Download Christian F. Mauro, Ph.D.

Christian F. Mauro, Ph.D.
Assistant Clinical Professor
Director, Psychosocial Treatment Clinic
Duke Child and Family Study Center
2608 Erwin Road
Lake View Pavilion Suite 300
Durham, NC 27705
(919) 668-0081
[email protected]
Cognitive Behavioral
Therapy for Children &
Adolescents with Anxiety
Disorders
AHEC Webinar
February 22, 2012
AGENDA
1)
2)
3)
4)
Review childhood anxiety disorders and their
prevalence
Understand the principles of Cognitive
Behavioral Therapy (CBT)
Learn the Key Components of CBT with
anxious youth
Working with Anxious Families
1) Review of Anxiety Disorders

“an overwhelming sense of
apprehension and fear often
marked by physiological signs
(sweating, tension, and
increased pulse), by doubt
concerning the reality and
nature of the threat, and by
self-doubt about one's capacity
to cope with it”
Normal Fears



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Infancy: loss of support, loud unexpected noises
1yr-3yrs: separation from attachment figure,
strangers, toilet, Dr. visits, dark
Preschool: animals, dark, ghosts, monsters,
sleeping alone, sudden changes,
Early School Age: being alone, health and harm
issues
Normal Fears (cont.)

Later School Age: tests (EOGS), failure, making
mistakes, rejection, robberies, kidnapping, wars,
current events, public speaking

Adolescence: social evaluation, appearance,
performance and competence in a variety of
domains
Fear and Anxiety
 Evolutionarily
Adaptive
 No Acute Onset (except PTSD)
 Many early risk factors both biological
and environmental
 Presentation varies with age
When does anxiety become a
“disorder”?

When fears are excessive, beyond voluntary
control, cannot be reasoned with, are not age
specific, persist over time, and result in:

Avoidance
Interference
Distress


Questions to Ask

Intensity?

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Out of proportion
Frequency?
Excessive
 Reassurance doesn’t
help


Content

Harmless situations or
events
Anxiety Disorders

Separation Anxiety Disorder

Generalized Anxiety Disorder

Social Phobia

Specific Phobia

Panic Disorder

Obsessive Compulsive Disorder
Separation Anxiety Disorder

Developmental differences

Insidious Development

Most often diagnosed in pre-pubescent
children.
Generalized Anxiety Disorder
C) ONE of the following:
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 asleep, staying
asleep, or restless unsatisfying sleep)
Generalized Anxiety Disorder
Common Worries:





Performance to the point of being perfectionistic
Little things (being late, being yelled at)
Adult concerns such as family finances, health
Usually begins in middle childhood
Somatic complaints, Sleep Problems, Subtle Avoidance
Social Phobia
Common characteristics:

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
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


Considered shy and quiet
Are reluctant to join group activities
Excessive concern with embarrassment, negative
evaluation, and rejection
Often have few friends
Endorse feelings of loneliness
Most often diagnosed in adolescents
Most common anxiety disorder in adults
High risk for developing depression
Specific Phobia
Types:
 Animal
 Natural Environment (heights, storms, water)
 Blood-Injection-Injury
 Situational (airplanes, elevators, dentist)
 Other (choking, vomiting, loud sounds, clowns)
* Phobic reaction is excessive and out of demand of the
situation, leads to avoidance, persists over time, and is
maladaptive compared to normal developmental fears
Panic Disorder


Panic Disorder with or without Agoraphobia
Agoraphobia = fear of open, public places
Difficult to diagnose in children:
 Hard for young children to verbalize fears but there
usually is a trigger
 Fears of specific autonomic symptoms usually occurs in
late adolescence.
Obsessive Compulsive Disorder

Normal developmental rituals (arranging toys & nighttime rituals) are not excessive, differ in content from
OCD rituals & typically dissipate by age 9

Children with OCD often do not recognize the
unreasonable nature of their obsessions or compulsions.

