission Our mission is to enhance the quality of life of children and youth with complex mental health or developmental challenges and to assist their families so these children can reach their full potential. IDEAS on Anxiety Child and Parent Resource Institute Presented By Dr. Karin Gleason, Psychologist Dina Barnes, Occupational Therapist Katharine Moody, Community Behaviour Consultant IDEAS team Intellectual Disabilities & Emotional Disorders Adaptive Strategies IDEAS Team We provide services for children and youth with intellectual disabilities and emotional disorders within a tertiary setting. We provide assessment, treatment and consultation to families, schools, and community partners We use an inter-professional approach, with a focus on education, adapted CBT, and environmental support IDEAS Team Team approach includes: Psychologist Speech Language Pathologist Occupational Therapist Social Worker Psychiatrist Community Behaviour Consultant Psychometrist What is the need? As many as 0% of children with an intellectual disability also have Mental Health Disorders (Dual Diagnosis) Half of those children present with two or more co-morbid disorders The complexity of these children leads to considerable potential for misattribution of behaviours and misdiagnoses. 1

2 Mental Health in Intellectual Disabilities The types of psychiatric disorders children/youth with intellectual disabilities experience are the same as those seen in the general population The child/youth's life circumstances or level of intellectual functioning may alter the appearance of the symptoms. Distribution of Mental Health Disorders in Children with Intellectual Disabilities (Emerson, 003) Anx/Dep/OCD Eating PDD Tic ADHD Conduct 8 % 18.8 % 0.77 % 1.6 % 17 % 1 % Incoming client description Incoming client description 55% are in a Specialized classroom 68% Require an increased share of Average Age: 1 years 53% Male; 7% Female Family Income between $5,000-$65,000 78% Live with a biological parent 71% Live in a two-parent household teacher time All have (or are thought to have) an Intellectual Disability 6% are on Psychotropic Medication(s) Pre-Screening data from 91 incoming clients Incoming Clients: Current Medications Stimulants SSRIs Antipsychotic Seizure Benzodiazepine Other 1 IDEAS: An Innovative Approach The treatment with the largest evidence base for Anxiety and Mood disorders in children is Cognitive Behaviour Therapy (CBT) with or without medication The problem: Most CBT approaches require a minimum cognitive age of 8 years. 5% are on two or more medications 7 The solution: CBT approaches are broken down into smaller, more concrete steps, using a number of extra supports to match the child/youth s strengths and needs.

3 What is an Intellectual Disability? Significant and lifelong limitations in Intellectual functioning (thinking and problem solving) Adaptive behaviour (everyday social and practical skills) This disability originates in the developmental period Struggles with Social judgment; assessment of risk Self-management of behaviour, emotions, interpersonal relationships Disruptive or aggressive behaviours that are linked to communication difficulties Gullibility, social naïveté and tendency to be easily led by others; high risk of victimization/exploitation Statistically Normal Curve What is Typical Anxiety? A normal and necessary human experience Uncomfortable state Fight, flight or freeze Warning signal real response to real or perceived danger When is Anxiety a disorder? The ANXIETY EQUATION by Dr. Padesky When anxiety is: Excessive Developmentally inappropriate Overestimate the DANGER! Causing significant impairment in the individual's life Underestimate the COPING! What if? What If? What if? 3

4 The Anxiety Triad Thoughts Evidence Informed Treatment for Anxiety Up and Down the Worry Hill by Dr. Aureen Wagner Taming Worry Dragons by Drs. Jane Garland and Sandra Clark Behaviour Physical Arousal OCD in Children and Adolescents: A CBT Treatment Manual by Dr. John March Anxiety Traps by Dr. Christine Padesky How is Anxiety in children typically treated? Traditional Anxiety Treatment Cognitive Behaviour Therapy Recognizing anxiety Relaxation & coping skills Cognitive restructuring Exposure & Habituation Medication Parent Education Adapted Anxiety treatment Adapting CBT for children with ID Focus on framework around child Life long coaching WHEN to use tools HOW to use tools PRACTICE using the tools More cues, reminders, visuals Steps are broken down and we stay longer at each step.

