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Treating Anxious Children and Youth 1 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] Treating Anxious Children and Youth 2 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. Treating Anxious Children and Youth 3 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. Treating Anxious Children and Youth 4 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. Treating Anxious Children and Youth 5 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 Treating Anxious Children and Youth 6 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 7 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 8 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.) Treating Anxious Children and Youth 9 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 References American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington, DC: Author. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Anderson, J. C., Williams, S. M., & McGee, R. (1987). DSM-III disorders in preadolescent children: Prevalence in a large sample from the general population. Archives of General Psychiatry, 44, 69-76. Barrett, P. M. (1998). Evaluation of cognitive-behavioral group treatments for childhood anxiety disorders. Journal of Clinical Child Psychology, 27, 459-468. 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. Barrett, P., Healy-Farrell, L. S., Dadds, M., & Boulter, N. (2005). Cognitive-behavioral family treatment of childhood obsessive-compulsive disorder: Long-term followup and predictors of outcome. Journal of the American Academy of Child & Adolescent Psychiatry, 44(10), 1005-1014. Barrett, P. M., Healy-Farrell, L., & March, J. S. (2004). Cognitive-behavioral family treatment of childhood obsessive-compulsive disorder: A controlled trial. Journal of American Academy of Child & Adolescent Psychology. 43, 46-62. Beidel, D. C., & Turner, S. M. (2005). Childhood anxiety disorders. A guide to research and treatment. Nueva York: Routledge. Costa e Silva, J. A. (1998). The public health impact of anxiety disorders: a WHO perspective. Acta Psychiatrica Scandinavica, 98, 2S–5S. Treating Anxious Children and Youth 11 Costello, E. J. & Angold, A. (1995). Epidemiology. In J. S. March (Eds.), Anxiety disorders in children and adolescents. New York: Guilford Press. 109-124. DuPont, R. L., Rice, D. P., & Miller, L. S., Shiraki, S. S., Rowland, C. R., & Harwood, H. J. (1996). Economic costs of anxiety. Anxiety, 2, 167-172. Foa, E. B., & Andrews, L. W. (2006). If your adolescent has an anxiety disorder: An essential resource for parents New York: Oxford University Press. Greenberg, P. E., Stiglin, L. E., Finkelstein, S. N., & Berndt, E. R. (1993). The economic burden of depression in 1990. Journal of Clinical Psychiatry, 54, 405-418. Greenberg, P. E., Sisitsky, T., Kessler, R. C., Finkelstein, S. N., Berndt, E. R., Davidson, J. R. T., Ballenger, J. C., & Fyer, A. J. (1999). The economic burden of anxiety disorders in the 1990s. Journal of Clinical Psychiatry, 60, 427-435. Huebner, D. Matthews, B. (2005). What to do when you worry too much: A kid's guide to overcoming anxiety Washington, D.C.: Magination Press. Kendall, P. C. (1994). Treating anxiety disorders in children: Results of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 62, 100-110. Kendall, P. C., Flannery-Schroeder, E., Panichelli-Mindel, S. M., Southam-Gerow, M., Henin, A., and Warman, M. (1997). Therapy for youths with anxiety disorders: A second randomized clinical trial. Journal of Consulting and Clinical Psychology. 65, 366-380. Kessler, R. C., Berglund, P., & Demler, O. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry, 62, 593-602. Treating Anxious Children and Youth 12 Law, D. D., & Crane, D. R. (2000). The influence of marital and family therapy on health care utilization in a health-maintenance organization. Journal of Marital & Family Therapy, 26(3), 281-291. Law, D. D., Crane, D. R., & Berge, J. M. (2003). The influence of individual, martial, and family therapy on high utilizers of health care. Journal of Marital & Family Therapy, 29(3), 353-363. Morris, T. L., & March, J. S. (2004). Anxiety disorders in children and adolescents (2nd ed.). New York: Guildford Press. National Coalition on Health Care. (2004). Facts on the cost of health care. Retrieved August 4, 2006, from http://www.nchc.org/facts/2007%20updates/cost.pdf. Northey, W. F., Jr., Wells, K. C., Silverman, W. K., Bailey, C. E., & Sprenkle, D. H. (2002). Childhood behavioral and emotional disorders. In Effectiveness Research in Marriage and Family Therapy. (pp. 89-121): American Association for Marriage and Family Therapy. Rapee, R. M., Spence, S. H., Cobham, V., & Wignall, A. M. (2000). Helping your anxious child: A step-by-step guide for parents. Oakland, CA: New Harbinger Spencer, E. D., DuPont, R. L., & DuPont, C. M. (2004). The anxiety cure for kids: A guide for parents. New York: Wiley. Waghorn, G. & Chant, D. (2005). Labor force activity by people with depression and anxiety disorders: A population-level second-order analysis. Acta Psychiatrica Scandinavica, 112(6), 415-424. Treating Anxious Children and Youth 13 Waghorn, G., Chant, D., White, P. (2005). Disability, employment and work performance among people with ICD-10 anxiety disorders. Australian and New Zealand Journal of Psychiatry, 39(1-2), 55-56.