Download Tough Kids: Practical Behavior Management

+High Incidence
Condition
Presentation:
Presented by
Chloe Ruebeck
Anxiety Disorders
University of Utah
May 05, 2009
Training School Psychologists to be Experts in Evidence Based Practice for Tertiary Students with Serious
Emotional Disturbance/Behavioral Disorders
Department of Educational Psychology
School Psychology Program
US Office of Education 84.325K
H325K080308
+
Common Anxiety Disorders in
Youth
Generalized Anxiety Disorder (GAD)
Obsessive Compulsive Disorder (OCD)
Social Phobia/School Phobia
Panic Attacks (among Adolescents)
+ DSM-IV-TR Diagnostic Criteria for 300.02
General Anxiety Disorder (Includes
Overanxious Disorder of Childhood)
A. Excessive anxiety and worry (apprehensive expectation), occurring
more days than not for at least 6 months, about a number of events
or activities (such as work or school performance).
B. The person finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the
following six symptoms (with at least some symptoms present for
more days than not for the past 6 months). Note: Only one of the
following items is required in children.
(1) restlessness or feeling keyed up or on edge (2) being easily fatigued (3)
difficulty concentrating or mind going blank (4) irritability (5) muscle
tension (6) sleep disturbance (difficulty falling or staying asleep, or restless
unsatisfying sleep)
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General Anxiety Disorder: DSM-IVTR Cont.
D. The focus of the anxiety and worry is not confined to
features of an Axis I disorder.
E. The anxiety, worry, or physical symptoms cause
clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
F. The disturbance is not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition (e.g.,
hyperthyroidism) and does not occur exclusively
during a Mood Disorder, a Psychotic Disorder, or a
Pervasive Developmental Disorder.
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Special Considerations
o
This disorder is highly developmentally linked, many fears and
anxieties may be outgrown.
o
Anxiety is a highly comorbid disorder with behavioral
disorders, depression, substance abuse and other anxiety
disorders; comorbidity rates ranging from 65-84% in
epidemiological and clinical samples (Bird, Gould, & Staghezza,
1993; Albano, Chorpita, Barlow, 2003) .
o
There are three considerations that should be taken into account
when diagnosing. First, is the anxiety produced by an actual
threat, then the youth’s developmental context, and lastly the
degree of impairment.
o
There are two types of anxieties, state and trait. State anxiety can
occur in certain situations and trait anxiety is more stable
occurring across situations (Cattell & Schier, 1961, 1963)
o
Anxiety can cause significant school problems for children both
academically and socially (Ginsburg & Silverman, 1996)
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History of Anxiety
Psychologists have struggled to understand what
causes anxiety, since the birth of modern
psychology.
For example, Freud’s early work focused on
childhood anxiety (Little Hans).
Most of the theories come from a behavioral
cognitive standpoint, that believes that fears can
be both learned and unlearned.
One of the best know examples in support of this
theory, is the study of Little Albert by John Watson
in 1920.
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Cause/Contributory Factors

According to Gray’s Model, the Behavioral Inhibition System (BIS)
causes anxiety. Anxiety symptoms occur when the Comparator
subsystem of the BIS predicts an aversive or unmatching future event
(1982).

Many of these aversive ideas come from individuals’ schemas. These
schemas are usually established early in development. A number of
theories for this acquisition are; “preparedness” (Seligman, 1970,1971),
two-factor theory (Mowrer, 1939), approach-withdrawal theory
(Delprato & McGlynn, 1984) and social learning theory (Bandura, 1977).

Some of the causes of these negative schemas are academic
performance, situational variables in the family or at school, stress and
pressure, perceived or real expectations by self or others, and degree of
success in social and academic situations (Huberty, 45-52).

