Download Running head: COSTS OF TREATING YOUTH ANXIETY

Treating Anxious Children and Youth
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Running head: TREATING ANXIOUS CHILDREN AND YOUTH
Treating anxious children and youth with family-based therapy interventions.
D. Phillip Scoville and D. Russell Crane
Brigham Young University
__________________________________
D. Phillip Scoville, MS, is a doctoral student in Marriage and Family Therapy at Brigham
Young University. D. Russell Crane, PhD, is a professor of Marriage and Family
Therapy at Brigham Young University.
Please direct correspondence to: D. Phillip Scoville, Marriage and Family Therapy, 274
TLRB, Brigham Young University, Provo, Utah, 84602. E-mail:
[email protected]
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Treating anxious children and youth with family-based therapy interventions.
“Melissa is 9 years old. Her mother brought her to the clinic because
several days earlier, Melissa told her mother that she was afraid she was going to
die. She thinks that she might die from getting sick and she would ‘lose
everything.’ She also worries that she might have a heart attack when she’s older
but ‘not now.’ She worries that her mother might die and that her father may get
sick. She worries that her parents won’t come back when they leave home because
something will happen to them. She worries about burglars ‘a little, but not as
much as about dying.’ She also worries about vomiting and choking and,
according to her mother, she has had two panic attacks” (Beidel & Turner,
2005).
Anxiety disorders are among the most commonly diagnosed and treated mental
illnesses, with an estimated 30% of the United States population suffering from at least
one anxiety disorder over their lifetime (Kessler et al., 2005). Another estimate ranks
anxiety disorders as the “most commonly seen [mental illnesses] in the primary care
sector” while covering “25% of the total burden” of psychiatric disorders (Costa e Silva,
1998, pp. 2, 4). Moreover, additional research suggests that 27 million people suffer from
anxiety disorders in the United States annually (Kessler et al., 2005). As for the case of
anxiety disorders among children and youth, Anderson, Williams, McGee (1987)
reported that anxiety disorders are the “most common form of psychopathology in
children” with 8-12% of children suffering anxiety disorders. Additionally, Costello and
Angold (1995) found estimated prevalence rates of “any anxiety disorder” to range
between 5.7% and 17.8% in children.
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Many individuals, families, and businesses are suffering the results of the
symptoms found within this particular class of disorders. Many symptoms at some point
are within the range of normal thoughts and actions. However, as the symptoms become
more extreme in nature (i.e., excessive worrying, fears, phobias, obsessions, compulsions,
or flashbacks), negative effects are rendered on individuals, families, and businesses in
our cities and neighborhoods. Research has demonstrated that anxiety disorders have
reduced work performance or degraded employment outlook for those suffering from an
anxiety disorder as compared to those without this disability of anxiety disorders
(Waghorn, Chant, White, & Whiteford, 2005; Waghorn & Chant, 2005).
The need of the consumer, clinical agencies, and insurance reimbursement
agencies to know the relevant information about the costs of treating anxiety disorders is
increasingly relevant in our managed care world. The overall cost of health care services
for children, youth, and adults continues to grow, suggesting the need for alternative,
more effective and less costly, forms of treatments. In 2004 the total health care
expenditures in the United States were 1.9 trillion dollars and is expected to reach 4
trillion in the next decade alone (National Coalition on Health Care, 2004). Anxiety
disorders are a huge part of the burden on the United States economy. In the 1990’s,
researchers found that anxiety disorders cost more than $42 billion per year (DuPont,
Rice, Miller, Shiraki, Rowland, & Harwood, 1996; Greenberg, Sisitsky, Kessler,
Finkelstein, Berndt, Davidson et al., 1999). Depression costs a similar amount on society
($44 billion, Greenberg, Stiglin, Finkelstein, & Berndt, 1993). No specific costs of the
burden of childhood and youth anxiety disorders have been reported.
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There is a clear need to assess and treat anxiety disorder effectively and costeffectively in an effort to reduce the costs of mental and medical health care. Health
utilization patterns following marital or family therapy have shown that family-based
interventions are associated with higher percentages of reducing health care costs in an
HMO (Law & Crane, 2000; Law, Crane, & Berge, 2003).
