Child and Adolescent Anxiety Disorders: Keeping Calm with Kids

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Child and Adolescent Anxiety Disorders Keeping
Calm with Kids

• Mark A. Reinecke, Ph.D.
• Northwestern University
• SASED
• Northern Illinois University
• Naperville, IL.
• February 28, 2014

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COI Disclosure

• Brian Harty Foundation
• HRSA GPE Psychology Training Grant (PI)

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Were Living in a Worried World

• Every life has its share of anxiety, worry,
  fear and dread

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Unemployment
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Terrorism
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Deficit Financial Security
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Saving for Retirement
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Global Warming
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Worries 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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Twenty 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?

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Lesson 1. AnxietyIt Works

• What exactly is anxiety?
• Based in Limbic system
• A normal, highly adaptive emotional state
• Facilitates response to a perceived threat

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A Plate with C. Elegans
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Sydney 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.

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First Complete Genetic Map
100 million base pairs 20,000 genes
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A Simple Nervous System
Nervous system consists of 302 neurons that form
a small-world network Their interconnections have
been completely mapped out
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C. Elegans
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Lesson 2.AnxietyThe Big A

• Anxiety has 4 components
• Affect
• Physiological
• Cognitive
• Behavioral
• Organizes perception, memory, action

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What 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

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Developmentally 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

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Normal Fears of Childhood
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Normal Fears of Teens
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Epidemiology

• 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

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DSM-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?)

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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

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Comorbidity Number of diagnoses in an anxiety
disordered sample
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Etiology and Maintenance
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Etiology

• Genetics
• Environment
• Temperament (shy, inhibited, risk averse)
• Parent
  Psychoeducation - Anxiety

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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

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Brain Metabolism in OCD

• Basal Ganglia (Caudate)
• R. Anterior Cingulate
• R Orbitofrontal Cortex

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The Essence of Anxiety

• Fearful Anticipation
• Rumination, Worry
• Vigilance
• Autonomic Arousal
• Avoidance
• Parent
  Psychoeducation - Anxiety

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The 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

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Anxious 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

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Parents, 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)

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Learning Theories

• Classical conditioning (E/RP)
• Operant conditioning (Contingency management)
• Vicarious or observational learning (modeling)
• Use all three in formulating and treating

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Assessment
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Making the Diagnosis

• K-SADS-PL
• Anxiety Disorders Interview Schedule for DSM-IV
  (ADIS-C/P)

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Assessing Fears and AnxietiesObservational
Methods

• Behavioral Avoidance Tests (BATs)
• Parent / Teacher / Clinician Ratings
• Monitoring -
  Anxiety

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Assessing Fears and Anxieties

• Think-aloud procedures
• Thought-listing procedures
• Cartoons with thought bubbles
• Fear Thermometer
• Self-Monitoring -Anxiety

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Assessing Fears and AnxietiesPhysiological
Methods

• Heart rate
• Sweat index
• Respiration
• Finger pulse volume
• Monitoring - Anxiety

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Assessing 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

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Assessment InstrumentOur Favorites

• Multidimensional Anxiety Scale for Children
  (MASC)
• Pediatric Anxiety Rating Scale (PARS)
• Monitoring - Anxiety

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Treatment Techniques Strategies

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William James

• The first fact for us
• is that some form of thinking goes on.

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Milton

• The mind is its own place, and in itself, can
  make a Heaven of Hell and a Hell of Heaven.

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William Shakespeare

• There is nothing either good or bad, but
  thinking makes it so.
• Hamlet Act II,
  Scene II

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Assumptions 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

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Cognitive 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

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Cognitive 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.

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Lesson 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.

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Cognitive Formulation-Salkovskis-

• Increased estimate of likelihood
• Increased estimate of awfulness
• Increased perception of responsibility

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Lesson 4.The Future is Uncertain

1. The hardest lesson of all
2. However much we would like a guarantee, we cant
   have it
3. To feel secure, we must accept ambiguity

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Lesson 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

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Lesson 5. Influence and Control
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Lesson 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?

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Maniacal 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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Being 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)

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Lesson 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

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Lesson 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?

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Lesson 9.Dont Dwell on That

• Rumination is common
• Content of thoughts similar in anxious and
  non-anxious individuals
• Secondary cognitions differ

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What Can Be Done?

• Mindful Acceptance
• Its just a thought
• Rational Disputation
• Challenge the secondary cognition
• Desensitization
• Schedule Rumination30 minutes a day
• Whats the solution?

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Lesson 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?

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Downward Arrow

• 1. If I dont get into Yale, it would be
  catastrophic!
• 2.
• 3.
• 4.
• 5.
• 6.
• 7.

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OCD-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

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Steven King

• Oh no! Ive got to stop thinking that!
• vs.
• Buckets of blood at the prom. Cool! Ill
  write a screen play!

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Appraisal in OCD
Individuals with OCD perceive their thoughts as

• more distressing
• more uncontrollable
• less acceptable
• more important

These appraisals serve as clinical targets.
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Intrusive Thoughts

• You just cant stop the flying monkeys!
• Hail Dorothy!

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CBT 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

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How 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

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Temple FEAR Program

• F Feeling frightened? Monitor
• E Expecting bad things? Cognitions
• A Attitudes Actions. Coping
• R Results Rewards Reinforce

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Kendalls 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

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Lesson 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

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Go With The Flow of the River
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Be Like a Stick
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Lesson 20.Live Wisely

• Judicious use of knowledge
• Open minded
• Altruistic, empathic
• Compassion
• Self-reflection
• Insight
• Tolerance
• Awareness of larger issues

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The Road to Wisdom
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Keep Calm and Carry On
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SummaryWhat 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

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Components of Effective Treatment

• Psychoeducation
• Relaxation
• Behavior management (reinforcement)
• Modeling
• Problem Solving
• Exposure

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Behavioral 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

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CBT 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

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Clinical OutcomesAn Empirically-Supported
Approach
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Kendall (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.

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Kendall 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.

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CBT 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

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POTSPediatric 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.

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CAMS 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
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CAMS Treatment Response
COMB gt CBT SRT gt PBO
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CAMS PARS Improvement
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Does 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

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Does 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.

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What 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)

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What Truly Matters

• Assessment
• Guided discovery
• Involvement
• Cooperative, collaborative rapport
• Relapse prevention
• Planning for generalization
• Arranging termination
• Individualizing the program
• Therapist flexibility (with fidelity)

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What 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

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What 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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Keep Calm and Carry On

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