Download Evidence-Based Individual Counseling with Children and

Evidence-Based Individual
Counseling with Children and
Adolescents with Anxiety
December 2, 2004
Carrie Franklin
Katie Myers
Misty Sommers-Tackett
Megan Stroh
Presentation Overview
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Introduction to Anxiety
Review of Empirically-Supported
Treatments
Description of Individual
Cognitive-Behavior Therapy
Illustration of a Sample Session
What did you Learn??
Questions/Discussion
Introduction to Anxiety
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Definition of Anxiety
Some Major Anxiety Disorders
Possible Etiology
Anxiety Disorders in the Schools
Definition of Anxiety
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A state of being uneasy,
apprehensive, or worried about what
may happen; concern about a
possible future event. Characterized
by a feeling of being powerless and
unable to cope with threatening
events, typically imaginary, and by
physical tension as shown by
sweating, trembling, etc.
(Webster’s Dictionary, 1999)
Why Anxiety???
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Most common and prevalent
class of disorders.
Other Characteristics:
~ Somatic complaints
~ Early onset
~ Chronic if untreated
~ High comorbidity
(Depressive Disorders)
(Mash & Barkley, 2003; and DSM-IV-TR, 2003)
When is Anxiety a Disorder?
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Transient fears and anxieties
are a normal part of
development
Clinically Significant Impairment
What does this mean??
~ Impairs functioning
~ Excessive/unreasonable
~ Difficult to control
(Mash & Barkley, 2003; and DSM-IV-TR, 2003)
Some Major Anxiety Disorders
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Separation Anxiety Disorder
Social Phobia
Specific Phobias
Generalized Anxiety Disorder
Separation Anxiety Disorder
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Excessive anxiety concerning
separation from the home or from
those to whom the person is
attached.
Prevalence = about 3.5%
Onset = preschool to 18yrs.
Usually develops after a life stress
Decreases in prevalence from
childhood through adolescence
(Mash & Barkley, 2003; and DSM-IV-TR, 2003)
Social Phobia
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Clinically significant anxiety
provoked by exposure to certain
types of social or performance
situations, often leading to avoidance
behavior.
Prevalence = 5 – 10 %
Onset = mid-teens
Stressful or humiliating experience
may cause onset
Duration may be lifelong if left
untreated
(Mash & Barkley, 2003; and DSM-IV-TR, 2003)
Specific Phobia
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Clinically significant anxiety
provoked by exposure to a specific
feared object or situation, often
leading to avoidance behavior.
Prevalence = 4 – 8 %
Onset = childhood or early
adolescence
Traumatic events can trigger a
phobia
Specific phobias in adolescence
increase the chances of additional
phobias later.
(Mash & Barkley, 2003; and DSM-IV-TR, 2003)
Generalized Anxiety Disorder
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Characterized by at least 6 months
of persistent and excessive anxiety
and worry.
Prevalence = about 5%
Onset = usually in childhood or
adolescence
Course is chronic
Exacerbated with stressful life events
(Mash & Barkley, 2003; and DSM-IV-TR, 2003)
Etiology
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Biological
Psychosocial
Family & Genetic Factors
Biological
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Behavioral Inhibition – low
arousal threshold
Parental panic disorder is
associated with behavioral
inhibition in 70 – 85% of their
children
(Mash & Barkley, 2003; and DSM-IV-TR, 2003)
Psychosocial
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Biological vulnerability +
stressful life events
Perception of control (or lack of
control)
Vulnerability can be affected by
support networks, coping skills,
or other resources.
(Mash & Barkley, 2003; and DSM-IV-TR, 2003)
Family & Genetic
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Children of clinically anxious
adults are 7 times more likely to
meet criteria for an anxiety
disorder.
Parental behavior may influence
the expression of anxiety in
children.
Parenting style is related to
anxiety in children.
(Mash & Barkley, 2003; and DSM-IV-TR, 2003)
Anxiety Disorders in the Schools
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Stress can lead to over arousal,
which may interfere with optimal
communication, performance, &
responsiveness.
This impacts education!
Most children with anxiety disorders
qualify for special education in Ohio
schools under the category
Emotional Disturbance
(Mash & Barkley, 2003)
(Ohio Model Policies and Procedures, 2003)
(Ohio Operating Standards, 2002)
Emotional Disturbance
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Characteristics:
~ Inability to learn
~ Inability to build/maintain
interpersonal relationships
~ Inappropriate types of behavior of
feelings
~ Pervasive mood of unhappiness or
depression
~ Tendency to develop physical
symptoms
(Ohio Model Policies and Procedures, 2003)
(Ohio Operating Standards, 2002)
Emotional Disturbance
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Qualifiers:
~ Long period of time
~ Marked degree
~ Adversely affects educational
performance
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Anxiety affects most children in
schools, but for these children,
school can seem unbearable.
(Ohio Model Policies and Procedures, 2003)
(Ohio Operating Standards, 2002)
Empirically Supported Tx
We are going to discuss:
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Medications
~ Sedatives
~ Heterocyclic Antidepressants
~ SSRI’s
Therapies that involve parents
~ Separation Anxiety
Group Therapy
~ Art Therapy
Alternative treatment considerations
Medications
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Sedatives (Librium (chlordiazepoxide), and Valium
(diazepam))
~ What they do: nervous system depressants,
reducing the effects of tension and overstimulation
by increasing the activity of the neurotransmitter
GABA.
