Title: Child and Adolescent Anxiety Disorders: Keeping Calm with Kids
1Child and Adolescent Anxiety Disorders Keeping
Calm with Kids
- Mark A. Reinecke, Ph.D.
- Northwestern University
- SASED
- Northern Illinois University
- Naperville, IL.
- February 28, 2014
2COI Disclosure
- Brian Harty Foundation
- HRSA GPE Psychology Training Grant (PI)
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7Were Living in a Worried World
- Every life has its share of anxiety, worry,
fear and dread
8Unemployment
9Terrorism
10Deficit Financial Security
11Saving for Retirement
12Global Warming
13Worries In Everyday Life
- Scheduling activities for 3 kids
- Bullying at school
- How will my son do on the ACT?
- Credit card debt
- Sick pet
- My hot water heater died
- Caring for grandparents
- Chronic illness
- My son shags cigarettesis he drinking?
- Empty nestkids leaving
- Boomerangkids returning
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15Twenty Lessons
- Lesson 1 Anxietyit works
- Lesson 2 AnxietyThe Big A
- Lesson 3 We overestimate risk when were
afraid - Lesson 4 The future is uncertain
- Lesson 5 Influence and control
- Lesson 6 You have the power to control the
level of anxiety you feel - Lesson 7 Perfect solutions dont exist
- Lesson 8 Sometimes bad things are
controllable sometimes not. - Lesson 9 Intrusive thoughts are normal. Its
the meaning that counts. - Lesson 10 Dwelling on problems impairs ones
ability to cope. - Lesson 11 Worrying is highly over rated.
- Lesson 12 Do not magnify the importance of
your physical sensations - Lesson 13 Its time to relax
- Lesson 14 Evaluate your thoughts themselves
- Lesson 15 Changing your thoughts
- Lesson 16 Avoiding problems is among the
worst things one can do. - Lesson 17 Social Anxiety Worrying a bit too
much what others think - Lesson 18 Whats really on your mind?
16 Lesson 1. AnxietyIt Works
- What exactly is anxiety?
- Based in Limbic system
- A normal, highly adaptive emotional state
- Facilitates response to a perceived threat
17A Plate with C. Elegans
18Sydney Brenner, D.Phil
- South African biologist
- Worked at CRC, Cambridge University
- Now at Salk Institute
- Nobel Prize in 2002
- Established C. Elegans as a model organism to
study genetics and cell development.
19First Complete Genetic Map
100 million base pairs 20,000 genes
20A Simple Nervous System
Nervous system consists of 302 neurons that form
a small-world network Their interconnections have
been completely mapped out
21C. Elegans
22Lesson 2.AnxietyThe Big A
- Anxiety has 4 components
- Affect
- Physiological
- Cognitive
- Behavioral
- Organizes perception, memory, action
23What Do Children Worry About?
- Five Factor Model (Ollendick, 1983)
- Failure Criticism
- Unknown
- Injury Small Animals
- Danger Death
- Medical Fears
- Child Psychoeducation Anxiety Parent
Psychoeducation - Anxiety -
24Developmentally Appropriate Fears
- Infancy Separation, strangers
- Early childhood Loud noises, dark, doctors,
animal - Middle childhood Frightening events (Scary
movies) - Adolescence New experiences, social rejection
- Parent Psychoeducation - Anxiety
- Child Psychoeducation - Anxiety
25Normal Fears of Childhood
26Normal Fears of Teens
27Epidemiology
- 5-18 of all children and adolescents
- 80 of adults with anxiety disorders report
anxiety symptoms prior to 18 yrs - High levels of comorbidity
- Increased risk of anxiety, substance abuse, and
depression in adulthood - Impaired academic, social, family functioning
28DSM-IV Anxiety Disorders
- Obsessive-Compulsive Disorder (OCD)
- Generalized Anxiety Disorder (GAD)
- Post Traumatic Stress Disorder (PTSD)
- Panic Disorder
- Separation Anxiety Disorder
- Social Phobia, Social Anxiety
- Simple Phobia
- Atypical Anxiety Disorder (School Phobia?)
