The Treatment of Childhood Anxiety

1. The Treatment of Childhood Anxiety Wednesday 5th March 2014 10:30am - 12pm AEDT

2. Before we start… • Ensure sound is on and volume turned up on your computer. • If you are experiencing problems with sound, dial in using your telephone as per details on your confirmation email (enter telephone number and password provided). • Dial 1800 733 416 for technical support (Redback). • Specific question/s may be asked throughout the webinar using the chat box - presenters will endeavour to answer them at the end of the webinar.

3. PRESENTERS: Prof Ronald M Rapee Centre for Emotional Health Macquarie University Carol Woolcock Child and Adolescent Psychotherapist and Social Worker Facilitator: Harry Lovelock, Senior Executive Manager APS

4. Treatment of anxiety in young children Ronald M Rapee Centre for Emotional Health Macquarie University

5. Who is this treatment for? • Children with a clinical anxiety disorder • Separation anxiety • Social anxiety • Generalised anxiety • Obsessive compulsive • Phobias • Anxiety is primary problem • Out of proportion to age and context

6. Characteristics of empirically-validated treatment for child anxiety • Individual (or group) sessions delivered by highly qualified therapist • 10-16 Sessions; ~ 60 min. • “CBT” – Education; Anxiety management (relaxation, cognitive restructuring); Exposure; Additional skills (problem solving, assertiveness, social skills, parenting). • May or may not include parents • Suitable for primarily anxious children; • aged 7-15

7. REMISSION OF ANXIETY DIAGNOSIS ACROSS ALL STUDIES IN TWO REVIEWS % DX-FREE JAMES ET AL (2005) CARTWRIGHT-HATTON ET AL, 2004

8. Meta-analyses of treatments for child anxiety E.S Note – Child self report

9. A detailed example the Cool Kids program

10. The Cool Kids Program Overview • Based on 18+ years of treatment outcome research • Uses a skills-based approach • Three age versions • Preschool • Primary school • High school • Three delivery versions of the program • Family/Community Version • School Version • Outreach Version • Specific Populations • Standard • Anxiety/Depression • High Functioning Autism • TBI

11. The Cool Kids Program - FEATURES • 10 sessions/ 12 weeks • Ages 7-17 • Parents included • Any/ all anxiety diagnoses • Workbooks – therapist, parent, child • Groups • 4-7 / age related • Diagnoses combined • Approx 2 hours • Two therapists • Together – separate - together

14. Does Cool Kids work?

15. COMPARISON WITH PLACEBOHUDSON ET AL (2009) 112 CHILDREN AGED 7-16 BROAD-BASED ANXIETY DISORDERS RANDOMLY ALLOCATED TO GROUP CBT (GCBT) COOL KIDS GROUP SUPPORT & ATTENTION (GSA) SUPPORTIVE ENVIRONMENT, INFORMATION ABOUT EMOTIONS, BUILDING RELATIONSHIPS Hudson, J. L. et al (2009). Journal of the American Academy of Child and Adolescent Psychiatry, 48(5), 533-544.

16. Features of Children Age ~ 10 yr Approx 45% female Primary dxs GAD ~ 50% Social ~ 20% SAD ~ 15% Comorbidity Anxiety ~ 80% Externalising ~ 15% Other ~ 5% N of Comorbid Diagnoses > 2

17. Primary Anxiety Disorder % no longer meeting criteria for primary anxiety disorder

18. Clinical Severity of Primary Anxiety Disorder Clinical Severity Rating

19. Delivering treatment to children aged 7-12

20. Who to include? • Principal diagnosis of anxiety (?) • Any anxiety disorder (PTSD?) • Aged 7 and up • Encourage both parents (need to consider child-minding, time) • Step parents, separated?