~ Side Effects:
• drowsiness, fatigue, weakness, lightheadedness, or speech problems.
• Take caution in hyperactive children
• Possible chemical dependence
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Not for long term use, only temporary relief of
anxiety symptoms, some are not tested in children,
most are primarily used for children with epilepsy.
Medications
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Heterocyclic Antidepressants (Imipramine) –
- What the do: Trycyclic – refers to the chemical
nature of the drug. They block seratonin reuptake,
as well as that of norepinephrine. (Most common
for School Phobia).
- Statistics: 70% response rate – just as effective as
SSRI’s, yet have more damaging side effects to the
heart and circulatory system.
- Side Effects: racing pulse, disrupted heart-beat,
dangerous for cardiac patients (sudden death), dry
eyes, blurred vision, constipation (drying of
intestines), urinary problems, weight gain, sexual
dysfunction, high lethality (potential for overdose =
suicide).
Notes: Just as useful as SSRI’s, but the side effects
are much more dangerous. Mainly used for panic
attacks, migraines, chronic pains, bed-wetting, and
bulimia. Dosage should be started low and
increased over time.
Medications
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SSRI’s (Zoloft, Prozac, Paxil)
- Most highly recommended due to lesser side
effects and less chance of overdose.
- What they do: Selective Serotonin Reuptake
Inhibitor – help to balance the level of serotonin,
which also affects other neurotransmitters in the
process.
- Have been shown to be just as effective as
trycyclics. Still have to be taken for long periods of
time before results are shown. (Caution! This
means that a patient should be monitored during the
first month of medication, as the drug is being
increased in dosage). These have been shown to
work better than sedatives in anxious patients.
- Side Effects: Nausea w/o vomiting, loose stool,
diarrhea, nervousness/anxiety, loss of appetite,
insomnia, drowsiness, headache, sexual
dysfunction. Tend to go away over time, but dosage
can be decreased to adjust. Chance of weight gain,
but less in SSRI’s than in trycyclics. Chance of
hypomania/mania, should not be given to bipolar
patients. Hair loss – most often in women. May
affect clotting.
Involving Parents
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Importance of parent involvement
Ways that parents can directly
impact children with anxiety
- Separation Anxiety
- Group behavioral therapy (OCD
article)
Other caregivers who could be
useful:
- School nurse
- Teacher
- Siblings/family members
Group Therapies
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Art Therapy
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An Art Therapy Group for Children
Traumatized by Parental Violence
and Separation.
Alternative Treatment Options
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Diet & Health considerations
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Avoid refined sugar, soft drinks, white
flour products, and sweetened fruit
juice.
Vegetables and fruit
Water (mineral or spring)
Regular exercise
Aerobic activity
Pay attention to your sleeping habits
Avoid tobacco and caffeine
Alternative Treatment Options
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Herbal Remedies for Anxiety
German Chamomile +
 Ginkgo +++
 Kava +
 Lemon Balm +
 Passion Flower +
 Skullcap o
 Valerian +
 Quality of evidence (o, +, ++, +++)
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Description of Individual
Cognitive-Behavior Therapy
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Group vs. Individual Therapy
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Computer Based Cognitive
Therapy
Group vs. Individual Therapy
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Patient Preferences
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Treatment
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Follow-up
Group Therapy
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What are the advantages to the
participants for group therapy?
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What are the disadvantages to
group therapy for participants?
Computer Based
Cognitive Therapy
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What is CCBT?
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How does it compare to internet
therapy?
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Why do patients like it?
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Case Studies
Advantages to CCBT
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Time
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Money
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Flexibility
More about CBT
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Why use CBT on children with
anxiety disorders?
CBT strategies
Role-playing activity
Effectiveness of CBT for
treatment of anxiety disorders
Why use CBT on children with
anxiety disorders?
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Anxiety has cognitive,
behavioral, and physiological
features.
CBT interventions effect change
in thoughts, feelings and
behavior.
CBT teaches the child how to
cope with anxiety in the future.
CBT Strategies
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Coping modeling
Cognitive restructuring
Exposure to anxiety provoking
situations
Role-playing
Contingent rewards for effort
More CBT Strategies
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Homework
Affective education
Awareness of bodily reactions
and cognitions
Relaxation procedures
Application of new skills
Role-Playing Activity
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What strategies are being used?
Effectiveness of CBT for
Treatment of Anxiety Disorders
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Kendall (1994) reported that 64% of
the children who participated in the
Coping Cat treatment no longer met
diagnostic criteria for their primary
diagnosis at post-treatment. These
gains were maintained at a one-year
follow-up and a three-year follow-up
(Kendall & Southam-Gerow, 1996).
More Evidence of CBT
Effectiveness
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A second randomized clinical trial of
treatment by Kendall et al. (1997),
reported that 50% of children who
received the Coping Cat treatment
were free from their primary anxiety
disorder at post-treatment. The
children who still met criteria for an
anxiety disorder at post-treatment
demonstrated significant positive
change and these gains were
maintained at a one-year follow-up.
More Evidence of CBT
Effectiveness
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Barrett, Duffy, Dadds, & Rapee
(2001) study shows beneficial effects
of CBT for childhood anxiety
disorders are maintained 5 to 7
years after treatment.
CBT is effective in treating panic
disorder with 75% of patients
achieving panic-free end states
(American Psychiatric Association,
1998).
“What did you learn??”
Review
of the
Pre-test