29 Serious Anxiety is Common
- GAD 2-5
- Social Anxiety 3-18
- Selective Mutism gt1
- Specific Phobias 3-20
- Separation Anxiety 3-5
- Panic 1
- PTSD 6
- OCD 1-4
30Comorbidity Number of diagnoses in an anxiety
disordered sample
31Etiology and Maintenance
32Etiology
- Genetics
- Environment
- Temperament (shy, inhibited, risk averse)
- Parent
Psychoeducation - Anxiety
33 Heritability of Psychiatric
DisordersHeritability Psychiatric
Disorder Other conditions
- Zero Language, Religion
- 20-40 Anxiety, Depression Myocard
ial Infarction - Bulimia Breast Cancer, Hip Fracture,
Personality - 40-60 Alcohol, Drug Dependence
Blood Pressure, Adult -
Onset Diabetes,
Plasma Cholesterol, Asthma - 60-80 Schizophrenia, Bipolar
Disorder Weight, Bone Density -
- 80-100 Autism Height, Brain
Volume
34Brain Metabolism in OCD
- Basal Ganglia (Caudate)
- R. Anterior Cingulate
- R Orbitofrontal Cortex
35The Essence of Anxiety
- Fearful Anticipation
- Rumination, Worry
- Vigilance
- Autonomic Arousal
- Avoidance
- Parent
Psychoeducation - Anxiety
36The Anxious Individual
- Cognitive contents incorporate themes of danger
and vulnerability. They view the world as a
dangerous place, and feel incapable of preventing
or managing these risks. Threats may be physical,
social, or psychological. Anxiety serves an
adaptive function in preparing the individual to
avoid threat. - Parent
Psychoeducation - Anxiety
37Anxious Children Tend To
- Experience their moods more intensely
- Demonstrate poor affect regulation
- Feel they are unable to manage situations
- Show inappropriate emotional expression
- Be viewed as labile, inflexible, negative
38Parents, Parenting Child Anxiety
- Family/parenting styles (inconsistent findings)
- Mothers (intrusive involvement in situations with
negative affect) - (Hudson, Comer Kendall, 2008)
- Fathers (limited risk-taking play behavior
unpredictable, punitive, explosive) - (Bogels et al, 2007 Hughes, Furr, Sood,
Barmish, Kendall, 2009) -
39Learning Theories
- Classical conditioning (E/RP)
- Operant conditioning (Contingency management)
- Vicarious or observational learning (modeling)
- Use all three in formulating and treating
40Assessment
41Making the Diagnosis
- K-SADS-PL
- Anxiety Disorders Interview Schedule for DSM-IV
(ADIS-C/P)
42Assessing Fears and AnxietiesObservational
Methods
- Behavioral Avoidance Tests (BATs)
- Parent / Teacher / Clinician Ratings
- Monitoring -
Anxiety
43Assessing Fears and Anxieties
- Think-aloud procedures
- Thought-listing procedures
- Cartoons with thought bubbles
- Fear Thermometer
- Self-Monitoring -Anxiety
44Assessing Fears and AnxietiesPhysiological
Methods
- Heart rate
- Sweat index
- Respiration
- Finger pulse volume
- Monitoring - Anxiety
45Assessing Fears and Anxieties-Self Report
Methods-
- Fear Survey Schedule for Children (FSSC)
- Scale for Child Anxiety Related Emotional
Disorders (SCARED) - Social Phobia and Anxiety Inventory for Children
(SPAI-C) - Negative Affectivity Self-Statement
Questionnaire (NASSQ) - Spence Childrens Anxiety Scale (SCAS)
- Monitoring - Anxiety
46Assessment InstrumentOur Favorites
- Multidimensional Anxiety Scale for Children
(MASC) - Pediatric Anxiety Rating Scale (PARS)
- Monitoring - Anxiety
47Treatment Techniques Strategies
48William James
-
- The first fact for us
- is that some form of thinking goes on.
