Intensive Treatments for Children and Adolescents with Anxiety Disorders

1. Intensive Treatments for Children and Adolescents with Anxiety Disorders Eduardo Bunge Ph.D Palo Alto University

2. Overview Empirically Supported “Intensive” Treatments Specific Phobia Panic Disorder Obsessive Compulsive Disorder

3. Why one session a week?

4. Clinical Case • 7 years old boy • Dog phobia • Parents are reluctant to long term treatment

5. Dilemma: with this kid would you... Suggest a gradual exposure weekly or one long session?

6. SPECIFIC PHOBIA One-Session Treatment Lars-Göran Öst Thomas Ollendick These guys are awesome! 

8. Specific Phobia N = 196 Age = 7-16 years

9. ≠ 82% Ost (2001)

10. Interesting data • Children with blood phobia respond less to OST (Ost, et al., 2001) • Girls respond better than boys(Ollendick, 2009) • Therapists with more experience = better results • (Ost, Svensson, Hellstrom y Lindwall, 2001)

11. Gradual exposure therapy & intensive Onesession? How?

12. Multi-component BT + CBT + Modeling + Systematic desensitization (Davis, Ollendick y Öst, 2009) Onesession? How?

13. OST Procedure Assessment Preparation 45 Min Exposure Session 3 Hrs Follow Up Phone

14. How to communicate? • This is teamwork • I will never do anything without first describing and showing it to you • I will always ask you for permission. • “Do you agree? "

15. Catastrophic cognitionsBunge, Gomar, Mandil (2008) The problem is the dog itself? or The problem is what he thinks of the dog?

16. Fears HierarchyBunge, Gomar, Mandil (2008)

18. “Look at me, I am doing it ... I did not believe I could do it, but I did.” Any impact in his self efficacy?

19. Example

20. Panic DisorderIntensive Treatment (Chase, Whitton & Pincus 2012) Intensive? How?

21. Clinical Case • Aaron, 16 years old • Panic Disorder with Agoraphobia • He didn’t attend to school the last 3 months • Academic and social impairment • He would like to solve this problem in a month • Intensive or weekly?

23. “11 weekly session format was: acceptable… • some requested a briefer treatment format • to enable a more rapid return to developmentally important social and academic activities. • …families living outside the catchment area of our clinic … • … might speed teens’ ability to resume their daily activities as well as increase treatment accessibility …” • (Pincus, et al., 2010)

25. Intensive Treatment Procedure Day 1 90-120 Min Psychoed Day 2 90-120 Min Cognitive Rest. Day 3 90-120 Min Interocp/ Exp Day 6 Adolescent on his own Day 7 Adolescent on his own Day 8 Progress & Relapse Prevention Maintenance 4 weeks Phone Day 4 6-7 Hrs Interocpt/ Exp + situational exposure Day 5 6-7 Hrs Interocpt/ Exp + situational exposure + Plan next days

26. Intensive Treatment Procedure • Involved • Therapist-assisted situational exposure exercises to more fully address agoraphobic avoidance. • Parents were • Provided with psychoeducation about panic • Actively involved in planning situational exposures outside the therapy session. • Diaphragmatic breathing • was not a significant focus of treatment • counter-indicated during interoceptive and situational exposure

28. Example

29. OCDIntensive Treatment Unbelivable!

30. Clinical Case • Daniele, 17 years old • OCD severe • Lives 600 miles away • There’s no OCD specialist in her town • She asked if she can have web-based sessions • Is there any other option?

31. J. Am. Acad. Child Adolesc. Psychiatry, 2007;46(4):469Y478. Previously: Two non-RCT (Franklin et al., 1998; & Storch et al., 2006)

32. N = 40 Age = 7 - 17 years 14 weekly sessions or 14 Intensive (daily) family-based CBT

33. Family-based format: at least one parent attending all sessions Intensive OCD Treatment Procedure* Week 1 Week 3 Week 2 Day 1 90 Min Day 1 90 Min Day 1 90 Min Day 2 90 Min Day 2 90 Min Day 2 90 Min Day 3 90 Min Day 3 90 Min Day 3 90 Min HW 60 M HW 60 M HW 60 M HW 60 M HW 60 M HW 60 M HW 60 M HW 60 M HW 60 M HW 60 M HW 60 M HW 60 M HW 60 M HW 60 M E/RP = Imaginal & in vivo. Increase difficulty Challenge: catastrophic consequences Psycho education OCD Model Hierarchy/SUDs Easy E/RP trial Cognitive restructuring Day 4 90 Min Day 4 90 Min Day 4 90 Min Day 5 90 Min Day 5 90 Min Day 5 90 Min E/RP = Imaginal & in vivo. Increase difficulty Challenge: catastrophic consequences Prepare the patient to manage symptoms independently Lewin, Storch, Merlo, Murphy, & Geffken , (2005)

34. Weekly Intensive Improvements Significant Hinder learning? OCD Symptoms Enhance Retention? Maximize performance • Greater reductions in: • Family accommodation • OCD-related impairment Modest deterioration Base Line Post Treatment F-Up 3-Mnths

35. “Intensive CBT was • as effective as weekly treatment • with some advantages immediately after treatment • differences were not found at follow-up suggesting the need for additional care following intensive treatment • This may come in the form of weekly in-person or telephone booster sessions.” (Storch et al, 2007)

36. Wrapping up

37. Weekly Intensive OCD 60 Min 60 Min 60 Min 60 Min OST S. Phobia Intensive Panic 

39. May the intensive force be with you Eduardo Bunge Ph.D Palo Alto University ETCI Foundation

40. English Resources

41. Resources in Spanish and Portuguese