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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 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? 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: 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 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 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 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 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 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 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 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 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 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 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 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 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 Anxiety Disorders Association of America www.adaa.org Association for Behavioral and Cognitive Therapies www.abct.org