In very young children compulsions often occur without
cognitive obsessions and are described as “urges”

In 90% of children - the symptom pattern changes
over time
Diagnostic Issues: Summary



Anxiety is a basic human emotion that is adaptive and
used to alert a person of a potential physical or
emotional threat
Anxiety is normal in certain contexts
young children – separation, dark, first day of school
middle childhood – tests, performance
adolescents – learning to drive, dating, appearance
Anxiety becomes pathological when it is pervasive,
intractable, leads to excessive avoidance, and
interferes with daily functioning.
Developmental Trajectory

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Birth
Toddler
Pre-K,KG
Elem. years
Adolescence
Adulthood
Anxious Temperament/Fussy
Behavioral Inhibition
Separation Anxiety Disorder
Generalized Anxiety Disorder
Social Phobia
Depression/Anxiety/Panic
Developmental Trajectory
Single disorders are episodic
 Comorbid disorders are common and
chronic
 Significant impairment and family burden
 Strongly predict adult psychopathology

Prevalence in Youth

Anxiety disorders are among the most common
conditions affecting youth

Eleven of 15 epidemiological studies estimate
the lifetime prevalence of ANY impairing
anxiety disorder at greater than 10%, several as
high as 25%
Prevalence In Youth
(Ages 9-16)

36.7% of all youth will have one psychiatric
disorder at some point

25% have 2 or more (comorbidity)

10% of 9-16 year olds will have an anxiety
disorder (12% girls, 8% boys)
Costello, EJ. Archives of General Psychiatry 2003 60:837-844.
Prevalence in Youth

Specific phobias are most frequent, followed by
Social phobia 7 - 9%

SAD, GAD and agoraphobia are in the range of
4 - 6%

OCD and panic disorder are less frequent,
between 1 - 3.5%
Unmet Need

Studies show that anxious youth in the
community are unlikely to receive adequate
assessment and treatment

In a primary care setting, only 31% of
youngsters identified with an anxiety disorder
received mental health care
40% for depressed youth
 79% for youngsters with ADHD

2) CBT Principles

Created by Classical Conditioning

Exacerbated by Stimulus Generalization

Maintained by Operant Conditioning
Classical Conditioning

UCS (loud noise)
>
UCR (fear)

>
CR (fear)

CS (song) = UCS (loud noise)
CS (baseball bear)

CS (baseball bear no song)
>
Extinction of
CR (fear)

CS (bear) + CS (song)
>
Spontaneous
Recovery of CR
Example (Cont.)

CS (all animals + songs)
>
CR (fear)
Stimulus
Generalization

CS (bear) + CS (song)
+ CS (happy, singing, dancing)
>
Counterconditioning

CS (bear) + UCS (song)
Repeated exposures
>
Habituation
Operant Conditioning

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Learning theory of Anxiety:
Positively reinforced by attention (reassurance)
& tangible rewards
Negatively reinforced by avoidance
Punishment of independent, nonanxious
behavior
Negative Reinforcement

An increase in the probability of a behavior
through the REMOVAL of an aversive stimulus

Example:
Child doesn’t want to go to school
 At height of tantrum parent gives in
 Child goes home and experiences relief

Negative Reinforcement (Child)
Anxiety
Avoid
Relief
Negative Reinforcement
Negative Reinforcement (Parent)
Tantrum
Giving
In
Relief
Negative Reinforcement
How Negative Reinforcement Works
Panic Attack
A
N
X
I
E
T
Y
Stimulus
Avoidance
Anticipatory
Anxiety
TIME
It works because….
 Prevents
Habituation
 Escape is Reinforced
 Giving in is Reinforced
 No experience of Mastery
Incorporating Cognition


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Self-efficacy – belief that one can effectively
cope with a feared object or event strongly
influences anxiety reactions
Real world performance accomplishments are
most effective means to increase self-efficacy
Guided modeling
Cognitive Biases

Anxiety is related to cognitive biases that occur
during information processing system

Schemas (info processing structures) tend to
direct more attention to dangers, interpret
ambiguous situations as threatening, and
remember fear relevant cues
Common Biases

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Low evaluations of self-efficacy
Use avoidance as a solution
Overestimate negative outcomes
Higher rates of negative thoughts
Negative self focus
Catastrophize predicted outcomes
Cognitive Behavioral Therapy

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Behavioral, cognitive, and affective interventions
to effect change in thoughts, feelings, behaviors
Emphasis on learning process, models, variables
maintaining the anxiety
(antecedents & consequences)
Information processing of child
Emotional experiencing style (Exposures)
All understood within cultural & social context
Current Evidence Base