-
49Milton
-
- The mind is its own place, and in itself, can
make a Heaven of Hell and a Hell of Heaven. -
-
50William Shakespeare
-
- There is nothing either good or bad, but
thinking makes it so. -
- Hamlet Act II,
Scene II
51Assumptions of Cognitive Therapy
- Cognitive Specificity Hypothesis Moods and
clinical disorders may be distinguished on the
basis of cognitive contents and processes. - If you change cognitions, one can manage anxiety
52Cognitive Concomitants of Anxiety
- Increased Vigilance
- Hypersensitivity to Threat Cues
- Appraisal of Situations as Threatening
- Overlook Safety Cues
- High Standard for Security or Guarantees
- Threat-Related Imagery
- These are the targets of treatment
53Cognitive Therapy in Practice
- Time limited, brief
- Problem-oriented, focused, strategic
- Collaborative therapeutic relationship
- Empirically-based, Personal Scientist
- Structured, active (agenda, homework)
- Clear consistent focus on cognitive contents
and processes, skills.
54Lesson 3. We Overestimate Risk When We Are
Afraid
- Anxietyƒ (impending threat) (impaired coping)
- The specific nature of the fear will differ
depending upon the perceived threat.
55Cognitive Formulation-Salkovskis-
- Increased estimate of likelihood
- Increased estimate of awfulness
- Increased perception of responsibility
56Lesson 4.The Future is Uncertain
- The hardest lesson of all
- However much we would like a guarantee, we cant
have it - To feel secure, we must accept ambiguity
57Lesson 5. Influence and Control
- Increased estimate of likelihood
- Increased estimate of awfulness
- Increased perception of responsibility
- Control exists on a continuum of degrees of
influence
58Lesson 5. Influence and Control
59Lesson 7.Perfectionism
- Do you believe
- For every problem there is a single, best
solution? - Theres always room for improvement?
- Perfection can and should be pursued, no matter
what the cost? - One should expect the best, and settle for
nothing less?
60Maniacal Perfectionism
- "I'm a maniacal perfectionist. And if I weren't,
I wouldn't have this company. .. It's the best
rap! Nobody's going to fault me for that. I have
proven that being a perfectionist can be
profitable and admirable when creating content
across the board in television, books,
newspapers, radio, videos. .. All that content is
impeccable." - Martha Stewart (2000)
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62Being Imperfectis highly desirable
- Trying to be perfect may be sort of inevitable
for people like us, who are smart and ambitious
and interested in the world and in its good
opinion. At one level it's too hard, and at
another, it's too cheap and easy. It requires you
mainly to read the zeitgeist of wherever and
whenever you happen to beand be the best of
whatever the zeitgeist dictates or requires. When
you're clever you can read them and do the
imitation required. But nothing important, or
meaningful, or beautiful, or interesting, or
great ever came out of imitations. The thing that
is really hard, and really amazing, is giving up
on being perfect and beginning the work of
becoming yourself. - Anna Quindlen (1999)
63Lesson 7.Perfect Solutions Dont Exist
- Perfect doesnt exist, conceptually or in
practice -
- Perfectionism is highly correlated with both
depression and anxiety - Failure to meet ideal standards is associated
with stress and guilt - In a changing world, flexibility and creativity
are more valuable than a relentless pursuit of
perfection
64Lesson 8.Sometimes You Can Take Control
- I should have seen this coming
- If only I had ____, wed be OK
- Perceptions of responsibility and control are
linked to mood - Did I actually cause this event?
- Did other factors contribute?
- How much influence do I actually have?
65Lesson 9.Dont Dwell on That
- Rumination is common
- Content of thoughts similar in anxious and
non-anxious individuals - Secondary cognitions differ
66What Can Be Done?
- Mindful Acceptance
- Its just a thought
- Rational Disputation
- Challenge the secondary cognition
- Desensitization
- Schedule Rumination30 minutes a day
- Whats the solution?