Anxiety Disorders
Many anxiety disorders have been reported in current diagnostic manuals
(Diagnostic and Statistical Manual of Mental Disorder, 4th Ed, Text Revision, 1994) and
literature in the field (Beidel & Turner, 2005). This article informs on 12 anxiety
disorders potentially found in children or youth. These disorders are panic disorders (with
and without agoraphobia), specific and social phobias, generalized anxiety disorder,
separation anxiety disorder, obsessive-compulsive disorder, post-traumatic stress
disorder, substance-induced anxiety disorder, anxiety disorders not otherwise specified
(NOS), dental, medical fears, and chronic illness, and school refusal (Please see Table 1
below for more detail on these specific disorders).
Treating Anxious Youth Effectively
In the evolution of anxiety disorder treatment, cognitive-behavioral is the
theoretical underpinning that has been able to establish effectiveness through randomized
clinical trials (Kendall, 1994; Kendall, Flannery-Schroeder, Panichelli-Mindel, SouthamGerow, Henin, and Warman, 1997; Barrett, Dadds, and Rapee, 1996; Barrett, 1998;
Barrett, Healy-Farrell, and March, 2004). There are effective forms of treating anxiety
disorders and family-based interventions are a highly effective subgroup of CBT
interventions.
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Table 1: Anxiety Disorders in Children and Youth
Panic Attacka
sudden onset of intense apprehension, fearfulness,
or terror – symptoms include shortness of breath,
palpitations, chest pain, choking, and fear of
“going crazy” or losing control at present
a
Agoraphobia
avoidance of places or situations from which
escape might be difficult or lacking help in case of
panic attack
Panic Disorder with Agoraphobia
recurrent unexpected panic attacks and
agoraphobia
Panic Disorder without
recurrent unexpected panic attacks where there is
Agoraphobia
persistent concern
Specific Phobia
provoked by exposure to a specific feared object or
situation, leading to avoidance behavior
Social Phobia
provoked by exposure to certain social or
performance situations, then avoiding them
Generalized Anxiety Disorder
6 months of persistent excessive worry
Separation Anxiety Disorderb
severe and unreasonable fear of separation from
parent or caregiver
Obsessive-Compulsive Disorder
marked by obsessions [cause anxiety and distress]
and/or compulsions [neutralize anxiety]
Post-Traumatic Stress Disorder
(re-experiencing of an extremely traumatic event
with symptoms of arousal and avoidance
Substance-Induced Anxiety
anxiety symptoms judged to be a direct
Disorder
physiological consequence of drug or medication
abuse or toxin exposure
Anxiety Not Otherwise Specified
for symptoms about which there is inadequate or
contradictory information
Dental, Medical Fears, and Chronic fears relating to these specific health-related
Illnessc
situations
c
School Refusal
refusal to attend school or difficulty remaining for
entire day
Notes: Disorders from Diagnostic and Statistical Manual for Mental Disorders Fourth
Edition – Text Revision (DSM IV –TR) unless otherwise specified.
a
= non-codable DSM IV-TR disorders
b
= only DSM IV-TR childhood anxiety disorder
c
= Additional Childhood or Adolescent Anxiety Disorders as described by Beidel and
Turner (2005).
Kendall’s clinical trials (1994; 1997) reported with individual-based cognitivebehavioral treatments 64% and 50% of treated children no longer met diagnostic criteria
at post-treatment as opposed to 5% and fewer of waitlist condition in reducing anxiety
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symptomology across the three DSM-III-R anxiety disorders (Separation Anxiety
Disorder, Avoidant Disorder, and Overanxious disorder). Thus, individual-based
cognitive-behavioral treatment has been shown to be an effective form of treating anxiety
disorders.
Barrett’s group (Barrett, Dadds, & Rapee, 1996; Barrett, 1998) reported on a
family-based cognitive-behavioral treatment of childhood anxiety disorders (a replication
study of Kendall’s random clinical trials). The two studies found that the family-based
CBT treatments were more effective than the compared individual-based treatments and
wait-list condition for treating childhood anxiety disorders. Researchers reported that
84% and 65% of the family-based CBT were diagnosis free at post-treatment as
compared to 57% and 65% of individual-based CBT and 30% and 25% of the wait-list
condition. At long-term (12 month & 6 year) follow-up, researchers reported that both
clinical treatments were more effective than the wait-list condition. Family-based CBT
was shown to be at least as effective as individual-based treatments, if not more effective
(Barrett, Healy-Farrell, & March, 2004; Barrett, Healy-Farrell, Dadds, & Boulter, 2005).
