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Internalising Disorders Margie Richardson 512-927

Internalising . Internalising

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Internalising Disorders Margie Richardson 512-927

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    2. Internalising Internalising…………………..Externalising Disordered mood…………..Dysregulated or emotions behaviour Keeping feelings ……………Acting out within feelings Overcontrol…………………….Undercontrol

    3. Anxiety disorders in children & adolescents Anxiety (& anx. disorders) in children Models for understanding anxiety Assessment Treatment

    4. Terminology Fear: a short-term physiological response produced by the brain and the body in response to a stressor Anxiety: a sense of apprehension, sharing many of the same symptoms as fear, building more slowly, lingering longer, typically associated with worrying about the future

    5. Nature of anxiety Anxiety exists on a continuum: everyday experience to psychopathological        Useful to normalise anxiety in therapy, emphasize adaptive uses        Important to know what is normal (King, Gullone et al) Cultural variability of what is normal

    6. Symptoms of anxiety in children (1) Physiological arousal: muscle tension, heart palpitations, abdominal pain, nausea, flushed face, headaches Behavioral: avoidance/escape trembling, nail-biting clinging, asking for reassurance

    7. Symptoms of anxiety in children (2) Cognitive: processing bias to focus on threat and danger catastrophizing low success expectancy excessive self-focus

    8. Key characteristics of child with an anxiety problem Processing neutral information negatively Attention is drawn to things not comfortable with  Withdrawal / avoidance of challenging situations

    10. Role of cognitions Alfano, Beidel & Turner review (2002): what sort of cognitions do anxious children display? do they differ over age? do they differ with different anxiety disorders? are they different in non-anxious or depressed children? does treatment targeting cognitions change cognitions? does treatment not targeting cognitions change cognitions?

    11. Diagnostic Categories (1) Prior to 1980 "Phobic neuroses"   DSM-III(1980) First classification of childhood anxiety   DSM-IIIR (1987) Separation anxiety disorder Avoidant disorder Overanxious disorder + adult anxiety disorders

    12. Diagnostic Categories (2) DSM-IV (1994) Separation Anxiety + adult anxiety disorders   (Avoidant > Social phobia Overanxious > GAD)   Impairment of functioning /distress

    13. Factor analysis of anxiety in children (Spence, 1997) Children aged 8 - 12 years - 6 factors: Separation anxiety PA/Agoraphobia OCD Social phobia Generalised anxiety disorder Physical injury Second order factor of anxiety in general

    14. Reactions to stressors Post Traumatic Stress Disorder Acute Stress Disorder Adjustment Disorder with anxiety or mixed anxiety and depression

    15. Developmental Nature of Anxiety Separation Anxiety highest in young children Primary school age often first come to attention Generalized & Social Anxiety increase with age OCD low rates for young children, onset often in adolescence Panic Disorder onset often adolescence

    17. Influence of family

    20. Neurobiological models of anxiety disorders Neuroimaging research: Amygdala in pathophysiology of PTSD and SAD Corticostriatal pathways in OCD Diffuse abnormalities in PD No cohesive models for SP (Rauch et al, 2003)

    21. Neurobiology of Anxiety Disorders Conclusion: Different anxiety disorders may represent different kinds of false alarm and may be mediated by different neurocircuits. Behaviour therapy /some medication seems to be effective in impacting on the neurobiology.

    22. Assessment Tools Clinical Interview Formal questionnaires/measures Monitoring scales

    23. Assessment Tools (1) Structured Diagnostic Interview:   Anxiety Disorders Interview Schedule for DSM-IV: Child Version (ADIS for DSM-IV-C; Albano & Silverman, 1996)

    24. Assessment Tools (2) Self- rating scales for children: Revised Children's Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1978)  State-Trait Anxiety Inventory for Children (STAI-C; Spielberger, 1973)  Fear Survey Schedule for Children - Revised (FSSC-R)  Spence Children's Anxiety Scale (SCAS)

    25. Assessment Tools (3) Parent and Teacher Rating Scales Conners  CBCL Behaviour Assessment System for Children (BASC)  SCAS-P Strengths and Difficulties Questionnaire (SDQ, Goodman, 2001)

    26. Assessment Tools (4) Cognitive Measures  Children's Automatic Thoughts Scale (CATS; Schniering, C.A. & Rapee, R.M.)  Impairment Global Rating of Severity: ADIS for DSM-IV-C Rating of interference: "how much does this problem interfere, stop you doing things, mess things up for you with your friends, family and schoolwork" 

    27. Assessment Tools (5) Monitoring Tools:  Fear Thermometer Diary

    30. Treatment approaches Behavioural Cognitive-behavioural therapy Family Therapy Medication

    31. CBT Treatment Development Coping Cat (Kendall, 1994) Family Treatment of Childhood Anxiety: Coping Koala (Barrett, Dadds, Rapee, 1996) Macquarie University Family Treatment Programme (Rapee, Wignall, Harris)

    32. Efficacy of treatments for children & adolescents Journal of Clinical Child Psychology, 1998, Volume 27: Ollendick & King’s review of behavioural and CBT treatments for phobic and anxiety disorders

    33. Efficacy of CBT Treatment

    34. Current CBT Approach: children Engagement, collaboration, assessment, psycho-education, monitoring

    36. Current CBT Resources Friends for Life Program (Barrett) Cool Kids Program (Rapee & Wignall) Helping Your Anxious Child (Rapee, Spence, Cobham, Wignall)

    39. Treatment approaches Behavioural Cognitive-behavioural therapy Family Therapy Medication

    40. Medication Usually in combination with psychological treatment in older or more severe cases School Refusal (anxiety + major depression): imipramine + CBT (Bernstein et al, 2000) OCD: SSRIs (eg fluoxetine, Prozac) as first choice; CMI (clomipramine) if non-responsive (Liebowitz et al, 2002)

    41. When to intervene? Younger children through parents, etc. Preventative work not yet shown to be effective. Primary age children (with involvement of parents) Adolescents

    42. Future directions Developmental nature of anxiety and interventions Role of cognition Effectiveness of treatments Relationship to other internalizing disorders

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