21. The Cool Kids ProgramContent • Psycho-education • Cognitive restructuring (Detective thinking) • Child management • In vivo exposure (plus rewards) • Skills training

22. Cool Kids Program – Session outline 1 • Session 1: What, Why and How? • Practice tasks: Children: Linking thoughts and feelings • Parents: Monitoring aspects of the child’s fears and worries • Session 2: Learning to Think Realistically • Practice tasks: Children: Detective Thinking • Parents: Cognitive Restructuring • Session 3: Parenting an Anxious Child • Practice tasks: Children: Detective thinking and self reward monitoring • Parents: Monitoring of parent management strategies

23. Cool Kids Program – Session outline 2 • Session 4: Fighting Fear by Facing Fear • Practice tasks: Children: Perform the first steps as planned. • Parents: Record details of steps and difficulties encountered. • Session 5: Creative Exposure • Practice tasks: Children: Completing Steps and using Worry Surfing • Parents: Monitor steps and difficulties faced. • Session 6: Identifying Problems and Difficulties • Practice tasks: Children: Completing Steps • Parents: Monitoring Steps and Assessing Social Skills

24. Cool Kids Program – Session outline 3 • Session 7: Social Skills and Assertiveness • Practice tasks: Children: Assertiveness checklists and completing steps • Parents: Monitoring steps and providing opportunities to practice assertiveness • Session 8: Sustaining Progress • Practice tasks: Children: Completing Steps • Parents: Monitoring Steps • Session 9: Reviewing Goals and the Final Push • Practice tasks: Children: Completing steps. • Parents: Monitoring steps. • Session 10: Maintaining Gains and Coping with Set-Backs • Practice tasks: Setting and implementing long term goals

25. An exampleExposure for separation fear

26. Developing exposure hierarchies • Explain principles through examples • Explain methods and procedures • Brainstorm avoided situations • Organise into related groups • Arrange in order of difficulty and brainstorm additional steps • Add rewards

27. STEP BY STEP PLAN Lashi’s Goal:to be able to stay at home with a sitter without worrying about Mum being out STEP 1: Staying home with Dad while Mum goes out for 10 Minutes.Reward: Extra Story when I go to bed_ STEP 2: Staying home with Grandma for 30 minutes Reward: Choose what we have for dinner STEP 3: Staying home with dad while Mum goes out for the afternoon Reward: Go bike riding with Mum STEP 4: Stay home with Grandma all dayReward: Choose activity for Mum and I to do STEP 5: Stay home with a sitter in the afternoonReward: Stay up a half-hour later than normal STEP 6: Stay home with a sitter for the dayReward: Mum will bring home a surprise STEP 7: Stay home with Dad while Mum goes out for the eveningReward: Have a friend over for dinner STEP 8: Stay home with Grandma while Mum goes out till late at nightReward: Go to Dinner at a restaurant STEP 9: Stay home with a sitter for a few hours in eveningReward: Have a few friends over to sleep for night STEP 10: Stay home with a sitter while Mum goes out for the nightReward: Go to Sega World with two friends

28. Delivering treatment to children aged 3-6

29. The Cool Little Kids program

30. Research format is run in groups (can be individual) Approx. 120 mins per session (individual standard session) Parents only – both parents (or main caregivers) strongly encouraged to attend Program 12 weeks/ 6 sessions (sessions 1-2 weekly, sessions 3-5 fortnightly, session 6 booster after month) Clinical severity – more sessions Combination of didactic presentation with therapeutic reflection & understanding Structure of sessions

31. Cool Little Kids – Session Outline 1. Psychoeducation and motivation 2. Management of parent overprotection 3. Graded exposure to child’s fears 4. Troubleshooting exposure & dealing with parent anxiety – especially related to exposure and overprotection 5. Troubleshooting exposure & dealing with parent anxiety 6. Review of strategies & discussion of future

32. Centre for Emotional Health Emotional Health Clinic PHONE: 02/ 9850-8711 www.centreforemotionalhealth.com.au

33. I KNOW IT’S JUST THEIR HABITAT BUT PLEASE DON’T BUG ME! Treatment of a 9 year old boy

34. PRESENTATION • James • 9 years old • 2 month history of extreme fear of bugs • Previously ‘loved’ bugs and had a collection of plastic bugs but has insisted they be placed in the rubbish • Symptoms of avoidance, “hysterical” crying, hyperventilation, sweating, sleep disturbance • Predicts he won’t attend school in term 4 as the topic of investigation is BUGS