5 Adapting interventions Adaptations include visual supports, concrete wording, co-therapy with parents/caregivers, a slower pace, and repetition to ensure mastery Incorporating family, educators, and other supports Focus may be on the framework around the child (adults coach, cue and support the use of coping strategies) Parent Education Sessions Inter-professional approach Can be first step of treatment Focus on understanding parent s role as coach and reframing expectations Opportunity for support from other parents who have similar experiences Relaxation Treatment Group Relaxation group consists of 5-6 weekly sessions for approximately 1 hour in length Clients range from about 7-15 years of age, clients of the IDEAS program at either the beginning, middle or end phases of team involvement Provides exposure to many different types of relaxation activities, some traditional and some adapted Many activities adapted from the Ready, Set, R.E.L.A.X. curriculum (Allen and Klein) Traditional vs. Adapted Approach Clients get exposure to many relax strategies- deep breathing, progressive muscle relaxation, guided imagery, yoga, music Parents have coffee and are able to connect, be reminded of role as coach, browse resources Parents are reminded of their role as coach, many clients not be able to use these strategies independently We talk about daily practice as a preventative At the end, OT meets with parents to review what their child responded to and focus on how and when to continue teaching, very individualized recommendations Adapted Relaxation Strategies Colouring- for example mandala's Drawing and painting Making crafts Hands on activities such a play doh or Floam Listening to favorite music Beading necklaces or bracelets Dancing Outdoor Activities such as going for a nature walk, hiking or bike riding School Work together to develop a common language Deliver the same information about anxiety and intellectual disability Emphasise practicing the preventative and response skills Focus on coaching not independent skill use Practice the skills you will need to make safety plan successful when you need it 5

6 Community Circle Bridge all the circles by working with community partners to connect family, school and community: deliver same info to therapists and supporters Let s Work through an Exercise Together Offer shadowing of individual treatment or community support attending parent education sessions Let s try. Think of an anxious child that you may work with Write down what you SEE when they are calm, alert, frustrated, upset and out of control Do not worry about filling in every blank; consider the behaviour you see and ask yourself where it might fall on this scale SAFETY OUT OF CONTROL Get HELP UPSET FRUSTRATED ALERT CALM REFOCUS AVOID TALKING GUIDED REDIRECTION Be a coach PRODUCTIVITY Build Skills PRACTICE and PREVENT Model What do we do? Now integrate recommendations, safety plans, Occupational Therapy or sensory based suggestions, communication strategies, leisure and other prevention skills Where would you put these ideas on the scale? How much support will the child need to use them? 6

7 How do we know this works? There is no established evidence base for the effectiveness of CBT with children/youth with Intellectual Disabilities. For the past 5 years, IDEAS team has been tracking symptom ratings, parenting stress, and outcome satisfaction. Tracking progress Developmental Behaviour Checklist to assess symptoms. CAFAS to assess treatment progress Parent Satisfaction with overall service coming soon: InterRAI, ChYMH-DD Our goal is to help complex children/youth and their families learn to manage their symptoms DBC - Parent Anxiety Score DBC - Parent Total Behaviour Problem Score Pre-Service Post-Service Pre-Service Post-Service N = 8; t(7) =.667, p<0.05 N = 8; t(7) =.396, p<0.001 CAFAS Total Behaviour Score Parent Satisfaction: Sense of Wellbeing Before Service 9.1 After Service Pre-Treatment Post-Treatment Child Wellbeing Family Wellbeing t() = 6.03, p<.001 Child: t(3) = , p<0.001 Family: t(1) = -.997, p<

8 Parent Group Overall Quality (6 Groups) Parent Group: How much did you learn? 69% 58% 6% 6% 1% 0 0 5% Poor Fair Good Very Good Excellent 0 % Nothing A Bit Some Good Amount A Lot Questions? Additional Resources Helping your anxious child: A step-by-step guide for parents by Ronald M. Rapee, New Harbinger Publications (000) Worried no more: Help and hope for anxious children by Aureen Pinto Wagner, Lighthouse Press, nd edition (005) Helping your child with selective mutism by Angela E. McHolm, Charles E. Cunningham, and Melanie K. Vanier, New Harbinger Publications (005) Talking back to OCD: The program that helps kids and teens say "no way" -- and parents say "way to go" by John S. March, The Guilford Press (007) What to do when you worry too much: A kid's guide to overcoming anxiety by Dawn Huebner, Bonnie Candace, Ellen Candace, Magination Press (006) Up and down the worry hill: A children's book about obsessive-compulsive disorder and its treatment by Aureen Wagner, Lighthouse Press, Inc. (00). Anxiety Disorders Association of British Columbia Anxiety Disorders Association of America Canadian Paediatric Society 8