Genetics also plays a role in anxious youth. Children of anxiety
disordered mothers are more likely to have anxiety. Another factor that
contributes to this, is modeling (Last, Hersen, Kazdin, Francis, & Grubb,
1987).
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EBP Assessment Procedures for
Anxiety

Behavior Rating Scales

Direct Observations

Functional Behavior Assessments

Parent/Child Interview
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EBP Assessment Procedures
Behavioral Rating Scales/Checklists:
Beck Anxiety Inventory (BAI)
Behavior Assessment Scale for Children-II (BASC)
Child Behavior Checklist (CBCL)
Revised Children’s Manifest Anxiety Scale (RCMAS)
Millon Adolescent Clinical Inventory (MACI)
Minnesota Multiphasic Personality Inventory-II (MMPI2)
Multidimensional Anxiety Scale for Children (MASC)
+
EBP Reviews
Barrios and O’Dell’s Review (1998)
Chorpita and Colleague’s Review (2002)
Silverman, Pina and Viswesvaran (2008)
+EBP Treatment/Interventions
(Chorpita, B.F., & Southam-Gerow. M.A. (2006). Fears and Anxieties. In Eric J. Mash & Russell A. Barkley,
Treatment of Childhood Disorders, Third Edition (pp. 271-335). New York, NY: The Guilford Press. )
Exposure
•
In vivo or direct exposure
•
In vitro or imagined exposure
•
Graduated exposure
•
Systematic Desensitization- relaxation training with
subsequent graduated exposure trials
•
Implosion- rehearsal of a feared stimulus or event, with
added meaning presented by the therapist
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EBP Treatment/Intervention Cont.
Modeling
•
Live Modeling- watching a person successfully interact with a
feared stimulus
•
Symbolic Modeling- through video or in a photograph
•
Covert Modeling- imagine the model interacting with feared
stimulus
•
Participant Modeling- First asked to watch and then to
perform the same behaviors as the model
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EBP Treatment/Intervention Cont.
Cognitive Techniques
•
Cognitive-behavioral therapy (e.g., Barrett, Dadds, & Rapee, 1996;
Kendall et al., 1997)
•
Self-management or Self-talk
•
Cognitive restructuring- first identify negative self-talk and
then the therapist can replace it with a more adaptive ones
•
Attributional retraining- a child is asked to distinguish his or
her attributions to many situations, the therapist can then
introduce alternative attributions and they can test them out
for efficacy
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EBP Treatment/Intervention Cont.
Other Effective Techniques
•
Emotion Skills Training- recognize, label and self-monitor
•
Relaxation Training
•
Contingency Management (typically paired with exposure)
•
Self-monitoring
•
Problem-solving Training
•
Medications- SSRIs (fluvoxamine, fluoxetine, sertraline,
clomipramine-most effective for OCD)
+
Fads and Non-EBP
Eye Movement Desensitization and Reprocessing (EMDR)
Treatment for Post Traumatic Stress disorder by Dr. Francine
Shapiro
+ Recent Intervention-Coping Cat for
Generalized and Social Anxiety Disorders
(Kendall, 2002)
•
A 16-20 cognitive-behavioral therapy session treatment
package that includes both a skills training and exposure
component, that is implemented in a small group format
•
First, they are taught the FEAR steps: Feeling frightened,
Expecting bad things to happen, Actions and attitudes to
take, and Results and rewards (first 8 sessions)
The specific steps are:
1. Recognizing anxious feelings and somatic reactions
2. The role of cognition and self-talk in exacerbating anxious
situations
3. Using problem-solving and coping skills to manage anxiety
4. The use of self-evaluation and self-reinforcement strategies
to help coping maintenance
•
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Coping Cat Cont.
•
The remaining 8-12 sessions focus on tailoring coping plan’s
for each child’s fears and anxieties, while implementing
modeling, in vivo exposures, role plays, relaxation training,
and contingent reinforcement
•
The Revised Children's Manifest Anxiety Scales (RCMAS)
was used as the dependent measure along with a battery of
other scales and interviews, children were given these scales
at pre and post test
•
Parents and teachers were also asked to report anxiety
symptoms using the CBCL
•
The parents reported that 71% of the children no longer had
their primary anxiety disorder as their primary disorder and
51% no longer met criteria for their primary anxiety
disorder at post-treatment (Kendall et. al., 1997).
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Conclusions

A number of treatments have shown to be efficacious in
reducing and treating anxiety related symptoms, moreover, a
combination of interventions may be the most effective in
treating children with anxiety disorder.