67Lesson 14.Evaluate Your Thoughts Make Then
Give Good Account of Themselves
- Whats the evidence?
- Is there another, more adaptive, way of looking
at this? - So what?
- Decatastrophize everything. Is it really that big
of a deal? - What can be done?
68Downward Arrow
- 1. If I dont get into Yale, it would be
catastrophic! - 2.
- 3.
- 4.
- 5.
- 6.
- 7.
69OCD-Intrusive Thoughts
- Negative intrusive thoughts are common.
- Intrusive thoughts are experienced by 90 of
individuals (Rachman DeSilva, 1978). - The content of intrusive thoughts does not
distinguish patients with OCD. - Appraisals of thoughts and beliefs about the need
to control negative thoughts does distinguish
patients with OCD. - Caregiver Psychoeducation
70Steven King
- Oh no! Ive got to stop thinking that!
- vs.
- Buckets of blood at the prom. Cool! Ill
write a screen play!
71Appraisal in OCD
Individuals with OCD perceive their thoughts as
- more distressing
- more uncontrollable
- less acceptable
- more important
These appraisals serve as clinical targets.
72Intrusive Thoughts
- You just cant stop the flying monkeys!
- Hail Dorothy!
73CBT principals for OCD
- Basis for CBT is same for children as adults
- Exposure facing the fear, trigger obsessive
thoughts and anxiety - Response prevention not performing the ritual
that decreases anxiety after the exposure
preventing compulsive rituals - Exposure, Activity
Selection, Relaxation
74How I Ran OCD Off My LandMarch, Mulle, Herbal
(1994)
- Four Stages, 16 session protocol
- Session 1 Neurobehavioral Model
- Session 2 Make OCD the problem
- Session 3 Mapping OCD
- Sessions 4-12 Exposure
- Caregiver
Psychoeducation, Monitoring, Exposure
75Temple FEAR Program
- F Feeling frightened? Monitor
- E Expecting bad things? Cognitions
- A Attitudes Actions. Coping
- R Results Rewards Reinforce
76Kendalls Coping Cat
- Build rapport, socialize to treatment
- Identify feelings, distinguish anxiety
- Identify somatic responses (F-step)
- Parent session
- Relaxation exercises, monitor tension
- Identify thoughts, self talk (E-step)
- Relaxation and cognitive change (A-step)
- Self-rating performance, reward (R-step)
- Parent session
- Practice FEAR
77Lesson 19.Flow With the Current of Life
- By letting it go, it all gets done
- But when you try and try, the world is beyond
winning. - Lao Tsu
78Go With The Flow of the River
79Be Like a Stick
80Lesson 20.Live Wisely
- Judicious use of knowledge
- Open minded
- Altruistic, empathic
- Compassion
- Self-reflection
- Insight
- Tolerance
- Awareness of larger issues
81The Road to Wisdom
82Keep Calm and Carry On
83SummaryWhat Works
- Keep in mind that anxiety works for you
- Think clearly. Keep problems in perspective
- Approach the things you fear
- Exposure, exposure, and more exposure
- Active problem solving, solution-focused thinking
- Balance active coping with mindful acceptance
- Take the long view, the larger view
- Live with faith, hope, and equanimity
84Components of Effective Treatment
- Psychoeducation
- Relaxation
- Behavior management (reinforcement)
- Modeling
- Problem Solving
- Exposure
85Behavioral Treatments
- Develop fear hierarchy
- Relaxation / Breathing / Pleasant Imagery
- Modeling
- Systematic Desensitization
- Prolonged Exposure, Flooding
- Contingency Management
- Self-Management
- Combined
- Cognitive Anxiety,
Modeling, Self Monitoring, Exposure
86CBT Tool Kit
- Develop fear hierarchy
- Exposure
- Self monitoring (Fear thermometer)
- Problem solving
- Rational Disputation Adaptive Self-Statements
- Contingency management
- Cognitive Anxiety, Exposure,
Modeling, Relaxation, Self-
Monitoring
87Clinical OutcomesAn Empirically-Supported
Approach
88Kendall (1994)First RCT of CBT with Anxious
Youth
- N47 9-13 years old
- CBT vs. Wait List Control
- Treatment 16 sessions of Coping Cat
- Respondents Self-report, parent, teacher
- Measures ADIS, RCMAS, STAIC, FSSC-R
- Clinically significant improvement Diagnosis
free at 1 year follow-up 60 vs. 10
- JCCP.
