Evidence-Based Individual Counseling with Children and Adolescents with Anxiety

1. Evidence-Based Individual Counseling with Children and Adolescents with Anxiety December 2, 2004 Carrie Franklin Katie Myers Misty Sommers-Tackett Megan Stroh

2. Presentation Overview • 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

3. Introduction to Anxiety • Definition of Anxiety • Some Major Anxiety Disorders • Possible Etiology • Anxiety Disorders in the Schools

4. Definition of Anxiety • 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)

5. Why Anxiety??? • 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)

6. When is Anxiety a Disorder? • 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)

7. Some Major Anxiety Disorders • Separation Anxiety Disorder • Social Phobia • Specific Phobias • Generalized Anxiety Disorder

8. Separation Anxiety Disorder • 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)

9. Social Phobia • 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)

10. Specific Phobia • 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)

11. Generalized Anxiety Disorder • 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)

12. Etiology • Biological • Psychosocial • Family & Genetic Factors

13. Biological • 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)

14. Psychosocial • 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)

15. Family & Genetic • 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)

16. Anxiety Disorders in the Schools • 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)

17. Emotional Disturbance • 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)

18. Emotional Disturbance • Qualifiers: ~ Long period of time ~ Marked degree ~ Adversely affects educational performance • Anxiety affects most children in schools, but for these children, school can seem unbearable. (Ohio Model Policies and Procedures, 2003) (Ohio Operating Standards, 2002)

19. Empirically Supported Tx We are going to discuss: • Medications ~ Sedatives ~ Heterocyclic Antidepressants ~ SSRI’s • Therapies that involve parents ~ Separation Anxiety • Group Therapy ~ Art Therapy • Alternative treatment considerations

20. Medications • 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, light- headedness, or speech problems. • Take caution in hyperactive children • Possible chemical dependence • 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.

21. Medications • 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.

22. Medications • 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.

23. Involving Parents • 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

24. Group Therapies • Art Therapy • An Art Therapy Group for Children Traumatized by Parental Violence and Separation.

25. Alternative Treatment Options • Diet & Health considerations • 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

26. Alternative Treatment Options • Herbal Remedies for Anxiety • German Chamomile + • Ginkgo +++ • Kava + • Lemon Balm + • Passion Flower + • Skullcap o • Valerian + • Quality of evidence (o, +, ++, +++)

27. Description of Individual Cognitive-Behavior Therapy • Group vs. Individual Therapy • Computer Based Cognitive Therapy

28. Group vs. Individual Therapy • Patient Preferences • Treatment • Follow-up

29. Group Therapy • What are the advantages to the participants for group therapy? • What are the disadvantages to group therapy for participants?

30. Computer Based Cognitive Therapy • What is CCBT? • How does it compare to internet therapy? • Why do patients like it? • Case Studies

31. Advantages to CCBT • Time • Money • Flexibility

32. More about CBT • Why use CBT on children with anxiety disorders? • CBT strategies • Role-playing activity • Effectiveness of CBT for treatment of anxiety disorders

33. Why use CBT on children with anxiety disorders? • 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.

34. CBT Strategies • Coping modeling • Cognitive restructuring • Exposure to anxiety provoking situations • Role-playing • Contingent rewards for effort

35. More CBT Strategies • Homework • Affective education • Awareness of bodily reactions and cognitions • Relaxation procedures • Application of new skills

36. Role-Playing Activity • What strategies are being used?

37. Effectiveness of CBT for Treatment of Anxiety Disorders • 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).

38. More Evidence of CBT Effectiveness • 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.

39. More Evidence of CBT Effectiveness • 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).

40. “What did you learn??”Review of the Pre-test