Between 1980 – 2010
98 Published RCTs
 53 Psychosocial and 45 Medication

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Broad Conclusion = Both CBT and SSRI
medications are effective
Child and Adolescent Anxiety
Multimodal Treatment Study (CAMS)

To advance our understanding of the treatment
of childhood anxiety disorders
Separation Anxiety Disorder
 Social Phobia
 Generalized Anxiety Disorder


Compare Medication vs. CBT vs. COMBO
Treatments Response Rates at Week 12
81
90
Percent Response
80
60
70
55
60
50
40
30
24
20
10
0
PBO
SER
CBT
COMB
PARS: Random Regression
18
COMB
SRT
CBT
PBO
14
10
6
WK 0
WK 4
WK 8
WK 12
3) Learning the Key
Components of CBT
Assessment

Multiple Informants
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Parents, Child, Teachers
Multiple methods
Structured Diagnostic Interview (ADIS, K-SADS)
 Behavioral Observations
 Rating Scales (PARS, MASC, RCADS)

Coping Cat
Phil Kendall, Ph.D.
Center for Child and Adolescent Anxiety
Disorders at Temple University
www.workbookpublishing.com
Cognitive Behavioral Therapy

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Cognitive Behavioral Therapy (CBT) program
includes:
Psychoeducation
Affective education
Awareness of bodily reactions and cognitive
activities when anxious
Identifying anxious self-talk and modifying it to
coping self-talk
Cognitive Behavioral Therapy
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Relaxation Training
Graduated exposure to anxiety-provoking situations
Practice of newly acquired skills in increasingly
anxiety provoking situations
Role-play procedures and coping modeling by the
therapist
Homework Assignments
Contingent Rewards
Fear Thermometer

SUDS
10-
NO WAY!
9-
Really hard!
7-
I don't think so!
5-
Maybe I can try but I'm not too sure.
3-
I'm a little scared but I can do it.
1-
No problem!
The “FEAR” Plan
F
– Feeling Frightened
 E – Expecting Bad Things to Happen
 A – Actions and Attitudes that can
Help
 R – Results and Rewards
Exposure:
The Key Ingredient
How to conduct exposures with
children and adolescents
General rule

What ever the name or the technique used, the
key essential ingredient to successful exposure is
prolonged, systematic, and repeated contact with
the avoided stimuli so habituation can occur
B before C, C before B?

Regardless of your theoretical bent

“Exposure is an emotional experience that corrects
dysfunctional associations between threat and the
feared stimuli”

“Exposure reinforces the patient’s perceived selfefficacy to cope successfully with the feared stimuli”
Aspects that are the different with
adults and children

Children generally need a stronger behaviorally
based component to their treatment

Extensive parental involvement
Fundamental principles in exposure
with children and adolescents

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Exposures should be progressive with respect to
the hierarchy of feared situations
Use of graduated exposure hierarchy is very
important when working with children
If too difficult, children are likely to refuse or not
return
 Children often difficulty predicting how anxious they
will be and will underestimate their anxiety
 Never force a child to do an exposure task

Fundamental principles in exposure
with children and adolescents
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Encourage the use of coping strategies to
facilitate remaining in the feared situation
Liberal use of coping modeling
Many repetitions of the exposure are needed; in
general, continue until the task becomes
“boring”
Exposures tend to be most effective when
prolonged, massed, and in vivo
Fundamental principles in exposure
with children and adolescents

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Review previously learned strategies and
exposure experiences before transitioning to
more difficult exposure
Parental involvement is crucial
Homework outside of therapy is necessary for
generalization
Always reward effort, not just success
4) Family Issues
Parent Involvement

Consultants – provide info to therapist

Collaborators – help carry out treatment
components

Co-clients – exhibit behaviors that contribute to
or maintain their child’s anxiety
Common Challenges

Rescuing the Child


Reinforces avoidance due to own discomfort with
child’s anxiety
Contingency Management Training

Teaching extinction = removal of unintentional
reinforcers such as reassurance and avoidance
Common Challenges

Negative Attitude/Attendance

Failure to Set Limits

Parent Psychopathology

Disagreement between parents
Resources
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Anxiety Disorders Association of America
www.adaa.org
Association for Behavioral and Cognitive
Therapies
www.abct.org