(1994), 62 100-110.
89Kendall et al. (1997) Follow-Up
- CBT vs. Wait List Control
- Treatment 16 sessions of Coping Cat
- Respondents Self-report, parent, teacher
- Measures ADIS, RCMAS, STAIC, FSSC-R
- Clinically significant improvement Diagnosis
free at 1 year follow-up 71 vs. 7 - JCCP
(1997), 65 366-380.
90CBT for OCDProbably a Well Established
Treatment
- March et al (1994) n15 open trial
- Piacentini et al. (1994) n3 open trial
- Knox et al. (1996) n4 open trial
- Scahill et al. (1996) n7 open trial
- Weever et al. (1997) n57 open trial
- Fischer et al. (1998) n15 open trial
- Franklin et al. (1998) n14 open trial
- Thienemann et al. (2001) n18 open trial
- Waters et al. (2001) n7 open trial
- Piacentini et al. (1999, 2002) n42 open trial
91POTSPediatric OCD Treatment Study
- CBT Sertraline (Zoloft) Combo PBO
- N112 7-17 years old
- Measure YBOCS
- Multisite, double blind PBO controlled
- Results 12 week Combo gtCBTSer gtPBO
- Remission Combo 54 CBT 40 Ser 21 PBO
4 - POTS Team (2004). Cognitive-behavior therapy,
Sertraline, and their combination for children
and adolescents with obsessive-compulsive
disorder. JAMA , 292 1969-1976.
92CAMS Drop Out by Treatment Condition
Treatment Condition Treatment Condition Treatment Condition Treatment Condition
COMB SRT CBT PBO
Completed Study 128 112 134 61
Dropped Out 12 8.6 21 15.8 5 3.6 15 19.7
Total 140 133 139 76
93 CAMS Treatment Response
COMB gt CBT SRT gt PBO
94CAMS PARS Improvement
95Does CBT Work? Compton et al. (2004)
- Review of 21 RCTs of CBT for childhood
depression and anxiety indicates that CBT is
currently the treatment of choice - Medium to large effects relative to waitlist,
inactive control, active control -
JAACAP (2004) 43 930-959
96Does CBT Work? Cartwright-Hatton et al. (2004)
- Review of 10 RCTs of CBT for child and
adolescent anxiety indicates CBT is effective
compared to no-treatment control. - Remission rate 56.5 (CBT) vs. 34.8 (control)
- Brit.
J. Clin. Psych., 43 421-436.
97What Enhances Improvement?
- Child involvement
- (Chu Kendall, 2004 Braswell, et al, 1985)
- Therapist relationship building strategies
- (Creed Kendall, 2005)
- Therapist flexibility (associated with increased
child involvement) (Kendall Chu, 2000) -
98What Truly Matters
- Assessment
- Guided discovery
- Involvement
- Cooperative, collaborative rapport
- Relapse prevention
- Planning for generalization
- Arranging termination
- Individualizing the program
- Therapist flexibility (with fidelity)
99What Not To Do(Kendall)
- Teachy-preachy style
- Forcing youth to talk about feelings
- Excessive focus on tasks
- Mechanical self-talk
- Tension and upset about scheduling
- Aversive context (interpersonal conflicts and
oppositionality) - Wimpy role-plays or exposure tasks
100What we dont know
- Proper role for parents in treatment
- Mechanisms of change
- How to help treatment nonresponders
- Active components of the program
- Effective methods for dissemination
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103 Keep Calm and Carry On
- www.keepcalmthebook.com
- www.amazon.com
- www.newharbinger.com