Presented at 2013 Accessibility Summit, McLean Bible Church, McLean, VA, April 20, 2013

1. Supporting Kids and Teens Who Struggle With
Anxiety
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

2. Learning Objectives:
 Recognize common signs and symptoms in kids
who struggle with anxiety
 Become familiar with contemporary
understanding of the causes of anxiety
 Examine the impact of anxiety on family
functioning and academic, social and spiritual
development in children and teens
 Review strategies for helping kids overcome
functional limitations associated with anxiety

3. “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)
Can a disability be a disability in some, but not all
environments?

4. 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, health
J Am Acad Child Adolesc Psychiatry 2007;46(2) 267-83.

5. 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

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

7. 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

8. 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

9. 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

10. Functional impairment in kids and teens
with anxiety…
Child Teenager
School: Difficulty separating from parents Test anxiety
Difficulty with class participation Difficulty with self-advocacy…getting help
Frequent trips to nurse‟s office Avoid extracurricular activities, social events
Performances, presentations Fear of failure inhibits class selection
Friends: Challenges in making new friends May depend on small circle of trusted friends
Parents often initiate social activity Challenges with group trips/activities
Difficulty with sleepovers Dating and breakups more challenging
Family: Often sleep with parents at night Slow to progress toward independence
Reluctant to try new activities Frequently reluctant to get driver‟s license
Conflict-dependence on electronic communication
Community: Less involved with sports, other May have more difficulty applying for jobs
extracurricular activities Less likely to docamps, travel experiences

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

12. 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.”

13. 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

14. Impacts of anxiety on church attendance and
spiritual development in children and teens…
Child Teenager
Weekend They prevent the family from They‟re reluctant to attend
Worship: attending… Reluctant to attend without friends
Difficulty separating from parents Uncomfortable with attention of group
Visiting new church challenging Transitions between age-group ministries difficult
Church Discomfort reading, praying aloud Disclosure in small groupschallenging
Activities: Reluctant to engage unfamiliar kids Unfamiliar places, experiences may be
Difficulty in unfamiliar environments threatening…retreats, mission trips
Spiritual Prone to misperceive who God is… More prone to ritualism
Disciplines Prayer, process of confession in Obsessions- doubting salvation, sinning against
some traditions challenging one‟s will
Group disciplines more challenging
Growing in Parents can model faith, practicing Parents can sensitively expose teens to new
faith at home: disciplines as a positive coping spiritual experiences
strategy

15. 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?

16. Tips for church staff and volunteers:
Kids with anxiety
 Don‟t call attention to an anxious child
 Kids 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 distress
 Leaders can watch for kids who are alone
 Offer to meet with parents when a child‟s anxiety
appears to interfere with ministry participation
 Remember…anxiety generally decreases with
experience (exposure)
 Remember potential areas of giftedness: administration,
organization, sensitivity to others

17. 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

18. 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

19. CAMS (Child-Adolescent Anxiety
Multimodal Study):
Response rates to treatment:
 Response rates: COMB: %Responders
80.7%, CBT: 59.7%, SER: 100
54.9%, PBO: 23.7% 80
 COMB>CBT=SER>PBO 60
 Effect Sizes: COMB: 0.86, 40
SER: 0.45, CBT: 0.31 20
%Responders
0
 No adverse effects>PBO in
medication groups
 Beneficial effects of COMB
vs. SER evident after week 8
Walkup JT et al, N Engl J Med, 2008;359:2753-2766

20. A final thought…
Rhett Smith-author of The
Anxious Christian
“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.”

21. 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

22. 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

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

24. 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/drgrcevich
http://www.facebook.com/pages/Key-Ministry/116940088329098
http://twitter.com/#!/drgrcevich
http://twitter.com/#!/KeyMinistry

25. Questions?

26. Additional Slides

27. 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.

28. Cognitive Behavioral Therapy (CBT)
Thoughts
Three Components:
 Cognitive
 Emotional/Physiological
 Behavioral Behavior Feelings

29. Cognitive Behavioral Therapy (CBT)
Unhealthy Process Healthy Process
Thoughts Distorted thinking: Overly More positive, acknowledge
negative, self-critical, success, balanced, and
selective and biased recognized strengths
Feelings Unpleasant, anxious, Pleasant, relaxed, happy,
depressed, angry calm
Behavior Avoid, give-up, Confront, try, appropriate
inappropriate

30. 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

31. 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- Gradually face fears
help skills

32. 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.

33. 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

34. Cognitive Behavioral Therapy (CBT)
Calming Strategy
 Catch your breath
 Accept negative feelings
 Label emotions
 Model coping skills

35. 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