35. Family Background • Resides with both parents • Has a physical condition that requires regular medical treatment • Recent criticism of James and his mother by the medical team for “Not trying hard enough”

36. ASSESSMENT • Assessment limited to current situation obtained from initial session with parents • Developmental history and family history obtained during previous contact with the family • Cognitively in average range • Receptive and expressive language a strength • Attends mainstream primary school • Good peer relationships • No behavioural concerns

37. Diagnosis • Does not meet the full DSM IV TR criteria for Specific Phobia as of less than 6 month duration • Meets the ICD10 diagnostic criteria for Specific (isolated) phobia • Does not meet the diagnostic criteria for any other Mood Disorder

38. Treatment Plan • Systematic desensitization • Six one hour sessions, Monday, Wednesday and Friday during the school holidays • Homework after each session to consolidate • Mother to sit in during sessions • Parents to address conflict with medical team

39. Overview of sessions 1. Establish contract with James 2. Relaxation techniques 3. Establish hierarchy of fears 4. Introduce drawings & photos of least feared 5. Introduce drawings & photos of most feared 6. Maintenance plan, celebration

40. Session 1. Contract • Reconnect. What’s happening in his life • Why has he come to see me? • Establish that James would like to be free of fears • Impact that the fears have on his life • Permission given to CW to name and talk about bugs • Agreement that I would never show him a live bug

41. CONSIDERATIONS • Importance of building rapport with the child (& the parent/carer) • Children do not always recognise that the fear is excessive or unreasonable so not essential for acknowledgement for treatment to begin • Can ask questions such as “Who is most concerned?” • Important for the child (& parent/carer) to be a willing partner in the treatment

42. Session 2. Relaxation • Establish current physical symptoms • Instruct James on relaxation techniques. He asked that his mother joined in so she could learn to relax too. • Self talk • Decide on a special word that he/mother could say to initiate relaxation (James asked mother to nominate one for herself) • Homework: practise relaxation when fears not present

43. CONSIDERATIONS • Children may not be able to describe all their physical or emotional symptoms and parents/carers can be helpful in describing what they have noticed about their child.

44. Session 3. Hierarchy of fears • Establish list from least to most concerning • Ants • Beetles • Flies • Butterflies • Mosquitoes • Spiders • What is his fear about each one?

45. CONSIDERATIONS • Important at this stage to accept what the child is telling you about what they fear even if it seems insignificant to you. E.g. ants might crawl on you. Asking what would happen then may lead to voicing the fear that ants might crawl into his eyes, mouth, nose, etc. • Check if the child has had any adverse experiences with bugs • Acknowledge the need to be cautious about some bugs.

46. Session 4. Introduce drawings & photos of ants • Discuss the plan for the session & gain agreement to proceed • Allow James to decide on proximity • Choose drawing that are non-threatening e.g. humorous cartoons from clip art. • Check for physical symptoms • Use relaxation techniques • Progress to more explicit drawings • Praise • Provide non threatening photos of ants • Homework: He can keep the drawings & photos, show them to dad and colour in if he likes

47. CONSIDERATIONS • Need to take care not to overwhelm the child with too much visual material this session • Explain each drawing, check proximity required. Expect maximum distance for the first few. Present one at a time, explaining each beforehand.

48. Session 5. Introduce drawings & photos of spiders • Discuss the plan for the session & gain agreement to proceed • Allow James to decide on proximity for each item • Choose drawings that are non-threatening e.g. humorous cartoons from clip art. • Check with him for symptoms • Use relaxation techniques • Progress to more explicit drawings • Praise • Provide non threatening photos of spiders • Homework: He can keep the drawings & photos, show them to dad and colour in if he likes

49. CONSIDERATIONS • It’s a huge leap from least to most feared • Talk about the bugs in between the two extremes • If more sessions available can focus on more of the bugs in the hierarchy. E.g. if 8 sessions available could include beetles and butterflies

50. Session 6. Maintenance and Celebration • Discuss returning to school and how he will manage the topic for the term • Praise • Review relaxation techniques • Where to from here? • Replace his plastic bugs? • Look at live bugs e.g. in a jar? • When is it OK to handle bugs? • When it is wise to avoid bugs?