Eisenberg, Cumberland, and Spinrad (1998), suggest that
getting the parents involved in treatment and encouraging
them to talk to their children, accept them and be supportive
could help improve their emotional competence.
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References

Albano, A.M., Chorpita, B.F., & Barlow, D.H. (2003). Childhood anxiety disorders. In E.J.
Mash & R.A. Barkley (Eds.), Child psychopathology (2nd ed., pp. 279-329). New York:
Guilford Press.

Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall.

Barrett, P. M., Dadds, M. R., & Rapee, R. M. (1996). Family treatment of childhood anxiety:
A controlled trial. Journal of Consulting and Clinical Psychology, 64, 333–342.

Bird, H.R., Gould, M.S., & Staghezza, B. M. (1993). Patterns of diagnostic comorbidity in a
community sample of children aged 9 through 16 years. Journal of the American Academy
of Child and Adolescent Psychiatry, 42 (4), 415-423.

Chorpita, B.F., & Southam-Gerow. M.A. (2006). Fears and Anxieties. In Eric J. Mash &
Russell A. Barkley, Treatment of Childhood Disorders, Third Edition (pp. 271-335). New
York, NY: The Guilford Press.

Delprato, D.J., & McGlynn, F. D. (1984). Behavioral theories of anxiety disorders. In S. M.
Turner (Ed.), Behavioral theories and treatment of anxiety (pp. 1-49). New York: Plenum
Press.

Eisenberg, N., Cumberland, A., & Spinrad, T. (1998). Parental socialization of emotion.
Psychological Inquiry, 9, 241–273.
+
References

Ginsburg, G. S., & Silverman, W. K. (1996). Phobic and anxiety disorders in Hispanic and
Caucasian youth. Journal of Anxiety Disorders, 10, 517–528.

http://www.emdr.com/briefdes.htm

Huberty, T. Children and Anxiety

Kendall, P. C. (2002). Coping Cat therapist manual. Ardmore, PA: Workbook.

Kendall, P. C., Flannery-Schroeder, E., Panichelli-Mindel, S. M., Southam- Gerow, M., Henin,
A., & Warman, M. (1997). Therapy for youths with anxiety disorders: A second randomized
clinical trial. Journal of Consulting and Clinical Psychology, 65, 366 –380.

Last, C. G., Hersen, M., Kazdin, A. E., Francis, G., & Grubb, H. J. (1987). Psychiatric illness
in the mothers of anxious children. American Journal of Psychiatry, 144, 1580 –1583.

Mowrer, O.H. (1939). A stimulus-response analysis of anxiety and its role as a reinforcing
agent. Psychological Review, 46, 553-565.

Seligman, M.E.P. (1970). On the generality of the laws of learning. Psychological Review,
77, 406-418.
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References

Silverman, W.K., Pina, A.A., & Viswesvaran, C. (2008). Evidence-based psychosocial
treatments for phobic and anxiety disorders in children and adolescents. Journal of
Clinical Child and Adolescent Psychology, 37, 105-130.

Suveg, C., Sood, E., Barmish, A., Tiwari, S., Hudson, J., & Kendall, P. (2008, December). 'I'd
rather not talk about it': Emotion parenting in families of children with an anxiety
disorder. Journal of Family Psychology, 22(6), 875-884.

Watson, J.B., & Rayner R. (1920). Conditioned emotional responses. Journal of
Experimental Psychology, 3, 1-14.