Treating Anxious Children and Youth
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Why Family-based Treatment?
Family factors have been suggested to have an association with the development
and maintenance of childhood anxiety (Barrett, 1998). These factors include parental
anxiety and depression, family conflict, marital discord, and parental reinforcement of
avoidance coping strategies, negative feedback and parental restrictions. Family-based
treatments are considered an optimal treatment because of their ability to address and
manage the problems arising from these family factors. Family treatments foster a
therapeutic environment for parents to model for their children how to manage and
handle their disorder with a professional guidance and direction.
As cognitive-behavioral family-based therapy has been shown to be effective for
treating anxious children and youth, family therapists will continue to have the
opportunity to provide services for those who experience anxiety disorders. As with
cognitive-behavioral treatments, other family therapy methods may be useful in the
treatment of anxiety disorders; however there is limited empirical evidence supporting
specific types of family therapy treatment for anxiety disorders. One possible reason for
this stems from the family therapist beginnings of leaving behind the medical model of
diagnosing and labeling patients.
Conclusion
Family-based therapy may be more beneficial for children and youth with anxiety
disorders because they see parents and siblings learn how to cope with and manage their
anxiety. Since the inception of family therapy, systemic thinking is an important part of
basic intervention to broaden the scope of the problem to more than just a problem child
but to include problematic communication and difficulties that parents have to address
Treating Anxious Children and Youth
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their own problems and concerns in the marriage and the family. Additionally, familybased treatments may cost less in treating anxiety disorders than individual treatment for
children and youth because treatment includes families (parents and siblings) in the
process of overcoming the anxiety and receiving all family members receiving support in
this process of overcoming their own anxieties. As parents learn to handle and manage
their own anxiety in treatment with one child will help them know how to better parent
and teach their other children who may also have a disorder or symptomology of anxiety.
Family therapy is an optimal form of treatment for children and youth with anxiety
disorders.
Resources
This section includes a selection of resources that are available for clinicians and
parents who may be treating children and youth with anxiety disorders. First, in this
article a list of three resources are provided to assist clinicians with interventions in
treating childhood and youth anxiety disorders. Second, a list for clinicians to refer
parents who have children or youth with an anxiety disorders. Lastly, additional internet
resources for both clinicians and parents are provided.
Resources for Clinicians
1) Childhood Anxiety Disorders: A Guide to Research and Treatment by Deborah C.
Beidel & Samuel M. Turner
2) Anxiety Disorders in Children and Adolescents (2nd ed.) by Tracy L. Morris and
John S. March
3) Childhood Emotional and Behavioral Disorders by Bill Northey, Karen Wells,
Wendy Silverman, and C. Everett Bailey, In Effectiveness Research in MFT by
Douglas Sprenkle (Ed.)
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Resources for Parents
1) The Anxiety Cure for Kids: A Guide for Parents by Elizabeth Dupont Spencer,
Robert L. Dupont, and Caroline M. Dupont
2) Helping Your Anxious Child: A Step-By-Step Guide for Parents by Sue Spence,
Vanessa Cobham, Ann Wignall, & Ronald M. Rapee
3) What to Do When You Worry Too Much: A Kid's Guide to Overcoming Anxiety
(What to Do Guides for Kids) by Dawn Huebner & Bonnie Matthews
4) If Your Adolescent Has an Anxiety Disorder: An Essential Resource for Parents
by Edna Foa & Linda Andrews
Web Resources
1) Dr. Paula Barrett’s FRIENDS Program - http://www.friendsinfo.net/index.html
2) Dr. Philip Kendall Coping Cat - http://www.workbookpublishing.com/anxiety.htm
3) Dr. Ron Rapee’s Anxiety & You - http://www.psy.mq.edu.au/MUARU/index.htm
Treating Anxious Children and Youth 10
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